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OBJECTIVE: The aim of this study was to determine relationships between moral injury (MI), well-being, and resilience among staff nurses and nurse leaders practicing during the COVID-19 (coronavirus disease 2019) pandemic. BACKGROUND: Attention to MI among health professionals, including nurses, increased in 2021, particularly related to the pandemic. Few studies examined MI, well-being, and resilience; even fewer provided implications for leadership/management. METHODS: The sample included 676 RNs practicing in Ohio. The electronic survey included assessments of MI, well-being, and resilience distributed via the Ohio Nurses Association and the schools of nursing alumni Listservs. RESULTS: There was a significant association between MI and negative well-being and negative association between MI and resilience. Differences were observed between staff nurses and leaders. CONCLUSIONS: This is the first study relating MI, resilience, and well-bring among nurses and nurse leaders during the pandemic. There is a need for additional research to further our understanding about nurses' health and well-being during the pandemic and beyond.

The construct of moral injury is relatively new, primarily studied in trauma-exposed military personnel, and measurement scales recently available to screen symptoms of moral injury. However, no scale exists for firefighters; consequently, resulting in limited data for the risk and protective factors of moral injury in firefighters. Firefighters are considered one of the most stressful occupations, responding to critical incidents involving personal threat or harm to self, a violation of core beliefs about the world, and witnessing pain and suffering of others. Exposures to a single traumatic event or cumulative traumatic events can result in posttraumatic stress disorder (PTSD), depression, suicide ideation and possibly risk for moral injury. The objective of this study aims to address the gap in available instruments by developing a moral injury scale for firefighters and assess the potential risk and protective factors of moral injury in firefighters.

OBJECTIVE: Volunteerism represents an important mechanism to promote resilience, empathy, and general well-being in medical students, a group that stands to benefit. Medical students report feelings of fatigue, burnout, exhaustion, and stress that correlates with poor academic performance, and significant decline in empathy over the ­3rd year of both MD and DO programs. Volunteer motivations have been shown to mediate participant well-being. The relationship between medical student volunteer motivations and specific outcomes during the COVID-19 pandemic has not been addressed. METHODS: We characterized features of medical student volunteers during the COVID-19 pandemic in 2020, including volunteering motivation using the Volunteer Functions Inventory, the types of activities in which they participated, and the physical, psychosocial, and emotional outcomes they experienced following volunteering. RESULTS: Altruistic and humanitarian values–centric motivation predicts positive volunteering outcomes including increased resilience, ability to deal with disappointment and loss, and ability to cope with the COVID-19 pandemic. Values-centric motivation also increases volunteer empathy independent of educational stage. Values-centric participants were more likely to select volunteering activities with patient contact, which promotes student empathy and resilience. Conversely, careercentric motivation does not predict positive outcomes. These students are more likely to engage in research-oriented activities. CONCLUSIONS: The efficacy of integrating volunteerism into medical school curricula may be limited by professional pressure that manifests as career-oriented motivation. We propose that practical integration should promote altruistic and humanitarian values–centric participant orientation to the volunteering process, which is associated with enhanced recruitment, preservation of empathy, and additional positive volunteering outcomes of interest.

According to Kirk & Rhodes (2011), Nooijen et al. (2018), and Saridi et al. (2019), the motivators and barriers to exercise are influenced by one’s occupation, especially among those in the healthcare field. We sought to examine the barriers and motivators to physical activity that are distinctive to clinicians. Community hospital clinicians were surveyed regarding motivators and barriers to exercise that they experience, their burnout levels as described by an adaptation of the Mini-Z single item burnout scale, and average weekly exercise habits. The top barriers and motivators were then correlated to burnout levels, levels of physical activity, and demographics. We received 64 total responses from clinicians. The overall average level of burnout was 2.37 and the median level was 2. Approximately 38% of clinicians reported adhering to American Heart Association (AHA) guidelines of 150 minutes of exercise per week, while 33% of clinicians exercise <75 minutes per week. The top general motivator was for one’s own well-being and the top clinician-related motivator was reducing stress. The top two barriers to exercise were COVID-19 concerns at an indoor exercise facility and a lack of time. Higher average levels of burnout were experienced by those who marked being too stressed or too burnt out as barriers to exercise. Because of clinicians’ roles in propagating healthy practices in their patients from their own habits, wellness programs should be aimed at capitalizing motivators to combat barriers that this group distinctively experiences. Efforts to improve physical and mental wellness among clinicians will translate into better provider and patient health outcomes.

OBJECTIVE: To quantify the prevalence of burnout in our surgical residency program and to assess the impact of a weekly wellness program for surgical residents through validated tools measuring mindfulness, self-compassion, flourishing, and burnout. Our hypothesis was that participants with more frequent attendance would: (1) be more mindful and self-compassionate and (2) experience less burnout and more flourishing. DESIGN: An optional one-hour weekly breakfast conference was facilitated by a senior surgical faculty member with the time protected from all clinical duties. Following a guided meditation, participants were given time for reflection and dialogue about their training experiences or led in a wellness exercise. TRANCE (tolerance, respect, anonymity, nonretaliation, compassion, egalitarianism) principles were utilized to create a safe and open environment. Residents were surveyed at the end of the study period, which was from March 2017 through June 2018. SETTING: The conference and data analysis was conducted at Denver Health Medical Center, affiliated with the University of Colorado School of Medicine. PARTICIPANTS: This study analyzed survey responses from 85 surgical residents. RESULTS: Following the wellness program, when answering the 2-question Maslach Burnout Inventory, 35.7% of residents reported feeling burned out by their work once a week or more, and 29.7% reported feeling more callous toward people once a week or more. After multivariate analysis, the only independent predictors of increased burnout were “not being married or in a committed relationship,” lower positive affect, and higher negative affect. Written feedback was overwhelmingly positive, and residents expressed gratitude for the conference, the opportunity for self-reflection, and open dialogue with attendings and colleagues. CONCLUSIONS: The prevalence of burnout is high among surgical residents. Allowing time to practice a mindfulness meditation while providing space for residents to share their experiences may be protective, and efforts should be made to reduce barriers to participation.

Although empirical evidence has shown that socially responsible human resource management (SRHRM) practices positively influence employees’ outcomes, knowledge on the social impact of SRHRM practices on employee well-being has been limited. Drawing upon the social information processing theory and attribution theory, we investigate whether, how, and when SRHRM practices increase the well-being of employees. Using multiphase and multilevel data from 474 employees in 50 companies, we find that SRHRM practices positively predict employee well-being and that the relationship is mediated by employees’ perspective-taking. Furthermore, substantive attributions strengthen the positive relationship between SRHRM practices and perspective-taking of employees, whereas symbolic attributions weaken this relationship. We also find that substantive attributions positively moderate the indirect effect of SRHRM practices on employee well-being through perspective-taking, whereas symbolic attributions negatively moderate this indirect effect. Our study contributes to the understanding of the complex effect that SRHRM has on employee well-being.

OBJECTIVE: Violence is a major preventable problem in emergency departments (EDs), and validated screening tools are needed to identify potentially violent patients. We aimed to test the utility of the Aggressive Behavior Risk Assessment Tool (ABRAT) for screening patients in the ED. METHODS: A prospective cohort study was conducted among adult and pediatric patients aged ≥10 years visiting 3 emergency departments in Michigan between May 1, 2021, and June 30, 2021. Triage nurses completed the 16‐item checklist using electronic health records (EHRs), and the occurrence of violent incidents were collected before ED disposition. A multivariate logistic regression model was applied to select a parsimonious set of items. RESULTS: Among 10,554 patients, 127 had ≥1 violent incidents (1.2%). The regression model resulted in a 7‐item ABRAT for EDs, including history of aggression and mental illness and reason for visit, as well as 4 violent behavior indicators. Receiver operating characteristics analysis showed that the area under the curve was 0.91 (95% confidence interval [CI], 0.87–0.95), with a sensitivity of 84.3% (95% CI, 76.5%–89.9%) and specificity of 95.3% (95% CI, 94.8%–95.7%) at the optimal cutoff score of 1. An alternative cutoff score of 4 for identifying patients at high risk for violence had a sensitivity and specificity of 70.1% and 98.9%, respectively. CONCLUSION: The ABRAT for EDs appears to be a simple yet comprehensive checklist with a high sensitivity and specificity for identifying potentially violent patients in EDs. The availability of such a screening checklist in the EHR may allow rapid identification of high‐risk patients and implementation of focused mitigation measures to protect emergency staff and patients.

OBJECTIVES: Involvement in adverse events can negatively impact physician well-being. Because burnout is increasingly recognized as a threat to patient safety, we examined the relationship between physician adverse event involvement and burnout as well as facilitators and barriers to support among physicians experiencing burnout. METHODS: We surveyed physicians in the United States who are members of the networking platform, Doximity. We conducted quantitative and qualitative analyses investigating experiences with adverse events, the impact of adverse events, the type of support the physician sought and received after the event, and burnout. RESULTS: Across specialties, involvement in an adverse event and burnout was common. Most respondents involved in an adverse event experienced emotional impact, but only a minority received support. Those reporting that the error resulted in emotional impact were more likely to experience burnout (adjusted odds ratio, 1.90; 95% confidence interval, 1.18–3.07); this association was mitigated by the most common form of support sought, peer support (adjusted odds ratio for burnout among those who received peer support versus those who did not, 0.65; 95% confidence interval, 0.52–0.82). Barriers to support after an adverse event include punitive culture and systems factors such as administrative bureaucracy. Facilitators that emerged include peer, professional, and spiritual support, mentorship, helping others, the learning environment, and improved/flexible working hours. CONCLUSIONS: Physicians who experienced emotional repercussions from adverse events were more likely to report burnout compared with those who did not. Respondents proposed barriers and facilitators to support that have not been widely implemented. Peer support may help mitigate physician burnout related to adverse events.

INTRODUCTION: Medical students experience burnout, depersonalization, and decreases in empathy throughout medical training. My Life, My Story (MLMS) is a narrative medicine project that aims to combat these adverse outcomes by teaching students to interview patients about their life story, with the goal of improving patient-centered care competencies, such as empathy. METHODS: The MLMS project was started in the Veterans Affairs (VA) system and has since spread to dozens of VA sites. We adapted and integrated this project into the Warren Alpert Medical School of Brown University curriculum. As part of the required curriculum, first- and third-year medical students participated in a life story interview with a community-based volunteer or a patient in the inpatient hospital setting, transcribed the story, and reviewed the written story with the patient. We assessed student perceptions of the project, changes in empathy, and changes in burnout symptoms. RESULTS: A total of 240 students participated in this project. Students spent an average of 70.7 minutes interviewing patients. A majority of the students believed MLMS was a good use of time (77%), fostered connection with patients (79%), and was effective in recognizing patients' thoughts and feelings (69%). DISCUSSION: To our knowledge, this is one of the first life story interview interventions to be implemented into a required medical school curriculum and outside the VA setting. MLMS may assist students in improving clinical empathy skills and create a structure for medical trainees to better understand their patients.

NCHWA’s Nursing Workforce Dashboard visualizes data from the 2018 National Sample Survey of Registered Nurses (NSSRN), which includes detailed information on the nursing workforce in the United States.

OBJECTIVE: Our research objectives were to (1) assess the correlation between PD perceptions and their residents’ reported experiences and (2) identify PD and program characteristics associated with alignment between PD perceptions and their residents’ reports. DESIGN, SETTING, PARTICIPANTS: A survey was administered to US general surgery residents following the 2019 American Board of Surgery In-Training Examination (ABSITE) to study wellness (burnout, thoughts of attrition, and suicidality) and mistreatment (gender discrimination, sexual harassment, racial/ethnic/religious discrimination, bullying). General surgery program directors (PDs) were surveyed about the degree to which they perceived mistreatment and wellness within their programs. Concordance between PDs’ perceptions and their residents’ reports was assessed using Spearman correlations. Multivariable logistic regression models examined factors associated with alignment between PDs and residents. RESULTS: Of 6,126 residents training at SECOND Trial-enrolled programs, 5,240 (85.5%) responded to the ABSITE survey. All 212 PDs of programs enrolled in the SECOND Trial (100%) responded to the PD survey. Nationally, the proportion of PDs perceiving wellness issues was similar to the proportion of residents reporting them (e.g., 54.9% of PDs perceive that burnout is a problem vs. 40.1% of residents experience at least one burnout symptom weekly); however, the proportion of PDs perceiving mistreatment vastly underestimated the proportion of residents reporting it (e.g., 9.3% of all PDs perceive vs. 65.9% of all residents report bullying). Correlations between PDs’ perceptions of problems within their program and their residents’ reports were weak for racial/ethnic/religious discrimination (r = 0.176, p = 0.019), sexual harassment (r = 0.180, p = 0.019), burnout (r = 0.198, p = 0.007), and thoughts of attrition (r = 0.193, p = 0.007), and non-existent for gender discrimination, bullying, or suicidality. Multivariable regression models did not identify any program or PD characteristics that were consistently associated with improved resident-program director alignment. CONCLUSIONS: Resident and PD perceptions were generally disparate regarding mistreatment, burnout, thoughts of attrition, and suicidality. Reconciling this discrepancy is critical to enacting meaningful change to improve the learning environment and resident well-being.

[This is an excerpt.] Health systems do not exist in isolation. Political, market, professional, and cultural forces heavily influence health care delivery, workplace stress, and health worker professional well-being. For decades, health workers have been reporting a loss of meaning in work due to overwhelming job demands and limited supportive resources in the environments in which they operate (Maslach, 2018). In the United States, up to 54 percent of nurses and physicians, 60 percent of medical students and residents, and 61 to 75 percent of pharmacists have symptoms of burnout—high emotional exhaustion, depersonalization (e.g., cynicism), or a low sense of personal accomplishment from work (Jones et al., 2017; NASEM, 2019; Patel et al., 2021). Burnout is a longstanding issue and a fundamental barrier to professional well-being. It was further exacerbated by the coronavirus disease 2019 (COVID-19) pandemic. Health workers who find joy, fulfillment, and meaning in their work can engage on a deeper level with their patients, who are at the heart of health care (Lai et al., 2022; NASEM, 2019). Thus, a thriving workforce is essential for delivering safe, high-quality, patient-centered care. [To read more, click View Resource.]

This resource is found in our Actionable Strategies for Health Organizations: Aligning Values (Establish a Culture of Shared Commitment) AND Actionable Strategies for Government: Empowering Workers & Strengthening Leadership and Governance (Invest in Programs and Evidence) AND Aligning Values & Improving Diversity, Equity & Inclusion (Aligning Values and Improving Diversity, Equity & Inclusion) AND Advancing Measurement & Accountability (Measure Well-Being).

Burnout, compassion fatigue, and perceived stress among undergraduate nursing students are significant factors leading to a poorer quality of life, decreased job satisfaction, and adversely impact patient outcomes. Burnout among undergraduate nursing students is a critical individual and workforce issue with contributing factors including a relentless schedule, academically challenging and rigorous programs, pressure to perform, and the completion of clinical hours caring for patients. This paper describes our feasibility study of a nature-based intervention (NBI) to reduce perceived stress and quality of life as it relates to burnout, and compassion fatigue. Quantitative data was collected through demographics, surveys, and electronic sensor data. The project's aim was to determine the feasibility of NBI monitored by NatureDoseTM to decrease perceived stress burnout and compassion fatigue among undergraduate nursing students.

[This is an excerpt.] Prior authorization is harming individuals with cancer, according to new survey results from ASCO. The survey found that prior authorization delays necessary care, worsens cancer care outcomes, and diverts clinicians from caring for their patients. [To read more, click View Resource.]

This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Reducing Administrative Burdens).

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[This is an excerpt.] Many current neonatologist staffing models do not support the needs of the evolving neonatology workforce, administrative obligations, and patient population. Decades ago, NICU coverage involved daily rounds by a neonatologist followed by night coverage using a home-call model [1]. Due to increasing patient volume and acuity, adequate NICU coverage now often requires 24-hour in-house neonatologists [2] in both private practice and academic settings. Since the same neonatologist may round before and after an overnight shift, shifts may last up to 36 h [3]. Weekends have always been expected, but are now compounded by frequency, in-hospital requirements, weekend conferences, and not balanced by commensurate days off. Meanwhile, expectations of academic productivity, teaching, quality improvement work, and administrative obligations are unchanged or increased, and must be done during increasingly scarce “non-clinical” time. [To read more, click View Resource.]

[This is an excerpt.] In 2020, there were 78,740 cases of nonfatal workplace injuries and illnesses that resulted in at least one day away from work among registered nurses in private industry. This was a 290.8-percent increase, about four times as many cases, compared with 2019, when there were 20,150 such cases. The increase in days away from work cases for registered nurses in private industry was driven by a drastic increase in cases due to exposure to harmful substances or environments. There were 660 of these cases in 2019 and 55,750 in 2020. Cases of work-related COVID-19 were coded within this category. [To read more, click View Resource.]

This resource is found in our Actionable Strategies for Health Organizations: Ensuring Physical & Mental Health (Workplace Violence Prevention).

[This is an excerpt.] On January 11, 2022, the Partners for Nurse Staffing, a collaboration of five professional organizations, launched the Nurse Staffing Think Tank. Charged with identifying recommendations to address the nurse staffing crisis within a 12-18 month implementation timeframe, the group met every other week for
a total of six meetings. The first meetings focused on identifying high-priority areas. Subsequent work conducted in small groups identified recommendations within each high-priority area, as well as action items and measurable outcomes. The target audience for this work includes nurses, health care leaders and policymakers. The result of this work provides an action plan for the necessary cultural shift in health care delivery that can drive improved nurse retention, healthier work environments and better patient outcomes. The recommendations described here are actionable for health system and hospital leaders. Actions under the category, “Healthy Work Environment,” also pertain to regulatory bodies, policymakers and specialty nursing organizations. [To read more, click View Resource.]

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This resource is found in our Actionable Strategies for Professional Associations: Spotlights: Professional Associations Operational Strategies (Workloads and Workflows).

PURPOSE: Psychotropic medications are used to manage behavioral symptoms of dementia in nursing homes despite limited efficacy and the risk of adverse effects, and may be considered an easier solution for the treatment of behavioral symptoms. However, non-pharmacologic interventions are preferable but are most effective with consistent staffing. To address this, the Centers for Medicare and Medicaid Services implemented additional regulatory scrutiny through F-tag for deficiencies of care, targeting inappropriate psychotropic medication use (F-758 tag). The purpose of this study was to examine associations between nurse staffing levels and the occurrence of deficiency citations for inappropriate psychotropic medication use in residents with dementia symptoms. DESIGN: This was secondary data analysis of a cross-sectional study using CASPER (Certification and Survey Provider Enhanced Reporting) and PBJ (Payroll-Based Journal) data from 14,548 Medicare or Medicaid-certified facilities surveyed between December 1, 2017 and December 31, 2018. METHODS: Staffing measures included nursing hours per resident day and registered nurse skill-mix. Generalized linear mixed models with facilities nested within states, were used to estimate the magnitude of the associations between the occurrence of inappropriate psychotropics use deficiency citations and nurse staffing levels. Covariates included facility location, size, ownership, the presence of dementia special care units, and the proportion of residents with dementia, depression, psychiatric disorders, mental behavioral symptoms, and residents with Medicare/Medicaid. RESULTS: There were 1875 facilities with deficiency citations regarding inappropriate psychotropics use for residents with dementia. When controlling for covariates, facilities with greater hours per resident day for registered nurses (odds ratio [OR] = 0.54, 95% confidence interval [CI] = 0.44–0.67), certified nursing assistants (OR = 0.87, 95% CI = 0.77–0.99) and total nurse staff (OR = 0.87, 95% CI = 0.79–0.96) had significantly lower odds of inappropriate psychotropics use deficiency citations. Nursing homes with greater registered nurse skill-mix had significantly lower odds of receiving the deficiency tags (OR = 0.10, 95% CI = 0.04–0.26). CONCLUSION: Citations for inappropriate psychotropic medication use among residents with dementia were less likely to occur in facilities with higher staffing levels for registered nurses, certified nursing assistants, total nurse staff, and greater registered nurse skill-mix. Facilities need to be equipped with adequate nurse staffing levels to facilitate the use of non-pharmacological interventions and reduce inappropriate psychotropic medication use. CLINICAL RELEVANCE: Adequate nursing staffing is associated with fewer deficiencies related to the use of psychotropic medications to treat behavioral symptoms. Nursing home administrators and policymakers need to focus on assuring adequate nurse staffing levels to provide safe and high-quality dementia care.

BACKGROUND: The time that nurses spent on documentation can be substantial and burdensome. To date it was unknown if documentation activities are related to the workload that nurses perceive. A distinction between clinical documentation and organizational documentation seems relevant. This study aims to gain insight into community nurses’ views on a potential relationship between their clinical and organizational documentation activities and their perceived nursing workload.

METHODS: A convergent mixed-methods design was used. A quantitative survey was completed by 195 Dutch community nurses and a further 28 community nurses participated in qualitative focus groups. For the survey an online questionnaire was used. Descriptive statistics, Wilcoxon signed-ranked tests, Spearman’s rank correlations and Wilcoxon rank-sum tests were used to analyse the survey data. Next, four qualitative focus groups were conducted in an iterative process of data collection - data analysis - more data collection, until data saturation was reached. In the qualitative analysis, the six steps of thematic analysis were followed.

RESULTS: The majority of the community nurses perceived a high workload due to documentation activities. Although survey data showed that nurses estimated that they spent twice as much time on clinical documentation as on organizational documentation, the workload they perceived from these two types of documentation was comparable. Focus-group participants found organizational documentation particularly redundant. Furthermore, the survey indicated that a perceived high workload was not related to actual time spent on clinical documentation, while actual time spent on organizational documentation was related to the perceived workload. In addition, the survey showed no associations between community nurses’ perceived workload and the user-friendliness of electronic health records. Yet focus-group participants did point towards the impact of limited user-friendliness on their perceived workload. Lastly, there was no association between the perceived workload and whether the nursing process was central in the electronic health records.

CONCLUSIONS: Community nurses often perceive a high workload due to clinical and organizational documentation activities. Decreasing the time nurses have to spend specifically on organizational documentation and improving the user-friendliness and intercommunicability of electronic health records appear to be important ways of reducing the workload that community nurses perceive.

This resource is found in our Actionable Strategies for Health Organizations: Improving Workload & Workflows (Reducing Administrative Burdens).

The critical concept of nursing shared governance is shared decision making between the bedside nurses and nurse leaders, which includes areas such as resources, nursing research/evidence-based practice projects, new equipment purchases, and staffing. This type of shared process allows for active engagement throughout the healthcare team to promote positive patient outcomes and also creates a culture of positivity and inclusion, which benefits job satisfaction.