10th Annual Evidence-Based Practice/Research Conference Evidence for Practice: Origins and New Directions October 8, 2018

General Session Abstracts 1.1-3.2 Poster Abstracts P1-P34


University Medical Center, New Orleans, LA
Background: Healthcare programs from inpatient hospitals to providers are focused on quality more than ever before. Providing quality care to patients is not only the right thing to do, but the reimbursement structure continues to evolve and revolves around patient outcomes with regard to payment for services. Specifically, the Centers for Medicare and Medicaid Services has implemented value-based purchasing that penalizes providers for poor quality care and never events such as hospital-acquired conditions (HAC). Nurses providing direct care to patients in the hospital are in the position to have an impact on reducing or eliminating HACs, thereby improving patient outcomes. Bedside nurses providing direct care need to be empowered to make necessary changes that influence nursing practice and impact patient care. Studies have demonstrated that a shared governance structure provides the work environment for empowering staff nurses as well as improving nursing satisfaction.

Methods:
The purpose of this quality improvement project was to create a nursing quality council (NQC) in a shared governance environment. The NQC was established with frontline staff nurses. The overall goal is to empower frontline staff nurses with the ability to impact the work environment that will lead to improved quality and care for patients. The specific quality indicators will focus on nursing-sensitive patient outcomes including catheter-associated urinary tract infections (CAUTI), central line-associated bloodstream infections (CLABSI), falls, and hospital-acquired pressure ulcers (HAPU).
Results: While a two-sample z-test allowing unequal variance did not prove to be statistically significant, the preliminary results demonstrate an improvement in falls and HAPU, with 2 of the 4 nursing-sensitive patient outcomes being measured.
Conclusion: This scholarly project was successful and met the aims and objectives. One of the "five must haves" for shared governance, a quality council, was established involving frontline, direct care staff nurses.

University of South Alabama, Mobile, AL
Background: An inundation of evidence, lack of confidence in translating evidence into practice, and a deficiency in working in interdisciplinary teams hinders healthcare providers from delivering the highest quality of care. To narrow the gap between knowledge generation and knowledge translation, providers from all disciplines must be able to communicate and collaborate with one another effectively. Therefore, a strategy for empowering interprofessional teams in the process of implementing evidence-based practices (EBP) to improve patient care is paramount. The purpose of this project was to develop an Interprofessional Evidence-Based Practice Council (IEBPC) to engage frontline staff in research, implementation of EBP, and interprofessional-shared governance to accelerate change within a hospital setting.

Methods:
Through an academic-practice partnership, a steering committee was formed, and hospital administrative support was obtained. Before guiding staff through the process of EBP and working in interprofessional teams, baseline data were obtained. Four instruments were utilized to gain insight into the current state of staffs' beliefs and competence, frequency of knowledge translation, and perceptions of the organizational culture and readiness for integration of EBP: EBP Beliefs Scale, EBP Implementation Scale, EBP Competence Scale, and Organizational Culture and Readiness for System-Wide Integration of EBP Scale.
Results: Findings indicated that although staff believe that EBP is effective in improving clinical care, there is a gap in the staff's understanding of fundamental concepts of EBP, the processes necessary to find and translate evidence into practice, and a lack of formalized training on working in interprofessional teams. Overall, staff reported potential satisfaction in participating in an IEBPC and were engaged in the process of improving the organizational readiness for the integration of EBP. These results will be used to guide further improvements in the development of the council.
Conclusion: Engaged frontline staff champions and leaders have the opportunity to play an integral role in the development of EBP cultures. This project is ongoing; however, it is hypothesized that the implementation of an IEBPC that utilizes an interprofessional shared governance model, as well as training in EBP and interprofessional collaboration, will have far-reaching patient-centered outcomes. Background: Historically, a medical/surgical unit with high patient volume and patient turnover experienced a high rate of peripheral intravenous infiltration and extravasation (PIVIE) (In 2015, the total PIVIE rate was 13.65 per 1000 patient days). In 2015, the unit began active participation in the hospital-wide PIVIE team which included the implementation of a prevention bundle. Following a spike in the rate in early 2017, unit leadership began to engage in intensive PIVIE reduction efforts.
Methods: Quality improvement unit leadership, using lean rapid process improvement principles, began leadership rounding every weekday on patients with peripheral intravenous lines (PIVs) starting in April 2017. Rounding included examining the PIV site, ensuring the "Touch-Look-Compare" (TLC) poster was actively utilized during each assessment, and educating and engaging family members in the TLC process. Missed bundle elements were resolved daily and data visually displayed in posted Pareto charts and the Kaizen Newspaper for ongoing improvement. In September 2017, night-shift team members were added to the PIVIE team. Team engagement efforts included encouragement to report mild PIVIEs and engaging child care technicians to examine PIV sites and to complete TLC assessment when vital signs are obtained.
Results: From January 2016-April 2017, the unit's total PIVIE rate was 7.90 per 1000 patient days. From May 2017-February 2018, the rate was 4.67 per 1000 patient days (P value = 0.021; utilizing a two-proportion test). The rate reduction was sustained after leadership transitioned daily rounding to clinical leaders.

Conclusion:
An intensive leadership rounding process led to a sustained drop in PIVIE occurrence. Next steps include ongoing education and training for this process to other medical/surgical units. Additionally, the leadership teams will continue to engage new team members in PIVIE prevention to ensure sustained results.

P4. Improving Communications and Perceptions of Mutual Support to Expedite a Major Perinatal Practice Change
Lori Noel, MSN, BSN, RN, CNOR

Ochsner Medical Center, Kenner, LA
Background: Increased newborn patient falls and adverse respiratory events identified failures in transitioning care from delivery to the first 2 hours after birth. Transition care models were not finalized, and best practice recommendations were loosely enforced. Perinatal staff were administered the TeamSTEPPS Teamwork Attitudes Questionnaire (T-TAQ) which identified poor communications and lack of team support. Through an interprofessional collaborative committee (ICC), this project sought to improve mutual support perceptions and team communications to implement practice change in a change-resistant environment.
Methods: Evidence-based research was applied to create a perinatal ICC that included representatives of all shifts and units, champions and detractors, and unit leaders. TeamSTEPPS Mutual Support education and simulation training was administered to nursing and ancillary staff. A newborn transition-in-care operational standard was created, and staffing practices were revised. The new model, based on the Association of Women's Health, Obstetric and Neonatal Nurses' guidelines, required the labor nurse to remain at the bedside during the 2-hour transition period. Complexity theory was applied, and Plan-Do-Study-Act (PDSA) and debriefing tools were utilized during model implementation.

University of Mississippi Medical Center, Jackson, MS
Background: Pediatric mild traumatic brain injury, or concussion, is an increasing population health concern. Some studies suggest that children with preexisting neuropsychological disorders such as behavioral disorders, learning disabilities, or mood disorders have a longer duration or increased symptoms after mild traumatic brain injury compared to children without premorbid conditions, but the evidence is mixed. Little scientific inquiry has been conducted to identify the impacts of concussion in children with premorbid neuropsychological conditions (PNPC), as they are often excluded from research because of their PNPC.

Methods:
A systematic review utilizing the Joanna Briggs Institute (JBI) methodology for reviews of etiology and risk was conducted with an a priori protocol to identify the associations of premorbid neuropsychological conditions on mild traumatic brain injury/concussion recovery time and symptom severity in children.
Results: Analysis revealed 12 articles for systematic review inclusion with significant study heterogeneity, as well as variation in study findings. Thus, a metaanalysis was unable to be conducted, and a JBI Grade of Evidence B was applied to findings.
Conclusion: Significant associations for prolonged recovery or increased symptom severity after mild traumatic brain injury were identified in children with premorbid histories of learning disorders and poor academic achievement; anxiety, depression, mood disorders, or other psychiatric illnesses; prior head injuries (especially with a history of multiple concussions); somatization (in females); sleep disorders (in males); and multiple neuropsychological conditions. Significant research gaps exist, but overall findings suggest that clinicians should incorporate postconcussion screening for premorbid neuropsychological conditions and closely monitor injury recovery.

P9. Using Critical Incident Stress Debriefing to Impact Perception of Support During Crisis in Adult Inpatient Nurses
Shannon West, BSN, RN, PCCN, CCRN-K

Ochsner Medical Center, New Orleans, LA
Background: Exposure to repeated stressors places healthcare workers at risk for compassion fatigue and burnout. Debriefing mitigates crisis and contributes to feelings of mutual support. A survey of registered nurses (RN) at a large, academic healthcare facility showed their perception of support during crisis varied from no support to excellent support, and 86% rated support as very important/essential. In 2017, a multidisciplinary team implemented the code lavender pilot for RNs on units with high mortality rates, aiming to determine the effectiveness of critical incident stress debriefing (CISD) and structured support on RNs' perception of workplace support during crisis.
Methods: Chaplains and patient flow coordinators (PFC) received training using the CISD tool to serve as responders who debrief nurses in crisis. Nurses received information on when and how to activate code lavender for individuals or groups experiencing crisis. Upon activation of code lavender, the response team, consisting of a chaplain, PFC, and nursing administrator, responded to the unit. Effectiveness of code lavender was evaluated through a postintervention survey of nurses and responders.
Results: Three months after initiating the pilot, code lavender was activated 4 times for individuals and once for a unit. The postintervention survey revealed that nurses appreciated the support but felt averse to responders due to the perception that responders did not understand the nurses' experience. The survey indicated that RNs did not activate code lavender on multiple occasions when criteria were met due to the perception that the response was not helpful. Feeling of support during crisis was not met due to lack of program utilization. The survey showed that chaplains and PFCs felt the need for additional training.
Conclusion: Barriers to utilization of code lavender were lack of buy-in and poor perception of response. We plan to provide formal training for responders to provide more robust support for RNs experiencing crisis in the future.

P10. Older Nurses' Experiences of Providing Direct Care in Hospital Nursing Units: A Qualitative Systematic Review
Alice Gaudine, PhD, RN; Karen Parsons, PhD, RN

Memorial University of Newfoundland, St. John's, Newfoundland
Background: Most developed countries are experiencing an aging workforce as their population ages. The retirement of aging nurses has contributed to a critical global nursing shortage that is anticipated to increase. This global nursing shortage is partly due to a consistent pattern of nurses leaving hospital settings or the workforce after the age of 50 years. The many reasons why older nurses leave the workforce early include shift work, the stress of a heavy workload, and perceived lack of responsiveness to nurses' concerns and chronic health conditions. It is important to understand the experience of older nurses in high-paced hospital nursing units. This systematic review integrated the literature on the experiences of older nurses providing direct nursing care.

Methods:
This review considered studies that included registered nurses ࣙ45 years who work as direct care nurses on any type of inpatient hospital nursing unit. This review considered studies that focused on qualitative data including the following methodologies: phenomenology, grounded theory, ethnography, action research, and feminist research. The databases searched included: CINAHL, PubMed, Psycinfo, Embase, AgeLine, Sociological Abstracts, and SocIN-DEX; the search was conducted on October 13, 2017.
Results: Three synthesized findings were identified consisting of 12 categories and 75 findings. The 3 synthesized findings extracted from the papers were (1) the love of nursing: it's who I am and I love it; (2) it's a rewarding but challenging and changing job; (3) it's a challenging job: can I keep up? Implications for nurse leaders and healthcare organizations stemming from our findings are identified.

Conclusion:
Older nurses love nursing and have created an identity around their profession, yet they identify many challenges and changes. To address the workforce shortage, it is important to address the implications of our findings for nurse leaders and healthcare organizations.

P11. Certification Central: Increasing Critical Care Registered Nurse Certification in the Pediatric Intensive Care Unit
Jamie A. Harrell, RN, BSN; Angela Layden, RN, CCRN

Ochsner Medical Center, New Orleans, LA
Background: Critical care nursing certification (CCRN) is a valued component in the education and confidence of a registered nurse. By obtaining the certification, the nurse not only develops and deepens his or her own education and understanding of nursing practice but also puts the patient's safety and care at the top of the priority list. It allows for the nurse to care for both the patient and the family, as well as contribute to the pediatric intensive care unit (PICU) team. Certification allows the nurse to demonstrate how to care for critically ill patients and show proficiencies in knowledge and skill involved in the critical care area. Louisiana had a 16% certification rate as of 2017. The PICU has a 32.9% certification rate. The intent of this project was to bring awareness to the importance and value of CCRN certification on both the personal and professional level.

Methods:
A unit ambassador was assigned to speak in groups as well as individually to interested staff nurses. Materials were included in the new hire packets for future test taking, and resources were provided for study materials. The ambassador recently took the certification examination herself and ensures that individuals know where to sign up and find the appropriate materials to study for the examination. The ambassador also works to promote a culture of certification among the unit. The ambassador focuses on personal and professional growth, the benefits to Ochsner of obtaining certification, and the need for continued participation on the unit.

Results:
The intent of this project was to increase the number of staff RNs considering and completing CCRN certification. Our initial percentage was 32.9%, and the goal was 45% over the next 12 months. After 5 months of implementing this practice, 37.5% of the staff qualified to sit for the exam, a 4.5% increase. The unit has had 2 additional nurses take the certification and pass. Three additional nurses expressed interest and/or have signed up for the test.

Conclusion:
With the help of the ambassador and the encouragement of other certified nurses, there is great potential to increase the number of CCRN-certified PICU nurses to ensure improved quality of care and safety to PICU patients. The certification percentage has increased with those eligible to sit for the test. All new hires have been presented with materials for the certification and will be contacted once they meet the requirements for taking the test. e10 Ochsner Journal

P12. Implementation of an Educational Session and Simulated Clinical Experience on Responding to Code Blue Emergencies: A Quality Improvement Project
Brandy Barbarin, MN, BSN, RN

LSU Health School of Nursing, New Orleans, LA
Background: The American Heart Association (AHA) established the Get With The Guidelines -Resuscitation (GWTG-R) quality improvement program to optimize outcomes through benchmarking, knowledge translation, and research. Three of the metrics tracked by GWTG-R are (1) initiate cardiopulmonary resuscitation (CPR) within 1 minute of cardiac arrest, (2) defibrillate within 2 minutes for shockable rhythms, and (3) administer epinephrine within 5 minutes for asystole and pulseless electrical activity. Baseline data on these 3 metrics were obtained from a large, teaching tertiary hospital located in an urban community in the Southeastern Region of the United States. Initiating CPR within 1 minute, defibrillating within 2 minutes, and administering epinephrine within 5 minutes in at least 85% of in-hospital cardiac arrests were not consistently being met. Studies show simulation training has a positive effect on staff performance and improved patient outcomes in code blue emergencies.

Methods:
For this project, a doctor of nursing practice student conducted educational sessions with code blue simulation and debriefing with registered nurses and patient care technicians on an inpatient medical-surgical unit for a period of 4 weeks. The sessions focused on collecting data during the first 5 minutes of the simulated cardiac arrest. The postsimulation debriefing topics of discussion included communication issues, safety, staff confidence, and compliance with AHA guidelines for in-hospital cardiac arrest response. The aims of this project were to improve code blue performance, patient outcomes, and resource utilization.
Results: All participants were basic life support-certified by the AHA. Data on time to initiating CPR and time to first shock was collected utilizing the code blue audit tool. The mean time to initiate chest compressions during the simulation sessions was 20.8 seconds (n=12). The mean time to deliver the first shock during the simulation sessions was 78.8 seconds (n=12). The results of the simulation effectiveness tool indicate that 100% of the participants (n=36) found the simulation sessions prepared them to respond to changes in patients' conditions and increased their confidence in their ability to prioritize care and interventions, communicate with patients, teach patients about their illness, report information to the healthcare team, foster patient safety, and use evidence-based practice to provide nursing care.

Conclusion:
Overall, the simulated clinical experience had a significant positive effect on performance in a code blue situation.

P13. Correlation of Primary Learner Assessment and Electronic Fetal Monitoring Education on RN Learning Outcomes
Sharon Cusanza, MSN, RN, NEA-BC

LAMMICO/Medical Interactive, Metairie, LA
Background: Timely and accurate interpretation of electronic fetal monitoring (EFM) data is critical to the safety of both a mother and fetus. To promote patient safety and mitigate risks related to this high-risk skill, Medical Interactive (MI) offers unique computer-based education through the Learning Management System (LMS). Upon completion of an EFM Primary Learner Assessment (PLA), the LMS generates an individualized learning plan of continuing education course recommendations to meet identified knowledge gaps. From an evidence-based practice perspective, research is warranted to determine improvements in knowledge and skills as well as patient safety perceptions as a result of completing these courses through the PLA in the LMS. Therefore, the primary purpose of this research study was to quantify changes in RN knowledge and skills as measured by improvement in preassessment and postassessment scores for the PLA obtained from the participant assessment and survey.
Methods: This survey research study included 55 RNs who work in labor and delivery units administering and interpreting EFM from 3 hospitals. Participants completed surveys and recommended EFM-related education. Subject duration was approximately 1 month for completion of the initial survey, continuing nursing education (CNE) courses, and associated pretest/posttest; then, a follow-up survey was completed approximately 15 days thereafter.

Results:
The average RN knowledge and skills between preassessment (73.3%) and postassessment (85.2%) scores showed a statistically significant improvement (paired t-test=7.96, P(T⇐t) two-tail <0.0001). There were also improvements between aggregated averages of pretest (70.1% correct) and posttest (80.5% correct) scores from completion of all the recommended and highly recommended CNE courses. An improvement was noted in averaged EFM practice-related questions obtained from the participant surveys at baseline (44%) and follow-up (93%) as well.

Conclusion:
As a result of the PLA and completion of recommended EFM courses through the learner-directed assessment and targeted education, the RN participants' knowledge and skills were improved. RN perceptions regarding outcomes were improved oxygen therapy, competence, and interpreting fetal rhythms and resulting interventions.

P14. Parent Satisfaction With Feeding Competence in Preterm Infants: Infant-Driven Feeding Compared With Standard Scheduled Feeding
Carrie Mayo, BSN, RN

Louisiana State University Health New Orleans, School of Nursing, New Orleans, LA
Background: Providing correct education about infant-driven feeding (IDF) while the infant and family are in the hospital can prevent the need for long-term rehabilitation after discharge. There is limited research on parent satisfaction with feeding education, especially comparing standard scheduled feeding (SSF) education with IDF. This project evaluated a feeding policy change from SSF to IDF and the resulting parent satisfaction with comfort of feeding at discharge.

Methods:
Parents were interviewed and surveyed prior to discharge regarding education and feelings of competence with feeding. After discharge, parents received the standard discharge call. All were asked about feeding progress and weight gain after discharge. A retrospective review of discharge surveys compared parent satisfaction and education with infants fed using SSF. The goal was to survey 50% or more of eligible parents during the 12-week implementation phase, with 100% of parents on IDF receiving education, and 85% of infants gaining weight between discharge and the first pediatrician appointment.
Results: Seventy-two percent of eligible parents participated in the evaluation, 100% of the parents surveyed were taught how to feed infants by reading cues, and 84% felt very confident or confident in their ability to feed at discharge. More than 95% of parents stated an understanding of reading an infant's readiness cues before and during feeding at discharge. More than 95% of infants gained weight between discharge and the first pediatrician visit.

Conclusion:
Parents of infants discharged on IDF feedings felt more confident at home than the parents of those discharged on SSF. IDF required greater parent education from nursing staff and therapists; however, evaluation demonstrated increased parent satisfaction, greater confidence at discharge and athome, and positive infant weight gain.

Ochsner Hospital for Children, New Orleans, LA
Background: Unplanned extubation (UE) is a serious adverse event that has the potential to cause severe hypoxia, increased risk of infection, airway trauma, prolonged mechanical ventilation, and increased length of stay. Additionally, UE is associated with an increase in costs due to increased supply usage, additional imaging and laboratory studies, and increased staffing requirements. Identified risk factors for UE include younger age, agitation/delirium, inadequate tube fixation, weaning from mechanical ventilation, bedside procedures, and high patient-nurse ratio. The published rates of UE in the pediatric population range between 0.11-6.4 events/100 ventilator days. The purpose of this project was to decrease UE in the pediatric intensive care unit (PICU) to <1 occurrence per 100 ventilator days using evidencebased strategies.
Methods: Using Plan-Do Study Act methodology, the following cycles for change were implemented over a 2-year timeline: education on proper sizing and application of commercial tube holder and root cause analysis of each UE that revealed 2 commonalities (undersedation and improper securement) that were consistent with published literature. Additional interventions included leader bedside rounding on the security of the endotracheal tube, implementation of a sedation-titration protocol to give bedside nurses greater autonomy in determining treatment for agitation, and standardization of the method to secure endotracheal tubes. Retrospective data was used to track the UE rates, preimplementation and postimplementation of these evidence-based interventions.
Results: Since project inception, the UE rate decreased from 1.4/100 ventilator days to 0.3/100 ventilator days with the implementation of evidence-based strategies. As a result of this quality improvement project, the PICU went 22 months without a UE event.
Conclusion: Through the implementation of an interprofessional quality improvement program, it is possible to reduce the incidence of UE adverse events. Ongoing monitoring and analysis will be essential to maintaining these low UE rates.
Methods: Critical ethnography serves as the appropriate methodology based on research questions. Research participants are full-time, medical-surgical floor nurses working 12-hour day shifts at a large hospital in Mississippi. Observation, individual interviews, and the Nurse Codependency Questionnaire (NCQ) completion yielded raw data. The researcher spent 5 consecutive shifts with 10 participants.

Results:
Research quantified concrete self-care behaviors such as nutrition, elimination, breaks, and hydration. Additionally, data analysis revealed several abstract self-care behaviors: support seeking, humor, expectation management, and authenticity. Six overarching themes emerged during data analysis: complaining, mistrust, inner conflict, collective caretaking, humor, and concrete self-care. Individual interview data corroborated observational data, and survey results triangulated findings. NCQ scores suggested minimal codependency among participants with a 0.92 Cronbach alpha reliability measure. Overall, the data suggest that cultural evolution is underway. Nurses adapt to strenuous environments and find new ways to engage in self-care.

Conclusion:
This research provides a glimpse into the subculture of medical-surgical nursing. Nurses have long been portrayed as weary, hungry, or variations of the like. While this imagery is relatable, evolution has begun. Nurses have found a way to minimize self-sacrifice through collective self-care. In caring for each other, they cared for themselves. Improved cultural self-awareness can revise antiquated stereotypes. Moreover, improvements in nursing benefit healthcare organizations financially and with regard to patient care quality. Future research should seek to better understand other facets of nursing culture. Conceptual exploration in future research seeks to redefine what it means to be a nurse.

P28. Using a Multidisciplinary Approach for the Reduction of Ventilator Hours in Coronary Artery Bypass Graft
Sylvia Laudun, DNP, MBA, RN, CPHQ; Eugene Parrino, MD

Ochsner Medical Center, New Orleans, LA
Background: A review of isolated coronary artery bypass graft (CABG) surgery cases at an academic health system from 2013-2017 revealed total median ventilator times that were 2.2-3.6 hours greater than Society of Thoracic Surgeons (STS) data during the same period. Variation in the center's median total ventilator hours was noted, while STS revealed a consistent reduction over time.

Methods:
In April 2017, a multidisciplinary team formed to design the ONE Path standardized care plan for CABG patients with the goal of improving care coordination and patient safety. Team meetings covered content development, electronic medical record testing, and implementation. The team reviewed retrospective data from the STS Adult Cardiac Surgery Database on total ventilator hours, extubation in the operating room (OR), initial intubation <6 hours, and reintubation events from 2016-2017 first quarter for isolated CABG patients. Cardiac surgeons met with cardiac anesthesiologists to propose methods to fast track appropriate patients in the OR and intensive care unit. In September 2017, implementation of ONE Path and changes in anesthesia OR practice occurred.
Results: Reduction in ventilation hours was essentially due to aggressive OR extubation and consistent care processes for early extubation. Pre-ONE Path implementation, 2017 median total ventilation time was 7.8 hours (n=77) vs 0.0 hours (n=74) 9 months postimplementation of ONE Path and anesthesia changes. Extubation in the OR increased from 7.8% to 55.4%, initial intubation <6 hours increased from 51.9% to 72.9%, and reintubation rates dropped from 7.8% to 5.4%.

Conclusion:
A reduction in ventilation hours suggests the benefit of a multidisciplinary team approach to care coordination to improve outcomes.

P29. Measuring Direct Care Nurses' and Nurse Leaders' Perceptions of a Healthy Work Environment Within Acute Care Settings
Penny Huddleston, PhD, RN, NEA-BC, CCRN

Baylor Scott & White Medical Center, Irving, TX
Background: Unhealthy work environments (UWEs) throughout healthcare organizations have been linked to absenteeism, ineffective delivery of healthcare to patients and families, high stress levels, poor communication, and ineffective collaboration and teamwork among healthcare professionals. Healthy work environments (HWE) lead to improved RN satisfaction.

Methods:
These studies were conducted to replicate the findings of the original studies to reassess the psychometric properties of the Healthy Work Environment Scale for Direct Care Nurses (HWES for DCNs) and the Healthy Work Environment Scale for Nurse Leaders (HWES for NLs), to strengthen the generalizability of the tool and to describe the direct care nurses' perceptions of an HWE. Using nonexploratory descriptive designs, direct care nurses and nurse leaders were requested to complete the corresponding survey.
Results: Principal component analysis on the HWES for DCNs revealed 39 items with 6 components with eigenvalues higher than 1.0. The components were identified as genuine teamwork and true collaboration, meaningful recognition, appropriate staffing, effective decision-making, physical and psychological safety, and authentic leadership. The HWE standard of skilled communication loaded on all 6 of the components. The Cronbach alpha was 0.957. HWES for NLs revealed 40 items with 5 components with eigenvalues higher than 1.0. The components were identified as skilled communication, genuine teamwork and true collaboration, authentic leadership and effective decision-making, meaningful recognition, appropriate staffing, and physical and psychological safety. The Cronbach alpha was 0.974.