positive work environments arthur pease nurs 750 paper r

Running head: POSITIVE WORK ENVIRONMENTS 1

Positive Work Environments

Arthur Pease

Stevenson University

Author Note

This paper was prepared for NURS 750- Nursing Leadership/Management Capstone,

taught in Spring 2016.

POSITIVE WORK ENVIRONMENTS 2

Positive Work Environment

Positive work environments help nursing staff to maintain a positive attitude to meet the

stress factors in the acute care facility. Positive work environments help improve job satisfaction

and retention of the professional nursing staff. Today’s rapid changes in the health care industry

are creating an environment of increased stress and dissatisfaction within the nursing work force.

Nurses are faced with change in the form of more demands and expectations from their facilities

employers due to the new requirements by the Centers for Medicare and Medicaid Services

(CMS). These changes are coming in the form of how the acute care facilities are being paid.

The new requirements are based upon quality measures as well as patient satisfaction scores

(CMS, 2016). Acute care facilities are experiencing greater financial demands from the CMS

with narrowing margins which are already under 4% with a field rate in the state of Maryland of

only 0.8% (MHA, 2013). This puts pressure on the acute care facilities which in turn puts the

pressure on the nursing staff (MHA, 2013).

The workplace environment needs to have an organizational structure that is conducive to

giving their nurses autonomy and support. While acute care facilities financial margins are

shrinking, so are the numbers of nurses and the result is a reduction of over 20% of the nursing

staff by the year 2020 (Gotschall, 2010). This creates a need for nursing leaders to look at how to

change the work environment structure to promote a positive workplace. Leaders and acute care

facilities need to create an organizational structure to help their nursing staff to adapt to the new

challenges and increase job satisfaction. Creation of a positive workspace will help the acute care

facilities to retain their most valuable resource, their professional nurses, and meet the CMS

regulations.


The objective of this paper will be to explore theories that show how a positive work

environment can increase nursing job satisfaction and retention. Theories such as the “Job

Demand Control Support Model” (JDCS Model) developed by Karasek & Theorell, (1992) help

to determine the concepts needed to produce such an environment. Karasek & Theorell were

pioneers in helping to show how the work environment had an impact on the health of the

worker. The work by Karasek, Baker, Marxer, Ahlbom & Theorell, (1981) showed in a

quantitative study how higher levels of workers with more freedoms and social outlets were able

to reduce the harmful effects of the negative stress brought on by these negative environments.

The environments that help to reduce this stress gave the staff greater freedom in choices and

autonomy (Karasek, et al., 1981). Many concepts have been derived from this work and the

framework is still used as a test of the working environment today. Concepts developed from

Karasek & Theorell, (1992) and others will be reviewed. These concepts will help to show how

using best practices and Evidence Base Practice (EBP) can develop a better organizational

structure. Using the improved organizational structure should help achieve a positive work

environment, job satisfaction and engaged professional nursing staff. Developing this positive

environment will further the efforts of the acute care facilities to improve nursing job satisfaction

and retention. Following improved nursing job satisfaction and retention acute care facilities will

achieve improved patient satisfaction and quality outcomes.

Lititure Review and Research

Background and Foundation

The foundation of the Job Demand Control Support Model” (JDCS Model) developed by

Karasek & Theorell (1992) was developed by Karasek & Theorell in an earlier Swedish study

which tracked a random sample of working men in Sweden (Karasek, et al., 1981). This study


used the association of the work environment and the development of Coronary Heart Disease

(CHD). The study adjusted for issues such as age, smoking overweight and education, over a six-

year period. The study founded two concepts which were termed as Job Demands and Decision

Latitude as the two variables to be measured in the study (Karasek, et al., 1981). Karasek felt that

there was little theory in integrating job stress into the existing studies at the time. These

concepts of measuring job stress and decision freedom, and psychosocial elements create the

basis of determining the cause and effect of an unhealthy and non-positive work environment.

This initial work by Karasek, et al., (1981) helped to develop into later concept by Karasek and

Theorell (1992) called the Job demand, control, support model (JDCS model). Job demand was

the term used to describe the job stressors that were encountered on the job (Karasek & Theorell,

1992). The term, control, was described as ability to make intellectual decisions and increase

personal freedom (Karasek & Theorell, 1992). The greater the freedom to make decisions, the

greater the stress is mitigated (Karasek & Theorell, 1992). The support system came from the

psychosocial experiences in the work place, these experiences helped the workers to feel a sense

of support and team work (Karasek & Theorell, 1992).

In 1980 the American Nursing Association (ANA) and the American Nursing

Credentialing Center (ANCC), began to research why certain hospitals were hiring and retaining

nurses while others couldn’t (ANCC, 2016). The need for nursing was increasing yet there were

shortages worldwide causing concern on how to meet the demands of an adequate professional

nursing staff (ANCC, 2016). This created the first study by nurses for nurses to determine how

to improve the working environment for the nursing profession. The study lead to what was to

become the Magnet Designation (ANCC, 2016). The ability to obtain the Magnet Designation

shows everyone that this facility has a culture that provides transformational leadership and an


organizational structure to help with nursing getting autonomy and social support. The use of

transformational leadership and organizational structure are two of the workplace cultural

attributes nurses are looking for in maintaining job satisfaction and a positive working

environment.

Nursing began to look at the study by Karasek et al. (1981) in a health care worker’s

satisfaction study by Landsbergis (1988). In the Landsbergis (1988) study the concepts of the job

demand, control, support (JDCS) model was further studied. Landsbergis (1988) found the

additional concept of, the greater the education by the healthcare worker the greater the freedom

in job decision, which resulted in higher job satisfaction (Landsbergis, 1988). Landsbergis

(1988) exemplified the nursing frustration in lack of autonomy as quoted by Sexton “They teach

us to think in nursing school, and they teach us that we have our own realm and skills, but on the

job we find we have no realm at all. Unless we have a specialty we're stuck. We do what the

doctor orders and we do not think” (1982, as cited in Landsbergis, 1988, p. 234). This is the

feeling that was common within the nursing profession, and in many facilities still exists today.

The previous studies helped to show the needed for more organizational structure studies. This

created need in developing a structure for organizations that acknowledged the needs of the

professional nurse. The following studies often refer back to the foundation of these original

studies which made it necessary to at least give explanation of the original studies that are now

very dated.

Supportive Studies

In looking at the profession of nursing and the many stressors, there are many

applications of Karasek and Theorell’s concepts with stress in the work place. There are many

stressors that have a detrimental effect on the work environment of nursing. Much of the research


has included the work of Karasek and Theorell (1992) using the JCDS model. The current

research is still using the JCDS model. While this is an important model it is important to look at

other models for job satisfaction and retention within the nursing profession.

Nursing bullying on the job can have a very negative impact not only on the job

environment but on nurse job satisfaction as well. Elfi Baillien∗, Nele De Cuyper and Hans De

Witte (2011) used the work of Karasek and Theorell (1992) in showing a direct relevancy of

bullying to the Job demand, control, support (JDCS) model. The typical studies have put the

quantitative measures of job demand versus job autonomy (Baillien, et al., 2011). Each of these

theories has its own measure, they work in synergy in helping to cope with the job environment

(Baillien, et al., 2011). While Karasek and Theorell (1992) model has been applied to the issues

of health, anxiety, depression, job satisfaction, sickness and burn out, Baillien, et al. (2011) felt

that there were no studies involving behavioral issues such as bullying. While there are many

definitions of bullying the end result is that it creates a stressful work environment (Baillien, et

al., 2011). It is also reasonable to assume as the individual becomes more strained and has less

autonomy they too can become the perpetrator or the victims of bullying. Baillien, et al. (2011)

used a longitudinal study with shorter time lags of 6 months. The conclusions of this study

supported Karasek and Theorell (1992) Job Demand, Control, Support (CDCS) Model and

concluded it dealt with both the perpetrator and the recipient. The results showed that the

perpetrator and the recipient both came out of the first round of stressors and felt they had no

relief from the job demands with little autonomy and support (Baillien, et al., 2011). This is even

a greater argument for how the work environment needs to have a positive organizational

structure.


Presseau, Johnston, Johnston, Elovainio, Hrisos, Steen, Stamp, Francis, Grimshaw,

Hawthorne, Hunter & Eccles (2014) felt the studies showed Karasek and Theorell (1992) was

environmental and did not include the individual character and features as part of this conceptual

theory. Presseau, et al. (2014) wanted to show this concept of the individual character should be

included with the environment and include individual perceptions of the environment. (Presseau,

et al. (2014) used a predictive national survey as their design for the study in the United

Kingdom. The method was to invite 2079 staff members from general practices and to use a

survey via the mail (Presseau, et al., 2014). The survey used questions to assess the various job

stressors including distress, absenteeism, control levels and their intentions to leave (Presseau, et

al., 2014). One thousand and five hundred and ninety surveys were returned back with greater

than eighty percent completed responses (Presseau, et al., 2014). Presseau, et al. (2014) were

able to determine, from their responses and results, that there needed to be more research in the

relation and concept of the individual effects on the Job Demand, Control, Support Model.

Presseau, et al. (2014) further suggested that while the absentee rate and intention to leave were

low the use of an intervention to allow the staff more control would help with the individual

distress levels experienced (Presseau, et al., 2014). It is important to note the validity of Karasek

and Theorell (1992) Job demand, control, support (JDCS) model is noted within the study.

Learning through problem solving under various combinations of Karasek and Theorell

(1992) Job Demand, Control, Support (JDCS) model was the purpose of the study by Bergman,

Ahlberg, Johansson, Stoetzer, Åborg, Hallsten & Lundberg, (2012). Bergman, et al. (2012)

wanted to determine if the Job Demand Control theory helped to promote greater learning

through problem solving. The premise was when the situation of greater demand with greater

control existed did this increased the problem solving skills and helped to foster greater learning


outside the work place (Bergman, et al. 2012). Bergman, et al. (2012) specifically wanted to

determine how this environment helped to increase the desire of education within the work place

as well as outside the workplace. This was longitudinal Study with random selection of the

population within Stockholm County in Sweden ages 20 to 64 (Bergman, et al. 2012). The

response rate was 53% with 42% men and 58% women across various professions with a mean

age of 42.1 years (Bergman, et al. 2012). The conclusions found less of an importance in job

demands but job control seemed to be important for both on the job learning as well as outside

learning (Bergman, et al. 2012). It was further determined that the working conditions with an

importance in learning had a greater potential impact on job satisfaction, productivity and helped

with absenteeism, sickness and a general overall wellness (Bergman, et al. 2012).

The Center for American Nurses, (2009) published an article that outline the Joint

Commissions statement on work place violence in the nursing workplace. The article was

promoting a program to help the nursing profession to deal with the issue of workplace bullying

causing an unhealthy work environment (Center for American Nurses, 2009). The article further

highlight the Joint Commission releasing new standards to reduce workplace violence, which the

Joint Commission considered a danger to patient safety (Center for American Nurses, 2009).

The American Nurses Association also endorses this position of eliminating bullying in

the workplace and in their statement they further discuss the negative environment caused by

bullying and lateral violence. ANA (2015) further argue that the toxic environment of bullying

causes retention issues of quality staff and is a major stressor. ANA (2015) did further lititure

reviews and the evidence shows 24% of staff nurses and 25% of nurse managers will leave their

place of employment due to this behavior. The issue is employers allow this hierarchal structure


and will not allow the nursing staff to have decision abilities. This is a direct association with the

Job demand control support Model.

American Nurses Credentialing Center (ANCC). (2016). ANCC magnet recognition is

founded from the studies derived from their research and work from 1980 thru1983. ANCC

(2016) started in 1994 giving the first magnet recognition with the use of fourteen components.

Then in 2008 they reduced the number to five with organizational structure listed as

organizational empowerment as the second component (ANCC, 2016). This is in direct

correlation with the job demand, control, support theory.

In the study by Lisa Gotschall, (2010). Creating healthy work environments to welcome

the new generation of registered nurses: What the millennials tell us, studied the new nursing

graduate population in the state of Maryland. Gotschall (2010) wanted to determine the cause as

shown by Trossman, that 50% of new graduates changed jobs within their first year and as many

as 6% are leaving the profession entirely (2009, as cited in Gotschall, 2010, p. 1). Gotschall

(2010) study intent was to determine the psychosocial work environment and how this

environment would affect the new graduates’ psychological health and job satisfaction. Gotschall

(2010) found that this study group in the state of Maryland correlated to the JDCS model where

these new nurses felt depressed and lacked any job satisfaction due to no control or social

support within the work environment. Gotschall (2010) revealed seven recommendations for

helping retain the new workforce and to develop a more supportive and functional work

environment. These recommendations included use of technology such as PDA’s that the new

nursing force was accustomed to using (Gotschall, 2010). Gotschall (2010) recommended

recognition and use of social support. Gotschall (2010) stated the need for collaborative and

respectful leaders, leadership training. Gotschall (2010) further recognized that nursing educators


needed to look at the current curriculum to better train nursing students for expectations and

ability to help change environments. Further recommendations by Gotschall (2010) included new

delivery models from collaborative efforts, rewards for the new initive by the new nurses, and

further studies looking at other methods than the JDCS model for change.

Shirey (2006) looked at the use of authentic leadership in helping to develop a healthy

workplace for the nursing profession. The American Association of Critical Care Nurses,

(AACN) endorsed this theory in the attempt to create positive work places (Shirey, 2006). The

theory is again the greater the stressors, the more need for greater decision and freedom to foster

a positive work environment. This approach also has an influence on the support of education

and increased degrees (Shirey, 2006).

Kivimäki, M., Nyberg, S. T., Fransson, E. I., Heikkilä, K., Alfredsson, L., Casini, A.,

& ... Batty, G. D. (2013) wanted to conceptually compare to job strain against the effect of a

healthy versus unhealthy lifestyle with coronary disease. They used individual data from a total

of 7 cohort studies to determine the effects of adding either a healthy or an unhealthy lifestyle to

the studies (Kivimäki et al. 2013). Kivimäki et al. (2013) had a mean follow-up of 7.3 years and

with 1086 events. The analysis showed that the individuals with high job stressors and unhealthy

lifestyles were 50% greater risk for coronary disease than those with high job stressors and

healthy lifestyles (Kivimäki et al. 2013). There was no data collected for the factor of freedom

and decision control.

Kogien, Moisés, & Cedaro, José Juliano. (2014) used the theory of Karasek & Theorell

(1992) in examining the role of the public emergency workers in Rondonia, Brazil. They found a

direct relation to the Job demand, control theory (Kogien et al. 2014). The sample was composed

of 189 nursing staff and median age of 32.79, all were practicing at the time of the study (Kogien


et al. 2014). It was again the amount of increased control and the correlation of job satisfaction

and higher motivation (Kogien et al. 2014).

Brunges & Foley-Brinza (2014) looked for projects to increase job satisfaction and create

a healthy work environment. found that they needed to look at other ideas such as a quiet area for

nursing decompression. Brunges & Foley-Brinza (2014) looked at the Magnet model to help

make the changes to the organizational structure. The use of concepts using nursing councils,

education with reward and recognition programs were components of their study (Brunges &

Foley-Brinza, 2014).

Change Implications

The studies show that the working environment within the nursing profession is greatly

controlled by the organizational structure and how the leadership is structured. The concepts

show proper structure and leadership are key to facilitating the changes necessary to improve and

create positive work environments. Research has shown that the work load and flow including

the productivity does not need to decrease in order to make the work environment more positive.

The nursing profession has long been an environment of eating their young, yet they are looking

to elevate their work to a level of other professions and to promote a professional environment.

While this is often assumed to only have consequences for the new nurse it is found the entire

nursing population is often working in a non-positive environment. Yet with over three decades

of Evidence Based Practice (EBP) the change has been slow and often nonexistent.

This is going to require the nursing leaders to begin to implement change from the

existing leadership style and organization structure, into one that is open to listening and looking

at how to change the very structures that have been in place for decades. Many Fortune 500

companies have transformed either their processes or chain of command in order to promote the


employee decision process and have experienced positive results and successes (APA. 2016).

One example is Ford Motor Corporation, ran a test of using team approach by allowing the

employee teams to ask questions and deal with suppliers, develop ways to reduce defects, and

suggest better processes with the machinery in the plants (APA. 2016). This process was so

successful they adopted this team approach across the entire organization (APA. 2016). The use

of telework is another way organizations have given employees more decision control and has

resulted in better social support and increased job satisfaction (APA. 2016). While this may

impractical for the nurse at bedside, it shows there needs to new creativity in organizational

structures.

The healthcare industry will need to think outside the box, yet better, leaders need to

throw away the box and rethink the work environment (McCallum, 2016). This would enable the

leader to use a creative approach and would help get the staff to participate in the decision

processes to bring new concepts and ideas forward. While this has been discussed within the last

two decades the healthcare environment has been slow to change and we are now facing a real

challenge. The ANA and ANCC have used the tenants of Magnet designation as a change in

processes and organizational structures to promote the positive work environment. While this has

proven to help change the work environments there still needs to be changes in gaining better

structures to give both autonomy and support to the professional nurse both new and

experienced.

Gotschall (2010) studied new nurse graduates in the state of Maryland and found that the

majority were suffering from job stress with little control and no social support and many were

suffering with depression. Gotschall (2010) also showed that the youngest of the new graduates

labeled as the millennials, those born after 1980, were suffering the greatest despair of the new

https://www.success.bz/authors/336/austin_mccallum


graduates. It is further expected that the nursing profession will grow by 19 % in 2022 (AACN,

2016). This is a false sense of security, as there will still be shortages due to the growth in needs

resulting in a ratio decrease of 40% (AACN, 2016) This will be further impact the baby boomers

creating one of the largest strains on the healthcare industry in history. This is a crisis in the

making that is silently creeping upon the whole health care industry.

New Understanding/ Best Practices Recommendations

Leaders will need to make real changes to improve this working environment. Perhaps

one of the greatest change motivators is the Magnet Designation that is being sought by many

organizations. The effort of the American Nurses Association (ANA) and the American Nurses

Credentialing Center (ANCC) is to help bridge the gap of the nursing shortage and the strain

created with under staffing and to help facilities to attract and retain staff (ANCC, 2016). In 1994

the first hospital was given magnet recognition (ANCC, 2016). In 2008 the magnet Program

transitioned from 14 tenants to five components: transformational leadership, structural

empowerment, exemplary professional practice, new knowledge, innovations, and

improvements, empirical outcomes (ANCC, 2016). These components are fundamental to the

studies over the decades. Leadership needs to look at the root causes of negative work

environments and master the vision to help change the organizational structure to facilitate the

positive work environment. Leaders will need to begin to use leadership rounding as a means of

getting one to one time with the professional nursing staff. Leadership rounding with careful

listening, will help to develop positive working environments. The use of the nurse residency

programs may be the way to give new graduates the support within the first year. These

programs have gain momentum throughout the profession. Education opportunities will need to

take a higher precedence in the work place as leaderships goals, including mentoring nursing


staff to seek advanced degrees. The leaders and facilities will need to include reimbursement

programs to help with the costs of this further education. Implementation of new leader training

to help fast track the younger nurses to leadership opportunities within the organization. Greater

opportunities for recognition and rewards. The use of new entry level leadership positions to help

begin the education of new leaders into leadership skills and training. Nurse leaders are in a

unique position to now make those decisions and act on making changes. There are great

opportunities for change in leadership styles and organizational structures in the present acute

care facilities.

Conclusion

In the context of looking at a positive work environment, the current nursing leaders are

going to be a major part of the changes for a brighter future. Magnet is helping to elevate the

autonomy of the nursing profession and encouraging better organizational structure and more

support from leaders. Much of this will be accomplished through advocating for advanced

degrees including the Bachelorette of Science in Nursing, Masters in Science for nursing

including Healthcare Management and Leadership, Education and Population Health. Doctorates

in Philosophy for nursing science and the push for nurses to be in leadership positions. These are

all areas that are helping to balance the Job Demand Control Support model in healthcare.

Without these changes Gotschall (2010) showed a sense of no control or support in the working

environment of nursing while experiencing large measure of job dissatisfaction and burnout. The

use of programs such as the nurse residency program will help the new graduates in getting the

social support and help needed in their first year. Gotschall (2010) showed many of the issues

that the profession of nursing has overcome within the last three decades and is making progress,

but has many silos still to remove. Leaders need to begin to make real changes and implement


the changes while listening to what is being said by the new nursing staff and the experienced

nursing staff. There will need to be fast track leadership programs to help new nurses become

leaders faster and to offer more incentives. Leaders will need to be more in touch with the staff

and working through issues that impact nursing at the bedside level. This will include such skills

as using transformational leadership and developing organizational structures to meet the

demands of the nursing staff to achieve job satisfaction and retention. The greatest need will

come in giving the nursing staff more educational opportunities, greater decision capability in the

organizational structure and better rewards and recognition programs. There is the opportunity

for nurse leaders to make major changes in the next couple of years in developing organizational

structures to promote a positive work environment.


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