Meeting Today’s Challenges: All In

This decade began with a very difficult year. Heightened awareness of systemic racism and a global pandemic have presented 2 challenges that call into question our personal, professional, and societal responses and responsibilities. At the same time, these challenges affirm the underlying values that drive critical care providers and practice and direct our path forward for the future. American Association of Critical-Care Nurses (AACN) President Elizabeth Bridges’ 2020–2021 theme encourages us that “This Is Our Moment” to be “All In.”

Critical care providers have intimate knowledge of the negative effects of health disparities on health, illness, and recovery. We see the effects of health disparities every day in our intensive care units (ICUs), and there is strong evidence that racial, social, and economic disparities make people more vulnerable to critical illness and trauma and negatively affect morbidity and mortality. ^{1, 2}  Recent data point to poorer outcomes in coronavirus disease 2019 (COVID-19) as well. ³  Social determinants of health disproportionately affect black and brown people and pervade every environment, from local neighborhoods to nations. Thus, if we are to improve health equity in critical care, we must advocate for equity not only in our own ICUs, but more broadly across the health care system and society at large.

We must advocate for our individual patients and their families, ensuring that we treat each person with dignity and respect. We must also accept a responsibility to work to make society more just for all. Commitment to social justice underpins all of the health professions. A core ethical principle of the World Health Organization is “to respect the dignity, worth, equality, diversity, and privacy of all persons.” ⁴  Respect for persons is explicit in the American Nurses Association Code of Ethics for Nurses, which forms the ethical bedrock of the nursing profession. Three of the Code’s 9 provisions directly address diversity and inclusion. ⁵  Provision 1 addresses the nurse’s responsibility to individuals (“The nurse practices with respect for the inherent dignity, worth, and unique attributes of every person” ^5(p1), while provisions 8 and 9 speak to wider societal obligations (“The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities” ^5(p31) and “The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy” ^5(p35). The AACN vision statement says, “AACN is dedicated to creating a healthcare system driven by the needs of patients and families where acute and critical care nurses make their optimal contribution.” ⁶  Our patients and families need and deserve a health care system that provides high-quality care for all patients, that addresses social determinants of health and health inequities head on, and that seeks to eliminate health disparities. Civil rights demonstrations have argued, “no justice, no peace.” We would also argue, no justice, no health. In the social justice challenge of true equality for every person, we must be All In.

The COVID-19 pandemic has loomed large over critical care throughout 2020, and it will continue to influence critical care for the foreseeable future. Clinical experience and emerging research are both important components of meeting this challenge. The American Journal of Critical Care continues to publish new high-quality evidence for the critical care community, moving high-impact papers forward as quickly as possible. However, it is important to recognize that the body of critical care knowledge generated from prior research can also inform our response to problems encountered in the current pandemic. Evidence related to prone positioning for patients receiving mechanical ventilation, ^{7, 8}  for example, has been directly applied to care of COVID-19 patients with good results. ⁹ 

Family-centered care, palliative care, healthy work environments, and measures to mitigate clinician’s moral distress all have robust evidence supporting their contributions to better patient outcomes. But pressing issues related to infection control, high patient acuity, and surges in ICU volume are viewed as imposing barriers while we strive to maintain evidence-based practices. A striking example is found in ICU visitation policies. Strict prohibitions on visitors to hospitals to reduce risk of COVID-19 spread have resulted in difficult situations for patients, families, and clinicians. These prohibitions are particularly complex at end of life, and they present complicated ethical dilemmas. ¹⁰  We applaud the commitment of clinicians to incorporating innovative approaches to meeting the needs of patients and their families in these extraordinary circumstances. AACN and DearWorld.org have partnered to showcase stories of nurses’ experiences during the COVID-19 pandemic, ¹¹  which provide beautiful exemplars of how nurses maintain a focus on meeting the needs of individual patients and families under difficult constraints and situations. Maintaining high-quality patient- and family-centered care requires that we be All In.

Healthy work environments are at risk of compromise during COVID-19. Shortages of personal protective equipment (PPE), adverse reactions to PPE, staffing shortages, high patient acuity and volume, moral distress, and lack of true collaboration all jeopardize not only nurse well-being but patient outcomes. AACN has been a leader in advancing health work environments, and has been assertive in COVID-19 advocacy efforts for nurses. ¹²  At the national level, AACN has worked determinedly and partnered with other organizations to bring work environment issues and solutions to the forefront. In fostering healthy work environments, and in order for nurses to make their optimal contribution, we must be All In.

Systemic racism and the COVID-19 global pandemic have posed exceptional challenges to health care providers and to society. These challenges also provide opportunities to improve human well-being now and in the future. Foundational values of the respect of every person’s worth and of social justice, coupled with a commitment to improving patient outcomes and healthy work environments, can enable us to emerge from the current crises stronger. We thank AACN President Elizabeth Bridges for her outstanding and inspirational 2020–2021 theme. This is our moment, and we are All In.