1. Running head: POSITIVE WORK ENVIRONMENTS 1
Positive Work Environments
Arthur Pease
Stevenson University
Author Note
This paper was prepared for NURS 750- Nursing Leadership/Management Capstone,
taught in Spring 2016.

2. POSITIVE WORK ENVIRONMENTS 2
Positive Work Environment
Positive work environments help nursing staff to maintain a positive attitude to meet the
stress factors in the acute care facility. Positive work environments help improve job satisfaction
and retention of the professional nursing staff. Today’s rapid changes in the health care industry
are creating an environment of increased stress and dissatisfaction within the nursing work force.
Nurses are faced with change in the form of more demands and expectations from their facilities
employers due to the new requirements by the Centers for Medicare and Medicaid Services
(CMS). These changes are coming in the form of how the acute care facilities are being paid.
The new requirements are based upon quality measures as well as patient satisfaction scores
(CMS, 2016). Acute care facilities are experiencing greater financial demands from the CMS
with narrowing margins which are already under 4% with a field rate in the state of Maryland of
only 0.8% (MHA, 2013). This puts pressure on the acute care facilities which in turn puts the
pressure on the nursing staff (MHA, 2013).
The workplace environment needs to have an organizational structure that is conducive to
giving their nurses autonomy and support. While acute care facilities financial margins are
shrinking, so are the numbers of nurses and the result is a reduction of over 20% of the nursing
staff by the year 2020 (Gotschall, 2010). This creates a need for nursing leaders to look at how to
change the work environment structure to promote a positive workplace. Leaders and acute care
facilities need to create an organizational structure to help their nursing staff to adapt to the new
challenges and increase job satisfaction. Creation of a positive workspace will help the acute care
facilities to retain their most valuable resource, their professional nurses, and meet the CMS
regulations.

3. POSITIVE WORK ENVIRONMENTS 3
The objective of this paper will be to explore theories that show how a positive work
environment can increase nursing job satisfaction and retention. Theories such as the “Job
Demand Control Support Model” (JDCS Model) developed by Karasek & Theorell, (1992) help
to determine the concepts needed to produce such an environment. Karasek & Theorell were
pioneers in helping to show how the work environment had an impact on the health of the
worker. The work by Karasek, Baker, Marxer, Ahlbom & Theorell, (1981) showed in a
quantitative study how higher levels of workers with more freedoms and social outlets were able
to reduce the harmful effects of the negative stress brought on by these negative environments.
The environments that help to reduce this stress gave the staff greater freedom in choices and
autonomy (Karasek, et al., 1981). Many concepts have been derived from this work and the
framework is still used as a test of the working environment today. Concepts developed from
Karasek & Theorell, (1992) and others will be reviewed. These concepts will help to show how
using best practices and Evidence Base Practice (EBP) can develop a better organizational
structure. Using the improved organizational structure should help achieve a positive work
environment, job satisfaction and engaged professional nursing staff. Developing this positive
environment will further the efforts of the acute care facilities to improve nursing job satisfaction
and retention. Following improved nursing job satisfaction and retention acute care facilities will
achieve improved patient satisfaction and quality outcomes.
Lititure Review and Research
Background and Foundation
The foundation of the Job Demand Control Support Model” (JDCS Model) developed by
Karasek & Theorell (1992) was developed by Karasek & Theorell in an earlier Swedish study
which tracked a random sample of working men in Sweden (Karasek, et al., 1981). This study

4. POSITIVE WORK ENVIRONMENTS 4
used the association of the work environment and the development of Coronary Heart Disease
(CHD). The study adjusted for issues such as age, smoking overweight and education, over a six-
year period. The study founded two concepts which were termed as Job Demands and Decision
Latitude as the two variables to be measured in the study (Karasek, et al., 1981). Karasek felt that
there was little theory in integrating job stress into the existing studies at the time. These
concepts of measuring job stress and decision freedom, and psychosocial elements create the
basis of determining the cause and effect of an unhealthy and non-positive work environment.
This initial work by Karasek, et al., (1981) helped to develop into later concept by Karasek and
Theorell (1992) called the Job demand, control, support model (JDCS model). Job demand was
the term used to describe the job stressors that were encountered on the job (Karasek & Theorell,
1992). The term, control, was described as ability to make intellectual decisions and increase
personal freedom (Karasek & Theorell, 1992). The greater the freedom to make decisions, the
greater the stress is mitigated (Karasek & Theorell, 1992). The support system came from the
psychosocial experiences in the work place, these experiences helped the workers to feel a sense
of support and team work (Karasek & Theorell, 1992).
In 1980 the American Nursing Association (ANA) and the American Nursing
Credentialing Center (ANCC), began to research why certain hospitals were hiring and retaining
nurses while others couldn’t (ANCC, 2016). The need for nursing was increasing yet there were
shortages worldwide causing concern on how to meet the demands of an adequate professional
nursing staff (ANCC, 2016). This created the first study by nurses for nurses to determine how
to improve the working environment for the nursing profession. The study lead to what was to
become the Magnet Designation (ANCC, 2016). The ability to obtain the Magnet Designation
shows everyone that this facility has a culture that provides transformational leadership and an

5. POSITIVE WORK ENVIRONMENTS 5
organizational structure to help with nursing getting autonomy and social support. The use of
transformational leadership and organizational structure are two of the workplace cultural
attributes nurses are looking for in maintaining job satisfaction and a positive working
environment.
Nursing began to look at the study by Karasek et al. (1981) in a health care worker’s
satisfaction study by Landsbergis (1988). In the Landsbergis (1988) study the concepts of the job
demand, control, support (JDCS) model was further studied. Landsbergis (1988) found the
additional concept of, the greater the education by the healthcare worker the greater the freedom
in job decision, which resulted in higher job satisfaction (Landsbergis, 1988). Landsbergis
(1988) exemplified the nursing frustration in lack of autonomy as quoted by Sexton “They teach
us to think in nursing school, and they teach us that we have our own realm and skills, but on the
job we find we have no realm at all. Unless we have a specialty we're stuck. We do what the
doctor orders and we do not think” (1982, as cited in Landsbergis, 1988, p. 234). This is the
feeling that was common within the nursing profession, and in many facilities still exists today.
The previous studies helped to show the needed for more organizational structure studies. This
created need in developing a structure for organizations that acknowledged the needs of the
professional nurse. The following studies often refer back to the foundation of these original
studies which made it necessary to at least give explanation of the original studies that are now
very dated.
Supportive Studies
In looking at the profession of nursing and the many stressors, there are many
applications of Karasek and Theorell’s concepts with stress in the work place. There are many
stressors that have a detrimental effect on the work environment of nursing. Much of the research

6. POSITIVE WORK ENVIRONMENTS 6
has included the work of Karasek and Theorell (1992) using the JCDS model. The current
research is still using the JCDS model. While this is an important model it is important to look at
other models for job satisfaction and retention within the nursing profession.
Nursing bullying on the job can have a very negative impact not only on the job
environment but on nurse job satisfaction as well. Elfi Baillien∗, Nele De Cuyper and Hans De
Witte (2011) used the work of Karasek and Theorell (1992) in showing a direct relevancy of
bullying to the Job demand, control, support (JDCS) model. The typical studies have put the
quantitative measures of job demand versus job autonomy (Baillien, et al., 2011). Each of these
theories has its own measure, they work in synergy in helping to cope with the job environment
(Baillien, et al., 2011). While Karasek and Theorell (1992) model has been applied to the issues
of health, anxiety, depression, job satisfaction, sickness and burn out, Baillien, et al. (2011) felt
that there were no studies involving behavioral issues such as bullying. While there are many
definitions of bullying the end result is that it creates a stressful work environment (Baillien, et
al., 2011). It is also reasonable to assume as the individual becomes more strained and has less
autonomy they too can become the perpetrator or the victims of bullying. Baillien, et al. (2011)
used a longitudinal study with shorter time lags of 6 months. The conclusions of this study
supported Karasek and Theorell (1992) Job Demand, Control, Support (CDCS) Model and
concluded it dealt with both the perpetrator and the recipient. The results showed that the
perpetrator and the recipient both came out of the first round of stressors and felt they had no
relief from the job demands with little autonomy and support (Baillien, et al., 2011). This is even
a greater argument for how the work environment needs to have a positive organizational
structure.

7. POSITIVE WORK ENVIRONMENTS 7
Presseau, Johnston, Johnston, Elovainio, Hrisos, Steen, Stamp, Francis, Grimshaw,
Hawthorne, Hunter & Eccles (2014) felt the studies showed Karasek and Theorell (1992) was
environmental and did not include the individual character and features as part of this conceptual
theory. Presseau, et al. (2014) wanted to show this concept of the individual character should be
included with the environment and include individual perceptions of the environment. (Presseau,
et al. (2014) used a predictive national survey as their design for the study in the United
Kingdom. The method was to invite 2079 staff members from general practices and to use a
survey via the mail (Presseau, et al., 2014). The survey used questions to assess the various job
stressors including distress, absenteeism, control levels and their intentions to leave (Presseau, et
al., 2014). One thousand and five hundred and ninety surveys were returned back with greater
than eighty percent completed responses (Presseau, et al., 2014). Presseau, et al. (2014) were
able to determine, from their responses and results, that there needed to be more research in the
relation and concept of the individual effects on the Job Demand, Control, Support Model.
Presseau, et al. (2014) further suggested that while the absentee rate and intention to leave were
low the use of an intervention to allow the staff more control would help with the individual
distress levels experienced (Presseau, et al., 2014). It is important to note the validity of Karasek
and Theorell (1992) Job demand, control, support (JDCS) model is noted within the study.
Learning through problem solving under various combinations of Karasek and Theorell
(1992) Job Demand, Control, Support (JDCS) model was the purpose of the study by Bergman,
Ahlberg, Johansson, Stoetzer, Åborg, Hallsten & Lundberg, (2012). Bergman, et al. (2012)
wanted to determine if the Job Demand Control theory helped to promote greater learning
through problem solving. The premise was when the situation of greater demand with greater
control existed did this increased the problem solving skills and helped to foster greater learning

8. POSITIVE WORK ENVIRONMENTS 8
outside the work place (Bergman, et al. 2012). Bergman, et al. (2012) specifically wanted to
determine how this environment helped to increase the desire of education within the work place
as well as outside the workplace. This was longitudinal Study with random selection of the
population within Stockholm County in Sweden ages 20 to 64 (Bergman, et al. 2012). The
response rate was 53% with 42% men and 58% women across various professions with a mean
age of 42.1 years (Bergman, et al. 2012). The conclusions found less of an importance in job
demands but job control seemed to be important for both on the job learning as well as outside
learning (Bergman, et al. 2012). It was further determined that the working conditions with an
importance in learning had a greater potential impact on job satisfaction, productivity and helped
with absenteeism, sickness and a general overall wellness (Bergman, et al. 2012).
The Center for American Nurses, (2009) published an article that outline the Joint
Commissions statement on work place violence in the nursing workplace. The article was
promoting a program to help the nursing profession to deal with the issue of workplace bullying
causing an unhealthy work environment (Center for American Nurses, 2009). The article further
highlight the Joint Commission releasing new standards to reduce workplace violence, which the
Joint Commission considered a danger to patient safety (Center for American Nurses, 2009).
The American Nurses Association also endorses this position of eliminating bullying in
the workplace and in their statement they further discuss the negative environment caused by
bullying and lateral violence. ANA (2015) further argue that the toxic environment of bullying
causes retention issues of quality staff and is a major stressor. ANA (2015) did further lititure
reviews and the evidence shows 24% of staff nurses and 25% of nurse managers will leave their
place of employment due to this behavior. The issue is employers allow this hierarchal structure

9. POSITIVE WORK ENVIRONMENTS 9
and will not allow the nursing staff to have decision abilities. This is a direct association with the
Job demand control support Model.
American Nurses Credentialing Center (ANCC). (2016). ANCC magnet recognition is
founded from the studies derived from their research and work from 1980 thru1983. ANCC
(2016) started in 1994 giving the first magnet recognition with the use of fourteen components.
Then in 2008 they reduced the number to five with organizational structure listed as
organizational empowerment as the second component (ANCC, 2016). This is in direct
correlation with the job demand, control, support theory.
In the study by Lisa Gotschall, (2010). Creating healthy work environments to welcome
the new generation of registered nurses: What the millennials tell us, studied the new nursing
graduate population in the state of Maryland. Gotschall (2010) wanted to determine the cause as
shown by Trossman, that 50% of new graduates changed jobs within their first year and as many
as 6% are leaving the profession entirely (2009, as cited in Gotschall, 2010, p. 1). Gotschall
(2010) study intent was to determine the psychosocial work environment and how this
environment would affect the new graduates’ psychological health and job satisfaction. Gotschall
(2010) found that this study group in the state of Maryland correlated to the JDCS model where
these new nurses felt depressed and lacked any job satisfaction due to no control or social
support within the work environment. Gotschall (2010) revealed seven recommendations for
helping retain the new workforce and to develop a more supportive and functional work
environment. These recommendations included use of technology such as PDA’s that the new
nursing force was accustomed to using (Gotschall, 2010). Gotschall (2010) recommended
recognition and use of social support. Gotschall (2010) stated the need for collaborative and
respectful leaders, leadership training. Gotschall (2010) further recognized that nursing educators

10. POSITIVE WORK ENVIRONMENTS 10
needed to look at the current curriculum to better train nursing students for expectations and
ability to help change environments. Further recommendations by Gotschall (2010) included new
delivery models from collaborative efforts, rewards for the new initive by the new nurses, and
further studies looking at other methods than the JDCS model for change.
Shirey (2006) looked at the use of authentic leadership in helping to develop a healthy
workplace for the nursing profession. The American Association of Critical Care Nurses,
(AACN) endorsed this theory in the attempt to create positive work places (Shirey, 2006). The
theory is again the greater the stressors, the more need for greater decision and freedom to foster
a positive work environment. This approach also has an influence on the support of education
and increased degrees (Shirey, 2006).
Kivimäki, M., Nyberg, S. T., Fransson, E. I., Heikkilä, K., Alfredsson, L., Casini, A., &
... Batty, G. D. (2013) wanted to conceptually compare to job strain against the effect of a
healthy versus unhealthy lifestyle with coronary disease. They used individual data from a total
of 7 cohort studies to determine the effects of adding either a healthy or an unhealthy lifestyle to
the studies (Kivimäki et al. 2013). Kivimäki et al. (2013) had a mean follow-up of 7.3 years and
with 1086 events. The analysis showed that the individuals with high job stressors and unhealthy
lifestyles were 50% greater risk for coronary disease than those with high job stressors and
healthy lifestyles (Kivimäki et al. 2013). There was no data collected for the factor of freedom
and decision control.
Kogien, Moisés, & Cedaro, José Juliano. (2014) used the theory of Karasek & Theorell
(1992) in examining the role of the public emergency workers in Rondonia, Brazil. They found a
direct relation to the Job demand, control theory (Kogien et al. 2014). The sample was composed
of 189 nursing staff and median age of 32.79, all were practicing at the time of the study (Kogien

11. POSITIVE WORK ENVIRONMENTS 11
et al. 2014). It was again the amount of increased control and the correlation of job satisfaction
and higher motivation (Kogien et al. 2014).
Brunges & Foley-Brinza (2014) looked for projects to increase job satisfaction and create
a healthy work environment. found that they needed to look at other ideas such as a quiet area for
nursing decompression. Brunges & Foley-Brinza (2014) looked at the Magnet model to help
make the changes to the organizational structure. The use of concepts using nursing councils,
education with reward and recognition programs were components of their study (Brunges &
Foley-Brinza, 2014).
Change Implications
The studies show that the working environment within the nursing profession is greatly
controlled by the organizational structure and how the leadership is structured. The concepts
show proper structure and leadership are key to facilitating the changes necessary to improve and
create positive work environments. Research has shown that the work load and flow including
the productivity does not need to decrease in order to make the work environment more positive.
The nursing profession has long been an environment of eating their young, yet they are looking
to elevate their work to a level of other professions and to promote a professional environment.
While this is often assumed to only have consequences for the new nurse it is found the entire
nursing population is often working in a non-positive environment. Yet with over three decades
of Evidence Based Practice (EBP) the change has been slow and often nonexistent.
This is going to require the nursing leaders to begin to implement change from the
existing leadership style and organization structure, into one that is open to listening and looking
at how to change the very structures that have been in place for decades. Many Fortune 500
companies have transformed either their processes or chain of command in order to promote the

12. POSITIVE WORK ENVIRONMENTS 12
employee decision process and have experienced positive results and successes (APA. 2016).
One example is Ford Motor Corporation, ran a test of using team approach by allowing the
employee teams to ask questions and deal with suppliers, develop ways to reduce defects, and
suggest better processes with the machinery in the plants (APA. 2016). This process was so
successful they adopted this team approach across the entire organization (APA. 2016). The use
of telework is another way organizations have given employees more decision control and has
resulted in better social support and increased job satisfaction (APA. 2016). While this may
impractical for the nurse at bedside, it shows there needs to new creativity in organizational
structures.
The healthcare industry will need to think outside the box, yet better, leaders need to
throw away the box and rethink the work environment (McCallum, 2016). This would enable the
leader to use a creative approach and would help get the staff to participate in the decision
processes to bring new concepts and ideas forward. While this has been discussed within the last
two decades the healthcare environment has been slow to change and we are now facing a real
challenge. The ANA and ANCC have used the tenants of Magnet designation as a change in
processes and organizational structures to promote the positive work environment. While this has
proven to help change the work environments there still needs to be changes in gaining better
structures to give both autonomy and support to the professional nurse both new and
experienced.
Gotschall (2010) studied new nurse graduates in the state of Maryland and found that the
majority were suffering from job stress with little control and no social support and many were
suffering with depression. Gotschall (2010) also showed that the youngest of the new graduates
labeled as the millennials, those born after 1980, were suffering the greatest despair of the new

13. POSITIVE WORK ENVIRONMENTS 13
graduates. It is further expected that the nursing profession will grow by 19 % in 2022 (AACN,
2016). This is a false sense of security, as there will still be shortages due to the growth in needs
resulting in a ratio decrease of 40% (AACN, 2016) This will be further impact the baby boomers
creating one of the largest strains on the healthcare industry in history. This is a crisis in the
making that is silently creeping upon the whole health care industry.
New Understanding/ Best Practices Recommendations
Leaders will need to make real changes to improve this working environment. Perhaps
one of the greatest change motivators is the Magnet Designation that is being sought by many
organizations. The effort of the American Nurses Association (ANA) and the American Nurses
Credentialing Center (ANCC) is to help bridge the gap of the nursing shortage and the strain
created with under staffing and to help facilities to attract and retain staff (ANCC, 2016). In 1994
the first hospital was given magnet recognition (ANCC, 2016). In 2008 the magnet Program
transitioned from 14 tenants to five components: transformational leadership, structural
empowerment, exemplary professional practice, new knowledge, innovations, and
improvements, empirical outcomes (ANCC, 2016). These components are fundamental to the
studies over the decades. Leadership needs to look at the root causes of negative work
environments and master the vision to help change the organizational structure to facilitate the
positive work environment. Leaders will need to begin to use leadership rounding as a means of
getting one to one time with the professional nursing staff. Leadership rounding with careful
listening, will help to develop positive working environments. The use of the nurse residency
programs may be the way to give new graduates the support within the first year. These
programs have gain momentum throughout the profession. Education opportunities will need to
take a higher precedence in the work place as leaderships goals, including mentoring nursing

14. POSITIVE WORK ENVIRONMENTS 14
staff to seek advanced degrees. The leaders and facilities will need to include reimbursement
programs to help with the costs of this further education. Implementation of new leader training
to help fast track the younger nurses to leadership opportunities within the organization. Greater
opportunities for recognition and rewards. The use of new entry level leadership positions to help
begin the education of new leaders into leadership skills and training. Nurse leaders are in a
unique position to now make those decisions and act on making changes. There are great
opportunities for change in leadership styles and organizational structures in the present acute
care facilities.
Conclusion
In the context of looking at a positive work environment, the current nursing leaders are
going to be a major part of the changes for a brighter future. Magnet is helping to elevate the
autonomy of the nursing profession and encouraging better organizational structure and more
support from leaders. Much of this will be accomplished through advocating for advanced
degrees including the Bachelorette of Science in Nursing, Masters in Science for nursing
including Healthcare Management and Leadership, Education and Population Health. Doctorates
in Philosophy for nursing science and the push for nurses to be in leadership positions. These are
all areas that are helping to balance the Job Demand Control Support model in healthcare.
Without these changes Gotschall (2010) showed a sense of no control or support in the working
environment of nursing while experiencing large measure of job dissatisfaction and burnout. The
use of programs such as the nurse residency program will help the new graduates in getting the
social support and help needed in their first year. Gotschall (2010) showed many of the issues
that the profession of nursing has overcome within the last three decades and is making progress,
but has many silos still to remove. Leaders need to begin to make real changes and implement

15. POSITIVE WORK ENVIRONMENTS 15
the changes while listening to what is being said by the new nursing staff and the experienced
nursing staff. There will need to be fast track leadership programs to help new nurses become
leaders faster and to offer more incentives. Leaders will need to be more in touch with the staff
and working through issues that impact nursing at the bedside level. This will include such skills
as using transformational leadership and developing organizational structures to meet the
demands of the nursing staff to achieve job satisfaction and retention. The greatest need will
come in giving the nursing staff more educational opportunities, greater decision capability in the
organizational structure and better rewards and recognition programs. There is the opportunity
for nurse leaders to make major changes in the next couple of years in developing organizational
structures to promote a positive work environment.

16. POSITIVE WORK ENVIRONMENTS 16
References
American Association of Colleges of Nursing (AACN). (2016) Nursing shortage. Retrieved http:
//www.aacn.nche.edu/media-relations/fact-sheets/nursing-shortage
American Nurses Credentialing Center (ANCC). (2016). ANCC magnet recognition. Retrieved
from http://www.nursecredentialing.org/Magnet
American Nurses Association (ANA), (2015, July 22). Position statements. Incivility, bullying,
and workplace violence. Retrieved from http://www.nursingworld.org/MainMenu
Categories/Policy-Advocacy/Positions-and-Resolutions/ANAPosit. ionStatements /
Position-tatements-Alphabetically/Incivility-Bullying-and-Workplace-Violence.html
American Psychological Association (APA), (2016). Occupational stress and employee control.
Retrieved from http://www.apa.org/research/action/control.aspx
Baillien, E., De Cuyper, N., & De Witte, H. (2011). Job autonomy and workload as antecedents
of workplace bullying: A two-wave test of Karasek's Job Demand Control Model for
targets and perpetrators. Journal of Occupational & Organizational Psychology, 84(1),
191-208. doi:10.1348/096317910X508371
Bergman, P. N., Ahlberg, G., Johansson, G., Stoetzer, U., Åborg, C., Hallsten, L., & Lundberg, I.
(2012). Do job demands and job control affect problem-solving? Work, 42(2), 195-203
9p.
Brunges, M., & Foley-Brinza, C. (2014). Projects for increasing job satisfaction and creating a
healthy work environment. AORN Journal, 100(6), 670-681 12p.
Center for American Nurses and [CMA]. (2009). Creating healthy work environments: a
collaborative approach. Chart, 10-10 1p.

17. POSITIVE WORK ENVIRONMENTS 17
Centers for Medicare & Medicaid Services (CMS), (2016). Health care payment learning and
action network. Retrieved from https://innovation.cms.gov/initiatives/Health-Care-
Payment-Learning-and-Action-Network/
Gotschall, L., (2010). Creating healthy work environments to welcome the new generation of
registered nurses: What the millennials tell us. Capella University. Retrieved from
http://pqdtopen.proquest.com/pubnum/3426515.html
Karasek, R. A... (1979). Job Demands, Job Decision Latitude, and Mental Strain: Implications
for Job Redesign. Administrative Science Quarterly, 24(2), 285–308.
Karasek, R., Baker, D., Marxer, F., Ahlbom, A., & Theorell, T. (1981). Job decision latitude, job
demands, and cardiovascular disease: a prospective study of Swedish men. American
journal of public health, 71(7), 694-705.
Karasek, R. A., & Theorell, T. (1990). Healthy work: Stress, productivity, and the reconstruction
of working life. New York: Basic Books.
Karasek, R., & Theorell, T. (1992). Healthy work: Stress, productivity, and the reconstruction of
working life. New York: Basic books.
Kivimäki, M., Nyberg, S. T., Fransson, E. I., Heikkilä, K., Alfredsson, L., Casini, A., & ... Batty,
G. D. (2013). Associations of job strain and lifestyle risk factors with risk of coronary
artery disease: A meta-analysis of individual participant data. Canadian Medical
Association Journal, 185(9), 763-769.
Kogien, Moisés, & Cedaro, José Juliano. (2014). Public emergency department: the psychosocial
impact on the physical domain of quality of life of nursing professionals. Revista Latino-

18. POSITIVE WORK ENVIRONMENTS 18
Americana de Enfermagem, 22(1), 51-58. https://dx.doi.org/10.1590/0104-
1169.3171.2387
Landsbergis, P. A. (1988). Occupational stress among health care workers: A test of the job
demands-control model. Journal of Organizational Behavior, 9(3), 217-239.
Maryland Hospital Association (MHA), (2013, April). Maryland hospitals = Maryland jobs April
2013. Retrieved from http://www.mhaonline.org/docs/default-
source/publications/maryland-hospitals-=-maryland-jobs---2013.pdf?sfvrsn=2
McCallum, A. (2016). Throw the “Box” Away! Retrieved from https://www.success. bz
/articles/601/throw_the_box_away
Presseau, J., Johnston, M., Johnston, D. W., Elovainio, M., Hrisos, S., Steen, N., & ... Eccles, M.
P. (2014). Environmental and individual correlates of distress: Testing Karasek's
demand‐control model in 99 primary care clinical environments. British Journal of
Health Psychology, 19(2), 292-310.
Sexton, P. (1982). The New Nightingales, Enquiry Press, New York.
Shirey, M. (2006). Authentic leaders creating healthy work environments for nursing
practice. American Journal of Critical Care, 15(3), 256-268 13p.
Trossman, S. (2009, June). Effective transitions. American Nurse Today, 25–27. Retrieved July
12, 2009, from http://www.AmericanNurseToday.com