Organizational mental health and wellness supports: Nursing retention toolkit
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- Goal statement
- Initiative – Zero-tolerance for violence, bullying and racism: Develop enforceable policy to address bullying and increase awareness of Bill C-3
- Initiative – Moral distress and injury care: Provide trauma-informed care (distinct from critical incidents), which involves an institution-wide cultural shift, and prioritizes trauma-informed principles of safety, choice, collaboration, trust, and empowerment
- Initiative – Best practices for vacation and time-off: Develop and implement practices and policies to ensure equitable opportunities for people to take time off work
Goal statement
Increase timely and fulsome access to appropriate and effective preventative and acute health and wellness supports, with an urgency and focus on mental health supports.
Initiative – Zero-tolerance for violence, bullying and racism: Develop enforceable policy to address bullying and increase awareness of Bill C‑3.
Intended outcome
- Improved knowledge of the standards regarding the psycho-social, mental, and emotional requirements among nurses that are to be honored in the workplace by patients, family members, colleagues, leadership, and management.
- Improved retention of nurses who may otherwise leave organizations owing to racism in the workplace.
Description
This initiative focuses on bringing awareness to the zero-tolerance behaviours that are not acceptable towards or within the nursing community. This initiative should include zero-tolerance for violence, zero-tolerance for bullying, and zero-tolerance for racism.
- Achieving zero-tolerance involves the development and implementation of policies, procedures, and actions against violence, bullying, and racism directed at nursing professionals, as well as internal, horizontal violence. Policies should be accompanied by organizational supports for nurses when incidences of violence, bullying, and racism do occur.
- Anti-racism policies are often embedded into EDI practices; however, anti-racism is not captured in EDI, and instead, organizations should adopt Equity, Diversity, Inclusion, and Anti-Racist (EDIA) practices, i.e., anti-racism should not be blanketed and "sandwiched" into EDI practices. For example, anti-racism practices need to promote allyship so people feel safe in an environment that supports zero tolerance for racism. EDI practices help to promote fairness and representation in the workplace, such as outlined in the Action Plan by the Diversity, Equity, Inclusion, and Belonging Council (DEIB) at Horizon Health Services.
Planning considerations include:
- Wrap-around programmatic supports: Policies alone are insufficient. A program of supports is critical to address nurses' needs including mental health after incidences occur. For example, nursing contracts can be revised to include leave for nurses who experience violence.
- Training for nursing teams: Comprehensive training on recognizing and addressing zero-tolerance for unacceptable behaviours, which includes what nurses and nursing teams can do in the moment when violence, bullying or racism is occurring (e.g., specific language that can be used, specific processes such as "Code Whites"), and training on horizontal violence (e.g., bullying and racism in the workplace among co-workers).
- Reporting mechanism: A confidential reporting system that ensures protection for those reporting.
- Awareness campaigns and community collaboration: Create awareness with campaigns and accompanying workshops, and engage nursing associations, unions, advocacy groups to amplify impact.
- Surveys on perceptions of safety: Conduct surveys to measure nurses' perceptions of safety, inclusion, and support within the organization or health system.
- Monitor number of reported incidents: Track and analyze trends to assess the impact of initiative (e.g., frequency and severity of incidents).
- Monitor policy compliance: Evaluate adherence to policy compliance and whether appropriate actions are taken in response to reported incidents. What happens after an incident is reported must be monitored and measured to understand the experience and outcomes of the nurses' journey throughout the process.
Target nursing population
All (Student, New Grad, Mid-Career, Late-Career, Managers and Faculty, etc.)
Stakeholder involvement and role of nurses
- Responsible: Nursing employers and organizations must acknowledge their role in addressing violence, bullying, and racism in the workplace and be equipped with the tools and strategies to:
- handle incidents with consequences,
- support victimized staff,
- prevent future occurrences.
- Accountable: Nursing employers, educational institutions, organizations, unions, and regulatory bodies must have accountability measures in place to enforce consequences for violence and bullying in the workplace. They must also promote cultural safety in the workplace by providing training opportunities.
- Consulted: All levels of nursing students and staff.
- Informed: Nurses need to be educated about what violence, bullying, and racism looks like in the workplace, as well as the measures that are taken to prevent occurrences and instill consequences. Nurses also need to be educated about what anti-racism looks like in the workplace and promote cultural safety.
Reference resources and examples (See appendix for links)
Call to action:
- Joyce's Principle: A call to action and a commitment from governments to end systemic racism lived by Indigenous people in health care and social services.
Legislation:
- Bill C‑3: This federal bill amends the Criminal Code in Canada to enhance protections for health care workers, including nurses.
Declaration:
- Nursing Declaration Against Anti-Black Racism in Nursing and Health Care: Nurse associations from across Canada joined together to create this nursing declaration, which can be referenced by health care organizations.
Toolkits and courses:
- Innovation, Science and Economic Development Canada's 50-30 Challenge: Your Diversity Advantage: An online toolkit designed for all Canadian organizations looking to implement equality, diversity, and inclusion practices.
- PSPNET Posttraumatic Stress Injury Resources: resources such as therapist and self-guided courses for public safety personnel and their families.
- Ontario Anti-Racism Directorate resources: Ontario's Anti-Racism Data Standards were established to help identify and monitor systemic racism and racial disparities within the public sector.
Reports and recommendations:
- House of Commons Standing Committee on Health Studies: Violence Facing Health Care Workers in Canada Report: Report with nine recommendations on how the health system can address workplace violence.
- Centennial College Anti-Black Racism Task Force Report: This task force report includes working group descriptions and the task force's commitments related to curriculum, education and awareness, and psychologically-safer environments, anti-racist and interculturally-competent leadership, human resources, data collection and reporting, which can be leveraged by health care organizations.
- Registered Nurses' Association of Ontario's (RNAO) Acknowledging, Addressing and Tackling Anti-Black Racism and Discrimination Within the Nursing Profession: The RNAO's Black Nurses Task Force (BNTF) released a report that features 19 recommendations, many of which are applicable at the health care organizational level.
- CASN Promoting Anti-Racism in Nursing Education in Canada Report: The CASN Anti-Racism in Nursing Education Working Group has prepared this report to present recommended strategies for schools of nursing to incorporate an anti-discriminatory pedagogy, provide culturally safe context for learning, and educate students to actively challenge racism. Recommendations within this report can be adapted by nurse employers and health care organizations.
Example policies, standards, communications materials:
- BCCNM Practice Standards on Indigenous Cultural Safety, Cultural Humility and Anti-Racism: BCCNM has established practice standards with principles related to self-reflective practice, building knowledge through education, anti‑racist practice, creating safe health care experiences, person-led care and strengths-based and trauma-informed practice.
- Horizon Health Network Code White: Horizon Health Network has policies for immediate action against violence, including Code White Team responders – a multidisciplinary team trained to provide a coordinated approach to violence intervention.
- IWK Health in Nova Scotia Antiviolence Posters: IWK Health has posters related to their anti-violence and anti-racism initiatives that can be leveraged by other organizations.
- BC Cancer Centre violence prevention and management policy: The policy has been implemented and is actively used by nurses.
- Canada Labour Code: The Act that defines the rights and responsibilities of workers and employers in federally regulated workplaces, and sets out federal labour law.
Initiative – Moral distress and injury care: Provide trauma-informed care (distinct from critical incidents), which involves an institution‑wide cultural shift, and prioritizes trauma‑informed principles of safety, choice, collaboration, trust, and empowerment.
Intended outcome
- Leading practices at the individual and organizational level to support nurses through morally distressing situations, including the removal of barriers to mental health care, and supports for post-moral-injury situations are created and implemented.
- Nurses are provided with the autonomy to create and utilize support plans.
- To protect them, nurses are removed from situations that cause morally distressing experiences.
Description
This initiative focuses on creating a cultural shift that provides support and healing to those who have experienced moral injury and distress in the workplace.
This initiative should include:
- Individualized care plans: Each moral distressing experience must be honoured alongside one's morals, feelings, and experiences, which may differ from others in similar situations. Nurses need the ability to apply trauma informed care to their own experiences and self-care. For example, Alberta Health Services offers trauma informed care training to staff, which includes a module on workplace trauma exposures and self-care.
- A single reporting system: Organizations can reduce the occurrence of nurses reliving traumatic experiences by implementing a single system to report the moral injury or distress in the workplace..
- Standardized care programs: Implement more standardized, structured care programs across the organization to support nurses during and after morally distressing situations.
- Cultural shift: Foster an environment that encourages and supports an individualized approach yet supports the broader nursing community within the organization and where all individuals feel a sense of responsibility to prioritize trauma-informed care (i.e. recognizes the impact of trauma and life experiences in order to deliver effective care).
Planning considerations include:
- Engagement of nurses in policy and protocol development: Co-develop trauma-informed care policies and protocols that are relevant to nurses experiencing moral distress or injury.
- Collaboration and consultation with mental health professionals: Seek expertise when developing resources and interventions tailored to nurses' needs and provide independent resources for nursing staff to utilize when seeking support as the uptake of external resources is higher in some regions compared to in-house employee assistance programs.
- Developing management competencies: Educate nurse leaders, managers, executives and directors in moral distress or injury care to increase comfort and confidence in responding to trauma-related situations.
- Referral procedure and training: Develop a process for nurse leaders, managers, executives and directors to refer individuals to the appropriate team or individual for support. Train managers and leaders on the referral procedure regularly.
- Appropriate trauma-informed mental health supports: Support for nurses should be provided by trained mental health clinicians who understand the nursing profession, the impact of personal trauma on a nurse's practice, and culturally sensitive care. Organizations may want to consider a float team of mental health clinicians to support heath workers, including nurses. Dedicated Occupational Health & Safety resources can be implemented to provide support and understand the nursing profession through additional training if required.
- Communication about available mental health supports: Equip nurses with the knowledge to be able to seek out information and mental health supports within the organization or externally, especially for nurses who are new to the organization.
- Monitoring procedures: Monitor utilization of support services, analyze trends in reported incidents to understand patterns and triggers, and track resolution time.
- Longer-term support resources: While organizations may have crisis counselling, long-term counselling options are limited, especially in rural areas. Additional resources (e.g., from Occupational Health & Safety) should be mobilized where needed.
Target nursing population
All (Student, New Grad, Mid-Career, Late-Career, Managers and Faculty, etc.)
Stakeholder involvement and role of nurses
- Responsible: Nursing employers and organizations must be responsible for:
- creating moral injury care practices,
- making practices accessible to all nurses,
- protecting nurses from morally distressing situations after they are reported.
- Accountable: Nursing employers, educational institutions, organizations must be accountable for implementing and providing moral injury care.
- Consulted and Informed: All levels of nursing staff.
Reference resources and examples (See appendix for links)
Immediate resources:
- 9‑8‑8 Suicide Crisis Helpline: Canada's national three-digit number for suicide prevention and emotional distress is available to everyone in Canada. Funded by the Government of Canada and led by the Centre for Addiction and Mental Health.
Standards and frameworks:
- Mental Health Commission of Canada (MHCC) National Standard for Psychological Health and Safety in the Workplace: The standard is a set of guidelines, tools and resources focused on promoting employees' psychological health and preventing psychological harm due to workplace factors.
- MHCC Quality Mental Health Care Framework: 10-dimension framework that can be implemented by organizations to support a healthy work-life environment for health care providers.
- Directive on the Prevention and Resolution of Workplace Harassment and Violence: requires Federal departments to better prevent and respond to harassment, and to provide support to those affected by harassment and violence in the federal public service.
Example programs:
- UHN CARES (Coping and Resilience for Employees and Staff): Program that provides a stepped care model to address health care worker (HCW) mental health, including a "self-triage" process based on their needs. Resources can be accessed through UHN's corporate intranet or through the program coordinator, including self-management tools, virtual group care, and individual self-referred counselling/psychiatric care.
- Expanded virtual mental health and cultural-humility supports for B.C. nurses: Nurses and Nurse Practitioners of British Columbia (NNPBC) implemented third-party virtual supports for nurses, which are available 24/7.
- Health PEI's third-party mental health support: Health PEI paired with MindBeacon to provide third-party mental health support for employees, including nurses. Uptake was higher in in-house EAP supports.
Initiative – Best practices for vacation and time-off: Develop and implement practices and policies to ensure equitable opportunities for people to take time off work.
Intended outcome
- Nurses and organizations will honour vacation time to prevent future burnout.
- Improved health and wellness as well as fulfilment at work.
- Equity in vacation schedules.
Description
This initiative focuses on providing vacation best practices to nursing teams by ensuring that nurses have autonomy, flexibility, and choice as to how vacation time is utilized. In order to implement vacation best practices, organizations require extra capacity in the system, and management competencies to plan, design and support best practices. While health system barriers exist (e.g., foundational issue of nursing shortages, legislation that forces nurses to work, organizational policies, and collective agreements), organizations may consider:
- Vacation relief float teams: The purpose of this team is to ensure nurses take vacation. Nurses are hired into vacation relief float teams as permanent employees and can work across units.
- Student roles: Organizations may have paid clinical externships for students, which provide exposure to different nursing units and teams. These roles may provide support especially during peak vacation periods. (See Safe Staffing Practices: Clinical supports for more considerations.)
Vacation best practices should include the following:
- Equitable opportunities: Nurses should have opportunities to take vacation time when desired and should be equitable for all nursing staff. This will encompass equitable leave opportunities at all seniority levels.
- Vacation versus sick time: Encourage taking days off (for mental or physical health) as sick leave rather than using up vacation days for this purpose.
- Active planning related to retirement and unlimited vacation carry-over policies: When individuals use banked up vacation in a single stretch of time (e.g., before retiring, or using many vacation days from unlimited carry-over), it can prevent others in the team from taking vacation. Include planning resources for teams with nurses close to retiring (e.g., retirement exit plans, relief dollars, re-evaluating the number of individuals permitted off at one time).
- Cultural shift: Re-enforcing with leadership the long-term benefits of nurses taking vacation and being able to disconnect from work (e.g., to support their well-being).
Target nursing population
All (Student, New Grad, Mid-Career, Late-Career, Managers and Faculty, etc.)
Stakeholder involvement and role of nurses
- Responsible: Nursing employers and organizations must encourage and honour a nurse's autonomy in setting and using vacation time.
- Accountable: Each nursing employer and organization is accountable for ensuring that best practices are in place for nurses to fairly utilize vacation time.
- Consulted: Collaboration between unions, nursing employers, organizations, and other regulatory bodies must occur to ensure that vacation rights are honoured and best practices are uniform across all nursing parties.
- Informed: Nurses must be informed of their rights to use vacation, along with their organization's responsibility to honour vacation time and requests.
Reference resources and examples (See appendix for links)
- Manitoba Nurses Union (MNU) and Vacation Requests: All approved vacation requests must be honoured by all nursing employers and organizations as per MNU collective agreements. Clear policies and communications about vacation requests and number of staff required in units during specific time periods are provided.
- Unit-Based Relief Team at Health Sciences Centre in Manitoba: Dedicated relief dollars are dedicated to nursing positions that cover vacation relief. Nurses are hired into a non-conforming schedule. This strategy has been very successful, more so than site based float positions that require nurses to work across multiple units in the organization.
- Undergraduate Nurse Employee Program in Alberta: Students in the nursing program are eligible to work as employees and can provide support for vacation relief, especially in the summer months.
- Shared Health Manitoba Clinical Transition Program: Students in the nursing program are paired with an experienced nurse and can provide support for vacation relief especially in the summer months.
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