Recently, I shared an article from Becker’s about the state of the nursing workforce with several colleagues (Taylor, 2025). One idea that stood out was the call to actively engage retired and late-career nurses in mentoring and precepting early-career nurses. At AzNA, this is a concept we frequently explore, and one we are working hard to bring to life through new initiatives.

After sharing the article, a colleague asked what AzNA is doing to address the many issues it raised. It was a powerful question, and I’d like to share my response with you.

Supporting the Nurse Anesthesia Workforce

The article highlighted projected growth in advanced practice nursing roles, including Nurse Practitioners (NPs) and Certified Registered Nurse Anesthetists (CRNAs). AzNA is proud to have distributed over $375,000 in stipends to NPs serving as preceptors through funding from the Arizona Department of Health Services, with more funding still available. (Visit aznurse.org/PreceptorGrant for more information and to apply)

To support the CRNA workforce, the AzNA Board helped form the “House of Nursing” to foster alignment with the Arizona Association of Nurse Anesthesiology. This collaboration helps ensure AzNA is informed about legislation and initiatives important to CRNAs, positioning us to offer timely support. We also watched the state budgeting process closely, as it included $500,000 for the Registered Nurse Anesthetist Clinical Rotation Program. This funding, administered by the Arizona Board of Nursing, supports health care institutions in expanding preceptor training capacity for nurse anesthetist students.

Prioritizing Wellbeing and Mental Health

Burnout and stress remain significant concerns in our profession. I’ve been honored to serve on the Steering Council of the Wellbeing Collaborative, an interprofessional group driving efforts to eliminate barriers to mental health care and foster a culture of support for provider wellbeing.

One of our proudest achievements is the successful passage of House Bill 2173, signed by Governor Hobbs, which removes invasive mental health questions from professional licensure applications in Arizona (H.B. 2173, 2025). This is a meaningful step forward in destigmatizing mental health care.

We are now gearing up for the Fall 2025 Wellbeing Summit, focused on creating a wellbeing-centered health ecosystem in Arizona. Registration is open, and I would love to see you there!

Strengthening Transition to Practice and Mentorship

Though nurse turnover and vacancy rates are declining, the cost of turnover is climbing. That’s why AzNA remains committed to supporting strong transition-to-practice efforts, from nursing school to residency and beyond. One exciting new initiative in development is the formation of a legacy Special Interest Group. This group will provide a space for late-career nurses to stay engaged and mentor the next generation.

Arizona is rich with nursing talent, and we want to ensure our experienced nurses have meaningful opportunities to give back. Are you interested in joining this group once it’s launched? Fill out this form to let us know!

Partnering for Workforce Innovation

We’re also proud to support the ongoing efforts of the Arizona Board of Nursing and the Arizona Hospital and Healthcare Association. These organizations are leading innovative grant-funded initiatives to improve onboarding, preceptorship, and support for hospital staff statewide.

I’m incredibly proud of the work being done across Arizona to advance and strengthen our nursing workforce. I hope you’ll stay engaged with AzNA as we continue building momentum and shaping the future of nursing in our state.

Introduction

The 2025 American Nurses Association (ANA) Membership Assembly held in Washington, D.C., showcased the collective strength and strategic vision of the American Nurses Enterprise. As the CEO of a constituent member association, I had the privilege of attending and contributing to dialogue with nurse leaders from across the nation. The Assembly was not merely a procedural event but a chance to align on policy, professional standards, and the future direction of the profession.

Strategic Themes from Leadership

ANA President Dr. Jennifer Mensik Kennedy opened the Assembly by underscoring the significant role nurses play in shaping public health, clinical practice, and policy. She emphasized that the over five million nurses in the United States possess untapped power and influence. Key highlights included the release of the updated Code of Ethics for Nurses in January 2025 and a recommitment to addressing systemic racism through the ongoing work of the National Commission to Address Racism in Nursing.

Hill Day and Policy Priorities

Hill Day 2025 was a major feature of the Assembly. Nurses engaged directly with legislators to advocate for policies that preserve access to care, maintain critical funding such as Title VIII Nursing Workforce Development programs and NIH research, support full practice authority for APRNs, and protect essential public health infrastructure. These efforts reflect a dual strategy: while ANA works nationally, state organizations such as AzNA focus on policy change at the local level.

Dialogue Forums: Collective Policy Development

Central to this year's Membership Assembly were three Dialogue Forums, each leading to actionable outcomes. These sessions engaged members in structured debate and consensus-building on emerging and critical issues.

Dialogue Forum #1: Advancing Rural Health Through Nursing Innovation

With approximately 46 million Americans living in rural areas, access to health care remains a significant challenge. This forum, led by representatives from Alabama, emphasized that rural communities face higher rates of chronic illness, maternal and infant mortality, and limited access to care. Participants called for nurse-led, community-based delivery models and stressed that telehealth, while promising, requires infrastructural and training investments. The assembly adopted a motion supporting policies that enable nurse-led delivery modalities tailored for rural contexts.

Dialogue Forum #2: Ethical Use of Artificial Intelligence in Nursing

The exponential growth of artificial intelligence (AI) in health care brings both promise and risk. Nurses highlighted ethical concerns, including the erosion of human connection and bias in algorithms. The forum emphasized that AI should augment, not replace, clinical judgment. Participants called for robust governance, nurse involvement in AI development, and integration of AI literacy into nursing education. The Assembly unanimously passed a motion for ANA to develop ethical and legal guidelines for AI adoption in nursing practice.

Dialogue Forum #3: Revising the Nursing Scope and Standards of Practice

The Scope and Standards of Practice, last revised in 2021, is under review for a 2026 update. Nurses expressed that current definitions no longer align with the complexity and breadth of modern nursing roles. Rising burnout, mental health concerns, and role ambiguity necessitate clearer delineation of responsibilities. Discussions emphasized incorporating mental health, professional boundaries, and workplace sustainability into the revised document. Although no motion was passed, feedback will shape the forthcoming edition.

ANA Enterprise Transformation and Vision

CEO Angela Beddoe's report framed the ANA Enterprise as a forward-thinking, adaptive organization. With a strong focus on transparency, member engagement, and brand realignment, the Enterprise aims to serve as a central force for nursing empowerment. Beddoe reiterated that ANA's future lies not in returning to past structures but in boldly creating new frameworks that reflect modern realities. The call to action: nurses must not only be trusted but respected and included in all decision-making spaces.

Conclusion

The 2025 Membership Assembly was a powerful reminder of the collective influence of the nursing profession. With a vision rooted in ethics, inclusivity, and innovation, the ANA and its affiliates are leading a transformation that prioritizes both patient outcomes and workforce sustainability. In the words of Shirley Chisholm, 'If they don't give you a seat at the table, bring a folding chair.' Nurses will not only bring a chair --- they are building the table.

• Enrolled in a prelicensure BSN Nursing Program or Associate Degree in Nursing with concurrent enrollment in a BSN Nursing Program
• Completed at least one semester of the BSN Nursing Program curriculum
• Member of Student Nurses Association
• Submission of a 7-10 minute video responding to the content criteria outline (downloaded file)
• If selected, recipient agrees to allow their submission video to be shown at AzNA's 2025 Convention on September 13, 2025.

Mentorship goes beyond being a professional courtesy; it serves as a vital leadership strategy that empowers the next generation of nurses to lead with confidence, equity, and purpose.  As healthcare becomes more complex, the demand for nurses who are not only clinically competent but also resilient, empowered, and inclusive leaders increases. One of the most effective ways to cultivate these leaders is through structured, intentional mentorship.

Early in my career, I often felt like the newest voice in the room. Yet, empowering nurse leaders within our state association connected with me through sincere actions: consistent check-ins, supportive words, and the memorable statement I encountered at my initial ANA Membership Assembly, “Your perspective matters."  This moment not only helped me find my voice but also shaped my leadership journey.

Those relationships fueled my journey into leadership: as the founder of the Emerging Nurse Professionals Chapter, AzNA Secretary, Chair of Nominations and Elections Committee for ANA, and currently as Secretary of the Nurse Practitioner Council and Chair of the ANA Committee on Bylaws. As a Consultant for the Student Nurses Association, I mentor nursing students across the state, driven by my commitment to mentorship in shaping our future leaders.

The American Nurses Association’s Code of Ethics urges nurses to advance the profession through collaboration and mentorship, promoting equity and reducing disparities (ANA, 2025). Inclusive leadership amplifies diverse voices and brings psychological safety. Integrating mentorship and inclusion yields transformational results.

Evidence from the Norwegian Nurses Organization’s mentorship program showed that mentees gained motivation, confidence, leadership clarity, and stress management skills. Mentors reported personal growth (Lysfjord & Skarstein, 2024). Participants found their collaboration constructive and energizing, with digital platforms providing flexibility and confidentiality.

The MENTOR framework, which stands for Modeling, Engaging, Nurturing, Tailoring, Ongoing support, and Respecting needs, redefines traditional mentorship through experiential learning, learner-centered approaches, and altruism (Appiah et al., 2025). It emphasizes active leadership development, co-created learning opportunities, and authentic relationships reflecting each mentee’s goals and context.

Flexible mentorship is crucial for nurses from underrepresented groups or juggling multiple roles. As a parent, doctoral student, and clinician, I’ve used text, email, and Zoom to connect with mentors. During the pandemic, these tools supported my growth. Nontraditional and first-generation nurses need adaptable mentorship models that acknowledge life’s complexities (Melrose, 2019).

Inclusive leadership promotes mentorship. Nurse leaders promote policies for equitable access to leadership development and mentorship. These efforts enhance job satisfaction, reduce burnout, and improve patient outcomes (Du et al., 2024).

To embed inclusive mentorship into daily culture, organizations can:

• Rotate leadership roles in team huddles to elevate diverse voices
• Use mentor-match boards aligned with mentee goals and lived experiences
• Facilitate peer-led discussions and reflective storytelling rounds
• Support both formal and informal mentorship opportunities, including virtual options

Leadership is about building relationships that instill confidence and create opportunities, not about titles. I lead today because someone mentored me to believe I could. Now it is our responsibility to mentor boldly, lead inclusively, and shape a stronger future for nursing.

For fifty years, our profession has relied on the term “burnout” to describe the suffering we experience in healthcare. While this language brought initial validation, it hasn’t led us to true healing. As a nurse who suffered three herniated discs catching a patient when equipment was unavailable, I know firsthand how our systems can traumatize us. This experience led me to research nurse-specific traumatization and develop healing pathways that address the real root of our distress.

The Nervous System Connection

When you’re working short-staffed, dealing with aggressive patients, or witnessing suffering you can’t alleviate, your body isn’t just “stressed”—it’s activating a protective biological response. Your sympathetic nervous system engages, releasing cortisol and adrenaline to prepare you to address a real or perceived threat to safety. This can result in chronic hyperarousal, leading to anxiety, hypervigilance, irritability, and sleep difficulties.

As nurses, we consistently function in environments that evoke this response. Have you noticed feeling constantly on edge, even after your shift ends? Perhaps you’re experiencing physical symptoms like orthostatic dysregulation—a condition newly graduated nurses show higher prevalence of, accompanied by autonomic nervous system modulation and increased stress and depressive symptoms (Yamashita et al., 2021).

These aren’t signs of weakness or “just burnout”—they are your body’s intelligent response to perceived danger.

The Cell Danger Response

At the cellular level, traumatic experiences trigger what scientists call the Cell Danger Response (CDR). First identified by Dr. Robert Naviaux (2014), CDR occurs when cells perceive danger and shift into a protective state. In CDR Stage 1, endangered cells lose connection with healthy cells, creating a whole-body “shutdown.” Your cells prioritize survival over normal functions like growth and repair.

For nurses experiencing chronic workplace trauma, this cellular response can become stuck, leading to physical symptoms that may be difficult to resolve through traditional approaches. The cells essentially “fortify their walls,” making it harder to absorb nutrients and expel toxins.

Have you wondered why, despite proper self-care, your body still feels depleted? This cellular understanding helps explain why traditional interventions may not be enough.

Nurse-Specific Traumatization: Different from Burnout

Research shows nurses experience specific types of workplace trauma, including insufficient resource trauma, second-victim trauma, workplace violence, system/medically induced trauma, and historical trauma. These experiences differ significantly from general occupational stress (Zhao et al., 2024).

When we report abuse by patients, we’re often gaslighted and asked how we could have prevented the incident—literally adding insult to injury. This creates a complex trauma response that is misunderstood when labeled simply as “burnout.”

The global nursing workforce has experienced mass, complex trauma secondary to healthcare system inadequacies and the pandemic. Within a decade, the world will have just over half the nurses it needs, with many leaving due to traumatization. We cannot wait for health systems to prioritize nurse safety.

Learning the Language of Your Nervous System

Healing begins with understanding how trauma affects your nervous system. As I explain in my book Nursing Our Healer’s Heart (Laws, 2023), each nurse must discover their unique “innate care plan” that guides their healing process.

Start by recognizing the signs of dysregulation in your body. When feeling overwhelmed:

• Notice physical sensations: racing heart, shallow breathing, tension.
• Identify your location in the autonomic nervous system map: fight/flight, fawn, or freeze?
• Apply regulation techniques: conscious breathing, grounding exercises, sensory awareness, trauma-informed movement.

By learning to navigate your nervous system professionally, you can maintain regulation even in challenging environments.

Moving Forward Together

When we understand nurse-specific traumatization through the lens of neurobiology and cellular adaptation, we open pathways to true healing. We can build communities of co-regulation, where we support each other’s nervous system regulation rather than collectively amplifying distress.

As I often share with nurses, “There’s nobody who’s broken. These are all nervous system adaptations to the trauma that person has experienced.” By embracing this trauma-informed perspective, we can work from our healed scars rather than open wounds to lead sustainable changes in healthcare.

The nursing profession is in crisis, but with proper understanding of our trauma responses, we can heal ourselves and transform our profession. We deserve nothing less.

As a busy nurse, you might find yourself feeling drawn to a new specialty, maybe the ICU, OR, or even community health but unsure how to make the leap without starting over. You are not alone. Many experienced nurses want to shift their practice areas but face barriers such as inadequate orientation, staffing gaps, or fear of being underprepared. That is where nursing fellowships come in.

Unlike residency programs designed for new graduates, fellowships are built for experienced nurses who are ready to bring their expertise into a new clinical area. These programs are competency-based, structured, and supportive. They offer nurses a safe, educational bridge to shift specialties while staying in the profession and advancing their careers.

We know there is a high demand for nurses in Arizona. According to recent reports, our state continues to face one of the highest projected nursing shortages in the nation (AZ Health Workforce, 2023). And nationally, we are seeing the workforce age, burn out, and retire faster than we can replace it (Haddad et al., 2023). If we are going to meet the needs of Arizona’s growing and aging population, we need to create flexible, sustainable pathways that help nurses grow in place, not grow out of their jobs.

I have seen firsthand how fellowships can change lives and systems. At one hospital, experienced med-surg nurses transitioned into high-acuity areas like the ICU and OR through a fellowship model that included dedicated time, specialty preceptorship, and outcome tracking. Not only did these nurses stay in the organization longer, but they also reported higher job satisfaction and professional confidence.

Setting up a nursing fellowship involves conducting a needs assessment, securing leadership buy-in, developing a structured curriculum with defined competencies, assigning dedicated mentors, and establishing evaluation metrics for nurse progression and program outcomes. What makes fellowship programs work? Three things: structure, mentorship, and organizational commitment. Nurses are matched with mentors in their new units, receive a customized learning plan, and are supported throughout their transition. Organizations also benefit. Fellowship models help reduce reliance on travel nurses, improve team stability, and increase retention, which can save hospitals tens of thousands of dollars per nurse retained (Sullivan et al., 2025).

In our post-pandemic world, nurses are craving autonomy, purpose, and wellness. Integrative fellowship programs also incorporate mindfulness, professional goal setting, and leadership development elements that are essential to fostering joy in practice and long-term engagement (Sullivan et al., 2025).

If we want to shape the future of nursing in Arizona, we must invest in nurses across all stages of their careers. Nursing fellowships offer a meaningful, evidence-based solution that connects nurses, communities, and care. Fellowships give experienced nurses the flexibility to grow, the tools to succeed, and the encouragement to stay.

Anxiety is one of the most common mental health challenges nurses encounter across all areas of clinical care—from emergency departments to primary care clinics. Whether it’s pre-surgical nerves, chronic stress, or generalized anxiety, nurses are uniquely positioned to support patients in understanding and managing their symptoms with both empathy and practical tools.

Nurses serve as compassionate educators and steady guides, helping patients navigate their anxiety and regain a sense of control. Here are several actionable strategies nurses can use to support anxious patients:

1. Normalize the Experience

Let patients know they are not alone. Reassure them that anxiety is a common and valid response to stress, illness, or uncertainty. Normalizing their experience helps reduce the shame and stigma they may feel.
Try saying: “Many people feel this way, especially when dealing with health concerns. You’re not alone, and there are things we can do to help.”

1. Teach Basic Grounding Techniques

Provide simple, effective tools patients can use in the moment.

• Box Breathing: Inhale for four seconds, hold for four, and exhale for four.
• 5-4-3-2-1 Grounding: Name 5 things you see, 4 things you can touch, 3 things you hear, 2 things you can smell, and 1 thing you can taste.

These techniques can be demonstrated briefly and offer patients a sense of calm and control.

1. Encourage Physical Relaxation

Even a small intervention—like prompting a patient to unclench their jaw or drop their shoulders—can help. Teaching simple progressive muscle relaxation at the bedside empowers patients to regulate their own stress response.

1. Promote Structure and Routine

Anxiety often thrives in chaos and unpredictability. Encourage patients to maintain regular routines, support sleep hygiene, reduce caffeine, and create daily rhythms that provide a sense of stability. Small changes can offer a calming framework for daily life.

1. Link Emotions to Physical Symptoms

Help patients understand that anxiety can manifest physically—chest tightness, gastrointestinal distress, dizziness, and fatigue are common symptoms. When patients can recognize these as part of their anxiety, it reduces fear and builds awareness of early signs.

1. Offer Resources

Provide patients with tangible resources, such as:

• Mental health hotline numbers
• Referrals to local therapists or support groups
• Free apps like Calm, Insight Timer, or MindShift
• Community wellness programs or counseling services

Giving patients a pamphlet, handout, or app recommendation shows thoughtful care and can be a meaningful next step toward support.

If a patient’s anxiety is persistent or significantly impairing, encourage them to connect with a mental health professional. Remind them that seeking help is a sign of strength, not failure.
You might say: “Just like you’d see a specialist for your heart or lungs, sometimes it helps to talk with someone trained to support your emotional health.”

Whole-Person Healing

Nurses do more than treat the body—we care for the whole person. By teaching patients how to manage anxiety, we help them reclaim their sense of safety, confidence, and peace of mind. One breath at a time.

Pain is a complex and multifaceted experience commonly encountered and expressed by
patients in clinical settings. Aromatherapy has emerged as a widely used complementary and
alternative therapy to promote physical and psychological well-being. The healthcare and
scientific communities have shown a growing interest in investigating and evaluating the
efficacy of aromatherapy in pain management and postoperative recovery. A notable example is
the study by Döner et al. (2024), which examined the effects of aromatherapy massage using
bergamot essential oil (BEO) on pain, functionality, sleep quality, and menopausal symptoms in
women with knee osteoarthritis. Sixty menopausal participants were randomly assigned to three
groups: the BEO group, which received massage with BEO diluted in sweet almond oil; a
placebo group, which received massage with sweet almond oil only; and a control group, which
received conventional physiotherapy (Döner et al., 2024). Massages were administered twice
weekly for four weeks, while pain and functionality were assessed using the Visual Analog Scale
(VAS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). At
the same time, sleep quality and menopausal symptoms were evaluated using the Pittsburgh
Sleep Quality Index (PSQI) and the Menopausal Symptoms Rating Scale (MSRS), respectively
(Döner et al., 2024). The findings indicated that aromatherapy massage with BEO significantly
improved functionality and reduced pain and menopausal symptoms, although it did not have a
significant effect on sleep quality.

Similarly, Bagheri et al. (2020) investigated the effects of inhaled lavender essential oil
on postoperative pain in patients undergoing inguinal hernia surgery. In this randomized clinical
trial involving 90 participants, the intervention group received four drops of 2% lavender
essential oil administered with oxygen for 20 minutes, while the control group inhaled oxygen
alone (Bagheri et al., 2020). Pain levels were assessed at 0 minutes, 2 hours, 6 hours, and 24
hours post-surgery (Bagheri et al., 2020). The results demonstrated significantly lower pain
levels in the intervention group at all time points, supporting the effectiveness of lavender
aromatherapy as a non-pharmacological intervention for managing postoperative pain.

These studies provide growing evidence that aromatherapy is a safe and well-tolerated
complementary approach to pain management. Aromatherapy is considered to reduce pain
perception and anxiety while enhancing overall patient well-being, whether administered
inhalation or massage. Although it should not replace conventional pharmacological treatments,
aromatherapy can be an important alternative to serve as a valuable adjunct to holistic care
strategies, therefore improving patient outcomes. Continued research is crucial to establish
standardized protocols and strengthen the evidence base for integrating these practices into
clinical care.

Author's Note: Germin Zaki is a clinical associate professor and, the director of the RN-BSN and CEP programs at Edson College of Nursing and Health Innovation - Arizona State University.

Healthcare professionals are the foundation of the medical system, committed to healing and
supporting others. Yet, ironically, many neglect their own physical and emotional well-being.
Self-care is often overlooked in the high-pressure environments that characterize healthcare
settings. Unfortunately, the consequences of chronic stress, lack of support, and failure to
prioritize self-care are grave—leading to burnout, mental health deterioration, and tragically,
suicide. In the United States, these trends have reached alarming levels, underscoring the urgent
need to foster a culture where provider well-being is prioritized.

Burnout: A Silent Epidemic Among Healthcare Providers
Burnout is characterized by emotional exhaustion, depersonalization, and a reduced sense of
personal accomplishment, and it is increasingly common among U.S. healthcare workers. A
2022 national study found that more than 60% of physicians reported at least one symptom of
burnout (Shanafelt et al., 2022). Nurses, mental health professionals, and allied staff are
similarly affected. This chronic stress is often driven by excessive workloads, administrative
burdens, long hours, and the emotional toll of patient care—especially in high-stakes
environments such as emergency rooms, oncology, and psychiatry.

When left unaddressed, burnout can lead to a cascade of negative outcomes, including poor job
performance, increased medical errors, strained interpersonal relationships, and mental
health issues such as depression and anxiety (West et al., 2018). Alarmingly, burnout is also a
predictor of suicidal ideation and substance misuse in healthcare providers.

Suicide in the Medical Community
Suicide rates among healthcare professionals, particularly physicians, are significantly higher
than the general population. The American Foundation for Suicide Prevention (AFSP) reports
that physicians die by suicide at twice the rate of the general population (AFSP, 2023).
Female physicians, in particular, are 2.27 times more likely to die by suicide compared to
women in other professions (Schernhammer & Colditz, 2004). These statistics are not just
numbers—they represent real people lost to a preventable tragedy.

A sobering example is the case of Dr. Lorna Breen, an emergency room physician in New York
City who died by suicide in April 2020 at the height of the COVID-19 pandemic. Despite being a
high-functioning, compassionate leader, Dr. Breen struggled silently with overwhelming stress,
trauma, and the fear of being stigmatized for seeking psychiatric help. Her family later
testified that she felt she could not ask for help without jeopardizing her career. Her tragic death
sparked national awareness and led to the Dr. Lorna Breen Health Care Provider Protection
Act, signed into law in 2022, to promote mental health support for healthcare workers (U.S.
Congress, 2022).

The Role of Self-Care in Prevention
Self-care is not a luxury for healthcare providers; it is a professional necessity. Engaging in
regular self-care practices—such as sleep hygiene, physical activity, nutrition, mindfulness,
social connection, and setting work boundaries—can protect against burnout and improve
resilience (Sexton et al., 2022). Additionally, organizations that promote wellness through
mental health days, access to therapy, and manageable work schedules contribute to a
culture where providers feel safe to seek help.

According to West et al. (2018), institutional-level interventions that focus on system change—
such as reducing excessive documentation, improving team communication, and supporting peer mentorship—have a greater impact on reducing burnout than individual-level strategies alone. However, these systemic changes must be paired with a culture that destigmatizes mental
health care, especially in professions where disclosure can still threaten licensure or reputation.

Breaking the Silence and Building Support

The fear of judgment or professional consequences remains one of the biggest barriers to self-
care and mental health treatment in healthcare. Providers often internalize unrealistic expectations of strength and perfectionism, leading them to suffer in silence. Initiatives such as
peer support programs, debriefing after critical incidents, and open conversations about provider well-being can foster emotional safety and normalize help-seeking behavior.
Moreover, training healthcare workers in emotional regulation, boundary-setting, and
reflective practice during medical and nursing education can embed self-care as a lifelong
professional skill—not a reactive solution.

Conclusion
The emotional cost of caregiving is steep, but it must not come at the expense of caregivers'
lives. Burnout and suicide among healthcare providers are preventable tragedies that stem in part from a systemic failure to support well-being. Embracing self-care as a core value—rather than an afterthought—can save lives, improve patient care, and build a more resilient workforce. In honoring those we've lost, like Dr. Lorna Breen, we are called to create a healthcare system
where healing begins with those who give care.

Authors: Jane M. Abucha

Affiliation: American University of Integrated Sciences

Corresponding Author: mesiloa@gmail.com

Keywords: NAFLD, Liver Cirrhosis, Risk Factors, Fibrosis, Genetic Predictors

Abstract

Background: Non-alcoholic fatty liver disease (NAFLD) affects approximately 25% of the global population and represents a growing cause of liver-related morbidity and mortality. Early identification of individuals at risk for progression to liver cirrhosis is crucial.

Purpose: This review aims to summarize the current evidence on clinical factors predicting NAFLD progression to cirrhosis.

Methods: A comprehensive literature search was conducted in PubMed and Scopus databases covering studies from 2010 to 2024. Keywords included NAFLD, cirrhosis, risk factors, fibrosis, and progression.

Results: Key predictors identified include metabolic syndrome components (obesity, diabetes, dyslipidemia), genetic variants (PNPLA3, TM6SF2), lifestyle factors (sedentary behavior, high-fructose diet), demographic traits (age, sex, ethnicity), and histological markers (fibrosis stage, NASH features). Non-invasive detection tools such as FIB-4, NFS, and elastography are valuable for early identification.

Conclusion: A combination of metabolic, genetic, lifestyle, and histological factors predicts NAFLD progression. Early detection and intervention are critical to prevent cirrhosis.

Key words: NAFLD, Liver cirrhosis, risk factors, fibrosis and progression

Introduction

Non-alcoholic fatty liver disease (NAFLD) persists as the leading cause of chronic liver disease worldwide, with an estimated global prevalence between  25% (Younossi et al., 2023) and 32% (Saghir, et al., 2024). NAFLD encompasses a spectrum ranging from simple steatosis to non-alcoholic steatohepatitis (NASH), fibrosis, and cirrhosis. Identifying predictors of disease progression is vital to prevent liver-related complications and mortality. This review explores key clinical, genetic, and lifestyle factors contributing to the transition from NAFLD to cirrhosis.

Methods

We conducted a narrative review using PubMed, Cochrane database and Scopus databases. Articles published between 2010 and 2024 were included. Search terms were "NAFLD," "liver cirrhosis," "risk factors," "fibrosis," and "progression." Both observational studies and meta-analyses were included. Exclusion criteria were studies focusing exclusively on alcoholic liver disease or pediatric populations.

Epidemiology of NAFLD and Cirrhosis

NAFLD affects about 25% of the global population, with the highest prevalence in the Middle East and South America (Younossi et al., 2024). Recent 2025 data shows even higher at 32% (Saghir, et al., 2024). Cirrhosis represents the end-stage of progressive fibrosis and is associated with significant morbidity and mortality

Literature review

Non-alcoholic fatty liver disease (NAFLD) has emerged as a major public health concern, affecting approximately 25% of the global population (Younossi et al., 2024). The disease spectrum ranges from simple steatosis to non-alcoholic steatohepatitis (NASH), which can progress to fibrosis and ultimately cirrhosis. Multiple studies have investigated the clinical factors that predict this progression.

Metabolic syndrome components are consistently identified as primary drivers of NAFLD advancement. Chalasani et al. (2023) emphasized the roles of obesity, type 2 diabetes, and dyslipidemia in accelerating liver fibrosis. Their guidance highlights that patients with diabetes are at particularly high risk, with nearly double the progression rates compared to non-diabetics. Moreover, insulin resistance has been shown to directly contribute to hepatic steatosis and inflammation, further promoting fibrosis (Sanyal et al., 2023).

Genetic predispositions also play a crucial role. Variants in the PNPLA3 gene, particularly the I148M allele, are strongly associated with increased liver fat content and fibrosis progression, independent of metabolic risk factors (Saghir et al. 2024). Similarly, TM6SF2 variants have been linked to higher fibrosis stages and NASH severity (Liu et al., 2023). These genetic markers are becoming valuable tools in risk stratification models.

Lifestyle and demographic factors further modulate disease risk. Sedentary behavior, high-fructose diets, and low physical activity levels are associated with worse liver outcomes (Younossi et al., 2024). Additionally, older age, male sex, and Hispanic ethnicity have been identified as demographic factors linked to higher progression rates (Anstee et al., 2013).

Histological studies remain the gold standard for assessing progression risk. According to Sanyal et al. (2023), the fibrosis stage is the strongest predictor of liver-related morbidity and mortality in NAFLD patients. Notably, the presence of ballooning degeneration and lobular inflammation hallmarks of NASH — significantly accelerate fibrosis progression.

Non-invasive detection strategies are gaining prominence in clinical practice. Tools such as the FIB-4 index, NAFLD fibrosis score (NFS), and transient elastography have demonstrated utility in identifying patients with advanced fibrosis (Chalasani et al., 2018). These methods offer a safer and more accessible alternative to liver biopsy, supporting earlier intervention.

Together, the literature underscores the multifactorial nature of NAFLD progression, highlighting the interplay between metabolic, genetic, lifestyle, and histological factors. Early identification of high-risk individuals through a combination of these predictors is critical to preventing liver cirrhosis.

The major risk factors in predicting the progression of NAFLD 

Metabolic Risk Factors

Metabolic syndrome is one of the most important contributors of NAFLD progression. Obesity, type 2 diabetes, dyslipidemia, and insulin resistance accelerate liver fibrosis (Chalasani, et al., 2018). Diabetics have nearly double the progression rate compared to non-diabetics (Sanyal et al., 2023).

Genetic Predictors

Genetics play a role such as PNPLA3 gene (I148M allele) is linked to increased liver fat and fibrosis, independent of metabolic factors (Saghir, et al., 2024). TM6SF2 variants have also predicts fibrosis severity (Liu et al., 2023).

Lifestyle and Demographic Influences

Lack of moderate activities, and high-fructose diets, also contributes to bad liver outcomes (Younossi et al., 2023). Older age, male sex, and Hispanic ethnicity are demographic traits associated with higher progression rates (Anstee et al., 2013).

Histological Markers

Fibrosis stage is the strongest predictor of morbidity and mortality. The presence of ballooning degeneration of the liver and inflammation accelerates the progression (Sanyal et al., 2023).

Non-Invasive Detection Tools

Tools such as the FIB-4 index, NAFLD fibrosis score (NFS), and transient elastography help identify patients with advanced fibrosis (Chalasani et al., 2018). These non-invasive methods support early detection and management.

Discussion

Current evidence-based research points to the multifactorial nature of NAFLD progression. Metabolic dysfunction, genetic susceptibility, lifestyle choices, and histological severity all interplay in disease advancement. Given that biopsy remains the current gold standard which clinical guidelines call for; however, non-invasive tools are increasingly reliable. There are still gaps in the combined predictive power non-invasive tools

Conclusion

Multiple studies continue to show the progression of NAFLD to cirrhosis which is associated with complex interplay of metabolic, genetic, lifestyle, and histological factors. Early detection through combined clinical and non-invasive tools is essential to prevent cirrhosis and its complications.

Introduction

The transition from nursing school to professional practice remains a critical phase for new nurses and their preceptors (Bohnarczyk & Cadmus, 2022). In 2021, the Maricopa County Board of Supervisors granted funds to implement a program for nursing workforce improvement. A team of subject matter experts implemented the Maricopa County Practice Readiness Program (MCPRP), an evidence-based intervention to enhance preceptor preparedness and foster student readiness for clinical practice. This article describes the development, implementation, key findings, and implications for nursing practice.

Identifying the Problem

Hospitals across Maricopa County reported challenges related to new graduate readiness, preceptor burnout, and inconsistent outcomes from preceptor training. Leadership and educators noted that traditional preceptor training lacked depth and left preceptors underprepared to mentor students in their final clinical rotation and into nursing. Simultaneously, students reported feeling overwhelmed during the transition. The concerns highlighted by those closest to the transition process were echoed nationwide and motivated the development of a practice readiness program that addressed both preceptor and student needs (Masso, et al., 2022).

Designing the Intervention

The MCPRP was implemented from 2022 to 2024 in collaboration with twelve hospitals across three healthcare systems. The program contained 10 self-paced online modules for preceptors. Training content included methods for teaching communication, prioritization, clinical judgment, and well-being (Liu, et al., 2019; Rusch, et al., 2019). 

Senior nursing students were asked to participate in research to evaluate their readiness to practice using validated Readiness to Practice Indicators (RPIs) from Galen Center for Professional Development. The RPIs are designed to track a student’s progress toward managing a full patient load. 

To evaluate the program’s effectiveness, researchers used validated tools including the Preceptor Self-Efficacy Questionnaire, Psychological Capital Questionnaire, Job Engagement Survey, and the Casey-Fink Readiness for Practice Survey (CFRPS). Institutional Review Board approval was obtained. Preceptors and students were recruited using convenience sampling methods.

Program Implementation

The evidence-based training used scenarios and printable resources to help preceptors learn how to teach critical skills identified by stakeholders and literature (Liu, et al., 2019; Rusch, et al., 2019). A one-hour application session was conducted after module completion to reinforce learning. Surveys were completed at baseline, after training, and after working with a student.

Students from ASU, UA, GCU, Arizona College, and GWCC were placed with trained preceptors in their final clinical rotation. These students completed pre- and post-rotation assessments using the CFRPS to track perceived readiness. Preceptors and students set goals for progression using RPIs.

Findings and Outcomes

The outcomes of the program were overwhelmingly positive. Preceptors (n = 160) demonstrated statistically significant increases in self-efficacy, multiple aspects of well-being, overall job engagement, and satisfaction with training (p < 0.05). Preceptors experienced a mild increase in turnover intent.

Students (n = 250) participating in the program also showed marked improvements. Following the clinical experience with a trained preceptor, 88.5% reported feeling prepared to manage a full patient assignment. Statistically significant improvements (p < 0.05) were seen across all four CFRPS subscales: Clinical Problem Solving, Learning Techniques, Professional Identity, and Trials and Tribulations. Students credited their improved confidence to the quality of mentorship received from trained preceptors.

Lessons Learned

Key lessons emerged from the program:

1. Structured Preceptor Training is Critical – Scenario-based training built confidence and improved preceptor effectiveness in supporting student learning.
2. Wellbeing Matters – Enhancing psychological capital contributed to increased preceptor engagement and confidence in the role.
3. Quality Preceptors Improve Student Readiness – Evidence-based preceptor preparation directly impacted students’ perceptions of practice readiness.
4. Ongoing Evaluation is Necessary – Continued data collection and refinement of training modules were vital to program success.

Next Steps

The MCPRP provides a model for enhancing the student to new graduate nurse transition to practice. Leveraging training programs based in adult learning theory with microlearning is recommended to engage busy nurses. Future research can explore long-term retention of new graduates and the cost-benefit analysis of reduced turnover related to preceptor support and training. 

Conclusion

The MCPRP underscores the power of targeted, evidence-based interventions that promote collaboration between education and practice to improve processes. Healthcare systems and schools of nursing can build a more confident, resilient, and practice-ready nursing workforce by investing in quality preceptor development that supports students in their final semester and beyond. 

2025 AzNA Convention

Navigating Arizona's Future: Connecting Nurses, Communities, and Care

Friday, September 12 - Saturday, September 13, 2025

 Learn from ANA President, Jennifer Mensik-Kennedy, previous ANA CEO, Marla Weston and others!

NCPD Contact Hours will be available

To register or get more information, visit www.aznurse.org/events.

AzNA is looking for exciting companies to exhibit at its upcoming 2025 Convention in September 2025. The event will take place in Mesa, Arizona on September 12-13, 2025.

For more information, visit www.aznurse.org/events or email Madi Moyer, AzNA Communication and Event Manager at madi@aznurse.org.