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Challenges in the nurse work environment, particularly those resulting from nurse shortages and the retirement wave, can affect the health and well-being of all Americans, not just nurses themselves or the health care organizations where they work. Many of the solutions to significantly expand the number of nurses in America will take many years to realize. However, there are some important changes that health care organizations can put into effect relatively quickly to enhance the work environment for nurses, which can improve care quality and safety, patient satisfaction, and the well-being of nurses. The biennial Survey of Registered Nurses by AMN Healthcare, which polled nearly 20 000 RNs, found that nurses are eager for many workplace changes that would create a healthier workplace while enhancing their professional and personal lives. These institutional changes also create opportunities for improving the health of the organizations themselves. Analysis of survey data found that improving professional development, flexibility and work-life balance, safety and team engagement, and organizational response to workplace violence can create a healthier workplace for nurses. These are known solutions that have yet to be fully engaged.

Nurse leaders in today’s health care settings bear the onerous responsibility of driving care outcomes despite evolving consumer demands, economic influences, scarce resources, and workforce challenges. Understanding registered nurses’ perspectives serves to inform nurse leaders’ decision-making and actions in rapidly evolving health care environments. Results from the AMN 2019 Survey of registered nurses provide insights from almost 20,000 nurses that provide care to patients every day. Knowledge from this survey can frame leaders’ strategic thinking and decision-making around workforce planning, recruitment, and retention, and sustaining healthy work environments. The report provides evidence that growing pressures on registered nurses will increase in the next decade and could impact quality of patient care, quality of life, retention, and the health and well-being of nurses. The survey also suggests sustainable solutions in the form of greater support for nurses in professional development, diverse workplace environments, and flexibility in work-life balance.

Healthcare-acquired infections are a tremendous challenge to the US medical system. Stethoscopes touch many patients, but current guidance from the Centers for Disease Control and Prevention does not support disinfection between each patient. Stethoscopes are rarely disinfected between patients by healthcare providers. When cultured, even after disinfection, stethoscopes have high rates of pathogen contamination, identical to that of unwashed hands. The consequence of these practices may bode poorly in the coronavirus 2019 disease (COVID-19) pandemic. Alternatively, the CDC recommends the use of disposable stethoscopes. However, these instruments have poor acoustic properties, and misdiagnoses have been documented. They may also serve as pathogen vectors among staff sharing them. Disposable aseptic stethoscope diaphragm barriers can provide increased safety without sacrificing stethoscope function. We recommend that the CDC consider the research regarding stethoscope hygiene and effective solutions to contemporize this guidance and elevate stethoscope hygiene to that of the hands, by requiring stethoscope disinfection or change of disposable barrier between every patient encounter.

Nurse bullying is a systemic, pervasive problem that begins well before nursing school and continues throughout a nurse's career. A significant percentage of nurses leave their first job due to the negative behaviors of their coworkers, and bullying is likely to exacerbate the growing nurse shortage. A bullying culture contributes to a poor nurse work environment, increased risk to patients, lower Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction scores, and greater nurse turnover, which costs the average hospital $4 million to $7 million a year. Addressing nurse bullying begins with acknowledging the problem, raising awareness, mitigating contributing factors, and creating and enforcing a strong antibullying policy. Nurses and stakeholders also must actively work to change the culture, and understand that bullying has no place in the nursing profession or anywhere else in health care.

Trauma nurses encounter multiple intense stressors on a regular basis. These nurses not only treat the injured patient following a traumatic event but then interact with family members who are also impacted by the event. Repeated experiences with significant trauma can have cumulative effects and negatively impact these nurses and the entire trauma team. Professional nursing associations make recommendations promoting wellness, and health care organizations implement wellness programs that foster and support mind, body, and spirit health. Individuals cope with and respond to stress in different ways, dependent on their unique backgrounds, beliefs, and support systems. Because of these differences, it is important for organizations to offer various ways for nurses and team members to process their reactions and use effective strategies to effectively manage stress. The organization highlighted in this case study offers several stress mitigation programs and techniques designed to support the overall health of trauma nurses and restore their emotional well-being, so that they are best able to care for their injured patients.

Improving the rate of survival among the 209,000 patients with an in-hospital cardiac arrest (IHCA) each year in the United States 1 depends on the provision of high quality cardiopulmonary resuscitation (CPR). Leading health care advisories, such as those of the Institute of Medicine 2 and the American Heart Association (AHA), 3 suggest that the current survival rate of 22.3% from IHCA 4 can be improved through organization- and systems-level continuous quality improvement initiatives. As a result of the high number of arrests with low survival rates and new initiatives focusing on continuous improvement, likely cardiac arrest and the provision of high quality CPR will be a Centers for Medicare & Medicaid core measure.

As nurse leaders, we lead with values that emerge from our clinical foundations, patient advocacy, ethics, sense of justice and moral centeredness. Creating environments that enable these to flourish within a context of business, finances, strategies, and standardization is the challenge for nurse and healthcare leaders of today. The pressures on the modern-day nursing system, profession, and organization have never been greater nor the need to keep humanity at the center of all we do. We are sharing our work to create an environment that focuses on excellence, through individual courage and professional bravery, with the goal of increasing understanding, informing opinions, and helping other organizations.

The current healthcare environment presents healthcare leaders with a number of challenges, many of which are generated from the continuing rise in cost, workforce shortages, and decreased access, especially for our most vulnerable patients—all leading to a declining health status of a nation. The ability of any leader to provide effective leadership in today's environment is challenging and requires significant intellectual, human, and financial resources. For the nursing profession, this presents a unique dilemma, one that Johansen1 views as an opportunity—a "dilemma flipping" opportunity. Dilemma-flipping opportunities arise when two opposing ideas can be merged into an opportunity for change.

COLE EDMONSON, FACHEThe GREATEST risk of silence is that eventually we become morally blind and deaf to difficult issues that arise in healthcare (Bird 1996). The specter of such a risk calls for highly ethical and moral leadership, especially in a system in desperate need of transformation. The choice to take the easy path, instead of the moral one, is unacceptable, whether for clinicians or healthcare executives. As the authors of the feature articles in this issue describe, achieving financial success and high-quality care delivery for any organization without a morally centric philosophy is at best a short-term and unsustainable approach.THE POWER OF A MORAL COMPASSThe concept of the moral compass in healthcare is based on four guiding points: (1) integrity, (2) responsibility, (3) compassion, and (4) forgiveness. Having the ability to visualize this compass creates a sense of direction toward an inspired vision. Healthcare organizations guided by leaders with a strong moral compass operate within a framework of humility and intellectual curiosity that is grounded in doing the right thing.Morals do not shift or change with time; rather, they are constant. The major difference between morals and ethics is that morals are personal characteristics of individuals and ethics involves a structure that is more applicable to systems and may be dependent on a number of external variables. Recognizing the difference between these two concepts can help executives understand how moral characteristics of individuals play out in the social context of ethical codes and systems.Some readers may easily miss the warning that Ruth W. Brinkley, FACHE, expresses in her article, so it is worth repeating here: Leaders must be ever mindful that their personal moral compass also serves as the moral compass of the companies they lead. This notion is cautionary in that leaders in healthcare, in general, have little formal training in broad ethical principles or in ethics frameworks that can be applied across business, clinical care, quality, safety, and service domains. More often, these leaders receive training only in compliance and business ethics; issues related to bioethics, for example, are absent from their training.Ethics Training and the Moral CompassWe see this trend in the nursing profession. A study by Grady and colleagues (2008) found that just 57 percent of nurses reported having any level of ethics education in their professional programs. Considering that nurse leaders represent the largest portion of all leaders in healthcare, a clear gap exists between the ideal state, in which moral and ethical leaders are able to draw on a knowledge base of ethics training in their practice, and the current state of practice.Jameton's (1984) seminal work frames the concept of moral distress as arising when one knows the morally right thing to do but cannot act on that knowledge because of organizational constraints. According to Jameton, moral issues are defined not by the scientific how-to but by the question of ought-to. For example, deciding how to provide care is different than deciding for whom the care should be provided.Jameton (1984) further notes that nurses act as the moral center of healthcare and provide the image and inspiration of ethical care and compassion. Corley (2002) found that nurses act as moral agents in the healthcare system, and as a result, patients, nurses, and the organizations in which they work all benefit. These moral acts lay the foundation for increasing nurse retention, promoting patient comfort, relieving patient suffering, and enhancing the reputation of the organization (Edmonson 2010).Can healthcare leaders who act in a morally courageous manner in difficult situations similarly affect these stakeholders? I hope and believe so.IS YOUR ORGANIZATION A HIGHLY RELIABLE MORAL ORGANIZATION?Many hospitals and health systems seek to become high-reliability organizations (HROs), in which what should happen does happen, and what should not happen does not. …

Incivility, horizontal violence, and/or bullying in health care is a growing problem and threat to patient safety. This article will provide an overview of bullying, synthesis of the literature, discussion of the effect on patients, nurses and organizations, and description of steps that can be implemented to eradicate bullying.

While nurse researchers and administrators in health care organizations need to collaborate to understand the variables that affect nursing practice environments and patient care outcomes, there are inherent risks associated with these collaborations that require careful consideration. A team of academic and hospital researchers found that in studying the off-peak (nights and weekends) nursing environment using institutional ethnography, which involved interviews of nurses and administrators, the subject of the research was frequently the hospitals where these individuals worked. Although the individuals who participated in the research consented to be interviewed about their work, it was less clear how and to what extent the anonymity of their organizations could be maintained. The risks and benefits encountered suggest the need for a decision-making process to be undertaken by collaborative research teams. This decision process and analysis can help ensure a fruitful research relationship that protects sensitive concerns of hospital entities while advancing our understanding of nursing practice environments and patient care outcomes. Important strategies include having all leaders and research team members discuss the agendas of all entities and individuals involved, including clearly delineating the roles, responsibilities, and contributions of all parties. In addition, any constraints or expectations of first right of review of publications needs to be negotiated from the outset. Collaborators need to review their agreements throughout the research process to avoid pitfalls that could adversely impact the relationships as well as the dissemination of knowledge gained.

Wondering where to begin to improve outcomes in patient satisfaction and nurse manager engagement? How about the middle manager! The nurse manager position most often represents the point in the organizational structure where the greatest pressure is directed from both leadership (above) and direct care staff (below). Positional authority is often moderate, at best, and in many organizations, the position is underrecognized and underrespected for the critical role in achieving organizational outcomes.

The 2014 International Nursing Administration Research Conference, "Pioneering Through Chaos: Leadership for a Changing World," was held at the Texas Woman's University in Dallas, Texas, in the fall of 2014. The program drew more than 100 attendees from 4 countries. The conference informed attendees from both academe and practice about the role of nursing administration in navigating the dynamic healthcare climate. This article will report on the insights from the conference presenters.

Moral distress among practicing nurses is frequently discussed in the nursing literature, along with well-developed recommendations for increasing moral courage in practicing nurses. Implementing these recommendations depends on nurse leaders being morally fit to lead and to create an environment in which moral courage actions can emerge. The literature is lacking pertaining to nurse leaders’ preparation to lead in a morally courageous and transformational manner in our current corporate environments and hierarchies of healthcare. In this article, the author reviews the literature addressing moral distress and moral courage among direct care nurses; describes the development of an intervention to strengthen the moral courage of nurse leaders; reports a study that involved implementing this intervention; presents the findings of this study; evaluates the effectiveness of the intervention; and discusses the findings in terms of lessons learned and future directions. He concludes with a call for healthcare leaders to demonstrate moral courage and create environments that promote morally courageous acts that enable nurses to remain centered on the patients, families, and communities we serve.