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There is no more liberating, no more exhilarating experience than to determine one’s position, state it bravely and then act boldly. Action creates its own courage; and courage is as contagious as fear.Eleanor Roosevelt1(p6)
It is with great joy and pride that I raise my voice today to celebrate the courage we have mustered and all we have achieved together since last May. We—as individuals, as an association, and as a profession—have much to celebrate. The boldness of our voices has begun to create the change so desperately needed throughout healthcare—in our work environments and in the lives of our patients and their families.
These nurses are real people. Human. Everyday nurses like you and me. They’re not superwomen. They weren’t born without fear. Each one would tell you she wasn’t a pro at speaking up. Yet, they didn’t let fear get in the way of bravely advocating for what they saw as the right thing to do. Lisa, Cindy, and Susan are committed to using their voices and their knowledge to create positive change. Are you also committed to doing what it takes to make these kind of positive changes happen in your environment?
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Strength in Numbers |
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As members of the nursing profession, 2.6 million strong in the United States, our power is greater yet. During the past year, nurses have banded together to create solutions to help mitigate the devastating impact of the nursing shortage.
Where did we get the strength and energy to achieve all this? I believe it came from our common vision about the future of healthcare and our collective realization that this future will not be created without our voice.
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Face the Challenges |
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AACN is doing this by listening to our members. Studying the environment. Collaborating with others. Experimenting and implementing new designs for a future that brings us closer to our vision—one in which the healthcare system will be driven by the needs of patients and their families. And one in which that system will demand and welcome nurses who are making their greatest contribution.
I am tired of talking about the dire predictions for the future. I’m ready for solutions that will take us to a different future. A future in which:
This future will not simply happen. However, it is possible if those of us invested in the health of healthcare make it happen through thoughtful and deliberate actions. We can create this future if 3 commitments become part of our very being, a part of who we are:
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Follow Our Purpose |
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Our purpose is where the buck stops, and to me it is crystal clear: If our healthcare system doesn’t work, our patients are in danger. That is where we must draw the line. If patients aren’t safe or don’t feel safe when they are in our care, things must change. Whatever the cause—a shortage of expert nurses, lack of collaboration, ineffective communication, inefficient systems—it must cease. Anything that gets in the way of achieving the best possible outcomes for patients must be eliminated. Our purpose—creating exceptional outcomes for critically ill patients and their families—must lead us, because that is why nurses do what we do.
In A Quick Guide to the Ethics of Choice, David Thomas3 suggests that, though there is never absolute certainty about the consequences of our actions, when the time to act has come, doing nothing is unethical. Not only do we learn little from inaction, but also much harm can result from it. The ethical route is to choose consciously and carry out deliberate actions that represent who we are and the commitment to our purpose. If we do not act by speaking up, how can we expect others—legislators, employers, the public—to value who we are and what we do?
Nurses save lives. Nurses rescue patients. Nurses do for others what they can’t do for themselves. We interpret data, give treatments, direct care, and act on the results. Because of our knowledge and skills in medicine, science, and nursing practice, we prevent a host of complications and bad outcomes for patients. We take patients from crisis to resolution. We bring about life-altering outcomes that are possible only with expert care further validated when we become certified nurses.
We have no choice but to identify and be led by our purpose. It will be the siren calling us always to the higher standard of being and acting—guiding us in how to work, how to serve, how to contribute.
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Use a Bold Voice |
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What is a "bold" voice? A bold voice isn’t a blaming voice or a whining voice. It doesn’t argue about who is right or wrong or about whose fault it is that we are faced with challenges. A bold voice moves past complaints to look for solutions. And solutions will be found if we work with others and take the time, give the thought, and have the patience to create the changes needed.
It must be the bold voice of nurses, because only nurses can truly inform administrators, physicians, elected officials, and the public about what we do to deliver safe, expert nursing care. Our bold voices must talk about the impact that nurses have on patients’ well-being. Most importantly, we must speak up about what is needed to ensure that nurses will stay and work wherever critically ill patients and their families are.
To quote American writer Henry Miller,3(p19) "Everything we shut our eyes to, everything we run away from, everything we deny, denigrate, or despise, serves to defeat us in the end." Merely denying or even despising current conditions will not only defeat us, but also endanger patients’ lives. AACN will not shut its eyes or turn away. We will not be defeated.
You can count on AACN to be a bold voice for critical care nurses now and always.
Bold voices are also focused voices. And, with so many critical issues demanding our attention, where should AACN’s voice focus?
An Ethical Approach
David Thomas3 proposes that an ethical approach is to work first on the issue that is causing the most pain to the organization. In fact, he warns us that ignoring painful issues is unethical. Ignoring painful issues allows them to grow and threatens the ability of an organization such as a patient care unit to accomplish its purpose.
Just as we cannot ignore pain in our patients, we cannot turn away from the pain within our organizations. We must commit to start with the most painful issue, then move to the next and the next, all the while creating improvement in a sequence that allows us to move our organization in an enlivening direction.
Because AACN recognizes the pain we experience in our work environments, that is where we have begun and will continue to focus the bold and powerful voice of the world’s largest specialty nursing organization. Nothing will improve in nursing, in critical care, or in the healthcare system until toxic work environments are eliminated.
The factors involved have become so universal that, some days, we hardly notice them. Chronic staffing shortages. Mandatory overtime. Floating. Rushing. Fatigue. Heavy lifting. Verbal abuse. Always, communication mishaps. These have become so much a part of our everyday work life that we’ve often resigned ourselves to accepting them as "just the way things are." But, accept them? We must not.
Last year, in surveys of practicing nurses,4–7 4 of 10 reported being dissatisfied with their work. More than half said they would not recommend nursing as a career. One of 5 planned to leave their current job within 1 year. Yet, more than 70% said that they would stay if changes were made in the work environment.
Creating Healthy Environments
We have no more time to wait. We must create inspiring work environments, ones in which both patients and nurses are healed. These are environments that Karlene Kerfoot, chief nursing officer at Clarian Health Partners, calls healing sanctuaries (oral communication, March 2003).
What makes a work environment alive, exciting, and healing? The answer starts with effective leadership—our courageous nurse managers who must receive our support. Faced with the challenges of staffing, budgets, and pressure from patients, families, physicians, administrators and nurses, nurse managers are sometimes the most overlooked and unsung heroes in critical care.
We must align with and stand behind our managers as they create an environment that supports excellent patient care. There is no time for "us versus them" attitudes. Competent managers can lead teams to excellence, but they cannot do it alone or without our support. Aligning with managers does not mean we always will agree. It does mean that we communicate honestly and respectfully, collaborate fully, and work together enthusiastically to advance us toward excellence.
To support these key orchestrators of front-line care, AACN is joining forces with 2 other strong organizations, the American Organization of Nurse Executives and the Association of periOperative Registered Nurses to help fill the tremendous void in educational opportunities for nurses who want to become managers and those who already are. The Nurse Manager Leadership Collaborative will provide fundamental tools and support for our gutsy colleagues who lead the units where critically ill patients receive care. It will establish formal links between leadership development and a manager’s work outcomes. It will also offer comprehensive role development programs and lifelong learning opportunities, creating learning communities of nurse managers, mentors, and experts who champion nursing excellence.
What about the environment itself?
Disrespectful and noncollaborative behavior creates negative, demoralizing, and unsafe conditions that directly and adversely affect not only nurses’ satisfaction, but also patient safety. Serious errors happen when someone, while caring for patients, is intimidated and communication fails. In response, AACN has demanded a "zero tolerance" stance for abuse and disrespect in the workplace.
There is a growing body of research linking poor communication and lack of collaboration with adverse patient outcomes. In fact, a report by JCAHO8 on the nursing shortage warned that abusive incidents between physicians and nurses have grave consequences for patients. An astounding 9 of 10 nurses reported witnessing disruptive incidents at work.9 The JCAHO echoed the call for a zero-tolerance stance on abuse and disrespect in the workplace.
In 1996, Linda Aiken’s study of Magnet hospitals10 showed a relationship between decreased mortality and the elements of a healthy work environment: decentralized decision making, standardization of nursing procedures, increased staffing ratios, and good relationships between nurses and physicians.
Ten years earlier, Knaus and his team at George Washington University studied interactions and outcomes in ICUs and found that fewer patients died when nurse-physician communication was effective.11
We all know that lack of respect isn’t just a "doctor-nurse" problem. Sometimes, nurses are disrespectful to other nurses, especially to new nurses. Therapists to physicians. Unit clerks to visitors. Dietitians to nursing assistants. You know the issues.
Setting a New Standard
It is past time to act. Disrespectful conduct and its results are dangerous and must not be tolerated. Waiting or hoping for someone else to come along and fix this problem will lead to endless repetitions of the same outcome. For the sake of patients, for the sake of our colleagues, and for our own sake, we can no longer be silent and inactive on the subject of abusive, noncollaborative environments. No matter who is involved, we must make it our business to ensure that demeaning behavior is not tolerated anywhere in the care of critically ill patients. Let’s set a new standard where the contributions of all team members—including families—are respected and honored in the care of our patients.
Nurses can’t do all this alone. We need effective systems that support our success. Broken systems that don’t allow nurses the time needed to manage patient care at the bedside increase the burden and contribute to bad outcomes for patients. These are the systems that turn nurses into what our colleague Ann Hendrich calls "hunters and gatherers" (written communication, March 2003), chasing down equipment and supplies, taking on clerical responsibilities. These are the systems where for every hour a nurse spends in direct care, another is spent hunting and gathering—and documenting!
We must be willing to give up those tasks. Then, we must engage in collaborative dialogue with managers, bringing evidence that these tasks waste time and money and get in the way of our ability to deliver safe, high-quality care. We must then be willing to help design new systems that work.
You probably have stories similar to something that happened where I work. One day, I overheard one of my staff nurse colleagues ordering a bedside commode. A few minutes later, I saw her prepare to leave the unit. When I asked her where she was headed, she replied, "To pick up a bedside commode. I’m lucky there’s one in central [service], but they’re short staffed today, so they told me I’d have to come pick it up. I’ll be right back."
"Wait a minute," I said and picked up the phone to call the director of central service. "We have a problem. A 20-year veteran ICU nurse was just on her way to pick up a piece of equipment, because your folks said they were working short. The unit’s full. She has two patients and a third one on the way. What’s wrong with this picture?" Five minutes later, the commode arrived, delivered cheerfully.
Finding Solutions Together
The nurse knew that the quickest way to get the job done was to do it herself. However, as long as we continue to feed into systems that don’t work and don’t support the work we must do at the bedside, the systems won’t change. We become a part of and contribute to a system that doesn’t work!
Now, here’s the punch line. A few days later, some nurses met with our vice president of nursing in one of her regular focus groups. They talked about how expecting nurses to do nonnursing tasks isn’t good for patients. They talked about disruptions to work and threats to patient safety when a nurse has to leave the unit to hunt and gather. Within a month, the system was changed. Central service now has runners who expedite pickup and delivery of equipment and supplies. The broken system was fixed because nurses spoke up and leaders listened. Rather than pointing fingers and placing blame, together they found a solution that worked.
In addition to supporting nurse managers, creating healthy work environments, and fixing broken systems, we must adjust our patient care models to reflect the inevitable reality that we will never have enough nurses to continue practicing as we do now.
We all know the dire projection that the United States will be short more than 400 000 nurses by the year 2020.12 The average age of nurses, which is 46, is climbing steadily, with more nurses leaving the field and fewer coming in. "Get us more nurses" is no longer an effective solution. This means we must be willing to ask—and answer—the tough questions about safe and effective staffing in critical care units. We must be willing to look critically at the needs of our patients and match them to the abilities of the nurse.
The AACN Synergy Model for Patient Care13 and AACN’s Staffing Blueprint14 outline this approach perfectly. These tools reinforce the fact that the care of critically ill patients is too complex for staffing decisions to be based on an arbitrary ratio. We are obligated to analyze the needs of each patient and match them with the skills, abilities, and experience of the nurse.
As Aldous Huxley said, "Facts do not cease to exist because they are ignored."15 The facts are clear that when the right level of nursing care is not available, negative patient outcomes—complications and mortality—increase. We must all become familiar with these facts and make sure others are as well. A good place to start is the landmark work of Peter Buerhaus and Jack Needleman16,17 linking inadequate nurse staffing with adverse patient outcomes and the VHA study18 that links high nursing staff turnover with increased mortality, longer lengths of stay, and a significantly higher cost of care. A bold voice backed up with clear facts is a highly effective tool for change.
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Be Responsible for Our Future |
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It shouldn’t surprise us that a nurse, given the current circumstances, might feel the same way and ask, "How can I, as one individual, make any difference in this madness we call healthcare?" I ask, "How can you not make a difference?" No one is more qualified, more called, more prepared, and more driven to make the changes needed to create a better future for healthcare than a nurse.
AACN believes that solutions to the critical issues of inadequate staffing and the nursing shortage will not be successful or lasting unless the problem of unhealthy work environments is corrected. Negative, demoralizing, and unsafe conditions in workplaces are widespread. This must not continue. Patients’ lives are at risk. Nurses’ valuable contributions are at risk. The mission and purpose of our organizations and the entire nursing profession are at risk.
John Wayne said, "Tomorrow is the most important thing in life. It comes to us at midnight very clean. It’s perfect when it arrives, and it puts itself in our hands and hopes we’ve learned something from yesterday."19
Let’s prepare for our tomorrow and imagine it before us, clean and perfect. The time has come to act—deliberately and powerfully, to focus our voice on tackling the painful issues we face in our work environments, to work on these issues relentlessly until they are resolved. It is the only choice we can make.
Reaffirm a Shared Vision
Our time together at the NTI (National Teaching Institute) is a gift. Being together amplifies our voice, our strength, and our power and gives us time to reaffirm our shared vision of the future, to gather our courage and our strength. We can take a look at who we are and who we are willing to become in the matter of making a difference in nursing and healthcare.
I invite you to raise your own bar and consider taking a step to becoming the powerful force that can create a new future.
Are you willing to agree to communicate to others clearly what doesn’t work? To identify what makes our work environment unhealthy and prevents us from safely and effectively meeting the needs of patients and their families?
Are you willing to declare that abusive and disrespectful interactions will always be challenged? Will you be willing to speak up and mediate when they occur? Will you join me in courageously managing our patients’ care by talking clearly and respectfully with colleagues, physicians, and families—always?
Are you willing to say that no one’s work is complete until everyone’s work is complete? To lead your team in making your workplace a fulfilling and healthy place?
Perhaps you want to play it safe. Perhaps you are not ready to say, "The buck stops with me." Maybe you have already become resigned and a bit cynical. Or, maybe, you just aren’t ready to make a promise you don’t know if you will keep. Maybe your fear feels bigger than your vision.
The poet Audre Lorde wrote that "When I dare to be powerful, to use my strength in the service of my vision, then it becomes less and less important whether I am afraid."20 If you dare to be powerful, if you are ready to make a promise that will make a difference, I challenge you to join me in making your promise public.
I invite you to make a statement of your intention to create a new future with a healthy work environment that works for everyone. I invite you to join me in making 3 promises:
Imagine thousands of voices boldly declaring a new vision for healthcare and a new day for nurses. Imagine thousands of nurses ready to create this new reality in the midst of the madness of healthcare. Imagine tomorrow is in our hands. It’s up to you and me. It’s as simple as giving your word.
For reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-2226; ask for product #006103.
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