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

Acute and critical care nurses repeatedly voice grave concern and moral distress about the deterioration of healthcare work environments in the United States. The following cases in point represent countless similar incidents occurring in American hospitals each day, showing the devastating impact of unhealthy work environments on the effectiveness of the American healthcare system.

	Case 1

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At 3:30 AM in a busy intensive care unit (ICU), a nurse prepares to give insulin to a patient who has an elevated blood sugar level. The sliding scale doses of insulin on the medication sheet are unclear and the physician’s order sheet is difficult to read. From past experience, the nurse knows how late night calls to this physician often result in verbal outbursts and demeaning slurs, no matter how valid the inquiry. Needing to act but not wanting another harassing encounter with the physician, the nurse makes a judgment of the appropriate dose and administers the insulin. Two hours later, she finds the patient completely unresponsive. To treat the critically low blood sugar level, she administers concentrated injections of glucose and calls for additional emergency help. Despite all attempts to restore the patient’s brain to consciousness, he never awakens and his brain never functions normally again.

	Case 2

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Two nurses leave a busy trauma ICU to accompany patients for urgent diagnostic tests, leaving 2 nurses in the unit "keeping an eye" on 3 critically ill patients each. One of the unit patients was recently intubated and requires a blood specimen to measure arterial blood gases. On his way to obtain the specimen, the nurse detours to check a ventilator alarm in another room, stops to answer an unexpected phone call, and clarifies an order for the unit secretary. Finally reaching the patient’s room, the nurse sees that the patient is breathing rapidly and has become visibly anxious. The nurse hurriedly draws the specimen. As he gathers the used supplies from the bedside, the protective needle cover slips off causing the dirty needle to stick deeply into his thumb.

	Case 3

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An emergency department (ED) task force develops a patient report form that can be transmitted to inpatient units in order to facilitate patient transfers and ease ED overcrowding. The new form is first used for an unstable head-injured patient. Although it is faxed to the ICU before the patient is moved, no one sees the form. When the patient arrives, no one is available to admit the patient. Tensions run high and the patient’s family becomes very angry. The ICU staff pitch in to cover so this new and critical patient can be admitted. In retrospect it is discovered that the ED staff did not negotiate design and use of the new form with the affected inpatient units.

	Case 4

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While preparing the annual budget, a nurse manager is instructed to submit a plan that further decreases ICU costs by 10%. Already behind on several other projects, the new manager is overwhelmed. Well aware that care by registered nurses is indispensable and intent on being fiscally responsible, the manager develops and submits a plan to discontinue evening clerical support and decrease nursing assistant hours. The director accepts the plan without question and asks the manager to inform the ICU staff. The manager relates the plan during an all-staff meeting in which he encounters significant negative nonverbal communication and very little spoken feedback. During the next week, tensions run high, rumors abound, 2 nurses resign, and morale reaches an all-time low.

	About the Standards

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Each day, thousands of medical errors harm the patients and families served by the American health-care system. Work environments that tolerate ineffective interpersonal relationships and do not support education to acquire necessary skills perpetuate unacceptable conditions. So do health professionals who experience moral distress over this state of affairs, yet remain silent and overwhelmed with resignation. Consider these all-too-familiar situations:

• A nurse chooses not to 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 are 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 1 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 are placed in leadership positions without adequate preparation and support for their roles. The resulting environment creates dissatisfaction and high turnover for nurse leaders and staff as well.
  
• Contentious relationships between nurses and administrators heighten 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 health-care today, especially when those resources are aimed at supporting education and development of essential skills. This is because of the mistaken perception that effective relationships do not affect an organization’s financial health. Nothing could be further from the truth. Relationship issues are real obstacles to the development of work environments in which patients and their families can receive safe, even excellent, care. Inattention to work relationships creates obstacles that may become the root cause of medical errors, hospital-acquired infections and other complications, patient readmission, and nurse turnover.

Adequately addressing the reputedly "soft" issues that involve relationships is the key to halting the epidemic of treatment-related harm to patients and the continued erosion of the bottom line in healthcare organizations. Indeed, the Institute of Medicine has reported that safety and quality problems exist in large part because dedicated health professionals work within systems that neither prepare nor support them to achieve optimal patient care outcomes.⁴ Addressing these issues aligns with nurses’ ethical obligations, specifically the obligations to establish, maintain and improve healthcare environments and employment conditions conducive to providing quality care consistent with the values of the profession, and maintain compassionate and caring relationships with "a commitment to fair treatment of individuals and integrity-preserving compromise."⁵

For more than 2 decades, AACN has advocated for principles such as interdisciplinary collaboration and effective leadership that are essential to healthy work environments.⁶ The standards continue this legacy and respond to the Institute of Medicine’s call for professional groups to serve as advocates for change.⁷ A 9-person panel developed the standards, drawing from extensive published and unpublished reports from individual nurses and other experts in healthcare organizations across the United States. Representing a wide range of roles, acute and critical care settings, and geographic locations in which nursing care is provided, 50 expert reviewers validated the standards, critical elements, and explanatory text.

	Essential Standards

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The American Association of Critical-Care Nurses recognizes the inextricable links among quality of the work environment, excellent nursing practice, and patient care outcomes. The AACN Synergy Model for Patient Care further affirms how excellent nursing practice is that which meets the needs of patients and their families.⁸ AACN is strategically committed to bringing its influence and resources to bear on creating work and care environments that are safe, healing, humane, and respectful of the rights, responsibilities, needs and contributions of all people—including patients, their families, and nurses.

Six standards for establishing and sustaining healthy work environments have been identified. The standards represent evidence-based and relationship-centered principles of professional performance. Each standard is considered essential because studies show that effective and sustainable outcomes do not emerge when any standard is considered optional. The standards align directly with the core competencies for health professionals recommended by the Institute of Medicine. They support the education of all health professionals "to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics."⁹ With these standards, AACN contributes to the implementation of elements in a healthy work environment articulated in 2004 by the 70-member Nursing Organizations Alliance. The standards further support the education of nurse leaders to acquire the core competencies of self-knowledge, strategic vision, risk-taking and creativity, interpersonal and communication effectiveness, and inspiration identified by the Robert Wood Johnson Executive Nurse Fellows Program.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. 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

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The standards provide a functional yardstick for performance and development of individuals, units, organizations, and systems. They reaffirm that safe and respectful environments are imperative and require systems, structures, and cultures that support communication, collaboration, decision making, staffing, recognition, and leadership.

These standards support the 9 provisions of the American Nurses Association Code of Ethics for Nurses and provide a framework to assist nurses in upholding their obligation to practice in ways consistent with appropriate ethical behavior.⁵ Properly implemented, the standards will ensure that acute and critical care nurses have the skills, resources, accountability, and authority to make decisions that ensure excellent professional nursing practice and optimal care for patients and their families. Implementation of the standards demonstrates an organization’s ethical responsibility. The standards can lead to excellence only when they have been adopted at every level of the organization—from the bedside to the boardroom. Adoption requires creating the systems, structures, and cultures that provide the ongoing collaborative education necessary to enhance and support the effort. This requires recognition by the organization that people often create and support unhealthy work environments because they lack the knowledge, skills, and experience to do otherwise.

Success will be further ensured when individuals are afforded the programs to acquire needed skills and willingly embrace implementation of the standards as a personal obligation, holding themselves and others accountable. This requires a committed partnership between nurses and their work environment. For example, safe staffing cannot be accomplished when a fatigued nurse works excessive overtime hours and perhaps attempts to maintain a second job. Careful scrutiny of these 6 standards (Figure) 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.

View larger version (49K): [in this window] [in a new window]   Interdependence of healthy work environment, clinical excellence, and optimal patient outcomes.

	Skilled Communication

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A culture of safety and excellence requires that individual nurses and healthcare organizations make it a priority to develop among professionals communication skills—including written, spoken, and nonverbal—that are on a par with expert clinical skills.^1,2 This culture expects civility and respects nurses who speak from their knowledge and authority.³ Patients in the care of clinically expert professionals suffer medical errors with alarming frequency.⁴ Nearly 3 in 4 errors are caused by human factors associated with interpersonal interactions.⁵ In addition, according to data from the Joint Commission on Accreditation of Healthcare Organizations, breakdown in team communication is a top contributor to sentinel events.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 more than 90% have witnessed disruptive behavior.¹ Nurses can encounter conflict in every dimension of their work. Be it conflict with others, or between their own personal and professional values, skilled communication supports the ethical obligation to seek resolution that preserves a nurse’s professional integrity while ensuring a patient’s safety and best interests.⁷ Ensuring that nurses are provided the education, competency mastery, and rewards to effectively negotiate these conflict-laden conditions would itself dramatically alter the environment.

  Critical Elements of Skilled Communication  

• 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 health-care 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.
  

	True Collaboration

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Nurses must be relentless in pursuing and fostering true collaboration.
True collaboration is a process, not an event. It must be ongoing and build over time, eventually resulting in a work culture in which joint communication and decision making between nurses and other disciplines and among nurses themselves becomes the norm. Unlike the lip service that collaboration is often given, in true collaboration the unique knowledge and abilities of each professional are respected to achieve safe, quality care for patients. Skilled communication, trust, knowledge, shared responsibility, mutual respect, optimism, and coordination are integral to successful collaboration.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 1 of the 3 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

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 of True Collaboration  

• 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.
  

	Effective Decision Making

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Nurses must be valued and committed partners in making policy, directing and evaluating clinical care, and leading organizational operations.
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 autonomy-accountability 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 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 of Effective Decision Making  

• The healthcare organization provides team members with support for and access to ongoing education and development programs focusing on strategies that ensure 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.
  

	Appropriate Staffing

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Staffing must ensure the effective match between patient needs and nurse competencies.
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 tactics—including technologies to reduce the demand and increase the efficiency of nurses’ work—can be undertaken.

  Critical Elements of Appropriate Staffing  

• 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 planning—including matching nurses’ competencies with patients’ assessed needs—through 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.
  

	Meaningful Recognition

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Nurses must be recognized and must recognize others for the value each brings to the work of the organization.
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 dis-satisfied 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 4 members and constituents of the American Association of Critical-Care Nurses 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.

  Critical Elements of Meaningful Recognition  

• 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.
  

	Authentic Leadership

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Nurse leaders must fully embrace the imperative of a healthy work environment, authentically live it, and engage others in its achievement.
Less than half of members of the American Association of Critical-Care Nurses 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 leaders—including managers, administrators, advanced practice nurses, educators, and other formal and informal clinical leaders—seldom 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

  Critical Elements of Authentic Leadership  

• 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.
  

	Call to Action

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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 6 standards offer the framework for health-care 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 2 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 in which 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.
  

	Visions of the Future

Top Case 1 Case 2 Case 3 Case 4 About the Standards Essential Standards Adoption and Implementation Skilled Communication True Collaboration Effective Decision Making Appropriate Staffing Meaningful Recognition Authentic Leadership Call to Action Visions of the Future REFERENCES About the Standards Skilled Communication  True Collaboration   Effective Decision... Appropriate... Meaningful... Authentic... Visions of the...

 
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 stories¹ 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.

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 1 or 2 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 3 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.

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 AM 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.

	ACKNOWLEDGMENTS

 
The American Association of Critical-Care Nurses recognizes the experts who contributed knowledge, counsel, and time. Executive Editor: Connie Barden, RN, MSN, CCRN, CCNS. Contributors: Kay Clevenger, RN, MSN; Roberta Fruth, RN, PhD, CCRN; Debra S. Gerardi, RN, JD, MPH; Wanda Johanson, RN, MN; Ramón Lavandero, RN, MA, MSN; Lisa J. Pettrey, RN, MS; Rosanne Raso, RN, MS, CNAA; Dana Woods, MBA. Reviewers: Bonnie Baloga-Altieri, MSN, RN, CNAA, BC; Linda Bell, MSN, RN; Nancy T. Blake, RN, MN, CCRN, CNAA; Debbie Brinker, RN, CNS, MN, MS, CCRN; Denise Buonocore, MSN, CCRN, APRN-BC; Suzanne M. Burns, RN, MSN, RRT, CCRN, ACNP; Marilyn Chow, RN, DNSc; Marianne Chulay, RN, DNSc; Sean Clarke, PhD, RN, CRNP; Joyce C. Clifford, PhD, RN; RADM Mary Pat Couig, MPH, RN; Joanne M. Disch, RN, PhD; John F. Dixon, RN, MSN; Jeff Doucette, RN, MS, CEN, CHE, CNAA, BC; Kathleen Dracup, RN, NP, DNSc; S. Ann Evans, RN, MS, MBA; Dorrie K. Fontaine, RN, DNSc; Ellen French; Caryl Goodyear-Bruch, RN, MSN, CCRN; Suzanne Gordon; Cathie Guzzetta, RN, PhD, HNC; Janie Heath, RN, MS, CCRN, ANP, ACNP; Lori Hendrickx, RN, EdD, CCRN; Mary E. Holtschneider, RN, BSN, MPA, EMT; Roberta Kaplow, RN, PhD, CCNS, CCRN; Marlene F. Kramer, RN, PhD; Phyllis Beck Kritek, RN, PhD; Deborah B. Laughon, RN, BSN, DBA, CCRN; Judith "Ski" Lower, RN, MSN, CCRN, CNRN; Kathleen M. McCauley, RN, PhD; Mary McKinley, RN, MSN, CCRN; Justine Medina, RN, MS;Nancy C. Molter, RN, MN, PhD; Jodi E. Mullen, RNC, MS, CCRN, CCNS; Christine M. Pacini, PhD, RN; Jessica Palmer, RN, MSN; Marilyn Petterson; SueEllen Pinkerton, RN, PhD; Carol A. Puz, RN, BSN, MS, CCRN; Cynda H. Rushton, RN, DNSc; Claudia Schmalenberg, RN, MS; Thomas Smith, MS, RN, CNAA; Sr Maurita Soukup, RSM, RN, DNSc; Denise Thornby, RN, MS; Nora Triola, PhD, RN, CNAA; Pamela Klauer Triolo, PhD, RN; Joan Vitello-Cicciu, PhD, RN, CNAA; Barbara C. Wallace, EdD, MPH, RNC; Suzanne White, MN, RN, CNAA.

	REFERENCES About the Standards

Top Case 1 Case 2 Case 3 Case 4 About the Standards Essential Standards Adoption and Implementation Skilled Communication True Collaboration Effective Decision Making Appropriate Staffing Meaningful Recognition Authentic Leadership Call to Action Visions of the Future REFERENCES About the Standards Skilled Communication  True Collaboration   Effective Decision... Appropriate... Meaningful... Authentic... Visions of the...

 

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	Skilled Communication

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	True Collaboration

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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.
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	Effective Decision Making

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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.
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	Appropriate Staffing

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8. American Association of Critical-Care Nurses. Position statement: main taining 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.

	Meaningful Recognition

Top Case 1 Case 2 Case 3 Case 4 About the Standards Essential Standards Adoption and Implementation Skilled Communication True Collaboration Effective Decision Making Appropriate Staffing Meaningful Recognition Authentic Leadership Call to Action Visions of the Future REFERENCES About the Standards Skilled Communication  True Collaboration   Effective Decision... Appropriate... Meaningful... Authentic... Visions of the...

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.
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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.

	Authentic Leadership

Top Case 1 Case 2 Case 3 Case 4 About the Standards Essential Standards Adoption and Implementation Skilled Communication True Collaboration Effective Decision Making Appropriate Staffing Meaningful Recognition Authentic Leadership Call to Action Visions of the Future REFERENCES About the Standards Skilled Communication  True Collaboration   Effective Decision... Appropriate... Meaningful... Authentic... Visions of the...

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.

	Visions of the Future

Top Case 1 Case 2 Case 3 Case 4 About the Standards Essential Standards Adoption and Implementation Skilled Communication True Collaboration Effective Decision Making Appropriate Staffing Meaningful Recognition Authentic Leadership Call to Action Visions of the Future REFERENCES About the Standards Skilled Communication  True Collaboration   Effective Decision... Appropriate... Meaningful... Authentic... Visions of the...

1. 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.

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