Longitudinal Evaluation of Implementation of AACN’s Healthy Work Environment Framework in an Intensive Care Unit Free

The turnover rate for bedside registered nurses in the United States is 22.5%, and 51.4% of hospitals report having a vacancy rate higher than 15%.¹  In 2023, 32.8% of newly licensed nurses left their position within 1 year, leading to further instability and risk to patient safety.^1–3  Turbulence within teams leads to increased burnout and strain on team members.²  Healthy work environments (HWEs) are associated with positive patient and staff outcomes, increased job satisfaction, and greater intent to stay.^4–9 

Staff engagement is essential for nurse leaders to promote retention, as disengagement is a major factor in turnover, particularly early in practice.⁸  Specifically, when leaders fail to partner with staff members and provide professional growth opportunities and adequate staffing levels, job satisfaction decreases, resulting in disengagement.⁸  Among the positive outcomes of HWEs are increased staff engagement, which mitigates burnout and compassion fatigue.² 

The American Association of Critical-Care Nurses (AACN) developed an evidence-based framework for improving local work environments.⁴  The framework consists of 6 standards: skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership. The purpose of this study was to use the AACN HWE framework to implement interventions and evaluate the effect on overall satisfaction and retention of registered nurses during a 6-year period.

This study used a prospective, longitudinal evaluation design comparing 4 independent cohorts to assess the impact that sustained implementation of HWE interventions had on our work environment during a 6-year period. We collected baseline data in July 2017 and postintervention data in April 2019, June 2021, and June 2023. The study took place in a 32-bed cardiothoracic intensive care unit (CTICU) at a large quaternary academic medical center in the southeastern United States. The patient population consisted of those who had undergone coronary artery bypass grafts, valve repairs or replacements, aortic surgeries, and heart and lung transplants, as well as patients requiring mechanical circulatory support, including ventricular assist devices, intra-aortic balloon pumps, and extracorporeal membrane oxygenation. Our unit had 165 registered nurses, and our primary nurse to patient ratio was 1:1 or 1:2. Unit leaders consisted of 1 nurse manager and 7 assistant nurse managers, who worked 50% of their time in direct patient care and 50% in administrative work. The health system’s institutional review board deemed this study exempt as a quality improvement project. The design of the evaluation of the HWE initiative used cross-sectional sampling and compared 4 independent cohorts, in 2017, 2019, 2021, and 2023; therefore, we followed the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines in presenting the results.¹⁰ 

In 2017, our team began using the publicly available AACN HWE Assessment Tool (HWEAT) as an objective measure to evaluate the local work environment overall and for each independent standard. The HWEAT consisted of 3 questions for each of the 6 HWE standards, totaling 18 questions (Table 1).¹¹  Responses indicated level of agreement using a 5-point Likert scale (1 = “strongly disagree”; 5 = “strongly agree”). Mean scores were calculated for each standard, and an overall score was obtained. The overall score was interpreted as follows: 1.00-2.99, “needs improvement”; 3.00-3.99, “good”; 4.00-5.00, “excellent.” In 2018, the AACN HWEAT was shown to be valid and reliable across each of the 6 standards (Cronbach α of 0.77 or better).^11,12  The Cronbach α value for each individual standard is shown in Table 2.

Unit leaders distributed the AACN HWEAT survey link to all CTICU nursing staff members (n = 165) in July 2017. The survey was open for responses for the entire month. Seventy-two nurses (42.1%) responded anonymously to the preimplementation survey. At the conclusion of the survey window, results were collated and returned by AACN to the local leadership team. In April 2019, June 2021, and June 2023 an anonymous electronic survey consisting of the HWE questions, supplemented with an area for write-in comments, was distributed to all registered nurses on the unit. This information was used to iteratively address each HWE standard during the 6-year period, as outlined below.

Poor communication contributes to sentinel events,¹³  medication errors, decreased quality of care, and staff burnout and turnover.^14,15  AACN described the need for staff members to be competent not only in clinical care but also in communication skills.¹⁶  The skilled communication scores were measured by questions 1, 6, and 14 on the HWEAT.

To promote communication skills, all unit preceptors and charge nurses took a basic communication class facilitated by the hospital-based clinical education department. Furthermore, TeamSTEPPS training, a validated standard supporting safe communication, was incorporated into the onboarding process for the interprofessional team.¹⁷  To enhance communication across the department, unit leaders hosted staff meetings 12 times per month both in person and virtually, accommodating those working night and weekend shifts. Structured bedside handoffs both from shift to shift and from the operating room ensured that accurate information was presented consistently during transitions of care. Finally, the unit held shift huddles to review patient information and outcomes, monitor patient flow, and address any staff concerns regarding safety, equipment, technology, and supplies.

Collaboration among the care team is critical to patient safety and the work environment.⁵  True collaboration was measured by questions 2, 10, and 15 on the HWEAT.

Nurse-to-nurse handoff in bedside reporting and daily interprofessional rounds were endorsed to promote collaboration among the team. Standard work surrounding interprofessional rounds supported a consistent daily process by identifying responsibilities for each role and expectations for review. Unit leaders conducted purposeful rounding with each staff member at least once per shift to address any safety concerns, questions, or resource needs. Unit-level leaders escalated concerns regarding barriers to care through a daily huddle consisting of leaders from multiple departments including supply chain and nursing.

Relationship building within the team is a critical component of true collaboration. Our HWE committee coordinated monthly social activities to promote relationships. In addition, the HWE committee organized an annual softball tournament, including teams from several hospital departments, to promote teamwork and socialization and raise money for the American Heart Association and HWE committee activities. Last, unit-based educational courses were taught not only by registered nurses but also by other health care professionals including physicians, respiratory therapists, and pharmacists to promote collaborative learning across the entire care team.

Ensuring that staff members involved in direct care are engaged in decision-making about organizational operations is critical to patient safety as well as staff and patient satisfaction.^17,18  Effective decision-making was measured by questions 7, 11, and 16 on the HWEAT.

Interprofessional rounds not only enhanced collaboration but also promoted effective decision-making. Several unit-based committees focused on performance improvement and research, facilitating evidence-based practice. Leaders and committee members partnered to regularly evaluate all current practices. Members of these groups identified improvement opportunities and partnered with the appropriate teams to evaluate new evidence, such as that pertaining to practices for patient extubation after cardiac surgery.¹⁹  Whether as a result of the work of these committees or other organizational needs, changes to unit protocols and policies were reviewed with all staff members, along with the rationale behind those changes and the evidence supporting them. Moreover, workflows and decision trees were created in conjunction with the charge nurses to promote the most effective decision-making related to staffing, patient assignments, and escalation of concerns.

When patient needs and nurse competencies are effectively matched, appropriate staffing is achieved, leading to enhanced staff satisfaction and patient outcomes.^20,21  Staffing is a complex issue that affects all aspects of a department and is influenced by workload, nurse competencies, interdisciplinary skill mix, and workforce trends. Appropriate staffing requires collaboration between leaders and nurses at the bedside.²²  Appropriate staffing was measured by questions 3, 8, and 12 on the HWEAT.

Prospective staffing, or hiring based on historical trends, prevented periods of short staffing related to unexpected turnover or small hiring pools.²³  Furthermore, a unit-based scheduling committee engaged bedside nurses in staffing and scheduling, ensuring that patient and nursing needs were met. The unit orientation structure involved a standardized approach to increasing nurse competency, with both bedside and didactic time included. Charge nurses used an electronic tool to ensure that patient needs were matched with a competent nurse. The charge nurses were also provided with a weekly orientation needs document that listed the types of assignments needed for new nurses to gain competence. The charge nurses used both of these tools to ensure appropriate assignments.

Meaningful recognition occurs when staff members are recognized and provide recognition themselves to others for the value of the work they perform and enhances morale, productivity, and patient outcomes.¹⁷  Meaningful recognition was measured by questions 4, 9, and 17.

To foster staff recognition, a monthly newsletter was initiated that included photographs from staff events, profiles of new nurses, and coverage of celebrations of staff birthdays and new professional certifications. The HWE committee also established an annual “Years of Service” breakfast for staff members who had worked on the unit for 5 years or more. These recognized team members also received a personalized gift. Additionally, the HWE committee coordinated activities for staff during National Nurses’ Week such as massages, pet therapy, snacks, and music lessons. On a biannual basis, the committee gave each of the preceptors and charge nurses recognition gifts, consisting of goody bags with pens and markers, coffee shop gift cards, and badge pins, accompanied by a handwritten note.

The HWE committee and unit leaders developed additional strategies to promote individual recognition. Leaders asked each team member how they preferred to be recognized and tracked this information in a shared electronic file. Examples included letters of thanks from patients, peers, or the leadership team, emails, and kudos given in a public setting, such as a staff meeting or huddle. Last, the team created a “Gratitude Tree” located in a public space, with each leaf on the tree representing an individual team member (Figure 1). This project allowed team members to be publicly recognized and thanked by staff members, patients, and family members.

To recognize the team as a whole, HWE committee members and unit leaders partnered to nominate the CTICU for an AACN Beacon of Excellence Award, which reflects a high standard for patient care and positive work environments.²⁴  The unit received a gold-level award in 2020 and again in 2023. These accomplishments were celebrated for several days with unit staff and hospital leaders.

Authentic leadership promotes staff satisfaction, engagement, and intent to stay.⁶  Authentic leaders not only embrace and exhibit the components of the HWE framework themselves but also encourage others to engage in an HWE.²⁵  Authentic leadership was measured by questions 5, 13, and 18 on the HWEAT.

In our department, the assistant nurse manager position is essential to authentic leadership. Given that their role is split between direct patient care and administrative responsibilities, these individuals genuinely understand the staff perspective. The assistant nurse managers spearheaded this evidence-based work in collaboration with bedside nurses interested in formalizing HWE interventions, further promoting team engagement and buy-in.

To promote authentic leadership, the nurse manager and assistant nurse managers participated in continuing education, performance improvement efforts, and simulation exercises to enhance their skills and abilities. Leaders’ rounding and presence on all shifts including nights and weekends allowed them to support and learn from the entire team. Regular staff forums allowed all staff members to provide feedback to the leaders regarding any component of unit operations. Participation in staff-led committees and initiatives allowed leaders to coach others while learning staff perspectives and to support staff innovation at the bedside. Translating staff members’ ideas into the practice setting built excitement and trust among the team. This engagement fostered strong relationships and affected staff members’ intent to stay.

We report the nurses’ demographic characteristics in year 1 (2017), year 2 (2019), year 3 (2021), and year 4 (2023) using mean and SD for continuous measures and count frequencies and percentages for categorical variables. We used a 1-way analysis of variance to compare unmatched multiple independent groups across the 4 measurement time periods (6 years). To control for increases in type I error rate caused by multiple comparisons, we used a Bonferroni test to adjust for false discovery rate. In this case, each subsequent comparison of the individual standards is compared in sequence. This method filters the tests of hypotheses that have errors (the null is accepted, signaling no difference) from the hypotheses that are judged important (the null is rejected, signaling a significant difference). Using this approach, it is possible for individual standards of the HWE to be statistically significant even though the P value for the overall test comparison is greater than .05.²⁶  Analyses were performed using IBM SPSS Statistics, version 26.

Before the intervention, the CTICU nurses (n = 165) had a mean (SD) age of 31 (0.8) years, had a mean of 5 years of nursing experience (median, 3; range, <1–30), were predominantly female (76.4%), and usually had a BSN or an MSN (86.1%) (Table 3). After the intervention (2019, 2021, and 2023), the nurses (n = 524) had a mean (SD) age of 30.3 (5.4), had a mean of 4 years of nursing experience (median, 2.2; range, <1–35), were predominantly female (78.4%), and usually had a BSN or an MSN (85.1%). There were no statistically significant differences in demographic characteristics between the cohorts (Table 3).

Seventy-two (43.6%), 64 (36.4%), 58 (36.9%), and 77 (40.3%) nurses responded to the survey in 2017, 2019, 2021, and 2023, respectively. Improvements in the overall HWE summary score were statistically significant (P = .01). Comparing the standards independently and using the Bonferroni approach to adjust for multiple comparisons, the scores for effective decision-making (mean, 4.01 vs 4.20; P = .02), true collaboration (mean, 3.43 vs 3.74; P = .004), meaningful recognition (mean, 3.37 vs 3.66; P = .009), authentic leadership (mean, 3.92 vs 4.10; P = .03), appropriate staffing (mean, 3.61 vs 3.88; P = .01), and skilled communication (mean, 3.75 vs 3.97; P = .02) improved significantly from 2017 to 2023 (Table 4).

Nurse turnover increased significantly during 2021 and 2022 due to the COVID-19 pandemic; although it decreased by 9% between 2022 and 2023, it remained 2.41% higher compared with 2017 (Figure 2). The median tenure of nurses decreased by 148 days between 2017 and 2023. The increased nurse turnover experienced during the pandemic is the primary reason for the reduction in tenure. In 2017, the self-reported top 2 reasons for leaving were to pursue a nurse practitioner or certified registered nurse anesthetist credential (n = 16, 34%) and relocation (n = 10, 21%) (Figure 3). After the intervention, the variability in reasons for turnover reflected, in part, the national trends seen during COVID-19. The top reasons for turnover were internal transfer, pursuing advanced practice degrees, and relocation (Figure 3). Other reasons for leaving the CTICU included travel nurse assignment, personal, external transfer, and probationary failure (Figure 3). Although it was not a formal variable in this study, patient outcomes data demonstrate a 50% reduction in central catheter–associated bloodstream infections, a 71.4% reduction in Clostridioides difficile infections, and a 19.3% reduction in hospital-acquired pressure injuries.

Findings of this longitudinal evaluation suggest that using the AACN HWE framework to structure and implement a unit-based effort contributes to an improved work environment and is sustainable for a 6-year period. This study highlights the critical need to continuously evaluate improvement efforts that affect work environments, using iterative findings and changes in the national climate to contextualize annual modifications in interventions and approaches. Using the AACN HWEAT tool provides a consistent approach to evaluating progress over time and distinguishing outcomes for each of the HWE standards, helping to identify areas requiring modification or additional attention. Providing nurses with opportunities to become involved in improvement efforts resulted in an increase in nurse engagement throughout the 6-year time frame. Despite the impact of the COVID-19 pandemic, the unit’s HWE scores were consistently in the “good” category or above for each standard.

Although numerous studies have demonstrated the benefit of implementing HWE standards, this study is unique in providing a focused, longitudinal evaluation of a large, complex nursing department. As compared with other empirical evaluations of the health of clinical work environments for acute and critical care nurses, our intervention content and delivery approach were consistent over time, and the results related to staff nurse satisfaction and other HWE domains consistently improved. Although Ulrich and colleagues²⁷  found a “dramatic” decline in staff nurse satisfaction in 2023 as compared with 2018, the current study offers encouraging insights into successful strategies that sustained HWE benefits during a 6-year period. Possible reasons for the observed unit-level improvement during a time when others saw decline include the strong HWE foundation of the department, specifically in terms of the authentic leadership and effective decision-making standards. Because of these strengths, the department restabilized more quickly than departments that did not have a strong HWE foundation. Another contributor to the sustained effects of the intervention was the investment that leaders made in maintaining intervention activities even during the pandemic, including careful monitoring of the use of travel nurses to mitigate alienation, nurture a community culture, and increase cross-shift floating among local nurses. Despite both seasonal and contextual changes that occurred during the 6-year period, maintaining an HWE remained a unit priority, and the health of the work environment improved with time.

Similar to the findings of Blake and colleagues²⁸  and Samoya,²⁹  the current study demonstrates the value of facilitating nurse-led committees focused on continuous improvement, policy creation, and education. These activities support bedside nurses’ sense of ownership of practice. Promoting nurse engagement through the HWE framework establishes trust within the team and generates motivation and buy-in into unit culture. Also, our study indicated that meaningful recognition is a driver of decreased burnout and increased joy in the workplace, as found by Sweeney and Wiseman,³⁰  but is a challenging standard to achieve consistently, as it is different for every person. Using multiple avenues for staff recognition helped to mitigate this challenge. Given the large size of our team, nurses often had very different perspectives on meaningful recognition, underscoring that a one-size-fits-all approach is less than ideal.³¹ 

The results of this work aligned with other findings noted in the literature that nurses who work in healthy environments have higher job satisfaction and higher intent to stay; moreover, they experience less moral distress and they deliver higher-quality care.^4–9,31,32  Current literature supports our work in that appropriate staffing, which includes ensuring nurse competence, is associated with enhanced patient outcomes.^32–34  Moreover, this study demonstrates that while changing the work environment requires consistent approaches and efforts, attempts to improve a single standard can lead to sustained effects on other standards, as also demonstrated in other studies.^30,34  For instance, standardizing handoffs from the operating room to the ICU in an effort to promote true collaboration also affected skilled communication and effective decision-making.

Last, although HWE scores and turnover were affected by the COVID-19 pandemic, the unit maintained “good” or better HWE scores and restabilized quickly after the pandemic. In fact, the unit now has the highest HWE scores it has ever received, even better than before the pandemic. Similarly, a 2021 update on national nurse work environments indicated that staff satisfaction was higher in units that were working on HWE standards than in those that were not.²⁷ 

This study has several limitations. First, it was conducted in a single unit of an academic medical center, which could limit generalizability of the findings. Second, AACN distribution of the survey allowed anonymity of participants but created challenges in ascertaining response bias. We were unable to capture nonresponders’ perspectives and determine differences in demographic characteristics between responders and nonresponders. Third, although it increased over time, the response rate was less than 50% for each administration of the survey. Fourth, the HWEAT was administered only to registered nurses and did not gather information from interprofessional team members, which could limit the impact of interventions. Last, administration of the HWEAT using the AACN website does not allow for open-ended responses, which would aid in gathering more targeted feedback for creating action plans.

This study reinforces the value of using an evidence-based approach, such as the AACN HWE framework, to evaluate the health of the work environment and implement strategies to improve it. Creating and sustaining an HWE is a journey that requires planning, dedicated staff members and leaders, and consistent evaluation. As outlined in the literature, improving the work environment is critical for enhancing staff and patient outcomes, and knowledge of practical and impactful strategies to implement HWEs is essential for nurse leaders. As the HWE journey continues, expanding the tenets of this work with input from the interprofessional team will be vital to the success of sustained efforts.