Santos, Susan R. PhD, RN; Simon, Stephen D. PhD; Carroll, Cathryn A. PhD, MA, MBA, RPh; Bainbridge, Lynda MBA, RN C; Cox, Karen S. PhD, RN, CNAA; Cunningham, Marion MBA, MN, RN; Teasley, Susan L. RN; Ott, Lynn MSN, RN
Many inpatient administrators are experiencing enormous difficulties recruiting and retaining registered nurses at a time when the consumption of healthcare goods and services is increasing. This increase is caused, in part, by better disease state management as well as advances in drug therapy and diagnostic capabilities. Concurrently, the age of the general population is increasing, as is the Registered Nurse (RN) workforce. In 1980 the average age of nurses was 40, whereas recent data indicate the average age to be 44 years.1 Nursing care provided on a typical inpatient nursing unit today requires competence and a physical stamina beyond that required in previous years. If that is the case, managers and executives must use good judgment about how to utilize scarce resources aimed at supporting staff nurses. To do this, we must have first accurately assessed what inpatient nurses indicate are the most problematic issues associated with their day‐to‐day work activity. It is also important that, when gathering such data, we determine if the age of the RN has a significant influence on those findings. Only then can we offer the appropriate support for nurses at the bedside.
This study describes variations in 3 domains of occupational adjustment—stress, strain, and coping—for a large sample of inpatient registered nurses from 4 diverse settings. The primary objectives for the study were to adequately describe stress, strain, and coping for inpatient registered nurses, and to determine if age influences differences in stress, strain, and coping scores.
Accurately characterizing occupational adjustment is an important step in designing effective interventions to reduce stress and strain, and increase coping within the nurse's work environment, particularly for Baby Boomer nurses, who constitute the largest age cohort of nurses working today.
The Occupational Stress Inventory‐Revised Edition (OSI‐R)2 was administered to a voluntary sample of RNs (n = 694) at 4 diverse hospitals in the Midwest. The study participants were from rural, urban, suburban, and specialty institutions. At each site, institutional review approval was obtained.
Participants were enrolled in the study through internal communication mechanisms at each site. Recruitment flyers and announcements at staff meetings were used to encourage participation. To ensure consistency in data collection, a team of trained research assistants administered the survey packets at each site. Data were collected at various times across all shifts during the week and on the weekend.
To ensure confidentiality for study participants, a unique study number was assigned to each individual completing the instrument and demographic sheet. Names of participants were not requested, and no sign‐in sheets were required for participation in the study. A room separate from the nursing unit was used for study participants to complete the data collection forms in a quiet environment. At all times, the research assistants were available for questions about the purpose of the study. However, the research assistants were prohibited from interpreting questionnaire items for the participants.
Survey Instrument: OSI‐R
Each participant received a survey packet. This packet contained an enrollment script/consent form, a demographic sheet, the OSI‐R survey, and the OSI‐R survey response sheet.
The OSI‐R is a paper‐and‐pencil 140‐item Likert scale instrument that takes approximately 30 minutes to complete. Three domains of occupational adjustment are assessed with this instrument. Subsumed within these 3 domains are 14 sub‐scales. The 3 domains include occupational stress, psychological strain, and coping. Occupational stress is measured by the Occupational Roles Questionnaire (ORQ) component of the OSI‐R. The ORQ measures job role overload, role insufficiency, role ambiguity, role boundary, responsibility, and physical environment. The Personal Strain Questionnaire (PSQ) segment of the OSI‐R measures psychological strain. The PSQ assesses 4 types of personal strain: vocational strain, psychological strain, interpersonal strain, and physical strain. Higher scores on the ORQ and PSQ sub‐scales represent more stress and strain than lower scores. Coping resources are measured by using the Personal Resources Questionnaire (PRQ) segment of the OSI‐R. The PRQ evaluates resources for coping. These resources include recreation, self‐care, social support, and rational/cognitive coping. Higher scores on the PRQ represent better coping than lower scores.2 All scales have alpha coefficients ranging from 0.70 to 0.94 and therefore are considered a good measure of the concepts under investigation.
Focus Group Interviews
Follow‐up focus groups were conducted using semi‐structured interview questions to clarify the finding of the OSI‐R. A typical line of questioning would be as follows: “The survey found that role overload was problematic for nurses here. Role overload is defined as workload that is increasing, unreasonable, and unsupported by needed resources. Participants may describe themselves as not feeling well trained or competent for the job at hand, needing more help, and/or working under tight deadlines.2 Can you tell us how specifically this manifests itself on your unit on a daily basis?” These questions were asked of the most problematic scores from each domain of the OSI‐R. After survey data from each institution were analyzed, 20 focus groups were held across the 4 sites. A total of 125 registered nurses from all age cohorts participated across these sites. At each site, at least 10% of survey participants attended these focus groups. No individual focus group had less than 5 or more than 10 participants.
Data from the OSI‐R were analyzed using the Statistical Package for Social Science (SPSS).3 Significance levels for all 2‐tailed tests were set at p = .05. Descriptive statistics were used to characterize the study participants and quantify the most problematic sub‐scales identified by the participants. The influence of age for each sub‐scale was determined using the analysis of variance test statistic (ANOVA). The Tukey HSD test statistic was used for post‐hoc analysis when indicated by significant ANOVAs. Only those results that held significant with the post hoc tests will be reported. Criterion for rejection was set at P = .05.
Since Hospital A represented such a large fraction (59%) of the participants from the total sample, it was important to determine if these data skewed the results. To determine if significance remained, we excluded data from Hospital A, and we reanalyzed the data from Hospitals B, C, and D using estimated marginal means. All findings held consistent without the influence of Hospital A participants.
Focus group data were individually hand coded by the 2 facilitators who conducted the group interviews. Themes were developed by each facilitator and compared. Congruent themes between investigators determined to be relevant are reported.
Table 1 details the participation from each age cohort, as well as the participation at each institution. Of the 694 participants, there were 55 (8%) Matures, born between 1919 and 1945; 368 (53%) Baby Boomers, born between 1946 and 1964; and 246 (35%) Generation Xers, born between 1965 and 1979.
The following results represent the findings for the primary research objectives:Adequately describe stress, strain, and coping of inpatient RNs, and determine if age influences differences in stress, strain, and coping scores.
The results of the most problematic or worst scores for the participants in each of the 3 domains —stress, strain, and coping—are listed in Table 2. Physical environment was found to be the most problematic for this sample of inpatient nurses. Responsibility was the second most problematic. Definitions for each of these domains are included in the text that follows. Table 3 represents the findings of the OSI‐R identifying significant scores in each domain of occupational adjustment (stress, strain, and coping).
Occupational Role Questionnaire (ORQ)—Stress Subscales
In 5 of the 10 stress sub‐scales, age significantly influenced the results. In these sub‐scales, higher scores are more negative. Four of the six stress subscales found that Baby Boomer nurses had significantly higher, or more negative, stress scores than their colleagues in the 2 other age cohorts of Matures and Generation Xers. Significant results included role overload (P =. 043), role insufficiency (P = .001), role ambiguity (P = .030), and role boundary (P = .023). The definitions of the findings are as follows:
Those who score high on role overload may describe their work load as increasing, unreasonable, and unsupported by needed resources. Participants may describe themselves as not feeling well trained or competent for the job at hand, needing more help, and/or working under tight deadlines. High scorers on role insufficiency indicate a poor fit between their skills and the job they are performing. They may also report that their career is not progressing and has little future. Needs for recognition and success may not have been met. They may report boredom and/or underutilization. High scorers on role ambiguity indicate an unclear sense of what they are expected to do, how they should be spending their time, and how they will be evaluated. They seem not to know where to begin on new projects and experience conflicting demands from supervisors. They also may report no clear sense of what they should do to “get ahead.” High scorers on role boundary may report feeling caught between conflicting supervisory demands and factions. They may report not feeling proud of what they do, or not having a stake in the enterprise. They also may report being unclear about authority lines and having more than one person telling them what to do.2(p12)
For both role overload and role insufficiency, the greatest influence on significance was found between Boomers and Xers. For role ambiguity and role boundary, the greatest influence on significance was found between scores for Boomers and Matures.
Generation Xers had worse scores than Baby Boomers or Matures on the sub‐scale of physical environment (P = .000). The significance was found more evenly distributed between scores for Xers and Matures and Xers and Boomers. High scorers on physical environment may report being exposed to high levels of noise, moisture, dust, heat, cold, light, poisonous substances, or unpleasant odors. They also may report having an erratic work schedule or feeling personally isolated.2
Personal Strain Questionnaire— Strain Subscales
Again, high scores are more negative for these 4 subscales. There was only one significant subscale in this domain of the OSI‐R: Baby Boomers again had significantly more interpersonal strain than other cohorts (P = .015). The significance was found between Boomers and Matures. “High scorers may report frequent quarrels or excessive dependency on family members, spouses, and friends. They also may report wanting to withdraw and have time alone or, conversely, not having time to spend with friends.”2(p12)
Personal Resources Questionnaire— Coping Subscales
Three of the four coping subscales found significant differences with age cohorts. High scores in these sub‐scales represent more positive findings or better coping. On 2 of the 3 coping subscales Baby Boomer respondents had worse scores, or poorer coping, than participants in the other age cohorts. These subscales were self‐care (P = .002), where Baby Boomers tied with Xers, and social support (P = .004). On the coping sub‐scales, high scores are preferred.
High scorers (on self‐care) may report that they regularly exercise, sleep 8 hours per day, are careful about their diet, practice relaxation techniques, and avoid harmful substances (eg, alcohol, drugs, tobacco, and coffee). High scorers (on social support) may report feeling that there is at least one person they can count on, one who values and/or loves them. They may report having sympathetic people with whom to talk about work problems and may report having help to do important things and/or things around the house. They also may report feeling close to another individual.2(p13)
Similar findings were presented by Santos and Cox.4 They found the highest scores on the stress and strain sub‐scales of the OSI‐R for their sample to be physical environment, physical strain, responsibility, and psychological strain. They also found that self‐care and recreation were the least effectively used forms of coping.
After the analysis was performed on the OSI‐R, focus groups were conducted to clarify the findings. A typical focus group question would be, “Role overload was defined as problematic for nurses who participated in this study. Role overload is defined as measuring ‘the extent to which job demands exceed resources (personal and workplace) and the extent to which the individual is able to accommodate workloads.’ Can you describe activities on your unit or day‐to‐day workload that reflect this definition?” The results indicate problems associated with key stressors in the workplace that could be grouped into 3 themes:
* Unit “speed‐up” (admissions, discharges, and transfers, or ADTs) and the use of staffing calculations that do not factor in this unit activity,
* The pressure to provide customer service and quality care, and
* Staff shortages.
Nurses were quick to point out that when the need for more staffing does arise, every effort is made by their managers to get nurses to come in. At times there simply is no one to call. Many nurses who participated in this study also indicated they have seen and continue to see nurses in leadership roles “all the way to the top” don scrubs and roll up their sleeves to help take care of patients. They also articulated that they receive information about the financial health of their organizations on a regular basis. This gives them the sense that they are helping the organization meet their budgets. Some of the focus group participants felt a great kinship to their peers and their organization. Many said it was like their “second family.”
Although the results indicate the average scores for the sample to be within normal limits, the participants' range of scores for each sub‐scale indicated there was room for improvement at all 4 sites.
Stress and Strain
The results of the quantitative findings indicate that the physical demands and the responsibility of inpatient nursing were most problematic. In addition, role boundary and role overload were found as key types of stress‐inducing roles. These findings only serve to validate our empirical and tacit knowledge about today's inpatient population. The patients seen in inpatient settings today are sicker, require more intense care and treatments, and need to be discharged as soon as they meet discharge criteria. The work can be physically backbreaking, with little “down time” due to rapid bed turnover and staffing shortages.
All of the issues identified seem amplified for the Baby Boomer RN. These nurses are caught between many competing demands for their time, both personally and professionally. Many have children they are still supporting and may even have grandchildren in their home. Simultaneously, some Baby Boomers are faced with sobering issues associated with their parents' health. In these 4 institutions the Baby Boomer nurses were the most seasoned, based on a cross tabulation with number of years in the RN role. Nurse Managers look to them to orient new graduates and keep the unit going. If they are in academic medical centers, the attending physicians seek them out to mentor new fellows or residents. They are the formal and informal leaders. They do not want to let patients or peers down when there are extra patients or when nurses call in sick. Given these characteristics, it is unclear how long this group of nurses will be able to keep up with the physical and psychological pressures of inpatient nursing, the turnover of staff, and their own personal stress associated with these factors, which are sometimes compounded by lifespan issues.
One explanation for the significantly worse scores on the sub‐scale of physical environment for Generation X nurses might be the transition from the student to employee role. Instead of taking care of a small number of patients or even one patient during the clinical experience, employees are expected to take a reasonable load of patients after an orientation period. This need to find supplies and coordinate care for patients who may or may not be in proximity to one another could pose a striking challenge to the novice nurse.5
Various forms of coping mechanisms are used to reduce stress and strain in our lives. Baby Boomer nurses had poorer coping on the social support segment of the coping sub scale. Individuals in this age cohort are pillars both in their workplace and at home. Instead of having others available for social support, their friends, family, and coworkers tend to lean on them.
A major finding in the focus group results are echoed in the finding of the Robert Wood Johnson Foundation‐commissioned study, Healthcare's Human Crisis: The American Nursing Shortage.6 Nurses from both studies conveyed the difficulty of relying on unit staffing based on the Hours Per Patient Day (HPPD) metric. Nurse managers and executives have struggled with this problem for many years. Perhaps the work conducted by Budreau et al. at the University of Iowa Hospitals and Clinics7 offers promise in applying the factors of census and staffing variability into the staffing mix. In their model, unit activity associated with admissions, discharges, and transfers (ADTs) is added to the traditional equation to provide a modification of the HPPD to a caregiver‐patient ratio (CGPR). However, patient acuity is an additional confounding issue. The industry has dealt with the gamut of acuity systems that range in the level of sophistication from highly automated to homegrown or manual. But at the end of the day, there is little consensus about such measures or their utility.
Regardless of the metric used for staffing or the type of acuity system integrated into our institutions, one thing is clear: the average age of nurses continues to climb. As they age, they may not be able to perform at the pace they once did. Therefore, even if healthcare leaders could adequately deal with the complexities associated with staffing or acuity, there is a dire need to take into account the age and physical capabilities of the staff remaining at the bedside. Accommodations may have to be made.1
Nurse executives might do well to consider the work of Rosabeth Kanter,8 the noted sociologist. Her work in the 1970s still holds true today. Her theory on “spill‐over” finds that, regardless of a person's ability to try to compartmentalize our work and home lives, we will invariably merge the spheres of work and home.
The mature nurses had statistically better coping scores on the sub‐scales of self‐care and recreation than other age cohorts. One explanation for these findings may be related to their place on the lifespan. Individuals in this age cohort may be eyeing retirement and have satisfied personal obligations to parents and/or children. This may produce considerably more personal time for self‐care activities and recreation. In addition, the financial drain of children and aging or sick parents may be abating, freeing more funds for recreational activities. This decrease in general life stressors may, as Rosabeth Kanter indicates, spillover into the workplace. It may be less stressful to work in a situation where you no longer have to worry about facing the second shift of caregiving when you leave the workplace.
Individual Hospital Projects
The hospitals participating in this study received customized reports, and are at various stages of planned interventions based on the findings. Senior administrators and participants from all sites were provided feedback, and have crafted specific interventions based on their unique findings. All sites shared the results in some format with the staff and had open dialogue to help determine the best course of action for their inpatient units. The results to date are exciting and encouraging. We continue to recruit additional institutions into the study. We have collected data at 8 diverse sites in the region for a total sample size of over 1000 registered nurses.
Support for Baby Boomer Nurses
The complex job of managing different generations of employees has healthcare executives caught among many factions of trying to be all things to their employees. It is difficult to tailor the workplace and benefits to suit both the younger and older generations. However, the findings of this study suggest we might do well to revisit the work environment and see if modifications can offer a friendlier environment —in particular for the older, more seasoned nurse. There may be other benefits or programs to offer this population of workers. For example, in addition to childcare, there may be a need for elder daycare or respite care programs to support workers who have older parents in their home due to failing health. Childcare for young children, although variable by geographic location and price, can be found. Eldercare, on the other hand, is not as prevalent. In addition, the workplace may need to be more ergonomically sensitive to the older worker.1
Educational programs aimed at educating individuals to proactively discuss how a difficult family choice will be made, such as end‐of‐life care for parents or siblings, may be well received. These issues are difficult to discuss at any time, but even more so in a state of crisis. Most organizations have employee assistance programs, but then again, they are typically sought out in times of crisis.
Perhaps the best place to start is to ask this group of nurses directly how they could be supported by the organization to retain their valuable experience at the bedside. When seasoned nurses leave, they takes with them tremendous knowledge and expertise. If we can retain these nurses on average an extra year, the brain drain we are currently experiencing could be slowed a bit.
Finally, recent literature in nursing suggests nurses in leadership roles realize these issues are at play. Rather than reinventing the wheel, nurses would do well to consult the literature available.6 However, it is difficult to shift to new ways of doing things. Nurses in leadership might do well to use the nursing process in making administrative decisions. In doing so, the influence of expensive quick fixes could be reduced.
Since the data were collected from only one region, the generalizability of these findings to other institutions or regions of the nation may be limited. However, in the Robert Wood Johnson‐commissioned report, those findings appear to be consistent across the United States.6 Also, the participation was voluntary. This may have lead to a self‐selection bias on the part of respondents, where the most satisfied or dissatisfied individuals participated.
Nurse executives need to evaluate how staff nurses frame the issues they find problematic. To do this work, we need valid and reliable instruments that assess fundamental issues at play in the workplace. Due to the complexities of these issues, it is important to take an additional step in clarifying these findings using a qualitative approach, such as focus groups. This will provide the staff nurse an opportunity to articulate the day‐to‐day activities that cause the most impediments to care, and will give the nurse manager and executive a way to keep the pulse of the organization. Once that is done, there is a greater chance that the interventions created by management to ameliorate work stressors will hit the target set by the nurses themselves.
Whether or not those in leadership agree with nurses may be irrelevant. The fact of the matter is that nurses' perceptions are their reality. The latest data indicate nurses are experiencing burnout and are unsure if they will be able to stay at the bedside, given the pace.9 At that rate, turnover of nursing staff will reach levels not yet seen in the history of the industry. In addition, the loss of seasoned and expert nurses away from inpatient settings or the nursing field at large may have a negative impact on the health of our nation's people
The RN workforce is aging. This is fact, and is to subject to little interpretation. If we are to keep our best nurses at the bedside, we must look for new and innovative ways to support their special needs—both physically and psychosocially—to avoid the bedside exodus currently in progress.
This study was funded in part by the Robert Wood Johnson Executive Nurse Fellowship project funds. Dr Cox is a 1999 Fellow. The authors thank Teresa Fee for manuscript preparation, Olivia Gonzales for data collection, Gail Echerd, former Chief Nurse Executive of Trinity Lutheran Hospital in Kansas City, Missouri, and the nurses who participated in this project.
© 2003 Lippincott Williams & Wilkins, Inc.