Many articles have been written during the COVID-19 pandemic about the serious workplace and personal issues experienced by nurses. Although I have mentioned some of these struggles in previous Critical Care Nurse (CCN) editorials, I have not dedicated a full column to the deplorable situation in which so many nurses find themselves. I mistakenly assumed readers were overloaded with pandemic-related information and aware that many organizations are advocating on behalf of nurses to improve the environment and overall working conditions. I now realize that many nurses at the bedside are justifiably concerned that your voices are not being heard.
A national US survey of critical care nurses reported physical and emotional symptoms of exhaustion, anxiety, sleeplessness, and moral distress.1 Working conditions have become increasingly demanding during the pandemic, patient acuity is high, the nursing shortage continues, nurse-to-patient ratios regularly exceed recognized standards, nurses are working extreme amounts of overtime, and many nurses have seen too much death, feel disrespected and undervalued, and are frustrated that they cannot provide the level of excellent care required for positive patient outcomes. In other words, many of you are working in unhealthy and unsafe work environments.
Nurses are angry. I hear you and I hear your pain. As a nurse, I share your deep concerns about the future of nursing. As Editor of CCN, I recognize the importance and privilege of having a national platform to call for positive change for all critical care nurses.
I should explain one of the realities of publishing, however. Early in the pandemic, I often sat down to write these editorials thinking the worst of the pandemic might be over by the time my words were printed. It is clear now that we will not be out of this mess by the time this editorial goes to press. A recent quote I encountered resonated with me: “Any effort to predict a future course beyond 30 days relies on pixie dust for its basis.”2 To meet deadlines for print, I am typically writing editorials 3 to 4 months before the final version will be seen by readers, leaving me to guess what lies ahead. Sometimes I miss the mark.
Thus far, COVID-19 waves have fluctuated throughout the country with respect to timing and impact. During various waves of the pandemic, we hoped for a final resolution. While our government instructed the vaccinated public to resume elements of usual life, the work environment for nurses and other health care providers continued to worsen. Nurses in one state might be breathing easier and hoping the pandemic was ending while nurses in another city or state might be experiencing a huge influx of acutely ill patients and worsening work conditions. Each wave came and went leaving more destruction in its path. Some of our international readers experienced virus-related surges before their arrival in the United States. Due to geography and other variables, some of the situations I discuss may not apply to all readers in all places at all times, and sometimes I may overgeneralize about your experience.
Our System Needs an Overhaul
One thing is clear: many critical care nurses have been working in unfathomable work environments that appear to be worsening. A major overhaul of acute and critical care nursing is needed. Nurses have told us loud and clear that they do not want to be heroes—you want a healthy, sustainable work environment. You are willing to work hard, but you also need time to care for yourselves. You deserve the simple things that other professions take for granted, such as having time to eat a meal or empty your bladder during a shift. You deserve to be fairly compensated for the difficult work you perform. You deserve to work in a healthy work environment that supports you and allows you to provide expert nursing care to the best of your ability.
In the spirit of the American Association of Critical-Care Nurses (AACN) Healthy Work Environment standards, health care organizations must strive for skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership.3 As the health care system is revamped, it is critical to ensure that adequate support and leadership are provided not only for bedside nurses,4 but the entire team, including nurse managers.5 Strong consideration should be given to other supportive roles such as clinical nurse specialists, whose engagement in patient care has been associated with improved patient outcomes and decreased cost.6
No Easy Answers
This editorial does not contain answers to fix our broken health care system; there are no easy answers. Major changes will take time, not only to create a system that works for all, but to create changes that are sustainable. Across the globe, nursing associations, hospitals, schools of nursing, and others are working to make substantive changes to acute and critical care nursing practice. They also are exploring how we train new nurses and looking to models that have worked in other health care disciplines. Frontline nurses have been involved in many of these initiatives. Your input is important to help create a system that works for you.
Many nurses I talk to believe we already had a nursing crisis before the pandemic. Now we have a crisis on steroids. Our nursing shortage was exacerbated by the pandemic, and the current situation is unsustainable. If changes are not made quickly, we risk losing more nurses, including experienced, expert nurses. Intensive care unit nurse and advocate Sandy Summers expressed this well: “Without nurses, an ICU bed is just a bed.”7 Obviously we cannot continue to work within this broken system; radical and meaningful change is needed. Many are trying to develop innovative ways to provide safe nursing care to acute and critically ill patients and their families.
A number of solutions have been implemented and others are under development. Some institutions have reduced documentation requirements to free up nursing time for direct patient care, which is a great example of de-implementation to remove or revise current practices to free up valuable nursing time.8 There may be other opportunities to de-implement tradition-based practices that are not evidence based. Also, other practices or tasks that do not require critical thinking or high levels of nursing skill might be delegated to trained assistants.7
Team nursing models are being used to manage increasing workloads with fewer registered nurses.9 In some cases, one nurse leads a team of nurses and/or health care providers from other disciplines to care for critically ill patients. I have heard stories of patient care being provided by student nurses, medical residents, and other allied health professionals. Although such solutions are intended to support nurses, they risk increasing nurse workload and stress depending on how thoughtfully they are implemented.
Although travel nurses and military nurses are being used to fill some of our patient care needs, this situation is not sustainable either. Some of you have reported working with travel nurses who have no experience caring for critically ill patients. This type of situation places additional burdens on the entire team, including local intensive care unit nurses and the nurse manager, not only to help the travel nurse become familiar with the local work environment and policies, but to become familiar with safe, evidence-based critical care nursing. The additional discrepancy in financial compensation between travel nurses and local nurses has become another great source of frustration.
Giving Nurses a Voice
Internationally, organizations such as Johnson & Johnson have been working with nurses and others to create a more sustainable workforce.10 Here at home, AACN has worked tirelessly throughout the pandemic to advocate for nurses, beginning with a board member’s visit to the White House in March 2020 to brief officials and the Coronavirus Task Force, demand safe work environments, and advocate for adequate personal protective equipment for frontline health care workers.11
AACN also has launched campaigns, educational efforts, and well-being resources during the pandemic to provide various opportunities to improve working conditions and to give nurses a voice. Here are examples:
An online portal for nurses to share stories in writing or through use of video12
The Hear Us Out Campaign to encourage vaccination in an unthreatening way13
Healthy Work Environment resources including implementation of a fifth national survey to capture nurses’ feedback during the crisis and recommend strategies for action3
A national staffing initiative co-led with the American Nurses Association to identify lasting solutions to chronic challenges to provide for safe and appropriate nurse staffing in the future14
Relationships with organizations such as the Office of the Surgeon General to ensure that your voices are heard at high-profile tables of influence
Nurses collectively have a powerful voice and want to be heard. You want employers, administrators, policy makers, government, nursing associations (including AACN), schools of nursing, the public, and other stakeholders to recognize that your current work situation is unhealthy and unsustainable. We cannot afford to lose more nurses, but we also cannot continue to expect nurses to work within this broken health care system without meaningful change.
In closing, I strongly echo the sentiments expressed by Sandy Summers7 and others: “We must treat nurses as a vital resource.” Nurses want to be heard. They want ACTION and they need it NOW!
To purchase electronic and print reprints, contact the American Association of Critical-Care Nurses, 27071 Aliso Creek Rd, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; email, firstname.lastname@example.org.
The statements and opinions contained in this editorial are solely those of the Editor.