In Brief In this project, a survey was used to measure certain life and work factors related to nurse well-being, and evidence-based interventions were implemented to address areas of concern. All categories improved except work-related stress, anxiety, and sleep.

In Brief In this study, lower perceived authentic nurse leadership (ANL) was associated with higher moral injury. Nurse leaders who possess ANL attributes may decrease moral injury among novice nurses and enhance their well-being.

In Brief This study assessed the Raedwoon program, a 25-day nursing leadership course, using a quasi-experimental design. It found overall improvements in leadership and nursing competencies, except in the “Inspire a Shared Vision” practice and documentation skills.

In Brief A large healthcare system examined its catheter-related practices following a system-wide increase in catheter-associated urinary tract infection (CAUTI) rates. A process improvement project resulted in a significant decline in CAUTIs and catheter utilization.

In Brief This study provides a detailed understanding of the nurse manager's contribution to implementing enhanced recovery after surgery and identifies the factors that influence this role. Ongoing training can better prepare future managers for this process.

FigureAs we seek to reframe our professional lives in the wake of the COVID-19 public health emergency, concern about healthcare work environments has escalated. The National Academy of Medicine, for instance, prioritized actions that address the work environment in their National Plan for Health Workforce Well-being, and the National Institute for Occupational Safety and Health (NIOSH) recently launched the Impact Wellbeing campaign with a primary goal of influencing system level change.1,2 The American Association of Critical-Care Nurses (AACN) similarly recognizes the importance of the healthcare work environment in their Standards for Establishing and Sustaining Healthy Work Environments.3 This column is the first in a series that will focus on creating positive changes in the context in which healthcare is delivered, so that our workforce can thrive and optimize patients' experiences. Background First published in 2005 and updated in 2016, AACN's Standards for Establishing and Sustaining Healthy Work Environments offer a framework for considering the relational and contextual elements that influence job satisfaction and care delivery (see Table 1). In fact, AACN's central advocacy priority is to improve the health of nurses' work environments. Resources to realize this goal include offering an open access, validated work environment assessment tool; conducting a series of national surveys to assess the state of acute and critical care work environments; and co-leading a partnership to address nurse staffing, consistently the lowest rated of the six standards. Table 1: - AACN's Standards for Establishing and Sustaining Healthy Work Environments Standard Definition Example Skilled Communication Be as proficient in communication skills as you are in clinical skills. A nurse is angry after a comment by another nurse and, rather than reacting, responds by asking for more information about the comment's meaning. True Collaboration Be relentless in pursuing and fostering true collaboration. When a nurse and another team member don't agree about the plan of care, they each take time to hear the other person's perspective. Effective Decision-Making Be committed partners in making policy, directing and evaluating clinical care, and leading organizational operations. Nurses serve on a hospital-wide committee with other members of the healthcare team to develop a plan to reduce the rate of hospital-associated infections. Appropriate Staffing Staffing must ensure the effective match between patient needs and nurse competencies. Patient assignments are adjusted to address a change in patient condition. Meaningful Recognition Be recognized and recognize others for the value each brings to the work of the organization. Nurses receive paid time to engage in professional development activities such as conference attendance. Authentic Leadership Fully embrace the imperative of a healthy work environment, authentically live it, and engage others in its achievement. Leaders routinely reach out to newly oriented nurses to hear their concerns and offer support. Source: American Association of Critical-Care Nurses. Standards for establishing and sustaining healthy work environments. 2016. www.aacn.org/nursing-excellence/standards/aacn-standards-for-establishing-and-sustaining-healthy-work-environments. Analysis of AACN's national survey data demonstrates an implementation gap. Nurses who report working in units that are actively engaged in implementing AACN's standards are less likely to report moral distress and intent to leave and are more likely to report a higher percentage of shifts with appropriate staffing.4 In the most recent study, conducted in 2021, nurses reported significantly lower ratings on all six standards than in the 2018 study.4 These findings support AACN's new approach, which is to connect with health systems, hospitals, and individual units to support implementation of these standards. Future Healthy Work Environments columns will describe the resulting projects and their outcomes. Why are our work environments unhealthy? The mission of healthcare prioritizes human connection and carefully considered interventions. This mission coexists with the business of healthcare, which prioritizes efficiency and productivity. These priorities aren't mutually exclusive, but the effort to align them magnifies the collective emotional stress in the work environment. Other sources of distress include: Increases in workplace violence. Many patients who seek healthcare do so not because they trust the healthcare system but rather because they have no other recourse. That desperation contributes to discordant communication, verbal abuse, and physical violence. Global increases in the incidence of healthcare workplace violence are both an outcome and a symptom of unhealthy work environments.5 Unclear goals of care. Patients who present with life-limiting illness face prognostic uncertainty and decisions that are ethically fraught. In a fast-paced environment, there's seldom time to sort through the ethical elements of care delivery, resulting in moral uncertainty and moral distress. Division among the team. Hospitals merging with larger systems creates efficiency through centralized resources but also less opportunity for those who make decisions to connect with the workforce affected by those decisions. In addition, AACN surveys show significant differences in the way managers and direct care nurses rate their work environments.4 These differing perceptions demonstrate a divide between leaders and staff. Because healthcare delivery is inherently a complex endeavor, environments that lack time and space for connection among team members feel hostile. It's frightening that nearly a quarter of nurses plan to leave the profession.6 At the same time, it's not surprising when considering that contextual barriers to care delivery compound the emotional toll of being with patients and witnessing their suffering. How can we move forward? The first step is conceptualizing the work environment as a changeable feature of our lives. The word "environment" sounds like a fixed entity, as stable and permanent as the physical structure of a healthcare facility. That perception casts changes in the work environment as unattainable. An alternative perspective is to apply the paradigm of risk factors for health problems, which are modifiable (such as tobacco use and dietary choices) and nonmodifiable (such as genetics and other preexisting conditions). For example, discordant views on appropriate goals of care for a critically ill patient may be unavoidable. What is modifiable, however, is the way we frame those differences and the responses we provide. If much of the work environment is composed of its occupants' behaviors, attitudes, and relationships, then each member has some power to contribute to its improvement. The illnesses and injuries we see in our patients are a constant reminder that profound and life-changing events aren't always in our control. Our day-to-day interactions, which may seem mundane by comparison, have an immense impact on the environment in which we work, and in that space, we have the opportunity for influence. What should be easy is terribly hard Another key step is recognizing that change is hard. AACN's six standards may seem straightforward but implementing them requires deliberate effort. They're not discrete but interrelated, and all are evidence-based. In addition to survey data demonstrating the implementation gap, seminal work shows that the impact of higher staffing levels on patient outcomes varies based on the health of the work environment. In settings with unhealthy work environments, higher staffing levels weren't associated with a decrease in 30-day patient mortality but in settings with higher staffing and a healthy work environment, mortality was significantly lower.7 Because implementing all six standards in an environment that's currently unhealthy is both unrealistic and overwhelming, nurses who seek to implement the standards can use the free Healthy Work Environment Assessment Tool and then select one standard, perhaps one with a lower score, and work only on that standard. Often, addressing one standard leads to improvements in the others. For instance, creating a program that demonstrates meaningful recognition means understanding what's meaningful to your colleagues. To determine that, teams use skilled communication and then, to develop an intervention, they rely on effective decision-making. The implementation of the process or program they develop will require authentic leadership and true collaboration. Recognizing how these actions and conversations connect to specific Healthy Work Environment standards reinforces each participant's contribution and begins the journey toward a healthier work environment. Creating change The care of acute and critically ill patients is emotionally fraught, and unhealthy work environments are a modifiable source of stress for our healthcare workforce. The AACN Healthy Work Environment standards provide a framework for creating change in the relationships we make and the context we experience in our professional lives. In later columns, we'll dive deeper into the evidence base for the Healthy Work Environment standards and share strategies that units and organizations have used to implement them.

In Brief Researchers evaluated if participation in a Narrative Nursing Leadership workshop minimized feelings of burnout among a focus group of nurse leaders. Stories were analyzed to identify constructs and key features of authentic nursing leadership theory.

Q I hear the term “new age leadership” a lot these days. How is this “new” leadership different from “old” leadership? Most theoretical foundations for leadership models and processes we follow these days are based on thinking from the middle and late Industrial Age of the 20th century. These theories reflect studies conducted in industrial, manufacturing, and corporate environments that were the predominant workplaces of the time. Even later 20th century leadership studies were conducted in business enterprises. Although many determinants of effective leader behaviors accurately depicted successful leader performance in the workplace, they predominantly focused on the leader's role and personal characteristics that supported leadership expression. In the context of the 21st century, an innovative and more contemporary understanding of complexity in human dynamics has developed that mirrors the complexity impact in other arenas. Newer notions have emerged of how humans act, interact, relate, and behave when alone, with others, and in complex social and work circumstances. This growing understanding of how complexity operates in our lives, how complex adaptive systems behave, and the emerging evidence suggests a different set of variables are at work.1 Past leadership practices have been challenged and newer applications of the leader role have materialized. None of this suggests that the leader behaviors we idealized in the past aren't useful or relevant going forward, but they must now be viewed within a larger context and a different frame of reference that includes this new learning about leadership in a complexity frame. In complex work environments, myriad forces influence the viability of certain behaviors and responses to the demands they create, which influence appropriate action(s). A confluence of forces constantly interacting and acting on each other demand particular responses that can generate a useful outcome. The leader must quickly adjust behaviors and practices in a way that tightly reflects the demands and needs that emerge from this conjunction of interacting forces. These forces are always in motion and acting on the choices and actions that, if positively managed, will increase the potential for positive outcomes. In this scenario, the leader is more conductor than director, more facilitator than controller, more agent than owner, and more coordinator than driver.2 Historical unilateral notions rooted in vertical structure and control unbundle in this environment. These singular and linear notions of work structures and relations now evolve toward a more robust response deeply embedded inside the multilateral, interacting, changing, constant maelstrom of dynamics that informs and reveals a trajectory of possibilities that leads to a preferred outcome. The leader is the agent managing these forces, acting within them and on them in ways that positively influence their applications and outcomes. These realities completely redefine the role characteristics of leadership in our time. These forces of change call for a deeper and broader understanding of the multifocal interface between systems and people and the proper application of leadership to positively address them.3 Every leader, whether new or seasoned, is now called to both learn and engage these emerging complex and “quantum” realties informing leadership capacity and expression.4 This call reflects the need for constant and lifelong leadership learning to ensure the continuing effectiveness of the role. The contemporary leader should now use available technology and media to add insight to skill development and preferences that support effective leadership that best addresses the increasing complexity in the system and in the effective leader's role. It's a new world, and it requires “new” leadership!

In Brief This study evaluated a pilot project designed to mentor clinical nurses using a formal program and ongoing support.

FigureAs a curious child, my mom frequently admonished me that “Curiosity killed the cat.” I thought this meant it would get me in trouble, and, yes, sometimes it did. Recently, I found myself saying the phrase to her, and she retorted, “But satisfaction brought it back!” What? How did I not know that the full quote mitigated the potential trouble and encouraged it after all? This has led me down a path with clear connections to nursing leadership in support of a culture of inquiry (COI). Don't get anxious about your role in encouraging inquiry in practice or even in the academic environment. I'm not talking about sophisticated research questions or disruptive innovation, although they can be part of a COI. My point is that the workplace “culture” should allow inquisitiveness. In our postpandemic world, leaving well enough alone won't work for us, nursing, or healthcare. Allowing curiosity to explore change and ideas at every single level is needed. We're not all creative by nature, so we must allow those who are to be free to question and create solutions. It's imperative that we emphasize the latter half of the idiom about satisfaction to bring hope, success, and progress. There are boundaries, don't get me wrong. Harvard Business Review recently published a paper and summarized it in a “Tip of the Day” on, yes, curiosity. The reality is, asking curious questions that aren't framed in a politically smart and constructive way can be viewed as negative, or even insubordinate. We know as leaders that political acumen is a requisite in our interactions and work, so it's not surprising that it's true for curiosity as well. Asking the “wrong” question can be a CLG (career-limiting gesture). “Productive curiosity” is intentional. If you ask questions directed toward finding solutions, you'll get productive answers that lead to real problem-solving. Figuring out the “right” questions is a leadership skill, sometimes learned by making mistakes. In a psychologically safe environment, that learning curve should be allowed. You also need structure and process to get there (hello Donabedian fans). Typical structures for a COI include educational programs on evidence-based practice, a budgeted position(s) either alone or in combination with another role, library access, protected time, unit- and campus-based forums and governance councils, academic-practice partnerships, fellowships, grants, and capitalizing on MSN/DNP projects. Some of these strategies have associated expenses, but most do not. Nurturing inquisitiveness and innovation is often considered in the context of our clinical staff; however, your curiosity matters as well, not only for exploring ideas. Building connections, an element of the American Organization for Nursing Leadership COI model, requires team building and interprofessional relationships; both do better when the leader is open to a deeper understanding of colleagues and team members and that involves curiosity.1 At this point, I'd be remiss not to mention relational leadership—you can't build connections without it. Challenging the status quo requires curiosity. Without it, we languish and lack forward momentum, staff engagement, agility, or even basic problem-solving. Don't kill the cat: let satisfaction be the reward for nurturing a COI. And listen to your mom; she's usually right.Figure[email protected]