THE WORLD OUTSIDE of the health care industry is waking up to how rising challenges in the nurse work environment can affect the health and well-being of all Americans, not just nurses themselves or the health care organizations where they work. An article by a cancer patient in the New York Times detailed her personal view of how overworked nurses were impeded from providing her quality care due to the burdens of nursing shortages on the unit where they worked.1 Such a scenario may be played out at hospitals across the nation. The shortage of nurses is a very real problem, one that likely will not be solved this decade as the nation's population rapidly ages.2 Older people utilize much more health care than the general population,3 while their conditions require more complex treatment due to greater acuity and comorbidities.4 The aging populace has also resulted in a wave of retirements among baby boomer nurses, and resulting difficulties in replacing their experience and specialty expertise. These factors can result in more problems ahead for patients and clinicians, making it imperative to implement solutions that create healthier workplaces for nurses despite growing burdens.
Many of the solutions to significantly expand the number of nurses in America will take many years to realize. The public and policy makers—not just the health care industry—need to be informed about the problems of and solutions to the nursing shortage, and how it can impact the quality and delivery of patient care. Public support and political will must arise to remove roadblocks and increase investment in training more nurses. This is a long-term process, and even when greater numbers of applicants are admitted to nursing schools, the bedside impact will take many years to reach fruition. However, there are some important changes that health care organizations can put into effect relatively quickly to enhance the work environment for nurses, which can improve care quality and safety, patient satisfaction, and the well-being of nurses.5
The biennial Survey of Registered Nurses,6 which polled nearly 20 000 RNs, found that nurses are eager for many workplace changes that would create a healthier workplace while enhancing their professional and personal lives. These institutional changes also create opportunities for improving the health of the organizations themselves.
The Survey was developed internally by AMN Healthcare and administered electronically. In addition to Survey items, participants answered 12 demographic questions, including age, gender, ethnicity, education, years of experience, practice specialty, and work setting. Survey items focused on workplace stressors, work-life balance, exposure to workplace violence, job and career satisfaction, causes of turnover, education and ongoing professional development, nurse shortages, and retirement plans.
Some of the demographic scores (mean values reported below) from 19 967 participants' completed surveys include:
- Gender—89% female, 10% male, 1% preferred not to state
- Years of nursing experience—19
- Hours worked per week—39
- Years at current organization—6.5
Seventy-eight percent of survey respondents reported working full-time, and 62% were employed in hospitals. Seventy-two percent of participants were Caucasian/non-Hispanic, 10% African American, 6% Asian/Pacific Islander, 5% Latino or Hispanic, 3% other, and 5% prefer not to state. Practice specialties were as follows:
|Postanesthesia care unit
|Telemetry/progressive care unit
|Women's health/labor and delivery
|Pediatrics/pediatric intensive care unit
|Neonatal intensive care unit/neonatal
FLEXIBILITY AND WORK-LIFE BALANCE
The Survey found that flexibility and work-life balance were the most important influences in RNs' intent to remain at their current jobs, more important than compensation and benefits. Nearly 40% of nurses said flexibility and work-life balance are most likely to keep them on the job, while 31% cited pay and benefits. Attention to the issue of intent to remain on the job is critical in the health care industry, as the nurse turnover rate has been steadily rising for years and took a significant leap in 2018 when it rose to 18.1%.7
A significant body of research has linked nurse job satisfaction to intent to turnover and to quality of care and patient satisfaction. In particular, nurse managers and organization leaders are urged to promote greater work-life balance to improve retention of new graduate nurses, which is a particular problem in the health care industry.8
The Survey found a clear correlation between nurses' job satisfaction and intention to remain at their current jobs with the health care organization's support for diversity and inclusion in the workplace. Sixty percent of nurses said the health care organizations where they work support diversity extremely well or very well, while 16% say their organization supports diversity only slightly well or not well at all. Within these findings, though, there is strong evidence showing that the level of support for diversity in the workplace is linked to nurse job satisfaction.
- Of those nurses who say their organizations support diversity “extremely well,” 43% are also extremely satisfied with their jobs, compared with only 5% who say their organizations do “not well at all” at supporting diversity.
- Of nurses who respond “not well at all” to how their organizations rate in supporting diversity, 45% “strongly agree” that they often feel like resigning from their position, compared with only 11% of those respondents that report their organizations do “extremely well” at supporting diversity.
Strongly supporting diversity in the workplace and in the community is within reach for most health care organizations. It may be achieved by realigning existing human resources, community support, candidate outreach, and population health efforts, or reexamining other priorities that could be adjusted with a commitment to diversity and inclusion.
For example, health care organizations already have in place human resources and talent management guidelines for hiring and promotions. Shifting priorities to include outreach to diversity candidates, and including them in candidate slates for hires and promotions, can create improvement in workforce diversity. Aligning current community support programs to emphasize diversity and inclusion can help attract more diverse job applicants to a health care organization while improving satisfaction of current staff.
Nurse leaders can take actions that support workforce diversity through talent development for their workforces, including support for internal minority employees in seeking formal academic education and applying for scholarships, grants, and tuition reimbursement programs through their organizations and communities. Partnering with schools, minority-owned businesses, community leaders, and diversity organizations to attract minority populations into health care careers can also enhance organizations' abilities in better understanding and addressing needs of vulnerable, underserved populations.
Organizational support for education, training, and other professional development is necessary to maintain and improve the quality of nursing; nurse responses to questions in the Survey on how their organizations support their professional development show a mixed experience. While most organizations offer some support, nearly 1 in 5 nurses say their employers offer none at all, and only 57% say their employers provide tuition reimbursement and 53% offer continuing education. Forty-three percent of nurses say that their organization does extremely well or very well at supporting their professional development, while 29% say their organization does slightly well or not well at all.
The Survey also shows that support for professional development is tied to higher career satisfaction and job satisfaction among nurses, along with better ability to provide quality care and greater likelihood of remaining at their current jobs. Fifty-two percent of nurses who work at organizations that do extremely well at supporting nurses' professional development are also extremely satisfied with their jobs. Of those nurses who work at organizations that do not do well at supporting professional development, only 7% are extremely satisfied with their jobs.
Professional development is important not only to maintain and improve patient care quality but also for nurse retention. Internships, residency programs, and transition-to-practice programs are promising interventions to improve nurse retention.9 Organizations that support professional development for nurses could see improved retention,10 which in turn improves the quality of patient care while reducing costs created by turnover.
Nurse leaders also have an important role in ongoing development of their teams, well beyond the early career strategies above aimed at successful transition into practice for new nurses. Mentor and career advancement programs can offer experienced nurses support in further developing and accomplishing specific personal and professional goals. While many organizations have formal programs to support ongoing professional development, partnering with local chapters of professional organizations and academic organizations can provide access to a wealth of external resources that enrich nurses' personal growth and career development.
SAFETY MEASURES, TEAM ENGAGEMENT, AND EFFECTIVE LEADERSHIP
Supporting nurses in providing the highest-quality care to patients is not only critical to health care organizations' care mission but also to nurse satisfaction and a healthy workplace environment. To provide the best support for quality nursing care, health care organizations need to consider the factors that nurses themselves say are the most important positive influences on their work.
The Survey found that when nurses were asked about the positive influences on their ability to provide quality patient care, the top 3 were safety practices, team engagement, and effective leadership, with 71% of nurses responding “a great deal” and “a lot” for safety practices, 70% for engagement of team members, 65% for effective leadership, 62% for staffing levels, 62% for skill mix on the unit, and 62% for interprofessional collaboration. All of these are major factors in nurse work environment, which has a significant impact on factors such as patient mortality,11 patient satisfaction, patient outcomes, quality ratings, and nurse well-being.5
The positive influences that nurses in the Survey say are most important are directly related to positive outcomes for patients, health care organizations, and nurses' careers. There is a strong positive relationship shown between employee engagement and nurse job satisfaction, improved patient experience, and patient outcomes,12 and a culture of safety at health care organizations.13 Effective leadership, such as relational leadership models, contributes to greater nurse job satisfaction14 and to better patient outcomes and satisfaction.15 And, improving safety practices is a positive step toward higher quality care and greater nurse job satisfaction, along with improved financial performance of hospitals.16
RESPONSE TO WORKPLACE VIOLENCE
An important opportunity for creating a healthier workplace environment for nurses is presented in analysis of Survey data on nurse exposure to workplace violence. The Survey showed that 41% of nurses had personally experienced bullying, incivility, or other form of violence in the workplace in the past year, while 27% said they had witnessed such violence. Only 11% said that their organization had addressed violence extremely well or very well.
Further analysis of Survey data revealed higher levels of overall satisfaction among nurses who said that their organizations did a good job of responding to incidences of workplace violence. In fact, job satisfaction, ability to provide quality care, intent to remain at their current organization, and direct leader trust were all higher among nurses who said their organization did very well in responding to incidences of violence compared with those nurses who said they have not personally experienced or witnessed workplace violence.
By effectively responding to workplace violence, health care organizations can enhance nurse satisfaction, which in turn can improve retention, workplace environment, and patient care quality. Effective interventions and responses to workplace violence are within reach of health care organizations. A variety of resources have been developed that are targeted to violence prevention for nurses and other clinical staff, from the first such program consisting of a video cassette and workbook developed in 1976 at a Canadian hospital17 that focused on de-escalation, physical/pharmacologic restraint, and safety for patients and health care workers. Current programs such as a 13-unit course from the National Institute of Occupational Safety and Health provide solutions for both health care organizations and individual nurses.18 In addition to content included in these early programs, ethical-legal considerations and protections for both patients and health care employees are essential additions to these training programs.
An analysis of health care workplace violence prevention programs19 found that such programs should be supplemented with organization-specific information regarding policies and procedures, emergency action plans, communication trees, localized risk assessment, and postincident procedures for both the clinicians and the organization, among other customized processes. The analysis also recommended dedicated management for workplace violence response and a systematic data-based approach by each organization to better assess both risk and response.
As we listen to the voice of nursing, we deepen our understanding of how serving the profession in turns serves our society. The solutions derived from the findings of the 2019 RN Survey are not necessarily new for the health care workplace environment. The need for more professional development, greater flexibility and work-life balance, increased efforts toward safety and team engagement, and improved response to workplace violence are known responses with research to back them up. Opportunities remain that require additional focus from health care, human resources, and nurse leaders and have yet to be fully engaged.
There is no single solution to the complexity faced in health care settings or within the ecosystem of health care where the nursing profession operates. However, there are numerous ways in which we can begin to address individual challenges, as we move to more holistic approaches that leverage our strengths. We can continue to change the trajectory of the profession and our nation's health in positive directions when we embrace the calls to action gleaned from these survey findings, along with continued research efforts, ever-changing practice environments, recent educational model changes, and technology advancements.
We should also never lose sight of our remarkable progress to date, and we should celebrate the tremendous uplifts to the profession that have been accomplished. When we listen to the voice of the most trusted and ethical profession in America, we can begin to understand our moral obligation to society. When we demonstrate our belief in ourselves, others will believe. When nurse leaders listen to the diverse voices of their workforce, they begin to understand evolving needs and their moral and ethical obligation to respond and take action.
1. Gubar S. The nursing
shortage is threatening our care. The New York Times. January 22, 2020. https://www.nytimes.com
. Accessed August 13, 2020.
2. Vespa J. The US joins other cultures with aging populations. US Census Bureau. The Graying of America: More Older Adults than Kids by 2035. https://www.census.gov/library/stories/2018/03/graying-america.html
. Published March 13, 2018. Accessed August 13, 2020.
5. Lake ET, Sanders J, Duan R, et al. A meta-analysis of the associations between the nurse work environment in hospitals and 4 sets of outcomes. Med Care. 2019;57(5):353–361. https://journals.lww.com/lww-medicalcare/Abstract/2019/05000/A_Meta_Analysis_of_the_Associations_Between_the.6.aspx
. Accessed September 13, 2019.
6. AMN Healthcare. Survey of Registered Nurses: A Challenging Decade Ahead. https://www.amnhealthcare.com/2019RNSurvey
. Published 2019. Accessed August 13, 2020.
7. Advisory Board. Turnover, Vacancy, and Premium Benchmark Generator. https://www.advisory.com/research/hr-advancement-center/resources/2019/turnover-vacancy-and-premium-labor-benchmark-trends
. Published July 7, 2019. Accessed September 13, 2019.
8. Boamah SA, Laschinger H. The influence of areas of worklife fit and work-life interference on burnout and turnover intentions among new graduate nurses. J Nurs Manage. 2016;24(2):E164–E174. https://onlinelibrary.wiley.com/doi/abs/10.1111/jonm.12318
9. Brook J, Aiken L H, Webb R, MacLaren J, Salmon D. Characteristics of successful interventions to reduce turnover and increase retention of early career nurses: a systematic review. Int J Nurs Stud. 2019;91:47–59. https://www.sciencedirect.com/science/article/abs/pii/S0020748918302591?via%3Dihub
11. Olds DM, Aiken LH, Cimiotti JP, Lake ET. Association of nurse work environment and safety climate on patient mortality: a cross-sectional study. Int J Nurs Stud. 2017;74:155–161. https://www.sciencedirect.com/science/article/abs/pii/S0020748917301293?via%3Dihub
12. Kutney-Lee A, Germack HD, Hatfield LA, et al. Nurse engagement in shared governance and patient and nurse outcomes. J Nurs Admin. 2016;46(11):605–612. https://journals.lww.com/jonajournal/Abstract/2016/11000/Nurse_Engagement_in_Shared_Governance_and_Patient.12.aspx
13. Collier SL, Fitzpatrick JJ, Siedlecki SL, Dolansky MA. Employee engagement and a culture of safety in the intensive care unit. J Nurs Admin. 2016;46(1):49–54. https://journals.lww.com/jonajournal/Abstract/2016/01000/Employee_Engagement_and_a_Culture_of_Safety_in_the.11.aspx
14. McCay R, Lyles AA, Larkey L. Nurse leadership style, nurse satisfaction, and patient satisfaction: a systematic review. J Nurs Care Qual. 2018;33(4):361–367. https://journals.lww.com/jncqjournal/Abstract/2018/10000/Nurse_Leadership_Style,_Nurse_Satisfaction,_and.10.aspx
16. Beauvais B, Richter JP, Kim FS, Sickels G, Hook T, Kiley S, Horal T. Does patient safety pay? Evaluating the association between surgical care improvement project performance and hospital profitability. J Healthc Manag. 2019;64(3):142–154. https://journals.lww.com/jhmonline/Abstract/2019/06000/Does_Patient_Safety_Pay__Evaluating_the.5.aspx
17. St. Thomas Psychiatric Hospital. A program for the prevention and management of disturbed behavior. Hosp Community Psychiatry. 1976;27(10):724–727.
18. National Institute for Occupational Safety and Health. Workplace violence prevention for nurses (CDC Course No. WB 1865 NIOSH, Pub. No. 2013–155). Washington, DC: U.S. Department of Health and Human Services; 2013. https://www.cdc.gov/niosh/topics/violence/training_nurses.html
. Last reviewed and revised October 3, 2019.
19. Arbury S, Zankowski D, Lipscomb J, Hodgson M. Workplace violence training programs for health care workers: an analysis of program elements. Workplace Health Saf. 2017;65(6):266–272. https://journals.sagepub.com/doi/full/10.1177/2165079916671534