Direct care registered nurse perceptions of the healthy work environment

1. Direct care registered nurse perceptions of the healthy work environment M. Anne Longo PhD, RN-BC, NEA-BC Society of Pediatric Nurses Conference Saturday, April 21, 2012

2. Objectives Define the healthy work environment of the direct care RN Discuss pediatric RN perceptions of their work environment Discuss study implications Generate ways to implement a sustainable healthy work environment

3. Introduction/statement of the problem Unhealthy work environments contribute to an increase in adverse events, poor care delivery and nurse dissatisfaction Role the frontline clinical nurse manager plays in establishing a sustainable healthy work environment leading to retention Role of the level of direct care RN Aiken, Clarke, Cheung, Sloane & Silber, 2003; Bernard Hodes Group, 2008; Robert Wood Johnson Foundation, 2009 Barden and Distrito, 2005; Kramer and Schmalenberg, 2008; Kovner etl. al., 2007; Benner, 1984; Altmann, 2007). Beal, Riley & Lancaster, 2008; Utriainen and Kyngas, 2009; Wong and Cummings, 2007; American Organization of Nurse Executives, 2002.

4. Research aims • To understand the direct care registered nurses perceptions of their own healthy work environment using the action research (AR) form of Appreciative Inquiry (AI). • Determine if the direct care RNs perceptions are related to their level of practice. • Determine if the RNs perception of their level of practice was the same as their manager.

5. Theoretical framework Benner, 1984 from Novice to Expert Model The American Association of Critical Care Nurses standards for establishing and sustaining healthy work environments Situational Leadership Model as a means of developing management strategies for the clinical managers to use Barden, C. E. e. (2005). AACN standards for establishing and sustaining healthy work environments. Aliso Viejo, California: American Association of Critical-Care Nurses. Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, California: Addison-Wesley. Blanchard, Ken. (2000). Situational Leadership®II: Teaching others. The Ken Blanchard Companies. Item#13538. V051602.

6. A Sustainable Healthy Work Environment Direct care RN Benner’s Novice to Expert Level of Practice Model Assessing/describing the healthy work environment Clinical nurse manager Focus of the study is the direct care RN perceptions of the healthy work environment Hersey and Blanchard’s Situational Leadership Strategies Self identifying level of practice Direct care RN Appreciation inquiry interviews Clinical nurse manager identifies their direct reports level of practice Longo, 2010

7. Definition of the healthy work environment • American Association of Critical Care Nurses (six standards) Skilled Communication True Collaboration Effective Decision Making Meaningful Recognition Authentic Leadership Appropriate Staffing • Registered Nurses of Ontario: Healthy Work Environment Best Practice Guidelines • International Council of Nurses: A Call to Action for Positive Practice Environments

8. Literature states the WHY Importance of leadership to establishing the work environment • Strengthening interpersonal relationships • Organizing nursing work • Leadership style related to lack of empowerment, communication and willingness to change (Utriainen and Kyngas, 2009; Coomber & Barriball, 2006; Saver, 2009; McGillis and Doran, 2007).

9. Mixed method research design Qualitative-Quantitative • Theoretical thrust • Core component • Supplementary component • Induction (Morse, Niehaus, Wolfe & Wilkins, 2006).

11. Research Design Qualitative “What attitudes and beliefs do you have about the standards of the healthy work environment within your own work setting? “Based upon your perceived level of practice, what do you believe to be the most important standard for your own work satisfaction? “What is the most important standard that affects patient outcomes?” “What would you like to tell say that we didn’t ask?

12. Research design quantitative • Provided with an explanation of the study including operational definitions of AACN’s six standards and Benner’s five levels of practicing nurses. 2. Completed a data collection tool comprised of identifying demographics 3. Self-identified their level of practice based upon Benner’s (1984) model of five levels of practice • Completed a tool rank ordering the importance of the six standards of the HWE in their own work environment: skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition and authentic leadership. Clinical Managers were asked to identify their direct reports level of practice

13. Site/Subjects/Demographics One hundred thirty seven direct care RNs work on the two study units. 44 % of direct care RNs on Unit 1 participated 50% of direct care RNs on Units 2 participated. The overall study participant is a female RNI in her 20’s with a BSN degree. A full 40% of the participants are in their first professional role and 73% have worked less than five years.

14. Demographics 66% of the participants are between the ages of 20-29. 58% of all who participated in the study work 12 hour shifts. The majority of direct care RNs are RNIs (34%), the units have 13% RNIIs but only 1.5% RNIIIs.

15. Nvivo results HWE standards % of HWE rankings

16. What do you perceive as the most important standard to your own work satisfaction? Patient outcomes? Overall themes: • Skilled communication • True collaboration • Effective decision making • Authentic leadership All four of these healthy work environment standards can be found in the literature as being necessary for staff satisfaction. In addition, the literature notes these same work environment standards are important to the younger RNs.

17. Novice RN from Unit 2 “Communication, you have to be informed about the general unit as a whole, not just your patients. Strong communication and teamwork for patient safety. I’m new and I probably ask 50,000 questions a day.” Competent RN from Unit 1 “Communication wise I think shift report needs to be revamped. Don’t need to know vital signs if they are fine. Face to face report is fine.”

18. Quantitative results The quantitative results confirmed the qualitative findings of skilled communication being the most important standard regardless of level of practice with p = .445, alpha = 0.05 and confidence interval = 95.

19. Quantitative results 47 of the 67 direct care RNs who participated chose skilled communication as either their number one or number two top choices for a cumulative 70%.

20. Independent t-test of the six standards of the healthy work environment and RN level of practice revealed no significant differencesIndependent t-test of the six standards of the healthy workenvironment and Age of direct care RN revealed no significant differences.

21. Direct care RN self-identified level of practice

22. Nonparametric correlation of RN level and Clinical manager level of practice

23. Discussion • Age • Patient population • Motivational factors • Setting • Clinical Managers • Patient Satisfaction data

24. Creating a sustainable healthy work environment Focus is developing techniques for skilled communication to be used by all disciplines as well as patients/parents • Situational leadership • Purposeful rounding • Motivational interviewing • Team STEPPs • Use of technology

25. Call to Action What is one concept learned from this research session that you will take back and explore/implement in your own unit/setting More info? Anne.Longo@cchmc.org