“You can't give what you don't have.” The implications of such a simple statement from Dr. Maureen Bisognano, keynote speaker at the 2016 Gothenburg International Forum on Quality and Safety in Healthcare, are far reaching given that burnout, emotional exhaustion, mental depletion, and disengagement are associated with the current state of our global nursing community. Studies report global rates of disengagement at 40% and nurse burnout in the US at 34%.1,2 These factors, and their relationship with poor well-being, ultimately have an adverse impact on nurses' overall health and ability to provide quality patient care. In light of the Institute for Healthcare Improvement's (IHI) Triple Aim of improving the patient experience of care, improving the health of populations, and reducing the per capita cost of healthcare, the growing problem with clinician burnout prompted healthcare leaders to focus on workforce well-being. The result was the introduction of the Quadruple Aim. This fourth aim recognizes that the success of the triple aim is greatly impacted by healthcare providers' well-being.
Factors contributing to a positive state of well-being include altruism, meaningful recognition, and self-care.3,4 Initiatives such as the IHI's Joy in Work and the American Nurses Association's (ANA) Healthy Nurse, Healthy Nation have embraced these characteristics and invoked a call to action within the healthcare community to create a culture that prioritizes staff well-being as a strategic initiative.5,6 Creating such a culture requires leadership commitment and a framework on which to build. Many nursing leaders have turned to the Pathway to Excellence® framework, which has a dedicated well-being standard.
This article describes how organizations use the Pathway framework to implement successful strategies to support their nurses' well-being.*
Impact of well-being on patient care
Well-being critically impacts overall health. A healthy nurse is defined as “actively focus[ing] on creating and maintaining a balance and synergy of physical, intellectual, emotional, social, spiritual, personal, and professional well-being.”7 When balance and synergy are challenged by high levels of work stress, the result can be depression; lower resilience; job dissatisfaction; and a propensity toward unhealthy lifestyle coping mechanisms, such as overeating, alcohol abuse, smoking, and reduced activity. Such behaviors may then lead to chronic health problems that negatively impact work effectiveness.8
A recent study surveyed 1,790 nurses across the US to determine the relationship between nurses' health and medical errors. Nurses reporting worse health were associated with a 26% to 71% higher likelihood of having medical errors.9 Additionally, an extensive review of the literature found that poor well-being (as defined by depression, anxiety, job stress, mental health, and distress) is correlated with poorer patient safety.10
Given the impact that poor well-being, and subsequently poor health, has on both healthcare providers and patient safety, investing in strategies to optimize the well-being of nurses should be a priority among healthcare leaders.
Framework for well-being
As the research builds on the correlation between well-being and patient safety, many organizations have made innovative strides in focusing on the nurse as a person. Along with national initiatives such as ANA's Healthy Nurse, Healthy Nation, terms such as chief wellness officer, resiliency centers, and mindfulness-based stress reduction programs are surfacing in the literature in association with some promising results.11,12 Traditional employee wellness programs continue as the mainstay for addressing staff well-being; however, a lack of framework results in poor participation.13 With hospital employee participation rates ranging from 30% to 42% and inconsistent engagement by those who do participate, a disconnect exists between interventions and outcomes.9
Such inconsistency should motivate healthcare organizations to improve the foundation of their employee wellness programs to increase participation and sustain engagement.9 Successful engagement relies on staff members owning their own well-being journey.14 Leaders at the organizational level and managers at the unit level who encourage nurses to be active participants in the design of an organization's wellness program are taking a critical step in developing a successful program.
A framework that requires a collaborative effort between management and staff to meet the needs of nurses and the community they serve is an underlying tenet of the Pathway to Excellence well-being standard. Its theme is that nurses must be active participants when organizations are designing well-being initiatives. This entails nurses having a voice on what well-being initiatives are important to them during and outside work hours, and expectations for the organization to assess the overall wellness of its nurses and act on that assessment. The well-being standard also incorporates additional themes consistent with well-being, such as meaningful recognition and altruism.
Nurse input is critical
Although not required, management is encouraged to have multiple avenues for nurses to voice their ideas regarding their well-being needs. Given the wide variety of nurse settings and roles in healthcare, this broad scope allows organizations to implement initiatives that have an impact at both an organizational level and at more specific unit or role levels. For example, a fitness program may suit staff needs at a system level, whereas music therapy—an emerging well-being intervention—may be useful to staff needs at the unit level.15 Since well-being initiatives are driven by the unique needs of each organization, examples submitted by healthcare organizations to the Pathway to Excellence Program office run the gamut.
Monroe Clinic, a Pathway-designated organization since 2014, utilized a multifaceted approach when developing its well-being initiatives. Input into the development and evaluation of nurse wellness initiatives at the organizational level are managed through the wellness committee. However, other avenues for input allow nurses to implement initiatives specific to their area of practice.
One such initiative aimed at promoting well-being during work hours was driven by the preceptor steering team, a subteam of the professional development program. Nurses on the team presented an idea to have an annual self-care education session specifically for nurse preceptors. The 2-hour event was offered to all primary preceptors. Activities included progressive muscle relaxation exercises, development of a self-care plan, paraffin wax for the hands, and a professional shoulder massage.
Evaluation data reflected high marks, with recommendations to continue with a reevaluation annually. The following year's session focused on networking, exercise, healthy eating, and hand massages. By having routine conversations with staff around well-being, management can assist in implementing smaller-scale initiatives, such as the self-care education session, that meet the needs of specific staff.
An obligation to assess well-being
Within the Pathway standards, having nurses drive well-being initiatives is balanced with having organizational leaders use tools to assess overall staff wellness and act on areas identified as a concern. Because the Pathway standards are typically nonprescriptive, organizations may choose readily available health risk assessments or create their own.
For example, Pathway-designated Broward Health Imperial Point (BHIP) combined both a standardized and individualized approach to assessing employee wellness. The organization surveyed staff using the Press Ganey partnership survey and drilled deeper by asking staff to evaluate the statement: “This organization supports the balance of work and personal responsibility.” In addition, BHIP incorporated less structured assessments identified by their shared governance councils. Through these various assessment tools, stress was identified as a pervasive health concern among staff.
The work derived out of BHIP's shared governance councils combined holistic care with Institutional Review Board-approved research to explore the question: “Does a brief meditation impact the caregiver's perception of the day?” The study measured the use of meditation to self-manage stress. Using a free smartphone app throughout the day, volunteers were asked to evaluate three statements both pre- and postmeditation: My thoughts are clear and organized, I have energy to care for my patients, and I'm feeling positive about my day. The volunteers then assessed the usefulness of the meditation exercises before and after using the app for 10 working shifts.
Results showed a statistically significant difference postmeditation regarding energy level, positive approach to the day, and clarity of thought. Based on these findings, meditation was introduced to support employee wellness. An even greater benefit noted by the organization was the systemic implications for educators and nurse administrators to promote organizational environments fostering a holistic approach to health and stress management with therapeutic techniques that can be practiced by all healthcare team members.
Working together for wellness
Well-being covers a wide range of complex states that can manifest in feelings of joy at one end of the spectrum to feelings of despair at the other end. In her keynote address, Dr. Bisognano challenged healthcare providers to change their approach from asking patients, “What's the matter?” to asking instead, “What matters to you?” This challenge can also be extended to healthcare leaders considering how to support staff well-being. For staff members to have what they need to give patients what matters to them, management and staff must work together to identify well-being initiatives best suited to the organization. The Pathway to Excellence well-being standard can assist leaders in facilitating that collaborative endeavor.
2. Aiken LH, Sermeus W, Van den Heede K, et al Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ
3. Sanders CL, Krugman M, Schloffman DH. Leading change to create a healthy and satisfying work environment. Nurs Adm Q
4. Trossman S. Advantages of altruism: volunteering has positive impact on nurses' well-being. Am Nurse Today
5. Perlo J, Balik B, Swensen S, Kabcenell A, Landsman J, Feeley D. IHI Framework for Improving Joy in Work
. Cambridge, MA: Institute for Healthcare Improvement; 2017.
6. Carpenter H. The healthy nurse: holistic nurses leading the way to wellness. Beginnings
8. Kurnat-Thoma E, El-Banna M, Oakcrum M, Tyroler J. Nurses' health promoting lifestyle behaviors in a community hospital. Appl Nurs Res
9. Melnyk BM, Orsolini L, Tan A, et al A national study links nurses' physical and mental health to medical errors and perceived worksite wellness. J Occup Environ Med
10. Hall LH, Johnson J, Watt I, Tsipa A, O'Connor DB. “Healthcare staff wellbeing, burnout, and patient safety: a systematic review. PLoS One
11. Cunningham T, Bartels J, Grant C, Ralph M. Mindfulness and medical review: a grassroots approach to improving work/life balance and nursing retention in a level I trauma center emergency department. J Emerg Nurs
12. Morrow E, Call M, Marcus R, Locke A. Focus on the quadruple aim: development of a resiliency center to promote faculty and staff wellness initiatives. Jt Comm J Qual Patient Saf
13. Goetzel RZ, Ozminkowski RJ. The health and cost benefits of work site health-promotion programs. Annu Rev Public Health
14. Jacobs B, McGovern J, Heinmiller J, Drenkard K. Engaging employees in well-being: moving from the triple aim to the quadruple aim. Nurs Adm Q
15. Ploukou S, Panagopoulou E. Playing music improves well-being of oncology nurses. Appl Nurs Res
* The examples provided in this article were granted permission for use.