Creating and sustaining a healthy work environment is a desirable goal for individuals, teams, and organizations and in health care, paramount to safe, patient care. Most, if not all, members of the workforce desire to be part of a vibrant, healthy work environment. Whether the organization is private or public, what often matters most to workers is for its members to abide by a compelling and shared organizational mission, based on principles of mutual respect, collegiality, quality, and excellence and guided by trustworthy, ethical, and visionary leaders at all levels of the organization. Employees desire and deserve a work environment where they are viewed as partners, valued as assets, and generously rewarded for their individual and collective contributions to the success of the organization. Highly desirable work environments generate high levels of employee satisfaction, engagement, and morale, and encourage free expression of diverse ideas. The American Psychological Association (2015) recognizes psychologically healthy work environments for their efforts to foster employee well-being while enhancing organizational performance. According to the American Psychological Association (2015), healthy environments benefit from improved work quality and productivity, lower absenteeism, employee engagement, less turnover, and better customer service ratings. The purpose of this study was two-fold: to measure practice-based nurses' and nursing faculty's perceptions of the health of their work environment and to describe the development and psychometric testing of the Healthy Work Environment Inventory (HWEI).
Elements of a Healthy Work Environment
Several organizations and researchers have identified essential elements of a healthy work environment. The following section highlights findings from the National Institute for Occupational Safety and Health, the Chronicle of Higher Education, and the Society for Human Resource Management.
National Institute for Occupational Safety and Health at the Centers for Disease Control and Prevention (2015) identified four categories of effective work environments consisting of 20 essential elements. The four categories include:
- Organizational culture and leadership.
- Program design.
- Program implementation and resources.
- Program evaluation.
Organizational culture and leadership includes the development of a human-centered culture with policies and programs that promote respect throughout the organization, foster a culture built on trust, and a clear commitment to worker health, safety, and well-being. Program design includes an establishment of clear principles, integration of relevant systems, elimination of occupational hazards, emphasis on workplace health and safety, and promotion of employee participation in the development, implementation, and evaluation of the organizational culture and programs. Incentives and rewards are aligned with the accomplishment of organizational objectives, valid and reliable instruments are used to measure workplace health, and adjustments are made based on these assessments to provide interventions for organizational health. In the category of program implementation and resources, organizations must be willing to consider a phased implementation of changes based on evidence; to provide adequate resources; to communicate openly, early, and often; and to have a long-term communication strategy. Organizations need to be data driven and strategically linked to program resource allocations. Accountability must be integrated at all levels of the organization and members are rewarded for success. In the category of program evaluation, there must be a menu of relevant measurements and integrated systems to track results and make program improvements. Healthy organizations learn from experience and adjust and modify based on established benchmarks and data.
Cockerell (2008) suggested that healthy work environments are inclusive and intentionally engage and genuinely value all members of the organization. Inclusive work environments are those in which all employees matter and are truly respected, valued, involved, and treated with dignity. The result of a healthy, inclusive work environment is one where employees are happy to come to work and eager to give their energy, creativity and loyalty (Cockerell, 2008). Alternately, when people do not feel included, they become apathetic and fail to perform at their full capacity. Inclusive work environments are also reliant on strong and effective leaders who are readily available; communicate clearly, directly, and honestly; and role model the behaviors they value and expect from others.
The Chronicle of Higher Education (2015) recognized 12 categories of workplace excellence for institutions of higher education, including collaborative governance, compensation and benefits, confidence in senior leadership, diversity, facilities, workspace and security, job satisfaction, professional and career development, respect and appreciation, supervisor or department chair relationship, teaching environment, tenure clarity in process, and work–life balance. Each year, these criteria are used to identify colleges and universities determined by faculty, staff, and college administrators to be great places to work.
For the past 10 years, the Society for Human Resource Management (2016) has conducted an annual employee survey to identify factors that influence overall employee satisfaction and engagement in the workplace. The survey assesses 43 aspects of employee job satisfaction and 37 aspects of employee engagement that are categorized into the following eight areas: career development, benefits, work environment, engagement opinions, compensation, employee relationships with management, conditions for engagement, and engagement behaviors. The purpose of the survey is to provide insight about employee preferences and highlights key areas for organizational development and improvement. The leading job satisfaction contributors in 2016 included respectful treatment of all employees at all levels, compensation and pay, benefits, and job security. Of note, the findings suggest that employees consider organizational culture to be of utmost importance.
Elements of a Healthy Work Environment in Nursing
According to the American Nurses Association (ANA, 2016), a healthy work environment is one that is safe, empowering, and satisfying, and where all leaders, managers, health care workers, and ancillary staff perform with a sense of professionalism, accountability, transparency, involvement, efficiency, and effectiveness while being mindful of the health and safety for all individuals. The National League for Nursing (2006) defined a healthful work environment in nursing education and published the Healthful Work Environment Tool Kit to assess nine elements that constitute a healthy academic work environment, including salaries, benefits, workload, collegial environment, role preparation and professional development, scholarship, institutional support, marketing and recognition, and leadership. The tool kit provides a measurement for academic work environment assessment and a platform for discussion of how nursing faculty and administrators can work together to enhance healthy nursing academic work environment.
Shirey (2006) defined a healthy work environment as a work setting where employees are able to meet organizational objectives and achieve personal satisfaction in their work. Further, healthy work environments are “supportive of the whole human being, patient-focused, and joyful workplaces” (p. 258). In 2005, the American Association of Critical-Care Nurses (AACN) reported that unhealthy work environments “contribute to medical errors, ineffective delivery of care, conflict, and stress among health professionals” (p. 4). The AACN identified six standards for establishing and sustaining healthy work environments, including skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership. In addition to these essential standards, C.M. Clark (2013) noted that healthy work environments also require a shared organizational vision, values, and team norms; creating and sustaining a high level of individual, team, and organizational civility; ethical and effective leadership, both formal and informal; and mastering communication and engaging in conflict with civility at all levels of the organization.
Work Environment Health and the Link to Civility
The 2013 Civility in America report (Weber Shandwick, 2013) described American perceptions of company civility and how business may be lost through uncivil consumer experiences. According to the report, the majority (70%) of respondents believed that incivility in the United States has reached crisis levels, and 81% believed that uncivil behavior is leading to an increase in violence. In the same report, 37% of respondents personally experienced workplace incivility, 33% believed the general tone of the workplace is uncivil, and 26% quit a job because it was an uncivil workplace. In the 2014 Civility in America report (Weber Shandwick, 2014), more than 9 of 10 of adults believed that civility is a problem and that incivility has reached crisis proportions in America. Although it may be obvious that targets of incivility are harmed, Houshmand, O'Reilly, Robinson, and Wolff (2012) found that those who witnessed bullying in their workplace were more likely to resign, even though they themselves were not the target.
The stakes are even higher in health care settings, where uncivil encounters can result in serious mistakes, preventable complications, and harm to patients, or even in a patient's death. Uncivil actions have detrimental effects on the health, well-being, and job satisfaction of nurses (Clark, 2013; Simons, 2008; Spence-Laschinger, Wong, Cummings, & Grau, 2014; Vessey, DeMarco, Gaffney, & Budin, 2009) and creates a heavy financial burden for health care organizations (Lewis & Malecha, 2011). For example, Sheehan, McCarthy, Barker, and Henderson (2001) noted that $23.8 billion are spent annually in the United States to cover direct and indirect costs associated with uncivil and violent workplace behaviors. The costs of incivility increase when expenses associated with supervising the employee, managing the situation, consulting with attorneys, and interviewing witnesses are considered (Griffin & Clark, 2014; Pearson & Porath, 2009; Porath & Pearson, 2013).
Pearson and Porath (2013) found that workplace incivility resulted in a significant decline in work performance and work effort, commitment to the organization, quality of work, employee retention, and lost work time due to being stressed about uncivil encounters. In the health care setting, incivility negatively affects nurse recruitment and retention. For example, early career nurses are especially vulnerable to the effects of verbal abuse (Budin, Brewer, Chao, & Kovner, 2013; Griffin & Clark, 2014) and may contribute to newly graduated nurses leaving their first job within 6 months (Bartholomew, 2006) or leaving the profession altogether (Duffield, O'Brien-Pallas, & Aitken, 2004). In addition, incivility taxes an already stressful health care environment and, therefore, it must be addressed.
As organizations seek to establish and sustain healthy work environments, a two-pronged approach is needed. Because the antecedents of workplace incivility are both interpersonal and organizational, interventions must be implemented at both levels. Although it is imperative to address and restore the individual worker-to-worker relationship, it is equally important to address organizational issues. Given the serious and often lasting consequences of workplace incivility, creating and sustaining healthy, civil work environments is an imperative for the profession.
Given that the culture of any organization is closely linked to employee recruitment, retention, and job satisfaction, and because patient safety is an unimpeachable goal in health care, assessing the elements of a healthy work environment is an important step toward improving the work environment and delivering quality patient care. Reflecting on the workplace culture and our relationships and interactions with others is an important step toward improving individual, team, and organizational success (Clark, 2015). The HWEI was developed as an evidence-based tool to assess the elements of a healthy work environment, raise awareness, and determine strengths and areas for improvement.
Designing the HWEI
The HWEI is an original 20-item Likert-type survey consisting of 20 essential elements of a healthy work environment. Participants rate the level of perceived work environment health of each element using the following response categories: 1 = completely untrue, 2 = somewhat untrue, 3 = neutral, 4 = somewhat true, and 5 = completely true. A total score can be calculated for the HWEI. Scores range from 20 to 100 and indicate the overall health of work environments: 90 to 100 = very healthy; 80 to 89 = healthy; 70 to 79 = moderately healthy; 60 to 69 = mildly healthy; 50 to 59 = unhealthy; and less than 50 = very unhealthy. The range of the total score for each level of overall health of the work environment is derived from the recommendations of the expert judgments based on a pilot test.
The HWEI was developed by the author (C.M.C.) based on extensive experience and expertise, a thorough review of the literature (AACN, 2005; ANA, 2016; Centers for Disease Control and Prevention, 2015; The Chronicle of Higher Education, 2015; Clark, 2013; Cockerell, 2008; Collins, 2001; Lewis & Malecha, 2011; Longo, 2010; Maxey, 2011; National League for Nursing, 2006; Pearson & Porath, 2009; Porath & Pearson, 2013; Robin & Burchell, 2013; Shirey, 2006; Simons, 2008; Spence-Laschinger et al., 2014; Vessey et al., 2009), consultation with and review by six content experts, and extensive pilot testing with more than 300 practice-based nurses and nursing faculty who did not participate in the study reported here. Responses from content experts and results of the pilot test were favorable regarding the ease of survey administration and completion, content validity, readability, and logical flow. Slight modifications were made to the revised survey on the basis of content expert review and participant feedback derived from pilot testing.
Initial data screening included an assessment of the mean and standard deviation of each item on the HWEI. Assumptions of normality were based on histograms, skewness, and kurtosis statistics. Items with a value >3 for the skewness statistic and <5 for the kurtosis statistic were assumed to have normal distribution. The use of response categories for each item was also examined to determine whether participants responded to some or all of the categories. Linearity was assessed using scatterplots and was assumed if distribution of data was in an oval-shaped pattern on the scatterplot. Data were considered suitable for analysis if Kaiser-Meyer-Olkin measure of sampling adequacy values were .50 or greater and Bartlett's test of sphericity was significant (p < .05). Correlation coefficients were assessed to ensure there were no significant negative correlations between variables. Correlation coefficients of greater than 0.30 were considered to have a reasonably strong positive relationship.
An exploratory factor analysis (EFA) of the HWEI was performed to determine the number of factors in the scale and to label the identified factors. Maximum likelihood estimation was used for factor extraction. Eigenvalues and the corresponding scree plot were evaluated to determine the number of factors to be retained. Assessment of the initial factor model included all factors to the left of the inflection point on the scree plot and factors with Eigenvalues greater than 1. An EFA was performed without data rotation for a 1-factor model. An EFA using oblique rotation (Promax) was performed if more than one factor was retained based on the assumption that items were correlated. If data rotation was necessary, the number of factors that provided the best-rotated factor structure were retained. A squared factor loading explained the amount of variance accounted for in the item by the factor. Items with factor loadings of .30 or greater were considered as having a reasonably strong association between the item and the factor (Kline, 1994). Factor correlations of .30 or greater were considered as reasonably strong if more than one factor was found. Pairwise deletion was used to exclude missing data from analysis and reporting of correlations. Listwise deletion was used to exclude missing data from analysis and reporting of the EFA. All missing data was assumed to be missing at random.
Cronbach's alpha was the statistical measure of reliability that was used for the analysis of the HWEI. The scale was considered reliable if Cronbach's alpha was greater than .70 (Furr & Bacharach, 2014). SPSS® version 23 software was used for all data analysis.
Institutional review board approval was obtained to conduct psychometric testing on the HWEI from two universities. The sample included nursing faculty and practice-based nurses throughout the United States. After obtaining consent, respondents completed the HWEI using two methods: a confidential link to complete the HWEI was posted on two Web sites using secure Web-based technology (Qualtrics®) or accessed by academic and practice-based nurses attending a national nursing conference, and a paper-and-pencil version was used to collect responses to the HWEI during four nursing workshops. All responses were collected anonymously and reported as aggregate data.
A total of 520 nurses completed the HWEI. No demographic or identifying information was collected because the purpose of the study was to ensure participants felt as comfortable as possible providing honest answers.
Preliminary Item Analysis
Item means ranged from 2.64 (SD = 1.31) to 3.63 (SD = 1.09). The mean for the scale was 64.05 (SD = 16.33). Table 1 presents the mean and standard deviation of each item. Standard deviations were similar for all items. Normality of each item response was assumed based on histograms, kurtosis (1.17 to −0.19), and skewness statistics (0.67 to 0.33). Linearity was assumed based on the shape of the scatterplots such that it is reasonable to assume there is a linear relationship among the items. Data were assumed to be suitable for analysis based on the Kaiser-Meyer-Olkin measure of sampling adequacy (.96), and sphericity was assumed based on Bartlett's test of sphericity (p < .001).
Mean, Standard Deviation (SD), and Factor Loadings for 1-Factor Model of the Healthy Work Environment Inventory
All response categories were used for each item. Six items (1, 6, 7, 12, 14, and 16) contained no missing data (N = 520). The remaining items on the scale each contained very few missed responses (1 to 5 participants not answering an item). The missing rate of 0.2% to 1% can be reasonably considered nonconsequential to valid statistical analysis (Schafer, 1999). Total possible scores for the HWEI range from 20 to 100. Total scores indicate the overall health of work environments: 90 to 100 = very healthy (n = 28); 80 to 89 = healthy (n = 80); 70 to 79 = moderately healthy (n = 78); 60 to 69 = mildly healthy (n = 123); 50 to 59 = unhealthy (n = 104); less than 50 = very unhealthy (n = 107). The mean score for this sample was 61.08 (SD = 15.59), indicating that this sample reported a mildly healthy work environment.
All pairs of the interitem correlations were positive and statistically significant (p < .001). The largest positive interitem correlation (.66, p < .001) was between “a clear and discernible level of trust between and among formal leadership and other members of the workplace” (item 2) and “communication at all levels of the organization is transparent, direct, and respectful” (item 3). The second largest positive interitem correlation (.66, p < .001) was between “a high level of employee satisfaction, engagement and morale” (item 6) and “majority of employees would recommend the organization as a good or great place to work to their family and friends” (item 20). “Provision of competitive salaries, benefits, compensations, and other rewards by the organization” (item 17) had the lowest interitem correlation overall, with seven of the correlations being less than .30. The two weakest of these interitem correlations were with “members of the organization live by a shared vision and mission based on trust, respect, and collegiality” (.23, p < .001) and “individual and collective achievements are celebrated and publicized in an equitable manner” (.21, p <.001; Table 2).
Interitem Correlations for 1-Factor Model of the Healthy Work Environment Inventory
Two factors with eigenvalues greater than 1.0 were extracted; the first eigenvalue was 9.65 and explained 45.82% of the variance, and the second eigenvalue was 1.27 and explained 3.84% of the variance. However, results from the 2-factor model indicated 11 items loading onto one factor, four factors loading onto the second factor, and four cross-loaded items. The goodness-of-fit statistics of the maximum likelihood estimation of the 1-factor model indicated a 1-factor model, χ2 (151) = 468.92, p < .01. In addition, the scree plot indicated a 1-factor model with an elbow leveling off at the second eigenvalue. Both the statistical and graphical approaches support that the instrument is unidimensional. In the 1-factor model, all factor loadings were greater than .4, and factor loadings ranged from .47 to .79 (Table 1). Cronbach's alpha was .94, indicating that the scale is reliable.
Scoring the HWEI
Numerical values may be assigned to each of the 20 elements of a healthy work environment (1 = completely untrue, 2 = somewhat untrue, 3 = neutral, 4 = somewhat true, and 5 = completely true). Scoring may be performed to evaluate the sample as a whole or to conduct comparisons across individual items and total scores. A total score ranging from 20 to 100 can also be calculated by summing all items on the HWEI to indicate the overall health of a work environment.
The scale was analyzed for both one and two factors. The one factor model was the best fit with all factor loadings greater than or equal to .47. All interitem correlations were positive and statistically significant. The HWEI appears to be a 1-factor scale that measures the same underlying construct of a healthy work environment. The scale is both reliable and internally consistent based on the Cronbach's alpha.
Although item 17 had an adequate factor loading (.47), it is worth mentioning that it had the lowest factor loading and interitem correlations overall. Item 17 pertains to whether the organization provides competitive salaries, benefits, compensations, and other rewards to an employee. Based on the results of this study, it can be suggested that monetary compensation for performing one's job may not be as important in a healthy work environment when compared with the other items on the scale. In his Theory of Motivation, Herzberg (2003) identified the same phenomenon and discussed how salaries and monetary compensation are less important to employees than interesting work and being challenged by the work they perform. However, it may be that the word competitive is what is driving the low interitem correlations; possibly using the word fair may better reflect the intent of the question. Therefore, we suggest that future researchers change item 17 to “The organization provides fair salaries, benefits, compensations, and other rewards.” Future psychometric research will be based on this change.
The total score for the scale indicates how healthy a work environment is based on the amount of satisfaction, civility, or incivility that exists. For this sample population, the majority of participants rated their work environment as being unhealthy in some capacity. The largest percentage of participants, approximately 23%, rated their work environment as mildly healthy (total score 60 to 69). An additional 20% rated their work environment as unhealthy (total score 50–59) and just over 20% of participants rated their work environment as very unhealthy (total score < 50). Fifteen percent of participants rated their work environment as moderately healthy (total score 70–79) and 15% rated their work environment as healthy (total score 80–89). Only 5% of participants rated their work environment as very healthy (total score > 90).
Application and Limitations
The HWEI is a 20-item psychometrically sound instrument used to measure perceptions of work environment health, to raise awareness, and generate group and organizational discussion about the perceived state of work environment health. The HWEI may be completed as an individual exercise or completed by all members of a team to compare perceptions of work environment health, to determine areas of work environment strength and improvement, and to form the basis for interviewing questions designed to better understand the health of a work environment.
Positive and professional role modeling is essential to promoting and sustaining healthy work environments and engaging others. Showing appreciation, treating people well, and abiding by the organization's mission and values is the responsibility of all members of the organization. However, leaders play a particularly important role in fostering supportive, healthy work environments by providing opportunities for productive conversation and open dialogue between and among its members (Clark & Springer, 2010; Cockerell, 2008; Porath & Pearson, 2013). Findings from the HWEI may be a conversation starter by providing insight into individual and collective perceptions regarding the health of a work environment and may be used to identify areas of strength and generate strategies to address areas for improvement. The HWEI may be used as a model to cocreate norms (ground rules) that are aligned with the organization's vision, mission, values, and strategic plan and that reflect a commitment to workplace health. Norms are imperative for effective team and organizational functioning and, once established, affirmed, and operationalized, provide a touchstone for promoting work environment health.
Items on the HWEI can be used to strategically develop interview questions (i.e., for interviewers and interviewees) that reflect the essential elements of a healthy work environment. For example, interviewees may ask questions such as:
- How does your organization live out its organizational vision, mission, and shared values?
- How would you describe the level of trust and quality of communication between leaders and other members of the organization?
- What policies has your organization established to address incivility and reward civility?
- Describe the leader's leadership style and specific attributes. How does his or her leadership style and attributes influence the workplace culture?
- Tell me about the organization's strategic approach to developing and sustaining a healthy work environment.
Interviewers may ask potential employees questions such as:
- Give one or two examples of what your previous coworkers might say if we asked them to describe your strengths and areas for improvement regarding collaboration and communication.
- What are your most significant contributions to promoting teamwork and collegiality among coworkers?
- Describe a challenging situation or conflict you have experienced. How did you handle it? What was the outcome?
- How do you see yourself contributing to the mission and values of the organization?
Focusing on the elements of a healthy work environment and striving to achieve or improve them is a win–win for all members of the organization including patients.
Limitations for the study include the use of a self-reporting tool. Another limitation is the collection of limited demographic information, although the nature of the scale warranted not having identifying information to ensure participants felt as comfortable as possible providing honest answers. Information regarding practice setting (e.g., hospital, academic, government) was not collected for all participants, therefore limiting a comparison across practice settings.
Assessing the elements of a healthy work environment is an important step toward improving the workplace and promoting individual, team, and organizational success. This article provides documentation of the development and validation of the HWEI, a psychometrically sound instrument used to measure perceptions of work environment health, to determine areas of workplace strength and improvement, and to form the basis for interviewing questions.
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Mean, Standard Deviation (SD), and Factor Loadings for 1-Factor Model of the Healthy Work Environment Inventory
|Item No.||Item Name||Mean (SD)||Factor Loading|
|1||Members of the organization live by a shared vision and mission based on trust, respect, and collegiality.||3.47 (1.07)||.67|
|2||There is a clear and discernible level of trust between and among formal leadership and other members of the workplace.||3.07 (1.20)||.69|
|3||Communication at all levels of the organization is transparent, direct, and respectful.||2.85 (1.16)||.72|
|4||Employees are viewed as assets and valued partners within the organization.||3.51 (1.51)||.76|
|5||Individual and collective achievements are celebrated and publicized in an equitable manner.||3.39 (1.19)||.66|
|6||There is a high level of employee satisfaction, engagement, and morale.||2.99 (1.12)||.78|
|7||The organizational culture is assessed on an ongoing basis, and measures are taken to improve the workplace culture based on the results of that assessment.||2.96 (1.31)||.68|
|8||Members of the organization are actively engaged in shared governance, joint decision making, and policy development, review, and revision.||3.41 (1.16)||.58|
|9||Teamwork and collaboration are promoted and are evident.||3.63 (1.09)||.73|
|10||There is a comprehensive mentoring program for all employees.||2.64 (1.31)||.59|
|11||There is an emphasis on employee wellness and self-care.||3.06 (1.31)||.67|
|12||There are sufficient resources for professional grown and development.||3.39 (1.24)||.61|
|13||Employees are treated in a fair and respectful manner.||3.43 (1.13)||.77|
|14||Workload is reasonable, manageable, and fairly distributed.||2.99 (1.21)||.57|
|15||Members of the organization employ effective conflict-resolution skills and address disagreements in a respectful and responsible manner.||2.90 (1.11)||.71|
|16||The organization encourages free expression of diverse and/or opposing ideas and perspectives.||3.20 (1.19)||.71|
|17||The organization provides competitive salaries, benefits, compensations, and other rewards.||3.36 (1.34)||.47|
|18||There are sufficient opportunities for promotion and career advancement.||3.22 (1.22)||.60|
|19||The organization attracts and retains “the best and the brightest.”||3.04 (1.13)||.66|
|20||The majority of employees would recommend the organization as a good or great place to work to their family and friends.||3.40 (1.12)||.79|
Interitem Correlations for 1-Factor Model of the Healthy Work Environment Inventorya
|Item No.||Item No.|