Bridging the gaps of healthcare inequity and nurse well-being : Nursing Management

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Department: Pathway to Excellence®

Bridging the gaps of healthcare inequity and nurse well-being

Moore, Kevin T. BSN, RN; Sepe, Paulette MSN, RN; Dans, Maricon MSN, RN

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Nursing Management (Springhouse) 53(12):p 6-10, December 2022. | DOI: 10.1097/01.NUMA.0000897476.26127.2b
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The American Nurses Credentialing Center's Pathway to Excellence® (PTE) and Pathway to Excellence in Long-term Care® programs provide a framework to assist healthcare organizations across the continuum in their pursuit of a positive practice environment. The Pathway standards address the recommendations from the National Academy of Medicine (NAM) report, The Future of Nursing 2020-2030: Charting a Path to Health Equity, released in 2021. Drafted during the height of the global pandemic, the report highlights healthcare disparities in communities and the risks to the well-being of healthcare workers, primarily nurses.1 This article aims to describe the alignment between the Pathway standards and the Future of Nursing (FON) report, and to highlight how healthcare organizations can employ the Pathway framework to meet the NAM's recommendations.


The mission of the PTE program is to “guide the positive transformation of practice environments in multiple settings to build global community healthcare organizations committed to nursing workplace excellence.”2 PTE is an evidence-based framework that, when used as a blueprint, can influence the structure of nursing environments through engagement, collaboration, and staff and patient safety, potentially leading to better patient outcomes.3,4 Transformation is achieved through the enculturation of the six evidence-based standards: shared decision-making, leadership, safety, quality, well-being, and professional development (see Figure 1).2 These six PTE standards have commonalities with the FON report, most notably in the areas of shared governance and well-being (see Table 1). In fact, the PTE standards within the Pathway framework are beacons for all healthcare organizations in caring for and empowering its nurses.2

Figure 1::
ANCC Pathway to Excellence® Framework for Positive Practice Environments.
Table 1: - PTE and FON crosswalk analysis
The following crosswalk compares the FON report recommendations and the PTE elements of performance (EOPs). The FON recommendations of a shared agenda, enabling the nurse workforce to address social determinants of health and health equity, the promotion of nurses' health and well-being, the incorporation of nursing expertise, and the strengthening and protection of the nursing workforce during response to public health emergencies are addressed in the PTE EOPs. Recommendations not captured in PTE standards are being addressed in the revision process for the Pathway to Excellence® and Pathway to Excellence in Long-term Care® Application Manual.
FON Recommendation PTE EOP
  1. Recommendation 1:

  2. National nursing organizations should initiate work to develop a shared agenda for addressing social determinants of health and achieving health equity, to include priorities across nursing practice, education, leadership...

  1. 1.4, 4.9, 5.6

  2. Shared governance structures at Pathway organizations support and involve nurses in the promotion of health in the community encompassing population health. Nurses are supported and recognized for their involvement in community volunteer activities.

  1. Recommendation 2:

  2. Health care...organizations...should initiate substantive actions to enable the nursing workforce to address social determinants of health and health equity more comprehensively, regardless of practice setting.

  1. 4.4, 4.5, 4.9, 6.5, 6.6, 6.8

  2. Pathway organizations foster professional growth and advancement, including ongoing education on the application of evidence-based practice and in the pursuit of improving population health.

  1. Recommendation 3:

  2. Employers...should initiate the implementation of structures, systems, and evidence-based interventions to promote nurses' health and well-being, especially as they take on new roles to advance health equity.

  1. 5.1, 5.2, 5.3. 5.4, 5.5, 5.8, 6.8

  2. Fostering staff well-being and resiliency are essential components of a Pathway organization's strategic plan. They assess the health of their employees and include nurses in planning and evaluating well-being initiatives. Nurses have opportunities to create work schedules supportive of their well-being. They're provided opportunities to address well-being when adverse events and compassion or physical fatigue occur. Professional growth is supported for nurses aspiring to lead.

  1. Recommendation 4:

  2. All organizations, including state and federal entities and employing organizations, should enable nurses to practice to the full extent of their education and training by removing barriers...

  1. Recommendation 5:

  2. Federal, tribal, state, local, and private payers and public health agencies should establish sustainable and flexible payment mechanisms to support nurses in both health care and public health, including school nurses, in addressing social needs, social determinants of health, and health equity.

  1. Recommendation 6:

  2. All public and private health care systems should incorporate nursing expertise in designing, generating, analyzing, and applying data to support initiatives focused on social determinants of health and health equity using diverse digital platforms, artificial intelligence, and other innovative technologies.

  1. 1.4

  2. Nurses at Pathway organizations use shared governance to promote health in their local communities as identified in a community health needs assessment or systematic approach to identify need.

  1. Recommendation 7:

  2. Nursing education programs, including continuing education, and accreditors and the National Council of State Boards of Nursing should ensure that nurses are prepared to address social determinants of health and achieve health equity.

  1. Organizational Overview (OO)

  2. Pathway organizational strategies optimize nursing workforce diversity and inclusion. Training is provided around diversity and inclusion for employees.

  3. 4.4, 4.5, 4.9, 6.5, 6.6, 6.8

  4. Pathway organizations foster professional growth and advancement, including ongoing education on the application of evidence-based practice and in the pursuit of improving population health.

  1. Recommendation 8:

  2. To enable nurses to address inequities within communities, federal agencies and other key stakeholders within and outside the nursing profession should strengthen and protect the nursing workforce during the response to such public health emergencies as the COVID-19 pandemic and natural disasters, including those related to climate change.

  1. 1.5, 2.5, 5.8, 5.9, 5.10

  2. Nurses are supported during planned or unplanned changes, adverse situations, and in addressing ethical concerns. They're strengthened and protected by organizational efforts to address physical and compassion fatigue, fostering resilience and safeguarding nursing workforce well-being.

  1. Recommendation 9:

  2. Convene representatives from nursing, public health, and health care to develop and support a research agenda and evidence base describing the impact of nursing interventions, including multisector collaboration, on social determinants of health, environmental health, health equity, and nurses' health and well-being.

Sources: National Academy of Medicine. The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. Washington, DC: The National Academies Press; 2021:355-376. American Nurses Credentialing Center. 2020 Pathway to Excellence®and Pathway to Excellence in Long-Term Care®Application Manual. Silver Spring, MD: ANA Enterprise; 2020:29-56.

The FON, a 500+ page document, lays out 54 points across the healthcare spectrum focusing on nursing's potential for creating equity, not only through health, healthcare, and healthcare access, but also through the employment and profession of nursing itself.1,5 Hassmiller presented “Charting a Path to Achieve Health Equity,” highlighting four key takeaways from the report: 1) fully supporting nurses, 2) permanently removing nurse practice behaviors, 3) valuing nursing contributions, and 4) preparing nurses to tackle and understand health equity.1 Hassmiller further amplified how the Pathway framework is “associated with promising data suggesting improved patient care, decreased emotional exhaustion, and higher job satisfaction.”1,5

Literature review

Paramount to the success of any healthcare organization is the nurse's sense of well-being. Nurses have been at the front line of the COVID-19 pandemic taking care of the sickest and most marginalized community members. The pandemic has affected the mental health and well-being of nurses and healthcare workers.6-8 Moreover, nurses experienced higher risks when compared with other providers.9 They've felt the impact of providing care with elevated levels of stress and hardship.6-8,10

Nurses are leaving the bedside due to exhaustion and burnout, a lack of trust in leaders, depression, anxiety, a decreased sense of psychological safety, and exacerbated moral distress.6-8,10-12 They are a high-risk group with a suicide rate 23% higher than the national average prior to the pandemic.10 The evidence isn't only anecdotal; it's peer-reviewed, proven, and palpable. The Pathway framework gives organizations a tool for creating a well-developed and empowered nursing voice that participates in shared decision-making about the resources for providing diverse and inclusive, high-quality, and safe care. It's an instrument that can be used for reducing nurse turnover, increasing job satisfaction, and putting current literature into action in support of nurse well-being.13

Implications for frontline nurses

The PTE and FON outline important implications for frontline nurses. Most important is the ever-present reminder that nurses must prioritize their own health and well-being in order to care for others. Nurses are natural leaders regardless of their practice or level of experience. As such, the PTE and FON encourage nurses to uphold the profession by acting to increase belonging and procure what's needed for safe, diverse, equitable, and inclusive nursing practice. For example, by following the guidelines set forth by the PTE and highlighted in the FON, nurses and nurse leaders may address the social needs and social determinants of health in marginalized communities through shared governance activities, evidence-based practice, and interprofessional collaboration. It's imperative that nurses at all levels understand their role in identifying and closing gaps both clinically and culturally in healthcare systems.1 It's equally important that nurses are empowered to affect cultural transformations and model well-being initiatives and self-care behaviors, such as physical and mental health activities, for their interprofessional colleagues.

Implications for nurse leaders

To achieve the goals set forth by the FON report, nurse leaders can transform their organizations to fully support nurses by valuing their voices, addressing practice barriers, and enhancing their understanding of health inequity. A positive practice environment motivates nurses to perform at their best and pursue professional development opportunities to enable them to contribute to the improvement of community health.14

Nurse well-being is fostered by leaders of Pathway organizations through open dialogue.15 Leaders who acknowledge that nurses' physical and mental well-being are imperative for the delivery of safe care to patients and residents will consider staff input when planning and evaluating well-being initiatives.16 Their organizations succeed because the nursing staff recognizes the positive practice environment in which they tirelessly serve their community.

An instrument for achieving expectations

The Pathway to Excellence framework and FON report are clearly aligned. Healthcare organizations across the continuum that demonstrate Pathway standards are in place within their organizational culture are situated to meet the demands of the nursing profession and the needs of the population served. Pathway nurses at all levels are an empowered voice in shared decision-making processes with their leaders. They contribute to the determination of safety, quality, and professional development processes at their respective organizations. They participate in the choosing, preparing, and appraising well-being activities. Finally, nurses in a Pathway-designated organization contribute to diverse, equitable, and inclusive healthcare delivery for their communities. Therefore, healthcare leaders with a vision of meeting the expectations set forth by the FON report may look to the Pathway framework as an instrument for achieving this goal.


1. Hassmiller S. The Future of Nursing 2020-2030: charting a path to achieve health equity. American Nurses Credentialing Center. 2021. Accessed October 26, 2021.
2. American Nurses Credentialing Center. 2020 Pathway to Excellence® and Pathway to Excellence in Long-Term Care® Application Manual. Silver Spring, MD: ANA Enterprise; 2020.
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6. American Nurses Foundation. Pulse on the nation's nurses COVID-19 survey series: mental health and wellness survey 2 results, December 2020. ANA Enterprise COVID-19 Resource Center. Accessed September 4, 2022.
7. American Nurses Foundation. Pulse on the nation's nurses COVID-19 survey series: workplace survey, June-July 2022. ANA Enterprise COVID-19 Resource Center. Accessed September 21, 2022.
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