Everyday Acts Can Effect Change
By Connie Barden, RN, MSN, CCNS, CCRN
President, American Association of Critical-Care Nurses
Recently nurses have told me that they
sometimes feel as if they're not doing enough in using their voice. Some seem
almost paralyzed, because they think that a "bold voice" has to be a "big voice"
to make a difference. "I feel bad that I haven't written letters to the editor
or talked with my legislator," one nurse told me. Although these avenues can be
used to influence change, we must not overlook the greater power of the messages
we speak every day, wherever we practice critical care nursing.
As I see it, the most effective, powerful
and pervasive voice is the one used relentlessly, day in and day out by nurses
committed to doing the right thing. They speak up for patients, families and
colleagues. They seek to heal our ailing healthcare system. Their voices aren't
usually flamboyant or boisterous. In fact, using a bold voice isn't an event at
all. It is instead a day-to-day way to influence enduring change.
A bold voice is a committed voice. A
committed voice speaks up now and always about nursing and healthcare issues. A
committed voice doesn't let us accept things as "just the way they are." A
committed voice calls us to find solutions to the challenges faced by everyone
in healthcare-and that includes patients and their families. These solutions
will not be found in grand and glorious events showcased by TV cameras and
headlines. They will be found in everyday interactions-at the bedside, in the
nurses' station, during staff and faculty meetings, and among peers-where the
standard of excellence we demand for our patients and ourselves is reflected.
You can make a difference with your bold
voice. Consider some of these powerful examples of how our fellow AACN members
used their everyday voice during the past year.
� During routine rounds, a part-time staff
nurse took the initiative to talk with her chief nursing officer about the
decreasing morale and dissatisfaction among the medical ICU staff. The CNO
listened. Focus groups were started. Changes were made. Nurse retention has
� During a staff meeting, a critical care
nurse boldly challenged colleagues to increase their level of knowledge and
prepare to take the CCRN certification exam. Six nurses accepted the challenge
and registered for the exam. Three more are lined up.
� In the family lounge, a nurse six months
out of school talked with the husband of a comatose patient about end-of-life
care decisions that were in conflict with the rest of the family's views. She
then worked with her preceptor to make certain the husband's wishes were carried
� Concerned about stress caused by the
continuous need for experienced nurses to be preceptors, a nurse with 21 years
of experience asked her manager for a break in precepting from time to time. The
unit now has a system that not only allows preceptors to rotate, but also
rewards those who choose to precept beyond what is required.
� At a staff meeting, nurses who recognized
the strain of frequent floating suggested a closed staffing trial between their
unit and another ICU. Morale is at an all-time high since the system started
four months ago.
� Because of her knowledge about the
unusual interaction between two medications, a clinical nurse specialist was
able to prevent an overdose by having a dialogue with the physician who had just
written an erroneous order.
� A staff nurse in graduate school asked
why nurses in her unit were still using saline when suctioning patients, even
though published studies show this is harmful. The practice was studied and
procedures were changed.
There are challenges and rewards when you
think of a bold and powerful voice as representing your commitment to a new way
of being. The challenge is that speaking with a bold and powerful voice isn't a
one-time event. When you are genuinely committed to having your voice matter, it
never ends. There will always be improvements that need to be made and issues
that need to be resolved. Many of those will demand that you speak up day after
The good news is that it gets easier and
more effective, and it works. Your voice makes a difference. In fact, results
will follow only when you speak up. If you are committed to creating change in
this work that we love so dearly, a powerful, respectful, focused and clear
voice is one of the few tools that can accomplish the change you desire.
Many years ago, anthropologist Margaret
Meade spoke boldly and powerfully when she reminded us to never "doubt that a
small group of thoughtful, committed people can change the world." "Indeed, "
Meade said, "it is the only thing that ever has."
You-as a critical care nurse committed to
using your voice with a focus of creating change and solutions-are the one who
will change the world of healthcare. This commitment is an everyday act of
courage, not a high profile media flash. By using your everyday voice
relentlessly to speak up about important issues, you become one of the real
heroes of healthcare. You become the nurse who finds solutions and makes change
happen. You create the future that finally works for our patients and the entire
Physicians Have Role in Improving
In their article, "Why This Nursing
Shortage Is Different," Berliner and Ginzberg1 provide a nice review of some
previously reported facts, as well as some refreshing perspectives on
international nurse recruitment. I found their discussion on working conditions
and job dissatisfaction accurate, but unfortunately limited. Limited in that the
article failed to clarify that physicians can play a role in improving nurses'
working conditions and job satisfaction, and making such improvements are not
only limited to just hospital management.
Another important consideration, especially
in a publication targeted at physicians, is how physicians' behavior can have
profound effects on nurses' working conditions and job satisfaction. Simply
telling a nurse they did a "nice job" with a patient or "that was a great save,
thanks" can help nurses feel good about both their work and their jobs. Most
nurses respect physicians and physicians' opinions so a positive comment from
them, when warranted, about good work and valuable contributions can have an
enormous positive impact on nurses' job satisfaction.
A discussion on the impact of disruptive
physician behavior on nurses' working conditions and job dissatisfaction would
have been useful, too. Certainly, physicians are not the only staff whose
behavior can be disruptive, but few hospitals have policies on how to handle
such behavior of medical staff who are not hospital employees. Dealing with such
cases can be very difficult.2 Yet, it only takes one malcontent physician to
come into a work setting and disrupt the tone and morale of those working there.
Comments intended to intimidate, undermine confidence, imply incompetence or
other verbal abuses beyond the bounds of fair professional comment can do more
than ruin a nurse's entire shift; they also undermine essential teamwork and
Berliner and Ginzberg's excellent article
could have also recommended including the importance of the physicians' role in
team building, communications, and collaboration in physician education.4 Also,
recommending that medical centers establish an approach to handle unacceptable
conduct of physicians who are subject to a different governance structure would
be useful to support staff who want to deal with such instances in professional
Robert Welton, RN, MSN
Professional Development Coordinator
Department of Patient Care Services
University of Maryland Medical Center
1. Berliner HS, Ginzberg E. Why this
hospital nursing shortage is different. JAMA. Dec, 2002;288:2742-2744.
2. Gawande A. When good doctors go bad. The
New Yorker, Aug, 2000;7:60-69.
3. Barnsteiner JH, Madigan C, Spray TL.
Instituting a disruptive conduct policy for medial staff. AACN Clinical Issues:
Advanced Practice in Acute and Critical Care. August 2001;12:378-382.
4. Haupt MT, Grenik A, Rogers P. Physician
education in critical care medicine. New Horizons. 1998;6.