Types of Intensive Care Units With the Healthiest, Most Productive Work

Environments
Claudia Schmalenberg and Marlene Kramer
Am J Crit Care 2007;16:458-468
2007 American Association of Critical-Care Nurses
Published online http://www.ajcconline.org
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AJCC, the American Journal of Critical Care, is the official peer-reviewed research
journal of the American Association of Critical-Care Nurses (AACN), published
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Challenges in the Critical Care Workplace

YPES OF INTENSIVE

CARE UNITS WITH THE

HEALTHIEST, MOST
PRODUCTIVE WORK
ENVIRONMENTS
By Claudia Schmalenberg, RN, MSN, and Marlene Kramer, RN, PhD

C E 2.0 Hours
Notice to CE enrollees:
A closed-book, multiple-choice examination following this article tests your understanding of
the following objectives:
1. Discuss 3 common trends in healthy work
environments.
2. Explain the relationship between the 8
essentials of a productive work environment
identified by staff nurses in magnet hospitals
and the 6 AACN standards of a healthy work
environment.
3. Discuss the relationship between healthy work
environments and magnet hospitals.
To read this article and take the CE test online,
visit www.ajcconline.org and click CE Articles in
This Issue. No CE test fee for AACN members.

458

Background The quality of nurses work environments in hospitals is of great concern. The American Association of CriticalCare Nurses has specified 6 standards essential to a healthy
(ie, satisfying and productive) work environment. These standards are sufficiently aligned to the Essentials of Magnetism
processes to make this tool suitable for measuring healthy
work environments.
Objectives To identify differences in staff nurses perceptions
of the work environment by type of intensive care unit.
Methods A cross-sectional descriptive design with strategic
sampling was used in this secondary analysis of data from 698
staff nurses working in 34 intensive care units in 8 magnet hospitals. Intensive care units were grouped into 4 types: medical,
including coronary care; surgical, including trauma and cardiovascular; neonatal and pediatric; and medical-surgical. All nurses
completed the Essentials of Magnetism instrument. Analysis
of variance was used to identify initial differences; multivariate
analysis of variance was used to control for covariates.
Results The intensive care nurses and units scored above the
National Magnet Hospital Profile mean on process variables
and on the Essentials of Magnetism outcome variables. Neonatal and pediatric units scored significantly higher than did the
other types of intensive care units sampled.
Conclusions Intensive care unit structures supported care
processes and relationships that resulted in job satisfaction
among nurses and high-quality care for patients in this strategic sample. Systematic study of the structures and processes
present in units reporting a healthy work environment can be
used to assist other clinical units in improving work environments. (American Journal of Critical Care. 2007;16:458-469)

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he American Association of Critical-Care Nurses (AACN) defines a healthy work

environment as a work setting in which structures are designed so that nurses can
achieve 2 outcomes: meet organizational objectives and achieve personal satisfaction in their work.1 AACN has identified 6 standards or relationship-centered
principles of professional performance2 through which these outcomes are to be
achieved. Environment is the aggregate of conditions and circumstances that influence an
organism, so each of the 6 standards is essential to a healthy work environment. The standards
are interdependent; none can be considered optional.3
Intensive care units (ICUs) have staffing and
other structures that differ from those of other clinical units. These structures differentially affect functional care processes and relationships that, in turn,
affect outcomes such as nurses job satisfaction and
their ability to give quality care to patients. Differences among types of ICU unitsadult and pediatric, medical and surgicalalso have been noted.4-6
Combining samples of nurses from various categories of ICUs may mask differences in structures
that enable care processes.
The Essentials of Magnetism (EOM) is a psychometrically sound instrument3 that measures 8 functional processes essential to a productive work
environment. The 8 processes are highly intercorrelated and interdependent; all are essential to a healthy
work environment. The AACN standards and the
EOM are not identical. The standards were identified
by leaders, experts, and a professional organization;
the EOM was compiled from the perspective of staff
nurses working in magnet hospitals.7 Both the standards and the EOM focus on processes or relationships, and both emphasize that it is not any one
process or relationship but the aggregate that constitutes a productive, healthy work environment.
This congruence and alignment between the standards and the EOM are sufficient to make the EOM
a suitable instrument for answering the questions
that guided our study: How healthy are ICU work
environments? Do some types of ICUs report healthier work environments than do others?

About the Authors

Claudia Schmalenberg is president of nursing at Health
Science Research Associates, Tahoe City, California.
Marlene Kramer is vice president of nursing at Health
Science Research Associates, Apache Junction, Arizona.
Corresponding author: Claudia Schmalenberg, RN, MSN,
Health Science Research Associates, PO Box 7667, Tahoe
City, CA 96145 (e-mail: claudializ@juno.com).

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Background
Structures
The structural elements and attributes of ICUs
that are linked to a healthy practice environment are a
physical layout that allows constant observation and
immediate access to patients; a high level of rapidly
developing technology; competent, experienced
nurses; a low nurse to patient ratio8; longevity of contact between nurses and physicians9-11; and a high
degree of medical specialization.10-12 ICUs also have
high medical pervasiveness, that is, a relatively small
number of physicians who are called and who visit
the unit frequently and for longer
periods than do physicians in other
units.13 Bedside rounds with physicians, nurses, healthcare workers
from other disciplines, the patient,
and the patients family all discussing
the patients progress and daily and
long-term goals are characteristic of
ICUs, particularly medical ICUs.10,11

A healthy
work environment enables
nurses to meet
organizational
objectives and
achieve personal
satisfaction in
their work.

Processes and Outcomes

The 6 relationship processes
identified in the AACN standards
are skilled communication, true collaboration, effective decision making, staffing that matches patients
needs and nurses competencies, meaningful recognition, and authentic leadership. Some processes
such as effective decision making have been positively linked to ICU structures,13,14 and ICU structures have been linked to patient outcomes such as
mortality and to nurse outcomes such as burnout,
job satisfaction, stress, and turnover.13,15 The functional processes and relationships that constitute a
productive, healthy work environment have not
been measured and studied in their aggregate.
The results of empirical studies of the effects of
ICU structures on processes and outcomes have been
mixed. In one study,14 ICU nurses had a greater need
for autonomy and scored higher in autonomy than

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459

did nurses in other types of clinical units. In another

study,16 researchers found no differences in autonomy scores between nurses in ICUs and emergency
departments and nurses in general medical-surgical
units. In still another study,4 ICU nurses scored the
lowest of all groups in autonomy.
Structures and nurse outcomes often are linked
by comparing scores of nurses from ICUs with scores
of nurses from other units. ICU nurses are reported
to have more occupational stress, less job satisfaction, and greater turnover than are nurses in other
types of units,13 although it also is reported that
medical-surgical nurses have higher occupational
stress and turnover than do nurses in other units.16
In a study of 55 516 registered nurses (2900
work groups) in 206 hospitals in 44 states, Boyle et
al13 reported that work group satisfaction was moderate across 10 types of clinical units. Nurses in pediatric units were the most satisfied of all, those in
emergency departments and perioperative services
were the least satisfied of all, and ICU nurses were
the most satisfied of nurses in the 7 remaining types
of units.13 When different clinical units were compared with respect to 8 attributes essential to a productive work environment, ICU
nurses scored higher on collegial/collaborative relationships between
nurses and physicians and perception
of adequate staffing and lower on
nurse manager support than did
nurses from other units (C.E.S. and
M.K., unpublished data, 2007).
In a classic study that showed
linkages between structures, processes,
and outcomes in assessing the quality of healthcare and work environments, Knaus et al15 examined the
relationship between ICU structures
and the patient outcome mortality
less than would be expected by acuity. The findings indicated that the
significantly lower mortality rates in
the ICUs studied nationwide were
due not to the structural elements of
ICUs but rather to the processes of teamwork and
collaboration between nurses and physicians. These
results illustrate the fundamental principle that,
although structure is critically important, structure
alone does not produce outcomes. Structures enable
processes that lead to outcomes.17

Compared with
other types of
clinical units,
ICUs score
moderate in job
satisfaction and
moderately high
on some factors
essential to a
productive work
environment.

Types of ICUs
In 3 studies,6,18,19 nurses in medical ICUs
(MICUs) reported more favorable components in

460

their work environments than did nurses in other

types of ICUs. In a study of 2323 nurses in 110 ICUs
in 64 hospitals, Cimiotti et al6 found that nurses in
MICUs and medical-surgical ICUs (MSICUs) perceived higher staffing levels than did nurses in coronary care units and surgical ICUs (SICUs). The
degree of collaboration between physicians and
nurses as perceived by nurses was related to positive
outcomes for patients in MICUs but not in SICUs or
MSICUs. Baggs et al18 reported that the degree of collaboration as perceived by physicians was not associated with outcomes in any type of ICU. In a study
by Ferrand et al19 of 3156 nurses and 521 physicians
from 133 French ICUs (90 MSICUs, 22 SICUs, and
21 MICUs), MICU nurses believed they were more
involved and more satisfied with end-of-life care
decisions than were nurses in SICUs or MSICUs.
The aggregation of ICUs into different types
was not consistent across these studies,6,18,19 making
the results difficult to interpret. In some, coronary
care units were grouped with MICUs; in others,
coronary care units were studied as separate types
of ICUs. None included neonatal ICUs (NICUs).
Measuring Nurses Work Environments
Few tools are available to measure nurses work
environments. Studies20,21 in which environments were
measured by using conceptually derived subscales
from the Nursing Work Index22 were based on individual rather than unit level data, lacked a theoretical
base, and measured presence of the attribute without regard to the steps or components of the process
or to the respondents definition of the concept. For
example, compare the statement I can practice
autonomously with Nurses on this unit make independent care decisions in that sphere of practice that
is uniquely nursing. Such differences make it difficult to relate, compare, or interpret the results.
With the EOM, both the components of the
work environment and the composite work environment can be measured; 90% of the items are written
from a clinical unit perspective and the remaining
10% are organizationally and unit based.3 The EOM
has a long developmental history. In 1984, 65 characteristics of a magnetic work environment, confirmed by the original investigators, were abstracted
from the original magnet hospital report, and a tool
to measure job satisfaction and productivity was
developed.23 After administration to thousands of
nurses during a 12-year period, the tool was condensed to the 37 most frequently selected items. In
2001, staff nurses in 14 magnet hospitals were asked
to identify the 10 attributes most important to being
able to give quality patient care (productivity).7 In

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the magnet hospital study,24 4 outcome criteria

attraction, retention, productivity, and job satisfactionwere used to designate magnet or excellent
work environments. In a causal modeling study,25
productivity accounted for more than 80% of the
variance in job satisfaction, attraction, and retention.
Hence, in the 2001 study,7 staff nurses were
asked to select the essential environmental attributes
on the basis of productivity alone. The 8 attributes
identified by staff nurses in magnet hospitals were
as follows:
1. Working with clinically competent peers
2. Collegial/collaborative relationships between
nurses and physicians
3. Clinical autonomy
4. Nurse manager support
5. Control over nursing practice
6. Perception that staffing is adequate
7. Support for education
8. A culture in which concern for the patient is
paramount (values)
On the basis of interviews with 279 staff nurses
and 132 leaders and managers in 14 magnet hospitals7 and participant observations of nurses in 12
other magnet hospitals,26 grounded theories were
generated.3,12,27 Items to measure each attribute of a
productive work environment were developed on
the basis of these theories and the definitions and
descriptions provided by nurses during interviews.
Each attribute is measured by using a subscale.
Weighting studies were done to determine relative importance of steps and components of the
process.3 For example, physician-nurse relationships
based on mutual power, trust, and respect (collaborative) are more instrumental in enabling quality
patient care than are student-teacher or friendly
stranger relationships, hence the item has greater
weight in the scoring. The weighted, composite score
for the 8 relationships or processes is a measure of a
healthy, productive work environment; it is labeled
professional job satisfaction to signify that it is
job satisfaction due to professional productivity.
Staff nurses describe this variable as an environment
that helps me do a good job, in which I can make
a difference in the care patients receive, or where
what I do helps patients get better and stay healthy.
Alignment is considerable between components
of a productive work environment as measured by
the EOM and the 6 AACN standards. Both the EOM
and the standards are based on relationships or
processes. The skilled communication standard is
most closely related to the process of working with
other nurses who are clinical competent but also to
support for education. An almost direct parallel

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exists between the true collaboration standard and

the process of establishing collegial and collaborative
relationships between nurses and physicians. True
collaboration also refers to one of the steps in the
clinical autonomy process, respect for the unique
knowledge and ability of each profession.2(p190)
Effective decision making is related to both the
clinical autonomy and the control of nursing
practice processes of the EOM. Appropriate staffing
parallels the EOM process of perceived adequacy
of staffing. The meaningful recognition standard is
most closely related to control of nursing practice,
and the authentic leadership standard is related to
nurse manager support.2 Both the EOM and the
AACN standards recognize the interrelationship and
interdependence of the components whose aggregate constitutes a snapshot of a specific environment. The EOM is used to measure a productive
work environment; the AACN standards define
healthy as productive and satisfying.2

Objectives of Study
The purpose of our study was to answer the following questions: To what extent do ICU nurses
confirm a healthy work environment? Are there differences in perception by type of ICU?
If some types of ICUs excel, systematic study of units that report
healthy work environments will
permit identification of structures
and practices that, when implemented, would improve the practice
environment of other clinical units.
Analysis of the individual processes
and relationships that lead to productive work environments will
enable assessment of the impact
that the AACN standards have had
on improving the work environment of nurses in ICUs and will
suggest specific areas and strategies
for change and improvement.

Design and Sample

Alignment and
correspondence
between the
Essentials of
Magnetism (EOM)
and the AACN
standards is
sufficient to
make the EOM
a suitable tool
to measure
healthy work
environments.

A cross-sectional descriptive
design with strategic sampling was
used in this secondary analysis of
data from a larger study28 designed to identify organizational structures and practices that enable
processes and relationships essential to a productive
work environment. The complete sample consisted
of 2990 staff nurses from 206 clinical units in 8
magnet hospitals. The ICU subsample was 698 staff
nurses from 34 ICUs grouped into 4 types: (1)

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Table 1
Number and percentage of nurses in each type of intensive
care unit by education, experience, and certification
No. (%) of nurses in each type of intensive care unita
Medical-surgical
(n = 158)

Variable

Surgical
(n = 157)

Medical
(n = 134)

Neonatal
(n = 249)

Total
(n = 698)

48 (19.7)
30 (12.3)
159 (65.2)
7 (2.9)
0 (0.0)

163 (23.9)
68 (10.0)
427 (62.5)
24 (3.5)
1 (0.1)

Education
Associates degree
Diploma
Bachelors degree
Masters degree
Doctoral degree

40
19
90
6
0

(25.8)
(12.3)
(58.1)
(3.9)
(0.0)

34 (21.9)
11 (7.1)
103 (66.5)
6 (3.9)
1 (0.6)

41
8
75
5
0

(31.8)
(6.2)
(58.1)
(3.9)
(0.0)

Experience, y
3
>3 to 5
>5 to 10
>10 to 15
>15 to 20
>20 to 30
>30

17
16
40
27
21
23
11

(11.0)
(10.3)
(25.8)
(17.4)
(13.5)
(14.8)
(7.1)

37 (24.5)
15 (9.9)
22 (14.6)
23 (15.2)
20 (13.2)
26 (17.2)
8 (5.3)

32
12
19
19
16
16
10

(25.8)
(9.7)
(15.3)
(15.3)
(12.9)
(12.9)
(8.1)

Certified

38 (35.2)

37 (26.1)

31 (23.1)

49
22
53
24
25
47
19

(20.5)
(9.2)
(22.2)
(10.0)
(10.5)
(19.7)
(7.9)

57 (25.6)

135
65
134
93
82
112
48

(20.2)
(9.7)
(20.0)
(13.9)
(12.3)
(16.7)
(7.2)

163 (26.9)

aData were not available for all nurses in each unit, so total number of nurses for each variable in each column may not match the total number listed in
the column heading. Percentages are calculated on the basis of available data. Because of rounding, not all percentages total 100.

medical and coronary care units labeled MICU; (2)

surgical, cardiovascular, and trauma units labeled
SICU; (3) neonatal and pediatric units labeled NICU;
and (4) mixed medical-surgical critical care units
labeled MSICU. The magnet hospitals selected for
the strategic sample had the highest or second highest composite EOM score in the 8 regions of the
country; selection between highest and second highest was done to balance the academic and community hospital samples.

Procedure
The EOM was administered to the staff nurse
population in each hospital during a 6-month
period in late 2005 and early 2006. Because the
study was one of work environment, only clinical
units with a complement of more than 5 registered
nurses (to protect anonymity) and a response rate
of 50% or more (to ensure representativeness) were
included. After approval was obtained from the
institutional review board, EOM data were collected
by on-site investigators.

Method
Instrument
The EOM was used to measure a healthy work
environment as defined by AACN. For 7 of the subscales, participants respond to a 4-point Likert scale
ranging from strongly agree to agree to disagree to
strongly disagree. For the subscale on the relationships between nurses and physicians, the options
are as follows: true for most physicians, most of the
time; true for some physicians, some of the time;
true for 1 or 2 physicians on occasion; not true for
any physicians. Some items are reverse scored. The
sum of the weighted items equals the score for the
subscale. Professional job satisfaction, equivalent to
productive work environment, is the composite score
for the 8 subscales. Two global-item outcome indicators were used to measure overall job satisfaction
and nurse-assessed quality of care. Both are 1 to 10
scales (10 high), and benchmarks are provided. Content validity indices for the 8 subscales range from
0.88 to 1.00, with a median of 0.92.3 Cronbach s
for subscales and outcome measures range from .80
to .90, with a median of .88.3

462

Data Analysis
Univariate analysis of scores on the EOM subscales, EOM total score, and outcome measures by
experience, education, certification, type of hospital,
and ICU subtype was used to detect significant differences. Multivariate analysis procedures were used
to control for differences.

Results
Description of the Sample
A total of 66% of the ICU nurses had a baccalaureate or higher degree; SICUs had the largest percentage (71%) of nurses with a baccalaureate degree or
higher (Table 1). Mean years of experience ranged
from 12 in MICUs and SICUs to 14 in MSICUs, with
a mean of 13. Among the ICU nurses in the sample,
27% were nationally certified; 60% had earned the
CCRN certification; 23%, the RN, C certification;
and the remaining 17% had certifications scattered
among 15 different specialties. The MSICUs had the
highest percentage (35%) of nationally certified
nurses. None of the differences among different

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types of ICUs with respect to experience (2 = 25.8;

P = .10), education (2 = 16.3; P = .18), or certification
(2 = 5.0; P = .17) were significant. Types of ICUs
differed significantly between the 3 academic hospitals and the 5 community hospitals (2 = 163.9;
P < .001). A total of 91% of the MSICUs were in
community hospitals; 74% of the NICUs were in
academic hospitals. SICU and MICUs were evenly
distributed between the 2 types of hospitals.
Which Types of ICUs Report the Healthiest
Work Environments?
In this strategic sample of 8 magnet hospitals
scoring above the mean29 on the National Magnet
Hospital Profile, the sample of 698 ICU nurses
reported a mean score of 292 for professional job
satisfaction, a score of 7.18 for overall job satisfaction (10-point scale, 10 high), and a score of 8.31
for nurse-assessed quality of care.
Covariate analysis of the EOM process and the
outcome scores, with education, experience, certification, and type of hospital controlled for, revealed
no significant differences among the 4 types of ICUs
in terms of education or certification. Differences in
scores by experience and type of hospital were significant (Table 2).
Follow-up analysis (data not shown) indicated
that nurses with 3 years or less of experience and
those with more than 30 years of experience scored
significantly higher (P = .001) on the essentials, support for education and patient-centered values, and
on the outcome, overall job satisfaction, than did
the other groups. For nurse-physician relationships,
nurses with more than 20 years of experience had
significantly higher scores than did nurses with more
than 3 and up to 5 years of experience. The consistently lowest scoring groups were the nurses with
more than 3 and up to 5 years of experience, more
than 10 and up to 15 years of experience, and more
than 5 and up to 10 years of experience. The 360
nurses from community hospitals scored significantly
higher on the essentials, clinically competent peers
(P = .001), control over practice (P = .003), and adequacy of staffing (P = .002), and on the outcomes,
professional job satisfaction (P = .04) and quality of
care (P = .007), than did the 338 nurses from academic hospitals. Nurses in academic hospitals scored
higher on nurse manager support (P = .001) and
patient-centered values (P = .007).
Covariate analysis indicated that the primary
differences in EOM process and the outcome scores
were due to the type of ICU (Table 2). Post hoc analysis indicated that NICUs had the highest scores of
all units on the outcome variables: professional job

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satisfaction, overall job satisfaction, and nurseassessed quality of care. Nurses in NICUs scored
significantly higher than did nurses in MSICUs on
professional job satisfaction, the overall measure of
a healthy work environment used in this study. Mean
scores and source of significant differences are presented in Table 3. Nurses in NICUs scored significantly
higher than did those in SICUs on nurse-assessed
quality of care. Nurses in NICUs had higher scores
than did nurses in the other types of ICUs on the
components of a healthy work environment, particularly the nurse-physician relationship, control of
nursing practice, perceived adequacy of staffing, and
patient-centered values. MICUs scored higher than
all other types of ICUs and significantly higher than
MSICUs on the other 4 components of a healthy
work environment: support for education, nurse
manager support, clinical autonomy, and clinically
competent peers.
Item analysis was done to ascertain steps and
components of the EOM processes that accounted
for significant differences in subscale scores. We used
the percentage of nurses responding affirmatively
(strongly agree and agree) rather than mean item
scores because the percentages
seemed conceptually more meaningful. Table 4 shows those items
for which differences were significant. NICU nurses reported the
highest percentage of positive factors in their work environments
such as equal trust, power, respectful
working relationships with physicians, and cohesive work groups,
and the absence of negative factors
such as bureaucratic rules that
inhibit decision making and a hospital culture that is reluctant to try
new things.

Nurses with
less than 3 years
and more than
30 years of
experience
report higher
job satisfaction
and patientcentered values.

Conclusions and Implications

Two-thirds of the ICU nurses in this sample
had a baccalaureate or higher degree. This percentage is well above the 50% goal set by nurse
executives in community hospitals and close to
the 70% goal set in academic hospitals.30 These
ICU nurses were quite experienced, with a mean
of 13 years of experience. About one-quarter were
nationally certified. This percentage (27%) is virtually the same as that reported in a recent study
(C.E.S. and M.K., unpublished data, 2007) of
10 514 nurses in 18 magnet and 16 comparison
hospitals, although ICU nurses were the clinical
group with the most national certifications. This

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463

Table 2
Significance of difference in Essentials of Magnetism (EOM)
process and outcome variables: multivariate analysis of variance
Type III sum of squares

Variable

Mean square

Type of intensive care unit (df = 3)

Process variables
Support for education
Nurse-physician relationships
Clinically competent peers
Clinical autonomy
Control of nursing practice
Perceived adequacy of staffing
Patient-centered values
Nurse manager support

38.936
1108.884
38.930
1989.967
1863.069
167.856
190.106
286.884

12.979
369.628
12.977
663.322
621.023
55.952
63.369
95.628

3.742
6.223
3.019
3.822
3.212
4.937
3.538
7.050

.01
<.001
.03
.01
.02
.002
.02
<.001

16 757.996
120.124
34.716

5585.999
40.041
11.572

4.044
10.217
5.513

.007
<.001
.001

7.637
6.759
0.240
93.478
43.712
7.924
0.185
0.014

7.637
6.759
0.240
93.478
43.712
7.924
0.185
0.014

2.202
0.114
0.056
0.539
0.226
0.699
0.010
0.001

.14
.74
.81
.46
.64
.40
.92
.97

548.426
0.102
3.486

548.426
0.102
3.486

0.397
0.026
1.661

.53
.87
.20

17.345
385.777
9.665
137.45
55.419
5.756
122.834
46.516

17.345
385.777
9.665
137.45
55.419
5.756
122.834
46.516

5.000
6.495
2.248
0.795
0.287
0.508
6.858
3.429

.03
.01
.13
.37
.59
.48
.009
.06

55.311
21.388
7.826

55.311
21.388
7.826

0.040
5.457
3.729

.84
.02
.05

3.576
11.887
51.298
232.153
771.688
76.408
137.063
138.793

3.576
11.887
51.298
232.153
771.688
76.408
137.063
138.793

1.031
0.200
11.933
1.338
3.991
6.742
7.653
10.232

.31
.66
.001
.25
.05
.01
.006
.001

7699.444
8.340
15.605

7699.444
8.340
15.605

5.574
2.128
7.435

.02
.14
.007

0.993
51.428
0.600
3.344
215.379
11.676
25.702
32.845

0.993
51.428
0.600
3.344
215.379
11.676
25.702
32.845

0.313
0.886
0.145
0.020
1.119
1.084
1.437
2.465

.58
.35
.70
.89
.29
.30
.23
.12

59.090
10.124
0.318

59.090
10.124
0.318

0.044
2.714
0.156

.83
.10
.69

Outcome variables
Professional job satisfaction (total EOM)
Overall job satisfaction
Nurse-assessed quality of care

Education (df = 1)
Process variables
Support for education
Nurse-physician relationships
Clinically competent peers
Clinical autonomy
Control of nursing practice
Perceived adequacy of staffing
Patient-centered values
Nurse manager support

Outcome variables
Professional job satisfaction (total EOM)
Overall job satisfaction
Nurse-assessed quality of care

Experience (df = 1)
Process variables
Support for education
Nurse-physician relationships
Clinically competent peers
Clinical autonomy
Control of nursing practice
Perceived adequacy of staffing
Patient-centered values
Nurse manager support

Outcome variables
Professional job satisfaction (total EOM)
Overall job satisfaction
Nurse-assessed quality of care

Type of hospital (df = 1)

Process variables
Support for education
Nurse-physician relationships
Clinically competent peers
Clinical autonomy
Control of nursing practice
Perceived adequacy of staffing
Patient-centered values
Nurse manager support

Outcome variables
Professional job satisfaction (total EOM)
Overall job satisfaction
Nurse-assessed quality of care

Certification (df = 1)
Process variables
Support for education
Nurse-physician relationships
Clinically competent peers
Clinical autonomy
Control of nursing practice
Perceived adequacy of staffing
Patient-centered values
Nurse manager support

Outcome variables
Professional job satisfaction (total EOM)
Overall job satisfaction
Nurse-assessed quality of care

464

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percentage of certified nurses seems quite low in

our strategic sample.
Nurses in the ICUs represented in this study
reported highly productive work environments that
reflect the 6 standards fashioned by AACN as measured by the professional job satisfaction score of the
EOM. This score for the ICU nurses in this study
was 292, a mean score that exceeds both the 2004
National Magnet Hospital Profile mean score of
289 and the mean score of 287 reported for 18
magnet hospitals in recent studies29 (C.E.S. and M.K.,
unpublished data, 2007). As of the end of 2006, 76
magnet hospitals had been tested with the EOM;
the 95th percentile for professional job satisfaction
for all magnet hospitals is 291.
When asked how satisfied they were with their
current nursing job, considering all aspects of the job,
salary, and fringe benefits as well as values, ideals,
and goals, ICU nurses rated their overall job satisfaction as 7.18 on a 10-point scale, where 10 is the highest score. This rating is within range but below the
National Magnet Hospital Profile mean score of
7.74, yet it is higher than the 6.86 mean score
reported for other magnet hospitals.29 The 7.18 score
is slightly above the 95th percentile score of 7.09.
The mean score for nurse-assessed quality of
patient care of 8.31 was one of the highest scores
obtained in any study that used the EOM. In both
the study of 18 magnet hospitals (C.E.S. and M.K.,
unpublished data, 2007) and the National Magnet
Hospital Profile,30 the mean score was 8.04. The
95th percentile score was 8.26. Thus, the ICU nurses
in our study not only confirmed healthy work environments but rated their overall job satisfaction as
high and rated the quality of care they give to
patients as outstanding.
Relationships between education and experience
and outcomes such as healthy, productive work environments, overall job satisfaction, and nurse-assessed
quality of care must be empirically determined. Our
results indicate that baccalaureate-educated nurses
are well prepared to avail themselves of opportunities that enable them to engage in processes and
relationships that lead to job satisfaction and quality patient care, perhaps better prepared than are
their less educated counterparts. Years of experience,
on the other hand, do not seem to progress in a
tidy fashion; both very inexperienced nurses and
very experienced nurses confirmed healthier work
environments than did other groups with different
levels of experience. Perhaps some nurses have 13
years of experience whereas others nurses have 1 year
repeated 13 times. Is it possible to coach/mentor
nurses and plan work activities so that each year

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employed is a year of high-quality experience?

What part does specialty certification play in
increasing nurses ability to use structures and
opportunities presented to improve satisfaction,
productivity, or processes such as autonomy and
clinical competence? Published reports suggest positive relationships between certification and clinical
competence31 and between certification and empowerment.32 However, a national critical care survey
indicated a perceived lack of organizational support
for specialty certification.33 In our study, MSICUs
had the largest percentage (35.2%) of certified nurses.
But these nurses scored lowest on the clinically
competent peers essential, and item analysis indicated the lowest perception on the item certification
is a mark of clinical competence.
This result seems to indicate that specialty certification was not highly valued by MSICU nurses or
by other types of ICUs. Either nurses do not recognize the potential of specialty certification as a baseline for many of the processes and relationships
inherent in a healthy and productive work environment, or financial support and recognition are
insufficient, or managers may need to refocus on
other types of educational programs
to serve as building blocks for certification. The value and relevance of
national certification as it affects a
healthy work environment must be
empirically studied. Without additional organizational support and
financial incentives, specialty certification may remain at a relatively
low level.
NICU nurses in this study
scored the highest on 4 of the process variables as
well as professional and overall job satisfaction and
nurse-assessed quality of care; MSICU nurses scored
the lowest on most variables. What is it about the
NICU work environment that leads clinical nurses
to proclaim the NICU as such an ideal work environment? It is probably not nurse attributes of education, experience, or certification because we found
no differences in these demographic characteristics
by type of ICU.
The differences between different types of ICUs
may be due to the structural feature degree of specialization. Empirical studies10,11,34 indicate that a
high degree of specialization is directly linked to
development of collegial and collaborative relationships between nurses and physicians, enactment of
clinical autonomous decisions, and perception of
high clinical competence. Of the 4 types of ICUs,
NICUs have both age specialization and medical

NICU nurses
report the highest
percentage of
positive attributes
in their work
environment.

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465

Table 3
Mean scores on essential attributes of a productive work environment by type of intensive care unit
Essential attributes of a productive work environment
Type of intensive
care unit

Nurse-physician
relationships

Neonatal
Medical
Surgical
Medical-surgical
All

47.88a
45.37+
44.69+
45.65+
46.14

PatientControl of
Adequacy centered
nursing practice of staffing values
72.79a
17.63a
32.82a
69.22+
69.79
70.99
71.02

16.76
16.96
16.57+
17.07

Support for
education

Clinical
autonomy

Nurse manager
support

Clinical
competence

12.11
12.28a
12.10
11.58+
12.02

77.90
80.52a
77.35
75.39+
77.71

23.68
24.58a
23.72
22.69+
23.64

12.19
12.46a
12.25
11.84+
12.17

32.13
31.90
31.58+
32.20

a This type of unit scored significantly higher (P .001) than units designated with a plus sign.

Table 4
Percentage of respondents indicating agreement
with items by type of intensive care unit
Type of intensive care unit
Medical-surgical
(n = 158)

Medical
(n = 134)

Surgical
(n = 157)

Neonatal
(n = 249)

84.2
16.6
55.7

80.6
14.2
51.9

79.0
10.8
54.1

91.9
6.5
49.4

81.0

81.3

80.3

88.7

36.3
81.6
44.9
75.8
59.9

25.6
85.0
34.6
84.2
71.4

28.7
78.8
40.1
78.4
59.7

17.8
89.8
27.2
86.1
69.4

64.6
57.3
44.9
78.2

60.4
62.7
45.5
79.2

70.1
57.5
52.9
86.6

80.2
69.7
57.8
92.0

65.8
36.1

75.4
29.9

69.7
33.5

84.2
25.9

68.4
83.5

67.9
87.3

72.1
89.6

82.9
92.7

Support for education: Pursuing education, extending

knowledge, and increasing competence is valued by others

83.4

89.5

86.6

92.7

Clinical competence: National certification is recognized as

evidence of high clinical competence

79.0

86.5

84.3

90.6

Nurse manager support: Nurse manager facilitates teamwork

77.1

87.3

84.1

86.9

26.3
73.9
84.8

29.3
80.5
94.0

29.3
75.8
91.1

14.9
86.2
94.3

73.9
88.0
75.6
79.7

73.0
91.8
76.9
84.3

79.0
91.7
75.5
79.0

86.2
93.9
87.4
92.6

Subscale and items

Nurse-physician relationships
Student-teacher with physician willing to teach
Hostile/abusive relationships
Friendly stranger relationships, formal, polite exchange of
information (eg, bus driver syndrome)
Collegial: physicians treat the nurses on this unit as equals
Clinical autonomous decision making
Autonomous decision making is risky; fear getting into trouble
Evidence-based practice provides knowledge base for decision making
Bureaucratic rules and regulations prevent or inhibit decision making
Held accountable in positive, constructive manner
Nursing administration wants us to function autonomously
Control over nursing practice
Control practice issues/policies at unit and departmental levels
Physicians, administrators recognize that nurses have control over nursing practice
Have control over nursing practice at unit level only
Have positive, effective outcomes from activities/councils related to control
over nursing practice
Perceived adequacy of staffing
Staffing is adequate for quality patient care
We deliver care differently from day to day because we do not have enough
staff or enough nurses
Staffing is adequate for safe patient care
Teamwork and group cohesiveness enable us to give quality care with the
current level of staffing

Cultural values, concern for patient

Department and/or hospital is reluctant to try new things
People are enthusiastic about their work here
Work together as a team, within nursing and with medicine/physical therapy,
occupational therapy, rehabilitation
Cost (money) is important, but good patient care comes first here
Contributions of all, nurses, nurse assistants, techs, are important and valued
Administration anticipates changes that need to be made and is proactive
Values are known, understood, shared, and frequently talked about here

466

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Outcome variables
Professional
job satisfaction
297a
293
288
286+
292

Global job
satisfaction
7.73a
7.08+
6.80+
6.81+
7.18

Quality of
care
8.57a
8.27
8.06+
8.22
8.31

specialization. Patients in NICUs are usually under

the supervision of a relatively small group of neonatologists. This arrangement leads to more frequent
contact between the same physicians and nurses
and hence more opportunity to develop collaborative and collegial relationships.10,11
The greater, deeper, more consistent family
involvement characteristic of NICUs may account
for the high professional and overall job satisfaction
scores. MSICUs are the least specialized, being the
equivalent of medical-surgical units in the intensive
or critical care area. In contrasting NICUs and MSICUs, the age of the patient also may affect degree
of specialization, because adult ICU patients often
have comorbid conditions that require a breadth of
knowledge, skill, and competence among the nurses,
whereas NICU nurses need depth of knowledge and
competence for a narrow age range.
All of the ICUs in this study, but particularly
the NICUs, are models of healthy, productive, professional work environments for nurses. Much can
be learned from studying their structures, practices,
and features. Just as none of the AACN 6 standards
of a healthy work environment is optional, neither
are the functional processes that staff nurses identify
as constituting a productive work environment. The
8 essentials are intercorrelated and interdependent,
some to a greater degree than others. Although all
these factors contribute to a healthy work environment, comparison of the performance of a unit
group of nurses on individual processes with the
high standards set by the nurses in this study will
yield information and direction that will permit formulation of strategies to improve specific nursing
work environments.
Relationships among functional processes
(essentials) also must be studied. Competence is
the basis for the mutual or equal power, trust, and
respect that characterize collaboration between
physicians and nurses.10,11 Physicians want nurses to
function autonomously, particularly in need to rescue situations, but only if the nurses are competent.12,32 The major goal of the essential support for

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education is to advance clinical competence. A key

support behavior of nurse manager support is making it possible for staff to attend seminars, programs,
and other educational activities.35
Specific help to individual units and hospitals
in creating and sustaining healthy work environments
can be further facilitated through analysis of items
on each of the process subscales. The scales are based
on grounded theory generated from interviews and
participant observations with nurses from 47 magnet hospitals. Items depict the steps or components
of each process. Determination of the percentage of
nurses in a unit who indicate that they can perform
each step or component will allow identification of
problem areas and what needs to be corrected to
produce healthy, productive work environments.
In summary, nurses in all ICUs in this study,
particularly those in NICUs, report healthy, productive work environments. Empirical study of ICUs and
the possible linkages and relationships between nurse
attributes, functional processes, and outcomes will
advance theory and management practice. Study and
analysis of subscale items will provide ideas and guidelines for assisting nurses and clinical units to achieve
healthy work environments wherein the organization
can be successful and nurses are happy and satisfied
because they can give the best possible care to patients.
ACKNOWLEDGMENTS
This multisite, evidence-based management practice initiative was a team effort. Nursing leaders and on-site investigators at each of the study sites contributed immeasurably
to the support and coordination for this project. Study sites
included The Miriam Hospital, Providence, Rhode Island;
St Cloud Hospital, St Cloud, Minnesota; St Josephs Hospital of Atlanta, Georgia; University of Colorado Hospital,
Denver; East Jefferson General Hospital, New Orleans,
Louisiana; Providence-St Vincents Hospital, Portland, Oregon; Childrens Mercy Hospitals and Clinics, Kansas City,
Missouri; and John C. Lincoln Hospital, Phoenix, Arizona.
Our sincere gratitude and appreciation are expressed to
the staff at those hospitals who participated in this study.
Without their generous contribution of time, spirit, effort,
and ideas this study could not have been done.
FINANCIAL DISCLOSURES
This work was funded in part by a grant from the American Association of Critical-Care Nurses.
eLetters
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SEE ALSO
To learn more about AACNs healthy work environment standards, visit http://ccn.aacnjournals.org and
read the article by Ulrich and colleagues, Critical
Care Nurses Work Environments Value of Excellence
in Beacon Units and Magnet Organizations (Critical
Care Nurse, June 2007).

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19. Ferrand E, Lemaire F, Regnier B, et al. Discrepancies
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To purchase electronic or print reprints, contact

The InnoVision Group, 101 Columbia, Aliso Viejo, CA
92656. Phone, (800) 809-2273 or (949) 362-2050 (ext
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CE Test

Test ID A0716052: Types of Intensive Care Units With the Healthiest, Most Productive Work Environments. Learning objectives:
1. Discuss 3 common trends in healthy work environments. 2. Explain the relationship between the 8 essentials of a productive work environment identified
by staff nurses in magnet hospitals and the 6 AACN standards of a healthy work environment. 3. Discuss the relationship between healthy work environments and magnet hospitals.

1. Which of the following statements best describes medical

pervasiveness?
a. One physician is more prominent than others in the intensive care unit (ICU)
setting
b. A small number of physicians who tend to spend longer periods of time in the
ICU setting
c. The ICU limits which physicians have privileges in the ICU setting
d. Overall, physicians spend more time in the ICU setting than on general medicalsurgical units

6. According to Table 1, which type of ICU had the highest number

of baccalaureate-prepared nurses?
a. Medical-surgical
c. Neonatal
b. Surgical
d. Medical

2. Which of the following has a signif icant impact on lowering

the mortality rates in ICUs?
a. Perception of adequate staffing
b. Perception of supportive administration
c. Process of teamwork and collaboration between nurses and physicians
d. Structural features characteristic of ICUs

8. Which 2 age groups reported the highest overall job satisfaction?

a. Those with 3 to 5 years experience and those with more than 30 years experience
b. Those with less than 3 years experience and those with more than 30 years
experience
c. Those with 5 to 10 years experience and those with more than 30 years experience
d. Those with less than 3 years experience and those with 5 to 10 years experience

3. What accounts for the more than 80% of the variance in job satisfaction,
attraction, and retention scores of nurses in acute care hospitals?
a. Productivity of quality patient care
c. Magnet designation
b. Meaningful recognition
d. Perceived adequacy of staffing

9. AACN def ines a healthy work environment as one in which nurses have
which of the following?
a. Increased job satisfaction and meaningful recognition
b. Increased job satisfaction and opportunity to give quality patient care
c. Opportunity to give quality patient care only
d. High education levels and length on nursing experienc

4. Which of the following attributes are identif ied by staff nurses

in magnet hospitals?
a. Career ladder structure, quality improvement program, peer review,
and recognition
b. Credentialed nurse leadership, all nursing staff with 1 to 1 ratios, career ladder
program
c. Critical thinking decision-making program, all nursing staffing with 1 to 1
ratios, new graduate nurse internship program
d. Working with clinically competent peers, clinical autonomy, nurse manager
support

7. What type of ICU was identif ied by nurses as having the best
environment for autonomous practice?
a. Medical-surgical
c. Neonatal
b. Surgical
d. Medical

10. What are some of the potential reasons suggested for small
percentages of certif ied nurses in ICUs?
a. Lack of financial support
b. Lack of recognition of the potential benefits of certification as a baseline for
essential processes
c. Managers who focus on other educational needs and benefits
d. All of the above
11. Which of the following statements is incorrect?
a. None of the 8 essential attributes are optional; they are intercorrelated and
interdependent.
b. There is a parallel between true collaboration and process of establishing
collegial and collaborative relationships.
c. There is no relationship between the 8 attributes and 6 AACN standards.
d. The Essentials of Magnetism tool is a way to measure healthy work environments.

5. What are the Essentials of Magnetism and the American Association

of Critical-Care Nurses (AACN) standards based on?
a. Relationships and processes
b. Research and best practice
c. Evidence-based practice and surveys
d. Staff interviews and observations

Test ID: A0716052 Contact hours: 2.0 Form expires: September 1, 2009. Test Answers: Mark only one box for your answer to each question. You may photocopy this form.

1. K a
Kb
Kc
Kd

2. K a
Kb
Kc
Kd

3. K a
Kb
Kc
Kd

4. K a
Kb
Kc
Kd

5. K a
Kb
Kc
Kd

6. K a
Kb
Kc
Kd

8. K a
Kb
Kc
Kd

7. K a
Kb
Kc
Kd

9. K a
Kb
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10. K a
Kb
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11. K a
Kb
Kc
Kd

Fee: AACN members, $0; nonmembers, $12 Passing score: 8 correct (73%) Category: O, Synergy CERP C Test writer: Roanna Payne, RN, BSN

Program evaluation

Name
Yes
K
K
K

For faster processing, take

this CE test online at
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The American Association of Critical-Care Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation.
AACN has been approved as a provider of continuing education in nursing by the State Boards of Nursing of Alabama (#ABNP0062), California (#01036), and Louisiana (#ABN12). AACN
programming meets the standards for most other states requiring mandatory continuing education credit for relicensure.

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