Read Healthy Work Environments: Standards text version

AACN STANDARDS FOR ESTABLISHING AND SUSTAINING HEALTHY WORK ENVIRONMENTS

A Journey to Excellence

AMERICAN ASSOCIATION of CRITICAL-CARE NURSES

Graphic Design: Lisa Valencia-Villaire This publication is available for download at the American Association of Critical-Care Nurses Web Site <www.aacn.org> Printed copies and permission for other uses available from: AACN 101 Columbia Aliso Viejo, CA 92656 Telephone 800-899-AACN Email: [email protected] Copyright © 2005, American Association of Critical-Care Nurses. All rights reserved.

Contents

A Message From the American Association of Critical-Care Nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Cases in Point . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

About the Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Standards and Guidelines Skilled Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 True Collaboration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 Effective Decision Making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 Appropriate Staffing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 Meaningful Recognition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32 Authentic Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

Call to Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39

Visions of the Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

A Message From the American Association of Critical-Care Nurses

In 2001, the American Association of Critical-Care Nurses made a commitment to actively promote the creation of healthy work environments that support and foster excellence in patient care wherever acute and critical care nurses practice. This commitment is based on the Association's dedication to optimal patient care and the recognition that the deepening nurse shortage cannot be reversed without healthy work environments that support excellence in nursing practice. There is mounting evidence that unhealthy work environments contribute to medical errors, ineffective delivery of care, and conflict and stress among health professionals. Negative, demoralizing and unsafe conditions in workplaces cannot be allowed to continue. The creation of healthy work environments is imperative to ensure patient safety, enhance staff recruitment and retention, and maintain an organization's financial viability. This document puts forth six essential standards for establishing and sustaining healthy work environments. The standards uniquely identify systemic behaviors that are often discounted, despite growing evidence that they contribute to creating unsafe conditions and obstruct the ability of individuals and organizations to achieve excellence. The public repeatedly identifies nurses as the profession most trusted to act honestly and ethically. Five times since 1999 nurses have topped Gallup's annual survey of honesty and ethics among professions.1 The public relies on nurses to bring about bold change that assures safe patient care and sets a path toward excellence. These standards honor the public's trust. "If you dare to be powerful," President Connie Barden urged association members in 2003, "if you are ready to make a promise that will make a difference, I challenge you to join me in making your promise public." President Barden signed a public statement of her personal commitment to create a new future with healthy work environments that benefit everyone. She called for nurses to do the same by promising to: · Identify the most pressing challenge in their immediate work environment. · Initiate discussions with their colleagues to find solutions to this challenge. · Remain actively involved in the solutions until they are working.

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The American Association of Critical-Care Nurses has committed to acting boldly, deliberately and relentlessly until issues that obstruct creation of healthy work environments are resolved. In response to President Barden's call, AACN defined two strategic platforms that now guide the Association's work environment initiatives: · Work and care environments must be safe, healing and humane, respectful of the rights, responsibilities, needs and contributions of patients, their families, nurses and all health professionals. · Excellence in acute and critical care nursing practice is driven by the needs of patients and their families and is achieved when nurses' competencies are matched to those needs. These landmark standards to establish and sustain healthy work environments represent another important step in fulfilling AACN's commitment. We challenge you to join us in creating healthy work environments by making these standards the norm. This requires the commitment of each nurse, each unit and each organization. We invite your thoughtful and decisive implementation as an individual, an organization or an association.

Kathleen M. McCauley, RN, PhD, BC, FAAN, FAHA President 2004-2005 American Association of Critical-Care Nurses

1. Moore, DW. Nurses top list in honesty and ethics poll. Gallup News Service, December 7, 2004. Available at: http://www.gallup.com/poll/content/login.aspx?ci=14236. Accessed December 17, 2004.

"It is wrong to keep quiet about what is harmful." ­Columban of Leinster Moral and political activist, Missionary, Teacher

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Acknowledgments

The American Association of Critical-Care Nurses recognizes with gratitude the experts who contributed knowledge, counsel and time to support the Association in making this contribution to the safety and advancement of healthcare. Reviewers were chosen for diversity of roles, perspectives and geographic location. Their probing review and candid recommendations generously reached far beyond what was asked of them, adding significant depth and richness to the document.

standards development

Executive Editor Connie Barden, RN, MSN, CCRN, CCNS, Clinical Nurse Specialist, Mercy Hospital, Miami, Florida Contributors Kay Clevenger, RN, MSN, Nurse Retention Officer, Clarian Health Partners, Indianapolis, Indiana Roberta Fruth, RN, PhD, CCRN, Consultant, Joint Commission Resources, Inc., Oak Brook, Illinois Debra S. Gerardi, RN, JD, MPH, President and Chief Executive Officer, Healthcare Mediations, Mountain View, California Wanda Johanson, RN, MN, Chief Executive Officer, American Association of Critical-Care Nurses, Aliso Viejo, California Ramón Lavandero, RN, MA, MSN, FAAN, Director, Development and Strategic Alliances, American Association of Critical-Care Nurses, Aliso Viejo, California, and Adjunct Associate Professor, Indiana University School of Nursing, Indianapolis, Indiana Lisa J. Pettrey, RN, MS, Director, Heart and Critical Care Services, Grant Medical Center, Columbus, Ohio Rosanne Raso, RN, MS, CNAA, Senior Vice President, Nursing Services, Lutheran Medical Center, Brooklyn, New York Dana Woods, MBA, Director, Marketing and Strategy Integration, American Association of Critical-Care Nurses, Aliso Viejo, California

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reviewers

Linda Bell, MSN, RN, Clinical Practice Specialist, American Association of Critical-Care Nurses, Aliso Viejo, California and Per Diem Staff Nurse-Critical Care, Loma Linda University Medical Center, Loma Linda, California Bonnie Baloga-Altieri, MSN, RN, CNAA, BC, Assistant Vice President, Nursing and Patient Services, Robert Wood Johnson University Hospital, New Brunswick, New Jersey Nancy T. Blake, RN, MN, CCRN, CNAA, Director, Critical Care Services, Childrens Hospital Los Angeles, Los Angeles, California Debbie Brinker, RN, CNS, MN, MS, CCRN, Clinical Instructor, Pediatrics/PICU, Intercollegiate College of Nursing and Washington State University, Spokane, Washington Denise Buonocore, MSN, CCRN, APRN-BC, Acute Care Nurse Practitioner, The Heart Institute, Bridgeport Hospital, Bridgeport, Connecticut, and Lecturer in Nursing, Yale University School of Nursing, New Haven, Connecticut Bernice Buresh, Journalist, Co-author, From Silence to Voice: What Nurses Know and Must Communicate to the Public Suzanne M. Burns, RN, MSN, RRT, CCRN, ACNP, FAAN, FCCM, Professor of Nursing, APN 2 MICU, University of Virginia, Charlottesville, Virginia Marilyn Chow, RN, DNSc, FAAN, Vice President, Patient Care Services, Kaiser Permanente, Oakland, California Marianne Chulay, RN, DNSc, FAAN, Consultant, Clinical Research and Critical Care Nursing, Chapel Hill, North Carolina Sean Clarke, PhD, RN, CRNP, Associate Director, Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania Joyce C. Clifford, PhD, RN, FAAN, Executive Director, Institute for Nursing Healthcare Leadership, Boston, Massachusetts RADM Mary Pat Couig, MPH, RN, FAAN, Chief Nurse Officer, United States Public Health Service, Washington, DC Joanne M. Disch, RN, PhD, FAAN, Professor and Director, Katharine J. Densford International Center for Nursing Leadership, Katherine R. and C. Walton Lillehei Chair in Nursing Leadership, School of Nursing, University of Minnesota, Minneapolis, Minnesota John F. Dixon, RN, MSN, Nurse Consultant for Nursing Leadership Development and Nursing Research, Baylor University Medical Center, Dallas, Texas Jeff Doucette, RN, MS, CEN, CHE, CNAA, BC, Associate Operating Officer, Emergency Services, Duke University Medical Center, Durham, North Carolina Kathleen Dracup, RN, NP, DNSc, FAAN, Dean and Professor, School of Nursing, University of California, San Francisco

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S. Ann Evans, RN, MS, MBA, FAAN, Vice President and Chief, Patient Care Services, Tallahassee Memorial HealthCare, Tallahassee, Florida Dorrie K. Fontaine, RN, DNSc, FAAN, Associate Dean for Academic Programs, School of Nursing, University of California, San Francisco, California Ellen French, Publications Director, American Association of Critical-Care Nurses, Aliso Viejo, California Caryl Goodyear-Bruch, RN, MSN, CCRN, Clinical Assistant Professor, University of Kansas Medical Center, Kansas City, Kansas Suzanne Gordon, Journalist and author, Life Support: Three Nurses on the Front Lines. Co-author, From Silence to Voice: What Nurses Know and Must Communicate to the Public. Assistant Adjunct Professor, School of Nursing, University of California, San Francisco Cathie Guzzetta, RN, PhD, HNC, FAAN, Nursing Research Consultant, Children's Medical Center of Dallas, Dallas, Texas Janie Heath, RN, MS, CCRN, ANP, ACNP, Assistant Professor of Nursing and Coordinator, Acute Care Nurse Practitioner and Critical Care Clinical Nurse Specialist Program, School of Nursing and Health Studies, Georgetown University, Washington, DC Lori Hendrickx, RN, EdD, CCRN, Associate Professor, South Dakota State University, Brookings, South Dakota Mary E. Holtschneider, RN, BSN, MPA, EMT, Clinical Nurse Educator, Duke University Health System, Durham, North Carolina Roberta Kaplow, RN, PhD, CCNS, CCRN, Clinical Professor, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia Marlene F. Kramer, RN, PhD, FAAN, Vice President, Nursing and Research Investigator, Health Science Research Associates, Apache Junction, Arizona Phyllis Beck Kritek, RN, PhD, FAAN, Independent Consultant, Trainer and Mediator, Richmond, Virginia Deborah B. Laughon, RN, BSN, DBA, CCRN, Manager of Systems Improvement, Lakeland Regional Medical Center, Lakeland, Florida Judith "Ski" Lower, RN, MSN, CCRN, CNRN, Nurse Manager, NCCU, Johns Hopkins Hospital, Baltimore, Maryland Angela Barron McBride, PhD, RN, FAAN, Distinguished Professor and University Dean Emerita, Indiana University School of Nursing, Indianapolis, Indiana Kathleen M. McCauley, RN, PhD, FAAN, Associate Professor of Cardiovascular Nursing, University of Pennsylvania School of Nursing, and Cardiovascular Clinical Specialist, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania Mary McKinley, RN, MSN, CCRN, Part-time Clinical VI Staff Nurse, Ohio Valley Medical Center, and Consultant, Critical Connections, Wheeling, West Virginia

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Justine Medina, RN, MS, Director of Professional Practice and Programs, American Association of Critical-Care Nurses, Aliso Viejo, California Nancy C. Molter, RN, MN, PhD, Research Nurse Program Manager, US Army Institute of Surgical Research, Ft. Sam Houston, Texas Jodi E. Mullen, RNC, MS, CCRN, CCNS, Clinical Nurse Specialist-PICU, The Children's Medical Center, Dayton, Ohio Christine M. Pacini, PhD, RN, Director of Education, Nursing & Patient Care Services, Methodist Hospital, Clarian Health Partners, Indianapolis, Indiana Jessica Palmer, RN, MSN, Clinical Operations Director, Duke University Hospital, Durham, North Carolina Marilyn Petterson, Managing Editor-AACN News, American Association of Critical-Care Nurses, Aliso Viejo, California SueEllen Pinkerton, RN, PhD, FAAN, Consultant, Star7 Strategies, Inc., Indialantic, Florida Carol A. Puz, RN, BSN, MS, CCRN, Education and Development Specialist, The Western Pennsylvania Hospital, West Penn Allegheny Health System, Pittsburgh, Pennsylvania Cynda H. Rushton, RN, DNSc, FAAN, Associate Professor of Nursing, Johns Hopkins University, Baltimore, Maryland Claudia Schmalenberg, RN, MS, Research Associate and Consultant, Health Science Research Associates, Tahoe City, California Thomas Smith, MS, RN, CNAA, Senior Vice President, Nursing and Patient Care Services, The Mount Sinai Hospital, New York, New York Sister Maurita Soukup, RSM, RN, DNSc, Vice President, Mercy Medical Center, The Iowa Heart Hospital, Des Moines, Iowa Denise Thornby, RN, MS, Director, Education and Professional Development and Clinical Administrator Group, Virginia Commonwealth University Health Systems, Richmond, Virginia Nora Triola, PhD, RN, CNAA, Vice President of Nursing & Patient Care Services, Methodist Hospital, Clarian Health Partners, Indianapolis, Indiana Pamela Klauer Triolo, PhD, RN, FAAN, Clinical Professor of Nursing, The University of Texas Health Science Center-Houston School of Nursing Joan Vitello-Cicciu, PhD, RN, CNAA, FAAN, Vice President of Patient Care Services and Chief Nursing Executive, St. Anne's Hospital, Fall River, Massachusetts Barbara C. Wallace, EdD, MPH, RNC, Beth Israel Deaconess Medical Center, Boston, Massachusetts and Wallace Associates, Media, Health & Corporate Communication Consulting, Stoughton, Massachusetts Suzanne White, MN, RN, FAAN, FCCM, FAHA, CNAA, Vice President, Patient Care Services and Chief Nursing Officer, Greenville Hospital System, University Medical Center, Greenville, South Carolina

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Cases in Point

Acute and critical care nurses repeatedly voice grave concern and moral distress about the deterioration of healthcare work environments in the United States. These four instances 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.

1 2 3 4

At 3:30 a.m. in a busy ICU, a nurse prepares to give insulin to a patient with 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, she 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 two nurses in the unit "keeping an eye" on three critically ill patients apiece. 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. He 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 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, he 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 where he encounters significant negative non-verbal communication and very little spoken feedback. During the next week, tensions run high, rumors abound, two nurses resign and morale reaches an all-time low.

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About the Standards

"Our lives begin to end the day we become silent about things that matter." ­Martin Luther King Jr.

Each day, thousands of medical errors harm the patients and families served by the American healthcare 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 again these all-too-familiar situations. · A nurse chooses to not call a physician known to be verbally abusive. The nurse uses her judgment to clarify a prescribed medication and administers a fatal dose of the wrong drug.1 · Additional patients added to a nurse's assignment during a busy weekend because on-call staff is not available and back up plans do not exist to cover variations in patient census. Patients are placed at risk for errors and injury and nurses are frustrated and angry. · Isolated decision making in one department leads to tension, frustration and a higher risk of errors by all involved. Whether affecting patient care or unit operations, decisions made without including all parties places everyone involved at risk. · Nurses placed in leadership positions without adequate preparation and support for their role. The resulting environment creates dissatisfaction and high turnover for nurse leaders and staff as well. · Contentious relationships between nurses and administrators heightened when managers are required to stretch their responsibilities without adequate preparation and coaching for success.2 Only 65% of hospital managers are held accountable for employee satisfaction.3 Each situation characterizes poor and ineffective relationships. Attention to work relationships is often dismissed as unworthy of resource allocation in healthcare 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 where 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 to maintain compassionate and caring relationships with "a commitment to fair treatment of individuals and integrity-preserving compromise."5

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Over more than two decades, AACN has advocated for principles such as interdisciplinary collaboration and effective leadership that are essential to healthy work environments.6 The standards in this document continue this legacy and respond to the Institute of Medicine's call for professional groups to serve as advocates for change. 7 A nine-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 where nursing care is provided, 50 expert reviewers validated the standards, critical elements and explanatory text.

6 essential standards

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 people­including 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 since 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.

essential

Absolutely required; not to be used up or sacrificed. Indispensable. Fundamental. Authoritative statement articulated and promulgated by the profession, by which the quality of practice, service or education can be judged. Structures, processes, programs and behaviors required for a standard to be achieved.

standard

critical elements

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.10 The 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.

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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: Skilled Communication Nurses must be as proficient in communication skills as they are in clinical skills. True Collaboration Nurses must be relentless in pursuing and fostering true collaboration. Effective Decision Making Nurses must be valued and committed partners in making policy, directing and evaluating clinical care and leading organizational operations. Appropriate Staffing Staffing must ensure the effective match between patient needs and nurse competencies. Meaningful Recognition Nurses must be recognized and must recognize others for the value each brings to the work of the organization. Authentic Leadership Nurse leaders must fully embrace the imperative of a healthy work environment, authentically live it and engage others in its achievement.

adoption and implementation

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 nine 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 assure 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 only lead to excellence when they have been adopted at every level of the organization­from 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 assured 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.

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Careful scrutiny of these six standards, as illustrated in Figure 1, 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 PATIENT OUTCOMES

SKILLED COMMUNICATION

AUTHENTIC LEADERSHIP

CLINICAL EXCELLENCE

HEALTHY RECOGNITION WORK ENVIRONMENT

TRUE

MEANINGFUL

COLLABORATION EFFECTIVE DECISION MAKING

APPROPRIATE STAFFING

figure 1

Interdependence of Healthy Work Environment, Clinical Excellence and Optimal Patient Outcomes.

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references

1. Greene J. The medical workplace. No abuse zone. Hosp Health Netw. March 2002;76:26,28. 2. American Association of Critical-Care Nurses. Strategic Market Research Study. Aliso Viejo, Calif: American Association of Critical-Care Nurses; 2003. 3. University Health System Consortium. Successful Practices for Workplace of Choice Employers. Oak Brook, Ill: UHC; 2003. 4. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001. 5. American Nurses Association. Code of Ethics for Nurses With Interpretive Statements. Washington, DC: American Nurses Publishing; 2001. 6. Adler D, Ayres S, Disch J, Greenbaum D, Lavandero R, Millar S. The organization of human resources in critical care units. Focus Crit Care. February 1983;101;43-44. 7. Kohn L, Corrigan J, Donaldson M, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000: 127. 8. Hardin S, Kaplow R. Synergy for Clinical Excellence: The AACN Synergy Model for Patient Care. Sudbury, Mass: Jones & Bartlett; 2004. 9. Greiner AC, Knebel E, eds. Health Professions Education: A Bridge to Quality. Washington, DC: National Academy Press; 2004. 10. Robert Wood Johnson Executive Nurse Fellows Program. Available at: http://www.futurehealth.ucsf.edu/rwj/. Accessed December 3, 2004.

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standard 1

Skilled Communication

Nurses must be as proficient in communication skills as they are in clinical skills.

skilled

Having familiar knowledge united with readiness and dexterity in its application

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 one-way delivery of information; it is a two-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 skills­including written, spoken and non-verbal­that 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 three in four 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.6 Intimidating 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 over 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.

"We cannot be truly human apart from communication ... to impede communication is to reduce people to the status of things." ­Paulo Freire International educator, Community activist

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critical elements

· The healthcare organization provides team members with support for and access to education

programs that develop critical communication skills including self-awareness, inquiry/dialogue, conflict management, negotiation, advocacy and listening. · Skilled communicators focus on finding solutions and achieving desirable outcomes. · Skilled communicators seek to protect and advance collaborative relationships among colleagues. · Skilled communicators invite and hear all relevant perspectives. · Skilled communicators call upon goodwill and mutual respect to build consensus and arrive at common understanding. · Skilled communicators demonstrate congruence between words and actions, holding others accountable for doing the same. · The healthcare organization establishes zero-tolerance policies and enforces them to address and eliminate abuse and disrespectful behavior in the workplace. · The healthcare organization establishes formal structures and processes that ensure effective information sharing among patients, families and the healthcare team. · Skilled communicators have access to appropriate communication technologies and are proficient in their use. · The healthcare organization establishes systems that require individuals and teams to formally evaluate the impact of communication on clinical, financial and work environment outcomes. · The healthcare organization includes communication as a criterion in its formal performance appraisal system and team members demonstrate skilled communication to qualify for professional advancement.

"It is ethical to request, encourage and deliver feedback on all facets of individual and organizational performance. It is unethical to ignore, discourage or fail to give feedback." ­David Thomas Ethicist, Ethics of Choice Training Program

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references

1. Joint Commission on Accreditation of Healthcare Organizations. Health care at the crossroads: strategies for addressing the evolving nursing crisis. Available at: http://www.jcaho.org/about+us/public+policy+initiatives/health+care+at+the+crossroads.pdf. Accessed October 4, 2004. 2. Institute for Safe Medication Practices. Intimidation: practitioners speak up about this unresolved problem: part I. ISMP Medication Safety Alert! March 11, 2004. 3. Buresh, B, Gordon S. From Silence to Voice: What Nurses Know and Must Communicate to the Public. Ottawa, Canada: Canadian Nurses Association; 2000. 4. Kohn L, Corrigan J, Donaldson M, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000. 5. Schaefer HG, Helmreich RL, Scheidegger D. Human factors and safety in emergency medicine. Resuscitation. 1994;28:221-225. 6. Joint Commission on Accreditation of Healthcare Organizations. Root Causes of Sentinel Events 1995-2003. http://www.jcaho.com/accredited+organizations/ambulatory+care/sentinel+events/root+causes+of+sentinel+event.htm. Accessed December 17, 2004. 7. American Nurses Association. Code of Ethics for Nurses With Interpretive Statements. Washington, DC: American Nurses Publishing; 2001.

suggested reading

Babcock L, Laschever S. Women Don't Ask: Negotiation and the Gender Divide. Princeton, NJ: Princeton University Press; 2003. Barden C. Speak up about things that matter. AACN News. August 2002;19:2. Barden C. Stop the abuse and disrespect. AACN News. November 2002;19:2. Barden C. Listening improves a bold voice. AACN News. January 2003;20:2. Barden C. Bold voices: fearless and essential. Presented at: AACN National Teaching Institute; May 19, 2003; Atlanta, Ga. Cloke K, Goldsmith J. Resolving Conflicts at Work: A Complete Guide for Everyone on the Job. San Francisco, Calif: Jossey-Bass; 2000. Fontaine D. Is it only a dream? AACN News. December 2003;20:2. Greene J. The medical workplace. No abuse zone. Hosp Health Netw. March 2002;76:26,28. Johnson B. Polarity Management: Identifying and Managing Unsolvable Problems. Amherst, Mass: HRD Press; 1992,1996. Karshmer J. Nine rules of thumb to make communications work. Nurs Manage. November 1992;23:80I-80J, 80N, 80P. Kolb DM, Williams J. The Shadow Negotiation: How Women Can Master the Hidden Agendas That Determine Bargaining Success. New York, NY: Simon & Schuster; 2000. Kritek PB. Negotiating at an Uneven Table: Developing Moral Courage in Resolving Our Conflicts. San Francisco, Calif: Jossey-Bass; 2002. Kritek PB. Conflict resolution in practice: an essential advanced practice nurse competency. In: Joel LA, ed. Advanced Practice Nursing: Essentials for Role Development. Philadelphia, Pa: FA Davis; 2004. Lederach JP. Building Peace: Sustainable Reconciliation in Divided Societies. Washington, DC: United States Institute of Peace; 1997. Page A, ed. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: Institute of Medicine Committee on the Work Environment for Nurses and Patient Safety; 2003. Patterson K, Grenny J, McMillan R, Switzler A. Crucial Conversations: Tools for Talking When the Stakes Are High. Hightstown, NJ; McGraw-Hill, 2002. Patterson K, Grenny J, McMillan R, Switzler A. Crucial Confrontations: Tools for Resolving Broken Promises, Violated Expectations, and Bad Behavior. Hightstown, NJ: McGraw-Hill; 2004. Porter-O'Grady T. When push comes to shove: managers as mediators. Nurs Manage. October 2003;34;34-40. Rosenstein, AH, O'Daniel, M. Disruptive behavior and clinical outcomes: perceptions of nurses & physicians. Am J Nurs. January 2005;105:54-64. Terez T. 22 Keys to Creating a Meaningful Workplace. Avon, Mass: Adams Media Corp; 2000. Thomas D. The Ethics of Choice: A Quick Guide. Omaha, Neb: David Thomas; 1993. Thornby D. Make waves: be a courageous messenger. AACN News. August 2000;17:8. Thornby D. Make waves: have the courage to confront. AACN News. August 2000;17:10. Thornby D. Make waves: always choose the "high road." AACN News. August 2001;18:2. Wheatley M. Turning to One Another: Simple Conversations to Restore Hope to the Future. San Francisco, Calif: Berrett-Koehler; 2002.

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19

standard 2

True Collaboration

Nurses must be relentless in pursuing and fostering true collaboration.

true

Sincerely felt or expressed. Not pretended. Worthy of being depended on

True collaboration is a process, not an event. It must be ongoing and build over time, eventually resulting in a work culture where 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.1 Without 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.4 Nearly 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 Further, nurse-physician collaboration has been found to be one of the three strongest predictors of psychological empowerment of nurses.6 Mutual respect between nurses and physicians for each other's knowledge and competence, coupled with a mutual concern that quality patient care will be provided are key organizational elements of work environments that attract and retain nurses.1,7,8 Additionally, an unresponsive bureaucracy generates organizational stress, which is significantly more predictive of nurse burnout and resignations than emotional stressors inherent in the work itself.9

"We are different so that we can know our need of one another, for no one is ultimately self-sufficient. A completely self-sufficient person would be sub-human." ­Archbishop Desmond Tutu Civil rights activist, Nobel Laureate

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Collaboration requires constant attention and nurturing, supported by formal processes and structures that foster joint communication and decision making. Evidence documenting differing perceptions about the importance and effectiveness of nurse-physician collaboration among nurses, physicians and healthcare executives points to an imperative that effective methods be developed to improve working relationships between nurses and physicians.10

critical elements

· The healthcare organization provides team members with support for and access to education programs that develop collaboration skills. · The healthcare organization creates, uses and evaluates processes that define each team member's accountability for collaboration and how unwillingness to collaborate will be addressed. · The healthcare organization creates, uses and evaluates operational structures that ensure the decision making authority of nurses is acknowledged and incorporated as the norm. · The healthcare organization ensures unrestricted access to structured forums, such as ethics committees, and makes available the time needed to resolve disputes among all critical participants, including patients, families and the healthcare team. · Every team member embraces true collaboration as an ongoing process and invests in its development to ensure a sustained culture of collaboration. · Every team member contributes to the achievement of common goals by giving power and respect to each person's voice, integrating individual differences, resolving competing interests and safeguarding the essential contribution each must make in order to achieve optimal outcomes. · Every team member acts with a high level of personal integrity. · Team members master skilled communication, an essential element of true collaboration. · Each team member demonstrates competence appropriate to his or her role and responsibilities. · Nurse managers and medical directors are equal partners in modeling and fostering true collaboration.

"It is ethical to be open to the possibility that your view is incomplete and therefore capable of revision. It is unethical to ignore information that could allow you and/or your organization to grow." ­David Thomas Ethicist, Ethics of Choice Training Program

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references

1. American Hospital Association Commission on Workforce for Hospitals and Health Systems. In Our Hands: How Hospital Leaders Can Build a Thriving Workforce. Chicago, Ill: American Hospital Association Commission on Workforce for Hospitals and Health Systems; 2002. 2. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. An evaluation of outcome from intensive care in major medical centers. Ann Intern Med. 1986;104:410-418. 3. Page A, ed. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: Institute of Medicine Committee on the Work Environment for Nurses and Patient Safety; 2003. 4. Kohn L, Corrigan J, Donaldson M, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000: 142. 5. American Association of Critical-Care Nurses. Strategic Market Research Study. Aliso Viejo, Calif: American Association of Critical-Care Nurses; 2003. 6. Larrabee JH, Janney MA, Ostrow CL, Withrow ML, Hobbs GR Jr, Burant C. Predicting registered nurse job satisfaction and intent to leave. J Nurs Admin. 2003;33:271-283. 7. American Organization of Nursing Executives. Healthy Work Environments: Striving for Excellence. Vol 2. Chicago, Ill: McManis & Monsalve Associates; 2003. 8. VitalSmarts. Silence Kills: The 7 Crucial Conversations in Healthcare. Provo, Utah: 2005. Available at: http://www.vitalsmarts.com. 9. Scott RA, Aiken LH, Mechanic D, Moravcsik J. Organizational aspects of caring. Milbank Q. 1995;73:77-95. 10. Rosenstein AH. Original research: nurse-physician relationships: impact on satisfaction and retention. Am J Nurs. June 2002;102:26-34.

suggested reading

American Association of Critical-Care Nurses. Zero Tolerance for Abuse. Available at: https://www.aacn.org/hwe. Accessed October 4, 2004. Baker C, Beglinger J, King S, Salyards M, Thompson A. Transforming negative work cultures: a practical strategy. J Nurs Adm. 2000;30:357-363. Barnsteiner J, Madigan C, Spray T. Instituting a disruptive conduct policy for medical staff. AACN Clin Issues. 2001;12:378-382. The Beckwith Institute for Innovation in Patient Care. Implementation of the transformational model for professional practice in health care organizations. Available at: http://www.beckwithinstitute.org/PDFs/BeckwithModelGrids.pdf. Accessed December 12, 2004. Dechairo-Marino AE, Jordan-Marsh M, Traiger G, Saulo M. Nurse-physician collaboration: action research and the lessons learned. J Nurs Admin. 2001;31:223-232. Disch J, Walton M, Barnsteiner J. The role of the clinical nurse specialist in creating a healthy work environment. AACN Clin Issues. 2001;12:345-355. Fisher R, Ury W. Getting to Yes: Negotiating Agreement Without Giving In. New York, NY: Penguin Books. 1991. Fontaine D. Why can't we get our arms around true collaboration? AACN News. January 2004;21:2. Forte P. The high cost of conflict. Nurs Econ. May-June 1997;15:119. Freeth D. Sustaining interprofessional collaboration. J Interprof Care. February 2001;15:37-46. Gerardi D. Using mediation techniques to manage conflict and create healthy work environments. AACN Clin Issues. 2004:15;183-192. Grap M, Strickland D, Tormey L, et al. Collaborative practice: development, implementation, and evaluation of a weaning protocol for patients receiving mechanical ventilation. Am J Crit Care. 2003;12:454-460. Hawryluck L, Espin S, Garwood K, Evans C, Lingard LA. Pulling together and pushing apart: tides of tension in the ICU team. Acad Med.2002;77(suppl):73-76. Kaissi A, Johnson T, Kirschbaum M. Measuring teamwork and patient safety attitudes of high-risk areas. Nurs Econ. 2003;21:211-218. Kenny G. The importance of nursing values in interprofessional collaboration. Br J Nurs. January 2002;11:65-68. Mansourimoaied M, Boman K, Causley T. Nurses' perceptions of interdisciplinary collaboration. Nursingconnections. Spring 2000;13:21-31. Page A, ed. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: Institute of Medicine Committee on the Work Environment for Nurses and Patient Safety; 2003. Rice RB. Collaboration as a tool for resolving the nursing shortage. J Nurs Educ. 2003;42:147-148. Rosenstein A. Nurse-physician relationships: impact on nurse satisfaction and retention. Am J Nurs. June 2002;102:26-34.

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Stichler JF. Developing collaborative relationships. AWHONN Lifelines. June 1998;2:53-54. Stone D, Patton B, Heen S. Difficult Conversations: How to Discuss What Matters Most. New York, NY: Penguin Books; 1999. Sullivan TJ. Collaboration: A Healthcare Imperative. New York, NY: McGraw-Hill; 1998. Surgenor SD, Blike GT, Corwin HL. Teamwork and collaboration in critical care: lessons from the cockpit. Crit Care Med. 2003;31:992-993. Thomas D. The Ethics of Choice: A Quick Guide. Omaha, Neb: David Thomas; 1993. Thornby D. Make waves: build bridges instead of barriers. AACN News. April 2001;18:4. Tracy MF, Ceronsky C. Creating a collaborative environment to care for complex patients and families. AACN Clin Issues. 2001;12:383-400. Van Ess Coeling H, Cukr PL. Communication styles that promote perceptions of collaboration, quality, and nurse satisfaction. J Nurs Care Qual. January 2000;14:63-74. Weinstein SM, Antonova S, Goryunova M. Enhancing nurse-physician collaboration: a staffing innovation. J Nurs Adm. 2003;33:193-195.

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standard 3

Effective Decision Making

Nurses must be valued and committed partners in making policy, directing and evaluating clinical care and leading organizational operations.

effective

Producing a strong impression or response

In order to fulfill their role as advocates, nurses must be involved in making decisions about patient care.1 A significant gap often exists between what nurses are accountable for and their ability to participate in decisions that affect those accountabilities. Evidence suggests that physicians, pharmacists, administrators and nurses assign primary responsibility for patient safety to nurses. However, only 8% of physicians recognize nurses as part of the decision making team.2 Other research reports that a majority of nurses feel relatively powerless to change things they dislike in their work environment.3 This autonomyaccountability gap interferes with nurses' ability to optimize their essential contribution and fulfill their obligations to the public as licensed professionals. As the single constant professional presence with hospitalized patients, nurses uniquely gather, filter, interpret and transform data from patients and the system into the meaningful information required to diagnose, treat and deliver care to a patient. This data management role of nurses is a vital link in the decision making activities of the entire healthcare team.4-6 Failure to incorporate the experienced perspective of nurses in clinical and operational decisions may result in costly errors, jeopardize patient safety and threaten the financial viability of healthcare organizations. Nurses believe that they provide high-quality nursing care and are accountable for their own practice.7,8 Nurses who do not have control over their practice become dissatisfied and are at risk for leaving an organization. Healthcare organizations recognized for attracting and retaining nurses have successfully implemented professional care models in which nurses have the responsibility and related authority for

"Individuals and organizations learn and evolve through conscious, deliberate action. Deliberate action is ethical. When the time to act has come, it is unethical not to do something." ­David Thomas Ethicist, Ethics of Choice Training Program

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patient care along with formal operational structures that support autonomous nursing practice. Their success is recognized by national programs such as the AACN Beacon Award for Critical Care Excellence, the Magnet Nursing Services Recognition Program and the Baldrige National Quality Program.9-11

critical elements

· The healthcare organization provides team members with support for and access to ongoing education and development programs focusing on strategies that assure collaborative decision making. Program content includes mutual goal setting, negotiation, facilitation, conflict management, systems thinking and performance improvement. · The healthcare organization clearly articulates organizational values and team members incorporate these values when making decisions. · The healthcare organization has operational structures in place that ensure the perspectives of patients and their families are incorporated into every decision affecting patient care. · Individual team members share accountability for effective decision making by acquiring necessary skills, mastering relevant content, assessing situations accurately, sharing fact-based information, communicating professional opinions clearly and inquiring actively. · The healthcare organization establishes systems, such as structured forums involving all departments and healthcare disciplines, to facilitate data-driven decisions. · The healthcare organization establishes deliberate decision making processes that ensure respect for the rights of every individual, incorporate all key perspectives and designate clear accountability. · The healthcare organization has fair and effective processes in place at all levels to objectively evaluate the results of decisions, including delayed decisions and indecision.

"People will not believe in [an organizational] change effort unless they have the opportunity to plan it, experience it, provide feedback, and own it. Involvement supports and sustains motivation, the essential ingredient for change." ­Robert F. Allen Advocate for cultural change and wellness

25

references

1. American Nurses Association. Code of Ethics for Nurses With Interpretive Statements. Washington, DC: American Nurses Publishing; 2001. 2. Greene J. The medical workplace. No abuse zone. Hosp Health Netw. March 2002;76:26,28. 3. Freeman-Cook A, Hoas H, Guttmannova K, Joyner JC. An error by any other name. Am J Nurs. June 2004;104:32-42. 4. Kimball B, O'Neil E. Healthcare's Human Crisis: The American Nursing Shortage. Princeton, NJ: The Robert Wood Johnson Foundation; 2002. 5. Fruth R. Organizational Technology and Professional Communications in a Hospital Setting. [dissertation]. Chicago, Ill: University of Illinois at Chicago;1995. 6. Nutt P. Why Decisions Fail. New York, NY: Berrett-Koehler Publishers; 2002. 7. American Hospital Association Commission on Workforce for Hospitals and Health Systems. In Our Hands: How Hospital Leaders Can Build a Thriving Workforce. Chicago, Ill: American Hospital Association Commission on Workforce for Hospitals and Health Systems; 2002. 8. American Organization of Nursing Executives. Healthy Work Environments: Striving for Excellence. Vol 2. Chicago, Ill: McManis & Monsalve Associates; 2003. 9. American Association of Critical-Care Nurses Beacon Award for Critical Care Excellence. Available at: http://www.aacn.org. Accessed December 17, 2004. 10. Magnet Nursing Services Recognition Program. Available at: http://www.ana.org/ancc/magnet.html. Accessed December 17, 2004. 11. Baldrige National Quality Program. Available at: http://www.baldrige.gov. Accessed December 17, 2004.

suggested reading

Clancy T. The art of decision-making. J Nurs Adm. 2003;33:343-349. Foley BJ, Kee CC, Minick P, Harvey SS, Jennings BM. Characteristics of nurses and hospital work environments that foster satisfaction and clinical expertise. J Nurs Adm. 2002;32:273-282. Fontaine D. From Our Town to our unit. AACN News. October 2003;20:2. Havens D, Vasey J. Measuring staff nurse decisional involvement: the decisional involvement scale. J Nurs Adm. 2003;33:331-336. Hinshaw AS, eds. Magnet Hospitals Revisited. Washington, DC: American Nurses Publishing; 2002:37. Kramer M, Schmalenberg C. Clinical autonomy scale. Staff nurses identify essentials of magnetism. In: McClure M, Hinshaw AS. Magnet Hospitals Revisited: Attraction and Retention of Professional Nurses. Washington, DC: American Nurses Publishing; 2002. Kramer M, Schmalenberg C. Magnet hospital staff nurses describe clinical autonomy. Nurs Outlook. 2003;51:13-19. Laschinger H, Havens D. Staff nurse work empowerment and perceived control over nursing practice: conditions for work effectiveness. J Nurs Adm. 1996;26:27-35. Porter-O'Grady T. Worker autonomy: the foundation of shared governance. J Nurs Adm. 2001;31:100. Porter-O'Grady T. Is shared governance still relevant? J Nurs Adm. 2001;31:468-473. Russo JE, Schoemaker P. Decision Traps: The Ten Barriers to Brilliant Decision-Making and How to Overcome Them. New York, NY: Simon and Schuster; 1990. Thomas D. The Ethics of Choice: A Quick Guide. Omaha, Neb: David Thomas; 1993. Winters, G, Klein, E. To Do or Not To Do: How Successful Leaders Make Better Decisions. Encinitas, Calif: Wisdom Heart Press; 2004. Woods D. Realizing your marketing influence, part 3: professional certification as a marketing tool. J Nurs Adm. 2002;32:379-386.

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27

standard 4

Appropriate Staffing

Staffing must ensure the effective match between patient needs and nurse competencies.

appropriate

Suitable for achieving a particular end

Inappropriate staffing is one of the most harmful threats to patient safety and to the well-being of nurses. Evidence suggests that better patient outcomes result when a higher proportion of care hours is provided by registered nurses, as compared with care by licensed practical nurses or nursing assistants.1 The likelihood of death or serious complications after surgery increases when fewer nurses are assigned to care for patients.2 Further research supports a relationship between specialty certification and clinical nursing expertise.3,4 Because nurses intercept 86% of all medication errors made by other professionals, an increase in these errors will likely occur when nurses are overworked, overstressed and in short supply.5 Inadequate staffing leads to nurse dissatisfaction, burnout and turnover.2 Nurse turnover jeopardizes the quality of care, increases patient costs and decreases hospital profitability.6 Staffing is a complex process with the goal of matching the needs of patients at multiple points throughout their illness with the skills and competencies of nurses. Because the condition of critically ill patients rapidly and continuously fluctuates, flexibility of nurse staffing that goes beyond fixed nurse-to-patient ratios is imperative.7 Relying on staffing ratios alone ignores variance in patient needs and acuity. Organizations must engage in dramatic innovation to devise and systematically test new staffing models. All staffing models require methods for ongoing evaluation of staffing decisions in relation to patient and system outcomes.8 This evaluation is essential in order to provide accurate trend data from which targeted improvement tactics­including technologies to reduce the demand and increase the efficiency of nurses' work­can be undertaken.

"Setting staffing levels that take into account the complexities of patient needs and nurses' skills and competencies must also be part of the solution." ­Joint Commission on Accreditation of Healthcare Organizations

28

critical elements

· The healthcare organization has staffing policies in place that are solidly grounded in ethical principles and support the professional obligation of nurses to provide high quality care. · Nurses participate in all organizational phases of the staffing process from education and planning­including matching nurses' competencies with patients' assessed needs­through evaluation. · The healthcare organization has formal processes in place to evaluate the effect of staffing decisions on patient and system outcomes. This evaluation includes analysis of when patient needs and nurse competencies are mismatched and how often contingency plans are implemented. · The healthcare organization has a system in place that facilitates team members' use of staffing and outcomes data to develop more effective staffing models. · The healthcare organization provides support services at every level of activity to ensure nurses can optimally focus on the priorities and requirements of patient and family care. · The healthcare organization adopts technologies that increase the effectiveness of nursing care delivery. Nurses are engaged in the selection, adaptation and evaluation of these technologies.

"Nurses are a hospital's most precious resource. The one that is in shortest supply. Would you expect a precious resource to go chasing after urinals and linen? Yet hospitals seem willing to spend hundreds of thousands of dollars recruiting new nurses, instead of addressing solvable system errors that will retain nurses in the first place." ­Dorrie Fontaine Clinician, Educator, AACN Past President

29

references

1. Needleman J, Buerhuas P, Mattke S, Stewart M, Zelevinsky K. Nursing staffing levels and the quality of care in hospitals. N Engl J Med. 2002;346:1715-1720. 2. Aiken L, Clarke S, Sloane DM, Sochalski J, Silber J. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288:1987-1993. 3. Foley BJ, Jennings BM, Kee CC, Minick P, Harvey SS. Characteristics of nurses and hospital work environments that foster satisfaction and clinical expertise. J Nurs Adm. 2002;325:273-282. 4. American Association of Critical-Care Nurses, AACN Certification Corporation. Safeguarding the Patient and the Profession: The Value of Critical Care Nurse Certification. Available at: http://www.aacn.org/certcorp/certcorp.nsf/vwdoc/BenefitsofCert. Accessed January 4, 2005. 5. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Study Group. JAMA. 1995;274:29-34. 6. VHA. Shortages impacting: quality of care, patient satisfaction and market share. Available at: https://www.vha.com/news /releases/public/021111.asp. Accessed October 4, 2004. 7. Snyder DA, Medina J, Bell L, Wavra, TA. AACN Delegation Handbook. (2004, second edition). Available at: https://www.aacn.org /__8825651000134c1b.nsf/0/b37a82e9fcc3c1cf882567530067ed9e?OpenDocument&Highlight=2,DELEGATION. Accessed December 17, 2004. 8. American Association of Critical-Care Nurses. Position statement: maintaining patient-focused care in an environment of nursing staff shortage and financial constraints. Available at: http://www.aacn.org/pdfLibra.NSF/Files/burson/$file/burson.pdf. Accessed December 17, 2004.

suggested reading

American Association of Critical-Care Nurses. Written statement to the Institute of Medicine Committee on Work Environment for Nurses and Patient Safety. Available at: http://www.aacn.org/aacn/hwe. Accessed January 17, 2005. American Association of Critical-Care Nurses. Staffing Blueprint: Constructing Your Staffing Solutions. Aliso Viejo, Calif; 1999. American Association of Critical-Care Nurses. Mandatory overtime: a statement from the American Association of Critical-Care Nurses. Available at: http://www.aacn.org/aacn/pubpolcy.nsf/72fe271374e4c5338825688e00776c20/7945af78da4b2d7988256ce000660bc5?OpenDocument. Accessed October 4, 2004. American Nurses Association. Code of Ethics for Nurses With Interpretive Statements. Washington, DC: American Nurses Publishing; 2001. Blegen M, Goode C, Reed L. Nurse staffing and patient outcomes. Nurs Res. January-February 1998;47:43-50. Cho SH. Nurse staffing and adverse patient outcomes: a systems approach. Nurs Outlook. March-April 2001;49:78-85. Clarke SP. Balancing staffing and safety. Nurs Manage. June 2003;34:44-48. Curley MAQ. Patient-nurse synergy: optimizing patients' outcomes. Am J Crit Care. 1998;7:64-72. Hardin S, Kaplow R. Synergy for Clinical Excellence: The AACN Synergy Model for Patient Care. San Francisco, Calif: Jones & Bartlett; 2004. Joint Commission on Accreditation of Healthcare Organizations. Health care at the crossroads: strategies for addressing the evolving nursing crisis. Available at: http://www.jcaho.org/about+us/public+policy+initiatives/health+care+at+the+crossroads.pdf. Accessed October 4, 2004. Joint Commission on Accreditation of Healthcare Organizations. Staffing Effectiveness in Hospitals. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations; 2003. Kovner C, Gergen PJ. Nurse staffing levels and adverse events following surgery in U.S. hospitals. Image J Nurs Sch. 1998;30:315-321. Lang TA, Hodge M, Olson V, Romano PS, Kravitz RL. Nurse-patient ratios: a systematic review on the effects of nurse staffing on patient, nurse employee, and hospital outcomes. J Nurs Adm. 2004;34:326-337. Lewis P, Latney C. Achieve best practice with an evidence-based approach. Create a collaborative environment that improves patient care through consistent outcomes measurement. Nurs Manage. December 2002;33:24, 26-8, 30. McClure M, Hinshaw AS. Magnet Hospitals Revisited: Attraction and Retention of Professional Nurses. Washington, DC: American Nurses Publishing; 2002. Nursing Knowledge International. The state of synergy. Excellence in nursing knowledge. Available at: http://www.nursingknowledge.org /Portal/main.aspx?PageID=3507&ContentID=55889. Accessed October 4, 2004. Page A, ed. Keeping Patients Safe: Transforming the Work Environment of Nurses. Washington, DC: Institute of Medicine Committee on the Work Environment for Nurses and Patient Safety; 2003. Potter P, Barr N, McSweeney M, Sledge J. Identifying nurse staffing and patient outcome relationships: a guide for change in care delivery. Nurs Econ. 2003;21:158-166. Thomas D. The Ethics of Choice: A Quick Guide. Omaha, Neb: David Thomas; 1993.

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31

standard 5

Meaningful Recognition

Nurses must be recognized and must recognize others for the value each brings to the work of the organization.

meaningful

Having meaning, function, or purpose. Significant

Recognition of the value and meaningfulness of one's contribution to an organization's work is a fundamental human need and an essential requisite to personal and professional development. People who are not recognized feel invisible, undervalued, unmotivated and disrespected. A majority of nurses are dissatisfied with the recognition they receive from their employer.1 This lack of recognition leads to discontent, poor morale, reduced productivity and suboptimal care outcomes. Inadequate recognition is cited as a primary reason for turnover among employees and is linked to decreasing nurse satisfaction.2-4 Three out of four American Association of Critical-Care Nurses' members and constituents rank recognition for their contributions as a central element of a healthy work environment.5 Hospitals recognized for attracting and retaining nurses emphasize personal growth and development, and provide multiple rewards for expertise and opportunities for clinical advancement.6 Like true collaboration, meaningful recognition is a process, not an event. It must be ongoing and build over time, becoming a norm within the work culture. Recognition has meaning only when it is relevant to the person being recognized. Recognition that is not congruent with a person's contributions or comes in tandem with emotionally charged organizational change is often perceived as disrespectful tokenism. Effective programs of recognition will not occur automatically and require formal structures and processes to ensure desired outcomes.

"Treat people as if they were what they ought to be, and you help them to become what they are capable of being." ­Johann Wolfgang von Goethe Philosopher, Poet, Playwright

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critical elements

· The healthcare organization has a comprehensive system in place that includes formal processes and structured forums that ensure a sustainable focus on recognizing all team members for their contributions and the value they bring to the work of the organization. · The healthcare organization establishes a systematic process for all team members to learn about the institution's recognition system and how to participate by recognizing the contributions of colleagues and the value they bring to the organization. · The healthcare organization's recognition system reaches from the bedside to the board table, ensuring individuals receive recognition consistent with their personal definition of meaning, fulfillment, development and advancement at every stage of their professional career. · The healthcare organization's recognition system includes processes which validate that recognition is meaningful to those being acknowledged. · Team members understand that everyone is responsible for playing an active role in the organization's recognition program and meaningfully recognizing contributions. · The healthcare organization regularly and comprehensively evaluates its recognition system, ensuring effective programs that help to move the organization toward a sustainable culture of excellence that values meaningful recognition.

"It is ethical to offer feedback to those from whom you or your organization receive services. It is unethical to allow outstanding performance to go unacknowledged ... just as it is unethical not to provide feedback to those whose performance or service threatens the optimal performance of you or your organization." ­David Thomas Ethicist, Ethics of Choice Training Program

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references

1. United States General Accounting Office. Nursing workforce: recruitment and retention of nurses and nurse aides is a growing concern. Available at: http://www.gao.gov/new.items/d01750t.pdf. Accessed October 6, 2004. 2. Cronin SN, Bechrerer D. Recognition of staff nurse job performance and achievements. J Nurs Adm. 1999;29:26-31. 3. McConnell CR. Employee recognition: a little oil on the troubled waters of change. Health Care Superv. June 1997;15:83-90. 4. Blegen MA, Goode CJ, Johnson M, Maas ML, McCloskey JC, Moorhead SA. Recognizing staff nurse job performance and achievements. Res Nurs Health. February 1992;15:57-66. 5. American Association of Critical-Care Nurses. Strategic Market Research Study. Aliso Viejo, Calif: American Association of Critical-Care Nurses; 2003. 6. American Hospital Association Commission on Workforce for Hospitals and Health Systems. In Our Hands: How Hospital Leaders Can Build a Thriving Workforce. Chicago, Ill: American Hospital Association Commission on Workforce for Hospitals and Health Systems; 2002.

suggested reading

Alspach G. Recognizing and rewarding nurse preceptors in critical care. Some answers. Crit Care Nurse. April 2003;23:13-20. Blegen MA, Goode CJ, Johnson M, Maas ML, McCloskey JC, Moorhead SA. Recognizing staff nurse job performance and achievements. Res Nurs Health. February 1992;15:57-66. Cronin SN, Bechrerer D. Recognition of staff nurse job performance and achievements. J Nurs Adm. 1999;29:26-31. Fontaine D. Giving credit, saying thanks. AACN News. November 2003;20:2. Freed D. Fifty-two effective, inexpensive ways to reward and recognize hospital employees. Health Care Manag (Frederick). September 1999;18:20-28. Kouzes J, Posner B. Encouraging the Heart: A Leader's Guide to Rewarding and Recognizing Others. San Francisco, Calif: Jossey-Bass; 2003. McConnell CR. Employee recognition: a little oil on the troubled waters of change. Health Care Superv. June 1997;15:83-90. McCoy J. Recognize, reward, retain. Nurs Manage. February 1999;30:41-43. Robinson K, Eck C, Keck B, Wells N. The Vanderbilt Professional Nursing Practice Program, part 1: growing and supporting professional nursing practice. J Nurs Adm. 2003;33:441-450. Thomas D. The Ethics of Choice: A Quick Guide. Omaha, Neb: David Thomas; 1993.

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standard 6

Authentic Leadership

Nurse leaders must fully embrace the imperative of a healthy work environment, authentically live it and engage others in its achievement.

authentic

Conforming to fact and therefore worthy of trust, reliance or belief

Less than half of the American Association of Critical-Care Nurses' members rank their relationships with their managers and administrators as positive, yet more than 90% identify effective leaders as an important element of a healthy work environment.1 A multitude of reports and white papers issued by leaders in all sectors of the healthcare community document the issue of inadequately positioned and prepared leaders in nursing and strongly call for effective measures to strengthen nursing leadership.2 Nurse leaders­including managers, administrators, advanced practice nurses, educators and other formal and informal clinical leaders­seldom have the support resources commensurate with their scope of responsibilities and often do not have access to key decision making forums within healthcare organizations. Nurse managers in particular are key to the retention of satisfied staff yet, all too often, receive little preparation, education, coaching or mentoring to ensure success in their role. Nurse leaders must be skilled communicators, team builders, agents for positive change, committed to service, results oriented and role models for collaborative practice.3 This requires skill in the core competencies of self-knowledge, strategic vision, risk-taking and creativity, interpersonal and communication effectiveness, and inspiration.4 Healthy work environments require that individual nurses and organizations commit to the development of nurse leaders in a systematic and comprehensive way. Nurse leaders must be positioned within key operational and governance bodies of the organization in order to inform and influence decisions that affect nursing practice and the environment in which it is practiced.2,3

"Managers assume that job security is of paramount importance to employees. Among workers, however, it ranks far below desire for respect, a higher standard of management ethics, increased recognition of employee contributions, and closer, more honest communications between employees and senior management." ­Robert H. Rosen Psychologist, Business Author, MacArthur Foundation Fellow

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critical elements

· The healthcare organization provides support for and access to educational programs to ensure that nurse leaders develop and enhance knowledge and abilities in: skilled communication, effective decision making, true collaboration, meaningful recognition, and ensuring resources to achieve appropriate staffing. · Nurse leaders demonstrate an understanding of the requirements and dynamics at the point of care and within this context successfully translate the vision of a healthy work environment. · Nurse leaders excel at generating visible enthusiasm for achieving the standards that create and sustain healthy work environments. · Nurse leaders lead the design of systems necessary to effectively implement and sustain standards for healthy work environments. · The healthcare organization ensures that nurse leaders are appropriately positioned in their pivotal role in creating and sustaining healthy work environments. This includes participation in key decision making forums, access to essential information and the authority to make necessary decisions. · The healthcare organization facilitates the efforts of nurse leaders to create and sustain a healthy work environment by providing the necessary time and financial and human resources. · The healthcare organization provides a formal co-mentoring program for all nurse leaders. Nurse leaders actively engage in the co-mentoring program. · Nurse leaders role model skilled communication, true collaboration, effective decision making, meaningful recognition and authentic leadership. · The healthcare organization includes the leadership contribution to creating and sustaining a healthy work environment as a criterion in each nurse leader's performance appraisal. Nurse leaders must demonstrate sustained leadership in creating and sustaining a healthy work environment to achieve professional advancement. · Nurse leaders and team members mutually and objectively evaluate the impact of leadership processes and decisions on the organization's progress toward creating and sustaining a healthy work environment.

"One of the most decisive functions of leadership is the creation, management, and when necessary, the destruction and rebuilding of culture." ­Edgar Schein Organizational behavior and culture pioneer

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references

1. American Association of Critical-Care Nurses. Strategic Market Research Study. Aliso Viejo, Calif: American Association of Critical-Care Nurses; 2003. 2. Kimball B, O'Neil E. Healthcare's Human Crisis: The American Nursing Shortage. Princeton, NJ: The Robert Wood Johnson Foundation; 2002. 3. American Hospital Association Commission on Workforce for Hospitals and Health Systems. In Our Hands: How Hospital Leaders Can Build a Thriving Workforce. Chicago, Ill: American Hospital Association Commission on Workforce for Hospitals and Health Systems; 2002. 4. Robert Wood Johnson Executive Nurse Fellows Program. Available at: http://www.futurehealth.ucsf.edu/rwj/. Accessed December 17, 2004.

suggested reading

American Association of Critical-Care Nurses. Staffing Blueprint: Constructing Your Staffing Solutions. Aliso Viejo, Calif: American Association of Critical-Care Nurses; 1999. American Organization of Nursing Executives. Healthy Work Environments: Striving for Excellence. Vol 2. Chicago, Ill: McManis & Monsalve Associates; 2003. Bennis W. On Becoming a Leader: The Leadership Classic--Updated and Expanded. Cambridge, Mass: Perseus Books Group, 2003. Bennis W, Goldsmith. Learning to Lead: A Workbook on Becoming a Leader. Cambridge, Mass: Perseus Books Group, 2003. Block P. The Answer to How Is Yes: Acting on What Matters. San Francisco, Calif: Berrett-Koehler; 2002. Byram DA. Leadership: a skill, not a role. AACN Clin Issues. 2000;11:463-469. Cashman K. Awakening the Leader Within. Hoboken, NJ: John Wiley & Sons; 2003. Center for Creative Leadership publications. Available at: http://www.ccl.org. Accessed December 12, 2004. Drucker PF, Senge PM. Leading in a Time of Change: What It Will Take to Lead Tomorrow. New York, NY: Peter F. Drucker Foundation for Nonprofit Management; 2001. Goleman D. Emotional Intelligence: Why It Can Matter More Than IQ. New York, NY: Bantam Books; 1994. Goleman D. Working With Emotional Intelligence. New York, NY: Bantam Books; 1998. Institute for Safe Medication Practices. Intimidation: Mapping a plan for cultural change in healthcare: part II. ISMP Medication Safety Alert! March 25, 2004. Joint Commission on Accreditation of Healthcare Organizations. Health care at the crossroads: strategies for addressing the evolving nursing crisis. Available at: http://www.jcaho.org/about+us/public+policy+initiatives/health+care+at+the+crossroads.pdf. Accessed October 4, 2004. Lowney C. Heroic Leadership. Chicago, Ill: Loyola Press; 2003. Manion J. From Management to Leadership: Interpersonal Skills for Success in Health Care. AHA Press. Smith AP. Partners at the bedside: the importance of nurse-physician relationships. Nurs Econ. 2004;22:161-164. Sullivan, E. Becoming Influential: A Guide for Nurses. Upper Saddle River, NJ: Pearson Prentice Hall; 2004. Tang JH. Evidence-based protocol: nurse retention. J Geront Nurs. March 2003;29:5-14.

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Call to Action

"Individuals and organizations learn and evolve through conscious, deliberate action. Deliberate action is ethical. When the time to act has come, it is unethical not to do something." ­David Thomas Ethicist, Ethics of Choice Training Program

Healthy work environments are essential to ensure patient safety, enhance staff recruitment and retention, and maintain an organization's financial viability. Inattention to relationship issues poses a serious obstacle to creating and sustaining those environments. Without them, the journey to excellence is impossible. The six standards put forth in this document offer the framework for healthcare organizations to elevate these competencies to the highest strategic and operational importance. The ensuing dialogue will guide the fundamental reprioritization and reallocation of resources necessary to create and sustain healthy work environments. For the American Association of Critical-Care Nurses, developing these standards is the first of two steps. The second step, already in progress, is to lead the way in developing practical and relevant resources to support individuals and organizations in standards implementation. AACN calls upon individual nurses, all health professionals, healthcare organizations and professional nursing associations to fulfill their obligation of creating healthy work environments where safety becomes the norm and excellence the goal. This call to action requires a fundamental shift in the work environments of this country and challenges: Nurses and all health professionals to: · Embrace the personal obligation to participate in creating healthy work environments. · Develop relationships in which individuals hold themselves and others accountable to professional behavioral standards. · Follow through until effective solutions have been realized. Healthcare organizations to: · Adopt and implement these standards as essential and nonnegotiable for all. · Establish the organizational systems and structures required for successful education, implementation and evaluation of the standards. · Demonstrate behaviors by example at every level of the organization. AACN and the community of nursing to: · Bring to national attention the urgency and importance of healthy work environments. · Promote these standards as essential to establishing and sustaining healthy work environments. · Develop resources to support individuals, organizations and health systems in successfully adopting the standards, and recognizing and publicizing their successes.

"There is no power greater than a community discovering what it cares about." ­Margaret Wheatley Organizational change and management author, International educator

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Visions of the Future

Health professionals in many organizations across the United States have begun their journey toward creating and sustaining healthy work environments. They have committed to addressing the tough issues that block the way. These powerful stories illuminate what is possible in work environments that call forth each individual's optimal contribution. Their inspiring successes paint a vivid picture of how this is necessary. Listen. Learn. Act. The future of American healthcare depends on it.

1 2 3

Skilled communication protects and advances collaborative relationships.

The doctor has superb knowledge about medicine and I have superb knowledge about nursing. Because of my constant assessment and observation, I know how the patient is responding to his illness and treatment better than the doctor does. Furthermore, we need each other's knowledge if we're going to help a patient. We respect each other and don't have to tiptoe around about what we think and observe. Once, we worked together all night on a 3-pound baby with generalized sepsis. We continually discussed what studies said should be done and not done. We tried one thing, then another, but unfortunately the baby died. Yet even in her grief, the mother told us how impressed she was at how we worked together. She said she could see her baby was receiving the best care possible.

True collaboration is an ongoing process built on mutual trust and respect.

Doctors and nurses in our unit have a mutual trust and respect that's outstanding. Doctors value nurses' opinions. If we say, "You need to come," they do and know we are not overreacting. And it's not just me and one or two docs; it's all of them. We make sure that we don't lose this trust, this respect. We are evaluated on how we work with the doctors. Do we work collaboratively? Do we put the patient first? And we make sure the new grads or even new hires talk to the doc "right." I teach new graduates that you don't call a doctor at three in the morning with a routine update that can wait. You carefully assess the patient and you bring all your knowledge and skill to bear. So when you do have to call, the doctor knows she's really needed and will hustle to get here.

Nurse leaders create a vision for a healthy work environment and model it in all their actions.

Why did I come to work here? Because of the nurse manager. When she interviewed me, she asked me what kind of support I would need from her. The openness of her question impressed me, so I told her. She said she could meet my expectations. Not try to or maybe, but that she could. Our manager is so respectful of the nurses, of our knowledge and of what we do. Day after day, her words and actions show that she believes each of us is very valuable. At unit meetings, our manager is the one who reminds us that what nurses know is different, but just as important, as what doctors know. She has earned my trust and respect, and I know I have earned hers. That's why I'm here and why I'll stay.

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4 5 6

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Meaningful recognition acknowledges the value of a person's contribution to the work of the organization.

"He's stable and doing all right," the outgoing nurse said during last night's shift report. To the receiving nurse, the patient was more restless than she thought he should be. His face was taut, yet his vital signs had not changed. The nurse consulted other more experienced nurses. They agreed with her observations, advising her to call the physician if she continued to feel uneasy or uncomfortable, or if the patient's vital signs changed. At 2:00 a.m. the nurse called the physician to describe what she saw and felt, including her inability to substantiate it with changes in vital signs. She emphasized the need for the physician to come in. He did and immediately started treatment for a collapsed lung. The nurse felt she had gone out on a limb in calling, but said she had faith in her own judgment. "Good call," the physician complimented her this morning, as did several nurses and our nurse manager. The nurse said this was something she would remember the rest of her life.

Remaining focused on matching nurses' competencies to patients' needs points the way to innovative staffing solutions.

Yesterday was one of the craziest days I can remember in this ICU. Patients waiting to be transferred in. Emergency open heart surgery in progress. A full Emergency Department. Like most days, our best-laid staffing plans looked hopeless. It was time to brainstorm at the assignment board. Our nurse manager and house supervisor joined us. Everyone's ideas were taken seriously and we came up with a new plan that really worked. An on-call nurse came in. Two orientees were reassigned so they could still learn, but help their preceptors more. One nurse took an extra patient until he was transferred. Each time a new patient arrived, we double-teamed until things settled down. Our manager stayed until we were sure the plan would work. At the end of the shift we were all tired, but proud that we developed a plan for our patients to get the best care. That's what teamwork means for me.

Advocating for patients requires involvement in decisions that affect patient care.

As a staff nurse, I never thought I would say this. I wouldn't miss our Product Evaluation Committee meeting. My manager asked me to be on the committee and I didn't even know what they did. Turns out they decide whether or not to buy certain products for the whole hospital--most of which affect nursing care. They listen to me when I talk about which products work for patients and which ones don't. Just the other day, the chairperson told me most committee members would never know a bedside nurse's perspective and thanked me again for the time I invest in the committee. I never knew my voice could make such a difference.

These illustrations are adapted from interviews with nurses in Magnet hospitals obtained by Marlene F. Kramer and Claudia Schmalenberg during the Dimensions of Magnetism study. See also chapter 2 of McClure M, Hinshaw AS. Magnet Hospitals Revisited: Attraction and Retention of Professional Nurses. Washington, DC: American Nurses Publishing; 2002.

Our Mission

Building on decades of clinical excellence, the American Association of Critical-Care Nurses provides and inspires leadership to establish work and care environments that are respectful, healing and humane. The key to AACN's success is through its members. Therefore, AACN is committed to providing the highest quality resources to maximize nurses' contribution to caring and improving the healthcare of critically ill patients and their families.

Our Vision

AACN is dedicated to creating a healthcare system driven by the needs of patients and families where critical care nurses make their optimal contribution.

Our Values

As AACN works to promote its mission and vision, it is guided by values which are rooted in, and arise from, the Association's history, traditions, and culture. Therefore, AACN, its members, volunteers and staff will: · Be accountable to uphold and consistently act in concert with ethical values and principles. · Advocate for organizational decisions that are driven by the needs of patients and families. · Act with integrity by communicating openly and honestly, keeping promises, honoring commitments and promoting loyalty in all relationships. · Collaborate with all essential stakeholders by creating synergistic relationships to promote common interests and shared values. · Provide leadership to transform thinking, structures and processes to address opportunities and challenges. · Demonstrate stewardship through fair and responsible management of resources. · Embrace life-long learning, inquiry, and critical thinking to enable each to make optimal contributions. · Commit to quality and excellence at all levels of the organization, meeting and exceeding standards and expectations. · Promote innovation through creativity and calculated risk taking. · Generate commitment and passion to the organization's causes and work.

Our Ethic of Care

AACN's mission, vision and values are rooted in an ethic of care that acknowledges the interrelatedness and interdependence of individuals, systems and society. An ethic of care respects individual uniqueness, personal relationships and the dynamic nature of life. Essential to an ethic of care are compassion, collaboration, accountability and trust. Within the context of interrelationships of individuals and circumstances, the traditional ethical principles of respect for persons, beneficence and justice provide a basis for deliberation and decision making.

AMERICAN ASSOCIATION of CRITICAL-CARE NURSES

Prod #130600

101 Columbia · Aliso Viejo, California 92656 · 800.899.AACN · www.aacn.org

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