A framework for achieving the National Plan for Health Workforce Well-Being recommendations : Nursing Management

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Department: Pathway to Excellence®

A framework for achieving the National Plan for Health Workforce Well-Being recommendations

Grant, Ernest J. PhD, RN, FAAN; Pabico, Christine PhD, RN, NE-BC, FAAN

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Nursing Management (Springhouse): October 2022 - Volume 53 - Issue 10 - p 9-15
doi: 10.1097/01.NUMA.0000874432.64403.fb
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Before the SARS-CoV-2 virus hit the shores of the US in February 2020, there were already deep concerns regarding the overwhelming demands placed on healthcare workers. No one could have anticipated the additional challenging impact COVID-19 would have on healthcare workers and the healthcare system. As organizations such as the American Nurses Association and the National Academy of Medicine (NAM) continued to monitor the rapid changes associated with the spread of the virus, it became evident that its toll greatly affected members of the healthcare team. Multiple surveys and self-reports from healthcare workers at all levels reflected feelings of overwhelming stress, anxiety, burnout, and mental anguish.1 The existing workforce shortage was exacerbated with many older workers choosing early retirement due to the higher risk of contracting the virus. Many workers who felt they were unappreciated and forced to work in an unsafe environment decided to leave their current place of employment for a new position or opportunity.

Early in the pandemic, surveys conducted by the American Nurses Foundation revealed nurses who were suffering from extreme financial strain, as well as extreme mental and physical fatigue.1 This phenomenon was also reported by other healthcare workers and grew as the pandemic lingered, contributing to worker shortage, burnout, and feelings of being unvalued.2 Organizations such as NAM recognized that, for healthcare workers to feel fulfilled in their jobs and personal lives, a prescriptive plan was needed to promote worker resilience, joy, and meaning. Thus, the National Plan for Health Workforce Well-Being was launched. The alignment of existing positive practice frameworks (see Figure 1) that provide structure in applying the National Plan for Health Workforce Well-Being's seven priorities further strengthens its potential to positively impact the well-being of the healthcare workforce.

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Figure 1::
ANCC Pathway to Excellence® Framework for Positive Practice Environments.

The National Plan

The National Plan for Health Workforce Well-Being prepared by NAM's Action Collaborative on Well-Being and Resilience—a network formed in 2017 consisting of more than 200 organizations committed to strengthening the health workforce and reversing burnout—had the intent of promoting clinician's well-being through prescriptive measures that would ensure a safe work environment and maintenance of a work-life balance.3 Additionally, the plan addresses the actions needed to improve healthcare and health systems at the organizational levels so that health and care are delivered in an equitable and trusted manner. As stated by the plan, its vision is that “patients are cared for by a health workforce that is thriving in an environment that fosters their well-being as they improve population health, enhance the care experience, reduce cost, and advance health equity, therefore achieving the “quadruple aim.”3

There are seven priority areas that identify immediate and long-term needs of the healthcare workforce that would promote a sustained state of well-being:

Priority Area #1: Create and sustain positive work and learning environments and culture. Transform health systems, and health education and training, by prioritizing and investing in efforts to optimize environments that prevent and reduce burnout, foster professional well-being, and support quality care.

Priority Area #2: Invest in measurement, assessment, strategies, and research. Expand the uptake of existing tools at the health system level and advance national research on decreasing health worker burnout and improving well-being.

Priority Area #3: Support mental health and reduce stigma. Provide support to health workers by eliminating barriers and reducing stigma associated with seeking services needed to address mental health challenges.

Priority Area #4: Address compliance, regulatory, and policy barriers for daily work. Prevent and reduce the unnecessary burdens that stem from laws, regulations, policies, and standards placed on health workers.

Priority Area #5: Engage effective technology tools. Optimize and expand the use of health information technologies that support health workers in providing high-quality patient care and serving population health, and minimize technologies that inhibit clinical decision-making or add to administrative burden.

Priority Area #6: Institutionalize well-being as a long-term value. Ensure COVID-19 recovery efforts address the toll on health worker well-being and bolster the public health and healthcare systems for future emergencies.

Priority Area #7: Recruit and retain a diverse and inclusive health workforce. Promote careers in the health professions and increase pathways and systems for a diverse, inclusive, and thriving workforce.

ANCC Pathway to Excellence

The American Nurses Credentialing Center (ANCC) Pathway to Excellence Program® (Pathway) has been leading the transformation of workplace culture and influencing healthcare systems and national policies since 2007. Pathway's mission is driven by the program's belief that every nurse deserves to work in an environment that supports their needs and safeguards their well-being.

Pathway is the premier designation for positive practice environments, recognizing organizations that substantiate the presence of Shared Decision-Making, Leadership, Safety, Quality, Well-being, and Professional Development. More important, the Pathway Framework for Positive Practice Environments (see Figure 1) provides an evidence-based blueprint for any organization wanting to create and sustain positive work environments regardless of their interest in the recognition.

The Well-being Standard added in the 2016 Pathway Application Manual requires organizations to assess their clinicians' well-being proactively and continuously, a requirement that makes it unique compared with other work environment models.4 Staff well-being and resilience must be included in the strategic planning efforts of Pathway to Excellence organizations.5 To achieve the recognition, organizations must implement support processes to foster staff resilience following adverse events but also must preemptively reduce clinician burnout and promote overall workforce well-being. Pathway also advocates for interprofessional collaboration, inclusivity, and respect, and a culture free of incivility, bullying, and violence.

Pathway organizations periodically assess their employees' health and implement appropriate health initiatives based on the results of those assessments. Most important to this process is having nurses at all levels be active participants in the selection, planning, and evaluation of the well-being initiatives selected. Furthermore, the framework hardwires recognition. Nurse leaders foster a culture of day-to-day recognition, and nurses are acknowledged for community volunteer activities. Finally, the Pathway framework underscores the importance of meaningful work and joy in the workplace.

Although safeguarding nurses' well-being has been a longstanding goal of Pathway, the relevance of its framework was amplified during the COVID-19 pandemic. The world recognized how nurses stood on the front lines of healthcare, dedicating their lives to protect the community. They also recognized the deleterious effects of the prolonged pandemic on nurses. As organizations committed to support nurses and other health caregivers, they sought proven evidence-based frameworks, and many have turned to Pathway.

A framework for achieving the National Plan's recommendations (crosswalk)

The National Plan for Health Workforce Well-Being also advocates for organization to have a structured approach as they try to strengthen their health workforce and reverse burnout. The Pathway Framework for Positive Practice Environments is strongly aligned with the recommendations, especially Priority Area #1; thus, it can be used by organizations as their blueprint to transform their culture and create positive work and learning environments.

The Pathway Program office developed a crosswalk (see Table 1) to compare alignment between the National Plan for Health Workforce Well-Being's recommendations and Pathway requirements (known as Elements of Performance or EOP) and these were the findings:

  • Of the 28 recommendations for Priority Area #1, 26 are applicable to healthcare settings. Out of the 26, 24 are requirements in the existing 2020 Pathway Application Manual (see Table 1).
  • There's also strong alignment seen in Priority Area #6 (reduce effects of COVID-19 on the health workforce) and Priority Area #7 (retain and recruit the next generation). Other priority areas are addressed as well throughout the six Pathway Standards.
  • Pathway requirements are revised every 4 years. Some recommendations that aren't addressed yet in the 2020 manual are being considered for addition by the Commission on Pathway to Excellence for the 2024 manual.
  • It's important to note that, in addition to the recommendations included in the National Plan for Health Workforce Well-Being, there are several other EOPs included in the 2020 Pathway requirements that safeguard the well-being of the healthcare workforce.
Table 1: - Crosswalk of the National Academy of Medicine's National Plan for Health Workforce Well-Being and Pathway to Excellence requirements
  1. The following crosswalk compares the National Plan for Health Workforce Well-Being's recommendations and Pathway to Excellence (PTE) requirements for alignment. The National Plan's recommendations for priority area #1 (create positive work and learning environments and culture) are mostly addressed in the existing PTE requirements (2020 Application Manual). There's also alignment in priority areas #6 (reduce effects of COVID-19 on the health workforce) and #7 (retain and recruit the next generation). Recommendations that were missing in the 2020 manual are being considered for the 2024 manual.

  2. Pathway Standards∗

  3. PS1 = Shared Decision-Making; PS2 = Leadership; PS3 = Safety; PS4 = Quality; PS5 = Well-being; PS6 = Professional Development

  4. Priority Area #1: Create and sustain positive work and learning environments and culture.

National Plan for Health Workforce Well-Being 2020 Pathway Standard∗ Element of Performance (EOP); Organizations are asked to demonstrate the following:
1A. Instill approaches to decrease workplace stress and burnout and improve health worker and learner well-being in strategic plans, organizational values, and human resources policies and procedures.
  1. EOP 5.2

  2. Senior leadership integrates employee well-being and resilience into strategic planning.

1B. Implement well-being onboarding programs for students as they enter health professions schools to build coping and resiliency skills.
  1. n/a. However, Pathway organizations ensure a supportive environment for newly graduated nurses as they transition to the practice setting.

  2. EOP 6.1

  3. Orienting nurses identifies their own orientation need(s) and resulting individualized orientation.

  4. EOP 6.2

  5. Strategies in place for newly graduated nurses to effectively transition to practice and a narrative written by a newly graduated nurse sharing the impact.

1C. Provide training opportunities for faculty to help integrate well-being into programming. n/a
1D. Set reasonable productivity expectations and provide adequate resources to support expectations.
2A. Examine institutional policies and organizational goals and objectives with an equity lens. Strategies to optimize nursing workforce diversity, equity, and inclusion (DEI) and training provided by the organization for employees around DEI.
2B. Revise clinical algorithms that erroneously rely on race.
2C. Establish policies and processes to support the timely reporting of and response to discriminatory behaviors. This includes a clear reporting process, support for reporters, and outcomes commensurate with the demonstrated behavior and situation.
2D. Establish mentorship programs to help all health workers thrive in educational, training, and practice environments.
  1. EOP 6.7

  2. Direct care nurse's description and impact of mentorship within the organization.

  3. EOP 6.8

  4. Organization fosters the growth of emerging nurse leaders.

  5. EOP 6.9

  6. Succession planning to develop nurses for a nursing leadership role and a narrative sharing that experience.

2E. Review leadership opportunities and pathways to ensure they're diverse-accessible, equitable, and inclusive, and are available at multiple levels of a health system and training program. Strategies to optimize nursing workforce DEI and training provided by the organization for employees around DEI.
2F. Provide appropriate education and trainings for workers, staff, and leaders to address issues (e.g., discrimination, lateral violence, bullying, harassment) and progress toward cultural humility.
3A. Provide mechanisms and systems to allow health workers to operate as teams.
  1. EOP 1.1

  2. Promotion of interprofessional decision-making with an example from a direct care nurse.

  3. EOP 1.5

  4. Interprofessional process that addresses how ethical concerns are managed within the organization with a narrative from a nurse.

  5. EOP 3.7

  6. Interprofessional decision-making process to transition patients from one level of care to another.

  7. EOP 4.6

  8. Interprofessional collaboration to meet quality initiatives with narratives from a nurse and a non-nurse.

3B. Invest in appropriate and flexible staffing plans that allow for safe patient care, including needed backup.
  1. EOP 3.5

  2. Direct care nurses communicate concern(s) about the long-term nurse staffing plan and an example from a nurse.

  3. EOP 3.6

  4. Direct care nurses have input on daily staffing decisions related to fluctuations in patient conditions, volume, or availability of qualified staff.

  5. EOP 5.5

  6. Opportunity provided to nurses to create work schedules that support nurse well-being.

  7. EOP 6.3

  8. Nurse competency is ensured when assigned to an area other than their primary area.

3C. Create and implement processes for meaningful recognition for all members of the health workforce.
  1. EOP 5.6

  2. Support and recognition of nurses' involvement in community volunteer activities.

  3. EOP 5.7

  4. Leadership fosters a culture of day-to-day recognition.

3D. Examine sick leave and personal time off, policies and staffing to accommodate health workers who need time off, regardless of their tenure.
  1. EOP 5.9

  2. Strategies in place to address physical fatigue experienced by the healthcare provider team.

  3. EOP 5.10

  4. Strategies to address compassion fatigue experienced by the healthcare provider team including narratives from a nurse and non-nurse.

3E. Develop and incentivize coverage systems that allow health workers to take time off, ensuring that frontline workers aren't responsible for patient care activities during their time away.
3F. Offer employee benefits such as childcare and elder care services.
  1. EOP 5.3 and 5.4

  2. Direct care nurses are involved in the selection, planning and evaluation of well-being initiatives selected for implementation.

3G. Ensure that health worker meal and rest breaks are expected and routine, not exceptional.
  1. EOP 5.3 and 5.4

  2. Direct care nurses are involved in the selection, planning and evaluation of well-being initiatives selected for implementation.

  3. EOP 5.9

  4. Strategies in place to address physical fatigue experienced by the healthcare provider team.

  5. EOP 5.10

  6. Strategies are in place to address compassion fatigue experienced by the healthcare provider team.

3H. Learn about health worker experiences directly by asking them and conducting surveys and listening sessions while they're employed and conducting exit interviews to understand why they're leaving their positions.
3I. Promote work-life integration for health workers through structures, such as sufficient staff, flexible schedules, access to and use of healthcare and healthy food options.
  1. EOP 5.5

  2. Nurses are provided opportunities to create work schedules that support nurse well-being.

3J. Address the accountability and reward systems and re-orient the promotion/tenure and salary processes so that they reward behaviors contributing to positive learning environments.
  1. EOP 2.9

  2. Retention strategies for senior nursing leadership.

  3. EOP 2.10

  4. Retention strategies for nurse managers.

4A. Use data to develop strategies that will improve well-being and decrease health worker burnout and distress on a continual basis.
  1. EOP 5.1

  2. The organization periodically assesses the health of its employees.

4B. Ensure that leaders consider well-being when making decisions to account for the potential impact on patients, the workforce, and their health system.
  1. EOP 5.2

  2. Senior leadership integrates employee well-being and resilience into strategic planning.

4C. Provide protected time for and empower managers, health workers, and other staff to address well-being in the workplace. Pathway Standard 5 is dedicated to safeguarding the well-being of nurses and other clinicians.
  1. 4D. Invest in well-being leadership roles, such as Chief Wellness Officers (and Chief Nursing and Chief Pharmacy Officer roles, as appropriate) that:

    • report to executive leadership and governance and are integrated in the leadership team,

    • facilitate uptake and accountability of well-being within the health workforce, and

    • are allocated the resources necessary to implement strategies that will improve health worker well-being.

Included in EOP 5.2 and often listed as part of the strategic planning in documents received from applicants.
5A. Establish and implement accountability measures and incentives for leaders (see Action 3J).
  1. EOP 2.9

  2. Retention strategies for senior nursing leadership.

  3. EOP 2.10

  4. Retention strategies for nurse managers.

5B. Fund and evaluate demonstration programs and grants in the workplace and learning environments.
5C. Decrease the amount of time between research and translating evidence into real-world settings.
  1. EOP 1.3

  2. Change in nursing practice based on published evidence and resulting from a shared governance initiative.

  3. EOP 4.4

  4. Educational opportunities regarding application of evidence-based practice (EBP) are provided for direct care nurses.

  5. EOP 4.5

  6. Example demonstrating nurses implementing EBP in a patient care area.

5D. Commit to shared governance with accountability systems to call out business values that conflict with social mission and reinforce discrimination/disparities. The Pathway Shared Decision-Making Standard requires organizations to promote a culture of interprofessional decision-making and create environments where direct care staff can provide input and share concerns.
  1. Priority Area #2: Invest in measurement, assessment, strategies, and research.

  2. Pathway nurses are educated about EBP so they can effectively participate in evaluating research studies and implementing EBP in their patient care area(s).

  3. Priority Area #3: Support mental health and reduce stigma.

  4. Pathway organizations foster resilience through support processes following adverse situations and to mitigate both physical and compassion fatigue. Applicants must describe the support opportunities offered by the organization to address the well-being of staff who have experienced an adverse situation that was work-related (EOP 5.8).

  5. Pathway organizations support professional development and nurses pursuing specialty certifications. This aligns with the recommendation to increase resources to support individuals seeking education to become mental health professionals.

  6. Priority Area #4: Address compliance, regulatory, and policy barriers for daily work.

  7. Priority Area #5: Engage effective technology tools.

  8. Direct care nurses are involved in the interprofessional decision-making process to select new technology within the organization.

  9. Priority Area #6: Institutionalize well-being as a long-term value.

  10. Pathway provides a free self-assessment of organizational culture tool to: 1) assess current state; and 2) identify gaps to desired state. Giving frontline nurses a voice is paramount in creating practice environments that make staff feel empowered and supported; thus, formal leaders are required to have strategies in place to accommodate and ensure participation in shared decision-making forums (EOP 2.1). Interprofessional education is also provided to promote respectful communication and a culture free from incivility, bullying, and workplace violence (EOP 3.3; EOP 4.3).

  11. Pathway organizations protect the safety and well-being of nurses, staff, and patients through safety policies and processes. Proactive and sustained measures are ensured by making well-being a focus on the strategic plan (EOP 5.2). Communicating the impact of well-being and its correlation with nurse and patient safety and outcomes is included when discussing the “why” for using the Pathway framework. In addition, Pathway organizations use external benchmarks to guide decisions about nursing practice (EOP 4.8), which aligns with the recommendation to use available data and science to inform decisions, priorities, and policies.

  12. Pathway organizations offer flexible scheduling to promote work-life balance. Opportunities are provided for nurses to create work schedules that support nurse well-being when quarantining, which can include hybrid work if needed, or to have adequate time off to safeguard their mental health.

  13. Priority Area #7: Recruit and retain a diverse and inclusive health workforce.

  14. Pathway organizations advocate for and support lifelong learning, ongoing education, and professional development, which aligns with the recommendation to invest in continuing education. The recommendation to revise policies to offer flexibility in terms of clinical schedules, job-sharing opportunities, remote work options, and opportunities to re-enter the workforce is supported. Pathway organizations provide flexible scheduling to allow nurses to create work schedules that support their well-being and personal life. Direct care nurses also have input in creating staffing plans and in making daily staffing decisions (EOP 3.5). Fluctuations in patient conditions, volume, or availability of qualified staff are some of the factors considered when making decisions about daily staffing (EOP 3.6).

  15. Team-based care is promoted. Interprofessional collaboration is fostered in all six Pathway Standards.


The first step to success

The Pathway's Framework strongly aligns with Priority Area #1 of the National Plan for Health Workforce Well-Being recommendations. There's also some concurrent alignment with Priority Areas #6 and #7. Long before the issuance of the recommendations and the COVID-19 pandemic, Pathway organizations recognized the importance of safeguarding worker well-being. The program has proven to create an environment in which team members feel supported knowing that they work in a safe, caring environment. Such feelings contribute to higher employee engagement and a more productive work culture. Employees also feel secure knowing that they can contribute to the work culture by participating in the periodic assessments of the work environment and serving on committees that promote safety. As organizations adopt the National Plan recommendations, examining the methods that have proven to be successful for Pathway organizations may serve as a template. Having an evidence-based framework as a blueprint will be a vital first step toward creating a positive work environment.

REFERENCES

1. American Nurses Foundation. Pulse on the Nation's Nurses, COVID-19 Survey Series: COVID-19 Impact Assessment Survey – The Second Year. 2022. www.nursingworld.org/practice-policy/work-environment/health-safety/disaster-preparedness/coronavirus/what-you-need-to-know/covid-19-impact-assessment-survey-the-second-year.
2. Amanullah S, Ramesh Shankar R. The impact of COVID-19 on physician burnout globally: a review. Healthcare (Basel). 2020;8(4):421.
3. National Academy of Medicine. National Plan for Health Workforce Well-Being. 2022. https://nam.edu/initiatives/clinician-resilience-and-well-being/national-plan-for-health-workforce-well-being.
4. Dans M, Pabico C, Tate M, Hume L. Understanding the new Pathway to Excellence® standards. Nurse Lead. 2017;15(1):49–52.
5. Bates M, Hargreaves J, McCright M, Pabico C, Hume L. Introducing the 2020 Pathway to Excellence® manual. Nurs Manage. 2020;51(4):7–10.
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