“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.