Our View of Courageous Care

Quality improvement can support courageous care by providing structure for efforts aimed at improving care at local sites. In a recent American Journal of Critical Care (AJCC) article describing quality improvement metrics and processes, the authors state, “Critical care nurses often perform most of the care, patient assessments, and evaluations in the ICU, which places them in the perfect position to identify, initiate, evaluate, and sustain quality initiatives.”²  No matter how well positioned nurses are to identify opportunities for improving care, change will not occur unless nurses act courageously. Quality improvement projects extend courageous care beyond the nurse’s interaction with an individual patient, and provide benefits far beyond the initial target.

Conducting original research to build the knowledge base for nursing care is also a manifestation of courageous care. Whereas quality improvement projects seek to enhance care by applying knowledge to a local situation, research seeks to find new knowledge that can be broadly applied. Many nursing activities arise from tradition or opinion, but have not been examined scientifically. Nursing research is needed to substantiate or refute the efficacy of long standing traditions of care. Further, it is necessary to actually test theoretically attractive new interventions. For example, what evidence do we have regarding optimal turning frequency for critically ill patients? Providing a “quiet time” for critically ill patients during the day has been widely adopted as a way of providing rest, but there is little research evaluating the practice.³  Might dimming lights and encouraging daytime sleep exacerbate circadian rhythm problems? Courageous care requires that we be willing to examine interventions impartially in order to fully understand risks and benefits.

Whereas it is important for nurses to embrace courageous care as individuals, it is also important for nurses to act as catalysts for courageous care within the interdisciplinary health care team. It is our responsibility to assist all members of the team to practice to the full extent of their education and training, and to support the synergy created by interdisciplinary care. More research about interdisciplinary teams is needed. An example of research about disciplinary perspectives is provided by Neville and colleagues⁴  in this issue of AJCC. They report an examination of nurse and physician perceptions of futile care. Interestingly, they found that when nurses and physicians evaluated the same patients on the same days, there was low concordance in their judgments about which patients were receiving futile treatment. The authors suggest that physician judgments may focus on mortality risk, whereas nursing judgments might be more influenced by patients’ suffering and nurses’ awareness of patient and family goals. Importantly, the group of patients for whom nurses and physicians agreed treatment was futile had the highest 6-month mortality—greater than either patients whose care was assessed as futile by physicians alone, or by nurses alone. They conclude that sharing of perceptions and collaborative relationships among providers is important.

The work environment can discourage or facilitate courageous care. Because healthy workplace environments are a crucial component of patient safety, courageous care must directly address any factors that undermine healthy work environments. Addressing workplace issues requires particular courage, as unhealthy behaviors may be deeply rooted and systemic. The AACN Healthy Work Environment Initiative⁵  focuses on 5 factors that are crucial to optimal nursing contributions and patient outcomes (skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership). Healthy work environments nurture courage in nurses and support efforts to effect changes that improve patient outcomes. For example, when nurses communicate skillfully, they are better able to state their case about what changes are needed and why. They are also able to understand and respect the viewpoints of others.

Nurses in a healthy work environment go beyond identifying issues—they engage colleagues, patients, and families in finding and implementing solutions to problems. AACN offers resources to assist in creating healthy work environments, which are important supports for courageous care.⁶  The TeamSTEPPS program, jointly developed by the Department of Defense’s Patient Safety Program and the Agency for Healthcare Research and Quality, encourages a healthy work environment that supports a culture of patient safety by providing interdisciplinary training and materials to improve communication and teamwork skills.⁷ 

There are many opportunities for critical care nurses to exhibit courageous care. Nurses do so in advocating for individual patients and their families, as well as in conducting quality improvement projects and research. At its best, however, courageous care is a team sport. Individual courage can and should be contagious, spreading throughout the health care team and resulting in better outcomes.