Virtually all of the literature related to healthy work environments focuses on the organizational factors that contribute to or detract from making a particular employment site a good place to work. These are the attributes that have rightly been accorded decades of research and academic attention, and countless published papers, presentations, and nodding acknowledgments from readers and listeners. Consequently, it might be easy for nurses to feel as though they individually have little ability to exert control over the larger environment in which they interact with patients and coworkers. Although some critical care nurses may still feel relatively powerless to improve the quality of their work setting, others may be gaining an expanded appreciation for how the power of 2 can enhance their surroundings.

From one of the early studies of job satisfaction in nursing,l we learned that various aspects of the work setting such as leadership style, decision making, autonomy, and organizational climate not only influenced a nurse’s job satisfaction, but, in turn, positively or adversely affected more pressing concerns of the day related to staff nurse attrition and turnover. Discovery and analysis of these organizational variables eventually led to their compilation and distillation into various instruments that enabled their further explication and measurement. Two of those instruments are the following:

  • The Index of Work Satisfaction, originally developed in 1972 to measure nurses’ job satisfaction,2,3 quantified the relative importance of a number of organizational features (Table 1).

  • The Nursing Work Index was originally developed by Kramer and Hafner,4 revised by Aiken and Patrician,5 and later augmented by Upenieks6 to gauge nurses’ perceptions of whether selected organizational attributes (Table 2) exist in their work settings.

For today’s nurses, the notion of an optimal work environment, that is, one that would draw them to both enter and remain employed for an extended portion of their nursing career, is perhaps most closely aligned with the American Nurses Credentialing Center’s Magnet Recognition Program and its 14 Forces of Magnetism, which, since 1983,7 have both distinguished and recognized health care facilities that were best able to recruit and retain nurses. Despite its recent transformation and reconfiguration into a 5-component empirical model,8 the Magnet Recognition Program remains rooted to its 14 organizational attributes foundation (Table 3).

As with many other professional issues having far-reaching implications for nurses and health care delivery, research and related professional initiatives have spawned numerous organizational variables cited as operative in positively or negatively affecting the quality of the nurse’s work environment:

  • Kramer and Schmalenberg designate attributes that staff nurses who work in magnet hospitals have identified as essential to their work environment in “Essentials of Magnetism”9 (Table 4)

  • For nurses who work in critical care, acute care, and progressive care areas, the attributes of a healthy work environment are embodied in the American Association of Critical-Care Nurses’ Standards for Establishing and Sustaining Healthy Work Environments10 listed in Table 5 

  • American Organization of Nurse Executives Key Organizational Success Factors11 (Table 6)

  • The Nursing Organizations Alliance’s Elements of a Healthful Practice/Work Environment12 (Table 7)

  • Institute of Medicine’s report, Keeping Patients Safe: Transforming the Work Environment of Nurses,13 which illuminates problems in nurses’ work environment that diminish patient safety (Table 8)

When these various sets of organizational influences on nurses’ work environment are compared, 3 issues seem abundantly apparent:

  1. Considerable concurrence exists regarding the relevance of many features.

  2. None of these compilations asserts that the nurse’s work environment is determined solely or predominantly by any single factor. Rather, all these sources posit explicitly or implicitly that a nurse’s work environment is composed of the accumulated effects of numerous, interrelated factors that affect job performance and job satisfaction.

  3. Almost without exception, the factors identified reflect attributes located at the organizational level of hierarchy, that is, influences such as organizational structures; operation of organizational systems; and/or organizational policies, procedures, or programs. Although these structures, processes, and programs are operationalized via mid-level or unit managers, there remains an apparent neglect for considering influences that operate primarily at the level of the individual nurse.

In the end, it seems to me, each nurse considers the nature of his or her work environment; deals with it the best he or she can each day; weighs its pros and cons from his or her own personal framework of needs, wants, and constraints; and decides whether to enter, remain, or leave employment at a particular facility. Is there anything else that matters to that individual nurse, anything else that colors that nurse’s deliberations and decision? I think the value of retaining every good nurse to remain in practice as long as possible makes it imperative that we examine the forces surrounding a nurse’s work environment from every possible level of influence —including the highly personal.

For more than 30 years, the Gallup organization has surveyed businesses of all sizes in a variety of industries in an attempt to identify the factors most important in determining sustained workplace excellence. In 1997, Gallup instituted a feedback system for employers, where employees are asked to complete a 12-item workplace evaluation survey to determine how well their needs are being met. After analyzing findings from this semiannual survey for nearly a decade, Gallup confirmed that responses to those 12 questions reliably enabled distinction of a company’s most highly engaged and productive employees from their less engaged counterparts (Table 9).14 

After compiling data from 10 million manager and employee interviews conducted across 114 different countries in 41 different languages, Gallup characterized its insights as 12: The Elements of Great Managing.15 Ten of the 12 elements identified as crucial in affording continued workplace excellence are as familiar to nurses, nurse managers, and nurse researchers as they are to corporate employees, managers, and business research firms (Table 10). Although all 12 survey questions are posed to employees, 2 items are conspicuous for their personal rather than organizational focus.

Caring About You As a Person

Survey item 5 relates to whether a supervisor (or someone at work) cares about them “as a person.” There are no definitions of what constitutes caring of this nature, so replies to this item would seem to require some degree of private introspection unless recent glaring incidents facilitate that response. As explained by Gallup,15 the relevance of this element owes to employees’ need for bonding that extends beyond their homes, churches, and neighborhoods and the benefits to the organization include employees who not only work harder, but who are 22% less likely to leave than those who don’t feel cared about at work. Findings like these are not hard to appreciate when we recall Maslow’s hierarchy of human needs, where, after the 2 highest priority needs (for physiologic requirements such as air, water, and food, and for physical safety and security), our next most important human need is for Belonging. Employees who believe they are important members of a valued organization work much harder than those who feel they are just another nameless FTE on the schedule.

Some suggested approaches for health care managers and staff who wish to demonstrate they care about colleagues include:

  • Extending every effort throughout the interview, onboarding, and orientation of new nursing staff to welcome, support, and embrace them as colleagues whose views are respected and whose contributions are needed.

  • Make identification of each staff member’s needs an ongoing component of performance reviews so all staff have an opportunity to make these known to managers and supervisors on a regular basis.

  • Ensure there is a mechanism in place for staff to readily communicate about changes in their needs or constraints when circumstances warrant.

  • Even if the unit is short-staffed, ensure that the needs of existing staff are not subsumed as less important than the needs of newly hired staff.

  • Pay considerable attention to how well new nursing staff are paired with their preceptors. If the pairing is not working effectively, find out why and fix it or change the preceptor. Monitor these working relationships to ensure they are mutually successful.

  • Provide multiple opportunities for existing staff to become acquainted with the background, interests, and assistance sought by new staff.

  • Provide multiple opportunities for new staff to meet and work alongside existing staff and learn their goals, accomplishments, and current challenges.

  • When you inquire about someone’s progress, interests, or preferences, be genuine. If you are just “going through the motions” of making inquiries, it’s better to refrain from asking than to ask and look past them after they start to reply.

  • Be a good listener. You may find out more about someone from listening to them than from peppering them with questions.

  • Play to their strengths. Even when a newly licensed nurse has limited clinical skills, try to emphasize what they are able to do well and build on that.

  • Don’t allow common forms of interruption (eg, cell phones, paging, texting, e-mails, passers-by gesturing or calling out) to intrude on conversations with staff whose needs you are attempting to meet.

Having a Best Friend at Work

Among Gallup’s mostly familiar dozen elements known to contribute to great organizational management, the true outlier at the personal level is the tenth survey item, which inquires whether the employee has a best friend at work. Gallup describes reactions of corporate executives and the press to this item along a continuum that ranges from curiosity to skepticism, scoffing to dismissal, and caustic to wary, admitting it likely would have deleted the item were it not for one glaring fact: it predicts employee performance18:

… its statistical significance was undeniable. Namely, in hundreds of focus groups and thousands of employee interviews …, friendship trumped such seemingly obvious employee motivators as pay and benefits.19 (p2)

As Rodd Wagner, a Principal at Gallup, and James Harter,18 (p2) Gallup’s Chief Scientist for Workplace Management and Well-Being, relate:

… large-scale, multi-company analyses confirmed that the Tenth Element is a scientifically salient ingredient in obtaining a number of business-relevant outcomes, including profitability, safety, inventory control, and—most notably—the emotional connection and loyalty of customers to the organization serving them.

At a personal level, having a best friend at work (BFAW) may convert an otherwise okay-but-not-great workplace into one that is tolerable. With just a modicum of introspection, however, we can acknowledge that the BFAW element brings considerably more; it affords someone with whom we can share and solicit candid information; suggestions on how to handle or improve our circumstances; insights that we trust and need to hear; critique we will listen to and act upon; nonjudgmental appraisals, assistance, and catharsis; and solace and a good laugh.

At an organizational level, where only about 30% of employees say they have a BFAW, having a BFAW is associated with the following:

Enhanced Profitability

Business units in the top quartile on BFAW demonstrate profitability 1% to 2% higher than those in the bottom quartile.18 

Enhanced Employee Engagement

Tom Rath, who leads Gallup’s Workplace Research and Leadership Consulting worldwide, relates that employees who report having a BFAW are 7 times more likely to be engaged workers than those who do not, get more done in less time, are more likely to innovate and share new ideas, and have fewer accidents.20 Gallup’s findings indicate that having a BFAW can transform a moderately engaged employee into a highly engaged one: 51% of staff who strongly agreed that they have a best friend at work were engaged employees compared to only 10% of those who disagreed with that statement.19 

Higher Staff Retention

Seventy-five percent of staff who have a BFAW plan to remain with that employer for at least the next year compared to only 51% of those who did not have a BFAW.19 When USA Today21 published a headline of “Best friends good for business” to characterize the Gallup press release related to this finding, the photo appearing under that headline showed 2 nurses who went to work at the same health maintenance organization in the 1970s and have remained best friends ever since. One nurse named Vivian summarized the effect of this friendship,21 (p1B) “I was ready to retire five years ago, but I’m still here, and the one reason is … Sylvia.”

Higher Customer Satisfaction

In service industries, customer ratings of staff with strong BFAW elements are 5% to 10% higher than those with low ratings.18 

Fewer Accidents

When 66% of team members strongly agree that they have a BFAW, that team averages 20% fewer accidents compared to teams in which only 33% of members strongly agree they have a BFAW. Employees at one electric utility company said that the lower accident rates occur naturally because those with a BFAW look out for their friend, remind their friend about using safety measures and equipment, remain vigilant in guarding their friend’s safety, come to their friend’s rescue or protection when warranted, and shudder at the thought of having to inform their friend’s family about an accident at work.18 

Nurse Engagement

More specific to nursing, not only is the level of engagement of a facility’s nursing staff important in mitigating medical errors, but nurse engagement is the No. 1 predictor of variations in patient mortality across hospitals and is a more important predictor of a hospital’s complication rates than either patient acuity or the size of the nursing staff.22 

Enhanced Team Coordination

Team members who have a BFAW work together more collaboratively to coordinate work activities.18 

Less Pilferage

Fewer supplies and equipment disappear from inventories when team members report having a BFAW—people don’t steal from their friends.18 

What is it about having a best friend at your work place that makes all of this possible? Political scientist and Harvard University professor Robert Putnam23 has chronicled the decline of American interpersonal, family, and community social ties over the past 25 years and suggests that this decline has left us socially impoverished and disconnected with elements that in past generations afforded much of the meaning and fabric of our lives.23 For many Americans—who are working longer hours; marrying later in life, if at all; divorcing often without remarrying; living alone; seeing family members less often; participating less in neighborhood, religious, community, club, and sporting events—there are dwindling numbers of face-to-face ties that bind us to others in meaningful ways. Given these trends, it seems quite plausible that the result, as Putnam contends, is that having a close colleague at work is a strong predictor—perhaps the strongest single predictor—of employee job satisfaction.23 

With that thought in mind, critical care nurses might consider the current status of their relationships with their colleagues, make repairs to tears, reestablish bridges over gaps, resume communications where silence has reigned, overcome inertia to catch up, and attend to conversations long neglected. Nurse managers can support the formation and strengthening of friendships among staff by creating conditions in which such relationships can evolve and thrive, for example by doing the following:

  • Giving new staff an opportunity to meet and better understand their colleagues by having them spend time during orientation working in a number of different patient care areas rather than just on their assigned unit;

  • Pairing new staff with preceptors who share some hobby, talent, or outside interest in common;

  • Enabling staff who work together well to self-schedule for the same work shifts;

  • Making time at staff meetings for each member to identify some professional or career interests (eg, presenting an inservice, preparing a poster presentation, publishing in a nursing journal, participating in a panel discussion, designing a PowerPoint presentation, returning to school) they would welcome colleague assistance with;

  • Designing and supporting staff involvement in voluntary charitable events (health fairs, first aid days, support groups) for the surrounding community;

  • Creating incentive programs with meaningful rewards that require staff participation in pairs;

  • Posting kudos about colleagues, their skills and interactions with patients, families, and other team members in a prominent location in the unit; and

  • Providing off-site celebrations, team-building events, or just reserving a few hours to relate appreciation for each other’s contributions.

Friendships and close alliances at work are not universally healthy either in themselves or for the organization. And, as mentioned, having a BFAW is no panacea for an optimal work environment without many other elements operating simultaneously. At least 2 related issues need to be addressed before leaving this topic: acknowledging some of the disadvantages related to friendships at work and noting one important caveat about workplace interpersonal alliances.


Not all friendships or their expressions are conducive to an effective or efficient work environment. Indeed, the oft-quoted business maxim that “familiarity breeds contempt” owes at least in part to problems that may arise when pairs or small groups of workers align18; for example:

  • Socializing or conversing in place of performing work

  • Camaraderie that socially divides or isolates other staff

  • Interactions that distract from or ignore patient or family needs

  • Emotional or romantic entanglements that interfere with work

  • Relationships that cross hierarchical levels, where suspicions or accusations of influence, cronyism, favoritism, or other problems arise

Just because some forms of close friendship don’t contribute to a satisfying work life, however, is no reason to dismiss the potential value-added benefits of the BFAW element.


The positive effects of working with a best friend are neither universal nor guaranteed, but rather are predicated on that setting being a generally good environment in which to work. Having a best friend at work will not disinfect a toxic workplace or insulate either person from all manner of work environment ills. To the contrary, in organizations where employee needs are unmet and managerial effectiveness is wanting, best friends may be among the earliest and strongest proponents of moving out or on to find employers more aligned with their professional and career values.

Critical care nurses who have a BFAW can attest to the bounty of beneficial effects. We do not need the Gallup Organization or any other research firm to generate hard data to tell us what life has already taught us firsthand. Although we don’t need to rely heavily on our BFAW for most of our work hours or work days, having them is wonderfully comforting and restorative when another one of “those days” creeps into our schedule and smudges an otherwise good day. If you have a BFAW, cherish and nurture that bond. If you don’t yet, seek and build one. We’ll all be better for it.

If you would like to share the benefits of having a BFAW with CCN readers, please send an e-mail to [email protected] with “BFAW Benefits” in the subject line, relating the benefits you have experienced. We’ll compile and share your experiences with CCN readers in a future issue.

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