Author: Brady, Marilyn S
Date published: January 1, 2010
Journal code: OJNR
The focus on healthy work environments began in clinical settings with the goals of improving patient safety, enhancing the recruitment and retention of nurses, and promoting excellence in clinical practice. Disch (2002) defined a healthy work environment as "a work setting in which policies, procedures and systems are designed so that employees are able to meet organizational objectives and achieve personal satisfaction in their work" (p. 3). This definition emphasizes the external factors that impact satisfaction; it focuses on those things that are under the influence of the organization. While an individual's inner predisposition to satisfaction is not under the influence of the organization, a component of promoting a healthy work environment does involve hiring individuals who are positive and have the potential to thrive once the proper environment is provided (Brooks et al., 2007).
The work environment is the result of numerous, interrelated factors (Alspach, 2009). The American Association of Critical-Care Nurses (AACN) has been instrumental in advancing the dialogue regarding healthy work environments as one way to promote excellence in the clinical setting. As part of the initiative to advance healthy work environments, AACN has identified six standards for establishing and sustaining healthy work environments, namely skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership (AACN, 2005). The AACN has noted that 'unhealthy' work environments in the clinical setting contribute to "medical errors, ineffective delivery of care, and conflict and stress among health professionals" (p.1), while a 'healthy' work environment is necessary to "ensure patient safety, enhance staff recruitment and retention, and maintain an organization's financial viability" (p.1). These characteristics of unhealthy versus healthy work environments have implications for the nursing academic environment. Hence, it is important for faculty members and administrators to initiate conversations regarding the impact of healthy versus unhealthy environments within the nursing education unit.
The Nursing Organization Alliance (NOA) (2004) drew upon the concurrent work of the American Organization of Nurse Executives (2004) and advocated for nine elements that support a healthy work environment. These elements included a collaborative practice culture; communication rich culture; a culture of accountability; the presence of adequate numbers of qualified nurses; the presence of expert, competent, credible, visible leadership; shared decision making at all levels; the encouragement of professional practice and continued growth/development; recognition of the value of nursing's contribution; and recognition of nurses for their meaningful contribution to practice (NOA, 2004). The National League for Nursing (NLN) adapted these elements and defined a 'healthful' work environment for nursing faculty as the context that enables faculty to provide quality nursing education (NLN, 2005a). These elements, along with the results of NLN's 2003 study of faculty role satisfaction (NLN, 2005b), became the foundation of The Healthful Work Environment (HWE) Tool KitŠ (NLN, 2006). The tool kit is designed to be used by anyone in the nursing education unit to evaluate the work environment in the nine areas identified as critical to a healthy work environment. These nine areas will be used in this article to organize the discussion of healthy academic work environments. The impact of each element on faculty satisfaction in nursing academic settings and approaches nursing faculty and nursing education administrators can use to work together to assess and enhance the health of nursing academic workplaces will be discussed.
Competitive salaries are fundamental to the recognition of faculty contributions and accomplishments (NLN, 2005a). A major challenge in the recruitment and retention of faculty is that salaries in the educational setting are often lower, and sometimes significantly lower, than those in the clinical setting (Kaufman, 2007b). This discrepancy can make it difficulty to recruit and retain faculty members. Additionally, there may be salary discrepancies among faculty within the institution and even within the nursing education unit. Some of the discrepancies within the institution may be based on the faculty member's credentials and longevity (Kaufman); such factors need to be determined to make accurate comparisons. Salary compression, which arise when new faculty are hired at comparatively higher salaries than those who have been at the institution long-term, can occur when faculty members are recruited from the clinical setting. Kaufman reported that of all of the factors evaluated in the NLN/Carnegie Foundation National Survey, Nurse Educators: Compensation, Workload and Teaching Practices, salary was the factor "with which nurse faculty were least satisfied at their current jobs" (Kaufman, p. 225). Moreover, 53 percent of faculty members in this survey gave "more compensation" as the reason for planning to leave their current position over the following year.
To address these salary concerns nursing education administrators are encouraged to work to improve faculty salaries by collecting salary data from regional and state peer institutions and from clinical settings. Administrators can then use this data as a basis for adjusting entry level salaries and for requesting salary adjustments for current faculty members. Although salary adjustments are possible, obtaining them can be a challenge, particularly in periods of budget constraints. Applicants for faculty positions should question how salary adjustments are made by asking whether adjustments are made across the board and/or whether adjustments are performance-based, merit adjustments (Miller, Norman, & Aiken, 2002). Potential faculty will also want to ask whether the institution has a system of promotion and tenure that is associated with salary adjustments. Another important question concerns whether all areas of faculty responsibility, including teaching excellence and scholarship, are considered equally in making salary adjustments, or whether one area weighs more heavily than another. In addition, applicants should determine whether the institution is part of a collective bargaining agreement, and if so how this agreement might impact salary negotiations.
Benefits expand the concept of compensation beyond salary. Faculty members will also want to consider such benefits as workspace, equipment, laboratory facilities (as appropriate), travel and scholarship dissemination support, intellectual property agreements, and other assets that support the work of the faculty (Miller et al., 2002). The availability of graduate-level teaching may also be important, as may resources for faculty members who wish to pursue an advanced degree. Sabbaticals and academic leaves may be offered by the institution as additional benefits.
The academic year schedule may be a benefit for faculty members who wish to take prolonged periods of time off during the summer months. However, with increasing enrollments, nursing courses may be offered year round; and faculty may be expected to do some summer teaching. To maintain a healthy work environment, nurse administrators should ensure that faculty members have options for nine, ten, and twelve month contracts. Another benefit could be joint-appointment contracts allowing faculty to fulfill both education and practice role responsibilities.
Ashraf and Williams (2008) noted that when funds are not available for higher salaries, benefits may become an area for negotiation, regardless of organizational participation or non- participation in collective bargaining. These authors have observed that "it is much easier and more politically expedient to raise fringe benefits and improve the work environment, and these changes are less likely to capture the attention of taxpayers" (p.149). One question applicants could ask would be whether or not flexible benefits packages that can be tailored to the needs of the individual faculty member are available. The ability of faculty members and administrators to negotiate effectively is essential in promoting a healthy work environment (Sarfaty et al., 2007).
Depending on the type of institution, the workload for nursing faculty members may include any or all of the following: teaching, advising, committee participation, practice, research, and/or service. The faculty member's ability to balance these competing responsibilities is critical if the environment is to be perceived as healthy. In the NLN/Carnegie Foundation Survey, Nurse Educators: Compensation, Workload and Teaching Practices, nurse educators reported working just over 56 hours per week while school was in session (Kaufman, 2007a).
Workload may be something that the nurse administrator or individual faculty member can negotiate. Release time may be an option for a faculty member who takes responsibility for a major project or administrative component. Although additional compensation may be provided for those engaged in practice, this does require institutional support for the distribution of revenue resulting from faculty practice (Sawyer, Alexander, Gordon, Juszczak, & Gilliss, 2000).
Workload for nursing faculty members may be calculated on clinical-contact hours, rather than credit hours, if the majority of their teaching time is in the clinical setting. Most nursing programs use a ratio ranging from two to four hours of clinical-contact time for every one-hour credit of classroom time. This means that faculty teaching 24 clinical-contact hours have a workload equivalent to 12 classroom hours, when one classroom hour is equal to two clinical-contact hours. Nurse administrators can work with faculty members to educate the institution's administrators regarding the nature of work in the clinical setting so as to make the case that clinical teaching is more comparable in intensity to a classroom setting than to a basic-science-laboratory setting. Obtaining permission from the clinical facility for college administrators to visit the clinical setting while students are providing patient care is one way to demonstrate to college administrators the intensity of the clinical faculty role.
Currently, due to faculty shortages, frozen positions, and increasing enrollments, workload may actually be increasing. This can impact the flexibility and autonomy that are seen as benefits in the nurse educator role. Also, faculty shortages may increase faculty-to-student ratios. While an individual state's nurse practice act may limit these ratios in the clinical setting, the overall number of students in the program relative to the number of faculty available may increase, thus increasing workload.
Nurse administrators and faculty members must collaborate to ensure that the distribution of workload remains consistent among the faculty. If the work environment is healthy, faculty members who perceive that they are treated fairly and that their work is valued and rewarded may be more tolerant of an increasing workload (Shirey, 2006). This is essential because work-life balance impacts faculty satisfaction (Rosser, 2004). This will become even more important as nurses in their 20s and 30s enter the nurse educator role because individuals in these generations "work to live, don't live to work" (Cipriano, 2007, p.10). Nursing education administrators will likely soon face the challenge of focusing on "commitment management, not time management" (Cipriano, p.10), working with all faculty members to provide adequate faculty coverage for teaching the classroom and clinical content included in the curriculum. Kaufman (2007c, p. 297) cited the "NLN/Carnegie Foundation Survey, Nurse Educators: Compensation, Workload and Teaching Practices, in observing that fully 45 percent of nurse educators who responded indicated that they were dissatisfied with their current workload and more than 25% of these respondents cited workload as a motivating factor in their intent to leave their current job.
The collegiality of the environment is dependent upon both organizational support and relationships with administrators, other faculty members, and students. Ulrich et al. (2009) reported that 'colleagues' were the main factor influencing retention in the 2009 follow-up survey of critical care nurses. This is consistent with the Gallup Organization finding that people who have a best friend at work are seven times more likely than those who do not have a best friend to be engaged in their job and organization (Hannon, 2006). In contrast to good relationships with colleagues are the "joy stealing" bullying and intimidating games identified by Heinrich (2007). The development of collegial relationships can be a challenge as faculty members generally work in isolation, whether it be teaching in the classroom or clinical setting, conducting research, writing articles or grants, or participating in faculty practice. Additionally, faculty members may actually be in competition for the same resources, a situation that can affect the work environment in a negative manner.
The nurse administrator can promote the development of collegial relationships in a variety of ways. One way to do this for new faculty members is through effective orientation and mentoring (Dunham-Taylor, Lynn, Moore, McDaniel, & Walker, 2008). Another approach could be organizing opportunities for faculty members to come together for a scholarly discussion without an identified agenda (Cumbie, Weinart, Luparell, Conley, & Smith, 2005). Alspach (2009) suggested that promoting involvement in voluntary charitable events and/or providing offsite opportunities for celebrations and recognition could also enhance collegial relationships. Communication and collaboration can enhance an environment of collegiality when faculty use both formal and informal methods of communication, and when communication goes both up and down and back and forth (Rudy, 2001).
Another factor to consider in relation to the collegial environment is the multiple generations that are now in the workforce. Nurse administrators are encouraged to facilitate the creation of teams and partnerships that cross generations, so that the strengths of each generation can be maximized. For example, it is often the novice educator who is the 'digital native' capable of mentoring the senior faculty member in the area of technology (Sawatzky & Enns, 2009).
A faculty member with a negative attitude or a prolonged "short-timer" can have a negative impact on the entire faculty group. This may occur with faculty members who had planned to retire but now need to stay in the workforce because of the current economic environment. The nurse administrator should make every attempt to promote a positive attitude among faculty. If this cannot be achieved, it falls to the nurse administrator to take the steps necessary to remove a negative and/or ineffective faculty member so that a healthy work environment for other faculty members can be maintained.
Disruptive behaviors can also have a negative influence in academic settings. Much has been written about lateral violence and bullying in clinical nursing settings. These behaviors can also occur in educational settings. Just as hospitals are developing policies to eliminate intimidating and disruptive behaviors, nursing education programs need to develop policies related to student-student, faculty-student, student-faculty and nursing staff-student occurrences of these behaviors. To decrease these disruptive behaviors faculty need to select clinical sites that are themselves healthy work environments. Faculty should also include classroom content on the principles of healthy work environments so that students can use this information when evaluating potential workplaces.
The issue of student incivility, i.e., the "intentional behavior of students to disrupt and interfere with the teaching and learning process of others" (Morrisette, 2001, p. 2), also needs to be addressed as a component of a healthy work environment in the academic setting. Negative student behaviors/comments can contribute to a faculty member's stress and intention to leave (Gates, 2000). Although student incivility may occur as a response to the behavior of a faculty member, it may also be unprovoked.
Role Preparation and Professional Development
In this era of a nursing faculty shortage, master's-prepared faculty from the clinical setting are frequently recruited to teach in associate degree nursing programs or in clinical tracks for baccalaureate nursing programs. While these individuals have experience in patient teaching, they often are not prepared for the nurse educator role. They may find it challenging to leave behind the role of expert clinician and become a novice faculty member. For example, novice educators may fall prey to 'occupational stress,' described as "the harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources or needs of the worker" (National Institute for Occupational Safety and Health, 2008, p. 1). If the new faculty member comes from a role that has been limited to an eight hour day, time management may become an issue when the educator's work expands to fill 50 to 60 hours per week. If this occurs, it is helpful to provide mentors for these novice educators, to help them set necessary boundaries and limits.
Opportunities for professional development may be limited in the current economic environment. Suggestions for providing professional development when funding is limited include bringing speakers/programs on topics of interest to the faculty, rather than sending individual faculty members to conferences/workshops; having nursing faculty members give presentations to their peers; and taking advantage of professional opportunities offered by other departments within the institution.
A healthy work environment in the academic nursing work setting is an environment that is supportive of scholarship, which involves a constant quest for new knowledge on the part of all faculty. A healthy work environment supports and promotes this quest. In addition faculty members need to have the opportunity to pursue up-to-date knowledge related to both theoretical content and clinical practice.
Scholarship takes different forms in nursing education depending on the type of institution. For faculty members in research institutions, scholarship specifically means the creation of new knowledge. However, all nursing faculty members are needed to assist in the scholarly development, validation, replication, and dissemination of evidencebased practice related to both teaching and clinical practice. Nursing education administrators can support these initiatives by incorporating scholarship into faculty evaluations and celebrating scholarly recognitions and rewards. In a healthy work environment faculty members work together to seek out the necessary internal and external resources that can support faculty scholarship.
Institutional support of the nursing education unit is necessary to support a healthy work environment. One way of determining the level of institutional support is to determine whether the nursing program is a distinct unit within the institution, be it a college, a division, or a department. Distinct units are more visible within the institution and are indicative of the level of institutional support. Another component of institutional support to evaluate is the presence of adequate personnel, financial, physical, and technological resources within the institution. Institutional support is necessary for 'functional congruence,' which Dendaas (2004) defined as "the capacity of a work environment to support instrumental tasks" (p. 16). This includes the right kind of space, access to important resources, appropriate levels of stimulation, and comfortable ambient conditions. The degree of functional congruence, or the "fit" of the physical resources provided by the institution with the needs of the nursing education unit, is an important consideration in promoting a healthy work environment.
Ulrich et al. (2009) reported that in the 2008 follow-up survey of critical care nurses' institutional support for certification was related to nurse satisfaction. While options for certification may be limited for nursing faculty members, the NLN does have a program for certification of nurse educators. If the educational institution does not already provide support for certification, the nurse administrator may wish to negotiate for such support. In addition, the nurse administrator can work with nursing faculty members to determine other types of institutional support that would promote a healthy work environment.
Marketing and Recognition
Nursing programs do need to market and promote themselves as being 'excellent.' The NLN has a "Centers of Excellence" program for educational facilities, similar to the Magnet Recognition ProgramŽ for clinical facilities. Even if the administrator and faculty members do not seek this designation, they should be able to describe what aspects of their program are 'excellent' or 'unique.'
For nurses in the clinical setting, recognition comes primarily from patients and their families, followed by that of other nurses (Ulrich et al., 2009). For nursing faculty, recognition comes first from students and graduates and then from other faculty members. For administrators, the recognition may come from the faculty or from sources external to the nursing education unit. There should be mechanisms in place for formal recognition. Such recognition could be internal, in the form of a faculty-member-of-the-year award as selected by peers or students. It could also be external in coming from agencies at local, state, or national levels. The nurse administrator is encouraged to nominate worthy faculty members for these distinctions. Nominees can be celebrated, whether or not they actually receive the top award, as it is an honor just to be nominated for an award.
The principles and elements found in the NLN's Healthful Work Environments for Nursing Faculty (2005a) include the "presence of expert, competent, credible, visible leadership" (p.1). In a meta-analysis of factors affecting job satisfaction in nursing faculty members, Gormley (2003) found a strong, significant effect size for "the relationship between faculty expectations of the chairperson's participation in curriculum and instruction and overall job satisfaction" (p. 177). This finding speaks directly to the need for the leader to be competent and credible. The importance of good leadership is echoed by the recent follow-up report on critical care nurses' work environments which found that the most frequently cited factor that would lead a nurse to reconsider leaving a current position was better leadership (Ulrich et al., 2009). Gormley (2003) reported that the factors of 'consideration' and 'initiating structure,' through which faculty members are given recognition and voice, were found to have a large effect size on faculty satisfaction. Faculty members were found to be more satisfied when they had input into decision making. If input is not an option, then the leader needs to help them understand the rationale for the decisions made.
The leadership of the nurse administrator is very influential in determining the culture of the organization and the overall health of the work environment. Nurse administrators need to recognize that they are leading a group of professionals. They need to learn how to lead by "letting go and listening, coaching, motivating and influencing, rather than by directing and controlling" (McManis & Monsalve Associates, 2003, p. 7) so that faculty members are empowered. It is recognized, however, that effective leadership styles are dependent on the situation. If the program has many novice nurse educators, a more authoritarian leadership style may be necessary initially. On the other hand, if the faculty members are experienced, a participative style would promote greater faculty satisfaction.
An important first step in evaluating the components of a healthy work environment is to establish a baseline measure of the satisfaction of faculty members. To assess current faculty satisfaction in each of the areas discussed above, the nurse administrator, or a faculty committee, could develop a survey by adapting questions from the HWE Tool KitŠ. Once the current level of satisfaction is established, the nurse administrator can develop and implement strategies to improve satisfaction with the work environment and continuously evaluate the outcomes of these strategies (Gazza & Young, 2008). Data obtained from an annual survey regarding the faculty members' satisfaction with the work environment can be aggregated and trended so that nurse administrators can identify changes in satisfaction or dissatisfaction early enough to remedy work environment problems, thus preventing loss of faculty.
Studies of the factors that impact a healthy work environment in the academic setting are still in the early stages of development. The primary focus currently is on compensation. However, all components of the environment need to be addressed. Research to identify evidence-based practices related to healthy work environments in academic settings is needed. Outcome measures related to healthy work environments will be faculty satisfaction, successful recruitment and retention, and excellence in nursing education. The increased faculty satisfaction that members who work in healthy work environments experience can serve to recruit both nursing students and clinical nurses into faculty roles. This faculty recruitment will become increasingly important as large numbers of current faculty members retire.
Nursing faculty satisfaction is influenced by a variety of factors related to healthy work environments. The NLN's tool kit is one way to evaluate and strengthen the current environment. Use of the questions and resources in this tool kit to initiate conversations within the nursing education unit can "be used to create healthful work environments that support faculty in their work, promote excellence and innovation, generate ideas for improving the work environment and contribute to the recruitment and retention of faculty" (NLN, 2006; 2007, para 2). These initial efforts can serve as a foundation for building healthy work environments throughout all levels of nursing education.
The author acknowledges the following individuals who contributed to the development of The Healthful Work Environment Tool KitŠ: Carol A. Fetters Andersen, MSN, RN; Carol A. Boswell, EdD, RN; Nancy DeBasio, PhD, RN; Dana Charles Clark, EdD, RN; Elizabeth A. Gazza, MSN, RN, FACCE; Layna Himmelberg, MSN, RN; Donna B. Jensen, PhD, RN; Melissa Lambert, MSN, RN; Karen Mittura, MSN, RN, CCRN; Karen Morin, DSN, RN; Mary Anne Rizzolo, EdD, RN, FAAN; Deborah Ulmer, PhD, RN; Mary Stedman, MS, RN, ANP, CNE; Max Veltman, MSN, RN, CPNP; Kathleen Walsh, EdD, RN,C; Patricia K. Young, PhD, RN.
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Š 2010 OJIN: The Online Journal of Issues in Nursing Article published January 31, 2010
* Combating Disruptive Behaviors: Strategies to Promote a Healthy Work Environment
Joy Longo, DNS, RNC-NIC (January 31, 2010)
* The Complex Work of RNs: Implications for Healthy Work Environments
Patricia R. Ebright, RN, DNS, CNS (January 31, 2010)
* A Healthy Work Environment: It Begins With You
Betty Kupperschmidt, EdD, RN, NEA, BC; Emma Kientz, MS, BS, CNS, CNE; Jackye Ward, MSHRM, RN, CNAABC; Becky Reinholz, MS, RN (January 31, 2010)
* Strategies for Enhancing Autonomy and Control Over Nursing Practice
Marla J. Weston, PhD, RN (January 31, 2010)
* Growing Future Nurse Leaders to Build and Sustain Healthy Work Environments at the Unit Level
Rose Sherman, EdD, RN, NEA-BC, CNL; Elizabeth Pross, PhD, RN (January 31, 2010)
Marilyn S. Brady, PhD, RN
Marilyn S. Brady, PhD, RN
Marilyn Brady is the department head for nursing at Trident Technical College in Charleston, SC. She has been a nurse educator in associate degree nursing programs for 31 years. She earned her BSN from the University of Delaware, her MSN from the University of Kentucky, and her PhD from the University of South Carolina. Dr. Brady chaired the National League for Nursing's (NLN's) Task Group on Healthful Work Environments, which developed NLN's Healthful Work Environment Tool KitŠ. She is currently a member of NLN's Nursing Education Advisory Council, and a site visitor and member of the Evaluator Review Panel for the NLN Accrediting Commission, Inc. She is also a member of the Editorial Review Board for the Journal of Nursing Education.