The American Association of Critical Care Nurses Provides a Magna Carta for the Nursing Profession: the AACN Standards for Establishing and Sustaining Healthy Work Environments

Critical care nurses work in intensive care units and for decades these were thought to be among the most stressful of environments within a hospital and in the nursing profession in general.  Yet, in a study by Schmalenberg & Kramer (2007) nurses within these units report satisfaction with their jobs at a rate significantly higher than nursing  as a profession overall,   with the subspecialties of neonatal and pediatric intensive care attaining even higher scores of satisfaction.

What is behind this story?

It could be the educational levels of  critical care nurses, but education alone does not explain the difference.  Intensive care nurses are among the most educated in that 50% of them have BSNs, and almost 20% have master’s degrees. But this level is exceeded within other specialties, including nursing administration, and advanced practice nurses in a variety of specialties other than critical care.

 Intensive care nurses are also among the highest paid among nursing staff, but salary alone does not provide enough of answer.  Nursing administrators are routinely paid better, and once again, many advanced nurse practitioners in group medical practices do even better.  

What probably provides the best explanation is the aggressive promotion of the AACN Standards for Establishing and Sustaining Healthy Work Environments. The AACN is the American Association of Critical Care Nurses, and in 2001  it began setting standards for establishing and sustaining healthy work environments (see 2010 download cited below).

What are the main points of this program? Readers can attain their own understanding by consulting the original document available at:    http://www.aacn.org/wd/hwe/content/hwehome.pcms?menu=community

What follows is my  own, personal understanding of what the key points are, played out in terms of situations and policy considerations  that are likely to be encountered in real-life critical care nursing.  Since I am not a qualified Critical Care Nurse, my insights are those of an interested person who is a professional in another area (BioMedical, Life Sciences, Food, Agricultural & Nutrition  Librarianship.)  My  paraphrases and simulations do not represent the exact wording of the AACN's documents, and may not be taken as necessarily representing their  official policy in all details and nuances, but I do hope that they help the reader gain some understanding of what the AACN is trying to do for its specialty and in a larger sense, for Nursing as a profession overall.   

Skilled communication

·     Staff nurses must be allowed to say what they actually believe is in the best interests of patient care or unit policies and procedures, and nurse managers should not merely be the administration’s parrot.   A nurse or nurse manager who will not speak up or listen,  is a danger to the patients, fellow nurses, and to the hospital.

 

·     Nurses should maintain credibility in the sense of  being not only truthful about what they know or don’t know, but must be able to back up what they say about their competency to  perform a procedure, for example by actually being able to perform the procedure.

 

·     The degree to which staff nurses participate in ongoing discussions and in meetings is a metric that ought to be incorporated into their annual evaluations, with the policy that staff nurses who contribute a lot of  insight and ideas ought to be rewarded for doing so.

 

·     Management  must have a regularly updated, readily accessible means by which it conveys hospital news, guidelines, and changes in policy.  Sporadically posted notices and hastily called meetings do not constitute a  communications policy; they are evidence of a lack of one.

 

·     Management must supply  up-to-date communication technology and support ongoing training for nurses  in its use.

 

 

·     Management must include nurses in assessing the success or failure of communications in terms of how they affect patient care, cost-savings, and morale.

 

·     Neither staff nurses nor nurse managers should be used as agent provocateurs  in an attempt to sniff out dissent, through ostensibly encouraging a free expression of opinion in bad faith, and then informing on those who disagree. 

 

·     Management must not tolerate public berating of nurses, nor sexual harassment. This includes actually enforcing  serious penalties for nurse managers,  hospital administrators, chiefs of service, and others who have historically wielded extraordinary power over nurses without having had to face consequences for being abusive  because they were regarded as less expendable than justly aggrieved nurses.

 

True Collaboration

·     Staff nurses must maintain their skills and pursue opportunities for continuing education or certification, so that the collective competence of the staff is raised, and the overall quality of patient care is maximized. Hospital administrations should not only underwrite individual skills enhancement but collaborative training of the unit as a team.

 

·     Staff nurses should share in the workload of the floor or unit, and when collaboration is required for the care of a particular patients, or for a particular project,  then it should be given fully and fairly. (Note: This does not mean that that nurses  chronically underwrite understaffing through silent forbearance  of being overstretched.)

 

·     Nurses within their units should seek to work out their grievances against each other and make reasonable accommodations with one another  in the interest of presenting the nursing profession’s input vis-à-vis other health care professionals on the floor. This does not require that the nursing staff have only one opinion, all the time, but that the nursing unit staff be able to come up with a nursing consensus on practices and procedures  on many issues, because nurses who work collaboratively work towards consensus whenever possible.

 

·     Nurse managers and chiefs of nursing services have a duty to advocate for the nursing staff with the medical staff and other staffs within the healthcare team as being professionals with their own body of specialized evidence-based knowledge to offer when designing new hospital procedures or allocating workloads.

·     Nurses should be represented on all personnel and  disciplinary boards within the hospital, including those that deal with complaint resolution with patients or their families.

Effective Decision Making

·     Nurses should expect each other actually to pay attention to the patient’s needs and maintain working nursing diagnoses and have proposals for care plan of treatment ready at situations such as change of shift, grand rounds, or patient and family conferences. Not being prepared at the time a decision is being made  effectively abrogates the right of nurses to have a say.

 

·     Staff nurses and nurse managers should not be automatically subordinated to other members of the healthcare team (particularly to all levels of physicians, including house officers), rather, that their input be regarded as important and be demonstrably taken into account on a regular basis.

 

·     Nurses should know and maintain a sense of the overall mission of the hospital and the unit, and ask of themselves and other members of the healthcare team: “Is this proposed policy or  decision consonant with what the hospital says it is all about.”

Appropriate Staffing

·     Patients have the right to the adequate staffing of nurses in the interests of safety.

 

·     Nurses have the right to an adequate number of fully qualified colleagues on duty so that they can pay the kind of attention to the needs of the patient that a true professional ought to render.

 

·     Whether  unionized or not, staff nurses should have a right to participate de jure via a representative or representatives of their own choosing in discussion of nursing cutbacks. While salaried nursing executives whose loyalties are to their boards of directors may be required publically  to follow the party line on staffing cutbacks, no staff nurse can be discharged for complaining about inadequate staff, unless that person is shown to be falsifying patient counts or some other independently verifiable factor. Statements of truth that are embarrassments to the administration should cause the administration to remediate the embarrassing situation, not discharge the teller of the embarrassing truth.

Meaningful Recognition

·     Nurses should be included in the formulation of hospital best practices, and in studies of evidence-based medicine to the point where they are recognized as  co-authors in any publications that result. Nurses should be given leave time to write grant proposals, participate in these studies, and write up their results.

 

·     Nurses who perform exemplarily or devise new procedures  or who have served for given landmark numbers of years (5,10,15, etc.) should be publically recognized with material rewards  and suitably designed permanent certificates and/or plaques  on a regular basis. These recognition ceremonies should be widely publicized formal occasions when other members of the health care team, including physicians, administrators, trustees, benefactors, and volunteers, are recognized.  

 

·     When nurses are promoted within the organization, attain a higher degree, an advanced certification, are elected to a nursing society or board, or have a new publication, the public affairs office of the hospital showed promote this news to the same degree they would of other valued members of the health care team.

Authentic Leadership

·     Units managers must demonstrate themselves worthy of leadership over their professional colleagues not through having an MBA or similar management training as their most important credential, but  first through being the most expert in actually caring for their patients. Those who cannot do the job at least as well as their best subordinates are in no position to judge the bedside care provided by them.

 

·     Servant leadership, where the nursing executive seeks to provide the material resources and moral support of her colleagues, first and foremost, is likely to be the most effective leadership, because it shows one’s fellow nurses that being on the side of the nurses is being on the side of excellence in patient care, and the advancement of clinical knowledge.

  

Tony Stankus FSLA tstankus@uark.edu Professor, Life Sciences Librarian, & Science Coordinator

University of Arkansas Libraries MULN 233 East

365 North McIlroy Avenue

Fayetteville AR 72701-4002

Voice 479-575-4031

Fax: 479-575-4592

 

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