How to get nurses to stay? Less talk, more action, says AACN president

The widespread shortage of nurses is the result of a foundational crack in hospital systems across the country, Amanda Bettencourt, PhD, APRN, president of the American Association of Critical-Care Nurses, told Becker's.

It's not about money and it's not about burnout, Dr. Bettencourt said. "Hospitals are failing to provide safe, healthy work environments, and the result is an absolute feeling among critical care nurses that hospitals don't have our backs."

In the AACN's most recent survey, published in the October 2022 issue of Critical Care Nurse, less than half of the participating nurses said their hospitals value their health and safety. 

Not an unlikely statistic considering a Press Ganey report said more than two nurses were assaulted every hour in the second quarter of 2022. 

"How can you provide excellent care when you feel like the place that you work for doesn't care about your health and safety? We had our patients' backs during the worst part of the pandemic — when we didn't know what to do. We raised our game and met the patients' needs," Dr. Bettencourt said. "And then nurses looked at our hospitals and said, 'What about us?'" 

As far back as 2004, the Institute of Medicine called on hospitals to create healthy work environments for nurses and pointed out the connection to patient safety and positive outcomes. "That was almost 20 years ago, so we know this problem has existed for a long time, and I think the pandemic just poured gasoline on that fire," she said.

But the solution, she added, is also not a secret. The AACN issued a strategy — with six distinct standards of care — for improving healthcare work environments almost 10 years ago. These include: skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition and authentic leadership. 

In addition to conducting research at the Children's Hospital of Philadelphia, Dr. Bettencourt is an assistant professor at the University of Pennsylvania School of Nursing, teaching clinical courses to undergraduate nurses in pediatrics. 

She said there's been a lot of talk about changing the work environment for nurses, but not enough action, adding the nursing exodus is the result of hospitals failing to put strategies in place to ensure healthy environments — places where nurses want to work because they feel valued.

Question: The most recent AACN national nurse work environment survey reiterates your point. Only 40 percent of all respondents indicated they were very satisfied with being a registered nurse, compared with 62 percent in 2018. Can you explain why you think a failure to focus on creating healthy work environments is directly tied to the nursing shortage?

Dr. Amanda Bettencourt: Nurses aren't going to stay in a work environment that is not good for them. And we know the best patient outcomes occur when our work environments are healthy. 

Creating a healthy work environment is an investment that pays dividends. A hospital can try many ways to attract nurses, but if any of those solutions are laid on top of an unhealthy work environment, they are going to fail. 

New nurses will not stay in a profession when they feel their health and safety is being threatened. And that's what we are seeing — more and more new graduate nurses leaving the acute care environment or the profession entirely after one or two years of practice. That's not a sustainable pipeline. 

Yes, we need more people to enter the nursing profession. But if we don't fix the problems, new nurses are coming into the same environment that's making today's nurses leave. So we can bring them in, but we'll lose them eventually, and we'll be back in the same place that we're in today. 

Q: What can hospitals start doing now to keep nurses from leaving the profession?

AB: We absolutely think that the work environment for nurses should be a critical point of attention for hospitals right now. Of the AACN's six standards for care, the ones that tend to make the biggest difference are things like respect from administration, having nurses at the tables for decision-making, having true collaboration and communication, and then making sure that leadership in those hospitals is authentic and collaborative. 

These are things that matter to nurses; everything in the work environment has to be healthy. Just adding more nurses is not enough if nurses are entering work environments that are not healthy. The AACN's six standards can be directly attributed to higher quality patient care, lower nurse turnover and lower incidence of violence against nurses.

Hospitals should have implemented these standards a long time ago. And now we are seeing the consequences of unhealthy work environments. Nurses are leaving. 

If you are a leader at a hospital and you've thought about implementing these six standards, now's the time to actually do it. They can make a huge difference in outcomes that matter to patients and outcomes that matter to hospitals. And they will go a long way to retaining  extremely talented and valuable acute and critical care nurses.

Q: Why haven't these six standards of care been implemented in all hospitals already?

AB: I know hospital leadership absolutely recognizes that these things are important as we are saying they are. Each one of these things is difficult to change; they're not easy fixes. We need  hospital leadership to be talking about these things, because that will mean they understand the need for the changes.

But it's going to take more than talking. Hospitals have to put effort and energy and resources into changing these things in a real and authentic way. It's time for them to put their money where their mouth is and put resources and effort into really making changes the nurses will feel. A nurse knows if they're working in a place that's healthy, that has appropriate staffing, that has authentic leadership. We can feel it. Whatever effort needs to be put in so that hospital culture changes and work environments for nurses are transformed — now is the time to do it. 

Q: In the AACN survey, only 47 percent of respondents said they agreed with the statement, "My organization values my health and safety," compared with 68 percent in 2018. What has to change?


AB: Violence against healthcare workers, in general, has been a problem for decades — again, protecting nurses is a core part of a healthy work environment. But it's clearly getting worse. Is it the pandemic or are there societal changes that have made nurses feel the retaliation from patients and families more often than before?


The AACN takes a strong stance on violence against healthcare workers; we have a "zero tolerance" policy. We support hospitals having a zero tolerance for violence against their workers. I think it's sad that I have to say that out loud. If I'm a nurse in a hospital and my patient assaults me in any kind of way, I would expect that my hospital would support me in that encounter. But it is very often the case that the patient is the one who is supported and the nurse is expected to assume that the risk of verbal, physical and even sexual assault comes with the job. 


It's not acceptable. It is not okay for a nurse to come into work every day and have to expect to be hit, slapped, bitten, verbally assaulted or sexually assaulted. These are not things that should happen, but they do. It's very demoralizing if something like this happens and hospitals don't support their nurses.


Q: Are hospitals doing enough to communicate "zero tolerance" policies regarding violence against nurses?

AB: It certainly has to be more than a message on a poster. I've heard recently from one of our members about a hospital where patients have to watch a video of the CEO of the hospital saying that violence against our workers will not be tolerated and you will be asked to leave if you don't comply. Other hospitals have done publicity campaigns online and [on] social media, through print and TV.

Doing campaigns like this can speak volumes to the clinicians who are worried for their health and safety. I think these things can go really far to help. But the question, then, is: Will hospitals follow through? Hospital response absolutely must be authentic. The policy has to be enforced. 

Q: Can you describe a time when, as a critical care nurse, you felt truly valued? 

AB: I took a travel assignment in a place (Shriners Children's Boston) that has been, to this day, the healthiest work environment I've ever worked in. On my very first day, I went into a very sick child's room and saw the team was having problems getting the child comfortable on a ventilator. The attending physician turned to me, introduced himself, and said, "Amanda, have you seen anything in the other places you've worked that might actually help this patient?"

He had just met me and valued my expertise right away. I gave a suggestion and we tried it! And it was much better for the patient. 

That physician made me feel like a valued person on the team on my very first day there. Knowing my input mattered, that everyone respected each other's clinical backgrounds and that the culture was one where everyone has something to learn from each other made all the difference to me. 

Q: How can hospitals focus on culture when they are so short-staffed?

AB: Everyone focuses on their staffing these days because there's absolutely a number of nurses needed or safe care can't be delivered. But healthcare is about more than numbers, and hospitals have to realize that. Excellent patient care requires other things — culture, the work environment, collaboration, leadership and not only communication but the right kind of communication. 

Sure, nurses might want better pay or better benefits. That's a part of it. But, also, nurses really want to be respected partners in the care of patients. We want to be respected by administration and have a voice in the changes being made with regard to patient care.

The way to create that culture starts by listening to nurses, caring about what we say. Respect us as clinical partners. This is not an initiative that comes only from the administration. It has to come from the team deciding that they want to change and work toward a healthier environment for everyone. 

If all hospitals committed to implementing the six standards of care, we would transform healthcare.

Q: Are these standards of care difficult to put in place to create the necessary culture?

AB: You know, the solutions we are suggesting seem simple on paper: communication, collaboration, decision-making, respect, trust — these are all things we want from our employers. Again, it has to be part of the culture. These things can't be ignored when we are stressed because turnover is high. That's when hospitals have to put in more effort to meet the standards. 

We all know communication matters and that collaboration is important. But we need to make sure that it happens across all the teams, across the whole organization.

I saw it firsthand. I decided to stop being a travel nurse and took a full-time staff position [at Shriners Children's Boston]. I realized I had never felt like I could make my optimal contribution as a nurse until I landed in a place with a healthy work environment. And that's what every nurse is looking for. 

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