Written Statement to the Institute of Medicine Committee on Work Environment for Nurses and Patient Safety

January 24, 2003

Mr. Chairman and Members of the Committee, it is a privilege for the American Association of Critical-Care Nurses to contribute to the success of this committee's important work.

The American Association of Critical-Care Nurses is the world's largest specialty nursing organization. With a mission of providing and inspiring leadership to establish work and care environments that are respectful, healing and humane, AACN is dedicated to the vision of a healthcare system driven by the needs of patients and families, where critical care nurses can make their optimal contribution.

Understandably, the relationship between working conditions in healthcare settings and patient safety is of primary concern to our association. We wholeheartedly support the Institute's efforts to identify key aspects of nurses' work environment that affect patient safety and recommend potential improvements.

Critical Care NursingCritical care nursing is the specialty that deals with actual or potential human responses to life-threatening problems. Of the 2.2 million working registered nurses in the United States, nearly 1.3 million take care of hospitalized patients. Of these, an estimated 403,000 are critical care nurses whose clinical practice is directly influenced by our association.1

They work wherever critically ill patients require care–intensive care units for adults, children and newborns, cardiac care units, air and ground transport, cardiac catheterization laboratories, progressive care and telemetry units, emergency departments and post-surgery recovery rooms, to name a few. With severely shortened hospital stays, critical care nurses also apply their skills in long term care, home health, outpatient surgery centers and clinics. AACN counts nearly 65,000 critical care nurses as members.
Key Aspects of Nurses' Work Environment Affecting Patient SafetyToday’s nurses are confronted with the challenge of providing a safe environment where patients can trust caregivers who attempt to deliver care despite a multitude of interfering forces that include personnel shortages, increased work hours, new therapies and technology, reimbursement structures and the ever-changing transformation of systems and processes. The host of issues affecting patient safety have been eloquently described and analyzed by many. Within the nursing community, AACN concurs with testimony from our colleagues from the American Nurses Association and the American Organization of Nurse Executives who have already identified and proposed solutions to the crisis of nurse shortage, overtime work, non-nursing duties and excessive documentation as key factors that jeopardize patient safety.
Toxic Work EnvironmentWe wish to single out an elusive factor upon which rests the success of all other solutions. Most of today’s safety initiatives seek to correct deficient systems and processes. However, those systems and processes are developed and implemented by people and, consequently, are often held hostage by the complexity of human relationships.

All too regularly, nurses from across the country contact AACN for guidance in navigating toxic work environments. Places where abusive and disrespectful interactions between colleagues are the norm. Whether nurse-to-nurse, experienced nurse to new nurse, physician to nurse or even when a nurse isn’t involved, the disrespectful and noncollaborative behaviors which make the workplace toxic create negative, even unsafe, conditions. Their negative impact on job satisfaction and morale directly and adversely jeopardize patient outcomes.

One reported case out of many involved a novice nurse who called a physician to clarify a prescribed medication.2 Snubbed by the physician, the nurse took her best guess and administered a fatal dose of the wrong drug. Not only are toxic work relationships like this unsafe, they are unethical, demoralizing and drive nurses out of nursing faster than anything else in healthcare.

Ironically–and it is impossible for us to raise the issue without immediately pointing to solutions–an organization assumes no financial burden by choosing to foster healthy work environments. Rather a zero tolerance environment characterized by mutual respect and collaboration will save untold millions of direct and indirect expense. Put simply, it is a question of establishing an organizational and personal commitment anchored in the inherent and unarguable values of quality healthcare.
Commitment to Collaboration

AACN’s Investment in Patient Safety
As a commitment to effective work relationships begins to take hold, can a culture of safety be created and maintained within an industry that is inundated with pressure and high-risk situations? Can the incidence of medical errors and patient injuries be reduced in a system so vulnerable to error?

The American Association of Critical-Care Nurses commits to continue as a leader in creating cultures of safety that benefit of critically ill patients and their caregivers alike.

AACN knows that the myriad factors affecting patient safety do not operate in isolation. It follows that those factors cannot be influenced by a single sector or group. This will only be accomplished when each player in the healthcare equation, caregivers and consumers alike, acknowledges shared accountability for an integrated and collaborative response to achieve success. AACN accepts its accountability and commits to dynamic collaboration with others of like mind.

Further, AACN has and will continue to invest heavily in developing the tools and resources needed by clinicians to create a culture of safety and making them readily available to clinicians across the country. In the remainder of this testimony, we will highlight examples of how our association and others are already supporting the committee’s charge of bringing forward potential improvements in healthcare working conditions.
The AACN Synergy Model For
Patient Care
Clinical leaders are responsible for establishing an environment where a patient’s needs are matched with a caregiver’s competencies. The American Association of Critical-Care Nurses Synergy Model for Patient Care is a practical organizational framework that leaders in every clinical area can use to organize the work of nurses and create an environment of safety.3-4 The model’s premise is a simple one–synergy occurs when patients’ needs drive nurses’ characteristics resulting in optimal patient outcomes.

The AACN Synergy Model identifies eight characteristics of patients that include complexity, vulnerability, predictability, stability, resiliency, resource availability, participation in care and participation in decision making. As a patient’s needs evolve, so does the depth of a nurse’s competence in eight characteristics that include clinical judgment and reasoning, advocacy, caring practices, collaboration, systems thinking, response to diversity, inquiry and facilitation of learning.

The model is being adopted by hospitals across the country as a framework for care delivery and professional advancement. One notable example is Children’s Hospital in Boston which several years ago developed nurses’ job descriptions based on the model. In 2001, Indianapolis-based Clarian Health Partners and AACN began a demonstration project that is integrating the model throughout the 1,500-bed health system.
Practice Standards
and Guidelines
The Agency for Healthcare Research and Quality has noted that adopting evidence-based practice standards may establish consistency of performance expectations across multiple individuals and organizations. AACN has been a leader in the development of practice standards for nurses.

Standards for acute and critical care nursing practice, first published 20 years ago, were most recently revised and released in the year 2000.5 The association also has produced seven series of research-based practice protocols on such topics as airway management, mechanical ventilation and monitoring technologies with new topics under development.
Staffing Guidelines
and Nurse Orientation
There is widespread agreement and a quickly growing body of evidence supporting the negative effect of staff shortages on patient safety. Legally mandated nurse-patient ratios have been introduced as a solution to staff shortages in some jurisdictions. Although appearing to solve the problem, mandatory staffing ratios are known to be a quick-fix that fails to recognize staffing is both a process and an outcome. The components of staffing a clinical area are intertwined and complex, often reflecting highly charged emotional issues.

Considering the fundamental belief that a patient’s needs must be matched with a caregiver’s competencies, the appropriate number and type of staff would be difficult to express staffing numbers or patterns as a single acceptable national, even regional or local, ratio or mix. A preset ratio does not address the needs of a specific group of patients at a specific time.

AACN’s Staffing Blueprint: Constructing Your Staffing Solutions was released in 1999 designed to bridge communication, facilitate problem solving and promote patient-focused care when making staffing decisions.6 The blueprint emphasizes that the solution to a staffing problem is a comprehensive strategic plan that links cost, implementation, competency and staff mix with patient outcomes. This will allow direct comparisons to be made between healthcare plans, hospitals and providers.

However, critical as adequate staffing may be to assure patient safety, there also is a glaring need for consistency and easy access in the fundamental knowledge nurses must acquire to safely care for critically ill patients and their families. For more than 30 years, AACN has been the leader in delineating core content for critical care nursing.

More recently the association invested nearly $1 million of its own resources to develop ECCO™–the first of its kind Internet-based Essentials of Critical Care Orientation. Launched in August 2002, ECCO is an interactive and self-paced program focusing on the fundamental knowledge needed for a nurse’s orientation to the care of critically ill patients. It is designed to orient novice nurses to critical care practice more efficiently and expediently in a consistent way across clinical units and hospitals nationwide. ECCO offers hospitals just-in-time learning as a complement or substitute to traditional labor intensive classroom course.

In a second clinical education initiative funded in part by the U.S. Department of Education Fund for the Improvement of Post-Secondary Education, AACN has partnered with Indiana University School of Nursing and Clarian Health Partners to develop a comprehensive online critical care nursing course that will complement ECCO and be especially appropriate for academic institutions.
CertificationThe Institute of Medicine’s Committee on Quality of Health Care in America linked patient safety with continuing competency. Recommendation 7.2 of its report To Err Is Human: Building a Safer Health System suggests that performance standards for health professionals should focus greater attention on patient safety and “health professional licensing bodies should implement periodic re-examinations and re-licensing of doctors, nurses and other key providers.”7

Because wide divergence about the requirements for re-licensure exists among state boards of nursing, specialty certification fulfills the IOM’s recommendation.

Through CCRN� and CCNS certification, the AACN Certification Corporation provides the gold standard in specialty certification for critical care staff nurses and advanced practice. Safeguarding the Patient and the Profession, a white paper submitted to the committee with this testimony, describes the significant benefits that specialty certification for nurses brings to the public, employers and nurses themselves.8

Hospitals that create a culture of professionalism, respect and retention–including support for continuing education and certification–are more likely to have the optimal supply and mix of experienced nurses to assure patient safety. From the consumer’s perspective, in a November 2002 nationwide poll by Harris Interactive, nearly eight of 10 respondents in a representative sample of the American public were aware that nurses could be certified. Higher, in fact, than their awareness that teachers or physicians could be certified. Three of four respondents also said they were much more likely to select a hospital that employs a high percentage of nurses with specialty certification.9
Two Innovative Safety InitiativesTwo nurse-led pilot projects are especially relevant to the committee’s work. One in Indiana, the other in California, both seek to develop a culture of safety across a healthcare system.

The AACN Synergy Model provides a compelling picture of how the work of patient care can be organized to assure a patient’s safe passage through the health system. Convinced that most patient safety initiatives adopt a fragmented approach to the problem, nurse lawyer Kathy Rapala and nurse executive Dr. Karlene Kerfoot at Clarian Health Partners in Indianapolis are piloting an innovative program to foster a culture of safety by designating an experienced clinician as “safe passage nurse” in each care unit. As the local safety expert, the safe passage nurse works jointly with the unit’s interdisciplinary care team, risk management and other departments to achieve a level of patient, employee and visitor safety that assures safe passage.

At Stanford Hospital & Clinics, nurse lawyer and mediation consultant Debra Gerardi is reframing the patient safety program from a non-punitive, mediation-based perspective. In order to create the non-punitive culture needed for effective root cause analysis and systems change, the Stanford project will help health professionals acquire the skills in effective communication and conflict management needed to prevent communication breakdowns and reach collaborative solutions. Although prompted by a commitment to assure patient safety, the beneficial effects of this approach for the entire hospital’s operation are obvious.
Developing Nurse Managers and LeadersOf any leadership role in healthcare today, a nurse manager has the most direct impact on the care and services that patients and families require throughout their healthcare experience. Nurse managers require well-honed skills in coaching, motivating and leading a professional team so that safe and effective care is delivered, supported by systems where quality improvement and effective stewardship of scarce resources are complementary. Regrettably, learning resources are limited and on-the-job learning is the norm for most nurse managers.

A partnership of AACN, AONE–the American Organization of Nurse Executives and AORN–the Association of periOperative Registered Nurses is developing the Nurse Manager Leadership Collaborative. The collaborative is a comprehensive and sustainable national professional development initiative through which nurse managers can acquire and deepen the knowledge and skills needed for optimal performance. It will offer products and services that support career-long development within a framework of collaborative partnership and evidence-based best practices.

A second AACN leadership resource is available in It’s All About You: A Blueprint for Influencing Practice, the association’s response to a survey of more than 700 critical care nurses from across the United States who identified factors that would help them meet the challenges of influencing their work environment. The publication guides them in developing skills of self-awareness, dialogue, conflict resolution and navigating change which the respondents identified specific skills that are essential to exerting that influence.10
ConclusionOptimal care for critically ill patients and their families requires sufficient numbers of expert clinicians who base their practice on the ethics and values of the nursing profession and on accepted evidence-based standards for clinical practice. Those clinicians must work in environments that are safe, healing, humane and respectful of the rights, responsibilities, needs and contributions of everyone involved.

Thank you for inviting the American Association of Critical-Care Nurses to support the committee’s work. AACN is available for continued dialogue as necessary and looks forward to the release of the final report.


  1. The Registered Nurse Population: National Sample Survey of Registered Nurses. Rockville, Md: Health Resources Services Administration, Bureau of Health Professions, Division of Nursing; 2000.
  2. Greene, J. No abuse zone. Hospitals and Health Networks. March 2002;26,28.
  3. Curley, MAQ. Patient-Nurse synergy: Optimizing patient's outcomes. Am J Crit Care. 1998;7:64-72.
  4. Kerfoot, K (2002). The leader as a synergist. Critical Care Nurse, Vol 22, No. 2
  5. American Association of Critical-Care Nurses. Standards for Acute and Critical Care Nursing Practice. Aliso Viejo, Calif: American Association of Critical-Care Nurses; 2000.
  6. American Association of Critical-Care Nurses. Staffing Blueprint: Constructing Your Staffing Solutions. Aliso Viejo, Calif: American Association of Critical-Care Nurses; 1999.
  7. Kohn L, Corrigan J, Donaldson M, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.
  8. American Association of Critical Care Nurses. Safeguarding the patient and the profession. (2002). Aliso Viejo, CA: American Association of Critical Care Nurses.
  9. Harris Interactive Inc. American Association of Critical-Care Nurses Survey. November 2002.
  10. American Association of Critical-Care Nurses. It’s All about You: A Blueprint for Influencing Practice. Aliso Viejo, Calif: American Association of Critical-Care Nurses; 2002.

Note: Source documents for references 6, 8 and 10 have been submitted to the committee under separate cover.

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