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Chapter 12 Workforce Advocacy and the Nursing Shortage Copyright © 2014 by Mosby, an

Promoting a Professional Practice Environment Copyright © 2014 by Mosby, an imprint of Elsevier

Overview Important research is validating the contribution of RNs Improved patient outcomes (Kane et al, 2007) Ø Prevention of premature mortality (Cho, Hwang, and Kim, 2008) Ø Increased hospital profitability (Needleman et al. , 2006; Unruh, 2008) Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 4

Overview (cont'd) Nurses struggle to deliver patient care against many barriers and with dwindling resources Commitment to patient care often places nurses in direct conflict with administrators The power the nurse can call on to resolve conflict and improve care is called “workforce advocacy” Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 5

Workforce Advocacy How a nurse reacts to challenges within the workplace and continues to advocate to improve patient care is a necessary focus for the profession Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 6

Opportunities and Challenges for Workforce Advocacy Identify mechanisms that provide opportunities for RNs to affect institutional policy Develop conflict resolution models that address RNs’ concerns about patient care Seek legislative solutions for workplace problems Develop legal centers for nurses Provide RNs with self-advocacy and patient advocacy information Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 7

Examples of Workforce Advocacy Promote occupational safety and health of nurses Use nurse practice acts and other legislative and regulatory protections Use the political process to influence legislative and regulatory agencies for the protection of nurses and patients Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 8

Examples of Workforce Advocacy (cont'd) Provide education regarding employment rights and responsibilities Develop skills related to public relations, media presentations, and conflict resolution Build coalitions and support groups to enable nurses to speak and advocate for their practices Participate in committee structures to ensure a nursing voice in safety and workplace issues Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 9

Issues in the Workplace Nursing shortage Appropriate staffing and mandatory overtime Patient advocacy and

Nursing Shortage Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Overview History of cyclic shortages documented since World War II The current shortage is more complex and long-lasting and will dwarf all shortages to date Downturn in the U. S. economy in 2009 led to an easing of the nursing shortage in some parts of the country Despite positive signs, analysts warn there is no longterm resolution of the nursing shortage Planning for an adequate nursing workforce is one of the most critical challenges of this century Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 12

Future RN Employment Opportunities Employment of RNs is expected to grow by 22% from 2008 to 2018, much faster than the average for all occupations Job openings will result from: Need to replace experienced nurses who leave the occupation Ø Median age of RN’s is 46 years Ø Technological advances in patient care Ø Increasing emphasis on preventive care Ø Rapid growth in the older population Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 13

Health Care as a Challenging Work Environment Comparison of three national random sample surveys of RNs, areas identified as affecting nursing satisfaction were: Opportunities to influence decisions about workplace organization Ø Recognition of accomplishments and work well done Ø Opportunities for professional development and advancement Ø Opportunities to influence decisions about patient care Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 14

Nursing School Enrollments Efforts to recruit more students into nursing have been successful Unfortunately, most schools and universities find themselves unable to expand their nursing programs because of a serious shortage of nursing faculty National and statewide efforts have resulted in increases in nursing school enrollments for 11 consecutive years Increases will not balance out the impending wave of RN retirements or employment changes as the economy recovers Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 15

Education Demands require not simply more RNs, but more RNs with the right education and skill Baccalaureate-prepared nurses with critical thinking, leadership, case management, and health promotion skills, IOM calls for 80% of nurses to be BS prepared by 2020. Ø Experienced RNs in critical care, emergency department, operating room, and neonatal intensive care Ø Master’s and doctorate-prepared RNs in advanced clinical specialties, teaching, and research Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 16

Faculty Shortage Aging of nursing faculty is one of the most critical problems that faces nursing Faculty salaries are a major contributor to the faculty shortage Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 17

Retention Depends on creating an environment conducive to professional autonomy that supports decision making and effective nurse-physician relationships Magnet hospitals: successful retention program; promotes standards for professional nursing practice and recognizes quality, excellence, and service Nurses in magnet hospitals have higher levels of autonomy, greater control over the practice setting, and better relationships with physicians Pathway to Excellence designation emerging as another model to improve retention Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 18

Retention (cont'd) In national survey, RNs were generally satisfied with their jobs, and satisfaction had increased over time Ø Increased satisfaction predicted by: Ø Ø Organizations who emphasized the quality of patient care Management that recognized the importance of nurses' personal and family lives Satisfaction with salary and benefits High job security Positive relationships with other nurses and with management Decreased satisfaction predicted by: Feeling stressed to the point of burnout Feeling burdened by too many non-nursing tasks Experiencing an increase in the number of patients assigned Having a general, negative overall view of the health care system Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 19

Aging Workforce and Retention Nurses older than 40 years represent nearly 70% of the workforce; Strategies for retaining the older, expert nurse: Provide greater flexibility in scheduling Ø Provide better ergonomics and health care design to decrease physical demands Ø Allow for greater participation in decision making Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 20

Emerging Workforce Recruitment and Retention Health care challenged to become the employer of choice for the younger generation Expectations of the 20 -something generation: Opportunities to gain advanced training, education, and certification Ø Ongoing coaching and feedback about performance Ø Manager to take a personal interest in them Ø Assistance to build a competitive portfolio Ø Comfortable with technology and excel at multitasking Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 21

Foreign Nurse Recruitment Long relied on as a remedy for nursing shortages 5. 1% of RNs licensed before 2004 and 8. 1% of RNs licensed since that time are foreign trained International nurses coming to work in the U. S. find supportive resources through the Commission on Graduates of Foreign Nursing Schools (CGFNS), including verification of the foreign nurse’s knowledge-based practice competency Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 22

1. During a public talk, a nurse is asked, “Who ensures that foreign nurses are properly trained and competent to practice as an RN? ” The nurse responds that monitoring of foreign nurses’ knowledge base and competencies is the jurisdiction of the: A. Commission of Graduates of Foreign Nursing Schools B. Employment and Training Administration C. Center for American Nurses D. U. S. Department of Labor Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 23

Nursing Salaries During the 1990 s, nursing salaries remained flat and contributed to the current shortage Salary compression has plagued the profession Sharp increase in RN wages in 2002 and 2003 Not clear if future wage increases will be needed to bring about a new equilibrium in the RN labor market Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 24

Work Environment Most common reasons for turnover Insufficient supply of qualified managers and experienced staff Ø Other career prospects Ø Workload and inappropriate staffing Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 25

Work Environment Nine elements of healthful work environment Ø Ø Ø Ø Collaborative practice culture Communication-rich culture Culture of accountability Presence of adequate numbers of qualified nurses Presence of expert, competent, credible, visible leadership Shared decision making at all levels Encouragement of professional practice and continued growth/development Recognition of the value of nursing’s contribution Ø Recognition of nurses for their contribution to practice Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 26

Appropriate Staffing and Mandatory Overtime Copyright © 2014 by Mosby, an imprint of Elsevier

Overview Factors contributing to nurse dissatisfaction within the workplace Inappropriate staffing levels Ø Increased requirement for mandatory overtime Ø Research has reinforced the importance of appropriate nurse staffing to affect nurse satisfaction and positive patient outcomes Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 28

Quantifying Appropriate Staffing Landmark study by Aiken et al. (2002) established links with appropriate staffing Surgical patients more likely to experience higher death rates from failure to rescue (insufficient nursing care) and from complications in hospital, with fewer nurses per patient Ø Nurses working in institutions plagued by insufficient staffing were more likely to experience emotional exhaustion and greater job dissatisfaction Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 29

Floating/Mandatory Overtime Increase in requirement in the 1990 s led to increase in need to float to other patient care units Increase in mandatory overtime/mandatory oncall requirements by some employers Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 30

Floating/Mandatory Overtime (cont'd) Studies of mandatory overtime in other industries demonstrated: Increased time lost to absenteeism Ø Increased injuries in absolute numbers and rate of incidence Ø Required 3 hours of work to produce an additional 2 hours of productivity Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 31

Floating/Mandatory Overtime (cont'd) Mandatory overtime may alleviate employer’s sense of urgency to find safer and more appropriate staffing Nurses may feel resentment that they bear the personal, professional, and legal burden for the staffing problem Nursing efforts to address mandatory overtime and inadequate staffing through professional practice advocacy have begun Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 32

Advocating for Safe Staffing Nurses across the country are concerned about inadequate staffing and excessive overtime Mandatory overtime and adequate staffing levels have become federal and state legislative issues As of 2012, 16 states enacted legislation restricting mandatory overtime Ø The first state to pass legislation addressing nurse staffing levels through fixed minimum ratios was California in 1999 Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 33

Advocating for Safe Staffing (cont'd) Chapter resources to guide decision making Questions about safe staffing to ask before accepting a position in a health care organization (Box 12 -5) Ø Resources to help decision making regarding adequate staffing and mandatory overtime (Box 12 -6) Ø Questions to guide decision making regarding accepting or refusing an assignment (Box 12 -7) Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 34

Shared Governance Gives nurses an active role in decision making Provides maximal participation and accountability for nursing practice Attributes include independence, accountability, and autonomy over nursing practice Results in increased job satisfaction and better patient outcomes Goes beyond participatory management to governance of nursing practice Questions should be asked about shared governance or participatory management models (Box 12 -8) Access to conflict resolution procedures is necessary Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 35

Patient Advocacy and Safety Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Overview Patient advocacy is the cornerstone of nursing Patients depend on nurses to ensure that they receive proper care Complex systems and complicated uses of technology lead to errors and adverse events Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 37

Patient Safety Findings of two major studies: errors kill some 44, 000 to 98, 000 people in U. S. hospitals annually 2004 IOM report examines safety from the perspective of the nurses’ work environment Provides evidence of the critical role nurses have in health care Ø Work environment characterized by serious threats to patient safety • Frequent failure to follow management practices necessary for safety • Unsafe workforce deployment • Unsafe work and workspace design • Punitive cultures that hinder the reporting and prevention of errors Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 38

Patient Safety (cont'd) National Center for Nursing Quality (NCNQ) Created to address patient safety and quality in nursing care and nurses’ work lives Ø Advocates for nursing quality through quality measurement, novel research, collaborative learning Ø National Database for Nursing Quality Indicators (NDNQI), a program of NCNQ, is the only database containing data collected at the nursing unit level to allow for empirical linkages between nursing care and patient outcomes Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 39

Errors in Health Care (cont'd) Transforming care at the bedside (TCAB) Ø Initiative to create a framework for change on hospital medical/surgical units by engaging front-line nurses and leaders to: • Improve the quality and safety of patient care • Increase the vitality and retention of nurses • Engage and improve the patient’s and family members’ experience of care • Improve the effectiveness of the entire care team Ø Ideas for transforming the way care is delivered come from nurses and others who are engaged in direct patient care Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 40

Whistle-Blower Protection Protects nurses who speak out about unsafe situations from being fired or subjected to other disciplinary actions by their employers Nurses want to be able to speak up for their patients without fear of retaliation Advocated for at the federal level and has passed in some states See Box 12 -9 for an overview of whistle blowing Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 41

2. An RN suspects that an employer hires nursing students at a higher rate of pay and allows them to perform certain procedures that require the skills of an RN. The nursing students enjoy the autonomy and extra pay. Before the RN participates in whistle-blowing, he or she should: A. File a formal complaint to The Joint Commission to initiate an investigation and receive protection from retaliation by the employer. B. Collect adequate documentation and, if possible, consult with the state nurses association before reporting to the state agency responsible for regulation of the employer. C. Remember that protection from retaliation by the employer is provided until unethical or illegal actions are reported in writing. D. Confront the individual suspected of wrongdoing and request that he or she stop the behavior. Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 42

Workplace Safety Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Overview Nurses’ safety and health an ongoing concern Categories of health hazards in the health care workplace Biologic Ø Ergonomic Ø Chemical Ø Psychological Ø Physical Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 44

Blood-Borne Pathogens Health care professionals at risk for exposure to hepatitis B and C, and HIV/AIDS Use of needlestick devices reduces worker injuries Needlestick Safety and Prevention Act signed into law in 2000 Requires the use of safer devices to protect from sharps injuries Ø Requires employers to involve nonmanagerial employees in the selection of effective engineering and work practice controls Ø Requires employers to maintain a sharps injury log including the brand of device being used Ø Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 45

Ergonomic Injuries Nursing is ranked second after industrial work for physical workload intensity ANA’s lifting initiative—Handle With Care— seeks to prevent back and other musculoskeletal injuries through education and increased use of assistive equipment and patient-handling devices Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 46

Barriers to Reporting Workplace Injuries Fear of repercussions such as disciplinary action Stigmatization as a complainer Harassment by supervisors and coworkers Denial of opportunities for promotion Termination of employment Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 47

Workplace Violence A major societal issue Nurses must proactively advocate for safe workplaces Ø Ø Ø Comprehensive organizational assessment to identify high-risk environments, psychological conditions, and populations that threaten workplace safety Zero tolerance policy for workplace violence, verbal and nonverbal threats, and related actions No employee who reports workplace violence faces reprisals Develop plans for maintaining security in the workplace Staff education to proactively address identification of and response to high-risk behaviors that can lead to violence Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 48

Advocating for a Safer Workplace ANA working with other nursing organizations to advocate for health care worker health and safety Advocate for administrative controls Adequate staffing Ø Health and safety committees Ø Engineering controls—ventilation and safer needlestick devices Ø Personal protective equipment—respirators and synthetic gloves Ø Although the health care industry is a dangerous place to work, many risks are avoidable and dangerous exposures are preventable Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 49