The Gratitude Campaign: A Multihospital Evidence-Based Practice Project.

Nurse well-being and optimism were tested in the midst of COVID-19 patient surges and staffing challenges. Using the American Nurses Foundation Gratitude Toolkit, a health system implemented monthly gratitude practices at 4 hospitals. Validated survey measures indicated that nurses' scores of self-perceived gratitude, flourishing behaviors, and mindfulness were maintained during this challenging time but did not statistically increase. Although statistical significance increases were not demonstrated, the gratitude campaign offered clinical significance through positive feedback and was sustained through the distribution of a toolkit disseminated across the health system.

Creating an Organizational Culture and Climate of Meaningful Recognition for Nurse Managers.

OBJECTIVES: To examine the current nurse manager (NM) recognition culture and climate in organizations and to develop a theoretical foundation for meaningful recognition. BACKGROUND: Nurse managers call for wider recognition, but the theoretical conceptualization and underpinnings of meaningful recognition are sparse in the literature. METHODS: A qualitative descriptive design was used utilizing individual interviews. The study participants included 30 individuals consisting of NMs, chief nursing officers, and chief nursing executives. Content analysis was conducted. RESULTS: A theoretical model with super-categories and supportive quotes was created to operationalize a culture and climate of meaningful recognition in the organizations represented by the sample. CONCLUSION: This qualitative descriptive study highlights the importance of recognizing the value of NMs for their contributions to nursing leadership and patient care. Implications of recognizing NMs are counteracting the feeling of being invisible and mitigating issues within the work environment.

American Academy of Nursing consensus recommendations to advance system level change for nurse well-being.

The COVID-19 pandemic has required close examination of workforce-related stressors that over decades have contributed to widespread burnout, negative health outcomes, including mental health outcomes, and the loss of the well-educated professionals who are the future of the nursing profession. In the United States and globally, evidence points to factors known to diminish well-being, including inequities, issues of minority status, persistent discrimination, and demanding work environments. The American Academy of Nursing (AAN), dedicated to organizational excellence, nursing leadership and evidence-based policy, develops statements reflecting its mission and those of its nursing affiliates and corporate member, The American Nurses Association. Within nursing, despite the efforts of its members toward advancement, professional fulfillment is often constrained by the systems in which nurses practice and workplace factors over which they have little control. Action by key organizations to initiate changes at systems levels in workplace safety, to increase professional mobility, and propel policies that increase access to health care resources could improve nurse well-being. This paper proposes recommendations from the AAN Expert Panels on Building Health Care System Excellence, Psychiatric Mental Health and Substance Use, and Global Health Expert Panels for the American Academy of Nursing to leverage related policy in the arenas of government and professional/healthcare organizations. Transforming health care work environments and advancing nurse well-being and equity can be accomplished through key, innovative policy changes. These will be achieved through collaboration among associations, organizations, nonprofit groups, and with the public and the media.

Impact of nurse burnout on organizational and position turnover.

BACKGROUND: The National Academies of Medicine describes clinician burnout as a serious threat to organizational health, including employee turnover. PURPOSE: To determine the relationship between resilience, burnout, and organizational and position turnover. METHODS: We surveyed direct care nurses in three hospitals 1 year apart between 2018 and 2019; 1,688 nurses completed 3,135 surveys included in analysis. FINDINGS: Fifty-four percent of nurses in our sample suffer from moderate burnout, with emotional exhaustion scores increasing by 10% and cynicism scores increasing 19% after 1 year. The impact of burnout on organizational turnover was significant, with a 12% increase in a nurse leaving for each unit increase on the emotional exhaustion scale, though it was not a factor in position turnover. DISCUSSION: These findings contribute to the growing body of evidence of nurse burnout and support policies and programs for annual measurement of burnout, increased employee wellbeing support, and improved work environments.

Using Text Messages to Support Nurse Well-being.

The COVID-19 pandemic caused significant nurse stress and contributed to burnout for a number of reasons, including but not limited to personal protective equipment shortages, furloughs, overtime, reassignment to unfamiliar work environments, and alternate staffing patterns, all of which contribute to grief, loss, fear, and anger. While the nursing profession and employers offered support and psychological first-aid resources, there was a disconnect in effectively linking stressed nurses with these needed resources. An innovative statewide pilot project in Arizona, RNconnect 2 Wellbeing, was created to determine whether nurses might respond to and use supportive resources via opt-in text messages. Over a 12-week enrollment trial, 2997 nurse users opted to receive brief, twice weekly, well-being text messages about subjects, such as increasing awareness, self-care, and gratitude. By the end of the pilot, 2777 nurse users remained enrolled (7% opt out). Convenience evaluation surveys were conducted at midpoint (n = 294) and pilot completion (n = 404). Satisfaction with the messages ranged from 73% to 86%. Forty-eight percent indicated they had integrated the resources into their daily lives. RNconnect 2 Wellbeing, an innovative and cost-effective approach to communicating with nurses, has laid the groundwork for the use of technology via brief text messages to improve nurse well-being.

Burnout, Compassion Fatigue, and Secondary Trauma in Nurses: Recognizing the Occupational Phenomenon and Personal Consequences of Caregiving.

Burnout and compassion fatigue describe the state of health care professionals' extended stress, emotional states, and prolonged duress after events. In the past few decades, burnout and compassion fatigue have received increased focus and attention. This article summarizes the evolution in moving from viewing burnout as an individual's problem to understanding burnout as an occupational phenomenon, additionally recognizing the powerful role secondary trauma contributes to compassion fatigue. As such, the causes and addressing the solutions of burnout are multifaceted and complex. Causes of burnout stem from external pressure of caring for patients and pressure from organizational policy and practices, including unhealthy work environments, poor communication, stigma, and more. The harm from burnout and secondary trauma in health care professionals can be profound, impacting a significant portion of the workforce and manifesting in real suffering, including depression, emotional trauma, and suicide. As health care professionals are daily at risk, the need to recognize, address, and treat burnout is a priority. Both personal resilience building activities for effective stress reduction in clinicians and system-level solutions to address root causes must be utilized to address burnout.

Nurse Leader Burnout, Satisfaction, and Work-Life Balance.

OBJECTIVE: To examine and report burnout, secondary trauma, and compassion satisfaction in acute care nurse leaders through a large mixed-methods research study. BACKGROUND: Although nurse leaders are removed from daily patient care activities, the pervasive challenges in the work environment create conditions for professional burnout. Nurse leaders must garner compassion satisfaction from different sources, including peer and staff interactions. METHODS: The Professional Quality of Life scale was given to nurse leaders at 29 hospitals in 1 health system. Sixteen leaders from 2 hospitals participated in qualitative interviews. RESULTS: Six hundred seventy-two nurse leaders from 29 hospitals reported similar levels of burnout across frontline, midlevel, and director-level leadership. Directors demonstrated higher levels of compassion satisfaction and lower levels of work-life balance. Four themes emerged representing areas of professional life that potentiate and alleviate compassion fatigue. CONCLUSIONS: All levels of nurse leaders must address the risk of burnout and can do so through individual and organizational resiliency strategies.

Decisional Involvement: Differences Related to Nurse Characteristics, Role, and Shared Leadership Participation.

A sample of 1933 registered nurses working in 24 hospitals with shared leadership was surveyed to examine perceptions of nurse decisional involvement. Council participation was associated with higher decisional involvement scores (P = .03), and nurse experience was a statistically significant predictor of decisional involvement (P < .01). Nurse manager and staff registered nurse scores were significantly different (P < .01). Shared leadership may promote staff nurse perceptions of involvement in decision-making.

Predictors of Compassion Fatigue and Compassion Satisfaction in Acute Care Nurses.

PURPOSE: To examine compassion fatigue and compassion satisfaction in acute care nurses across multiple specialties in a hospital-based setting. DESIGN: A cross-sectional electronic survey design was used to collect data from direct care nurses in a 700-bed, quaternary care, teaching facility in the southwestern United States. METHODS: A total of 491 direct care registered nurses completed a survey measuring their professional quality of life (burnout, secondary traumatic stress, and compassion satisfaction). Analysis was conducted to assess for differences between demographics, specialties, job satisfaction, and intent to leave their current position. FINDINGS: Significant predictors of burnout included lack of meaningful recognition, nurses with more years of experience, and nurses in the "Millennial" generation (ages 21-33 years). Receiving meaningful recognition, higher job satisfaction, nurses in the "Baby Boomer" generation (ages 50-65 years), and nurses with fewer years of experience significantly predicted compassion satisfaction. No significant differences were noted across nurse specialties, units, or departments. CONCLUSIONS: This study adds to the literature the impact meaningful recognition may have on compassion satisfaction and fatigue. Our findings provide a potential explanation for the lack of retention of nurses in the millennial generation who leave their positions with limited years of experience. Based on our research, meaningful recognition may increase compassion satisfaction, positively impact retention, and elevate job satisfaction. CLINICAL RELEVANCE: Compassion fatigue in nurses has clear implications for nursing retention and the quality of care. Organizations willing to invest in reducing compassion fatigue have the potential to improve financial savings by reducing turnover and adverse events associated with burnout.

The relationship of training and education to leadership practices in frontline nurse leaders.

BACKGROUND: Although organizations strive to develop transformational leaders, frontline nurse managers and directors are often inadequately prepared and lack transformational leadership (TL) behaviors. OBJECTIVE: To examine the relationship of TL practices, nurse characteristics, and formal leadership training of frontline nurse leaders in a large health system. METHODS: A survey of 512 frontline nurse leaders in 23 hospitals assessed demographic characteristics, the amount of leadership training received, and self-perceived leadership behaviors, measured through the Leadership Practices Inventory. RESULTS: Formal training influences only 1 component of TL behaviors, helping train leaders to model the way for their employees. Increasing a nurse leader's level of formal education has a significant effect in improving overall TL practices and behaviors that inspire a shared vision and challenge the process. CONCLUSION: To build transformational frontline nurse leaders, organizations should balance formal leadership training programs with advanced degree attainment to encourage leaders to envision and challenge the future.

Excellence and evidence in staffing: a data-driven model for excellence in staffing (2nd edition).

The Patient Protection and Affordable Care Act (PPACA, 2010) and the Institute of Medicine's (IOM, 2011) Future of Nursing report have prompted changes in the U.S. health care system. This has also stimulated a new direction of thinking for the profession of nursing. New payment and priority structures, where value is placed ahead of volume in care, will start to define our health system in new and unknown ways for years. One thing we all know for sure: we cannot afford the same inefficient models and systems of care of yesterday any longer. The Data-Driven Model for Excellence in Staffing was created as the organizing framework to lead the development of best practices for nurse staffing across the continuum through research and innovation. Regardless of the setting, nurses must integrate multiple concepts with the value of professional nursing to create new care and staffing models. Traditional models demonstrate that nurses are a commodity. If the profession is to make any significant changes in nurse staffing, it is through the articulation of the value of our professional practice within the overall health care environment. This position paper is organized around the concepts from the Data-Driven Model for Excellence in Staffing. The main concepts are: Core Concept 1: Users and Patients of Health Care, Core Concept 2: Providers of Health Care, Core Concept 3: Environment of Care, Core Concept 4: Delivery of Care, Core Concept 5: Quality, Safety, and Outcomes of Care. This position paper provides a comprehensive view of those concepts and components, why those concepts and components are important in this new era of nurse staffing, and a 3-year challenge that will push the nursing profession forward in all settings across the care continuum. There are decades of research supporting various changes to nurse staffing. Yet little has been done to move that research into practice and operations. While the primary goal of this position paper is to generate research and innovative thinking about nurse staffing across all health care settings, a second goal is to stimulate additional publications. This includes a goal of at least 20 articles in Nursing Economic$ on best practices in staffing and care models from across the continuum over the next 3 years.

Lower mortality in magnet hospitals.

BACKGROUND: Although there is evidence that hospitals recognized for nursing excellence--Magnet hospitals--are successful in attracting and retaining nurses, it is uncertain whether Magnet recognition is associated with better patient outcomes than non-Magnets, and if so why. OBJECTIVES: To determine whether Magnet hospitals have lower risk-adjusted mortality and failure-to-rescue compared with non-Magnet hospitals, and to determine the most likely explanations. METHOD AND STUDY DESIGN: Analysis of linked patient, nurse, and hospital data on 56 Magnet and 508 non-Magnet hospitals. Logistic regression models were used to estimate differences in the odds of mortality and failure-to-rescue for surgical patients treated in Magnet versus non-Magnet hospitals, and to determine the extent to which differences in outcomes can be explained by nursing after accounting for patient and hospital differences. RESULTS: Magnet hospitals had significantly better work environments and higher proportions of nurses with bachelor's degrees and specialty certification. These nursing factors explained much of the Magnet hospital effect on patient outcomes. However, patients treated in Magnet hospitals had 14% lower odds of mortality (odds ratio 0.86; 95% confidence interval, 0.76-0.98; P=0.02) and 12% lower odds of failure-to-rescue (odds ratio 0.88; 95% confidence interval, 0.77-1.01; P=0.07) while controlling for nursing factors as well as hospital and patient differences. CONCLUSIONS: The lower mortality we find in Magnet hospitals is largely attributable to measured nursing characteristics but there is a mortality advantage above and beyond what we could measure. Magnet recognition identifies existing quality and stimulates further positive organizational behavior that improves patient outcomes.

Creative approaches to increasing hospital-based nursing research.

Magnet-designated and aspiring hospitals use research and evidence-based practice initiatives to demonstrate new knowledge and innovation, a key component of the Magnet Recognition Program. Four creative approaches to supporting and conducting institutional nursing research and the implementation of evidence-based care are illustrated, along with examples of successful nurse staff-led projects.

Impact of nurse staffing mandates on safety-net hospitals: lessons from California.

CONTEXT: California is the first and only state to implement a patient-to-nurse ratio mandate for hospitals. Increasing nurse staffing is an important organizational intervention for improving patient outcomes. Evidence suggests that staffing improved in California hospitals after the mandate was enacted, but the outcome for hospitals bearing a disproportionate share of uncompensated care-safety-net hospitals-remains unclear. One concern was that California's mandate would burden safety-net hospitals without improving staffing or that hospitals would reduce their skill mix, that is, the proportion of registered nurses of all nursing staff. We examined the differential effect of California's staffing mandate on safety-net and non-safety-net hospitals. METHODS: We used a time-series design with Annual Hospital Disclosure data files from the California Office of Statewide Health Planning and Development (OSHPD) for the years 1998 to 2007 to assess differences in the effect of California's mandate on staffing outcomes in safety-net and non-safety-net hospitals. FINDINGS: The mandate resulted in significant staffing improvements, on average nearly a full patient per nurse fewer (-0.98) for all California hospitals. The greatest effect was in those hospitals with the lowest staffing levels at the outset, both safety-net and non-safety-net hospitals, as the legislation intended. The mandate led to significantly improved staffing levels for safety-net hospitals, although there was a small but significant difference in the effect on staffing levels of safety-net and non-safety-net hospitals. Regarding skill mix, a marginally higher proportion of registered nurses was seen in non-safety-net hospitals following the mandate, while the skill mix remained essentially unchanged for safety-net hospitals. The difference between the two groups of hospitals was not significant. CONCLUSIONS: California's mandate improved staffing for all hospitals, including safety-net hospitals. Furthermore, improvement did not come at the cost of a reduced skill mix, as was feared. Alternative and more targeted designs, however, might yield further improvement for safety-net hospitals and reduce potential disparities in the staffing and skill mix of safety-net and non-safety-net hospitals.

Nurse outcomes in Magnet® and non-Magnet hospitals.

The important goals of Magnet® hospitals are to create supportive professional nursing care environments. A recently published paper found little difference in work environments between Magnet and non-Magnet hospitals. The aim of this study was to determine whether work environments, staffing, and nurse outcomes differ between Magnet and non-Magnet hospitals. A secondary analysis of data from a 4-state survey of 26,276 nurses in 567 acute care hospitals to evaluate differences in work environments and nurse outcomes in Magnet and non-Magnet hospitals was conducted. Magnet hospitals had significantly better work environments (t = -5.29, P < .001) and more highly educated nurses (t = -2.27, P < .001). Magnet hospital nurses were 18% less likely to be dissatisfied with their job (P < .05) and 13% less likely to report high burnout (P < .05). Magnet hospitals have significantly better work environments than non-Magnet hospitals. The better work environments of Magnet hospitals are associated with lower levels of nurse job dissatisfaction and burnout.

Medical Assistant Psychological Safety Linked to Leader Inclusiveness in Ambulatory Care Settings.

OBJECTIVES: Studies in hospitals show that leader behaviors and power distance between healthcare professionals influence psychological safety (PS). However, little research on PS in outpatient settings exists. The main objective of this study was to explore factors that influence the PS of medical assistants (MAs) working in ambulatory care. METHODS: A cross-sectional web-based survey consisting of items to assess PS and factors known to influence PS was distributed nationally to certified medical assistants (CMA) who obtained certification from the American Association of Medical Assistants. To evaluate relationships between variables, bivariate analyses and ordinary least squares regression were conducted on responses from those working in ambulatory care. RESULTS: From the 54,196 email addresses contacted, 7,467 individuals (13.8%) responded to one or more survey questions; of them, 4,674 reported working in ambulatory care. Similar to research involving other types of healthcare professionals, results showed that leader inclusiveness meaningfully predicted variation in PS (R2 = 0.21, p < 0.001). Power distance (as conceived in this study) was not associated with PS. CONCLUSIONS: This study adds to a growing body of literature showing that supportive leader behaviors positively impact PS. Greater attention to leadership development in health professions educational programs should be considered.

Beyond Burnout and Resilience: The Disillusionment Phase of COVID-19.

In caring for patients during the COVID-19 pandemic, nurses are experiencing a crisis of emotional highs and lows that will have lasting implications for their professional and personal well-being. As a result, much attention has been focused on nurse burnout, but the range of nurses' experiences is more nuanced, complicated, and profound. With the recognition that the nursing workforce was already experiencing burnout before the pandemic, this article explores how individuals respond to disasters and the detrimental effects of the repeated surges of critically ill patients, which have led nurses to experience an extended period of disillusionment that includes secondary traumatic stress, cumulative grief, and moral distress. This article describes the range of psychological responses to the COVID-19 pandemic so that nurse leaders can better identify resources and interventions to support nurses.

The dimensions of nursing surveillance: a concept analysis.

AIM: This paper is a report of an analysis of the concept of nursing surveillance. BACKGROUND: Nursing surveillance, a primary function of acute care nurses, is critical to patient safety and outcomes. Although it has been associated with patient outcomes and organizational context of care, little knowledge has been generated about the conceptual and operational process of surveillance. DATA SOURCES: A search using the CINAHL, Medline and PubMed databases was used to compile an international data set of 18 papers and 4 book chapters published from 1985 to 2009. REVIEW METHODS: Rodger's evolutionary concept analysis techniques were used to analyse surveillance in a systems framework. This method focused the search to nursing surveillance (as opposed to other medical uses of the term) and used a theoretical framework to guide the analysis. RESULTS: The examination of the literature clarifies the multifaceted nature of nursing surveillance in the acute care setting. Surveillance involves purposeful and ongoing acquisition, interpretation and synthesis of patient data for clinical decision-making. Behavioural activities and multiple cognitive processes are used in surveillance in order for the nurse to make decisions for patient safety and health maintenance. A systems approach to the analysis also demonstrates how organizational characteristics and contextual factors influence the process in the acute care environment. CONCLUSION: This conceptual analysis describes the nature of the surveillance process and clarifies the concept for effective communication and future use in health services research.

Nurse outcomes in Magnet® and non-magnet hospitals.

The important goals of Magnet hospitals are to create supportive professional nursing care environments. A recently published paper found little difference in work environments between Magnet and non-Magnet hospitals. The aim of this study was to determine whether work environments, staffing, and nurse outcomes differ between Magnet and non-Magnet hospitals. A secondary analysis of data from a 4-state survey of 26,276 nurses in 567 acute care hospitals to evaluate differences in work environments and nurse outcomes in Magnet and non-Magnet hospitals was conducted. Magnet hospitals had significantly better work environments (t = -5.29, P < .001) and more highly educated nurses (t = -2.27, P < .001). Magnet hospital nurses were 18% less likely to be dissatisfied with their job (P < .05) and 13% less likely to report high burnout (P < .05). Magnet hospitals have significantly better work environments than non-Magnet hospitals. The better work environments of Magnet hospitals are associated with lower levels of nurse job dissatisfaction and burnout.

Key Elements of the Critical Care Work Environment Associated With Burnout and Compassion Satisfaction.

BACKGROUND: As the role of a health care system's influence on nurse burnout becomes better understood, an under-standing of the impact of a nurses' work environment on burnout and well-being is also imperative. OBJECTIVE: To identify the key elements of a healthy work environment associated with burnout, secondary trauma, and compassion satisfaction, as well as the effect of burnout and the work environment on nurse turnover. METHODS: A total of 779 nurses in 24 critical care units at 13 hospitals completed a survey measuring burnout and quality of the work environment. Actual unit-level data for nurse turnover during a 5-month period were queried and compared with the survey results. RESULTS: Among nurses in the sample, 61% experience moderate burnout. In models controlling for key nurse characteristics including age, level of education, and professional recognition, 3 key elements of the work environment emerged as significant predictors of burnout: staffing, meaningful recognition, and effective decision-making. The latter 2 elements also predicted more compassion satisfaction among critical care nurses. In line with previous research, these findings affirm that younger age is associated with more burnout and less compassion satisfaction. CONCLUSIONS: Efforts are recommended on these 3 elements of the work environment (staffing, meaningful recognition, effective decision-making) as part of a holistic, systems-based approach to addressing burnout and well-being. Such efforts, in addition to supporting personal resilience-building activities, should be undertaken especially with younger members of the workforce in order to begin to address the crisis of burnout in health care.