Hospital RNs' and CNOs' perceptions of the impact of the nursing shortage on the quality of care

The results of analyses of the 2002 and 2004 National Sample Surveys of RNs and the 2004 National Sample of CNOs document the widespread perception that the shortage of nurses is a major problem for the overall quality of patient care in hospitals. In the eyes of the majority of hospital RNs and CNOs surveyed, care processes involving communication, timely response to pages and telephone calls, delays in patient discharges, and the time patients had to wait for tests and procedures were all affected negatively by the nursing shortage. These results are not encouraging.     

American Academy of Ambulatory Care Nursing position statement: the role of the registered nurse in ambulatory care

Ambulatory care nurses are leaders in their practice settings and across the continuum of care. They are uniquely qualified to influence organizational standards related to patient safety and care delivery in the ambulatory care setting. The current ambulatory care setting is diverse and multifaceted, requiring nurses highly skilled in patient assessment and with the ability to implement a broad range of nursing interventions in a variety of settings. The future of the American health care system depends upon our ability to utilize RNs to the fullest extent of their expertise, licensure, and certification.     

Health care reform: current updates and future initiatives for ambulatory care nursing

While the signing of the Patient Protection and Affordable Care Act was a historical event marking the beginning of health care reform in the United States, it signaled the start of a golden age for ambulatory care nursing. Ambulatory care RNs are well-positioned to fully participate in health care reform initiatives. RNs are well-positioned to lead, facilitate, and/or participate in all patient care medical homes' and accountable care organizations' quality and safety initiatives through enhanced use of major ambulatory care RN role dimensions such as advocacy, telehealth, patient education, care coordination and transitional care, and community outreach. RNs are also well-positioned to provide patient-centered care, coordinate care, and manage transitions across ambulatory care settings. For the golden age of ambulatory care nursing to become a reality, initiatives surrounding competencies, education modules, and leadership must be addressed immediately.     

Trends in the experiences of hospital-employed registered nurses: results from three national surveys

The comparative results of three national surveys provide the only known source of data describing the evolving state of the nursing workforce over time in this country. These national random sample surveys expose the harmful effects of a lingering shortage of nurses and make plain that much work remains to be done to improve the experiences of hospital-employed RNs. At the same time, nurses and others involved in hospital patient care should be encouraged by the improvements that have been made in recent years, despite the presence of a nursing shortage.     

Evolution of the chronic care role of the registered nurse in primary care

High-quality, accessible, and efficient primary care is needed as the U.S. health care system undergoes significant change. Advancing the role of registered nurses in the primary care setting is important to the solution. A large academic health center implemented five initiatives to improve the care of chronically ill patients through the expanded role of RNs in the context of the health care team. Role evolution of nurses in the pilots required some continuing education and some additional nursing support to release the pilot nurses from their usual duties. These strategies allowed the nurses to apply interventions that enhanced the coordination of care and promoted patient self-management skills. Some short-term improvements in health status were realized and barriers to self-care were identified and resolved.     

Building a nursing research fellowship in a community hospital

Often, registered nurses feel that they are using "evidence" to guide practice, but in reality the sources of evidence are not based on research. The nursing leadership team at Northwest Community Hospital was committed to integrating evidence-based practice and nursing research into the clinical setting for RNs at all levels of the organization. The scope of the fellowship program enabled direct care RNs to receive protected release time for a 12-month period to develop a research proposal, implement the study, and disseminate the findings. The Nursing Research Fellowship Program was successful from the perspective of the Magnet appraisers who recognized the program as a Magnet exemplar, the chief executive officer, the CNE, members of the nursing leadership team, professional colleagues, the fellows and partners, and registered nurses at all levels in the organization. Nursing research is now part of the professional nursing culture.     

Factors influencing work productivity and intent to stay in nursing

The researchers document the individual and workplace characteristics associated with decreased work productivity and intent to stay in nursing for nurses employed in direct patient care in the hospital setting. Factors associated with decreased work productivity were age, total years worked as a RN, quality of care provided, job stress score, having had a job injury, and having a health problem. Nurse leaders must place additional efforts on changes needed to improve the hospital workplace environment to decrease job stress, improve RNs' ability to provide quality care, and to assure the health and safety of nurses. Reducing job stress and providing adequate staffing so quality of care can be provided will enhance job satisfaction which will also encourage RNs to stay at the bedside. Improved work environments may delay older RNs' retirement from the workforce.     

Registered nurses' perspectives on health care and the 2008 presidential election

As this historic presidential election draws near, what do RNs think of our nation's priorities? Which candidates do they think will be most effective in shaping our health care system and addressing the most pressing issues of our time? The results of this survey show that RNs do not identify overwhelmingly with one political ideology or party and, in fact, they closely resemble the public on these political dimensions. The data also show that RNs identify health care issues as the most important problem facing the nation. RNs who believe that it is the responsibility of the government to provide health insurance to those without it, have more confidence in the government to achieve this outcome, and are more likely to be Democrats than Republicans. The presidential election is expected to be highly contested and could be determined by a relatively small margin of votes and, thus, nurses should recognize their chances of influencing the outcome of the election. The data from this survey provide baseline information potentially useful to increasing the political influence of the nursing profession, informing other organizations about where they might align with nurses, and helping candidates and the political parties compete more effectively in seeking the support of roughly 3 million RN voters.     

Registered nurses: the impact of wages on labour force participation and hours worked – are wages an effective mechanism for addressing RN shortages with evidence from 1960 to 2008?

Registered nurses (RNs) are critical producers and coordinators of patient care in acute and non-acute settings (Needleman et al. 2011). The Affordable Care Act coupled with an ageing population, are increasing demand for health care and, in turn, RNs. Numbering 3 million, RNs comprise the largest professional occupation in health care. Therefore, the labour force participation and hours worked are of keen interest to stakeholders and policymakers. Rising demand may exacerbate nursing shortages and have important effects on costs. We estimate the impact of wages on participation and hours worked as a possible policy tool to increase nursing supply. In 2008, the RN wage had a positive and significant effect on participation and a small positive but only marginally significant effect on hours worked given participation. The latter elasticity for married females (single females) was 0.11 (0.33). Therefore, the elasticity of hours worked with respect to the nurse wage is and unlikely to have an important effect on the participation rates or hours worked of currently trained female RNs. Consequently, wage increases are unlikely to be an effective policy to increase the labour supply among the currently licensed RNs and will not relieve any short-term nursing shortage.     

Enculturation of professional contract nurses: a concept analysis

The concept enculturation, an essential component of integration into the work arrangement of professional contract nurses, also known as travel nurses, is analyzed. These registered nurses are contracted by hospitals through health care staffing service firms, for temporary work assignments. The work of travel RNs involves frequent recurring episodes of integration to health care teams at hospitals throughout the nation. Rodgers Evolutionary Method (Rodgers & Knafl, 2000) is applied to analyze the concept of enculturation, leading to a pragmatic perspective on its meaning and utility. This work may contribute new knowledge applicable to future nursing research.     

End-of-life care in United States: current reality and future promise--a policy review

Data collection and analysis of that data are vital to developing effective outcome measures when it comes to improvements in the cost and quality of delivered health care. The present state of end-of-life care in the United States is evaluated, focusing on statistics of disparities in access to and type of care provided across the country. Although only a few portions of the Patient Protection and Affordable Care Act deal with end-of-life care reform, the multiple innovative efforts occurring at state and local levels are proving very effective in improving end-of-life care. Possible improvements and obstacles to those improvements, and the involvement of the profession of nursing are highlighted. The focus of this investigation is to determine if the evidence supports the following imperative: that the money spent for end-of-life care be spent in a manner that benefits the patient and complements his or her wishes.     

Redesigning nursing work in long-term care environments

The authors present a highly statistically oriented argument for examining work attitudes and activities among three groups of caregivers [RNs, RPNs, and HCAs] working in long-term care. The investigators used both work sampling, written surveys, and interviews with a sample of 46 caregivers in a large university-affiliated LTC facility in Toronto, Canada. While RNs stated their strong affinity for direct patient care activities, they perform the lowest percentage of direct care, chiefly due to their accountability for planning and coordinating the care provided by others. The HCAs who provided the bulk of direct patient care "valued it the least," apparently finding little gratification with this aspect of their role. This study suggests that there is a need to examine and clarify work roles and perceptions for all caregivers as part of any work redesign process. A higher level of RN involvement in direct patient care activities, along with "attention to enhancing the importance" of these activities for staff employed in the HCA role, could be beneficial.     

Palliative care: a paradigm of care responsive to the demands for health care reform in America

Palliative care is poised to become a universally available approach to health care which addresses both the needs of patients and families experiencing serious, progressive, and life-threatening illness, and also the costs of delivering such needed services. Palliative care and hospice are part of a continuum of care with palliative care provided at any time during the illness trajectory, while hospice care is offered at the end of life. Within the context of health care reform, we believe palliative care addresses critical economic imperatives while enhancing quality of life even as death approaches. As leaders in health care, advance practice nurses, specifically, and the nursing community in general are best positioned with the knowledge, expertise, and commitment to advance the specialty of palliative care and lead the way in the reform of America's health care system.     

The nursing shortage continues as faculty shortage grows

To combat the nursing shortage, efforts to promote nursing as a career have been successful. However, academic nursing institutions are not adequately prepared for this new influx of applicants. The lack of faculty to educate the growing demand for baccalaureate-prepared RNs directly impacts the nursing shortage. The nursing shortage thus directly impacts safe patient care. The main reasons for the lack of faculty to meet the demand for more nurses include the increased age of the current faculty and the declining number of years left to teach, expected increases in faculty retirements, less compensation for academic teaching than positions in clinical areas for master's-prepared nurses, and finally, not enough master's and doctoral-prepared nurses to fill the needed nurse educator positions It is in the best interest of the nursing profession to do what it does best by incorporating the nursing process to solve the faculty shortage and secure its future in order to protect the lives of patients.     

Nurses who do not nurse: factors that predict non-nursing work in the U.S. registered nursing labor market

Registered nurses (RNs) who work outside of nursing have seldom been examined. This aim of this study was to compare the 122,178 (4%) of RNs who are employed outside of nursing to those who work in nursing jobs in terms of sociodemographic, market, and political variables to determine if these groups are substantively different from one another. Using a logit regression model, wages were a significant predictor of working outside of nursing for unmarried nurses but not for married nurses. Married and unmarried male nurses were more likely to work outside of nursing. Baccalaureate education, children under age 6, higher family income, and years since graduation increased the odds of working outside of nursing for married nurses. Ultimately, identifying characteristics on which these groups differ may inform future policy directions that could target nurses who may leave nursing at a time when retention efforts might be effective to alter their trajectory away from the profession.     

Nurses leading the response to the crisis of palliative care for vulnerable populations

All nurses are prepared to be generalists in palliative care. Within the discipline there are nurses who seek advanced educational preparation and develop clinical expertise in palliative care nursing. These are our leaders in palliative care nursing who can exert influence in all health care settings to support nurses providing palliative care. It is nurses and advanced practice nurses in partnership who are capable of developing and advocating for palliative care across settings. The focus of care is the person, not the diagnosis or the setting. The viewpoint that "all nursing care is palliative care" can transform health care with nurses taking the lead.     

The impact of nurse staffing on hospital costs and patient length of stay: a systematic review

Research examining the relationships between nurse staffing, hospital costs, and length of stay is varied using a range of methods and definitions. This lack of coherence in definitions and measurement tools for cost and length of stay makes it difficult to conclude with certainty the results of nurse staffing on hospital cost and length of stay. However, the evidence reflected that significant reductions in cost and length of stay may be possible with higher ratios of nursing personnel in hospital settings. Sufficient numbers of RNs may prevent patient adverse events that cause patients to stay longer than necessary. Patient costs were also reduced with greater RN staffing as RNs have higher knowledge and skill levels to provide more effective nursing care as well as reduce patient resource consumption. Hospital administrators are encouraged to use higher ratios of RNs to non-licensed personnel to achieve their objectives of quality patient outcomes and cost containment.     

The potential imposition of wage controls on nurses: a threat to nurses, patients, and hospitals

When there are shortages of RNs, hospitals and health care organizations in competitive nurse labor markets respond by increasing wages: some hospitals will respond faster and some will offer higher wages than others. The wage increase brings about two important short and long-run outcomes that, together, will increase the supply of RNs in the labor market. Because wage controls prevent the flexibility of wages to adjust, they can cause a shortage to develop when the demand for RNs is increasing (as in the 1970s), and wage controls will lengthen the duration of a shortage once it has begun. The impacts of prolonged RN shortages are multifaceted and destructive to nurses, patients, and hospitals. Looking ahead over the next 15 years when the demand for RNs is expected to grow by roughly 3% per year and the supply of RNs by much less than that, a new nursing shortage is projected to develop and reach a deficit of 285,000 RNs by 2020. The worst thing that could happen to the nursing profession would be to impose wage controls on nurses as this would prevent the needed short and long-run labor supply responses from developing and thereby eliminate the shortage.     

Nursing overtime: why, how much, and under what working conditions?

To provide the best care to patients, the physical wellness of nursing staff is essential. Current evidence indicates long work hours can lead to adverse nurse and patient outcomes. To provide quality and safe patient care, both staff nurses and nurse managers need to recognize the adverse effects of overtime, whether it is mandatory or voluntary. Results of this study showed overtime was not used more when there was an increase in nursing shortages. Further, overtime was not used to control shortages; rather, understaffing was an underlying condition of the nursing practice, at least in the study sample. Thus, efforts must be made not only to prevent nurses from working long hours, but also to resolve the problem of understaffing in order to retain qualified nurses in hospitals.     

Ambulatory care registered nurse performance measurement

On March 1-2, 2010, a state-of-the-science invitational conference titled "Ambulatory Care Registered Nurse Performance Measurement" was held to focus on measuring quality at the RN provider level in ambulatory care. The conference was devoted to ambulatory care RN performance measurement and quality of health care. The specific emphasis was on formulating a research agenda and developing a strategy to study the testable components of the RN role related to care coordination and care transitions, improving patient outcomes, decreasing health care costs, and promoting sustainable system change. The objectives were achieved through presentations and discussion among expert inter-professional participants from nursing, public health, managed care, research, practice, and policy. Conference speakers identified priority areas for a unified practice, policy, and research agenda. Crucial elements of the strategic dialogue focused on issues and implications for nursing and inter-professional practice, quality, and pay-for-performance.