Corey-Lisle, Patricia MSN, RN, CS-P; Tarzian, Anita J. PhD, RN; Cohen, Marlene Z. PhD, RN; Trinkoff, Alison M. ScD, RN
The main strategy implemented to contain the escalating costs of providing healthcare has been managed competition. The expansion of managed care, a form of managed competition, has been synonymous with healthcare reform. A form of managed care was first described in 1932, with the suggestion of prepayment to medical practices for the provision of health services for specific groups of people such as teachers or farm workers.1 However, this idea did not come into popular practice until the early 1970s. In reaction to skyrocketing costs of providing healthcare benefits, Congress passed the Health Maintenance Organization (HMO) Act in 1973. This bill provided financing for the expansions of HMOs and required employers to offer HMO services to their employees if requested by an HMO provider.1
The increased market penetration of HMOs with the advent of managed care has made dramatic changes in the practice of nursing. Economic reorganization has led to an increase in the number of individuals covered by managed-care contracts, fewer hospital beds, and job redesign for nursing staff.2 Results of these changes have led to concerns about the quality, costs, and access to care by providers and consumers alike.3-5
Shindul-Rothschild and associates5 conducted a national survey of a convenience sample of 7,000 nurses' views on healthcare and nursing practice and found that nurses perceived downsizing, restructuring of jobs, and increased use of unlicensed assistive personnel as predominant factors that resulted in decreased quality of care. Nurses reported that they are taking care of more patients, more seriously ill patients, and that they have greater supervisory responsibilities and less time to provide nursing care. Miller6 recently asked nurses in clinical practice about their concerns and noted that the biggest challenge in the changing healthcare climate is keeping the "care" in nursing care. One concern is that nurses' ability to provide care for patients is being jeopardized by financial pressures requiring nurses to be "doing more with less."6(p30)
With escalating costs and concerns from both providers and consumers about containing costs while maintaining quality of care, it is important to look at the broader picture when making decisions about changes in policy. Healthcare reform has far-reaching effects on individual institutions that must balance both the quality of care and the cost of providing care. Institutional policies influence the individual healthcare worker, who, in turn, must strike a balance between professional roles and personal roles. The inverse also is true: each professional nurse has an effect on the institution and its ability to provide quality care while controlling costs.
When department of nursing budgets account for at least 50% of a hospital's operating expenses, healthcare reform initiatives to decrease operating expenses have direct and indirect effects on the individual nurse. In the following analysis, nurses' perceptions of healthcare reform's effects on the practice of nursing and their responses to these changes are described.
During the fall of 1994, 6,000 registered nurses (RNs) with active licenses were selected randomly for the Nurses Worklife and Health Study. The sample was selected using balanced stratified sampling, a method that combines probability sampling with model-based selection of stratum elements using an auxiliary variable.7-9 This maximized the chance of selecting a sample generalizable to the U.S. RN population as a whole. States were stratified using the number of RNs per state as the auxiliary variable. From this, 10 states were chosen and allocated across strata using an optimal allocation formula. After excluding duplicate names and those with out-of-state addresses, 600 nurses were selected from each of the 10 states by means of simple random sampling, for a total sample of 6,000 nurses.
An eight-page anonymous questionnaire was mailed to each nurse. The survey collected information on substance use, working conditions, psychological well-being, and other life-style and behavioral practices. The final page of this questionnaire asked respondents to record any thoughts or comments regarding topics covered in the survey; the remainder of the page was left blank for open-ended comments.
Seventy-eight percent of the nurses with an opportunity to participate responded to the mailed survey in the fall of 1994 (n = 4,438 of 5,726 eligible addresses). The sample was predominantly female (96%) and white (94%), with a mean age of 41.8 years. Most were married (74%), with only 9% never married. Almost one half had a bachelors (BSN) or higher degree (47%); roughly one third (31%) lived in rural areas; and 90% of the nurses were employed. Sociodemographic and work characteristics of the sample were similar to estimates obtained in a national planning survey of nurses.10
From the respondents who completed the survey, 25% (n = 1,098) chose to make comments on the last page. Many of these narrative comments related to changes in the healthcare system and the nurses' perceptions about the impact of these changes on their practice. Demographic data from nurses who made comments related to healthcare reform (n = 375) were compared with data from all other nurses who returned the survey (n = 4,063). Student's t test results revealed no significant differences between the two groups for age or years of experience (Table 1).
There were no differences between the groups making healthcare comments and those not making healthcare comments in location of work (hospital or nonhospital). Chi-square analysis revealed a significant difference between type of work (clinical vs. nonclinical) and level of nursing education (diploma or associates degree vs. BSN or higher degree). Diploma and associate degree nurses were overrepresented compared with the total sample, as were nurses with clinical positions (staff, agency, or clinical nurse specialist) in the subgroup who wrote comments related to healthcare reform (Table 2). The overrepresentation of clinical nurses is consistent with the content of the healthcare reform comments because these comments mostly relate to clinical work and also may reflect those in entry-level jobs who may be affected more by healthcare changes.
Comments that were written on the final page of the survey were typed into a word processing program and checked for accuracy. These texts were reviewed for understanding and then subjected to content analysis.11 Key words and phrases from the texts were highlighted. Textual excerpts then were organized according to key word/phrase categories. From these categories, themes were identified and described using narrative excerpts from each corresponding category.
Frequency counts were made for broad categories (e.g., healthcare reform) rather than individual word counts, to maintain consistency with the solicitation of general (rather than more directed) comments at the end of the survey. This method of content analysis and description of the results allowed for more contextualization of written comments. Lack of contextualization often is noted as a weakness of strictly quantitative content analysis.12 Key categories and themes were validated independently. This content analysis found that 375 comments referred to the nurses' experiences related to healthcare reform.
Results of Content Analysis
Figure 1 is intended to orient the reader to the description and discussion of themes that were identified by content analysis. It displays an overview of the issues revealed by the analysis. Healthcare reform was viewed by many nurses to refer to hospital budget cuts, increased government regulations, and profit concerns. Budget cuts translated into the downsizing of staff. The staffing changes resulted in fewer RN staff and more unlicensed assistive personnel. These staffing changes resulted in increased work load for nurses, who believed that patients were not receiving quality care. The combined effects of increased work load, changing work assignments, and staff mix exerted its influence on nurses in positive or negative ways. Some viewed it as an opportunity to obtain a new job or additional education. Others expressed mounting stress or dissatisfaction leading to a change in their job or profession. Following are the major themes identified in the content analysis.
Many nurses linked reduced reimbursement with healthcare reform. One nurse commented, "The healthcare reforms I've witnessed in my hospital are ridiculous and often unsafe.... Hospitals are becoming too business focused and in doing so, the welfare of the patients and their family is losing its importance." Many nurses noted that the budget or "bottom line" was often the only focus of administrators: "The hospital administration has blindfolds on. Nursing has always been the cement that holds the implementation of care for the patient together. Now administration seeks a cheaper way-lay off qualified nurses and replace them with [nursing assistants].... Insanity rules."
Some pointed blame at the state and federal levels: "State and federal regulations in long-term care facilities and in psychiatric institutions have become too unrealistic for anyone to humanly keep up with the OBRA [Omnibus Budget Reconciliation Act], state, and JCAHO [Joint Commission on Accreditation of Healthcare Organizations]. It is a difficult enough job as a director of nurses to maintain dignity, care and the practically unattainable goals of documentation expected when Medicaid cuts are decreasing budgets." Many believed that decisions made by hospital administrators in reaction to these budget cuts were not motivated by concern for patients or staff, but rather, to maintain corporate profit margins.
One way that these changes affected nurses was causing fear for their job security because nurses were asked to work in unfamiliar patient care areas, were laid off, or were asked to take unpaid time off. Some nurses opted to work per diem in response to the threat of job loss or after being laid off. In such cases, they had little or no benefits, such as health insurance or paid sick leave. Although some responded to this uncertainty with flexibility and optimism ("I feel fortunate that I am able to work in the nursing pool and can choose my work days"), for most it resulted in reduced morale ("It is very discouraging to know that your job is never secure," "We are required to take mandatory time off-10% a pay period plus at the hospital's convenience. Needless to say, morale at my workplace is very low.")
It was noted that this reduced staffing came at a time of increased patient acuity and resulted in nurses doing more work with fewer resources. One nurse wrote, "[We] are being asked to do more in less time. Ancillary personnel are being let go, and we are being asked to perform blood draws, EKGs [electrocardiograms], [and] minor PFTs [pulmonary function tests] while trying to interview and prepare a patient for his upcoming surgery. All of this in 30 to 40 minutes, and they prefer less time than that!"
Nurses reported being forced to supervise technical assistants. Many wrote that this dangerously compromised quality patient care and patient safety: [I am concerned with] the training of people off the street to be hospital techs [with] little training to give bedside care. The nurse's license is on the line [because] ...she is responsible for the tech's care," or "I really feel bad about RNs still working in hospitals-[who] have been left with greater responsibility, housekeepers [whose] jobs have been changed to include bed baths.... Complaints from community-poor nursing care!"
Demands of Paperwork
Many nurses described burdensome demands of paperwork. As an example of the perceived prioritization of paperwork over quality patient care, a nurse wrote that she spent "4 hours one day trying to get prior approval from Medicaid for a package of adult diapers." Another said, "We are currently sinking under bureaucratic paperwork and regulations....If I ever leave nursing, it will be because I spent so much time writing [that] I couldn't properly care for my patients!" One nurse described "...the stress of getting everything on paper-lawyer perfect-rather than taking care of a sick patient who is depending on you and healthcare for answers." All these factors made it difficult, if not "impossible," to provide the kind of patient care that nurses were educated to give. One nurse wrote, "What happened to all that we were taught in school about emotional and spiritual care? Isn't it a proven fact that people heal faster if they are emotionally healthy? I feel like a machine, they just keep piling on the work and taking away the staff." One nurse left her staff position because of the stress she felt not being able to "accomplish everything that needed to get done (and I'm very efficient!)." Another nurse expressed her feelings metaphorically: "I love music and I love to dance, but I'm dancing as fast as I can."
Not surprisingly, some nurses expressed having decreased morale and increased levels of stress in response to this combination of being "overworked, underpaid, [and] unappreciated." One nurse wrote "...most feelings of anxiety, irritability, or feeling like crying ... were directly caused by work where they have our staffing at unsafe and frustrating levels in an attempt to save money." Compounding the stress of increased work load demands was fear and frustration at not being properly cross-trained in patient care areas to which nurses were assigned. One nurse asked, "...[another] issue is performing duties [you are] not trained to do but told you must do them on a particular unit or health care setting. Can you refuse? Can you be fired?"
The level of information administration shared with staff and the amount of control the nursing staff members believed that they had (i.e., measures that administrators did or did not implement to decrease uncertainty) was linked with nurses' responses. One nurse described a work situation in which "management is continually coming up with new plans, documentation, and rules which keep staff being able to develop a routine for getting work done and make staff nervous and stressed because of uncertainty [of] just what it is they will want next. This, combined with state requirements/changes, undermines staff's confidence and resilience. This affects patients, who in turn are stressed and uncertain, making them more difficult to give proper care to. A noisy chaotic and continually changing ... workplace is conducive to stress and burnout!"
Many nurses mentioned leaving their jobs or changing to less stressful positions. "I was a great ER [emergency room] nurse for 12 years but left because of unbelievable demands to meet, including patient load and acuity, increased paperwork, being called in on days off and having to take call." This nurse and others gave up jobs they "loved" because of insupportable work load demands and escalating levels of stress. Another noted, "It's a shame [that] I had to give up the challenge of high-tech hospital work to have less stress and a more pleasant supportive working environment." Some stated that they had left the nursing profession altogether. A few worried that the exodus of experienced nurses in hospitals had left patients without expert caretakers and had left new RNs with few role models from whom they could learn.
Others viewed changes in the healthcare system as a challenge to be faced with innovation and flexibility. Some nurses stated that their education and training allowed more flexibility, opting to reduce stress by working two or more part-time jobs. The variability of multiple jobs allowed them to feel challenged without feeling overly burdened. Some nurses saw the option of working part time as a valuable way for them to balance family obligations. One nurse wrote, "This survey reflects high job satisfaction because I am independently employed as a community-based child birth educator in addition to my position as a clinical instructor, and this combination allows ample time with my family. I think the best part of a nursing career is the kind of job flexibility."
Several nurses commented on other sources of stress in the workplace. These included the attitudes of coworkers, and the presence or lack of support, respect, and recognition of nurses' work. Several nurses complained that other nurses engaged in "back-stabbing" and other "unprofessional" behaviors. Those who were happy in their profession often commented about positive relationships with colleagues and an atmosphere of "teamwork." One nurse commented, "My supervisors and most surgeons I work with do treat me with respect....Most people I work with in my department are supportive and understanding."
There was a range of responses related to nursing's image in general. A common theme was that nurses were being taken advantage of because of their history of powerlessness. One nurse wrote, "I feel [that] as RNs, we are letting ourselves be manipulated by big business and always [have] been." Several nurses viewed organized political activity in nursing as necessary to secure safe working conditions for nurses and adequate patient care for those in need ("We need to take a giant step forward right smack dab into the political arena").
Higher education in nursing was viewed by some nurses as the key to "choice" and "survival." Several commented that more education in nursing provided them with better opportunities: "I feel fortunate and 'job secure' because of my educational background and chosen career path," and "I see such a bright possible future for nursing, especially in advanced practice...." Others lamented the lack of respect for their experience and how limited their options were as diploma or associate degree nurses ("...RNs [like me] whose expertise is from acute care settings ... should not be required to return to school or obtain advanced degrees in a setting where ... life experiences ... are not even considered," and "My diploma was supposed to be grandfathered, but I'm penalized for not having a BSN/MSN. I was assistant director of nursing in my last job, and since moving, my experience has no value. Very discouraging!").
Some wrote that they felt "trapped" and had reduced job options ("Unless you have an advanced degree in nursing,...there isn't much out there."). Others complained that administration did not value advanced education in nursing: "As director of a home health agency with a BS degree, I was let go and replaced by an RN with an associates degree ... to save the organization money. My argument for the retention of [a] BS-RN with broader educational background was not considered."
Several nurses equated higher education in nursing with a move toward more specialized care. This resulted in fragmented rather than holistic patient-centered care. As two nurses put it, "Nursing care today is pathetic. Everyone is specialized-no one gives nursing care," and "... patients [in a busy cardiothoracic unit] did not receive quality care-it was a factory, and the patients were the "widgets" pushed through the system. Quality care takes time."
The survey comments reflect nurses' perceptions and responses to healthcare reform. Some remarks made by the respondents reflect what is reported in the occupational stress literature for nurses. For example, stressful events that occur in the work environment relate to role conflict, ambiguity, fears about job security, work overload, lack of support from supervisors, dealing with uncooperative patients, difficulties with physicians, lack of cohesion with coworkers, and shift assignment.13-15 Current research also reports that work load and scheduling stressors have the strongest negative effects on a staff's job morale and functioning.16
Although some of the individuals reacted to healthcare reform changes with frustration, reduced job satisfaction, and job changes, others perceived opportunities for individual growth and the growth of the profession. Situating the reactions to healthcare reform of these nurses within a discussion of stress theories may add some insight to the diversity of responses.
Stress has been defined theoretically using one of three orientations: as a stimulus, as a response, and as a transaction. When stress is defined as a stimulus, it is viewed as causing a disrupted response. This definition of stress assumes that all individuals respond in the same way to the same events. An example of this is the Social Readjustment Rating Scale, developed by Holmes and colleagues.17-18 This tool assigns stress points to various life events but does not consider individual variation or human experience.
Selye proposed a biological response theory of stress, the General Adaptation Syndrome.19 He defined stress as the "non-specific response of the body to any demand made upon it."19 Stress, as Selye used the term, is a physiologic response that occurs regardless of whether feelings are pleasant or unpleasant. Selye20 suggested differentiating distress (unpleasant or "bad" stress) from eustress (pleasant or "good" stress). Although he noted that perception has a critical role in stress experiences, he did not incorporate it into his General Adaptation Syndrome.
Another orientation views stress as a transaction, arising from person-environment exchanges. Benner and Wrubel21 provide an example of this. An individual encounters disruption of meanings, understandings, and smooth functioning so that loss, threat, and challenge are experienced. New skills, interpretations, or acknowledgement of sorrow are needed, with the focus remaining on the individual's unique response to stress. Lazarus's work22 is the basis of this definition of stress, which includes cognitive, affective, and adaptation or coping responses. This definition acknowledges the existence of individual differences and human experiences. A transaction theory of stress could allow for greater understanding of the diversity of responses to work stressors. This could enhance understanding of job satisfaction and morale, which influences productivity and quality of care.
Blegen's meta-analysis found that the strongest negative relationship to job satisfaction was stress, and the strongest positive relationship to job satisfaction was commitment. Significant positive relationships were found between job satisfaction and communication with supervisors, autonomy, recognition, and communication with peers.23 Job satisfaction is a balance between work stressors and work rewards. High-ranking stressors were not necessarily negatively related to job satisfaction. High-stress factors identified by Schaefer and colleagues16 included: the need to make rapid decisions, cardiac arrest, death of a patient, caring for chronically ill or dying patients, and amount of knowledge required for the position. These patient care task stressors were associated with higher job satisfaction.
Excessive work load was highly rated as both a stressor and a significant factor in low job satisfaction in a 1985 study testing the relationship between perceived job stress, job satisfaction, and psychological symptoms in critical care nurses.24 In general, high levels of perceived stress are correlated strongly to low levels of job satisfaction.23,25-27 Job satisfaction is influenced positively by the challenging aspects of work duties, autonomy, supportive supervisory staff, feeling appreciated, and work group cohesiveness.16,23-29
Nurses frequently mention the importance of relationships among coworkers and management and the effects of perceived lack of support.24 The comments used in this analysis highlight the relationship of challenging work, autonomy, and supportive communications among coworkers with job satisfaction. If nurses are expressing decreased trust and respect for administration, then this lack of trust could account for decreased commitment and job performance.
Research has found that one of the most important aspects of maintaining a positive work environment is management style.29 A supportive organizational environment results in more positive supervisory behaviors, greater job satisfaction, and work group relations.25 Supportive supervisory styles may lead to a reduction in role ambiguity, and this in turn may lead to more supportive relationships between coworkers. It also has been reported that high perceptions of social support and peer cohesion consistently and significantly relate to the level of job morale.27
Nurses who responded to our survey described the negative effects of stress, which have been mentioned in the literature. However, some of the nurses responded that they saw these changes as opportunities. These positive comments were consistent with research literature describing factors associated with job satisfaction. The findings in this study must be interpreted cautiously because the individuals were not asked specifically to comment on healthcare reform. The responses that were received were spontaneous and may not adequately represent the entire sample. However, with 34% of the comments received pertaining to healthcare reform, it appears that this was a significant nursing issue.
Thus, an understanding of nurses' perceptions of changes brought about by healthcare reform is important for shaping the way that nursing care is delivered in the future. Administrators can support their nursing staff members by recognizing that change may lead to stress. This stress can be perceived either negatively or positively. To promote healthy coping mechanisms for the staff, nursing administrators should foster nurses' participation in work reorganization. Change should be undertaken in a manner that demonstrates respect and value for the nursing staff. If the nurses perceive change as an opportunity for growth, increased autonomy, intellectual stimulation, and group cohesion, this should have a positive impact on job satisfaction and productivity. Policies encouraging these outcomes should have been beneficial economic and patient care outcomes.
1. McFarlane M. Managed care: nursing's friend or foe. Nurs Spectrum
2. Buerhaus PI, Staiger DO. Managed care and the nurse workforce. JAMA
3. National Coalition on Health Care. How Americans perceive the health care system: a report on a national survey. J Health Care Finance
4. Service Employees International Union. Health Professionals' Views of Quality: A National Survey
. Presented to the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry, Dec 1997.
5. Shindul-Rothschild J, Berry D, Long-Middleton E. Where have all the nurses gone? The results of our patient care survey. Am J Nurs
6. Miller KL. Keeping the care in nursing care. J Nurs Adm.
7. Royall RM., Cumberland WG. An empirical study of the ratio estimator and estimators of its variance. J Am Stat Assn
8. Thompson SK. Sampling
. New York: Wiley and Sons; 1992.
9. Trinkoff AM, Storr CL. Incorporating auxiliary variables into probability sampling designs. Nurs Res
. 1997;46(3): 182-185.
10. Moses EB. The Registered Nurse Population: Findings from the National Sample Survey of Registered Nurses
. Rockville, MD: U.S. Department of Health and Human Services; 1994:DHHS publication no. PHS 55-4872.
11. Weber RP. Basic Content Analysis
. London: Sage; 1985.
12. Manning PK, Cullum-Swan B. Narrative, content, and semiotic analysis. In: Denzin NK, Lincoln YS, eds. Handbook of Qualitative Research
13. Motowidlo SJ, Packard JS, Manning MR. Occupational stress: its causes and consequences for job performance. J Appl Psychol
14. Parasuraman S, Drake BH, Zammuto RF. The effects of nursing care modalities and shift assignments on nurses' work experiences and job attitudes. Nurs Res.
15. Robinson SE, Roth SL, Keim J, Levenson, M, Flentje JR, Bashor K. Nurse burnout: work related and demographic factors as culprits. Res Nurs Health
16. Schaefer JA, Moos RH. Effects of work stressors and work climate on long-term care staff's job morale and functioning. Res Nurs Health
17. Holmes TA, Masuda M. Magnitude estimations of social readjustments. J Psychosom Res
18. Holmes TA, Rahe R. The social readjustment rating scale. J Psychosom Res
19. Selye H. Stress without Distress
. Philadelphia: JB Lippincott; 1974.
20. Selye H. The Stress of Life
, New York: McGraw Hill; 1956.
21. Benner P, Wrubel J. The Primacy of Caring: Stress and Coping in Health and Illness
. Menlo Park, CA: Addison-Wesley; 1989.
22. Lazarus RS. Psychological Stress and the Coping Process
. New York: McGraw Hill; 1966.
23. Blegen MA. Nurses' job satisfaction: a meta-analysis of related variables. Nurs Res
24. Norbeck JS. Perceived job stress, job satisfaction, and psychological symptoms in critical care nursing. Res Nurs Health
25. Revicki DA, May HJ. Organizational characteristics, occupational stress, and mental health in nurses. Behav Med
26. Stechmiller JK, Yarandi HN. Predictors of burnout in critical care nurses. Heart Lung
27. Cohen MZ. The meaning of cancer and oncology nursing: link to effective care. Semin Oncol Nurs
28. Gaynor SE, Verdin JA, Bucko JP. Peer social support: a key to care giver morale and satisfaction. J Nurs Adm
29. Leveck ML, Jones CB. The nursing practice environment, staff retention, and quality of care. Res Nurs Health
© 1999 Lippincott Williams & Wilkins, Inc.