Commitment and Care: The benefits of a healthy workplace for nurses, their patients and the system

Main Messages

  • Canada s nursing shortage is at least in part due to a work environment that burns out the experienced and discourages new recruits. But that environment can be changed.
  • The job satisfaction level of nursing staff has been shown to be a strong determinant of the overall satisfaction level of clients. Satisfaction improves with manageable workloads and when employers make it easier to balance work and home life.
  • Nurses greatly stressed and vulnerable to injury have a higher absentee and disability rate than almost any other profession, which disrupts care, makes planning difficult and costs the healthcare system a great deal of money.
  • Increased workloads improve short-term productivity but increase long-term costs, as nurse stress and illness may lead to poor judgment and low productivity that can hurt patients.
  • Delegating more work to aides and unit clerks so nurses can concentrate on their patients reduces some of that stress.
  • Nurses work best and have more loyalty to their employers when their expertise is respected, they have some control over their lives (such as the ability to set their own hours) and they are free to practice to the full scope of their education.
  • Keeping staff is easier in a less-stressful, more supportive workplace, and good relations on the care-delivery team benefit patients and may even reduce death rates. Reducing staff turnover and letting nurses practice independently within a co-operative setting could do much to improve the work atmosphere.
  • There are many other ideas in this report some based on experience, some drawn from research evidence that can help improve nurses working environment. Some are as simple as providing parking spaces close to the building for the safety of night workers; others, such as multi-year funding for the healthcare system, require co-operation on every level, from employers to the federal government.

Executive Summary

The Canadian healthcare system is facing a nursing shortage that threatens patient care. Many nurses, physically and mentally exhausted, quit; employers can t fill those vacancies, while paradoxically other nurses can t find secure jobs with hours that suit them. Meanwhile, nursing schools can’t keep up with the demand for new recruits.

While caring for the sick and dying has always been demanding, many of the problems facing nurses today seem to arise from work environments that have grown increasingly difficult through the cutbacks and upheavals of the 1990s. This paper was commissioned to answer two questions:

What is the impact of the working environment on the health of the nursing workforce (and hence, potentially, on patient outcomes)?

What effective solutions could be implemented to improve the quality of the nursing work environment (and hence, potentially, patient outcomes)?

Research has made it clear that problems with nurses work and work environments, including stress, heavy workloads, long hours, injury and poor relations with other professions can affect their physical and psychological health. Research across occupations has shown long periods of job strain affect personal relationships and increase sick time, turnover and inefficiency.

To prepare this report, we did a wide-ranging survey of peer-reviewed research on nursing and work in general; read a vast array of other writing on the state of nursing; and interviewed or held focus groups with healthsystem managers, nurses, government employees, educators, representatives of nurses associations and unions.

From these sources, we outlined the problems facing nurses and defined them as issues of work pressure, job security, workplace safety, support from managers and colleagues, control over practice, scheduling and through stronger leadership roles for nurses and rewards. There is no denying the seriousness of the challenges facing nursing, but we found many solid ideas for improving the situation.

There are clear reasons why those running the healthcare system from the largest hospital to a small community clinic as well as the ministries who set their budgets and shape policy at the federal and provincial level, need to act. Organizations that do not create quality environments to attract new recruits and retain experienced nurses risk shortages that may endanger patients.

What can be done? Nurses, like most people, need some basic predictability in their lives. That means they need to get back a sense of job security and feel that the risk of injury and workplace violence has been reduced. Longer budget cycles would help employers ensure that jobs won t disappear.

Better equipment and more staff can help reduce the risk of injuries, which increases when there is no one to help turn a patient or when a nurse gets so busy and overextended that she pricks herself with a used needle.

Studies show good relations among caregivers benefit patients, even to the point of reducing mortality. We believe that means nurses need more support on the job, from managers who understand their work, respect their expertise and can offer a sense of security and community. It means rebuilding a team approach to nursing where the focus can be on the patient and not on inter-professional conflict. It means ensuring a manageable workload; it means offering educational and career opportunities and the time to pursue them.

One study found that nurses job satisfaction is the strongest determinant of clients overall satisfaction. Like most people, nurses work best when they have a sense of control over their jobs and their lives. That sense of control can be created by giving nurses more voice in patient-care planning, more voice in policy-making and more say over the way they work (such as being able to set their own hours or not making them work mandatory overtime).

A demoralized worker is not a productive worker, and nurses have a sense they are not valued by the healthcare system for which they work so hard. Despite the increasing shift of care into the home and other non-hospital settings, community nurses are often paid less than their hospital counterparts. Some casual nurses have more say in their hours than fulltime employees. Money isn t everything, but it is an important measure of worth. Incremental pay increases recognizing expertise and experience, combined with more opportunities in management and a clearer voice in running the system, would improve the status of nurses in their own eyes and throughout the system.

This summary outlines some ideas for improving working conditions in healthcare. There are many more in the report itself, ranging from finding more positions for nurse practitioners to including standards for healthy workplaces in hospital accreditation. Some are simple to act on locally; others will require co-operation. If better patient outcomes are to be attained, governments, employers, educators and nurses must work together to create a healthy nursing work environment.