Conversation Is Critical: Teaching Critical Care Nurses a Framework for Peer Feedback

Critical care nurses assess, treat, and monitor critically ill patients while also providing basic care and coordinating with the interprofessional team. Critical care nursing is a specialty with an intense nursing workload. In this fast-paced environment, nurses are at high risk for burnout, anxiety, and workplace incivility, all of which are associated with increased turnover.1,2 Labor costs are one of the highest expenditures in health care organizations. Each percentage change in turnover can cost or save an organization approximately $262 500. The cost to replace 1 nurse is approximately $56 300. In 2024, the national average critical care nurse turnover rate was 19.4%, exceeding the national nurse turnover average of 18.4%.3 To maintain a robust nursing workforce, we must address nurse turnover rates. A healthy work environment characterized by effective communication, collaboration, and shared decision-making has been proved to decrease turnover and engage nurses while improving patient care.4With stress on time, tasks, and attention, critical care nurses need go-to strategies to effectively and respectfully communicate with each other and the health care team. Skilled communication is as critical as clinical expertise in nursing practice.4 Communication is also part of creating a civil work environment characterized by clear communication, responsible conflict management, and meaningful dialogue.5 Workplace incivility remains commonplace in health care, with a reported prevalence of from 67.5% to 90.4%.5 A workplace with low civility contributes to nurse burnout, which, in turn, is associated with nurse turnover. Improved communication skills can help to mitigate burnout.6,7 Nurses need communication skills at the ready to have effective, respectful conversations to address patient and family, quality and safety, and interpersonal concerns.In 2023, the medical intensive care unit (MICU) at the ChristianaCare campus in Newark, Delaware, had the highest rate of nurse turnover (9.92%) among the 4 intensive care units at the campus. The issues in the MICU were not isolated but rather reflected national trends evident in average nurse turnover rates. The Clinical Scene Investigator (CSI) Academy team leveraged the Healthy Work Environment Assessment Tool (HWEAT) to identify areas of opportunity for improvement to help promote retention by enhancing a healthy work environment. In this preintervention assessment, 82 of 105 nurses (72%) completed the survey. The survey results identified the standards for Skilled Communication (mean score, 3.85) and True Collaboration (mean score, 3.64) as areas of opportunity. The scores for these standards were in the range for "somewhat healthy" of 3.00 to 3.99. For additional insight into the nurses' perception of their work environment, the CSI team distributed the Workplace Civility Index. In particular, scores on the statement "[I] speak directly to the person with whom I have an issue" were among the lowest (3.91 on a scale ranging from 1 = almost never to 5 = almost always).8,9 As a result, the CSI team chose to implement a structured framework for critical care nurses to use when giving and receiving peer feedback. The framework addressed communication and collaboration, which would in turn enhance workplace civility.The purpose of this CSI project was to improve skilled communication among nurses to promote true collaboration and workplace civility to decrease nurse turnover. The project slogan "Conversation Is Critical: Let's Get to the Point" calls out the need for clear communication among nurses, especially in the high stakes of critical care. Even when their emotions are heightened, their tasks are mounting, and their attention is pulled in multiple directions, nurses must be articulate and work seamlessly together to deliver complex patient care. Peer feedback is essential to that teamwork. By teaching nurses a structured framework for peer feedback, we can set expectations for how we communicate what we need to know. Feedback helps the individual and the team to grow, problem-solve, and identify better ways of working. The goals for this project included the following: increase HWEAT scores for Skilled Communication and True Collaboration, increase Workplace Civility Index scores, and decrease nurse turnover.The CSI Academy led the MICU team in developing a project plan including a timeline for implementation with key activities. The project kicked off in April 2024 with a launch party that included presentations from experts, self-paced education, refreshments, and a visit from popular local volunteers—puppies!— to increase staff participation. The team worked with content expert Dr Katie Godfrey, Director of the Center for WorkLife Wellbeing at ChristianaCare, to develop education on peer feedback. The education targeted communication skills using a structured framework. Education was offered during the project kickoff and at the project midpoint (September 2024) on types of feedback; feedback frameworks, such as the Situation, Behavior, Impact, and Future framework; and feedback strategies for facilitating conversation.The team leveraged required staff meeting time, which is recorded for later viewing on Microsoft Teams, to maximize the impact of the education by minimizing effects on staff coverage and time. Ongoing project support was provided through bulletin boards, monthly educational "one-pagers," and monthly raffles. In addition, staff wore badge reels featuring the project logo and badge buddies listing feedback strategies and examples. Project participants attended staff meetings to share project content and reinforce concepts to promote continued implementation. The team aimed to put the frameworks into regular, purposeful practice on the unit to make peer feedback part of unit culture.Overall, the outcomes of the project were positive. A higher percentage of nurses participated in the post-implementation HWEAT than in the preimplementation survey, 82 of 105 (78%) before compared with 75 of 84 (89%) after implementation, demonstrating staff buy-in. The aggregate HWEAT score improved from 4.02 to 4.11, as did scores on every healthy work environment standard (Figure 1). Scores for Skilled Communication and True Collaboration increased to 3.97 and 3.71 after implementation, respectively. Participation in the Workplace Civility Index increased from 76 of 108 staff members (70%) to 78 of 101 staff members (77%). Overall scores on the index ranged from 57 to 100 before implementation and from 62 to 100 after implementation of the framework, and the mean workplace civility score increased from 89.4 (civil) to 93 (very civil). Mean scores for the focused question "[I] speak directly to the person with whom I have an issue" improved from 3.91 to 4.15. A decrease in the rate of nurse turnover to 6.9% (7 nurses) from April to December 2024 also showed the success of the project and its impact on the unit's culture of communication, collaboration, and civility (Figure 2). The potential fiscal impact on the organization based on nurse retention as a measure was $281 500 in cost savings related to labor expenditure.Creating a healthy work environment in which nurses confidently communicate and feel safe giving and receiving feedback can help nurses stay engaged in their bedside role and speak up about patient care and fosters a workplace hallmarked by true collaboration. In turn, such an environment promotes a civil workplace that is associated with decreased turnover. This structured feedback framework for critical conversations in the MICU has had an unmistakable impact on the unit's culture. Giving and receiving peer feedback is now integrated into the daily nursing practice of both novice and experienced nurses. Sharing and receiving feedback has become the norm rather than the exception. The project team is collaborating with the organization's shared governance to share the project initiative broadly. Both within the unit and throughout the organization, there are plans to implement healthy work environment champions. In addition, the health care team members, including advanced practice providers, respiratory therapists, and physicians, have expressed interest in developing their peer-to-peer communication skills to enhance workplace civility.The authors thank Marian Altman and the American Association of Critical-Care Nurses Clinical Scene Investigator Academy; Dr Katie Godfrey, Director, the Center for WorkLife Wellbeing; and the Nursing Excellence Team at ChristianaCare.