1 Slađana Režić
2 Jelena Slijepčević
1,3,4 Adriano Friganović
5 Evanthia Georgiou
1 Department for Health Care Quality Assurance and Improvement, UHC Zagreb, Zagreb, Croatia
2 Department of Education and Professional Development of Nursing, UHC Zagreb, Zagreb, Croatia
3 University of Applied Health Sciences, Zagreb, Croatia
4 University of Rijeka, Faculty of Health Studies, Rijeka, Croatia
5 Education Sector, Nursing Services, Ministry of Health, Nicosia, Cyprus
https://doi.org/10.24141/2/9/2/4
Author for correspondence:
Adriano Friganović
University Hospital Centre Zagreb, Zagreb, Croatia E-mail: adriano@hdmsarist.hr
Keywords: focus group, training course, healthy working environment, intensive care units
In recent years, research on healthy work environ- ments in health care facilities has increased as they are recognized as a key factor in ensuring high-quali- ty, safe patient care, as well as the element that leads to higher productivity and staff satisfaction (1). The World Health Organization defines a healthy work environment as a workplace that supports the whole human being, is patient-focused and joyful, and ena- bles healthcare workers to meet the needs of their patients and their families as well as the goals of the unit and organization (2). Health workers are crucial for the sustainability of health facilities, yet many European countries are faced with health workforce shortages (3).
In their research, Salehi et al demonstrated the re- lationship between a healthy working environment and job satisfaction and the intention to leave work among intensive care nurses (4). Motley et al state that it is important for managers in healthcare insti- tutions to support healthy work environments, as these are essential for retaining good quality staff
(5). The work environment is also very strongly asso- ciated with indicators of nursing care quality in hos- pital settings: patient mortality rate, falls, bedsores, medication malpractice, repeated admission to hos- pital, length of hospitalization, and infections related to nursing care (6).
A group of authors in Croatia found that the impli- cations of nursing care rationing and nurses’ dissat- isfaction was associated to poor quality of nursing care provided to patients (7). Association between rationing of nursing care and nurse’s satisfaction has also been confirmed on a wider European sample (8).
Kester et al. wanted to examine the effect of the implementation of AACN standards on staff satisfac- tion, turnover, and tenure two years after initial im- plementation. The results of the study showed that there was statistical significance in all standards ex- cept in the skilled communication standard (9).
Wei et al conducted a systematic review of studies on nurse work environments in the USA, to identify elements that affect the improvement of nurse work environments. The authors found that work environ- ments affect nurses in a way that leads to impaired
mental health, job dissatisfaction, and retention. The review also stated that there is a link between the work environment and work performance and pro- ductivity. The authors found that it is necessary to continuously improve work environments (10).
Samur and Intepeler wanted to find out the nurses’ perspectives on healthy work environments. They conducted a qualitative descriptive design using in-depth semi-structured interviews and identified two key components: one related to “physical envi- ronment regulations” and the other related to “ad- ministrative arrangements”. They believe that it is necessary to work on improving healthy work envi- ronments, especially by preventing work accidents and injuries (11).
In 2001, the American Association of Critical-Care Nurses (AACN) made a commitment to actively pro- mote the creation of healthy work environments in critical care units. In 2005 the AACN published their Standards for Establishing and Sustaining Healthy Work Environments: Journey to Excellence. After the 2005 publication of the AACN standards, research was conducted on the impact of work environment on team effectiveness, patient outcomes, patient safety, nurse retention, and burnout syndrome in healthcare professionals. The AACN established six standards based on evidence: skilled communication, true collaboration, effective decision making, appro- priate staffing, meaningful recognition, and authen- tic leadership (12, 13).
The HWE4CCN project (2019-2022) was developed to be the first open, multilingual combined course for professional educators in the nursing field, aimed at healthy work environments in ICUs. The project was based on the six standards of the American Asso- ciation of Critical Care Nurses – AACN). The project coordinator is the Cyprus Nurses and Midwives Asso- ciation, and the partners are the Universität Interna- tional de Catalunya, the Polish Society of Anesthesia and Intensive Care Nurses, Croatian Nurses Soci- ety of Anesthesia, Resuscitation, Intensive Care and Transfusion and the European Federation of Critical Care Nursing Associations as an associate partner. The project was supported by Media Partners SRL (Romania).
As part of the project, focus groups were used to validate the online training content and identify best practices.
The aim of the research was to evaluate training courses designed to promote healthy working envi- ronments in intensive care units.
A qualitative design using focus groups was employed. The focus group was conducted live for an hour. Two focus groups were conducted, each consisting of four participants. Due to restrictions imposed by the COV- ID-19 pandemic, the study was limited to a sample of eight participants. Despite the small sample size, the researchers deemed it sufficient to reach data satura- tion, as no new themes emerged during the second focus group and participants expressed consistent perspectives regarding their work environment (14). Nevertheless, the limited number of participants is acknowledged as a constraint, and the authors recom- mend conducting follow-up research with a larger and more diverse sample to enhance the robustness and transferability of the findings.
The focus groups were led by two people, one con- ducted a semi-structured interview due to her expe- rience in conducting qualitative research, while the other person took notes and recorded the conversa- tion. At the beginning of the focus group, it was ex- plained that the conversation would be recorded and that the results would be used for scientific work. Each participant signed an informed consent for the recording and use of data obtained during the focus group. Each participant had the opportunity to add something at the end of the focus group.
Two focus group discussions were conducted with nurses who participated in respective training cours- es. Four nurses participated in each focus group dis-
cussion, a total of 8 respondents were included in the research. Focus group discussions have been con- ducted in January 2021. The participants were nurs- es who work in critical care departments and who participated in at least one workshop on a healthy work environment.
Table 1. Characteristics of focus group participants | |||
Gender | Age in years | Experience in the CCU in years | Number of standards listened prior the focus group |
1. Focus group | |||
Female | 32 | 7 | 4 |
Female | 24 | 1 | 4 |
Female | 35 | 10 | 6 |
Male | 20 | 1 | 4 |
2. Focus group | |||
Male | 24 | 2 | 4 |
Female | 27 | 2 | 3 |
Female | 39 | 19 | 2 |
Female | 27 | 2 | 4 |
The moderator used a semi-structured interview guide. Table 2 shows the questions addressed to the participants of the focus groups. Focus groups were organized on January 15, 2021 and January 22, 2021, shortly after the training. They were moderated by a researcher with clinical experience in intensive care and expertise in conducting focus group discussions. The average duration of the focus groups was 60 minutes. At the end of each focus group, the modera- tor summarized main discussion points, and partici- pants were encouraged to correct or add comments to ensure veracity and verifiability. Each focus group session was video recorded.
The data obtained by conducting the focus groups were transcribed word for word by one of the authors of the study. Participants were given the transcribed text to add to or confirm what was said in the fo-
cus group. Both researchers who conducted the fo- cus group worked separately on coding the text. The researchers cross-checked the codes and looked for preliminary themes based on the initial codes. Pre- liminary themes were reviewed and revised by two researchers. Each topic is given a name that reflects the content expressed in the focus groups.
Table 2. Questions for focus group participants
1. What challenges did you face while holding the course? What would you change?
What motivated you to take the course? Who do
2. you think should implement the HWE standards
and in what way?
To what extent is the course relevant to you and
your work environment? What information was most useful to you, and which will you apply in
your work?
4. To what extent could this course affect your work
environment?
Approval for conducting the study was obtained from the Ethics Committee of the UHC Zagreb, where the research was conducted. Also, each respondent gave written consent to participate in the study.
There is consensus among all respondents that the working environment is important for their optimal functioning during work. Since work in ICUs is incred- ibly stressful, the working environment is the fac- tor that makes a huge difference: whether it will be stress reliever or increase it further.
“The fact that we are all working in such a stress- ful environment does not mean that every day must be stressful and bad. I mean... these work- shops are perfect for improvement.” (G1)
After participating in training courses, nurses be- came aware of previously overlooked aspects of dai- ly work, such as the motivating effect of appropriate praise, and the benefits of adequate conflict man- agement, which, when improved on a personal level, can contribute to a healthier working environment. However, to achieve significant improvement, they emphasized the need to raise awareness of these aspects among all employees in the unit, especially to head nurses, whose leading and communication skills contribute the most to the overall atmosphere in the unit. Therefore, it is recommended to include as many nurses as possible, starting from the head nurses.
“Personally, it has definitely affected me, but I’m just sorry that maybe the department head nurs- es aren’t as present at such workshops as they might be, because as the colleague said, it all ac- tually starts with them. So, they are the people who should try to create a positive atmosphere, who should resolve conflicts so that they do not discriminate against anyone, etc., and I think that maybe for them there should be a little more or- ganized activities... workshops... Because they really hold the whole department in their hands. I won’t say that they determine everyone’s des- tiny, but they really have a noticeably big impact on the workers and their satisfaction.” (G2)
“I think more focus should be put on the head nurses of the wards and not just the wards, maybe the head nurses of the departments or something like that. They can change something because, re- alistically, let’s be honest, we can’t really change anything. We can point out some things, we can say: ‘this is not good for us, this does not suit us, maybe we could ... ‘ But in fact, we do not have too much of an influence, so I think it would be better suited, let’s say, better suited for them.” (G4)
However, there is a dose of skepticism towards the head nurses and their willingness to adjust their es- tablished approach. Participants pointed out there was no formal/standardized education and prepara- tion for head/leading positions so far, just a transfer of knowledge from one leading nurse to the other so there is no unified leading approach, but it depends on the character and skills of individual. Therefore, it is necessary to incorporate certain standards which head nurses can easily follow and play a role in an even better way.
“…but I think that people who are of a certain age already have their personality and their... I don’t know how to express myself... basically, their mode of operation – they will be difficult to change. But the truth is that head nurses have a big impact because they are there every day, they could change something, and we… not so much. Because we sometimes... I don’t see some of the co-workers sometimes for a week.” (G6)
One participant pointed out the necessity of involve- ment of physicians they work with, too, as they see a lack of understanding for nurses from some physicians.
Another argument to continue with training courses is that a healthy working environment is considered as the first line of prevention of burnout and leaving the job.
“I think this is certainly very important because if people take all the stress from work home, if they are not only stressed but maybe also nervous be- cause of other co-workers, if they take it all home, they will experience burnout much sooner and I think a healthy work environment is the first level of prevention in such things.” (G1)
Attendance at training courses (lifelong learning) is still very much determined by individual motivation and a desire to learn. Personal growth and develop- ment as well as the wish to contribute personally to a healthier work environment was the main motiva- tion for nurses to participate in respective training courses. Some participants were encouraged by the trainers themselves.
The reason why nurses do not participate in different courses to a larger extent is not seen as much in cov- ered topics (they state that the employer/superiors recognize the need and to a greater extent organize various useful courses and trainings), as in the fact that nurses have to attend courses in their own free time (sometimes before or after the shift), and with- out some kind of compensation.
It is suggested to the employer to give a day off for some training courses attended or at least symbolic financial compensation, which would affect the mo- tivation and greater satisfaction of the employees.
“The employees were not really interested in in- vesting their free time to attend a course. They
said it was a problem for them, they wanted days off... Simply, few people wanted to invest time in training, without you having to force them, at least that’s my impression.” (G3)
There is an opinion this is an investment in employ- ees which will pay off to the employer later on: em- ployees will be much more trained / educated and will therefore contribute a higher quality of work.
Forced participation in courses does not make sense because employees are not interested and motivated to listen to them for several hours, as well as training courses that they cannot apply in their working en- vironment, therefore there is no benefit neither for nurses nor for the employer.
It is advisable to put a greater focus on the wishes and needs of employees, to give them the opportu- nity to choose the training they are interested in and that they consider to be useful in their work to a cer- tain extent.
The following training topics were highlighted posi- tively: leadership, mentoring, skilled communication, and conflict management. Some of them are pointed out because nurses recognized considerable room for improvement and welcomed an effort to address these areas, some because they already apply knowl- edge from training courses to improve the working environment. Furthermore, their vision of good func- tioning regarding each topic is described.
It is particularly important that the leading nurse or shift manager is skilled (trained) in managing people and working in a dynamic and challenging environment.
“A head nurse or shift manager should be the per- son who has the level of knowledge and general ability to be able to control the whole depart- ment.” (G2)
Leading nurses were not (formally) trained for that role so far, these skills and knowledge were transmitted from nurse to nurse, so respondents see these roles as very undefined and dependent on individual com- petence/ability to perform. They think that manage- ment and mentoring roles should be strictly defined so the person coming to that position exactly knows what their assignments and responsibilities are.
Head/leading nurses should adjust the approach to in- dividual nurses considering their previous experience
(whether it is an experienced nurse in some other field or department, or it is a nurse without any previ- ous experience) and knowledge, while respecting sug- gestions of younger/newer employees as well.
The praising system should be adjusted along with work experience and knowledge, with a different kind of recognition, praising for beginners and al- ready experienced nurses.
Meaningful recognition is more important to young- er/new employees, it contributes a lot to their great- er security in work and motivation.
“…how much this one word ‘great’, ‘bravo’ and ‘great reaction’ means to someone who has just started working in the system, and how much it actually motivates for further work, and I think it is rarely applied, and actually this little word can help a lot.” (G5)
Mentoring is not considered a strong point, as there are no strictly defined guidelines outlining mentor’s assignments and responsibilities.
“So I think we are very bad with that part of men- toring and all that, I think it all floats somewhere and there is nothing exactly defined – how, what, where – we should have procedures about it, so that the person who gets that position can look up and see – aha, I have to do this, this and that, I have to check this and that.” (G7)
Head nurses’ communication should be adjusted to each of the employees, considering their personali- ties in order to get the best out of them. It is also im- portant to raise awareness of some aspects of com- munication among employees that can change their relationship positively. As one respondent would say: it is important to learn how to communicate with each other, regardless of the current mood.
One participant stated the necessity of including the communication of all stakeholders involved in patient care (physicians, physiotherapists and even cleaning staff).
Skilled communication is a field where shortcomings are seen as well, therefore training in this field is welcomed by both, leading and shift nurses, as well as physicians.
“If such workshops were to be held continuously, they would benefit everyone, both supervisors and us who are working shifts.” (G1)
“Someone may not be in a good mood that day, someone may have gotten up on the wrong side of the bed, someone is great and we simply must learn to communicate somehow – as you were saying... sorry... as you were all saying, after situ- ations like these... never talk during resuscitation or any other similar procedure, but afterwards yes, by all means, maybe even include physicians in the communication and absolutely include head nurses and, of course, other co-workers. But physicians should definitely be included.” (G2)
Conflicts occur sometimes during work among col- leagues for different reasons. One respondent pointed out the situation when he implemented a new, more constructive approach to conflict resolu- tion, the way he was taught in this course so it can be concluded that courses are already giving certain results.
“Well, take me for example... Three days ago, I suggested how to solve a conflict between two co-workers after the event.” (G4)
“The thing with the aggressive, passive-aggres- sive thing... those conflicts, how to behave, I mean, we always, maybe unconsciously, experi- ence during the day, during the working day, and it’s just, like, ‘react patiently’, I think I myself am passive so it’s not that I burst easily, but it accu- mulates in me and then when I need to burst then it’s like: ‘don’t, don’t, don’t’ (laughter), so, there were, there were a lot of those segments.” (G6)
The training courses that the respondents participat- ed in so far are very positively evaluated. Participants complimented the educators’ communication skills as well as their ability to encourage all the participants in a discussion.
Respondents pointed out that it is not enough just to narrate about a certain topic, but to demonstrate by showing it through examples, illustrate through games, role playing, etc. In such training courses participants get more involved (they are not passive listeners) and adopt and remember the content to a larger extent. Courses regarding the healthy work- ing environment were consistent with the above findings. All the respondents expressed high levels of motivation to participate in future similar courses and to recommend them to their colleagues.
“Well, it’s important to show people how it works, and to present it, I mean, live... I mean, not only to talk about it, but to really show it on examples.” (G1)
Participants suggest more frequent similar courses, as well as multiple courses on the one (same) topic so the participants could absorb the content to a higher degree.
They also point out the importance of informal gath- erings before or after such courses (refers to live courses which participants are more prone to), where they can evaluate and exchange experiences in a re- laxed environment which is stimulating for bonding and creating a better work environment.
Suggestions for improvement point out the need to include a larger number of participants in such train- ing courses, but in smaller groups, with a duration of up to 4 hours per training.
An important aspect of courses praised, especially in the second group discussion was their good, relaxed atmosphere, with participants feeling comfortable to
“Well, I think our supervisors, head nurses should recognize the need for a healthy work environ- ment and implement it and encourage people to go to workshops. Of course, including the nurs- ing manager on the hospital level, the level of the organization, but certainly the department head nurse should be someone who takes care of all of us employees. I would leave it to this level.” (G3)
“Maybe like you say... first separate them, then confront them all together, and then mix us all together to communicate something, to do some- thing, because if they’re in one group and we’re in another group, we will talk our stuff, and they will talk theirs and again: where are we? Mix us all, at one point mix us all together...” (G2)
A useful tool for informing nurses about the training courses could be leaflets containing most relevant in- formation such as the duration of course, main goals and benefits for nurses.
include and express their opinion. It is also one of the most prominent reasons for the recommendation of
courses to colleagues.
“So, I was... It was really great for me. it was one
of the segments that makes you take part every time because you learn something new every time and the atmosphere is quite relaxed, infor- mal. This informal part of the course is actually
quite okay. I think that will be extremely attrac- tive to people.” (G2)
“It was good because the whole atmosphere of the course was so relaxed and there were no wrong answers, and every answer was correct because it represented the opinion of individuals. I think this is the best approach to this course and the result is definitely positive after each training or lecture.” (G8)
Participants consider head nurses to have a main role in recognizing the need for education and encour- agement of other nurses to participate in training courses. It is suggested to organize the courses for head nurses first, so they can promote the courses and motivate others based on their own experience. After the separate courses for head and other nurs- es, it is suggested to organize courses for all of them together where different experiences and points of view can be exchanged.
Feedback from participants shows how important the work environment is for nurses. All participants agreed that the training course on the standards of a healthy working environment improved their knowl- edge and skills, and they believe that this will be re- flected in the quality of their work and cooperation with other healthcare professionals. They empha- sized the pleasant atmosphere, the preparation of the coaches and the interactive participation.
These results are not surprising because other stud- ies have also confirmed the importance of the work environment. Thus, Amaliyah and Tukimin state that some aspects of the work environment, such as rec- ognition for quality work or enough staff in relation to the number of patients, affect the quality of health care (15). In his research, Salehi et al also found a positive connection between the work environment and employee satisfaction (4).
Our feedback emphasizes management staff, with nurses referring to both head nurses and doctors. Participants believe that by implementing the stand- ards of a healthy working environment, management
staff would get the necessary skills that would im- prove work quality and increase staff satisfaction. Similar results indicating that managers do not sup- port nurses were obtained by other researchers (11, 16). Nurses believe that their managers should work together with them to build a working environment based on cooperation, trust, and motivation, and not worry only about numbers and limits (11).
Nurses believe that leadership is extremely im- portant and that it is a prerequisite for creating a healthy work environment. In their research, Hegazy et al stated that leadership is the path to excellence in nursing (16).
The participants believe that education for employ- ees should be organized in a way that encourages personal growth and development and that they should not be forced to attend education that does not interest them. Also, they placed considerable emphasis on mentoring, which does not have clear- ly defined roles, thus making it difficult to evaluate mentoring work. In addition, mentoring should be re- warded.
Since this paper is part of a broader project, similar results were observed in other participating coun- tries. Participants expressed high levels of satisfac- tion with the training and emphasized that a healthy working environment is extremely important for the quality of work and the well-being of employ- ees. All participating countries reported a positive response, with participants noting that the training was content-rich, clearly structured, and interactive. These characteristics further contributed to the high acceptance of the programme among participants. However, a common challenge across all countries was the implementation of the training in an online environment, which required additional adaptation of learning methods and efforts to ensure active en- gagement from participants. Despite these technical and logistical challenges, evaluations indicated that participants’ expectations were largely met (17).
Nurses in Cyprus and Croatia highlighted that such training should be made available to other health- care professionals as well, not only to nurses, since a healthy working environment is a shared responsibil- ity of the entire healthcare team. In contrast, nurses from Spain particularly emphasized the importance of promoting the training within healthcare institu- tions in order to ensure broader implementation and long-term impact. In Poland, participants expressed
the belief that even small, incremental steps can lead to positive changes in the workplace, underlining the importance of continuous yet realistic interventions. These findings reflect a shared perception among healthcare professionals from different countries regarding the importance of education on healthy work environments, and they confirm the relevance and applicability of the training module in an interna- tional context (17).
The report was created with a time delay, which means that some nurses’ attitudes and preferences may have changed since the focus group discussions. Therefore, caution is advised when considering rec- ommendations.
Focus group discussions were moderated by the same person who held the training courses (which is not in line with research practices), therefore the bias in respondents’ answers to some degree can be expected.
A notable limitation of this study is the small sample size, constrained by public health measures during the COVID-19 pandemic. While thematic saturation was likely achieved – as evidenced by the repeti- tion of key themes across focus groups – caution is warranted in interpreting and generalizing the find- ings. Prior research suggests that saturation can be reached with relatively few focus groups in studies with narrowly defined populations and focused re- search questions (14). Nevertheless, replication of the study with a larger and more heterogeneous sample would contribute to confirming the findings and expanding their applicability to broader clinical contexts.
The responses from nurses in this study show that there is a clear recognition of the need to change the working environment and that the concept of a healthy working environment must be an integral part of nurse education. The course taken by nurses can be integrated into continuous professional de- velopment programs not only for nurses working in intensive care units but also for other healthcare pro- viders. Special emphasis should be placed on train- ing nurse managers who, by completing the course, would acquire the necessary competencies for ef- fectively managing healthcare teams and fostering a supportive work environment.
However, it is important to note that the study includ- ed a small sample size, which may have influenced the results. Future research should involve a larger and more diverse sample to confirm the findings and to ensure that the conclusions are generalizable across different clinical settings. Additionally, the moderator of the focus groups should not also serve as the edu- cational trainer, as this could introduce bias into the discussion and the results, as the facilitator’s influ- ence could shape participants’ responses.
Conceptualization and methodology (SR, JS, AF, EG); Data curation and formal analysis (SR, JS, AF, EG); in- vestigation and project administration (SR, JS, AF, EG); and writing – original draft and review & editing (SR, JS, AF, EG). All authors have approved the final manuscript.
The authors declare no conflicts of interest.
To all partners participated from Cyprus, Romania, and Poland.
This research did not receive any specific grant from funding agencies in the public, commercial, or not- for-profit sectors.
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