Working conditions really have deteriorated for nurses. Are CEOs paying attention?

Last week I wrote about why many doctors and nurses believe the word “burnout” – which has been thrown around plenty these days – fails to convey the institutional failings that they confront everyday at work.

The comments and shares show that the piece clearly struck a nerve.?

This week, I want to take the question one step further: what does a healthy work environment look like?

A new paper in the journal Critical Care Nurse underlines just how rapidly conditions – and morale – have been deteriorating. One number in particular stands out to lead author Beth Ulrich, EdD, RN, FACHE, FAONL, FAAN , a professor of the Cizik School of Nursing at UTHealth – and that’s how many nurses are not just dissatisfied with their jobs, but with their profession entirely.

Over the past four years, there’s been a near-20-point decline in the number of nurses who say they’re “very satisfied” with being a nurse, from 62% in 2018 to just 40% last October.?

Those numbers come from a survey of thousands of nurses that the AACN (American Association of Critical-Care Nurses) has conducted every few years since 2006. Last year, it expanded the number of respondents to include nurses in all practice areas, with the overwhelming majority (or 92%) working in acute-care hospitals.?

What Ulrich and her co-authors found after analyzing the data was a decline in all measures that would define a healthy work environment: from having input in decision-making, to being recognized for hard work, to having appropriate levels of staffing, to feeling physically and psychologically safe.?

“It’s been so unhealthy that now they're saying, not only do I not want to be [at my job], but I don't want to be anywhere else either,” Ulrich said in an interview. “We've really got to figure out a way to re-engage those nurses and help bring joy back into the profession – because we don't want to lose that percentage of nurses who were very satisfied being a nurse and now aren't.”

Nurses in smaller, one-hospital communities might be particularly at risk of leaving the profession, she added, because there are fewer opportunities for them to go elsewhere.

In the survey, the largest decline since 2018 was around staffing, and specifically staffing that matches patient needs with nurses who have the competencies to care for them.

But staffing hasn’t been the only factor contributing to decreased satisfaction, Ulrich said. The nursing shortage was also bad in 2006, for instance, but that alone didn’t cause a fall-off in how nurses felt about being a nurse.?

Rather, it’s been a confluence of issues – most of them existing before the pandemic, but all of them now getting worse. Some of the dissatisfaction also comes down to feeling disrespected in the workplace, like being asked to reuse or go without personal protective equipment during the early days of the pandemic, Ulrich said.

One area where nurses have felt like their concerns have been ignored is around workplace violence, something that’s been well-documented as getting worse. Nurses have long held one of the most dangerous jobs in healthcare but these days less than half of the AACN’s survey respondents said they feel like their safety is valued, down from 68% in 2018.

Compounding all those issues, Ulrich added, is also the overarching feeling of “pandemic uncertainty” – how much longer will nurses need to muscle through??

The exodus from nursing is already in full swing; nursing turnover this year stands at 27.1% for U.S. hospitals, “an exponential increase” over 2021, according to Dani Bowie, DNP, RN, NE-BC , vice president of clinical strategy and transformation at software company Trusted Health. “That's a very costly impact to our patients and also the operating budget of the health system,” she said.

Two factors have contributed to the increase, she noted. Mental health and wellbeing still haven’t recovered from the peak of the pandemic. And nurses are looking for more flexibility in their schedules.

Bowie is part of the Nurse Staffing Think Tank – a partnership between the AACN and other healthcare organizations – that published recommendations this past spring that aim to address the crisis in nursing. The group focused on recommendations that healthcare organizations could implement over the next 12 to 18 months.?

The recommendations include a long list of possible solutions, from addressing workplace violence, to tailoring compensation packages for different life stages, to setting up an internal travel agency for nurses who want that experience.

Bowie also acknowledged the pressure facing frontline managers, who can have anywhere from 85 to 110 direct reports.??

“The experience of our frontline managers is just as hard as the direct care nurse in that their workload is very heavy,” she said. “They were not given the tools and technology they needed to do staffing and scheduling well, so they spend 60% of their time just trying to fill shifts, which doesn't give them time to think strategically.”?

There are also generational factors to consider. Gen Z nurses – thrown into a world with virtual onboarding, overworked managers and struggling coworkers – haven’t known anything but covid, and more than half say they don’t plan to stay in the profession their entire career. Baby Boomers, on the other hand, were once willing to defer their retirements, but are now at the point where they’re ready to leave en masse, Ulrich said.?

Yet getting health systems to recognize the return on their investment for addressing the crisis continues to be a challenge. When asked about whether health systems have started to enact these recommendations – which were designed to be achievable in the short- to intermediate-term – Bowie said many have reached out about flexible staffing arrangements or setting up an internal travel agency.

But she acknowledged that progress at health systems can be slow. “If they continue to cut [incentives or benefits], they further walk down the path of losing their workforce, which is very dangerous for them right now,” she said.

Staffing is the most expensive line item for any health system, but there are lower-hanging fruit that don’t cost anything, Ulrich pointed out. “Culture trumps the other stuff every time,” she said, referring to policies like zero-tolerance for workplace violence, consistent communication throughout all levels of the organization and giving nurses a seat at the decision-making table.

Meanwhile, failing to invest in a healthy work environment creates more costs down the road, not only due to turnover but also medical errors.??

“The first thing to remember is that [creating] healthy work environments for nurses isn't just about nurses,” Ulrich said. “It's about nurses and patients. That's a big piece of the connection that we have to help people make.”

How would your employer score as a healthy work environment? Have things gotten better or worse? And what would help at this time?