With the ongoing stressors of the COVID-19 pandemic adding to the physical, emotional, and mental exhaustion among nurse practitioners (NPs) nationwide, Clinical Advisor is examining the standards of what constitutes a healthy work environment and what our readers can do to create healthy boundaries.

“Many institutions are stepping up and providing deep support beyond what we saw in the early days of the COVID-19 pandemic,” said April N. Kapu, DNP, APRN, ACNP-BC, FAANP, FCCN, FAAN, President of the American Association of Nurse Practitioners (AANP). “Working extra hours for days or a week after a natural disaster is understandable, but “you cannot work in crisis mode over months and years,” emphasized Dr Kapu, who is an acute care NP at Vanderbilt University Medical Center, associate dean for clinical and community partnerships, and professor of nursing at Vanderbilt University School of Nursing in Nashville, Tenn.

These healthier organizations have policies in place on how many days and hours can be worked in a row, vacation days, and employee assistance programs for counseling and support services. These efforts are paying off. According to Dr Kapu, these institutions are “where we are seeing better retention and engaged employees.”

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April Kapu Headshot
April N. Kapu, DNP, APRN, ACNP-BC,

One of the support systems that have been put in place is “a proactive system to reach out to NPs to talk, about their day, about anything, but just to talk and listen. Their stories are powerful and moving, it is important to be heard,” Dr Kapu said. Debriefings are essential for NPs working in ICUs given the sheer number of deaths witnessed during the COVID-19 pandemic. “We need to take time to debrief, acknowledge what has happened, and grieve. The grief process is just as important for NPs as it is for everyone,” she said.  

“Intensive care unit NPs are seeing more death than we have ever experienced and in patients who were doing great before they got COVID-19; now, we are there, holding their hand as their families say goodbye,” she said. “Words cannot describe how the pandemic is impacting each and every NP let alone health care worker,” Dr Kapu said.

Burnout Before and During the Pandemic

As Dr. Kapu noted, clinicians were burned out even before the added stressors of the COVID-19 pandemic. Research conducted by Dr Kapu and colleagues found that 60% of advanced practice registered nurses (APRNs) reported currently or previously experiencing burnout.

A survey of nephrology nurses showed that 62% reported experiencing burnout before the pandemic. Nearly 50% had symptoms of anxiety (Generalized Anxiety Disorder-7 scores ≥5).1 During the pandemic, 56% of these clinicians reported caring for COVID-19 patients and 62% were somewhat or very worried about COVID-19.

Standards for Healthy Work Environments

To combat burnout, the American Association of Critical-Care Nurses (AACN) has outlined 6 essential standards that provide an evidence-based framework for creating a healthy work environment2:

  1. Skilled communication
  2. True collaboration
  3. Effective decision making
  4. Appropriate staffing
  5. Meaningful recognition
  6. Authentic leadership

The AACN offers a free assessment tool that teams can use to measure their work environment against the 6 standards. The tool also generates a report with recommended steps and resources to enact change in the work environment and measure progress.

Implementation of the AACN standards was associated with significant improvements in nursing outcomes such as increased job retention and satisfaction and fewer reports of abuse, according to a survey of 8080 critical care nurses.2 The findings are based on responses to the Critical Elements of a Healthy Work Environment Scale in 2013 and 2018.

Few respondents (5%) said that the standards were fully implemented at their institution, 18% said the implementation process was well underway, 21% said their unit was just beginning to start implementation, and 56% said that the process had not started.2 Nurses in units that had not implemented the healthy work environment standards were more likely to intend to leave their job than those in units that had implemented the standards (59% vs 39%).

Both inadequate staffing and verbal and physical abuse remained major concerns among this cohort of critical care nurses.2 More than 60% of participants reported staffing issues and 198,340 incidents of physical and mental well-being issues (verbal/physical abuse, discrimination, sexual harassment) were reported by 6017 participants. These issues contributed to the intent of 54% of respondents to leave their positions in the next 1 to 3 years.

Healthy work environments also affect patients with research showing that patients in hospitals with poor work environments are 16% less likely to survive an in-hospital cardiac arrest compared with those in hospitals with better work environments.3 Poor work environment is also significantly associated with higher 30-day readmission rates following surgery and reductions in hospital accidents including medication errors.4

Catherine J. Goodhue, MN, CPNP-PC, and Deborah G. Harris, MN, CPNP-AC/PC, CNS, offered the following suggestions on what health care facilities can do to create a healthier environment5:

  • Flexible scheduling practices – offer both 8-hour and 12-hour shifts, part-time and full-time jobs, and moonlighting in other critical care/acute care areas at the facility
  • Offer residency or fellowship programs for NPs
  • Promote mentorship/preceptor roles
  • Employ a director of APRN who can bring issues to the attention of the executive leadership team
  • Allow NPs voices to be heard through surveys, focus groups, and small group meetings

A Message to NPs

During these stressful times, Dr Kapu reminds NPs to go back to the basics — make sure that you are eating, hydrating, sleeping, getting outside for fresh air and walks, exercising, and taking time off. “As we approach year 3 of the pandemic, this is the time for self-care,” she said.

“You have to stop and say, I can’t go on like this forever, on an empty tank of gas,” Dr Kapu said. “You’ve got to refuel, recharge. If you don’t, you are not going to be able to bring your very best self to your patients, which is really why we entered this profession in the first place.”


1. Montoya V, Donnini K, Gauthier-Loiselle M, et al. Mental health and health-related quality of life among nephrology nurses: a survey-based cross-sectional study. Nephrol Nurs J. 2021;48(5):447-461.

2. Ulrich B, Barden C, Cassidy L, Varn-Davis N. Critical care nurse work environments 2018: findings and implications. Crit Care Nurse. 2019;39(2):67-84. doi:10.4037/ccn2019605

3. McHugh MD, Rochman MF, Sloane DM, et al. Better nurse staffing and nurse work environments associated with increased survival of in-hospital cardiac arrest patients. Med Care. 2016;54(1):74-80. doi:10.1097/MLR.0000000000000456

4. Ma C, McHugh MD, Aiken LH. Organization of hospital nursing and 30-day readmissions in Medicare patients undergoing surgery. Med Care. 2015;53(1):65-70. doi:10.1097/MLR.0000000000000258

5. Goodhue CJ, Harris DG. Nurse practitioner job satisfaction and the healthy work environment. AACN Adv Crit Care. 2019;30(3):274-277. doi:10.4037/aacnacc2019451