American Association of Critical-Care Nurses

FigureTHE TRANSITION OF new-to-practice nurses into acute care often generates spirited debate. Should new nurses even practice in complex settings such as critical care? Are they sufficiently prepared upon graduation? What kind of learning and experience do they require after graduation? Should this learning consist of only hands-on experience, or can it be a combination of hands-on work and simulation? ECRI's Top 10 Patient Safety Concerns 2024 expands the debate by listing “Challenges transitioning newly trained clinicians from education into practice” as its number one safety concern.1 Founded in 1968 as the Emergency Care Research Institute, ECRI has become the leading independent, nonprofit organization dedicated to improving the safety, quality, and cost-effectiveness of care across healthcare settings. ECRI generates the Top 10 list by analyzing its database of nearly 6 million clinical events according to severity, frequency, breadth, insidiousness, and organizational risk. COMPLEX PRACTICE SETTINGS Healthcare's complexity grows relentlessly. It challenges educators to incorporate the quickly changing needs of acute care during the already limited time available to prepare nurses for comprehensive professional practice. Consequently, the declining number of experienced nurses at the bedside is further challenged to support new nurses transitioning to practice. Not surprisingly, in a 2022 American Nurses Foundation survey of more than 11,000 nurses, 30% of nurses with less than 2 years of experience reported feeling unprepared to practice independently.2 Some healthcare leaders disagree with ECRI's decision to identify transition to practice as a top safety priority. I challenge this. As a nurse leader credentialed in quality and safety, I ask why it took so long to recognize how this decisive milestone in a nurse's career impacts safety? ADDRESSING SAFETY CONCERNS Concerns about failure to rescue were voiced before the COVID-19 pandemic further highlighted these issues.3 Several themes impact new nurses' response to a patient's need for rescue, including clinical and educational preparation in nursing training; experience with emergent situations; the development of clinical reasoning; a supportive environment; and low confidence, both as a new nurse and when responding to emergencies.4,5 Experienced nurses are linchpins for the seamless transition of new nurses into practice. Yet the number of experienced nurses continues to shrink in most practice settings. More experienced nurses than anticipated have opted already for early retirement. Those practicing beyond expected retirement will eventually add to the queue of retiring nurses in coming years. Other nurses are drawn to new opportunities outside of hospital-based care. Approximately 27% of critical care nurses worldwide are projected to leave practice.6 All told, the nursing workforce is expected to have up to 900,000 nurses leave the profession by 2027.7 On a positive note, reports that this number is stabilizing are encouraging.8 We can't become complacent, discounting the negative impact of fewer experienced nurses to train and mentor new ones about quality and patient safety. Consider that failure to rescue is only one safety event of concern until a new nurse learns to prioritize care needs in a complex, chaotic acute care setting. TRANSITION TO PRACTICE Transition to practice starts during a nurse's professional education, not after graduation. Incorporating how to assess, monitor, and evaluate the critical needs of acute care patients through a quality and safety lens can't be optional. Innovative programs will accelerate academic-practice partnerships. Education institutions should adopt “earn-as-you-learn” models, offer elective courses on complex patient care, and develop specialty programs in collaboration with hospitals and nursing professional associations. Once nurses are employed, the inclination to shorten orientation time must be firmly resisted. A planned orientation program customized by an experienced preceptor to an individual nurse's needs will identify a new nurse's knowledge gaps and close them before the nurse can independently care for patients. New nurse transition-to-practice is a complex process that demands adequate resources and time to ensure nurse retention and patient safety. Failure to address this critical time will lead to unintended adverse events. Nurse leaders must advocate for nurses and patients to ensure their safety.

FigureAs we seek to reframe our professional lives in the wake of the COVID-19 public health emergency, concern about healthcare work environments has escalated. The National Academy of Medicine, for instance, prioritized actions that address the work environment in their National Plan for Health Workforce Well-being, and the National Institute for Occupational Safety and Health (NIOSH) recently launched the Impact Wellbeing campaign with a primary goal of influencing system level change.1,2 The American Association of Critical-Care Nurses (AACN) similarly recognizes the importance of the healthcare work environment in their Standards for Establishing and Sustaining Healthy Work Environments.3 This column is the first in a series that will focus on creating positive changes in the context in which healthcare is delivered, so that our workforce can thrive and optimize patients' experiences. Background First published in 2005 and updated in 2016, AACN's Standards for Establishing and Sustaining Healthy Work Environments offer a framework for considering the relational and contextual elements that influence job satisfaction and care delivery (see Table 1). In fact, AACN's central advocacy priority is to improve the health of nurses' work environments. Resources to realize this goal include offering an open access, validated work environment assessment tool; conducting a series of national surveys to assess the state of acute and critical care work environments; and co-leading a partnership to address nurse staffing, consistently the lowest rated of the six standards. Table 1: - AACN's Standards for Establishing and Sustaining Healthy Work Environments Standard Definition Example Skilled Communication Be as proficient in communication skills as you are in clinical skills. A nurse is angry after a comment by another nurse and, rather than reacting, responds by asking for more information about the comment's meaning. True Collaboration Be relentless in pursuing and fostering true collaboration. When a nurse and another team member don't agree about the plan of care, they each take time to hear the other person's perspective. Effective Decision-Making Be committed partners in making policy, directing and evaluating clinical care, and leading organizational operations. Nurses serve on a hospital-wide committee with other members of the healthcare team to develop a plan to reduce the rate of hospital-associated infections. Appropriate Staffing Staffing must ensure the effective match between patient needs and nurse competencies. Patient assignments are adjusted to address a change in patient condition. Meaningful Recognition Be recognized and recognize others for the value each brings to the work of the organization. Nurses receive paid time to engage in professional development activities such as conference attendance. Authentic Leadership Fully embrace the imperative of a healthy work environment, authentically live it, and engage others in its achievement. Leaders routinely reach out to newly oriented nurses to hear their concerns and offer support. Source: American Association of Critical-Care Nurses. Standards for establishing and sustaining healthy work environments. 2016. www.aacn.org/nursing-excellence/standards/aacn-standards-for-establishing-and-sustaining-healthy-work-environments. Analysis of AACN's national survey data demonstrates an implementation gap. Nurses who report working in units that are actively engaged in implementing AACN's standards are less likely to report moral distress and intent to leave and are more likely to report a higher percentage of shifts with appropriate staffing.4 In the most recent study, conducted in 2021, nurses reported significantly lower ratings on all six standards than in the 2018 study.4 These findings support AACN's new approach, which is to connect with health systems, hospitals, and individual units to support implementation of these standards. Future Healthy Work Environments columns will describe the resulting projects and their outcomes. Why are our work environments unhealthy? The mission of healthcare prioritizes human connection and carefully considered interventions. This mission coexists with the business of healthcare, which prioritizes efficiency and productivity. These priorities aren't mutually exclusive, but the effort to align them magnifies the collective emotional stress in the work environment. Other sources of distress include: Increases in workplace violence. Many patients who seek healthcare do so not because they trust the healthcare system but rather because they have no other recourse. That desperation contributes to discordant communication, verbal abuse, and physical violence. Global increases in the incidence of healthcare workplace violence are both an outcome and a symptom of unhealthy work environments.5 Unclear goals of care. Patients who present with life-limiting illness face prognostic uncertainty and decisions that are ethically fraught. In a fast-paced environment, there's seldom time to sort through the ethical elements of care delivery, resulting in moral uncertainty and moral distress. Division among the team. Hospitals merging with larger systems creates efficiency through centralized resources but also less opportunity for those who make decisions to connect with the workforce affected by those decisions. In addition, AACN surveys show significant differences in the way managers and direct care nurses rate their work environments.4 These differing perceptions demonstrate a divide between leaders and staff. Because healthcare delivery is inherently a complex endeavor, environments that lack time and space for connection among team members feel hostile. It's frightening that nearly a quarter of nurses plan to leave the profession.6 At the same time, it's not surprising when considering that contextual barriers to care delivery compound the emotional toll of being with patients and witnessing their suffering. How can we move forward? The first step is conceptualizing the work environment as a changeable feature of our lives. The word "environment" sounds like a fixed entity, as stable and permanent as the physical structure of a healthcare facility. That perception casts changes in the work environment as unattainable. An alternative perspective is to apply the paradigm of risk factors for health problems, which are modifiable (such as tobacco use and dietary choices) and nonmodifiable (such as genetics and other preexisting conditions). For example, discordant views on appropriate goals of care for a critically ill patient may be unavoidable. What is modifiable, however, is the way we frame those differences and the responses we provide. If much of the work environment is composed of its occupants' behaviors, attitudes, and relationships, then each member has some power to contribute to its improvement. The illnesses and injuries we see in our patients are a constant reminder that profound and life-changing events aren't always in our control. Our day-to-day interactions, which may seem mundane by comparison, have an immense impact on the environment in which we work, and in that space, we have the opportunity for influence. What should be easy is terribly hard Another key step is recognizing that change is hard. AACN's six standards may seem straightforward but implementing them requires deliberate effort. They're not discrete but interrelated, and all are evidence-based. In addition to survey data demonstrating the implementation gap, seminal work shows that the impact of higher staffing levels on patient outcomes varies based on the health of the work environment. In settings with unhealthy work environments, higher staffing levels weren't associated with a decrease in 30-day patient mortality but in settings with higher staffing and a healthy work environment, mortality was significantly lower.7 Because implementing all six standards in an environment that's currently unhealthy is both unrealistic and overwhelming, nurses who seek to implement the standards can use the free Healthy Work Environment Assessment Tool and then select one standard, perhaps one with a lower score, and work only on that standard. Often, addressing one standard leads to improvements in the others. For instance, creating a program that demonstrates meaningful recognition means understanding what's meaningful to your colleagues. To determine that, teams use skilled communication and then, to develop an intervention, they rely on effective decision-making. The implementation of the process or program they develop will require authentic leadership and true collaboration. Recognizing how these actions and conversations connect to specific Healthy Work Environment standards reinforces each participant's contribution and begins the journey toward a healthier work environment. Creating change The care of acute and critically ill patients is emotionally fraught, and unhealthy work environments are a modifiable source of stress for our healthcare workforce. The AACN Healthy Work Environment standards provide a framework for creating change in the relationships we make and the context we experience in our professional lives. In later columns, we'll dive deeper into the evidence base for the Healthy Work Environment standards and share strategies that units and organizations have used to implement them.

In hospitalized patients, QT/QTc (heart rate corrected) prolongation on the electrocardiogram (ECG) increases the risk of torsade de pointes. Manual measurements are time-consuming and often inaccurate. Some bedside monitors automatically and continuously measure QT/QTc; however, the agreement between computerized versus nurse-measured values has not been evaluated. The aim of this study was to examine the agreement between computerized QT/QTc and bedside and expert nurses who used electronic calipers. This was a prospective observational study in 3 intensive care units. Up to 2 QT/QTc measurements (milliseconds) per patient were collected. Bland-Altman test was used to analyze measurement agreement. A total of 54 QT/QTc measurements from 34 patients admitted to the ICU were included. The mean difference (bias) for QT comparisons was as follows: computerized versus expert nurses, -11.04 ± 4.45 milliseconds (95% confidence interval [CI], -2.3 to -19.8; P = .016), and computerized versus bedside nurses, -13.72 ± 6.70 (95% CI, -0.70 to -26.8; P = .044). The mean bias for QTc comparisons was as follows: computerized versus expert nurses, -12.46 ± 5.80 (95% CI, -1.1 to -23.8; P = .035), and computerized versus bedside nurses, -18.49 ± 7.90 (95% CI, -3.0 to -33.9; P = .022). Computerized QT/QTc measurements calculated by bedside monitor software and measurements performed by nurses were in close agreement; statistically significant differences were found, but differences were less than 20 milliseconds (on-half of a small box), indicating no clinical significance. Computerized measurements may be a suitable alternative to nurse-measured QT/QTc. This could reduce inaccuracies and nurse burden while increasing adherence to practice recommendations. Further research comparing computerized QT/QTc from bedside monitoring to standard 12-lead electrocardiogram in a larger sample, including non-ICU patients, is needed.

FigureThe stresses never stop, the requests pile up, the help is limited, and then burnout sets in. Bedside nursing requires many elements: a safe practice, a compassionate touch, an inquiring mind, and a desire to do it day after day. When work gets tough, the hardworking nurse gets tougher. Is it any wonder that nurses are all so tired? The societal pressure of being “modern day heroes” during a ravaging pandemic while still caring for oneself and a family has left nurses empty and worn out. Nurses live with long lists of tasks to complete and patients to please. Any bedside nurse today knows the weight of the stress, anxiety, guilt, strain, fear, and uncertainty. Where can relief be found? Perhaps relief may come from an unlikely source that typically carries even more weight for the bedside nurse. Maybe Christian nursing students are the load lifters, the weight bearers. I recently accompanied a group of six students on a clinical rotation at an inner-city hospital in Denver. This clinical site had experienced significant turnover in the last 6 months, like many other hospitals. Experienced nurses had left for better paying travel assignments. Beloved managers and directors had left for work away from the onslaught of COVID-19. This group had lost two peers to the virus. The remaining nurses were depleted and worn thin, watching as their peers were replaced with travel nurses and new graduate nurses. My students were not greeted with enthusiasm, optimism, or a passion to train the next generation of nurses. Instead, we heard grumblings of “more work” and “oh no, not students again!” In 5 weeks at our clinical site, the nursing students gave not what was deserved, but what was desperately needed. Day after day, we held up heavy arms and aimed to make the load a little lighter. Student nurses answered every call light. They gave the nursing assistants breaks and measured vital signs on all patients, not just their own. The students toileted, dressed, and sat with the most confused patients. They accepted without question any task that could lighten a load. They changed batteries on telemetry monitors, emptied trash cans, changed bed linens, fed, toileted, ambulated, and repeatedly taught patients. These students left the clinical days exhausted and drained. Care was provided to patients, but ultimately, these nurses in training cared for their professional nurse colleagues by working with grace. One student commented, “When we were introduced to the staff nurses who would be our proctors for the day, you could feel the burnout and sensed that they felt we were an extra burden. I was quick to say I was there to help. A few took me up on that offer. After a few hours of assistance, nurses relaxed and began to teach more as they worked. I left with the satisfaction of knowing that I had cared for patients and the nursing staff!” What is grace? It has an unassuming definition, right? I would define it as unmerited love or courtesy. Piper (2020) described grace as “undeserved favor” or “action or the power or the influence or the force of this disposition, which produces real, practical outcomes in people's lives.” Zahl (2007) called it “love that seeks you out when you have nothing to give in return. Grace is love coming at you that has nothing to do with you. Grace is being loved when you are unlovable” (p. 36). Zahl also defined grace as “one-way love” (p. 70). Christian nursing students have a unique opportunity to operate on this one-way street—the opportunity to produce a real and practical outcome in someone else's life. The last thing the nurses at our clinical site expected was to be loved by our students. The student behavior on display did not match what was deserved. We typically think about nursing students ministering to patients, but don't often consider that the nurse preceptors may be the ones on the receiving end of that ministry. This one-way, grace-laden ministry of love was unexpected, which is what made it so powerful.

Sherman RO. Published by Rose Sherman; 2021. Paperback; 258 pages.Some nurses are called to leadership. An effective nursing leader needs many skills, and the career path often includes obtaining a graduate education and gaining clinical expertise. In addition, nursing leaders should continue to learn from experts on current thinking to be successful. In The Nuts and Bolts of Nursing Leadership: Your Toolkit for Success, the author defines the areas of accountability of a nursing leader, specifically of the nurse manager, and incorporates key points from established leadership experts.The book is organized into 5 parts: Transitioning Into Leadership, Communicating and Collaborating in Leadership Roles, Leading High Performance Teams, Leading in Organizations, and Your Leadership Toolkit. In each part, the chapters start with foundational information and continue to expand on that information. In addition, chapters include key points and references. The final part, Your Leadership Toolkit, contains actionable items and tools to support the application of the material discussed in the book. The information in this book is appropriate for both new and experienced leaders; the topics are well explored and can be applied to any organization.One of the greatest challenges that affects nursing today is staffing. Research suggests that staffing can impact such outcomes as patient clinical indicators, patient and staff satisfaction, turnover, and institutional financial performance. Although there is no magic solution to the staffing challenge, Sherman provides details of how nursing leaders can develop and drive staffing solutions that appeal to all stakeholders and optimize performance outcomes.In The Nuts and Bolts of Nursing Leadership, Sherman discusses how to determine what you can and cannot control, how to establish boundaries, and how to foster resilience in yourself and your teams. These skills are crucial to the health, wellness, and success of nursing leaders and the nurses they guide and mentor. Also, using these skills, nurses can establish their own legacy and develop as leaders and innovators of the future.This book includes many references, most of them current and some classic but still relevant. Many aspiring and current nursing leaders may not have read these works and can benefit from learning more about the contribution to and influence on leadership best practices of these references.The Nuts and Bolts of Nursing Leadership provides an excellent overview of the components of successful nursing leadership. This book would be a wonderful tool for business leaders who join health care organizations; it provides insight into the unique culture of nursing and how best to collaborate with nursing leaders and partners. The Nuts and Bolts of Nursing Leadership can help readers understand the thinking and prioritization applied at the point of care and how the influence of an organization is established through its frontline health care providers.Tedeschi RG, Moore BA, Falke K, Goldberg J. Independently published; 2020. Paperback; 290 pages.The experience of trauma changes a person. Initially, the experience is almost always negative and can affect the rest of someone’s life. However, the authors of Transformed by Trauma have found that trauma can lead to finding purpose and growth in the pain experienced. Transformed by Trauma includes true stories of veterans and their family members who found such purpose and growth in their experiences with trauma.Clinton C. Back Bay Books; 2005. Paperback; 304 pages.This book is the biography of a former slave who became the only Black female known to have repeatedly and successfully led other slaves to freedom as a “conductor” on the Underground Railroad. The accomplishments of this remarkable woman do not end there; Tubman went on to be a Civil War nurse, spy, scout, and military commander. After the war, she was a well-known philanthropist and leader in the women’s suffrage movement. Harriet Tubman: The Road to Freedom is a well-written biography of an amazing person.McChrystal S, Collins T, Silverman D, Fussell C. Portfolio; 2015. Hardcover; 304 pages.In 2004, General Stanley McChrystal took over command of the Joint Special Operations Task Force only to discover that tactics in use at that time were woefully inadequate to defeat Al-Qaeda. He needed to lead the organization toward a faster, flatter, and more flexible command structure—a “team of teams.” General McChrystal decentralized power to allow small groups the freedom to experiment and share what they learned across the entire special operations command. This change allowed teams to respond more quickly, communicate more freely, and make better and faster decisions. Team of Teams is an excellent read for those looking to promote leading from the bedside.

In Brief This article explores common causes of quality improvement project failure and key strategies for success, including partnering with a clinical nurse specialist to facilitate sustainable change.

Patients with isolated left ventricular failure may have positive outcomes after being implanted with a left ventricular assist device. Unfortunately, almost half of patients with heart failure and reduced ejection fraction also have evidence of right ventricular dysfunction. For a subset of this population with severe biventricular failure, or those who develop right ventricular dysfunction after left ventricular assist device implantation, patients may necessitate biventricular assist devices or the total artificial heart. This overview of mechanical circulatory support devices will enhance nurses' ability to differentiate criteria for implantation, current practice, and outcomes with a focus on durable ventricular assist devices and the total artificial heart. A review of the literature involved searching CINAHL and PubMed databases using keywords biventricular assist devices, total artificial heart, and durable mechanical circulatory support. Results were narrowed to articles based on adults, 18 years or older. Seventy-eight relevant articles were identified, and 8 articles compared the durable biventricular assist devices. Similar patient outcomes were found when comparing the use of left ventricular assist devices as biventricular support versus the total artificial heart. The decision to implant the appropriate durable mechanical circulatory support for a patient in biventricular failure is complex and dependent on patient factors.