The future of nursing and the U.S. healthcare system is at an 'urgent crossroads.'
About 100,000 RNs left the workforce during the COVID-19 pandemic in the past two years due to stress, burnout, and retirement, and about one-fifth of RNs nationally are projected to do the same by 2027.
Those sobering numbers were unveiled Thursday by The National Council of State Boards of Nursing (NCSBN) in research titled “Examining the Impact of the COVID-19 Pandemic on Burnout & Stress Among U.S. Nurses,” in a panel at the National Press Club.
The study is considered to be the most comprehensive and only research in existence uncovering the alarming data reflecting the pandemic’s far-reaching and distressing implications for the healthcare system. The research was gathered as part of a biennial nursing workforce study conducted by NCSBN and the National Forum of State Nursing Workforce Centers.
Research findings reveal for the first time how the nursing workforce was affected by the pandemic, how many left the workforce during this period, and forecast how many U.S. nurses intend to leave the workforce. The research also examined how nurses experienced pandemic-related heightened workplace burnout and stress.
Other key findings include:
In addition to the 100,000 RNs who already have left, another 610,388 RNs reported an “intent to leave” the workforce by 2027 due to stress, burnout, and retirement.
188,962 additional RNs younger than 40 years old reported similar intentions.
62% of those surveyed reported an increase in their workload during the pandemic.
A quarter to half of nurses reported feeling emotionally drained (50.8%), used up (56.4%), fatigued (49.7%), burned out (45.1%), or at the end of their rope (29.4%) “a few times a week” or “every day.”
These issues were most pronounced with nurses with 10 or fewer years of experience, driving an overall 3.3% decline in the U.S. nursing workforce in the past two years.
Licensed practical/vocational nurses, who generally work in long-term care settings caring for the most vulnerable populations, have seen their ranks decline by 33,811 since the beginning of the pandemic. This trend continues.
Research also suggested that nurses’ workloads and unprecedented levels of burnout during pandemic were key in accelerating nurses’ exits from the workforce, particularly for younger, less-experienced RNs.
Such high turnover further affects the post-pandemic nursing workplace by disrupting the clinical preparedness of new nurse graduates, the research says. Early career data for new entrants into the profession suggest decreased practice and assessment proficiency.
In the face of such troubling data, the NCSBN is calling for significant action to foster a more resilient and safe U.S. nursing workforce moving forward.
“The data is clear: the future of nursing and of the U.S. healthcare ecosystem is at an urgent crossroads,” said Maryann Alexander, PhD, RN, FAAN, the NCSBN’s chief officer of nursing regulation. “The pandemic has stressed nurses to leave the workforce and has expedited an intent to leave in the near future, which will become a greater crisis and threaten patient populations if solutions are not enacted immediately.”
“There is an urgent opportunity today for healthcare systems, policymakers, regulators, and academic leaders to coalesce and enact solutions that will spur positive systemic evolution to address these challenges and maximize patient protection in care into the future,” she said.
Panelists who presented and analyzed the research were:
Robyn Begley, CEO of the American Organization of Nurse Executives and chief nursing officer at AtlantiCare
New evidence-based bundle standardizes SICU's clinical alarm management practices.
After a Florida hospital surgical intensive care unit (SICU) improved clinical alarm management practices, staff became more sensitive to alarms and fewer alarms were missed, according to a study published in Critical Care Nurse.
"Clinical alarms are important, but they also contribute to a noisy hospital environment for patients and clinicians,” said lead author Stephanie Bosma, DNP, APRN, FNP-BC, an advanced practice nurse practitioner at the hospital. “With high sensitivity and low specificity, monitors can generate an overwhelming number of alarms, many of which are false or nonactionable alerts.”
“Our project gave alarm management skills much-needed attention and introduced a new tool to help staff maximize the benefits of clinical alarms,” she said.
A key piece of the initiative was an evidenced-based, nurse-driven, patient-specific bundle called the CEASE bundle. This five-step tool addresses:
Communication: Focuses on working with colleagues—fellow nurses, respiratory therapists, providers, and patient care technicians—to identify patient-specific goals, and determine when to suspend or silence alarms while performing care activities that induce nonactionable alarms
Electrodes: Targets proper skin preparation for daily ECG electrode and pulse oximeter changes
Appropriateness: Encompasses choosing appropriate monitoring parameters with physician and interprofessional team members
Setup: Includes customizing alarm parameters for individual patients at the beginning of each shift
Education: Involves continuing education on clinical alarm monitoring systems
To help nurses adapt, the CEASE bundle was introduced during their regular staff meetings, and descriptions were placed around the unit for easy reference.
Some 82% of nurses reported, via a survey administered to all SICU nurses before and following implementation, that the CEASE bundle helped decrease their alarm fatigue and 83% reported the bundle was helpful and they would continue to use it.
Overall, implementing the CEASE bundle improved nurses' alarm management practices, perceptions, and attitudes, according to the article. Nurses reported that setting alarm parameters was less complex, staff were sensitive to alarms and responded quickly, and there were fewer instances of alarms being missed.
As a result of the project, alarm management skills and monitor training are being more formally integrated into education already required for nurses at the hospital.
Including advanced practice providers in a practice redesign benefits physicians and patients, nurse leader says.
If the question is how to take care of more—and sicker—patients with fewer physicians, one answer lies in redesigning a practice with advanced practice providers (APPs) and allowing each clinical team member to practice at the top of their scope, says Allison Dimsdale, DNP, NP-C, AACC, FAANP, associate vice president for advanced practice for the Private Diagnostic Clinic at Duke University Health System.
Dimsdale has led Duke’s ambulatory practice redesign and watched while the strategy spread into all of the health system’s ambulatory specialty practices.
Dimsdale spoke with HealthLeaders about how she and her colleagues collaborated to benefit both Duke’s clinicians and patients.
This transcript has been lightly edited for clarity and brevity.
HealthLeaders: What is your definition of practice redesign?
Allison Dimsdale: With healthcare, we're experiencing what we have come to define as a new normal. We have a lot of patients, and we don’t have the resources that we used to have. The data is clear, and to me, it's shocking. The Association of American Medical Colleges talks about a shortfall of 139,000 physicians by the year 2033. We’re going to have to find a way to take care of people.
My focus is advanced practice providers, which are nurse practitioners (NPs), and physician assistants (PAs). We have 335,000 NPs and 159,000 PAs in practice in our country, and many more coming out of school. It makes sense that if our absolute top goal is to take care of lives, then we have to optimize our clinical workforce. We need to not burn out our physicians; we need to bring new clinicians into the mix. And then we have to manage all of the cultural pieces that are involved in putting them together in the same practice. And that's what I call practice redesign.
Forty years ago, you would have a single physician and maybe a nurse, and they would do everything for a patient. Now, a patient might have a primary care provider, a cardiologist, a nephrologist, a physical therapist and then they might want to see a nutritionist, so they already have a team. If we can put those teams together in such a way that they have more resources rather than having to struggle to find the resources, then, ultimately, their health is going to be better.
So, we navigate these market trends and we look at all these new regulatory updates, which are coming down the pike all the time, and then we look at new and innovative workforce strategies to figure out what our new normal is going to be. When I think about redesigning our practice, it's redesigning from that single physician—or in an academic medical center, a bunch of physicians—and finding a way to put all of these different team members together, with everyone working to the top of their scope, their licensure, and their training. Then they are bringing care in a multidisciplinary manner to that patient, and I believe those patients are going to be healthier in the long run.
Allison Dimsdale, associate vice president for advanced practice, Private Diagnostic Clinic, Duke University Health System / Photo courtesy of Duke Health
HL: When is it necessary to re-engineer the way patients receive care?
Dimsdale: I think about it in two ways. Number one is in the complexity of that patient who’s getting out of the hospital, sooner than perhaps they would have 10 or 15 years ago. They need a higher level of care from the ambulatory standpoint, and when I say ambulatory, I mean they go to an office, or maybe they have homecare services rather than lying in bed at the hospital.
When there are not enough providers or clinicians and the patients are sick enough that they need people with more expertise, then we have to rethink this. In our medical center, we looked around and said, “Here at Duke, we have 1,400 nurse practitioners and physician assistants, many of whom have a 10- or a 20-year tenure. They’re working with world-class physicians. How about we deploy them to see patients autonomously, but still collaboratively as a team member with the physicians and take care of these patients?”
And so, when we started doing that specialty, we found that the patients loved it. They had more resources. They had more choice of visits. If somebody was in the hospital and they needed to have a follow-up visit three or four days later, they weren’t being asked to wait. There was always someone to see them.
The other part of this is, as we try to optimize our clinical workforce, we focus on quality care. We’ve got 40 years of workforce data and outcomes data, which show that the patients who are taken care of by APPs have just as good an outcome as the ones who are taken care of by physicians. We know their care is safe, and we also know that it's cost-effective; we can know that because a physician is paid two to three times more than an APP and an APP is going to bill a little bit less. Same quality, same safety, and yet it's cheaper care, so it’s a win-win for the patients and it’s a win-win for the healthcare organization, whether it's a little private practice at the end of a country road or a large academic medical center. It just makes sense.
A lot of physician groups will get upset and say, “Well, you know that an APP is not a physician,” and I will never say that they are. They don’t have that level of training, but the data shows they can do 85% of what a physician can do. The other 15% should be done by a physician and by elevating the complexity of what the physician does in the course of their daily work by offloading a lot of that other 85% to the APP, then we have everybody working to the top of their scope and we still increase access.
HL: You’ve touched on this a little, but what does practice redesign look like in your organization?
Dimsdale: We started in 2010 in my practice of cardiology, and along with the cardiologists, we had a group of six NPs and PAs that had about 75 years of combined experience with high-quality training and yet, they were working far below scope, basically doing the work of a nurse. We had an access issue because our next available appointment for a new patient was a month away, and that's not OK if somebody's calling because they're dizzy or because they have chest pain.
We received funding to hire nurse clinicians to form the hub of an interprofessional team consisting of four physicians, one APP, and the nurse clinician. The model that we chose for our patient population was that the APP would see return patients, acutely triaged patients, and hospital follow-up patients. This freed up the physicians to see complex patients new to our practice and establish a plan of care. This met our aim of all members of the team working to the top of their scope of practice, while increasing access for our patients.
From there, it was so successful that it spread across our health system in all our ambulatory specialty practices. Each one looks a little bit different because each specialty practice is going to be different. For example, in dermatology, APPs might do general dermatology and the physicians might do the surgical subspecialty part of that.
As we move toward value-based care, we have to take care of lots of people, especially as Medicaid is expanded throughout our country. My mantra is everyone on the team will be working to the top of their scope and that means the top of their license, their board certification, and their training, and that aligns with how we attract and engage and retain the best talent. It’s worked. We have amazing people who come to work with our organization, and they stay.
HL: What are key tips you would suggest in implementing practice redesign?
Dimsdale: I would say first of all, look at where the need is. Then look at the resources that you may already have that are well-trained, that are well-ensconced within your organization, that understand how you practice. And then figure out if you can change anything about the way that they're working right now, in order to get them to the top of their scope.
Ask them, “What are you doing that you think could be done by someone else to the top of their scope?” This is a question that's being asked all over the country right now about advanced practice, but it’s also true for physicians, nurses, and medical assistants, as the nursing shortage is real. We need to be creative about how we deploy people, and how we put them together in teams. Some of our teams use EMTs while others use athletic trainers alongside physical therapists. We’ve found that utilizing pharmacy technicians to help with some of the paperwork required by pharmaceutical companies and insurance companies can be incredibly beneficial.
Once you've figured out who you have, and how you can use them to achieve your goal, then anticipate where the barriers are going to lie, and have a ready answer for every naysayer who comes toward you with a complaint or reason why it can't work—because it's working all over the country and it's working beautifully.
The Utah foundation's goals include improving educational and health equity while combatting the nursing shortage.
The new Nightingale Foundation has been launched to tackle the nursing shortage and pave the way for traditionally underserved populations to attend Nightingale College, a nursing school based in Salt Lake City, Utah.
The 501(c)(3) nonprofit organization will provide Nightingale nursing students with financial resources needed to attend and complete their academic programs. Those funding programs are expected to begin in early 2024, according to the foundation.
“Creating the Nightingale Foundation is an exciting leap forward in increasing access for populations who need financial resources to complete their nursing programs,” said Jonathan Tanner, the foundation’s vice president. “The foundation will be uniquely suited to address the needs of many underserved and underrepresented populations.”
The foundation will not only strive to serve current and prospective nursing students by offering scholarships and alternative funding options to finance attendance in pre- and post-licensure academic programs, but also to assist in building a diverse nursing workforce across the United States.
With a focus on removing barriers for equitable access to nursing education, particularly for nontraditional students, it will support Nightingale College’s current and prospective nursing students in identifying, developing, and increasing access to pre- and post-graduate nursing education resources.
Indeed, nursing over the next decade will demand a larger, more diversified workforce prepared to respond to future public health emergencies and address systemic inequities that have fueled health disparities, says a 2021 report from the National Academy of Medicine.
The report identified several priorities to meet the needs of the U.S. population and the nursing profession for the next decade including promoting diversity, inclusivity, and equity in nursing education and the workforce. Nursing students and faculty not only need to reflect the diversity of the U.S. population but also need to help dismantle structural racism prevalent in education and the workforce, it said.
“With the nursing shortage at an all-time high, it is vital that barriers to accessing nursing education are removed,” noted Katy Shoemaker, the foundation’s executive director. “Nightingale Foundation will pave the way for traditionally underserved populations to attend college and complete their nursing degrees, ultimately increasing health equity in the communities they serve.”
A nurse’s ability to think more critically and make the right decisions is now part of the National Council Licensure Examination (NCLEX).
The Next Generation NCLEX (NGN) is an enhancement of the prevailing NCLEX, using real-world case studies to measure a nurse's ability to think more critically and make the right decisions, according to the National Council of State Boards of Nursing (NCSBN).
At the core of this enhanced exam is the NCSBN Clinical Judgment Measurement Model (NCJMM), developed by NCSBN researchers as a framework for the measurement of clinical judgment and decision-making within the context of a standardized examination.
“While clinical judgment and decision-making have been important elements in most prelicensure education programs for many years, significant research and development were required to isolate and measure these traits with psychometric rigor,” according to the NCSBN.
To create the measurement model, which is more than a decade in the making, NCSBN researchers first drew upon the prevailing literature in nursing, nurse pedagogy, cognitive psychology, psychological assessment, and decision science related to decision-making and nursing clinical judgment. Investigations and deep analysis followed.
“The contributions of countless nurses and nursing educators who participated in various research studies and more than 250,000 aspiring nurses volunteered to take sample questions on the NGN special research section in the NLCEX exam also helped to create the NGN,” noted the NCSBN.
“The result of this work was an evidence-based framework for developing, classifying, and scoring test items that was not only technologically attainable, but feasible within the current computerized adaptive testing paradigm of the NCLEX."
While the NCJMM does not define—or redefine—clinical judgment, it does allow, for the first time, a method for NCSBN to measure and draw suppositions regarding the nursing clinical judgment and decision-making ability of prospective entry-level nurses, who are required to make increasingly complex decisions while delivering patient care, the national council says.
“Because clinical judgment underlies almost all of a nurse’s activities, it is of paramount importance to NCSBN,” said Philip Dickison, PhD, RN, chief operating officer of NCSBN. “We need to be able to measure it effectively to safeguard public protection. We need to help ensure that when a regulatory body licenses a nurse to practice, they are safe to care for you and your loved ones.”
Reducing administrative burden for both clinicians and nurse leaders is a top pain point, HCA Healthcare CNE says.
HCA Healthcare nurses are using ever-developing technology that has enhanced communication, decreased administrative burden, and provides skill development—all with the goal of improving patient care, says Sammie Mosier, DHA, MBA, BSN, NE-BC, CMSRN, senior vice president and chief nurse executive.
Mosier, who has led the Nashville, Tennessee-based healthcare system’s 93,000 RNs since the end of 2021, spoke with HealthLeaders about how HCA vigorously embraces technology to decrease redundant or unnecessary documentation so nurses can increase the time they spend with patients.
This transcript has been lightly edited for clarity and brevity.
HealthLeaders: What are some of the top technology solutions that HCA has implemented?
Sammie Mosier: One we have implemented very wide scale is our iMobile platform where smartphones are deployed to caregivers, or nurses and beyond, to improve communications. It has secure text messaging, so they can send that without worry. Obviously, they can make phone calls, but then the platform also has the ability to provide some updates from our EHR so they get those alerts directly to their phone. Any critical labs for the patient or other necessary information are right there at their fingertips. Our nurses love that technology, and it has enhanced communication among the care team.
We’ve continued to invest in that platform so that we can improve the workload for other areas. One example that we did last year was wound care imaging, so that after a nurse takes the photo, it's a seamless integration with our EHR. Prior to that, nurses had to take a photo, print it off, and scan it in, which took about 20 minutes per image. It removes time for administrative tasks so the nurse can focus on patients.
The technology even ensures that our nurses have skill development tools and resources right there at their fingertips. We are also leveraging that for patient assignments; we call it our CTA—Care Team Assignment platform. Nurses once had to log into multiple systems to provide patient care and Care Team Assignment is the ability for the nurse to log in once and that assignment is leveraged by all the other technologies, so again, it’s seamless for them.
HL: What are the top pain points at HCA that technology can help with?
Mosier: Reducing administrative burden for both our clinicians and nurse leaders, as well. Leveraging automation and other technologies to push that information appropriately to the right care team member so they can take action versus having to look through the data. That's a big focus right now, especially with our nurse leaders. They have multiple reports that they have to navigate through to find whatever is necessary to run that unit, and if we're able to push that to them in a more holistic view, then that allows them more time to spend with their staff. Our focus is to get those nurse leaders engaged with the staff as well as our patients.
HL: How do you test new technology?
Mosier: It's elbow to elbow with frontline staff. We have an innovation lab here in our corporate office where our informatics teams can work to do those initial tests and then move out into the field where we’re able to work side by side with clinicians to get their perspectives—the good and the bad—to make sure that it is a technology that we believe in and that we want to pilot. We do work with our vendors to improve the technology. I would also add our care transformation innovation teams have departments and a couple of hospitals that are identified as hub hospitals, which means those departments and hospitals serve as test labs for the technologies.
Sammie Mosier, senior vice president and chief nurse executive, HCA Healthcare / Photo courtesy of HCA Healthcare
HL: What new technologies would you like to see introduced at HCA?
Mosier: Virtual nursing and the ability for a remote nurse to come into the patient room through video and interact with the patient to reduce some of the workload burden and administrative tasks for the practicing staff nurse at the bedside. We are piloting that in a couple of our hospitals right now and looking to expand that. What we're seeing is the ability to have a virtual nurse handle admission, discharge, and other use cases to assist and take away administrative burden from the bedside nurse. So that's really exciting.
Our pilots are going well. We're seeing a lot of both nurse and patient satisfaction; about 85% of our patients are receptive to that model.
HL: Why is patient satisfaction higher with virtual nursing?
Mosier: When we first started, it was because the remote nurse didn't have a mask on. It was part of the perception of seeing that smiling face. As we've evolved, we're seeing that the virtual nurse can spend a little more time with the patient, particularly in the discharge area. While that physical nurse is there removing IVs and lines and getting the patient prepared, that virtual nurse is doing the education, answering the questions, and we're seeing that patient satisfaction for discharge is improving.
HL: How much of HCA’s technology is innovated and developed by HCA?
Mosier: It’s a mix. We call for innovation, so we’re more progressive in this space. We have a dedicated week called Coding for the Caregivers, and that is an opportunity for our nursing team and our informatics teams to work together to fast-track ideas around technology. Our IT colleagues pause for a full week and work to bring the ideas of our nurses together to develop more of a proof of concept. That’s a very exciting week we have here. I know a lot of vendors do this innovation exercise, but this is one we've been doing in-house, and this will be our third year.
It’s a great opportunity to understand the pain points that the nurses are facing and then those potential solutions they identify. They then work with our IT colleagues to see if it's something we can build in-house or if we need to leverage a partner to do that. And a couple are selected as winners, and they are funded to bring to a pilot.
HL: What are the most-challenging barriers to healthcare tech innovation?
Mosier: Most of our nursing technologies are focused on reducing that workload burden, but sometimes things are created without the nurse in mind. A particular technology may work very well for another clinician, but sometimes that puts more workload on the nurse. We need to make sure that we have nurses incorporated on the front end of all these designs, so that they can call out those barriers and we can have a better product. So that would be my No. 1 barrier.
Better mental health, new bonuses, and social media engagement have helped improve working conditions.
Despite the nursing industry’s challenges, 80% of nurses plan to stay with their profession until retirement even though most (84%) do not think issues such as understaffing, burnout and pay are improving quickly enough, a new study reveals.
The percentage of nurses who are staying on until retirement is up from 55% in 2022, according to the 2023 State of U.S. Nursing Report, just released by healthcare career marketplace Incredible Health, that included the platform’s proprietary data of more than 700,000 nurses and results from a survey of more than 3,000 nurses.
“There is no doubt that we are seeing improvements in key areas within nursing likely due to market forces and hospital executive attention,” said Iman Abuzeid, MD, Incredible Health’s co-founder and CEO. “However, there are several identifiable areas where more focus by health systems, nursing education leaders, and Incredible Health would have a significant impact on the overall nursing experience and make the field more highly attractive to new nurses.”
Some of those areas for improvement include:
Staffing shortages: Most surveyed nurses (93%) reported that staffing has worsened over the last year. Consequently, 73% identify inadequate staffing as their top concern in the industry, and 55% report being dissatisfied with staffing in their own facilities. Burnout closely follows staffing as a main concern and is the top reason nurses would leave the industry ahead of retirement.
Compensation gaps: Only one-third (33%) of surveyed nurses reported feeling fairly compensated in their roles. Nearly two-thirds (65%) reported they have considered leaving a permanent position to take a travel nurse role primarily for a pay increase.
Economic stresses: Most (84%) reported increased stress at work due to the state of the economy and 69% of nurses reported being affected by the economic downturn via layoffs, delaying retirement, and picking up additional jobs to make ends meet.
Other key findings from the study include:
54% of those surveyed would continue to recommend a career in nursing
25% of nurses reported their health systems are using virtual nursing.
62% are not hopeful about the next generation of nurses
63% feel that AI in the industry will create an imbalance between older and younger generations
Looking ahead
There has been a 10% decrease in the number of nurses planning to leave their roles within a year since the last State of Nursing report in March 2022, which likely is due to improvements in several areas, this year’s report says, including:
Stronger mental health: Mental wellness is no longer in decline, with nurses reporting a one-point increase from 25% in 2021 to 26% in 2023 of good mental health, following years of pervasive burnout and stress due to the pandemic.
Bigger signing bonuses: Signing bonuses are on the rise, suggesting organizations are leveraging bonuses to bridge salary gaps. The average bonus of $11,767 was, on average, 8% higher than last year.
Social media as a source of community: More than half (60%) of nurses believe it is important to use social media as a nurse in today’s healthcare industry, with 77% of respondents saying it’s a source of community and support. A large number (52%) say they communicate with their health systems via social media.
Bad behavior at work is profoundly costly for retention, well-being, and productivity.
Effective managers remain pivotal to retaining employees in the face of rising rates of workplace incivility, says a report released today.
But they have their work cut out for them. One in four employees reported experiencing rude, disrespectful, or aggressive behavior in the workplace, according to the new meQuilibrium Self Check survey of 5,483 employees.
The most common forms of incivility were identified as being ignored (26.1%), having one’s judgment questioned (24.2%), and coworkers addressing colleagues in an unprofessional manner (17.3%), the report says.
Fewer employees experienced severe forms of workplace incivility, but remains distressingly common, with about one in 20 employees reporting being targeted with angry outbursts, yelled or cursed at, accused of incompetence, or the butt of jokes from coworkers.
Incivility at work is profoundly costly for retention, well-being, and productivity for both employees and the organization as a whole, the report says.
Employees in high-incivility work environments report an elevated risk of job worries (42.4%), burnout (37%), and low motivation (33.5%), all of which affect productivity and turnover. Workplace incivility raises the risk of endorsing “quiet quitting” by 87% and increases fivefold the risk that an individual will seriously consider quitting their job, the report says.
“Additionally, workplace incivility can create a toxic work environment that undermines team cohesion and collaboration, erodes trust between employees and their managers, and can ultimately damage the organization's reputation,” the report says.
Managing the problem
The solution lies with managers who promote team mental well-being and who provide a culture of psychological safety, according to the report.
Psychological safety is the shared belief of team members that it’s OK to take risks, offer suggestions, speak up about concerns, ask questions, and to admit mistakes—all without fear of repercussions. Employees on teams characterized by high levels of psychological safety rarely experience uncivil behavior in the workplace, the report notes.
Managers who are attentive to team well-being can reduce turnover risk by as much as 78%, the report says. That’s because well-supported employees are:
25% less likely to struggle with stress symptoms
33% less likely to have a difficulty in getting motivated in the morning
56% less likely to experience high work stress
“Effective managers who support team mental well-being dramatically improve retention and speed innovation by ensuring psychologically safe environments,” said Jan Bruce, CEO and co-founder, meQuilibrium. “Supportive managers cut burnout risk, boost productivity, and provide an important buffer against incivility.”
Take action
The report suggests three avenues for action:
1. Think differently about upskilling and caring for managers. Managers are at higher risk of poor outcomes than the teams they lead, reporting higher levels of stress-related productivity impairment, higher burnout, and elevated turnover risk compared to non-managers.
Reminding managers to put on their own “oxygen mask” first is an important first step so they can lead by modeling resilience while maintaining their own well-being.
2. Think bigger than expanded EAP to solve for productivity and performance. Providing access to wraparound or extended EAP services is a necessary—but limited—step to support employee emotional well-being due in no small part to the stigma attached to seeking help for mental health issues.
Rather than focusing purely on clinical mental health treatment, take a broader approach to advancing well-being.
3. Think beyond symptoms to root causes: address the risks in the psychosocial environment. Conducting an inventory of psychosocial risks in the workplace is an essential, yet underused, step in addressing the underlying causes of diminished well-being at work.
A comprehensive risk assessment can help leaders see the extent of well-being risks presented by the work environment. Using a validated, evidence-based tool such as the Copenhagen Psychosocial Inventory (COPSOQ) is the critical first step in understanding the extent to which the structure and nature of the workplace environment impacts well-being.
The award honors an AONL member recognized by the nursing community as a significant leader in the nursing profession and served AONL in a significant leadership capacity.
Pappas, as a senior leader of Emory Healthcare and the Woodruff Health Sciences Center, leads Emory Healthcare’s nursing workforce, which consists of more than 8,000 nurses across the organization’s 11 hospitals and more than 250 clinic locations.
Five Emory Healthcare operating units are Magnet® designated, and Pappas works to establish this same nursing excellence throughout Emory Healthcare. She is also a faculty member for Emory’s Nell Hodgson Woodruff School of Nursing.
This honor follows another prominent accolade Pappas received at the end of last year when the Georgia Hospital Association (GHA) presented her with the Hospital Hero Award for her outstanding contributions to the healthcare field, particularly the field of nursing. Pappas was one of five individuals to receive the statewide award.
“Emory and the entire healthcare industry are fortunate to have Sharon Pappas’ expertise and her passion for the well-being of nurses and patients,” Earl Rogers, GHA president and CEO said at the time.
An example of that is Emory’s Care Partner program that she and her chief nurses developed during the height of the COVID-19 pandemic when they realized that having a "no visitors" policy like most other hospitals around country was not good for most patients.
“The chief nurses realized that patients needed family members with them as part of their healing, so they came up with a concept called Care Partner, which was different than a visitor," she told HealthLeaders in explaining the program. A visitor socializes and boosts a patient's spirits, but the Care Partner—a family member or trusted friend—has a purposeful role in contributing to patient care, she said.
"It became very important to our frontline clinical nurses who were having to spend an extraordinary amount of time on FaceTime or on the phone, updating families," Pappas explained. "The Care Partner could also, with a patient's permission as appropriate, communicate with broader family constituents who were interested and worried."
Serving nurses and patients
Pappas served on the National Academy of Science, Engineering, & Medicine Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-being, which issued a report being used to measure burnout and improve work conditions for nurses and others in healthcare on a national scale.
She also has authored multiple publications contributing to the international body of knowledge on how improving healthcare cultures through inclusion in decision-making, respect, and leadership contributes to patient care. One of these publications, Quantum Leadership, is a textbook commonly used in Doctor of Nursing Practice programs across the United States.
Pappas previously served as a member of the AONL board of directors and currently represents AONL on the American Nurses Credentialing Center’s Commission on Magnet® Recognition. She recently chaired the AONL Workforce Subcommittee on Leadership.
Pappas is a fellow of the American Academy of Nursing and past chair of its Expert Panel on Building Health System Excellence. She has received numerous honors including the AONE Research and American Association of Colleges of Nursing’s Exemplary Academic Practice Partnership awards. She earned her Ph.D. at University of Colorado, Denver, master of science in Nursing from Georgia College, and bachelor’s degree from the Medical College of Georgia.
'There was not a barrier that she couldn't move out of the way,' Yale New Haven Hospital CNO says of innovator Michele Santoro, RN.
With Michele Santoro’s self-described “questioning attitude,” she has become a highly regarded innovator at Yale New Haven Hospital, been named a Magnet® Nurse of the Year, and saved uncountable lives when cardiac patients worldwide became disconnected from an external monitoring device platform after a vendor’s software update.
With her innovative spirit, Santoro, RN, BSN, a clinical nurse at Yale New Haven Hospital Heart and Vascular Center in New Haven, Connecticut, has developed a monitoring, scheduling, and tracking system for patients with remote cardiac monitoring devices as well as a new process to prepare patients’ skin for surgical procedures. And she’s just getting started.
“She’s an example of so many others in this organization," says Ena Williams, senior vice president and chief nursing officer at Yale New Haven Hospital. “One of the things that is so special is this idea that there was not a wall high enough that she couldn't get over or there was not a barrier that she couldn’t move out of the way.”
Santoro spoke with HealthLeaders about her solutions to care problems and how Yale New Haven supports nurse innovators.
This transcript has been lightly edited for clarity and brevity.
HealthLeaders: How were you able to figure out that thousands of cardiac patients worldwide had been disconnected from an external monitoring device platform?
Michele Santoro: We do know our patient population and who is disconnected from their external monitor and this particular morning, I noticed a large amount of patients disconnected. In investigating, I found a common denominator: all of them were pacemakers and they were all the same model. I notified the vendor of the issue and they confirmed that it was from a software update that they didn’t know about and that it affected patients globally.
HL: You have developed a monitoring, scheduling, and tracking system for patients with remote cardiac monitoring devices. How did you identify that gap and create a solution?
Santoro: I was hired to come in to run a remote device clinic and when I opened up the five different vendor sites, I noticed there were thousands of patients disconnected and with missed transmissions. I had to call each patient to determine their status and where they were living, and that took a year. In the midst of doing that, I took all five vendor sites and we put them under one comprehensive database tracking system. When we did that, we were able to go from 2,100 to zero patients in one year, lost to follow-up.
The biggest thing about this is we've oriented and trained our staff on the new process, so those patients are not disconnected or missed, and everybody stays safe. During COVID, it was huge to know that our patients would be safely monitored from home and that they were all connected when they couldn't come into the office for almost a year.
HL: You developed a new process to prepare patients’ skin for surgical procedures. Tell me about that.
Santoro: There was no standardization for the documentation process for skin assessment, pre- and post-cardiac device. I identified these agents that contributed to the loss of integrity, pre- and post-op and put them into our safety incident tracking system. We realized that the biggest thing was the change in the dressing process for post-op. There was no standardization across the system.
So, we set out with a multidisciplinary team to standardize the documentation, and it was just amazing because we've had no issues. I see the patients post-op seven to 10 days, and I've never seen an issue again, and it’s been years.
HL: Nurses are known as natural innovators. Are you innovative because you’re a nurse, or have you always been that way?
Santoro: I have to say I've always been this way. I think it's my inner self. I've always had a questioning attitude and never been afraid to bring my concerns to authority. I don’t know if that’s a good thing or bad thing sometimes.
HL: How has Yale New Haven helped to foster your spirit of innovation?
Santoro: I've worked in a few organizations over the years and Yale New Haven is definitely a high reliability organization. This culture has empowered me to identify safety issues and track trends. I am so blessed to have such support of direct management and senior leadership. My direct manager, Annette Dagostino, stands behind me and guides me every day. I don't know many nurses that can say that they know their vice president or president, or their CNO.
The nursing autonomy and nursing shared governance at Yale New Haven empowers us to have the ability to do evidence-based practice and make changes and collaborate with different teams. We're just really lucky.
HL: What solutions are you working on now?
Santoro: I have research data for eight years that I collected on my own and I’m working on it with two nursing colleagues. It’s a study, with approximately 400 subjects, and it’s about the implantable loop recorder, a little cardiac monitoring device that goes under the skin.
I’m finding that some providers like to remove them prematurely and not let them stay in for the three-, four-, or five-year battery life as we are finding significant arrhythmias that have been detected. So, they're trying to pull them out sooner than they need to. When they say, “We need to leave them in only for six months to a year,” I’m finding life-threatening arrythmias in two-and-a-half years to three years.
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