AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence

The American Association of Critical-Care Nurses recognizes the inextricable links among quality of the work environment, excellent nursing practice, and patient care outcomes. In this article, the 6 standards for establishing and sustaining healthy work environments are discussed. With these standards, AACN contributes to the implementation of elements in a healthy work environment articulated in 2004 by the 70-member Nursing Organizations Alliance.Acute and critical care nurses repeatedly voice grave concern and moral distress about the deterioration of healthcare work environments in the United States. The following cases in point represent countless similar incidents occurring in American hospitals each day, showing the devastating impact of unhealthy work environments on the effectiveness of the American healthcare system.At 3:30 am in a busy intensive care unit (ICU), a nurse prepares to give insulin to a patient who has an elevated blood sugar level. The sliding scale doses of insulin on the medication sheet are unclear and the physician’s order sheet is difficult to read. From past experience, the nurse knows how late night calls to this physician often result in verbal outbursts and demeaning slurs, no matter how valid the inquiry. Needing to act but not wanting another harassing encounter with the physician, the nurse makes a judgment of the appropriate dose and administers the insulin. Two hours later, she finds the patient completely unresponsive. To treat the critically low blood sugar level, she administers concentrated injections of glucose and calls for additional emergency help. Despite all attempts to restore the patient’s brain to consciousness, he never awakens and his brain never functions normally again.Two nurses leave a busy trauma ICU to accompany patients for urgent diagnostic tests, leaving 2 nurses in the unit “keeping an eye” on 3 critically ill patients each. One of the unit patients was recently intubated and requires a blood specimen to measure arterial blood gases. On his way to obtain the specimen, the nurse detours to check a ventilator alarm in another room, stops to answer an unexpected phone call, and clarifies an order for the unit secretary. Finally reaching the patient’s room, the nurse sees that the patient is breathing rapidly and has become visibly anxious. The nurse hurriedly draws the specimen. As he gathers the used supplies from the bedside, the protective needle cover slips off causing the dirty needle to stick deeply into his thumb.An emergency department (ED) task force develops a patient report form that can be transmitted to inpatient units in order to facilitate patient transfers and ease ED overcrowding. The new form is first used for an unstable head-injured patient. Although it is faxed to the ICU before the patient is moved, no one sees the form. When the patient arrives, no one is available to admit the patient. Tensions run high and the patient’s family becomes very angry. The ICU staff pitch in to cover so this new and critical patient can be admitted. In retrospect it is discovered that the ED staff did not negotiate design and use of the new form with the affected inpatient units.While preparing the annual budget, a nurse manager is instructed to submit a plan that further decreases ICU costs by 10%. Already behind on several other projects, the new manager is overwhelmed. Well aware that care by registered nurses is indispensable and intent on being fiscally responsible, the manager develops and submits a plan to discontinue evening clerical support and decrease nursing assistant hours. The director accepts the plan without question and asks the manager to inform the ICU staff. The manager relates the plan during an all-staff meeting in which he encounters significant negative nonverbal communication and very little spoken feedback. During the next week, tensions run high, rumors abound, 2 nurses resign, and morale reaches an all-time low.Each day, thousands of medical errors harm the patients and families served by the American health-care system. Work environments that tolerate ineffective interpersonal relationships and do not support education to acquire necessary skills perpetuate unacceptable conditions. So do health professionals who experience moral distress over this state of affairs, yet remain silent and overwhelmed with resignation. Consider these all-too-familiar situations:Each situation characterizes poor and ineffective relationships. Attention to work relationships is often dismissed as unworthy of resource allocation in health-care today, especially when those resources are aimed at supporting education and development of essential skills. This is because of the mistaken perception that effective relationships do not affect an organization’s financial health. Nothing could be further from the truth. Relationship issues are real obstacles to the development of work environments in which patients and their families can receive safe, even excellent, care. Inattention to work relationships creates obstacles that may become the root cause of medical errors, hospital-acquired infections and other complications, patient readmission, and nurse turnover.Adequately addressing the reputedly “soft” issues that involve relationships is the key to halting the epidemic of treatment-related harm to patients and the continued erosion of the bottom line in healthcare organizations. Indeed, the Institute of Medicine has reported that safety and quality problems exist in large part because dedicated health professionals work within systems that neither prepare nor support them to achieve optimal patient care outcomes.4 Addressing these issues aligns with nurses’ ethical obligations, specifically the obligations to establish, maintain and improve healthcare environments and employment conditions conducive to providing quality care consistent with the values of the profession, and maintain compassionate and caring relationships with “a commitment to fair treatment of individuals and integrity-preserving compromise.”5For more than 2 decades, AACN has advocated for principles such as interdisciplinary collaboration and effective leadership that are essential to healthy work environments.6 The standards continue this legacy and respond to the Institute of Medicine’s call for professional groups to serve as advocates for change.7 A 9-person panel developed the standards, drawing from extensive published and unpublished reports from individual nurses and other experts in healthcare organizations across the United States. Representing a wide range of roles, acute and critical care settings, and geographic locations in which nursing care is provided, 50 expert reviewers validated the standards, critical elements, and explanatory text.The American Association of Critical-Care Nurses recognizes the inextricable links among quality of the work environment, excellent nursing practice, and patient care outcomes. The AACN Synergy Model for Patient Care further affirms how excellent nursing practice is that which meets the needs of patients and their families.8 AACN is strategically committed to bringing its influence and resources to bear on creating work and care environments that are safe, healing, humane, and respectful of the rights, responsibilities, needs and contributions of all people—including patients, their families, and nurses.Six standards for establishing and sustaining healthy work environments have been identified. The standards represent evidence-based and relationship-centered principles of professional performance. Each standard is considered essential because studies show that effective and sustainable outcomes do not emerge when any standard is considered optional. The standards align directly with the core competencies for health professionals recommended by the Institute of Medicine. They support the education of all health professionals “to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics.”9 With these standards, AACN contributes to the implementation of elements in a healthy work environment articulated in 2004 by the 70-member Nursing Organizations Alliance. The standards further support the education of nurse leaders to acquire the core competencies of self-knowledge, strategic vision, risk-taking and creativity, interpersonal and communication effectiveness, and inspiration identified by the Robert Wood Johnson Executive Nurse Fellows Program.10The standards are neither detailed nor exhaustive. They do not address dimensions such as physical safety, clinical practice, clinical and academic education, and credentialing—all of which are amply addressed by a multitude of statutory, regulatory, and professional agencies and organizations. The standards are designed to be used as a foundation for thoughtful reflection and engaged dialogue about the current realities of each work environment. Critical elements required for successful implementation accompany each standard. Working collaboratively, individuals and groups within an organization should determine the priority and depth of application required to implement each standard.The standards for establishing and sustaining healthy work environments are:The standards provide a functional yardstick for performance and development of individuals, units, organizations, and systems. They reaffirm that safe and respectful environments are imperative and require systems, structures, and cultures that support communication, collaboration, decision making, staffing, recognition, and leadership.These standards support the 9 provisions of the American Nurses Association Code of Ethics for Nurses and provide a framework to assist nurses in upholding their obligation to practice in ways consistent with appropriate ethical behavior.5 Properly implemented, the standards will ensure that acute and critical care nurses have the skills, resources, accountability, and authority to make decisions that ensure excellent professional nursing practice and optimal care for patients and their families. Implementation of the standards demonstrates an organization’s ethical responsibility. The standards can lead to excellence only when they have been adopted at every level of the organization—from the bedside to the boardroom. Adoption requires creating the systems, structures, and cultures that provide the ongoing collaborative education necessary to enhance and support the effort. This requires recognition by the organization that people often create and support unhealthy work environments because they lack the knowledge, skills, and experience to do otherwise.Success will be further ensured when individuals are afforded the programs to acquire needed skills and willingly embrace implementation of the standards as a personal obligation, holding themselves and others accountable. This requires a committed partnership between nurses and their work environment. For example, safe staffing cannot be accomplished when a fatigued nurse works excessive overtime hours and perhaps attempts to maintain a second job. Careful scrutiny of these 6 standards (FigureF1) immediately reveals the interdependence of each standard. For example, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership depend upon skilled communication and true collaboration. Likewise, authentic leadership is imperative to ensure sustainable implementation of the other behavior-based standards.Optimal care of patients mandates that the specialized knowledge and skills of nurses, physicians, administrators, and multiple other professionals be integrated. This integration will be accomplished only through frequent, respectful interaction and skilled communication. Skilled communication is more than the 1-way delivery of information; it is a 2-way dialogue in which people think and decide together.A culture of safety and excellence requires that individual nurses and healthcare organizations make it a priority to develop among professionals communication skills—including written, spoken, and nonverbal—that are on a par with expert clinical skills.1,2 This culture expects civility and respects nurses who speak from their knowledge and authority.3 Patients in the care of clinically expert professionals suffer medical errors with alarming frequency.4 Nearly 3 in 4 errors are caused by human factors associated with interpersonal interactions.5 In addition, according to data from the Joint Commission on Accreditation of Healthcare Organizations, breakdown in team communication is a top contributor to sentinel events.6Intimidating behavior and deficient interpersonal relationships lead to mistrust, chronic stress, and dissatisfaction among nurses. This unhealthy situation contributes to nurses leaving their positions and often their profession altogether. More than half of nurses surveyed report they have been subject to verbal abuse and more than 90% have witnessed disruptive behavior.1 Nurses can encounter conflict in every dimension of their work. Be it conflict with others, or between their own personal and professional values, skilled communication supports the ethical obligation to seek resolution that preserves a nurse’s professional integrity while ensuring a patient’s safety and best interests.7 Ensuring that nurses are provided the education, competency mastery, and rewards to effectively negotiate these conflict-laden conditions would itself dramatically alter the environment.True collaboration is a process, not an event. It must be ongoing and build over time, eventually resulting in a work culture in which joint communication and decision making between nurses and other disciplines and among nurses themselves becomes the norm. Unlike the lip service that collaboration is often given, in true collaboration the unique knowledge and abilities of each professional are respected to achieve safe, quality care for patients. Skilled communication, trust, knowledge, shared responsibility, mutual respect, optimism, and coordination are integral to successful collaboration.1Without the synchronous, ongoing collaborative work of healthcare professionals from multiple disciplines, patient and family needs cannot be optimally satisfied within the complexities of today’s healthcare system. Extensive evidence shows the negative impact of poor collaboration on various measurable indicators including patient and family satisfaction, patient safety and outcomes, professional staff satisfaction, nurse retention, and cost.2,3 The Institute of Medicine points to “a historical lack of interprofessional cooperation” as one of the cultural barriers to safety in hospitals.4Nearly 90% of the American Association of Critical-Care Nurses’ members and constituents report that collaboration with physicians and administrators is among the most important elements in creating a healthy work environment.5 collaboration has been to be of the 3 of of between nurses and physicians for each knowledge and with a mutual concern that quality patient care will be provided, are key elements of work environments that and an stress, which is more of nurse and than in the work requires and by and that joint communication and decision about the and effectiveness of collaboration among nurses, physicians, and healthcare points to an imperative that effective be developed to improve relationships between nurses and their as nurses must be in making decisions about patient A significant often between nurses are for and their to in decisions that affect those that physicians, administrators, and nurses for patient safety to nurses. only of physicians nurses as part of the reports that a of nurses to they in their work This with nurses’ to their essential and their obligations to the as the professional with patients, nurses and data from patients and the into the meaningful required to and deliver care to a patient. 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