Nurses have faced extreme challenges in the past 2 years. Although all members of the critical care team have been affected by the COVID-19 pandemic, the impact on nurses has been disproportionately large. Critical care nurses are the frontline health care workers who have the most direct involvement with critically ill patients. Nursing care requires nearly constant presence at the patient’s bedside for extended periods, and caring for patients with COVID-19 is mentally, emotionally, and physically exhausting. The toll of the pandemic on nurses is illustrated by research that documents adverse effects including increased anxiety, sleep disturbances, and moral distress.1–3 By May 2021, about 115 000 nurses and health care workers had died of COVID-19.4 Nurses recognize these negative effects on the profession. A recent national survey of 6500 critical care nurses conducted by the American Association of Critical-Care Nurses (AACN) found that a stunning 92% of these nurses believe the pandemic has depleted nurses and will cut their careers short.5
Despite widespread news coverage highlighting the struggles of frontline health care workers during the COVID-19 pandemic, public awareness of the realities of nurses’ experiences and the effect of nurses’ well-being on patient outcomes remains superficial and incomplete. The “Hear Us Out” campaign5 was launched in September 2021 by AACN to alert the public to the realities of COVID-19 care in intensive care units (ICUs) and to encourage vaccination. Vaccination is a crucial strategy that benefits individuals by reducing risk of critical illness and also benefits society by reducing ICU utilization. The health care system is unsustainable without high-quality, appropriately staffed nursing care; as the campaign points out, “A hospital without nurses can’t save your life.”5
Staffing shortages in nursing, and particularly in critical care, have accelerated and become dire. Nursing shortages impact quality of care and patient outcomes, exacerbate nursing distress, and strain human and financial resources of health systems. In the AACN survey described above, 66% of the nurses who responded said that they have considered leaving the profession because of their pandemic experiences.5 A widely circulated September 2021 Associated Press News report stated,
The COVID-19 pandemic has created a nurse staffing crisis that is forcing many US hospitals to pay top dollar to get the help they need to handle the crush of patients this summer. The problem, health leaders say, is twofold: Nurses are quitting or retiring, exhausted or demoralized by the crisis. And many are leaving for lucrative temporary jobs with traveling-nurse agencies …6
“Although nurses can practice self-care, nurse well-being cannot be solely the responsibility of the individual nurse; health care organizations must engage in systemic support for nurses’ resilience.”
The well-being of nurses is central to provision of health care and to the viability of health care systems. Although nurses can practice self-care, nurse well-being cannot be solely the responsibility of the individual nurse; health care organizations must engage in systemic support for nurses’ resilience.3 Fortunately, an evidence-based blueprint for improving nurse well-being exists. The central elements are encompassed in the standards of a healthy work environment. Healthy work environments enable nurses to practice in a manner that maximizes their contributions to patient and family outcomes and that has broad benefits not only for nursing and patients, but for all members of the health care team. Organizations with healthy work environments are better able to recruit and retain nurses and to deliver better patient outcomes and satisfaction; a healthy work environment can yield financial benefit. AACN has been committed to promoting creation of healthy work environments for 2 decades. Since 2001, AACN has continuously advocated for structuring the health care work environment to enable nurses to provide excellent care and has been instrumental in building the standards, supporting evidence, and resources for implementation of healthy work environments.
Six essential standards for establishing and sustaining healthy work environments have been articulated by AACN as follows:
Skilled Communication. Nurses must be as proficient in communication skills as they are in clinical skills.
True Collaboration. Nurses must be relentless in pursuing and fostering true collaboration.
Effective Decision-making. Nurses must be valued and committed partners in making policy, directing and evaluating clinical care, and leading organizational operations.
Appropriate Staffing. Staffing must ensure the effective match between patient needs and nurse competencies.
Meaningful Recognition. Nurses must be recognized and must recognize others for the value each brings to the work of the organization.
Authentic Leadership. Nurse leaders must fully embrace the imperative of a healthy work environment, authentically live it, and engage others in its achievement.7
Taken together, these standards enable nurses to control nursing practice, deliver excellent care, and be full partners in health care delivery. Healthy work environments maximize the contributions of nursing, improve nurse well-being, and have potential to mitigate the stresses accompanying pandemic ICU care. What is required is the will and the resources to create and maintain healthy work environments, and this commitment is even more urgent in our current crisis.
Despite the essential importance of healthy work environments to nurse well-being, much of the public conversation about recruitment and retention of nurses has centered on compensation. In our opinion, current compensation models have serious shortcomings that have destabilized health systems and further demoralized nurses. Large differentials in pay between the permanent nursing staff and the premium pay of temporary staff result in permanent staff feeling undervalued, as do recruitment incentives that are not accompanied by robust parallel retention incentives. The current situation has brought national attention to compensation issues; a more accurate assessment of the value and costs of nursing care is long overdue. Models of health care payment will need to change in order to recognize the essential contributions of nurses to patient outcomes; paying nurses and other health care workers less than they are worth subsidizes health care at the expense of those who provide it. However, although appropriate compensation is an important factor, a focus on pay as the only satisfier for nurses is misguided and will not solve the larger systemic problems underlying nursing distress.
Traditionally, January has been viewed as a time for new beginnings. Let our 2022 resolution be that we will work to establish and maintain healthy work environments in every acute and critical care setting. We have the knowledge and tools necessary to accomplish this resolution. Restoring the well-being of nurses through improving the health care work environment will have broad benefits for patients, families, the health care team, health systems, and society. The need is urgent, and the time is now.
“What is required is the will and the resources to create and maintain healthy work environments, and this commitment is even more urgent in our current crisis.”
The statements and opinions contained in this editorial are solely those of the coeditors in chief.
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