Deteriorating work environments for critical care nurses: how urgent is this issue and what can be done?

Critical care units have the highest nurse turnover with unhealthy work environments listed among the top factors (O'Brien-Pallas et al., 2010). The cost of nurse turnover in the intensive care unit (ICU) is multi-faceted. As nurses make the decision to leave the ICU, not only is there a large financial cost to the organization in terms of the financial resources required to recruit and retrain additional nurses but there is also a significant cost to staff morale, productivity and patient safety. As the international nursing shortage worsens and is compounded by deteriorating work environments in critical care, we are seeing a change in the proportion of experienced nurses to new graduate or novice nurses working in the ICU. As this trend continues globally, an increased exodus of experienced ICU nurses with an increased proportion of novice nurses joining ICUs, it will most certainly have a negative impact on the quality and safety of patient care. How healthy is your work environment? Healthy work environments are those defined as: ‘…a practice setting that maximizes health and well-being of nurses, quality of patient outcomes and organizational system performance’ (Registered Nurses Association of Ontario (RNAO), 2013). There are many factors that influence our perception of the environment that we work in. Included among the most crucial factors that matter most are: workload and resources, leadership ability and style, collegial nurse/physician relationships, praise and recognition, participation in decision-making and time to nurse. In a systematic review that examined leadership practices and intent to stay among nurses, a relational leadership style was found to positively influence work environment and intent to stay among nurses (Cowden et al., 2011). Transformational nurse leaders are inspirational, utilize shared decision making, mentor nurses, are visible and provide praise and recognition. Visibility can be very difficult and challenging for nurse managers because many have a large span of control with extremely large numbers of nurses reporting to them and potentially more than one unit to manage. A growing trend appears to be an influx of managers who are not nurses by profession and are charged with managing nurses. It is unclear what impact having non-nurse managers in areas such as critical care will have on the current nursing workforce, retention and staff nurses' perception of the work environment. Peer group cohesion and strong relations with physicians have important implications for the work environment we work in. How would you rate relationships with your coworkers? When relationships in the workplace are strained, decreased work satisfaction and burnout can result. Supportive coworkers can ease transition of new nurses into critical care and increase their likelihood of staying on the job. What strategies does your unit have in place to foster strong teams? Because nurses have many transferable skills, the issue is that experienced nurses may not only decide to leave the ICU but may decide to leave the nursing profession altogether when they are dissatisfied with their work environment. It is important to note that when a nurse makes the decision to leave her position that this decision is typically made gradually over 6–12 months in advance of leaving. One of the top concrete forms of recognition that nurses list would motivate them to stay on the job is the availability of professional development opportunities such as conferences, formal education, inservices and workshops that provide ongoing learning opportunities (Abualrub and Al-Zaru, 2008; Ulrich et al., 2009). An example of a professional development opportunity that is gaining traction among critical care nurses and has been linked to intent to stay in the ICU and in the nursing profession, is participation in high-fidelity simulation (Goldsworthy, 2015). Simulation provides a hands-on, experiential learning activity for critical care nurses through participation in comprehensive case-based scenarios. Through simulated cases that mimic the critical care setting, nurses can build their competency and confidence by repetition of high risk/low frequency skills in a safe environment. The need to develop strategies to improve work environments for critical care nurses is urgent. If deteriorating work environments are not addressed immediately, we will continue to lose greater numbers of critical care nurses. Who better to develop solutions and strategies than the front line ICU nurses? Investing in retention strategies for critical care nurses with stable, sustainable funding will assist in stabilizing the critical care nurse workforce globally. I would urge critical care nurses to join together, develop action teams to work on solutions and strategies related to this important issue. Once innovations are developed in this area of improving work environments and retaining our experienced critical care nurse workforce, it will become important to share these successes with other nurses at local and international gatherings (i.e. the BACCN annual conference). Working with nurses from other countries to add to potential strategies may broaden our thinking around this important issue. It may be time to convene an international ‘think tank’ on work environments for critical care nurses. Again, I ask you, how healthy is your work environment? Do you have strong leadership and relational managers? Do you have collaborative nurse/physician relations? Do you feel your effort is valued and that you receive recognition and praise for a job well done? Is there an investment in ongoing professional development opportunities such as simulation and a culture of learning for nurses on your unit? How manageable is the workload and do you have the resources available to do the job in your unit? Do you have ‘time to nurse’ and are you involved in decision making? If you have answered ‘no’ to any of these questions, this is the time to act. There has never been a better time to join together, have a voice and take a grass roots approach to developing strategies that will work. Not only will this improve our working environments but it may also stem the flow of highly experienced nurses from critical care. More research is needed to determine strategies that will facilitate healthy work environments for nurses. The empirical literature has established the risks to nurse retention and poor patient outcomes related to deteriorating work environments. We need to urgently continue the dialogue and push this agenda forward by working together to create and trial solutions and strategies that will improve working conditions for all nurses.

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