It is recognized that nurses play an important role in the safety and quality of care. According to Clark and Donaldson, 2008 the Institute of Medicine (IOM) published a “landmark report” in 1996 recognizing this impact and focusing activities on improvements in healthcare quality https://www.ncbi.nlm.nih.gov/books/NBK2676/. These authors quote from this report, ““Nursing is a critical factor in determining the quality of care in hospitals and the nature of patient outcomes”1 (p. 92)” https://www.ncbi.nlm.nih.gov/books/NBK2676/. In 2018 primary focus for improvements on patient outcomes remains on nurse staffing and nurse satisfaction. According to the American Association of Colleges of Nursing (AACN) the U.S. is expected to experience an intensified nursing shortage as baby-boomers age http://www.aacnnursing.org/News-Information/Fact-Sheets/Nursing-Shortage. The Bureau of Labor and Statistics (BLS) 2014-2024 report identifies that the “health care sector continues to outpace other employment when compared to other sectors” http://chwsny.org/wp-content/uploads/2016/04/BLS-Health-Care-Employment-Projections_2016.pdf.
This is great for employment opportunity for those seeking health care roles. The reality for nursing and for patient quality may not be so promising. Although nursing is listed as one of the “top occupations for job growth” the AACN cites the BLS noting that “the RN workforce is expected to grow from 2.7 million in 2014 to 3.2 million in 2024, an increase of 439,300 or 16%. The Bureau also projects the need for 649,100 replacement nurses in the workforce bringing the total number of job openings for nurses due to growth and replacements to 1.09 million by 2024” http://www.aacnnursing.org/News-Information/Fact-Sheets/Nursing-Shortage. For those who are right to fill the role of the Registered Nurse this is great news. There is opportunity for employment. The reality is however that the roles and responsibilities of the Registered Nurse are challenging, ethically, morally, physically, and emotionally. It does not benefit the outcomes of our patients for nurses to serve in their roles because it is a job and there is always opportunity for employment. We need caring, compassionate, strong, independent yet collaborative, educated, patient focused nurses who have a passion for their work and who understand it is more than just a job.
There is more however, those that are right for the role of the Registered Nurse are seeking other opportunities because of these challenges. According to the Robert Wood Foundation (2014) “one in five new nurses leaves their first job within one year . . .” https://www.rwjf.org/en/library/articles-and-news/2014/09/nearly-one-in-five-new-nurses-leave-first-job-within-a-year–acc.html. This is in addition to the large numbers of retiring nurses, the lack of nursing educators to be able to admit more students to nursing programs, and the lack of “young people” to replace retiring nurses http://customwritingtips.com/component/k2/item/12365-the-nursing-shortage-and-the-effect-it-has-on-care.html. Health Care environments are also to blame. Along with unfilled vacancies nurses are stressed with unsafe nurse to patient ratio’s, mandated overtime, fatigue, lack of growth opportunity, low pay, poor growth opportunity, minimal orientation opportunities, lack of mentorship, and hostile work environments.
In response to this on-going crisis our governing and leadership organizations such as but not limited to the American Nurses Association, Sigma Theta Tau International, and American Association of College of Nursing have taken action to promote awareness and campaign for the development of our profession. For example, as cited on the Sigma Theta Tau International website, Sigma Theta Tau International recognizes the on-going nurse vacancy issues as a “threat to the future of the world’s health care system” and they recommend steps to reverse this trend now https://www.sigmanursing.org/why-sigma/about-sigma/sigma-media/nursing-shortage-information/facts-on-the-nursing-shortage-in-north-america.
In addition to the on-going efforts of our professional leadership I believe that solutions to this crisis can also be found in grass-roots efforts to support positive patient outcomes. As nurses we need to rise up together and in continued effort to advocate for our patients to make changes at and from the closest to the patient level in care. Let’s take a look at just a few things we can do or do better:
According to Mackusick and Minik (2010) all nurses in their study reported an “unfriendly workplace” to be a cause of RN attrition or turnover https://www.amsn.org/sites/default/files/documents/practice-resources/healthy-work-environment/resources/MSNJ_MacKusick_19_06.pdf. The examples provided included sexual harassment, belittling, lack of support and nurses attacking their own. In 2011 the Health Foundation Inspiring Improvement published a report linking poor organizational culture and climate to patient care outcomes. Linkages between climate and outcomes found in this review of research, demonstrate increases in medication errors, readmission rates for congestive heart failure and heart attack patients, nursing injuries, urinary tract infections, decreases in patient satisfaction, and more. The article concluded that “hospitals with better safety climate overall had fewer patient safety incidents” http://patientsafety.health.org.uk/sites/default/files/resources/does_improving_safety_culture_affect_outcomes.pdf.
According to the University of Mexico, “the 2016 National Healthcare Retention and RN Staffing Report” identifies that “the average cost of turnover a nurse ranges from $37,700 to $58,400. Hospitals can lose $5.2 million to $8.1 million annually” and this cost continues to rise https://rnbsnonline.unm.edu/articles/high-cost-of-nurse-turnover.aspx.
Nurses, we must advocate for our patients. The financial loss that RN turnover causes to the organizations we serve is great and this trickles down to those we are here to serve. We need to stop our own negative and harmful behaviors toward each other. It is our responsibility to actively engage in the creation of a positive work environment and to demand that creating, maintaining, and sustaining a positive supportive culture be a priority. We have the right to also expect that our management and administration do the same and we must actively advocate for this to happen. Toxic managers and leaders should be provided with the opportunity to change or to move on. This is also true for toxic physicians, nurses, and staff.
In 2010 the National Advisory Council on Nurse Education and Practice published a report focusing on the Impact of the Nursing Faculty Shortage. In this report it is noted that applications to nursing programs are turned away do to the lack of faculty to teach in these programs. This discussion includes recruitment reasons such as low pay for educators, lack of supportive and creative learning environments and retention issues such as limited time to retirement once nurses have achieved the required qualifications to serve as nursing faculty https://www.hrsa.gov/advisorycommittees/bhpradvisory/nacnep/Reports/ninthreport.pdf.
Sigma Theta Tau International recommends the promotion of higher education to nurses of all educational levels https://www.sigmanursing.org/why-sigma/about-sigma/sigma-media/nursing-shortage-information/facts-on-the-nursing-shortage-in-north-america. This requires creative and innovative opportunities to be designed by schools of nursing for nurses to return to school. Access to programs should not be limiting. High standards and rigor should be maintained however, this is necessary to avoid patient care errors, and turnover of professional nurses due to an inability to manage the stress and responsibilities of the role. As nurses a “grow your own focus” may just promote environments in which nurses do not eat their young but rather promote the growth and development of others, the profession and role model these positive behaviors.
I have personally talked with faculty who did not remain in their roles because they were expected to pass students who were unable to demonstrate safety, who were criticized for maintaining standards in the classroom, who were minimally paid and could not earn enough to pay back student loans for advanced degrees, or did not have support for creativity and growth in higher education. We need to assist those in higher education administration to understand the importance of safety in nursing care, building relationships and partnerships for our programs within and outside of the institution, and to provide support and resources to keep up with current teaching and practice standards.
Also, maintaining high standards is not the same as belittling and eating young. It is important for us to promote our standards and help others understand that the difficulty of school is not to be feared but rather welcomed to assure that all nurses are prepared to accept the roles and responsibilities for patient care. Nurses must be competent and knowledgeable and have the ability to function as a partner of the health care team. Rather than talking about how hard and awful nursing school is, we should be celebrating our success and be proud of the rigor and responsibility, sending positive images to those who are interested in becoming one of us.
Harrington and Heidkamp (2013) report that “by 2020 nearly half of all Registered Nurses will be traditional retirement age” https://www.dol.gov/odep/pdf/NTAR-AgingWorkforceHealthCare.pdf. How can we slow this inevitable situation? New nurses need the support and stability of our aging nurse population and patients need the level of critical thinking and action that this nursing population holds. In this same article strategies are suggested for retention of this valuable population of nurses. These include:
- Ergonomics of the work environment such as lowering cupboards, moving work stations closer to the patient, better lighting in care areas, and resting locations for proper breaks
- Creative scheduling that includes shorter work hours, flexible schedules, job sharing and mentorship and educator roles
- Phased retirement strategies to create a gradual loss of experience giving time to the organization to train and prepare others to fill this void
When an organization and the nurses within that organization demonstrate a value for the experience and skill set of the nurses around them others do the same. It can be suggested that when employees feel valued, and that value is demonstrated, retention of all employees rise https://www.dol.gov/odep/pdf/NTAR-AgingWorkforceHealthCare.pdf.
Community and Political Involvement
Nurses, as a profession our leadership organizations such as the American Nurses Association, the National League for Nurses, Sigma Theta Tau International, and more, do much to promote us and to assure we have a political voice. These associations are focusing on the retention and growth of nursing as a profession. We all should be a member of a larger nursing organization and offer support where we can. We should be active in legislative efforts to increase standards in our profession, to assure we have safe staffing ratios and environments of care. When we are active we not only help to improve our own nursing experience but we help promote an image in which others want to be a part of.
There is also much we can do without needing to leave our back yard if we wish not too. It is important to communicate who we are and why our profession is important at our local level. To do this we can:
- Run for local office
- Join community committees
- Participate in volunteer activities
- Get involved in health policy development
- Host community education opportunities
- Engage in professional recruitment opportunities by allowing others to see and hear what you do
Being involved helps to promote our ability to advocate for our roles and our importance in the community. Nurses do not just exist in hospitals and demonstrating this provides others with an ability to see the diverse career opportunities nurse have. I believe nurses are the key to reducing health care costs in a community. Every community, business, organization, and school should employ them!
Thank you for taking the time to read this week’s Talk Tuesday. I am hopeful you have found at least one take away that you can reflect on and apply in your practice today. Before you leave my site please take time to follow my blog by entering your email address. I would also like for you to take the time to visit my website at https://upvisionconsulting.com/
The Legal Nurse
Clarke, S. P., and Donaldson, N. E. (2008). Nurse staffing and patient care quality and safety. Patient Quality and Safety: An Evidence Based Handbook for Nurses. Retrieved at https://www.ncbi.nlm.nih.gov/books/NBK2676/
Harrington, L. and Heidkamp, M. (2013). The aging workforce. Challenges for the healthcare industry workforce. The NTAR Leadership Center. Retrieved at https://www.dol.gov/odep/pdf/NTAR-AgingWorkforceHealthCare.pdf
Mackusick, C. I. and Minik, P. (2010). Why are nurses leaving. Findings from an initial qualitative study on nursing attrition. Research for Practice. MEDSURG Nursing v19(6). Retrieved at https://www.amsn.org/sites/default/files/documents/practice-resources/healthy-work-environment/resources/MSNJ_MacKusick_19_06.pdf
National Advisory Council on Nurse Education and Practice (2010). The impact of the nursing faculty shortage on nurse education and practice. Ninth Annual Report. Retrieved at https://www.hrsa.gov/advisorycommittees/bhpradvisory/nacnep/Reports/ninthreport.pdf
Research Scan (2011). Does improving safety culture improve patient outcomes? The Health Foundation Inspiring Improvement. Retrieved at http://patientsafety.health.org.uk/sites/default/files/resources/does_improving_safety_culture_affect_outcomes.pdf