performance while ensuring optimal patient

outcomes. Managers direct patient care delivery

and provide constant surveillance of nursing

competencies, productivity and financial targets,

regulatory requirements and patient care qual-

pPlanning, organizing, staffing, directing and

controlling—these are the classical roles of

managers as prescribed initially by Fayol (1949)

and later by Drucker (1954) in all industries

including nursing managers at all levels of the

organizational hierarchy. Nurse managers’ days

are filled with attending meetings, engaging in

discussions to enhance patient care delivery, and

serving on task forces to improve staffing and

productivity in order to achieve better financial

Jaynelle F. Stichler, DNSc, FACHE, FAAN

http://nwh.awhonn.org © 2009, AWHONN 341

Creating a Healthy, Positive

Work Environment

A Leadership Imperative

342 Nursing for Women’s Health Volume 13 Issue 4

ity. Leaders may or may not be managers, but

the one thing that sets leaders apart is that they

create and foster followers. Managers may have

subordinates, but leaders have willing followers.

Without followers, one simply is not a leader.

Classic books on leadership indicate that

the leader must have vision that must be clearly

articulated in a manner that influences others to

follow. Leaders influence organizational culture

through their vision and belief of what an ideal

hospital or health care system is. The culture of

the organization can be described as the “person-

ality” of the place, and it’s characterized by the

specific beliefs and values that guide all behavior

and actions within the organization. The leader

sets the culture of the organization by reward-

ing and recognizing followers for espousing the

organization’s values, demonstrating acceptable

behavioral norms and acting in ways that are the

organization’s “way” of doing things.

In some organizations, leaders have directed

nurses (and sometimes the entire organiza-

tion) on journeys to transform the professional

culture with aspirations for a Magnet designa-

tion or to be noted as a Planetree hospital. Both

designations require major work to create work

environments that reflect a just culture, reduce

incivility and promote optimal professional

interactions.

The Work EnvironmentSince the publication of the Institute of Medi-

cine’s sentinel books on the state of health care

quality with recommendations for improving

patient outcomes by enhancing the professional

workplace and nurses’ work experiences (Insti-

tute of Medicine, 2003, 2004; Kohn, Corrigan,

& Donaldson, 2000), serious evaluation of the

work environment has occurred. The purpose

of this article is to provide an overview of the

critical elements for establishing and sustaining

a positive and healthy work environment, in-

cluding the physical work environment, which

is often neglected in evidence-based articles

about the work environment.

Effects of a Healthy EnvironmentThe concept of healthy work environments is

defined as a work setting where “employees

are able to meet organizational objectives and

achieve personal satisfaction in their work”

(Shirey, 2006). Shirey noted that a healthy

work environment is one where employees feel

physically and emotionally safe as a result of

being treated fairly and respectfully by leaders

they trust, and an organizational culture that

supports and encourages open communication

and interdisciplinary collaboration. Research-

ers have demonstrated the effect of a positive

work environment on nurses’ job satisfac-

tion, recruitment and retention, autonomy,

interpersonal relationships, opportunities for

professional development and advancement

(Ulrich, Buerhaus, Donelan, Norman, & Dittus,

2007), empowerment, control over practice

(Upenieks, 2003), self-nurturance, life satis-

faction (Nemcek & James, 2007) and optimal

patient outcomes (Laschinger & Leiter, 2006).

The literature is equally replete with evidence

that the leader’s style and relationship with staff

is one of the greatest factors in developing a

positive and healthy work environment (Shirey;

Tomey, 2009).

The relevance of a positive and healthy work

environment for the nursing work experience

and patient outcomes was recognized by the

American Organization of Nurse Executives

(McManis & Monsalve Associates, 2003) when

the results of their study of nurse retention and

workplace issues led to the identification of

key success factors for ensuring a positive work

environment (see Box 1). Similarly, the Ameri-

can Association of Critical Care Nurses (2005)

developed a set of national standards for estab-

lishing and sustaining healthy work environ-

ments. The Healthy Work Environments Initiative

The leader’s style

and relationship

with staff is

one of the

greatest factors

in developing

a positive and

healthy work

environment

Jaynelle F. Stichler, DNSc,

FACHE, FAAN, is an

associate professor at San

Diego State University in

San Diego, CA. Address cor-

respondence to: jstichler@

aol.com.

DOI: 10.1111/j.1751-486X.2009.01445.x

Box 1.Components of a Positive Work Environment

• Leadership development and effectiveness

• Empowered and collaborative decision-making

• Work design and service delivery innovation

• Professional growth and account-ability

• Reward and recognition systems

• A values-driven culture

August | September 2009 Nursing for Women’s Health 343

the other with one centralized station.

Nurses in the decentralized configura-

tion spent more time coordinating

patients’ care, consulting with others

about patients’ care, collaborating

about patient care decisions with two

or more team members and providing

leadership in decision-making about

options related to the patients’ needs for

medication, treatments or interventions

and balancing risks with the benefits.

According to Gurascio-Howard and

Malloch, the alcove or cluster design

placed the nurse in closer proximity to

patients and increased collaboration op-

portunities that involved the interaction

of two or more team members. The

result of this physical design led to less

time spent in providing patient infor-

mation to other caregivers because they

were already actively involved as a team

participant in the patient’s care. This

finding has repercussions for nurses,

since there is evidence that supports the

association between teamwork, peer

cohesion and increased levels of job

satisfaction (Kotzer & Areliana, 2008;

Schmalenberg & Kramer, 2007).

Although Gurascio-Howard and

Malloch’s (2007) study compared two

includes standards for communication,

collaboration, decision-making, staffing,

recognition and authentic leadership,

which are all recognized in evidence-

based literature as essential components

for a healthy work environment.

Most of the studies in the literature

focus on the leader’s authenticity, the

organizational culture and milieu for

professional practice, interdisciplinary

communication and relationships, and

the work itself with staffing standards

and safety initiatives, but little is men-

tioned about the importance of the

physical work environment as a critical

factor in creating and sustaining a

healthy work environment.

The Physical EnvironmentOnly recently has there been an inter-

est in studying the effects of the physi-

cal environment as a critical factor in

creating a healthy work environment.

The design of the patient care unit has

been shown to affect nurse efficiency

and fatigue (Hendrich et al., 2008),

nurse stress and levels of alertness

(Cohen, 2006; Pati, Harvey, & Barach,

2008; Vischer, 2008), number and

quality of patient encounters (Gu-

rascio-Howard & Malloch, 2007) and

even compliance with hand washing

(Cohen; Joseph, 2006).

When considering the influence of

the hospital’s design on healthy work

environments, one cannot ignore

how long hallways; centralized supply,

pharmacy and equipment rooms; and

centralized nursing stations affect

nurses’ levels of fatigue, stress and men-

tal acuity. There is compelling evidence

to support decentralized or distribu-

tive nursing documentation stations

to decrease distances from the point of

service in the patient’s room to the doc-

umentation area or to areas to obtain

medications, supplies or equipment.

Decentralized nursing stations with an

observation window into the patient’s

room provide nurses with a clear line

of sight, allowing them to react more

quickly when a patient has an emergent

need. Gurascio-Howard and Malloch

(2007) reported significant differences

in the time nurses spent coordinating,

consulting, providing patient informa-

tion, collaborating and providing lead-

ership when they compared two units

with different configurations—one

with decentralized nursing stations and

The design of the patient care unit has been

shown to affect nurse efficiency and fatigue

344 Nursing for Women’s Health Volume 13 Issue 4

medical-surgical nursing unit designs, the study

also has implications for the physical design

of labor and delivery, women’s acute care and

mother-infant care units. Patient rooms that are

clustered in groups of 2, 4, 6, 8 or 12 (a number

divisible by 2 or 4) with decentralized nurs-

ing documentation areas, supply alcoves and

medication rooms minimize walking distances

from the patient point of service and the nurses’

work process areas. While there are no official

standards for the sizing of the clusters of patient

rooms, the clustering of patient rooms into

neighborhoods reduces the scale of long hall-

ways and has a positive effect on nurse-nurse

interaction and nurse-patient engagement

(Ritchey & Stichler, 2008). Reducing the overall

scale of the unit also reduces nurse fatigue as

noted in the study by Hendrich et al. (2008),

who reported that nurses walk approximately

8.5 miles per 12-hour shift in a long rectilinear

patient unit design.

Physical Designs to Reduce StressProviding patient care in a fast-paced

environment, such as in maternal-newborn

care settings, is stressful for nurses and other

health care providers. While the lounge

provides a space where nurses can get away

from the unit for their breaks and meals, it

often doesn’t provide a calm, quiet environment

for reducing the stress level for nurses. Many

lounges serve as multipurpose environments

where nurses congregate for staff meetings

and education or simply to discuss their opin-

ions, both positive and negative. In an effort to

create and sustain a healthy work environment,

many hospitals are developing “respite” rooms

for high-acuity areas where the nurses and

other providers can retreat for a few minutes

of quiet meditation, free of ambient chatter

and noise. The intent is to reduce the staff ’s

stress levels in an effort to support their positive

health.

Orientation to outside views and nature has

long been known to be healthful for patients,

and supporting evidence of this notion has led

to the development of healing environments

and philosophies such as Planetree (Frampton,

Gilpin, & Charmel, 2003; Malkin, 2006) and

to regulatory requirements for a window in

each patient’s room. Until recently, the need for

windows in nurses’ work areas was not known.

In a recent study, Pati et al. (2008) studied the

level of acute stress, chronic stress and alertness

of nurses before and after 12-hour shift among

nurses working in areas with exterior views

compared with those who did not have an ex-

terior view from the work area. The researchers

controlled for physical environment stressors

While the concept

of healing

environments

was originally

developed

to humanize

the hospital

experience for

patients, it also

has relevance

in creating and

sustaining healthy

work environments

for nurses and

other health care

providers.

August | September 2009 Nursing for Women’s Health 345

for patients, it also has relevance in creating

and sustaining healthy work environments for

nurses and other health care providers.

Healing of an open wound occurs from

deep within the wound itself, and, in fact, if an

infected wound is closed before healing occurs,

the condition often worsens with death of the

affected tissue. This example of wound healing

can be applied to the developing healthy work

environments, as well. Sadly, in some organiza-

tions, nurses are exposed to hostile work inter-

actions from other nurses, physicians or other

providers or to physical environments that

increase the potential for personal injury. These

conditions are similar to a festering wound,

and nurses are negatively affected by such work

environments. A healing environment for the

staff addresses the behavioral standards that

reduce incivility and encourages respect, trust

and collaboration. A healing environment also

creates a physical environment that reduces the

potential for workplace injuries from clutter

or overcrowding in work spaces from lack of

appropriate storage space for equipment and

supplies, unsafe patient lifting or positioning

due to unavailability of safe patient mobiliza-

tion devices, cross-contamination from poor

ventilation or air filtering systems, or allergic

responses to environmental pollutants and

noxious smells.

Healing designs include elements of nature

either through living plants in the lobby or

waiting areas or artwork that features photo-

graphs or paintings of peaceful natural scenes.

Healing designs create spaces and places where

nurses can congregate to fulfill social needs and

support teamwork, while addressing the need

for quiet space for short periods of respite from

high-intensity patient care demands. Healing

environments provide natural light, views of

nature, controlled noise levels and furniture and

finishes to create a soft soothing milieu in spite

of the hectic pace of a busy patient care area.

ConclusionCreating a healthy work environment is a leader-

ship imperative. Not only must the cultural and

behavioral norms be addressed, but a safe, clean

environment that reduces nurses’ fatigue and

stress, enhances mental acuity and alertness and

supports interdisciplinary collaboration is also

critically needed. Nurses are the most important

such as lighting, noise, thermal and ergonomic

conditions, nurses’ workload and their per-

sonal characteristics such as age and experience

level. The researcher reported that 64 percent

of nurses who were exposed to outside views

had acute stress levels that remained the same

or were reduced from the beginning to the

end of the shift, and 71 percent of these were

exposed to views of nature. Nurses whose stress

levels increased during the shift (56 percent)

did not have views to the outside for their

work areas. Similarly, nurses whose alertness

levels remained the same or increased over the

duration of the 12-hour shift had exposure to

views of nature, whereas nurses whose alertness

acuity decreased did not have an external view

in their work areas. This study has implications

for the design of all types of nursing units,

but specifically resonates with traditionally

designed labor/delivery/recovery (LDR) units

where the nurses’ station is located in the center

of the patient unit offering little exposure to

outside views. In some states, LDR units are not

required to have external windows, since the

room is considered to be a procedural room

rather than a patient room, such as a labor/de-

livery/recovery/postpartum unit (LDRP), which

does require exterior windows. These types of

environments where the nurses rarely see “the

light of day” or have the opportunity to orient

themselves to the outside can have negative ef-

fects on mood and alertness and stress levels.

Promoting Healing Through DesignThe concept of healing environments was

first described by the researchers and Board

of Directors at the Center for Health Design

(Joseph, 2006; Malkin, 2006; Ulrich, Zimring,

Joseph, Quan, & Choudhary, 2004) as a place

for patients that has connections to nature,

options and choices for patients, access to social

support, elimination of environmental stres-

sors such as noise, clutter, noxious odors, and

positive distractions or diversion from pain,

loneliness or depressive feelings from being ill

and hospitalized. Huelat (2003) defined the

concept as a place that creates a pleasurable

experience by offering hope and solace regard-

less of the stressful circumstances. While the

concept of healing environments was originally

developed to humanize the hospital experience

Healing

environments

provide natural

light, views of

nature, controlled

noise levels and

furniture and

finishes to create

a soft soothing

milieu in spite of

the hectic pace

of a busy patient

care area

346 Nursing for Women’s Health Volume 13 Issue 4

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element to a healing environment for patients

and, therefore, it’s critical that leaders ensure that

the care setting provides a safe, healing physical

environment for staff as well. A healthy work en-

vironment provides a healing milieu for patient

care and addresses the space, place and person—

space for optimal patient care delivery, a place

that encourages healing and a person (nurse)

who demonstrates compassionate caring because

of the positive work environment. NWH

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