3. Nursing and the Work Environment: Improving Outcomes

3.1. Changing Roles in the Nursing Work Environment

Identifying approaches for enhancing the nursing work environment is a key step towards improving the quality of patient care institutions and the health care system in general.  A better work environment may require changes such as increasing nurse-to-patient staffing ratios, making better use of technology, and developing more effective and efficient processes.  Dysfunctional work environments and associated practices are a significant contributor to nurse stress and burnout.  In a 2002 survey, more than 60 percent of nurses agreed or strongly agreed that stress and/or burnout was an issue.  In a 2004 survey, 55 percent of respondents expressed the same view (Buerhaus et al., 2005). 

The National Advisory Council on Nurse Education and Practice supports initiatives to optimize the nursing work environment.  It recommends evaluating and improving the nursing work environment and workflow processes to enhance nurse retention, safety, satisfaction, productivity, and patient outcomes (for example, via “Enhancing Patient Care” grants that address the aging workforce, decrease job burnout, reduce latent errors, lessen burdensome paperwork, and facilitate technological solutions).

Assessing Outcomes

The growing demand for health care value (cost, quality, and access) by consumers, employers, and funders of health care services contributes to the need for specific nursing outcome measures in education and practice.  Much of the research currently available on nursing outcomes is, in part, the result of an initiative of the American Nursing Association (ANA).  Begun in 1994, this initiative funded analysis of existing large datasets to determine the relationship between nursing skill mix and nursing quality indicators in hospitals.  This initiative led to the development of the National Database of Nursing Quality Indicators (Blakeney, 2005).  Since the initial ANA efforts, the National Quality Forum has put forth a set of 15 national standardized performance measures to assess the extent to which nurses in acute care hospitals contribute to patient safety, health care quality, and a professional work environment.  These 15 consensus standards are intended to be used by providers, purchasers, and consumers to assess the quality of hospital nursing care, and to identify areas for improving outcomes and processes of care (National Quality Forum, 2004).  Research is underway to assess the usefulness of these standards in hospital practice, and to identify other nursing-sensitive measures that could be used to supplement these benchmarks.

Although the research base is growing in this area, nursing would benefit from continued research that addresses the work environment, processes of care, and the relationship of specific nursing interventions to patient outcomes.  The evidence that clearly links patient outcomes with work environment, specific nursing practices, nurse skills/knowledge, and nursing-related institutional factors is small, commensurate with the limited research in this area.  One of the limitations is that the state of the science in evaluation for nursing-related outcomes requires more development. 

Organizations such as the American Nurses Credentialing Center (ANCC) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) have developed methodologies for evaluating the quality of patient care.  The ANCC’s Magnet Recognition Program® was developed to recognize health care organizations that provide nursing excellence.  The program uses quantitative and qualitative methodologies to evaluate nursing services and medical care and provides a vehicle for disseminating successful nursing practices and strategies.  Magnet status is awarded to hospitals that satisfy a set of criteria designed to measure the quality of their nursing services and patient care.  Among the criteria are patient outcomes, nurse job satisfaction, staff nurse turnover rate, appropriate grievance resolution, nursing involvement in data collection, and decision-making in patient care delivery.  Recognizing quality patient care, nursing excellence, and innovations in professional nursing practice, the Magnet Recognition Program provides consumers with a benchmark to measure the quality of care that they can expect to receive.

The objective of Magnet hospitals is to promote open communication among nurses and other members of the health care team, as well as staffing practices that lead to an appropriate personnel mix, to attain the best patient outcomes and work environment for staff.  The Magnet designation is often touted by designated hospitals as they promote their nurse-friendly work environments as part of their efforts to attract prospective employees.

3.2. The Importance of Retention

As discussed in section 1.3., the supply of nurses is not keeping up with demand.  Retention is important not only because of the growing shortage, but also because there are significant costs associated with nursing staff turnover.  A survey of turnover in acute care facilities found that replacement costs for nurse positions are equal to or greater than two times a regular nurse's annual salary (Robert Wood Johnson Foundation, 2006a).  Given a national average for medical-surgical nurse of $46,832, the cost replacing just one is $92,442.  Recruiting costs include human resource expenses advertising and interviewing, increased use traveling nurses, overtime, temporary replacement per diem lost productivity, training, terminal payouts.  If hospital with 100 nurses experienced turnover at 21.3 percent in 2000, expenditures associated would amount to over $1.9 million 2006a).

Approaches for Improving Retention

The National Advisory Council on Nurse Education tion and Practice recommends implementing evidence-based RN retention models across the health care system. The objective of retention efforts is to retain experienced and qualified RNs in the health care system. Research shows that compelling benefits plans are more important for promoting retention than they are for promoting recruitment. This is especially true for older nurses who have a stronger preference for benefits and retirement plans. Benefits plans should be structured to appeal to different demographic groups. For example, child care may be a more relevant benefit for younger nurses while an elder-care subsidy would be an appropriate benefit for older nurses (Robert Wood Johnson Foundation, 2006a).

As discussed in section 1.3, evidence shows some recent improvement in overall job satisfaction which may improve future retention rates. Recent data suggest that nurses are becoming more satisfied with their careers than they have been in the recent past. In 2004, 33 percent of RNs employed in hospitals were “very satisfied” with their current jobs and with nursing as a career, up from 21 percent in 2002 (Buerhaus et al., 2005).

3.3. Improving the Nursing Work Environment

Operating quality health care institutions and an effective and responsive health care system requires complementary nursing work environments, clinical practices, and organizational structures. There is evidence that poorly defined processes in the work environment can lead to inefficiency, excessive errors, and the need for significant “work arounds.” Work arounds are short-term remedies that “patch” immediate problems so nurses can continue to concentrate on the patient care task. Nurses performing this sort of first-order problem solving do not alter the underlying conditions that gave rise to barriers to task completion in the first place, and so, while the immediate situation at hand may be resolved, the failure, or one just like it, is likely to recur. This means that although the behavior appears to provide a solution to a system failure, the solution is a temporary measure. Meanwhile, an opportunity for organizational learning is lost. Because first-order problem solving is time consuming and tiring, over time, it can lead to nurses feeling frustrated and worn out from swimming upstream against an incessant tide of small, annoying problems (Tucker & Edmondson, 2002).

As Tucker and Edmondson (2002) noted,

…nursing units were designed to maximize individual unit efficiency. Nursing labor is expensive and in short supply. Understandably, hospitals can ill afford to have nurses routinely working with slack resources. This staffing model leads to an organizational design where workers do not have time to resolve underlying causes of problems that arise in daily activities. Instead, nurses are barely able to keep up with the required responsibilities and are in essence forced to quickly patch problems so they can complete their immediate responsibilities. Thus, in this situation it is possible for an individual worker to be working non-stop while the content of the work technically adds little value to the customer’s experience because of the amount of rework and unnecessary steps.

Insufficient management of variability in patient demand puts stress on the health care system in general and on nursing in particular. Litvak and colleagues (2005) suggested techniques for minimizing unnecessary variability to reduce stress on nurses and improve patient outcomes. The authors recommend identifying forms of artificial variation and conducting pilot programs to test operational changes. As an example, operating room (OR) schedules can be a source of artificial variation on patient census that can strain nursing resources. Rearranging OR schedules to minimize peaks and valleys in patient census can alleviate one source of artificial variation that contributes to nurses’ stress.

As part of its effort to address some of the practice-related issues associated with the work environment, HRSA provides grants for Enhancing Patient Care Delivery Systems. Practice priority areas for these grants include, among other areas: providing managed care, quality improvement, and other skills needed to practice in existing and emerging organized health care systems; enhancing patient care delivery systems by enhancing collaboration and communication among nurses and other health care professionals; and promoting nurse involvement in the organizational and clinical decision-making processes of a health care facility.

The Use of Technology

Information technology has the potential for improving nurses’ job satisfaction, and therefore nurse retention, by assisting with many routine aspects of their jobs.  According to a recent survey of Maryland nurses conducted by the Maryland Workplace Subcommittee of the Maryland Statewide Commission on the Crisis in Nursing (MSCCN), “too much time spent on non-direct care activities” was identified as one of nurses' top concerns (Maryland Statewide Commission on the Crisis in Nursing, 2005).  Information technology can be used for applications such as nurse scheduling, medication administration, and online patient charts and records, providing nurses with more time to focus on health care delivery and minimizing time spent on the administrative aspects of clinical practice.  Such uses of technology can also improve efficiency and reduce errors.  The Committee on Quality of Health Care in America Institute of Medicine’s (2001) goal of cutting medical errors in half in five years has not occurred.  Research suggests that a significant challenge in reducing errors is to place increased attention to “latent errors.”  Latent errors are factors not under the direct control of front-line workers – e.g., poor systems design or poor communication (Aiken, 2005).

The use of ergonomic technology can help reduce injuries.  The rate of overexertion injuries among hospital nurses is almost twice that of other workers in private industry (United States Department of Labor, Bureau of Labor Statistics, 1997).  Nursing aides, orderlies, and attendants – a subset of the occupational group nursing, psychiatric, and home health aides – consistently ranked among the detailed occupations reporting the most cases of workplace injuries and illnesses during 1995 through 2004.  In 2004, for example, nursing aides, orderlies, and attendants reported the third highest number of injuries and illnesses.  Only truck drivers, laborers, and material movers reported more cases of injuries and illnesses (Hoskins, 2006). 

Lifting and transferring patients is a frequent cause of back and shoulder overexertion injuries for nurses.  Ergonomic technology, such as assistive devices for lifting and transferring patients, can reduce injury and increase job satisfaction (Owen, 2000).  For instance, some hospital beds can be lowered to 18 inches off the ground to reduce injuries in the event a patient were to fall out of bed. The beds also can be raised so that nurses can work with patients without bending over beds at awkward angles.

The Occupational Safety and Health Administration (OSHA) (2005) has created guidelines to help staff nurses, certified nursing assistants, nursing supervisors, physical therapists, physicians, and nursing home residents with their assessments of lifting and repositioning tasks.  These care providers and their patients can collaboratively determine when to use assistive devices including gait/transfer belts and full body slings and which devices may be most appropriate.  The Occupational Safety and Health Administration (2005) recommends minimizing manual lifting of residents and eliminating this activity when feasible.

OSHA’s “Ergonomics: Guidelines for Nursing Homes,” also provides an overview of assistive ergonomic technologies available to the health care industry (Occupational Safety and Health Administration, 2005).  For instance, powered sit-to-stand or standing assist devices can help patients transfer from a sitting to a standing position.  Portable or ceiling-mounted sling lift devices can lift or transfer residents who are totally dependent, are partial- or non-weight bearing, are very heavy, or have other physical limitations.  Non-motorized devices like transfer boards can also reduce the need for nurse support when a patient is moving from one level surface to another.  By incorporating ergonomic technologies, the number and severity of injuries resulting from physical demands – and associated costs – can be substantially reduced (United States General Accounting Office, 1997).

The James A. Haley Veterans Affairs Hospital in Florida is developing a prototype concept room that automates patient handling to serve as a leading laboratory for patient care facility designers.  This computer-controlled room would have a built-in patient handling and transfer system to permit all daily care patient tasks while providing a safe environment for patients and caregivers (United States Department of Veterans Affairs, 2006).

Technology can play a significant role in addressing the challenges associated with the changing health care environment.  Technology does not replace nurses, but there are ways to use technology to enhance the nursing workforce by ensuring adequate skill mix and staffing, and helping to prepare new nurses.  In addition, it can enable new capabilities and new ways of performing work that can improve efficiency, reduce errors, and improve quality of care.  

For instance, Personal Digital Assistants (PDAs) are handheld computers that can allow nurses to be more effective and more organized.  These mobile instruments can provide access to evidence-based medicine (EBM), medical reference material, and other clinical data resources at the point of care, thus increasing the extent to which evidence is incorporated into patient care decisions (Wilcox & La Tella, 2001).  Software for PDAs allows for quick access to current drug databases and medical calculators.  PDAs can help nurses to organize and track patient data, and document treatments and assessments as they are performed.  Because PDAs can allow bedside data collection and charting, they may reduce trips to and from the nurse’s station (Davenport, 2004).  Wilcox and La Tella (2001) noted that wireless technologies have potential for the rapid exchange of clinical laboratory results and efficient electronic communication of patient information.  Thus, these devices provide the potential for true continuity of care across the healthcare system.  Grasso, Genest, Yung, and Arnold (2002) reported decreased incidence of errors in discharge medication lists that were generated by PDAs instead of being hand transcribed.  In a four-month period before the use of PDAs was introduced, 20 of the 110 hand-transcribed lists (22 percent) contained errors. In the four-month period after the use of PDAs was implemented, seven of the 90 PDA-generated lists (eight percent) contained errors.  The researchers concluded that use of a PDA may be helpful in providing safer patient care.

In 2004, President Bush announced a federal mandate of widespread adoption of Electronic Health Records (EHRs) for most Americans by 2014.  The Health Information Management Systems Society’s (HIMSS, as cited in National Institutes of Health (NIH) National Center for Research Resources, 2006) defines EHRs as follows:

The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports. The EHR automates and streamlines the clinician's workflow. The EHR has the ability to generate a complete record of a clinical patient encounter, as well as supporting other care-related activities directly or indirectly via interface – including evidence-based decision support, quality management, and outcomes reporting.

EHR use is credited with increased efficiencies and improved accuracy, timeliness, availability, and productivity.  In environments with EHRs, clinicians, including nurses, spend less time updating static data, such as demographic and prior health history, because this information is already in the patients’ records.  Clinicians also have much greater access to improved organizational tools, and alert screens which identify medication allergies and other needed reminders (National Institutes of Health, National Center for Research Resources, 2006).  EHRs make patient information more readily available to health care providers, so there is improved likelihood of preventing adverse drug interactions, and better communication about patients among different providers and across shifts. 

EHRs may present some challenges to workflow processes, including increased documentation time (for example, slow system responses, system crashes, and multiple screens), decreased interdisciplinary communication, and impaired critical thinking through the overuse of checkboxes and other automated documentation.  System crashes are especially problematic because clinicians, particularly at in-patient facilities, will not know what patient treatments are needed or if medications are due (National Institutes of Health, National Center for Research Resources, 2006).

Members of AONE participated in a national survey to determine the information that nurse administrators considered essential for new nurses.  Results revealed the most critical skills were the effective use of email, operation of basic Windows applications, and database searches (McCannon & O’Neal, 2003).  Knowledge of nursing-specific software such as bedside charting and computer-activated medication dispensers was considered to be most important for new RNs.  The National Advisory Council on Nurse Education and Practice recommends employing and integrating technology into the educational process and curriculum content.

Within nursing education, the curriculum and teaching methods must address emerging clinical practice realities.  Students must be prepared to work in environments that are increasingly reliant upon information technology systems as applied to delivery of health care, research, and education.  Schools of nursing must re-design curricula and use innovative teaching approaches, pursue options for adequate funding of innovative nursing education including public and private investments, expand teaching capacity via the use of technology, and link practice needs with educational preparation.

One example of such a public-private partnership is The Johns Hopkins University School of Nursing and Eclipsys, a provider of information solutions to hospitals and health systems across North America.  In 2004, the two organizations formed a partnership to teach students, as part of the curricula, to interact easily with health care information technology and learn to use a wealth of evidence-based, best-practices clinical content, and knowledge management tools (Writsel, 2004).

Integrating information technology into nursing education and practice has the potential to improve health care quality, prevent medical errors, and reduce health care costs.  This integration may also increase administrative efficiencies, decrease paperwork, and expand access to affordable care.