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

Abstract

The American Association of Critical-Care Nurses recognizes the inextricable links among quality of the work environment, excellent nursing practice, and patient care outcomes. In this article, the 6 standards for establishing and sustaining healthy work environments are discussed. With these standards, AACN contributes to the implementation of elements in a healthy work environment articulated in 2004 by the 70-member Nursing Organizations Alliance.Acute and critical care nurses repeatedly voice grave concern and moral distress about the deterioration of healthcare work environments in the United States. The following cases in point represent countless similar incidents occurring in American hospitals each day, showing the devastating impact of unhealthy work environments on the effectiveness of the American healthcare system.At 3:30 am in a busy intensive care unit (ICU), a nurse prepares to give insulin to a patient who has an elevated blood sugar level. The sliding scale doses of insulin on the medication sheet are unclear and the physician’s order sheet is difficult to read. From past experience, the nurse knows how late night calls to this physician often result in verbal outbursts and demeaning slurs, no matter how valid the inquiry. Needing to act but not wanting another harassing encounter with the physician, the nurse makes a judgment of the appropriate dose and administers the insulin. Two hours later, she finds the patient completely unresponsive. To treat the critically low blood sugar level, she administers concentrated injections of glucose and calls for additional emergency help. Despite all attempts to restore the patient’s brain to consciousness, he never awakens and his brain never functions normally again.Two nurses leave a busy trauma ICU to accompany patients for urgent diagnostic tests, leaving 2 nurses in the unit “keeping an eye” on 3 critically ill patients each. One of the unit patients was recently intubated and requires a blood specimen to measure arterial blood gases. On his way to obtain the specimen, the nurse detours to check a ventilator alarm in another room, stops to answer an unexpected phone call, and clarifies an order for the unit secretary. Finally reaching the patient’s room, the nurse sees that the patient is breathing rapidly and has become visibly anxious. The nurse hurriedly draws the specimen. As he gathers the used supplies from the bedside, the protective needle cover slips off causing the dirty needle to stick deeply into his thumb.An emergency department (ED) task force develops a patient report form that can be transmitted to inpatient units in order to facilitate patient transfers and ease ED overcrowding. The new form is first used for an unstable head-injured patient. Although it is faxed to the ICU before the patient is moved, no one sees the form. When the patient arrives, no one is available to admit the patient. Tensions run high and the patient’s family becomes very angry. The ICU staff pitch in to cover so this new and critical patient can be admitted. In retrospect it is discovered that the ED staff did not negotiate design and use of the new form with the affected inpatient units.While preparing the annual budget, a nurse manager is instructed to submit a plan that further decreases ICU costs by 10%. Already behind on several other projects, the new manager is overwhelmed. Well aware that care by registered nurses is indispensable and intent on being fiscally responsible, the manager develops and submits a plan to discontinue evening clerical support and decrease nursing assistant hours. The director accepts the plan without question and asks the manager to inform the ICU staff. The manager relates the plan during an all-staff meeting in which he encounters significant negative nonverbal communication and very little spoken feedback. During the next week, tensions run high, rumors abound, 2 nurses resign, and morale reaches an all-time low.Each day, thousands of medical errors harm the patients and families served by the American health-care system. Work environments that tolerate ineffective interpersonal relationships and do not support education to acquire necessary skills perpetuate unacceptable conditions. So do health professionals who experience moral distress over this state of affairs, yet remain silent and overwhelmed with resignation. Consider these all-too-familiar situations:Each situation characterizes poor and ineffective relationships. Attention to work relationships is often dismissed as unworthy of resource allocation in health-care today, especially when those resources are aimed at supporting education and development of essential skills. This is because of the mistaken perception that effective relationships do not affect an organization’s financial health. Nothing could be further from the truth. Relationship issues are real obstacles to the development of work environments in which patients and their families can receive s