Running head: HEALTHY WORK ENVIRONMENT 1 A Project Plan: Healthy Work Environment and Unit Culture Susanne A. Woltschlaeger-Brooks Michigan State University College of Nursing April 6, 2022 HEALTHY WORK ENVIRONMENT 2 Table of Contents Abstract ........................................................................................................................................... 5 Background and Significance ......................................................................................................... 8 Problem Statement .................................................................................................................... 11 Organizational Assessment Gap Analysis of Project Site ........................................................ 11 Purpose of the Project ............................................................................................................... 12 Evidence Based Practice Model/QI Model ............................................................................... 13 Review of the Literature ............................................................................................................... 14 Search Strategy ......................................................................................................................... 14 Nursing Practice Environment .................................................................................................. 15 Autonomy ................................................................................................................................. 15 Managerial Support ................................................................................................................... 15 Staffing/Resource Adequacy .................................................................................................... 16 Effective Interpersonal Relations .............................................................................................. 16 RN Turnover ............................................................................................................................. 17 Quality....................................................................................................................................... 17 Summary ................................................................................................................................... 18 Goals, Objectives and Expected Outcomes .................................................................................. 18 Methods......................................................................................................................................... 20 Project Site and Population ....................................................................................................... 20 Metrics. ..................................................................................................................................... 21 Patient experience. .................................................................................................................... 21 Team member engagement. ...................................................................................................... 21 Ethical Considerations/Protection of Human Subjects ............................................................. 22 Setting Facilitators and Barriers................................................................................................ 23 The Intervention and Data Collection Procedure...................................................................... 24 Timeline .................................................................................................................................... 27 Measurement Instruments/Tools ............................................................................................... 27 Outcome measures. ............................................................................................................... 27 Process measures. ................................................................................................................. 28 Counterbalance measures...................................................................................................... 28 HEALTHY WORK ENVIRONMENT 3 Implementation ............................................................................................................................. 28 Analysis......................................................................................................................................... 35 Turnover and Churn .................................................................................................................. 35 Engagement and Belonging ...................................................................................................... 41 Likelihood to Recommend ........................................................................................................ 43 Sustainability Plan ........................................................................................................................ 44 Discussion/Implications for Nursing ............................................................................................ 45 Cost-Benefit Analysis/Budget ...................................................................................................... 49 Conclusion .................................................................................................................................... 49 References ..................................................................................................................................... 52 Appendix A Figure 1. Fishbone Diagram .................................................................................... 59 Appendix B Strengths/Weaknesses/Opportunities/Threats (SWOT) ........................................... 60 Appendix C Key Recommendations Contributing to the Development of a HWE from the Joint Commission, IHI and AACN in Comparison to Strategies Implemented in the Past on Neuroscience Clinical Unit ........................................................................................................... 62 Appendix D Figure 2. IHI Framework for Improving Joy in Work ............................................. 66 Appendix E Figure 3. PRISMA Diagram ..................................................................................... 67 Appendix F Literature Evaluation Table ...................................................................................... 68 Appendix G Synthesis Table Themes and Outcomes ................................................................... 95 Appendix H Top ICD 10 Admission Codes Served by the Neuroscience Clinical Unit During 2019 Through March 2021 ......................................................................................................... 103 Appendix I Primary Roles, Headcount and FTE Allocation ...................................................... 104 Appendix J Employee Engagement Scores March 2021 Listening Survey Aligned with HWE Concepts ...................................................................................................................................... 105 Appendix K MSU IRB................................................................................................................ 106 Appendix L Spectrum Health IRB .............................................................................................. 107 Appendix M Facility Level of Support ....................................................................................... 108 Appendix N Gantt Chart ............................................................................................................. 109 HEALTHY WORK ENVIRONMENT 4 ..................................................................................................................................................... 110 Appendix O “What matters to you?” script ................................................................................ 111 Appendix P Bright Spots Communication Board ...................................................................... 114 Appendix Q Summaries “What matters to you?” Conversations ............................................... 115 Appendix R Pull Card Front and Back ....................................................................................... 120 Appendix S Facilitating Bright Spots Communication Board Charge Nurse Guide .................. 121 Appendix T Neuroscience Clinical Unit Rolling Twelve Month Transfer Percentage .............. 123 Appendix U Neuroscience Clinical Unit Rolling Twelve Month Churn Percentage ................. 124 Appendix V Comparison of Like Units Twelve Month Rolling Transfer Percentage ............... 125 Appendix W Comparison of Like Units Twelve Month Rolling Churn Percentage .................. 126 Appendix X Travel RN Headcount per Unit by Month .............................................................. 127 Appendix Y Figure 4. RN Vacancy Percentage ......................................................................... 128 Appendix Z Figure 5. Belonging Overall ................................................................................... 129 Appendix AA Figure 6. Belonging RN ...................................................................................... 130 Appendix BB Figure 7. Belonging NT ....................................................................................... 131 Appendix CC Figure 8. Engagement Overall ............................................................................. 132 Appendix DD Figure 9. Engagement RN ................................................................................... 133 Appendix EE Figure 10. Engagement NT .................................................................................. 134 Appendix FF Comparison of Like Units Likelihood to Recommend Top Box Performance .... 135 Appendix GG Budget ................................................................................................................ 136 HEALTHY WORK ENVIRONMENT 5 Abstract Background and Review of Literature: A Healthy Work Environment (HWE) has broad implications impacting wellness and retention of team members, recruitment, quality and safety of care delivered, and the overall organizational culture. A review of the literature demonstrates various factors contribute to the presence or absence of a HWE. Purpose: The purpose of this evidence-based quality improvement project is to improve the HWE and ultimately decrease team member churn, increase team member belonging and engagement as well as likelihood to recommend on a neuroscience clinical unit within a large midwestern Magnet ® designated hospital. Methods: Key interventions were implemented focusing on the fundamental core components of the IHI Framework for Improving Joy in Work: camaraderie and teamwork, choice and autonomy, meaning and purpose, and physical and psychological safety. Implementation Plan / Procedure: Following the IHI Framework for Improving Joy in Work, “What matters to you?” conversations to identify impediments to joy at work were held with team members. Targeted strategies to address impediments were developed and implemented. Results/Interpretation: Effectiveness of the IHI Framework for Improving Joy in Work was evaluated by comparing pre and post implementation data for rolling twelve month transfer and churn percentage, engagement and belonging scores, and likelihood to recommend. The twelve month rolling transfer and churn percentage decreased from August 2021 to January 2022. Belonging and engagement scores decreased from July 2021 to November 2021. Likelihood to recommend decreased from August 2021 to January 2022. Implications/Conclusion: The COVID-19 pandemic impacted the implementation of the IHI Framework for Improving Joy in Work as it proved to be a significant disruption impacting overall stress, staffing levels, and tested the resilience of healthcare organizations across the nation. It is recommended that the HEALTHY WORK ENVIRONMENT 6 neuroscience clinical unit consider continued application of the IHI Framework for Improving Joy in Work as a strategy to recover from the COVID-19 pandemic. Keywords: Healthy work environment, Practice environment, nurs*, turnover, pandemic HEALTHY WORK ENVIRONMENT 7 A Project Plan: Healthy Work Environment and Unit Culture The practice environment for nurses is impacted by various factors including the size of an organization, professional hierarchies and relations, leadership characteristics, degree of autonomy and cultural awareness (Numminen et al., 2015). Frameworks have been developed to capture the elements of a Healthy Work Environment (HWE) including the World Health Organization (WHO) Healthy Workplace Model which depicts the integration of the physical and psychosocial work environment, personal health resources and enterprise community in relation to leadership engagement and worker involvement (Burton, 2010). In addition, the organizing framework for the HWE Best Practice Guidelines Project outlines similar concepts depicting the interplay of external factors (macro level), organizational factors (meso level), and individual factors (micro level), as they transcend across structural policy components, professional occupational components and cognitive/psycho/socio/cultural components ultimately influencing nurse, patient, organizational and societal outcomes (Registered Nurses’ Association Ontario [RNAO], 2008). HWEs for nurses are safe, empowering, and satisfying practice settings that augment the health and well-being of the nurse and maximize patient, organizational and societal outcomes (American Nurses Association, 2018; RNOA, 2008). The American Association of Critical-Care Nurses (AACN) has outlined essential standards to ensure a HWE. These standards include skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership (AACN, 2016). A HWE impacts individual team members, patient outcomes, and the overall organizational culture (Ulrich, Barden, Cassidy, & Varn-Davis, 2019; Wei, Sewell, Woody, & Rose, 2018). The purpose of this evidence-based quality improvement project is to implement the IHI Framework for Improving Joy in Work as an evidence-based strategy aimed at improving HEALTHY WORK ENVIRONMENT 8 the HWE and ultimately improving churn, team member sense of belonging, and engagement on a neuroscience clinical unit within a large midwestern Magnet ® designated hospital. Churn includes all departures from the clinical unit as well as internal transfers to other areas within the organization. Background and Significance Lack of a HWE can disrupt the physical and psychological safety of team members, contribute to anxiety, sleep disorders, burnout and emotional exhaustion (Bambi et al., 2018; Ulrich et al., 2019; Wei et al., 2017). Interpersonal relationships, including nurse-nurse, nurse- manager, and nurse-physician, are also impacted ultimately affecting psychological health and overall performance and productivity (Bambi et al., 2018; Ulrich et al., 2019; Wei et al., 2017). In addition, lack of a HWE can result in decreased quality of patient care delivered, including patient risk of death, failure to rescue, and increased likelihood of readmission (Ulrich et al., 2019; Wei et al., 2017). From an organizational perspective, organizations lacking a HWE experience decreased team member job satisfaction and organizational commitment resulting in challenges with retention, decreased productivity, and overall organizational safety (Bambi et al., 2018; Wei et al., 2017). Nursing Solutions, INC (NSI) is a national nursing recruitment firm which surveys over 3,000 hospitals across the United States to evaluate healthcare turnover, retention initiatives, vacancy rates, recruitment metrics and staffing strategies (NSI, 2021). Nationally, in 2020, the hospital turnover rate for registered nurses (RNs) increased by 2.8 % with a national average of 18.7 % (NSI, 2021). Average cost of turnover for a bedside registered nurse (RN) is $40,038 and results in the average hospital losing between $3.6 - $6.5 million annually (NSI, 2021). Each percent change in RN turnover will impact, either positively or negatively, the bottom line by $270,800 annually (NSI, 2021). HEALTHY WORK ENVIRONMENT 9 Various factors contribute to an unhealthy work environment. Incivility and intimidating, disruptive behaviors negatively impact teamwork, communication, and professionalism within the health care team (Crawford et al., 2019; The Joint Commission [TJC], 2008). In turn, these behaviors result in decreased staff engagement, productivity, and organizational commitment, and an organizational culture which ultimately, if not addressed, negatively impacts patient safety, quality of care and optimal patient outcomes (AACN, 2016; Bambi et al., 2018; Crawford et al., 2019; Perlo, Balik, Swensen, Kabcenell, Landsman, & Feeley, 2017; TJC, 2008; Ulrich et al., 2019; Wei et al., 2017). Recognizing the significance of the work environment in the delivery of safe patient care, regulatory standards and strategies targeting front line team members, nursing leadership, and organizations as a whole, have been created by TJC, The Institute for Healthcare Improvement (IHI) and the AACN to assist health care leaders in creating a HWE. An adult inpatient neuroscience clinical unit within a large midwestern healthcare system has faced ongoing challenges with turnover with a January 2020 to December 2020 12-month rolling churn rate (includes transfers off clinical unit and those who left the organization) of 58.9% (Human Resources Information Services [HRIS], 2021). In 2020, transfers off the unit increased by 17.6% (HRIS, 2021). In 2019, the total RN orientation hours on this unit were 5,269.70 at an orientation cost of $142,955.99 (HRIS, 2021). In 2020, RN orientation hours increased to 8,024.92 at a cost of $227,413.84 (HRIS, 2021). From January to June 2021, orientation hours were 1,476.55 at a cost of $41,800.37 (HRIS, 2021). The clinical unit has experienced high turnover of nurse managers with four nurse managers over the previous six years, and less than desirable quality indicators including an inpatient fall rate per 1000 patient days of 8.42 (national benchmark at or less than 3.960), inpatient fall with injury rate per 1000 patient days of 0.94 (national benchmark at or less than 0.590), a belonging score of 55 (scale of HEALTHY WORK ENVIRONMENT 10 100, overall organizational average of 69), and an employee engagement score of 54 (scale of 100, overall organizational average of 72); Patient Quality, Safety, and Experience Department, 2021). As of May 2021, the clinical unit had approximately 20 open RN positions, having spent over $200,000 in contract labor in January and February of 2021 (HRIS, 2021). Seventy-five percent of the primarily female staff are between the ages of 20-29, 19% are between the ages 30 - 39, and 5% are over the age 40 (HRIS, 2021). Fifty-nine percent of the team members had one year or less tenure (HRIS, 2021). Despite engagement from employee relations and operational leadership, the nurse manager described a continued fundamental lack of trust and a culture of toxic negativity, intimidation and strong lateral violence (V. Tumbleson, personal communication, May 26, 2021). The practice environment on the unit has faced ongoing challenges and has been described as toxic by the current nurse manager and clinical director. Behaviors such as intimidation, lack of trust in leadership, and lack of individual accountability are deep-seated and pervasive, resulting in ongoing challenges such as RN and Nurse Technician (NT) churn and belonging and engagement scores well below company average (HRIS, 2021). Intentional efforts including clarification of charge RN expectations and accountability, provider and RN collaboration efforts, evaluation of hours per patient day (HPPD), and revision of new hire orientation and ongoing professional development opportunities were paused, and therefore have not had a measurable impact, due to the Coronavirus Disease 2019 (COVID-19) and continued challenges with increased census and patient acuity. HEALTHY WORK ENVIRONMENT 11 Problem Statement Despite engagement from operational leadership and human resources, the practice environment on an adult inpatient neuroscience clinical unit within a large mid-western healthcare system continues to face significant challenges. These challenges involve creating and maintaining a HWE as evidenced by significant RN and NT churn and belonging and engagement scores well below company average. Organizational Assessment Gap Analysis of Project Site The Fishbone diagram allows for the display of various causes and their impact on the outcome, ultimately assisting in the identification of areas for improvement (IHI, 2021). Using the Fishbone diagram, factors contributing to the climate of the current work environment were identified and organized into the following categories: environment, equipment, people, methods and materials (see Appendix A for Figure 1. Fishbone diagram). For purposes of this evidence- based quality improvement project, the area of focus was on lack of belonging, team member engagement, and unit culture. The intent of the Strengths/Weaknesses/Opportunities/Threats (SWOT) analysis is to identify strengths and weaknesses internal to the organization as well as opportunities or threats that may contribute to or interfere with the success of the project (Terhaar et al., 2021). The SWOT analysis assisted in outlining the level of engagement of key stakeholders, attributes of the current organizational climate on the clinical unit, and detail surrounding threats to the success of the implementation of the project plan. Key findings from the SWOT which were considered included the strength of high level of engagement from the nursing director, nurse manager, nurse educator and clinical nurse specialist, with a corresponding high level of appreciation for evidence-based strategies. An opportunity to highlight was the fundamental HEALTHY WORK ENVIRONMENT 12 threat team members expressed to their physical safety, pervasive and embedded negative culture of incivility, lack of trust in leadership and overarching lack of team member engagement (see Appendix B for SWOT analysis). An element of the gap analysis included a comparison of strategies implemented by the current operational leadership and human resources in comparison to strategies recommended by TJC, IHI and AACN to improve the practice environment (see Appendix C for TJC, IHI and AACN key HWE recommendations in comparison to neuroscience clinical unit implemented strategies). Prior intentions to implement an action plan aimed at improving the climate on the unit have been thwarted by the COVID-19 pandemic, limiting the intervention to three strategies: clarification of charge RN expectations, improved leadership ongoing communication and transparency, and holding team members accountable for identifiable professional behavior concerns. Purpose of the Project The purpose of this evidence-based quality improvement project was to implement strategies to influence the four critical components of the IHI Framework; physical and psychological safety, meaning and purpose, choice and autonomy, and camaraderie and teamwork (Perlo et al., 2017). Strategies, including “What matters to you?” conversations, development of a communication board, daily huddles and charge nurse team building, were aimed at improving the HWE and ultimately decreasing churn from 58.9% to 50%, increasing team member sense of belonging from 55 to 60, and increasing team member engagement from 54 to 59 on a neuroscience clinical unit within a large midwestern Magnet ® designated hospital by January 2022. HEALTHY WORK ENVIRONMENT 13 Evidence Based Practice Model/QI Model The IHI Framework for Improving Joy in Work (Perlo et al., 2017) and the Plan Do Study Act (PDSA) model served as the models on which this evidence-based quality improvement project was based. The IHI Framework delineates nine core components which contribute to a healthy workforce with happy, healthy, and productive people (see Appendix D Figure 2. IHI Framework for Improving Joy in Work). The nine components are real-time measurement, wellness and resilience, daily improvement, camaraderie and teamwork, participative management, recognition and rewards, choice and autonomy, meaning and purpose, and physical and psychological safety. Of these, camaraderie and teamwork, choice and autonomy, meaning and purpose, and physical and psychological safety are fundamental and central to the framework. In addition to these, although not listed as a component of the framework, fairness and equity must also be present. The framework further outlines the responsibility of senior leaders (all nine components), managers and core leaders (five components) and individuals (three components). Specifically, managers and core leaders are responsible for real-time measurement, wellness and resilience, daily improvement, camaraderie and teamwork, and participative management. Individuals are responsible for real-time measurement, wellness and resilience, and daily improvement (Perlo et al., 2017). The PDSA model was leveraged to guide the implementation and testing of the proposed interventions. The four stages of the PDSA model include planning of the change and observation, implementing the change on a small scale, evaluating the data, and refining the intervention based upon the data gleaned (Fineout-Overholt & Stevens, 2019). The primary interventions for this evidence-based quality improvement project were intended to positively impact the HWE by focusing on the fundamental core components of the IHI framework: HEALTHY WORK ENVIRONMENT 14 camaraderie and teamwork, choice and autonomy, meaning and purpose, and physical and psychological safety (Perlo et al., 2017). The application of the PDSA model allowed for targeted evaluation and refinement of the actionable items on a small scale prior to broader implementation (IHI, 2021). Review of the Literature Search Strategy The Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PubMed of the U.S National Library of Medicine National Institutes of Health databases were searched using the defined key terms/phrases “Healthy work environment” OR “Practice Environment” AND nurs* AND turnover (see Appendix E Figure 3. PRISMA diagram). An academic health sciences librarian was consulted for assistance in development of search terms and strategies as initial search results within PubMed were excessive and irrelevant to the topic of interest. Removal of duplicates resulted in a total of 96 records of which the abstracts were reviewed. This resulted in 37 full text articles, which included nine additional relevant publications identified through reference searches. The 37 full text articles were further assessed for eligibility resulting in the identification of 26 potential articles for inclusion in the synthesis. Further evaluation, including the use of qualitative and quantitative critical appraisal checklists from the Joanna Briggs Institute, was conducted (Lockwood, Munn, & Porritt, 2015; Moola et al., 2020). Eleven research articles were chosen for inclusion in the synthesis (see Appendices F and G for evaluation table and synthesis table themes and outcomes). The following synthesis discusses themes, characteristics and applicable interventions identified as contributing to a HWE and impacting RN sense of belonging, engagement and ultimately churn. HEALTHY WORK ENVIRONMENT 15 Nursing Practice Environment Quality leadership, interpersonal relationships, and environmental elements such as supportive structures, access to resources and professional development opportunities, contribute to the overall health of the nursing practice environment (RNOA, 2008; Shirey, 2017). Contextual factors, such as the organizational culture and climate further influence the practice environment at both the macro and micro level respectively (RNOA, 2008; Shirey, 2017). Recognizing the connection between belongingness and job satisfaction to the practice environment, the Practice Environment Scale of the Nursing Work Index (PES-NWI), the Belongingness Scale - Clinical Placement Experience BS-CPE and the Nurse Workplace Relational Environment Scale (NWRES) are tools that have been presented in the literature as a means to evaluate characteristics which contribute to the practice environment (Numminen et al., 2015; Perlo et al., 2017; Reinhardt, León, & Amatya, 2020). Autonomy HWE’s were shown to have a positive relationship with nurses’ perceptions of autonomy (Wei et al., 2018). Furthermore, a positive association was identified between autonomy, decision latitude and job satisfaction (Reinhart et al., 2020; Van Bogaert et al., 2018) and contributes to the overall satisfaction of millennial nurses (O’Hara, Burke, Ditomassi, & Palan, 2019). On the contrary, Nelson - Brantley, Park, and Bergquist-Beringer (2018) identified that nurse participation in hospital affairs did not show a significant association with RN turnover. Managerial Support Actual or perceived managerial support and leadership ability was positively associated with RN turnover or intention to leave the role (Nelson - Brantley et al., 2018; Numminen et al., HEALTHY WORK ENVIRONMENT 16 2015; Ulrich et al., 2019) and was identified as a key driver in the creation and sustainment of a HWE and in the satisfaction of the millennial nursing workforce (O’Hara et al., 2019; Shirey, 2017). At the macro level, there is a strong positive correlation between overall organizational support and sense of autonomy and job satisfaction (Reinhardt et al., 2020). Specific leadership attributes such as authenticity, empowerment, giving and receiving of feedback, setting clear expectations, as well as emotional intelligence, competence and vision were identified as qualities of a leader contributing to a HWE and impacting intent to stay (Shirey, 2017; Van Osch et al., 2018). Of interest, Nelson-Brantley et al. (2018) identified that as managerial support increased, RN turnover also increased by 8.3%. The authors attributed this to the belief that supportive managers may encourage team members to advance within the profession of nursing or seek other opportunities within the organization to further develop professionally. Staffing/Resource Adequacy Appropriate staffing and access to resources is significantly related to the health and productivity of the work environment including RN turnover, workload, job satisfaction, perceived effectiveness of the front line nurse manager, and RN satisfaction with the quality of care provided (Nelson - Brantley et al., 2018; Numminen et al, 2015; Shirey, 2017; Ulrich et al., 2019; Van Bogaert et al., 2018). Effective Interpersonal Relations Camaraderie, teamwork, and a sense of connectedness have been shown to positively impact the perceptions of the practice environment and overall work satisfaction and are identified as key elements within the IHI Framework (Numminen et al., 2015; O’Hara et al., HEALTHY WORK ENVIRONMENT 17 2019; Perlo et al., 2017; Reinhardt et al., 2020). Leadership styles which embed key values such as respect, honest feedback, open communication and trust contribute to the development of empowering relationships and a safe working environment (RNOA, 2008; Shirey, 2017). RN Turnover An inverse relationship was identified between the presence of HWE characteristics such as dedication, staffing, respect from administration and front line management, meaningful relationships, and participation in hospital affairs and RN turnover rates including intention to leave the hospital or intention to leave the profession (Nelson-Brantley et al., 2018; Numminen et al., 2015; Van Bogaert et al., 2018; Ulrich et al., 2019). Emotional exhaustion was shown to be positively associated with intention to leave the hospital and intention to leave the profession (Van Bogaert et al., 2018). Quality The overall practice environment including nurse participation in hospital affairs, decision latitude, social capital and staff engagement, impacted RN satisfaction with the quality of care being provided including overall safety (Numminen et al., 2015; Perlo et al., 2017; Van Bogaert et al., 2018; Wei et al., 2018). Of interest, Nelson - Brantley et al. (2018) determined that the subscale of nursing foundations for quality of care on the PES-NWI was highly correlated with RN participation in hospital affairs. Considering this, there was not a significant association between RN participation, and henceforth quality, and RN - physician relations or unit turnover. HEALTHY WORK ENVIRONMENT 18 Summary The synthesis of the literature identified key themes, influenced by the actual or perceived presence or absence of managerial support, which contribute to a HWE including autonomy, decision latitude, camaraderie and connectedness, civility, and staffing and resources. There were varying results indicating the impact of engagement in hospital affairs on team member engagement and turnover. From the perspective of quality, the subjective assessment of quality care at the unit level was influenced by nurses who felt empowered and had decision latitude. Based upon these findings, elements of the IHI Framework will be implemented. The underlying premise of the IHI Framework is by understanding barriers to joy in work, and focusing on restoring joy, leaders have the ability to engage and partner with team members in creating strategies to influence joy in work ultimately impacting elements such as team member engagement and turnover rates (Perlo et al., 2017). Goals, Objectives and Expected Outcomes The following four steps of the IHI Framework were implemented as part of this evidence-based quality improvement project on the unit: 1. implement “What matters to you?” conversations with RNs, NTs, unit secretaries and nursing supervisor, 2. identify unique impediments to joy in work, 3. in partnership with manager, commit to making joy in work a shared responsibility, 4. and leverage PDSA to test the approaches in improving joy in work. The overarching desire was to influence four of the nine components which are critical to the improvement of joy in the workplace (Perlo et al., 2017). Physical and psychological safety, HEALTHY WORK ENVIRONMENT 19 meaning and purpose, choice and autonomy, and camaraderie and teamwork are foundational to the application of the IHI Framework. Considering this, the objective of this evidence-based quality improvement project was to implement strategies targeting the four foundational components with the goal of improving the overall HWE on the unit with an ultimate desired state of improving churn from 58.9% to 50%, belonging from 55 to 60, and engagement from 54 to 59 by January 2022. The following strategies, targeting the four foundational elements of the IHI Framework, were implemented: Meaning and purpose / Physical and psychological safety • Over the course of two weeks, in collaboration with nurse manager, “What matters to you?” conversations with RNs, NTs, unit secretaries, and supervisors on the neuroscience clinical unit were implemented. Conversations were intended to assist in identifying “bright spots” in the work environment as well as impediments or “pebbles in their shoes” (Perlo et al., 2017, p. 8). • A communication board, functioning as a daily visual management tool, was created and implemented based upon feedback from team members. The board made visible impediments identified during “What matters to you?” conversations, as well as function as a tool to add additional impediments and ideas for improvement as they arise. Additionally, daily bright spots were celebrated on the communication board. • A structure for daily huddles and review of the communication board was developed and implemented. Choice and autonomy HEALTHY WORK ENVIRONMENT 20 • Daily huddles, communication board and charge nurse meetings were leveraged as a forum to solicit ongoing input and feedback from team members on the status of addressing prioritized impediments. • “What makes today great” was implemented during daily huddles (led by charge nurses). Camaraderie and teamwork • Charge nurse team building activities to start each charge nurse meeting were developed and implemented by the doctoral student. • The doctoral student collaborated with charge nurses to solicit input / feedback from team members on prioritized impediments and strategies to address them during daily huddles. Methods Project Site and Population The selected unit was a 38-bed inpatient neuroscience clinical unit which provides care for general neurology, neurosurgical and medical/surgical patients age 19 and older. The average daily census (ADC) is 35. The primary admission codes served by the unit during 2019 through March 2021 were epilepsy and seizure disorders, brain and central nervous system cancer, and ischemic stroke (see Appendix H for top 10 ICD admission codes served by the neuroscience clinical unit during 2019 through March 2021). The neuroscience clinical unit team is comprised of 47.71 Full Time Equivalents (FTEs) including 35 RNs for a total of 30.21 FTEs (see Appendix I for primary roles, headcount and FTE allocation). As of June 2021, there were 18.9 open RN requisitions with a current 38% vacancy rate. In respects to Integrated Disability HEALTHY WORK ENVIRONMENT 21 Management (IDM) in calendar years 2019 and 2020, there were 54 injuries reported resulting in 1,178 total lost days and 219 total restricted days (IDM, 2021). Metrics. Metrics are leveraged to evaluate the impact of the care provided on the neuroscience clinical unit and the overall contribution to ensuring the organization’s mission to improve health, inspire hope and save lives, is achieved. Metrics such as patient and team member satisfaction are indicators of the status of the clinical unit in driving toward meeting the overall organizational mission. Patient experience. In respects to patient experience, the neuroscience clinical unit continues to face opportunities. The health care organization leverages the Quality, Safety and Experience Grade Point Average (GPA) scale to measure and evaluate quality, safety and experience against industry peers (Elmouchi, 2020). The GPA scale leverages the following methodology: 1.0 reflects metrics falling below the 50th percentile nationally; 2.0 - 2.9 is between the 50th - 75th percentile nationally; 3.0-3.9 is between the 75th and 89th percentile; and 4.0 is greater than the 90th percentile. During the rolling performance period of October 2020 thru May 2021, the Neuroscience clinical unit had a likelihood to recommend GPA of 1, which is below the 50th percentile. In May 2021, with 23 survey respondents, the likelihood to recommend score increased from April 55.6% to 78.3%, which is a GPA of 3, between the 75th - 89th percentile. For the 2021 calendar year performance period patient satisfaction scores, in respects to communication with nurses, the neuroscience clinical unit had a GPA of 1, below the 50th percentile. Team member engagement. The organization leverages the Glint employee listening survey to evaluate team member engagement six times annually. The March 2021 neuroscience clinical unit team member engagement survey had a 62% response rate with an overall HEALTHY WORK ENVIRONMENT 22 engagement score of 56, which is an increase of 2 from the prior survey. Company, meaning the healthcare organization as a whole, had an overall response of 60% with an average engagement score of 74. Categories within the employee engagement survey such as feedback, empowerment, recognition, engagement, belonging, and resources align with concepts of a HWE (see Appendix J for employee engagement scores March 2021 listening survey aligned with HWE concepts). From an organizational perspective, the unit based goal, determined by the clinical nursing director and based upon employee engagement scores in the fourth quarter of 2020, is to improve the belonging score from 46 to 51 by December 2021. Ethical Considerations/Protection of Human Subjects Michigan State University Internal Review Board (IRB) approval was obtained prior to initiating this evidence-based quality improvement Doctorate of Nursing Practice Project (see Appendix K MSU IRB). The official IRB Determination Form was submitted upon proposal approval. This evidence-based quality improvement project did not involve any component of research nor did it identify, access, or utilize any protected health information. Participants impacted by the interventions implemented as elements of the IHI Framework were team members including RNs, NTs, unit secretaries, and a nursing supervisor who report to the clinical nurse manager on the neuroscience clinical unit. The interventions implemented were consistent with other interventions that operational leaders could choose to independently initiate within their clinical spaces in an attempt to improve team member belonging, engagement and ultimately team member churn. The IHI Framework did not expose the clinical team members of the neuroscience clinical unit to any greater risk than they would encounter as a part of a usual clinical shift on the neuroscience clinical unit or as an employed team member of this large midwestern Magnet ® designated hospital. As a result, the organizational IRB deemed the HEALTHY WORK ENVIRONMENT 23 project as non-human research and therefore did not require full review by the organizations IRB (see Appendix L Spectrum Health IRB). Benefits to this evidence-based quality improvement project included the utilization of a defined framework and quality improvement model for implementation and evaluation of recommended interventions, potential improvement in team member sense of belonging, engagement and ultimately churn as well as an increase in likelihood to recommend. Setting Facilitators and Barriers As previously described, the neuroscience clinical unit is an inpatient unit within a large midwestern, Magnet ® designated hospital. Implementation of the interventions intended to impact team member sense of belonging, engagement and ultimately churn required interactions with front line clinical team members as well as unit leadership, including the nurse manager, clinical director, nurse educator, clinical nurse specialist and nurse supervisor. Interactions with personnel included: • Partnering with nurse manager to prepare for “What matters to you?” conversations. • Facilitating “What matters to you?” conversations with team members including charge nurses, travel RNs, nursing supervisor and nurse manager. • Partnering with nurse manager, charge nurses, nursing supervisor and team members to prioritize impediments identified during “What matters to you?” conversations. • Attending monthly charge nurse meetings and facilitating team building activities. HEALTHY WORK ENVIRONMENT 24 • Participating in daily huddles to mentor charge nurses in soliciting input and feedback from all team members in addressing prioritized impediments identified from “What matters to you?” conversations. Time, dedication, patience and commitment were necessary in order to effectively influence a positive change in the HWE. The neuroscience clinical unit culture is deep-seated and pervasive, which will require perseverance to successfully influence. Strong engagement, commitment and eagerness from unit leadership as well as human resources were key facilitators to the implementation of the IHI Framework. Resources required for the successful implementation of the interventions included time, space for meetings and team building activities, and supplies for the creation of the communication board. A constraint which was considered was the availability of adequate time to develop relationships with team members in order to build trust and successfully engage them in the “What matters to you?” conversations as well as the prioritization of the identified impediments to joy in work and implementation of interventions to address impediments. Potential team member engagement and buy-in was considered the fundamental barrier to the success of the implementation of this evidence-based quality improvement project. Facility support to implement the above mentioned interventions as part of the evidence- based quality improvement project was obtained (see Appendix M for facility letter of support). The Intervention and Data Collection Procedure The PDSA model provided the framework for the implementation and ongoing evaluation of this evidence-based quality improvement project. The IHI Framework is based upon four steps for leaders: 1. Ask staff, “What matters to you?” HEALTHY WORK ENVIRONMENT 25 2. Identify unique impediments to joy in work in the local context. 3. Commit to a systems approach to making joy in work a shared responsibility at all levels of the organization. 4. Use improvement science to test the approaches (Perlo et al., 2017, p. 8). A Gantt chart (see Appendix N for Gantt chart) provides detail of the interventions in relationship to the defined timeline. Overall, “What matters to you?” conversations with team members of the Neuroscience clinical unit provided insight into what team members identify as impediments to their work and ultimately negatively impacting the health of the environment. Initially, upon development of the project proposal, the impediments identified during the “What matters to you?” conversations were to be prioritized with the charge nurses and then with all team members. Strategies to address the impediments were then to be created by all team members and implemented. The use of daily huddles, the communication board, and defined process and outcome measures, allowed for the ongoing evaluation of the impact of the interventions and provided insight on areas where refinement may be necessary. In addition to the nurse manager and nurse supervisor, charge nurses are identified as informal operational leaders on the neuroscience clinical unit. Recognizing this, team building activities were implemented with the charge nurses as they, alongside the nurse manager, facilitated daily huddles which solicited input and feedback from all team members in response to the prioritized impediments and strategies for improvement. As noted in the timeline (see Appendix N for Gantt chart), many of the interventions overlapped and occurred in tandem with one another. The following lists the primary interventions: HEALTHY WORK ENVIRONMENT 26 • Implementation of “What matters to you?” conversations with all team members. Identify “what makes a good day” and “what are pebbles in your shoes?” The doctoral student facilitated the “What matters to you?” conversations. • Input and feedback was solicited from all team members during the “What matters to you conversations?” to solidify prioritization of impediments and identification of strategies to implement during daily huddles. • The doctoral student created and implemented a daily visual management strategy, communication board, to make visible identified impediments and associated strategies to address. • “What makes today great” and “pebbles in your shoes” was incorporated into the daily huddle. The doctoral student partnered with the nurse manager in coaching charge nurses in soliciting input and feedback from team members during daily huddles. • In order to develop charge nurses as a team, charge nurse team building activities, developed and led by the doctoral student, were included in monthly charge nurse meetings. The goal of this evidence-based quality improvement project was to improve the overall HWE on the neuroscience clinical unit with an ultimate desired state of improving churn from 58.9% to 50%, belonging from 55 to 60, and engagement from 54 to 59 by January 2022. The communication board allowed for an in the moment pulse on the impact of the defined interventions. Outcome measures, including RN and NT churn rate, turnover rate, belongingness score, and engagement score were evaluated on a monthly basis from HEALTHY WORK ENVIRONMENT 27 August 2021 to January 2022. In addition, likelihood to recommend as a counterbalance measure was evaluated during the same timeframe. Timeline A Gantt chart (see Appendix N for Gantt chart) outlines the timeline for this evidence- based quality improvement project in detail. Measurement Instruments/Tools Recognizing that no single validated measure of joy in work has been identified, system and local measures can be considered to evaluate progress in achieving joy in work (Perlo et al., 2017). Examples of system level measures include team member satisfaction, engagement, burnout, turnover, retention, employee wellbeing, workplace injuries, or absenteeism (Perlo et al., 2017). From a local perspective, measurement is focused on real time evaluation of daily or weekly improvements which are initiated and tracked by the team members and unit leaders. The primary and secondary outcome measures, process measures, and counterbalance measures which were monitored to evaluate the impact of this evidence-based quality improvement project, and the tools which were leveraged, are as follows: Outcome measures. Primary. • Overall churn rate [RNs and NTs who left the clinical unit, retrievable through human resources information services (HRIS)] • RN churn rate [number of RNs who have left the clinical unit, retrievable through HRIS] HEALTHY WORK ENVIRONMENT 28 • Overall belongingness score [Glint employee listening survey, measured 6 times annually, retrievable from unit leadership] • Overall engagement score [Glint employee listening survey, measured 6 times annually, retrievable from unit leadership] Secondary. • Overall turnover rate [RNs and NTs who left the health system, retrievable through HRIS] • RN turnover rate [number of employees who have left the health system, retrievable through HRIS] • NT churn rate [retrievable through HRIS] • NT turnover rate [retrievable through HRIS] Process measures. • Daily visual management in the form of a communication board to capture “bright spots” and “pebbles in your shoe” Counterbalance measures. • Likelihood to recommend [Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), available monthly, retrievable from unit leadership] Implementation The authoring of the project proposal occurred in Spring/Summer of 2021. On May 17th , which was the start of the academic calendar, the seven day average for new reported COVID - 19 cases in Michigan was 1,992. On August 19, 2021, completion of the semester, the seven day average for new reported cases was 1,539. The initial “What matters to you?” conversation took HEALTHY WORK ENVIRONMENT 29 place on September 20, 2021 which had a seven day average for new reported COVID - 19 cases of 3,233. The kick-off of the “Bright Spots Communication Board” occurred on October 13, 2021, which had a seven day average for new reported COVID - 19 cases of 4,393 (The New York Times, 2021). In November 2021, the healthcare organization was facing extremely high census with a record setting inpatient volume of 1,134 equating to 100.53% capacity in non- overflow beds and 90.21% capacity when considering the opening of 79 total overflow beds (M. Vincent, personal communication, December 7, 2021). In addition, the organization experienced a gradual increase in length of stay with a peak average length of stay of 5.02 days in October 2021 in relation to an average length of stay of 4.38 in June 2021 (M. Vincent, personal communication, December 7, 2021). On November 17th, the hospital system had 359 hospitalized COVID-19 patients, 81 of which were in the intensive care unit, and 59 of those patients on a ventilator (Bulson, 2021). On November 18th, the healthcare system’s command center transitioned to red status for the first time since the onset of the pandemic in March 2020 (Elmouchi, 2021). The purpose of this evidence-based quality improvement project was to improve the overall HWE with the implementation of the IHI Framework and ultimately improving churn from 58.9% to 50%, team member belonging from 55 to 60, and team member engagement from 54 to 59 on a neuroscience clinical unit within a large midwestern Magnet ® designated hospital by January 2022. At the time of actual project implementation, these metrics were as follows: • In August 2021, the rolling 12 month churn for RN and NT combined was 55.2% • In July 2021, team member belonging was 55 (12 below company) • In July 2021, team member engagement was 51 (18 below company) • In August 2021, likelihood to recommend: 69.7% HEALTHY WORK ENVIRONMENT 30 Initially, the “What matters to you?” conversations were intended to be held with groups of team members in like roles. Specifically, charge nurses and the nursing supervisor together and separate conversations with the remaining team members. For ease of scheduling, and to allow team members more options to choose from that would work with their schedule, sessions were open to all team members regardless of role. Twenty percent of the total RNs on the clinical unit were travel RNs, and they were also invited to participate. Unlike the IHI Framework six, rather than one, “What matters to you?” conversations were facilitated by the doctoral student during the week of September 20th. The nurse manager of the neuroscience clinical unit was present at all sessions. Zero to 7 team members participated in each session, either virtually via Microsoft TEAMS© or in person, with a total of 14 participants over six sessions. Team members included RNs, NTs, unit secretaries, and the inpatient supervisor. A script was developed to facilitate the discussion (see Appendix O “What matters to you?” script). The intent of the “What matters to you?” conversations was to identify unit specific “bright spots” as well as “pebbles in your shoes” and to engage team members in the development of strategies to increase “bright spots” and decrease “pebbles.” Based upon discussion and feedback from the “What matters to you?” conversations, the Bright Spots Communication Board (see Appendix P Bright Spots Communication Board) was created. The prototype of the Bright Spots Communication Board (board) was active on October 13, 2021. The purpose of the board is to display the “bright spots,” “pebbles in your shoes,” and the strategies to increase “bright spots” and chip away at the “pebbles in your shoes” which were identified during the initial “What matters to you?” conversations. The board is intended to show progress in achieving these strategies as well as allow the opportunity to identify “bright spots” HEALTHY WORK ENVIRONMENT 31 and “pebbles in your shoes” twice daily during already established measurement for daily improvement (MDI) team huddles. In the initial project plan, the intent was to engage charge nurses in setting priorities, and developing associated strategies to address the “pebbles in your shoes” based upon the outcome of the six “What matters to you?” conversations. However, as the conversations evolved, it became apparent that each session was identifying similar “pebbles.” Therefore, prioritization by the charge nurses was not needed. Input from participants was gathered during each conversation to identify strategies on how to best address the “pebbles.” The primary areas of opportunity identified during the conversations were related to staffing and supplies (see Appendix Q Summaries of “What matters to you?” conversations). Staffing concerns shared included having insufficient team members to care for the patient census on the unit, charge nurses in full patient care assignments while also functioning in support roles such as unit secretary in addition to maintaining charge nurse responsibilities and, competency of team members pulled to the neuroscience clinical unit. From a staffing perspective, the facilitator directed the conversation toward what is the role of the team in staffing the neuroscience clinical unit and how could the presence or absence of a welcoming environment impact the stability of the neuroscience clinical unit team. Discussion evolved into defining characteristics of an environment which would entice pull nurses, nursing students and new graduate float pool nurses to work on the neuroscience clinical unit. Opportunities identified during the conversations focused on creating a welcoming environment and included setting expectations for charge nurses in greeting non - unit based staff to the unit including an intentional check-in by the charge nurse with non - unit based staff. In addition, the use of “pull cards” was resurrected. Pull cards are pocket sized cards intended for distribution to team HEALTHY WORK ENVIRONMENT 32 members who have been pulled to the neuroscience clinical unit. The cards were refreshed and revised and can be used to provide helpful information to those not familiar with the unit (see Appendix R for Pull Card Front and Back). The charge nurse is to ensure that all team members pulled to the neuroscience clinical unit receive the pull card. Due to a delay within the organizations document services department, as well as multiple competing priorities within the organization, the pull cards intended for distribution by the charge nurses to team members pulled to the Neuroscience clinical unit were not available until mid - November at which time distribution began. Over the course of the past two years, availability of supplies has become a significant “pebble” on the neuroscience clinical unit. Daily frustrations team members face on the neuroscience clinical unit related to availability of supplies are beyond the challenges faced within the hospital due to the impact of the pandemic on supply chains across the nation. For example tubing for a patient controlled anesthesia pump, which was no longer used within the organization, was available on the unit whereas tubing needed for an epidural pump that was used within the organization was not. Recent changes in personnel responsible for the maintenance of supplies on the unit has likely contributed to the inconsistent availability of supplies needed, proper stocking of supplies, and overall maintenance/inventory of supplies. The addition of the supplies section on the board is intended to assist the nurse manager and charge nurses in in-the-moment identification of what supplies team members are missing during their shift as well as what supplies they have that they never use. Sticky notes and dry erase markers are available on the board for team members to either fill out in the moment and stick on the board or write directly on the dry erase board. The nurse manager and charge nurses are able to grab the sticky notes and align the supply needs in a much more timely fashion. This has also HEALTHY WORK ENVIRONMENT 33 assisted in highlighting the timeliness of addressing identified gaps in supply inventory and escalation to appropriate leadership within supply chain services. The focus of the board changes as “pebbles” are resolved and new one’s form. Charge nurses are considered a part of the leadership team for the neuroscience clinical unit. Monthly meetings with the nurse manager, supervisor and charge nurses are scheduled by the nurse manager and focus on key goals and objectives for the neuroscience clinical unit at the given time. During the timeframe from September 2021 - February 2022 charge nurse meetings focused on elements of the IHI Framework and building teamwork, developing charge nurses in aspects of leadership, and setting role expectations. It was the expectation that the charge nurses would facilitate the review of the board twice daily during MDI huddles. To assist with team building, the doctoral student developed and implemented team building activities intended for each charge nurse meeting scheduled during this time frame. In addition, the doctoral student leveraged charge nurse meetings to provide guidance on how to facilitate the board during huddle. Expectations were also set by the nurse manager and doctoral student in defining the role of the charge nurse in creating and contributing to a HWE. One charge nurse was in attendance for the September meeting. The nurse manager attributed this to a break in communication and failure to include a link to a virtual meeting in the body of the invite. As a result, the September meeting was cancelled. One week prior to the October charge nurse meeting, the nurse manager sent an email to charge nurses reiterating expectation to attend either via Microsoft Teams © or in person. The focus of the October charge nurse meeting was team building and an introduction to the role of the charge nurse in facilitating the board during daily huddles. The October team building activity, facilitated by the doctoral student, had each charge nurse share one word they strongly associated with and why. HEALTHY WORK ENVIRONMENT 34 In addition, the charge nurse expectation document (see Appendix S Facilitating Bright Spots Communication Board Charge Nurse Guide) was reviewed with the charge nurses and inpatient supervisor by the doctoral student and reiterated by the nurse manager. “Hope” was one term shared by more than one charge nurse during the October charge nurse meeting. During the December charge nurse meeting, the doctoral student reflected on the October meeting and asked the charge nurses to share their hope for the neuroscience clinical unit team and what could they do to contribute to achieving this goal. Participants were asked to write their thoughts down as well as share with the team. The nurse manager shared the thoughts, anonymously, in a unit newsletter. Due to staffing and unit census, the January charge nurse meeting was cancelled. In February, the unit manager reminded the charge nurses of what they had shared in December in respect to what they hoped for the neuroscience clinical unit and how they were going to contribute to achieving this goal. The doctoral student asked the charge nurses to reflect on the previous two months and share an example of when they supported or encouraged a team member that contributed to achieving what they had hoped for the neuroscience clinical unit as well as share a scenario where, in reflection, they might have taken a different approach. Implementation of the twice daily review of the board during huddle began the day following the October charge nurse meeting in which they received instructions on facilitation of the board. The charge nurses facilitate review of the board twice daily, 11:00 and 23:00. To assist in ongoing coaching and development of the charge nurses, the nurse manager, inpatient supervisor and the doctoral student participated in huddles when feasible. Specifically, the doctoral student rounded on the neuroscience clinical unit weekly connecting with the charge nurse for that particular day and the nurse manager, to debrief on the use of the board as well as participate in the 11:00 huddle. During the February charge nurse meeting, the charge nurses HEALTHY WORK ENVIRONMENT 35 reflected on the continued use of the board. There was unanimous agreement of the positive impact of the board both in regards to highlighting of the “bright spots” as well as the “pebbles in my shoe.” There was discussion surrounding the location of the board, as it is currently visible to patients and family members. Analysis Effectiveness of the implementation of the IHI Framework on the neuroscience clinical unit was evaluated by comparing pre and post implementation data for rolling twelve month transfer percentage, rolling twelve month churn percentage, engagement score, belonging score, and likelihood to recommend. As previously mentioned, the organization implemented various strategies to stabilize an extremely volatile workforce during the COVID - 19 pandemic. When evaluating the impact of the IHI Framework, the assessment of turnover, churn, belonging and engagement scores beyond the neuroscience clinical unit was warranted. Comparison to like units, either in size or patient population, allowed the opportunity to consider the potential impact of the IHI Framework in light of the COVID -19 pandemic as well as stabilization efforts implemented across the organization. Turnover and Churn Turnover, as defined by the organization, includes team members who have left the organization. Twelve month rolling transfer percentage was leveraged to assess RN, NT and overall turnover from the neuroscience clinical unit. Churn includes turnover as well as those who remained within the organization but transferred from one clinical area to another. Twelve month rolling churn percentage was evaluated to assess RN, NT and overall churn on the HEALTHY WORK ENVIRONMENT 36 neuroscience clinical unit. Implementation of the IHI Framework began in September 2021. Therefore, August 2021 was considered the pre-implementation data point in evaluating turnover and churn and October, November, December 2021 and January 2022 were considered post implementation data points. Overall, RNs and NTs combined, the twelve month rolling transfer percentage for the neuroscience clinical unit decreased from August 2021 to January 2022 (see Appendix T Neuroscience Clinical Unit Rolling Twelve Month Transfer Percentage). That said, the RN twelve month rolling transfer percentage increased at the time of project implementation, showed a slight decrease in November of 2021, followed by a peak in December 2021. In January 2022, however, the RN rolling transfer percentage decreased to the lowest percentage since pre project implementation. Nurse technician’s also experienced an increase in rolling twelve month transfer percentage with a decrease noted in January 2022. Evaluation of the twelve month rolling churn percentage, for RNs and NTs of the neuroscience clinical unit, during the same time period, revealed an initial increase with a peak in December 2021 (see Appendix U Neuroscience Clinical Unit Rolling Twelve Month Churn Percentage). This was followed by a decrease in January 2022. The twelve month rolling churn percentage for the RN indicated an initial increase in September followed by a slight dip in October 2021. November and December 2021 reflect an increase in the twelve month rolling churn percentage followed by a decrease in January 2022. The RN rolling twelve month churn percentage in January was the lowest since project implementation. NTs’ experienced an increase in the twelve month rolling churn percentage over the course of project implementation. HEALTHY WORK ENVIRONMENT 37 Recognizing the potential broader impact of the pandemic, turnover and churn from the neuroscience clinical unit was compared to three additional clinical units within the healthcare organization. Unit A and Unit B were considered comparable in size whereas Unit C was comparable in patient population served. As stated, the neuroscience clinical unit experienced an increase in the overall twelve month rolling transfer percentage in September and October 2021 followed by a slight dip in November 2021 and then increase in December 2021 (see Appendix V Comparison of Like Units Twelve Month Rolling Transfer Percentage). January showed a decrease in twelve month rolling transfer percentage which was below the August 2021 transfer percentage. Unit A, comparable in size, experienced an increase in twelve month rolling transfer percentage from August 2021 through January 2022. Unit B, also comparable in size, experienced a similar pattern as the neuroscience clinical unit with an initial increase in twelve month rolling transfer percentage followed by a decrease in October and November and then increase in December and January with the January data point being greater than August 2021. Unit C, comparable in patient population served, also experienced an increase in twelve month rolling transfer percentage. The twelve month rolling transfer percentage was lower in January 2022 in comparison to August 2021 for the neuroscience clinical unit. Units A, B and C all experienced an increase from August 2021 to January 2022. In respects to twelve month rolling churn percentage, the neuroscience clinical unit experienced an overall increase from August through December 2021. This was followed by a decrease in January 2022 (see Appendix W Comparison of Like Units Twelve Month Rolling Churn Percentage). Both Units A (size) and C (population) experienced increases in twelve month rolling churn percentage whereas Unit B (size) saw an increase from August to HEALTHY WORK ENVIRONMENT 38 September, saw a dip in October and November, followed by an increase in January. The neuroscience clinical unit was the only unit to see a decrease in the twelve month rolling churn from December 2021 to January 2022. The January 2022 twelve month rolling churn percentage was 6% greater than the August 2021 percentage. In comparison, Unit A, B and C increases from August 2021 to January 2022 were 9.2%, 27.6% and 14.7 % respectively. In summary, the neuroscience clinical unit experienced a decrease from October to November in both overall and RN twelve month rolling transfer percentage. Unit B (size) also experienced an overall decrease in both October and November. Units A, B and C experienced an increase in overall transfer percentage from August 2021 to January 2022. In respects to twelve month rolling churn percentage, the neuroscience clinical unit, Units A, B and C all experienced an increase in the twelve month overall rolling churn percentage from August 2021 to January 2022. However, the neuroscience clinical unit experienced the lowest increase. The neuroscience clinical unit did not experience gradual improvement in turnover or churn during the project implementation timeframe. The turnover and churn experienced by the neuroscience clinical unit, as well as Units A, B, and C is consistent with what was seen across the nation as the pandemic worsened RN turnover in academic medical centers, community hospitals and health systems (Grimley, Gruebling, Kurani, & Marshall, 2021). Although the neuroscience clinical unit itself was not a dedicated COVID - 19 unit, there were multiple units within the hospital which were. From an organizational perspective, this resulted in a shift of resources to support COVID - 19 designated units while shifting other patient populations from newly COVID-19 designated units to other clinical units within the hospital system. In an attempt to stabilize the extremely volatile nursing workforce the organization implemented various compensation packages in the fall of 2021. The compensation HEALTHY WORK ENVIRONMENT 39 packages included the activation of a $10,000 RN sign on bonus and a $12,000 RN retention bonus for select clinical areas in September and October, respectively. The recruitment bonus includes a two year commitment on the unit to which one was hired, whereas with the optional retention bonus, participating RNs sign a promissory note to stay on their current unit through December 2022. Team members who accepted the retention bonus were required to pay back the full amount if they transferred from their unit, or left the organization, prior to January 2022. They were expected to pay back half the amount if they were to transfer or leave the organization between January 2022 and December 2022. Approximately 88% of RNs (29/33) on the neuroscience clinical unit and 91% of eligible RNs across the organization chose to participate in the retention bonus (B. Minnesma, personal communication, December 12, 2021). In addition, in September 2021, wage adjustments were implemented impacting both the RN and NT workforce. Despite the implementation of the RN recruitment and retention incentives, the organization experienced ongoing challenges with stabilization of the workforce. These initiatives may have stabilized the twelve month rolling transfer and churn percentages. In addition, as previously stated, in November the healthcare system’s command center transitioned to red status for the first time since the onset of the pandemic in March 2020. This was in response to record setting census, high patient acuity, including extremely high COVID - 19 patient population and significant staffing challenges. This reality may have contributed to the increase in twelve month rolling transfer and churn percentage across the clinical units. In addition, RN vacancy rate and number of travel RNs are variables to consider when interpreting turnover and churn. It would be expected that a unit with a higher vacancy rate or with greater number of travel RNs would experience a decrease in turnover or churn as there are less employees to actually depart from the unit. Although the neuroscience clinical unit HEALTHY WORK ENVIRONMENT 40 experienced a decrease in rolling transfer and churn percentage from December 2021 to January 2022, the neuroscience clinical unit had the most travel RNs per month from August 2021 thru January 2022 in comparison to units A, B and C (see Appendix X Travel RN Headcount per Unit by Month). Unit A (size) did not have travel RNs at any point (J. Coble, personal communication, February 23, 2022). In August 2021, there were 56.0 travel RN FTEs within the healthcare organization. This gradually increased to 185.0 travel RN FTEs the end of January 2022 (J. Brandt, personal communication, February 23, 2022). Although the neuroscience clinical unit had the highest number of travel RNs from August 2021 - January 2022, they did not consistently have the highest RN vacancy rate in comparison to Units A, B and C (see Appendix Y Figure 4. RN Vacancy Percentage). Unit C (population) maintained a higher overall RN vacancy rate from August 2021 - January 2022 (L. Lenhardt, personal communication, February 23, 2022). Lastly, the data analysis did not consider turnover or churn influenced by academic progression such as NTs transitioning into the RN role or bedside RNs transitioning into an advanced practice clinician or a leadership role. Although the neuroscience clinical unit did not experience an overall improvement in turnover or churn during the project implementation timeframe they did experience a decrease in both twelve month rolling transfer and churn percentage from December 2021 to January 2022. Unlike RNs, NTs did not receive monetary recruitment or retention incentives. HEALTHY WORK ENVIRONMENT 41 Engagement and Belonging Engagement and belonging were measured via the Glint employee listening survey. The Glint employee listening survey includes up to 16 questions and is launched six times annually to all team members within the healthcare organization. Engagement is assessed with the question “How happy are you working at [organization name]?” and belonging is evaluated with the question “I feel a sense of belonging at [organization name].” Due to the pandemic, the September 2021 engagement survey was not deployed. As a result, the July 2021 data point reflects team member engagement and belonging prior to implementation of the IHI Framework and the November 2021 data point reflects team member engagement and belonging post implementation. Belonging and engagement was evaluated for RN and NT role overall as well as RN and NT roles individually. The neuroscience clinical unit experienced a decrease in both belonging and engagement scores from July 2021 to November 2021. The RN response rate in November, however, decreased from 77% in July to 58% in November. In comparison to units A, B, and C, the neuroscience clinical unit experienced the lowest overall (including RNs and NTs) belonging score in July 2021 followed by the lowest overall belonging score in November 2021. The neuroscience clinical unit also experienced the greatest overall decrease, decreasing by 5, from July to November 2021 in comparison to the other like units (see Appendix Z Figure 5. Belonging Overall). In evaluating the RN and NT roles individually, the RN belonging score from July 2021 to November 2021 remained unchanged at 49 for the neuroscience clinical unit. Although unchanged, the RN belonging score for the neuroscience clinical unit was lower in comparison to like units (see Appendix AA Figure 6. Belonging RN). The belonging score decreased from July HEALTHY WORK ENVIRONMENT 42 2021 to November 2021 for all comparable units with the exception of Unit C, comparable in patient population. NT belonging scores also decreased from July 2021 to November 2021 for all clinical units with the exception of Unit B (size), which remained stable (see Appendix BB Figure 7. Belonging NT). In respects to engagement, in comparison to units A, B, and C, the neuroscience clinical unit experienced the lowest overall (including RNs and NTs) engagement score in July 2021 followed by the lowest overall engagement score in November 2021. Like the neuroscience clinical unit, Unit B (size) also experienced a decrease in engagement. Units A (size) and C (population), however, remained stable from July to November (see Appendix CC Figure 8. Engagement Overall). In evaluating the RN and NT roles individually, the RN engagement score decreased from July 2021 to November 2021 for the neuroscience clinical unit as well as Unit B (size). Unit A (size) remained unchanged, whereas Unit C (population) experienced an increase from July to November (see Appendix DD Figure 9. Engagement RN). NT engagement scores also decreased from July 2021 to November 2021 for all clinical units with the exception of Unit B (size), which experienced an increase (see Appendix EE Figure 10. Engagement NT). As previously stated, in addition to impacting twelve month transfer and churn percentage, the presence of travel RNs may also influence the sense of belonging and engagement for employees of the organization. As the number of travel RNs increase on a clinical unit, the development of relationships between team members may be impacted. This could be attributed to the contract type nature of travel RN employment. From August 2021 to January 2022, the neuroscience clinical unit had the most travel RNs each month in comparison to like units with November, the time the Glint employee listening survey was launched, having HEALTHY WORK ENVIRONMENT 43 the most travel RNs (see Appendix X Travel RN Headcount per Unit by Month). In addition, the recruitment and retention strategies implemented by the organization targeted RNs and did not include NTs. Likelihood to Recommend Likelihood to recommend (LTR) is evaluated with the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) question “Would you recommend this hospital to your friends and family?” In August of 2021, pre-implementation of IHI Framework, 69.7% of neuroscience clinical unit patient respondents (n=33) replied to the question “Would you recommend this hospital to your friends and family?” in the “top box” with “yes, definitely.” During the month of project implementation, September, the percentage of respondents who responded with “yes, definitely” increased to 94.7% (n = 19). Unfortunately, October LTR decreased to 54.6% (n=33) followed by an increase to 60.9% in November. However, December “top box” decreased to 40.70% (n=27) and then increased in January 2022 to 63.8% (n=47) (see Appendix FF Comparison of Like Units Likelihood to Recommend Top Box Performance). Based upon an evaluation of national data, Press Ganey (2021) identified an overall decline in perceptions of care across all care settings since March of 2020, including “likelihood to recommend.” Of interest, patients with COVID-19 were more likely to definitely recommend a hospital in comparison to patients without COVID - 19 (Press Ganey, 2021). Recognizing the impact of the pandemic on perceptions of care and patient satisfaction nationally, units comparable in size or patient population to the neuroscience clinical unit were also evaluated (see Appendix FF Comparison of Like Units Likelihood to Recommend Top Box Performance). Consistent with the neuroscience clinical unit, Units A and B, comparable in size, saw an initial increase in “top box” performance from August to September 2021. The HEALTHY WORK ENVIRONMENT 44 neuroscience clinical unit, Unit A (size) and Unit C (population) all experienced an increase in LTR from October to November followed by a decrease in December and an increase in January. This was unlike Unit B (size) which saw a slight decrease from October to November and then increases in both December and January. The December decrease in LTR for the neuroscience clinical unit, Unit A (size) and Unit C (population) corresponds with the healthcare system transitioning from yellow to red, crisis status, in response to the pandemic as well as increased twelve month rolling transfer and churn percentages for all clinical units evaluated. In addition, the neuroscience clinical unit experienced the greatest number of travel RNs in November and December. Unit A (size), who had the greatest LTR for November and January, did not have travel RNs. Sustainability Plan In addition to significant nurse leader engagement from the neuroscience clinical unit, integration of the review of the board during MDI huddles contributed to the successful sustainability of the project. Daily review of “bright spots” and “pebbles in my shoe” continues despite the turnover of seven charge nurses, three from nights and four from days, as well as the doctoral student being on holiday break, and therefore not present on the neuroscience clinical unit, from December 13, 2021 to January 10, 2022. Key elements contributing to the success of the board include engagement and expectation setting from the nurse manager, embedding review of the board during established MDI huddles, and charge nurse perceived value of review of “bright spots” and “pebbles in my shoe.” In addition, the nurse manager discusses the board during charge nurse meetings, particularly focusing on “pebbles in my shoe” and progress toward resolving identified issues. The pull cards created to assist team members pulled to the neuroscience clinical unit were sent to document services for formatting and assignment of a HEALTHY WORK ENVIRONMENT 45 document number. This allows the unit secretary the ability to simply order copies of the cards and have them delivered to the unit ready to use. Lastly, ongoing monthly charge nurse meetings, facilitated by the nurse manager, provide an established forum for continued development and team building of the charge nurses. Discussion/Implications for Nursing At the time of project implementation, healthcare organizations across the nation continued to face significant challenges secondary to the COVID-19 pandemic (Sharma et al., 2021). These challenges, which overwhelmed healthcare systems, included rapid and unprecedented changes in workload and policy development, an ever growing weary and unstable workforce, increased acuity and patient volumes overburdening health care systems, staffing challenges, supply chain shortages, and an extreme market competitiveness for health care clinicians, all of which impacted turnover and team member satisfaction with their role and/or profession (Buerhaus, 2021; Joslin & Joslin, 2020; Raso, Fitzpatrick, & Masick, 2021; Sharma et al., 2021). Physical and psychological safety, meaning and purpose, choice and autonomy, and camaraderie and teamwork are four of the nine critical elements that are described as fundamental human needs that must be addressed with the implementation of the IHI Framework and are central for improving joy in work (Perlo et al., 2017). The COVID -19 pandemic impacted each of these elements to an unprecedented extent, beyond the boundaries of the neuroscience clinical unit, and likely impacted the outcome of this evidence-based project. Psychological safety, a characteristic of the team, occurs when the overall climate is one in which team members feel free and safe to share their thoughts and feelings without retribution (Perlo et al., 2017). A pandemic creates a high stress and high risk environment in which health HEALTHY WORK ENVIRONMENT 46 care clinicians can experience a wide range of physical and emotional symptoms including difficulty sleeping, burnout, distress, exhaustion, worry and anxiety, fear, physical pain, anger and irritability, and extreme sadness and depression (Chatmon & Rooney, 2021; Chen et al., 2021; Forrest et al., 2021; Holton et al., 2021). Nationally, nurse leaders struggled with responding to the emotional health and well-being of their team members (Joslin & Joslin, 2020). Physical safety occurs when team members feel free from physical harm at work including exposure to infection (Perlo et al., 2017). The pandemic impacted resources globally including the availability of personal protective equipment (PPE) as well as access to an effective vaccine. Fear of personal safety due to actual or perceived lack of adequate PPE impacted health care clinicians across the nation while fears around transmission to family members and the community at large contributed to emotional distress and burnout (Sharma et al., 2021). Additionally, psychological and physical safety of health care clinicians is threatened with increased patient and family aggression in the form of physical violence and verbal assaults during emergent situations such as a pandemic regardless of the socio-economic status of the region (Muñoz del Carpio-Toia, Begazo Muñoz del Carpio, Mayta-Tristan, Esperanza Alarcón- Yaquetto, & Málaga, 2021; Devi, S., 2020). In respects to choice and autonomy, Perlo et al. (2017) indicates the environment supports team members having a choice and a voice in decisions on processes, changes and improvements that impact them. In the face of the pandemic many decisions within the healthcare organization, which were influenced by the Centers for Disease Control (CDC) and the Kent County Health Department, were made rapidly with the best information available at a given moment in time, and not always with input from all key stakeholders. These decisions HEALTHY WORK ENVIRONMENT 47 included limitations on number of visitors, scheduling and cancelling of surgical procedures, activation of critical staffing, and the implementation of mask and vaccine mandates. Nationally, in late 2020, just above 60% of adults in the United States (US) intended to receive the vaccine once available. Variables influencing an individual’s decision to vaccinate include beliefs surrounding the safety and efficacy of the vaccine, race, age, education level, cultural beliefs, levels of trust in government leaders and agencies, and political affiliations (Salmon, Opel, Dudley, Brewer, & Breiman, 2021). In addition, political influence versus public health became forceful drivers in influencing how individuals responded to mask and vaccine mandates as well as “lock downs” nationally (Navarro & Markel, 2021). Similar to what was seen across the nation, enactment of mask and vaccine mandates within the healthcare organization resulted in a divide among the workforce as some perceived the mandates as an infringement on civil rights versus protecting the greater good of the community. Personal beliefs also influenced an individual’s response to the mandates as belief in a higher power to protect against the virus and the belief in science and medicine came to a head. On October 18th, the health care organization mandated all team members either obtain the full vaccine series or submit, and receive approval, for a religious or medical vaccine exemption. On the neuroscience clinical unit 16 team members (11 RNs, 3 NTs, and 2 unit secretaries) requested, and were granted, an exemption. Perlo et al. (2021) define camaraderie and teamwork as being reflective of social cohesion and trusting relationships, including trust in the organizational leadership as well as transparent communication. As previously discussed, the public health response to the pandemic became heavily politcized, a divide among civic and social obligation versus an infringement on individual freedoms (Navarro & Markel, 2021). HEALTHY WORK ENVIRONMENT 48 Lastly, meaning and purpose relates to team members finding a sense of meaning in their work. Does their work make a difference (Perlo et al., 2017)? Despite symptoms of acute stress, anxiety and depression, health care clinicians report an increased sense of meaning and purpose early in the COVID-19 pandemic (Shechter et al., 2020). As health care clinicians continue to face the unrelenting challenges of the pandemic, finding meaning and purpose in their work may become increasingly questioned for some. Fundamentally, the COVID-19 pandemic impacted the implementation of the IHI Framework. The COVID-19 pandemic proved to be a significant disruption impacting overall stress and testing the resilience of healthcare organizations across the nation. Due to the volatility of the nursing work force and ultimate staffing crisis, various monetary stabilization efforts were activated within the healthcare organization during implementation of the IHI Framework. Although an improvement of team member churn, belonging and engagement was not experienced on the neuroscience clinical unit, it is unknown if the change which did occur was less than what would have occurred in the absence of the monetary recruitment and retention efforts. Additionally, with the exception of a wage adjustment, the recruitment and retention efforts, at this point, have been focused on RNs only. An additional consideration is the impact of the “virtual first” policy of the organization, an outcome of the COVID-19 pandemic, on the implementation of the IHI Framework. Due to the “virtual first” environment all “What matters to you?” conversations and charge nurse meetings allowed for participation either virtually or in person. This impacted the implementation of the project in two ways. The “What matters to you?” conversations, as outlined in the IHI Framework, are intended to be in person with the use of white boards to allow participants the ability to visualize what is being shared. Considering the “virtual first” approach of the HEALTHY WORK ENVIRONMENT 49 organization, the doctoral student pivoted the facilitation of the conversations to a hybrid model to allow virtual or in person participation. In addition, team building activities with the charge nurses during monthly charge nurse meetings were flexible to allow both in person and virtual participation. The presence of the many challenges presented by the pandemic likely contributed or influenced the outcome of this evidence-based quality improvement project. Cost-Benefit Analysis/Budget Personnel and supply costs contributed to the overall cost of $9,403.23 associated with the implementation of this evidence-based quality improvement project (see Appendix GG for budget). As previously stated, the average cost of turnover for a bedside RN is $40,038 and results in the average hospital losing between $3.6 - $6.5 million annually (NSI, 2021). Each percent change in RN turnover will impact, either positively or negatively, the bottom line by $270,800 annually (NSI, 2021). The benefit of achieving the goal of improving the overall HWE on the neuroscience clinical unit with an ultimate desired state of improving RN churn, RN and NT sense of belonging, and RN and NT engagement clearly outweighs the cost associated with the implementation of the IHI Framework. Conclusion The purpose of this evidence-based quality improvement project was to improve the HWE on the neuroscience clinical unit by implementing strategies to influence the four critical components of the IHI Framework (physical and psychological safety, meaning and purpose, choice and autonomy, and camaraderie and teamwork) ultimately improving turnover, churn, and team member belonging and engagement on a neuroscience clinical unit within a large midwestern Magnet ® designated hospital. Likelihood to recommend was also evaluated as a HEALTHY WORK ENVIRONMENT 50 counterbalance measure. Effectiveness of the implementation of the IHI Framework on the neuroscience clinical unit was evaluated by comparing pre and post implementation data for rolling twelve month transfer and churn percentage, team member engagement and belonging scores, and likelihood to recommend as demonstrated by HCAHPS. Overall, the twelve month rolling transfer and churn percentage for the neuroscience clinical unit decreased from August 2021 to January 2022. The neuroscience clinical unit experienced a decrease in both belonging and engagement scores from July 2021 to November 2021. In respects to likelihood to recommend, the neuroscience clinical unit saw an initial increase from August to September which was followed by a decrease in December 2021. January 2022 demonstrated an increase from December, however, remained below August 2021 “top box.” Unfortunately implementation and evaluation of the IHI Framework occurred during the peak of COVID-19 pandemic for this particular healthcare organization and surrounding community. As a result, various factors likely influenced the outcome of this project. Interventions, including recruitment and retention bonuses, were implemented by the healthcare organization in an attempt to stabilize an exceptionally volatile workforce during a time of extreme patient volumes and acuity. In addition, unprecedented vacancy rates across departments in combination with volumes of travel RNs heretofore not experienced by the organization contributed to the significant stress on the healthcare organization. The emotional toll of the COVID-19 pandemic on health care clinicians both personally and professionally cannot be underestimated. Considering the impact of the COVID-19 pandemic on physical and psychological safety, meaning and purpose, choice and autonomy, and camaraderie and teamwork, which are four of HEALTHY WORK ENVIRONMENT 51 the nine critical elements of the IHI Framework, it is recommended that the neuroscience clinical unit consider holding “What matters to you conversations?” as the healthcare organization begins to stabilize post pandemic. Ongoing monitoring of turnover and churn, as well as team member belonging and engagement will continue to provide visibility to the impact of the IHI Framework. Lastly, implementation of the IHI Framework may be a strategy to consider as healthcare organizations begin to recover from the COVID-19 pandemic. In addition to the COVID - 19 pandemic, the presence of travel RNs and unit vacancy rate were variables likely impacting the outcome of this project. Geographical layout, size of clinical unit and patient population served may be additional factors which influence team member turnover, churn, sense of belonging and engagement as well as likelihood to recommend. Recognizing this, acknowledging the size, layout and patient population of the neuroscience clinical unit, a future consideration may be to evaluate these variables and their potential impact on belonging and engagement scores. HEALTHY WORK ENVIRONMENT 52 References American Association of Critical Care Nurses. (2016). AACN standards for establishing and sustaining healthy work environments (2nd ed.). Retrieved from https://www.aacn.org/WD/HWE/Docs/HWEStandards.pdf American Nurses Association. (2018). Healthy work environment. Retrieved from https://www.nursingworld.org/practice-policy/work-environment/ Bambi, S., Guazzini, A., Piredda, M., Lucchini, A., Grazia De Marinis, M., & Rasero, L. (2019). 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The state of the science of nurse work environments in the United States: A systematic review. International Journal of Nursing Sciences, 5, 287-300. doi:10.1016/j.ijnss.2018.04.010 HEALTHY WORK ENVIRONMENT 59 Appendix A Figure 1. Fishbone Diagram People Uniqueness of patient population served Equipment Increased acuity, evolving procedures, changing Supplies Patient population Environment Insufficient people Lack of Preceptor development / Fast paced resources to meet Supply chain staffing expectations during accountability inadequate Lack of model of shift Leadership First Year Grad RNs care development NTs not ”lifelong” ~ students Lack of adequate unit storage Unit Culture Ambiguity around Increased Physical and Team Turnover/churn impact on team Healthy Work Environment Psychological abuse from engagement Lack of “belonging” patient/family Interdisciplinary Physical Environment (unit design, flow, Lack of support dynamic Lack of “team” throughput) Emotionally 24/7 operation taxing/level of Work environment: support increased churn, toxic relationships, Prioritization of expectations during Characteristics of lack of collaboration shift Poor patient outcomes Students – shifts conflicting RNs / NTs Hourly Wage with classes retained Various levels Ongoing Shift Length Shift differentials engagement with Professional Nurse Residency Development Additional shift requirements Program On since 2020 Accountability / expectations Self-care items Lack of NT Charge nurses Increased use of Residency Program Team members contingent labor Incentives/recognitions Methods Materials Figure A1. Fishbone diagram depicting factors contributing to the climate of the current work environment were identified and organized into the following categories: environment, equipment, people, methods and materials. HEALTHY WORK ENVIRONMENT 60 Appendix B Strengths/Weaknesses/Opportunities/Threats (SWOT) Strengths • Clinical Nursing Director and Nurse manager of clinical unit highly engaged • Nurse manager previously held sessions with charge nurses as well as team members • Developed “Leadership Commitment Statement” for charge nurses. This statement, which was signed by the charge nurses, clearly articulates the expectations of the role • Preparing to implement “Staffing Pilot” which will pull charge nurse out of assignment during night shift • Clinical Nurse Specialist highly engaged • Nurse Educator highly engaged • Support from Employee Relations / Human Resources (HR). Prior to the COVID - 19 Pandemic, partnered with HR to create “Culture Timeline/Action Plan.” Not implemented due to COVID • High appreciation for implementation of evidence-based strategies [preceptor program/development] • Team is “nimble” and accustomed to change (may not support the change, but are accustomed to change) • Nurse manager describes team as “having so much potential” • Categories of feedback, empowerment, recognition, engagement, belonging and resources on the March 2021 listening survey, although below company, all improved in comparison to the prior survey Weaknesses • Negative culture “nurses eat their young” on unit persistent for years • Toxic and intimidating environment • Lack of engagement by clinical staff ~ lack of functioning shared governance council or committees on clinical unit • Lack of peer-to-peer accountability • Recognition and engagement initiatives/strategies implemented by leadership seen as attempts to “pacify.” Overall “lack of gratitude” • Low likelihood to recommend scores on unit • High rate of falls with injury on unit • Neuro patient population ~ high level of employee assault due to patient population served • High nursing turnover within first year of employment • Lack of structure surrounding preceptor development • Multiple nurse manager leaders over years • Inconsistent styles of manager leadership over years • Lack of trust in leadership • Front line staff contributing to negative culture high tenure on unit • Historically, previous nurse managers not holding negative staff accountable for behavior • Team work is “segregated” ~ helping those within their “group” HEALTHY WORK ENVIRONMENT 61 Opportunities • Address / implement strategies to address “eat their young” culture on unit. • Improve patient satisfaction scores on unit • Improve falls with injury rate on unit • Increase team member expertise and awareness in the identification and prevention of escalating behaviors in patients • Engage security services presence • Enhance Nursing Preceptor Development (Preceptor identification and development, ongoing evaluation) • Enhance nurse manager support and development • Increased focus on prioritization of priorities and alignment with strategic plan • Engaging charge nurse and preceptors • Enhancement of preceptor curriculum • Support “healthy” unit turnover • Improvement in employee engagement scores • Implement shared governance council on unit • Intentional partnership with security services and / or de-escalation training • Decrease physical injury / IDM cases Threats • Physical threats and actual attacks to team member safety from patients and visitors • Competing priorities within organization • Initial worsening of turnover • Initial impact on employee engagement scores • Failure of executive leadership to recognize reasoning behind initial decrease in engagement scores • Nurse educator time constraints in enhancing preceptor program • Scheduling of worked shifts for new team members conflicting with nurse residency program cadence • Number of orientees exceeds number of developed preceptors • Toxic members of the team • Vacancy rate • IDM cases HEALTHY WORK ENVIRONMENT 62 Appendix C Key Recommendations Contributing to the Development of a HWE from the Joint Commission, IHI and AACN in Comparison to Strategies Implemented in the Past on Neuroscience Clinical Unit Recommended Joint Commission IHI AACN Neuroscience strategies Clinical Unit General • Teamwork • Meaning and • Skilled • Staffing Concepts / • Communication purpose communication • Charge RN Critical • Collaborative • Choice and • Effective loyalty and Components work autonomy decision accountability environment • Recognition making • Addressing and rewards • Appropriate professionalism • Camaraderie staffing and and teamwork • True disrespectful • Daily collaboration behavior when improvement • Meaningful aware • Wellness and recognition Resilience • Authentic • Real-time Leadership measurement • Participative management Behaviors: Address behaviors, Everyone plays a Implementation of Senior leaders including overt and role in nurturing charge RN Managers and passive behaviors, joy in the accountability and core leaders that threaten workplace performance Individuals performance of the expectations team Address professionalism or Hospital must have disrespectful a code of conduct behavior. defining acceptable and inappropriate behaviors. Leaders must implement a process for managing disruptive and inappropriate behaviors. HEALTHY WORK ENVIRONMENT 63 Ensure basic Hold team Physical and Staffing policies From an fundamental pre members psychological grounded in ethical organizational - conditions are accountable for safety ~ includes principles. perspective, met inappropriate offering support increased focus on behaviors for second Nurses participate team member victims. in all phases of the safety and well- staffing process. being. Meaning and purpose System - early Choice and stages of piloting autonomy “Peer to Peer” Camaraderie and support program teamwork (second victim). Fairness and equity System - Professional Group / Team Debrief available for team members after traumatic events. Communication Develop and What matters to Establish zero Monthly charge / structure for implement zero you tolerance policies RN team building regular tolerance policies. conversations. to address and (Leadership communication Listen and learn. eliminate abuse Assimilation Develop and other planned July 2021) organizational Establish policies disrespectful process for and practices to behavior. Weekly “What is addressing address harm and Val up to” intimidating and safety concerns, Establish formal newsletter disruptive structures and behaviors. Develop huddles, processes to ensure Daily Monitoring workgroups, or effective and Daily team meetings to respectful Improvement focus on bright communication. (MDI) huddles spots or impediments to Include joy in work. communication as “Pause for joyful element of moment” performance evaluation. Identification of Assess team Identify Met 1:1 with each key member impediments in team member opportunities perceptions of the daily work (2019) to discuss seriousness and (“pebbles in their current culture on extent of shoes”) unit. unprofessional HEALTHY WORK ENVIRONMENT 64 behaviors. Staffing - actively recruiting team members Collaborate on Set priorities and Interprofessional setting priorities address together education and / Collaboration / coaching to Decision making develop collaboration skills. Ensure decision making authority of nurses is acknowledged and incorporated into the norm. Transparency in “What matters to Planning to identified you” conduct leader opportunities communication assimilation board exercise in July 2021. Transparency on Documentation small tests of and public display change of small tests of change based upon opportunities identified by “what matters to you conversation” Meaningful Comprehensive recognition system in place including formal processes and forums to ensure sustainable focus on recognition of team members. Team members recognize that everyone is responsible for playing an active role in meaningful recognition. HEALTHY WORK ENVIRONMENT 65 Education Educate team Provide regular Organization Annual Code of members on training and provides support Excellence appropriate and competency for and access to competency. inappropriate training to ensure education and professional skills and develop coaching to ensure Collaborating with behavior based trust to achieve leadership Nursing Practice upon code of desired culture. development in and Development conduct. authentic on initial leadership, onboarding / Skills based communication, orientation training and decision making, curriculum for coaching on true collaboration, neurosciences. relationship meaningful building and recognition, and Pilot revised collaborative appropriate preceptor practice including: staffing. curriculum. how to provide feedback and conflict resolution. HEALTHY WORK ENVIRONMENT 66 Appendix D Figure 2. IHI Framework for Improving Joy in Work Figure 2. IHI Framework for Improving Joy in Work, by Perlo, J., Balik, B., Swensen, S., Kabcenell, A., Landsman, J., & Feeley, D. (2017). IHI framework for improving joy at work. Institute for Healthcare Improvement. HEALTHY WORK ENVIRONMENT 67 Appendix E Figure 3. PRISMA Diagram Other records identified Records identified through Additional records identified (n = 9) CINAHL through PubMed (n = 66) (n = 68) Records after duplicates removed (n = 96) Records screened Records excluded (n = 96) (n = 68) Full-text articles assessed Full-text articles excluded for eligibility (n =26) (n =37) Studies included in qualitative synthesis (n = 4) Studies included in quantitative synthesis (n = 7) Figure 3. Depiction of key terms and phrases leveraged in searching defined databases and delineation of flow identifying number of publications reviewed and ultimately included in review of literature. HEALTHY WORK ENVIRONMENT 68 Appendix F Literature Evaluation Table 1. Nelson-Brantley, H., Park, S. H., & Bergquist-Beringer, S. (2018). Characteristics of the nursing practice environment associated with lower unit - level RN turnover. Journal of Nursing Administration, 48, 31-37. doi:10.1097/NNA.0000000000000567 Purpose of study: Examine which characteristics of NPE were associated with actual RN turnover in acute care hospitals Conceptual Design/Method Sample/Setting Major Variables Measurement of Data Analysis Study Findings LOE/ Framework Studied and Major Variables Implications for Their Practice Definitions N/A Secondary analysis Convenience IV 1 = NPE NPE, Practice Descriptive Overall NPE LOE VI of 2011 NDNQI Sample Environment statistics and turnover: RN turnover and IV 2 = Scale of the Various variables RN survey 1002 acute care professional Nursing Work Multivariate For each point influence RN hospital units autonomy Index (PES-NWI), linear increase in turnover Cross sectional, from 162 Included in regression mean PES- including the correlational design hospitals in IV 3 = NDNQI RN NWI total NPE. United States exemplary Survey, score: RN Recognizing the professional Cronbach’s alpha turnover rates influence of nursing practice =.82, for each decreased autonomy, subscale alpha > 14.8% exemplary IV 4 = .80. B=-0.16; 95% professional managerial CI, -.23 to -.09; nursing practice, support Average monthly P <.01 managerial RN Turnover rate. support, staffing IV 5 = staffing RN turnover and interpersonal and resource decrease by 1% relations can adequacy for every year assist nurse increase in age, leaders in IV 6 = effective B = -.01; 95% responding to interprofessiona CI, -.01 to potential or actual l relations 0.00; P < .01 RN turnover. and increased IV 7 = age 2% for every year increase in mean RN HEALTHY WORK ENVIRONMENT 69 IV 8 = years’ tenure on unit experience B = -.02; 95% CI, -.03 to .02; IV 9 = P < .01. education level For each point RN increase in staffing and DV = RN resource PES- Turnover NWI subscale, Proportion of RN turnover permanent, decreased by direct care RNs 14.8%, B = - who left their .16; 95% CI, - position for any .23 to -.09; P < reason .01. For each point increase in the managerial support PES- NWI subscale, RN turnover increased by 8.3%, B = .08; 95% CI, 0.00 to 0.15; P < .05. RN participation in hospital affairs (P = .21) and collegial RN physician relations (P = 0.49) were not significant HEALTHY WORK ENVIRONMENT 70 Hospital ownership, Case Mix Index, unit mean age RN, tenure and education level were all significantly associated with RN turnover 2. Numminen, O., Ruoppa, E., Leino-Kilpi, H., Isoaho, H., Hupli, M., & Meretoja, R. (2015). Practice environment and its association with professional competence and work-related factors: perception of newly graduated nurses. Journal of Nursing Management, 24, E1-E11, doi:10.1111/jonm.12280 Purpose of study: To examine the perception of new graduate nurses on their practice environment and the association of the practice environment with their self-assessed competence, turnover intent and job satisfaction. Conceptual Design/Method Sample/Setting Major Variables Measurement of Data Analysis Study Findings LOE/ Framework Studied and Major Variables Implications for Their Practice Definitions N/A Quantitative, All NGNs Research Practice Frequency Perceptions of LOE VI descriptive, registered by questions: Environment distributions, practice comparative, cross- the National 1. What is the Scale of the percentages, environment: The clinical unit sectional design Supervisory newly Nursing Work means, ranges most positive in which this Authority for graduated Index (PES-NWI) and standard perceptions project is being Welfare and nurses’ - measures nurses’ deviations to were in implemented has Health Care perception of perception of summarize collegial nurse- a high percentage within one year their practice practice data. physician of newly graduate in Finland. environment? environment relations nurses. 2. Are newly MANOVA to subscale N = 318 graduated Nurse estimate (Cronbach’s Strong significant nurses’ Competence Scale associations alpha 0.862) associations perceptions of - measures nurses’ between between practice the practice self-assessed practice Most positive environment and environment competence environment perceptions work related associated with and work (score > 3) factors. their self- related factors were related to Highlighted the HEALTHY WORK ENVIRONMENT 71 assessed Turnover and differences collaboration, significance of professional intentions - two in the teamwork, nursing competence, questions perceptions of relationships management and turnover frequency in practice between nurses leadership in intentions and considering environment and physicians, creating a positive job satisfaction? changing of job between the working with environment and and changing of nurse groups clinically impact of profession with higher and competent collegial Job satisfaction - lower nurses, relationships. satisfaction with competence opportunities orientation; levels. for career satisfaction with development current job; Pearson’s and high satisfaction with correlation administrative quality of care coefficient expectations of estimated nursing care associations quality. between nurses perceptions of Correlation the practice between environment nurses’ and perception of professional practice competence. environment and professional competence was statistically significant and positive, yet weak (r = 0.241, p < 0.001) Nurses at a higher HEALTHY WORK ENVIRONMENT 72 competence level had a more positive perception of their practice environment (F = 7.95, p = 0.005) Strong association between: PES-NWI overall and Intention to leave job (F- ratio 28.38, p < 0.0001; Nurse participation in hospital affairs and intention to leave job (F- ratio 17.33, p < .0001), Intention to leave profession (F- ratio 16.79, p < .0001), and satisfaction with the quality of care (F-ratio 16.90, p < .0001); Nurse manager ability, leadership HEALTHY WORK ENVIRONMENT 73 support of nurses and intention to leave job (F- ratio 17.01, p < .0001); and Staffing and resource adequacy and satisfaction with the quality of care (F-ratio 14.08, p < .0001). 3. O’Hara, M. A., Burke, D., Ditomassi, M., & Palan Lopez, R. (2019). Assessment of millennial nurses’ job satisfaction and professional practice environment. Journal of Nursing Administration, 49, doi:10.1097/NNA.0000000000000777 Purpose of study: Assess the relationship between demographic factors (age, gender, race, ethnicity, work status, and experience) and the professional practice environment, and work satisfaction to increase understanding of millennial nurses (born between 1981 and 1997). Conceptual Design/Method Sample/Setting Major Variables Measurement of Data Analysis Study Findings LOE/ Framework Studied and Major Variables Implications for Their Practice Definitions Practice Secondary analysis Staff responses Demographics: PPWEI which Descriptive Supportive LOE VI Environment of data previously from the 2017 age, gender, measures the statistics leadership Conceptual collected (cross Staff race, work following Multivariate accounts for an Autonomy, Framework sectional) Perceptions of status, highest subscales: regression additional 63% teamwork, and the Professional degree in Autonomy and analysis to of variance work motivation Practice nursing, years control over identify (F=456.11, p = contribute to the Environment of experience in practice relationship .0001) work satisfaction collected in a nursing, and Communication between of millennial large, Magnet ® years of nursing Cultural demographics Work nurses. With recognized in current Sensitivity and the motivation supportive academic setting. Handling subscales of (F=76.06, p = leadership being a medical center. disagreement and the PPWEI to .0000), key driver to their Professional conflict work resources for satisfaction. N = 825 with Practice Nurse - Physician satisfaction quality patient 375 (45%) Environment relationships care (F = 21.3, HEALTHY WORK ENVIRONMENT 74 being millennial Staffing and p = . 0001) and nurses. resources teamwork (F = Supportive 5.8, p = 0.017) leadership Teamwork Work motivation Work satisfaction measured using “Overall, how satisfied or dissatisfied are you working in your primary unit/department?” 4. Perlo, J., Balik, B., Swensen, S., Kabcenell, A., Landsman, J., & Feeley, D. (2017). IHI framework for improving joy in work. Retrieved from http://www.ihi.org/Topics/Joy-In-Work/Pages/default.aspx Purpose of study: Intended to serve as a guide for health care organizations to engage in conversation and dialogue with colleagues to ultimately enable them to better understand the barriers to joy in work, and partner in creating and implementing high leverage strategies to address the identified issues. Conceptual Design/Method Sample/Setting Major Variables Measurement of Data Analysis Study Findings LOE/ Framework Studied and Major Variables Implications for Their Practice Definitions IHI Framework N/A N/A Definitions There is no single IHI created LOE V for Improving within the IHI validated measure four steps Joy in Work Framework key to evaluate joy in leaders can Four primary to note: work. implement (as steps for leaders Recommended: well as clearly are outlined as Camaraderie - two or three defined they move their and teamwork - system level strategies) to teams to finding Commensality, measures such as improve joy in joy in work. social cohesion, satisfaction, work: productive engagement, 1. Ask staff Tools provided to teams, shared burnout, turnover, “what matters facilitate: understanding, absenteeism) to you” - “What matters to you” HEALTHY WORK ENVIRONMENT 75 trusting - Local level 2. Identify conversation relationships measures; “three unique guide daily questions” impediments to - Change ideas, as Participative or “pulse survey” joy in work in well as illustrative management - (could also be the local examples, for co-production system level) context each component of joy; leaders 3. Commit to a of the IHI create space to The IHI systems framework hear, listen, and Framework for approach to involve before Improving Joy in making joy in acting, clear Work outlines key work a shared communication elements in responsibility and consensus relation to at all levels of building as a contributors the part of decision resulting in happy, organization. making healthy, 4. Use productive people: improvement Choice and Individuals: science to test autonomy - - Real time approaches to Environment management improving joy supports choice - Wellness and in work in your and flexibility resilience organization. in work, hours, - Daily and use of improvement electronic health records Managers and core leaders: Meaning and - in addition to the purpose - daily above, work is camaraderie and connected to teamwork what called - participative individuals to management practice, line of sight to Senior leaders: organization mission and HEALTHY WORK ENVIRONMENT 76 goals, - in addition to the constancy of above, recognition purpose and rewards - choice and Physical and autonomy Psychological - meaning and safety - purpose equitable - physical and environment psychological free from harm. safety Just culture that is safe and respectful, support for the Second Victim. 5. Registered Nurses’ Association of Ontario. (2008). Healthy work environments best practice guidelines: Workplace health, safety and well-being of the nurse. Retrieved from https://rnao.ca/bpg/guidelines/workplace-health-safety-and-well-being-nurse Purpose of study: To outline specific recommended interventions, based upon current best practice, in promoting the health, safety and well-being of the nurse and engage decision makers. Conceptual Design/Method Sample/Setting Major Variables Measurement of Data Analysis Study Findings LOE/ Framework Studied and Major Variables Implications for Their Practice Definitions Conceptual Guideline NA Recommendatio Systematic review Recommendati Presentation of LOE V Model for ns grouped into of literature, by ons related to the Healthy Work following Joanna Briggs organization Comprehensive Outline of Environments themes: Institute, 1994 - practice Conceptual potential for Nurses - 1. Organization 2005 on outlined - Model for strategies to Components, practice Workplace health including Healthy Work influence a Factors & 2. Research and safety for creation of Environments healthy workplace Outcomes 3. Education nurses culture, climate for Nurses culture 4. System and practices which Additional that support, delineates the Organizational literature obtained promote and work Culture - shared by panel members maintain staff environment as HEALTHY WORK ENVIRONMENT 77 beliefs, values, as relevant and health, well a product of assumptions, related to being and interdependenc symbols, workplace health, safety as well e among the ceremonies and safety and well- as focus on individual, rituals that being of the nurse, establishment organizational define an current of and external organization’s occupational organizational systems. culture and health and safety practices that Interventions norms. A legistlation foster mutual must target all characteristic of responsibility three levels the and (micro, meso organization, accountability and macro) in not the by individual order to impact individuals nurses and the nurse, within. organizational patient, leaders to organization, Organizational ensure a safe and Climate - the work community. atmosphere of environment. the work environment. Forms more quickly and alters more rapidly than organizational culture. 6. Reinhardt, A. C., León, T. G., & Amatya, A. (2020). Why nurses stay: Analysis of the registered nurse workforce and the relationship to work environments. Applied Nursing Research, 55. doi:10.1016/j.apnr.2020.151316 Purpose of study: Examine how factors [sense of belonging, work environment characteristics, and workplace violence efforts] impact the duration of employment. Investigate if there is a relationship between demographic variables and length of employment in a nurses first professional experience. Conceptual Design/Method Sample/Setting Major Variables Measurement of Data Analysis Study Findings LOE/ Framework Studied and Major Variables Implications for Their Practice Definitions HEALTHY WORK ENVIRONMENT 78 Kanter’s Descriptive Convenience Survey tool Survey Pearsons BS-CPE LOE VI Structural correlational random sample correlations: Demographic Product - negative Empowerment survey study of 258/700 IV 1 = sense of questionnaire momentum correlation with Limitations to Model licensed belonging: self- correlation all NWI - R consider registered nurses esteem Belongingness coefficients subscales and include: BS- New Mexico IV 2 = sense of Scale-Clinical Fisher’s z - NWRES CPE was belonging: self- Placement transformation workplace developed to efficacy Experience (BS- conflict (r = - evaluate CPE), Levett- Cronbach’s 0.214) belonging in IV 3 = sense of Jones & alpha nursing students belonging: Lathlean, BS-CPE during clinical connectedness Cronbach’s Kaplan Meier subscales experiences. alpha 0.92. method positively Further IV 4 = correlated with evaluation of the Demographic Nurse Log rank tests work tool with variables Workplace environment professional Relational (r=0.527) and nurses may be Select Environment job satisfaction of additional composite score Scale subscales of value. An factors in the (NWRES), NWRES additional work Duddle & (r=0.417) limitation, as environment Boughton, highlighted by that encourage Cronbach’s NWRES the authors, is RN retention: alpha 0.872, subscales and the evaluation of DV 1 = subscales range NWI - R benefits and pay professional 0.781 - 0.972. subscales together versus autonomy negatively separately as Nurses Work correlated for influencers of DV 2 = control Index - Revised work job satisfaction. of practice (NWI - R), environment and Aiken & job satisfaction Recommended DV 3 = collegial Patrician, and had a for relationships Cronbach’s positive consideration as alpha 0.96, correlation for operational DV 4 = subscale alphas workplace leaders develop organizational 0.84 - 0.91. conflict. strategies support targeted toward HEALTHY WORK ENVIRONMENT 79 Strong negative the retention of DV 5 = work correlation RNs in the environment NWI-R healthcare autonomy (r=- setting. This DV 6 = .204), collegial research article workplace relationships identifies a conflict (r=-.218) and positive DV 7 = job NWRES job correlation satisfaction satisfaction between Strong elements of DV 8 = length correlation belonging, of employment between particularly first professional NWRES work esteem, efficacy, profession environment and and NWI-R collegial connectedness relationships (r= could an -.209). improved work environment as BS-CPE well as positive improved job correlation to satisfaction. NWRES work environment (r=.527), job satisfaction (r=0.417); negative to conflict (r= - .214). Cronbach alpha subdomains BSE-CPE and NWI-R > 0.8 Cronbach alpha for NWRES work HEALTHY WORK ENVIRONMENT 80 environment 0.9, work conflict 0.68, job satisfaction 0.67 Length of stay first job ADN (70.9 months)> doctoral degrees (15.6 months) Significant diff btw white, more likely to stay, and other races based on likelihood to stay first position Analysis between BS- CPE and NWRES, indicates relationship btw sense of belonging and connection with the workplace environment (r=.527) Average work environment score highest for nurses with HEALTHY WORK ENVIRONMENT 81 doctoral degrees (53.6). However, workplace conflict score highest for nurses with doctorate (16.0) or professional degree (15.2). Workplace conflict highest for nurses with Asian ethnicity (16.2). BS-CPE higher among Asian nurses ( 128.0) and lowest among native American nurses (119.1). BS-CPE highest for nurses with diploma (130.3) and lowest among MSN (123.6). Length of stay first profession, longest for native American (100.5) and HEALTHY WORK ENVIRONMENT 82 shortest for Asian nurses (42.0). Length of stay in first job longest for nurses with ADN (70.9) and shortest for nurses with doctoral degrees (15.6). 7. Shirey, M. R. (2017). Leadership practices for healthy work environments. Nursing Management, 48, 42-50. doi:10.1097/01.NUMA.0000515796.79720.e6 Purpose of study: Literature search to identify the top 10 research articles describing leadership practices of nursing leaders which are required for creating and sustaining healthy work environments in the healthcare setting. Conceptual Design/Method Sample/Setting Major Variables Measurement of Data Analysis Study Findings LOE/ Framework Studied and Major Variables Implications for Their Practice Definitions N/A Literature review N/A Four themes Theme 1: Quality N/A Leadership LOE V and synthesis of 10 were identified Leadership style, relational articles of which as critical includes: engagement, Contributes to the four were evidence-based leadership cultivation of body of descriptive, one leadership attributes and supporting knowledge in was a Delphi study, practices in the style, emotional structure and identifying one was a creation and intelligence, recognizing the specific secondary data sustainment of leadership impact of leadership analysis of a HWE’s in competence, and contextual practices to qualitative study, healthcare: vision advocacy factors contribute to the one was a meta- quality and messaging. A contribute to creation and analysis, and three leadership, relational style the sustainment of a were reviews of the relational was preferred over development HWE. literature exchanges, a task oriented and environmental style. sustainment of elements, and a HWE. HEALTHY WORK ENVIRONMENT 83 contextual Theme 2: factors. Relational Contextual exchanges: the factors include relationships organizational between managers climate and and workers, good culture. communication and collaboration, impacts unit engagement and job satisfaction as well as improved patient outcomes Theme 3: Environmental elements: certain elements such as supportive structures, access to resources, ongoing developmental opportunities must be evident to ensure a HWE. Poor communication, lack of shared decision making, and low levels of meaningful recognition contribute to the decline of a HWE. HEALTHY WORK ENVIRONMENT 84 Theme 4: Contextual factors: Includes organizational culture and climate. Organizational culture is a broad (macro) concept whereas organizational climate is focused at a micro level. 8. Ulrich, B., Barden, C., Cassidy, L., & Varn-Davis, N. (2019). Critical care nurse work environments 2018: Findings and implications. Critical Care Nurse, 39, 67-84. doi:10.4037/ccn2019605 Purpose of study: To evaluate the current state of critical care nurse work environments. Conceptual Design/Method Sample/Setting Major Variables Measurement of Data Analysis Study Findings LOE/ Framework Studied and Major Variables Implications for Their Practice Definitions N/A Cross sectional Convenience Evaluation of Critical Elements Descriptive Perception of LOE VI Mixed methods sample of all the health of the of a Healthy Work statistic work RNs (N=8080) work Environment environment: HWE consistently in the AACN environment in Scale (a part of Spearman rank Five lowest ranked higher in database at time the participants the AACN correlation to ranked unit clinical unit in of study work units and Critical Care measure degree elements: comparison to the organizations: Nurse Work of association 1. nurse leaders organization. Overall Environment between 2. RNs perception of Survey) ordinal level engaged in Significant work variables technologies to difference in environment increase results from Skilled effectiveness of nurses working in communication care delivery units with HWE HEALTHY WORK ENVIRONMENT 85 and true 3. RN staffing standards collaboration ensures match implemented. Effective between patient decision making needs and RN Nurse managers Appropriate competencies profoundly staffing 4. Structured impact the work Meaningful process to environment. recognition resolve Authentic disputes leadership 5. Formal processes to evaluate the effect of staffing decisions on patient and system outcomes Communica- tion and collaboration moderately positively associated with job satisfaction (r=0.37, r=0.35 respectively), quality of care (r = 0.37, r = 0.37), frontline nurse manager overall effectiveness (r = 0.38, r = 0.37), and intent to not HEALTHY WORK ENVIRONMENT 86 leave current position (r = - 0.15, r = -0.15). Respect from other RNs rated the highest in comparison to respect from other health care colleagues, physicians, front line nurse managers, and administration. Job satisfaction positively associated respect from FLNMs (r = .50), communication (r = 0.37), and intent to not leave one’s current position (r = - .43). Recognition most meaningful when from patients or families or other RNs. HEALTHY WORK ENVIRONMENT 87 Authentic leadership - perceived overall effectiveness of FLNM was moderately related to the health of the environment (r = 0.50), nurses job satisfaction (r = 0.55), and intent to leave (r = -0.26). 9. Van Bogaert, P., Van heusden, D., Slootmans, S., Roosen, I., Van Aken, P., Hans, G. H., & Franck, E. (2018). Staff empowerment and engagement in a Magnet® recognized and Joint Commission international accredited academic centre in Belgium: a cross-sectional survey. BMC Health Services Research, 18, 756. doi:10-.1186/s12913-018-3562-3 Purpose of study: This study described a component of a research program that focused on organizational features of nurses’ workplaces in relation to nurse and patient outcomes. This study’s aim is to investigate associations between work characteristics and job satisfaction, turn over intentions and perceived quality of care as dependent variables. Conceptual Design/Method Sample/Setting Major Variables Measurement of Data Analysis Study Findings LOE/ Framework Studied and Major Variables Implications for Their Practice Definitions Kanter’s Model Cross sectional 600 bed IV 1 = work Work Hierarchical Intention to LOE VI of Structural academic acute characteristic characteristics - 3 regression leave Empowerment care center in social capital scales analysis profession There are a fair Belgium Generation Y, amount of IV 2 = work Work engagement OR = 13.60 (P limitations with Convenience characteristic - shortened < .001); this study. The sample decision latitude Utrecht Work Generation X, validity and N = 1236 Engagement scale OR = 5.86 (P < reliability of the IV 3 = work (Vigor, .01) tools used were (Nursing staff characteristic Dedication, not consistently N =864 (65%) workload absorption) Social capital defined. Quality (OR = 2.51, P of care was a HEALTHY WORK ENVIRONMENT 88 Healthcare staff IV 4 = work Burnout - Maslach < .001) and subjective N = 131 engagement Burnout Inventory decision measurement Medical staff (Emotional latitude (OR = versus actual N = 24) IV 5 = burnout exhaustion, 6.15, P = < benchmarking Depersonalization .001) were data such as DV 1 = job , Personal positively NDNQI. The satisfaction accomplishment) while workload variables of Perceived quality was negatively intention to leave DV 2 = of care in the unit ( OR = .34, P < the organization intention to and in the hospital .001) and intention to leave hospital [4 point Likert associated with leave the scale] staff very profession are not DV 3 = satisfied in job representative of intention to Job outcomes satisfaction actual turnover, leave profession Aiken et al (2001) rather a Quality of care measurement of DV 4 = Cronbach’s alpha at unit assessed intent. Lastly, the perceived majority scales = at excellent results were quality of care 0.71 - 0.92, was positive reflective of all decision latitude = associated with study participants 0.63, social capital without depersonalization (OR = 4.63, P differentiation = 0.66 in nursing < .001) and between staff decision professions. latitude (OR = 1.97, P < .001) Despite the limitations, Intention to including this leave hospital study does add to (OR = .52, P < the overall body .001) and of knowledge and profession (OR is consistent with = .54, P < .001) results of other negatively comparative associated with research. dedication Recognizing the impact of social HEALTHY WORK ENVIRONMENT 89 Emotional capital, decision exhaustion was latitude, and positive workload on the associated with perceived impact intention to on job outcomes leave the and quality of hospital (OR = care is an 1.72, P < .001) important and intention to consideration for leave the nurse leaders in profession (OR striving for = 1.95, P < decreased .001) turnover and improved quality of care. 10. Van Osch, M., Scarborough, K., Crowe, S., Wolff, A.C., & Reimer-Kirkham, S. (2017). Understanding the factors which promote registered nurses’ intent to stay in emergency and critical care areas. Journal of Clinical Nursing, 27, 1209-1215. doi:10.1111/jocn.14167 Purpose of study: Explore influential factors and strategies that promote an experienced nurse’s intent to stay in their emergency or critical care area. Conceptual Design/Method Sample/Setting Major Variables Measurement of Data Analysis Study Findings LOE/ Framework Studied and Major Variables Implications for Their Practice Definitions Focus groups Qualitative Nurses with two Sample Interpretive Transcripts Four major Level VI interpretive or more years questions: descriptive design. from focus themes Identification of descriptive design - of experience What factors groups were identified specific strategies Focus group within the same promote you to read, reviewed which which influence ED or ICU continue and coded by influence a the intent to stay N = 13 working in the the research nurses intent to by ED and ICU same team. Patterns stay: nurses including: department? and emerging 1. leadership Manager who Were there any categories were (managers, were fully unit/employer identified. clinical nurse engaged, open to strategies that From the educators, giving and influenced you categories, charge nurses) receiving to stay in your broader themes 2. interpersonal feedback, setting department? were relationships clear developed. expectations, HEALTHY WORK ENVIRONMENT 90 3. Practice conveying sense environment of value, respect 4. Personal and lifestyle / job acknowledgment. fit Interprofessional relationships In addition, including being valued, importance of respected and social connections acknowledged with nursing peers. Practice environment included aspects of mentorship and teamwork, autonomy in practice, trust in peers. In respects to personal lifestyle/job fit, proximity to home, work life balance and flexible work schedule were identified as factors. 11. Wei, H., Sewell, K. A., Woody, G., & Rose, M. (2018). The state of the science of nurse work environments in the United States: A systematic review. International Journal of Nursing Sciences, 5, 287-300. doi:10.10.1016/j.ijnss.2018.04.010 Purpose of study: To identify, evaluate, and summarize the major foci of studies about nurse work environment in the United States published between 2005 - 2017 as well as to provide insight into strategies targeted at improving the work environment of the nurse. Conceptual Design/Method Sample/Setting Major Variables Measurement of Data Analysis Study Findings LOE/ Framework Studied and Major Variables Implications for Their Practice Definitions HEALTHY WORK ENVIRONMENT 91 Miles, Systematic Review 54 studies Top three Five major themes Impact of LOE V Huberman and included and instruments identified: HWE on Saldana’s reviewed used to evaluate 1. The impacts of nurses’ Strategies to constant nurse HWE on nurses’ outcomes: promote the work comparative environments: outcomes such as - HWE were environment method - Practice psychological positively focus on the Environment of health, emotional associated with perspective of the the Nursing strains, job nurses’ nurse, the nurse Work Index satisfaction, and psychological leader and the Revised job retention health and organization - Essentials of 2. The negatively overall. Magnetism II associations correlated with - AACN between HWE nurses’ Additionally, the Healthy Work and nurse emotional AACN six Environment workplace strains. standards to Assessment interpersonal - when nurses promote a HWE Tool relationships, job perceived were reiterated: performance, and higher caring 1. skilled productivity behaviors communication 3. The effects of within the 2. true HWE on patient workplace, collaboration care quality they had 3. effective 4. The influences significantly decision making of HEW on lower scores on 4. appropriate hospital accidental compassion staffing safety fatigue, stress, 5. meaningful 5. The and burnout recognition relationships and higher 6. authentic between nurse scores on work leadership leadership and relationships, work job satisfaction, environments. and compassion satisfaction. Impact of HWE on job HEALTHY WORK ENVIRONMENT 92 satisfaction and retention: - HWEs were significantly positively correlated with job satisfaction and retention - HWEs had a positive relationship with nurses’ perceptions of autonomy, control over practice, nurse- physician relationships, and organizational support Impact of HWE on nurse workplace interpersonal relationships, job performance, and productivity - Nurse workplace relationships were a significant factor affecting nurses’ HEALTHY WORK ENVIRONMENT 93 psychological health, job performance and productivity. - Workplace relationships were vital in establishing and maintaining a HWE. Impact of HWE on job performance and productivity - To promote nurses performance and productivity, both intrinsic and extrinsic factors are to be addressed, including the creation of a culture of caring. Impact of HWE on patient care quality HEALTHY WORK ENVIRONMENT 94 - Patient care quality was significantly associated with nursing work environments - patient risk of death and failure to rescue were significantly lower in HWE. Impact of HWE on hospital safety - HWE were inversely correlated with nurses’ occupational injuries Relationship between HWE and nurse leadership - Nurse leadership is a significant component of health work environments HEALTHY WORK ENVIRONMENT 95 Appendix G Synthesis Table Themes and Outcomes Studies Design Sample Nursing Autonomy Managerial Staffing/ Effective RN Quality Size Practice Support Resource Inter- Turnover Environment Adequacy of personal Relations Nelson - Cross N = 162 Nurse For each For each Participation For each Measured using the PES- Brantley, et sectional, hospitals participation point point in hospital point NWI sub-scale “nursing al., 2018, correlational in hospital increase in increase in affairs and increase in foundations for quality of Characteristics N = 1002 affairs did not the staffing and collegial RN mean PES- care.” Ultimately of the nursing hospital show a managerial resource - Provider NWI total excluded from research as practice units significant support PES- PES-NWI relations score: RN highly correlated to nurse environment association to NWI subscale, were not turnover participation in hospital associated RN turnover subscale, RN RN turnover significant in rates affairs (r = 0.86). with lower (P = .21) turnover decreased impacting decreased unit level increased by by 14.8%, B RN turnover 14.8% turnover. 8.3%, B = = -.16; 95% B=-0.16; .08; 95% CI, CI, -.23 to - 95% CI, - 0.00 to 0.15; .09; P < .01. .23 to -.09; P < .05. P <.01 Numminen et Cross N = 318 Strong Nurse Staffing and Perceptions Nurse participation in al., 2015, sectional association manager resource of practice hospital affairs and Practice between: ability, adequacy environment: intention to leave job (F- environment PES-NWI leadership and most positive ratio 17.33, p < .0001), and its overall and support of satisfaction perceptions Intention to leave association Intention to nurses and with the were in profession (F-ratio 16.79, with leave job (F- intention to quality of collegial p < .0001), and professional ratio 28.38, p leave job (F- care (F-ratio nurse- satisfaction with the competence < 0.0001; ratio 17.01, p 14.08, p < physician quality of care (F-ratio and work- < .0001); .0001). relations 16.90, p < .0001); related factors: subscale HEALTHY WORK ENVIRONMENT 96 perception of Nurse (Cronbach’s newly participation alpha 0.862) graduated in hospital nurses affairs and intention to leave job (F- ratio 17.33, p < .0001), Intention to leave profession (F- ratio 16.79, p < .0001), and satisfaction with the quality of care (F-ratio 16.90, p < .0001); O’Hara et al., Descriptive N = 825, Autonomy Supportive Teamwork 2019, Study 375 (45%) contributes to leadership contributes to Assessment of were millennial key driver to millennial millennial millennial nurse work millennial nurse work nurses’ job satisfaction nurse work satisfaction satisfaction satisfaction and professional practice environment Perlo, J., et al., White paper N/A Joy is more Choice and Creating joy Camaraderie Lower levels of staff 2017, IHI than the autonomy is and and engagement linked with Framework absence of an element of engagement teamwork lower quality patient care, for improving burnout. It is the IHI is a key role identified as including safety, and joy in work. about Framework element of HEALTHY WORK ENVIRONMENT 97 connections to for improving of effective IHI burnout limits providers meaning and joy in work leaders. framework empathy. purpose. Participative Engagement is management often used as key element an imprecise of IHI measure for framework. joy. Reinhardt, A., Descriptive N = 258 BS-CPE Subset of Subset of Subset of BS- Length of et al., 2020, correlational Belongingness NWI - R, NWI - R CPE employ- Why nurses subscales autonomy (organization connected- ment first stay: Analysis positively al support) ness profess- of the correlated Strong Strong ional registered with work negative positive Subset of position nurse environment correlation correlation NWRES workforce and (r=0.527) and NWI-R between belonging, Length of the job autonomy (r = NWI-R support, stay first relationship to satisfaction -.204) organization collegial profession, work subscales of NWRES job and NWI - R relationships, longest for environments. NWRES satisfaction autonomy (r commun- native (r=0.417) = 0.795, P < ication, American .01) conflict (100.5 m.) Analysis and between BS- Strong Strong shortest for CPE and negative negative Asian NWRES, correlation correlation nurses indicates between NWI-R (42.0 m.). relationship NWI-R collegial btw sense of organization relationships Length of belonging and and NWRES (r=-.218) and stay in first connection job NWRES job job longest with the satisfaction (r satisfaction for nurses workplace = - .149, P < with ADN .05) (70.9 m.) HEALTHY WORK ENVIRONMENT 98 environment Strong and (r=.527) Subset of correlation shortest for NWRES between nurses with (workplace NWRES doctoral conflict) work degrees Statistically environment (15.6 m.). significant and NWI-R negative collegial correlation relationships between (r= -.209). NWRES workplace Connected- conflict and ness and all subscales belonging of the BS- Support CPE relationships Registered Guideline Organizational Individual Incorporation Nurses climate versus nurses of values Association of organizational accepting such as Ontario, 2008, culture accountability respect, Healthy work for own work honesty, environments life balance feedback, best practice trust and guidelines: cooperation Workplace health, safety and well-being of the nurse Shirey, M, Literature 10 articles Evidence - Quality Environmen Relational 2017, synthesis reviewed based Leadership tal elements exchanges Leadership leadership was practices for practices to identified as create and one of four HEALTHY WORK ENVIRONMENT 99 healthy work sustain HWEs: themes in environments. quality creating and leadership, sustaining relational HWE exchanges, environmental elements, and contextual factors Ulrich et al., Cross N = 8080 Highest rated Perceived Appropriate Communicati Better 2019, Critical sectional work unit overall staffing on and staffing, care nurse elements: effectiveness significantly collaboration higher work RNs are as of frontline related to all positively salary/impr environments proficient in nurse work associated oved 2018: communicatio manager was environment with job benefits, Findings and n skills as in related to components, satisfaction, better implications clinical skills, health of the including quality of leadership, RNs recognize environment, job care, more others for the nurses’ job satisfaction, frontline respect value they satisfaction, intent to not nurse from bring to the and intent to leave, manager administrat work of the leave. respect for effectiveness ion and organization, RNs by and intent to frontline Structured front line not leave manageme processes are manager, current nt, and in place to organization position. more engage valuing meaningful patients and health and Respect recognition families in safety, positively were decision perceived associated variables making, overall with job identified RNs pursue effectivenes satisfaction, as and foster true s of communicati influencing collaboration, frontline on, and intent those who HEALTHY WORK ENVIRONMENT 100 RNs influence nurse to not leave intended to decisions that manager, one’s current leave to affect the valuing RNs position. potentially quality of as partners stay. patient care and RNs influencing decisions that impact quality of patient care. Van Bogaert Cross N = 1236 Decision Workload Social capital Intention to Quality of care at unit et al., 2018, sectional latitude (OR = was (shared leave assessed at excellent was Staff (Nursing 6.15, P = < negatively values and hospital positive associated with empowerment staff .001) was (OR = .34, perceived (OR = .52, social capital (OR = 4.63, and N =864 positively P < .001) mutual trust) P < .001) P < .001) and decision engagement in (65%) associated associated (OR = 2.51, and latitude (OR = 1.97, P < a Magnet® with staff very with staff P < .001) was profession .001) recognized Healthcar satisfied in job very positively (OR = .54, and Joint e staff N = satisfaction satisfied in associated P < .001) Commission 131 job with staff negatively international Medical satisfaction very satisfied associated accredited staff in job with academic N = 24) satisfaction dedication centre in Belgium: a Emotional cross-sectional exhaustion survey. was positive associated with intention to leave the hospital (OR = HEALTHY WORK ENVIRONMENT 101 1.72, P < .001) and intention to leave the profession (OR = 1.95, P < .001) Van Osch, M Interpretive N = 13 Overall nature Fully Social et al., 2018. descriptive of practice engaged connections Understanding design environment managers, with peers. the factors Focus contributes to open to Relationships which Groups intent to stay. giving and with promote receiving providers. registered feedback, set nurses’ intent clear to stay in expectations, emergency focus on and critical improvement care areas. and resolve issues. Wei, H., et al., Systematic 54 articles HWEs had a Nurse Workplace HWEs Patient care quality was 2018, The review positive leadership is relationships were significantly associated state of the relationship a significant were vital in significantl with nursing work science of with nurses’ component of establishing y positively environments nurse work perceptions of health work and correlated - patient risk of death and environments autonomy, environments maintaining a with job failure to rescue were in the United control over HWE. satisfaction significantly lower in States: A practice, and HWE. systematic nurse- retention review physician relationships, HEALTHY WORK ENVIRONMENT 102 and organizational support HEALTHY WORK ENVIRONMENT 103 Appendix H Top ICD 10 Admission Codes Served by the Neuroscience Clinical Unit During 2019 Through March 2021 Diagnosis Total Epilepsy and seizure disorders 761 Brain, CNS cancer 530 Ischemic stroke 525 Degenerative spine and disc injury 496 Septicemia 377 Dementia and cognitive disorders 292 Hemorrhagic stroke 279 Neurologic disease 240 Skull fracture and major brain injury 225 Neuromuscular disease 153 Note. 7,488 admissions 2019 through March 2021 HEALTHY WORK ENVIRONMENT 104 Appendix I Primary Roles, Headcount and FTE Allocation Job Level Headcount FTE Clerical & Admin - Other 3 1.9 LPN & Med Support - 25 14.6 Other Registered Nurse 35 30.21 Supervisor 1 1.0 Total 64 47.71 HEALTHY WORK ENVIRONMENT 105 Appendix J Employee Engagement Scores March 2021 Listening Survey Aligned with HWE Concepts Category Question Score (in relation Company to previous survey) Feedback My leader provides me with 64 (+ 10) 77 feedback that helps me improve my performance Empowerment I feel empowered to make 60 (+8) 72 decisions regarding my work Recognition I feel satisfied with the 58 (+11) 69 recognition or praise I receive for my work. Engagement How happy are you working at 56 (+2) 74 XX. Belonging I feel a sense of belonging at 55 (+ 5) 69 XX. Resources I have the resources I need to do 48 (+ 2) 72 my job well. HEALTHY WORK ENVIRONMENT 106 Appendix K MSU IRB HEALTHY WORK ENVIRONMENT 107 Appendix L Spectrum Health IRB HEALTHY WORK ENVIRONMENT 108 Appendix M Facility Level of Support HEALTHY WORK ENVIRONMENT 109 Appendix N Gantt Chart HEALTHY WORK ENVIRONMENT 110 HEALTHY WORK ENVIRONMENT 111 Appendix O “What matters to you?” script 1. Sue Introduce self MSU graduate nursing student spending time with Val on 4 S through the end of the year … I’m looking at what impacts a healthy work environment and specifically, what brings people (you) joy in your work / what are the bright spots in your day, and what are the “pebbles in your shoes?” that take away from Joy in your work. You may be wondering “why joy?”….. Well, Joy is one of healthcare’s greatest assets…focusing on an asset helps us in designing innovative solutions to what may be impeding our joy at work. Joy is more than the absence of burnout…. It is important to have joy in your work, the intent is to create an environment together that will contribute to bringing joy to work to 4 South. With that, the overall purpose here today is to have meaningful, open, conversations with you to understand: • What matters to you in your daily work? • What helps make a good day? • When you are at your best, what does that look like? • and what gets in the way of a good day? Now, before we get started, I’m going to turn it over to Val for a moment, “Val, can you share why you are interested in what matters to your team and what makes a good day for you?” 2. Val ~ purpose of the conversation Share why you are interested in what matters to staff. Share what makes a good day for you. 3. Sue ~ Move into asking questions as outlined in the guide (choose one question at a time before moving onto another question) Step 1: What matters to you? Build on assets and bright spots So when we think about bright spots or assets….Would anyone like to share (ask these first): Why they decided to work in health care? What makes you proud to work here? What is the most meaningful or best part of your work? What matters to you in your work? How do you know when you made a difference? When your team is at their best…what does that look and feel like? What makes a good day? (ask this one last) HEALTHY WORK ENVIRONMENT 112 Step 2: Identify unique impediments to joy in work “what are the pebbles in your shoes?” So what gets in the way of what matters? What are “the pebbles in your shoes?” What gets in the way of a good day? What frustrates you in your day? • statements to help conversation develop: o “Help me understand what that looks like? o What happened yesterday that would be an example of that? o Link to assets / bright spots: “What from our bright spots list would help us?” o Use brainstorming tools to generate ideas for overcoming impediments. Step 3: Co-design next steps ~ • Based upon our conversation today, we have gathered these items as what you identify as bright spots or assets as well as the “pebbles in your shoes” or impediments. Anything else anyone would like to add? • Looking at your list….is there something that we (all of us) could tackle starting today? A small test that could contribute to building on the assets and start to remove “pebbles from your shoes?” o Anything that you can think of that as individuals everyone could start working on? Step 4: Use improvement science to test approaches to improving joy in work Val and I will be facilitating these sessions throughout the course of the week to solicit input and feedback from the entire team. To keep the momentum started each team will identify, from their list, like you did, what they could start tackling today….. because improvement is part of our daily work, something that is an essential part of each person’s role… May be as simple as “I will say hi to two people in the hall today” Or I will ask 1 colleague if they need help with something. I will be creating a communication board to display bright spots and “pebbles in your shoes”…. not only what comes out of our conversations throughout the course of this week, but also as an ongoing indicator of how to measure improvement daily as well as to capture “bright spots” what made today great and additional “pebbles” as they arise. The goal is to review the board as a team daily and provide brief updates… Any thoughts / recommendations on where the board could be placed and what it could look like? Closing HEALTHY WORK ENVIRONMENT 113 • Sue ~ I really appreciate you taking the time to share what your bright spots are in your day as well as your pebbles in your shoes. The intent of today was for all of us to understand: • What matters to you in your daily work? • What helps make a good day? • When you are at your best, what does that look like? • and what gets in the way of a good day? Then we can begin to individually identify how we can contribute to a good day, and together start to work to removing the pebbles. HEALTHY WORK ENVIRONMENT 114 Appendix P Bright Spots Communication Board HEALTHY WORK ENVIRONMENT 115 Appendix Q Summaries “What matters to you?” Conversations HEALTHY WORK ENVIRONMENT 116 Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 HEALTHY WORK ENVIRONMENT 117 Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 HEALTHY WORK ENVIRONMENT 118 Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 HEALTHY WORK ENVIRONMENT 119 Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 HEALTHY WORK ENVIRONMENT 120 Appendix R Pull Card Front and Back HEALTHY WORK ENVIRONMENT 121 Appendix S Facilitating Bright Spots Communication Board Charge Nurse Guide Purpose of the Bright Spots Communication Board The purpose of the Bright Spots Communication Board is to display “Bright Spots”, “Pebbles in your shoes” and strategies to increase “Bright spots” and chip away at the “Pebbles in your shoes” which were identified during the initial “What matters to you?” conversations. The Bright Spots Communication Board is intended to show progress in achieving these strategies as well as allow the opportunity to identify “Bright Spots” and “Pebbles in your shoes” on an ongoing basis. Based upon the recent “What matters to you?” conversations, the current focus of the board is on supplies and staffing. Supplies ~ identifying what supplies team members were missing during their shift as well as what supplies they have that they never use. What supplies are in the patient room that they don’t need? What supplies are not in the patient room that they need. Staffing ~ to capture intentional actions by 4 South team members to assist in enticing others to want to work on 4 South as well as stay on 4 South. What about the 4 South environment would make someone want to stay as part of the 4 South team? The focus can, and will, change as “pebbles” are resolved and new one’s form. Role of Charge Nurse in facilitating updates / conversation of Bright Spots Communication Board As charge nurses you are asked to facilitate the Bright Spots Communication Board during daily huddles by reviewing and encouraging brief dialogue for each section as described below. As frontline leaders on the 4 South team, you are asked to role model positive attitude and help in encouraging others in identifying “Bright Spots” or in assisting potential strategies that the team can implement to overcome “Pebbles.” Role of Charge Nurse in facilitating each section of Bright Spots Communication Board Bright Spots ASK • Can anyone share a Bright Spot of their day? • What is making today a good day thus far? • Can anyone share a difference they made with a patient or family member today or in a recent shift? (If you have guests on your unit ~ students, pull nurses, resource staff, etc…. highlight them as a bright spot!) WRITE ON BOARD • Using markers ~ quickly jot down bright spots on the Communication Board. Encourage team members to write on the board in the moment as bright spots occur, they don’t need to wait for huddle! Pebbles in Shoes ASK • What is getting in the way of a good day today? • Any ideas / thoughts how we can partner to address / tackle what is getting in the way of making today a good day? WRITE ON BOARD HEALTHY WORK ENVIRONMENT 122 • Using markers ~ quickly jot down on Communication Board what is getting in the way of making today a good day. Encourage / role model dialogue on how to overcome, or at least peck away at, what is getting in the way of making today a good day. For example, if staffing is getting in the way of a good day ~ acknowledge, yes ~ we are running under what we would call for… have people connected with their buddies and / or included NTs in prioritizing care / needs for their team? Anything that the CN can lean in on and assist with? Anything that could be done differently with the assignment ~ if not now, then for the next shift? Supplies The goal is to identify specific opportunities with supplies and where they are housed. During the “What matters to you?” conversations it was shared that the team is often searching for supplies and that supplies are not always stored in the ideal location. During huddle • Remind team members to use the sticky notes to identify: o What supplies do you need that you can’t find? o What supplies do you have that you don’t need? o Supplies that need to go in room? o Supplies that need to come out of room? Staffing As a team, making 4 South a unit that others want to work on will help with overall staffing. The team needs to welcome EVERYONE and support EVERYONE to the unit. During huddle • Intentionally welcome all non-4 South staff to the unit. • Welcome them and thank them for partnering with the 4 South team today. Additional charge nurse expectations for creating a welcoming and supportive environment on 4 South: Introduce yourself to every non - 4 South team member who is on your unit. o “Hi XXX., my name is XXX. I am the charge nurse. Welcome to our unit. I will be checking in on you throughout the shift, but if you need anything, please let me know. o “This card (provide individual with “pull card”) has some key information on it, including my number.” o “Have you been to our unit before?” (If not…) “let me give you a tour.” • During course of shift intentionally connect with each team member, minimally once every 4 hours, to see if they are doing OK or if they need assistance. • Ask them ~ “any bright spots so far in your shift that you would like to highlight?” AND “any pebbles I can help with?” • It is the expectation of the charge nurse to create a welcoming environment. As front-line leaders on the 4 South team, you are role modeling behavior that is both appropriate, and contributing to a welcoming environment, as well as behavior that is not. Be mindful of the conversations you are taking part in…. negatively talking about others, “throwing them under the bus,” saying things you wouldn’t say if they were standing next to you….are all behaviors that contribute to a non-welcoming environment ~ which, ultimately, impacts your staffing on the unit. HEALTHY WORK ENVIRONMENT 123 Appendix T Neuroscience Clinical Unit Rolling Twelve Month Transfer Percentage 2021 2022 August September October November December January Overall 34.40% 36.60% 37.40% 36.70% 40.90% 30.30% RN 31.10% 34.60% 33.20% 31.60% 35.50% 25.70% NT 39.90% 39.90% 43.90% 44.30% 48.80% 37.00% HEALTHY WORK ENVIRONMENT 124 Appendix U Neuroscience Clinical Unit Rolling Twelve Month Churn Percentage 2021 2022 August September October November December January Overall 61.30% 70.20% 71.60% 74.90% 81.70% 67.30% RN 55.10% 64.30% 63.80% 65.90% 71.10% 51.30% NT 71.80% 79.70% 83.70% 88.60% 97.60% 90.40% HEALTHY WORK ENVIRONMENT 125 Appendix V Comparison of Like Units Twelve Month Rolling Transfer Percentage 2021 2022 August September October November December January Neuro 34.40% 36.60% 37.40% 36.70% 40.90% 30.30% Unit A 18.80% 22.90% 27.10% 27.20% 27.30% 29.80% (Size) Unit B 20.90% 27.70% 26.10% 24.40% 29.60% 32.80% (Size) Unit C 11.00% 11.30% 11.50% 11.80% 16.20% 17.90% (Population) HEALTHY WORK ENVIRONMENT 126 Appendix W Comparison of Like Units Twelve Month Rolling Churn Percentage 2021 2022 August September October November December January Neuro 61.30% 70.20% 71.60% 74.90% 81.70% 67.30% Unit A (Size) 22.90% 27.00% 31.30% 31.40% 31.50% 32.10% Unit B (Size) 48.00% 59.60% 58.70% 57.70% 66.00% 75.60% Unit C 40.50% 41.40% 46.20% 47.20% 56.80% 62.70% (Population) HEALTHY WORK ENVIRONMENT 127 Appendix X Travel RN Headcount per Unit by Month Aug-21 Sep-21 Oct-21 Nov-21 Dec-21 Jan-22 Neuroscience Unit 3 6 9 11 10 9 Unit A (SIZE) 0 0 0 0 0 0 Unit B (SIZE) 0 0 1 1 1 2 Unit C 2 5 6 4 3 3 (POPULATION) HEALTHY WORK ENVIRONMENT 128 Appendix Y Figure 4. RN Vacancy Percentage Neuroscience Unit Unit A (Size) Unit B (Size) Unit C (Population) 50.00% 47.30% 46.70% 45.00% 46.00% 45.00% 43.00% 42.00% 40.00% 41.00% 38.00% 35.00% 35.50% 35.00% 34.00% PERCENT VACANCY 30.00% 27.00% 27.00% 25.00% 22.00% 23.00% 20.00% 15.00% 10.00% 8.00% 9.00% 9.00% 9.00% 5.00% 5.00% 0.00% AUG-21 SEP-21 OCT-21 NOV-21 DEC-21 JAN-22 Figure 4. Monthly comparison of RN vacancy percentage between neuroscience clinical unit and units A, B and C from August 2021 to January 2022. HEALTHY WORK ENVIRONMENT 129 Appendix Z Figure 5. Belonging Overall Belonging Overall Jul-21 Belonging Overall Nov-21 80 70 75 74 68 67 66 60 65 59 50 56 55 51 40 30 20 10 0 Neuro Unit A (Size) Unit B (Size) Unit C Company (Population) Figure 5. Comparison of overall belonging scores for neuroscience clinical unit in relation to Units A, B and C as well as the healthcare organization (company) overall. HEALTHY WORK ENVIRONMENT 130 Appendix AA Figure 6. Belonging RN Belonging RN Jul-21 Belonging RN Nov-21 80 70 73 71 60 67 66 61 63 58 50 52 49 49 40 30 20 10 0 Neuro Unit A (Size) Unit B (Size) Unit C Company (Population) Figure 6. Comparison of RN belonging scores for neuroscience clinical unit in relation to Units A, B and C as well as the healthcare organization (company) overall. HEALTHY WORK ENVIRONMENT 131 Appendix BB Figure 7. Belonging NT Belonging NT Jul-21 Belonging NT Nov-21 80 70 76 74 73 60 65 67 66 50 57 56 56 54 40 30 20 10 0 Neuro Unit A (Size) Unit B (Size) Unit C Company (Population) Figure 7. Comparison of NT belonging scores for neuroscience clinical unit in relation to Units A, B and C as well as the healthcare organization (company) overall. HEALTHY WORK ENVIRONMENT 132 Appendix CC Figure 8. Engagement Overall Engagement Overall Jul-21 Engagement Overall Nov-21 80 70 71 71 69 69 60 66 66 60 59 50 52 40 46 30 20 10 0 Neuro Unit A (Size) Unit B (Size) Unit C Company (Population) Figure 8. Comparison of overall engagement scores for neuroscience clinical unit in relation to Units A, B and C as well as the healthcare organization (company) overall. HEALTHY WORK ENVIRONMENT 133 Appendix DD Figure 9. Engagement RN Engagement RN Jul-21 Engagement RN Nov-21 80 70 68 68 69 69 60 61 63 60 50 57 40 46 45 30 20 10 0 Neuro Unit A (Size) Unit B (Size) Unit C Company (Population) Figure 9. Comparison of RN engagement scores for neuroscience clinical unit in relation to Units A, B and C as well as the healthcare organization (company) overall. HEALTHY WORK ENVIRONMENT 134 Appendix EE Figure 10. Engagement NT Engagement NT Jul-21 Engagement NT Nov-21 80 70 75 72 71 69 69 60 59 50 56 55 53 50 40 30 20 10 0 Neuro Unit A (Size) Unit B (Size) Unit C Company (Population) Figure 10. Comparison of NT engagement scores for neuroscience clinical unit in relation to Units A, B and C as well as the healthcare organization (company) overall. HEALTHY WORK ENVIRONMENT 135 Appendix FF Comparison of Like Units Likelihood to Recommend Top Box Performance 2021 2022 August September October November December January Neuro 69.70% 94.70% 54.60% 60.90% 40.70% 63.80% Unit A 60.00% 79.20% 55.60% 74.10% 69.20% 88.00% Unit B 68.90% 69.20% 65.50% 65.2% 73.90% 71.40% Unit C 72.20% 66.67% 60% 70.60% 50.00% 80.00% HEALTHY WORK ENVIRONMENT 136 Appendix GG Budget HEALTHY WORK ENVIRONMENT 137