The Crisis Around Nurses: Time to Act
On August 1, the editors at CriticalCareNurse published a report based on a survey of nurses that was executed last fall. The report was authored by Beth Ulrich, Ed.D., Linda Cassidy, Ph.D., APRN, Connie Barden, M.S.N., R.N., Natasha Varn-Davis, Ph.D., and Sarah A. Delgado, M.S.N., RN., and entitled “National Nurse Work Environments-October 2021: A Status Report.” CriticalCareNurse is sponsored by the Aliso Viejo, California-based American Association of Critical-Care Nurses (AACN). As the association’s website describes it, “For more than 50 years, the American Association of Critical-Care Nurses (AACN) has been dedicated to acute and critical care nursing excellence. The organization's vision is to create a healthcare system driven by the needs of patients and their families in which acute and critical care nurses make their optimal contribution. AACN is the world's largest specialty nursing organization, with more than 130,000 members and over 200 chapters in the United States.”
As the authors note at the outset of the article, “The health of nurse work environments has been shown to affect both patient and nurse outcomes. In 2005, the American Association of Critical-Care Nurses published the AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence, and a second edition was published in 2016. The American Association of Critical-Care Nurses conducted critical care nurse work environment studies in 2006, 2008, 2013, 2018, and, most recently, October 2021, which was expanded to include registered nurses in all areas of practice.”
To that end, the author’s report state that they wanted to compare the results of their October 2021 study with the results of previous studies. They surveyed 9,335 registered nurses. The results? “The health of nurse work environments has declined dramatically since the 2018 study,” they write. “However, as in 2018, evidence of a positive relationship exists between implementation of the American Association of Critical-Care Nurses Healthy Work Environment Standards and the health of nurse work environments, between the health of nurse work environments and job satisfaction, and between job satisfaction and the intent of nurses to leave their current positions or to stay.”
As the article’s authors note, “The American Association of Critical-Care Nurses (AACN) has long recognized that healthy work environments (HWEs) are essential for nurses to provide their optimal contribution to patient care and has made a long-standing commitment to make HWEs one of the organization’s top advocacy priorities. In 2005, AACN released the AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence. This landmark document outlined 6 essential standards that serve as a foundation in which HWEs can evolve: Skilled Communication, True Collaboration, Effective Decision-making, Appropriate Staffing, Meaningful Recognition, and Authentic Leadership. Since their release, evidence continues to substantiate the 6 HWE standards, which were reaffirmed in 2016.”
The American Association of Critical-Care Nurses conducted four large-scale surveys of the nurse work environment between 2006 and 2018. As the article’s authors noted, “Although results showed some progress in the health of the work environment, overall improvement was not consistent or sustained. The COVID-19 pandemic has grossly exacerbated longstanding, systemic flaws inherent in health care work environments, further unveiling the fragility of hospitals and health care systems. In an effort to assess the current state of the nurse work environment, AACN conducted its fifth survey earlier than scheduled—in October 2021—because of concerns about the implications of the public health crisis on nurses and their work environments. The study was expanded to include registered nurses (RNs) in all areas of practice. The purpose of this article is to share the preliminary results, highlight data from before and during the pandemic, and discuss strategies for improvement.”
For context, the researchers note that “Evidence supporting the association between HWEs and optimal patient and nurse outcomes has spanned decades. It is clear that HWEs play a critical role in better patient care in hospitals. A meta-analysis conducted by Lake and colleagues7 shows that healthier work environments are associated with lower odds of poor patient outcomes such as mortality, adverse hospital-acquired events, and poor safety outcomes. Patients cared for in better nurse work environments also reported greater satisfaction and gave higher ratings for quality of care. These results are consistent with the systematic review by Wei et al, which showed that HWEs have a positive association with patient survival and other patient quality outcomes. In fact, HWEs have been identified as a key factor in patient safety and less missed patient care.”
Further, they write, “Nurse psychological health and well-being is also strongly associated with the health of the work environment. Nurses who work in healthier work environments report less burnout, less job dissatisfaction, and a lower intent to leave their organizations. The ongoing stressors of the COVID-19 pandemic have been associated with reports of nurses and other health care staff planning to leave their organizations at escalating and unparalleled rates. The overall work environment and specifically staffing are among the most influential factors in the decision to stay or leave a current position. Healthy work environments are also associated with better hospital and health system viability. Patients cared for in hospitals with better work environments report higher levels of satisfaction, and patients are more likely to recommend the hospital to family and friends.”
But here’s what they found:
> Only 24 percent of RNs responding to the survey believe that they have the right number of nurses with the right knowledge and skills more than 75 percent of the time or all of the time, compared with the 39 percent who said so in 2018.
> Further, 25 percent reported having appropriate staffing 50 to 75 percent of the time, 27 percent reporting having appropriate staffing 25 to 49 percent of the time, and 24 percent reporting having appropriate staffing less than 25 percent of the time.
> In that regard, “The mean rating of the CEHWE [Critical Elements of a Healthy Work Environment] criteria on “RN staffing ensures the effective match between patient needs and nurse competencies” declined significantly from 2018 to 2021 (2.66 to 2.33) to the lowest level recorded in any of the previous four studies. However, 58 percent of the participants who strongly agreed with the statement “RN staffing ensures the effective match between patient needs and nurse competencies” and 49 percent of the participants who reported that their unit had appropriate staffing more than 75 percent of the time said that they had no plans to leave their current position in the next three years.”
> Fewer than 50 percent of survey respondents agreed that “My organization values my health and safety,” compared with the 68 percent who said so in the 2018 study. “Verbal abuse, physical abuse, sexual harassment, and discrimination were reported as occurring frequently.”
> Indeed, fully 72 percent of respondents had experienced at least one negative incident of some kind. Sixty-five percent had experienced verbal abuse at least once, 28 percent had experienced physical abuse at least once, 23 percent had experienced discrimination at least once, and 13 percent had experienced sexual harassment at least once.
> When asked about recognition, and from whom it is most meaningful, 39 percent of respondents said it is most meaningful when coming from patients and families; while 25 percent said it was most meaningful when coming from other RNs, and 12 percent from nurse managers.
> Compared to 2018, when 24 percent of survey respondents had rated the quality of care in their patient care organizations as “excellent,” in October 2021, only 16 percent said so. Also, of note, 41 percent of nurse managers reported the quality of care on their unit as excellent, compared with only 28 percent of direct-care RNs.
> Just 60 percent of survey respondents reported that they were emotionally healthy or very emotionally healthy, though the degree of emotional health increased with years of nursing experience: 49 percent of those with 0-10 years’ experience said so, while 59 percent with 11-20 years’ experience said so, and 72 percent of those with more than 20 years’ experience said so.
> Respondents were asked, “To what extent, in your work as a nurse, do you experience moral distress?” The percentage of participants who reported that they experience moral distress very frequently doubled from 11 percent in 2018 to 22 percent in 2021. The frequency of moral distress also differed by years of nursing experience and how often the participants cared for patients with COVID-19, with 18 percent of respondents with more than 20 years’ experience saying they felt moral distress very frequently compared with 23 percent with 11-20 years’ experience saying so, 25 percent of those with 6-10 years’ experience saying so, and 24 percent of those with 0-5 years’ experience saying so.
The researchers conclude that “Actions to improve nursing work environments are urgently needed to correct the cycle of inappropriate staffing and nurse attrition. Failure to address the staffing deficits shown in this study will have devastating implications on the nursing profession and acutely ill patients, even if the toll of the pandemic wanes. Immediate action is needed to address the staffing crisis; however, addressing staffing without addressing the health of the work environment is futile because of the symbiotic nature of their relationship. One cannot exist without the other. Healthy work environments are essential for nurses to provide their optimal contribution and derive fulfillment from their work.” Indeed, they write, It is time for bold, intentional, and relentless efforts to create and sustain healthy work environments that foster excellence in patient care and optimal outcomes for patients, nurses, and other members of the health care team.”
I found all of these survey results to be meaningful, and some to be very meaningful. Clearly, nurses as a group are in psychological distress these days. Granted, this survey was executed in October 2021, when some hospitals were still overflowing with COVID-19 cases, and the intensity of the pandemic has ebbed considerably since then. At the same time, many nurses are expressing very deep longer-term malaise and even psychological and physical exhaustion.
The challenge, of course, is that there are no easy answers to any of this. Even before the onset of the pandemic, the nursing corps was collectively aging, with the average age of floor nurses nearing 50 years of age in some states—an unsustainable level of aging in such a difficult and physically and mentally demanding clinical profession. And that in itself was going to be a problem.
But this survey also garnered other troubling results, including not only that nurses are experiencing great stress because of under-staffing; but also that they’re often feeling disrespected, and even at times threatened, or even attacked. One would hope that some of the terrible incidents we heard about during the worst of the pandemic, when, hideously, nurses were verbally abused, threatened, or even, in a small number of cases, physically attacked, would have diminished tremendously by now. Even so, longer-term trauma can still have an impact; and many nurses, who were already stressed in a general way, experienced massive trauma during the worst of the pandemic.
So what’s to be done? Hospital and health system executives are already paying nurses as much as they can; CFOs and consultants have been telling me that salaries have been going up over the past year-and-a-half, as the leaders of patient care organizations attempt to compete both to attract and to retain nurses in an environment of tremendous competition for their services. Beyond that, the leaders at some forward-thinking organizations are doing more, trying to find ways to ensure that nurses have the level of psychological and cultural support that they need, beyond a salary bump or two.
The other key element here is that surveys and reports are confirming that a significant number of nurses are leaving inpatient care to go into less-intense (literally) work environments, from outpatient clinic work to, in some cases, visiting-nurse work, or even non-clinical work altogether (and yes, we definitely do need more nurses in clinical informatics and clinical management, as well). So hospital leaders specifically, need to rethink how they support their floor nurses who are on the front lines.
Ultimately, it seems clear that a combination of strategies and tactics will be necessary. I see several different elements here. The first, yes, is pay—but not just giving nurses more money; instead, hospital executives, including nurse executives, will need to work out really good strategic retention plans, some of which will need to couple higher pay with time-linked incentives to stay—along with really good programs to prove to nurses that executives are listening to them, and are making the changes they need, in order to feel respected, supported, and yes, empowered.
And yes, IT automation can help. The leaders of hospitals, medical groups, and integrated health systems need to do everything possible to reduce alert fatigue, reduce the massive level of minute-to-minute interruptions that nurses experience, and also reduce the technology “noise” they experience on a day-to-day level. Some progress in that area has already been made; for example, it was only a few years ago that a small number of nurses actually began wearing carpenters’ tool belts because of the large number of mobile devices they were having to carry. Some of that (literal) weight has been taken off them, as health CIOs, CMIOs, CNIOs, and CTOs have been able to reduce the number of devices that nurses have been carrying.
Honestly, everything matters. But what’s clear in reading the results of that survey is that the leaders of hospitals, medical groups, and health systems need to step up—and soon—in order to develop and execute strategies to successfully attract and retain nurses (RNs, but others as well), as well as all the needed clinicians, in order to ensure that they maintain the staffing levels necessary to survive—and thrive. And some of this gets into the “soft” areas—how does one develop a strategy to ensure that nurses feel respected, for example?—but even so, the practical outcomes for even the “softest” issues, will be “hard” ones, as reflected in retention levels—not to mention, in the levels of care quality, efficiency, and the patient and family experience. In any case, clearly, the time is now—and the place is our patient care organizations.
