Three out of four nurses report concerns about stress and overwork — and 70% report feeling burned out. These numbers are alarming because, in addition to negatively impacting nurses' well-being, stress and burnout are linked to an increase in adverse patient outcomes, lower workforce productivity, and higher rates of nurse turnover.

To reduce frontline stress and burnout, nurse leaders are striving to build individual nurse resilience through engagement and wellness initiatives. In fact, hospitals and health systems have never been more committed to nurse engagement, retention, and wellness.

Despite this commitment, these initiatives alone are not sufficient, because stress and burnout are still increasing. As a result, health care leaders are now asking: What are we overlooking that is undermining nurse resilience?

According to Maslow's hierarchy of needs, individuals can't reach their full potential if they are struggling with basic needs. But in today's health care environment, there are unaddressed needs — or "cracks in the foundation" — undermining nurse resilience and leading to burnout.

The four cracks in the foundation are:

1. Violence and point-of-care safety threats are now commonplace in health care settings.
2. Nurses feel they have to make compromises in care delivery.
3. Staff bounce from traumatic experiences to other care activities with no time to recover.
4. New technology, responsibilities, and care protocols cause nurses to feel "isolated in a crowd".

Use this report to learn how to address these cracks in the foundation.

Use this section to address the crack in the foundation: violence and point-of-care safety threats are now commonplace in health care settings (starting on p. 17).

• Practice 1: Disruptive Behavior Algorithm (p. 21)
  Supporting Tool: Additional Resources from Sharp Grossmont Hospital
  
  
• Practice 2: Security-Driven Unit Rounding (p. 29)
  Support Tool: Security Rounding Tool
  
  
• Practice 3: Frontline De-escalation Team (p. 35)
  Supporting Tool: Valley Health’s Code Atlas Protocol
  Supporting Tool: Valley Health’s Code Atlas Summary Report
  
  
• Practice 4: Behavioral Health Emergency Response Team (p. 44)
  Supporting Tool: Mission Health's BERT Flow Diagram
  Supporting Tool: Froedtert Hospital’s BERT First Responder Responsibilities

Use this section to address the crack in the foundation: nurses feel they have to make compromises in care delivery. (starting on p. 51)

• Practice 5: Staffing Assumptions Leadership Exercise (p. 56)
  Supporting Tool: Valley Children’s Health Care Action Planning Selection Guide
• Practice 6: Frontline Moral Distress Consult (p. 63)

Use this section to address the crack in the foundation: staff bounce from traumatic experiences to other care activities with no time to recover. (starting on p. 69)

• Practice 7: Manager-Triggered Psychological First Aid (p. 73)
  Supporting Tool: Main Line Health’s Critical Incident Response Team (CIRT) Report Form
  Supporting Tool: Main Line Health’s CIRT Brochure
  Supporting Tool: Main Line Health’s CIRT Flyer
• Practice 8: Embedded Emotional Support Bundle (p. 81)
• Expert Insight: How Advocate Children's 'Bounce Back Kits' Improve Nurse Resilience

Use this section to address the crack in the foundation: new technology, responsibilities, and care protocols cause nurses to feel "isolated in a crowd." (starting on p. 89)

• Practice 9: 90-Second Storytelling (p. 93)
• Practice 10: Routine Clinical Reflections (p. 96)

• Practice 11: Float Nurse Unit Civility Survey (p. 103)
  Expert Insight: How to identify hotspots of incivility among staff
• Practice 12: Staff-Driven Code of Conduct (p. 107)
  Supporting Tool: Northumbria Healthcare NHS Foundation Trust's Ward Charter