1. American Association of Critical-Care Nurses: Healthy Work Environments Gena Furgeson Kimberlee Gurizzian Amy Johns Brandi Miller Adetunji Ojo Joella Show

2. History of the American Association of Critical-Care Nurses (AACN) According to the AACN (2012): Intensive care units (ICUs) were first developed in the 1950s, and cardiac care units (CCUs) were introduced in the 1960s, causing the need for nurses trained in intensive care to increase significantly. The American Association of Cardiovascular Nurses was established in 1969 to help educate nurses working in CCUs and ICUs. In 1971, the organization changed its name to the American Association of Critical-Care Nurses. Today, AACN provides knowledge and resources, including publication of the Healthy Work Environments (HWE) standards, to more than 500,000 nurse members.

3. History of the Healthy Work Environments (HWE) Standards “Our lives begin to end the day we become silent about things that matter.” –Martin Luther King Jr. (AACN, 2005, p. 11) According to the AACN (2005): In 2001, the AACN committed to promoting the creation of healthy work environments for acute and critical care nurses. A healthy work environment supports and fosters excellence in patient care. Evidence shows that unhealthy work environments contribute to medical errors, conflict, and stress among health professionals. In 2005, six essential standards were published to help health care organizations establish and sustain healthy work environments: Skilled Communication True Collaboration Effective Decision Making Appropriate Staffing Meaningful Recognition Authentic Leadership

4. Skilled Communication “Nurses must be as proficient in communication skills as they are in clinical skills.” (AACN, 2005, p. 16) “The AACN standards affirm that skilled communicators should be solution and outcome focused, seek to advance collaboration, seek out and hear various perspectives, use mutual respect to build common understanding, build accountability for actions, and build structures for effective information sharing.” (Goran, 2012, p. 293)

5. Skilled Communication Critical Elements (Goran, 2012) Healthy work environments begin with skilled communication. “The overlap of care that occurs at the patient's bedside must support open, positive, and ethical communication in an emotionally and physically safe environment” (Goran, 2012, p. 295). True collaboration in a healthy work environment requires skilled communication. Skilled communication requires: Communication education Effective listening skills Acknowledgement of our own misconceptions Willingness to change our nursing practice “Attentiveness to verbal and nonverbal communication” (Goran, 2012, p. 293) Speaking directly without preconceived notions “The Five-Factor Model for Becoming a Skilled Communicator emphasizes 5 required elements (awareness of self-deception, becoming authentic, candid, mindful, and reflective) as necessary for becoming a skilled communicator” (Goran, 2012, p. 293). Communication errors are the direct cause of sentinel events, medication errors, delays in treatment, and wrong-site surgeries.

6. True Collaboration “Nurses must be relentless in pursuing and fostering true collaboration.” (AACN, 2005, p. 20) “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 (AACN, 2005, p. 20)

7. True Collaboration Critical Elements (AACN, 2005) Education programs that develop collaboration skills will be offered, supported and encouraged by the healthcare organization. A structured process for the evaluation of a team member’s collaborative efforts and consequences for their neglect will be developed. Decision-making authority of nurses will be an integral part of the structure of the healthcare organization. Conflict resolution, a collaborative skill, will be guaranteed to be offered to patients, families and healthcare team members. Access to forums for viewpoint exchange will be unrestricted. A culture of collaboration will have the full engagement and commitment of every team member. A culture of respect for the opinions, interests and contributions of each team member will be developed to facilitate the achievement of the common goals of the organization and the individuals in it. Actions of the individual team members will be self-governed by holding themselves to the highest standards of personal integrity. Effective and professional communication, a learned skill, is an essential component of true collaboration and will be a learning goal of every team member. The role and responsibility of the team member will dictate the facets and development of their professional competency. An equal partnership in the development, facilitation and modeling of true collaboration will be demonstrated by nurse managers and medical directors.

8. Effective Decision Making “Nurses must be valued and committed partners in making policy, directing and evaluating clinical care and leading organizational operations.” (AACN, 2005, p. 24) According to Gawlinski, “every nurse with an open mind and an open heart sees things that might be done better or thinks about changes that will improve patients’ care and outcomes” (2008, p. 325). Institutions that involve clinicians in decision making unleash the creativity of the staff, educate staff through involvement, create internal expertise, and improve patient experience. When nurses influence positive change in patient outcomes they feel a sense of achievement and satisfaction (Gawlinski, 2008).

9. Effective Decision Making Critical Elements (AACN, 2005) The health care organization develops and provides educational programs focused on collaborative decision making including mutual goal setting, negotiation, facilitation, conflict management, system thinking and performance improvement. The values of the healthcare institution are clearly articulated and the employees implement them during decision making. The organization assures that the patients and their families are involved in every decision affecting care. Each member of the healthcare team is accountable for acquiring necessary skills, mastering relevant content, accurately assessing situations, sharing factual information, communicating clearly and inquiring actively. All organizational departments and disciplines are involved in systems that facilitate data-driven decisions. The decision making process of the organization insures respect for individual rights while incorporating key perspectives and designating clear accountability. The process that the health care organization has established is fair, effective, and evaluates the results of its decisions.

10. Appropriate Staffing According to the AACN (2005): Inappropriate staffing is one of the most harmful threats to patient safety and to the well- being of nurses. Adequate staffing, with trained, qualified professionals results in better patient outcomes when compared to staffing with Licensed Professional Nurses or Certified Nursing Assistants. The likelihood of death or serious complication after surgery increases when there are fewer nurses assigned to provide care. Medication errors increase when nurses are overworked, overstressed, and in short supply. Inadequate staffing leads to nurse dissatisfaction and burnout, which increases nurse turnover and decreases profitability. To prevent problems associated with inappropriate staffing, it is important to (AACN, 2005): Match the needs of patients with the skills and competency of nurses. Be flexible with nurse-to-patient ratios as patient conditions change. Evaluate patient needs throughout the shift to provide appropriate staffing. Provide training and education to improve and increase the number of skilled professional nursing staff. Balance the nurse-to-patient ratio to reduce stress, burnout, and dissatisfaction (HCA, n.d.).

11. Appropriate Staffing Critical Elements (AACN, 2005) Staffing policies are ethical and support nurses’ obligation to provide the best care. Nurses are involved in all phases of the staffing process, from education and planning through evaluation, and assist in matching nurse skills with patient needs. Organizations have a process in place to evaluate the outcome of staffing decisions, including when staffing does not appropriately match patient needs. Organizations have a process in place to use staffing and outcome data to improve future staffing models. Organizations support nurses so that they can provide the best patient care. Organizations promote technology to improve nursing care and nurses participate in evaluating the effectiveness of those technologies.

12. Meaningful Recognition “Nurses must be recognized and must recognize others for the value each brings to the work of the organization.” (AACN, 2005, p. 32) According to Kramer, Schmalenberg, and Maguire (2010), a meaningful recognition structure is one of the nine most important environment- improving structures identified in a meta-analysis of the standards published by seven different agencies (American Nurses Credentialing Center, American Association of Colleges of Nursing, American Association of Critical-Care Nurses, American Organization of Nurse Executives, Nursing Organization Alliance, Joint Commission on Accreditation of Healthcare Organizations, Institute of Medicine).

13. Meaningful Recognition Critical Elements (AACN, 2005) A structured system ensuring a recognition program that values the contributions of all team members A systematic process to teach all team members about the organization’s recognition programs A comprehensive program that recognizes all team members “from the bedside to the board table” (AACN, 2005, p. 33) Processes to ensure that the form of recognition is meaningful to team members An understanding that all team members must be actively involved in the recognition program A regular and comprehensive evaluation of the program to ensure that it is promoting a sustainable culture of excellence

14. Authentic Leadership “ Nurse leaders must fully embrace the imperative of a healthy work environment, authentically live it and engage others in its achievement. ” (AACN, 2005, p. 37) “Authentic leadership… has been identified as ‘the glue that holds together a healthy work environment.’” (Shirey, 2006, p. 257)

15. Authentic Leadership Critical Elements (AACN, 2005) The education of nurse leaders in skilled communication, effective decision making, true collaboration, meaningful recognition, and appropriate staffing techniques will be provided, supported and encouraged by the healthcare organization. A mastery of point-of-care dynamics and processes will be required of nurse leaders, as these leadership skills and vision will help to achieve a healthy work environment for the team. Nurse leaders will model visible enthusiasm and support of the structures and processes determined to create a healthy work environment. Healthy work environment development efforts should be led by nurse leaders. The healthcare organization will facilitate the development of the healthy work environment by placing nurse leaders in integral positions for accessing crucial information and decision making and will grant them authority to do so. Resources of time, finances, and personnel will be provided by the healthcare organization as needed to develop and maintain the healthy work environment. Co-mentoring among nurse leaders will be a program that is fully supported and encouraged by the healthcare organization and nurse leaders will actively engage these programs. The critical healthy work environment elements of skilled communication, true collaboration, effective decision making, meaningful recognition and authentic leadership will be modeled by nurse leaders. Healthy work environment creation and maintenance criteria will be included in the evaluation of a nurse leader’s performance and will be required for nurse leader professional advancement.

16. Impact on Practice: Gena The six HWE standards established by the AACN guide my current practice as a nurse in the hospital setting in the following ways: An annual survey by Press-Ganey is performed by McLaren Northern Michigan to check our culture of safety for patients and employees based on the HWE standards. After the first survey, three years ago, our administration realized what they assumed to be true about the culture within our hospital was vastly different from what the employees felt. Based on that first survey, the following changes were initiated. A copy of the article Break the Bullying Cycle (Townsend, 2012) was given to all employees. Crucial Conversations (Patterson, Grenny, McMillan, & Switzler, 2011) was mandatory in 2011 for current employees, then heavily encouraged for new employees after employment for a couple years, but available to all employees. TeamSTEPPS (AHRQ, 2008) was implemented. It was started in 2011 for all employees (including administration) with an annual refresher course. In 2012 it became standard in all new colleague orientation, including volunteers and nursing students for clinical rotations.

17. Impact on Practice: Kimberlee In my current practice as a pre-operative and post-anesthesia care unit (PACU) nurse, the AACN HWE standards relate to my practice in many ways. The surgical care environment is fast-paced and interdisciplinary interaction occurs frequently utilizing skilled communication and collaboration. The RN, CRNA, anesthesiologist, and surgeon collaborate openly with mutual respect when caring for the individual patient. For example, in the PACU, if pain management or anxiety is of concern, I can contact the CRNA, anesthesiologist or surgeon and they will respond immediately and be receptive to my input. The interaction involves relaying assessment of the situation, sharing facts, and coming to a mutual decision, which is an example of effective decision making. According to the appropriate staffing standard, the level of staffing in the department matches “nurses’ competencies with patients’ assessed needs” (AACN, 2005, p. 29). Not all nurses in the Surgical Care Department are qualified to work in the PACU; only those that are qualified staff the PACU. All members of the Surgical Care Department recognize each other and acknowledge each team member’s contribution to patient care. The charge nurse in the department displays authentic leadership every day by displaying clear communication, open collaboration, effective decision making and genuine appreciation of staff.

18. Impact on Practice: Amy The six HWE standards established by the AACN guide my current practice as an orthopedic nurse in a hospital setting in the following ways: My work environment is largely shaped by these standards and most of my coworkers and managers actively try to create a positive and healthy place to work that provides excellent patient care. I feel challenged and yet supported. These standards go beyond the minimum standards of practice and provide me with encouragement and support to work in a higher plane. These standards show me how to be a leader that will not accept an emotionally unhealthy work environment and how to change and improve one that is unhealthy or has areas that need to be improved upon. These standards and the research behind them show that they are proven to improve patient outcomes and increase staff retention and satisfaction. It is of tremendous value to me that these standards speak to human emotional needs and are evidence-based techniques to improve patient care and employee satisfaction.

19. Impact on Practice: Brandi As a staff nurse at Metro Hospital on the Telemetry Unit, my practice is influenced in several ways by the HWE standards. Following are two examples. During my three-month orientation, my nurse manager would call me into her office to chat every couple weeks. Each time, I was petrified that I had done something wrong, and was going to be fired. However, each time, she just wanted to take a few minutes and let me know that my patients felt I was doing an excellent job. She wanted to know how I felt about my progress, and if I needed anything from her. I feel this demonstrated her commitment to Authentic Leadership. One of the clinical coordinators on day shift regularly sends out an e-mail where she recognizes staff. She picks a sampling of staff, and states three good things about each staff member. Throughout the year, she recognizes every staff member (on both day and night shifts). These e-mails are not only motivational, but they also help me to recognize the valuable contributions that others are making, and are an excellent example of Meaningful Recognition.

20. Impact on Practice: Adetunji When I started working at Great Lakes Specialty Hospital as a charge nurse, we had a very high nurse turnover rate due to understaffing and heavy workload. To reduce turnover, the hospital hired more nurses and increased the per diem pool to twice the size recommended by corporate policy. After I was promoted to Director of Quality Management, we reviewed patient acuity levels and revamped our staffing model to provide better and more appropriate staffing. Staff competencies are considered when assigning patients. The charge nurse reviews the assignments as patients are admitted and discharged. Education classes are scheduled year-round to promote skills improvement and competency.

21. Impact on Practice: Joella As a staff nurse on a medical-oncology-telemetry unit, the six HWE standards recognized by the AACN influence my nursing practice in the following ways: I avoid nursing errors by participating in skilled communication in my nursing practice. I strive for true collaboration in my nursing practice by participating in communication between the different multidisciplinary teams in the hospital setting. I participate in effective decision making in my nursing practice by working as a point nurse on my unit and by discussing my concerns and ideas with my nursing manager and supervisors. I encourage appropriate staffing by educating nurses to staff by acuity and not by nurse-patient ratios during my shift as point nurse. I participate in meaningful recognition by giving positive feedback to the managers regarding staff in the different multidisciplinary teams. I participate in authentic leadership in my nursing practice by being fun, honest, and friendly with my coworkers in all of the interdisciplinary teams in the hospital setting.

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