1. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 12 Workforce Advocacy and the Nursing Shortage

2. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Promoting a Professional Practice Environment

3. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Overview  Important research is validating the contribution of registered nurses (RNs). Improved patient outcomes (Cho et al, 2002) Improved patient outcomes (Cho et al, 2002) Prevention of premature mortality (Aiken et al, 2002 & 2003) Prevention of premature mortality (Aiken et al, 2002 & 2003) Increased hospital profitability (McCue et al, 2003; Needleman et al, 2006) Increased hospital profitability (McCue et al, 2003; Needleman et al, 2006)

4. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Overview  Nurses are struggling 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.”

5. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. From Workplace Advocacy to Workforce Advocacy  In 2003, the Center for American Nurses (Center) was created as an independent national professional association and an associate organizational member of the American Nurses Association (ANA).

6. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. From Workplace Advocacy to Workforce Advocacy  The Center addresses the needs of nurses who are not represented by collective bargaining. Shifted from workplace advocacy to workforce Shifted from workplace advocacy to workforce Shift is having the individual nurse, rather than the nurse’s workplace, as the focus. Shift is having the individual nurse, rather than the nurse’s workplace, as the focus. Embraces the “Workforce Advocacy Ecosystem Model” Embraces the “Workforce Advocacy Ecosystem Model”  Workforce staffing  Workflow design  Personal/ social factors  Physical environment  Organizational factors

7. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. From Workplace Advocacy to Workforce Advocacy  Five opportunities and challenges for workforce advocacy programs Identify mechanisms that provide opportunities for RNs to affect institutional policy Identify mechanisms that provide opportunities for RNs to affect institutional policy Develop conflict resolution models that address RNs’ concerns about patient care Develop conflict resolution models that address RNs’ concerns about patient care Seek legislative solutions for workplace problems. Seek legislative solutions for workplace problems. Develop legal centers for nurses Develop legal centers for nurses Provide RNs with self-advocacy and patient advocacy information Provide RNs with self-advocacy and patient advocacy information

8. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. From Workplace Advocacy to Workforce Advocacy  Examples of workforce advocacy Promoting the occupational safety and health of nurses Promoting the occupational safety and health of nurses Using Nursing Practice Acts and other legislative and regulatory protections Using Nursing Practice Acts and other legislative and regulatory protections Using the political process to influence legislative and regulatory agencies for the protection of nurses and patients Using the political process to influence legislative and regulatory agencies for the protection of nurses and patients

9. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. From Workplace Advocacy to Workforce Advocacy Providing education regarding employment rights and responsibilities Providing education regarding employment rights and responsibilities Developing skills related to public relations, media presentations, and conflict resolution Developing skills related to public relations, media presentations, and conflict resolution Building coalitions and support groups to enable nurses to speak and advocate for their professional practices Building coalitions and support groups to enable nurses to speak and advocate for their professional practices Participating in committee structures to ensure a nursing voice in safety and workplace issues Participating in committee structures to ensure a nursing voice in safety and workplace issues

10. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Workplace Issues Overview  Nursing shortage  Appropriate staffing and mandatory overtime  Patient advocacy and safety  Workplace safety

11. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Shortage

12. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Overview  Cyclic shortage in the late 1990s and early 2000 was a direct result of the struggle to implement managed care  The current shortage is more complex and long lasting and will dwarf all shortages to date  By 2020, the deficit of nurses will be near 1 million  RNs are projected to create the second largest number of new jobs among all occupations  Planning for an adequate nursing workforce will be one of the most critical challenges of the new century  Despite recent increases in graduation rates of new nurses, the demand for nurses will continue to outpace the supply

13. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Health Care: No Longer a Favored Employer  Health care has moved to a less-favored employment setting for the following reasons: In an information economy, young people view health care as “low-tech” In an information economy, young people view health care as “low-tech” Health care is seen as chaotic and unstable Health care is seen as chaotic and unstable Health care is only one of many choices for women Health care is only one of many choices for women In a short-stay hospital system, nurses are not able to focus on relationships with patients In a short-stay hospital system, nurses are not able to focus on relationships with patients Hospitals that demand 24 hrs/day, 7 days/wk are seen as unacceptable in an information society where people schedule work to their own convenience Hospitals that demand 24 hrs/day, 7 days/wk are seen as unacceptable in an information society where people schedule work to their own convenience

14. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Health Care: No Longer a Favored Employer  Health care systems must redesign work and workplace environments to attract and retain RNs

15. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Insufficient Nursing School Enrollments  Smaller numbers of individuals are available to enter the workforce because birth cohorts born after 1955 are smaller in population size  Career opportunities for women have expanded outside nursing  Nursing schools are unable to expand enrollments significantly because of a serious shortage of nursing faculty

16. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Insufficient Nursing School Enrollments  Recruitment efforts have resulted in increases in nursing school enrollments for 6 consecutive years (2001-2006)  Increases continue to fall below projected need

17. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Insufficient Nursing School Enrollments  Current recruitment efforts Nurses for a Healthier Tomorrow—coalition formed by 21 of the leading nursing and health care organizations Nurses for a Healthier Tomorrow—coalition formed by 21 of the leading nursing and health care organizations Nursing: The Ultimate Adventure—video produced by the National Student Nurses’ Association Nursing: The Ultimate Adventure—video produced by the National Student Nurses’ Association Johnson & Johnson Campaign for Nursing’s Future Johnson & Johnson Campaign for Nursing’s Future  Improving the way new nurses are introduced into the work culture with orientation, mentoring, and preceptor programs is essential

18. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Education  Current and projected demands require not simply more RNs, but more RNs of the right educational and skill mix Baccalaureate-prepared nurses with critical thinking, leadership, case management, and health promotion skills Baccalaureate-prepared nurses with critical thinking, leadership, case management, and health promotion skills Experienced RNs in critical care, emergency room, operating room, and neonatal intensive care Experienced RNs in critical care, emergency room, operating room, and neonatal intensive care Master’s and doctorate-prepared RNs in advanced clinical specialties, teaching, and research Master’s and doctorate-prepared RNs in advanced clinical specialties, teaching, and research

19. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. 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

20. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Retention  Nurse retention primarily depends on creating an environment conducive to professional autonomy that supports decision making and effective nurse-physician relationships  Magnet hospitals: successful retention program focused on promoting standards for professional nursing practice and on recognizing quality, excellence, and service  Nurses in magnet hospitals have higher levels of autonomy, greater control over the practice setting, and better relationships with physicians.  Nurse Friendly TM designation is emerging as another model for improvement

21. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Aging Workforce and Retention  Nurses older than 40 years now represent nearly 60% of the workforce, and almost all will reach retirement age by 2010  Strategies for retaining the older, expert nurse: Provide greater flexibility in scheduling Provide greater flexibility in scheduling Offer innovative new positions such as mentor, research assistant, or safety officer Offer innovative new positions such as mentor, research assistant, or safety officer Provide better ergonomics and health care design to decrease physical demands Provide better ergonomics and health care design to decrease physical demands Improve introduction to technology Improve introduction to technology Allow for greater participation in decision making Allow for greater participation in decision making

22. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Aging Workforce and Retention  Health care organizations’ challenge will be to create environments in which baby boomer nurses and generation X nurses can thrive

23. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Emerging Workforce Recruitment and Retention  Health care is challenged to become the employer of choice for the younger generation  Expectations of the twenty-something generation: Opportunities to gain advanced training, education, and certification Opportunities to gain advanced training, education, and certification Ongoing coaching and feedback about performance Ongoing coaching and feedback about performance Manager to take a personal interest in them Manager to take a personal interest in them Assistance to build a competitive portfolio Assistance to build a competitive portfolio Comfortable with technology and excel at multitasking Comfortable with technology and excel at multitasking

24. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Emerging Workforce Recruitment and Retention  Four generations may be present in the workplace at one time with a resulting clash in ideas and goals

25. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Foreign Nurse Recruitment  Long relied upon as a remedy for nursing shortages  Problematic as a method of resolving the U.S. shortage Current shortage is worldwide Current shortage is worldwide Foreign nurse recruitment is open to abuse Foreign nurse recruitment is open to abuse

26. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Compensation  During the 1990s, nursing salaries remained flat and contributed to the current shortage  Salary compression has long plagued the profession  Sharp increase in RN wages occurred in 2002 and 2004 Median annual RN salary was $57,784 in 2004 Median annual RN salary was $57,784 in 2004 Substantial growth in wages may occur over the next 10 to 15 years Substantial growth in wages may occur over the next 10 to 15 years  Cumulative real wage growth between 2002 and 2016 must exceed 55.4% to affect the shortage

27. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Work Environment  Most common reasons for turnover Insufficient supply of qualified managers and experienced staff Insufficient supply of qualified managers and experienced staff Other career prospects Other career prospects Workload and inappropriate staffing Workload and inappropriate staffing

28. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Work Environment  Principles & Elements of a Healthful Practice/Work Environment Established by a coalition of more than 65 national nursing organizations Established by a coalition of more than 65 national nursing organizations

29. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Work Environment  Nine elements of healthful work environment:  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  Recognition of nurses for their contribution to practice

30. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Appropriate Staffing and Mandatory Overtime

31. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Overview  Factors contributing to nurse dissatisfaction within the workplace Inappropriate staffing levels Inappropriate staffing levels Increased requirement for mandatory overtime Increased requirement for mandatory overtime  During the 1990s, health care systems sought and implemented the advice of consulting firms to reduce the cost of health care, thus reducing nursing staff

32. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Quantifying Appropriate Staffing  Landmark study by Aiken et al (2002) established links with appropriate staffing Surgical patients were more likely to experience higher death rates from failure to rescue (insufficient nursing care) and from complications in hospital, with fewer nurses per patient Surgical patients were more likely to experience higher death rates from failure to rescue (insufficient nursing care) and from complications in hospital, with fewer nurses per patient Nurses working in institutions plagued by insufficient staffing were more likely to experience emotional exhaustion and greater job dissatisfaction Nurses working in institutions plagued by insufficient staffing were more likely to experience emotional exhaustion and greater job dissatisfaction

33. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Floating/Mandatory Overtime  Increase in requirement in the 1990s led to increase in need to float to other patient care units  Increase in mandatory overtime/mandatory on-call requirements by some employers

34. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Floating/Mandatory Overtime  Studies of mandatory overtime in other industries demonstrated the following: Increased time lost to absenteeism Increased time lost to absenteeism Increased injuries in absolute numbers and rate of incidence Increased injuries in absolute numbers and rate of incidence Required 3 hours of work to produce an additional 2 hours of productivity Required 3 hours of work to produce an additional 2 hours of productivity

35. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Floating/Mandatory Overtime  Mandatory overtime may alleviate the 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

36. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. 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  The first state to pass legislation addressing nurse staffing levels was California in 1999

37. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Advocating for Safe Staffing  Chapter resources to guide decision making Questions about safe staffing to ask before accepting a position in a health care organization (Box 12-6) Questions about safe staffing to ask before accepting a position in a health care organization (Box 12-6) Resources to help decision making regarding adequate staffing and mandatory overtime (Box 12-7) Resources to help decision making regarding adequate staffing and mandatory overtime (Box 12-7) Questions to guide decision making regarding accepting or refusing an assignment (Box 12-8) Questions to guide decision making regarding accepting or refusing an assignment (Box 12-8)

38. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Advocating for Safe Staffing  Realistic concerns about nurses’ ability to provide safe care highlighted in IOM reports: The Adequacy of Nurse Staffing in Hospitals and Nursing Homes (Wunderlich, Sloan, and Davis, 1996) The Adequacy of Nurse Staffing in Hospitals and Nursing Homes (Wunderlich, Sloan, and Davis, 1996) To Err Is Human: Building a Safer Health Care System (Kohn, Corrigan, and Donaldson, 2000) To Err Is Human: Building a Safer Health Care System (Kohn, Corrigan, and Donaldson, 2000) Keeping Patients Safe: Transforming the Work Environment of Nurses (Page, 2004) Keeping Patients Safe: Transforming the Work Environment of Nurses (Page, 2004)

39. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. 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

40. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Shared Governance  Questions should be asked about shared governance or participatory management models (Box 12-10)  Access to conflict resolution procedures is necessary

41. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Patient Safety

42. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate 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

43. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Errors in Health Care  Findings of two major studies indicate that errors kill some 44,000 to 98,000 people in U.S. hospitals annually  2004 Institute of Medicine (IOM) report examines safety from the perspective of the nurses’ work environment. Provides evidence of the critical role nurses have in health care Provides evidence of the critical role nurses have in health care

44. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Errors in Health Care  Found that the typical work environment is 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

45. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Errors in Health Care Recommendations Recommendations  Transformational leadership and evidence- based management  Maximizing workforce capability  Design of work and workspace to prevent and mitigate errors  Creating and sustaining a culture of safety

46. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. 100,000 Lives Campaign  Successful strategy used to address patient safety, launched by the IOM Focused on a few proven interventions Focused on a few proven interventions Implemented on a wide scale by hospitals across the country Implemented on a wide scale by hospitals across the country

47. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. 100,000 Lives Campaign  Goal was to implement changes proven to prevent avoidable deaths in six areas: Rapid response teams Rapid response teams Evidence-based care for acute myocardial infarction Evidence-based care for acute myocardial infarction Medication reconciliation Medication reconciliation Central line infection Central line infection Prevention of surgical site infection Prevention of surgical site infection Prevention of ventilator-associated pneumonia Prevention of ventilator-associated pneumonia

48. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. 100,000 Lives Campaign  Whistle-blower protection Protects nurses who speak out about unsafe situations from being fired or subjected to other disciplinary actions by their employers 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 through appropriate channels without fear of retaliation Nurses want to be able to speak up for their patients through appropriate channels without fear of retaliation Advocated for at the federal level and has passed in some states Advocated for at the federal level and has passed in some states

49. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Workplace Safety

50. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Overview  Safety and health of nurses continue to be an ongoing concern  Categories of health hazards in the health care workplace Biologic Biologic Ergonomic Ergonomic Chemical Chemical Psychologic Psychologic Physical Physical

51. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Blood-Borne Pathogens  Health care professionals at risk for exposure to hepatitis B and C and HIV/AIDS  Use of safer 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 Requires the use of safer devices to protect from sharps injuries Requires employers to involve nonmanagerial employees in the selection of effective engineering and work practice controls Requires employers to involve nonmanagerial employees in the selection of effective engineering and work practice controls Requires employers to maintain a sharps injury log Requires employers to maintain a sharps injury log

52. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Ergonomic Injuries  Nursing is ranked second after industrial work for physical workload intensity  As of 2005, four states (California, Texas, New York, and Ohio) passed legislation to minimize manual lifting of patients  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

53. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Barriers to Reporting Workplace Injuries  Fear of repercussions such as disciplinary action  Stigmatization as a complainer  Harassment by supervisors and co-workers  Denial of opportunities for promotion  Termination of employment

54. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Workplace Violence  Has become a major societal issue  Nurses must proactively advocate for safe workplaces. Comprehensive organizational assessment to identify high-risk environments, psychologic conditions, and populations that threaten workplace safety Comprehensive organizational assessment to identify high-risk environments, psychologic conditions, and populations that threaten workplace safety Zero tolerance policy for workplace violence, verbal and nonverbal threats, and related actions Zero tolerance policy for workplace violence, verbal and nonverbal threats, and related actions Ensure that no employee who reports or experiences workplace violence faces reprisals Ensure that no employee who reports or experiences workplace violence faces reprisals Develop comprehensive plans for maintaining security in the workplace Develop comprehensive 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 Staff education to proactively address identification of and response to high-risk behaviors that can lead to violence

55. Mosby items and derived items © 2008 by Mosby, Inc., an affiliate of Elsevier Inc. Advocating for a Safer Workplace  ANA is working in collaboration with other nursing organizations to advocate for health care worker health and safety  ANA-affiliated Center for American Nurses (CAN) advocates for administrative controls Adequate staffing Adequate staffing Health and safety committees Health and safety committees Engineering controls—ventilation and safer needlestick devices Engineering controls—ventilation and safer needlestick devices Personal protective equipment—respirators and synthetic gloves Personal protective equipment—respirators and synthetic gloves  Although the health care industry is a dangerous place to work, many risks are avoidable and dangerous exposures are preventable