Retaining the Best: Recognizing What Meaningful Recognition Is to Nurses as a Strategy for Nurse Leaders : JONA: The Journal of Nursing Administration

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Retaining the Best

Recognizing What Meaningful Recognition Is to Nurses as a Strategy for Nurse Leaders

Sweeney, Cynthia Divens DNP, RN, CNOR, NEA-BC, FAAN; Wiseman, Rebecca PhD, RN

Author Information
JONA: The Journal of Nursing Administration 53(2):p 81-87, February 2023. | DOI: 10.1097/NNA.0000000000001248

Abstract

Nurses account for more than half of the world's health workers, with an estimated 28 million nurses worldwide.1 According to the World Health Organization's 2020 report on the state of nursing in the world, there will be a global shortfall of 5.9 million nurses by 2030.1 In the United States, there is a growing need for RNs, which has been estimated at 200 000 annually.2 Employment of RNs in the United States is projected to continue to grow 9% from 2020 to 2030, faster than the average for all occupations according to the US Bureau of Labor Statistics.2

On January 21, 2020, the Centers for Disease Control and Prevention confirmed the first case of severe acute respiratory syndrome coronavirus 2 (COVID-19). The healthcare system has been stretched further as total cases in the United States reached more than 89 million by July 2022.3 Meeting the gap between nursing resources and demand has been an ongoing challenge to nurse leaders and is worsened by the physical and emotional demands the global pandemic continues to place on the nursing workforce. How can the continuing shortfall in the nursing workforce be mitigated to supply quality nursing care and ultimately better healthcare outcomes? As researchers, we felt that examining our own state, Maryland, was a starting point to explore the insights of nurses on what is meaningful recognition to them. Maryland, like other states, is challenged to meet demand for nursing care. In the state of Maryland, estimates prior to the pandemic expected a shortfall of 12 000 RNs by 2030.2 Currently, there are 68 300 RNs in the state to service a population of 6 million people, approximately 11.3 nurses per 1000 people.3 More than 1 million COVID cases impacted healthcare settings in Maryland since the start of the pandemic.3 Using the American Association of Critical-Care Nurses (AACN) Healthy Work Environment (HWE) as our theoretical framework, we explored what meaningful recognition means to nurses in our state, given the effects of the pandemic on our already stressed workforce.

Background

The positive impact of creating and sustaining a healthy work environment (HWE) is well documented. To be an HWE, the following 6 components must be in place: skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, and authentic leadership.4 Meaningful recognition is a low-cost, high-impact strategy associated with job embeddedness and engagement in the workplace.5 It is an important component of an HWE and a good starting point for organizations to create environments of practice that attract and retain nurses. To effectively use this strategy, congruency in what is valued as meaningful recognition should exist between nurses and the organizations that employ them.6 Identifying what meaningful recognition is to nurses can optimize its impact on our nursing workforce, the patients they care for, and the nursing profession.

Sigma Theta Tau International (Sigma) members within the state of Maryland were asked to participate in this research. Sigma is the international honor society of nursing with the mission of “Developing nurse leaders anywhere to improve healthcare everywhere.”7 It was felt Sigma nurses would provide insights into meaningful recognition as nurses who are leaders at all levels of nursing, they represent a variety of nursing practice environments, both leadership and clinical; they are committed to the profession of nursing as demonstrated by their elective membership and are supportive of opportunities to contribute to nursing knowledge. This study was conducted with the Pi at-Large chapter of Sigma at the University of Maryland as the lead chapter and included all Sigma chapters within the state of Maryland in the sample. This exploration of what is valued as meaningful recognition by nurses is an important step to collectively move past the pandemic in the healthcare landscape, armed with new knowledge of what is important to nurses now.

Review of the Literature

The benefit of working within an HWE has been demonstrated in the literature. Meaningful recognition as a component acknowledges how a person's actions affect the life of another, is relevant to the recipient, is equivalent to their contribution, and provides significant positive feedback.4,8 Recognition that is meaningful to the individual endures over time in the positive impact of the feedback, often lasting throughout a person's life.8 Use of meaningful recognition is demonstrated to be a valuable strategy for healthcare organizations in supporting retention and recruiting efforts, as well as establishing workplace cultures of excellence.9 Using meaningful recognition contributes to compassion satisfaction and can mitigate the effects of compassion fatigue, which comprised burnout and secondary traumatic stress.5 This affect is especially important in the recovery of healthcare organizations, following the traumatic impact of the pandemic. In a study of critical care nurses from 13 hospitals, a lack of meaningful recognition, along with staffing and effective decision-making, components of an HWE, was a predictor for burnout.10 This study suggested that efforts be focused on these 3 elements as part of a systems-based approach to addressing burnout and the well-being of nurses, especially in younger nurses.10 Salvant et al11 found that younger generations of nurses (Gen Z/Millennial = ≤35 years) valued recognition less than older generations (Gen X/Baby Boomer = >35 years). In their study of trauma ICU nurses and their leaders, they found no significant differences between different forms of employee recognition. However, the highest scored form of recognition among staff nurses was salary increases commensurate with their performance.

The leaders most valued a public celebration for nurses' years of service, followed by posting complimentary patient evaluations of staff. This was in keeping with findings that Gen Xers and Baby Boomers significantly rated public and written acknowledgment higher than younger generations.11 This study found substantial differences in preferred recognition from a generational aspect. In another study using focus groups of staff nurses and nursing leadership, the concepts of an HWE were explored across 5 hospitals. Using a thematic content analysis, themes about meaningful recognition emerged. Clinical staff nurses and their managers felt that 1 type of recognition does not fit all. A subtheme for clinical nurses was to understand how people want to be acknowledged. Nurse managers' subtheme was that recognition should be meaningful in how the person wants to receive it.6 Nurse managers also felt that recognition for managers was lacking.6 A convenience sample of direct care pediatric RNs supplied insights through focus group content analysis. In this study, 3 key themes emerged regarding recognition: understanding what actions are worthy of meaningful recognition; that meaningful recognition matters; and meaningful recognition is unique to the individual; that is, one size is not good for all.12 Meaningful recognition continues to be important to nurses. It is clear from the literature that a deeper understanding across nurse practice settings, demographics, and roles can inform the use of meaningful recognition for nurses by their organizations.

Methods

Design and Research Questions

A descriptive correlational design was used to explore what meaningful recognition is to nurses. A sentiment analysis of narrative responses was used to identify themes in addition to quantifying survey responses. Data were collected using 2 instruments, the Recognition Questionnaire and the Healthy Work Environment Assessment Tool (HWEAT).13,14 The Recognition Questionnaire's subscales of salary, private verbal feedback, written acknowledgment, schedule adjustment, and opportunities for growth and development had Cronbach's α coefficients ranging from 0.64 to 0.89.13,15 This instrument was used to study which forms of recognition are most meaningful to nurses. The HWEAT has established reliability in earlier work with a Cronbach's α score of 0.80 or better and was used to explore nurses' perceptions of their work environment.14 Permissions were obtained to use the instruments. A demographic questionnaire collected data about the participant's educational preparation, nursing employment, state of licensure, and years of nursing work experience, among other demographic attributes. The researchers wanted to understand from this sample what is meaningful recognition to them and the implications for nursing practice and organizations.

Procedure

The study proposal was submitted to the University of Maryland institutional review board and was determined to be exempt. A convenience sample made up of current Sigma Theta Tau International members who are active in 1 of 8 chapters in the state of Maryland was invited to participate in this study. A description of the study was sent to the leadership of each chapter, requesting dissemination to their chapter members. Opportunities to ask questions regarding the study were provided. Of the 8 chapters, 7 responded that they would participate. A link to the online survey was then sent with a letter of introduction from the researchers to each chapter. Each chapter sent the letter of introduction with the survey link along with a message from the chapter leadership to encourage member participation. Respondents were informed that they would complete a demographic questionnaire and 2 study questionnaires taking approximately 20 minutes to complete. Respondents had to agree to take part in the study in order to progress through the online survey and were informed that participation in the study was voluntary and that no incentives were provided. Completion of the study questionnaires implied consent to take part in the study. All responses were anonymous, with no identifying personal information asked. The demographic survey did not ask the respondent their chapter name, so all data were reported in aggregate. The total number of chapter members for these 7 chapters totaled 2636. Data were collected using a secure platform through the University of Maryland. Only the principal investigators had access to the findings. Once analysis is completed and results reported, the data will be destroyed.

Data Analysis and Results

Descriptive analysis and the use of sentiment review for themes were used. Summaries of themes and behaviors were provided to the research team for review and analysis. A total of 163 respondents (6%) completed the online survey. As the sample was drawn from Sigma chapters, it is consistent that participants demonstrated higher educational levels: 31 baccalaureate degrees (19%), 71 master's degrees (44%), and 61 doctoral degrees (37%). The majority of the respondents had greater than 30 years of experience (48.1%), and those with less than 5 years of experience represented 13%.

Those identifying as White represented 81.6% (n = 133), with 6.1% (n = 10) identifying as Black/African Americans and 3.7% (n = 6) as Asian. Females were the majority at 96.9% (n = 158), with 1.9% identifying as male (n = 3) and 1.2% (n = 2) declining to answer. Most respondents worked in direct patient care (39.1% [n = 64]), with educators as the next largest group (33.5%; n = 55). Nurses in management and executive roles (10.6% [n = 17]) and those identifying as being in “other” and indirect care roles (16.8% [n = 27]) completed the survey. Advanced practice RNs represented one-fourth of the respondents (24.9% [n = 40]) and a minority of nurses held licenses from a compact state (13.5% [n = 22]).

Meaningful Recognition Instrument

The Recognition Questionnaire was used to examine which forms of recognition are most meaningful to nurses.13 The 30-item instrument consists of a 5-point Likert response format ranging from 1 (not at all) to 5 (great).13 All items showed moderate to great agreement with the importance of meaningful recognition strategies. Those items where 60% or higher of the respondents rated the importance as “considerable” or “great” agreement were selected for further review (Table 1). Question 31 was an open-ended area for comments about different forms of recognition that staff felt was meaningful. Question 32 was a question related to global recognition reflecting the nurse's current level of recognition in their role. This item asked respondents their level of agreement with the statement, “I am acknowledged/recognized for my achievements and job performance by the management team.” The average response was 2.73 on a 4-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree). Agreement with this statement was consistent with the range of responses on the 30 individual items. In this question, respondents were asked to list other examples of recognition that they would consider meaningful. Forty-five comments were received, and after a thematic review, 3 categories emerged: 1) financial rewards; 2) public/personal acknowledgment of work and efforts; 3) and professional development opportunities. Financial rewards included incentives for retention and for years of service to the organization, yearly salary increases in recognition of performance not just across-the-board cost-of-living increases, pay increases commensurate with hospital earnings, hazard pay, bonus pay for exceptional work efforts, paid time off for exceptional work efforts, and improved benefits to include retirement plan contributions and accrual of more time off for length of service (Table 2).

Table 1 - Priority Meaningful Recognition Strategies Based on Percent of Respondents
Item Not at All, % Very Little, % Moderate, % Considerable, % Great, % Subtotal Considerable/Great, %
Salary increases are commensurate with level of performance 9.1 2.1 9.8 17.5 61.5 79.0
Consulting with you on important department decisions 3.5 9.2 9.9 40.8 36.6 77.4
Giving a day off with pay to attend a workshop 7.7 6.3 14.7 19.6 51.7 71.3
Meeting with you to provide support and assistance toward professional and career goals 4.9 9.2 16.9 31.7 37.3 69.0
Giving private verbal feedback 2.1 7.6 21.5 49.3 19.4 68.7
Recommending you as an expert speaker 7.7 7.7 17.5 36.4 30.8 67.2
Asking you to participate in strategic and operational planning 6.3 9.9 16.9 34.5 32.4 66.9
Encouraging you to develop your expertise 4.3 9.2 20.6 35.5 30.5 66.0
Acknowledging you for consistently taking on additional responsibilities 4.2 12.0 18.3 36.6 28.9 65.5
Sending a communication regarding your performance to senior leaders 4.2 9.9 22.5 33.8 29.6 63.4
Asking you to represent department in your work environment 4.9 9.8 23.8 37.8 23.8 61.6
Providing on-the-job feedback for your work performance to senior leaders 2.1 12.1 25.5 37.6 22.7 60.2

Table 2 - Meaningful Recognition Sample Thematic Statements
Theme Statement
Financial rewards Significant wage increases commensurate with the risks and responsibilities and hardships of nursing. The salaries are too low.
Promotion with pay increase, additional support (staffing or other) to accomplish work.
Better benefits, such as paid maternity leave.
At-will bonus given by leadership for exceptional work efforts.
Better staffing and guaranteed breaks.
Public/personal acknowledgment of work and efforts Used to get pins when a patient recognized you; 3 patients wrote to my manager, and it did not matter anymore because of COVID was what I was told.
I am not one for public recognition, so to me the most important thing is my boss telling me that my work is important to the organization and my contributions are valued. She took me to lunch one day to thank me for my work and support. That was the best recognition I have received!
In my last employment, we had monthly award meetings, and folks were singled out and given a plaque, or a pin, and a letter in your personnel file. One time they gave out umbrellas with the logo of the institution—they became a hot property! Everyone wanted one!!
Using my professional title with the same respect that is accorded to others.
Identifying me as a key stakeholder or knowledge leader.
Being nominated for external rewards and recognitions.
DAISY Award, monthly award with picture posted on unit.
Being involved in change processes, having a voice.
Opportunity to evaluate leaders and their adherence to values of professional behavior.
Professional development opportunities Funding and paid days off to attend conferences.
Chairing committees related to problem solving, participate in evidence-based projects.
Opportunities for advancement.
Recognition for leadership potential and support for advancement.
Offering to support educational aspirations, based on merit, with time and money offsets.

Public/personal acknowledgment of work and efforts included being listed on the department website with information about expertise and training, being introduced by name and rank rather than as “my nurse,” announcing awards or publications in newsletters, and respect for professional role and responsibilities (Table 2).

Professional development opportunities were highly valued with flexibility to attend conferences, take on leadership roles, and pursue further education/training, earning certifications (Table 2).

Although the sample size was small, and it was not feasible to conduct statistical analyses, there were some interesting trends that emerged from the responses among years of experience, racial/ethnic identity, gender, work role, and place of employment. Respondents who identified as Black or African American (6.1% [n = 10]) rated 22 of the 30 items as not at all/very little as meaningful recognition strategies. Respondents identifying as being of the male gender (1.9% [n = 3]) found 12 of the 30 items as not at all/very little as meaningful recognition strategies. Differences were noted between direct care, indirect care, and educator roles on which items were of not at all/very little importance. Although this instrument was developed for acute care settings, it was surprising to find that those working in hospital/acute care settings (39.1% [n = 64]) found 13 of the 30 items as not at all/very little importance. These items were focused on public recognition and extra work projects. One puzzling finding was that the item “salary increases commensurate with level of performance” was rated as not at all/very little. Further exploration of this item may need to differentiate between merit pay and across the board increases.

Healthy Work Environment Assessment Tool

The HWEAT was developed by the AACN as a screening tool to supply a snapshot of hospital work environments. It consists of 18 questions relative to the 6 standards of a healthy work environment.14 Each standard is assessed by 3 questions (Healthy Work Environment Standards and Related Subscale Questions, Supplemental Digital Content 1, https://links.lww.com/JONA/A984). The instrument consists of a 5-point Likert response format ranging from 1 (strongly disagree) to 5 (strongly agree), with 3 as neutral. In this study, of the 18 questions, only 1 earned a response rate of greater than 50% on the agree and strongly agree scale: Leaders and staff are careful to consider the patient's and family's perspectives whenever they are making important decisions (58.9%). Eleven of the remaining 17 items received neutral scores. It is difficult to ascertain the nature of the neutral scoring as multiple types of hospital management were included in each item, and not all respondents worked within a hospital setting. Three of the HWEAT items address meaningful recognition (items 4, 9, and 17). Respondents were neutral on whether the items contributed to meaningful recognition (Table 3).

Table 3 - Healthy Work Environment Meaningful Recognition Items and Percent Selected
Item Strongly Disagree, % Disagree, % Neutral, % Agree, % Strongly Agree, %
The formal reward and recognition systems work to make nurses and other staff feel valued. 16.5 20.0 39.1 18.3 6.1
Administrators, nurse managers, physicians, nurses, and other staff members speak up and let people know when they have done a good job. 7.8 12.9 37.1 33.6 8.6
Nurse leaders are given access and authority required to play a role in making key decisions. 4.4 17.5 36.8 32.5 8.8
Percentages in bold type represent the highest percentage of agreement related to MR.

Discussion and Implications for Practice

The top meaningful recognition strategies involve reasonable payment for level of service provided, public recognition within the organization, and the profession and opportunities for professional development.

Although payment was the top form of meaningful recognition as a priority strategy (Table 1), most comments on the form of meaningful recognition were focused on acknowledgment for the work done ranging from the use of a professional title to 1:1 private acknowledgment to a public celebration of accomplishment (Table 2). This provides leaders with leeway in their approach to meaningful recognition, while being mindful of individual needs. There are differences among nurses working in direct/acute care areas and indirect care areas. Nurse educators have different points of interest based on academic rewards and recognition systems. Nurses in the primary care and public health/policy arenas have different organizational structures. One survey instrument may not be able to differentiate the intrinsic and extrinsic recognition strategies that resonate across work settings. Although 11 of the 18 items of the HWEAT received a neutral score, leaders can see this as an opportunity to move the dial in a more positive direction from the middle rather than as a negative starting point. The trend seen across ethnic/racial and gender groups was a strong reminder that “one size does not fit all.” The results of this study highlight the importance of developing instruments that address the different realities experienced by colleagues across work settings, communities, regions, and nations. Nursing leaders should consider the importance of ongoing 1:1 conversations with nursing staff to gain insights into what each nurse perceives as important recognition and use those insights. Those conversations alone are meaningful recognition based on the findings of this study.

Limitations

This was a small convenience sample, and the data may not be generalizable. Sigma members are considered highly educated and professionally motivated, which may not represent the current nursing workforce. As a Right to Work state, there are no RN unions in the state, which may also be considered a limitation.

The instruments were developed prior to the pandemic experiences, which changed the realities of the nursing workforce. The respondents may have had different priorities and expectations not captured by these instruments. These tools were not intentionally designed to address differences between roles, work settings, gender, and racial/ethnic concerns regarding meaningful recognition and an HWE.

Recommendations for Future Research

This study should be replicated to a larger and more diverse population to better represent the demographic, cultural, and racial perspectives of nurses in the current healthcare landscape. Expanding this study to the international community of nurses in Sigma and beyond would provide a more robust global picture of what meaningful recognition means to nurses as recovery from the pandemic progresses. This study provided a pilot test of the instruments, identifying gaps in capturing the diversity of the population. Instruments sensitive to diversity should be developed to better leverage the use of meaningful recognition in our nursing workforce.

Conclusion

Although payment was the top form of meaningful recognition as a priority strategy, most comments on the form of meaningful recognition were focused on acknowledgment for the work done, ranging from the use of a professional title to 1:1 private acknowledgment to a public celebration of accomplishment. These differences provide leaders with leeway in their strategic approach to meaningful recognition, while being mindful of the individual preferences in recognizing them. Meaningful recognition for nurses is as unique as the nurses who receive it. Being sensitive to these differences is important and can be a form of meaningful recognition.

Acknowledgments

The authors thank Ann Rachel Willingham, MSN, RN, NEA-BC, Emory University Hospital, and Ann Marie Brooks, PhD, RN.

References

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