Web of Mutuality: Relational Integrity in Critical Care Nursing

Long before the COVID-19 pandemic, relationships with patients and colleagues were the fuel that kept nurses coming back day after day. Consistently identified as the most ethical and trusted profession for more than 2 decades, nursing has enjoyed positive regard and admiration by patients for its ethical standards, reliable care, and presence.1 Teams comprised of diverse clinicians and other health care workers created a foundation of competence and confidence that contributed to safety, quality, and camaraderie. Leaders and organizations, responsible for creating a supportive environment, invested in programs of nursing excellence such as American Nurses Credentialing Center’s Magnet or Pathways to Excellence programs. In many communities, there were partnerships with health care systems and the people they served. In some places there was a sense of shared purpose and solidarity.But things have changed. Levels of violence against nurses have skyrocketed.2,3 Patients are turning against nurses’ expertise and advice in favor of unsubstantiated treatments or practices, and disrespect has become normalized.4 Health care teams are fractured by staff turnover, short-term assignments by externally employed nurses, and a “brain drain” of experience as the workforce is populated by less experienced clinicians.5 Communication is transactional and largely relegated to disembodied electronic memes or texts. Leaders and organizations are struggling to compensate for losses after the pandemic and are relying on historical strategies of increased throughput and efficiency to balance the budget. Nurses and other clinicians continue to be asked to do more with less. Societal upheaval, conflict, and uncertainty have destabilized relationships in neighborhoods and communities. Arguably, the relational integrity of everyone has been eroded.Relational integrity, a key component of moral resilience, refers to the dynamic interplay of the personal integrity of everyone engaged in the delivery of health care.6 This includes clinicians, health care workers, leaders, communities, and the people served—our patients and their families. Beyond personal integrity, it encompasses the values and commitments inherent to our professions, as outlined in our codes of ethics. Relational integrity is reflected in our choices, behaviors, actions, and professionalism, and it acknowledges that our moral compass is primarily executed in the context of relationships with others. This type of integrity refers to the inevitability of our personal integrity being tethered to, and thus influenced by, the integrity of patients, other clinicians, leaders, and the institutions within which we practice. Our interdependence and interconnection with each other are reflected in myriad ways including the micromoments of connection that occur every day. Collectively, we resonate with each other’s integrity when it is manifest and when it is degraded. We detect these signals of alignment or misalignment in our bodies, hearts, and minds. Relational integrity fluctuates in practice settings between everyone being whole and undiminished and their wholeness being fractured temporarily or permanently.The quality of relationships between clinicians and patients, interprofessional clinicians and their leaders, and with the broader community is influenced by relational integrity. As a dynamic ecosystem, it involves mutual respect, skillful communication, and authentic collaboration. Maintaining relational integrity is key to building strong relationships among clinicians, patients, and interprofessional teams, and to gaining the respect and collaboration needed for desired results. It encompasses effective, mindful communication and is essential for achieving positive patient care outcomes, fostering moral resilience, and promoting staff engagement and fulfillment. When relational integrity is intact, all parties feel seen and heard, communication is transparent and honest, and there is respect for patients’ experiences and clinician’s expertise. Empathy, understanding, trust, and curiosity flourish, thereby contributing to everyone’s wholeness and sense of belonging. When relational integrity is fractured, clinicians do not feel supported, respected, or empowered; likewise, staff morale and engagement can suffer and may lead to increased moral suffering or burnout. This breakdown can result in breaches of trust, poor collaboration, ineffective communication, delayed interventions, medical errors, and ultimately poorer patient outcomes.7 This dynamic web of relationships extends into communities and society at-large. Beyond the walls of health care organizations, there are complex social, political, economic, racial, and cultural forces that impact the personal, professional, and relational integrity of clinicians and those they serve. When there is alignment in values, behaviors, policies, and practices, integrity thrives. When patterns of degraded relational integrity accumulate in a context of constrained work environments, societal and community disintegration, conflict and violence, the insidious erosion of the integrity of the health care enterprise and the people in it becomes undeniable.It’s a busy night in the emergency department (ED). Nurse Isaac clocks in for his night shift and receives the nursing shift report from the outgoing day shift nurses. There are 8 rooms in Issacs’s section of the ED, each separated by curtains. Because of the high patient census, 15 patients are shuffled into the section that was built to accommodate less than half that number. Isaac is the only nurse in his section tonight. He pauses when he notices the name of the ED physician in charge for the evening, Dr Fay. He recalls their prior interactions have been challenging.Anthony, a 65-year-old man, arrives at the ED with a chief complaint of chest pain and shortness of breath. The patient has a history of tobacco use, chronic obstructive pulmonary disease (COPD), and high blood pressure, as well as a positive family history of acute coronary syndrome. An electrocardiogram (ECG) is ordered by Ava, the triage nurse, while Ruby, the clinical nursing assistant, takes Anthony in a wheelchair to Isaac’s section and places him on a cardiac monitor with a pulse oximeter and blood pressure cuff. Isaac is preoccupied, attempting to deescalate the ire of a patient waiting over 2 hours to be seen by a doctor for a superficial laceration to their arm who is demanding to speak with management.Meanwhile Chris, the ECG technician, has the printout of the ECG in hand and is waiting outside a patient’s room to share the results as the doctor finishes assessing the patient. Five minutes later, Dr Fay steps out of the room and is handed the ECG report; it shows non–ST-elevated myocardial infarction (NSTEMI). After taking the ECG printout from Chris, Dr Fay mutters something unintelligible and enters the room where Isaac is attending to the irate patient. Dr Fay comments to the patient that there is an urgent situation requiring Isaac’s attention and that the patient’s issues will have to wait. Isaac and Dr Fay hurriedly enter Anthony’s bedspace to find him diaphoretic and dyspneic, with chest pain described as a 9 out of 10. Isaac quickly introduces himself to the patient but is cut off by Dr Fay, who introduces themself as “the doctor.” Dr Fay performs an assessment on Anthony and then proceeds to walk out of the room before being stopped by Isaac, who asks for verbal confirmation of the plan of care. Dr Fay tells Isaac that orders can be seen in the electronic medical record (EMR). Isaac reminds Dr Fay to order a respiratory swab because Anthony will need those results to be admitted to the cardiac intensive care unit (CICU). Dr Fay nods dismissively and walks off. Isaac turns toward Anthony, noticing his anxious expression, and reassures him that the team is doing their best to help him and asks if there is anyone he would like Isaac to contact.Isaac initiates his own assessment of the patient. He repositions Anthony to support his breathing and titrates supplemental oxygen to an appropriate rate given his history of COPD. Isaac builds rapport with Anthony through small talk as he implements Dr Fay’s orders, which have appeared in the EMR. Isaac notices that the respiratory swab was not ordered. He knows that hospital policy requires that patients admitted to the hospital must have a respiratory swab test result before being transferred to a room. Wary of Dr Fay’s reaction to being reminded a second time, Isaac opts to use the electronic messaging system to send the doctor a reminder to order the swab.Over the next 5 hours, Isaac’s attention is split across 15 patients. Despite the high patient volume, limited resources, and no relief, Isaac manages to keep up with his most critical patients, to the chagrin of those patients who are more stable yet still in need of care. Finally, he sees that a bed has been made available in the CICU for Anthony. Isaac immediately calls up to the floor to give a nursing report. The receiving CICU nurse notes that the respiratory swab result has not been recorded and reminds Isaac that they will need those results before Anthony can be transported.Exasperated by the delay, Isaac checks the EMR to see that Dr Fay has neither ordered the test nor acknowledged his electronic message. He leaves his section to remind Dr Fay in person to place the orders. The doctor tells Isaac to wait while they review a resident’s charting for another patient. Isaac stands anxiously at the desk. He looks back at his section and sees several colleagues gathering around Anthony’s room. A code alarm is triggered, and Isaac and several doctors rush over to the room to find Anthony cyanotic with agonal breaths and oxygenation of 60%. Anthony becomes pulseless, compressions are started, and he is intubated. Return of spontaneous circulation is achieved after several rounds of cardiopulmonary resuscitation.Anthony has been stabilized for now, albeit in worse condition than before. Ava, the charge nurse, calls the CICU manager to expedite transfer to the floor. Isaac overhears Dr Fay commenting to Ava that this could probably been avoided if Anthony’s nurse had not been distracted. Ava responds by saying that Isaac is one of the most capable nurses on the team, and Anthony is fortunate to be in his care. Isaac finally gives his hand-off to the nurse in the CICU, who says about the missing respiratory swab, “Aren’t you aware of the hospital policy?”Clinical practice is fundamentally relational work where patients and health care workers meet each other in a complex, often uncertain, and rapidly evolving context. Each person in the dynamic brings with them their unique moral fingerprint of values, beliefs, and principles along with their cultural and social practices. Our clinical work engages our human vulnerabilities and interdependence. Relational integrity includes being true to one’s own moral compass while establishing effective engagement and boundaries in relationships and decisions.6 The inter-connection of everyone’s integrity is particularly vital when considering the situations that clinicians must navigate, balancing competing obligations to their patients and their surrogates, the institutions where they practice, and the broader society. Clinicians such as those in Isaac’s case must consider what they owe their patients and each other in the context of health care relationships, and what commitments and expectations they are willing to enact and hold themselves and each other accountable for.Respecting everyone’s humanity, especially the people we serve, is a crucial component of relational integrity.6 Isaac demonstrates this when, amid a crisis, he introduces himself before conducting his assessment and when he builds rapport while providing care and reassurance to ease Anthony’s anxiety. Relational integrity is upheld when we attune to the needs of others and respond in ways that nurture respect and wholeness. Isaac noticed Anthony’s expression of concern, and despite the time constraints, paused to reassure Anthony and offered to reach out to people important to him. Throughout the scenario, Isaac connected with his core values of respect for the inherent dignity of his patients and prevention and minimization of harm by prioritizing those at greatest risk of compromise; he did all this, to the best of his abilities, in a fair, equitable, and compassionate manner. Research suggests that when there is alignment between organizational and health care worker personal and profession values, the necessary conditions for compassion to arise are enhanced.8 Isaac leveraged his knowledge, skills, and experience to navigate the complexity without exacerbating the tenuous relationships and circumstances that he found himself in. Although it is not explicitly stated, he likely used a variety of self-regulatory skills and self-stewardship practices to support his ability to remain stable amid the chaotic ED.8,9As illustrated in the case, teamwork is necessary for safe, high-quality care. Relational integrity leverages the shared interdependence and humanity of the entire clinical team. It depends upon solidarity of purpose and invites the contributions of all to achieve the desired patient outcomes, organizational priorities, and professional goals.6 When a team is “divided, lacks solidarity, or is weakened by cowardice or ineffective leadership, it can disable the entire group.”6 Relational integrity is fundamentally inclusive of the diversity of values, perspectives, and contributions of everyone and creates an environment where no one is left out. Personal and professional integrity is a foundation for relational integrity. It requires knowing what one stands for and having the confidence and courage to defend against threats or challenges while maintaining respectful relationships with others. Ava stood firm in her values of respect and fairness when she responded to Dr Fay’s appraisal of Isaac’s performance. She leveraged her integrity by constructively offering an alternative view and modeled respectful engagement with someone holding a different perspective. This illustrates the small ways that integrity can be fortified or eroded by the behaviors of a few. When one person’s integrity is upheld, relational integrity thrives; when it is compromised, the collective integrity of everyone is eroded. This expanded view of integrity enlarges the sphere of individual integrity to include awareness and sensitivity to the integrity of others and helps to define and honor the boundaries of relationships, roles, and authority.Although this scenario is fictional, it reflects the lived experiences of health care providers and their patients. Further, it also highlights some of the explicit and implicit challenges and advantages to relational integrity. While there are individual decisions that impact the patient and professional experiences, there are also decisions made at the social, political, and institutional levels that trickle down to impact those individual decisions. Relational integrity resides within a dynamic social-ecological context that is impacted by the interplay among complex and often dissonant influences. Imbalances in power or authority, constraints imposed by hierarchical systems, and dependencies on others to enact one’s responsibilities creates challenges to shared purpose and values.6 Intact personal and professional values and integrity are necessary to inform group process, clinical practice, and organizational policy and culture. Alignment with organizational values is needed to support and encourage clinicians to meet their individual and shared moral commitments and organizational priorities without disproportionate stress, distress, or degraded well-being.Whether an individual is a nurse, doctor, medical technician, or ancillary staff, the shape of one’s practice is formed by many hands and executed through relational engagement, trust, and collaboration. In Anthony’s case involving the ED team who transfers him to the CICU, there were numerous junctures where relational integrity was fractured. The doctor and nurse assigned to the patient have a history of poor communication and a lack of trust. The nurse hesitates to speak up when he notices a change in the patient’s condition, because the doctor has a pattern of dismissing concerns. The patient’s condition deteriorates, eventually requiring intubation and mechanical ventilation. The lack of communication and trust between the doctor and nurse delays the initiation of appropriate treatment, resulting in a longer hospital stay and increased risk of complications. Other members of the ED team such as Chris, the ECG technician, also hesitate to breech the role-based hierarchical norms of the ED. Dr Fay demonstrates a pattern of dismissive responses to the suggestions of other team members and engages in gossip and degrading verbal and nonverbal communication. An interpersonal slight between the CICU nurse and Isaac during the handoff add to the adversity.These dynamics occur within an environment where already depleted clinicians are expected to safely manage unrealistic numbers of patients without sufficient resources. As a result, their ability to be flexible and collaborative is significantly impaired. Where there is a lack of trust, transparent communication, and collaboration, nurses may begin to feel increasingly frustrated, unsupported, and ignored.10 They become hesitant to speak up and advocate for their patient’s needs, as they fear being reprimanded or ignored. Burnout ensues as the nurse becomes disenchanted with the work environment, and moral suffering escalates as the gap between values and actions become more discordant.8 The accumulated stress, burnout, and moral residue contributes to attrition and ongoing recruitment and retention challenges. One in five health care workers have quit since 2020, and a recent survey by Elsevier Health found that 47% plan to leave their jobs by 2025.11 This loss of personnel is bound to further disrupt relational integrity in an already strained health care system. These cumulative circumstances can be understood as breeches of commitments and values by health care organizations or leaders who have implicitly promised to provide the resources necessary to fulfill one’s role requirements.In a broader sociopolitical and organizational perspective, Isaac begins his shift by walking into an unsafe practice arena, whereby he is expected to care for and monitor 15 patients by himself.12,13 It is an impossible task that is the current reality for many nurses in the United States. More than 90% of nurses say that their workplaces are understaffed.13 Meanwhile, decade’s worth of studies demonstrate that patient outcomes are improved by increasing nursing-to-patient staffing. Driscoll et al14 conducted a systematic review that suggested staffing more nurses reduces the risk of adverse events and in-hospital mortality.Indeed, inadequate staffing is a systemic issue that needs to be addressed at the legislative and institutional levels of care. However, legislators can often be too distanced from the consequences of well-intentioned but inadequate or even harmful legislation, making it hard for them to improve hospital conditions. What follows is a breech in relational integrity that reverberates from political and organizational policies and practices that undermine the ability of nurses and other health care workers to practice in accordance with their personal and professional values. When these spheres of relational integrity are fractured, it initiates a cascade of degraded relational integrity among leaders, other health care workers, and the people to be served. It animates a narrative of “Us vs Them,” rather than pulling stakeholders into shared purpose and commitments. Furthermore, in the face of scientific data supporting increased staffing to ensure safe patient care, historical budgetary patterns that relegate nursing services to a flat cost rather than a value proposition allows health care leaders to continue to balance the budget by cutting nursing services.15,16 This way of operating could be changed without legislative mandates, but it would involve a fundamental paradigm shift.Relational integrity is fractured when there is a dissonance in values between clinicians and staff and their health care organization’s values.8 When clinicians do not have the time, resources, or support to enact their professional commitments, personal and relational integrity is compromised. The degree of organizational effectiveness is negatively correlated with moral injury scores among nurses during the pandemic.17 These high-level patterns shape the context of care in our scenario.Embedded within the broader sociopolitical context, relational integrity is challenged by an unhealthy hierarchical culture of practice. There are 2 significant moments when deference to hierarchical norms led to a delay in communication that placed Anthony at risk. The first is when Chris, the ECG technician, delays interrupting Dr Fay to present Anthony’s ECG results, an important step toward early identification and intervention on the patient’s behalf. The second moment is when Isaac steps away from his section to remind Dr Fay to order the respiratory swab. In these instances, both Isaac and Chris are concerned that interrupting the doctor would be a sign of disrespect to the hierarchical positioning of the physician. Throughout the scenario, Dr Fay demonstrates a pattern of dismissive responses to the suggestions of other team members and engages in gossip and degrading verbal and nonverbal communication. Relational integrity is compromised when any member of the team engages in behaviors or communication that causes interpersonal harms. Vertical or horizontal interpersonal violence, bullying, disrespect, or microaggressions can erode trust and the integrity of the moral community.18 These patterns are likely exacerbated when stress and exhaustion become the norm rather than the exception.Whereas communication—the ability to receive and relay information to achieve mutual understanding—is the cornerstone of quality health care, a hierarchical culture that places excess emphasis on rigidly defined roles and their perceived significance and authority can hinder quality health care. Such cultures can lead to communication failures, as those perceived as lower-ranking individuals refrain from speaking up when higher-ranking individuals fail to listen or respond. In one study, nearly one-third of the health care team feared repercussions from flagging potential errors.19 This can have unintended consequences for patient outcomes. When members of the clinical team do not raise safety concerns, it can contribute to medication errors, cause delays in treatment decisions or procedures, and compromise patient hygiene and relational care.20 Left unchecked, rigid hierarchies can suppress the voices of lower-ranked individuals, placing them in conflict with their professional responsibility to speak up on behalf of patient care and thereby eroding the relational integrity of everyone.Clinicians such as those in the case study attempt to navigate the pressures that such hierarchical cultures place on interprofessional communication by using the direct messaging system within the EMR. Direct messaging allows for a secure, real-time exchange of patient information, which can aid in timely and accurate decision-making and agreement over the plan of patient care. Naturally, the implementation of digital communication between health care professional leads to a decrease in their face-to-face communications. Despite the potential for faster communication, digital communication can undermine the collective responsibility for an effective, relational workflow.21 Electronic communication tends to be cryptic and devoid of the context that is needed for understanding the meaning behind the words, which can undermine the alignment of the goals and plan of care among team members who may have diverse perspectives and values.22,23 When conflict among the team is not surfaced or addressed, overt and covert responses begin to emerge that further degrade team functioning and relational integrity.Relational integrity thrives when we know each other as human beings rather than solely by our roles or positions. Less face time among the clinical team negatively impacts the relationship-building necessary for establishing trust and camaraderie between colleagues. Trust-building includes building faith in others’ capability, character, and communication.24 Effective teamwork is facilitated when we know who we can count on, when our capabilities are appreciated and understood, and when we speak with good purpose and clarity.24 Data suggest that physician responsiveness to direct messaging is influenced by the level of trust established between themselves and nurses.25 Myriad factors influence the building of trust, including time pressures and prior experiences.25Indeed, building trusting relationships among clinicians takes time, and until sufficient time is invested, clinicians’ interactions will be premised on underdeveloped trust or patterns of interpersonal betrayal. Evidence has demonstrated that, during the pandemic, nurses experienced betrayal by health care professionals they once trusted, by their leaders, and by people outside of health care.17,26 The time required to nurture interprofessional trust, however, is undercut by the high turnover rate often brought on by burnout. In a recent survey of nurses, physicians, and advanced practice providers, 25% were considering switching careers, with nearly 90% of these respondents citing burnout as the primary reason.27 Until there is actionable commitment from hospitals and legislators to alleviate underlying causes of burnout, interprofessional relationships among clinicians will continue to suffer from high staffing turnover.28,29The spheres of relational integrity involving the sociopolitical, health care organizations, and team culture have a direct impact on the patients nurses are dedicated to serving. Anthony and the other patients under Isaac’s care likely experienced varying degrees of dignitary harms associated with not being listened to or known as a person by the people caring for them.30 Despite Issacs’s efforts to engage with Anthony within the complexity of the situation, it is likely that both parties experienced a relational disconnect. When nurses cannot provide the care they know they are capable of and are committed to, it begins to erode their identity as nurses, which creates stress, distress, and moral suffering.31 Over time, these types of residues accumulate and impact nurses’ personal, professional, and relational integrity and their well-being and commitment to their jobs and the profession.Although the scenario presented serves to highlight the challenges to relational integrity, it also provides a framework for imagining how intact relational integrity would alter the course of Anthony’s care. Beginning with the sociopolitical integrity surrounding health care infrastructure, an intact investment would guarantee sufficient staffing so that no clinician would walk into a scenario where they are expected to manage an unsafe number of patients. Strategies such as mandated staffing ratios have been proposed as an external lever to achieve this goal.30 Data suggest that improved staffing ratios are related to decreases in in-hospital mortality, missed care, and likelihood of death.12,14 Whether mandated ratios will ultimately achieve the intended goals remains to be sufficiently studied.32 Regardless of the mechanism to accomplish the goal, nurses should be empowered and authorized to make allocation decisions based on patient needs and nursing capacities, including limitations on safe admissions, transfers, or discharges. As the American Association of Critical-Care Nurses has long envisioned—“a health care system that is driven by the needs of patients and families where acute and critical care nurses make their optimal contribution” might become a reality.33 Accomplishing this goal will require a fundamental paradigm shift that begins with aligning organizational values with the professional values of those delivering care. New models of shared governance and cocreated solutions and accountabilities for processes and outcomes will be necessary.In the typical hierarchical structure of health care, it’s necessary to question authority in cases of a potential error or unsafe situation. Hierarchy has its place, but it can also hinder open communication, as medical professionals may be hesitant to challenge their superiors without fear of negative consequences.34 Relational integrity depends upon an environment of inquiry, discernment, and safety to bring concerns to the attention of those authorized and responsible for addressing them without fear or shame.6 Unhealthy hierarchical structures and unbalanced power dynamics in health care teams create barriers for open communication among team members and can further undermine relational integrity. Nurses may find it challenging to express their opinions to higher-status individuals due to fear of criticism or rejection. When there is an environment where nurses’ or others’ views, perspectives or input is systematically silenced or discounted, a key element of relational integrity is violated. Clinical authority gradients between nurses and physicians can exacerbate this issue.35 An unhealthy hierarchical structure can reinforce attitudes of superiority or entitlement by those with more authority and lead to dismissive behaviors toward the input of nurses in clinical practice. This may result in suboptimal patient care, as physicians, for example, might overlook important details that nurses bring to their attention and cause patient harm. This was evident in Anthony’s case when opportunities to incorporate the input of all the team members were limited or discredited.Without the negative consequences of hierarchy and various types of interpersonal harms influencing the communication between health care team members, the case study may have played out differently. First, Chris, the ECG technician, would have felt more comfortable interrupting a patient examination to hand the ECG report to Dr Fay, who would in turn have appreciated Chris’s attention to an urgent situation. Early recognition of NSTEMI leads to earlier interventions that ultimately improve patient outcomes.36 Next, Dr Fay and Isaac might have come to the same understanding on the importance of ordering the respiratory swab as a necessary step for transferring Anthony to a higher level of care. Isaac would not have hesitated in speaking up and would not have had to step away from his section to find the doctor. We can imagine how these hierarchical structures can negatively affect patient care when nurses fear speaking up or advocating when they perceive a concern. Consistent with the tenets of relational integrity, individuals, teams, organizations, and the broader community/society have a shared responsibility to contribute to a climate of relational integrity (Figure).Relational integrity is the foundation of trust and collaboration among health care professionals that leads to improved job satisfaction, increased clinician retention, and better patient outcomes. It fosters effective communication, shared decision-making, mutual respect, and a supportive work environment, creating a positive and collaborative team dynamic. Intact relational integrity in health care settings is critical to promoting and maintaining a collaborative and supportive environment that benefits both patients and health care professionals. Strategies such as adequate human and material resources, empowering nurses to make allocation decisions, new models of shared governance, and cocreated solutions and accountabilities for processes and outcomes can shift organizational values to align with professional values and create a climate of inquiry, discernment, and safety, ultimately improving the quality of care provided.We acknowledge the contributions of our nursing colleagues in helping us enhance our understanding of this topic. We honor the contributions of all nurses in all roles and specialties who are serving so many people in need of their services.