AACN News—June 2004—Opinions

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Vol. 21, No. 6, JUNE 2004

President's Note

Rising Above
New Questions, New Opportunities

By Dorrie Fontaine, RN, DNSc, FAAN
AACN President

Following are excerpts from the President's Address delivered by President Dorrie Fontaine, RN, DNSc, FAAN, at the opening session of the 2004 National Teaching Institute and Critical Care Exposition in Orlando, Fla. The full text with references is available online or by calling (800) 899-2226. Request Item # 6105.

One year ago, when I started my term as president, I selected "Rising Above" as the theme to guide my activities for the year. Rising above means seeking a new level of consciousness, seeing realities for what they are and arming ourselves with knowledge we can use with confidence and strength to focus on solutions for making an enduring difference.

Think of eagles. Their priorities are simple: How do we get food? Straightforward. And fatal when not achieved. The priorities of our fast-paced, emotionally charged work situations are straightforward, too. But critical, because when we don't succeed, people die, families unravel, nurses crash and burn. Just like eagles, only by rising above can we gain a new perspective that expands our awareness of what is happening and shows us better courses of action and paths to take.

Responses From the Field
As I traveled and wrote columns for AACN News, your responses made me realize that my individual goals as president of AACN were on target. I wanted to make the association personal for as many nurses as I could and hit nerves that would force us to rise above.

In visiting acute and critical care units, meeting nurses and reading e-mails, I didn't hear a defeated listing of the same old problems. Instead, I found a genuine yearning for solutions, an appreciation of the possibilities that come from new understandings and a willingness to sustain optimism.

Here's what I saw on the ground and what I saw when I rose above:
� I saw units with only one CCRN or none at all. Nurses who want to become certified, but are afraid of failing. Rising above, I saw more than 40,000 certified nurses, their names proudly displayed on wall plaques in their unit.
� I heard deep concern about staffing, mandatory ratios, the pros and cons of collective bargaining. Alongside were applications for the new AACN Beacon designation for excellence in critical care and hospitalwide implementation of the AACN Synergy Model for Patient Care.
� I saw catastrophic threats to patient safety, but nurses outside of ICUs eager to acquire the new knowledge and skills they need to deal with increasing patient acuity.
� I heard continued worry about hiring new graduates in critical care units, but four generations of nurses with differing styles working side-by-side and finding ways to leverage each other's contributions.
� I saw limited visiting hours with inconsistent family presence during invasive procedures and CPR. But when I rose above, I saw the growing evidence from studies like AACN's national survey of family presence with the Emergency Nurses Association that supports the benefit of family access.
� And everywhere, I saw exquisite caring by acute and critical care nurses. Nurses who know how to make their units what Patricia Benner calls "a less scary place for patients and families."

How do we capitalize on opportunities to rise above to find the solutions we urgently need when our time, energy and resources are limited? How do we zero in on the core issues? How do we resist the impulse to simply react to the dozens of symptoms that cry for attention but don't get us closer to solving the real problems?

Learning to handle "crucial conversations" when the stakes are high will bring the positive results we need in dealing with patient safety, moral distress and collaboration-three critical issues that spill over into every corner of our work. Get a tight grip on those conversations, and we're well on our way to the right future for patients, their families and ourselves.

Patient Safety
Last fall, the Institute of Medicine issued a second landmark study of patient safety. It pointed to eroding trust in hospital administration, lack of clinical leaders and lack of nurse involvement in patient care decisions as major factors in creating environments that support error making. AACN's written testimony to the IOM emphasized that we're helping health professionals acquire skills in effective communication and conflict management to prevent communication breakdowns and reach collaborative solutions.

In a riveting book titled Internal Bleeding, two physician colleagues rise above to offer thoughtful and workable solutions to fix systems errors and change hospital cultures to prevent catastrophic mistakes. A Harvard Business School study titled "Why Hospitals Don't Learn From Failure" offers hard evidence that nurses patch problems, rarely taking action to address the underlying cause, and that hospitals don't always value nurses as the most precious resource they are. Imagine a work world where we are treated as a precious resource. How would it make us act? What can we do to create that world?

Moral Distress
Moral distress is a force of epidemic proportions that is steadily eroding healthy work environments. We must boldly rise above to acknowledge and name it as a source of great suffering for nurses. Moral distress rears its head when we know the ethically appropriate action to take, but are unable to act upon it. Or, when the demands of a situation require us to go against our personal and professional values, undermining our integrity and authenticity.

Palliative and end-of-life care have other implications for us. Palliative care is not what nurses do when they have finished doing everything else. If we tell ourselves that we're only caring for those who will die until a bed is found somewhere else, we essentially abandon them and deny them the care they require and deserve.

We're often uncomfortable standing at a bed alongside people who are experiencing unspoken grief. Yet, the only way we can determine the appropriate response to someone's needs is by being fully present in the relationship with them. That's how we will ensure that our care isn't just about doing things to people. This means providing holistic care. Today, this is harder than ever to accomplish. But we have no choice.

I challenge us to take time to be with people even when it may make us uncomfortable. Finding and making time, seeing the resulting magic of being with people is the work of nurses.

Working effectively with visitors still seems to hit a nerve with many of us, sometimes generating heartbreaking moral distress for everyone involved. When Dr. Nancy Molter was president of AACN, she wrote an article titled "Families Are Not Visitors in Critical Care Units: They Belong There." Nancy is right. Families belong in units. Ten years later, the evidence shows that we still miss the mark. Evidence also confirms the benefits of sometimes having families present during invasive procedures and CPR.

How we invite families to where they rightfully belong. How we orchestrate death and promote palliative and end-of-life care. How our policies help families integrate the experience. These tell the story of a unit's culture.

What is a genuinely collaborative, healthy work environment? Dr. Joyce Clifford, who received this year's Marguerite Rodgers Kinney Award for a Distinguished Career from AACN in recognition of her 30 years as nurse-in-chief at The Beth Israel Hospital in Boston, described collaboration this way:

Certainly respect, trust and a willingness to take the time to learn about the work of others are part of it. The skills needed include very good communication and listening skills; competence, which helps to build respect and trust; and a high level of integrity, so people can count on you for what you say you can, and will, do.

Respect. Trust. Competence. Integrity. These are what collaboration is all about. Unarguably, nurse managers are key in developing the collaboration that creates and sustains a healthy work environment. Unfortunately, nurse managers are squeezed between the competing goals of healthy patients and healthy bottom lines. But really, everybody is squeezed one way or another. How do we get people out of the squeeze?

Nurse managers can make that happen with our help and support. And with a heavy dose of what has been called love-driven or caring-driven leadership. Love and caring engages others with a positive attitude that unlocks their potential. This may be just what our worn-down acute and critical care units crave. The loyal many who have stuck it out through countless nursing shortages are ready to be inspired to work instead of being made to work.

Leadership driven by love and caring means units where meeting the needs of patients and families is the focus. Units where the precious resource of nurse is respected, valued and trusted. Input into unit decisions. Zero tolerance for abuse by anyone. No mandatory overtime. These become the norm.

What Is Next?
Catherine Gillis, dean of the Yale School of Nursing, calls nursing "the most optimistic of sciences." Three action steps will help us focus and embrace the practical optimism of nursing.

First, we need to figure out where we fit to make the optimal contribution that AACN's vision invites. What role should we be in? Are we leaders who rally people to tackle massive change or who can help an established culture of excellence to mature? Maybe we're followers who enthusiastically sign on when someone else leads the way. Or skilled coaches who excel at helping novice nurses become competent.

Once we find our fit, we need to rise above and discern what is most pressing and nonnegotiable, given our individual abilities.

But finding where we fit and discerning what is most pressing and nonnegotiable are hollow unless we commit to taking action. We need to make or renew our commitment to:
� Identify the most pressing challenge in our immediate work environment.
� Initiate dialogue with our colleagues to find solutions to this challenge.
� Remain actively involved in the solutions until they are working.

The energy needed to make or renew this commitment comes from fresh courage, which comes from the camaraderie and strength of association, the bonds of caring that unite us together forever in AACN. Fresh courage enables us to see the landscape as it is, to consider possibility and to respond with generosity. It reminds us that nursing is the most optimistic of sciences, because human caring makes a difference, makes everything possible.

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