Future of Nursing 2020-2030: Supporting the Health and Well-being of Nurses.

Abstract

Awareness of the value of healthy work environments is not new. Researchers have found that healthy work environments support better patient outcomes1–3 and better nurse outcomes by lowering the proportion of nurses intending to leave a position in the next 6 months.4–6 The American Association of Critical-Care Nurses (AACN) published the first Healthy Work Environment standards in 2005,7 later updating them with minor revisions in 2016. The standards remained the same in both versions: skilled communication, true collaboration, effective decision-making, appropriate staffing, authentic leadership, and meaningful recognition.8Now more than ever, healthy work environments matter. The pandemic— with its surges of very sick patients, increased number of deaths, and added patient support needs amid visitation limits—has increased nurse stress, including moral distress.9–12 These pressures make it a critical time to support the health and well-being of nurses in order to improve retention and patient safety. A recent study by Melnyk et al13 emphasized that nurse leaders and health care systems need to prioritize the health of nurses by prioritizing resolution of systems issues, ensuring a culture of wellness in order to increase quality care and reduce medical errors.13The Future of Nursing 2020-2030 report sets up several priorities, but the focus of this column will be recommendation 3: The report suggests that if nurses are going to tackle health equity and social determinants of health,14 they must first address their own well-being. When the environment does not support nurse well-being, staff turnover is high and quality of patient care is affected, costing hospitals an estimated $3.6-6.1 million annually. All of this ultimately impacts hospitals’ ability to care for vulnerable populations.15The National Academy of Medicine (NAM) has previously underscored the importance of supporting clinician well-being.16 Taking Action on Clinician Burnout defines well-being as Health care organizations have significant work to do to improve all aspects of nurses’ well-being, including physical, mental, social, and moral well-being.Taking Action on Clinician Burnout addresses several factors that impact clinicians’ well-being. The first recommendation is to address the larger social setting in which the health care industry operates including laws, the regulatory framework, professional standards, and societal values. The second recommendation in the report addresses health care organizations’ structures and processes, including leadership, management, policies, and procedures. The third recommendation addresses “front line care delivery,” which involves teamwork between clinicians, organizational culture, and professional relationships.16 All of these recommendations can be impacted by implementing AACN’s healthy work environment standards, improving nurse well-being.Communication is essential to a healthy work environment. Communication was among 5 health care staff requests Shanafelt et al11 identified during the COVID-19 pandemic (hear me [feedback channels], protect me [adequate personal protective equipment), prepare me [rapid training as needed], support me [physical and family needs], and care for me [provide holistic support for individuals and their families]). Nurse leaders should heed this request by listening to their staff, being honest, and providing clear and transparent communication. Staff respect when people tell them the truth; if there are things that cannot be changed, let the staff know and let them know why. Staff also need to be able to communicate not only with their leadership but among team members. Several programs can help an organization improve their team communication, including TeamSTEPPS.17AACN states that nurses must be relentless in supporting true collaboration,7 including breaking down silos between disciplines and recognizing what the entire team brings to the bedside to care for patients and to work collaboratively on organizational initiatives. In a study, Ulrich et al,6 found that communication and collaboration highly correlated with job satisfaction, quality of care, frontline nurse manager overall effectiveness, and nurses’ intent to leave their current job. An organization that supports collaboration focuses on structures and processes to decrease or eliminate workplace incivility and bullying and has zero tolerance for workplace violence. In addition, a culture that enables true collaboration will support diversity and inclusion. Organizations should offer training in structural racism and implicit bias to assist staff in gaining self-awareness and emotional intelligence, which may help staff identify ways they contribute to a work environment that does not support teamwork or health equity. Problematic behaviors and attitudes are often unconscious, so awareness by staff can address individual contributions to a culture.Gratitude and meaningful recognition are important elements for staff to feel respected and recognized for a job well done. The DAISY Award has helped improve meaningful recognition and decrease compassion fatigue, as studied by Kelly and Lefton.18 They found that meaningful recognition was a significant predictor of decreased burnout, decreased secondary traumatic stress, and increased compassion satisfaction. In addition, recognition that is related to a specific situation in which the nurse had an impact is more meaningful to the staff. Recognizing these incidents at staff meetings is another way to acknowledge staff contributions in a way more meaningful than a generic thank you.Supporting staff to engage in decision-making about issues that impact their work and the care that they give patients is one of the most important things that nurse leaders can do. AACN encourages nurses to partner with leadership to implement policies and procedures and make decisions that impact their work environment. Nurses who have and use their voice will take ownership in their unit. The Future of Nursing Report 2010-2020 encouraged nurses to be committed partners with physicians and to be accountable for the care that they give together with other members of the team.19 Nurses who feel like part of a team can confidently make better decisions.Appropriate staffing, per NAM, entails “Sufficient human resources to enable nurses to provide high-quality person-, family-, and community centered care effectively and safely.”14 It is one of the more challenging standards to implement historically; Ulrich et al6 confirmed that appropriate staffing remains a problem for nurses.6 With the pandemic, staff are retiring early or leaving the profession, resulting in critical shortages throughout the country. Nurses experience fatigue and burnout when their units are chronically short-staffed, so managing staffing in this environment is essential. Ways for nurse managers to do this include improving the work environment so staff feel supported, showing gratitude to the staff for what they are doing to keep patients safe, ensuring staff get their appropriate breaks to allow them to refresh, and listening to their concerns so that things can improve. Taking these steps can improve retention and ultimately improve staffing.Nurse leaders have the ability to impact the health and well-being of nurses by providing support and setting the culture of the department by acting as a role model. Authentic leaders ensure that bullying behavior is addressed and that there is zero tolerance for workplace violence. Ulrich et al6 suggest that nurse leaders develop a culture where nurses feel that they are heard and that actions are taken to address unsafe conditions. Blake et al4 found that the strongest predictor of nurses’ intent to stay in their job was the support that they felt from the leader. The leadership style sets the tone for the department. Nurse leaders also are at risk for burnout and need to seek resources and identify their own needs to maintain their well-being. If the nurse leader is experiencing burnout, they will not have the energy to support their staff. Therefore nurse leaders should practice self-care, such as healthy eating habits, getting enough sleep, and doing what they can to have a balanced life and take time off to re-energize. Healthy Nurse, Healthy Nation by the American Nurses’ Association is a good framework for practicing self-care and includes fitness and exercise programs, recommendations on healthy eating and sleep habits, and mindfulness resources.20By implementing the AACN’s Healthy Work Environment standards, organizations demonstrate commitment to supporting nurses’ well-being. There are numerous structures and process that, when put in place, can improve the work environment. What may work at one organization may not work at another, so it is worthwhile to get the frontline staff involved in any changes that take place. They need an opportunity to speak to what issues are impacting them the most and what processes would be the best to implement to decrease turnover and improve patient care. The Future of Nursing 2020-2030 has important recommendations to support nurses’ well-being.14 Supporting nurses’ well-being will allow them to optimally manage the patients in their care. In addition to implementing the Healthy Work Environment standards, nurses need to manage their own well-being, including eating healthy, getting enough sleep, and exercising. The Future of Nursing 2020-2030 charts a path to achieve health equity, and that can only be done when nurses are well themselves.