Am J Crit Care 2007 Schmalenberg 458 68

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Types of Intensive Care Units With the Healthiest, Most Productive Work Environments Claudia Schmalenberg and Marlene Kramer

Am J Crit Care 2007;16:458-468

 © 2007 American Association of Critical-Care Nurses Published online http://www.ajcconline.org Personal use only. For copyright permission information: http://ajcc.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT

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AJCC, the American Journal of Critical Care, is the official peer-reviewed research  journal of the American American Association of Critical-Care Nurses (AACN), (AACN), published bimonthly by The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright © 2007 by AACN. All rights reserved.

Challenges in the Critical Care Workplace

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 YPES OF INTENSIVE

C ARE UNITS W ITH THE HEALTHIEST , MOST  PRODUCTIVE W ORK  ENVIRONMENTS By Claudia Schmalenberg, RN, MSN, and Marlene Kramer, RN, PhD

CE

2.0 Hours Notice to CE enrollees:

 A closed-book, multiple-choice examination following this article tests your understanding of  the following objectives: 1. Discuss 3 common trends in healthy work  environments. 2. Explain the relationship between the 8 essentials of a productive work environment  identified by staff nurses in magnet hospitals and the 6 AACN standards of a healthy work  environment. 3. Discuss the relationship between healthy work  environments and magnet hospitals. To read this article and take the CE test online, visit www.ajcconline.org and click “CE Articles in This Issue.” No CE test fee for AACN members.

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Background The quality of nurses’ work environments in hospitals is of great concern. The American Association of CriticalCare Nurses has specified 6 standards essential to a healthy (ie, satisfying and productive) work environment. These standards are sufficiently aligned to the Essentials of Magnetism processes to make this tool suitable for measuring healthy work environments. Objectives To identify differences in staff nurses’ perceptions of the work environment by type of intensive care unit. Methods A cross-sectional descriptive design with strategic sampling was used in this secondary analysis of data from 698 staff nurses working in 34 intensive care units in 8 magnet hospitals. Intensive care units were grouped into 4 types: medical, including coronary care; surgical, including trauma and cardiovascular; neonatal and pediatric; and medical-surgical. All nurses completed the Essentials of Magnetism instrument. Analysis of variance was used to identify initial differences; multivariate analysis of variance was used to control for covariates. Results The intensive care nurses and units scored above the National Magnet Hospital Profile mean on process variables and on the Essentials of Magnetism outcome variables. Neonatal and pediatric units scored significantly higher than did the other types of intensive care units sampled. Conclusions Intensive care unit structures supported care processes and relationships that resulted in job satisfaction among nurses and high-quality care for patients in this strategic sample. Systematic study of the structures and processes present in units reporting a healthy work environment can be used to assist other clinical units in improving work environments. (American Journal of Critical Care. 2007;16:458-469)

A JCC  AMERICAN JOURNAL OF CRITICAL CARE, September 2007, Volume 16, No. 5

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he American Association of Critical-Care Nurses (AACN) defines a healthy work  environment as a work setting in which structures are designed so that nurses can achieve 2 outcomes: meet organizational objectives and achieve personal satisfaction in their work.1 AACN has identified 6 standards or relationship-centered principles of professional performance2 through which these outcomes are to be achieved. Environment is the aggregate of conditions and circumstances that influence an organism, so each of the 6 standards is essential to a healthy work environment. The standards are interdependent; none can be considered optional. 3

Intensive care units (ICUs) have staffing and other structures that differ from those of other clinical units. These structures differentially affect functional care processes and relationships that, in turn, affect outcomes such as nurses’ job satisfaction and their ability to give quality care to patients. Differences among types of ICU units—adult and pediatric, medical and surgical—also have been noted. 4-6 Combining samples of nurses from various categories of ICUs may mask differences in structures that enable care processes.  The Essentials of Magnetism (EOM) is a psychometrically sound instrument 3 that measures 8 functional processes essential to a productive work  environment. The 8 processes are highly intercorrelated and interdependent; all are essential to a healthy   work environment. The AACN standards and the EOM are not identical. The standards were identified by leaders, experts, and a professional organization; the EOM was compiled from the perspective of staff  nurses working in magnet hospitals.7 Both the standards and the EOM focus on processes or relationships, and both emphasize that it is not any one process or relationship but the aggregate that constitutes a productive, healthy work environment.  This congruence and alignment between the standards and the EOM are sufficient to make the EOM a suitable instrument for answering the questions that guided our study: How healthy are ICU work  environments? Do some types of ICUs report healthier work environments than do others?

About the Authors Claudia Schmalenberg is president of nursing at Health Science Research Associates, Tahoe City, California. Marlene Kramer is vice president of nursing at Health Science Research Associates, Apache Junction, Arizona. Corresponding author: Claudia Schmalenberg, RN, MSN, Health Science Research Associates, PO Box 7667, Tahoe City, CA 96145 (e-mail: [email protected]).

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Background Structures  The structural elements and attributes of ICUs that are linked to a healthy practice environment are a physical layout that allows constant observation and immediate access to patients; a high level of rapidly  developing technology; competent, experienced nurses; a low nurse to patient ratio8; longevity of contact between nurses and physicians9-11; and a high degree of medical specialization.10-12 ICUs also have high “medical pervasiveness,” that is, a relatively small number of physicians who are called and who visit  the unit frequently and for longer  periods than do physicians in other  units.13 Bedside rounds with physicians, nurses, healthcare workers from other disciplines, the patient, and the patient’s family all discussing  the patient’s progress and daily and long-term goals are characteristic of  ICUs, particularly medical ICUs.10,11

A healthy work environment enables nurses to meet organizational objectives and achieve personal satisfaction in  their work.

Processes and Outcomes  The 6 relationship processes identified in the AACN standards are skilled communication, true collaboration, effective decision making, staffing that matches patients’ needs and nurses’ competencies, meaningful recognition, and authentic leadership. Some processes such as effective decision making have been positively linked to ICU structures,13,14 and ICU structures have been linked to patient outcomes such as mortality and to nurse outcomes such as burnout, job satisfaction, stress, and turnover.13,15 The functional processes and relationships that constitute a productive, healthy work environment have not  been measured and studied in their aggregate.  The results of empirical studies of the effects of  ICU structures on processes and outcomes have been mixed. In one study,14 ICU nurses had a greater need for autonomy and scored higher in autonomy than

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did nurses in other types of clinical units. In another  study,16 researchers found no differences in autonomy scores between nurses in ICUs and emergency  departments and nurses in general medical-surgical units. In still another study,4 ICU nurses scored the lowest of all groups in autonomy. Structures and nurse outcomes often are linked by comparing scores of nurses from ICUs with scores of nurses from other units. ICU nurses are reported to have more occupational stress, less job satisfaction, and greater turnover than are nurses in other  types of units,13 although it also is reported that  medical-surgical nurses have higher occupational stress and turnover than do nurses in other units.16 In a study of 55 516 registered nurses (2900  work groups) in 206 hospitals in 44 states, Boyle et  al13 reported that work group satisfaction was moderate across 10 types of clinical units. Nurses in pediatric units were the most satisfied of all, those in emergency departments and perioperative services  were the least satisfied of all, and ICU nurses were the most satisfied of nurses in the 7 remaining types of units.13 When different clinical units were compared with respect to 8 attributes essential to a productive work environment, ICU nurses scored higher on collegial/collaborative relationships between nurses and physicians and perception of adequate staffing and lower on nurse manager support than did nurses from other units (C.E.S. and M.K., unpublished data, 2007). In a classic study that showed linkages between structures, processes, and outcomes in assessing the quality of healthcare and work environments, Knaus et al15 examined the relationship between ICU structures and the patient outcome “mortality  less than would be expected by acuity.” The findings indicated that the significantly lower mortality rates in the ICUs studied nationwide were due not to the structural elements of  ICUs but rather to the processes of teamwork and collaboration between nurses and physicians. These results illustrate the fundamental principle that, although structure is critically important, structure alone does not produce outcomes. Structures enable processes that lead to outcomes.17

Compared with other types of clinical units, ICUs score moderate in job satisfaction and moderately high on some factors essential to a productive work environment.

Types of ICUs In 3 studies,6,18,19 nurses in medical ICUs (MICUs) reported more favorable components in

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their work environments than did nurses in other  types of ICUs. In a study of 2323 nurses in 110 ICUs in 64 hospitals, Cimiotti et al6 found that nurses in MICUs and medical-surgical ICUs (MSICUs) perceived higher staffing levels than did nurses in coronary care units and surgical ICUs (SICUs). The degree of collaboration between physicians and nurses as perceived by nurses was related to positive outcomes for patients in MICUs but not in SICUs or  MSICUs. Baggs et al18 reported that the degree of collaboration as perceived by physicians was not associated with outcomes in any type of ICU. In a study  by Ferrand et al19 of 3156 nurses and 521 physicians from 133 French ICUs (90 MSICUs, 22 SICUs, and 21 MICUs), MICU nurses believed they were more involved and more satisfied with “end-of-life” care decisions than were nurses in SICUs or MSICUs.  The aggregation of ICUs into different types  was not consistent across these studies,6,18,19 making  the results difficult to interpret. In some, coronary  care units were grouped with MICUs; in others, coronary care units were studied as separate types of ICUs. None included neonatal ICUs (NICUs). Measuring Nurses’ Work Environments Few tools are available to measure nurses’ work  environments. Studies20,21 in which environments were measured by using conceptually derived subscales from the Nursing Work Index 22  were based on indi vidual rather than unit level data, lacked a theoretical base, and measured “presence” of the attribute without regard to the steps or components of the process or to the respondent’s definition of the concept. For  example, compare the statement “I can practice autonomously” with “Nurses on this unit make independent care decisions in that sphere of practice that  is uniquely nursing.” Such differences make it difficult to relate, compare, or interpret the results.  With the EOM, both the components of the  work environment and the composite work environment can be measured; 90% of the items are written from a clinical unit perspective and the remaining  10% are organizationally and unit based.3 The EOM has a long developmental history. In 1984, 65 characteristics of a magnetic work environment, confirmed by the original investigators, were abstracted from the original magnet hospital report, and a tool to measure job satisfaction and productivity was developed.23 After administration to thousands of  nurses during a 12-year period, the tool was condensed to the 37 most frequently selected items. In 2001, staff nurses in 14 magnet hospitals were asked to identify the 10 attributes most important to “being  able to give quality patient care” (productivity).7 In

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the magnet hospital study,24 4 outcome criteria— attraction, retention, productivity, and job satisfaction—were used to designate magnet or excellent   work environments. In a causal modeling study,25 productivity accounted for more than 80% of the  variance in job satisfaction, attraction, and retention. Hence, in the 2001 study,7 staff nurses were asked to select the essential environmental attributes on the basis of productivity alone. The 8 attributes identified by staff nurses in magnet hospitals were as follows: 1. Working with clinically competent peers 2. Collegial/collaborative relationships between nurses and physicians 3. Clinical autonomy  4. Nurse manager support  5. Control over nursing practice 6. Perception that staffing is adequate 7. Support for education 8. A culture in which concern for the patient is paramount (values) On the basis of interviews with 279 staff nurses and 132 leaders and managers in 14 magnet hospitals7 and participant observations of nurses in 12 other magnet hospitals,26 grounded theories were generated.3,12,27 Items to measure each attribute of a productive work environment were developed on the basis of these theories and the definitions and descriptions provided by nurses during interviews. Each attribute is measured by using a subscale.  Weighting studies were done to determine relative importance of steps and components of the process.3 For example, physician-nurse relationships based on mutual power, trust, and respect (collaborative) are more instrumental in enabling quality  patient care than are student-teacher or “friendly  stranger” relationships, hence the item has greater   weight in the scoring. The weighted, composite score for the 8 relationships or processes is a measure of a healthy, productive work environment; it is labeled “professional job satisfaction” to signify that it is job satisfaction due to professional productivity. Staff nurses describe this variable as an environment  “that helps me do a good job,” “in which I can make a difference in the care patients receive,” or where “what I do helps patients get better and stay healthy.”  Alignment is considerable between components of a productive work environment as measured by  the EOM and the 6 AACN standards. Both the EOM and the standards are based on relationships or  processes. The skilled communication standard is most closely related to the process of “working with other nurses who are clinical competent” but also to “support for education.” An almost direct parallel

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exists between the true collaboration standard and the process of establishing collegial and collaborative relationships between nurses and physicians. True collaboration also refers to one of the steps in the clinical autonomy process, “respect for the unique knowledge and ability of each profession.”2(p190) Effective decision making is related to both the “clinical autonomy” and the “control of nursing  practice” processes of the EOM. Appropriate staffing  parallels the EOM process of “perceived adequacy  of staffing.” The meaningful recognition standard is most closely related to “control of nursing practice,” and the authentic leadership standard is related to “nurse manager support.”2 Both the EOM and the  AACN standards recognize the interrelationship and interdependence of the components whose aggregate constitutes a snapshot of a specific environment. The EOM is used to measure a productive  work environment; the AACN standards define healthy  as productive and satisfying.2

Objectives of Study  The purpose of our study was to answer the following questions: To what extent do ICU nurses confirm a healthy work environment? Are there differences in perception by type of ICU? If some types of ICUs excel, systematic study of units that report  healthy work environments will permit identification of structures and practices that, when implemented, would improve the practice environment of other clinical units.  Analysis of the individual processes and relationships that lead to productive work environments will enable assessment of the impact  that the AACN standards have had on improving the work environment of nurses in ICUs and will suggest specific areas and strategies for change and improvement.

Design and Sample

Alignment and correspondence between the Essentials of Magnetism (EOM) and the AACN standards is sufficient to make the EOM a suitable tool  to measure healthy work environments.

 A cross-sectional descriptive design with strategic sampling was used in this secondary analysis of  data from a larger study 28 designed to identify organizational structures and practices that enable processes and relationships essential to a productive  work environment. The complete sample consisted of 2990 staff nurses from 206 clinical units in 8 magnet hospitals. The ICU subsample was 698 staff  nurses from 34 ICUs grouped into 4 types: (1)

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CE Test

Test ID A0716052: Types of Intensive Care Units With the Healthiest, Most Productive Work Environments. Learning objectives: 1. Discuss 3 common trends in healthy work environments. 2. Explain the relationship between the 8 essentials of a productive work environment identified by staff nurses in magnet hospitals and the 6 AACN standards of a healthy work environment. 3. Discuss the relationship between healthy work environments and magnet hospitals. 1. Which of the following statements best describes “medical pervasiveness”? a. One physician is more prominent than others in the intensive care unit (ICU) setting b. A small number of physicians who tend to spend longer periods of time in the ICU setting c. The ICU limits which physicians have privileges in the ICU setting d. Overall, physicians spend more time in the ICU setting than on general medicalsurgical units

6. According to Table 1, which type of ICU had the highest number of baccalaureate-prepared nurses? a. Medical-surgical c. Neonatal b. Surgical d. Medical

2. Which of the following has a signi f icant impact on lowering the mortality rates in ICUs? a. Perception of adequate staffing b. Perception of supportive administration c. Process of teamwork and collaboration between nurses and physicians d. Structural features characteristic of ICUs

8. Which 2 age groups reported the highest overall job satisfaction? a. Those with 3 to 5 years’ experience and those with more than 30 years’ experience b. Those with less than 3 years’ experience and those with more than 30 years’ experience c. Those with 5 to 10 years’ experience and those with more than 30 years’ experience d. Those with less than 3 years’ experience and those with 5 to 10 years’ experience

3. What accounts for the more than 80% of the variance i n job satisfact ion, attraction, and retention scores of nurses in acute care hospitals? a. Productivity of quality patient care c. Magnet designation b. Meaningful recognition d. Perceived adequacy of staffing

9. AACN defines a healthy work environment as one in which nurses have which of the following? a. Increased job satisfaction and meaningful recognition b. Increased job satisfaction and opportunity to give quality patient care c. Opportunity to give quality patient care only d. High education levels and length on nursing experienc

4. Which of the following attributes are identif ied by staf f nurses in magnet hospitals? a. Career ladder structure, quality improvement program, peer review, and recognition b. Credentialed nurse leadership, all nursing staff with 1 to 1 ratios, career ladder program c. Critical thinking decision-making program, all nursing staffing with 1 to 1 ratios, new graduate nurse internship program d. Working with clinically competent peers, clinical autonomy, nurse manager support

7. What typ e of ICU was identif ied by nurses as havi ng the best environment for autonomous practice? a. Medical-surgical c. Neonatal b. Surgical d. Medical

10. What are some of the potential reasons suggested for small percentages of certif ied nurses in ICUs? a. Lack of financial support b. Lack of recognition of the potential benefits of certification as a baseline for essential processes c. Managers who focus on other educational needs and benefits d. All of the above 11. Which of the following statements is incorrect? a. None of the 8 essential attributes are optional; they are intercorrelated and interdependent. b. There is a parallel between true collaboration and process of establishing collegial and collaborative relationships. c. There is no relationship between the 8 attributes and 6 AACN standards. d. The Essentials of Magnetism tool is a way to measure healthy work environments.

5. What are the Essential s of Magnetism and the A merican Association of Critical-Care Nurses (AACN) standards based on? a. Relationships and processes b. Research and best practice c. Evidence-based practice and surveys d. Staff interviews and observations

Test ID: A0716052 Contact hours: 2.0 Form expires: September 1, 2009. Test Answers: Mark only one box for your answer to each question. You may photocopy this form.

1.  a b c d

2.  a b c d

3.  a b c d

4.  a b c d

5.  a b c d

6.  a b c d

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7.  a b c d

9.  a b c d

10.  a b c d

11.  a b c d

Fee: AACN members, $0; nonmembers, $12 Passing score: 8 correct (73%) Category: O, Synergy CERP C Test writer: Roanna Payne,RN, BSN

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The American Association of Critical-Care Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. AACN has been approved as a provider of continuing education in nursing by the State Boards of Nursing of Alabama (#ABNP0062), California (#01036), and Louisiana (#ABN12). AACN programming meets the standards for most other states requiring mandatory continuing education credit for relicensure.

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