Heal the healer: empowering healthcare providers to enact systems-level wellness changes. A mixed methods survey study

Abstract

Background:

Pre-pandemic studies highlight burnout among early career nurses, with environmental and interpersonal factors contributing to high turnover rates. The Dr Lorna Breen Health Care Provider Protection Act, enacted in the United States (U.S.) in 2022, catalysed the formation of this investigatory team, which used a socio-ecological approach to address nurse burnout and mental health in Nebraska, United States.

Aims:

This study evaluated the effectiveness of a webinar series designed to address key drivers of nurse burnout through evidence-based content. The series focused on equipping participants with knowledge and practical strategies to promote systems-level change and improve workforce well-being.

Methods:

A mixed methods survey design was employed to analyse changes in knowledge, subjective competence, intention to implement skills, perceived barriers, and impact on team performance.

Results:

Attendees who completed the webinar evaluations (N = 277 unique respondents) reported enhancements in knowledge and subjective competence post-webinar(s). Thematic content analysis of qualitative responses identified themes related to problem-solving, awareness, advocacy, and education. Barriers included organisational structure, financial constraints, and resistance to change.

Conclusions:

The webinar series showed promise as a scalable, systems-level intervention for nurse well-being, highlighting the need to address organisational and cultural factors beyond individual behaviour change.

Introduction

Globally, burnout among nurses has been recognised as a critical threat to healthcare system stability and patient safety, with the International Council of Nurses identifying the need for global policy responses to reduce workplace stress and improve working conditions (International Council of Nurses[ICN], 2021b). Before the COVID-19 pandemic and its deleterious effect on the well-being of healthcare workers, the United States (US) nursing workforce was experiencing an epidemic of burnout, job turnover and rising behavioural health concerns (Spence Laschinger and Fida, 2014). In the US, among nurses who left their jobs in 2017, 31.5% cited burnout – characterised as emotional, physical and mental exhaustion, depersonalisation, and feelings of diminished personal accomplishments resulting from prolonged and excessive stress (Shah et al., 2021). Pre-pandemic studies of US-based early career nurses signalled severe burnout in upwards of 66% of new graduates (Brewer et al., 2012). Burnout is among the leading contributors to turnover due to a myriad of environmental (e.g. heavy workloads) and interpersonal (e.g. lack of supervisor support, bullying/incivility in the workplace) factors and high emotional and physical demands (Özkan, 2022). Workforce shortages further fuel the relationship, as lack of adequate staff is routinely credited with exacerbating burnout (Shah et al., 2021).

The COVID-19 pandemic accelerated these trends and placed never-before-seen demands on an already strained nursing workforce globally (ICN, 2021a; Veenema et al., 2022). Burdened by the challenges faced by the general population (e.g. financial concerns, fears for the health/safety of their family), the nursing workforce was simultaneously forced to manage the demands of their profession (e.g. required to work longer hours, alter their work assignments to fill needs, caring for gravely ill patients). Emerging global estimates of the toll on nurse mental health and well-being indicate a significant rise in turnover intention in the post-pandemic era, signalling an ongoing, negative impact on nurse psychological well-being (Falatah, 2021; ICN, 2021a; Veenema et al., 2022).

Nationwide, a cadre of wellness interventions, programmes, and centres have been implemented in healthcare settings to address the rising needs of the nursing workforce. The mechanism of action within traditional wellness interventions frequently centres on individual behaviour change through skill acquisition and daily practice of stress reduction techniques (e.g. mindfulness-based stress reduction) (Cohen et al., 2023). While shown to be efficacious, processes that affect systems-level change are often unaddressed, and the burden of responsibility for achieving personal wellness falls on the individual (Arnold-Forster et al., 2022). Failure to intervene in the larger work environment and culture mitigates the potency of traditional interventions (Sindhu and Adashi, 2022).

Marred by the scars of the COVID-19 pandemic, there was national recognition that systemic changes to improve the well-being of our healthcare workers were long overdue. Further catalysed by the suicide of a prominent New York physician, the Dr Lorna Breen Health Care Provider Protection Act was signed into law in 2022, thereby establishing federal funding mechanisms to investigate, implement and disseminate strategies to improve the mental health and well-being of the healthcare workforce (Sindhu and Adashi, 2022). Our team was one of 45 grantees funded through the groundbreaking Act, which allocated $103 million from American Rescue Plan funds to address burnout and promote mental health in the nation’s healthcare workforce. Recognising that burnout and well-being are multifaceted constructs requiring integrated individual and systems-level action, this investigatory team employed a socio-ecological lens to address nurse burnout and mental health conditions along the trainee-to-practise continuum.

Guided by the extant literature and constituent feedback, one of the team’s initiatives was a 5-part ‘Heal the Healer’ (HTH) series to strategically address systems-level drivers of healthcare burnout. The HTH Webinar Series centred on the overarching theme of incivility and bullying in the workplace, with a particular focus on how these issues manifest in healthcare settings and strategies to mitigate their impact. The series approached the topic from multiple, interconnected angles, ranging from interpersonal communication to systemic workforce challenges, offering a comprehensive and layered understanding of the problem. Each webinar contributed a unique perspective while collectively reinforcing the need for both individual empowerment and organisational change to foster healthier work environments. The study explored how the HTH series impacted participant knowledge acquisition and subjective competence while assessing attendee intent to change practice, increase team performance, and perceived barriers to implementing systems-level wellness strategies.

Methods

Participants

Participants were notified of the webinar series via electronic communication platforms. These were: email listservs and websites available through the institutional continuing education office, the Nebraska Board of Nursing, Nebraska-based educational institutions, rural clinics, and critical access hospitals, and national nursing listservs. Anyone working within a healthcare organisation was invited to participate (i.e. no exclusion criteria for registrants).

Procedures and study design

A 5-part webinar series –HTH – was implemented to educate the state-wide nursing workforce on factors influencing burnout and turnover and ways to create systems-level change. A webinar series was selected over in-person events to maximise regional engagement, reach and participation by removing common barriers such as travel requirements, clinic disruptions, and other logistical challenges. To further increase accessibility and flexibility, each webinar was recorded and made available for asynchronous viewing. The webinars were designed as standalone sessions, allowing individuals to register only for the topics most relevant to their interests and needs, without the expectation of attending a set number of sessions. Each webinar was 60 minutes long, and topics were guided by the extant literature, refined based on constituent feedback, and aligned with our overarching series objectives to (1) increase awareness of empirically supported and state-specific factors contributing to burnout; (2) build practical skills to drive workplace change within the individual’s immediate environment, and (3) impart knowledge to articulate the criticality of systemic wellness services to institutional leadership teams to promote a horizontal approach. Registration fees were eliminated to increase attendance, and continuing education contact hours were awarded for meeting participation criteria.

To access continuing education credit after each webinar, attendees were required to complete an evaluation survey based on nationally accepted professional development models (Interprofessional Education Collaborative, 2023; Moore et al., 2009), consisting of quantitative and qualitative components (see Supplemental material 1). A 5-point Likert-type scale (strongly agree to strongly disagree) was used to rate knowledge acquisition (e.g. ‘My level of knowledge about this topic was enhanced after completing this activity’.) and increased subjective competence (e.g. ‘My overall ability to effectively communicate with patients was enhanced after completing this activity’.). Additionally, respondents provided open-ended responses about intended behaviour change towards strategies, performance or patient care; perceived barriers that may interfere with identified changes and impact on team performance.

Data analysis

Quantitative data analysis relied on frequency counts and descriptive statistics based on two-tailed tests with a significance level of α = 0.05. Statistical analyses were performed using IBM SPSS Statistics Version 28. Paired samples t-tests were used to compare participants’ ratings of enhancements in their knowledge and subjective competence (e.g. ability to effectively communicate, identify problem behaviour, and discuss the impact) after participating in each webinar.

Qualitative responses were analysed in aggregate to identify themes related to the overall webinar series. The thematic content analysis approach allowed themes to be identified from participant responses rather than being guided by a predetermined theoretical framework. The lead analyst (JPR) conducted a thematic content analysis, which led to the development of codes and a codebook. The initial coding structure was presented to the research team (KMPC, AEH, DG), which then provided input. Using this feedback, the lead analyst reviewed and revised the data and the codebook as needed. A second analyst (DG) then independently reviewed and coded the responses. The two analysts (JPR, DG) met to resolve conflicts and reach a consensus. Anchor quotations were identified for each theme. This study was written to align with the Template for Intervention Description and Replication (TIDieR) checklist (Hoffmann et al., 2014).

The sponsoring institution’s Office of Regulatory Affairs determined that this project does not constitute human subject research as defined at 45CFR46.102.

Results

Total attendance across all 5 webinars was 759 individuals (with 140 individuals attending 2 or more webinars). Of those, a total of 555 evaluation surveys were collected (across the 5-part HTH series) with 277 unique respondents captured. Of 277 unique respondents across the 5-part HTH series, 136 attended 1 webinar, 57 individuals attended 2 webinars, 44 attended 3 webinars, 27 attended 4 webinars and 12 attended all 5 webinars. The highest attended webinar was entitled, ‘Tips for Improving Communication and Interaction with Patients and Coworkers’ with 258 individuals in attendance. Across the 5-part series, most participants were registered nurses (78.2%–91.7% of attendees; see Table 1).

Table 1.

Professional licences of Heal the Healer (HTH) webinar respondents.

Professional licence	HTH #1 N = 188 n (%)	HTH #2 N = 67 n (%)	HTH #3 N = 103n (%)	HTH #4 N = 120 n (%)	HTH #5 N = 77 n (%)
Nurse practitioner	4 (2.1)	1 (1.5)	5 (4.9)	1 (0.8)	1 (1.3)
Registered nurse	147 (78.2)	59 (88.1)	88 (85.4)	110 (91.7)	70 (90.9)
Social worker	4 (2.1)	N/A	1 (1.0)	N/A	N/A
Licensed practical nurse	13 (6.9)	6 (9.0)	6 (5.8)	3 (2.5)	5 (6.5)
Physical therapist	1 (0.5)	N/A	1 (1.0)	N/A	N/A
Other	19 (10.1)	1 (1.5)	2 (1.9)	6 (5.0)	1 (1.3)

N/A indicates there were no respondents represented within this professional role.

Series participants were predominantly nurses, including trainees, practising professionals, and senior leaders. Participants hailed from across the state, including urban, suburban and rural areas, and various practise settings (e.g. critical access hospitals and private practice). Although the primary target audience was healthcare providers in Nebraska, a predominantly rural state with a dispersed population with pockets of urban population, attendees from an additional 10 states were represented. The decision to include attendees from other states was made because, despite its rurality, Nebraska’s healthcare workforce needs mirror that of more populous states, especially in the aftermath of the COVID-19 pandemic.

Quantitative evaluation

Quantitative responses were treated as independent cases and analysed by their respective HTH webinars, as each event had unique learning objectives. There was a statistically significant change in knowledge acquisition after participating in the activity across all five webinars (see Table 2). After completing the webinar, respondents’ ratings signalled a significant enhancement in their knowledge about the topic (HTH #1: t(187) = −10.68, p < .001; HTH #2: t(66) = −7.44, p < .001; HTH #3: t(100) = −11.60, p < 0.001; HTH #4: t(116) = −10.28, p < 0.001; HTH #5: t(73) = −9.73, p < 0.001). Similarly, statistically significant increases were observed in subjective competence about the topic. Specifically, respondents indicated that the webinar enhanced their skill level in effectively communicating with stakeholders, identifying problematic behaviour (e.g. bullying/incivility) and discussing the impact of burnout (HTH #1: t(186) = −8.62, p < 0.001; HTH #2: t(64) = −8.51, p < 0.001; HTH #3: t(101) = −11.84, p < 0.001; HTH #4: t(118) = −8.83, p < 0.001; HTH #5: t(75) = −9.21, p < 0.001).

Table 2.

Changes in knowledge acquisition and subjective competence by HTH webinar.

Evaluation Metrics	HTH #1			HTH #2			HTH #3			HTH #4			HTH #5
	Pre	Post	t (df)	Pre	Post	t (df)	Pre	Post	t (df)	Pre	Post	t (df)	Pre	Post	t (df)
	M (SD)	M (SD)		M (SD)	M (SD)		M (SD)	M (SD)		M (SD)	M (SD)		M (SD)	M (SD)
Knowledge acquisition and enhancement	2.70 (0.68)	3.41 (0.63)	−10.68 (187)**	2.21 (1.02)	3.27 (0.59)	−7.44 (66)**	2.41 (0.85)	3.46 (0.54)	−11.60 (100)**	2.53 (0.87)	3.42 (0.61)	−10.28 (116)**	2.24 (0.87)	3.34 (0.58)	−9.73 (73)**
Subjective competence	2.93 (0.59)	3.43 (0.64)	−8.62 (186)**	2.25 (0.92)	3.22 (0.60)	−8.51 (64)**	2.39 (0.80)	3.40 (0.55)	−11.84 (101)**	2.70 (0.80)	3.39 (0.61)	−8.83 (118)**	2.45 (0.81)	3.32 (0.57)	−9.21 (75)**

M: mean; SD: Standard deviation; df: degrees of freedom; HTH: Heal the Healer (HTH)

^**p < 0.001.

Qualitative/open-ended evaluation

Thematic content analysis of the open-ended evaluation questions (i.e. intent to apply new knowledge, perceived barriers that interfere with practise changes, and team performance impact) generated the following themes (Braun and Clarke, 2006). See Table 3 for a summary of themes by evaluation question with illustrative quotations.

Table 3.

Evaluation question, themes, illustrative quotation and respondent percentage.

Question/Themes	Illustrative quote	Respondent percentage n (%)
Describe what changes you intend to make involving strategies, performance or patient care.
Problem-solving	‘Stop and ask questions, think about the fact there could be miscommunication going on. Address things in the moment’.	147 (38)
Awareness	‘Continue to teach and utilise therapeutic communication techniques. Breath before responding esp emotional. Pay attention to my audience and clarify or ask questions if not understanding. Maintain awareness of body language and encourage communication’.	107 (28)
Advocacy	‘To be an Upstander and speak up if incivility or bullying affects me or the people surrounding me, at the workplace or elsewhere’.	61 (16)
Education	‘Looking into integration of mental health knowledge and awareness at a high school level. Suggesting simulations with behavioral health components are added to ACU/ICU staff trainings’.	53 (14)
Tell us more about the barriers that may prevent practise change for you or your team.
Organisational structure and support	‘Lack of support in utilising techniques among nursing staff’. ‘Getting top executives to listen and to enact change’.	44 (23)
Financial constraints	‘always looking at the financial budget concerns of new programs and initiatives’.	42 (22)
Staffing and resources	‘Limited staffing makes it harder to take time or communicate issues in a timely manner’. ‘Staffing shortages increase burnout and increase the likelihood of burnout and continued cycle’.	28 (15)
Culture change	‘Acceptable culture of bullying between staff members has been long accepted and will time and meaningful steps to change’.	25 (13)
Knowledge and training	‘Lack of knowledge & support’. ‘lack of awareness and education to address the issue’.	13 (7)
Resistance to change	‘People tend to be resistant to change and talking about the “hard stuff”’	10 (5)
Patient factors	‘Patient buy-in to improving outcomes’. ‘patient responsiveness and participation’.	5 (3)
Communication and engagement issues	‘Staff buy in to communication and time to walk away or debrief’.	7 (4)
Describe how the information from this activity will increase your team’s overall performance.
Increased awareness	‘If more than one person incorporates the activities then eventually over time the culture may change’	101 (25)
Effective communication	‘This activity provided insight on the different types of personalities and how to engage with others in with a positive mindset. Along with what steps can be taken to improve communication and interactions with patients and coworkers’.	55 (14)
Staff well-being	‘Any improvement in an individual’s ability for de-escalating themselves will improve team performance as a whole’.	39 (10)
Positive work environment	‘Everyone is accountable for trying to meet people where they are at, conducting self professionally and working as a team respectfully. This information should help us all do better, be more empathetic and find ways to dis-engage or de-escalate difficult situations or personalities. And practice self-care when needed’.	45 (11)
Patient care	‘Working in a Specialty clinic with Mental Health Nurse Practitioners, this webinar will allow me to be more aware of patient needs and how I can improve them’. ‘Improve efficiencies if everyone is focused on the patients, not outside factors, personality conflicts, bullying, etc’.	7 (2)
Impactful outcomes	‘Being able to share this information in practice will change the workplace dynamic when leading by example’. ‘within teams when one or more members show actions that are positive others will want to understand how this is done and we can support and mentor each other’.	25 (6)
Teamwork	‘have to work together as a team and be respectful professionals, value the work we do and work hard at change to see change’.	56 (14)
Nursing focus	‘Guidance in the changes we have seen in the nursing career since COVID and the continued need to recover in numbers’ ‘It was interesting to me how the younger nurses feel there is more bullying than the older nurses. I hope no matter what our ages are that we can all be here for each other’	23 (6)

Describe what changes you intend to make involving strategies, performance or patient care

This question generated 388 unique responses across the series. Of those, 368 responses (95%) were analysable and contributed to generating the four themes below.

Problem-solving captured participants’ desire to implement tangible, actionable strategies to improve interpersonal dynamics, workflow processes and overall communication in their workplace. Respondents described specific steps, such as pausing to de-escalate during tense interactions, engaging in real-time clarification of misunderstandings, or creating team-based protocols to address common pain points: ‘Stop and ask questions, think about the fact there could be miscommunication going on. Address things in the moment’. These responses suggest that the webinars empowered participants not just to recognise problems, but to feel more confident in taking immediate and practical action in response.

Awareness responses highlighted recognising, understanding and being conscious of certain behaviours, emotions or situations, especially those that may contribute to burnout, incivility, or other negative outcomes. The emphasis here is on mindfulness, self-reflection, and being attuned to oneself and one’s environment. Participants emphasised a heightened awareness of their own communication styles, emotional triggers and the broader interpersonal climate within their work units: ‘Maintain awareness of body language and encourage communication’. Responses included increased mindfulness in interactions, enhanced ability to reflect before responding, and recognition of body language and tone.

Advocacy responses underscored the importance of speaking out, taking a stand, promoting or supporting certain causes, issues, or individuals. This theme is about championing change, rights or interventions that benefit healthcare providers and patients. Respondents described feeling more prepared to serve as advocates for themselves, their peers and their patients, especially in the context of workplace incivility and bullying. This included ‘upstander’ behaviour (e.g. actively intervening in harmful dynamics) as well as speaking to leadership about structural changes needed to improve well-being: ‘To be an Upstander and speak up if incivility or bullying affects me or the people surrounding me, at the workplace or elsewhere’. The advocacy theme suggests that the series fostered not only personal empowerment but also a sense of collective responsibility and moral courage.

Education responses stressed the importance of knowledge, training or information to oneself or others. This theme includes the idea of promoting understanding, developing skills or facilitating learning on topics related to healthcare, patient care and workplace dynamics. Responses indicated plans to incorporate mental health education into onboarding, simulations or team training sessions, especially in high-stress settings like Acute and/or Intensive Care Units (ACU/ICU): ‘Suggesting simulations with behavioural health components are added to ACU/ICU staff trainings’. Participants saw themselves as conduits for change, capable of fostering broader organisational learning.

Tell us more about the barriers that may prevent practise change for you or your team

Of the 188 respondents, 174 responses (93%) were analysable and contributed to the development of eight themes.

Organisational structure and support responses describe how the hierarchy, policies and support systems within an organisation affect the ability to implement practise changes. It includes aspects such as leadership, decision-making processes, and organisational backing. Respondents frequently cited hierarchical limitations, lack of leadership engagement and insufficient institutional buy-in as key obstacles to implementing change. Comments revealed frustration with decision-makers’ inaccessibility or unwillingness to prioritise wellness initiatives: ‘Getting top executives to listen and to enact change’. This theme underscores a disconnect between frontline awareness and administrative action, which limits the scalability of improvements.

Financial constraints relate to the limitations imposed by budgetary constraints, cost implications and financial resources required to enact practise changes. Participants pointed to limited budgets and competing financial priorities as barriers to adopting new interventions. This included concerns about funding staff training, acquiring resources for new initiatives, or sustaining programmes beyond pilot phases: ‘Always looking at the financial budget concerns of new programmes and initiatives’. These financial concerns reinforce the structural limitations placed on even the most motivated individuals.

Staffing and resources involves issues related to the availability and allocation of staff and other resources necessary for implementing changes in practice. It includes concerns about workforce availability, equipment, and time. Respondents acknowledged that chronic understaffing, high workloads, and lack of protected time directly inhibit their ability to engage in improvement efforts: ‘Limited staffing makes it harder to take time or communicate issues in a timely manner’. Even when knowledge and intent were present, these resource gaps created operational roadblocks. The theme illustrates how structural burnout drivers actively impede implementation of change.

Culture change refers to the challenges associated with altering the established norms, attitudes and behaviours within an organisation or group to adopt new practices. Changing ingrained norms, especially around toxic behaviours like bullying or incivility, was perceived as a long-term and difficult process. Many respondents described workplace cultures that tolerate, normalise, or even reinforce negative behaviours: ‘Acceptable culture of bullying between staff members has been long accepted and will take time and meaningful steps to change’. This theme highlights the inertia within institutional norms and the resistance faced by those trying to reshape them.

Knowledge and training

This theme referred to the need for, and potential lack of, appropriate education, training, and understanding required to implement new practices effectively. Participants identified the need for ongoing education, particularly for peers and supervisors who might not have attended the webinars: ‘Lack of awareness and education to address the issue’. They also described uncertainty about how to apply the learned strategies in complex or ambiguous situations. This theme reveals a gap between learning and application that could be bridged with structured follow-up.

Resistance to change highlighted the reluctance or opposition to change by individuals or groups, often due to comfort with existing practices, scepticism, or fear of the unknown. Respondents shared that some colleagues and managers were overtly resistant to change, dismissing new strategies as unnecessary or burdensome. This reluctance was often rooted in a preference for maintaining the status quo or a discomfort with addressing emotionally charged topics: ‘People tend to be resistant to change and talking about the “hard stuff.”’ It underscores the importance of both communication strategy and leadership modelling to foster readiness for change.

Patient factors

This theme focused on aspects related to patients who may hinder practise changes, such as patient adherence to treatment, demographics, or specific patient needs. Some respondents identified patient behaviour or circumstances (e.g. noncompliance, complex needs) as indirect barriers to applying new interpersonal techniques or wellness-focused practices: ‘Patient buy-in to improving outcomes’. These barriers point to the challenges of implementing system-wide improvements in real-world, high-stress settings.

Communication and engagement issues identified problems in effectively communicating and engaging with relevant stakeholders (e.g. staff, patients), which limits the implementation of new practices. Participants noted that poor communication structures, unclear expectations, or limited engagement from key stakeholders undermined efforts to initiate change: ‘Staff buy-in to communication and time to walk away or debrief’. This theme reflects the critical need for coordinated team communication and formalised channels to sustain improvements.

Describe how the information from this activity will increase your team’s overall performance

Four hundred and one individuals answered this question across the series. Of the 401 responses, 351 (88%) were analysable and contributed to generating eight themes.

Increased awareness in the workplace refers to understanding and recognising various aspects, such as mental health, diversity, communication styles, and workplace dynamics. It is about being cognisant of the factors that affect team performance, individual well-being, and overall organisational culture. It involves promoting empathetic engagement and applying learned strategies to create a respectful work environment. Participants reported that increased awareness would lead to more inclusive, emotionally intelligent and supportive workplace cultures. Several noted that if even a few team members adopted the strategies, ripple effects could shift broader team dynamics: ‘If more than one person incorporates the activities then eventually over time the culture may change’. This awareness was framed as foundational for further change.

Effective communication is the clear, open and empathetic exchange of information, fostering accountability and understanding within a team. It involves using techniques that reduce misunderstandings, enhance teamwork, and improve interactions with co-workers and patients. This theme emphasises the importance of non-threatening language, active listening, respectful discourse, and the sharing of best practices to resolve conflicts and build a cooperative work culture: ‘This activity provided insight on the different types of personalities and how to engage with others in a positive mindset’. It is supported by recognising that clear and compassionate communication is integral to efficiency, workplace harmony, and overall team performance. The most frequently mentioned change was a perceived improvement in team communication (e.g. more respectful language, clearer expectations and greater confidence navigating conflict). This theme directly ties to increased psychological safety and efficiency, reinforcing the practical utility of the webinars’ content.

Staff well-being focuses on providers’ health, including physical and mental aspects, and recognising its positive impact on patient care and the workplace atmosphere. This theme emphasises creating an environment where staff feel valued, supported and mentally and physically healthy. Respondents emphasised that improved communication and stress management would reduce emotional exhaustion, prevent escalation and promote personal resilience: ‘Any improvement in an individual’s ability for de-escalating themselves will improve team performance as a whole’. In turn, they linked individual well-being with improved team morale and patient care outcomes.

Positive work environment refers to creating a workplace fostering a culture of support, collaboration and respect among staff members. The focus is on developing a nurturing and harmonious environment that addresses and mitigates conflict and stress, encourages positive interactions, and values each member’s contribution. This theme recognises that the work environment directly impacts staff morale and engagement. Participants envisioned more respectful, empathetic and collaborative cultures as a result of implementing webinar strategies: ‘The information should help us all do better, be more empathetic and find ways to dis-engage or de-escalate difficult situations or personalities’. This theme reflects hope that a supportive climate will emerge as both a goal and a by-product of the interventions.

Patient care highlights aspects of healthcare delivery, focusing on improving patient satisfaction, understanding needs, and ensuring that care is patient-centred. Respondents connected staff improvement with more patient-centred, efficient, and compassionate care. Several noted that improved team functioning would reduce distractions and emotional fatigue, thereby allowing for greater focus on patient needs: ‘Improve efficiencies if everyone is focused on the patients, not outside factors, personality conflicts, bullying, etc’.

Impactful outcomes refer to the beneficial effects on team performance and workplace dynamics that result from applying new information, effective mentorship, and fostering a respectful and engaging environment. It involves positive changes that enhance the quantitative metrics of success and the qualitative aspects of workplace culture. This theme captured concrete improvements in workplace dynamics, including reduced conflict, stronger mentorship, and increased collaboration. It also reflects a belief that intentional behaviour modelling could inspire change in others: ‘Being able to share this information in practice will change the workplace dynamic when leading by example’.

Teamwork emphasises the importance of collaboration, clear communication, and the collective effort to work cohesively towards common goals. The focus is building a unified team that values respect, hard work, and shared objectives. Participants expressed enthusiasm for more unified, coordinated teams. They described how clearer roles, better communication and shared values could increase accountability and cohesion as core components of effective healthcare delivery: ‘Have to work together as a team and be respectful professionals, value the work we do and work hard at change to see change’.

Nursing focus addresses key issues and areas of development within the nursing profession. This theme encompasses activities related to recruitment, retention, professional learning and development, and the well-being of nurses. Respondents framed the insights from the series as directly applicable to nursing-specific challenges, including retention, onboarding and professional identity development: ‘Guidance in the changes we have seen in the nursing career since COVID and the continued need to recover in numbers’. Several noted that the webinars provided language and tools to support and mentor younger nurses, which could improve retention and morale long-term.

Discussion

The COVID-19 pandemic spotlighted the fragility of our healthcare system and created a call to action to address the health and well-being needs of our healthcare workforce (Laws, 2022). Wellness programmes focused on individual-level change (e.g. mindfulness-based stress reduction) have demonstrated success (Bartlett et al., 2019). However, many place the onus of psychological well-being on the healthcare workers themselves rather than striving for wide-reaching, organisational, managerial and budgetary changes. Although there remains a place for programmes that teach symptom prevention and mitigation, there is a growing recognition of the need for systems-level change that addresses the complex, multifactorial factors contributing to burnout and turnover (National Academies of Sciences, Engineering and Medicine; National Academy of Medicine and Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being, 2019). In response, major medical organisations and public health entities have conceptualised equally complex and comprehensive system-oriented strategies. For example, the World Health Organization (WHO, 2020) called for improved working conditions, actions to address workforce shortages and the integration of nurses into policy leadership roles. Yet, ‘bottom-up’ and grassroots interventions as a mechanism for change have been overlooked.

The HTH series provided a novel approach to wellness interventions for several reasons. Namely, we sought to empower healthcare workers ‘in the trenches’ as agents of systems-level change. Webinars were curated and designed for frontline nurses to increase knowledge, awareness and skills to advocate for systems-level change. This included practical applications of responding to workplace bullying/incivility, navigating difficult interactions with patients and caregivers and speaking confidently in the financial incentives for implementing structural workplace changes. Within this framework, participants were armed with return-on-investment data, developed advocacy language and taught behavioural principles to drive change within their own units and larger organisations.

Our results suggest that participants developed a deeper knowledge base of topics known to impact burnout. Similarly, their subjective competence, including their ability to communicate information with stakeholders, signals that the HTH series was effective in its objectives (i.e. increasing awareness, building practical skills, and imparting knowledge). Beyond knowledge acquisition and skill building, participants expressed intention to implement practical interventions to address workplace concerns (Problem-solving), greater awareness of environmental factors contributing to burnout (Awareness), championing workplace change (Advocacy) and facilitating learning on topics related to workplace dynamics (Education). Respondents readily identified lingering barriers preventing practise change, including lack of organisational support, resistance to change, the necessity of altering the existing culture, cost implications and staffing constraints, and engaging relevant stakeholders to implement practices. Despite these barriers, there was widespread endorsement that successful implementation would result in enhanced team performance via empathetic information exchange (Effective communication), physical and mental health (Staff well-being), building a unified team that works together effectively (Teamwork) and fostering a respectful and engaging environment (Impactful outcomes). Although these findings highlight relevance to burnout-related constructs, it is important to note that burnout was not directly measured in this study nor assessed as a formal outcome. Rather, the HTH series was designed with the broader intent of addressing known contributors to burnout, as well as promoting wellness and retention in the healthcare workforce.

Results suggest this alternative approach to healthcare wellness is efficacious in increasing knowledge, fostering self-confidence and skill building and empowering change talk. Once more, respondents affirmatively identified specific ways team performance would be improved by implementing the series’ principles. Even still, nearly half of all respondents anticipated barriers to enacting change despite acquiring the requisite knowledge and intent to implement skills. Identifying and dismantling such barriers is an area of future exploration. Nevertheless, our respondents’ reports of perceived barriers dovetail nicely with conversations internationally, in which ‘top-down’ healthcare systemic changes are proposed to address burnout and reduce turnover (Buchan and Catton, 2023). Speculation may indicate that the combination of a ‘bottom-up’ (present study) approach and the ‘top-down’ national conversation has great potential to catalyse meaningful progress.

To maximise the impact of wellness initiatives like the HTH series, healthcare institutions must pursue comprehensive, multilevel strategies that extend beyond individual behaviour change. The Dr Lorna Breen Health Care Provider Protection Act offers a compelling national call to action, underscoring the urgent need for systemic efforts to protect clinician well-being, not only in response to acute crises like the COVID-19 pandemic but also as an enduring organisational imperative (Sindhu and Adashi, 2022). Our findings, though rooted in a single state-based intervention (with some national attendees), are generalisable across healthcare systems and settings. They reinforce the role of environmental, structural and cultural forces in psychological distress and retention issues (National Academies of Sciences, Engineering and Medicine; National Academy of Medicine and Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being, 2019; Shah et al., 2021). As such, future efforts must engage a coalition of stakeholders, including healthcare providers, professional associations, trade unions and educational institutions, to ensure that the burden of wellness does not fall solely on the individual (Arnold-Forster et al., 2022; National Academies of Sciences, Engineering and Medicine; National Academy of Medicine and Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being, 2019).

Although we recognise there is a place for implementing more traditional wellness interventions (e.g. mindfulness-based stress reduction), such programmes can be perceived as placing the burden of wellness on the individual. Indeed, the application of individual-level stress management and wellness techniques (e.g. self-care, self-coping) with the expectation of reversing the systemic healthcare culture contributing to our current burnout and turnover epidemic is inappropriate and misleading (Gregory et al., 2018). When individuals continue to experience high levels of burnout or distress arising from structural or systemic issues, inappropriately applying such interventions may cause said techniques to lose their potency (at best) or send the message that the individual has failed (at worst). Instead, we are called to enact meaningful, institutional change or risk perpetuating the myth that individually applied techniques are suitable replacements for a system in need of disruption.

Indeed, national organisations and professional societies are calling for the implementation of multilevel interventions capable of adapting to the dynamics and complexities of our healthcare system. At the organisation level, this can include elevating healthcare worker well-being at the same priority level as financial and quality performance metrics (Dunn et al., 2007), reorganising clinic structures (Reid et al., 2010), and schedule and staffing changes (Panagioti et al., 2017). Specifically, organisations should enact policies that address burnout as a workforce safety issue, incorporate wellness metrics into institutional quality frameworks and prioritise interventions that promote influence over work environment and clinical meaning (Dunn et al., 2007; West et al., 2016). Strategic resource allocation must support staffing models that reduce overload, emphasise leadership pathways that champion adaptive interventions, fund continuing education and skill development, and enhance teamwork (Brand et al., 2017; Panagioti et al., 2017). Collectively, these actions affirm that wellness is not a personal luxury, but a shared organisational responsibility and a critical component of care quality, workforce retention and system sustainability.

Some research trends indicate organisation-level change yields slightly better results in achieving desired outcomes (Panagioti et al., 2017), whereas other reviews indicate a combination of individually focused and organisation-level interventions is likely needed to yield the most robust and long-lasting effects (Awa et al., 2010; West et al., 2016). Another international systematic review indicates employee choice from a range of intervention activities and a flexible intervention that adapts based on employee involvement and evaluation may also be important for success (Brand et al., 2017). Nevertheless and despite national calls and recommendations for change, all systematic reviews to date punctuate the need for more rigorous and high-quality studies of healthcare wellness interventions is evident to fully elucidate mechanisms of action and understand what type, how much of, and for whom, interventions are most effective (Awa et al., 2010; Brand et al., 2017; National Academies of Sciences, Engineering and Medicine; National Academy of Medicine and Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being, 2019; Panagioti et al., 2017).

The present study is not without its limitations. Specifically, data are limited to the individuals’ proximal ratings of knowledge acquisition and intent to change. The absence of longitudinal data capture hinders our ability to conclude the effect of the webinars on actual and sustained behaviour change via implementation. In addition, participant demographic data were not collected, as such information is not routinely gathered through the existing webinar registration system. As a result, we were unable to assess potential differences in experience, satisfaction or perceived impact across demographic groups (e.g. age, gender, years in practice), job classification (e.g. direct care provider, administrative/leadership roles) or practise settings (e.g. critical access hospitals, rural health clinics, academic institutions). Without said granularity, it is difficult to discern which unique characteristics of the attendees or subgroups can be agents of change in their workplace once equipped with the requisite knowledge and skills. This omission has been noted as a key limitation and identified as a priority area for future improvement. Incorporating demographic data collection in future efforts would allow for more tailored content development, nuanced analysis, and better-informed strategies to support workforce well-being across varied healthcare contexts. Despite these limitations, findings suggest participants were overwhelmingly empowered by series content and recognised the utility of the information.

Limitations aside, our findings indicate that the nursing community is eager to learn and motivated to enact change in the workplace if armed with the necessary knowledge and skills. Even still, perceived barriers to implementation repeatedly centre around the lack of administrative buy-in and support for workplace scalability. These results suggest that a ‘bottom-up’ approach may best be augmented with ‘top-down’ support. Future wellness interventions should consider shifting towards nurse empowerment to enact change via knowledge acquisition and practical skill building. Ongoing research should examine how this forum impacts behaviour change over time and ways healthcare administration can further enhance nurse-led change to increase the adoption and sustainability of practices.

Conclusion

This study provides critical insights into addressing burnout and turnover in the nursing workforce by introducing a novel ‘bottom-up’ wellness intervention approach through the HTH series. The findings demonstrate that nursing professionals are eager to implement systems-level change when equipped with knowledge and practical skills. The HTH series effectively increased participants’ knowledge and subjective competence, empowering them to advocate for, and drive, workplace improvements. However, barriers such as lack of organisational support and resistance to change were frequently cited. The contribution of this study to nursing lies in highlighting the importance of empowering nurses as change agents while recognising that sustainable progress requires both grassroots initiatives and organisational (‘top-down’) support. Future efforts should focus on enhancing administrative buy-in and continuing research on long-term behaviour change, ultimately fostering a collaborative environment where nurses can lead systemic improvements in workforce well-being.

Key points for policy, practice and/or research.

• The ‘Healing the Healers’ series improved nurses’ knowledge and skills, empowering them to advocate for systems-level change and positively influence nursing practice.

• Participants identified organisational barriers, highlighting the need for health and social care policies that support structural changes for the successful implementation of wellness initiatives.

• A combination of grassroots efforts and leadership-driven support is necessary to create sustainable changes in workplace well-being, requiring policies that engage healthcare administration.

• Future research should focus on long-term studies to evaluate the sustained impact of wellness interventions on burnout, turnover and workplace performance.

• Wellness interventions must evolve to address both individual and systemic factors, shifting from placing the burden on healthcare workers to making well-being an organisational priority.

Biography

Katrina Poppert Cordts is a paediatric psychologist and behavioural health workforce development specialist. Her work centres on systems-level change to promote health behaviour, healthcare wellness and workforce recruitment and retention.

Juan Paulo Ramírez is the Chief Data Strategist at the Nebraska Center for Nursing. He specialises in data analysis, grant writing and geographic information systems (GIS).

Dominic Gliko is a registered nurse and a psychiatric/mental health nurse practitioner. He specialises in care for gender-diverse individuals and supporting those experiencing minority stressors.

Valeta Creason-Wahl is an educational projects coordinator with continuing interprofessional development and innovation in the College of Nursing.

Kami Wattenbach is a student services professional, currently serving as the Project Coordinator for the Nebraska Collaborative Investment in Nurses team. Her work focuses on student services, programming and wellness.

Tiffany Moore is an associate professor who teaches nursing students at all levels. Her research emphasis is chronic stress in the maternal/infant population. Clinically, she is a Forensic Nurse Examiner.

Heidi Keeler serves as administrator in the area of workforce and accredited professional development. Her research focuses on innovative systems-level programmatic solutions to workforce growth and skills/competency acquisition.

Alyson E Hanish is a paediatric sleep researcher and nurse educator. She serves as Director of the Nebraska Collaborative Investment in Nurses – focused on improving burnout and behavioural health in our health workforce.