Over the past decade, professional organisations have developed and endorsed tools to create and sustain healthy work environments in hospitals. The American Association of Critical-Care Nurses and the American College of Chest Physicians were the primary architects of a framework comprised of six evidence-based standards.Reference McCauley and Irwin 1 In 2009, the American Association of Critical-Care Nurses developed the Healthy Work Environment Assessment Survey for organisations to measure the health of their workplace. 2 The operational definitions of the six standards are outlined in Table 1. The six standards align directly with the core competencies for healthcare professionals recommended by the Institute of Medicine. 3
Table 1 American Association of Critical-Care Nurses (AACN) operational definitions: healthy work environment standards.
Used with permission of the American Association of Critical-Care Nurses (AACN)
The concept of “healthy” work environments extends beyond healthcare organisations to other industries. Lencioni makes the case that the single most important advantage that any company can achieve is organisational health;Reference Lencioni 4 however, he acknowledges that measuring the health of the work environment can be challenging.
The variety of costs associated with unhealthy work environments are described in the literature, including broken rules, mistakes, lack of support, incompetence, poor teamwork, disrespect, and micromanagement across America’s healthcare institutions.Reference Lewis and Malecha 5 As reported by the Joint Commission, the root causes of over 60% of sentinel events are related to human factors, communication, and leadership. 6 It is well established in the literature that medical errors and patient harm are associated with fear of “speaking up”.Reference Gutkind 7 In addition, unhealthy work environments are associated with nursing staff turnover and dissatisfaction.Reference Aiken, Clarke, Sloane, Sochalski and Silber 8 , Reference Aiken, Clarke and Sloane 9
Our large cardiovascular programme in a paediatric, quaternary-care, academic teaching hospital has made the health of the work environment a strategic priority. Since 2010, the programme has used the American Association of Critical-Care Nurses’ Healthy Work Environment Assessment Survey to elicit interdisciplinary staff perceptions every 2 years.Reference Hickey 10 The American Association of Critical-Care Nurses’ Survey is proposed as a generalisable tool that can be used in any organisational department. It is not intended to diagnose specific issues, but rather to identify areas for improvement.
Findings from the Healthy Work Environment Assessment highlighted the need for more specific assessment in some patient-care areas – for example, in the cardiac catheterisation laboratory, the survey revealed that the staff perceived hostility within the team as evidenced by lower scores in the skilled communication and true collaboration domains. During this time period, the unit was challenged by increased patient volume and complexity and the introduction of new staff members. Not only was a strategy for identifying staff concerns and creating solutions needed, but also this strategy needed to be implemented within a short time frame. This manuscript describes a novel strategy to create a friendly tool for staff to complete that communicates their perception of the health of the work environment through measurement.
Clinical setting
The cardiac catheterisation laboratory is a unique environment for introducing an assessment tool. Permanent staff for the cardiac catheterisation laboratory include 20 nursing staff, 10 catheterisation laboratory technicians, four MRI technicians, and six administrative staff personnel. In addition, there are three cardiac anaesthesia physicians, two interventional cardiologists, two electrophysiology physicians, and two to four cardiac MRI/echocardiography physicians present in the unit on any given day. This cardiac imaging unit includes three bi-plane and one single-plane catheterisation laboratories, one cardiac MRI suite, a 10-bed recovery and procedure area, and two echocardiography suites. In this environment, nursing and cardiac anaesthesia staff provide support to the electrophysiology, echocardiography, cardiac MRI, and interventional cardiology teams by moving the patients through their procedures and recovery. In addition, these teams engage in the coordination of multiple complex procedures for critically ill patients with complex diagnoses, including the organisation of combined surgical catheterisation procedures, which creates unique systems and communication challenges. Each year, the cardiac catheterisation laboratory performs more than 1400 interventional cardiology procedures, 600–700 electrophysiology procedures, 1100 cardiac MRIs, as well as additional procedures with sedation or anaesthesia. These procedures occur 5 days per week from 7 am to 7 pm with emergent cases occurring in the evenings and weekends. With this unique and challenging environment, the leadership team in the cardiac catheterisation laboratory wanted to better understand how staff appraised the work environment and what they identified as the most influential factors, both positive and negative.
Materials and methods
Development of the REAL Indicator
The initiative to better understand how staff viewed the work environment was overseen by the unit-based Quality Improvement Committee, which consisted of the nursing leader, a nurse champion, a physician, and a research assistant specialist. To achieve their goal, the Quality Improvement Committee decided to develop an accessible tool for the staff. The tool includes a 6-point numerical scale that is associated with visual images. These images were chosen because they closely resemble commonly recognised emoticons. Each image was associated with a description of happiness, satisfaction, or frustration with the work environment. The tool descriptions were developed in collaboration with staff, the core leadership group from the cardiac catheterisation laboratory, and a survey methodologist. On this scale, the highest value corresponds to the most positive experience and image (Fig 1). The numerical values support the ability to monitor trend over time. Using concepts of Appreciative Inquiry, staff were asked to identify “What is going well?” and “What can be improved?”.Reference Hammond 11 The qualitative feedback has been a valuable portion of the tool as it allows staff to identify specific challenges and solutions for a positive work experience. Both offer insight into the environment and opportunities to target improvement strategies based on identified challenges. The tool was named the REAL Indicator – Relative Environment Assessment Lens (© 2015 Boston Children’s Hospital. All rights reserved). For purposes of this manuscript, the tool will be referred to as the REAL Indicator©. Face validity was established by seeking feedback from staff who worked in the cardiac catheterisation laboratory.
Figure 1 Cardiac Catheterisation Laboratory: The REAL Indicator©. REAL=Relative Environment Assessment Lens.
Implementation of the REAL Indicator©
In 2010 and 2011, the REAL Indicator© was distributed intermittently while in an early stage of development. The monthly goal was for staff to complete 10–12 surveys. Of these, there would typically be three to five comments for feedback. Initially, it was challenging to get staff engagement and commitment to the concept; however, as staff saw unit-based initiatives and process changes being developed from their comments, staff engagement and commitment to the concept increased.
From May, 2012 to May, 2014, the use of the survey gained popularity among staff averaging 25–35 responses per month (range: 20–40) with comments similar in number. The staff seized the opportunity to identify challenges to patient care as well as solutions and recognise their co-workers for participating in a positive working environment.
Paper copies of the REAL Indicator© survey are available to the interdisciplinary teams in common locations throughout the unit and via email. In addition, the survey is distributed approximately five times each month to the interdisciplinary staff in the unit by the nursing and technician champions. In order to protect the confidentiality of the participant, there are two locked boxes in the unit, in which the staff drop their completed surveys. The research assistant retrieves all the completed surveys from these locked boxes. Written comments are provided to the nursing champion in a word document to further protect confidentiality. Data on staff perception of “How their day is going” are sorted according to the visual image numerical scale into the six categories and displayed as a stacked bar graph. All written comments are reviewed and summarised thematically removing any identifiers to protect confidentiality. A summary of the results and Quality Improvement dashboards containing the REAL Indicator survey results are disseminated at a number of monthly forums. The dashboard highlights results of ongoing Quality Improvement projects including those focused on rebleed events and laboratory start times. These include unit-based staff meetings, the Quality Improvement Committee, and the Cardiovascular Clinical Operations Committee. In each of these settings, the results and comments are used to facilitate discussion of issues and identification of solutions and possible initiatives. The discussion of the results and issues allow all staff to confirm results and be involved even if they did not fill out a survey themselves. All solutions and/or initiatives are developed, operationalised, and evaluated in a consensus-based manner. As results are broadly disseminated and all solutions and initiatives are developed in a consensus-based manner, disciplines are not specifically sought out to complete the tool. Based on the experience in the cardiac catheterisation laboratory, the REAL Indicator© was adopted in the cardiovascular operating room in July, 2013. Utilising their Healthy Work Environment Assessment results and staff feedback, the REAL Indicator© tool was modified to include additional questions about what impacted the staff member’s day. In total, eight domains were identified and rated on a Likert scale (Fig 2). The cardiovascular operating room work environment is similar to the cardiac catheterisation laboratory, with many of the same interdisciplinary staff members providing care in both areas.
Figure 2 Cardiovascular Operating Room: The REAL Indicator©. REAL=Relative Environment Assessment Lens.
Figure 3 Cardiac Catheterisation Laboratory: REAL Indicator© Graph of Monthly Results. REAL=Relative Environment Assessment Lens.
Similar to the process in the cardiac catheterisation laboratory, the cardiovascular operating room results are shared at the monthly, unit-based Clinical Operations meeting and posted for staff review. Comments requesting leadership follow-up are handled in a confidential and sensitive manner, keeping the focus on improving the health of the work environment for all team members to ultimately ensure safe and effective patient care.
Results
From July, 2013 to April, 2014, results from the REAL Indicator© in the cardiac catheterisation laboratory indicated an overall good work environment (Fig 3). The goal of 80% of the respondents reporting their work environment to be “Great”, “Good”, or “Satisfactory” was met each month. On average, from July, 2013 to April, 2014, 36.4% (range: 21–59%) of the respondents reported their work environment to be “Great” and 41.7% (range: 17–53.3%) reported it to be “Good”. During this time period, an average of 12.8% (range: 7–22.6%) reported their work environment to be “Satisfactory”. On average, 2.26% (range: 0–7%) reported that they were “Frustrated” with the work environment and 2.5% (range: 0–9.5%) reported that they “Need a New Job”.
Figure 4 Cardiovascular Operating Room: REAL Indicator© Graph of Monthly Results. REAL=Relative Environment Assessment Lens.
During the same time period, the goal of 80% of cardiovascular operating room respondents reporting their work environment to be “Great”, “Good”, or “Satisfactory” was met four times (Fig 4). On average, 72.7% of cardiovascular operating room respondents reported their work environment to be “Great”, “Good”, or “Satisfactory”. During this time period, an average of 19.4% (range: 0–37.5%) of staff reported their work environment to be “Great” and 33.6% (range: 13.6–50%) reported it to be “Good”. On average, 19.8% (range: 6.3–60%) of the staff responded that their work environment was “Satisfactory”. On average, 10.8% (range: 0–31.3%) of operating room staff responded that they were “Frustrated” with their work environment and 4.2% (range: 0–12.5%) reported that they “Need a New Job”.
For the cardiac catheterisation laboratory and cardiovascular operating room, common themes related to the open-ended questions, “What is going well?”, “What could be improved?”, and “Suggestions for Improvement”, were similar. The following three common themes arose in both areas: Communication, Teamwork, and Mutual Respect. These themes directly align with the six standards of the American Association of Critical-Care Nurses’ Healthy Work Environment Assessment Survey.
The success of the REAL Indicator© in the cardiac catheterisation laboratory and cardiovascular operating room resulted in expanding its use across other patient care areas as well as in other hospital departments – that is, information services and marketing – where there was an interest in improving the work environment.
Targeted improvement initiatives
Many initiatives relating to each of the six standards of the American Association of Critical-Care Nurses’ Healthy Work Environment framework have come directly from feedback received from the REAL Indicator© responses. Selected examples are organised by Healthy Work Environment standards in Table 2. To illustrate the significance of the REAL Indicator©, a written comment in January, 2011 identified confusion concerning pre-procedural practice. In the work environment, there were practice variations among physicians regarding time to meet with patients and families. Some physicians preferred to see the patient and the family the day before, some the morning of the procedure, and some wanted both times. The variability in practice was confusing for staff. On occasion, it was difficult to know which patient still needed to see their physician, which caused unnecessary delays in the laboratory start time. In a collaborative effort with the pre-operative clinic nurse practitioners, a process was created and implemented to identify which physician needed to see the patient the morning of the procedure. The clinic staff places an Alert on the front of the patient’s chart in order to identify the name of the physician to be called before the start of the procedure. This effort has reduced confusion and frustration at the beginning of the day and assisted in facilitation of case starts.
Table 2 Targeted Initiatives Organized by American Association of Critical-Care Nurses’ Healthy Work Environment Standards.
Limitations
To date, the REAL Indicator© has undergone preliminary validity testing. As part of the development and implementation of the REAL Indicator©, face validity has been confirmed by the interdisciplinary staff. Monthly data assessment has provided important information on the performance of the tool and ability to develop initiatives to address staff responses. Future validation of the tool will include construct validity correlating to the American Association of Critical-Care Nurses’ Healthy Work Environment Assessment Survey
Discussion
Development and implementation of the REAL Indicator© enhanced the ability to specifically understand the issues of concern as perceived by the interdisciplinary staff. This tool facilitates direct comment and opportunities for improvement in an ongoing manner. Although opportunities for improvement in both clinical areas are evident, the cardiac catheterisation laboratory was consistently able to meet the identified target of 80% of the respondents perceiving their environment to be “Satisfactory” or above. Within the cardiac catheterisation laboratory, these results are reflective of the initiatives that have been put into place, especially regarding meaningful recognition. The quantitative results and comments indicate that catheterisation laboratory respondents were less frustrated since the tool was initiated, as their concerns are being recognised and addressed. As the tool has been in use in the cardiovascular operating room for a shorter period of time, the results are not yet reflective of their unit initiatives being implemented; however, overall, the results indicate an improvement in the daily work environment. Respondents indicated that they “needed a new job” in only one of the last 5 months (December, 2013 to April, 2014) as compared with 4 of the initial 5 months before any initiatives being implemented. Of note, the staff in both areas believed that the results reflected the challenges of high volume, acuity, and stress among staff in months demonstrating increased results of “Frustrated” and “Need a New Job”. In both areas, commitment and engagement to the tool have increased as staff saw their concerns and suggestions being addressed. For staff, the value of the tool increased after they began seeing positive results from the tool.
In general, the interdisciplinary staff enjoy working in the programme and appreciate the recognition for the care they provide to patients and families. Staff repeatedly identified communication, teamwork, and mutual respect as important elements of their job satisfaction as well as ability to deliver effective patient care. The REAL Indicator© is a valuable means to understand the impact of the environment, identify opportunities for improvement, and recognise the importance of teamwork and interdisciplinary collaboration to support excellence in clinical delivery of care.
Conclusion
The REAL Indicator© has become a valuable tool in assessing the specific issues of the clinical area and identifying opportunities for improvement. Given the feasibility and positive response of this tool in the cardiac catheterisation laboratory, it is now being used in many other patient-care areas where staff and leaders believe they need to understand the health of the environment in a more specific and frequent time frame. The accessibility of the tool has been extremely valuable when clinical areas are challenged by periods of high volume, acuity, and stress among the interdisciplinary staff. It provides a tool for discussion and a process for creating solutions. Our experience with this tool shows promise for its use across all areas of healthcare and interdisciplinary teams. As it is an ongoing reflection of individual staff perception of the work environment, it provides opportunity for regular, focused discussion about the collective health of the work environment.
Acknowledgements
The investigators acknowledge the following for their contributions and support: Sandra Coombs for working as a research assistant on the project, Dr Sonja Ziniel for reviewing and editing the survey tool, and Dr Lisa Bergersen for providing input towards the development of the tool and representation of the results on the Quality Improvement dashboard.
Financial Support
This project has received funding from Boston Children’s Hospital Innovation Acceleration Programme’s Innovestment Grant.
Conflicts of Interest
None.
Ethical Standards
The authors assert that this project is exempt from institutional review board (IRB) review due to the fact that it is a quality-improvement project involving hospital staff and no patient health information was collected. All responses were voluntary, anonymous, and confidential, unless identifying information was voluntarily given by respondents for follow-up purposes.
