In American Association of Critical-Care Nurses (AACN) President Amanda Bettencourt’s recent column, she encouraged nurses to advocate for themselves to effect change in their work environment.1 She did not say that change would be easy—she said change was possible. Her vision for innovation, leadership, and individual nurses making a difference provides hope for the future of our profession. Many have lamented that nurses in some workplaces have not been invited to the decision-making table at their respective institutions.2 Hospitals exist to provide 24-7 nursing care to patients,3 and nurses are essential to quality patient care. Nurses are positioned as key stakeholders to shape the future of the nursing profession.
Inadequate staffing has escalated because of the COVID-19 pandemic. The AACN advocacy for adequate nurse staffing has included a letter to the Centers for Medicare & Medicaid Services, expressing concern that hospitals are failing to meet the CMS Condition of Participation to provide adequate numbers of licensed registered nurses.4 As indicated in the letter, several of AACN’s healthy work environment (HWE) studies found that appropriate staffing had the lowest scores compared with other HWE standards (true collaboration, skilled communication, meaningful recognition, authentic leadership, and effective decision-making).5 Similarly, Pun et al6 found that nurses consistently reported lower scores for appropriate staffing compared with other health care disciplines. In addition to the hardships experienced by nurses and other health care professionals during the pandemic,6 understaffing has been associated with poor patient outcomes such as infections, missed care, and mortality.3 Understaffing is jeopardizing the quality of patient care and contributing to increased hospital length of stay. According to the Institute for Healthcare Improvement (IHI), “one is not zero” when it comes to patient safety.7
Becoming a high-reliability organization is a goal for many health systems, yet without adequate nurse staffing they are positioned to fail. A high-reliability organization should focus on deviations from the expected and potential failures that may occur because of operational problems.8 Many health care systems are failing nurses and their patients by their perceived complacency related to the understaffing of nurses.
A healthy nursing profession is critical to retain, recruit, and prevent distress among nurses who work in hospitals. The pandemic and subsequent mass exodus of experienced nurses from hospitals have demonstrated that historical models of nursing care and status quo work environments are not sustainable for the future of nursing.9 Nurses continue to focus on patient outcomes, but nurses alone can only do so much. Dr Salvon-Harman, Vice President of Safety at IHI, says that “culture may eat strategy for lunch, but relationships eat culture for breakfast.”10 Hospital administrators have much work to do to rebuild a sense of belonging and trust with nurses. Health systems should begin by providing adequate staffing levels for safe patient care and HWEs. If solutions are not readily available, health care systems have a responsibility to nurses to be transparent about their plans to improve nurse staffing. Dr Berwick of IHI echoed these thoughts in his recent statement: “To the health care leaders out there: You are my friends. I respect you. I know you are working hard already. But you do not get a free pass on these societal issues.” He emphasized that health system leaders must add issues such as the joy and well-being of the health care workforce to their current agendas.
Numerous stakeholders, including AACN, collaborated in the development of the National Academy of Medicine (NAM) 2022 Plan for Health Workforce Well-Being.11 Seven priority areas were identified, and the top priority is to “create and sustain positive work and learning environments and culture.”11 This plan addresses the complexity of the current workforce issues and determines that complexity alone should not be an excuse for inaction. National plans for immediate and long-term solutions were identified. In addition, NAM stressed that no single actor can make changes on their own. Actors at all levels need to become engaged in actively seeking and creating positive changes. According to NAM, actors are defined as individual health care workers, health systems, academic institutions, and insurers/payers. Health care systems should reach out to their nurses and encourage their participation in the process to rebuild and sustain adequate nurse staffing. Collaborative work to improve the work environment and support safe patient care may also be a step toward repairing relationships between nurses and hospital administrators.
Some nurses may feel hesitant to work alongside hospital leaders and administrators. In addition to strained relationships related to the pandemic, there are reports of nurse whistleblowers being fired for publicly announcing unsafe nurse staffing.12 As we navigate these trying times, I hope some of you can find the strength to support NAM’s goal for all actors to work collaboratively and help to create change to achieve appropriate staffing.
Another source of assistance may include Doctor of Nursing Practice (DNP) students and graduates who are positioned to lead quality improvement projects. Evidence-based quality improvement projects implement practice changes based on research evidence into the clinical setting to improve a recognized problem.13 These projects typically involve an interprofessional team of key stakeholders. According to the American Association of Colleges of Nursing, more than 40 000 nurses in the United States are currently enrolled in DNP programs.14 Many DNP students and graduates are employed by health systems. Nurses and health systems might consider collaborating with DNP students and graduates to improve HWE standards such as appropriate staffing.
There are 6 HWE standards, so changing all of them at once may seem like a daunting task. Consider the idiom, “Don’t bite off more than you can chew.” Projects with a narrow scope may be more manageable to change practice and sustain the changes over time. Focus on improving one HWE standard at a time.
The idea of adequate nurse staffing and a healthier work environment brings feelings of hope. Some of you may be fortunate enough to work in a healthy environment. Throughout these challenging times, I have seen units celebrate their achievements after earning AACN Beacon awards for clinical excellence and individual nurses celebrate specialty certifications. I applaud all of you for your continued commitment to improvement! For the greater good of the nursing profession, I encourage nurses who currently have adequate staffing and/ or an HWE to share your strategies and your stories. We need to hear from you.
As we continue to seek answers to challenges such as understaffing, we know that nurses must be part of the solution. Consider the collaborative messages from NAM and AACN’s president Amanda Bettencourt—do not give up, get involved. Start today to make tomorrow better.
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The statements and opinions contained in this editorial are solely those of the Editor.