American Academy of Nursing consensus recommendations to advance system level change for nurse well-being

The COVID-19 pandemic has required close examination of workforce-related stressors that over decades have contributed to widespread burnout, negative health outcomes, including mental health outcomes, and the loss of the welleducated professionals who are the future of the nursing profession. In the United States and globally, evidence points to factors known to diminish wellbeing, including inequities, issues of minority status, persistent discrimination, and demanding work environments. The American Academy of Nursing (AAN), dedicated to organizational excellence, nursing leadership and evidence-based policy, develops statements reflecting its mission and those of its nursing affiliates and corporate member, The American Nurses Association. Within nursing, despite the efforts of its members toward advancement, professional fulfillment is often constrained by the systems in which nurses practice and workplace factors over which they have little control. Action by key organizations to initiate changes at systems levels in workplace safety, to increase professional mobility, and propel policies that increase access to health care resources could improve nurse well-being. This paper proposes recommendations from the AAN Expert Panels on Building Health Care System Excellence, Psychiatric Mental Health and Substance Use, and Global Health Expert Panels for the American Academy of Nursing to leverage related policy in the arenas of government and professional/healthcare organizations. Transforming health care work environments and advancing nurse well-being and equity can be accomplished through key, innovative policy changes. These will be achieved through collaboration among associations, organizations, nonprofit groups, and with the public and the media.

# Background
The workplace demands of the COVID-19 pandemic continue to augment documented factors which increase risks to well-being and contribute to health challenges for nurses and other healthcare professionals. The lack of unified global and national responses to the COVID-19 pandemic exposed skeletal public health structures poorly equipped to detect and manage widespread infectious disease. It has prompted closer examination of stressors that over decades have contributed to widespread burnout, negative health outcomes, including mental health, and the loss of nurses to the profession as a result of such factors [bib_ref] A blueprint for leadership during COVID-19, Rosa [/bib_ref] [bib_ref] An expanded institutional-and national-level blueprint to address nurse burnout and moral suffering..., Schlak [/bib_ref]. Reports collected during 2020 to 2021 indicate that 50% of nurses were considering leaving their jobs and that 47% of those intent on doing so stated that work is negatively affecting their health and well-being . Research over years prior to the global pandemic created momentum to recognize burnout as an occupational phenomenon in health care workers , and describes how health care systems play a role in the departure of clinicians from their respective professions . Evidence suggests the need for organizations to effectively support clinician well-being by adopting transformative approaches to disrupt existing practices, structures, and policies that contribute to workplace hazards and stressors . This position statement provides the rationale for evidence-based actions and policies urging transformative change. Leadership by the American Academy of Nursing and its members, in collaboration with other nursing and interdisciplinary organizations, can spearhead important system wide changes.
Federal and state regulations governing licensure, workplace rights, professional mobility, and constrained scope of practice shape operations in health care organizations. Failure to prioritize clinician wellbeing and the compartmentalization of employee wellness create a disconnect between employee wellbeing and existing standards of quality patient care . National and state policies supporting income equality, job security [bib_ref] Nurse advocacy: Adopting a health in all policies approach, Williams [/bib_ref] , advancement opportunities, workplace safety, and protection from discrimination are legal safeguards which strengthen the profession and society [bib_ref] Tackling discrimination and systemic racism in academic and workplace settings, Brathwaite [/bib_ref] [bib_ref] Black nurses in action: A social movement to end racism and discrimination, Brathwaite [/bib_ref] [bib_ref] National Academy of Medicine (NAM). (2022). Resource compendium for healthcare worker well-being, Moceri [/bib_ref] [bib_ref] Implications of workplace Violence and harassmaent among National Health Service staff working..., Rhead [/bib_ref] [bib_ref] The experience of discrimination by US and Internationally educated nurses in hospital..., Wheeler [/bib_ref]. Federal legislation, such as the U.S. Title VIII Reinvestment Act, which supports enhancing nursing workforce infrastructure, modernizing curricula, and improving technology, is insufficiently funded and lacks mechanisms to support workforce health and professional advancement derived from retention of experienced professional mentors (AONL, 2022a).
In the United States, licensure and accreditation boards and standards for the best practices set expectations that increase job demands, especially in the face of limited resources, resulting in threats to patient safety and quality of care . In addition, licensure requirements which limit nurses' mobility and constrain the scope of practice, can detract from the provision of advanced nursing practice and nurse's attainment of professional fulfillment. Educational institutions, unions, and professional organizations lobby to influence financial support and policy changes in partnerships with healthcare organizations, but rarely does such action focus on factors that directly affect nursing workplace issues. Now, the dire circumstances of the COVID-19 pandemic have prompted significant initiatives in the U.S., Canada, and around the globe that focus on self-care, safety, wellness activities, and improved access to health resources . Few measurable outcomes on professionals' health and well-being are used by healthcare organizations. When evidence-based models developed by nursing and medicine to decrease stress and foster resilience are available, these are rarely built into health care industry operations. Activities designed to strengthen well-being, including approaches such as onsite employee assistance, wellness initiatives, staffing based on patient need, and early interventions for traumatic stress, have not been widely adopted [bib_ref] Common ground: AONL, ANA, and HFMA outcomes-based staffing report provides guidance, Begley [/bib_ref]. There is an ongoing need for increased stewardship and governance within nursing as cited in the AAN Magnet Hospital research and research from other disciplines that demonstrate the relationships between increased engagement and productivity, and decreased stress and burnout [bib_ref] Leader autonomy and support in the workplace: A metaanalytic review, Slemp [/bib_ref].
Nurses worldwide continue to report the high levels of stress and burnout in the ongoing COVID-19 pandemic . Citing the pandemic, nurses intending to leave the profession range upward from 11% to 21% . Identified reasons for exit include lack of employer support (31%), inadequate staffing (45%) and the inability to provide quality care (25%) (ANF, 2021). Erosion of nursing's core values intensifies their distress and 38%-42% of nurses report clinically significant symptoms of trauma and moral injury [bib_ref] Moral injury and moral resilience in health care workers during COVID-19 pandemic, Rushton [/bib_ref]. Chronic understaffing is consistently linked to burnout and job dissatisfaction and the safety and the quality of patient care [bib_ref] Chronic hospital nurse understaffing meets COVID-19: an observational study, Lasater [/bib_ref]. Recognizing the importance of staffing in the promotion and protection of nurse well-being, the International Council of Nurses (ICN) has issued positions statements on evidence-based staffing (2018) and mental health, 2021). The strains of chronic understaffing extend to nurse managers, 36% of whom reported feeling emotionally unhealthy (AONL, 2021). Examples of stressful conditions include extended sequential days of work, back-to-back shifts, and frequent shift rotations which contribute to sleep deprivation, compromising cognitive acuity and competent role performance .
The workforce issues that erode nurse well-being and quality of life and preceded the pandemic are now magnified by its scope and duration, adding to longstanding psychological burden. These issues include high levels of stress, fear of illness, secondary trauma and burnout, in addition to moral distress [bib_ref] Psychological impact of COVID-19 outbreak on frontline nurses: A cross-sectional survey study, Nie [/bib_ref]. Workplace safety factors like violence (1 in 4 U.S. nurses are assaulted [American Nurses Association ANA, 2022, n.d.]), and assaults by patients and visitors (9.33% worldwide) persist at high rates. These factors increase risks for on-the-job injuries, chronic illness (obesity, cardiovascular disease) and poor mental health outcomes. Structural racism, discrimination related to sexual preference, varied levels of ability, minority group membership, health status, and gender orientation are documented in negative outcomes for mental and overall health of health care professionals [bib_ref] National Academy of Medicine (NAM). (2022). Resource compendium for healthcare worker well-being, Moceri [/bib_ref] [bib_ref] Implications of workplace Violence and harassmaent among National Health Service staff working..., Rhead [/bib_ref] [bib_ref] Self-valuation: Attending to the most important instrument in the practice of medicine, Trockel [/bib_ref] [bib_ref] The experience of discrimination by US and Internationally educated nurses in hospital..., Wheeler [/bib_ref]. Critical indicators of the levels of nurses' health include rates of suicide [bib_ref] Association of US Nurse and Physician Occupation With Risk of Suicide, Davis [/bib_ref] [bib_ref] A longitudinal analysis of nurse suicide in the United States (2005-2016) with..., Davidson [/bib_ref] , risky substance use [bib_ref] Substance use disorders among registered nurses: prevalence, risks and perceptions in a..., Kunyk [/bib_ref] and depression, which are almost twice those of other professions . The power imbalance at decision-making tables underscores limited nursing influence and results in uneven rates of professional advancement at all levels.
The National Academy of Medicine Action Collaborative on Clinician Well-being (NASEM, 2019) and the Institute for Health care Improvement's Framework for Improving Joy in Work [bib_ref] IHI framework for improving joy in work. IHI White Paper, Perlo [/bib_ref] note that employer practices and professional organizations that promote wellness and retention of a healthy workforce show results in high levels of patient care. In 2019, the NAM Action Collaborative on Well-being recommended six goals for eliminating clinician burnout and enhancing professional well-being. The first calls for the transformation of "health care work systems by creating positive work environments that prevent and reduce burnout, foster professional well-being and support quality care. The nursing profession pioneered establishing, naming, and sustaining core elements that define a healthy work environment [bib_ref] Magnet hospitals: attraction and retention of professional nurses. American Academy of Nursing, Mcclure [/bib_ref] , specifically documenting the direct linkage of the benefits of a positive work environment to nurse and patient outcomes [bib_ref] Nurse outcomes in Magnet O and non-magnet hospitals, Kelly [/bib_ref]. Yet adoption and integration of such transformations into workplace culture remain elusive for many leaders and healthcare corporations. Employment characterized by safe working conditions, income equality, and job security, is a key social domain linked to wellness [bib_ref] Nurse advocacy: Adopting a health in all policies approach, Williams [/bib_ref]. While interventions have the potential to foster psychological resilience, activities like mindfulness, meditation, and yoga alone are insufficient to balance the effects of system wide stressors that nurses negotiate on a daily basis [bib_ref] Psychological interventions to foster resilience in healthcare professionals, Kunzler [/bib_ref]. Healthcare organizations have key roles in building systems that allow separation of work from home environments as places of rest, recuperation, and relaxation [bib_ref] Caring for health care workers during crisis: Creating a resilience organization, Shanafelt [/bib_ref]. Powerful tools like changes in employment structures and benefits, insurance coverage for mental health, support for help seeking and easy linkages to resources like parental leave and personal days, support well-being and foster job retention .
Following overall health care trends, nursing has moved from its early public health orientation to be increasingly illness focused, with little curricular content emphasizing health education or identifying frameworks that support clinician well-being and patient and wellness initiatives. Regulatory bodies link frank illness (substance use disorders) to consumer outcomes, yet bypass evidence-based health risk factors which contribute to maladaptive coping by nurses, absenteeism, departure from the profession and levels of physical health well below that of the average American (ANA, 2020). The Future of Nursing Report 2020 to 2030 (NASEM, 2021) warns of increasing rates in the profession of poor mental health, including substance use disorders, and suicide [bib_ref] A longitudinal analysis of nurse suicide in the United States (2005-2016) with..., Davidson [/bib_ref] [bib_ref] Substance use among nurses and nursing students: A joint position statement of..., Strobbe [/bib_ref] [bib_ref] Nurses with substance use disorders: Where we are and what needs to..., Worley [/bib_ref]. Indices suggest that evidence-based risk reducers like physical activity, nutrition, quality of life, safety, and rest are often abandoned in the face of shift work, overtime, and constant rotation in work settings. Long held traditions of "hardiness," stoicism, and stigma around mental health overshadow changes in attitude that could result in the adoption of resilience building activities and healthy lifestyle behaviors. Stigma which labels help seeking as an indicator of weakness [bib_ref] Breaking silence, breaking stigma. NAM Perspectives, Salwan [/bib_ref] [bib_ref] Experiencing stigma as a nurse with mental illness, Peterson [/bib_ref] , is a major barrier sufficient to deter seeking care, even in the cases of depression and addiction, and further contributes to late intervention and poorer mental and physical health outcomes [bib_ref] Impact of workplace discrimination and harassment among National Health Service staff working..., Rhead [/bib_ref] [bib_ref] The experience of discrimination by US and Internationally educated nurses in hospital..., Wheeler [/bib_ref]. The cultures of settings that employ nurses often undermine healthy behavioral change, adoption of self-care and assistance to colleagues with health problems.

## Need for action
The American Academy of Nursing's (AAN) mission is to improve health and achieve health equity by influencing policy. The AAN's nearly 3,000 expert members are charged with creating and driving evidencebased policy initiatives, including support of nurses and healthcare providers during crises like the COVID-19 pandemic. This crisis illuminates the N u r s O u t l o o k 7 1 ( 2 0 2 3 ) 1 0 1 9 1 7 ongoing need for support for nurse well-being equal to that advocated for consumers. Efforts to support healthcare workers' safety, resilience and mental health have appeared in federal legislation . HHS has convened medical, nursing and minority organizations to address the workforce pipeline (HHS, 2022). The American Nurses Association's National Commission to Address Racism in Nursing provides a multifactorial review and multipronged approaches to action (ANA, 2022b). Many national, and international nursing organizations have promoted resilience programs . The improvements necessary to significantly affect health care workforce outcomes will fall short without coordinated efforts to leverage policy at legislative and organizational levels. The AAN is the premier nursing organization to lead policy initiatives to strengthen nurse leadership, innovation, and science. Advancing policy in support of nurse well-being requires collaboration among associations, organizations, nonprofit organizations and with the public. This document has purposively put forward consensus recommendations from three AAN expert panels in order to advocate and promote systematic change and advancement of well-being for nurses at system levels.

## Recommendations to influence policy
Recommendation #1: Advocate for System Wide Change to Achieve Healthier Work Environments
If we are to advance nurse well-being, organizational, and governmental efforts must be transformative to promote safe staffing, improve the uptake of recommendations on a healthy work environment, and continue to advance knowledge in the science of well-being.
Safe Staffing: The imperatives of the COVID-19 pandemic have accelerated the translation of existing knowledge and the evidence into recommendations for stakeholder and organization action to improve outcomes for staff [bib_ref] An expanded institutional-and national-level blueprint to address nurse burnout and moral suffering..., Schlak [/bib_ref] and evaluation of models for safer, growth-promoting healthcare environments (including ways to track implementation fidelity and continuous quality improvement). Collaboration and expansion of existing knowledge learned during the pandemic, such as the Think Tank Recommendations from The Partners for Nurse Staffing Collaborative (2022), demonstrate how systems can promote successful models and policy for dissemination. These efforts promote translation of research into action, and demonstrate how adequate staffing, an essential of a healthy work environment, is critical to significant improvements in the well-being of the workforce, quality care, and improved patient outcomes , and the Registered Nurses' Association of Ontario International Program on Evidence-based Guidelines and Healthy Work Environments, reinforce nursing expertise and leadership on healthy work environments. Similarly, demonstrated models for nursing governance in health care organizations and schools of nursing can consolidate concerns on clinical demands and academic workloads and advancement, and support autonomy at provider, faculty, and administrative levels. Legislation and regulatory policies which reinforce healthy work environments through advancing workplace safety by allocation of sufficient resources, standardization of security guidelines and enforcing mandatory workforce continuing education on national safety standards are underdeveloped. Activism, visibility and support by AAN members can strengthen dissemination and enforcement. National acceptance of professional nursing full scope of practice, certification and license mobility will facilitate consumer access to professional nursing care, nurse career advancement and the desirability of nursing careers. Support Research on Workplace Issues: Research on the efficacy and the effectiveness of intervention models for work-related stress, recovery and peer assistance programs for health professionals, initiatives by regional hospital associations and state agencies to limit violence, and state policies on nurse staffing ratios and healthier work environments remain limited. Organization and member efforts to urge greater research funding for federal agencies like the NIH and AHRQ might advance these research agendas.

## Recommendation #2 support inclusivity/diversity, freedom from discrimination and equal opportunity for career advancement
A healthy work environment must address the culture, policies, and environment of an organization that contribute to nurse well-being. Policy must address structural racism, cultural racism, and discrimination based on identity, place, and circumstances and promote a diverse workforce (Partners for Nurses Staffing, 2022). AAN intentionally works toward healthy lives for all people, including nurses, through the dismantling of structural and institutional racism (AAN, 2021).
Legislative Action: Federal and workplace policies on inclusivity/diversity and protection from racial, gender, ability, sexual orientation and other forms of discrimination should be widely disseminated and enforced. Nursing perspectives and work-related concerns were not addressed in the National Academy of Sciences and Engineering report (NASEM, 2019) and pose considerable challenges to the profession. These include the failure to implement due process and adherence to Americans with Disabilities (ADA) guidelines for nurses with mental health/substance use and other disabling conditions, and state laws that restrict autonomy for advanced practice nurses . Nurse leaders can support legislation for macro level system transformation around structural racism, greater workforce diversity and the calling out of workplace issues, such as bullying, lateral violence, incivility, and provider directed violence (ANA 2019a). All negatively influence nurse well-being [bib_ref] An integrative review of nurse-tonurse incivility, hostility, and workplace violence: A GPS..., Crawford [/bib_ref].

## Recommendation #3: strategically advance efforts on the health and well-being of nurses
Retention of a healthy workforce in support of highquality practice and quality of life requires endorsing a continuum of health from wellness to recovery and thriving. While state regulatory bodies act to protect the public, emphasis on professionals' health and well-being is lacking. A national requirement for states to adopt the ADA requirements for Monitor and endorse legislation, aligning with other entities, to support federal and regional workplace policies on inclusivity/diversity and protection from racial, gender, ability, sexual orientation and other forms of discrimination Implement due process and adherence to Americans with Disabilities (ADA) guidelines for nurses with mental health/substance use disorders and state laws that restrict autonomy for advanced practice nurses Lead efforts in support of the development and implementation of changes to increase nursing's capacity to shape human resource policies in support of safe evidence-based standards and nursing practice Support legislation for macro level system transformation around structural racism, greater workforce diversity, and workplace issues, such as bullying, lateral violence, incivility and provider directed violence Recommendation #3: Strategically Advance Efforts on the Health and Well-being of Nurses
Recommend establishing a national requirement for states to adopt the ADA requirements for licensure questions, removing barriers for accessing employment of those recovering from mental health and substance use disorders Support major initiatives to destigmatize substance use disorders, mental health, and pathways to recovery and education for reduced risks for chronic illness, healthy lifestyles, and treatment of trauma/traumatic stress Dialogue with state and national nursing regulatory bodies in support of nurses' rights to comprehensive treatment for mental health/substance use disorders leading to recovery and successful return to practice N u r s O u t l o o k 7 1 ( 2 0 2 3 ) 1 0 1 9 1 7 licensure questions, removing the barriers for accessing licensure by persons in recovery from mental health and substance use disorders, should be developed. Pejorative language, stigma, and discriminatory hiring practices continue to hold nurses with health problems apart from the professional mainstream; major initiatives are needed to destigmatize substance use disorders, mental health and other disabilities and pathways to recovery. Federal funding to increase access to evidencebased mental health and substance use disorders treatment is essential [fig_ref] Table 1 -: Recommendations to Influence Policy on Clinician Well-beingRecommendation #1 [/fig_ref].

# Conclusion
The COVID-19 pandemic has re-enforced longstanding compromises on nurses' health and well-being and national and international health professional groups have recognized the need for organizational, social, and cultural change. There is an urgent need for the public, organizations, legislators, and the profession to act meaningfully at legislative, system, and organizational levels. AAN is the repository of expertise in its member panels, history of advocacy and network of partners and can be a significant instrument for change. Ongoing partnerships with other organizations can illuminate the links between clinician health and quality in education, practice and certification.
[table] Table 1 -: Recommendations to Influence Policy on Clinician Well-beingRecommendation #1: Advocate for Systematic Change to Achieve Healthier Work Environments Support and advocacy for legislation on recommended requirements for nurse staffing that optimizes nurses' roles and scope of practice Reinforce nursing expertise and leadership in establishing healthy work environments through legislation and regulation Establish forums for endorsing evidence-based practices to advance healthy work environments, including across the learning continuum in academic and clinic environments Expand advocacy for national and global research funding to NIH agencies and AHRQ on related agendas Disseminate evidence and rationale for changes in oped and editorials to the public, government and non profit health care agencies.Recommendation #2: Implement and Support Policy on Inclusivity/Diversity, Freedom from Discrimination and Equal Opportunity for Career Advancement [/table]