Hi, good morning. Thank you so much for the invitation to present today. So while the title of my session is specific to nursing, what I'd like to do is to inform a conversation really about the collective actions that we all need to take together to move this forward. What are the challenges as we're experiencing caring for acute and critically ill patients as well? I have no conflicts to declare, and those are my objectives. So where are we? Well, here is some data to inform the conversation that I'd like to have this morning. In the last year, RN positions per year have been growing, but in 2021, we lost 100,000 RNs. But what's also very much concerning is that by 2033, we're going to have a projected shortfall of over 3 million of our low-paid wage earners who also support us in critical care, and over 140,000 physicians. The American Association of Critical Care Nurses, AACN, Work Environment Survey found that 24% of the respondents indicated that they did not have the appropriate staff with the appropriate skill levels to care for patients over 75% of the time. And 36% of the respondents indicated their intent to leave their position within a year. These numbers are borne out in the turnover data that you can see here. And to add to this crisis is the fact that you cannot simply replace an experienced care provider. It takes months. So these are some data I wanted to show you to inform what are actions that we can collectively do together. Now while many actions that we often talk about for staffing or that are related to wellness involve the individual, it's really important that we talk, and to be successful, we need to talk at a national level. So AACN and other healthcare organizations have called on CMS to publish clear parameters about what they mean about adequate nurse staffing. That definition does not yet exist. AACN is also leading a national initiative and partner with other major nursing organizations and healthcare finance organizations, as well as with the AIHI, to address the critical solutions for associated with both acute and critical care staffing. Now the membership of these groups, I think, are very well positioned to address what I consider the concept of value-driven nursing, which is that idea of rather than considering nursing as a cost center, nursing is considered as a service line to be promoted and to be enhanced. Now, a major step this summer from the task force was to identify and degree upon a definition, a working definition of what is appropriate staffing. And what I'd like you to note here is that it's more than numbers. Appropriate staffing aligns the nurses with the needs of the patient with a goal of quality care within a healthy work environment. You can't have any one of those to meet the needs of the nurses or the patients as well. Now one of the things that I think we all learned during the pandemic is that we can provide just-in-time critical care education. AACN and the major critical care medical societies have and continue to be leaders in the provision of this care. But we've also learned, as you heard from our colleague as well, that the care that we provide is unique, and while it can be augmented, it cannot be replaced. So the pandemic has brought into clear view the increasing specialization and expertise required to care for our acute and critically ill patients. So our models must consider not only the need to recruit individuals into critical care, but also to use innovative strategies to ensure that we have enough critical care professionals, nurses, advanced practice providers, physicians, respiratory therapists, pharmacists, all to care for these complex patients. Now as evidenced by the data that I've shown you and the definition of appropriate staffing, we need to not only recruit and train, we need perhaps even more importantly to retain experienced nurses. In 2021, the AACN work environment survey found an inverse relationship between perceptions of appropriate staffing and intent to leave. And among the individuals who said they had appropriate staffing less than 25% of the time, 32% of them said they were planning to leave their position within six months. Now under the nurses who indicated they had an intent to leave, I think what's important here is to look at what the top items they said would maybe keep them. And those were things such as a higher salary and benefits, better staffing, and also more respect from administration. And we must address these factors. But what I want you to note is that in addition to staffing and appropriate compensation, which we must address, there are other factors that also are associated with the intent to leave. So there's not one simple solution to this problem. So I wonder what can we collectively do and what questions do we collectively need to be asking to explore the solutions as we begin to address these challenges within our own health care organizations right now. So how do we move forward? How can we address this complex issue? A major aspect that we need to address now is our immediate environment as embodied in the healthy work environment. And on the left side of the screen, you can see the components of the healthy work environment. And those include such things as true collaboration, skilled communication, and effective decision making, which cross all aspects of the care providers. In 2021, over 9,000 nurses responded to this survey. And the results were no surprise that the RNs' perception of their environment has decreased since 2018. This is our reality. This is the soup we're all swimming in. But I think there is some good news because I think there are some things that we can begin to do now. We can take steps to optimize the health of our work environment while we're also working on the other issues of staffing and reimbursement. Here are some additional data from the survey that explores the effects of the implementation of a healthy work environment initiatives and perceptions on appropriate staffing and patient care. And what you can see is that there is a direct relationship between the healthy work environment and the perceptions of patient staffing, of the quality of care, and the nurses' satisfaction with their current position. And that nursing satisfaction translates into an intent to stay. Healthy work environments are also protective as indicated by the data on the intent to leave and on moral distress. Now what's important to note is that HWE applies to all care providers. This is not a nursing-specific initiative. So let me give you an example of the inextricable links between staffing, the work environment, and patient and staff outcomes. How research informs the practices, the initiatives that we need to take moving forward. So these are some results from a study by Lake in 2020 that explored the relationships between the characteristics of the work environment and staffing and missed care. We know that missed care is associated with adverse patient outcomes. And a recent systematic review by Stemmer found that unfinished work is also associated with nurses' reduced job satisfaction and intent to leave. So if you look at the types of care that are most commonly missed, what I see is care essential to preventing adverse outcomes. But I also see care that is associated with long-term outcomes. This study also identified critical components of the professional environments associated with missed care. There was an inverse relationship between the presence of a healthy work environment, including shared decision-making, leadership, staffing, and collegial nurse-physician relationships. And of note, a recent meta-analysis related to the retention of millennial nurses also found that creating a healthy work environment that's collaborative, fair, flexible, challenging, and provides opportunities for growth is what will engage those nurses and keep them in your organizations. Now Lake's study also explored, then, the changes in the work environment and staffing between 2006 and 2016 and its association with missed care. And what I thought was most interesting is that, well, the strongest effect was associated with the environment, with improved staffing having a lesser effect. So while we must address staffing, if we want to improve care and care outcomes and retention, we need to look beyond staffing as the sole answer. We all need to contribute to a healthy work environment. As they say, a rising tide lifts all boats. During the pandemic, advanced practice nurses were allowed to practice to their full scope of training and education with full practice authority. It's important to note that these providers of scope were not expanded. They were accepted. This is a map from the American Association of Nurse Practitioners. This is where we're at today. And I ask you, what care are we missing by restricting the practice of vital, qualified members of our health care team? Advanced practice providers are a part of the staffing solution. A paper by Dr. Timothy Buckman describes the integration of advanced practice providers into critical care at Emory. The outcomes of this care model, which now involve over 100 APPs, have demonstrated better care with healthier discharges, more discharges to home, fewer discharges to long-term care, reduced costs, and fewer readmissions. Finally, the Critical Care Societies Collaborative, representing the four major critical care organizations, convened a task force to address the critical care crisis in the United States. The group summarized areas that must be addressed and developed four national recommendations, including adopting common standards of care, leveraging information technology, and advocating for the support of policymakers to develop incentives and to define the optimum roles for intensive care professionals. This is a roadmap to address the critical care crisis. The FOCUS task force published these recommendations in 2004. The crisis they were hoping to avert is now upon us. It's time to act. Collectively, we don't have another 20 years. Thank you so much for the opportunity to present.

nursing challenges

staffing crisis

work environment

experienced nurses

healthcare collaboration