In 2007 the Institute for Healthcare Improvement presented what is now called the “Triple Aim” as a framework that describes an approach for optimizing health system performance. The institute has indicated that new designs are needed to simultaneously pursue the 3 dimensions of the Triple Aim: (1) improving the patient experience of care (including quality and satisfaction), (2) improving the health of populations, and (3) reducing the per capita cost of health care.1
The primary focus of the Triple Aim is patient care. Patient care is widely accepted in the United States as an important agenda, but the Triple Aim also has 2 secondary goals: improving the patient experience and reducing costs.2 This article addresses the health care provider’s work environment, the Triple Aim, and the evolution of what is known as the “Quadruple Aim.” Healthy work environments are related to the goals of the Triple Aim. Improvement of the work environment provides an opportunity to promote joy in the workplace. Interventions to improve the work environment of health care providers are consistent with the Healthy Work Environment standards of the American Association of Critical-Care Nurses (AACN).3
Healthy Work Environments and Patient Safety
Health care organizations are seeking ways to improve the work environment because research has shown a direct link between a healthy work environment and patient safety.4,5 Problems in nurses’ work environments can lead to feelings of being overwhelmed at work, emotional exhaustion, and burnout. Lyndon6 has reported that burnout is common among health care workers and that the characteristics of the health care environment that contribute to burnout include time pressure, lack of control over work processes, role conflict, and poor relationships between professional groups and with leadership. Other factors contributing to stress and burnout are lack of support for the staff when errors occur, violence in the workplace, and moral distress.6
Given the recent research linking the quality of the work environment to patient outcomes, many organizations have advocated for expansion of the Triple Aim to include a fourth dimension of attaining joy in work (hence the Quadruple Aim).2,4,5 Because of the high risk of clinician burnout, in 2017 the National Academy of Medicine launched the Collaborative on Clinician Well-being and Resilience.7 The purpose of this group was to assess and understand what is driving clinical distress and burnout and make recommendations to help solve these problems. This group and others have made recommendations in support of the Quadruple Aim, advocating improvements in the work life of health care workers as foundational to achieving the Triple Aim.7,8 These recommendations focus on interventions to address burnout and promote joy in work.
Promoting Joy in Work Through Effective Decision-making, Authentic Leadership, and Professional Development
Specific strategies can be used to create a positive, healthy work environment. In accordance with the AACN Healthy Work Environment standard of effective decision-making, nurses should participate in hospital affairs.9 Bedside nurses can participate in shared governance, where they can use their voices to change policies and understand the rationale behind decisions made. Such participation can encourage empowerment, in which the nurse feels involved and supported and has access to needed resources to make a valuable impact on the health care organization. An employee who feels valued will be more loyal to the organization and experience increased job satisfaction, reducing burnout and the desire to seek employment elsewhere.9
In addition to facilitating participation in shared governance, nurse leaders should be authentic and spearhead the implementation of a healthy work environment. Nurse managers should strive to be visible, accessible, and receptive to their staff members. For shared governance to be successful, managers must establish trusting and collaborative relationships with staff members to facilitate change and growth. Research has shown that employee resignations are more frequently due to perceived characteristics of the manager than to quality of the organization.9 A nurse leader can be highly instrumental in developing shared principles and culture, building a sense of community within the unit, and conveying a vision for the future. This established trust and respect between managers and employees can foster greater commitment to an organization, which in turn promotes retention and contributes to a positive, healthy work environment.9
Another strategy for fostering joy in work is promoting professional nursing practice in a meaningful and effective manner. Professional development programs, such as a clinical ladder program for professional advancement, enhance recruitment efforts and foster retention through recognition of excellence in nursing.9 Clinical ladder programs promote education, experience, professionalism, leadership, teaching, and advocacy, frequently with the potential for monetary compensation. Other ways of promoting professional development are encouraging nurses to attend conferences and to earn additional certifications to advance their own nursing practice.9 Although these components of professional development may improve retention and reduce turnover, creating an overall positive, healthy work environment seems to make the biggest impact on improving the quality of care and facilitating interprofessional collaboration.
Staffing and a Healthy Work Environment
In addition to effective decision-making and authentic leadership, another important standard of a positive, healthy work environment is appropriate staffing.3 According to the American Nurses Association, adequate staffing levels have led to a reduction in medication errors, decreased patient complications and mortality, enhanced patient satisfaction, eased nursing fatigue and burnout, and improved nurse retention.10 In particular any adequate staffing model must account for patient acuity, unlicensed assistive employees, and the skill sets, education, and experience of the nurses on the unit. Sufficient and appropriate staffing is paramount to providing safe and high-quality patient care and is one of the AACN Healthy Work Environment standards.3 To implement this component of a positive, healthy work environment, a staffing and scheduling committee can be created. Examples of goals for a staffing committee are improving staff morale, expanding staff power over the work environment through self-governance actions, and initiating flexible scheduling options.10
Another important aspect of appropriate staffing is the provision of adequate, uninterrupted breaks.10 Nurses have described experiencing burnout as a result of missing or skipping their breaks and meals, which can lead to feelings of emotional exhaustion and depersonalization.11 This lack of a meal or rest period can negatively affect the nurse’s physical and mental performance, potentially harming the nurse-patient relationship and resulting in a substandard quality of care. Monaghan et al12 have shown that periodic breaks strengthen short-term performance and reduce fatigue. They also found that guaranteeing break time for nurses could reduce negative nurse and patient outcomes, because long hours were associated with errors and job-related injuries. Although management can encourage nurses to take breaks, authentic leaders need to provide support for staff by implementing a float nurse to provide patient coverage. Moreover, nursing leadership should provide initial and continuing education that encourages nurses to prioritize their personal needs, such as eating, drinking water, and taking rest periods. Such education can highlight the importance of self-care, encourage retention, and reduce the chances of nurse burnout.12
Skilled Communication and True Collaboration in a Healthy Work Environment
Along with appropriate staffing and adequate rest breaks, true collaboration among an interprofessional team is needed to ensure a positive, healthy work environment. Excellent communication is required to encourage collaboration and collegiality among all members of the health care team. In particular collegiality distinguishes different domains of professional practice and highlights each person’s unique contribution to the patient’s plan of care.12 Strategies to enhance interprofessional relationships include interdisciplinary rounds, collaborative practice orders, and critical pathways and protocols.12
Interdisciplinary rounds are particularly important when the patient and family members are also involved. Rounds can focus on the goals for the day, answer patient and family questions, and encourage open communication.13,14 This collaborative environment in which the patient is put first helps build mutual respect and trust among professionals. When the nurse feels like an empowered, valued member of the interprofessional team, patient goals are achieved more readily and a sense of loyalty to the unit and patient care team develops.13
Leadership Strategies to Promote Joy in Work
Are leaders asking staff members about their work experiences, and are they listening when they are told directly about issues at work that contribute to nurse burnout? One of the current authors (Fitzpatrick) had similar conversations with staff members at a children’s hospital, which brought to light problems such as chronic short staffing, high-acuity patients who did not survive, large numbers of violent and threatening patients and visitors, and lack of appreciation and acknowledgment from leadership. Communicating with staff members regularly about what is being done to improve such situations decreases burnout and makes room for the possibility of joy. Staff members should be encouraged to make a strong commitment to self-care and to create their own personal self-care plan both at work and away from work, and for times of crisis as well as calmer periods.
Achieving joy in work may seem like a monumental task, but it is not. Leaders should start by checking in with themselves. Are they optimistic? Do they contribute to creating a positive “vibe” in their area? They should also check in with each other, which can help build and nurture their relationships. Leaders should pay attention to the body language of staff members during conversations about shifts and current situations. Something as simple as having a senior leader such as a chief executive officer, chief operating officer, or chief nursing officer visit patient care areas monthly to shake hands and say “thank you,” “we appreciate you,” and “we know you’ve been working really hard, and we couldn’t do it without you” makes a big impression. Ensuring that leaders are knowledgeable about tough situations and acknowledging staff contributions can go a long way toward addressing burnout.
Dispatching spiritual care services representatives to provide a “Tea for the Soul” event for staff, which allows them to retreat to a quiet spot for a warm cup of tea, a cookie, and an ear for listening, is invaluable. Asking a unit if a small group would be willing to do the postmortem care for a long-term patient on another unit whose death was particularly emotional can ease burnout and mental distress.
A card-signing campaign of supportive messages from every unit in the hospital for an affected sister hospital immediately after a horrific mass shooting bolsters staff members to keep doing their important, tough work and deeply touches all involved. Hiring people whose sole responsibility is to foster the well-being of staff is important. A recognizable on-site employee assistance provider, who not only sees clients in the office but can come onto the unit during tough times, can help relieve distress. Having someone available to help debrief after an error is made can help support a nurse who might be a “second victim” if he or she were not able to talk about the incident with someone outside the unit staff. Supporting staff through those moments restores spirits and creates room for experiencing joy. Too much unaddressed mental anguish will result in reduced employee engagement and ultimately compromised safety and quality outcomes. Having designated employees to provide staff support paves the way to achieving joy in work.
To ensure that health care providers can experience joy in work, care must be taken to address their needs. This is not an insurmountable task. Implementing some or all of these activities not only can allow staff to experience joy at work but also may improve patient satisfaction and safety.4,5 Putting these structures and processes in place is the first step toward improving outcomes for both patients and nurses.
The authors declare no conflicts of interest.