Assignment

qualitiativeadmincommunication.pdf

Home >Applied Sciences homework help >Assignment

JONA Volume 43, Number 5, pp 266-273 Copyright B 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

T H E J O U R N A L O F N U R S I N G A D M I N I S T R A T I O N

Communication and the Healthy Work Environment Nurse Managers’ Perceptions

Sheila Q. Hartung, PhD, RN

Mindi Miller, PhD, RN, CRRN

OBJECTIVE: A qualitative design was used to deci- pher the viewpoints of nurse managers about com- munication trends associated with their leadership roles and unit subcultures. BACKGROUND: Disruptive behaviors such as poor communication and inadequate teamwork have been associated with patient harm and deficient workplace cultures. However, few studies have focused on nurse managers’ perceptions of communication and a healthy workplace. METHODS: A descriptive qualitative study was con- ducted using 12 in-depth interviews of 6 nurse managers to better understand communication patterns of man- agers. Analysis identified 5 themes and 13 subthemes. RESULTS: Workplace processes were identified that either promoted or hindered managers’ abilities to set a positive tone and to stay connected to their staff, ensuring effective communication while meeting multiple unit and institutional challenges. CONCLUSIONS: Findings can be used to strengthen communication practices, obviate communication dis- connects, and ensure a healthy workplace.

Ineffective communication and the lack of teamwork are factors associated with poor patient outcomes and non-productive organizational cultures. Previous stud- ies correlate the nurse managers’ (NMs’) leadership style with the productivity of workers and the retention of staff. However, few studies have focused on the NMs’ view of their impact on communication and its relationship to a healthy work environment (HWE).

Background

Effective skilled communication is a key characteristic of professional collaboration.1-4 The landmark In- stitute of Medicine (IOM) report, To Err Is Human,5

and other studies6-8 document poor teamwork and a lack of communication as contributing to patient harm and death. Accrediting agencies acknowledge communication problems as a cause of adverse events and are targeted in The Joint Commission (TJC) 2011 National Patient Safety Goals.9 Testimony given by TJC to the Robert Wood Johnson Foundation and the IOM identified challenging healthcare quality and patient safety issues as a result of negative work environments.10

The American Association of Critical Care Nurses (AACN) initiated a study in 2004 with VitalSmarts focused on caregiver interactions and the impact on patient well-being. The results linked health profes- sionals’ abilities to discuss emotionally and politically risky factors with patient safety issues and outcomes.11

From this study, AACN established 6 evidence-based standards to establish and sustain HWEs: skilled com- munication, true collaboration, effective decision mak- ing, appropriate staffing, meaningful recognition, and authentic leadership.12

266 JONA � Vol. 43, No. 5 � May 2013

Author Affiliations: Assistant Professor (Dr Hartung) and Associate Professor (Dr Miller), Department of Nursing, Bloomsburg University, Pennsylvania.

This study was funded by a grant received by the Administrative Committee for Research, Geisinger Medical Center, Danville, Pennsylvania (clinical research grant SRC-042).

The authors declare no conflicts of interest. Correspondence: Dr Hartung, Department of Nursing,

Bloomsburg University, 400 E 2nd St, Bloomsburg, PA 17815 (shartung@bloomu.edu).

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jonajournal.com).

DOI: 10.1097/NNA.0b013e31828eeb3c

mailto:shartung@bloomu.edu

http://www.jonajournal.com

Review of Literature

Although there has been much discussion about key factors that impact the HWE of nurses,13-18 accom- plishing these elements continues to be challenging to organizations and nursing professionals.19 Strong, authentic leadership skills are needed to maintain the health of nurses’ work environments.20,21 While healthcare leaders play key roles in recruiting and re- taining nurses, attention is needed at the unit level where NMs are on the frontline for influencing healthy work practices.22,23 However, staff nurses and nurses in leadership roles differ in their opinions of what constitutes healthy workplaces.24 Research at the unit level demonstrates that leadership and empower- ment influence burnout, job satisfaction, and reten- tion,14,25 which further impact nurses’ organizational commitment.26

Pearson et al,27 while synthesizing evidence on effective leadership traits, concluded that a combina- tion of leadership styles fosters HWEs. Voluminous research exists supporting that the nurse leader’s style and relationships with staff are critical to a HWE and to help to protect patients from harm.28,29 Heath et al30

confirmed 3 elements to help nursing leaders support HWEs: effective communication, collaborative re- lationships, and promotion of decision-making among nurses. The communication patterns of NMs in the and maintenance of a healthy workplace have been largely unexplored.

Methods

Study Design and Purpose

At a tertiary care center in Northcentral Pennsylvania, the accountabilities of the operations manager (re- ferred to in this article as NM) include clinical care activities, budgets, personnel, quality care initiatives, and others. Few studies have focused on the NMs’ per- ceptions of their role and accountabilities related to communication. The aim of this descriptive qualitative study was to understand how NMs in a large tertiary care center view communication practices in the pa- tient care setting.

Methodology

Qualitative methods are useful when little is known about a phenomenon,31 such as NMs’ perceptions of communication, and discovery is desired. Qualitative research is a naturalistic inquiry that involves the col- lection and interpretation of words or images, the con- duct of inductive analysis, and a focus on the meaning for the participants.32 This method of research is cy- clic in nature, and data collection alternates with data analysis, which drives further data collection. Essen-

tially, the research process fluctuates between activ- ities in the field gathering information and activities focused on data analysis. The research concludes when the data categories or themes are fully saturated when new information ceases to add to the understanding of the category.33

Procedures

Sample and Setting In this study, the researchers collected data through purposive sampling of 6 NMs using a semistructured interview format and open-ended questioning. Each of the 6 participants received 2 interviews resulting in a total of 12 in-depth interviews. Initially, 4 broad questions were asked with more probing follow-up questions to clarify and expand participant responses. Additional data collected included demographic in- formation, interview transcripts, and researcher field notes. Demographic data of NMs included age, high- est level of education, current enrollment in an edu- cational program, presence of certification, years of practice as an RN, and years as an NM.

Data Collection Procedures Following approval by the institutional review boards of the tertiary care center and educational institution, 40 NMs of inpatient and outpatient units as identified by their job titles in the organization were invited to participate in this study. To ensure confidentiality, a non-nurse research coordinator sent an introductory e-mail, providing details about the study and offering to schedule interviews. Agreement to schedule the inter- view implied consent. None of the participants or NMs invited to participate was supervised by either of the researchers. One NM participant who was known to one of the researchers was assigned to be interviewed by the other researcher. Audiotapes and notes from interviews were kept in a locked file without identi- fiers, and NM participants were randomly assigned an identification number. During the 2nd interview, the participant reviewed the initial transcript as tran- scribed by the non-nurse research coordinator for veri- fication or correction. The participant was also verbally given a description of the researchers’ initial data cat- egories, and the participant verified and clarified the researchers’ understanding of the NM perspectives.

Data Analysis Procedures Following each interview, a summary of the transcript and an evolving description of categories were shared between the 2 study researchers prior to reentering the field for continued data collection. The evolving pat- tern of themes and categories guided the revision or inclusion of questions or probes in subsequent inter- views. The team continued this cyclic nature of data

JONA � Vol. 43, No. 5 � May 2013 267

collection and analysis until there were no new data cat- egories or patterns uncovered. The qualitative analysis was refined over several months until the researchers reached agreement on the underlying meanings. Two qualitative data analysis (QDA) software programs, ATLAS.ti (Berlin, Germany) and NVivo (Melbourne, Australia), enabled researchers to code, annotate, and compare segments of information and organize all data segments and notes relevant to an idea. The researchers used the software’s organizational and coding features to input all data such as transcripts, notes, and concepts and categorize the data passages. In the final analysis, 5 themes and 13 subthemes were identified. See Table, Supplemental Digital Content 1, which summarizes the themes and subthemes identified through analysis as illustrated by participant quotations, http://links .lww.com/JONA/A223.

Results

Tone of Communication

Subtheme 1: Overwhelming, Ever-Changing, and Impossible Participants were asked to provide descriptions (ad- jectives) about communication on their units. Three of the 6 participants described the tone of communi- cation as overwhelming, ever-changing, and impossible at times. Additional descriptors included inconsis- tent, difficult, and mind-boggling. However, 2 of the 6 participants described the tone of communica- tion as striving to be open and positive but needing improvement.

Subtheme 2: Providing an Honest and Approachable Sounding Board Managers perceived that the communication between them and staff was healthier when the content and process were viewed as honest. Ultimately, if they (NM) were honest and showed a positive demeanor, there was reciprocal communication (from staff). All NM respondents voiced a belief in the importance of encouraging discussion and direct communica- tion. Several participants defined their role as being approachable.

Subtheme 3: Promoting Positivity Nurse managers detailed methods they used to pro- mote positivity on the unit. Strategies included ‘‘building up’’ the staff versus trying to ‘‘keep everything and everyone in line.’’ A majority of the participants de- scribed that scheduling regular time to communicate with staff was instrumental in ensuring constructive and positive communication. Organizing the unit around a shared governance system was seen as promoting positivity on the unit. ‘‘Open’’ was used to imply sev- eral positive traits, such as being open-minded. How-

ever, 1 participant described ‘‘open’’ as a negative at- tribute when used in context of being ‘‘open-mouthed’’ that facilitated unit gossip.

Subtheme 4: Hindering All NMs in this study described factors that hindered effective communication on the unit. For instance, par- ticipants detailed detrimental communication patterns such as bombarding staff with information, trying to keep everything and everyone in line, and communi- cating to staff rather than with staff. At least half of the participants detailed generational differences in com- munication that led to differing interpretations of the message and hindered unit functioning. One partici- pant warned that NM colleagues had delusions of open communication on their unit, which obviated im- provement in workplace communication.

Tools of Communication

Subtheme 1: Tools That Promote Communication Participants described the ideal tool for effective com- munication as face-to-face communication, although frequently other alternatives were necessary. Managers described how they would 1st assess and then select the best communication tool such as e-mail, telephone, distribution of meeting minutes, weekly updates from education staff, unit newsletters, bulletin boards (in bathrooms, conference rooms, or organized on the units according to the various unit councils), or the unit web- page. Communication books were viewed as ineffective; notebooks ‘‘went missing,’’ and notations by staff were inconsistent. All participants detailed both positive and negative perceptions related to the value of meetings, committees, and e-mail (subtheme 2 below).

Subtheme 2: Two Sides of the Coin: Meetings, Committees, and E-mail Participants identified several tools of communication as having both positive and negative connotations. E-mail messages traveled up to administrators and down to staff, but these messages were often perceived as overused, repetitive, or overwhelming. Committee responsibilities were time-consuming, and meetings in general were reported as redundant. Some staff members were uncomfortable using electronic communication, particularly older generations (baby boom generation or generation X). Managers concluded that meetings, committees, and e-mail were methods that could be used effectively, if designed to reduce inefficiencies.

Approaches and Processes That Enhance Healthy Communication

Subtheme 1: Communication Is a Journey Nurse managers viewed healthy workplace communi- cation as an ongoing goal that was never fully realized.

268 JONA � Vol. 43, No. 5 � May 2013

http://links.lww.com/JONA/A223

One participant emphasized the importance of believ- ing in the message so staff would subsequently em- brace the information. Several processes were employed by NMs such as regularly taking the temperature of the unit by making rounds, touching base with staff, discussing the current functioning of the unit, follow- ing up with issues, and redirecting negativity to keep communication focused on the patient, the family, and the appropriate teamwork.

Subtheme 2: Communication Is a Learned Skill and You Need to Practice It In order to accomplish efficient communication, all NMs described the need for regular communication, using a variety of different methods while reiterating the message. All participants identified a need to learn more about communication and to refine their skills in this area. Managers desired ways to catch staff at- tention, to improve attendance at unit meetings, and to deliver information in the least offensive way. Four of the 6 managers expressed a desire to improve their negotiation and compromise skills to benefit employ- ees coming from different generations.

Subtheme 3: Communication Is the Most Important Part of the Job Nurse managers concluded that communication was the most important part of their job and was integral to their work. Different communication styles of man- ager colleagues were viewed as assets for meeting staff need. They learned communication tips from each other. While participants identified that e-mail and re- dundancy of messages were necessary parts of their job, NMs reported that careful selection of communi- cation methods was vital to their role and success.

Setting the Tone of Communication

Subtheme 1: Carving Out the Time and Being the Example Four of the 6 NMs identified that the most important way to set the tone of communication on the unit was to be available for the staff. A manager’s availability and visibility were perceived as necessary for pro- moting direct communication. Two of the NMs were responsible for more than 1 unit. Staff on these units verbalized dissatisfaction about sharing their NM and identified them as being unavailable. Four of the 6 managers described that, in order to set the tone for the unit, they needed to be the example.

The Manager’s Role

Subtheme 1: Ensuring Effective Communication All managers interviewed stated that they were the primary vehicle for staff to receive accurate, timely, and important information from administration. One

of the primary methods for efficient communication was through unit meetings. However, unit meetings were difficult to achieve where all staff could be in attendance at the same time because of the duties and schedules of healthcare providers. Nurse managers believed that they needed to hold their staff account- able for the content and process of communication. Advanced education was encouraged by 2 managers who reported that staff who were obtaining a bac- calaureate or master’s degree in nursing displayed im- provement in their communication skills with their peers and the NM.

Subtheme 2: Ensuring the HWE Of major importance to promote healthier work- places were staff empowerment and shared governance. Managers encouraged staff to communicate with each other and to address and confront teammates as needed. Participants described a number of successful strategies to improve communication: open and honest discus- sions, finding more time to communicate, listening, gaining and giving feedback, addressing rumors quickly, taking responsibility for the communication on the unit, taking opportunities to praise staff, and circling back. Additionally, ensuring that staff understood that they were appreciated and valued was a key role of the NM.

Subtheme 3: Challenges to the HWE By far, the most frequently identified challenges to HWEs were large numbers of staff, the diversity of staff (in educational preparation, perspectives, and generations), and time constraints. Managers who were responsible for more than 1 unit felt ‘‘spread too thin,’’ ‘‘pulled in different directions,’’ and ineffective in ensuring the HWE. Generational differences among staff were demonstrated in the variety of perspectives regarding life, work, technology, and change; the pa- tience for learning and gaining knowledge and skills; the degree of needed nurturance and mentoring; and communication method preferences.

Subtheme 4: Manager’s Support for Maintaining Good Communication In order to provide effective communication, partic- ipants identified that they needed support from a variety of people in their personal and professional life, a sense of humor, and increased efficiencies in the institution. One NM described the support of unit communication champions in order to set the right tone of communication. Effective communication cen- tered on the methods used by managers to reduce redundancies and condense and disseminate impor- tant messages.

JONA � Vol. 43, No. 5 � May 2013 269

Subtheme 5: Workplace Fallout The subtheme, workplace fallout, was defined as sec- ondary consequences inherent in the manager’s position that impact the workplace environment and communi- cation. One of the primary consequences in the NMs’ position was the feeling of being sandwiched between the staff needs and management role and accountabil- ities. The majority of participants described spending im- mense energy and time trying to balance the needs of staff with the needs of management. Several NMs de- scribed ‘‘being pulled in different directions’’ and being ‘‘spread too thin.’’ Nurse managers felt physically and emotionally stretched by their complex responsibilities.

Discussion and Recommendations

General categories were identified in the NM inter- view transcripts: communication tone, tools, processes,

and role. Themes were identified by using QDA meth- odologies that analyzed adjectives, phrases, and words. Based on the findings of this study, recommendations in 4 general categories are offered for NMs and ad- ministrators to enhance communication and the HWE (Table 1).

There were 4 subthemes that emerged from the tone of communication. The amount of information to be disseminated was described as voluminous or overwhelming, and the task of circulating large amounts of data was compounded by the challenge of constantly changing information. While NMs did not overwhelmingly identify the word ‘‘stress’’ or ‘‘stress- ful,’’ the discussion surrounding the overwhelming nature of unit communication was characterized by the researchers as stressful. Managers identified the need to promote positive and frequent discussions to prevent ineffectiveness. These findings are consistent

Table 1. Communication and NMs’ Perceptions: Discussion and Recommendations Based on Findings

Theme Findings Recommendations for NM and Administrators

Tone of communication

Overwhelming Create and ensure visionary, approachable, visible, open management styles19Stressful34

Ensure accessibilityImpossible Encourage discussion and debate, honest, and frank dialogue

with staff1Inconsistent Promote a constructive and listening approach to staff where

NM is focused on building the staff (not controlling them) and encouraging staff problem solving

Tools of communication

Use of various methods to disseminate (ie, e-mail, unit meetings, bathroom stalls)35

Critically evaluate the use of communication methods for effectiveness and efficiency with various employees

Effective communication is a learned skill requiring practice

Increase awareness of the value of tools with various employees

Seek out formal and continuing education in communication techniques and approaches including generational differences and expectations

Carve out time (make time) to communicate and model the behaviors

Practice, practice, practice

Processes to enhance healthy communication

Multiple NM roles enacted to ensure and promote a HWE

Plan and hold sacred regular and consistent time to communicate with staff

Multiple challenges to NM role Seek input and understand perspectives NM supportive persons identified Embrace and believe in the message

Evaluate and increase efficiency of information from top administrators27

Reduce meetings outside unit or evaluate redundancies Seek out communication champions in unit staff, colleagues,

and administrators Take responsibility for communication and hold staff

accountable to the range of communication responsibilities (receiving, interacting, disseminating)

Role NM is sandwiched between unit and administrative responsibilities20,21,36

Ensure authentic leadership20,21 and emotional intelligence27

Crisis communication takes precedence while philosophical approaches become secondary

Implement or ensure authentic and true shared governance

Colleague/peers may believe they are open or authentic but may not be

Utilize colleague/peer debriefing and NM team building

270 JONA � Vol. 43, No. 5 � May 2013

with research into NM stress and work complexity that found that the tasks, work volume, and perfor- mance expectations impact NMs’ perceptions of stress.34 The importance of NMs in creating and en- suring an open and honest unit tone of communi- cation is also consistent with a meta-analysis that identified that it was crucial for nursing management styles to be visionary, visible, open, rich and including skilled communication.19 The study findings through- out the theme were also consistent with the IOM recommendation to rectify internal communication patterns on the unit to ensure that the executive or NM is accessible, approachable, and encouraging open and frank dialogue as these are essential elements of a learning organization.1

Within the second theme of tools of communi- cation, various methods were used to disseminate information throughout the unit. Announcements were routinely posted in multiple venues including e-mail, unit meetings, and bathroom stalls. Effective communication was described as a learned skill that required practice. Time management for NMs was a tool that provided the means for carving out enough time to achieve and improve the dissemination and interpretation of information. Utilizing multiple venues for communication is consistent with research and lit- erature both within the United States and beyond.35

In this study, managers reported wearing differ- ent hats that included mentoring, supervising, and educating members of the team that is consistent with classic literature describing the various roles of man- agers. The managers’ role in ensuring and promot- ing a HWE was described as supporting staff in the decisions they made about the unit functioning; modeling honesty, respect, and positivity; being the example for staff; providing the staff with the tools that they needed to perform their jobs; and empow- ering staff. Overall, these roles are consistent with previous research and literature surrounding the de- scription of authentic leadership20,21 and emotional intelligence.27 Clearly, the NMs in this small sample described the desire to provide authentic leadership and emotional intelligence in their unit roles; how- ever, participants did not specifically name or describe these characteristics as such. Challenges to the man- agers’ abilities to ensure the HWE included large staff numbers or managerial responsibilities for multiple units, diverse staff with differing opinions and abili- ties, lack of formal staff education or training on how to communicate effectively, indirect messages to staff, significant committee responsibilities and meetings scheduled outside the unit, and not holding staff ac- countable to the range of responsibilities including communication. Several of these challenges have also been reflected in previous research on the stress and

complexity of NM work.34 There is evidence that a supportive structure within the organization designed to empower or support leaders, who in turn provide empowerment and support to their staff, can result in the creation and maintenance of a positive HWE.27

Within the theme of workplace fallout, descrip- tion of NMs being sandwiched between unit respon- sibilities and administrative responsibilities is also extensively detailed in the literature.20,21,36 In this sample, a consequence of being sandwiched between the unit staff and management responsibilities was that crisis communication took precedence while more philosophical discussions regarding unit functioning or approaches took a secondary or minor role. A unique finding in this study was the challenge of NMs in im- plementing true shared governance and open commu- nication when the reality was perceived as less or when the goal of authentic or transformative leadership was not truly reflected in the organizational culture. One nurse characterized it as a delusion of NMs in believing they are open communicators or authentic leaders when they are not. Managers may not be aware of this deficit unless they perform honest self-reflection or until an- other colleague brings this deficit to their attention.

Limitations

Three significant limitations are noted in this study: purposive sampling techniques, self-report data, and geographic location. Although the use of purposive sampling in a qualitative study limits generalizability to other cases, the sampling technique is consistent with the goal of qualitative research in understanding the phenomenon in question by sampling those per- sons or sites that have experienced the phenomenon.32

Additionally, there was a geographic limitation to the sample and setting as the data were obtained in 1 large tertiary care center in the center of the state, described as a suburban town area surrounded by rural areas. This study may be limited in its applicability to rural healthcare settings and other geographic locations.

Future Research

Future research on generational communication and value differences is warranted. Several NM participants in this study identified the challenges of providing lead- ership to a diverse generational workforce. Future re- search extending beyond the challenges of the diverse workforce but inclusive of the NMs’ communication impact on patient outcomes, nurse retention, and unit functioning is needed.

Conclusion

Findings from this study suggest that NMs have a crucial impact on workplace health and staff communication. Results identified multiple venues for

JONA � Vol. 43, No. 5 � May 2013 271

disseminating information, promoting and strength- ening positive communication, and ensuring the HWE. Future research is proposed to extend descrip- tion beyond a single tertiary care center to rural and community institutions.

Acknowledgment The authors thank Dr Adele Spegman at the Geisinger Medical Center, Center for Health Research, for as- sistance in the development of the research proposal and peer review of the initial codings and findings.

References

1. Institute of Medicine, Committee on the Work Environment

for Nurses and Patient Safety, Board on Health Care Ser- vices. Page A, ed. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: National Academies Press; 2004.

2. Gittell JF, Seidner R, Wimbush J. A relational model of how high-performance work systems work. Organ Sci. 2010; 21(2):490-506.

3. Triola N. Dialogue and discourse: are we having the right conversations? Crit Care Nurse. 2006;26(1):60-66.

4. McDonald G, Vickers MH, Mohan S, Wilkes L, Jackson D.

Workplace conversations: building and maintaining collab-

orative capital. Contemp Nurse. 2010;36(1-2):96-105. 5. Institute of Medicine, Committee on Quality of Health Care

in America. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.

6. Propp KM, Apker J, Zabava Ford WS, Wallace N, Serbenski M,

Hofmeister N. Meeting the complex needs of the health care

team: identification of nurse-team communication practices perceived to enhance patient outcomes. Qual Health Res. 2010;20(1):15-28.

7. Aiken HL, Clark SP, Sloane DM. Hospital staffing, organi-

zation, and quality of care: cross-national findings. Nurs Outlook. 2002;50:187-194.

8. Kazanjian A, Breem C, Wong J, Reid R. Effect of the hospital

nursing environment on patient mortality: a systematic re-

view. J Health Serv Res Policy. 2005;10(2):111-117. 9. The Joint Commission on Accreditation of Hospitals

(JCAHO) Web site. 2011 Hospital National Patient Safety

Goals. http://www.jointcommission.org/assets/1/6/HAP_

NPSG_6-10-11.pdf. Accessed August 4, 2011. 10. Testimony submitted to the Robert Wood Johnson Foundation

Initiative on the Future of Nursing at the Institute of Medicine.

http://www.jointcommission.org/assets/1/18/RWJ_Future_ of_Nursing.pdf. Accessed August 4, 2011.

11. Maxfield D, Grenny J, McMillan R, Patterson K, Switzler A.

Silence kills: The seven crucial conversations in healthcare.

2005. http://www.aacn.org/WD/practice/docs/publicpolicy/ silencekills.pdf. Accessed August 4, 2011.

12. American Association of Critical-Care Nurses (AACN).

AACN standards for establishing and sustaining healthy work

environments: a journey to excellence. 2005. http://www.aacn .org/WD/HWE/Docs/HWEStandards.pdf. Accessed August 8,

2011.

13. Friese CR. Nurse practice environments and outcomes: im- plications for oncology nursing. Oncol Nurs Forum. 2005; 32(4):765-772.

14. Laschinger HKS, Leiter M, Day A, Gilin D. Workplace

empowerment, incivility, and burnout: Impact on staff nurse

recruitment and retention outcomes. J Nurs Manage. 2009; 17:302-311.

15. Friese CR, Lake ET, Aiken LH, Silber JH, Sochalski J.

Hospital nurse practice environments and outcomes for

surgical oncology patients. Health Serv Res. 2008;43(4): 1145-1162.

16. Stone PW, Mooney-Kane C, Larson EL, et al. Nurse working

conditions and patient safety outcomes. Med Care. 2007; 45(6):571-578.

17. Aiken LH, Clarke SP, Sloane DM, Lake ET, Cheney T.

Effects of hospital care environment on patient mortality

and nurse outcomes. J Nurs Adm. 2008;38(5):223-229. 18. Kane RL, Shamliyan TA, Mueller C, Duval S, Wilt TJ. The

association of registered nurse staffing levels and patient out-

comes: systematic review and meta-analysis. Med Care. 2007; 45(12):1195-1204.

19. Kramer M, Schmalenberg C, Maguire P. Nine structures and leadership practices essential for a magnetic (healthy) work

environment. Nurs Admin Q. 2010;34(1):4-17. 20. Shirey MR. Authentic leaders creating healthy work envi-

ronments for nursing practice. Am J Crit Care. 2006;15(3): 256-267.

21. Shirey MR. Authentic leadership, organizational culture,

and healthy work environments. Crit Care Nurs Q. 2009; 32(3):189-198.

22. Sherman R, Pross E. Growing future nurse leaders to build

and sustain healthy work environments at the unit level.

Online J Issues Nurs. 2010;15(1):Manuscript 1. 23. Anthony MK, Standing TS, Glick JA, et al. Leadership and

nurse retention: the pivotal role of nurse managers. J Nurs Adm. 2005;35(3):146-155.

24. Kramer M, Schmalenberg C. Confirmation of a healthy work environment. Crit Care Nurse. 2008;28(2):56-63.

25. Laschinger HKS, Finegan J, Wilk P. Situational and dis

positional influences on nurses’ workplace well-being: the role of empowering unit leadership. Nurs Res. 2011;60(2): 124-131.

26. Laschinger HKS, Finegan J, Wilk P. Context matters: the

impact of unit leadership and empowerment on nurses’ or- ganizational commitment. J Nurs Adm. 2009;39(5):228-235.

27. Pearson A, Laschinger H, Porritt K, Jordan Z, Tucker D,

Long L. Comprehensive systematic review of evidence on

developing and sustaining nursing leadership that fosters a healthy work environment in healthcare. Int J Evid Based Healthc. 2007;5:208-253.

28. Tomey AM. Nursing leadership and management effects work environments. J Nurs Manage. 2009;17:15-25.

29. Cummings GC, Midodzi WK, Wong CA, Estabrooks CA.

The contribution of hospital nursing leadership styles to

30-day patient mortality. Nurs Res. 2010;59(5):331-339.

272 JONA � Vol. 43, No. 5 � May 2013

http://www.jointcommission.org/assets/1/6/HAP_NPSG_6-10-11.pdf

http://www.jointcommission.org/assets/1/18/RWJ_Future_of_Nursing.pdf

http://www.aacn.org/WD/practice/docs/publicpolicy/silencekills.pdf

http://www.aacn.org/WD/HWE/Docs/HWEStandards.pdf

30. Heath J, Johanson W, Blake N. Healthy work environments: a validation of the literature. J Nurs Adm. 2004;34(11):524-530.

31. Morse JM, Field PA. Qualitative Research Methods for Health Professionals. 2nd ed. Thousand Oaks, CA: Sage; 1995.

32. Creswell JW. Qualitative Inquiry and Research Design: Choos- ing Among Five Approaches. Thousand Oaks, CA: Sage; 2007.

33. Streubert HJ, Carpenter DR. Qualitative Research in Nursing: Advancing the Humanistic Imperative. 2nd ed. Philadelphia, PA: Lippincott; 1999.

34. Shirey MR, McDaniel AM, Ebright PR, Fisher ML, Doebbeling BN. Understanding nurse manager stress and

work complexity: factors that make a difference. J Nurs Adm. 2010;40(2):82-91.

35. Timmins F. Managers’ duty to maintain good workplace communications skills. Nurs Manage. 2011;18(2):30-34.

36. Shirey MR, Ebright PR, McDaniel AM. Sleepless in

America: nurse managers cope with stress and complexity.

J Nurs Adm. 2008;38(3):125-131.

JONA � Vol. 43, No. 5 � May 2013 273