This article describes the work experience of a national cohort of 229 RNs who participated in a survey on work environment at two different time periods. Survey results of the RNs’ experience within two and a half years of their initial RN licensure (time period two) are described in detail, and comparisons are made to their experiences one year earlier (time period one). Using Krippendorff’s technique for content analysis, six inter-related themes emerged at time period two. Findings indicate that the working environment of RNs impacts both nurses’ satisfaction and their dissatisfaction. Factors associated with dissatisfaction center on the lack of nurse manager leadership, persistent verbal abuse, high patient-to-nurse ratios, and the physical demands of bedside nursing that result in injuries. Suggestions from the nurses themselves are used to guide strategies to improve the work environment and retain nurses.
Key words: Work environment, registered nurses, nurse retention, nursing, leadership, management, professional practice, qualitative research, content analysis, turnover, job satisfaction, nurses’ work perception, workload
Improving retention of new RNs can be particularly cost effective, given the evidence suggesting that higher turnover exists among new RNs compared to all RNs. More than 40% of the currently working registered nurses (RNs) will begin to approach retirement age in the next 10 years (Norman et al., 2005). Nursing graduates, numbering about 92,000 in 2006 (National League for Nursing [NLN], 2008) represent a vital source of replacement for the retiring cohorts, especially in hospitals, the first job setting for over 80% of new nurses (Kovner et al., 2007). Retaining the new RNs in nursing is essential to help ameliorate the projected shortage of 260, 000 RNs by the year 2025 (Buerhaus, Auerbach, & Staiger, 2009). At the organizational level, RN retention is important for maintaining adequate nurse staffing that is critical for ensuring quality patient outcomes (Kane, Shamliyan, Mueller, Duval, & Wilt, 2007). Further, improved retention minimizes turnover costs that range from $82,000 to $88,000 per RN (Jones, 2008).
Improving retention of new RNs can be particularly cost effective, given the evidence suggesting that higher turnover exists among new RNs compared to all RNs. While average yearly turnover rates of all RNs range from about 5% to 21% (PricewaterhouseCoopers’ Health Research Institute, 2007), turnover rates for the RNs in the first year of practice range from about 18% in a nationally representative sample of new RNs (Brewer et al., 2009) to about 50% in less representative United States (U.S.) samples (Salt, Cummings, & Profetto-McGrath, 2008; Scott, Engelke, & Swanson, 2008). Structured residency programs, however, have been shown to reduce new nurses’ turnover in the first year of practice from 20% to 12% in one study (Halfer, Graf, & Sullivan, 2008) and from between 20% and 54% to between 4% and 28% in a systematic review of 16 studies (Salt et al.).
In order to optimize new RNs’ retention, organizational leaders must be sensitive to the RNs’ perceptions of their work environment and to evolving needs in the initial years of practice. In order to optimize new RNs’ retention, organizational leaders must be sensitive to the RNs’ perceptions of their work environment and to evolving needs in the initial years of practice. Substantial evidence exists about the factors that are generally associated with RN retention. These factors include job opportunities (local and non-local job opportunities), personal characteristics (work motivation, positive and negative affectivity, and education), work attitudes (job satisfaction, autonomy, and organizational commitment), and work attributes (shift type and unit type) (Aiken, Clarke, Sloane, Lake, & Cheney, 2008; Blegen 1993; Coomber & Barriball, 2007; Garon & Ringl, 2004; Irvine & Evans, 1995; Kovner, Brewer, Wu, Cheng, & Suzuki, 2006; Zangaro & Soeken, 2007). However, research about the factors specific to new RN retention is less abundant.
The purpose of this study was to identify work experiences in a cohort of nurses within two and a half years of their initial RN licensure. These findings were compared with findings from this same cohort when they were surveyed about their work experiences one year earlier. Nurse leaders can use the findings of this study to guide development of retention strategies to effectively retain new nurses who are at different stages of their beginning nursing practice.
Literature Review
Several quantitative studies have illuminated factors linked to new nurses’ actual turnover (Suzuki et al., 2006) and turnover intentions within the first two years of practice (Beecroft, Dorey, & Wenten, 2008; Roberts, Jones, & Lynn, 2004; Scott et al., 2008), while two studies were extended to RNs working between two and three years (Kovner, Brewer, Greene, & Fairchild, 2009; Lavoie-Tremblay, O’Brien-Pallas, Gelinas, Desforges, & Marchionni, 2008). Job satisfaction (Beecroft et al.; Kovner et al.; Roberts et al.; Scott et al., 2008), organizational commitment (Beecroft et al.; Kovner et al.), professional status, work group cohesion (Beecroft et al.), promotional opportunities, and age (Kovner et al.) were found to be negatively related to turnover intentions. Conversely, local and non-local job opportunities and having a baccalaureate degree versus an associate degree in nursing (Kovner et al.), lack of social support (Beecroft et al.; Lavoie-Tremblay et al.), discrepancy between the effort invested in the job and rewards received from the job (Lavoie-Tremblay et al.), and not being assigned to the unit of choice (Beecroft et al.) were positively related to turnover intentions. Less education and lack of peer support were also associated with actual turnover (Suzuki et al.).
Review of qualitative studies of new nurses’ work experiences within the first two years of practice in the U.S. (Delaney, 2003; Deppoliti, 2008; Godinez, Schweiger, Gruver, & Ryan, 1999; Hodges, Keeley, & Troyan, 2008; Pellico, Brewer, & Kovner, 2009; Yancey, 2005) and abroad (Duchscher, 2001, 2008; Maben, Latter, & Clark, 2007; Mooney, 2007; Newton & McKenna, 2007; O’Shea & Kelly, 2007; Wangensteen, Johansson, & Nordström, 2008) revealed common findings. The main source of stress for new nurses resulted from the conflicting demands of practice realities, including compromised quality of patient care (Duchscher, 2001; Mooney), time and workload pressures (Delaney; Duchscher, 2008; Hodges et al., 2008; Newton & McKenna; Pellico, Brewer, & Kovner, 2009), staffing shortages (Maben et al.), and the ideals of patient-centered, evidence-based, quality, and safe patient care (Deppoliti; Maben et al.; Yancey). Further, novice nurses reported feeling underprepared to perform a number of clinical nursing skills (assessing patients and administering medications) and non-clinical skills (communicating with physicians, coordinating care, and educating patients and families) (Delaney; Godinez et al.; Hodges et al.; O’Shea & Kelly; Pellico, Brewer, & Kovner, 2009). Learning the workplace culture (Hodges et al.; Newton & McKenna; Yancey) and structure (computer and paging systems) (Delaney; Godinez et al.) was also necessary for a successful transition from a student to a professional nurse role. During the transition phase, new nurses expressed a need for mentoring, guidance, and acceptance from their senior nurse colleagues (Duchscher, 2001; Godinez et al.; Wangensteen et al.), but they often experienced disruptive work behaviors from other nurses (Delaney; Duchscher, 2008; Mooney; Pellico, Brewer, & Kovner, 2009; Yancey) and physicians (Deppoliti; Pellico et al.).
Although most nurses endured the challenges in the transition phase and were able to achieve personal and professional growth from the experience (Delaney, 2003; Duchscher, 2008;Hodges et al., 2008; Newton & McKenna, 2007), some questioned their ability to withstand the realities of practice (Duchscher; Hodges et al.). Others planned to improve ingrained nursing practices that they perceived as suboptimal (Pellico, Brewer, & Kovner, 2009), to leave their current jobs to find a better professional fit in another setting (Deppoliti, 2008; Maben et al., 2007; Wangensteen et al., 2008), or to return to school (Yancey, 2005).
This current study adds to the literature presented above by revealing work experiences of RNs who were in practice for up to two and a half years. Further, the study offers a valuable insight about the evolving work needs of new nurses in their initial years of practice based on a comparison of nurses’ work experiences over time.
Method
Design
This qualitative study is a secondary data analysis of comments about work experiences that new RNs provided to an open-response question at the end of two specifically timed surveys that are part of a multi-year study. The first survey (time period one) was completed by Newly Licensed Registered Nurses (NLRNs) between the 6th and 18th month of licensure and the subsequent survey was completed by the same RNs one year later, i.e. between 18 and 30 months of employment (time period two). The nurses responded specifically to the question, “If you would like to make any other comments about the survey, please feel free to write below or on the back of this booklet,” on both surveys. Responses described in this article came from nurses who responded to the question on both the time period one survey and the time period two survey.
The first wave of data collection for the full study occurred from January to March of 2006 and resulted in a sample of 3,380 RNs for a response rate of 58%. Seventy-one percent of the RNs from the first data collection wave (N = 2,395) completed the survey during the second wave of data collection that occurred from January to March of 2007. A total of 271 RNs responded with comments on both surveys about their work experiences. The qualitative analysis of these comments from time period one is described in detail elsewhere (Pellico, Kovner, & Brewer, 2009). This report will analyze specifically the RNs’ perceptions of their work environment as reported in the time period two survey. This analysis will be compared to earlier research findings (time period one) when appropriate. Given the unique opportunity of following a cohort of nurses as they transition from novice NLRNs to experienced RNs, a qualitative approach was selected to gain insight into the challenges of the work environment at two points in time as written in the RNs’ comments.
The design of the original quantitative study was to use a longitudinal survey design to follow career trajectories of NLRNs randomly selected from 34 states and the District of Columbia over a period of 10 years. To date the survey instrument has been administered during the years of 2006 and 2007 to collect data using valid and reliable Likert-type scales in four main areas: (a) work setting (hospital, community) and position (staff RN, nurse manager), (b) demographics (age, gender), (c) work-related attitudes (autonomy, job satisfaction) and attributes (unit type, shift type), and (d) market-level variables (non-employment rate). Methods, sampling, and measures used in the original study are described in detail elsewhere (Kovner et al., 2007).
Sample
Permission to conduct the study was granted by the New York University and University of Buffalo Institutional Review Boards. The sample for this segment of the longitudinal study was comprised of a national sample of 271 RNs who provided comments about their work experiences in surveys at two separate intervals (time period one being the first 6-18 months of practice for the NLRNs, and time period two being one year later). We analyzed comments from a sample of 271 RNs; 42 comments unrelated to the research (e.g. comments related to address or name changes) were removed, resulting in an analytic sample of 229 RNs. The RNs who provided comments had a mean age of 35 years, with a range of 23 to 60 years of age. They were primarily White (83%), women (89%) whose entry into practice was an associate degree (AD) (54%), baccalaureate degree (BS) (39%), diploma (6%), and master’s or doctoral degree (1%). Almost 77% of the RNs at time period two were employed in inpatient hospitals settings compared to 82% at time period one. The overall turnover rate for the RNs in hospitals settings at time period two was 8.8%. Almost 93% of the hospitals were non-magnet institutions. The majority of RNs were employed full time (76%), while 24% worked part time.
Data Analysis
In this secondary analysis, content analysis was used to identify the repetitive themes regarding the work environment for this national sample of RNs at time period two. Krippendorff (2004) defined content analysis as “an empirically grounded method, exploratory in process and predictive or inferential in intent” (p. xvii). The research question that guided this study was, “What are the experiences of nurses related to their work environment at time period two, and how do the experiences compare to time period one?” In content analysis units are identified from the original text. The authors chose thematic units for this study because of the “descriptive richness” and “link to readers’ understanding” (Krippendorff, p. 108).
Initially, a data-entry person typed and entered into an Excel spread sheet all the RNs’ written comments. Three of the four authors read in entirety the comments from the Excel spreadsheet so a sense of the whole could be determined. Coding consisted of selecting passages related to RNs’ work experience. Selected passages were enumerated and categorized with these authors noting unique comments as well as recurrent passages. Identified data were grouped together or clustered based on shared characteristics; dendrograms or tree-like diagrams were created to illustrate how data collapsed into clusters. An audit trail that recorded personal reflections and methodological decisions was created and shared by all authors.
Results
Content analysis revealed six inter-related themes at time period two, whereas at time period one, fives themes were found for NLRNs (Pellico, Kovner, & Brewer, 2009). Thematic comparison based upon the length of time in professional practice is presented in the Table. All thematic units will be initially described for time period two and when appropriate comparisons will be made to time period one so that the readers can consider the changing needs of RNs based upon experience.
Theme One: Pressured Time
Of particular concern is the pervasive sense of pressured time that is draining to nurses at time period two and causing them to either consider or actually leave hospital nursing. Nurses at time period two complained of an inability to perform their responsibilities within the time frame of their shift. The primary reasons noted included the increased acuity of patients, high patient-to-nurse ratio, and inordinate paper work. The result is a consistent inability to “get out” on time, which impacts nurses’ personal lives. Three different nurses, in order, specifically a female nurse from Maine (AD graduate), a female nurse from New Jersey (AD graduate), and a male nurse from New York (BS graduate), described the pervasive nature of time constraints in this manner:
I work much harder and since Oct. '06 I have only left work "on time" three times. Most days I work over 8 hours and do not get "overtime" pay since I work part time. As a mother of 2 children, getting out "on time" would be nice due to sports, appointments, etc.
My biggest frustration with the nursing profession is time. I find myself rushing to get my paperwork done and I don't have the support from my peers or supervisor. My number one concern is charting and that should take priority after patient care.
Bureaucratic demands put on staff are often unrealistic, redundant and unachievable due to time constraints and the overcrowding of ERs.
In contrast to time period one theme, described as Need for Speed, where NLRNs were initially concerned about their ability to perform necessary skills in a proficient and timely manner, a year later, nurses noted how colleagues’ inefficiency impacted their work flow. Nurses, rather than focusing on internal capability, are, at time period two, noting the external influence of others on their work. The following two female AD nurses’ comments from Mississippi and Massachusetts capture these feelings of frustration associated with “others”:
What gets me most fired up is other nurses in other departments always trying to pass the buck and never take into account time, like change of shift and/or lunch times.
At times it is difficult to complete my duties in a timely fashion because of situations out of my control like: MD's slow response to pages/calls, delayed lab/X-ray reports, discharge placement issues (including family member indecisiveness).
In addition, nurses at time period two are noting the work environment’s impact on recently graduated RNs and are concerned that “orientation for new nurses has shortened in the past year” related to the nursing shortage. Of particular concern is the pervasive sense of pressured time that is draining to nurses at time period two and causing them to either consider or actually leave hospital nursing. As a female BS nurse from Colorado explained, “Rarely do we downshift from max potential and the pace is exhausting physically, mentally and emotionally. While I love what I do, the pace is overwhelming and I will leave the hospital setting as a result.”
Theme Two: The Reality of Being a Nurse is Nothing Like the Dream
Initially the nurses entered the profession with the hope of improving the lives of their patients. However, at time period two, the high patient-to-nurse ratio was deemed to be so unsafe as to jeopardize not only patient care but their license as well. A female BS nurse from Oklahoma commented:
I enjoy working in an ICU/CCU environment, but staffing is consistently low and providing safe and excellent care to the best of my ability is difficult or impossible at times. This is becoming the norm rather than the exception and after my first two year commitment to the hospital where I work is completed, I will be resigning from a full time position at that facility and will consider other job opportunities when that time comes.
Lack of support staff, equipment, consistent standards of care for patient populations, continued assignment of non-nursing duties, and non-responsive management are issues the nurses commonly confront. Lack of support staff, equipment, consistent standards of care for patient populations, continued assignment of non-nursing duties, and non-responsive management are issues the nurses commonly confront. Nurses link the source of the unsafe working conditions to institutional profit and insurance reimbursement to institutions rather than the nursing shortage. A female AD nurse from Nevada commented on the insurance industry’s impact on healthcare:
One thing is for sure…, nursing as a whole needs help in being united. The whole healthcare system here is compromising patient care - the insurance are like Gods out here, they are out of control. They dictate what to give or they won't pay… People here need help.
The lack of the voice of nurses in determining working conditions, such as safe patient ratios, further elicited disillusionment with the nursing profession. Nurses expected to be treated as professionals, to advocate for patients, and to have an active voice in decision making. Instead they are “disappointed at the 'blue collar' mentality and lack of professionalism.” The heart of the frustration and disappointment is leveled at nursing and healthcare management. Two female nurses’ comments from Maine (diploma graduate) and California (BS graduate) and a male nurse’s comments from Pennsylvania (AD graduate) illustrate this finding:
Nursing is a profession but is not treated as such by employers or even most nurses. As professionals we, by definition, should govern ourselves. Nurses for the most part allow their employer to make career choices for them, determine safe practice for nurses, determine the monetary worth of a nurse.
The management in my department is uneducated and unprofessional and for that reason I plan to leave when my contract is complete.
The management [in named department] was absolutely hideous. The focus of the management gave no consideration to the nursing staff or, more importantly, to the well-being of the patient. This has lead to a departure of the majority of quality, experienced nursing staff.
Some nurses called for unionization as a means to improve the quality of the work environment; others suggested better pay that equates with the daily “life and death” responsibilities of an RN. Nearly all the comments supported the need to lower the ratio of patient to nurse and provide additional support to the bedside RN. Magnet hospitals fared no better according to participant comments. The two comments below are from BS-prepared female nurses at magnet hospitals in Texas and Indiana:
The frustrations I have with my job (understaffing, slow/unresponsive administrator, new rules that are burdensome in terms of time, etc) seem to be universal with all nurses in organizations - at least the ones I have spoken with. I work for a magnet hospital that pays reasonably well on a unit with a varied and interesting patient population… I believe I would have to leave nursing all together to avoid those things I find troublesome with my current job.
The management is terrible, the morale is low, nurses are leaving right and left… No one cares. We never get appreciation or recognition for the good things we do only the bad…Where I work things are bad at this time and this is a Magnet hospital.
...at time period two...nurses now switch the source of blame away from academic preparation to the external pressure on hospitals that trickles down to the unit level and to poor management. At time period one, the theme, Colliding Expectations, captured the NLRNs’ descriptions of discord between practice realities and their internalized image of nursing. They expected to have a voice in patient care decisions, to be treated as colleagues by physicians and nurses, and to have reasonable workloads. They attributed many of their concerns to academic institutions that did not prepare them adequately for the practice environment and were holding out hope that with improved nursing skills they would transition into their nursing role.
However, at time period two the tensions between the nurses’ personal view of nursing and their lived experience continue. The challenges nurses find at time period two continue to include high acuity patient populations, high patient to nurse ratios, a lack of voice in measures to improve the quality of patient care, and a lack of evidenced-based practice. However, nurses now switch the source of blame away from academic preparation to the external pressure on hospitals that trickles down to the unit level and to poor management. Nurses encourage administrators to “really work on retention” rather than simply recruitment and to demonstrate loyalty to employees. As reflected in many comments, participants now openly ponder whether the work environment is universally poor. The two comments below from female BS nurses in Pennsylvania and Virginia illustrate this consideration:
Greatest dissatisfaction at job continues to be unresponsive, non-supportive management. Speaking with fellow RNs working at other institutions - nursing management is universally in need of restructuring.
There are way too many patients, too few staff/resources and Management is totally out of touch with Reality. Welcome to my job...Currently I am very dissatisfied with my job… The reality of being a nurse is nothing like the dream.
Theme Three: Growing Weary
...many of the nurses commented on the importance of the dyad relationship of physician and nurse to their professional satisfaction. At time period two, the nurses’ comments described an unrelenting level of exhaustion. They have grown weary of verbal abuse by colleagues, the onerous work of bedside nursing, the consistent lack of equipment, poor management, inordinate level of paperwork/computer work, and strain of the profession that creeps into their family life.
The verbal abuse that was felt at time period one as a NLRN, unfortunately continues to be noted in the participants’ comments a year later. The “yelling,” “rude,” and “poor behavior” is primarily associated with physicians; “99% of verbal abuse is from physicians” and to a lesser extent nursing colleagues, family members, and hospital management. Interestingly, many of the nurses commented on the importance of the dyad relationship of physician and nurse to their professional satisfaction. The persistence of a detrimental working environment caused many of the participants to leave their original positions, even if the move was associated with decreased wages. The following comments from female nurses, specifically an AD nurse in Minnesota, and two BS RNs in North Carolina, and Texas support the widespread and recurring nature of this issue for nurses:
If I could do it over again I never would have wasted 4 years in school getting a nursing degree. I have never been treated so poorly in any job as I was at the hospital job I had. I understand why there is a nursing shortage. The "OLD" nurses either need to treat the new nurses with kindness, respect and understanding or - get out (quit) if they hate their life and their jobs that bad. The doctors also need to treat the nurses with more respect - a day didn't go by when one or more rude doctors was yelling about something. All in all, a very BAD experience.
I was unprepared for the appalling way that physicians speak to nurses; physician poor behavior interfered with my goal to give my patients best care. Even a year after leaving nursing, I can't conceive of returning to the toxic environment that I experienced while being employed in the [named medical center] ICU.
I am shocked by the amount of backstabbing that the more experienced nurses are involved in. They are supposed to be setting the example for the nurses with less experience, but I have noticed that they take every opportunity they can to tear the newer nurses down, or point out their flaws to co-workers. Incidentally, most of what they point out (in the newer nurses) has to do with a lack of experience, confidence, or needed information (that one acquires by being told or taught). They forget that they weren't always the hot shot NICU nurses that they think they are now. They were once novices.
In addition, at time period two, the physical strain of bedside nursing is exacting its toll in the form of preterm labor and back and shoulder injuries, as well as numerous “bumps and bruises.” Along with the physical stress, the nurses’ comments detail mental strain associated with work load, complex patient acuity, technology, teratogenic agents, and “dirty” needle sticks. Physically and mentally, nurses at time period two are weary. As a result many nurses either look for positions with less physical and mental demands or return to school. Interestingly, even if the nurses are pleased with their current position, the physical and mental strain associated with hospital nursing is causing them to look for other nursing opportunities, while there are some nurses who feel trapped. The following comments from female RNs, in order, are from an AD nurse in North Carolina, and BS graduates in Minnesota, Georgia and Tennessee:
I have currently been searching for a job outside of the hospital since my scholarship obligation will be met in one month. My doctor has advised me to change my hours, since 12 hour nights has taken a toll on my body. I have developed arthritis in my spine due to abuse caused by occupation. I have interviewed with several Doctors' Offices and been offered a job at each one. These jobs pay about 35% less than I am making now. I have a family and can't take the pay cut or reduction in benefits. I feel trapped in the hospital where I have no choice but to continue taking the abuse of Doctors and patients' families.
I'm planning to go back for CRNA school. I feel that nurses are underpaid and overworked. I made that decision after having lost a pregnancy early after lifting heavy patient and going into preterm labor.
I stopped working in the hospital full time - specialty surgery - transplant - and started working for the kidney MDs in their office because of stress and my back.
I feel like this job I currently hold was a fabulous first job as a graduate nurse/new RN. However, after two years in this job I feel it has become too demanding physically and mentally. The stress level has risen greatly. I look forward to new experiences in nursing.
The nurses commented that assistance is needed to help with the physical labor of nursing, but noted that when there is “only one CNA for 15-20 patients,” little support is available. In addition nurses continued to complain of a lack of needed equipment. As a female BS nurse from Georgia noted, “My job satisfaction, morale in my new unit and personal current and long term health would be greatly improved by my hospital buying bariatric equipment.”
The nurses suggested the need for hospital administrators to begin to consider nursing safety and satisfaction along with customer satisfaction scores. At time period two, nurses are weary of the ever increasing demand for “administrative duties” and “state regulations” that impact RNs in the form of paper/computer work which takes them away from patient care. In addition, comments revealed that nurses attempted to bring their concerns to the “attention of supervisors/management and still the situation remains unrectified.” The nurses suggested the need for hospital administrators to begin to consider nursing safety and satisfaction along with customer satisfaction scores. RNs at time period two are also distressed at the “lack of rewards” for their services. In commenting on the fixed 3% annual raises and inadequate charge nurse pay, “I don't think the charge nurses get paid enough for the extra responsibility they have charging. I'm putting my license on the line for an extra $0.25/hour - that's not right.”
Finally, the strain of the work of nursing after more than two years is influencing the nurses’ personal lives. The constant inability to get out on time, shift work, and weekend/holiday working schedule is of particular concern when the nurses are parents. A female BS nurse from Tennessee described the weariness experienced at time period two thus:
The work environment and morale are at all time low, work hours and demands are up - persons working short or RNs working as LPNs and CNAs to fill the void. After the past 4 months I'm getting weary. I know there are more opportunities out there and I believe things will eventually settle down BUT WHEN?
In sum, the theme at time period one of How Dare You described the unacceptable communication patterns between providers and hospital management that caused NLRNs to either leave their employer or consider leaving after “the year” was completed. A year later, the verbal abuse continues to be noted but is augmented by a work environment that causes an enduring level of exhaustion leaving the RNs both physically and mentally weary.
Theme Four: Getting Out
At time period two, several RNs were simply leaving hospital nursing. Many believed they needed a year of experience in the hospital before moving on to other areas in nursing and now that the year was completed, they were following through on their plans and resigning from in-patient institutions. Nurses’ comments revealed they are "overworked," "overstressed," "underpaid," and "unappreciated." ...one RN...noted that given the current work stress in hospitals, nursing schools have a responsibility to educate students into the diversity of employment options for nurses outside of hospitals.The burdensome physical work, strain on their family life, and fear for patient safety has resulted in their looking for RN positions outside of in-patient institutions, regardless of salary differences. Additionally, many comments suggested that contractually RNs are unable to leave until their obligations have been completed. One nurse reported that “I have every intention of leaving my current position once my contract is up, however to do so beforehand would cost me $5,000.” The following comment is from a female diploma RN in Arkansas:
Nurses are very underpaid and underappreciated. I thank God for my current job because it was definitely a blessing from him and although I am proud that I became an RN & because I love my current job I must say if I had to go back to hospital nursing I will probably go back to school for something else… Although Surgery Centers pay less than hospitals, this RN position gives me more flexibility with my family, especially our children's school and sports schedules and no longer required weekends, holidays, and call.
A few of those who have come to nursing as a second career are returning to their original profession once they have become disenchanted with the nursing profession. A female AD RN from Alabama noted:
I have an elementary education degree. The hours are so much better for me. If I work in a hospital setting the nurses are over worked, understaffed, and are often pulled to another floor or asked to work on their off days. The amount of hours/money paid is not worth quitting my teaching job… I went back to education where I felt more comfortable and appreciated.
However, many RNs make a distinction between the profession and their current position; that is, they acknowledge they find fulfillment in their new career, just not in their current position, which implies they are not leaving nursing per se, just the current employer. A female BS nurse’s comment from Georgia illustrates this finding, “I first worked on a med/surg floor at the hospital and was MISERABLE. I left after 4 1/2 months and moved to public health (health department). I am immeasurably more happy now.”
Additionally, one female diploma RN from Ohio noted that given the current work stress in hospitals, nursing schools have a responsibility to educate students into the diversity of employment options for nurses outside of hospitals. She explained:
At the time I completed the initial survey, I was struggling as a staff nurse for a major hospital on med/surg - observation unit. I had serious regrets about ever becoming an RN.… I now think nursing school puts too much emphasis on employment in hospitals. Students would be better served to learn more of the vast and various employment settings available to RNs.
At time period one, the theme You Want Too Much described NLRNs’ impression that their work environment demanded too much work, responsibility, and pressure with too little rewards. These findings persisted at time period two where comments suggested that the nurses in this study are considering or have followed through on their threat of leaving hospital nursing, and that the perceived perk of tuition reimbursement is now viewed as a restraining force.
Theme Five: Finding One’s Niche
Some RNs at time period two have found a home in nursing. They feel the internal reward of helping others and experience support professionally from their institution. Some RNs at time period two have found a home in nursing. They feel the internal reward of helping others and experience support professionally from their institution. Expressions like, “challenging,” “interesting varied opportunities,” and prospects of “continued professional growth” are dominant findings in their comments. Not surprisingly, many note that they have found their perfect niche in major medical centers that offer nurses a vast array of diverse positions. The satisfied RNs have a voice in the decision making on their unit or in their position and leave at the end of the work satisfied with the level of care provided. Likewise, the collaborative spirit that exists between physicians and nurses, nurses and nurses, and direct managers leaves them professionally content. Patient/nurse ratios are based upon acuity and “over census is taken serious[ly].” Additional benefits include competitive salaries, health insurance, bonuses, and mentoring of new RNs. Some noted that flexibility in scheduling has helped them achieve satisfaction with their current position; this flexibility has allowed for eight hour versus twelve hour shifts. While the twelve hour shift allows for fewer days at work, the eight hour shift aids their family obligations. As noted by a female AD nurse from South Carolina:
One of the biggest factors to my decision to change departments was the 12 hour shifts. My new position has an 8 hour shift which allows me to take care of a little bit of home responsibilities every day instead of spending my entire day off trying to catch up on laundry, groceries, etc.
A further finding is that some nurses are avoiding distress and capitalizing on their personal power over management because of the nursing shortage. Consider a female AD nurse’s comment from Connecticut, “I have two jobs now as a nurse. I work in two different EDs. I don't feel so trapped and unhappy. My first employer treats me better now that she knows I could leave at any time to work at another ED.
An overwhelming level of distress was associated with nurses’ work environment in this study. Yet, it is clear, that some institutions are capable of creating satisfactory working conditions, as illustrated in the comments of a female AD nurse from Minnesota and AD male nurses from Florida and Pennsylvania:
I am a 0.5 nurse in an academic research hospital with challenging pediatric patients. I've found a good work environment is critical in keeping nurses on our stressful heme/onc floor.
It is a zoo out there! Working at the Federal Government as an RN is the best! Better patients, serving our war heroes.
I have moved on and… I am really enjoying my new job. The [new position] has great benefits, treats staff with respect, and, most importantly, is focused on actually doing the best thing for the patient.
NLRNs at time period one were holding out hope for the future, and the theme Change is On the Horizon suggested optimism for the future as NLRNs spoke to transforming the systems where care is provided. It appears that for many their hope was realized.
Theme Six: Upward Mobility
...institutions offering RNs prospects for positions that are “varied, challenging and with more opportunities for learning and growth” may retain them. By time period two, several nurses in this study were heading back to school. Many comments revealed nurses are pursuing master's degrees with a specialty as a family nurse practitioner or nursing education while others are completing their baccalaureate degree. Reasons for the return have included either a personal desire for advancement or a need to escape “the physical demands of bedside nursing.” If not returning for additional academic degrees, they noted preparing for certifications or changing positions to ones that offer opportunities for challenges and advancement, particularly in critical care and emergency medicine. The RNs commented that institutions offering RNs prospects for positions that are “varied, challenging and with more opportunities for learning and growth” may retain them. Other suggestions to satisfy RNs included “more feedback at work, a mentoring program (after orientation & preceptorship ends), increased recognition, performance bonuses, increased pay for work performance or at annual review, a face-to-face annual review, and more job in-services.” In addition, their comments indicated that they expect to vary their positions over a career and will not be “long-term employees.” The following comments are from a BS RN in Arkansas and from an AD graduate Massachusetts, both of whom are female:
My main comment about job satisfaction is that I am satisfied but not content with my job. I would like to return to school and further my nursing education (Masters, etc.). If not for my desire to return to school I think I would be content with my current job.
I am satisfied with my job at present, but eventually plan to look for work at a larger institution with more opportunities.
This was a new theme for time period two and therefore no corresponding theme exists for time period one.
Discussion
The findings from time period two suggest that the focus of RNs’ frustration has shifted from self to environmental inefficiencies. Of particular note is the striking absence of RNs’ reports of personal inadequacy related to basic clinical skills in time period two as compared to the period one (Pellico et al., 2009). This finding supports others’ research of new RNs’ transitioning experience, where mastery of basic clinical skills allows nurses to see their actions within a larger context (Benner, 1982; Deppoliti, 2008; Duchscher, 2008; Yancey, 2005).
To address the specific work needs of the RNs...in their second and third years of practice, development of an advanced residency program is proposed. Although, some evidence exists about the positive effect of structured RN residency programs on the transitioning experience of new RNs in their first year of practice (Halfer et al., 2008; Salt et al., 2008), the extant literature is deficient in offering recommendations for improving work experiences of RNs in their second and third years of practice. To address the specific work needs of the RNs who are in their second and third years of practice, development of an advanced residency program is proposed. The program should be structured to provide the RNs with opportunities to effectively respond to environmental pressures illustrated in the themes from time period two (see Table).
As evident from the theme, The Reality of Being a Nurse is Nothing Like the Dream, the RNs identified the lack of nurse manager leadership as an obstacle in securing optimal staffing, workload, and the voice for staff RNs. These findings are consistent with research that shows nurse managers are not well prepared for this complex role (Anthony et al., 2005; Sherman, Bishop, Eggenberger, & Karden, 2007). Yet their ability to manage is essential for RNs’ job satisfaction (Boyle, Bott, Hansen, Woods, & Taunton, 1999; Bratt, Broome, Kelber, & Lostocco, 2000; Cox, Teasley, Lacey, Carroll, & Sexton, 2007; Friese, 2005; Hall, 2007; Lageson, 2004; Smith, Hood, Waldman, & Smith, 2005; Urden, 1999). While formal education and mentoring of nurse leaders should improve their management skills over time (Cummings et al., 2008; Mackoff & Triolo, 2008a, 2008b), an advanced residency could offer a centralized support system to buffer the effects of environmental pressures that unit-based nurse leaders or coworkers with different levels of work experience are not able to provide. For example, as part of the advanced residency, discussion-based forums led by experts from academia and from within the organization can be organized to create a dialogue with staff RNs about quality and safety in institutions, with particular emphasis on improving system inefficiencies.
Inefficiencies identified in the theme Pressured Time, such as patient load and acuity, redundancy in charting, delays in diagnostic testing, discharges, transfers, and interdisciplinary communication, also noted by Hendrich, Chow, Skierczynski, & Lu (2008), exert time and workload pressures that preclude the RNs from providing what they deem is optimal patient care. Bolton, Gassert, and Cipriano (2008) highlighted the need to involve the staff RNs in design of smart technologies (e.g., radiofrequency identification technology for tracking equipment and patient movement; voice communication devices, robots, handhelds) to optimize care processes and RN mental and quantitative workload, and thus increase the time for direct patient care. The advanced residency program could offer workshops where healthcare technology and equipment designers and nurses can partner to propose designs that can improve workflow obstacles that the RNs observe in their daily practice.
Organizational leadership should be alert to the needs of the RNs to learn new skills and advance professionally as soon as they enter their second year of practice. The RNs reported Getting Out of hospital settings because they were Growing Weary of verbal abuse and bullying by their nurse colleagues and physicians, a prevalent, but often neglected problem in the healthcare environment (Hader, 2008; Johnson & Rea, 2009; Nachreiner, Gerberich, Ryan, & McGovern, 2007; Rowe & Sherlock, 2005). To combat this growing problem, the advanced residency program could provide for a neutral ground where nurses could share their experiences of verbal abuse and bullying, be educated about the warning signs of abuse and reporting mechanisms, and participate in assertiveness training (Gallant-Roman, 2008). The advanced residency could also include interdisciplinary teamwork and communication training to develop the teamwork skills of the health professionals who continue to be educated in silos, but are expected to work in teams.
Musculoskeletal injuries (Gershon et al., 2007) are pervasive in nurses’ work environment and the RNs in this study reported that they are Growing Weary of the physical demands of bedside nursing that result in injuries. As part of advanced residency, the staff RNs could team up with an occupational health nurse to form an ergonomics committee to advocate for organizational adoption of patient lift equipment and lift teams that are shown to reduce injury rates and cost associated with lost work time (Chhokar et al., 2005; Guthrie, Westphal, Dahlman, Berg, Behnam, & Ferrell, 2004; Morgan & Chow, 2007) and to dispel the common assumption that proper body mechanics training alone is effective for preventing work related injuries (American Nurse Association [ANA], 2006).
Similar to the extant literature (Deppoliti, 2008; Lavoie-Tremblay et al. 2008; Maben, 2007; Wangensteen et al., 2008; Yancey, 2005) the RNs in this study report Finding One’s Niche in the jobs that offer variety, flexibility, and opportunities for learning and professional growth. Alternatively, the RNs who perceived that their work environment lacked opportunities for growth, learning, and mentoring reported pursuing graduate education or certifications to allow for Upward Mobility and an escape from the workload of bedside nursing. Organizational leadership should be alert to the needs of the RNs to learn new skills and advance professionally as soon as they enter their second year of practice. Advanced residency program could offer career counseling and organize internal job fair or networking events to connect staff RNs with mentors from within the organization based on mutual career interests. For example, the advanced-residency program could facilitate matching staff RNs who are pursuing graduate education in nursing administration, nursing education, or informatics with mentors who work in administration, education, or informatics within the organization. Further, the advanced residency could facilitate involvement of staff RNs interested in developing research skills in ongoing research in the hospital or an associated academic center in an area related to the RNs’ clinical specialty.
Conclusion
...the key contribution of the study is the highlighting...changing work needs of the RNs as they transition from a school to a work setting, and...from the first year of practice, onward. We believe that the key contribution of the study is the highlighting of the changing work needs of the RNs as they transition from a school to a work setting, and then again from the first year of practice, onward. Therefore, the focus of retention strategies should differ between these two time periods, first to offer support in clinical competency through an initial residency and then to offer support specific to work needs in the second and third years of practice through an advanced-residency program, such as the program that we described. The proposed advanced-residency program could be structured based on the needs of the RNs identified in this study. However, caution is warranted in generalizing the findings from this study to a general population of RNs who are in their second and third years of practice, because the findings of this study are based on the perceptions of nurses who may have been particularly satisfied or dissatisfied with their jobs, and who took the time to provide written comments about their experiences.
Acknowledgment
Funding was provided by the Robert Wood Johnson Foundation.
Authors
Linda Honan Pellico, PhD, APRN
E-mail: linda.pellico@yale.edu
Dr. Pellico is an Assistant Professor at Yale University School of Nursing, where she has taught medical surgical nursing in their accelerated graduate entry program for the past 20 years. Her research interests are in the areas of educational pedagogy, accelerated teaching and learning, and qualitative methods.
Maja Djukic, PhD, RN
E-mail: md1359@nyu.edu
Dr. Djukic is a research scientist at the College of Nursing, New York University (NYU), where she recently served as a Mary Clark Rockefeller Doctoral Fellow. Currently, she is working with Dr. Christine Kovner on the Robert Wood Johnson Foundation funded study “New Graduate Registered Nurse Panel Survey.” Her research focuses on the physical and social aspects of nurses’ work environment. Her dissertation examined the impact of physical work environment, including architectural, interior design, and ambient features, on nurses’ work satisfaction. Dr. Djukic received her Master’s degree in Nursing Education from NYU.
Christine Tassone Kovner, PhD, RN, FAAN
E-mail: ctk1@nyu.edu
Dr. Kovner is a Professor at the College of Nursing, New York University (NYU), Senior Fellow at the Hartford Institute for Geriatric Nursing at NYU, and a Faculty Fellow at the NYU Langone Medical Center. Dr. Kovner’s research focuses on the cost and use of health personnel. She is currently the principal investigator of a panel study on newly licensed registered nurses, who will be followed over ten years following graduation. That study is funded by the Robert Wood Johnson Foundation. She has recently completed two Agency for Healthcare Research and Quality funded grants. One was on nurses’ decisions to work and the other was on nurses’ working conditions.
Carol S. Brewer, PhD, RN
E-mail: csbrewer@buffalo.edu
Dr. Brewer is a Professor of Nursing at the School of Nursing, University at Buffalo and the Director of Nursing for the New York State Area Health Education System Statewide Office. Dr. Brewer’s research has focused on understanding the dynamics and responses of RNs as they make workforce decisions, which is key to developing effective policy. She is Co-Principal Investigator of two grants from the Robert Wood Johnson Foundation to study newly licensed registered nurses over ten years. She has also served as the Principal Investigator on two grants funded by the Agency for Healthcare Research and Quality, a study of workforce decisions of RNs in Western New York, and a national panel study to examine workforce behavior of RNs in Metropolitan Statistical Areas.
Brewer, C.S., Kovner, C.K., Greene, W., Tukov-Shuser, M., Fairchild, S., & Djukic, M. (2009). Understanding newly licensed registered nurses' work behavior: Do work attributes directly impact turnover? Manuscript submitted for publication.
Buerhaus, P. I., Auerbach, D. I., & Staiger, D. O. (2009). The recent surge in nurse employment: Causes and implications. Health Affairs, 28(4), 657-668.
© 2009 OJIN: The Online Journal of Issues in Nursing
Article published November 2, 2009
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