An experienced critical care nurse arrives at the intensive care unit, rejuvenated after a day off and eager to provide top-notch patient care that day. Although this nurse derives satisfaction from serving as a preceptor for new staff, the nurse also cherishes those days when all work responsibilities center on patient care and at least a few minutes can be found to actually listen to, support, and teach patients.

With a hefty assignment to Mrs Clark, the most clinically challenging and unstable patient in the unit, and the elderly Mr Loomis, whose family needs considerable instruction on how to safely manage his insulin injections before his scheduled discharge later that day, the nurse checks both patients, launches care of Mrs Clark whose blood pressure is trending down again, and begins making mental notes of how the Loomis patient and family education can best be provided. Suddenly, the nurse manager appears and breathlessly relates that she needs the nurse to take a new admission with head and chest trauma who is on his way up to the unit. Before the nurse can relate even the tiniest detail regarding the previously assigned patients, the manager quickly continues, “I know this seems like a handful, so I’m going to give you an orientee as an extra pair of hands. I have worked for weeks to convince this new graduate to join our staff and today was the only day she could start orientation, so please give her your fullest support because she’s scared to death of making a mistake. Thanks. Gotta run ’cause I’m late for a meeting.”

Attempting to regroup priorities and return attention to Mrs Clark’s dropping blood pressure, another interruption arrives in the guise of a fellow staff nurse who pokes his head into the room, pleading, “Would you please come to the nurse’s station and retrieve your orientee? It seems our new graduate expected a welcoming committee and is threatening to leave if her preceptor doesn’t materialize soon! The rest of us have heavier assignments than you right now, so we don’t have time to deal with her. The unit clerk said that you are her preceptor. Oh wow! Here comes a new admission. I’ve got to get back to my patients before something else happens! See ya.”

Does any of that scenario have a ring of familiarity? Unfortunately, for many critical care nurses, scenes such as this—rife with disappointment; frustration; anger; stress; paltry communications that arrive too little and too late, if at all; lack of respect for their opinions in decision making that directly affects them; indifference to their needs for consideration or recognition or support; strained relationships with colleagues and coworkers; inadequate staffing; and a continual and demoralizing thwarting of their ability to provide patients and families with just good (never mind great) nursing care—play out daily, testing the mettle of even the most dedicated among us. For many, the resounding lamentation, “I love critical care nursing, but...” is followed by one or another expression that can be summed up as, “so much around it is just becoming untenable.” What is “around it,” the environment within which we practice, has been recognized as influential for many years but has gained renewed attention more recently as a major contributor to staff turnover, low morale, errors, and incidents that harm patients, as well as our profound shortage of nurses.

Before some of our youngest critical care nurses were born, the American Association of Critical-Care Nurses (AACN) developed and later published its Scope of Practice statement,1 which defined the reach of our practice as encompassing critical care nurses, critically ill or injured patients, and the critical care environment. In 1991, AACN reaffirmed its commitment to improving working conditions for its members by adopting “a healthy work environment” as its number 1 advocacy priority. Again, a decade later, AACN reiterated its dedication to this issue through active participation in creation of healthy work environments for critical care and acute care nurses. The outcome of this latest initiative is the AACN Standards for Establishing and Sustaining Healthy Work Environments (HWE).2 

The AACN HWE standards, developed by a panel of 9 and reviewed and validated by a cadre of 50 experts, include 6 standards that reflect evidence-based principles of professional performance. Each of these standards is designated as essential, meaning “absolutely required,” “not to be sacrificed,” “fundamental,” and “indispensable.”2 In addition, each standard includes a set of critical elements, defined as “structures, processes, programs and behaviors required for a standard to be achieved.”2 A synopsis of the HWE standards and their critical elements is provided below; a full detailing of the standards is available at AACN’s Web site,

1. Skilled Communication

Nurses must be as proficient in communication skills as they are in clinical skills.

Critical Elements

  • Provide staff support for educational programs that develop communication skills

  • Focus on finding solutions and achieving outcomes

  • Foster collaborative relationships

  • Listen to all perspectives

  • Build consensus based on goodwill and mutual respect

  • Ensure consistency between words and actions

  • Demonstrate zero tolerance for abusive or disrespectful staff behavior

  • Ensure effective communication among patients, families, and staff

  • Provide technologies that enhance communication

  • Determine the impact of communication on practice, financial, and environmental outcomes

  • Require skilled communication as a prerequisite for staff promotions

2. True Collaboration

Nurses must be relentless in pursuing and fostering true collaboration.

Critical Elements

  • Provide staff support for educational programs that develop collaboration skills

  • Define staff accountability for collaboration and consequences of not collaborating

  • Make it standard operating procedure for nurses to materially and meaningfully participate as decision makers

  • Ensure effective and timely mechanisms are available for resolving care disputes

  • Ensure that staff have the communication skills requisite for collaboration

  • Demonstrate mutual respect for all healthcare team members

  • Demonstrate professional competence

  • Demonstrate professional integrity

  • Nurse and physician directors collaborate as equal partners

3. Effective Decision Making

Nurses must be valued and committed partners in making policy, directing and evaluating clinical care, and leading organizational operations.

Critical Elements

  • Provide staff support for educational programs that develop and improve staff skills in collaborative decision making

  • Integrate organizational values in decisions

  • Include patients and family in all decisions affecting patient care

  • Make each individual on healthcare team accountable for effective decision making

  • Facilitate data-driven decision making

  • Ensure that decisions respect individual rights, consider all stakeholders, and hold decision makers accountable

  • Objectively evaluate results of decisions, delayed decisions, and indecisions

4. Appropriate Staffing

Staffing must ensure the effective match between patient needs and nurse competencies.

Critical Elements

  • Staffing policies support nurses’ obligations to provide quality care

  • Nurses participate in all phases of the staffing process

  • Evaluate the effect of staffing decisions on patients, matching of nurse competencies, and system outcomes

  • Enable data-driven improvements in staffing models

  • Support nurses so they can focus on care of patients and families

  • Ensure that nurses participate in selection of technologies to improve delivery of care

5. Meaningful Recognition

Nurses must be recognized and must recognize others for the value each brings to the work of the organization.

Critical Elements

  • Create formal mechanisms that recognize the value of staff contributions

  • Disseminate instructions on how staff can recognize the contributions of colleagues

  • Design a recognition system that spans all organizational levels and affords recognitions appropriate and significant to each level

  • Verify whether recognitions are meaningful to recipients

  • Ensure that staff understand how to actively participate in recognizing others

  • Appraise recognition mechanisms to ensure they foster a culture of excellence

6. Authentic Leadership

Nurse leaders must fully embrace the imperative of a healthy work environment, authentically live it and engage others in its achievement.

Critical Elements

  • Support provision of educational programs to develop and enhance nurse leadership skills

  • Demonstrate understanding of mutual interplay between quality of work environment and point of care

  • Exemplify enthusiasm for creating and sustaining a healthy work environment

  • Provide the information, opportunities, time, funding, mentoring, and human resources that nurse leaders need to make sound decisions for improving healthy work environments

  • Walk the talk—that is, ensure that nurse leaders consistently exemplify the skills inherent in these standards

  • Require creating and sustaining a healthy work environment as prerequisites for nurse leader performance appraisals and promotions

  • Ensure that leadership processes and decisions are objectively evaluated for their impact on healthy work environments

As AACN now proceeds with development of practical strategies and resources for implementing these standards, the association is issuing a call to action for making these depictions the norm. The HWE standards do not purport to be a panacea for all of the ills that plague the work-place where acute, subacute, and critical care nurses (or any other healthcare professionals) practice, but they surely provide a plan and suggest processes and procedures that can lend helping hands out of this mire. We don’t need to work in a quicksand environment, but we do need to help pull ourselves out. A lifeline has been offered. Will you take hold?

Disch J. Scope of practice defined.
Focus on AACN
. May/June
American Association of Critical-Care Nurses. AACN standards for establishing and sustaining healthy work environments: a journey to excellence.
Am J Crit Care


Editor’s note: The complete Healthy Workplace Environment Standards have been published in the

American Journal of Critical Care
They can also be downloaded from AACN’s Web site,