Changing the work environment in intensive care units to achieve patient-focused care: the time has come

American Journal of Critical Care, Nov, 2006 by Kathleen McCauley, Richard S. Irwin

The American Association of Critical-Care Nurses Standards for Establishing and Sustaining Healthy Work Environments and the American College of Chest Physicians Patient-Focused Care project are complementary initiatives that provide a road map for creating practice environments where interdisciplinary, patient-focused care can thrive. Healthy work environments are so influential that failure to address the issue would result in deleterious effects for every aspect of acute and critical care practice. Skilled communication and true collaboration are crucial for transforming work environments. The American College of Chest Physicians project on patient-focused care was born out of a realization that medicine as currently practiced is too fragmented, too focused on turf battles that hinder communication, and too divorced from a real understanding of what patients expect and need from their healthcare providers. Communication as well as continuity and concordance with the patients' wishes are foundational premises of care that is patient-focused and safe. Some individuals may achieve some level of genuine patient-focused care even when they practice in a toxic work environment because they are gifted communicators who embrace true collaboration. At best, most likely those efforts will be hit-or-miss and such heroism will be impossible to sustain if the environment is not transformed into a model that reflects standards and initiatives set out by the American Association of Critical-Care Nurses and the American College of Chest Physicians. Other innovative models of care delivery remain unreported. The successes and failures of these models should be shared with the professional community.

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The landmark Institute of Medicine (IOM) document To Err Is Human: Building a Safer Health System (1) transformed the way we think about patients' safety. By making public the dangers that patients face when they enter the current healthcare system, the IOM used its influence effectively to call for dramatic transformations in the way we evaluate errors and changed the focus of error prevention from individual punishment to one of system redesign. In Crossing the Quality Chasm: A New Health System for the 21st Century, (2) the IOM then attacked the dysfunctional processes of our past and current healthcare system (eg, pervasive poor communication and noninterdisciplinary, often isolationist decision-making behavior). By focusing on effective team performance, data-driven analysis of system failures, and continuous process improvements to reduce risk, the IOM called for a revolution in the way we communicate with each other, anticipate and modify patients' risk, and evaluate our effectiveness.

The leaders of the American Association of Critical-Care Nurses (AACN) and the American College of Chest Physicians (ACCP) have a long history of thoughtful dialogue about the important issues in critical care practice and have collaborated on key initiatives to enhance the practice knowledge of their members. Over the years, as their relationship has matured, the organizations have come to respect and value each other's perspective, benefited from the unique knowledge and worldview each brings to planning for the future, and used this perspective to grow in ways that would not have been possible without this collaborative relationship.

As past presidents of AACN and ACCP, in this article we describe how the AACN Standards for Establishing and Sustaining Healthy Work Environments (3) and the ACCP Patient-Focused Care project (4) demonstrate true collaboration and synergy of thought. Together, these complementary initiatives provide a road map for creating the kind of practice environment where interdisciplinary, patient-focused care, as called for by the IOM, can thrive.

Response to a Flawed Health System

AACN's decision to establish standards for healthy work environments grew from a strategic planning process in which the association identified the 3 most important issues facing its members and critical care nurses at large on which AACN's voice and action would have the greatest effect. A healthy work environment was one of those issues and was judged to be so influential that failure to address it would result in deleterious effects for every aspect of critical care practice. A task force and national review panel led by past AACN president Connie Barden developed the standards that were launched at a Washington, DC, press conference in January 2005. More than 30 000 copies of the standards were downloaded from the AACN Web site the first month after their release; the number downloaded now exceeds 120 000. These standards are guiding transformation of the care environment in many institutions across the United States.

The standards have been presented in several AACN publications. (3,5) The 6 standards--addressing skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership--were derived from a strong base of research evidence. Each standard is considered essential, and the standards are designed to be used together, not as stand-alone organizational goals. The standards are forceful statements describing the actions required to transform the health of the work environment (see Table).