Healthy Work Environment: Resolutions for 2020

Making New Year’s resolutions is a common tradition. For 2020, we propose 2 resolutions that will support individual health and contribute to the health of our work environments. First, let each of us respect and take care of ourselves. Second, let us individually and collectively respect and take care of all of our coworkers. Each of these resolutions will support our own health and the health of our work environments.

The American Association of Critical-Care Nurses (AACN) made a strong commitment to promoting healthy work environments in 2001 and led the development of 6 standards that are the foundation of healthy work environments.¹  These standards—skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership—support improved outcomes for both patients and nurses and for the health care team. Resources to assess and improve the health of the workplace are available on the AACN website. Much of the work on healthy work environments has focused on and been led by nurses, but the standards that improve the workplace for nurses also can have benefits for all members of the health care team.

The standard airplane safety briefing advises passengers to put their own oxygen mask on before helping others. This focus on self-care underlies our recommendation that the first resolution for 2020 should be to respect and take care of ourselves. The American Nurses Association (ANA) founded the Healthy Nurse, Healthy Nation initiative to encourage nurses to engage in healthy behaviors in 5 areas: physical activity, nutrition, rest, quality of life, and safety.²  According to the ANA, benefits of better health extend beyond the individual nurse, to the family, the community, the work environment, and patients, because healthier nurses can serve as role models, educators, and advocates. A recent review found evidence that mindfulness interventions can enhance nurses’ self-care, with associated improvements in patient satisfaction and patient safety.³ 

A healthy work environment is important to every member of the health care team, and respect and caring for others on the health care team is as important as self-care. The experiences of the most vulnerable members of the team may serve as a barometer of the environment as a whole. The employment of nursing assistants in acute care settings, including intensive care units, has been growing during the past 2 decades.⁴ 

Nursing assistants are vulnerable employees for several reasons. As a group, nursing assistants are generally the lowest paid members of the health care team. The median annual wage for nursing assistants is $25 710, and their median hourly wage of $12.36 is significantly less than the $15.95 median hourly wage for all US workers.⁵  Several other factors have a negative impact on nursing assistants’ work conditions, including emotional and physical job demands, lack of essential educational training, heavy workloads, and limited opportunities for advancement.⁶  Nursing assistants have higher rates of injuries and illnesses than the national average for caregivers.⁶  Lack of respect from registered nurse (RN) colleagues, peers, and management, and a lack of recognition for their work and contributions, increase job dissatisfaction and can lead to compassion fatigue and burnout among nursing assistants.

Research suggests that when nursing assistants are used a substitutes for RNs, quality of care suffers and mortality is worse.⁴  Addition of nursing assistants to unit staffing does not improve quality of care if preexisting environmental and staffing issues are not remedied concurrently.⁵  This should not be surprising; in an interdisciplinary care team, members are not interchangeable. No rational administrator would propose that only the number of team members matters, or that physicians, advanced practice nurses, nurses, physical therapists, and pharmacists are substitutable for one another. Any plan that substitutes nursing assistants for RNs in an attempt to reduce costs is doomed to fail and runs counter to supporting a healthy work environment.

However, nursing assistants can and do add real value in support of the care of acutely ill patients if they are well trained, well supervised, and well respected. More recently, Needleman and colleagues⁷  studied the effects of shifts with low staffing of RNs and/or nursing support staff (licensed practical nurses and nursing assistants) on inpatient hospital mortality. The hospitals they studied used nursing assistants in support of rather than in substitution for RNs, adding nursing assistants to the existing complement of RN nursing staff. More than 40% of the 66 871 shifts analyzed were in intensive care units. They found higher mortality associated with low RN staffing, low nursing assistant staffing, and low staffing of RNs and nursing assistants concurrently. They speculated that higher mortality when RN staffing is adequate but nursing support staffing is low may indicate either that nursing support staff act to provide an early warning to RNs about changes in a patient’s condition, or that without adequate support staff, RNs must take on support tasks which crowd out other essential work. A study by Lindh Falk and colleagues supports that while providing care, nursing assistants ask questions and talk to patients, enabling them to convey important information to RNs.⁸  Nursing assistants deserve respect as persons and as members of the health care team who make important contributions to patient care.

It is possible to improve the working environment for nursing assistants, and doing so has benefits for patients. Last year, several reports provided evidence of interventions targeted to nursing assistants. Dreher and colleagues designed a 90-minute evidence-based education program to address compassion fatigue awareness and teach self-care skills to nursing assistants.⁵  Following a single intervention, the participants reported that the program was helpful in improving their self-care and benefitted their families as well. Turnover at 3 months was reduced, and the effects of the program persisted at the 3 month follow-up. Another hospital created a nursing assistant task force that developed multiple strategies to enhance education, provide meaningful recognition, and involve nursing assistants in improving work conditions.⁶  These measures increased nursing assistant satisfaction and reduced vacancies. Importantly, reducing compassion fatigue and making the workplace healthier for nursing assistants also leads to improved care for patients.

More research is needed about how to establish and maintain healthy work environments that support all members of the team, including the most vulnerable. Nurses are well positioned to lead in assessing workplace health and ensuring that all members of the team benefit from the 6 AACN healthy workplace standards. For our own good and the good of our patients and coworkers, let us begin 2020 committed to resolutions that will support our own health and the health of our work environments.