Supporting and Retaining Nurses in Trying Times

Transition to Practice: Onboarding Components for Establishing and Sustaining Healthy Work Environments.

Keeping Healthcare Workers Safe Through Policy Initiatives

Background: Workplace violence (WPV) in healthcare, particularly in emergency departments (EDs), is a growing and complex issue that significantly impacts healthcare providers (HCPs). Following the COVID-19 pandemic, the rates of WPV have increased globally, contributing to increased burnout, reduced morale, and heightened challenges in staff retention within EDs. Objective: This study aimed to explore HCPs' perspectives on WPV in EDs. The insights gathered were intended to inform targeted interventions in a quality improvement initiative focused on addressing WPV in our healthcare institutions. Methods: A qualitative study involving semi-structured interviews was conducted with 52 HCPs across two urban EDs at a multi-site academic health center. Participants from various roles and shifts shared experiences related to safety, leadership, training, and security. Interviews were recorded, transcribed, anonymized, and thematically analyzed to identify key themes surrounding WPV in EDs. Results: The thematic analysis identified four main themes, including (1) Violence is Part of the Job, (2) Leadership Dynamics regarding WPV, (3) Disconnect Among ED Staff During WPV Response, and (4) Enhancing Systems and Culture for Effective WPV Management. These themes provide a comprehensive view of HCPs' experiences and offer actionable recommendations for healthcare organizations seeking to address WPV. Conclusions: The study provides valuable qualitative insights into WPV in EDs, emphasizing the importance of addressing cultural, structural, and procedural gaps. These findings can guide the development of more supportive and effective strategies to create a safer environment for ED staff. Further rounds of interviews are planned post-intervention to assess changes in HCPs' perceptions and experiences.

A decline in employee engagement in an organization often originates from the presence of toxic work environments which affects overall performance and productivity, thereby posing a significant threat to the company’s success. Therefore, this research aimed to explore the impact of toxic work environments on employee engagement. Employee well-being and supportive work culture were used as mediating factors to analyze the correlation between employee engagement and toxic work environments. The research was conducted among 600 respondents in the coal mining industry using Partial Least Squares Structural Equation Modeling 4.1.0 as the quantitative methodology to determine the correlation. The results showed a clear reduction in employee engagement due to toxic work environments, with employee well-being and supportive work culture having negative effects. To reduce the harmful effects of toxic work environments, a supportive work culture and employee well-being were crucial mediating variables. Furthermore, the results suggested that the mediators could improve the level of engagement among workers. This research further contributed to the theory and subsequent publication offering intervention from corporate and government organizations. Future publications should consider pre- and post-intervention to measure toxic work environments’ effect on employee engagement.

Workplace violence—any threat or act of physical violence, harassment, intimidation, or other threatening behavior1—is a serious problem worldwide.2 Health care workers have an increased risk of workplace violence compared with workers in private industry.3 Nurses are the most common victims,4–6 and patients are the main perpetrators (however, visitors and employees also can precipitate workplace violence).3 In 2014, the US Bureau of Labor Statistics7 reported that serious workplace violence is more than 3 times higher in health care settings than other workplaces, with an incidence of 16.2 per 10 000 employees. Such estimates are conservative because of gross underreporting of workplace violence in health care settings.2,3,8–10The percentage of nurses reporting having experienced verbal threats or actual physical violence ranges from 33% to 65% (Australia),11 to 50% (Switzerland),12 to 76% (US).10 A systematic review1 of 50 international studies revealed that patients' aggression toward nurses was similar in type (verbal abuse reported 3 times as often as physical assault in any setting), location and context (nurses in emergency departments commonly report higher rates),10 individual consequences (physical injury, short- and long-term trauma), and organizational consequences (eg, absenteeism, low morale, job dissatisfaction, increased turnover, worker's compensation, heightened security, property damage, litigation) in different countries.8 Risk factors include individual influences such as history of aggression, psychiatric disorders, substance abuse, stress/frustration/anxiety, powerlessness, and perceptions that violence is tolerated. Environmental risk factors for workplace violence include unrestricted access, inadequate security, long wait times, overcrowding, weekends/off-shifts, and lack of aggression management training.2,3,10,13,14 As education is a critical solution to arm nurses with knowledge, skill, and confidence to prevent and respond to situations involving workplace violence, the PICO (patient population, intervention, comparator, outcome) question for this evidence synthesis is, What effect does deescalation education have on nurse outcomes of aggression management knowledge and performance and clinical outcomes (incidence and severity of violence)?The strategy included searching the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and MEDLINE. Key words included violence, hospital violence, acute care, nurses, aggression management, and deescalation education. The search was limited to research from the past 10 years.Seven original research papers15–21 were retrieved. Of these, 2 were systematic reviews, 1 was an integrative review, 3 were pre-post studies, and 1 was a qualitative study. Table 1 outlines main findings of these 7 studies that enrolled registered nurses and nursing students in medical/surgical, emergency department, or intensive care unit settings. Aggression management interventions included rapid 45-minute in-service training sessions,16 twenty-four 50-minute sessions in several days,20,21 4-hour18 and 1-day sessions,17,18 and a deescalation kit (poster and in-service training session).18 Topics included prevention (situational awareness, self-reflection), assessment (risk factors, causes/types of aggression), intervention (deescalation based on nonviolent crisis intervention model), and postevent coping.Main benefits of education related to aggression management for acute care nurses can be described via the Kirkpatrick 4-level evaluation model22 (see Figure). Nurses responded (level 1) favorably, gaining knowledge, skills, and confidence (level 2) to manage aggressive situations (level 3) more effectively. In 1 study,15 nurses reflected how education related to aggression management helped them consciously pay more attention to patients' cues and their body language (eg, voice, gestures, posture, distance) and use of deescalation techniques. Despite favorable effects on practice, attitudes toward aggression largely did not change. In 1 study,15 nurses' attitude (positive or negative evaluation of patient's behavior) determined their emotional response to the situation. If illness-related factors were implicated, nurses did not attribute blame, which allowed them to remain emotionally detached. But when behavior was perceived as offensive or disrespectful, nurses attributed blame, which then triggered an emotional response.15A small body of low-quality evidence (mostly level C) is available about aggression management education for nurses practicing in acute care (nonpsychiatric) settings (Table 2). The benefits of education included improvement in knowledge, skills, and confidence related to aggression management, as well as increased reporting and some reduction in the incidence and severity of workplace violence. However, nurses' attitudes toward aggression or coping during aggressive situations did not change. In a systematic review of deescalation education in mental health, Price and colleagues24 identified that confidence or anxiety regulation was not a reliable predictor of performance. Rather, the ability to relate to the aggressor interpersonally played the critical role. Although weak, some evidence supported attitudinal change to patient aggression as a mechanism for improving clinical performance.In a 2015 position statement, the American Nurses Association25 indicated that "the nursing profession will no longer tolerate violence of any kind from any source." Potera26 advocated reporting, legislation, and education as the touchstones for eradicating workplace violence. Recognizing that workplace violence occurs in clinical settings beyond psychiatry, the National Database of Nursing Quality Indicators (NDNQI)27 expanded the "Assault against nursing personnel" for medical-surgical settings. Better reporting of incidents of workplace violence may build a case for the need for education about aggression management to prepare nurses in the key elements of deescalation (Table 3) in acute care settings. The Occupational Safety and Health Administration30 noted that education about aggression management is most effective when tailored to the unit's risk profile or the organization's specific clinical context. Such customization includes specifying who needs the education (eg, clinical nurses, charge nurses, assistant nurse managers), and at what interval. Educational planning can be aided by considering patient populations served and historical trends in workplace violence of each unit.31 Aggression management programs should strive to achieve the educational outcomes shown in Table 4 by blending didactic content with opportunities for nurses to practice skills using real case studies that cover the array of aggression scenarios specific to their populations.24,30 Competency can then be evaluated and feedback given to nurses about how they managed actual aggressive situations in clinical practice.24More research is needed to evaluate aggression management education with acute care nurses. A promising area of this research focuses on strategies to assist nurses in developing empathetic and compassionate responses to aggression. Previous research has suggested that the ability to relate to an aggressor and thereby understand his or her needs may serve as a powerful mediator and thus help nurses improve performance in the midst of aggression.

Introduction: The work attitude of nurses considerably influence their productivity, work efficiency, and quality of patient care. Consequently, the association between absenteeism and job commitment is a topic of interest in most healthcare organizations, particularly in nursing, because it directly impacts patient safety, especially those in critical care units (CCUs). This study evaluated the association between factors leading to absenteeism among nurses and their job commitment in the CCU. Methods: This study involving a correlational research design included 210 critical care nurses from a tertiary government hospital in Saudi Arabia enrolled using a non-probability convenient sampling technique. Self-administered questionnaires developed by researchers were used for the analysis. Results: The most common factors leading to absenteeism among nurses were work routine exhaustion (mean [M]: 2.45, standard deviation [SD]: 1.07), an uncontrolled attitude toward absenteeism (M: 2.43, SD: 1.10), family-related issues (M: 2.41, SD: 1.01), and an unhealthy working environment (M: 2.41, SD: 0.97). Moreover, the nurses also expressed low commitment to their job (composite M: 3.20, SD: 0.98). A significant association was observed between the factors leading to absenteeism among nurses in the CCU and their job commitment. Conclusion: The factors leading to absenteeism among nurses in the CCU were exhaustion from their routine work, an uncontrolled attitude toward absenteeism, family-related problems, and an unhealthy working environment. An inadequate nursing workforce due to absenteeism may compromise the quality of care provided to patients. Understaffing due to absenteeism can also result in an over workload, fatigue, and low morale among nurses on duty. Furthermore, a lack of job commitment may affect patient outcomes and safety

Background: Workplace violence (WPV) is a serious occupational hazard that can undermine nurses’ professionalism, increase stress, and contribute to a toxic work environment. Repeated exposure to WPV is particularly concerning as it can diminish motivation, reduce job satisfaction, and negatively affect the quality of care. In hospitals located on remote small islands, where frequent interpersonal encounters are inevitable due to limited staffing and close community ties, the challenges faced by WPV-victimized nurses can be even more complex. Objective: This study aimed to explore how nurses working in a remote island hospital perceive and experience WPV Methods: A descriptive phenomenological approach was employed to capture the lived experiences of nurses at Sabang City Hospital who had experienced WPV. Participants were selected purposively. Data were collected using demographic questionnaires, semi-structured in-depth interviews, field notes, and audio recordings. The interviews explored the nature of WPV incidents, emotional and psychological impacts, and expectations for organizational support. Data were analyzed thematically to identify patterns and shared meanings. Results: Three key themes emerged: (1) perceiving WPV as a source of sadness, distress, and long-lasting trauma; (2) recognizing WPV as encompassing both verbal (insults, threats) and non-verbal (intimidation, neglect) forms; and (3) expecting more active roles from superiors and hospital management, including prevention, immediate intervention, and post-incident support. Conclusion: Nurses’ varied perceptions of WPV reflect the urgent need for structured prevention strategies and responsive management interventions. Strengthening organizational policies and support mechanisms is critical to safeguarding nurses’ well-being and fostering a safe, respectful workplace.

Addressing workplace violence with the Pathway to Excellence® framework.

Background Workplace violence has gained significant attention over the last few decades. Violence against health care workers is a complex and persistent occupational hazard facing the health profession and constitutes almost a quarter of all violence at work. This study was conducted to assess the prevalence and pattern of workplace violence among Healthcare workers in Tertiary Health facilities in Benin - City, Nigeria with a view to making recommendations that will enhance the safety of the healthcare workers and improve patient care. Methods A descriptive cross-sectional study was carried out among healthcare workers in tertiary healthcare facilities in Benin City. Benin City is the capital of Edo State, Nigeria. Edo State is in the South-South geo-political zone of Nigeria and is the country's central gateway to the North, East, and West. Respondents were selected using the stratified sampling technique. Data was collected using a pre-tested structured questionnaire adapted from the International Labour Organization/World Health Organization joint programme on workplace violence in the health sector confidential survey. Data analysis was carried out using IBM SPSS version 22.0 software. A p-value <0.05 was considered statistically significant. Results A total of 386 healthcare workers, with a mean age (SD) of 33.9 ± 6.0 years and male: female ratio of 1:1.7 participated in the study. Physical, verbal, sexual and emotional violence were suffered by 285 (73.8%), 267 (69.2%), 133 (34.5%) and 104 (26.9%) respectively in the workplace. Overall, majority, 323 (83.7%) of respondents had experienced workplace violence. Being female, single and nursing profession were significantly associated with workplace violence (p < 0.001). Conclusions The prevalence of workplace violence was high among the studied group. Interventions focusing on the fundamental role of prevention in effectively combating violence at work is recommended. Key messages Violence against health care workers is an occupational hazard facing the health profession and constitutes almost a quarter of all violence at work. Prevalence of workplace violence was high among the studied group. The most common pattern of workplace violence was physical violence.

Pediatric cardiac surgery is complex and has significant risk, requiring interprofessional teamwork for optimal outcomes. Unhealthy work environments have been linked to poor patient outcomes, staff dissatisfaction, and intention to leave. We describe the interprofessional health of pediatric cardiovascular operating room (CVOR) work environments in the United States and the establishment of a healthy work environment (HWE) benchmark score. Utilizing the American Association of Critical Care Nurses Healthy Work Environments Assessment Tool (HWEAT), interprofessional staff from 11 pediatric CVORs were surveyed. Responses were aggregated, summarized, and stratified by role to examine differences. The following phase used an e-Delphi approach to obtain expert consensus on a benchmark target. Across 11 centers, 179 (60%) completed surveys were reviewed. The interprofessional mean HWEAT score was 3.55 (2.65-4.34). Mean scores for each standard were within the "good" range. Participants reported the highest scores for effective decision-making, with a mean of 3.69 (3.00-4.20). Meaningful recognition scored lowest, mean 3.26 (2.33-4.07). When stratified, surgeons reported higher overall HWE scores (M = 3.79, SD = 0.13) than nurses (M = 3.41, SD = 0.19; P = 0.02, two-tailed). The proposed benchmark was 3.50. This is the first time the American Association of Critical Care Nurses HWEAT has been used to describe the interprofessional health of work environments in pediatric CVORs in the United States. The targeted benchmark can support pediatric CVOR improvement strategies. Creating and sustaining an HWE is an interprofessional opportunity to support high-quality patient outcomes and clinical excellence.

Purpose: To compare the competencies of registered nurses with an international perspective.Background: Rapid changes in scientific developments have important effects on the nursing profession. To adapt to these changes, the essential competencies of graduate nurses are updated by professional organizations.Methods: The document analysis method, one of the qualitative research methods, was used. The study included 9 countries that are members of the International Council of Nurses (ICN), which have a national nursing association, nursing undergraduate program professional qualification criteria, and accreditation structure. Countries' expected competencies from registered nurses were compared in line with the “Nursing Care Continuum Framework and Competencies” published by ICN in 2008, and similarities and differences were analyzed and interpreted. Results: Results show that competency guidelines are published by different organizations, and there is no standard classification of competencies. While 90.91% of the countries include accountability in their professional competence guides, ethical and legal practices and, principles of care are in all of the countries. 81.82% of the countries include leadership and management. Professional, personal, and quality development is addressed by all countries.Conclusions: It was determined the majority of nurse competencies are met by the countries included in the study, and language unity is achieved to a large extent. However, there are differences in the content and handling of competencies. It is clear that there is a need for further research that addresses the issue of professional competencies in nursing in-depth.

The American Association of Critical Care Nurses Standards for Establishing and Sustaining Healthy Work Environments: Off the Printed Page and into Practice

In 2021, food industry workers represented approximately one-tenth of the total labour force in Malaysia. There was an estimated 15% of working-age adults who experienced a mental disorder worldwide in 2019. To make the situation worse, service workers in food retail and food services face tremendous stress and mental health consequences during the COVID-19 pandemic. Various study found that worsening mental health and psychological distress have been accelerated substantially by the pandemic. An unsafe or unhealthy working environment can undermine mental health, as poor mental health can interfere with a person’s ability to work if left unsupported. This systematic review aimed to evaluate findings related to factors associated with depression, anxiety, and stress among food industry workers. Articles related to these factors were collected electronically from two different databases (EBSCOHOST and Scopus). An independent reviewers screened the titles and abstracts of the collected articles from each database, and then stored them in Google Sheet based on the inclusion and exclusion criteria. Next, the included articles were critically appraised to assess the quality of the studies using the Mixed Methods Appraisal Tool (MMAT). Out of the 292 articles identified, four were included in the final review. Sociodemographic characteristics, as well as biological, psychological, and occupational factors were found to be associated with common mental issues among food industry workers. By identifying the risk factors, specific interventions can be implemented by the employers and other relevant parties to prevent, promote, protect, and support the mental health well-being of food industry workers. These findings may be utilised to improve the implementation of key interventions directed to prevent, promote, protect, and support the mental health of food industry workers. Consequently, an enabling environment can be created to address mental health at work, as outlined by the World Health Organization (WHO). Employers may adapt or revamp their work environment to minimise exposure to psychological risks among their workers, which could prevent workers from experiencing adverse mental health conditions. Workers should also be equipped with awareness and skills, as well as opportunities to recognise and act early on mental health issues in order to promote and protect their mental health. Moreover, workers with pre-existing or ongoing mental health conditions should receive support to access job opportunities, or continue working, and thrive at work, since good mental health status at work can improve an individual’s performance and productivity.

Objective: This case study describes the introduction and evaluation of a structured perioperative education program for novice nurses in the theatre setting to address ongoing retention and attrition rates of skilled perioperative nurses. Background: A proficient and dynamic workforce is essential for speciality areas, including surgical theatre environments. Whilst perioperative nurse education occurs at undergraduate and postgraduate universities, assimilation and further development of skills into the work environment takes time and requires a supportive workplace culture. Lack of support and exposure to clinical experience limits the competency and confidence of novice nurses, which negatively affects retention in specialty areas. Study Design: Twenty novice nurses underwent a three-month rotation across 14 perioperative speciality areas with an assigned nurse mentor between 2021 and 2024. An educational learning package was developed to track the knowledge, confidence, and capability of novice nurses. Focus group sessions were held every three months, and surveys were administered to assess the overall effectiveness of the program. Results: Nineteen novice nurses reported increased confidence in their knowledge and overall confidence in the clinical area. Findings demonstrated that the program’s structure was a strength, while organisational impacts were the main barrier, including a lack of staff and time pressures identified as barriers. Overall, workplace culture was improved for all staff with improvements in staff retention. Conclusion: The retention of skilled perioperative staff is essential for best patient outcomes, organisational efficiencies, and a positive work culture and environment. This project has been successful in bridging the theory-practice gap, promoting skill acquisition and professional confidence for NN, whilst enhancing positive workplace culture and staff retention within the study setting. There is a need to review the self-paced learning booklets to enhance the documentation and to show completion by all participants. Implications for practice: Attrition rates in speciality areas that require a high level of ability, such as the perioperative environment, remain a constant concern for healthcare. This study proves the importance of investing in skill development for novice perioperative nurses through a structured educational program in the clinical setting. Supportive frameworks enhance nurses’ knowledge and confidence, leading to retention in speciality areas.

The main objective of this paper was to study the causes of stress on the hotel and restaurant employees in Surkhet valley. In addition to this, it focuses on the techniques of stress management and its impact on employee performance. Descriptive research design was applied in this research and primary data was collected through the questionnaire, which includes the personal interview, mail questionnaire, telephone interview and Google Form. There were 150 respondents. among them 83 were from hotel and 67 were from restaurants. The finding of the study concluded that unhealthy working environment was the primary causes of the stress in hotel and restaurant industry. To overcome such stress majority of the respondents, prefer to listen music and this study also find that there is an inverse relationship between stress and the employee performance.