Chaging unhealthy work environments: unhealthy work environments lie at the heart of global nursing shortages. Improvements must be made to protect nurses' health and well-being and ensure patient safety.

As nursing organisations and nurses around the world prepare to celebrate the birthday of the founder of modern nursing Florence Nightingale on May 12, the International Council of Nurses (ICN) has launched a global call for improvements in the health work environment.

Working conditions in many countries have deteriorated, says ICN, as governments have continued to under invest in the health sector. This has had a serious, negative impact on the recruitment and retention of health personnel, the productivity and performance of health facilities, and ultimately on patient outcomes. Positive practice environments must be established throughout the health sector if national and international health goals are to be met. "We believe patients and the public have the right to the highest performance from nurses and other health care professionals," said ICN president Hiroko Minami. "This can only be achieved in a workplace that enables and sustains a motivated, well prepared workforce."

In its information and action toot kit (Positive practice environments: Quality workplaces = quality patient care), to be used by managers, frontline nurses, chief executives, professional associations and/or regulatory bodies, ICN describes the critical shortage of nurses as "a global nursing workforce crisis.

"The reasons for the shortage are varied and complex, but key among them are unhealthy work environments that weaken performance or alienate nurses and, too often, drive them away--from specific work settings or from the nursing profession itself."

The kit highlights some health care environments that do support nurses' work and well-being--"they support excellence and have the power to attract and keep nurses. These have come to be called positive practice environments." Characteristics of such environments include good recruitment and retention strategies and policies; continuing education; development and recognition programmes; adequate pay; sufficient equipment and supplies; and a safe working environment. For optimal social and psychological well-being, nurses need demands that fit the resources available; job security and workplace safety; good social support from colleagues and managers; meaningful work; a high level of influence in the workplace; and a balance between effort and reward.

Information in the kit points to the dramatic situation in developing countries where chronic nursing shortage is worsened by heavy external migration of nurses in search of better working conditions and quality of life. In Ghana, for example, more than 500 nurses left the country in 2000 for higher paying jobs in richer countries--more than double the number of nursing graduates Ghana produced that year. One study showed that nurses' organisations from 33 countries reported that the outflow of nurses to more affluent countries was a serious to extremely serious problem that worsened the already-existing shortage. (1)

Unhealthy environments affect nurses' physical and psychological health through the stress of heavy workloads, long hours, tow professional status, difficult relations in the workplace and a variety of workplace hazards, the kit states. "long periods of job strain affect personal relationships and increase sick time, conflict, job dissatisfaction, turnover and inefficiency" (1) In contrast, nurses in "magnet" hospital environments (the term used to refer to a facility that is able to attract and retain a staff of well qualified nurses and consistently provide quality care) have lower burnout rates, higher job satisfaction and better patient outcomes. In these hospitals, leadership is strong, autonomy encouraged and teamwork valued--all aspects contributing to nurse satisfaction.

Several countries, including the US and Australia, are turning to minimum, mandated nurse: patient ratios as one of a number of strategies to improve working conditions and facilitate the return of nurses to practice, as well as promote safe staffing and patient care. There is also considerable evidence that a higher registered nurse skill mix corresponds to a tower incidence of medication errors, fewer pressure ulcers and higher patient satisfaction. (2) Fewer errors occur when nurses work in less hierarchical environments where members of the health team, including physicians and nurses, work well and respectfully together.

Workplace violence

Violence in the workplace is a reality for many nurses, the kit states. Potential perpetrators include fellow nurses, other professionals, patients or their families. Data shows that the health sector is more prone to workplace violence than any other, that it is "a global occupational hazard, a growing public health concern and a violation of human and workers' rights" Factors to be addressed to stop the spiral of workplace violence include organisational and environmental factors like job design, patient flow, management style and ward structure.

The IND kit includes in its annexes a nurse work environment assessment tool, comprising a series of questions for organisations, nurses, government, national nursing associations and regulatory bodies. These are designed to stimulate thinking and develop strategies that lead to positive work environments. There are also suggested strategies nurses and organisations can use to encourage the development of positive practice environments, along with fact sheets on how to prevent needlestick injuries and the benefits of immunisations for health care workers; ICN position statements on patient safety; abuse and violence against nursing personnel; and occupational health and safety for nurses. The kit can be accessed online at www.icn.indkit.htm.

References

(1) International Council of Nurses. (2007) Positive practice environments: Quality workproces = quality patient care. Information and action tool kit. Geneva: author, p2

(2) ibid, p13