More work + changing roles = less satisfaction for providers and patients
More work + changing roles = less satisfaction for providers and patients
Organizational restructuring impacts quality of care nurses give patients
Editor’s Note: This is the first of a three-part series looking at how effective definitions of provider roles can enhance patient, physician, and staff satisfaction. In this article, we will look at some of the most recent research on nurses’ job role complexity. Next month, experts will share their thoughts on why proper definition is important and how to achieve it. In January, Patient-Focused Care and Satisfaction will look at organizations that have had a problem in this area and how they solved it.
It is not news to most nurses that in the last decade, they have taken on an increasingly important role in hospitals. They spend more time managing other staff, working with administration, and caring for patients in ways that used to be the purview of physicians. In many ways, those changes have been positive, raising the importance of nurses in the eyes of their other health care colleagues and giving them more decision-making power.
But at the same time they are taking on more important functions that have a great impact on patient care, many nurses find themselves burdened with work formerly handled by clerical staff, aides, and nursing assistants that were eliminated as part of cost-containment programs. And a slew of recent research suggests that the changing roles of nurses and the increasing complexity of what they do is having a negative impact on patient, staff, and even physician satisfaction. Worse yet, it may adversely affect quality of care and patient outcomes.
Two studies, one released in February by the Chicago-based American Organization of Nurses (AONE) and the other in 1997 by the Amherst, NY, consulting and research firm EC Murphy LLC, explain this disturbing trend.
"The competencies we need now are very different than what we needed before," says Marjorie Beyers, PhD, RN, FAAN, AONE’s executive director. "There has been a blending of roles, and we have to take on both clinical and business knowledge. Technology is changing, reimbursement is changing, and all it takes keeping up by nurses."
Mark Murphy, vice president of business development at EC Murphy, was part of a team that conducted a survey of more than 47,600 nurses in 1997. The nurses worked at some 138 acute care facilities and reported on their roles. The study found that the typical RN has an excessive number of activities to do, resulting in a loss of focus on the core activities that affect patient care. There is also significant job overlap with other job classes. Those characteristics lead to reduced morale, declining patient and physician satisfaction, and increased health care costs, the study says.
The AONE study found that many of the 338 acute care facilities surveyed are finding it more and more difficult to find nurses with competence, skills, and the appropriate experience to meet their expanding roles. And even when hospitals do find such staff, those hospitals will continue to find it a challenge to retain them.
Twice as much work as they need
"If you ask nursing leaders what their key core activities are, they list maybe 30 things," says Murphy. "What we found was that they do those activities about 51.4% of the RN time. But the rest of the time is spent doing other tasks — clerical activities or patient care activities that could be more appropriately performed by others, like nonclinical patient transport and toileting assistance."
Indeed, the study found that nurses report some 74 activities they commonly perform during the course of their job, he says.
The overlap issue the survey illuminated is as distressing to nurses as the core activities problem, continues Murphy. "One thing we found was that RNs say that 71% of the work they do is also performed by other job classes. We have a de facto blurring of the boundaries between them and other groups."
While most people could intuitively guess that those issues are bad for hospitals and health care in general, the study found specific evidence that that was so.
Emmet Murphy, PhD, president and CEO of EC Murphy, says the importance in getting work roles right goes beyond keeping staff and patient satisfaction levels high. "There is a correlation between productivity, morale, and motivation of the nurse, patient satisfaction, cost per discharge, and the complexity of the job."
Complex RN role negatively impacts care
There is a sense in hospitals, Emmet Murphy continues, that administrators can cut costs by shunting work traditionally done by physicians onto nurses on one end, and by cutting some of the lower job categories and making nurses do that work, too. But it is a false economy. By increasing stress and dissatisfaction, the hospitals increase the number of days nurses call in sick. They also increase the difficulty of finding and retaining good nurses.
The AONE study confirmed that the changing role of nurses is leading to more job stress and dissatisfaction. "Shortages of nurses in clinical specialty areas and nurse executives and managers contributed to the perception that clinical and management support for staff nurses is lacking," the executive summary states. "This lack contributes to a difficult, dissatisfying environment for experienced nurses, novices, patients, and physicians."
Perhaps most significantly, the EC Murphy study found that the more complex the RN role was, the bigger the threat to quality of care. "Complexity and loss of focus threaten clinical quality because they diffuse the energy that RNs should focus on patient care," the study states.1
The EC Murphy survey also concluded that organizations with more complex RN roles had higher health care delivery costs. Using the nonclinical transport example, nurses at one facility studied accounted for 11% to 13% of the time spent on patient transport, and 17% to 24% of the cost. A radiology escort accounted for just over a fifth of the time, but only 14% of the cost. This facility eliminated the nonclinical transport function from the RN role and was able to increase the time nurses spent on direct patient care while saving money.2
The survey points out another issue, says Mark Murphy. "Many hospitals are trying to eliminate labor costs through the reduction of full-time employees." But that can also have an impact on patient satisfaction and on mortality and morbidity. "What we have found is that the best way to use labor dollars more effectively is to leverage the three issues of focus: 1) whether you are doing the right work; 2) overlap — whether anyone else is doing the work; and 3) complexity — whether the job itself has too many parts."
If you do that, you can cut some of these extra labor costs that result from sick and tired nurses and high turnover rates. "You can keep those costs out for the long term, improve patient, employee, and physician satisfaction, and protect quality of care," Mark Murphy says. "If you are the CEO and face balanced budget pressures, this is the most effective way to manage your organization’s labor costs."
There is no single right answer to the problem, Mark Murphy says. "It really depends on the mix of staff you have in place and how hard you find it to hire various kinds of people. You have to create RN ideals and other ideal roles; and then based on your current practice, migrate over to that ideal."
Emmet Murphy is quick to point out that there really is no "bad guy. It’s more an issue of people having to work harder at getting the roles right," he says. "The only people who can solve this is nurses and managers."
Beyers also has a caveat. "What we found in our study is that much of medicine is local," she says. "The problems you will find in one particular hospital may be very different than what you have in another. And that means that the solutions are different."
She thinks that things will improve, particularly as funding for new nursing administration graduate studies comes on-line. But since that funding has been absent for some six years, "there is still some catching up to do."
EC Murphy hopes to contribute to the problem solving by conducting another study that gathers potential answers and looks at how health care organizations have put them into action.
References
1. Murphy EC, Ruch S, Pepicello J, et al. Managing an increasingly complex system. Nurs Manage 1997; 28:33-36, 38.
2. Murphy EC, Murphy M. Cutting healthcare costs through work force reductions. Healthcare Financial Management July 1996; 64-69.
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