GRUMPY CLINICIANS at the bedside can translate into high turnover, unhappy patients, and lower quality of care. But the solution may lie less in pay and perks than in redefining the control and influence that nurses and other clinicians wield in their daily work, according to researchers and managers.
Words such as control, collaboration, influence, autonomy, and respect are frequently mentioned in job satisfaction discussions, said Anna Gilmore-Hall, RN, director of labor relations and workplace advocacy for the American Nurses Association. When dissatisfied nurses turn to a union for help, they are most often worried about patient care, Gilmore-Hall said. “They say that if they had increased control over how they performed their work, it would increase their job satisfaction.”
But, she added, “the employers are reacting to a very competitive marketplace.” As employers work to reduce costs, in many cases “job satisfaction for RNs really isn’t high on their list of priorities.”
Ignoring nurse job satisfaction will only be detrimental to health care and the managers responsible for it, said Steve Strasser, PhD, president of HealthCare Research Systems, a market research company in Columbus, Ohio. Research, Strasser said, has demonstrated that nursing care is the primary factor in how patients view their hospital stay. “The issue is that the more satisfied patients are with nurses, the more satisfied they are with their stay.” His company is working with a hospital that cut too deeply into its nursing work force and is rehiring nurses after patient satisfaction scores slid.
Patient satisfaction is no small matter as hospitals battle to keep beds full, said Linda Aiken, PhD, RN, director of the Center for Health Services and Policy Research at the University of Pennsylvania School of Nursing in Philadelphia. And unhappy nurses have ample opportunity to pass their concerns along if they choose, Strasser said. “They are the closest point of service. They are the ones who get the pain meds there on time and so on.”
Some facilities have begun to address morale with focus groups and surveys. At Memorial Healthcare System in Houston, Margaret Loper, RN, started meeting with clusters of RNs and LVNs two years ago. Helping people, she learned, was what they enjoyed most about their work. “What made them feel really good was at the end of the day, they had given quality care—that they had done the very best for their patients.”
But in today’s healthcare climate, with sicker patients and leaner staffs, some nurses feel overwhelmed, Loper said. They may collapse at home after a long stressful day, only to realize they had never returned, as promised, to talk to a particular patient. Memorial, which includes nine hospitals, is making changes, including increasing staff on one unit and considering more flexible staffing on another, Loper said. “They would like to have control over the work day,” Loper said, and she thinks that’s a reasonable request. “They are adults—give them parameters and let them operate within those parameters.”
Nurses prefer a decentralized management structure, in which more decisions are made on the unit level, and they can work more efficiently in that structure, Aiken said. Aiken’s research involves about 40 hospitals designated as magnet facilities by the American Academy of Nursing for providing a good working environment.
Allowing clinicians to make more bedside decisions, she said, can actually be more cost-effective. “My basic position is clinicians know best how to invest resources to get the best possible patient outcomes.”
Health care also can be improved when nurses have more opportunities to collaborate with physicians, according to Judith Gedney Baggs, PhD, RN, an assistant professor in the University of Rochester School of Nursing in New York. In her study of nurse-physician collaboration on transferring patients out of the ICU, Baggs found that collaboration increased satisfaction among nurses more than among physicians. The study was published in the American Journal of Critical Care in September. “If the nurse believes there has been collaboration, she believes a better decision-making process is going on,” Baggs said.
A chain-of-command system was developed at Presbyterian Hospital in Dallas after nurses said they lacked sufficient recourse if they disagreed with a physician’s decision, according to Mike Evans, PhD, RN, vice president for nursing. Now a nurse can first appeal to the charge nurse, and if the charge nurse agrees, the concern will be passed up through channels, along with follow-up consultations with the physician. “It has the full support of the medical leadership,” Evans said.
Evans is no newcomer to the issue of nursing satisfaction; he did his dissertation on it. “Nurses are the heart of health care,” he said. “And if they are satisfied, it’s going to have positive repercussions down the line” on quality of care.
Presbyterian has made several changes since 1995, when it began surveying about 500 nurses annually to address a turnover rate of 22 percent. Pay was not the issue. “No hospital can afford not to be within the market range on salaries, benefits,” Evans said, adding that Presbyterian’s pay was above average. The survey revealed frustration with what was seen as a lack of control on the job, as well as no recognition from supervisors.
Since then, Presbyterian has expanded the nursing service’s governing council to ensure that a nurse is elected from each unit, Evans said. By the end of the fiscal year in September, turnover fell to 10 percent. Key quality measures, including medication errors, hospital-acquired infections, and bedsores, have also improved.
Time and logistical constraints always impede organizations’ efforts to boost clinician satisfaction, Baggs said. However, even minor changes in routine procedures can drive home the message that the bedside clinician’s voice really matters. Nurses, for example, can join physicians on rounds and in continuing education classes when the course work overlaps. Nurses and physicians can begin routinely jotting their notes in the same area of the patient’s chart so they can benefit from each other’s perspective.
Getting nurses more involved from the start, Baggs said, can frequently pay off over the long haul by reducing aggravation and improving quality of care.