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.