Appendix E

The State of Working Conditions for Inpatient Registered Nurses

Karen Cox, Ph.D., R.N., C.N.A.A.
Senior Vice President For Patient Care Services Children¹s Mercy Hospitals and Clinics
Assistant Dean for Clinical Partnerships
University of Missouri ‹ Kansas City School of Nursing

Thank your for the invitation to present to the council. My name is Karen Cox. I have had the opportunity to assess the perception of the work environment of inpatient registered nurses locally, regionally and nationally. Nurses are clearly dissatisfied with their work environment. Determining the root causes of this dissatisfaction will provide the basis for developing interventions to improve the work environment.

As a Robert Wood Johnson Executive Nurse Fellow, I had the opportunity to coordinate the nursing focus groups for the report "Health Care¹s Human Crisis: The American Nursing Shortage" prepared by Bobbie Kimball, RN, MBA and Edward O¹Neil, MPA, PhD. The report was prepared for the Robert Wood Johnson Foundation in April 2002.

The results are similar to local work I conducted. I will provide an overview.

The State of Working Conditions of Inpatient Registered Nurses

Presentation to National Advisory Council on Nurse Education Practice

1. Most nurses plan to stay in nursing. However, they have concerns that as they age, they will be unable to continue given the heavy workloads and chaotic work environment. Even though nurses were satisfied with their career choice, most of them could not imagine continuing in a patient setting for any length of time unless work conditions dramatically improved. Most would not recommend nursing to others unless they believe the individual had a realistic understanding of the demanding and physical work required of them. The overall belief was that an individual must possess the intrinsic desire to work in service to others to be successful for the long term.
   
   
2. The number one concern of nurses in all the groups was their increased daily workload. The respondents have seen their patient assignments increase over the last several years with either the same or higher acuity. Many are assigned eight to ten patients with little or no ancillary support. Because of shortened lengths of stay, they may have as many as 12 patients during a 12-hour period. This increase in work intensity is physically and emotionally exhausting and raises concerns in their minds about safety of the care they provide. The other concerning factor that the nurses brought up related to workload was that they perceive managers and administrators really saw each nurse as equally capable of performing the same functions and level of work and little consideration was given to how an in experienced or agency nurses, who require more supervision and have more questions, increased the burden on those more senior or competent staff. Managers seem to ignore the differences with their true goal of maintaining staffing at a defined number per shift based on census and it generally failed to take patient acuity into account. Many nurses believed that hours per patient per day was the only factor considered when determining staffing levels.
   
   Ancillary support also impacts the perception of workload. In the past hospitals may have said they were not going to make any decreases to nursing staff. However, cuts were made in ancillary and allied health staff. As a result, nurses end up taking more responsibilities outside their typical scope. Those things may include spending considerable time answering phones, obtaining equipment, supplies, medications, transporting patients off the unit and in some cases assuming some allied health responsibilities. This best illustrates by an example in one market where the staff had recently been given heavier patient. Shortly after they were assigned more patients to be responsible for, patient satisfaction scores dropped. This was very concerning to hospital leadership. Many executives performance bonuses or pay are tied directly to these scores. The administrative staff brought in outside consultants to do mandatory "be nice classes". This was not only irritating but demonstrated to the nurses that the administrators had little or no appreciation for that connection between workload and how it impacts patient satisfaction.
   
   
3. Nurses are confused about the financial issues surrounding healthcare. The nurses in the groups were pretty savvy in their financial understanding and the challenges facing hospitals. For instance they understand the Balanced Budget Act and decreased reimbursement by third party payors. That being said, they still had difficulty understanding some of the things done about the organization level. The focus group findings do support that nurses, as most hospital employees, probably do not understand the difference between capital and operating budgets and see them much more interchangeable that they are. It is difficult, they said, to see new construction when they have been told to cut end-of-shift overtime and when patient care supply levels are decreased. They see an increased reliance on costly temporary nurses and bonus pay as incongruent with hospital claims that they cannot afford to increase nurses¹salaries or benefits. Probably the biggest issue around the finances that directly impacted nurses was salary compression. They felt it was very demoralizing when the practice of paying higher rates to entry level nurses and offering sign-on bonuses were used. Many felt that the entry level salary for nurses was quite adequate; however, the compression where by a nurse with five years of experience and a nurse with fifteen years of experience had very little difference in their salaries was hard to understand. They felt this detracts from people being satisfied or even going into the nursing profession. Also, nurses in one market really did describe feeling like a commodity. One day they are begged to come in to work and the next day they are told they have to stay home. Often times they felt that this was a resource allocation issue and gave the example that there were days where all the surgeons wanted to operate so the hospital made every effort to let them operate the day they wanted and the next day there were very few surgeons working. They talked about the stress that puts on the system.
   
   
4. Nurses felt relatively powerless to change things they dislike in their work environment. Now, the nurses who felt most positive about their jobs believed that there were ways to make their concerns known. Unfortunately, they were the minority of the nurses in the groups. The majority, who felt powerless, had two different perspectives on this. One felt that they were in a work environment where structures existed that allowed input and administrators and managers were generally empathetic, but that empathy did now always take form in seeing actions or changes made. The other group felt that not only people had not interest in their opinions but that they were expected to do as they were told and that they might be labeled in a very negative way when they did bring issues. Even those who did not really support unions philosophically, thought that organizing might be the only way to make substantial improvements in that environment.
   
   
5. Nurse managers can make a significant difference in how nurses perceive their jobs and several respondents reported that they had supportive first-line managers. They described these managers as very committed to patient care and they are clinically competent to provide care and frequently do so. They view these managers as advocates and partners with administration. They work hard to make sure there are enough staff and adequate equipment and supplies for them to do their work. Most nurses said that they were no longer able to be supported by nurse managers because they had two to four units to oversee and they also had very little influence or input at the administrative level. Interestingly, one focus group suggested that completely eliminating this role would be a way to free-up dollars to increase staff salaries. Nurses also said that they felt like their managers were just as frustrated as they were.
   
   
6. Respondents felt little commitment from nursing schools and employers to adequately educate, train and orient new nurses. There is also limited support for continuing education. This was very interesting­in one market across several hospitals nurses reported getting only two weeks of clinical orientation regardless if they had experience in the sub-specialty or if they were new graduate nurses. Nurses also felt nursing education is doing a disservice to students by not preparing them adequately for what the realities of their workload would be like. This in many ways creates a vicious cycle of nurses who come in, get oriented and quickly overwhelm and leave.
   
   The issue of continuing education is also a concern. Very few of the nurses reported being paid to attend education classes and seminars, even when employers required it. Most seemed unaware that this is a violation of the Fair Labor Standards Act. For nurses, this lack of interest in their ongoing professional development further reinforces the perception that a nurse is not valued as a professional.
   
   
7. The nurses' suggestions to address the nursing shortage.

Workload and Work Environment

• Decrease individual workloads.
• Provide support staff: clerical staff, nurse technicians, transport technicians, etc.
• Empower nurse managers to be able to fully support their units.
• Listen and take action regarding concerns in the work environment.

Financial

• Increase salaries

Respect and Support

• Encourage physicians to treat nurses as colleagues

Education and Professional Development

• Improve the orientation process
• Provide paid continuing education

In summary, generally nurses from the focus groups express similar concerns regarding work environment, a sense of powerlessness to effect change and physical and emotional exhaustion.

In addition, as part of my work as a Robert Wood Johnson Nurse Fellow, I conducted work environment assessments at seven hospitals in the Kansas City area. Using both quantitative and qualitative research methods yielded very similar findings. The most pervasive theme in the Kansas City focus groups was the role of the nurse manager and the lack of support nurses perceived having from front-line managers. Many felt that the nurse managers were not clinically competent and; therefore, not able to provide them with the support they needed and not being able to advocate for them.

The Positive Work Environment

We know what works. The Magnet designation process developed by the American Nurses Credentialling Center has identified the gold standard of nursing care. Hospitals can use the criteria to assess their actual environment with the preferred environment and implement changes.

The Magnet program works to promote an environment that supports professional nursing practice. It recognizes the need for strong nursing leadership­leaders that are knowledgeable and advocate for staff. Nurses are given autonomy and encouraged to use their independent judgment. Significant emphasis is placed on professional development i.e., inservice continuing education and career development.

The American Association of Colleagues of Nursing (AACN) had developed the hallmarks of professional practice. This document describes eight key characteristics that nursing students can use to examine the work environment of potential employers. This document is currently used by nurses from baccalaureate education as they begin their initial job searches.

It will likely take action at the regulatory/policy level to encourage hospitals to formally or informally adopt Magnet standards. Funding from the National Reinvestment Act could give priority to Magnet designated facilities to further define the impact on cost and quality. Medicare and Medicaid funding rates could be higher to Magnet designated facilities, acknowledging that there may be some additional costs to be offset. The JCAHO could incorporate designation and give a more prestigious ranking to hospitals. Hospitals often say they cannot afford to embrace Magnet criteria. The evidence would say they cannot afford not to.

We are at a crossroads in the practice of inpatient nursing. Addressing nurses¹ perception of their work environment must be a priority. The health of the population is at risk.