AACN Issues a Call to Action
for Healthy Work Environment

By Lorraine Steefel, RN, MSN, TN
January 28, 2005

Sicker patients. Hospitals turning into “huge ICUs.” To contend with today’s health care challenges, nurses must have exquisite clinical skills and excellent communication skills, says Kathleen McCauley, RN, PhD, CS, FAAN, FAHA, president of the American Association of Critical-Care Nurses (AACN).

At a national briefing and webcast in Washington, D.C., on Jan. 26, AACN and VitalSmarts, a leading consulting firm, addressed the impact of communication on medical errors, patient safety, and the work environment. The goal: to transform health care’s prevalent culture of poor communication that fosters medical error and dissatisfaction.

“We aim to provide a culture of communication and respect,” says McCauley, who is also an associate professor of cardiovascular nursing at the University of Pennsylvania School of Nursing in Philadelphia.

Relying on data from a VitalSmarts national survey of more than 1,700 nurses, physicians, and other health care hospital workers, VitalSmarts President Joseph Grenny proposed that colleagues shrink the communication gap by addressing each other about seven problem categories they frequently encounter: broken rules, mistakes, lack of support, incompetence, poor teamwork, disrespect, and micromanagement.

“We’re not saying health workers exhibit rampant incompetence,” says Grenny. More than half surveyed said they occasionally witnessed problems — colleagues’ taking shortcuts that could be dangerous to patients or routinely making poor clinical judgments. These problems existed for long periods of time without the colleagues being held accountable.

Fewer than 10% confronted their colleagues about their concerns. They lacked either the confidence or ability to confront them, feared retaliation, or didn’t think it was their responsibility. Some shared the concerns with their managers, but few managers approached the coworkers.

VitalSmarts’ report, “Silence Kills: The Seven Crucial Conversations for Healthcare,” suggests that failing to talk about these problem areas is a major contributor to unacceptable error rates and unhealthy work environments. On the positive side, health care providers who spoke up to resolve problems around them observed better patient outcomes and were more satisfied and committed to staying on the job.

The study recommends that hospitals learn from the minority who hold the
crucial conversations with colleagues. It provides practical steps to overcome communications obstacles, among them:

1. Use a survey to establish a baseline measure of the seven crucial conversations and set a clear target for improvement.
2. Conduct focus group interviews with teams that include top administrators, key physicians, and managers to learn what prevents crucial conversations.
3. Use results of the baseline survey to show where conversations aren’t
   happening or aren’t effective.
4. Form teams within these problem areas to identify obstacles and develop solutions that can be tested.

Panelist Karlene Kerfoot, RN, PhD, CNAA, FAAN, senior vice president for patient care services and chief nursing officer at Clarian Health Partners, Indianapolis, said that Clarian’s focus on creating a culture of collaboration and safety has led to improved safety overall and greater recruitment and retention there. “We’re on a journey to make a difference for our staff and patients,” she said. “We’re an incubator for the healthy work environment.”

In 1991, AACN adopted the healthy work environment as its No.1 advocacy priority. AACN remains acutely aware of the issues and consequences of unhealthy work environments through research and almost daily contact with its more than 100,000 constituents, says AACN Past President Connie Barden, RN, MSN, CCNS, CCRN. “Nothing will change in health care unless work environment issues are addressed,” she says.

AACN’s new Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence proposes six essential and interdependent standards: skilled communication, authentic leadership, meaningful recognition, appropriate staffing, true collaboration, and effective decision making. Each is supported by critical elements necessary for the standard to be achieved. “The standards are a blueprint for how to create a healthy work environment,” says Barden, executive editor for the document.

The panel was convened, says Barden, to underscore the serious issues of an unhealthy work environment and its impact on patients, families, and health care professionals. It’s a call to action, she says, “to adopt and implement the standards and accept accountability for your part in creating a healthy work environment where collaboration and communication become the norm.”

Lorraine Steefel, RN, MSN, CTN, is a senior staff writer for Nursing Spectrum.