Nursing and Nursing Education Public Policies and Private Actions (1983) / Chapter Skim
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CHAPTER VII IMPROVING THE USE OF NURSING RESOURCES
CHAPTER VII IMPROVING THE USE OF NURSING RESOURCES
Pages 190-214
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From page 190... ...
We have observed that many hospitals appear to be moving gradually toward a greater proportion of registered nurses (RNs) in relation to other types of nursing service personnel (see Chapter II, Table 10)
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From page 191... ...
Because financial constraints probably will limit expansion of nursing education during the remainder of the 1980s, managers must examine how to adapt to local supply conditions without simply calling for additional education slots. This may mean developing strategies to increase the number of hours that part-time nurses work, encouraging inactive nurses to reenter the field, adjusting staffing patterns to make more effective use of current staff, or reducing excessive turnover.
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From page 192... ...
.3 Recent studies estimate that by 1982 the turnover rate had on average fallen to between 20 and 30 percent per annum for full-time RN staff.4,5,6,7 For the average RN today, turnover rates do not appear to be any higher than for women in many other occupations. Among all working women, the average tenure per job in 1978 was about the same in the health industry (2.7 years)
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From page 193... ...
They nonetheless constitute a sizable group, and they spend an average of almost $100,000 per year on recruitment.9 A trend of moderating turnover seems to be confirmed by information from several states. A Maryland Hospital Association survey, for example, shows a drop in turnover of 12 percent over 2 years in the Washington, D.C., metropolitan area, from 36 percent in 1980 to 20 percent in 1982.1O Recent reports from California indicate a turnover rate in 1981 of 37 percent, apparently higher than the national average, but nonetheless the lowest in the state since 1977.11 In North Carolina, hospital turnover rates declined from 23.2 percent in 1980 to 22.1 percent by September 1982.12 Although poor retention and high turnover in nursing may be less severe than commonly believed, the committee concludes that serious problems exist in the management of nurse resources.
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From page 194... ...
Nonetheless, these studies are useful in that they suggest the types of frustration many nurses experience in their work situations. A review of recent surveys identified factors most frequently cited by nurses: attitude and behavior of nursing managers; limited professional growth, advancement, achievement, and intellectual environment of the practice setting; salaries; schedules; relationships with other nurses; and working conditions characterized by understaffing, lack of recognition, too much paperwork, poor relationships with physicians, an oppressive organizational hierarchy, and little job security.17 In her critical review of the literature on nursing job satisfaction conducted for the study, Stuart notes that every major study of this issue since the 1960s has pointed to the factors of autonomy, interpersonal relations, and job status as critical components of overall job satisfaction.*
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From page 195... ...
Lack of Opportunities for Career Progression Many nurses have had little to lose by changing jobs frequently or by dropping out of work for periods of time, because rewards for continuous job tenure, especially in clinical nursing, appear to be minimal. Multiple regression analysis of data from the National Sample Survey of Registered Nurses, November 1980, confirms the perception that employers do not pay a premium for experience (Appendix 7~.
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From page 196... ...
A third group are potential careerists who may benefit from learning about existing career paths or training opportunities.22 Career-oriented nurses present difficult challenges to health care managers but important opportunities as well. They demand educational opportunity for professional advancement and more authority to make decisions about patient care, to develop their own operating policies, and to influence the larger institutional resource allocation decisions that ultimately affect nursing practice.
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From page 197... ...
Employers are experimenting with a number of techniques to engage and retain career nurses in addition to the salary changes discussed in the following sections. One set of strategies involves restructuring the workplace, not only in schedules and incentives to work less popular shifts or positions, but also in reorganizing the delivery of nursing services in the institution so that patient needs based on severity of conditions are more closely matched to the ability level of the staff.
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From page 198... ...
Observers also have questioned the extent to which nurses' salaries fully reflect education, responsibility, and work environment.28,29 In 1978, general staff nurses working in hospitals earned approximately the same amount per year (814,270) as did school teachers ($14,200~; about $4,000 per year more than all female professional, technical, and kindred workers; and about $1,200 per year more than production workers in manufacturing industries.30~31 In general, earnings in occupations with a large number of women are lower than in occupations whose incumbents have similar educational backgrounds and age distributions, but who usually are men.32~33 Data from the 1970 census showed that RNs who worked full tome earned $5,603; a person with equivalent educational attainment and median age in a comparable occupation -- mathematical technician, in which 95 percent of employees are men -- had earnings of $10,331.34 In 1981, RNs ranked 15 among the 20 occupations with the highest median earnings for women employed full time.
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From page 199... ...
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From page 200... ...
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From page 201... ...
In some instances, this reconciliation process may be forcefully placed on management's agenda by nurses' organizing into a union, which has been described as a response to their "inability to communicate with management and their perception of authoritarian behavior on the part of management."39 In other instances, hospitals have created structures that enhance employee management principles of communication and a sense of participation in the decisions that affect the nurse's daily worklife. The work environment has been referred to consistently throughout this chapter as a key factor in whether nurses remain in a particular facility or in the practice of nursing.
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From page 202... ...
Even though labor force participation rates for nurses are generally high, hospitals and other employers experiencing chronic shortages may not be taking full advantage of various techniques to make better use of the number of nurses in the existing supply. Part-t ime nurse s can be encouraged to work addit tonal hours, and inactive nurses can be persuaded to return as part- or full-time employees .
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From page 203... ...
Therefore we performed a multivariate analysis of data from the National Sample Survey of Registered Nurses, November 1980, to measure the effect of the presence of children in the home, controlling for educational background, marital status, student status, sex, race, age, geographic region and length of experience (Appendix 7~. The analysis revealed that the presence of children under six significantly reduces the probability of a nurse's working full time and substantially increases the probability of her working part tome or not working.
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From page 204... ...
Indicative of both nurses' and employers' interests in seeking new hiring arrangements is the growth of temporary service agencies, which now appear to have peaked at placing about 37,000 nurses.48 Through these organizations, nurses can earn higher salaries, choose their schedules, and not be subjected to the organizational stresses imposed on a permanent employee in a particular hospital or on a particular floor. Hospitals use temporary service agencies to put nurses in hard-to-fill positions, temporarily paying a higher wage but avoiding salary increases to permanent employees; to circumvent personnel freezes; to adjust staff size to occupancy levels; and to make up for planned and unplanned absences of the permanent staff.49 Whatever the merits or disadvantages of temporary agencies, concern about their overuse and their costs has led to other arrangements.
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From page 205... ...
The specific measures listed below merit serious consideration, especially by those health care institutions with severe recruitment and retention problems: believes that employers' maintaining adeanate nurse · child care facilities and arrangments for the care of other dependents, especially during hours when private care is difficult, such as nights and weekends · work schedules adapted to the personal needs of nursing staff · improved salary structures in the context of an overall strategy to improve productivity and rationalize the use of the hospital's nursing resources · fringe benefit options so that nurses can select those most appropriate to their needs · special educational opportunities for nurses wishing to prepare themselves for reentry into active practice. After reviewing numerous published descriptions of innovative projects that health care institutions have undertaken, the committee believes that the kinds of actions listed above hold the greatest promise for enhancing labor force participation.
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From page 206... ...
Institutions should monitor these effects to determine whether such measures attract more reentrants or reduce the effective nursing service supply. Improved Salary Employers should consider increasing salary levels in order to attract inactive nurses into the labor force and to encourage part-time nurses to work more hours.
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From page 207... ...
While opportunities for professional satisfaction can often outweigh the lure of higher wages, nursing homes -- with their reputation for the isolation that understaffing produces and limited freedom to control the kind of nursing practice in the institution -- are, not surprisingly, viewed as low-status work settings by many registered nurses.65 Until there is more progress in addressing the financing and educational issues of care for the elderly, discussed in Chapter VI, there will be low effective demand by nursing homes for nurses. Nursing homes will continue to have difficulty offering quality professional nursing services.
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From page 208... ...
Ef forts of this sort will, the committee believes, both improve the quality of nursing care by addressing sources of d i sc ant ent, and e nhanc e the image o f the pr of e s s i on, thu s at trac ti ng greater numbers of good candidates into nursing. RE OOMME:NDATION 16 The proportion of nurses who choose to work in their profession is high, but examination of conventional management, organization, and salary structures indicates that employers could improve the supply and j ob tenure by the f ol lowing: · providing opportunities for career advancement in clinical nursing as well as in administration · ensuring that mer it and experience rewarded by salary increases · assessing the need to raise nurse salaries if vacancies remain unf tiled · encouraging greater involvement of nurses in decisions about patient care, management, and governanc e of the inst it ut ion · ident if ying the maj or deterrents to nurse labor force part ic ipation in their own localities and responding by adapting conditions of work, child care, and compensation packages to encourage part-time nurses to increase their labor force partic ipation and to attract some inactive nurses back to work.
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From page 209... ...
Finally, nursing service departments could rearrange patterns of staffing and assignments to raise productivity without claiming a greater proportion of the hospital budget. Nursing services in health care institutions, particularly hospitals, traditionally have been treated as an undifferentiated component of a daily cost or charge that covers room, board and other expenditures, as contrasted with other services that contribute to revenue generation.
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From page 210... ...
REOOMMENDATION 17 Lack of precise information about current costs and utilization of nursing service personnel makes it difficult for nursing service administrators and hospital managers to make the most appropriate and cost effective decisions about assignment of nurses. Hospitals, working with federal and state governments and other third-party payers, should conduct studies and experiments to determine the feasibility and means of creating separate revenue and cost centers for direct nursing care units within the institution for case lapis costing and revenue setting, and for other fiscal management alternatives.
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From page 211... ...
From national sample survey of registered nurses, November, 1980 (Report No. 82-5, Revised June 1982)
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From page 212... ...
Registered nurses licensed in 1978: An analytic report prepared for subscribers to the NLN _ _ .
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1977 national sample survey of registered nurses: A report on the nurse population - _ and factors affecting their supply NTIS Publication No.
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From page 214... ...
The labor market for registered nurses: A three-equation model. The Review of Economics and Statistics, 1971, 53~3~.
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