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

Claudia Schmalenberg, RN, MSN; Marlene Kramer, RN, PhD


Am J Crit Care. 2007;16(5):458-468. 

In This Article

Abstract and Introduction

Background The quality of nurses' work environments in hospitals is of great concern. The American Association of Critical-Care 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.

The 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 performance[2] 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 units -- adult and pediatric, medical and surgical -- also have been noted.[4,5,6] 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 psycho-metrically sound instrument[3] 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?


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