Latest critical care nurse survey results reveal both good and bad conditions
According to the 2018 AACN Critical Care Nurse Work Environment Study, the health of the critical care nurse work environment – based on more than 6,000 respondents has improved since the previous study in 2013. But results also show some disturbing revelations that call for more improvement.
For example, AACN said inappropriate staffing was an issue noted by more than 60 percent of participants. An alarming number of physical and mental well-being problems – 198,340 incidents among more than 6,000 respondents – were reported. And one-third of the participants also indicated they were planning to leave their current job with a year. On a more positive note, the survey results showed some evidence that adoption of the AACN Healthy Work Environment standards are making a difference.
Author Beth Ulrich, EdD, RN, FACHE, FAAN, published a study of the results in the journal Critical Care Nurse earlier this year and said despite overall findings, it’s important to put them in proper perspective. “The context in which surveys occur is important when interpreting the results, especially when comparing outcomes of surveys conducted at different points in time,” she said, noting that the first study was conducted in 2006 when the U.S. was facing a severe nursing shortage.
“Health care organizations were competing for RNs and trying hard to retain employed RNs. By the time the second study was conducted in 2008, a national recession was resulting in low vacancy rates as RNs returned to the workforce or increased their work hours to compensate for job losses for other family members and losses in retirement funds. The downstream effect of these RNs returning to work and increasing their hours was a decreased demand or need for new graduate RNs - many new graduate RNs could not find work for months after graduation.”
In 2013, Ulrich continued, the U.S. economy was improving, and healthcare was moving in a new direction after passage of the Patient Protection and Affordable Care Act, in which reimbursement was based on patient outcomes. Furthermore, segments of the new ACA had been revoked or changed, leaving some healthcare organizations that had been implementing the value-based model uncertain of how to continue. Overall, Ulrich said a “major shift in focus to care beyond traditional hospital walls affected resources and priorities for acute and critical units and caregivers.”
Below is a brief review of the survey findings.
Communication, collaboration, and respect: Communication, collaboration, and respect all showed improvement in all measures, but there is still room to improve. In 2015, the Controlled Risk Insurance Company estimated that failures in communication were responsible for 30 percent of all hospital and medical practice malpractice claims for the previous 5 years. In 2017, The Joint Commission identified communication during handoffs as a critical problem and issued a sentinel event alert. Participants who planned to leave their positions in the next 12 to 36 months indicated that more respect from administration and frontline nurse managers would influence them to stay.
Effective decision-making: The rebound of the ratings on the effective decision-making items of the Critical Elements of a Healthy Work Environment Scale is good news. The Institute of Medicine report on the future of nursing stressed the need for nurses to be involved as full partners in decision-making. Involvement also requires accountability and noted that nurses must act as full partners with physicians and other health professionals and must be accountable for their own contributions to delivering high quality care while working in collaboration with leaders from other health professions.
Appropriate staffing: Appropriate staffing is the most concerning issue with only 39 percent of participants reporting that their unit had appropriate staffing more than 75 percent of the time. The discrepancy between the views of the frontline nurse managers and the direct-care staff may indicate a lack of communication. Much of the work that participants reported is not getting done is the work that RNs should be doing, such as critical thinking, teaching planning care, and preparing patients for discharge. The American Nurses Association found that adequate staffing is associated with reduction in medical and medication errors, fewer patient complications, decreased mortality rate, improved patient satisfaction, reduction in nurse fatigue, decreased nurse burnout, and improved nurse retention and job satisfaction.
Meaningful recognition: Participants reported that the most meaningful recognition comes from patients and families. This finding is consistent across all four of the AACN work environment surveys since 2006. The challenge for organizations is to explore ways to facilitate this recognition and to gain understanding about other types of recognition that may be more under the control of unit and organizational leaders.
Authentic leadership: All ratings of authentic leadership improved since the 2013 study. Nurse managers have been found to profoundly influence nurse work environments. Press Ganey Associates analyzed the 2016 National Database of Nursing Quality Indicators data from 171,789 nurses and found significant relationships between nurse manager performance ratings and the quality of nurse work environments. For nurses in critical care units, nurse managers also had a strong impact on nurse outcomes, including job enjoyment and intent to stay. The results of the current study are consistent with the findings of Press Ganey Associates.
Physical and mental safety: Almost one-third of the participants did not believe their organizations valued their health and safety. More than 198,000 incidences of verbal abuse, physical abuse, discrimination, and sexual harassment within the prior 12 months were reported. The abuse most frequently was by patients and families. More than 40 percent of the participants who experienced abuse did not report the incidents, most often because they did not think anything would be done about it. A sentinel event alert from The Joint Commission issued in December 2018 emphasized the importance of developing a reporting culture to ensure safety. Incivility affects the organization as well as individual nurses. The higher the levels of incivility, the lower the productivity. Burnout has become so pervasive that the National Academy of Medicine launched a major initiative promoting clinician well-being, combating burnout, and developing the skill of resilience. The initiative includes an extensive knowledge hub and information on solutions to improve patient care by caring for caregivers.
Beacon units and Magnet organizations: Beacon units and Magnet hospitals have healthier work environments than do units and hospitals that have not received these awards. In a pediatric cardiac intensive care unit, one study indicated that staff perception of professionalism as being high or very high increased 32 percent after receiving the Beacon Award for Excellence, and significant improvement also was documented in teamwork and collaboration between nurses.
Implementation of HWE standards: The 2018 study provides evidence that implementing the AACN HWE standards makes a difference. The results confirm significant relationships between implementation of the HWE standards and important outcomes such as job satisfaction, quality of care on the unit, top-of-license practice, appropriate staffing, communication and collaboration, opportunities to influence decisions, and intent to leave. One study revealed a 49 percent decrease in staff absenteeism and a 75 percent decrease in patient falls after adoption.
Job and career satisfaction and career plans: The finding that 33 percent of the participants intend to leave their current positions in the next 12 months and another 22 percent say they intend to leave in the next 3 years is concerning. Nurses are highly satisfied they chose nursing as a career, but less satisfied with their current jobs. The good news is that many of those planning to leave have described what it would take for them to reconsider, notably better staffing, better leadership, higher salary and benefits, and more respect from administration.
