Work Abuse on Nurses: Seven Mondays in a Week: The Consequences of Society’s Decline in Civility

Would you look forward to work each day if you knew there was a possibility you would be verbally or physically abused?

Emergency departments are experiencing an increase in use by the public. Hospitals are unable to keep up. An analysis of this use points to one unintended consequence of a non universal private health care system. The emergency department of a hospital is the only location in an overburdened health care system where any patient who shows up must be treated regardless of ability to pay. With state facilities and programs for mentally ill citizens, and those suffering drug addiction being eliminated these patients often end up in emergency wards. Visits to emergency departments(ED) for alcohol or drug related incidents are on the rise.

Emergency departments are often overcrowded. Overcrowding is defined as all beds in use and the waiting room full for more than 6 hours a day, patients placed in halls, and seriously ill patients having to wait more than 1 hour to see a doctor. (1)
Long waits are more then rule than the exception. Add sickness, trauma, mental illness and drug use to the lack of privacy, and a less than ideal situation is created for patients to appropriately cope with stress.

Nurses who execute care and spend the most time in triage and treatment suffer the brunt of patient and family frustration. They are subject to verbal and physical abuse at unacceptable rates. Studies have shown that health care workers are the most likely to suffer workplace violence after prison guards and police officers. In a profession where healing and mercy are requirements it is disturbing that nurses are subject to these assaults.

Nurses are abused verbally by been sworn or yelled at, or called names. Physical violence includes being spat upon, scratched, hit, slapped, kicked, or stabbed. Injuries can range from the not visible to months taken off work for severe injuries.

The Emergency Nurses Association believes that violent incidents are underreported according to a recent survey. Nurses often don’t report incidents. They fear it will reflect badly on them as being less than competent. Or they believe that the administration will not take them seriously or be indifferent. They do have some basis to believe that as up to 75% of medical centers do not respond to reported workplace violence. Also many institutions do not have workplace violence policies or prevention programs. Nurses also believe that abuse by patients and families are part of the job. In some cases they can empathize with the scenario that created the violence. Often they believe if they press charges that the perpetrator will escape conviction because they were mentally ill or high on drugs.

 Nurses associations are advocating to end violence against nurses. The Pennsylvania Association of Staff Nurses and Allied Professionals had a conference in early November, Massachusetts Nursing Association is one that has done a lot of work in raising awareness. The Occupational Safety and Health Administration office has issued guidelines for medical centers to address this challenge. However, these guidelines should become enforceable standards. The survey shows that hospitals with a zero tolerance workplace violence program have less than half the number of incidents of other medical centers that have no policy.

In Massachusetts, a House representative and a senator have introduced an act requiring Health Care Employers to Develop and Implement Programs to Prevent Workplace Violence. 26 states now have more strict penalties for assaults on nurses. New York very recently made assaulting a nurse a felony same as assaulting a police officer, firefighter, or EMS personnel. In contrast, 2 states that were going to move these assaults from misdemeanor to felony killed the proposal. Another state deferred the decision. Even in hospitals where severe assaults have disabled staff, the administration has only struck committees yet have failed to disclose when the committee would meet or the results of the meeting.

Prevention and being proactive are the keys to meeting this challenge. If administration is committed to training all staff and encourages reporting of incidents there would be progress towards prevention. Administration must also be committed to having adequate staffing levels at all times in the ED. Several bodies such as the American College of Emergency Physicians and the International Association for Healthcare Security and Safety, have made recommendations such as yearly risk assessments especially if the hospital is located in an area where there is high crime or gang activity. If it means having metal detectors and visitor sign-in those should be put in place as one hospital in Detroit did. Why would anyone need to bring a gun or a knife into the ED?

In the Institute of Medicine’s(IOM) report in 2007 on emergency care in the US they commented that that crowding, boarding, and ambulance diversion were the total opposite of high quality medical care. The Joint Commission for Accreditation of Hospitals had tried in 2004 to institute strong measures to counteract these now common practices but pressure from hospitals caused the measures to be watered down. In no uncertain terms the IOM’s report recommends that these measures be reinstated. Decreasing crowding, boarding and ambulance diversion would go a long way to dealing with ED violence and allow high quality emergency care. The violence is only a symptom; the root caused must be addressed.

One interesting fact is that less than half of ED patients require urgent care. To reduce wait times hospitals are considering NPs to treat non urgent patients.

The Ed puts a microscope on societal attitudes to nurses, health care, and especially violence. The examination is not pretty. Why do patients feel they need to act out their frustrations on someone that will ultimately help them get better? Why aren’t hospital executives proactively seeking to prevent violent incidents? The IOM notes that hospitals have no financial incentives to reduce ED crowding.  Are numbers and dollars more important than patients and staff safety and well being? Has society become so desensitized to assaults that it is seen as an inevitable part of life? How can anyone tolerate that a nurse can be abused on the job? Acceptance of the unacceptable says a lot about the people that have the power to change it.



The Preparation of Nurses to Enter Complex Practice

The unprecedented need for more nurses has led to an examination of the state of nursing education in the nation. This article will present several recent views that discuss both the need for a greater number of nurses and increasing the quality and relevance of nursing education.

A number of factors are preventing nursing education from reaching its full potential.  Nursing education has not changed significantly in the last half century. Clinical training availability is of paramount concern. RNs typically have little financial incentive to leave clinical nursing to become instructors. Half of all present faculty will retire within this decade. They are not being replaced at the same rate and yet there will be a need for even more instructors quite soon.

It has been suggested that the many ways to enter nursing does not encourage enough graduates to continue on past the ADN or BSN therefore missing the opportunity to become instructors.  Without faculty, potential applicants will not become nurses. Unfortunately, many thousands of applicants are turned away yearly.  How to correct this situation?

In Educating Nurses A Call for Radical Transformation Patricia Benner set out to investigate present nursing education with this question: Are nurses graduates adequately prepared to practice to their maximum potential? The answer she found was no. There were strong points in present nursing education but areas where changes could be made. This is not entirely because of any shortfall of nursing education. There are pressures, challenges, and issues that place unprecedented demand on the nursing profession. Many of them originate outside of the nursing profession.

The first challenge is the state of professions in general. The author mentions that one hallmark that distinguishes professions from other career paths is it’s sense of social responsibility. Professions must advance society’s good. Yet in recent decades society and therefore the professions have placed more of an emphasis on technical knowledge and adherence to the business model. Health care professions and nursing have not been immune to this philosophical shift in the professions. Nurses must often feel caught between their core values and fulfilling the bottom line, especially given that much of health care in the nation is private and for profit.

The turmoil in the health care system does not create the ideal environment for nurses to be adequately prepared on graduation. Turmoil and change can often result in philosophies that deal with crises in a short term way, often sacrificing long term vision as a result. For example the enormous need for more nurses puts pressure on educational institutions to lower admission requirements and to fast track students to achieve the numbers over quality. That urgency will only increase this decade, so nursing education needs to transform as Benner stated.

What does this transformation look like? She emphasizes the importance of integration of the 3 foundations of nursing education.

All three foundations must be integrated and not taught in isolation. The first foundation is nursing knowledge and science. Yet the acquisition of knowledge is not the end goal. Learning must be experiential, situated coaching in a community of practice. She stresses clinical reasoning and teaching for a sense of salience which she describes as gauging what is important to know and do for a patient and his/ her particular situation. It is knowing how to use the knowledge the student has acquired. Health care is unpredictable and open ended so the student must be able to evaluate what is the best course of action. She cites 2 examples of this from her interviews with instructors:

The student didn’t realize that 7 days was too long for a patient with an appendectomy to be in hospital. So they examined the patient and took a better history. Although they looked at the report it wasn’t as thorough as it could be; it did not provide any clues. Through investigation they discovered gangrene in his colon; that was why he was there so long.

In her second example a supposedly stable patient was deteriorating rapidly. Yet the staff nurse responsible for the patient did not think the changes warranted action. The instructor insisted the patient should go to ICU. She engaged the student by asking her What one test could we do to prove the deterioration? They decided on the blood gasses test which was done immediately. The test showed the patient needed to go to ICU.

 The last pillar is ethical formation and ‘comportment’. Formation involves looking beyond technical skill of the profession to the moral content eg obligations and demands which involves character formation. For instance when students see less than ideal practice that involves nurses treating patients badly how does one deal with that as a nurse?  How does a nurse help peers look at their practice to make positive change? Is that possible when in the beginning one doesn’t have institutional authority? Can a nurse help make changes in the professionalism of their peers? What about when a patient refuses a simple life prolonging intervention?

At present only around 20% of ADN graduates go on to the BSN. This is in part due to the time it can take to get any degree, which is time taken away from work and family. The goal of articulated programs is to streamline the process from ADN to BSN and beyond.  Regional innovations in nursing education are addressing this challenge. One of them is the Oregon Consortium of Nursing Education. Schools in Oregon have partnered to first of all envision the type of nurse that the population would need. Building on this vision they created a common curriculum and share resources. The consortium is committed to ongoing faculty development. City University of New York has received a Robert Wood Johnson Foundation grant for their program.

Because nursing practices in the space between medical diagnosis /treatment and the patients experience of wellness and illness a nurse requires both technical knowledge and expert relational skills. The education of nurses must prepare them to be lifelong clinical learners.

As one student said: “I have the honor of being present with and learning from patients in intimate, vulnerable, scary situations. I get to regularly advocate for the underserved in the hospital setting. I have access to environments I would otherwise never been exposed to, I have learned, grown and broadened my world perspective. I better understand how our system works and hope some day this knowledge will help me make changes in the system.”

Health care systems and society must recognize that improving education of nurses is a high priority. But nurses must take the initiative if they do not.

Educating Nurses: A Call For Radical Transformation. P Benner et al. The Carnegie Foundation for the Advancement of Teaching 2010 Jossey Bass


The Nursing Village around the World: How the US is Influencing Nurse Migration

Every nurse would agree that sharing skills, knowledge, experience, and technology to improve lives of patients worldwide is indisputably necessary. What is the role of US nursing in this unfolding phenomenon?

With the effects of increased globalization the world is becoming a global village. How is the migration of nurses to the US affecting worldwide health care?

A starting point for this discussion would be to evaluate the experiences of internationally educated nurses in the US. What has been their journey?

Internationally educated nurses comprise a growing percentage of newly licensed RNs in the US, a trend that will continue. 68% of these nurses have at least a bachelor’s degree in nursing compared to 50% of US educated nurses.(1) The most common ways nurses find work are through either the placement model where nurses work for the medical center. Integration and wages are more likely to be equal to US educated nurses in the placement model. In the staffing model nurses work for the agency which charges the health care organization and pays nurses a percentage of the hourly charge. Nurses are bound by an 18-36 month contract to work for the same employer. In the staffing model there is a  penalty to break the contract in the form of an expensive fee. Curiously Canadian nurses are not under contract in this manner. Wage differentials not based on training, threats of withholding of documents or immigration status, forced overtime, and lack of training were reported by internationally educated nurses working in nursing homes. In this study internationally educated nurses were reluctant to participate in focus groups, a reticence in part based of fear of possible reprisal from recruiting agencies.

A study conducted by M.M. Jose was based on interviews of internationally educated nurses. It is one of the few studies on the experiences of these nurses conducted in the US. From the interviews 6 themes were evident: Internationally educated nurses came to the US with dreams of a better life, then encountered the beginning of a difficult journey, a shocking reality of adjusting to life in a new country.  They rose above the challenges of work: One nurse explained that she overcame her inexperience which her peers sometimes interpreted as incompetence. These nurses next stage in their new life was feeling and doing better, and finally through their experiences became ready to help others on their own journeys. It is the last that is the key for the US role in advancing nursing globally. Internationally educated nurses’ migration to the US can have vast influence and benefit in the rest of the world. How is that happening?

How does migration affect the countries where nurses migrate from? Nurses working in the US do send money back to their home country, which are called remittances. Remittances can comprise a significant benefit to the receiving countries. Remittances also positively affect the social factors such as poverty and access to education that can provide opportunity for better health care. Yet if internationally educated nurses are actively recruited from countries with severe nurse shortages this has and will have an adverse affect on health care delivery in general. If the medical workers who remain in a home country suffer more difficult working conditions due to understaffing, patients are affected and staff turnover increases a negative feedback situation that is hard to correct.

But migration can also elevate the status of nursing in the countries that provide nurses. This is the case in India where migrating nurses have influenced more students to enter nursing.

Easier and less expensive travel, and the ease of communication via the internet has resulted in globalization. Thus migration may no longer be one way and permanent.  Migrating nurses create and maintain multiple ties between countries is more the reality for many. A study on nurse migration in 2002 found that up to 50% of nurses return to their country of origin usually within 5 years of departure.

So what are some ways that US nursing is sharing its vast resources to improve health care delivery in developing countries? Many of the initiatives are a result of collaboration and partnerships between organizations, be they private companies, educational institutions, medical centers, or non government organizations.

The International Centre for Nurse Migration is a partnership between the International Council of Nurses and the CGFNS. Its vision is to establish effective migration policy and practice that ‘facilitates safe patient care and positive practice environments for migrant nurses.’ It is a resource for research and policy discussion, and has been in existence since 2005.

Some recruiting companies are creating programs either in countries where nurse migration occurs, or in the US. For example, nurses who plan to migrate may be required to work in their home country for a period of a few years acquiring experience, before working in the US. The recruiting companies then assist the source hospitals in planning for the resulting vacancies. US educators also have initiated exchange programs with source countries’ educational institutions to train both faculty and staff.  Hospitals have also participated in sister programs where relationships are established to share technology and information. Some companies create training programs in source countries for their recruits that are also open to all staff. The internet has made diaspora networks a means to share vital knowledge with nations who want to improve their health care delivery. Even if migrating nurses never return to their original country they now have the means to stay connected and contribute to innovation through technological channels even if they are not physically present.

Patients’ right to effective health care must be balanced with nurses’ right to migrate. An examination and discussion of international migration begins with more research and data collection. Because of globalization, migration will continue. Its nature is dynamic, and it is now easier for nurses who wish to migrate to be able to access the information necessary to make it a successful journey.

International migration that is a positive experience for all parties will establish the global significance of nursing. The internationally educated nurses who work in the US contribute to health care delivery in both the US, for example by enhancing culturally sensitive care, and in their home country, by the sharing of knowledge. Continued collaboration, and coordination through the many modes of communication will ensure that patients in the US and abroad have access to excellent health care, and advance nursing everywhere in the world.

(2) http://intlnursemigration.org (Return Migration of Nurses Fact Sheet)

US based Recruitment of Foreign Educated Nurses American Journal of Nursing June 2010 Vol. 110 No 6 pp 38-48

Lived Experiences of Internationally Educated Nurses in Hospitals in the United States of America International Nursing Review 2011 Vol. 58 pp 123-129


How to Care for Grandma and Grandpa? Nursing Innovations Forge New Paths

 To improve and refine the quality of health care that the elderly receive in America will require not only more health care workers but professionals that are trained in geriatric care and understand the specific needs of the elderly. Currently, only approximately 2% of nurses are trained in geriatric care.

One participant in the geriatric care scene is the John A. Hartford Foundation a philanthropic organization which advocates on behalf of the elderly. Since 1996 they have been emphasizing the importance of nurses and nursing in elevating the care of the elderly. The foundation created a number of initiatives to increase the quality medical care the elderly receive. One is the Hartford Institute of Geriatric Nursing.  The vision statement realizes that education, research, and policy are key factors in moving best practice to standard practice but more importantly, education, research, and policy must translate or affect nursing practice. It is affiliated with the New York University College of Nursing and during its existence has been a pioneer in many areas of geriatric nursing.

Let’s take a hypothetical grandparent who goes to the hospital via the emergency department. What would an ideal care situation look like?

If the hospital was part of the Nurses Improving Care for Healthsystem Elders(NICHE)  it would have a set of protocols staff would follow for elderly patients. These protocols would focus on the areas of care that affect the elderly the most. Staff would try and avoid the use of restraints to prevent falls. They would take concerted action to avoid pressure ulcers, and would manage pain to avoid delirium and sleep disorders. The hospital would have a Geriatric Resource Nurse that staff could consult. If Grandma had to stay in the hospital her ward might be a Acute Care for the Elderly(ACE) unit where the physical environment is specifically designed to prevent functional decline with a less institutional like atmosphere.. Nurses would have resources like ‘Try This’ available at the bedside through technology. The goal for Grandma would be to avoid preventable adverse events, especially in terms of proper interventions and prescription treatments. Hopefully Grandma’s stay would be short and she would not have to return to the hospital again, and with comprehensive post stay transition care could return to her own home.

Currently over 300 hospitals are part of the NICHE network. NICHE is not a program per se. It provides the support, tools, and principles to bring about a change in hospital culture towards the goal of patient centered care for specifically for the elderly. Hospitals first complete the Geriatric Institutional Assessment Profile(GIAP) to find out where their organization can make changes to progress towards that goal.

The ‘Try This’ bedside resource is centered around conditions specific to the elderly population and consist of two pages; the first page describing the importance of the condition and the second page an assessment that can be administered in a short time. There is also a book available called Geriatric Nursing Protocols for Best Practice. It is presently in its third edition and is also available for use at the bedside to enable nurses to find information quickly.

The Foundation also created the Building Academic Geriatric Nursing Capacity. Celebrating its tenth year this initiative partnered with nursing schools and the American Academy of Nursing. The goal is to support the next generation of nursing scholars, researchers and most importantly future nurses. In 2004 the Atlantic Philanthropies also became a partner and there are now 9 Hartford Centers of Geriatric Nursing Excellence, which are educational institutions that are committed leaders in geriatric nursing maintenance and expansion.

There is a movement to formally prepare nursing students in geriatric care by changing and adding to the curriculum of nursing programs. For instance in Minnesota 10 nursing schools have set a goal for increasing geriatric topics in their curricula. It is called the West Central Initiative.

 Highlighting excellence in geriatric nursing will help advance its importance nationally. The Foundation partnered with the AACN and has awards for curriculum excellence in the baccalaureate program that increases student competence in aging. For example, one award recipient Valparaiso College of Nursing integrated geriatric content into every course. One required course is called the Aging Process. The goal of this course was to change students’ attitudes towards the elderly. This is accomplished by students role playing an elderly person for a day to establish empathy and understanding. Students also make wellness presentations to healthy older adults. In their senior year they work with the elderly in extended care or rehabilitation units of hospitals. These activities create a comprehensive compassionate education of aging and geriatric medical care. In partnership with AONE, the foundation also created and award for hospitals that strive towards best practices in geriatric care. Recognition of excellence can be a motivating factor in change at the institutional level.

In the area of policy development the Foundation has initiated forums to create the opportunity for discussion on geriatric care.

Strategic partnerships enable leveraging of resources to attain a larger goal or greater impact. One example of this is the Foundation’s partnership with the American Nurses’ Association, American Nurses Credentialing Center(ANCC) and Atlantic Philanthropies. Called Nurse Competence in Aging, the focus of this partnership was to increase geriatric competence(comprised of skill knowledge and attitude) of nurse specialists , with a three part approach. The first is working through the 57 respective specialty organizations to assist in their involvement in pursuing best practices. A list of the activities of each association is online at http://download.journals.elsevierhealth.com/pdfs/journals/0197-4572/PIIS0197457207003163.pdf. If a specialty organization acquires funding through the NCA initiative it becomes a Specialty Nursing Association Partner in Geriatrics(SNAPG).

The initiative also encourages nurse specialists to acquire certification in geriatric care, to validate competence in that area. 

At present too many assumptions are made about the medical care of the elderly. What may be good care for a younger person may not be ideal for someone older. Care for this age group must include more input from the patient. The initiatives discussed in this article show there is a steady increase in resources for all nurses who realize the importance of geriatric competence.


Nursing Innovations Forge New Paths

Nurses enable health through both clinical judgment and technical knowledge. Yet their immeasurable skills such as the ability to support and comfort produce measurable results. For example,

Nurses are teachers of theirs peers and patients. Good nurses look at the whole person or patient. Nurses communicate, execute, and innovate, all with an attitude of caring. Nurses are the most trusted of the health care professionals. Nurses apply their knowledge with compassion to a positive measurable end.

These immeasurable skills that nurses possess will bring the solution to the next great challenge the US health care system faces: the aging of the baby boomers. Around 2030 there will be over 70 million people 65 or older. The fastest growing segment of the population is the oldest at 85+ years. Although people are living longer it’s not necessarily better. As they age they usually need more health care. Half of hospital patients are 65 or older. Two thirds of the elderly will need long term care at some point in their life. The average 75 year old has three chronic conditions and 4 or more prescriptions. 42% of people age 85 or older have Alzheimer’s disease. It’s so easy to list statistics but how to make those later years truly golden? It is nurses who will lead the way. Why? There are reasons other than those already listed. First of all there are more nurses than any other health care professional. Secondly, nurses are aging along with the baby boomers. Half of all nurses will be 50 or older by 2020. This will enable them to empathize with the possible challenges baby boomers face as they age.

The present health care system is unprepared for the aging of the baby boomers. They are not alone in their assessment. Reform is necessary. The foundation of that reform will be a change in attitude towards the elderly and a change in attitude in provision of care. Research by the RAND Group and UCLA shows the elderly gradually receive less care than they actually need. Resident clinics utilizing the Assessing Care of Vulnerable Elders (ACOVE) initiative shows that even the basic assessments for preventive measures are lacking in many of these clinics. The evaluation of the performance of resident MDs at over 2000 patients in 52 clinics showed that screening for at risk medical or physical conditions, for example mobility function status, or memory was at unacceptably low percentages. There was also few electronic medical records or reminder systems in place.

Current Medicare payment guidelines do not include long term care services, coordination or collaboration of providers, ongoing monitoring of chronic conditions, or any service provided by non MDs.

Nurse led innovations are changing how the elderly receive care. The goal is to maintain independence and dignity while ensuring the perils of aging are taken in stride. This change in perspective towards the care of the elderly will also include an active participation of both patient and caregiver. It is a fact that patient and caregiver engagement leads to better medical outcomes and greater patient satisfaction.

A number of nurse led innovations from the Raise the Voice initiative of the American Academy of Nursing are directed at the elderly population using strategies to prevent hospitalization for acute episodes or to keep seniors in their homes and communities as long as safely possible. These nurses, called Edge Runners are enablers and facilitators. For instance, in the Caregiver Skill Building Intervention caregivers are taught coping skills to deal with their patient’s behavior. The goal is to ward off caregiver burnout and depression. If successful, nursing home placement for the patient is delayed by 1-5 years.

In the SeniorWise program the focus is to keep seniors with MCI or Alzheimer’s mentally fit and happy for as long as possible, by the modification of risk factors, improving memory and other interventions.

The success of the Senior ASSIST Program(Assisting Seniors to Stay Independent through Services and Teaching) is measure in how long their clients stay in the program which is often many years. A geriatric trained RN makes home visits and teaches the senior to manage their health. The RN also coordinates with the senior’s doctor and helps them access other health services. This program is an important bridge to the time when an elderly person would qualify for Medicare services.

Health care worker roles will need to be changed. Change includes expansion such as allowing NPs to practice to the full extent of their licenses and revamping roles of many health care workers.  Ways also need to be explored to broaden the responsibility of workers at different levels of training.

One common factor of successful innovations in delivery of health care to the elderly is interdisciplinary teams and coordination of care. Again nurses have led the way here. 

So far we have seen that a shift in attitude towards care of the elderly must include their input.  Any interventions, strategies, or care must focus on prevention and maintenance of good health or management of chronic conditions to avoid acute episodes that require emergency care or hospitalization. The development of interdisciplinary teams can ensure that seniors can remain in the community and stay independent as long as possible. The team must include the senior’s health goals as the center of their care plan.



“Keeping a Wiser Workforce”*

Over 50% of workers are age 50 or over in the nation.(1) The graying of America’s working population is approaching and with it the understanding that knowledge transfer will be a much discussed challenge. Indeed organizations like the American Association of Retired Persons (AARP) are looking at various industries and the impact the retirement of the baby boomers will have on the workforce. The transition in technical knowledge based professions will be affected the most which includes nursing.

Although there is a current artificial unemployment situation in the nursing profession this is short term. Issues of profitability and companies wanting to stay financially viable means teaching institutions have reduced expenses. For hospitals, training new nurses costs money so there is a reluctance to hire. But it is expensive to replace a nurse who has long tenure. However, when demand for services and nurse retirement peak, medical centers may find themselves unprepared due to current cutbacks.

This blog has in the past outlined the unfolding nurse shortage. There are well qualified applicants for nursing schools but lack of space and faculty means they are turned away. Nurse turnover and retention of new graduates are problems. All of these factors only exacerbate the challenge of keeping nurses employed and fulfilled long enough for them to gain experience and hopefully in some cases further education.

Many of the factors that contribute to the challenge can be solved if experienced nurses stay in the profession.

So why do those nurses exit the profession? A significant reason is stress, caused by such factors as inadequate staffing levels, physically demanding work which can cause injury, work life balance especially if there is eldercare, or feeling undervalued or unappreciated, due to lack of support.

What are health care organizations doing to address experienced nurse retention?

The Robert Wood Johnson Foundation decided to examine the challenge and began with a white paper in 2006 that outlined possible evidence based solutions that could be implemented to retain older nurses.

In 2007 the Foundation started the program by funding the Wisdom at Work Retaining Experienced Nurses Initiative. They chose 13 health care organizations to receive 18 month grants of $75,000 to examine the solution to the challenge in a work environment. The 13 were selected by the following criteria: They were organizations recognized nationally for nursing, design, or technology achievements and they already had retention programs in place. Their programs focused on one of three areas: workplace design/ ergonomics, staffing/human resources,(change in organizational culture), or using technology to improve work process.

Nursing can be physically demanding especially when patient movement is involved, and there is always risk of injury. Many of the programs that fell into the ergonomics category were aimed at reducing the impact of patient movement with lift teams and other strategies. A few of the programs involved nurse input.

The human resource or staffing programs had adequate staffing levels as a key component. A couple initiatives involved experienced nurses controlling the admission process. One program kept nurses on their own units rather than shifting them to unfamiliar units. 2 involved increasing nurse wellness and job satisfaction. Another implemented a virtual ICU that experienced nurses could monitor from several locations.

In 2007, the Foundation examined case studies of top performing companies in terms of staff retention of older workers. 7 companies were selected 4 of which were health care organizations. All 7 organizations have been awarded distinctions such as Fortune 500 List of 100 best companies or American AARP’s Best Employers for Workers over 50. The next few paragraphs will summarize their successes.

Bon Secours Health System in Richmond, Virginia’s mission statement that workers remain for life is not merely lip service, but is executed through timely ongoing efficient communication. This communication involves staff input through surveys and feedback. They monitor patient satisfaction, quality outcomes as well as financial performance. They encourage flexible work and retirement arrangements, innovative benefits and professional development.

Monongalia Hospital in West Virginia has focused on strengthening the nursing culture in its medical centre with the goal of excellent patient care. Nurses were involved in the planning the design of the new addition to the hospital, an unprecedented involvement of staff in decision making. Monongalia understood that quality patient care involves nursing input, and to leverage nursing skill they use technology.

At Scripps Health in San Diego workplace culture and benefits are organized and adapted according to the differing life cycles of its nurses. There is a system wide forecasting of employment needs which is kept current. There are focused retention strategies to prevent talent loss, one of which is their mentoring program. Each employee decides how to achieve professional success and Scripps helps them get there. There are differing benefits for employees to select depending on their needs such as eldercare benefits and phased retirement options.

Carondelet Health Network in Arizona was always competing for staff with Phoenix and California and relied on contract labor to hire nurses. Executives decided to invest in the professional development of nurses as a way of retaining staff. They created an on site BSN program with paid tuition. They also partnered with a local university to offer a free MSN program as well with the stipulation that after graduation the nurses would serve as adjunct faculty. Retention has increased and the use of contract nurses has decreased.

Retention strategies must be able to be replicated nationally to be effective. This can occur if there is a system wide commitment to understanding the value of experienced nurses. This cultural shift must be supported by planning and making the business case for investing in strategies, and learning from other medical centers’ best practices. Feedback and data must be collected diligently on a regular basis. It may be that hospitals will collect data such as quantifying the value of experienced nurses. Other professions have done that and so can health care. Organizations must be open minded as situations change and not be tempted to apply temporary Band aid solutions.

If experienced workers stay in the profession and advance to leadership roles for example, the nurses entering the workforce will more easily acquire critical thinking skills and will be able to approach clinical situations in ‘the context of broader outcomes’(2). Leadership in medical organizations need to recognize this is a pressing issue and be proactive in keeping valuable veteran nurses.



The Unnamed Frustration, Fatigue, and Anxiety (1)

Consider these medical situations that nurses have been involved in:

A child is admitted to ER with possible symptoms of abuse. A doctor allows the patient to be discharged despite the nurse’s intuition about the situation. The child returns to the ER 2 days later dead on arrival. (2)

A patient was in severe enough pain to be crying out. Increased ammonia levels caused him mental confusion. The doctors wanted to monitor his mental state and ordered that pain medication be withheld. Twelve hours later he died. (3)

Readers could list many more situations like this in the various settings where nurses practice. These situations involve peers, patients, caregivers, and administration. The resultant feelings of frustration and helplessness have given rise to the term moral distress. Factors included in this phrase are cognitive dissonance, and psychological disequilibrium. But behind those fancy scientific terms lie the real crux of the matter. The nurse feels helpless, angry, and dissatisfied. Moral distress occurs when a nurse reaches a moral decision but is unable to execute her values, training, and knowledge. In other words the nursing goal is stymied and now a less than ideal outcome must be accepted. The nurse is impacted because she/he is the most involved in care, sees the consequences first hand, and because ethics are the basis of the nursing profession.

There are many reasons why a nurse might be unable to carry out maximum nursing care. Some factors are external, some internal. Nurse must collaborate with doctors and other professional colleagues. Nurses must deal with employer policy and sometimes consider cost of care. Another factor contributing to constraint are advances in technology which can increase life expectancy, but also affects the trajectory of chronic disease. Health care is expensive and medical centers have budget requirements which affect staffing levels. Nurses are pressed for time. There could be culture and values mismatch or challenges between patients, caregivers and nurses.

Moral distress in nurses is often created when there are 2 conflicting principles. For example, nurses must often choose between honoring patient autonomy and giving the best nursing care which to some extent relies on patient compliance. What if the patient is non compliant? Nurses must sometimes weigh legality and morality, for example, doctors might order tests because of the perceived possibility of legal action, but the nurse believes they are unnecessary.

Nurse researchers have developed a way to measure moral distress in nurses using the Moral Distress scale. It measures frequency and intensity of moral distress, using a Likert scale of 0-6. The most frequent situation that causes moral distress in nurses is unnecessary patient suffering, or circumstances that constrain action to relieve patient suffering.

One study researched risk factors and early warning signs of situations that could lead to possible moral distress. The researchers reasoned that if the situation could be identified early enough it could be solved in a proactive instead of an after the fact reactive manner. Moral distress in nurses would be avoided and the quality of care would be better. Medical centers would benefit from dealing with moral distress of medical staff to increase the likelihood of better work engagement and job satisfaction.

In the study the risk factors that can lead to moral distress were classified in the following categories: Individual risk factors were patient vulnerability listed as decreased mental functioning or psychiatric condition, elderly or very young, developmentally delayed, English as a second language, no relatives, homeless. End of life, suffering, and failed treatment are also individual risk factors.

Family risk factors can include the family being against the treatment plan, family uncertainty, stubbornness or unrealistic expectations, caregiver disagreement, caregivers not honoring patient wishes, denying comfort care or family indifference.

There are risk factors at the professional level which include team conflict, unethical behavior, over optimism by peers, stubbornness, fear of litigation, ignoring patient wishes or advance directives.

Risks exist at the system level as well with polices either vague or strict, limited resources, and lack of professional collaboration.

Helping nurses identify risk factors and early indicators of situations that could escalate into ethical dilemmas will avert moral distress. As indicated in this space in a previous article, nursing intuition is a scientifically valid phenomenon. Empowering nurses to proactively manage patient situations where moral distress can occur would be beneficial to everyone involved.

The early indications of a possible ethical dilemma are categorized as follows: Signs of conflict, which can include arguing between family members or medical staff, family expressing anger and mistrust of the staff, and nurses objecting to either prescribed treatment or family decisions. Patient suffering is another indication, for example unrelieved discomfort, or pain from different treatments and their complications, anxiety, and labored breathing.

Poor communication and unrealistic expectations from either patient or family are also early indications of possible ethical challenges. Ethical violations include not honoring patient autonomy, right to information, and standard of care. If the patient is treated without respect, or fraud is committed these are also signs of an ethical challenge.
Signs of nurse distress include the nurse believing treatment is futile, expressing concern over patient suffering, feeling powerless in the organizational structure of the medical center, and feeling regret that the nurse didn’t advocate enough for the patient.

Moral distress must be addressed both at the institutional and individual level.  For institutions moral distress is a factor in nurse burnout, turnover, and nurse retention. This can only exacerbate the upcoming lack of health care providers in the near future. But more importantly, moral distress affects nurses’ perception of themselves and the care they provide. Could it alter a nurse’s professional self image?  Can nurses compartmentalize self perception so that moral compromise in one’s professional life does not impact one’s ‘true’ self? Can nurses end up acting for pragmatic reasons alone due to moral distress?

The purpose of this space is always to end on a hopeful note, however. There is hope that nurses are identifying and coping positively with moral distress. Moral distress situations can prompt nurses to take action and become more assertive in changing their workplace to increase understanding of these situations. The self awareness that comes from reflection on one’s practice can lead to professional self development, and strength of character. Of course this is not going to occur without some changes at the employer level. Part 2 will deal with those innovative people and institutions that have pioneered the nursing professional championing ethics in the workplace.