Healing the Healers: Fifty Years of Global Challenges and Progress in Nurse Psychological Wellbeing

Global health workforce shortages are projected to reach up to 10 million by 2030 (WHO 2022a), and protecting nurses' psychological wellbeing is essential for attracting and retaining staff who are critical to sustaining current and future healthcare delivery. Over the past 50 years, the nursing profession has undergone profound transformation, particularly in the area that has shaped much of my own career: nurse psychological wellbeing at work. Having begun my nurse training in 1979, my professional journey has almost spanned the lifetime of this journal, 47 of its 50 years. When training as an RN (not a degree programme) the focus was on clinical competence, obedience and discipline, with nothing related to the emotional or psychological realities of the work. The curriculum contained little, if anything, about stress, burnout, or moral distress, despite my early and vivid experiences of all three. Equally in clinical practice there was minimal recognition or support for the psychological demands placed on nurses and we were very much thrown in at the very deep end with students carrying extraordinary responsibilities; being left in charge of a men's surgical ward on night duty as a third-year student, with only a second-year colleague alongside me is a stark and very stressful memory. At the time, not knowing what I didn't know felt protective, ignorance as insulation, but it was certainly not protective for the patients. Just 2 years after qualifying, I left nursing; I thought for good, overwhelmed by burnout and moral distress (Maben 2015). My interest in the psychological well-being of nurses began then, although it would be another 10 years before I embarked on an academic research career in this area. Historically, nursing emphasised duty, moral resilience and self-sacrifice (Baly 1995) and the recognition of the importance of nurse wellbeing at work developed slowly. I believe the first paper in the Journal of Advanced Nursing (JAN) to focus on psychological wellbeing was written by Sister Dolan and published in 1987 (Dolan 1987); it examined the relationship between burnout and job satisfaction in nurses. The shift toward exploring psychological aspects of nursing, including stress, burnout and emotional resilience became more prominent in the 1990s, as the profession began to recognise the importance of the psychological health of nurses in relation to nursing practice. Today, the concept of nurse psychological wellbeing and self-care has become a cornerstone of professional practice, central to workforce sustainability, the quality and safety of patient care and the performance of entire health systems. In this commentary, I trace this journey and highlight the key work that has shaped our understanding of this fundamentally important topic, including insights from my own research. The work of Isabel Menzies Lyte in 1960 was one of the first studies to examine nurse psychological wellbeing. She took a case-study approach to the social problems of nursing, identifying that nurses' work generates high levels of anxiety, which organisations manage by creating social systems and routines that may protect nurses collectively, but may displace stress onto individual staff. Her ‘social defenses against anxiety’ theory explains how institutional structures, role fragmentation and ritualised procedures reduce immediate emotional strain while preventing individuals from processing fear, leaving nurses more stressed and less able to respond creatively (Menzies 1960). A decade later, broader nursing education reform already enacted in many countries, began to shift nurse roles from purely bedside tasks toward more autonomous and expanded practice roles (e.g., in the UK, the Briggs Report of 1972 laid out the need for nurse research, professional development and greater autonomy) (Briggs 1972). These changes indirectly impacted wellbeing by altering role expectations, job design and professional identity. Studies in the 1970's focused on stress, examining job strain and emotional exhaustion in nursing populations (Freudenberger 1974; Maslach 1976) and although the term burnout was coined in 1974 (Freudenberger 1974), it was in the 1980's that the Maslach Burnout Inventory (MBI) was developed (Maslach and Jackson 1981) which has come to define elements of nurse psychological wellbeing. While initially not nursing-specific, it was soon applied to nursing and became foundational for research on nurse psychological wellbeing providing the first validated tool to measure the three aspects of burnout: emotional exhaustion, depersonalisation and reduced personal accomplishment. Research in the USA in the 1980's, started to focus on the environments in which nurses worked. Aiken (1982) examined how the organisation and nurse staffing of hospitals, the ‘work environment’, affected both nurses and patients. The Magnet hospitals research (McClure 1983) identified a small set of hospitals that consistently attracted and retained nurses by creating excellent practice environments. Hospitals with supportive leadership, strong nurse autonomy, opportunities for development and collaborative nurse–physician relationships showed lower turnover, less burnout and better patient outcomes; environments that enabled nurses to exercise control, feel supported and practise in ways that reflected their professional values. Some of my early research demonstrated how important this alignment with professional values is for nurse retention. In my doctoral work, I identified sustained idealists as those practising in environments that allow new nurses to uphold the values instilled during their education. In contrast, compromised idealists experience an erosion of these values through organisational pressures. This leads to moral distress, lower job satisfaction and partial withdrawal from aspects of care. Finally, crushed idealists have their initial values overwhelmed by systemic constraints. They experienced profound disillusionment and emotional exhaustion and left the profession early, some after as little as 15 months post-qualification (Maben et al. 2006, 2007). Furthermore, over time there has been increasing attention paid toward moral distress (Jameton 1984; Wilkinson 1987). This occurs when actions conflict with deeply held values. Psychological distress, frustration and a sense of compromised integrity follow when external constraints, institutional policy, resource shortages or hierarchical decisions prevent someone from acting on their own moral values or ethical judgement. We have also seen growing recognition of vicarious trauma and secondary traumatic stress among frontline staff (McCann and Pearlman 1990; Figley 1995) which have been applied to nursing work more recently (e.g., Sinclair and Hamill 2007; Nolte et al. 2017). The landmark US report To Err Is Human (Institute of Medicine 1999) also highlighted systemic contributors to adverse outcomes, linking staff wellbeing to patient safety. In 2014 the US ‘Triple Aim’– improving the patient experience of care, improving the health of populations and reducing per capita cost, was expanded to the ‘Quadruple Aim’ by adding a fourth goal: improving the work life and wellbeing of health-care providers. This change recognises that clinician and staff experience is a prerequisite for achieving better patient outcomes, safer care and sustainable cost reductions. During this period legislative and policy levers to improve wellbeing also emerged. For example, nurse staffing ratio laws (such as California's AB394) drew attention to the connection between staffing levels, nurse workload and both patient and nurse outcomes. Poor work environments correlated with higher nurse burnout, lower job satisfaction and greater intent to leave, whilst adequate staffing helps protect nurse wellbeing by reducing overload, fatigue and in turn improving job satisfaction and retention (Aiken et al. 2008). Our recent monograph argues that nurse staffing, psychological safety, teamwork and willingness to speak up, together with good staff health and psychological wellbeing at work, are essential environmental prerequisites for healthcare improvement and high-quality care (Maben, Ball, and Edmondson 2023). In parallel, over the last 20 years, technology and electronic health records began to reshape clinical workflows in some countries. Although intended to improve efficiency, they also created new burdens, increased documentation requirements, frequent alerts and reduced time for direct patient care, which have negatively affected wellbeing and, at times, made the Registered Nurse (RN) role less satisfying. These changes coincided in many countries, with greater reliance on second-level nurses and assistants, removing RNs from the bedside and increasing their oversight and administrative responsibilities. Some have argued that this shift has sometimes displaced direct patient interactions for RNs, known to be some of the most rewarding aspects of nursing, making care less safe (Leary 2017). The links between staff wellbeing and patient experience and indeed patient outcomes, are now well established (e.g., Boorman 2009; Raleigh et al. 2012; Maben et al. 2012). My work, for the first time, linked staff and patient experience at the individual patient–staff level and demonstrated that staff wellbeing is an antecedent rather than a consequence of patient experience. Thus, systematically enhancing staff wellbeing is not only important in its own right, given employers' duty of care to their employees, but is also critical to maintaining high-quality patient care and experience. Staff motivation and wellbeing strongly influence patient experience and local work climate, including coworker and supervisor support, a positive organisational culture and low emotional exhaustion, is critical to sustaining staff wellbeing and enabling compassionate, safe and responsive care (Maben et al. 2012). Terminology has also changed over time. Nurse wellbeing is multifaceted. Encompassing physical health, emotional affect, job satisfaction, work-life integration and the ability to provide safe, compassionate care. Psychological ill-health includes stress, anxiety, low mood, together with early causes (such as trauma or moral distress) and consequences over time (burnout, absenteeism, reduced resilience, retention problems) (Taylor et al. 2024). Early 19th-century discourse on nursing emphasised self-sacrifice and the earliest research studies focused on concepts such as work stress, anxiety and occupational strain and did not use contemporary terms like ‘wellbeing’ or ‘burnout’ which are now well understood and well established. Use of the term wellbeing has however become ubiquitous and perhaps as a result has recently been critiqued as performative, giving rise to the term ‘wellbeing washing’, the practice of presenting superficial or performative wellbeing initiatives that reduce support to a tick-box exercise and leave nurses feeling unsupported (personal communication). Contemporary research frames wellbeing as closely tied to work environment, staffing, leadership, relational job design, organisational culture systemic supports and thriving and flourishing at work, rather than mere survival (West et al. 2020). A large body of research has thus documented various elements of the problem and the association between staff psychological wellbeing and patient experience. Ongoing research is developing and testing interventions that help staff deliver high-quality care while also supporting psychological wellbeing. For many years there was a focus on offering individuals specific training such as mindfulness and resilience training. Whilst this may at times be helpful, targeting individual coping rather than changing organisational factors like workload, staffing and culture cannot be the only answer (Maben et al. 2024; Stewart et al. 2024). Over time it has been recognised that individual interventions are not enough and there has been something of a backlash about promoting individual resilience whilst staff have no control over or ability to improve workplace conditions. Just before the pandemic we argued that resilience training for nurses cannot be a substitute for safe, well-resourced working conditions (Maben and Bridges 2020). We cited Traynor (2017) to warn that framing resilience as an individual duty risks blaming staff for problems that arise from systemic issues and it should not be used as a mechanism to shift responsibility away from employers onto individual practitioners. Asking nurses to be ‘resilient enough’ to cope with chronic understaffing, excessive workloads and organisational failures is unacceptable. In the 1980s and 90s clinical supervision became an important space for nurses to process their work and gain insight from other experienced nurses (Faugier and Butterworth 1994). Whilst the focus was on clinical aspects of caring it also allowed nurses to reflect on their practice and their emotional responses to challenging situations. There were also attempts to do group clinical supervision which may be considered forerunners to Schwartz Rounds (see below). From 2010 onwards, increasing emphasis was placed on evidence-based organisational strategies to enhance staff wellbeing, with Magnet approaches evaluated in new settings (Chen and Johantgen 2010; Sermeus et al. 2022) alongside the development of novel interventions and whole new ways of working (e.g., Buurtzorg nursing in the Netherlands). As opportunities for staff to come together and process work-related challenges diminished, due to increased workload and longer shift times, new approaches were introduced to create dedicated reflective spaces. One example is Schwartz Rounds which were initially developed and evaluated in the United States and subsequently implemented in the United Kingdom, Ireland and Australia. In the US, Lown and Manning demonstrated that Schwartz Rounds provide a safe, in which staff reflect on the emotional and relational of care, understanding and to compassionate practice. They also a with including greater emotional support, reduced of and to The first that Schwartz Rounds staff feel more reduced and increased and for and as well as enhancing and teamwork (Maben et al. was also with reduced psychological distress, with from to over with only minimal change in held Rounds provide a reflective space in which staff the emotional and ethical challenges of their work, the focus from individual resilience to relational and organisational work examining among and has used a to the and the need to shift away from focused interventions toward approaches that fundamentally through change and culture improvement (Maben et al. 2024; et al. are healthcare staff in developing to wellbeing alongside recognition that essential such as to and be and that interventions should be closely with identified problems to support wellbeing and (Maben et al. et al. these the causes of psychological ill-health more than that most interventions need not be may be in some such as those with frequent trauma at (such as or working in This body of work also how organisational in rather than staff psychological wellbeing. and are consistently in particularly staff and in countries, although the is This research also in to improve psychological wellbeing, including the of promoting wellbeing a in which organisational staff and that interventions recognise chronic (Maben, et al. Maben et al. 2024). In there are now many interventions to support wellbeing in some making it to know which to or and not all are evaluated or of In contrast, many Global health by nurse psychological health support and emotional et al. et al. there is and and many challenges (see The pandemic a systemic that the psychological on health systems and the to recognise that supporting nurse psychological wellbeing is not but is essential for sustaining the workforce and patient safety. The pandemic and in nurse wellbeing. Although some (Maben et al. for example, and for these were and responses that opportunities for support rather than sustainable Our research (Maben et al. that the pandemic workplace including stress and moral distress and high emotional and a greater and strain on and There was in some countries, including the UK, and Australia. 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