former Vice President Al Gore offered a clarion call for climate action in the book and documentary An Inconvenient Truth. 1 Almost 20 years later, faced with rising global temperatures and concern from climate scientists, some Americans still do not feel the urgency to act.They think the news about rising global temperatures has been overstated, and they may not see media and governmental reports as credible. 2There have also been specific calls to health care organizations and providers by the Centers for Disease Control and Prevention, the World Health Organization, the Paris Agreement, The Joint Commission, and others to take action toward environmental sustainability.Fortunately, the majority of people working in health care do believe the science surrounding climate change and understand the potential negative effects on public health.However, some feel they have insufficient knowledge and lack of support regarding promoting environmentally sustainable changes, as the topic may be viewed as controversial and too risky professionally. 3In addition, nurses may not have the knowledge required to identify potential environmental health impacts in the assessment and management of patients.Those who are already overwhelmed due to time constraints, inadequate staffing, and unhealthy work environments may not have the energy to focus on environmental issues.This symposium highlights the steps individuals and organizations can take to combat climate change and how to begin the journey toward environmental sustainability.It also addresses the potential outcomes of a changing climate that may be seen and experienced by health care providers, patients and their families, and those in communities.In this issue, Shelby describes her journey to becoming more knowledgeable about how she as a nurse could advocate for creating sustainable changes in the health care setting.She provides key information and resources for nurses on developing a green practice and leading changes within their health care settings.In a complementary perspective, Pate provides a call to action for hospitals to engage in making changes to lessen the impact on climate change.Together, these 2 articles provide ideas and encouragement for nurses to address ways that health care organizations and providers can increase their actions and contributions to combat climate change.

Palliative care is interdisciplinary care that addresses suffering and improves the quality of care for patients and families when patients are facing a life-threatening illness. Palliative care needs in the intensive care unit include communication regarding diagnosis and prognosis, goals-of-care conversations, multidimensional pain and symptom management, and end-of-life care that may include withdrawal of mechanical ventilation and life support. Registered nurses spend the greatest amount of time with patients and families who are facing death and serious illness, so nurses must be armed with adequate training, knowledge, and necessary tools to address patient and caregiver needs and deliver high-quality, patient-centered palliative care. Innovative approaches to integrating palliative care are important components of care for intensive care nurses. This article reviews 2 evidence-based practice projects, a serious illness support tool and the 3 Wishes Project, to add to the palliative care toolkit for registered nurses and other team members.

The COVID-19 pandemic exacerbated staffing challenges in intensive care units, with increased burnout and moral distress cited as major problems. A healthy work environment is critical to nurses' success and wellbeing. During the pandemic, a survey by the American Association of Critical-Care Nurses revealed decreased composite scores in each of the 6 critical elements of a healthy work environment. Hospital units that improved even 1 critical element reported higher job satisfaction. The use of telehealth tools by expert nurses expanded care delivery during the pandemic by improving response to acutely and critically ill patients while supporting hospital-based nurses. All of the critical elements of a healthy work environment are relevant to the tele-critical care nurse's role and challenges. This article describes how tele-critical care nurses were affected by the pandemic and how healthy work environment strategies promoted successful nurse and patient outcomes.

For decades, tele-critical care (TCC) programs have provided expert population surveillance with standardized clinical interventions for critically ill patients. The COVID-19 pandemic created massive strains on critical care resources. For this report, standard questions were used to solicit COVID-19 pandemic workflow and service modifications from a network of TCC leaders to describe the rapid expansion of TCC-supported services during the pandemic. In this article, leaders from 7 TCC programs report on the effective use of services to support changing hospital needs during the pandemic in areas such as clinical education, personal protective equipment stewardship, expansion of virtual care, and creative staffing models, among others.

Long before the COVID-19 pandemic, relationships with patients and colleagues were the fuel that kept nurses coming back day after day. Consistently identified as the most ethical and trusted profession for more than 2 decades, nursing has enjoyed positive regard and admiration by patients for its ethical standards, reliable care, and presence.1 Teams comprised of diverse clinicians and other health care workers created a foundation of competence and confidence that contributed to safety, quality, and camaraderie. Leaders and organizations, responsible for creating a supportive environment, invested in programs of nursing excellence such as American Nurses Credentialing Center’s Magnet or Pathways to Excellence programs. In many communities, there were partnerships with health care systems and the people they served. In some places there was a sense of shared purpose and solidarity.But things have changed. Levels of violence against nurses have skyrocketed.2,3 Patients are turning against nurses’ expertise and advice in favor of unsubstantiated treatments or practices, and disrespect has become normalized.4 Health care teams are fractured by staff turnover, short-term assignments by externally employed nurses, and a “brain drain” of experience as the workforce is populated by less experienced clinicians.5 Communication is transactional and largely relegated to disembodied electronic memes or texts. Leaders and organizations are struggling to compensate for losses after the pandemic and are relying on historical strategies of increased throughput and efficiency to balance the budget. Nurses and other clinicians continue to be asked to do more with less. Societal upheaval, conflict, and uncertainty have destabilized relationships in neighborhoods and communities. Arguably, the relational integrity of everyone has been eroded.Relational integrity, a key component of moral resilience, refers to the dynamic interplay of the personal integrity of everyone engaged in the delivery of health care.6 This includes clinicians, health care workers, leaders, communities, and the people served—our patients and their families. Beyond personal integrity, it encompasses the values and commitments inherent to our professions, as outlined in our codes of ethics. Relational integrity is reflected in our choices, behaviors, actions, and professionalism, and it acknowledges that our moral compass is primarily executed in the context of relationships with others. This type of integrity refers to the inevitability of our personal integrity being tethered to, and thus influenced by, the integrity of patients, other clinicians, leaders, and the institutions within which we practice. Our interdependence and interconnection with each other are reflected in myriad ways including the micromoments of connection that occur every day. Collectively, we resonate with each other’s integrity when it is manifest and when it is degraded. We detect these signals of alignment or misalignment in our bodies, hearts, and minds. Relational integrity fluctuates in practice settings between everyone being whole and undiminished and their wholeness being fractured temporarily or permanently.The quality of relationships between clinicians and patients, interprofessional clinicians and their leaders, and with the broader community is influenced by relational integrity. As a dynamic ecosystem, it involves mutual respect, skillful communication, and authentic collaboration. Maintaining relational integrity is key to building strong relationships among clinicians, patients, and interprofessional teams, and to gaining the respect and collaboration needed for desired results. It encompasses effective, mindful communication and is essential for achieving positive patient care outcomes, fostering moral resilience, and promoting staff engagement and fulfillment. When relational integrity is intact, all parties feel seen and heard, communication is transparent and honest, and there is respect for patients’ experiences and clinician’s expertise. Empathy, understanding, trust, and curiosity flourish, thereby contributing to everyone’s wholeness and sense of belonging. When relational integrity is fractured, clinicians do not feel supported, respected, or empowered; likewise, staff morale and engagement can suffer and may lead to increased moral suffering or burnout. This breakdown can result in breaches of trust, poor collaboration, ineffective communication, delayed interventions, medical errors, and ultimately poorer patient outcomes.7 This dynamic web of relationships extends into communities and society at-large. Beyond the walls of health care organizations, there are complex social, political, economic, racial, and cultural forces that impact the personal, professional, and relational integrity of clinicians and those they serve. When there is alignment in values, behaviors, policies, and practices, integrity thrives. When patterns of degraded relational integrity accumulate in a context of constrained work environments, societal and community disintegration, conflict and violence, the insidious erosion of the integrity of the health care enterprise and the people in it becomes undeniable.It’s a busy night in the emergency department (ED). Nurse Isaac clocks in for his night shift and receives the nursing shift report from the outgoing day shift nurses. There are 8 rooms in Issacs’s section of the ED, each separated by curtains. Because of the high patient census, 15 patients are shuffled into the section that was built to accommodate less than half that number. Isaac is the only nurse in his section tonight. He pauses when he notices the name of the ED physician in charge for the evening, Dr Fay. He recalls their prior interactions have been challenging.Anthony, a 65-year-old man, arrives at the ED with a chief complaint of chest pain and shortness of breath. The patient has a history of tobacco use, chronic obstructive pulmonary disease (COPD), and high blood pressure, as well as a positive family history of acute coronary syndrome. An electrocardiogram (ECG) is ordered by Ava, the triage nurse, while Ruby, the clinical nursing assistant, takes Anthony in a wheelchair to Isaac’s section and places him on a cardiac monitor with a pulse oximeter and blood pressure cuff. Isaac is preoccupied, attempting to deescalate the ire of a patient waiting over 2 hours to be seen by a doctor for a superficial laceration to their arm who is demanding to speak with management.Meanwhile Chris, the ECG technician, has the printout of the ECG in hand and is waiting outside a patient’s room to share the results as the doctor finishes assessing the patient. Five minutes later, Dr Fay steps out of the room and is handed the ECG report; it shows non–ST-elevated myocardial infarction (NSTEMI). After taking the ECG printout from Chris, Dr Fay mutters something unintelligible and enters the room where Isaac is attending to the irate patient. Dr Fay comments to the patient that there is an urgent situation requiring Isaac’s attention and that the patient’s issues will have to wait. Isaac and Dr Fay hurriedly enter Anthony’s bedspace to find him diaphoretic and dyspneic, with chest pain described as a 9 out of 10. Isaac quickly introduces himself to the patient but is cut off by Dr Fay, who introduces themself as “the doctor.” Dr Fay performs an assessment on Anthony and then proceeds to walk out of the room before being stopped by Isaac, who asks for verbal confirmation of the plan of care. Dr Fay tells Isaac that orders can be seen in the electronic medical record (EMR). Isaac reminds Dr Fay to order a respiratory swab because Anthony will need those results to be admitted to the cardiac intensive care unit (CICU). Dr Fay nods dismissively and walks off. Isaac turns toward Anthony, noticing his anxious expression, and reassures him that the team is doing their best to help him and asks if there is anyone he would like Isaac to contact.Isaac initiates his own assessment of the patient. He repositions Anthony to support his breathing and titrates supplemental oxygen to an appropriate rate given his history of COPD. Isaac builds rapport with Anthony through small talk as he implements Dr Fay’s orders, which have appeared in the EMR. Isaac notices that the respiratory swab was not ordered. He knows that hospital policy requires that patients admitted to the hospital must have a respiratory swab test result before being transferred to a room. Wary of Dr Fay’s reaction to being reminded a second time, Isaac opts to use the electronic messaging system to send the doctor a reminder to order the swab.Over the next 5 hours, Isaac’s attention is split across 15 patients. Despite the high patient volume, limited resources, and no relief, Isaac manages to keep up with his most critical patients, to the chagrin of those patients who are more stable yet still in need of care. Finally, he sees that a bed has been made available in the CICU for Anthony. Isaac immediately calls up to the floor to give a nursing report. The receiving CICU nurse notes that the respiratory swab result has not been recorded and reminds Isaac that they will need those results before Anthony can be transported.Exasperated by the delay, Isaac checks the EMR to see that Dr Fay has neither ordered the test nor acknowledged his electronic message. He leaves his section to remind Dr Fay in person to place the orders. The doctor tells Isaac to wait while they review a resident’s charting for another patient. Isaac stands anxiously at the desk. He looks back at his section and sees several colleagues gathering around Anthony’s room. A code alarm is triggered, and Isaac and several doctors rush over to the room to find Anthony cyanotic with agonal breaths and oxygenation of 60%. Anthony becomes pulseless, compressions are started, and he is intubated. Return of spontaneous circulation is achieved after several rounds of cardiopulmonary resuscitation.Anthony has been stabilized for now, albeit in worse condition than before. Ava, the charge nurse, calls the CICU manager to expedite transfer to the floor. Isaac overhears Dr Fay commenting to Ava that this could probably been avoided if Anthony’s nurse had not been distracted. Ava responds by saying that Isaac is one of the most capable nurses on the team, and Anthony is fortunate to be in his care. Isaac finally gives his hand-off to the nurse in the CICU, who says about the missing respiratory swab, “Aren’t you aware of the hospital policy?”Clinical practice is fundamentally relational work where patients and health care workers meet each other in a complex, often uncertain, and rapidly evolving context. Each person in the dynamic brings with them their unique moral fingerprint of values, beliefs, and principles along with their cultural and social practices. Our clinical work engages our human vulnerabilities and interdependence. Relational integrity includes being true to one’s own moral compass while establishing effective engagement and boundaries in relationships and decisions.6 The inter-connection of everyone’s integrity is particularly vital when considering the situations that clinicians must navigate, balancing competing obligations to their patients and their surrogates, the institutions where they practice, and the broader society. Clinicians such as those in Isaac’s case must consider what they owe their patients and each other in the context of health care relationships, and what commitments and expectations they are willing to enact and hold themselves and each other accountable for.Respecting everyone’s humanity, especially the people we serve, is a crucial component of relational integrity.6 Isaac demonstrates this when, amid a crisis, he introduces himself before conducting his assessment and when he builds rapport while providing care and reassurance to ease Anthony’s anxiety. Relational integrity is upheld when we attune to the needs of others and respond in ways that nurture respect and wholeness. Isaac noticed Anthony’s expression of concern, and despite the time constraints, paused to reassure Anthony and offered to reach out to people important to him. Throughout the scenario, Isaac connected with his core values of respect for the inherent dignity of his patients and prevention and minimization of harm by prioritizing those at greatest risk of compromise; he did all this, to the best of his abilities, in a fair, equitable, and compassionate manner. Research suggests that when there is alignment between organizational and health care worker personal and profession values, the necessary conditions for compassion to arise are enhanced.8 Isaac leveraged his knowledge, skills, and experience to navigate the complexity without exacerbating the tenuous relationships and circumstances that he found himself in. Although it is not explicitly stated, he likely used a variety of self-regulatory skills and self-stewardship practices to support his ability to remain stable amid the chaotic ED.8,9As illustrated in the case, teamwork is necessary for safe, high-quality care. Relational integrity leverages the shared interdependence and humanity of the entire clinical team. It depends upon solidarity of purpose and invites the contributions of all to achieve the desired patient outcomes, organizational priorities, and professional goals.6 When a team is “divided, lacks solidarity, or is weakened by cowardice or ineffective leadership, it can disable the entire group.”6 Relational integrity is fundamentally inclusive of the diversity of values, perspectives, and contributions of everyone and creates an environment where no one is left out. Personal and professional integrity is a foundation for relational integrity. It requires knowing what one stands for and having the confidence and courage to defend against threats or challenges while maintaining respectful relationships with others. Ava stood firm in her values of respect and fairness when she responded to Dr Fay’s appraisal of Isaac’s performance. She leveraged her integrity by constructively offering an alternative view and modeled respectful engagement with someone holding a different perspective. This illustrates the small ways that integrity can be fortified or eroded by the behaviors of a few. When one person’s integrity is upheld, relational integrity thrives; when it is compromised, the collective integrity of everyone is eroded. This expanded view of integrity enlarges the sphere of individual integrity to include awareness and sensitivity to the integrity of others and helps to define and honor the boundaries of relationships, roles, and authority.Although this scenario is fictional, it reflects the lived experiences of health care providers and their patients. Further, it also highlights some of the explicit and implicit challenges and advantages to relational integrity. While there are individual decisions that impact the patient and professional experiences, there are also decisions made at the social, political, and institutional levels that trickle down to impact those individual decisions. Relational integrity resides within a dynamic social-ecological context that is impacted by the interplay among complex and often dissonant influences. Imbalances in power or authority, constraints imposed by hierarchical systems, and dependencies on others to enact one’s responsibilities creates challenges to shared purpose and values.6 Intact personal and professional values and integrity are necessary to inform group process, clinical practice, and organizational policy and culture. Alignment with organizational values is needed to support and encourage clinicians to meet their individual and shared moral commitments and organizational priorities without disproportionate stress, distress, or degraded well-being.Whether an individual is a nurse, doctor, medical technician, or ancillary staff, the shape of one’s practice is formed by many hands and executed through relational engagement, trust, and collaboration. In Anthony’s case involving the ED team who transfers him to the CICU, there were numerous junctures where relational integrity was fractured. The doctor and nurse assigned to the patient have a history of poor communication and a lack of trust. The nurse hesitates to speak up when he notices a change in the patient’s condition, because the doctor has a pattern of dismissing concerns. The patient’s condition deteriorates, eventually requiring intubation and mechanical ventilation. The lack of communication and trust between the doctor and nurse delays the initiation of appropriate treatment, resulting in a longer hospital stay and increased risk of complications. Other members of the ED team such as Chris, the ECG technician, also hesitate to breech the role-based hierarchical norms of the ED. Dr Fay demonstrates a pattern of dismissive responses to the suggestions of other team members and engages in gossip and degrading verbal and nonverbal communication. An interpersonal between the CICU nurse and Isaac the to the occur within an environment where clinicians are to of patients without As a their ability to be and is there is a lack of trust, transparent communication, and collaboration, nurses may to feel and become to speak up and for their patient’s as they being or as the nurse becomes with the work environment, and moral suffering as the between values and become more The stress, and moral to and and in health care workers have and a by Health found that plan to their by This of is to relational integrity in an health care circumstances can be as of commitments and values by health care organizations or who have to the necessary to one’s a broader and organizational Isaac his shift by into an practice he is to care for and monitor 15 patients by It is an that is the for many nurses in the than of nurses that their are of that patient are by a review that more nurses the risk of and is a that needs to be at the and institutional levels of care. can often be from the of but or it for them to hospital is a breech in relational integrity that from and organizational and practices that the ability of nurses and other health care workers to practice in with their personal and professional When these of relational integrity are fractured, it initiates a of degraded relational integrity among leaders, other health care workers, and the people to be served. It a of than into shared purpose and in the of increased to patient care, historical patterns that nursing to a than a health care to continue to balance the by nursing This of could be without but it would a integrity is fractured when there is a in values between clinicians and staff and their health care When clinicians do not have the time, resources, or support to enact their professional personal and relational integrity is The of organizational is with moral among nurses the patterns shape the context of care in our within the broader relational integrity is by an hierarchical of practice. There are 2 when to hierarchical norms to a in communication that Anthony at The is when Chris, the ECG technician, delays Dr Fay to Anthony’s ECG an important toward and on the patient’s The second is when Isaac steps from his section to remind Dr Fay to order the respiratory In these Isaac and are that the doctor would be a of disrespect to the hierarchical of the Throughout the scenario, Dr Fay demonstrates a pattern of dismissive responses to the suggestions of other team members and engages in gossip and degrading verbal and nonverbal communication. Relational integrity is when of the team engages in behaviors or communication that interpersonal or interpersonal violence, or can trust and the integrity of the moral patterns are likely when and become the than the ability to and to achieve mutual the of quality health care, a hierarchical that places on and their and can quality health care. can lead to communication as those as from up when to or In one of the health care team from This can have for patient When members of the clinical team do not it can to errors, delays in decisions or and patient and relational can the of them in conflict with their professional to speak up on of patient care and thereby the relational integrity of such as those in the case to navigate the that such hierarchical place on interprofessional communication by the messaging system within the EMR. messaging for a of patient which can in and and over the plan of patient care. the of communication between health care professional to a in their Despite the for communication, communication can the collective for an effective, relational communication to be and of the context that is needed for the the which can the alignment of the and plan of care among team members who may have diverse and When conflict among the team is not or and responses to that team and relational integrity when we each other as human than by our or time among the clinical team the necessary for establishing trust and between includes building in and teamwork is when we who we can when our are and and when we speak with purpose and that physician to messaging is influenced by the of trust between themselves and the building of trust, including time and prior building relationships among clinicians takes time, and time is interactions will be on trust or patterns of interpersonal has the pandemic, nurses experienced by health care they by their leaders, and by people outside of health The time to nurture interprofessional trust, is by the high rate often on by burnout. In a of nurses, and practice were considering with of these as the there is from and to of interprofessional relationships among clinicians will continue to suffer from high of relational integrity involving the health care organizations, and team have a impact on the patients nurses are to Anthony and the other patients Isaac’s care likely experienced of with not being to or as a person by the people for Despite Issacs’s to with Anthony within the complexity of the it is likely that parties experienced a relational When nurses the care they they are capable of and are to, it to their as nurses, which creates stress, distress, and moral time, these of accumulate and impact nurses’ personal, professional, and relational integrity and their and to their and the the scenario to the challenges to relational integrity, it also a for relational integrity would the of Anthony’s care. with the integrity health care an would that no would walk into a scenario where they are to an of patients. such as have been as an to achieve this that are to in care, and of will ultimately achieve the to be of the to the nurses be and to decisions on patient needs and nursing including on or As the American of Nurses has health care system that is by the needs of patients and where acute and critical care nurses their become a this will a shift that with organizational values with the professional values of those care. of shared and and for and will be the hierarchical of health care, necessary to in of a or has its but it can also communication, as medical may be to their without of Relational integrity depends upon an environment of and to to the attention of those and responsible for them without or hierarchical and power in health care teams for communication among team members and can relational integrity. Nurses may find it to their to to of or When there is an environment where nurses’ or or is or a key of relational integrity is between nurses and can this An hierarchical can of or by those with more and lead to dismissive behaviors toward the of nurses in clinical practice. This may result in patient care, as for important that nurses to their attention and patient This was in Anthony’s case when to the of all the team members were limited or the of and of interpersonal the communication between health care team the case may have out Chris, the ECG technician, would have more a patient to hand the ECG report to Dr Fay, who would in have attention to an urgent of to that ultimately patient Dr Fay and Isaac have to the on the of the respiratory swab as a necessary for Anthony to a of care. Isaac would not have in up and would not have had to from his section to find the We can these hierarchical can patient care when nurses up or when they a with the of relational integrity, teams, organizations, and the broader have a shared to to a of relational integrity integrity is the foundation of trust and collaboration among health care that to increased and patient It effective communication, shared mutual respect, and a supportive work environment, creating a positive and team Intact relational integrity in health care settings is critical to promoting and maintaining a and supportive environment that patients and health care such as human and resources, nurses to of shared and and for and can shift organizational values to with professional values and a of and safety, ultimately the quality of care the contributions of our nursing colleagues in our of this We honor the contributions of all nurses in all and who are many people in need of their

Advanced practice registered nurses and physician assistants, collectively termed advanced practice providers (APPs), have been part of telehealth for many years. During the COVID-19 pandemic, APPs experienced the growth in roles, responsibilities, and tools used for telehealth care delivery. This article uses examples from 3 health systems to highlight the ways in which telehealth use was expanded due to the pandemic, how APP roles were altered across the United States during and after the pandemic, and implications for future practice.