Leadership and staff from the London Health Sciences Centre (LHSC) Nursing Resource Team (NRT), including members of their Continuous Quality Improvement (CQI) Council, attended the first Southern Ontario Nursing Resource Team Conference (SONRTC), held March 2012 in Toronto. The SONRTC highlighted healthy work environments (HWEs), noting vast differences among the province's various organizations. Conversely, CQI Council members anecdotally acknowledged similar inconsistencies in HWEs across the various inpatient departments at LHSC. In fact, the mobility of the NRT role allows these nurses to make an unbiased observation about the culture, behaviours and practices of specific units as well as cross-reference departments regarding HWEs. Studies have documented that HWEs have a direct impact on the quality of patient care. Furthermore, the literature supports a relationship between HWEs and nurse job satisfaction. Based on this heightened awareness, the NRT CQI Council aimed to investigate HWEs at LHSC. The American Association of Critical Care Nurses (AACN) Standards for Establishing and Sustaining Healthy Work Environments was adapted in developing a survey for measuring HWEs based on the perceptions of NRT staff. Each of the departments was evaluated in terms of the following indicators: skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition and authentic leadership (AACN 2005). Ultimately, the Building a Healthy Work Environment: A Nursing Resource Team Perspective survey was employed with NRT nurses at LHSC, and data was collected for use by leadership and staff for creating HWE strategies aimed at improving the quality of patient care.

Introduction

In March 2012, members of the LHSC Nursing Resource Team CQI Council attended the first Southern Ontario Nursing Resource Team Conference (SONRTC). A common theme regarding healthy work environment (HWE) was highlighted by NRT nurses across the region, noting that the work environment varied significantly from one unit to another. The NRT nurses observed that units demonstrating a more collaborative culture invariably received them more positively. The Registered Nurses' Association of Ontario defines a HWE as "a practice setting that maximizes the health and wellbeing of nurses, patient quality outcomes and organizational performance" (RNAO 2006). Inspired by this shared experience and a renewed awareness of the importance of healthy environments within the workplace, the NRT CQI Council reached a consensus that examining and subsequently fostering a HWE would become a priority of its work. According to Stichler (2009: 181), a "HWE is critical to patient safety outcomes, nursing job satisfaction and organizational commitment and turnover."

Many acute care centres across Ontario have shifted towards a Nursing Resource Team (NRT) model in order to manage short-term vacancies (e.g., sick calls). NRTs are often confused with "float nurses" who traditionally played more of a contingency role than today's NRT nurse (Dziuba-Ellis 2006). The NRT at LHSC is a Nursing Professional Practice workforce planning strategy comprising specially trained registered nurses (RNs) appropriated to fill gaps in staffing for a wide variety of inpatient settings, including medicine, surgical, paediatric, renal, emergency, obstetrical and critical care units. NRT nurses provide essential nursing services across LHSC's multi-site hospitals, University Hospital (UH) and Victoria Hospital (VH), respectively. Unlike "float nurses," who maintain a casual work status and whose role is primarily assisting floor nurses, the NRT is made up of both part-time and full-time nurses who are skilled in providing direct patient care and are given independent patient assignments.

NRTs have increasingly been utilized as a workforce planning strategy, reflecting the organizational need for available skilled nursing staff to fill short-term vacancies and therefore complement departmental nursing teams. For most organizations, implementation of an NRT results in a dramatic decrease in casual "float nurses," and as a result, decreased dependency on agency nurses. In addition, NRTs address issues related to insufficient nursing capacity, thus decreasing the need for paying overtime to full-time staff and overextending them to the point of burnout (Baumann and Kolotylo 2005). The adaptability of nurses working under a centralized nursing framework affords the NRT nurses diverse and continuous practice that allows them to work in a variety of medical and surgical specialties, including critical care settings. In addition, NRT nurses typically have a good grasp related to locating and utilizing corporate policies. This ability to maintain a corporate viewpoint while applying unit-specific practices allows NRT nurses to evaluate what processes are likely to be successfully implemented across the organization. In recognizing this global viewpoint, NRT nurses are also uniquely poised to compare various aspects of an organization's HWE.

Background

NRT nurses ponder, "Where am I working today?" And depending on the answer to this question, they anticipate how their day will unfold, based on how they were previously received on the unit (Good and Bishop 2011).

An extensive literature review revealed that many studies quantify HWE by leadership and/or staff perceptions of their own clinical areas; however, no studies were identified as having measured HWEs from an objective outsider's perspective. Based on this gap in the literature, the NRT CQI Council launched a pilot project aimed at investigating LHSC's HWEs from the perspective of the NRT nurse. Also delineated from the literature was the AACN's (2005) Standards for Establishing and Sustaining Healthy Work Environments (see Appendix A at: add URL), including skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition and authentic leadership (AACN 2005: 189). These six standards are quoted often in HWE research and literature (Helton 2009; Maiden 2010; Robichaux and Parsons 2009; Shirey 2009; Shirey and Fisher 2008; Stichler 2009; Alspach 2009; Clevenger 2008; Gilmore 2007; Kerfoot and Lavandero 2005; Kramer and Schmalenbery 2008; Parsons et al. 2007). Based on these standards, the AACN developed a HWE assessment tool consisting of an 18-question survey. Subsequently, the NRT CQI Council adopted the AACN (2005) Standards for Establishing and Sustaining Healthy Work Environments as a foundation for creating their own HWE survey focusing on the unique perspective of NRT nurses at LHSC (see Appendix B below). This was the beginning of what would become a pilot NRT CQI project aimed at examining the HWEs at LHSC.

Design and Implementation

This CQI project brought NRT staff together and permitted discussion of HWEs with the added perspective of being a virtual unit. With placements across the organization, NRT nurses are in a unique position to evaluate the operational processes and cultures that exist within departments as well as provide a global view of the intercommunication and cross-functioning among units. For example, the surgical floor at UH implemented "verbal bedside reporting" because of the positive feedback from NRT staff who had experienced this practice on other inpatient units.

Nevertheless, the main objective for this project was to develop a HWE survey that leverages the observations of NRT nurses and supports improved patient safety and staff satisfaction. According to Maiden (2010), "nurse working conditions have been shown to affect patient outcomes, so a good work environment helps nurses sustain patient safety." With the results from the HWE survey, the NRT vision was to initiate dialogue between leadership and staff. Similar to the goals laid out by the AACN's Standards for Establishing and Sustaining Healthy Work Environments, their goal was "a thoughtful reflection and engaged dialogue about the current realities of each work environment" (AACN 2005: 13).

In the spirit of collaboration, the NRT CQI Council members sat down and explored the AACN standards within the context of their various workplaces in order to gain a deeper understanding of what a HWE means to an NRT nurse. The following discussion ensued.

Beginning with the AACN (2005) standard for skilled communication, the NRT staff noted how important it is for receiving units to demonstrate to staff and patients that they "walk the talk" and adhere to the code of conduct. The indicators for skilled communication are as follows:

1. There is consistency between words said and actions of all staff.
2. A zero-tolerance policy is enforced to support staff and to eliminate abuse and disrespect.
3. I have access to education in the form of updated resources and technology, inservices, access to a clinical educator, and knowledge and support from other staff.

With regard to the AACN (2005) standard for true collaboration, the NRT staff agreed that although there is never a guarantee how unit staff will receive NRT nurses, strong communication skills are required to open the door to effective teamwork. It is the desire of all NRT nurses that their technical skills are recognized and respected by the professional team. However, if efforts towards healthy communication are not reciprocated, then true collaboration cannot be achieved. The indicators for true collaboration are as follows:

1. My knowledge and skills are accepted and respected by team members.
2. Collaborative relationships are supported and nurtured by all staff.

In light of LHSC's core values of trust, respect and collaboration, effective decision-making is not only based on knowledge and critical thinking but is also a moral and ethical obligation to respect patient, family and staff values. NRT staff expressed deep satisfaction in having the opportunity to advocate for patient- and family-centred care and place clients' needs before pre-existing social or relational challenges on the unit. The indicators for effective decision-making are as follows:

1. Core values of the organization are considered in all levels of decision-making.
2. Perspectives of patients and families are incorporated in decision-making processes.
3. All team members share accountability in decision-making and support data-driven decisions.

As objective observers, the effects of nurse shortages and higher patient acuity are apparent to NRT staff. For all nurses, dissatisfaction is often experienced when they are unable to fully meet their patients' needs or uphold their professional practice standards. The NRT group also commented that appropriate staffing involves a unit leader's assessment of the NRT nurses' experience and technical skills in order to match their assignment. The indicators for effective appropriate staffing are as follows:

1. Staffing is appropriate to support high-quality patient care.
2. There are appropriate strategies in place to support and evaluate adequate staffing (including times of staffing shortages).
3. My patient assignment appropriately reflects my competency level.

NRT staff indicated the importance of receiving and giving meaningful recognition, especially as a vehicle to forming trusting relationships with clinical staff. Moreover, due to their mobile nature, often NRT nurses do not have the opportunity for first-hand follow-up with patient outcomes or to receive positive feedback. In order to meet the AACN standard for meaningful recognition, the NRT nurses highlighted the importance of sharing a sense of belonging with the team and recognition that their contributions were significant. The indicators for meaningful recognition are as follows:

1. My value and contributions are recognized by team members.
2. All team members meaningfully recognize the contributions of others.

For NRT staff, authentic leadership represents honesty, transparency and a genuine interest in what others are experiencing in the workplace. Leadership plays a key role in influencing the culture of a unit and affects the perceptions that staff may have about the NRT role. The indicators for authentic leadership are as follows:

1. The unit leader role-models effective communication, collaboration, effective decision-making, meaningful recognition and authentic leadership.
2. The unit leader is accessible and receptive to concerns and suggestions.

The aforementioned indicators are a representation of what NRT nurses value most about HWEs. Although there are added indicators within the AACN (2005) assessment tool (e.g., physical space), that are greatly valuable, they were excluded from the NRT's HWE survey.

Lessons Learned

HWEs remain a focus of healthcare organizations, which must continue to measure the degree of satisfaction derived from the practice environment with the appropriate tools and resources for all staff. However, available tools to understand HWEs from the NRT nurse's professional perspective remain limited in their ability to draw clear data and conclusions. The complexity of the environment for NRT staff, given their cross-cultural impact and daily changing peer contacts, further challenges determining the variables necessary to accurately capture HWEs for the NRT nurse. But the impact of satisfaction on nurse, patient and organizational outcomes is significant. The first step in improving the work environment for NRT nurses is to clearly define their environment, which may further explicate the type of tool required to capture their perspective.

Next Steps

The NRT will continue to refine the study process, including its survey, study design and measurable outcomes for future use in research. With the data collected thus far, the CQI team will analyze, discuss and disseminate results with the appropriate stakeholders, as well as explore strategies to improve its own HWE. Other considerations include developing an NRT network across the province in order to build a shared understanding of the challenges and positive influences that NRT nurses have in organizational HWEs. Another important outcome was an educational presentation for clinical leaders, expounding the role of NRT nurses within our organization.

Conclusion

Through collaboration and shared understanding, the NRT staff have gained a new perspective of HWEs within the context of their virtual unit. As a result of their efforts, a new conversation has been ignited within and between units regarding improving the work environment for staff, patients and families. Beginning with a small group of NRT nurses, who came together to form a CQI council, an idea for sharing their unique perspective of HWEs blossomed into a collaborative, intraprofessional CQI initiative for improving the organizational HWEs at LHSC. This initiative represents a greater awareness of the contributions made by all nurses, their accountability to one another and to their patients, affirming that when NRT nurses ask themselves "Where am I working today?," no matter where they go, they know that they are making a difference.

Appendix A

AACN Standards for Establishing and Sustaining Healthy Work Environments (AACN 2005: 189):

• Skilled Communication – Nurses must be as proficient in communication skills as they are in clinical skills.
• True Collaboration – Nurses must be relentless in pursuing and fostering true collaboration.
• Effective Decision-Making – Nurses must be valued and committed partners in making policy, directing and evaluating clinical care, and leading organizational operations.
• Appropriate Staffing – Staffing must ensure the effective match between patient needs and nurse competencies.
• Meaningful Recognition – Nurses must be recognized and must recognize others for the value each brings to the work of the organization.
• Authentic Leadership – Nurse leaders must fully embrace the imperative of a healthy work environment, authentically live it and engage others in its achievement.

Appendix B

Building a Healthy Workplace: A Nursing Resource Team Perspective:

1. Skilled Communication
   • There is consistency between words said and actions of all staff.
   • A zero-tolerance policy is enforced to support staff and to eliminate abuse and disrespect.
   • I have access to education in the form of updated resources and technology, inservices, access to a clinical educator, and knowledge and support from other staff.
2. True Collaboration
   • My knowledge and skills are accepted and respected by team members.
   • Collaborative relationships are supported and nurtured by all staff.
3. Effective Decision-Making
   • Core values of the organization are considered in all levels of decision-making.
   • Perspectives of patients and families are incorporated in decision-making processes.
   • All team members share accountability in decision-making and support data-driven decisions.
4. Appropriate Staffing
   • Staffing is appropriate to support high-quality patient care.
   • There are appropriate strategies in place to support and evaluate adequate staffing (including times of staffing shortages).
   • My patient assignment appropriately reflects my competency level.
5. Meaningful Recognition
   • My value and contributions are recognized by team members.
   • All team members meaningfully recognize the contributions of others.
6. Authentic Leadership
   • The unit leader role-models effective communication, collaboration, effective decision-making, meaningful recognition and authentic leadership.
   • The unit leader is accessible and receptive to concerns and suggestions.

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