Nurse Staffing Issues Mark Doherty, Clint Ludlow, Ilia Mondoy, Andrea Peters, Ashley Roberts Hospitals with low nurse staffing levels tend to have higher rates of poor patient outcomes such as pneumonia, shock, cardiac arrest, and urinary tract infections, according to research funded by the Agency for Healthcare Research and Quality (AHRQ) and others.
Hospital nurse staffing is a concern because of the effects a shortage has on patient safety and quality of care (Buerhaus, Donelan, Ulrich, Norman, & Dittus, 2005; Ulrich, Buerhaus, Donelan, Norman, & Dittus, 2005).
Staffing • “Although hospitals with low nurse staffing levels tend to have higher rates of poor patient outcomes, increasing staffing levels is not easy. Major factors contributing to lower staffing levels include the needs of today's higher acuity patients for more care and a nationwide gap between the number of available positions and the number of registered nurses (RNs) qualified and willing to fill them. This is evident from an average vacancy rate of 13 percent,” (Stanton, Mark 2004).
Age • 2004 average age for nurses estimated to be 48.8 Years. (HRSA) • Why? • Fewer Nurses entering workforce • Large cohort moving into their 50’s and 60’s • In 2004, only 8% of population under 30. • 41.1% over 50. • In 2000, 33% over 50. • An aging workforce has contributed to the nursing shortage in the United States. The average age of a practicing RN is currently 46.8 years (Health Resources and Services Administration [HRSA], 2004) and it is predicted that by 2010 over 40% of the RN workforce will be over age 50 (Norman et al., 2005)
Full time Status • 29.7 % nurses in 2004 were employed part time. • 45% of married nurses with children under age 6 work part time • 28% of bedside nurses report working longer than 12 hours per day (Trinkoff, Geiger-Brown, Brady, Lipscomb, & Muntaner, 2006)
Faculty Shortage (Yordy, 2006) • Academic Preparation needed to teach: Doctoral is considered ideal, which is prohibitive to some in this field. • Culture of working, then teaching later in life • 17% of member schools of American Association of Colleges of Nursing provided research based doctor prepared programs. • Small # of students in programs: 1603 full time and 1836 part time students. • 416 graduates in 2004, averages to 4.5 students per program. • Salaries: Can make more in clinical setting.
Recruitment/Retention • Sign on bonuses: $6000 for new nurses who sign contract to stay for x amount of years. • Retention bonuses: for experienced nurses, after 1 year of hire can get tuition reimbursement. • Incentive pay: Experienced nurses get paid more to work evenings/nights • 12 hour days.
Recruitment/Retention Continued • average hospital vacancy rate for RNs in the United States is 8.5% to 14% with vacancy rates of over 14% in medicalsurgical and critical care areas(American Hospital Association [AHA], 2004, 2006) • According to one estimate, because of job stress, one in five nurses plan to leave the profession within the next 5 years, and almost 50% often think about leaving (Federation of Nurses and Health Professionals, 2001) • The most frequently reported reason for leaving nursing for those who intended to leave was job stress (28.4%) and retirement (16.3%)
Nurses speak out on staffing In the article, “Benchmarking Nurse Staffing Levels: The Development of a Nationwide Feedback Tool,” surveys of nurses were collected internationally with results showing percentages of nurses in different countries who thought the optimal nurse staffing levels were met: • Belgium 59% • Finland 50% • USA, Canada, Scotland, England, Germany 38-29%
Current staffing tools account for patient clinical needs but not other workload factors such as psychosocial care.
Effects of acuity on care and staffing • In the article, “Association Between Nursing Workload and Mortality of ICU Patients,” findings indicated that differences among nurse characteristics as well as patient care demands effect ICU patient mortality. “Proper nurse staffing levels should be based on the estimation of total patient acuity, rather than the absolute number of patients.” • In some EDs, RN gets 3 pts regardless if they’re trauma patients or less acute ones; but in other EDs, RNs get less patients when working trauma and float when there are currently no traumas.
Lateral violence • Been in literature for over 25 years • LV overtly or covertly directing their dissatisfaction inward toward: (a) those less powerful than themselves, (b) themselves, and (c) each other. • Covert has the biggest impact • Common manifestations of LV • Anon-verbal innuendo, • verbal affront, undermining activities, • withholding information, • sabotage, infighting, scapegoating, • backstabbing, • failure to respect privacy • Broken confidences • Typically verbal or emotional abuse • Can become physical
Lateral Violence Origin Theories • Oppressed-group model theory (Roberts 1983) • Nurses are an oppressed and powerless group dominated by others • Nursing profession mostly women and have to report to male physicians and administrators • Sensitivity and caring view as less important or even negative when compared to those of medical practitioners • Nurses lack autonomy, control over their work, and self-esteem and subscribe submissive-aggressive syndrome • Submissive-aggressive syndrome • When nurses feel they lost power and react by overpowering others • through aggressiveness • Oppression theory • Members of an oppressed group display common behavioral characteristics low self esteem and self-hatred • LV evolves from feelings of low self-esteem and lack of respect from others in the work environment • Nurse perceive themselves as powerless and oppressed in the health care setting • Leads to feelings of alienation and lack of control over practice • Leads to cycle of low self-esteem and powerlessness • Nurses manifest frustrations to other nurses lateral to them rather than confronting the issue because of risk of retaliation by leadership in the healthcare system.
Types of Violence • Lateral/Horizontal/Bullying/Mobbing • Internal- Violence that occurs within an organization; nurse-nurse or manager-nurse • Client- When a client initiates an act of violence against an employee or organization • Organizational- When an organization acts against employees with layoffs or changes that affect employees • External- From a force outside the control of an organization or it’s employees (gangs). • Third Party- When an act is witnessed by a third party • Nurse-initiated- When a nurse becomes violent to those within his or her care. • Nursing work violence- That which is experienced by nurses due to mass casualties or extreme situations (terrorists)…
Lateral Violence • Problem Effects: • 2007: 18 percent of CCRNs reported verbal abuse from another RN • 2007: 25-32% of nursing interactions were reported as ‘fair to low quality’ among CCRNs • Physical symptoms • Weight gain/loss • HTN • Cardiac palpitations • IBS • Leads to job dissatisfaction • Sleeping disorders- tiredness • Psychological symptoms • Low Confidence • Depression • Acute anxiety • Post-traumatic disorder • Low self-esteem and poor morale • Feel disconnected from other staff • Use of excessive sick leave • Drains nurses enthusiasm • Burnout
Lateral Violence • Effects on Others • Family and friends of nurses also suffer stress, anxiety and anger • Nurse turnover costs $22,000 to $64,000 for one nurse, and the cost to replace that nurse can be up to $145,000 in some areas. • Trust is eroded for remaining staff dealing with LV • LV can affect recruitment if facility develops bad rep • Detriment to patients • Staff lack initiative to do job well • Impaired interpersonal relationship between nurses can cause errors, accidents, and poor work performance. • Intimidation leads to nurse changing the way they handled an order
91% RN’s experienced LV • 94% witnessed it taking place - 76% considered LV to be moderate to sever • Patients and their families make more complaints about LV if it is continuously observed • ~60% newly registered RNs leave their first position within six months of employment because of some form of LV, 20% do not return to the nursing profession • 33%-37% turnover rate for clinical practicing nurses
Symptoms of workplace stress • Cognitive- memory problems, indecisiveness, inability to concentrate, poor judgment, trouble thinking clearly, seeing only the negative side of an issue, anxious or racing thoughts, constant worrying, loss of objectivity, and fearful anticipation that something will happen. • Physical- headaches or backaches, muscle tension and stiffness, diarrhea or constipation, nausea, dizziness, insomnia, chest pain, rapid pulse, weight gain or loss, skin breakout (i.e. hives or eczema), loss of sex drive, and frequent colds
Stress • Emotional- moodiness, agitation, restlessness, short temper, irritability, impatience, inability to relax, feeling tense, feeling overwhelmed, a sense of loneliness or isolation, and depression • Behavioral- eating more or less, sleeping too much or too little, isolating oneself from others, procrastinating, neglecting responsibilities, using substances (i.e. alcohol, cigarettes, or drugs) to relax, nail biting, pacing, teeth grinding, jaw clenching, overdoing activities (i.e. exercising or shopping), overreacting to unexpected problems, and picking fights with others.
Workplace stressors cause • Costs to the institution • absenteeism • employee turnovers • short- and long-term disabilities • medication expenses related to psychotherapeutic medications • workplace accidents, and worker’s compensation claims and lawsuits
Coping Methods Solutions • Avoid unnecessary stress- say no, limit the to-do list • Alter the situation- compromise, be assertive • Accept the things you cannot change- look for the positive, learn to forgive • Adapt to the stressor- reframe standards, adjust standards • Take care of personal needs- set relaxation time, exercise regularly, keep a sense of humor • It is best to incorporate a few of these to get the best stress relief
Faculty Solutions • Faculty Loan Repayment Program (HRSA) • Will pay up to $20,000 a for two years of service, up to $40,000. X 400 = $40,000 • Tax Liability benefit. • Attempts to entice nurses back to school in order to increase the amount of nursing faculty. • Facilities adopt friendly “rules for relationships” • Nurse’s Higher Education and Loan Repayment Act (H.R. 1460) • Other state programs
Solutions Individual nurse -Acknowledge the part they play in the LV cycle -Make an effort to care about each other -Carefronting -Uses biblical Concepts of forgiveness, respect, and courage to confront hostility in the workplace. -Personal needs of an individual are integrated with the wants and needs of others • Involves caring enough to confront the person and situation in a responsible manner Cognitive Rehearsal • Based on scientific evidence • Role Play LV situations with nurses and practice actions to deal with LV • A study found that newly licensed nurses depersonalize the incident when role-playing, and allows them to ask questions and continue to learn • Retention rate of nurses was positively affected.
6 general principles to remedy LV issues • 1. Defuse intense anger, temper anger thoughts by using relaxation techniques and mediation and, after emotions have subsided, have a discussion about the incident • 2. Resolve to release anger; don’t hold on—accomplishes nothing. • 3. Consult an expert when conflict is festering in the workplace • 4. Demonstrate care and compassion for your coworkers and reach out to those who are struggling with personal issues and reach out to those who are struggling with personal issues • 5. Compliment rather than complain • 6. Cultivate team spirit by including socialization outside fo the work place, • Birthdays, certifications • Make new nurses feel welcome The CENTER for American Nurses recommends the following strategies to eliminate disruptive behavior (lateral violence and bullying): • Nurses and nurse leaders, managers and supervisors adopt and model professional ethical behavior • Recognize and appropriately address bullying and disruptive behavior in the workplace through enhanced conflict management and conflict resolution • Reflect on your own behavior and communicate respectfully with each other • Participate in collaborative interdisciplinary initiatives to prevent abuse • Work to ensure the mission, vision and values of their workplaces that are reflective of the Code of Ethics for Nurses (American Nurses Association, 2001) and standards set by the profession, in order to eliminate disruptive behavior (lateral violence and bullying).
Management • Canada, UK, and Scandinavian countries have laws protecting workers from LV • U.S. offers new protection under the new Joint Commission mandates. • Managers should analyze the culture of the work unit • Assess for verbal/nonverbal clues of LV • Raise LV issues when observed at staff meetings • Staff should be allowed to share their stories • Training on conflict management and educational offerings that describe how to defend against LV can be instituted
Organizations • Implement zero tolerance policies that address disruptive behaviors (lateral violence and bullying) and indicate such behaviors will not be tolerated. The organizations should adopt zero tolerance policies that include appropriate investigation and due process necessary to provide adequate safeguards to nurses and others who are accused of lateral violence or bullying. (See appendix for sample policy). • Promote a Culture of Safety that encourages open and respectful communication among all healthcare providers and staff (The Joint Commission, 2007). • Provide support to any individual impacted by lateral violence and/or bullying. • Provide education and counseling to victims and the perpetrators of horizontal violence and bullying. • Nursing Continuing Education and Academic Programs • Disseminate information to nurses and students that address conflict and provide information about how to change disruptive behavior in the workplace. • Implement continuing education programs related to bullying and lateral violence and interventions to address such behaviors. • Develop educational programs regarding bullying and strategies on how to recognize and address such disruptive behavior. • Develop and implement curricula that educate nursing students on the incidence of disruptive behaviors including lateral violence and bullying, along with steps to take to eradicate this behavior.
Nursing Research • Continue to research the contributing factors and the process of lateral violence and bullying behaviors. • Build on previous and current studies while seeking to explore innovative interventions on how to eliminate manifestations of disruptive behaviors • Evaluate the efficacy of promising strategies in eliminating disruptive behaviors (lateral violence and bullying) from the workplace.
References • Congresswoman Tammy Baldwin. Press Release. Baldwin Introduces Loan Repayment Program. Retrieved April 11th, 2009. http://tammybaldwin.house.gov/PRArticle.aspx?NewsID=1537 • Lambert VA, Lambert CE. (2008). Nurses' workplace stressors and coping strategies. Indian Journal of Palliative Care. 38-44. • Stanton, Mark (2004). Hospital nurse staffing and quality of care. Agency for Healthcare Research and Quality. Research in Action 14 • U. S. Census Bureau. U. S. Population Projections. Retrieved April 5th 2009. • U.S. Department of Health and Home Services Health Resources and Services Administration. Faculty Loan Repayment Program. Retrieved April 11th, 2009. http://bhpr.hrsa.gov/DSA/flrp/1.htm • U.S. Department of Health and Human Services. Retrieved April 5th, 2009. http://bhpr.hrsa.gov/healthworkforce/rnsurvey04/3.htm. • Yordy, Karl (2006). The nursing faculty shortage: A crisis for health care. Robert Wood Johnson Foundation