June 12, 2009 Editor's note: In 2005, the American Association of Critical-Care Nurses (AACN) issued national standards

s for establishing and sustaining healthy work environments for critical care nurses. In 2006, and again in 2008, AACN, the Gannett Healthcare Group, and the Bernard Hodes Group conducted a national survey of over 5500 critical care registered nurses to determine whether these standards were being met. A presentation on the newest survey and the issue of healthy work environments was featured at the AACN's 36th Annual National Teaching Institute and Critical Care Exposition, held from May 16 to May 21 in New Orleans, Louisiana. To find out more about the challenges nurses face in their current work environments, Medscape Nursinginterviewed presenter Beth Ulrich, EdD, RN, FACHE, FAAN, a coauthor of the work environment survey published in Critical Care Nurse in April 2009. Dr. Ulrich is vice president of business analytics and research for Versant, an organization that provides hospitals with nurse residency programs. Dr. Ulrich has also led the consulting services division of the Gannett Healthcare Group and is editor for the Nephrology Nursing Journal. Medscape: What do you think are the most important findings of the newest nurses' work environment survey? Dr. Ulrich: What was very consistent in the survey is that nurses often rated their unit or department higher than the overall organization in which they worked. Research tells us that frontline managers have a lot to do with whether nurses stay on the job, so that's probably a good thing. We also saw lots of personal reports of abuse and harassment slightly down from the 2006 survey but the numbers were still higher than we would like. Almost 60% of respondents reported verbal abuse and 16% reported sexual harassment. That's a bit scary, and it continues to be an issue. We also saw the number of respondents who said their organizations offer no support for certification go up to 24%. Despite the research that says nurses with certification are more confident, make fewer errors, and are more satisfied with their jobs, there are still gaps in organizational support. But we did find that those nurses who felt supported in certification felt more respected, were less likely to be verbally abused, and were more satisfied with being a nurse. They also rated the quality of patient care in their organization higher than those who did not have good support for certification. So nurses see support of certification as support for excellence, and that is totally legitimate. Medscape: What did the survey tell you about nurses leaving the profession, and their dissatisfaction with unhealthy work environments? Dr. Ulrich: When we asked nurses whether they plan to leave their current position in the next 12 months to 3 years, about 56% said no. There are a lot of reports in the media about nurses leaving the profession, but we found that only 2% are actually looking to leave nursing entirely. They're looking to go back to school, to retire, to get promoted, or to get another position and do something different. We also asked our respondents about how satisfied they are with being a nurse. More than 65% said they were satisfied with being a registered nurse, but only 32% are satisfied with their current position. There's something intrinsically rewarding about being a nurse. But nurses do have dissatisfaction with their current positions, and that often has to do with work environment. When we asked people

who planned to leave to choose what factors would make them stay, the top answer was better leadership. Other answers had to do with salary and benefits, better staffing, [and] more opportunities for professional development, as well as more respect. So they really gave us some answers about what is needed to improve the work environment for nurses. Medscape: What has your research told you about the dangers of abuse of nurses, and what advice would you give nurses facing abuse? Dr. Ulrich: There's a fair number of studies that show that disruptive behavior as well as abuse leads to lowered patient safety. If a nurse is verbally abused, [he or] she's less likely to want to collaborate with the abuser, whether it's a physician or another nurse, to improve patient outcomes. As well as creating difficult work environments, abuse of nurses and disruptive behavior has been connected to medical errors, [and] even mortality in operating rooms. If a nurse is facing abuse, it's important that [he or] she turn to the resources offered by organizations such as the AACN. It's crucial to be able to state your case and be assertive when reporting the abuse. You have to know what you should put up with vs what you shouldn't, but abuse should not be tolerated, and when organizations say they have zero tolerance for abuse, they should mean it. What we found in our survey was that there are places that have policies against abuse but fail to implement them. Medscape: What did the survey tell you about communication and collaboration among nurses and the healthcare teams in which they work? Dr. Ulrich: Communication and collaboration [are] huge. We did find some minor improvements since 2006 in the survey, especially in nurse-to-nurse collaboration. The research does show that when nurses and doctors collaborate, patients do better and nurses are more satisfied in their jobs. Nurses are more fulfilled as professionals when there's collaboration in the workplace, but you can't collaborate if you can't communicate. So being able to take the time to listen is important, especially for nurse managers. But the problem is that most critical care nurses work in chaotic environments where the organizations run on tight budgets and the patients are very sick. So nurse managers tend to firefight what's ahead of them on each shift. When you have to fight to get enough resources, it can be a struggle to keep your head above water on a given shift, never mind finding time to talk to staff nurses. But that's the very thing that can help improve the working environment for nurses. Medscape: How does nurses' satisfaction with their jobs compare to that of other workers? Dr. Ulrich: We asked nurses who participated in the survey whether they would tell someone else to be a nurse. That's where the rubber meets the road, because you can say you love nursing, but if you can't recommend it to someone else, it doesn't mean anything. In both 2006 and 2008, 88% to 90% of respondents said they would definitely or probably recommend nursing, and 65% said they would definitely recommend the profession. We tend to be a bit insular in nursing and only look at what's going on in our own careers. But when you look at satisfaction scores for other professions, such as teachers and physicians, and you find that 65% of nurses are very satisfied, that looks pretty good.

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