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Fix the Health of Your Work Environment and Retain Nurses

Analysis  |  By Jennifer Thew RN  
   June 14, 2019

Healthy work environments could also improve patient outcomes.

Editor's note: This article includes excerpts from the March/April 2019 HealthLeaders magazine cover story, Want to Keep Nurses at the Bedside? Here's How.

What do nurses cite as the most common reason for leaving their jobs? It's the work environment, according to the 2018 Press Ganey Nursing Special Report: Optimizing the Nursing Workforce: Key Drivers of Intent to Stay for Newly Licensed and Experienced Nurses.

The study analyzed responses of nearly 250,000 RNs to identify trends in intent to stay based on age, tenure, and unit type, as well as drivers of intent to stay.

"Dissatisfaction with the work environment was the most commonly cited reason for leaving," Christy Dempsey, RN, MSN, CNOR, CENP, FAAN, chief nursing officer at Press Ganey,  says. Nurses across all age groups and experience levels cited this as a reason they planned to leave their job within the next year.

A 2018 article in the International Journal of Nursing Sciences, authors reviewed 54 studies on the nursing work environment and found not only do healthy work environments promote a stable and sufficient workforce, they also "promote hospital safety, encourage nurse performance and productivity, improve patient care quality, and support healthcare organizations' financial viability."

The Characteristics of a Healthy Work Environment

What does a healthy work environment look like? According to the American Association of Critical-Care Nurses, it's a place where healthcare professionals can make their optimal contribution. The American Nurses Association describes healthy work environments as safe, empowering, and satisfying.

Stanford Children's Health and Lucile Packard Children's Hospital Stanford in Palo Alto, California, is one organization that has committed to creating a healthy work environment to support nurses in delivering optimal patient care.

"The work environment, workloads, and the impact of things like technology and new innovations in healthcare—it's really challenging to keep up," says Kelly Johnson, PhD, RN, NEA-BC, vice president, patient care services and chief nursing officer at the organization. "[We need to] provide environments where nurses are supported in professional growth and development and staying abreast of new evidence-based practices [so they can] get to the top of their game regarding professional nursing practice."

Nursing Practice Model Focuses on Caring Science to Improve Environment

The organization has made a formal commitment to creating a healthy work environment and culture.

"We're looking at lots of initiatives around wellness in the workforce," Johnson says, "and how we promote professional fulfillment and prevent burnout and look at moral resilience and intentional integrity in healthcare."

This includes designing a nursing professional practice model, which addresses the holistic needs of both patients and staff, and implements concepts from Dr. Jean Watson's Caring Science Theory and HeartMath.

According to its website, HeartMath is a "system that empowers people to self-regulate their emotions and behaviors to reduce stress, increase resilience, and unlock their natural intuitive guidance for making more effective choices."

The core concept of the Caring Science Theory, according to The Watson Caring Science Institute's website, is "a relational caring for self and others based on a moral/ethical/
philosophical foundation of love and values."

Some principles included in the theory are:

  • Moral commitment to protect and enhance human dignity
  • Respect/"love" for the person—honoring his/her needs, wishes, routines, and rituals
  • Heart-centered/healing caring based on practicing and honoring wholeness of mind-body-spirit in self and each other
  • Inner harmony (equanimity)—maintaining balance

Watson also outlines 10 Caritas processes that include "creating a healing environment at all levels, whereby wholeness, beauty, comfort, dignity, and peace are potentiated."

Johnson says these processes are threaded throughout all aspects of the work environment and include self-care activities. For example, the organization is in the process of creating "Caritas carts" filled with healthy snacks that can be delivered during leader rounding. This helps leaders make rounding intentional while supporting staff who may be busy and need a reminder to care for themselves.

"Our practice and practice environment reflects this theoretical foundation and embodies the theory in our practices. SCH is one of the first organizations to implement the integrated model with Caring Science and HeartMath," Johnson explains.

The organization has 23 Caritas coaches and several HeartMath trainers that educate the nurses on these self-care concepts.

"We do a lot of work around self-care and creating a work environment that is caring and healing, not only for the patients and families to receive care, but for our nurses to work in a place where we care about each other and we care about ourselves," Johnson says.

The Importance of Professional Development in Creating a Healthy Work Environment

Professional development is another component of a healthy work environment, and Stanford Children's Health and Lucile Packard Children's Hospital has developed programs to support nurses in the various stages of their careers.

For example, once a newly licensed RN joins the organization, the nurse is supported by a yearlong new-graduate residency and transition-to-practice program. The program enables the hospital to hire new grads into all specialties, including ones that are more challenging to fill, such as the neonatal ICU or cardiovascular care. The program has shown successful retention outcomes.

"We are close to 100% retention," she says.

Total nurse turnover is around 7%, notes Johnson. According to the recruitment firm NSI Nursing Solutions, Inc., the average national turnover rate for bedside RNs was 16.8% in 2017.

"That is the fact, [considering] that we have some high retirement areas, such as our neonatal intensive care unit and some of our maternity services," she points out.

Nurses are supported in their professional development through personal success plans, a succession planning development program, certification programs, and advanced degree programs.

Johnson says in fiscal year 2019, the organization formalized creation and assessment of personal success plans, which will be reviewed annually with a nurse's manager.

"It is a formal program where part of [the nurse's] evaluation process is developing a personal development plan and making sure that we document it and track progress towards it," she explains.

While all nurses at healthcare organizations are expected to help advance the organization's strategic goals, the personal success plans will help nurses hone their individual personal and professional goals. For example, this could mean working toward a master's degree or achieving specialty certification.

To celebrate nurses' various achievements throughout the year, the organization has an annual awards banquet.

Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.


Nurses cite the work environment as the most common reason for leaving their jobs.

The American Nurses Association describes a healthy work environment as safe, empowering, and satisfying.

Nursing practice models can support a healthy work environment.

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