Blueprints for well-being

Modeling the way through Human-Centered Leadership and Pathway to Excellence

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As the ground in healthcare continues to shift beneath our feet, we can now confidently describe the world we live in as peripandemic. Not quite pandemic and not quite postpandemic. Assuredly, the ship of hope that we'd return to a “normal” prepandemic state has sailed. Persistent workforce turbulence alongside persistent high-acuity and high-volume patients has created what one nurse leader describes as “the eye of the hurricane that never moves on.”

As you can imagine, nursing practice environments are under the microscope as leaders aim to create and support positive and healthy places to deliver care. As leaders are seeking proven ways that will foster their workforce to thrive, many are finding the ANCC Pathway to Excellence^® (PTE) Framework for Positive Practice Environments™ (ANCC Pathway Framework) with its Well-Being Standard and the contemporary, evidence-based, relational leadership theory Human-Centered Leadership in Healthcare (HCL-HC) as great solutions.^1,2 HCL-HC is grounded in the essence of nursing, complexity, and systems science with the first dimension of “Self” as the central starting point to create a positive practice environment. This unique dimension of “it starts with you” sets HCL-HC apart from traditional healthcare leadership theories borrowed from the business world.³ Similarly, PTE posits that modeling the way through application of HCL-HC can cultivate well-being and a positive practice environment.

Background

Relational Leadership: HCL-HC

Healthcare is a business designed to organize and operationalize teams composed of humans who are charged with caring for other humans. Sounds complex, doesn't it? It is. In the persistent chaos and complexity of today's healthcare environment, leaders must harmonize the science (business skills) and art (relational skills) of nursing.⁴ An integrative review of nursing leadership practices revealed relational (soft skills) or people-focused leadership was a primary driver for creating and sustaining a positive practice environment.⁵ An additional systematic review of leadership styles and associated outcomes found people-focused leadership resulted in improved nurse satisfaction, improved perception of practice environment, improved health and well-being, and increased productivity.⁶ This evidence, along with a recent study looking at the specific relational leadership approach (HCL-HC), further validated the connection between people-focused leadership and healthy work environment standards as defined by the American Association of Critical-Care Nurses.^7,8

Relational leadership is an approach focusing on people, relationships, and communication whereas traditional, task-focused leadership styles are characterized as transactional, top-down, and dissonant.⁶ Although appropriate in some situations, when transactional leadership dominates, nurses on the receiving end often become disengaged, find less meaning in their work, and miss the link between decisions and the “why.”⁶ If this sounds less than inspiring, you're correct. If you've felt distance, dissonance, and a disconnect with your leader, more than likely, you experienced a less-than-positive practice environment.

Now, consider a practice environment in which you experienced relational leadership. How was it different? Relational leaders who use an approach such as HCL-HC, prioritize self-care to model the way for their teams which, in essence, provides permission for the team members to do the same. Did your relational leader seek to Awaken potential in you and your team members that even you couldn't see? HCL-HC leaders coach, mentor, and advocate for individual team members' professional growth because they know individual success transforms into organizational success. The result is a culture of excellence with the associated patient outcomes of quality and safety, and the workforce outcomes of increased education and certification.

A relational leader also brings unity to the community by being a Connector. How did the relational leader in your life create a psychologically safe space where you and your colleagues could share not only the problems, but the solutions? Relational leaders prioritize extending trust and engineering a practice environment that harnesses the strengths of team members. Imagine an environment where you're plugged into committees or teams that align with your passions instead of being “voluntold.”

Finally, a relational leader who embraces HCL-HC recognizes humanity in self and others. Remember that relational leader again: How did they Uphold you and your colleagues? The answer probably lies in their ability to be mindful, present, and make you feel as if you were a whole person with an identity that extends well beyond the hospital.

Despite the complexity of healthcare and the equally complex humans who comprise teams and customers, if relationships are front and center, the practice environment will reflect a culture of well-being for all. And isn't that what this world needs now more than ever? Positive practice environments are the bedrock of any organization's success in illustrating the mediating role a healthy team can have on patient outcomes, safety, and quality. If this all sounds like the ANCC Pathway to Excellence roadmap, you're on the right track. (See Figure 1 for a conceptual model illustrating the dimensions of HCL and Figure 2 for the ANCC Pathway to Excellence Framework for Positive Practice Environments.)

Figure 1:: Human-Centered Leadership in Healthcare

Figure 2:: ANCC Pathway to Excellence^® Framework for Positive Practice Environments

Leading with a human-centered approach fits hand in glove with the ANCC Pathway Framework, especially the standard dedicated to safeguarding workforce well-being. The ANCC's call for organizations to prioritize strategies to address resilience, physical fatigue, and compassion fatigue is timely in light of the peripandemic state of healthcare.¹ The ANCC Pathway Framework isn't prescriptive, and organizations are innovative in how they meet the requirements. Human-Centered Leadership offers some creative evidence-based strategies for addressing well-being and for enculturating the Pathway Standards through the dimensions of Self, Awakener, Connector, and Upholder.

Resilience. What does well-being have to do with resilience? When you were a child, do you remember having a toy with a big balloon that had a rubber band handle attached to it? The idea was to hold onto the handle and punch the balloon away from you and it would bounce back. No matter how hard or fast you punched the balloon, it always bounced back. Sounds like resilience, which has been described as the ability to recover from difficult situations. Rubber bands, representing resilience, are strong, flexible, durable, and hard to break. With our toy, the rubber band allows for the balloon to “bounce back.” However, if the balloon is low on air, it doesn't matter how strong the rubber band is because the balloon won't have the ability to bounce back quickly or at all.

In this metaphor, well-being is represented by the balloon. If we aren't committed to consistent and persistent practices of well-being, we too will lose air and can't recover as quickly from stressful situations.³ At its core, resilience is reflected in our individual and collective behaviors of emotional, social, and environmental awareness. With this awareness as the starting point, reflective practice and adaptability emerge as practical tools nurses can use at work or at home to strengthen resilience.

Table 1: - Conceptual definitions of each HCL dimension, its associated attributes, and alignment with the ANCC Pathway Framework

HCL-HC: Dimensions and Attributes		ANCC Pathway to Excellence Framework for Creating Positive Practice Environments
Self	Practices to support self
Well-Being	Approaches life satisfaction through a holistic, subjective, and multidimensional approach while finding balance in the elements of physical, emotional, social, spiritual, intellectual, and financial health.	Pathway Standard 5 (Well-Being): Ensures proactive and sustained measures to prioritize well-being and encourages all nurses, including nurse leaders, to practice self-care. Given the correlation of well-being with nurse and patient safety and outcomes, Pathway leaders create work schedules that support well-being.
Self-Care	Maintains a healthy relationship with self, focusing on physical, mental, and spiritual care. The way we treat ourselves.
Self-Compassion	Views life struggles with understanding, kindness, and grace. The way we relate to ourselves.
Self-Aware	Understands the underlying intentions that steer our thoughts, actions, and behaviors. The way we see ourselves.
Mindfulness	Checks in with self in the moment to note and acknowledge feelings and thoughts.
Awakener	Cultivates our people
Motivator	Establishes a learning culture with high expectations for ongoing learning for self and others.	Pathway Standard 6 (Professional Development): Recognizes the importance of solid onboarding, lifelong learning, ongoing education, and professional development to the delivery of safe and effective patient care. The foundation of developing competent and collaborative staff begins with a comprehensive orientation that includes individualization of learning needs. This ensures a smooth transition into practice. Guidance from mentors fosters the growth and development of emerging leaders essential for succession planning. Ensuring team members' professional growth and individual success leads to organizational success. Pathway Standard 2 (Leadership): Ensures that nurse managers receive role-specific orientation and leaders equally strive to increase their core knowledge and role competency through leadership development activities, along with feedback from colleagues and nursing staff.
Coach	Provides honest feedback and addresses behaviors inconsistent with learning culture.
Mentor	Advises on member accountability for individual growth plans.
Architect	Designs structures/processes so innovation can emerge.
Advocate	Ensures resources are available for best practice and professional growth.
Connector	Builds our community
Collaborator	Unifies others around shared mission and vision.	Pathway Standard 4 (Quality): Ensures that staff are aligned with the organization's mission, vision, values, and goals. Direct care nurses are involved in the review and implementation of evidence-based practice. Pathway Standard 1 (Shared Decision-Making): Encourages and embraces input from direct care nurses and other disciplines in making decisions that impact care delivery. Interprofessional collaboration is integral to engaging staff, building teamwork, and strengthening the shared-governance culture.
Supporter	Supports, recognizes, and appreciates independent problem-solving and individual contributions at the point of service.
Edgewalker	Embraces change/chaos by endorsing experimentation of ideas to generate innovation.
Engineer	Ensures people are plugged into processes/structures for emergence of new ideas.
Authentic Communicator	Builds mutual respect and trust through nurturing intentional connections with others.
Upholder	Recognizes humanity in others
Mindful	Focuses attention, awareness, and energy on the present.	Pathway Standard 3 (Safety): Ensures nurses' safety and well-being are safeguarded. A safe environment includes having measures to create a culture free of incivility, bullying, and violence. Interprofessional decision-making ensures diverse thoughts are welcomed and an inclusive culture is promoted. Pathway Standard 4 (Quality): Ensures educational sessions that address respectful communication are offered. Pathway Standard 5 (Well-Being): Ensures leaders embrace a shared governance culture and creates an environment that supports workforce well-being. This includes role modeling behaviors of self-care.
Others-Oriented	Supports with respect, kindness, empathy, and empowerment.
Emotionally Aware	Recognizes and embraces humanity at all levels; self-reflective.
Socially and Organizationally Aware	Leads with an open mind.
Personally Well and Healthy	Practices self-care, self-compassion, and self-awareness.

Compassion fatigue. How does compassion for others relate to compassion for ourselves and our well-being? If you break down the word compassion, the Latin root is pati or passio, which means to suffer, and the prefix com- means with.¹⁷ Thus, compassion has two parts in which the nurse first recognizes suffering or pain in another human being and then seeks to address or “sit” with the other person in their time of need. It seems compassion is woven into the cloth of nursing itself, but how exhausting it must be to persistently “sit with” the suffering of others.

As you might have guessed, compassion fatigue has always been a challenge in nursing; however, the pandemic spawned its own pandemic within the profession. Compassion fatigue is pervasive because nurses have dealt with persistent suffering in ways no one could have imagined. So how do organizations, leaders, and nurses tackle this problem?

Consider starting with change from the literal inside-out. Build strategic opportunities for nurses to learn how to be self-compassionate in a world that has expected selfless compassion for others. Self-compassion is the way we relate to ourselves. Think about it this way. If a friend makes a mistake, how do we talk with them, treat them, or care for them? We don't blame and shame; rather, we console, coach, and cheer them on. What if, when we find ourselves overwhelmed by persistent compassion fatigue or when we've made a mistake, we treated ourselves like we'd treat our best friend?

In a culture of well-being, prioritizing self-compassion creates space for nurses to recognize humanity in themselves and in others. Also, recent research has shown self-compassion diminished the effect of perceived stress on job burnout in nurses.¹⁸ How do we harness our own ability for self-compassion to address or mitigate compassion fatigue?

Physical fatigue. It's humanly impossible to be “others-oriented” every second of every day, whether at work or at home. We can't be everything to everyone. As much as our compassionate nursing hearts might want to take on extra shifts, often the toll begins to show in our physical well-being. Just like compassion fatigue, physical fatigue is a problem for individuals and teams challenged to care for higher-acuity and higher-volume patients during persistent workforce deficits. So how can organizations and nurses mitigate physical fatigue while enhancing well-being?

Let's go back and recall HCL-HC's first and most important dimension: “It starts with you.”^2,3 Using the physiologic metaphor of the heart, consider how the first part of the heartbeat (systole) sends blood filled with oxygen and nutrients to itself. In the second part of the heartbeat (diastole), the heart then pushes oxygen and nutrients to the rest of the body. Get it? The most central part of our being is telling us how to do it! Taking a cue from our hearts, it only makes sense that human-centered leaders would model the way and, in essence, provide permission for their teams to do the same.

Table 2: - Resilience—HCL-HC Dimensions in Action

Self in Action! Mindfulness is your new superpower. Integrate evidence-based mindfulness. Mindfulness practices have been shown to mitigate perceived stress in nurses, which can also strengthen resilience.9 Partnering with Human Resources to offer a validated, evidence-based program such as Mindfulness-Based Stress Reduction (MBSR) as a benefit is one way to show nurses and staff the organization is invested in their well-being.10,11 If there are nurses in graduate programs, such as master's or Doctor of Nursing Practice (DNP) programs, harnessing their expertise to implement MBSR as their student project is a good way to pilot the program. Show how small moments have a big impact. Challenge unit- and entity-level shared governance nurses to develop creative and positive campaigns around Micro-Mindful-Moments. For example, one organization's nursing retention council created a social media campaign/channel where nurses shared their everyday experiences of mindfulness, such as handwashing or pausing before entering a patient's room. Be sure your policies are aligned with the social media venue.

Connector in Action! Bring in the dogs for stress reduction and perhaps some research. Bring in the pets! Research shows that pet therapy for healthcare team members mitigates stress and promotes resilience, which leads to improved care delivery, fewer errors, and improved patient satisfaction scores.12 Specifically, having dogs available to interact with staff provided a break in the daily stress and allowed the team members to reset and return to their patients feeling relaxed and happy.13 Consider partnering with volunteer services or your local pet therapy organizations to set a regular schedule for having pets, most commonly dogs, provide consistent visits for your unit or hospital. Finally, you could integrate a nurse-driven research project into this plan by measuring stress and resilience.

Awakener in Action! Onsite counseling support for staff and social support for communities Normalize support and counseling. Onsite counselors for individual or peer support have also been shown to benefit nurses and their interprofessional colleagues by allowing them to safely talk about their emotions and the shared human experience of persistent stress.14,15 Harness collaborative partnerships between human resources, executive leadership, and behavioral health services to develop creative opportunities for psychologically safe spaces. Invite nurses to the table to develop what these programs look like regarding timing, venues, and types of support, such as individual and peer. Invite the community. Consider community-level opportunities to engage staff alongside the populations and patients they serve. Public-facing town halls with a workshop format for dedicated topics such as MBSR provide outreach and address community-specific health objectives related to peripandemic concerns, such as social isolation and infectious disease precautions.14

Upholder in Action! Reflection to build a resilient mindset3,16 Provide tools for reflective practice that allow team members to debrief with themselves outside of work hours using free-text journaling or a set of prompts such as the SBAR.16 Situation: Reflect on an experience or event, big or small, positive or negative, that impacted your day. What happened? Background: What was it about my sense of well-being that influenced the situation? Mind? Body? Spirit? What was going on for me that day, such as other stressors or events? Assessment: What's really going on? What didn't it go the way it was intended? What did I want to happen? Recommendation: What would I do differently if this situation were to ever happen again? What do I need to let go of to move on? Build reflection into the workday by providing respite rooms or quiet break areas for reflection.3,16 Consider designing short reflection breaks (10-15 minutes) and provide journals for the staff. Based on team input and feedback, consider peer reflection in small groups. Sometimes it helps to know you're not alone in the struggles and stressors.

Discussion and takeaways

HCL-HC is a blueprint that organizations in pursuit of Pathway to Excellence may consider, especially to enculturate the Well-Being Standard. Organizations would be well-served to weave the foundational concept of “it starts with you, but it's not about you” into the fabric of their values and credo. When people at all levels model the way for prioritizing self-care, an interesting phenomenon occurs. Well-being begets well-being.

Table 3: - Compassion fatigue—HCL-HC Dimensions in Action

Self in Action! Mindfulness, self-awareness, and self-compassion in action3 Take a pulse. Perform a needs assessment through individual interviews or focus groups to get a pulse check on the pain points for nurses and their holistic wellness. Ask what types of programs would fit into their work and home life. For example, implement virtual mindfulness or wellness education that has continuing-education credits. Check your blind spots. During huddles or staff meetings, create a challenge for your team members to embrace feedback from trusted colleagues to reveal blind spots. Consider asking two questions of a professional and/or personal confidant to elicit helpful feedback: 1) What am I like when I'm at my best? 2) What am I like when I'm at my worst? Make it safe. Practice just culture by nurturing a safe psychological space to learn from mistakes.19,20 As imperfect humans, we lead the way by embracing mistakes and seeing them as an opportunity for growth. Consider integrating a way to honor the courage of someone who has made a mistake and spoken up about it. For example, highlight growth opportunities through shared stories in huddles or regular staff meetings. Also, reflective journaling helps individuals identify mistakes, learn from them, and put that learning into a positive future action. This illustrates how to integrate self-compassion into the practice environment.

Awakener in Action! Channel passions for individual and collective well-being Harness strengths and passions. Leaders sit alongside nurses for 1:1 self-assessment and leader assessment of the nurse's wellness strengths and contributions to the unit with an intentional conversation to honor individual passions.3 For example, a nurse identifies how mentoring, not necessarily precepting, new nurses is what brings joy and meaning to their work. The leader and nurse can then work together to create a plan that harnesses the nurse's passion for mentoring. This becomes a win-win-win for the experienced nurse, the new nurse, and ultimately the patients. Volunteer instead of voluntold. Consider ways to channel compassion and self-compassion through unique volunteer opportunities that benefit your patient population.3 For example, facilitate opportunities for the nurses and team to “adopt” local residents of a long-term-care facility for holiday visits. Reward commitment. Recognize nurses who have given extra time and energy to the unit with time off for professional development, such as a conference registration or a certification prep course.3

Connector in Action! Healthy boundaries Establish healthy boundaries. Healthy boundaries in professional and personal life are a form of self-care and serve as rules for how others should behave around us, as well as how we behave around others. What do healthy boundaries look like? Nurse leaders, shared governance councils, and organizations can support nurse-driven initiatives with features such as the following: Ground rules with common language to communicate and honor flexibility without compromising self in an unhealthy way. This might look like negotiating for a middle ground around requests for additional shifts or, as a leader, being asked to take on more duties. Ground rules for meetings and committees that call out respecting the values and opinions of others, even if they're different from ours. For example, assigning a “devil's advocate” provides a safe role where ideas can be challenged to ensure all perspectives are considered. Nurture realistic optimism. Consider integrating the appreciative inquiry (AI) process into professional governance councils or staff meetings to unveil a possibilities-focused approach to problems and change management. AI harnesses the ingenuity of the nurse innovators and influencers to co-create positive change in the practice environment. AI gives “life” to living systems and acknowledges the strengths in the individual team members.21

Upholder in Action! Learn to read the room and read yourself! Pay attention to your emotions! Try to name them as they occur. As you explore your feelings, your brain will become stronger at identifying them and learning from them, so you can respond rather than react. Consider workshops on emotional intelligence or HCL-HC for your nurses and leaders. To embed emotional intelligence, consider having nurses become facilitators of HCL-HC. Expand the definition of team. Support nurse-driven activities that honor personal well-being and build team relationships. For example, encourage and then support unit or entity shared governance councils in creating team learning activities, such as an escape room on the unit or a planned offsite activity such as the American Heart Association Heart Walk. Also, consider coordinating a “sister unit” potluck for CCU and the Cardiac Stepdown unit. Alternatively, if in a clinic, imagine sharing a healthy meal between two teams that don't often interact such as Orthopedics and Obstetrics. This illustrates social and organizational awareness to create a culture of caring.

Table 4: - Physical fatigue—HCL-HC Dimensions in Action

Self in Action! Model the way to harmony in physical wellness. Model the way. Leaders model the way in holistic self-care by prioritizing it and expecting the same from their team. For example, when the leader prioritizes time for yoga, the gym, or walking, the team members are provided implicit permission to do the same. This could be during work hours and allotted breaks or after hours. Walk the talk. For 1:1 meetings with nurses, consider doing walking meetings or finding a quiet space outside.

Connector in Action! Drive partnerships inside and outside the organization. Creative and caring scheduling for the win! Facilitate creative and caring scheduling through shared governance councils. For example, the voice of the nursing team guides creative time frames for shifts that align with unit needs and the needs of team members. Harvest healthy community partnerships. Support nurse-driven ideas for nutrition and community support, such as a local farmer's market onsite once a week.

Awakener in Action! Focus on fit and ownership in the hiring process. Foster ownership instead of renting. Involve staff in interviews to awaken ownership in hiring colleagues who fit the positive culture. As the staff grows in quality and quantity, scheduling becomes more flexible for the whole team.

Upholder in Action! Read the room and the people to care in the moment. Call a code. Consider having your unit or entity shared governance councils work to create a nurse-driven internal “code system” where nurses or team members can let others know in a safe and nonjudgmental way that they need help or a complete break. This is different from a traditional Code Lavender; rather, this is a way to provide in-the-moment respite or assistance. For this example, let's call it a Code Lifeguard. A nurse who is feeling stressed comes to the nurses' station and says, “I'm barely keeping my head above water.” This means the nurse's colleagues know to offer assistance such as, “What do you need right now?” and then they help the nurse get back to a less stressed state. If a nurse is feeling overwhelmed, the nurse would say, “I'm drowning.” This indicates the nurse needs a complete break for 10-15 minutes (or whatever time frame is deemed appropriate). Colleagues instruct the nurse to take a break, and they cover the nurse's work and patients for the 10-15 minutes of respite.

If the CNO prioritizes well-being, the directors will feel an implicit permission to do the same, which will then pass on to the nurse managers, the charge nurses, and the frontline nurses. In the end, who's the biggest winner? The patients, families, and communities those nurses serve. The stories will write themselves as you integrate people-focused and nurse-driven ways to strengthen resilience, flip the script on compassion fatigue, and mitigate physical fatigue. Architect success using HCL-HC to engineer well-being for all.