American Association Of Critical-Care Nurses Research Articles

[Best evidence summary for awake prone positioning in treating hypoxemic due to COVID-19 infection].

Objective: To retrieve, evaluate, and summarize the best evidence for the treatment of hypoxemia in patients with COVID-19 infection using the awake prone positioning, with the aim of guiding healthcare professionals in the standardized implementation of this therapy. Methods: A systematic search was conducted in databases including UpToDate, BMJ Best Practice, JBI Evidence-Based Healthcare Center, American Association of Critical-Care Nurses, Intensive Care Society, European Respiratory Society, World Health Organization website, Cochrane Library, PubMed, China National Knowledge Infrastructure (CNKI), and Wanfang. The retrieved literature was subjected to quality assessment and evidence extraction. Results: A total of ten publications were included, consisting of one thematic evidence summary, one guideline, two systematic reviews, three randomized controlled trials, and three expert consensus statements. This summary synthesizes thirty key pieces of evidence in five categories: organizational management and training, risk assessment, preparatory operations, implementation key points, and risk control. Conclusions: Awake prone positioning is beneficial for improving hypoxemia in patients with COVID-19 and is easy to implement. Medical institutions should develop nursing management systems, operational standards, and best practices for awake prone positioning based on evidence-based evidence in order to improve the quality of care management for such patients.

Healthy Work Environment Standards in Tele-Critical Care Nursing.

The COVID-19 pandemic exacerbated staffing challenges in intensive care units, with increased burnout and moral distress cited as major problems. A healthy work environment is critical to nurses' success and wellbeing. During the pandemic, a survey by the American Association of Critical-Care Nurses revealed decreased composite scores in each of the 6 critical elements of a healthy work environment. Hospital units that improved even 1 critical element reported higher job satisfaction. The use of telehealth tools by expert nurses expanded care delivery during the pandemic by improving response to acutely and critically ill patients while supporting hospital-based nurses. All of the critical elements of a healthy work environment are relevant to the tele-critical care nurse's role and challenges. This article describes how tele-critical care nurses were affected by the pandemic and how healthy work environment strategies promoted successful nurse and patient outcomes.

Evaluating the Health of the Work Environment and the Perception of New Nurses During the Transition to Practice in Critical Care.

New nurses are the major source of hiring for most hospitals. They fill vacancies left by seasoned nurses creating an experience-complexity gap. Turnover among new-graduate nurses is as high as 85% in the first 2 years. The purpose of this study was to provide a deeper understanding of the factors contributing to turnover. The specific aims were (1) to better understand novice nurses' perceptions of their transition to critical-care practice and (2) to describe all eligible critical-care nurses' perceptions of a healthy work environment. A quantitative descriptive design was used. Data were collected over 3 weeks in February 2022 from novice nurses (n = 12) who completed the Casey-Fink Nurse Experience Survey and from novice and experienced nurses (n = 47) who completed the American Association of Critical-Care Nurses' Healthy Work Environment Assessment Tool. Data were analyzed using descriptive statistics. Respondents to the Casey-Fink Nurse Experience Survey (n = 12) indicated feeling well supported by family, friends, and preceptors, although they felt less positive about prioritizing care, organizing patient needs, and recommending changes to the plan of care. The overall mean score on the Health Work Environment Assessment Tool was 2.99 (n = 47), indicating the need for improvement. Responses varied by unit, years of experience, and certification status. This study contributes to the evolving body of nursing knowledge and has provided a more detailed understanding of the health of the work environment and perceptions of new nurses during the transition to practice.

Ten Years Later, Alarm Fatigue Is Still a Safety Concern.

Ten years after the publication of a landmark article in AACN Advanced Critical Care, alarm fatigue continues to be an issue that researchers, clinicians, and organizations aim to remediate. Alarm fatigue contributes to missed alarms and medical errors that result in patient death, increased clinical workload and burnout, and interference with patient recovery. Led by the American Association of Critical-Care Nurses, national patient safety organizations continue to prioritize efforts to battle alarm fatigue and have proposed alarm management strategies to mitigate the effects of alarm fatigue. Similarly, clinical efforts now use simulation studies, individualized alarm thresholds, and interdisciplinary teams to optimize alarm use. Finally, engineering research efforts have innovated the standard alarm to convey information more effectively for medical users. By focusing on patient and provider safety, clinical workflow, and alarm technology, efforts to reduce alarm fatigue over the past 10 years have been grounded in an evidence-based and personnel-focused approach.

Perceived Impact of Affect Labeling and Social Sharing in Healthcare: Insights from a Pilot Study and Opportunities for Future Investigation

Burnout and declining well-being among healthcare professionals is an ongoing concern. This pilot project aims to explore how affect labeling and social sharing of feelings can impact emotional well-being and perceived connection among teams using an intervention to facilitate sharing of feeling during daily huddles. The population sample included staff across six nursing units within two acute care hospitals. One thousand ninety-one feelings were shared. Four distinct themes emerged in postpilot participant interviews; psychological safety, mindfulness, connection, and bonding. The results of this study can provide insights into the development of future interventions to promote well-being among healthcare professionals. Burnout and declining well-being among healthcare professionals is an ongoing concern. This pilot project aims to explore how affect labeling and social sharing of feelings can impact emotional well-being and perceived connection among teams using an intervention to facilitate sharing of feeling during daily huddles. The population sample included staff across six nursing units within two acute care hospitals. One thousand ninety-one feelings were shared. Four distinct themes emerged in postpilot participant interviews; psychological safety, mindfulness, connection, and bonding. The results of this study can provide insights into the development of future interventions to promote well-being among healthcare professionals. Key Points•Interventions are needed to improve healthcare professional well-being.•Affect labeling and social sharing utilizing a Feeling Wheel is a way to manage one’s emotions and connect with peers. Future work is needed to better understand the role of this intervention in improving emotional and overall well-being. •Interventions are needed to improve healthcare professional well-being.•Affect labeling and social sharing utilizing a Feeling Wheel is a way to manage one’s emotions and connect with peers. Future work is needed to better understand the role of this intervention in improving emotional and overall well-being. The instability and declining well-being of the healthcare workforce continue to outpace recovery efforts. Healthcare professionals (HCPs) are tired and burnt out, and this has been well documented by several prominent nursing and healthcare-related organizations.1American Association of Critical-Care Nurses (AACN)Healthy Work Environments. Aacn.org, 2019https://www.aacn.org/nursing-excellence/healthy-work-environmentsDate accessed: April 17, 2023Google Scholar,2American Nurses AssociationNurse burnout: what is it & how to prevent it. ANA.https://www.nursingworld.org/practice-policy/work-environment/health-safety/nurse-burnout-and-how-to-prevent-it/Date: 2023Date accessed: April 23, 2023Google Scholar Additionally, up to 50% of nurses now report intentions to leave the profession,3Naegle M.A. Kelly L.A. Embree J.L. et al.American academy of nursing consensus recommendations to advance system level change for nurse well-being.Nurs Outlook. 2023; 71101917Abstract Full Text Full Text PDF Scopus (1) Google Scholar which means there will not be enough nurses left in the profession to care for our growing patient population. This “silent pandemic” has been declared a national priority by leading nursing organizations including the American Nurses Association, American Organization of Nurse Leader, and, more broadly, by the US Surgeon General. Interventions must be implemented to counteract these threats and promote well-being in the nursing profession.4Altman M. Delgado S. The importance of nurse well-being and how to achieve it.Crit Care Nurse. 2021; 41: 69-71Crossref PubMed Scopus (1) Google Scholar,5Patrician P.A. Bakerjian D. Billings R. et al.Nurse well-being: a concept analysis.Nurs Outlook. 2022; 70: 639-650Abstract Full Text Full Text PDF Scopus (4) Google Scholar Emotional intelligence, or the comprehensive ability to perceive; understand; and then manage one’s emotions, can help HCPs manage stress; minimize negative emotions; improve their physical and mental health; facilitate a healthy work environment; and reduce burnout.6Prufeta P. Emotional intelligence of nurse managers: an exploratory study.J Nurs Adm. 2017; 47: 134-139Crossref PubMed Scopus (17) Google Scholar, 7Christianson K. Fogg L. Kremer M. Relationship between emotional intelligence and clinical performance in student registered nurse anesthetists.Nurs Educ Perspect. 2020; 42: 104-106Crossref Scopus (5) Google Scholar, 8Anari N. The relationships between the emotional intelligence and job satisfaction: empirical findings from higher education institution in Malaysia.J Health Care Prof Soc Sci. 2012; 5: 124-139Google Scholar Therefore, interventions that focus on self-awareness and management of emotions, as well as social awareness and relationship management, may result in improved well-being and connection among peers. Understanding and managing emotions plays a crucial role in overall well-being, both personally and professionally. One effective strategy for emotional regulation is affect labeling.9Marks E. Walker R. Ojalehto H. Bedard-Gilligan M. Zellner L. Affect labeling to facilitate inhibitory learning: clinical considerations.Cogn Behav Pract. 2019; 26: 210-213Crossref Scopus (5) Google Scholar Social sharing is another practice that can foster connection and build empathy and trust.10Keltner D. Haidt J. Social functions of emotions at four levels of analysis.Cogn Emot. 1999; 13: 505-521Crossref Scopus (1162) Google Scholar These practices have been shown to positively impact various aspects of well-being (see Table 1). The pilot project aims to understand how affect labeling and social sharing by HCPs in a team setting relates to one’s emotional well-being and perceived connection among healthcare team members. The following table expands on the key variables that were used to develop the conceptual model in Figure 1. This model provided the framework for the project.Table 1Variables Impacting Well-beingVariableDefinitionImpact on Well-beingAffect labelingProcess of identifying and verbally expressing one's emotions9Marks E. Walker R. Ojalehto H. Bedard-Gilligan M. Zellner L. Affect labeling to facilitate inhibitory learning: clinical considerations.Cogn Behav Pract. 2019; 26: 210-213Crossref Scopus (5) Google Scholar•Important tool for nurses in promoting both personal and professional well-being.11Vitale E. The mindfulness and the emotional regulation skills in Italian nurses during the COVID 19 pandemic: a descriptive survey-correlational study.J Holist Nurs. 2021; 39: 345-355Crossref Scopus (8) Google Scholar•Method of improving nurses' well-being due to increased empathy and understanding towards others.12Tamir M. Ford B. Should people pursue feelings that feel good or feelings that do good? Emotional preferences and well-being.Emotion. 2012; 12: 1061-1070Crossref Scopus (78) Google ScholarSocial sharing of emotionExpressing emotions with others.10Keltner D. Haidt J. Social functions of emotions at four levels of analysis.Cogn Emot. 1999; 13: 505-521Crossref Scopus (1162) Google Scholar•Positive impact on one's well-being, relationships, and overall health; reducing stress and enhancing interpersonal relationships.10Keltner D. Haidt J. Social functions of emotions at four levels of analysis.Cogn Emot. 1999; 13: 505-521Crossref Scopus (1162) Google Scholar,12Tamir M. Ford B. Should people pursue feelings that feel good or feelings that do good? Emotional preferences and well-being.Emotion. 2012; 12: 1061-1070Crossref Scopus (78) Google Scholar•Validation and support from social networks lead to feelings of connectedness and improved well-being.13Gross J. John O. Individual differences in two emotion regulation processes: implications for affect, relationships, and well-being.J Pers Soc Psychol. 2003; 85: 348-362Crossref PubMed Scopus (6342) Google ScholarHuman ConnectionConnections with others can be classified as positive or negative. The lack of human connection is loneliness, while positive human connection is empathy.14Soler-Gonzalez J. Delgado-Bolton R. Vivanco L. Human connections and their roles in the occupational well-being of healthcare professionals: a study on loneliness and empathy.Front Psychol. 2017; 8: 1475Crossref Scopus (31) Google Scholar•Developing positive human connections is important in influencing worker well-being.14Soler-Gonzalez J. Delgado-Bolton R. Vivanco L. Human connections and their roles in the occupational well-being of healthcare professionals: a study on loneliness and empathy.Front Psychol. 2017; 8: 1475Crossref Scopus (31) Google Scholar•Work environments supporting the promotion of civil working relationships through human interactive connection and the personal development of resilience contribute to lower burnout and emotional exhaustion resulting in increased professional satisfaction.15Hart P.L. Brannan J.D. De Chesnay M. Resilience in nurses: an integrative review.J Nurs Manage. 2014; 22: 720-734Crossref PubMed Scopus (255) Google ScholarEmotional Well-beingSuccessfully navigating stress and adapting in challenging times.16National Institutes of HealthEmotional wellness toolkit.https://www.nih.gov/health-information/emotional-wellness-toolkitDate: 2022Date accessed: April 30, 2023Google Scholar A component of well-being,4Altman M. Delgado S. The importance of nurse well-being and how to achieve it.Crit Care Nurse. 2021; 41: 69-71Crossref PubMed Scopus (1) Google Scholar,5Patrician P.A. Bakerjian D. Billings R. et al.Nurse well-being: a concept analysis.Nurs Outlook. 2022; 70: 639-650Abstract Full Text Full Text PDF Scopus (4) Google Scholar and referred to as emotional wellness or emotional health.•Addressing emotional well-being can impact overall well-being.4Altman M. Delgado S. The importance of nurse well-being and how to achieve it.Crit Care Nurse. 2021; 41: 69-71Crossref PubMed Scopus (1) Google Scholar,5Patrician P.A. Bakerjian D. Billings R. et al.Nurse well-being: a concept analysis.Nurs Outlook. 2022; 70: 639-650Abstract Full Text Full Text PDF Scopus (4) Google Scholar•Many interventions aimed at improving well-being are focused on the emotional aspects of well-being.4Altman M. Delgado S. The importance of nurse well-being and how to achieve it.Crit Care Nurse. 2021; 41: 69-71Crossref PubMed Scopus (1) Google Scholar Open table in a new tab Figure 1 depicts the ripple effect of labeling and social sharing on human connection and emotional well-being. Comparable to the ripple effect of a single drop in a larger body of water, the reaction that can occur has a meaningful influence on the surrounding environment and overall well-being. The population sample for this investigation included registered nurses and patient care techs across six inpatient nursing units within two acute care hospitals in the same state. The chief nursing office of each facility selected units with varying attributes. Figure 2 outlines the process used for the 4-week pilot period. The Feeling Wheel (Figure 3) was placed on the respective units in a highly trafficked, visible area prior to rollout to generate excitement and promote curiosity prior to implementation of the pilot.Figure 3Feeling Wheel.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The Feeling Wheel is a tool created by Gloria Wilcox in 1982 to help people identify and express emotions.17Wilcox G. The feeling wheel: a tool for expanding awareness of emotions and increasing spontaneity and intimacy.Trans Anal J. 2017; 12: 274-276Google Scholar Wilcox’s original tool was adapted for the pilot project to convey an equal focus on negative and positive emotions for participants to select (Figure 3). A total of 78 unique feelings are divided into six segments corresponding to six primary feelings: joyful, powerful, peaceful, mad, sad, and scared. During the 4-week pilot period, 1091 check-ins (Figure 4) were completed. Due to the anonymity of the check-ins upon submission for data analysis, these check-ins cannot be considered unique check-ins. Check-in data did ebb and flow over time. Leaders saw decreased check-ins during the night and weekend shifts throughout the pilot period. Hospital 2 had more consistent check-ins over time, whereas Hospital 1 had a decrease in participation over the pilot period. The most common emotion labeled over the 4-week pilot period was “Tired,” which is categorized on the Feeling Wheel as “Sad” (Figure 5). Furthermore, “Sad” was the most labeled primary emotion category (Figure 6).Figure 5Top 15 Identified Emotions Across Pilot Participants.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6Primary Category Check-ins Across Pilot Participants.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Four themes emerged from the interviews with participants: “Building a culture of psychological safety,” “Affect labeling/mindfulness as a practice of habit,” “Connection and bonding with team members,” and “Impact of connection and bonding on the professional environment.” The Feeling Wheel pilot brought forward whether a culture of psychological safety existed on the units or had to be cultivated. Psychological safety is a condition in a group dynamic when team members feel emotionally and physically safe with one another.18Psychological safety.in: Mcray J. Leadership Glossary: Essential Terms for the 21st century. Mission Bell Media, Stratford2015: 144Google Scholar One nurse stated, “It was awkward to share my feelings in a whole group” while another stated “At first it was awkward, but then became easier and helped the team to connect on how they were feeling at work.” Another participant stated they “were not comfortable sharing with the group because night shift is not a feeling group.” Other participants expressed difficulty sharing suboptimal feelings with their team because of their preceptor or charge nurse. They were concerned that their team may feel that they may be the cause of their suboptimal feelings. Only 1 participant said they already incorporated a daily practice of checking in with themselves and identifying emotions prepilot. This participant found it helpful, and the pilot helped this participant see the benefit for the unit. The other participants responded very similarly conveying that “connecting a feeling to an emotion was helpful” and the fact that being more aware of feelings “enhanced [their] mood while at work.” One participant stated, “Being comfortable with our emotions allows us to lean on each other” and another stated “I had an epiphany that how people really felt was not always how they were acting.” The Feeling Wheel pilot shed additional light on the team connection variance between the pilot units. One nurse said, “Our unit is a family. We are all close friends already. The pilot did not impact these connections. It is common for our team to work through emotions together due to the numerous emotionally charged situations we encounter every day.” Another nurse stated, “I used the information on how others were feeling to check in with them. It was helpful to see when others had the same feelings. It helped validate my feelings and was a good conversation starter.” Tenured participants stated that the pilot allowed them to help coach new members, better support the team, and created a sense of belonging. Overall, participants felt the pilot enhanced connection with team members and helped them connect and check-in with one another. A charge nurse participant stated that during rough nights, she would intentionally ask the team members “How can we help each other get out of these feelings?” prompting conversation and dialog amongst the teams. Unanimously, the participants conveyed that their emotions directly impact the work environment. “Everything we do impacts the care environment and culture. If we feel like we belong, then we are more engaged.” One participant conveyed that the practice was helpful in reframing emotions stating, “We blame the organization when we really need to look inward.” Most participants declared that affect labeling was helpful and allowed the team to identify where they were emotionally to intervene sooner as individuals and as a collective. Overall, participants found the practice helpful due to the space to share and connect with their teammates more uniquely than ever before. As stated previously, there is a need for interventions to improve well-being for HCPs. This project aimed to understand how affect labeling and social sharing by HCPs in a team setting relates to one’s emotional well-being and perceived connection among healthcare team members. The implementation methods and change management strategies are essential to understand and an opportunity for future work. Although this intervention was not consistently sustained throughout all six units for the pilot period, sustainment was achieved at 1 hospital. The decreased participation from Hospital 1 was attributed to competing priorities during the huddle time. Huddles typically take place at the start of each shift. While this is an opportune time to share information with the entire team gathered, there is often an abundance of information shared that can be overwhelming and lead to communication inefficiencies. The timing of the intervention is an important consideration for successful implementation. Additionally, there was a decrease in check-ins on night and weekend shifts. This decrease was thought to be related to leadership presence during day shift huddles which may have prompted more engagement. The Feeling Wheel was used to promote affect labeling and sharing of emotions. While the effectiveness of the wheel was not directly measured, and there may be other ways to promote reflection and sharing, the wheel provided a quick way to identify feelings and share the feelings directly on the wheel. It also allowed participants to “connect a feeling to an emotion,” 1 participant described. The use of the wheel also allowed the participants to use consistent language when relating to one another. The pilot steering team realized there may have been confusion about whether “tired” meant emotionally or physically tired. After the pilot, it was noted that “tired” was selected most frequently. After the pilot, “tired” was changed to “weary” to better describe the emotional state. Other emotions that were added were frazzled, triggered, burned out, exhausted, and terrified. The participant feedback revealed the need for psychological safety. This is an important finding because this intervention may not be effective in environments where psychological safety is lacking or absent. Conversely, this intervention could help to develop psychological safety as the participant feedback revealed sharing became easier with time. Although the project did not hypothesize the cause-and-effect relationship, the qualitative feedback received showed a meaningful impact and a greater sense of bonding, psychological safety, and improvement of the professional environment. Throughout this project and after collecting qualitative feedback from the end users, the authors identified several opportunities for future investigation.1.Correlating suboptimal feelings with systemic operational challenges: The team members expressed suboptimal feelings and commented on the need for fixes to address the challenges. Further investigation is necessary to understand the relationship between suboptimal feelings and systemic operational challenges such as workforce shortages.2.Examining the impact of nursing culture on emotional expression: A common misconception in nursing culture is that nurses should compartmentalize their emotions and feelings from the work environment. Nurses tend to put on an armor of stoicism, which can lead to a lack of emotional expression. Future research can investigate how nursing culture affects emotional expression and strategies to encourage nurses to give themselves permission to feel and be human in the workplace.3.Investigating the relationship between leadership styles and psychological safety: Different leadership styles can have varying effects on the psychological safety of team members. Leaders who are more comfortable with leading with vulnerability may model desired behaviors and increase the act of affect labeling and social sharing of their team. Future research can examine the impact of different leadership styles on psychological safety and vulnerability in teams and how this can affect team performance and well-being. As healthcare teams continue working under extreme challenges, they will face obstacles with workforce shortages and must have opportunities to connect and care for themselves, personally and professionally. Developing emotional intelligence, such as identifying and sharing feelings, can help nurses better understand and manage their own emotions and consider those of their peers. This skill can lead to improved communication, increased empathy, and stronger connections among team members, all of which can help reduce stress and burnout. Creating a sense of belonging and connection can enhance professional fulfillment and emotional well-being. By identifying and implementing interventions to support affect labeling and social sharing, nurse leaders can help their teams feel more supported, leading to deeper connections and increased engagement.

From dusk to dawn: A healthy work environment for nurses working night shift.

In Brief Associated Multimedia This study examines the relationship among night-shift direct care nurses' perceptions of their work environment, job enjoyment, and the American Association of Critical-Care Nurses' Healthy Work Environment Assessment benchmark data.

Authentic Leadership: Pearls of Wisdom

The global pandemic has strained health care delivery systems and the workforce running them. Amid this landscape, nurse burnout has reached an all-time high.1 Although the nursing shortage was already at crisis levels before the pandemic, COVID-19 exacerbated the emotional exhaustion nurses faced, contributing to what is now dubbed the “Great Resignation.”2 According to the 2022 NSI National Health Care Retention and RN Staffing Report, the registered nurse (RN) turnover rate increased by 8.4%, to an average of 27.1% in 2021, outpacing hospital turnover at 25.9% for the first time since the survey was conducted.2 Moreover, a study of over 5000 nurses found that at least 11% of nurses intended to leave the profession at the height of the pandemic, and another 20% were undecided.2With such a significant decline in nursing supply, it is clear the nursing shortage cannot be resolved overnight. However, nurse leaders can start addressing turnover by fostering healthy work environments and nurse well-being. Healthy work environments share several important characteristics, defined by the American Association of Critical-Care Nurses (AACN) as skilled communication, true collaboration, effective decision-making, appropriate staffing, authentic leadership, and meaningful recognition.3 Organizations that demonstrate these attributes experience greater employee engagement and lower turnover.4By implementing authentic leadership, nurse leaders have the greatest impact on healthy work environments. Authentic nurse leaders create supportive work environments that decrease staff turnover, promote emotional well-being, and have been associated with better nurse satisfaction and patient outcomes. But what is authentic leadership, and how can nurse leaders embed this style into their practice? This column aims to define authentic nurse leadership and provide practical tips for implementing this leadership style.The concept of authentic leadership arose and evolved over the past 20 years in response to several business scandals that highlighted the poor outcomes of arrogant leaders.5 Today, authentic leadership encapsulates leaders who empower others and create a sense of purpose and optimism. It is a style in which the leader acts in a way that supports their personal values.6 A nurse leadership model developed by Giordano-Mulligan and Eckardt7 conceptualizes leader caring and other attributes, differentiating authentic leadership in the context of the nursing profession. Authentic nurse leadership comprises 5 key attributes: moral-ethical perspective, self-awareness, relational integrity, shared decision-making, and caring.6 The authentic nurse leader’s alignment of personal and organizational values cultivates credibility, trust, and respect. Leaders who possess self-awareness have a greater understanding of their strengths and vulnerabilities. They have a strong moral foundation that allows them to act in ways that support their core values. Authentic nurse leaders build connections and communication styles that promote psychological safety, facilitating a culture of open ideas. In health care systems, nurse leaders are often overwhelmed with responsibilities and tasks that take time away from developing authentic leadership styles. However, with some practice, nurse leaders can use the following skills to promote authentic leadership at work.Authentic nurse leaders know their values, beliefs, and morals. They know where they stand on critical issues and are true to themselves with their actions and decisions. Take the time to perform a personal inventory. Act with courage and confidence when it is most needed. Articulate what is important to you and what is nonnegotiable in your work environment. These values should be transparent and communicated to your team members.Authentic nurse leaders walk the walk and talk the talk. They do not just tell staff what to do and why to do it. They model the behavior themselves and have a vision. Consider a leader who tells you how important it is to perform hourly rounds on patients. If that leader never leaves her office, her credibility in asking for this is diminished. Authentic leaders regularly highlight the importance of hourly rounding and model it.One of the critical authentic leadership attributes is openness. When talking to staff, nurse leaders should practice active-listening skills. Active listening means hearing verbal messages and being aware of nonverbal cues and signals. For example, a new graduate nurse may tell the leader about her excitement about meeting her preceptor in the first week but 2 weeks later begins to avoid eye contact and give one-word answers when asked if the preceptor has been a good teacher. Authentic leaders also listen without distraction, meaning they are present with staff in the moment and avoid interruptions. This means avoiding multitasking and putting away the cell phone when speaking to an employee.Nurse leaders already understand the clinical strengths and weaknesses of team members. However, this is not the only information valuable to the authentic leader. Authentic leaders take the time to get to know team members more personally. Whether that means knowing which team member plays flag football or aspires to be a nurse educator, get to know what motivates your team. Doing so helps to build trust.Authentic leaders do not just expect their team members to share personal information without sharing it themselves. Nurses want to see their leaders as real people too. Talk about your family, where you like to travel, or your future career aspirations. Tell your team members honestly when you have made a mistake and express remorse if you unintentionally hurt someone. These practices help others see you as genuine.Gone are the days when nurse leaders sit in offices and wait for staff to come to them. Authentic leaders create opportunities to meet staff where they are at the point of care. Consider setting aside time to shadow frontline nurses and observe their workflows. Round on your team members just as you would on patients. These encounters often lead organically to conversations about workflows and engender trust between leader and employee. Often, employees take this time to share suggestions for improving the work environment with the leader or request additional resources.The idea that nurse leaders must be available 24/7 has, at best, created a culture that self-care in leadership should not exist. At worst, it may create a culture that self-care in nursing should not exist. Nurse leaders who take time to refuel through well-being activities are better positioned to support their teams, normalize self-care, and encourage staff to prioritize their own well-being. Compassion, empathy, and awareness of your needs are foundational in caring for others. Plan for time off. Be open about when you are unavailable and who will be the point of contact so you can enjoy uninterrupted time to re-energize and be present.During the pandemic, nurses were thanked profusely by their leaders and the general public, who had coined them health care heroes. As time passes, generic thank you messages become less impactful. Authentic leaders dole out personal, targeted messages of gratitude that address specific instances. For example, a nurse leader rounding on patients hears one nurse’s name repeatedly mentioned for his compassionate nature. The authentic nurse leader may then write a thank you note directly to this nurse giving thanks for great care and may also recognize the nurse in a monthly staff meeting.In these challenging times, clinical outcomes may not mirror prepandemic levels. But sometimes, even preventing a further decline in outcomes is worthy of celebration. Don’t wait until you achieve a national benchmark to celebrate success. Let’s say your telemetry unit has been experiencing a high rate of falls, double the national average. In the past month, your rate has stayed higher than benchmarks, but you replaced 2 falls with injury with 2 witnessed falls. Congratulations! That is a success, and authentic leaders take the time to celebrate these small milestones with their teams.Authentic leaders share decision-making. They look for opportunities to give staff a voice, whether that be in a robust shared-governance model or an employee open forum. Create chances for nurses to speak up and tell you what they need. When nurses come to you with problems, do not send them away until they have a solution. Work with them to brainstorm suggestions or connect them with resources who can help. Empowering your team members gives them the confidence to make their own decisions and makes them feel their suggestions are considered.Authentic nurse leaders understand they are not perfect. Authentic leadership is a journey of self-discovery and self-awareness. The journey of self-improvement should not end. Rather, authentic leaders seek out opportunities to improve themselves. Be transparent about your opportunities and tell your team how you plan to improve. The ability to learn and self-reflect is the hallmark of an authentic leader.Authentic nurse leadership is a distinct style that focuses on openness, honesty, and trust. Although the suggestions here do not address all aspects of this type of leadership, they do provide a start on changes you can make to become a more authentic leader. Authentic nurse leaders lead from the heart and practice what they preach. They create healthier environments for their teams and themselves. Do not get caught up in the details of this leadership style. Just remember what Oscar Wilde once said: “Be yourself. Everyone else is already taken.”8 If you can adapt your style to include some of these characteristics, you can expect improved morale, decreased turnover, and greater employee satisfaction.

Staying Informed of Best Evidence to Guide Practice

The need to identify new clinical questions and seek best evidence to guide practice during the delivery of care is something all health care clinicians encounter.1,2 Health care information to guide practice changes rapidly, as do standards for care, best practice guidelines, and regulatory standards. Providers (physicians, advanced practice nurses [APRNs], physician assistants), bedside nurses, and other health care clinicians need just-in-time tools to facilitate staying informed of current best evidence. Electronic health record (EHR) platforms often contain clinical decision-support tools to guide practice; however, factors that impact effectiveness of information disseminated this way include clinician trust, alert fatigue, and perceived accuracy of the alert.3-5 Acquiring skills and resources to stay informed of current best evidence is essential in today’s fast paced health care environment.A recent scoping review6 that explored APRN implementation of evidence-based practice (EBP) in routine care found that while nurses believed in EBP and that standardization of care improved outcomes, barriers in practice remain. Barriers found in this study are not new to EBP translation, specifically, perceived lack of time to implement EBP and lack of support from leadership and colleagues to change practice.6,7Multiple strategies are required for APRNs and acute and critical care bedside nurses to remain well informed, allowing for EBP translation during the daily care of patients. First, an individual needs to be a knowledgeable consumer of the evidence. The clinician needs to develop skills and strategies to determine what is rigorous, high-quality evidence to consider for guiding practice, as well as skills to include patient preferences within clinical decisions. Evaluation of evidence occurs through determining the level of evidence and strength of a given study and synthesizing evidence across studies. The level of evidence is most often assessed through a research methodology hierarchy of rigor and quality of the study (eg, absence of bias).7 Synthesizing involves assessing multiple studies to determine if the findings from the research studies, critically reviewed, are congruent and can be used to guide intervention decisions.6,8 Evidence hierarchies, or pyramids, often referred to as level of evidence, are used to determine the strength of the study, based on research methodology. The more rigorous the research methodology, the higher the level of evidence. For example, a meta-analysis of randomized controlled trials is often considered level 1, or the highest rigor, based on research methodology. To determine the quality of the study, multiple tools are available to facilitate learning the skills for reviewing studies for strength and quality; however, the important concept to remember is that not all evidence hierarchies are the same. Thus, the clinician should know which evidence hierarchy is being used when discussing research studies to inform practice.The Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group criteria is used by many national organizations in developing and revising practice guidelines. The goal of the GRADE Working Group9 is to reduce confusion associated with multiple evidence hierarchies and provide a process for synthesis of evidence to guide practice recommendations. Gaining skills in understanding GRADE criteria can facilitate meaningful clinical discussions about best evidence and adoption of guidelines for specific conditions. A brief introductory video is available on the GRADE workgroup website9 that provides an overview of the history and current criteria (www.gradeworkinggroup.org).Being an evidence-based clinician requires developing strategies to stay informed. Having the current best evidence come to your email inbox is both an efficient and effective approach. This column will share only a few strategies, as many more continue to evolve. The key for nurses is locating easily accessible, valid, and reliable resources to help remain current with changing practice guidelines and evolving best practices.For journals you frequently read or wish to be informed of for the latest studies, subscribing to an eTOC that can be delivered to your email inbox is an efficient way to stay abreast of the literature.10 You will be alerted when journals publish a new issue and will receive the table of contents, eTOC, for the latest issue. Subscription can be on a per journal basis at each publisher’s website or multiple journals can be followed by subscribing through JournalTOCs (www.journaltocs.ac.uk/index.php).11 For individual subscriptions, simply go to the publisher website of the journal you want to follow, create an account, and sign up to receive eTOCs (for example, for AACN Advanced Critical Care, visit https://aacnjournals.org/my-account/alerts). Most journals provide this service for free. If you would like to follow multiple journals and manage them in one place, create an account with JournalTOCs and then use the search function to identify journals of interest. Click the checkbox next to the journal title, and it will be saved to your account. You can also indicate your desire to receive email alerts. With a free individual account, you can follow up to 20 journals.PubMed12 offers tools that allow you to stay current with the latest research and evidence. To optimize your use of this national database and search engine, create a National Center for Biotechnology Information (NCBI) account using your internet browser, current releases of Microsoft Edge, ORCID, or your institution’s log-in service. With a PubMed account, you will be able to save search strings on topics related to clinical practice and research interests. Once you enter your search strategy or string on the PubMed main search page, select “Create Alert.” This will save search strings and allow the system to email alerts of new publications that coincide with the search strategy. As the user, you decide how frequently (daily, weekly, monthly) you would like to receive email alerts of new literature that falls within the scope of the saved search. These alerts will be sent to the email associated with the NCBI account. The email account, the search terms, and frequency of the alerts can be edited within the NCBI account. Health science librarians are very skilled in helping clinicians navigate searches within PubMed, creating search strings, and facilitating alert patterns that will not overwhelm the clinician’s inbox with unnecessary emails. A step-by-step tutorial is also available at the National Institutes of Health website.13 Email alerts will contain a summary or abstracts of new articles based on your selection. PubMed alerts are an easy and efficient way to be notified of current articles on fast-changing topics for which you want updated evidence and newly published research studies.Podcasts are digital audio presentations made available through the internet or mobile devices. Many are free, most require registration, and some require membership fees. There are numerous podcasts available that range in average episode duration from 10 minutes to an hour addressing diverse health care topics. The American Association of Critical-Care Nurses provides a podcast series addressing leadership topics and a COVID-19 management series that was developed to support clinicians during the height of the pandemic.14 The Society of Critical Care Medicine provides a wide range of critical care practice–focused podcasts on topics relevant to caring for adult and pediatric populations.15 The JAMA Network offers a variety of podcasts that explore clinical reviews, clinical practice topics, latest research summaries and medical news, and more.16 The site does require registration, but most of their podcasts are free. The European Medical Journal Podcast shares conversations that address health care trends and innovations around the world.17 Many of the podcasts at this site are clinically (disease) focused, but the site also investigates nonclinically focused topics such as the impact of robots in health care. A podcast that explores women leaders in health care, HIT Like a Girl Pod, shares a broad range of topics regarding the impact of women in health care.18 TED Health provides a large variety of health care topic podcasts delivered by experts.19 You do need to join this site and it will individualize suggested podcasts based on your listening choices. An APRN-focused podcast, NP Pulse: The Voice of the Nurse Practitioner, is available to help with role development, research, and leadership.20 Other leading health care organizations also provide podcasts that allow for an easy way to listen and learn while driving to work, exercising, or doing other activities.As digital technology becomes a mainstay in how clinicians search for evidence, numerous mobile health applications (mHealth apps) are emerging to facilitate point-of-care information.4 Ascertaining which mHealth apps to trust can be overwhelming. Researchers who explore the utility of mHealth apps have provided guidance on characteristics to weigh in choosing an app: (1) availability of the app on either Android or iOS; (2) internet connection requirements for use; (3) size of the application (it is recommended that the app be less than 50 MB); (4) frequency of clinical updates; and (5) cost (whether the app is free or has associated subscription fees).5,21-23 A growing number of mHealth apps are associated with leading health care organizations and provide diagnostic and treatment guidance. Other mHealth apps provide pharmacology, clinical practice guidelines (eg, US Preventive Services Task Force, www.uspreventiveservicestaskforce.org/apps; Guideline Central, www.guidelinecentral.com/get-the-app), and learning platforms (ie, physical assessment apps). A recent scoping review of 305 studies demonstrated that the mHealth apps most used in practice included UpToDate, Micromedex, Epocrates, MD Consult, and LexiComp.4 However, more mHealth apps continue to be developed to guide practice based on current best evidence. Thus, when considering an mHealth app, be thoughtful about utility, frequency of use, frequency of updates, and accuracy of the information provided.The digital technology explosion has both improved and complicated clinical practice.1,24 As more digitally competent clinicians enter the health care workforce, it is essential for the nurse to be equally competent in critiquing new evidence to guide practice and to develop strategies to easily access current evidence. A recent systematic review and meta-analysis found that when clinicians use electronic knowledge resources, there was an increased frequency of answering clinical questions, positive benefits to patient care, and increased efficiency in time to find answers.1The key to staying informed is developing systems for accessing reliable evidence to guide practice. In today’s practice, it’s essential for nurses to simplify processes of surfacing new evidence and use digital resources that optimize learning and guide care decisions. Acute and critical care nurses are central to translating current best evidence into practice to optimize care provided to vulnerable patients. Having reliable resources can facilitate meeting the expectation of being an evidence-informed clinician.6,8

Reengaging in Nursing

Q I love nursing, but I am thinking about giving it up. How can I reengage in my profession?A Sarah K. Wells, MSN, RN, CEN, CNL, and Sarah A. Delgado, MSN, RN, ACNP, reply:Nursing, in its most basic form, is the act of caring for someone who is sick.1 Nurses join the profession expecting to provide skilled and informed care for others when they need it most. When care delivery does not meet our expectations, job dissatisfaction, burnout, and moral distress threaten our emotional well-being and our ability to feel psychologically safe. In addition, nurses are reporting increased violence and abuse in the workplace, which threaten physical safety.2 These experiences generate an intent to change roles and even change professions. There are many tools and strategies that can support reengaging with nursing and reigniting your nursing passion.First, nurses need to know that they are not alone in wanting to leave nursing. In its latest survey on the work environment of critical care nurses, conducted in October 2021, the American Association of Critical-Care Nurses (AACN) received more than 9000 responses.3 The results showed that 67% of the respondents planned to leave their current position within the next 3 years. Reported contributing factors to this intention included poor staffing, increasing moral distress, and feeling like the quality of patient care was worsening. We face immense challenges in health care, and often they feel insurmountable.To address moral distress, AACN recommends the following steps4: There are many ways to reconnect with our nursing identity to find increased joy and satisfaction in our profession.The final decision is up to you, but the good news is that you have so many options. Nursing is a diverse and dynamic profession with many opportunities for change and growth. Whatever your interests, there is a space for you in our field.Remember, you are never alone in your journey. Whether you need time to self-reflect, recharge, or reconnect with your nurse self, AACN and the rest of your nursing community will be there when you are ready to reengage.

Just Keep MOVEN: An Evidence-Based Approach to Improving Outcomes in Patients Receiving Mechanical Ventilation

Immobility is a major risk factor for many complications related to being in an intensive care unit (ICU). Approximately 40% or more of muscle strength can be lost in the first week of being immobilized.1 Immobility and functional decline are associated with an increased risk of delirium, pneumonia, prolonged mechanical ventilation, pressure injuries, deep vein thrombosis, increased cardiac workload, reduction of cardiac output, decreased orthostatic tolerance, and increased production of proinflammatory cytokines.1,2Mobilizing patients who are receiving mechanical ventilation has been shown to be safe and effective in decreasing morbidity and mortality.3–5 Studies have demonstrated that routinely mobilizing these patients can reduce ventilator-associated events such as pneumonia, reduce the duration of ventilation, and reduce ICU and hospital length of stay.1–8 Despite the common perception of a risk of harm to the patient, a systematic review indicated that mobilizing patients in the ICU who were undergoing mechanical ventilation was associated with only a 2.6% incidence of adverse effects, with only 0.6% requiring medical intervention.3 Nurses can improve outcomes for patients receiving mechanical ventilation by implementing an early progressive mobility protocol.Penn Presbyterian Medical Center (PPMC) is a 365-bed, Magnet-designated, level I trauma center in Philadelphia, Pennsylvania. The heart and vascular ICU (HVICU) at PPMC is a 20-bed unit that provides care to critically ill adult medical and surgical cardiac patients. It serves a high-acuity patient population, with many requiring advanced mechanical circulatory support such as venovenous or venoarterial extracorporeal membrane oxygenation (ECMO), a ventricular assist device, the Impella device (Abiomed), an intra-aortic balloon pump, or continuous renal replacement therapy. Because of the complex nature of these patients’ conditions, many of the patients were perceived by staff members as being too hemodynamically unstable to be mobilized. Random medical record audits of patients in the HVICU who were receiving mechanical ventilation revealed that only 6% of these patients per day were being mobilized out of bed. Through participation in the American Association of Critical-Care Nurses (AACN) Clinical Scene Investigators (CSI) Academy, a group of 4 nurses identified mobility as an area of opportunity to improve patients’ outcomes and set out to implement a standardized protocol for mobilizing patients receiving mechanical ventilation.The purpose of this project was to increase the mobility of patients in the HVICU who were receiving mechanical ventilation by creating a standardized protocol. A literature review was conducted, and the AACN early progressive mobility protocol was adopted to guide safety screening and the implementation of progressive mobility interventions (Figure 1).6 The goals set for the project were as follows: The CSI team started by conducting a survey of the staff to identify what they perceived as barriers to mobilizing patients receiving mechanical ventilation. The top 3 barriers identified were hemodynamic instability, lack of time, and lack of personnel or support staff. The team sought to address these barriers by using a standardized screening tool to easily identify which patients were safe to mobilize, educating interdisciplinary staff members on the safety and benefits of mobility, and adopting a “mobility champion shift” in which a mobility champion, either a nurse or a certified nurse aide (CNA), would be present on the unit for a few hours during the day to assist with mobility.Baseline data for ICU length of stay and ventilator days were obtained for the 12 months before project kickoff. The group conducted random medical record audits of patients in the HVICU who were receiving mechanical ventilation to obtain baseline data for mobility levels achieved and registered nurse documentation. Because the mobility protocol safety screening process spelled out the acronym “MOVEN,” the slogan “Just Keep MOVEN” and a fish logo were adopted to promote the project.Before launching the project, the CSI team educated staff members one-on-one and at shift huddle with nurses, CNAs, advanced practice providers, physicians, respiratory therapists, physical therapists (PTs), and occupational therapists (OTs). To promote buy-in from key stakeholders, the project was also presented at multiple leadership meetings. Providers were encouraged to include a mobility goal as part of discussion in daily rounds.On the week of kickoff, lunch was provided for day shift and night shift staff members as another opportunity for education and to promote the project. Treats and “badge buddies” with the mobility protocol tool printed on them were handed out to staff members. Mobility champions were given T-shirts with the logo and slogan to be worn during mobility shifts so that staff members could easily identify the mobility champion for the day. Laminated copies of the mobility protocol were displayed on every patient’s door, and there was a designated place on the whiteboards to write each patient’s mobility goal for the day. Mobility champions and bedside nurses worked closely with PTs, OTs, respiratory therapists, and perfusionists, if necessary, to mobilize patients receiving mechanical ventilation who were deemed appropriate according to the safety screening protocol.After the first few weeks, the CSI team, in discussion with mobility champions and PTs and OTs, perceived a need to demonstrate safe practices for mobilizing these patients to all members of the nursing staff. A group of PTs and OTs hosted a workshop on mobilization techniques designed to ensure the safety of both staff members and patients. A slideshow with videos was sent to all staff members for the benefit of anyone who could not attend the workshop.After a few more weeks, a “master mover” incentive program was initiated to continue promoting the project and to keep staff members motivated. Champions would nominate a nurse or CNA who was especially proactive in mobilizing their patients to be named “master mover,” who received either a tumbler or a fleece blanket with the PPMC logo. Their photograph was displayed on a bulletin board on the unit that was decorated with the fish logo and slogan and the MOVEN acronym.Postintervention data were collected over a 6-month period. The data showed that patients receiving mechanical ventilation were consistently reaching much higher mobility levels in the postintervention period compared with the preintervention period (Figure 2). The rate at which these patients got out of bed per day increased from 6% before the intervention (August 2020 to August 2021) to 40% after the intervention (August 2021 to January 2022). Nurses were documenting mobility an average of 2.59 times per day after implementation of the intervention, compared with 1.98 times per day before implementation, representing a 31% increase. Moreover, the ICU length of stay for patients receiving mechanical ventilation decreased by 12%. In contrast, there was a slight increase in average number of ventilator days per month during the intervention period, from 282.1 days to 298.7 days. The CSI team speculated that because the intervention period also coincided with a COVID-19 surge, the increase could be attributed to an overall increase in the number of patients needing mechanical ventilation who were admitted to the unit.The CSI Academy is designed to support and empower bedside nurses to become leaders who can create lasting change, influence unit culture, and improve patients’ outcomes. It also serves to facilitate collaboration across different units and hospitals so that ideas can be shared between clinicians and best practices can be replicated in other facilities. Because of the success of the mobility project in the HVICU, other units in the hospital have expressed interest in implementing similar mobility protocols. During this project, an early mobility protocol for ECMO patients was also developed. This protocol helped patients qualify for lung transplant on the basis of their functional status and improved the functional status of patients being weaned from ECMO.One unexpected outcome of the current project was improved unit morale. Implementing this project after experiencing tremendous loss and grief during the COVID-19 pandemic allowed staff members to feel empowered to make a positive difference in patients’ outcomes. Collaborating with PTs and OTs to set goals for patients and seeing patients reach those goals was fulfilling and rewarding.The author thanks fellow CSI team members Elizabeth Haemmerle, BSN, RN, CCRN, Dolores Risica, BSN, RN, CCRN, and Doug Lens, BSN, RN, CCRN, and coaches Meg Welde, BSN, RN, and Helen Chacko, DNP, RN, CCRN, for their efforts and cooperation in making this project successful. Thanks are also due to the AACN CSI Academy, especially Marian Altman, PhD, RN, CNS-BC, CCRN-K, and Debbie Brinker, MSN, RN, CNS, for their essential support and resources.

Composing a Life that Works with a Life that Counts for Nurses.

The life of a nurse since the Covid-19 pandemic is characterized by high rates of anxiety, depression, and burnout, leading national organizations to declare the nursing shortage a national emergency. Solutions cite work-life balance, but this term has no clear guiding definition. Experts in the organizational psychology and personal development literature suggest other ways to reconsider this dilemma, that of integration. In this paper the concept of integration is proposed to focus on relationships with family and friends, work, and oneself. The American Association of Critical-Care Nurses 'standards for a healthy work environment are used to frame the benefits of an integrated life. Strategies to achieve an integrated life, one with meaning and purpose, are described to create more happiness and joy and to begin to mitigate the nursing shortage.

Keeping Healthcare Workers Safe Through Policy Initiatives

Before the COVID-19 pandemic, violence against healthcare workers was already on the rise. According to the U.S. Bureau of Labor Statistics (BLS), violent incidents among healthcare and social assistance workers rose from 6.4 per 10,000 in 2011 to 10.4 per 10,000 in 2018 (Jones, 2021Jones, M. (2021, May 17,. Preventing workplace violence in healthcare. American Association of Critical-Care Nurses. https://www.aacn.org/blog/preventing-workplace-violence-in-healthcareGoogle Scholar). A 2016 Bureau of Labor Statistics report found the violence rate against registered nurses to be three times that of all other occupations (Jones, 2021Jones, M. (2021, May 17,. Preventing workplace violence in healthcare. American Association of Critical-Care Nurses. https://www.aacn.org/blog/preventing-workplace-violence-in-healthcareGoogle Scholar). One impact of staffing shortages are increasing wait times to access care. These situations lead to frustrating and chaotic environments for patients and their family members, which contributes to increased violence against providers (Willa Ernst, 2022Willa Ernst, S. (2022, November 23. Survey shows Texas nursing shortage reaches record lows. Houston Public Media. https://www.houstonpublicmedia.org/articles/news/health-science/2022/11/23/437984/texas-nursing-shortage-reaches-record-lows/Google Scholar). As part of an ongoing attempt to quell the healthcare workforce shortage, lawmakers and stakeholders are approaching more traditional workforce policy solutions as well as those to address the alarming rate of violence against providers. The National Institute for Occupational Safety and Health (NIOSH) defines workplace violence as “violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty” (NIOSH, 2002). Workplace violence is broken into four types, with two being most prevalent in the healthcare workforce: (a) an act or threat of violence by a patient who receives services from the professional and (b) violence between coworkers in the healthcare setting (American Nurses Association, 2021American Nurses Association Workplace Violence. 2021, March; (https://www.nursingworld.org/practice-policy/advocacy/state/workplace-violence2/)Google Scholar). In February 2020, NIOSH cited staffing shortages and a lack of workplace and regulatory protective measures among the reasons for workplace violence against healthcare professionals (NIOSH, 2020). As workplace violence increases, many nurses cite the dangerous conditions as a reason for leaving the profession or changing jobs (Ernst, 2022Ernst, S. W. (2022, November 23,. Survey shows Texas nursing shortage reaches record lows. Houston Public Media. https://www.houstonpublicmedia.org/articles/news/health-science/2022/11/23/437984/texas-nursing-shortage-reaches-record-lows/Google Scholar). “Nurses are now finding their voice and saying, ‘we shouldn’t have to tolerate this anymore,’ specifically around workplace violence. So some nurses are choosing to leave to go find alternative places to work outside of the hospital setting,” said Texas Nurses Association President Serena Bumpus (Ernst, 2022Ernst, S. W. (2022, November 23,. Survey shows Texas nursing shortage reaches record lows. Houston Public Media. https://www.houstonpublicmedia.org/articles/news/health-science/2022/11/23/437984/texas-nursing-shortage-reaches-record-lows/Google Scholar). A cyclical scenario presents itself—workplace violence deters healthcare workers from remaining in their profession, which exacerbates the workforce shortage that contributes to even more incidents of violence. The American Nurses Association categorizes state law responses to workplace violence into several categories, with many states fitting into multiple categories. The categories include mandated employer-run violence prevention programs, identification tag and badge laws to protect the identity of a nurse and thus prevent targeted or stalking behavior, facility signage, and increased criminal penalties, among others (American Nurses Association, 2021American Nurses Association Workplace Violence. 2021, March; (https://www.nursingworld.org/practice-policy/advocacy/state/workplace-violence2/)Google Scholar). The increase of staffing shortages linked to the COVID-19 pandemic has brought further attention to this serious issue at both the state and national levels. State lawmakers and stakeholders have been developing and advocating for policy solutions to address the workplace violence crisis, which they hope will in turn ease the shortages. Whether addressing the criminal penalties of patients, family members, and others inflicting violence or mandating that facilities develop policies to address violence against staff, the past several legislative sessions saw many states looking to address the rise in workplace violence in their jurisdictions. In July 2021, Rhode Island enacted Senate Bill 55 and House Bill 6018, also known as the Workplace Violence Prevention Act (State of Rhode Island General Assembly, 2021). State Senate President Ruggerio commented on the bill: “Nurses and other front-line hospital staff deserve no less. They should not have to accept violence or harassment as a routine element of their job” (State of Rhode Island General Assembly, 2021). The bill creates policies for workers to file complaints within the facility and with the Department of Health, provides protections for those workers, mandates facilities to create workplace safety committees to identify existing and potential hazards, and provides training on assault prevention (State of Rhode Island General Assembly, 2021). Lawmakers heard testimony from United Nurses and Allied Professionals, which reported the results of a survey: Members working in hospitals found that 42% said their unit had experienced a violent or near miss violent episode requiring intervention by the local police; 67.8% said they had personally experienced workplace violence on the job; and 63.7% said they have at times felt unsafe working in their unit (State of Rhode Island General Assembly, 2021). In Louisiana, two bills were enacted to address workplace violence against healthcare workers. The first, House Bill 312 (2022), called on licensed healthcare facilities to act. The bill mandates that facilities display signs stating that violence against healthcare staff are not tolerated and could result in a felony (H.B. 312, 2022). All facilities must also develop violence prevention plans and are prohibited from taking retaliatory actions against workers who report incidents of workplace violence (H.B. 312, 2022). This protection for workers is important given that the American Association of Critical-Care Nurses cites fear of retaliation as a common reason for nurses failing to report violent incidents (Jones, 2021Jones, M. (2021, May 17,. Preventing workplace violence in healthcare. American Association of Critical-Care Nurses. https://www.aacn.org/blog/preventing-workplace-violence-in-healthcareGoogle Scholar). The bill also prevents facilities from discouraging reporting and, once a report is filed, from taking any retaliatory action against a complainant: “No regulated entity shall discharge, demote, suspend, threaten, or harass an employee, or discriminate against an employee in the terms and conditions of his employment” (H.B. 312, 2022). In the Louisiana Senate, State Senator Connick championed Senate Bill 136 (2022). The bill created a new crime of violence to include “battery of emergency room personnel, emergency services personnel, or a healthcare professional” as well as a related crime of assault. The bill also set punishments for repeat offenders (S.B. 136, 2022). In 2018, the Maryland Nurses Association and Maryland Hospital Association (MHA) created a steering committee aimed at preventing violence in hospitals, and in 2020, they successfully lobbied to pass a modification to the state’s healthcare worker identification badge law (MHA, 2020). The bill, House Bill 364, amended a law requiring the full first and last name of the employee to be displayed on their badge (MHA, 2020). In testimony before a house committee, MHA testified that “requiring name badges to show a caregiver’s full name can put them at risk if a patient intends to harm them—physically or emotionally through stalking or cyberbullying” (MHA, 2020). A similar bill passed in Pennsylvania the same year (Warren, 2020Warren, L. (2020, February 19. First name is enough: Pass a law to protect healthcare workers. SEIU Pennsylvania. https://seiuhcpa.org/first-name-is-enough-pass-a-law-to-protect-healthcare-workers/Google Scholar). In states where protection laws were already in place for some healthcare workers, many bills were filed to expand the professionals covered by the laws. In Delaware, House Bill 324 expanded protections for nurses and physicians to include “any person providing health care treatment or employed by a health care provider” (H.B. 324, 2022). While state lawmakers debate violence prevention legislation, several recent collective bargaining agreements have addressed the issue and mandated facilities take action to protect healthcare staff above and beyond what is mandated in state law. In California, Kaiser Permanente tentatively agreed to a deal with unionized registered nurse and nurse practitioner staff in November 2022 (Landi and Muoio, 2022Landi H. Muoio D. Kaiser Permanente averts strike as nurses win 22.5% pay hike in new deal.Fierce Healthcare. 2022, November 20; https://www.fiercehealthcare.com/providers/kaiser-permanente-averts-strike-nurses-win-225-pay-hike-new-dealGoogle Scholar). Provisions of the deal included the creation of new nursing positions as well as commitments by the employer to combat workplace violence (Landi and Muoio, 2022Landi H. Muoio D. Kaiser Permanente averts strike as nurses win 22.5% pay hike in new deal.Fierce Healthcare. 2022, November 20; https://www.fiercehealthcare.com/providers/kaiser-permanente-averts-strike-nurses-win-225-pay-hike-new-dealGoogle Scholar). Part of the plan will be to extend workplace violence plans to include locations outside of emergency rooms, such as in clinics and parking lots (Landi and Muoio, 2022Landi H. Muoio D. Kaiser Permanente averts strike as nurses win 22.5% pay hike in new deal.Fierce Healthcare. 2022, November 20; https://www.fiercehealthcare.com/providers/kaiser-permanente-averts-strike-nurses-win-225-pay-hike-new-dealGoogle Scholar). The deal would also “create an investigation process for incidents of workplace violence and [a process for] trauma counseling for nurses” (Landi and Muoio, 2022Landi H. Muoio D. Kaiser Permanente averts strike as nurses win 22.5% pay hike in new deal.Fierce Healthcare. 2022, November 20; https://www.fiercehealthcare.com/providers/kaiser-permanente-averts-strike-nurses-win-225-pay-hike-new-dealGoogle Scholar). Temple University nurses in Pennsylvania also secured specific provisions to address violence prevention in their union contract negotiations (Laughlin, 2022Laughlin J. Unionized Pa. health care workers fine new bargaining strength in the wake of COVID.The Philadelphia Inquirer. 2022, November 22; https://www.inquirer.com/news/temple-nurse-union-labor-strike-health-care-hospital-20221122.htmlGoogle Scholar). In addition to reforming a process for fielding complaints and incident reports, Temple University “also agreed to place weapons detectors and security personnel at every hospital entrance” (Laughlin, 2022Laughlin J. Unionized Pa. health care workers fine new bargaining strength in the wake of COVID.The Philadelphia Inquirer. 2022, November 22; https://www.inquirer.com/news/temple-nurse-union-labor-strike-health-care-hospital-20221122.htmlGoogle Scholar). The contract provisions came in part due to a violent incident involving a nursing assistant at a nearby hospital (Laughlin, 2022Laughlin J. Unionized Pa. health care workers fine new bargaining strength in the wake of COVID.The Philadelphia Inquirer. 2022, November 22; https://www.inquirer.com/news/temple-nurse-union-labor-strike-health-care-hospital-20221122.htmlGoogle Scholar). Stakeholders, bargaining agreements, and state lawmakers will most certainly continue to explore and adopt provisions aimed at reducing workplace violence in the healthcare industry as they move into the 2023 legislative session. Pre-filed bills in Texas already indicate the continuation of actions to curb violence. Texas House Bill 112 and Senate Bill 240 would mandate certain facilities form a Workplace Violence Prevention Committee and adopt prevention policies and a plan to protect workers (H.B. 112, 2022; S.B. 240, 2022). If successful, these policies across the country will not only prevent incidents of violence toward workers but also strengthen the nursing workforce, which will aid in preventing resignations and thus lower the rates of violence across systems.

Adapting the Healthy Work Environment Assessment Tool for French-Canadian Intensive Care Nurses.

Self-administered instruments are used to measure components of work environments that cannot be measured directly. The Healthy Work Environment Assessment Tool (HWEAT) of the American Association of Critical-Care Nurses is a promising instrument. However, it is available only in English and Japanese, precluding its use in other populations and cross-national comparisons. To describe the Canadian French translation and cross-cultural adaptation of the HWEAT (F-HWEAT) and to explore its factor structure and psychometric properties. Cross-cultural adaptation of the HWEAT and collection of evidence of validity via an electronic cross-sectional survey. A total of 564 intensive care unit nurses participated in the validation study. Confirmatory factor analysis supported the presence of a single overarching factor measured by the F-HWEAT. The Cronbach α for the instrument was 0.89 (95% CI, 0.88-0.91). The mean and median interitem correlations were both 0.32, and item-partial total correlations ranged from 0.33 to 0.64. The overall F-HWEAT score indicated that nurses believed their work environment needed improvements. Moderate positive correlations were found between the overall F-HWEAT score and nurses' perceptions of care quality (r = 0.45 [95% CI, 0.38-0.51]) and safety (r = 0.48 [95% CI, 0.40-0.55]). The results support the use of the F-HWEAT in French-speaking populations. Using the F-HWEAT will help elucidate areas needing improvement and expand global dialogues about healthy critical care work environments. With this information, nurse leaders and researchers can develop and implement modern strategies to improve the work conditions of intensive care unit nurses.

Starting Now: Implementing the Healthy Work Environment Standards Is More Important Than Ever

At the American Association of Critical-Care Nurses’ (AACN’s) National Teaching Institute in May 2022, incoming president Amanda Bettencourt revealed her presidential theme for 2022-2023: “Starting Now.” Bettencourt shared thoughts that are very relevant to where our profession is now and what we need to do to move forward, including: “Rebooting ourselves for a new AACN year, we will start now with renewed hope. Because hope transforms. We can break new ground. And, along the way, let’s be prepared to ruffle some feathers. We will do this together. We are not alone. And we will do it Starting Now.”1(p2)Another critical observation for nurses in her address: we need to advocate for ourselves “because sacrificing our own well-being benefits no one.”1 In her recent video blog, Bettencourt adds that although we can’t forget the events of the last few years, it is time to celebrate our successes and move forward to heal because most nurses want to work in a healthy work environment; it is time to advocate for a healthy work environment.2 These are words that all nurses, including nurse leaders, need to act upon, starting now.Several research studies have been published in the past few months relating to nurses’ work environments. This column will highlight the key findings of these studies as well as discuss the results of the newly published AACN 2021 work environment survey, which show a direct association between implementing healthy work environment standards and improving the work environment. I will close the column with suggestions for implementing the 6 AACN healthy work environment standards: skilled communication, true collaboration, effective decision-making, appropriate staffing, authentic leadership, and meaningful recognition.3Studies on staff nurse recruitment and retention, conducted by the Health Resources and Services Administration and others, have been published in 2018 and 2019, prior to the pandemic. The issues impacting our profession have changed significantly since then, driving the need for us to change the course of our future. One of the most recent studies on the status of nursing recruitment and retention is the 2022 National Health Care Retention and Registered Nurse (RN) Staffing Report, published by NSI Nursing Solutions.4 This study was done in January 2022 and was sent to 3000 hospitals across the country to gather data on health care turnover, retention initiatives, vacancy rates, recruitment metrics, and staffing strategies; 272 hospitals responded.4 This study quotes the US Bureau of Labor Statistics that our profession is projected to grow 16%, adding about 2.6 million new jobs through 2030. Will the number of staff leaving the profession increase if things don’t improve? That is possible and why changes need to occur immediately.The NSI study references “The Great Resignation,” which is exacerbating concerning trends noted in previous studies. For example, hospital turnover since 2021 has increased by 6.4%, with the current rate at 25.09%.4 The authors also report that hospitals lost 2.47% of their workforce since 2021, which was higher than expected.4 This study suggests that for each 1% increase in turnover, the overall cost to the hospital is $262 300 per year, with the cost of replacing a bedside RN estimated to be $46 100; that cost is likely much higher to replace a nurse in a specialty area.4 This report concludes with a statement that the majority of the hospitals identified retention as a “key strategic imperative.” Furthermore, one third of nurses left in the first year, and the majority left within 5 years.4Additionally, the authors of the NSI study focused on recruitment challenges. Recruiting staff nurses for the operating room (OR) is the most challenging, followed by the intensive care unit (ICU) and emergency department (ED).4 An additional challenge to recruiting staff nurses was the outrageous rates that hospitals were paying for travel nurses from agencies while simultaneously trying to recruit full-time staff. During COVID-19, travel nurse salaries increased 200%,4 averaging $150-250 per hour. This costs the average hospital more than $4 million for 20 travel RNs.4 Across the country, staff nurses in facilities have felt demoralized by the salaries paid for agency staff who often were less capable of taking care of the most critically ill patients. This trend of spending a lot of money for temporary help needs to stop in order to improve our work environment. Without appropriate staffing, you cannot have a healthy work environment and without a healthy work environment, it is hard to retain staff.In 2020 and 2021, the American Nurses Foundation partnered with Joslin Marketing to survey 12 000 nurses across the country regarding their mental health and wellness and the impact of the pandemic on nurses. It was decided in August 2021 to add a question to look at the current emotional health of nurses. In an alarming finding, younger nurses closest to the point of service reported more emotional distress than their peers.5 Of particular interest was the difference by work area (See Table).5 These data are concerning but require greater understanding before we can address these problems.In addition, the 2022 study found that nurses managed their well-being by spending time with friends and family. Specific examples of activities with family and friends included: maintaining a healthy diet; receiving accurate COVID-19 information; religious community, spiritual direction; practicing or receiving expressions of gratitude; and regular exercise.5In July 2020, February 2021, and August 2021, the American Organization of Nurse Leaders and Joslin Marketing partnered to conduct a longitudinal study examining the impact of the pandemic on nursing leadership.6 This study was focused on nurse leaders: nurse managers, directors, and chief nursing officers. The top challenges that participants identified were surge staffing, training, and relocation; emotional health and well-being of staff; staff retention, furloughs, and layoffs; and communicating and implementing change policies.6 At the beginning of the pandemic, a significant challenge was access to personal protective equipment and other supplies.6 The August 2021 survey revealed that 25% of the nurse leaders said that they were “not emotionally healthy,” a concerning data point given that leaders need to be emotionally healthy in order to support their staff. The percentage of participants reporting they were “not emotionally healthy” was even higher among nurse managers.6 Retention for nurse leaders was slightly higher than other studies have reported for frontline staff; 80% of leaders said that they did not intend to leave their job. Improving nurse leader well-being requires support from administration for work-life balance.6 Having nurse leaders who themselves are struggling impacts the organization’s ability to maintain a healthy work environment.The National Nurse Work Environments study is part of a longitudinal look at nurses’ work environments over time. The first study was done in 2006, with follow-up studies in 2008, 2013, and 2018. The most recent study was conducted in the fall of 2021, during the pandemic. Approximately 10 000 nurses responded, with 9335 meeting the criteria of being an RN. The nurses surveyed describe work environments that have dramatically declined in quality.7 The biggest decline was in staffing, which has only gotten worse during the pandemic. The highest scoring standard was communication, but the score was most reflective of RN-to-RN communication; scores were lower for RN-to-nurse manager communication and even lower for communication between the RN and administration.7 The nurses stated that meaningful recognition was important; however they emphasized recognition needed to be meaningful and not just a generic statement of gratitude. They also noted that recognition from patients and families was very important to them.7 Perceptions of effective decision-making have declined as well; only 56% of nurses responded that they felt like “valued and committed partners in making policy, directing and evaluating clinical care, and leading organizational operations.”7(p5) Nurses who scored themselves higher in feeling like a valued and committed partner also felt that they had an authentic leader.7We know from previous research that healthy work environments correlate directly with nurse retention and good patient outcomes.8,9 The results of this study showed that nurses on units that had implemented even one of the AACN healthy work environment standards fully had higher reported job satisfaction; better quality of care on the unit; appropriate staffing, communication, and collaboration; opportunities to influence decisions; and a lower intent to leave. The results also show that the more standards that are implemented the better the job satisfaction. The 3 things that nurses cited would change their likelihood to stay in their job were higher salaries and benefits, better staffing, and more respect from administration.7Over the next year with AACN president Amanda Bettencourt’s monthly updates, we will hear more regarding how we can move forward in the coming year to implement change related to her theme of “Starting Now.” It is important for leaders to acknowledge the trauma staff nurses have experienced while also moving forward to make corrections in high-impact areas. The lower the rate a hospital pays to supplemental agency nurses, the easier it will be to attract staff back to hospitals and away from agency employment. It is important that hospitals stay competitive in the market.As we listen to Bettencourt’s regular messages on her theme, we need to keep in mind her advice about having hope, “because hope transforms,” and hope can help lead change for a workforce that has said in many of the surveys above that they are experiencing burnout.To implement healthy work environments, we must start by asking nurses in every area what they believe is impacting their work environment. For example, the challenges faced by staff nurses in the ED may be different than those faced by staff in the ICU; solutions will need to be tailored to the issues of the particular unit. The AACN Healthy Work Environment Tool (found at https://mini.aacn.org/dm/HWE/TabbedAdminHome.aspx) is an easy way to survey the staff and can be used anonymously by signing up on the AACN website. Once the unit completes the survey, a report is generated that can give the unit some tangible resources to implement on their units. For example, for communication issues, TeamSTEPPS is a suggested process for implementing a structured communication tool.As units work on solutions to identified problems, it’s worth remembering communication and collaboration frequently go together. As such, a multidisciplinary team can conduct projects and work on activities, allowing the team to work together on solutions. Coming to consensus on solutions that work for both physicians and nurses promotes joint accountability.Research by Ulrich et al7 has also shown a relationship between effective decision-making and authentic leadership. Organizations need to offer leadership development and support nurse managers. If nurse managers are drained and do not feel that they have the energy to support themselves, they will not be able to support their staff. Raso and colleagues10-13 have done several studies on clinical nurses’ perceptions of leader behaviors affecting their work environment. They emphasize the importance of relational competencies, caring behaviors, and visibility of support for the staff, characteristics essential to a healthy work environment.13 We know that meaningful recognition is important for staff, but it is also important that managers are recognized for their caring behaviors. The DAISY Foundation has a DAISY Nurse Leader Award to recognize nurse managers (https://www.daisyfoundation.org/daisy-award/nurse-leader-award).There are also numerous new projects that AACN is putting in place for staffing and resilience; it takes a village to build support. One person can make a difference, but everyone in an organization needs to be onboard to support sustainable change, including all levels of administration and C-suite staff; townhall meetings and transparency also need to be embedded in the organization. Authentic leaders not only support healthy work environments but model the behaviors.We have to acknowledge the trauma our staff have experienced and understand we have a long road to recovery. We have a lot of unintended consequences of the pandemic, and this discussion is a very short snapshot of the studies examining these impacts. There are many resources on the AACN website in the healthy work environment section. It is important that we focus on making necessary changes based on some of the suggestions above. It is also important that we take Amanda Bettencourt’s advice and do this STARTING NOW.

Using Project-Based Learning to Teach Advanced Practice Nurses About Quality Improvement

The universal challenge for clinicians worldwide is to provide safe and quality patient care that is based on the best available evidence. Despite current studies indicating that patients who receive evidence-based care have better outcomes, it is well documented that current care performed at the bedside is not based on the best current available evidence because of the delay from “bench to bedside.”1 Clinical inquiry aims to improve patient safety and quality of care through methodical exploration of a clinically significant phenomenon. So why are advanced practice nurses (APNs) not routinely formulating clinical inquiries in their daily clinical practice?Advanced practice nurses play a critical role in clinical inquiry, as we are able to identify local gaps in practice, processes, or systems that have the potential to negatively affect patient outcomes. Through curiosity about best available evidence, APNs can effectively guide clinical decision-making. Advanced practice nurses also have a perspective from patients about best care given their position at the bedside, bringing the literature and the patient perspective into alignment. Accordingly, a wide range of literature documents improvements in patient care and safety using quality improvement (QI) initiatives that have been developed and implemented by APNs. Therefore, with access to the right tools and education on how to best engage in and perform QI, APNs are poised to improve the quality of care and safety of patients. Despite adequate education, most APNs remain inexperienced in executing clinical inquiry independently in the clinical practice setting. Literature is still lacking on how to most effectively teach APNs in the clinical practice setting about clinical inquiry, specifically QI. Project-based learning (PjBL) is one teaching methodology, based in experiential adult learning theory and grounded in the notion that we as APNs learn better by doing; seeing and participating as a case unfolds in the form of PjBL provides important insights and demonstrates how to succeed in conducting a QI.The purpose of this column is to provide evidence for teaching QI to APNs in the clinical practice setting through the use of PjBL as a teaching methodology for facilitating more effective QI education.Quality improvement uses a systematic approach to distinguishing current practice from best practice and evidence-based practice (EBP). Quality improvement is about identifying gaps in performance in practice, process, or systems within an organization and implementing strategies to improve outcomes related to cost and productivity of work and care, quality of care, patient satisfaction, provider satisfaction, and ultimately patient outcomes. Advanced practice nurses are vital to QI given their presence at the bedside within the clinical practice setting. Regardless of widespread acknowledgement of the importance of QI in the clinical practice setting, it is likely not being used as effectively as possible. The Essentials: Core Competencies for Professional Nursing Education cite necessary competencies related to QI in the nursing scope of practice within broader domains at each education level.2 Among entry-level and advanced-level nursing education, nurses are prepared to participate in and develop initiatives that are aimed at quality and safety. If nurses have the knowledge and skills to participate in and develop QI, why is it not being done or done better?Despite their educational preparation, most APNs are unclear on how to successfully take a QI project from an idea to implementation. Education beyond the academic setting is needed even among doctor of nursing practice (DNP)-prepared nurses.3 To carefully construct a QI project, APNs must accurately identify a gap in their practice, engage with members of the interdisciplinary team and key stakeholders, evaluate the literature to determine best practice, develop a well-constructed plan, implement their plan, evaluate outcomes, and disseminate their findings internally to the organization and externally. Little guidance can be found in the literature on how to teach APNs about QI, particularly in the context of their clinical practice. Studies have shown that a lack of available continuing education and on-the-ground training about QI processes and a lack of mentorship within the practice setting remain barriers to nurses commencing projects.4-6Other barriers to QI exist at the provider and health-system levels; therefore, it is imperative that barriers to engagement in QI be addressed and overcome. Within the literature, barriers to engagement at the provider and health-system levels have included time constraints, heavy workload, lack of educational opportunities and mentorship, and the unique hospital or clinic-based culture.6-8 In addition, there is a notable lack of knowledge and skills among those who are practicing.9 Continuing education and training have been identified as facilitators of QI,4,8,10 and yet, these resources can be difficult to find. Education about QI has been associated with increased knowledge, skills, competency, and QI implementation and is urged by leading professional nursing organizations including the American Nurses Association and its subsidiaries.11Over the past decade, the number of APNs pursuing DNP degrees has grown exponentially. In a recent publication by the American Association of Colleges of Nursing, DNP graduates endorsed applying requisite skills in QI improvement to improve practice, processes, and systems in the clinical practice setting.12 All APNs, regardless of degree, can benefit from continuing to build skills and confidence for executing QI studies. The clinical practice arena provides an opportune setting to support APNs in pursuing advanced skills for improvement science through continuing education—education that provides APNs in the practice setting with the tools necessary to succeed. There is a need to promote the development, engagement, and mentorship of APNs interested in engaging in QI.6Quality improvement education with APNs new to QI at the bedside needs to be fostered, using teaching methodologies that encourage participation in existing projects in collaboration with mentorship with experienced colleagues.3,13 Several methods for teaching QI have been explored in the literature.14 Most methodologies for teaching QI have been explored in the academic setting with little evidence for teaching methodologies that can be applied in the clinical practice setting. Methodologies range from simple to complex, isolated to blended. Those that use active learning have been found to be more effective than traditional teaching methods such as didactic lectures.15Project-based learning is one teaching approach that has the potential to be used in the clinical practice setting to allow APNs to develop the knowledge and skills to execute QI more effectively, thus improving the development, design, and rigor of QI initiatives (Figure). Project-based learning encourages APNs who are novices in QI to collaborate with colleagues who have expertise in the clinical problem of interest. Through a standardized process, APNs obtain guidance and feedback on how to best facilitate nurse-led, evidence-based best practice initiatives. Rooted in constructivism, PjBL is a learner-focused teaching methodology that uses active learning and immersion to convey new knowledge (Figure). Project-based learning challenges the learner to apply theoretical knowledge and skills to real-world experiences in collaboration with faculty and others with expertise in the clinical problem.18 Through experiential learning, students engage in “learning by doing,” using an approach that is hands-on, clinically relevant, and culturally meaningful in the hospital setting.Advanced practice nurses curious about how to successfully develop, implement, and evaluate a QI project using PjBL can adopt a mentor-APN and learner-APN relationship through a professional nursing organization or several practice-based national networks (eg, the American Association of Critical-Care Nurses or the American Association of Nurse Practitioners). Project-based learning in the context of a QI project follows the EBP model with the intention of targeting specific learning goals through formal teaching principles and methods. The 7 steps for implementing PjBL can be sequentially followed, as depicted in the Figure. Through the steps, the mentor-APN provides support and guidance to accomplish successful transfer of knowledge, understanding, and skills while promoting learner-APN independence.19 Operationalization of learning goals for PjBL in QI projects can be found in the Table.Defining the problem is the foundation upon which to develop the QI project. The problem should be an important practice, process, or system issue that is identified, through discussion with other APNs and organizational leadership at different levels, as relevant within the context of the organization. After identification of the problem to be addressed, a broad clinical question should be developed that the learner-APN intends to answer. The initial clinical question will help drive subsequent steps.Sustained inquiry entails a deeper dive into the problem through the discovery and interpretation of relevant literature and iterative revision of the initial clinical question based on the literature.19 The learner-APN should appraise and synthesize the body of evidence related to the identified clinical problem. Accordingly, the learner-APN will formulate substantial conclusions of the most effective approaches to address the clinical problem that is based on the best evidence available. The learner-APN may propose alternative or complementary clinical questions.Quality improvement should be based on conclusive evidence. A key characteristic of authenticity is ensuring applicability within the real-world context.19 Real-world context can be related to quality and safety standards as deemed by regulatory or quality agencies, significance within the organization, relevance to current clinical practice, and vested interest in the clinical problem by the learner-APN.Integration of learner-APN input in the QI project is the basis for voice and choice.19 Development and implementation of the QI project should be based on the ideas of the learner-APN with guidance from the mentor-APN. Voice and choice fosters better learner-APN engagement and accountability within the QI project.Reflection involves learner-APN and mentor-APN self-evaluation of their role and performance within the QI project and evaluation of the outcomes associated with the QI project.19 Self-evaluation may involve specific knowledge and skill attained, quality of work, and barriers encountered with interventions implemented. Analysis of outcome data to determine the effectiveness of the practice, process, or system improvement should also be reflected upon.Methodical assessment of the learning process and the QI project is necessary to evaluate initial goals. Critique allows learner-APN views to be shared and acknowledged.19 Subsequently, the learner-APN is able to apply learned views to the revision of the QI project, resulting in an iterative process of improvement to both the learning process and the QI project.Dissemination of the QI project findings should take place within the organization and externally to achieve learner-APN knowledge translation and practice change. Internally, dissemination of the findings to organizational stakeholders, from unit leadership to hospital leadership, should take place. Externally, dissemination of outcomes can take place through presentation at professional meetings or publication within peer-reviewed journals to contribute to the current literature.Project-based learning is an innovative, evidence-based strategy by which learners are exposed to opportunities and challenges in the health care environment that may not be appreciated using other teaching methodologies. Project-based learning has been associated with improved learning outcomes, critical thinking and problem-solving skills, and competence by solving actual problems in an educational environment using dialogue between faculty and nursing students.20-25 Although little evidence exists regarding its use in the clinical practice setting in the nursing profession, PjBL specifically for QI has been shown to be an effective teaching strategy and increases knowledge and confidence in the academic setting.16,26 Current literature has demonstrated positive effects for PjBL on knowledge, critical thinking, problem-solving, and teamwork, among others.Project-based learning has been used infrequently by APNs in the clinical practice setting. Most QI learning tools offered in the clinical practice setting are executed through isolated didactic lecture rather than “learn by doing.” In contrast to the project-based, layered learning that takes place with PjBL, other QI tools for use in the clinical setting offer “micro-learning” in small, app-based segments.21 One example, BiteSizedQI, a mobile application developed for use by both clinicians and patients, offers small “sound bites” to provide the language and skills necessary for QI in clinical settings.27 Based on principles of Lean Six Sigma, the app shows a series of videos that build low-literacy, user-friendly questions and answers to reinforce content and evaluate learning. Similarly, the Institute for Healthcare Improvement web-based tools offer web-based skills development and online certification using learning modules and post-test quizzes.28 Unlike PjBL, these web-based programs deliver content and validate knowledge achievement without the added benefit of clinical context. Providing the clinical context adds meaningful learning and insight for APNs practicing in the clinical setting. Integration of PjBL into the clinical practice setting for APNs learning about QI should be a considered procedure to ensure accurate and standardized execution of QI can be achieved.Substantial evidence exists for the use of PjBL in the academic setting for teaching QI to nursing students; this experience may be applied in the clinical practice setting when teaching QI to APNs. Project-based learning is an effective teaching methodology for practicing APNs, in that it promotes the transfer of knowledge into clinical practice in a contextually and culturally meaningful way, addressing both the cognitive and psychomotor domains. Successful implementation of PjBL in the clinical practice setting engages the novice and expert APN together in QI and may be particularly advantageous for APNs pursuing clinical inquiry.

Assessment of the Critical Care Work Environment of Intensive Care Unit Nurses in Saudi Arabia.

Nurses play a major role in the delivery of complex and challenging critical care in intensive care units (ICUs). Assessment of work environment is essential indicators of hospital management and can be applied to workforce planning and identifying nursing profession needs. The American Association of Critical-Care Nurses (AACN) recognized six standards for a healthy work environment and developed the Healthy Work Environment Assessment Tool (HWEAT). The aim of this study was to assess the work environment of ICU nurses in Jazan, Saudi Arabia. This cross-sectional study was conducted at public and private hospitals. Data were collected using a self-administered questionnaire that included the sociodemographic characteristics and the AACN HWEAT. Data were analyzed to obtain descriptive and inferential statistics. The Mann-Whitney U and Kruskal-Wallis tests were employed to compare demographic data, on the basis of the overall mean HWEAT score. The study participants were 238 ICU nurses, who were predominantly female (83%). The mean overall HWEAT score was 3.55±1.03, which is within the "good" range, and was higher for male nurses (3.66), nurses aged ≥41 years (3.76), and nurses with postgraduate education (4.04), work experiences of >10 years (3.63), and alternate work shifts (3.6). Nurses in private hospitals had significantly higher overall scores than nurses in public hospitals (3.83 vs 3.19, P<0.001). All HWEAT standards ("effective decision-making", "authentic leadership", "appropriate staffing", "true collaboration", "skilled communication", and "meaningful recognition") were rated as good (mean range, 3.43-3.63). The study results could assist hospitals in prioritizing the adoption of AACN HWE standards. A target benchmark of "good" was established for both the overall score and each standard, which indicates a good work environment as perceived by ICU nurses. In Addition, interpersonal differences should be considered when developing improvement initiatives.

Appropriate Staffing After the Pandemic: A New Challenge for Healthy Work Environments

When the American Association of Critical-Care Nurses (AACN) launched the Healthy Work Environment (HWE) Standards in 2005, nurses finally had guidance to help improve their work environment. The 6 HWE standards are appropriate staffing, skilled communication, true collaboration, authentic leadership, meaningful recognition, and effective decision-making.1 The HWE standards were introduced by Dorrie Fontaine, then president of AACN, and the president of the Joint Commission, which demonstrated the commitment these bodies had to improving health care work environments. The HWE standards were released shortly after the VitalSmarts “Silence Kills” study,2 which focused on the importance of the communication and collaboration of the team for patient safety.3Through the years, Ulrich et al have studied work environments to monitor changes over time. The baseline report was done in 2006,4 and at that time, 50% of the research participants knew healthy work environments existed and about 50% of them felt that communication and staffing were the lowest scoring standards.4 The follow-up survey was done in 2008. At that time, most of the nurses were satisfied with nursing as a career, and they felt that (1) their unit’s work environments were better than the organization’s, (2) improved leadership could decrease turnover, and (3) for the most part things had not changed significantly from the baseline study.5 The 2013 study reported that the quality of work environments had declined, with the largest declines in the area of effective decision-making.6 In this study, nurses reported that they were aware of appropriate staffing for patient safety, but they also stated that their staffing had also declined. In 2018, there was some good news. Some of the HWE standard areas had improved and were higher than all previous studies, especially in the areas of communication, collaboration, decision-making, and meaningful recognition.7 Staffing had increased since the 2013 study but was still lower than the previous 2 studies. Many nurses reported in the 2018 study that they were planning on leaving their organization in the next 12 months.7 The last study was completed in the fall of 2021. These results should be published soon; it is anticipated that the findings will reflect the fall 2021 pandemic challenges being faced in health care environments.New challenges surfaced in late 2021 and continue in 2022. Staffing was poor overall during the pandemic, and the many COVID-19 surges caused additional demand for care for large numbers of critically ill patients at a national level.8 In 2022, many millennials are leaving their current positions for higher paying jobs through travel agencies or to pursue sign-on bonuses. Even those nurses who like their jobs and have positive comments about their managers are taking new higher paying positions in the hopes of buying new homes, paying off school loans, or being in a better financial position. This year is being labeled the year of the “Great Resignation.”8 This nursing shortage and the related variables are unlike anything we have previously seen. Hospitals are closing beds because of nursing shortages and are reporting millions of dollars lost as a result of the pandemic and having to decrease volumes in operating rooms and procedural areas to shift staffing to the high-acuity critically ill patients.9AACN has been leading the way to improve staffing. In September 2018, the Guiding Principles of Staffing were published on the AACN website.10 The focus of the Guiding Principles is to address not only the numbers of staff but the needs of the patients and the competencies of the nurse. Staffing needs to be viewed as a “dynamic process.” AACN’s call to action on staffing states that “Meaningful and sustainable change to traditional staffing models is a moral imperative that requires urgent collaborative action.”10 The 8 guiding principles are10AACN has collaborated with the American Nurses Association (ANA), the American Organization of Nurse Leaders (AONL), the Healthcare Financial Management Association (HFMA), and the Institute for Healthcare Improvement (IHI) to recommend solutions to the staffing crisis. This Think Tank met early in 2022 and put forth a set of priorities and recommendations to provide strategies that can be implemented in 12 to 18 months. The group developed an action plan to change the culture in health care delivery with the goal of improved nurse retention, better patient outcomes, and healthier work environments.11 The priority topics addressed in the recommendations are11The Think Tank recommendations focus on not only what health care system leaders need to do the address the issues but also what policy makers and professional organizations should do. A detailed list of recommendations can be found on the Staffing Think Tank page (www.nursingworld.org/practice-policy/nurse-staffing/nurse-staffing-task-force).It is time that we address our pressing issues to support a healthy work environment, particularly in ensuring adequate staffing to provide safe and effective care. To quote our AACN 2022-2023 president’s theme Starting Now, we have an opportunity to do things differently and reimagine our profession. We cannot continue to do things the same way and expect different results. Our staff and our patients need us to act now.

National Nurse Work Environments - October 2021: A Status Report.

The health of nurse work environments has been shown to affect both patient and nurse outcomes. In 2005, the American Association of Critical-Care Nurses published the AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence, and a second edition was published in 2016. The American Association of Critical-Care Nurses conducted critical care nurse work environment studies in 2006, 2008, 2013, 2018, and, most recently, October 2021, which was expanded to include registered nurses in all areas of practice. To report the results of the October 2021 study with comparisons to previous studies and recommendations for continued improvement and to evaluate the current state of nurse work environments. An online survey was used. A total of 9862 registered nurses responded to the survey; 9335 met the study criteria of currently practicing as a registered nurse. The health of nurse work environments has declined dramatically since the 2018 study. However, as in 2018, evidence of a positive relationship exists between implementation of the American Association of Critical-Care Nurses Healthy Work Environment Standards and the health of nurse work environments, between the health of nurse work environments and job satisfaction, and between job satisfaction and the intent of nurses to leave their current positions or to stay. It is time for bold, intentional, and relentless efforts to create and sustain healthy work environments that foster excellence in patient care and optimal outcomes for patients, nurses, and other members of the health care team.

A Hospital's Roadmap for Improving Nursing Excellence Using AACN's Healthy Work Environment Standards.

The nursing profession is in crisis as we move out of pandemic-related staffing pressures and move into shortages driven by retirement of the Baby Boom generation. Burnout in nursing was significant prior to the pandemic.1 According to Buerhaus,2 factors driving the current staff shortage include the retirement of one-third of the nursing workforce between 2010 and 2030, an increase in demand for nurses as the result of the expansion in both inpatient and outpatient specialties, and a growing number of frontline nurses who want to move into advanced practice positions. Per Buerhaus,2 an estimated 640 000 nurses will retire between 2020 and 2030, although some may have left early over the past 2 years because of the pandemic.Traditional recruitment and retention strategies such as sign-on bonuses and other financial incentives are temporary solutions for the larger problem. Sign-on bonuses, for example, were given during the last major nursing shortage in the early 2000s; they did not remedy the larger trend. Sign-on bonuses are an insufficient measure for resolving large shortages, and they can be demoralizing for current staff who have chosen to stay.3 According to Burke and Ropp,3 “the sign-on bonus is an expensive, short-lived tactic to fill slots.”This column will focus on one hospital’s attempt to implement long-term plans focused on the American Association of Critical-Care Nurses (AACN) Healthy Work Environment Standards: skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership.4 Per Munro and Hope in an American Journal of Critical Care editorial before the pandemic, the standards “support improved outcomes for both patients and nurses and for the health care team.”5According to AACN, for skilled communication to occur, “Nurses must be as proficient in communication skills as they are in clinical skills.”4 Blake et al6 found that the better the communication and collaboration, the better the patient outcomes. Collaboration and communication are increasingly essential in hospitals, and as such, hospitals are developing programs to encourage teamwork. TeamSTEPPS is a good example of a program that can be implemented to train staff in formal communication processes.7 The Joint Commission has set a leadership standard to ensure abusive behavior is dealt with by management; they have also developed hand-off communication recommendations because a large percentage of sentinel events had inadequate communication as a root cause.8 One method to improve collaboration is a triad leadership team for each unit: a nurse leader, a physician leader, and an administrative leader. This triad model with joint accountability brings the team closer together in order to address issues.Decision-making is improving in many health care systems with the implementation of shared governance. The primary purpose of the Shared Governance Council (SGC) at Los Angeles County University of Southern California (LAC+USC) Medical Center is to implement and continuously improve the unit- and department-specific Relationship©Based Care (RBC) delivery model and related outcomes. The SGC enculturates a shared governance decision-making model within the organization, which allows clinical staff to express and manage their practice and offers a high level of professional autonomy and accountability for the nursing staff. The SGC assumes accountability for the operation and integration of shared governance. A dynamic partnership between those who provide service or support within a health care system will promote excellence, collaboration, timely communication, shared decision-making, accountability, and ownership. This partnership is accomplished by using the account-abilities for shared decision-making to guide the work of the nursing staff. Responsibilities of the SCG include practice or service issues, the practice or work environment, performance improvement, and professional development. Shared governance enables sustainable, accountability-based decisions to support an interprofessional design for excellent patient care.9 Shared governance assures that decisions are aligned with the organizational mission, vision, values, and strategic goals and fully empowers professional practice scope.Bedside nurses in health care today are challenged with more complex patients and increased health care demands.10 California’s nurse-to-patient ratios (as established by California Assembly Bill 394) define the maximum number of patients to whom a nurse can be assigned. Furthermore, the law requires a patient classification system that calculates the amount of nursing care a patient will need for a specific shift. The law was developed to improve staffing and patient outcomes, as research has indicated that higher staffing levels improve patient outcomes.11A staffing, scheduling, and patient acuity system is an example of an evidence-based system that provides tools to assign staff on the basis of patient acuity as determined by nursing outcomes classification and standard outcome sets that minimally adhere to nurse-to-patient ratios. Advanced technology calculates staffing by patient acuity and hours of care to determine individual patient care needs. The system automatically extracts predetermined patient care data points from clinical documentation. Our system standardizes acuity levels and hours of care needed for each patient. Furthermore, it removes subjective assessments and allows for equity of assignments among nursing staff. This acuity tool helps eliminate the need to make patient care assignments on the basis of patient location and personal bias or staffing ratios alone. Data are collected from the clinical documentation with alignment of previous admission, discharge and transfers, and adjusted hours per patient day. Patient acuity levels are also based on budget data, which helps facilitate staffing assignments. A 75% documentation threshold is required to generate patient acuity. The frontline trained nursing staff complete peer review audits and interrater reliability monitoring to validate the tool monthly. Thus, nursing staff learn to trust the system and ensure the system pulls the appropriate patient care data points to compute patient acuity. The goal is to provide tools and data to determine when there is a need for additional nursing staff higher than the mandated patient-nurse ratios, make equitable assignments, and promote optimal decision-making in real time.While scheduling shifts for nurses is an important part of daily staffing, having strategies to recruit, decrease turnover, and meet staffing needs of patients is also important for retention. Self-scheduling is one strategy that offers flexibility to both the employee and the hospital by allowing nurses to work shifts that meet their personal needs and accommodate a work-life balance. A great recruiting tool, self-scheduling provides a sense of autonomy in the work environment and creates a sense of professionalism. The interactive process in self-scheduling provides transparency, as nurses can see coworker preferences and department needs, and can improve communication and increase team building. Self-scheduling reduces conflicts and enables nurses to trade shifts with peers. Employees feel more in control of their lives, which improves staff satisfaction. Self-scheduling also lets the manager spends less time preparing schedules and can be used as a strategy to decrease absenteeism and improve staff retention and satisfaction.The staffing, scheduling, and patient acuity application system supports self-scheduling and is web-based, allowing staff to see their current daily schedule. The system provides real-time data and has features to improve communication between coworkers and managers. For example, when a nurse wants to change shifts, it provides a view of their current schedule, all staff available whose schedules could accommodate the trade, and a view of what those changes would reflect to the nurse’s schedule. One text is sent to all potential staff who could trade, and managers can evaluate those trades and approve with electronic data to track all changes, approvals, and communication. In addition, the system can be used to alert staff within 24 hours of increased staffing needs due to absenteeism or increased patient acuity. One mass communication is sent to all nurses who are available, who can then respond with tracked electronic communication.Safe staffing is essential to maximizing patient outcomes and staff satisfaction, and self-scheduling is a great tool to reach that goal.When considering the daily challenges of running a hospital, combined with the impact of COVID-19 on nursing staff, it is easy to lose sight of what is important: recognizing nurses and their accomplishments, whether big or small. Now more than ever, having a meaningful recognition program is vital to nurses feeling valued and appreciated. A healthy working environment that supports nurse retention recognizes individual or team successes in a genuine, consistent, and meaningful way. As a proud DAISY partner, LAC+USC Medical Center continues to celebrate and recognize an extraordinary front-line nurse every month for the compassionate way they deliver care. In 2021, we expanded our DAISY recognition program to include the DAISY Nurse Leader Award in time for Boss’ Day. The dedication, hard work, innovative ideas, and adaptability our nurse managers demonstrated amid the pandemic was truly remarkable, and we needed to ensure they are acknowledged and recognized.Each member of the health care team is important, thus we have the Shining Star award to honor ancillary staff: clerks, nursing assistants, and technicians who go above and beyond and shine the brightest for the benefit of others. Awardees exhibit the qualities of a STAR: supportive and sincere, trustworthy and a team player, adaptable and a patient advocate, and respectful and responsible. Elevating and embedding relevant, strong, and meaningful recognition practices inspires employees to contribute to a healthy and professional work environment.Authentic leadership is an important to tool in promoting nurse retention. Blake et al6 found that nursing leadership was the most important factor related to nurses’ intent to leave their job in the next 6 months in the pediatric intensive care unit (P &lt; .01).6 Old-school top-down management styles are no longer effective. Nurse managers need to understand their role as chief retention officers and servant leaders. In order to do that, there needs to be a professional development program for nurse managers. Many nurse managers are promoted on the basis of their clinical skills and nursing expertise in their unit. When we fail to provide professional development for nurse managers, they may fail in their new roles, which in turn results in high turnover. The organization should provide ongoing education and mentoring of managers tailored to support nurse manager competencies. Saifman and Sherman12 noted that leadership development, coaching, and mentoring are needed for ongoing competency development, quoting leadership expert John Maxwell: “our own ability as leaders will ultimately be measured by how well those who follow us are prepared to lead in our absence.”New graduate residency programs have been in place for more than 20 years. Data have shown a significant decrease in turnover in the first 2 years, relative to what turnover looked like before these programs. The Practice Transition Accreditation Program for Registered Nurse Residency is a structured, comprehensive program for registered nurses with less than 12 months of experience. The programs support skills acquisition for new graduates and include organizational orientation, practice-based experience, and supplemental activities to promote nursing professional development.13 Structured, accredited nurse residency programs lasting 6 to 12 months have been shown to improve new graduate retention, competence, and the confidence required to practice autonomously and in collaboration with other disciplines.14 The data showing the benefit of new graduate transition to practice programs underscore that these programs are essential for onboarding new graduates; they can aid in retention of new graduates and be a cornerstone of a successful retention program. Trepanier and colleagues15 found that the 12-month turnover across 15 primarily community-based hospitals decreased from a mean of 36.8% preresidency to a mean of 6.41% postresidency. New graduate programs build confidence and competence, which ensures a rewarding transition to practice.16AACN’s Healthy Work Environment Standards are a blueprint to implement a healthy work environment. This was one facility’s roadmap to support a healthy work environment. It is a journey, and our work is not done, as we have to hire staff to fill open positions and closely collaborate with the frontline staff to meet their needs and support retention.

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

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.