Impact of Work Environment on Home Care Nurses and Quality of Care A Program of Research

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Impact of Work Environment on Home Care Nurses
and Quality of CareA Program of Research

• Linda Flynn, PhD, RN
• NJ Collaborating Center for Nursing
• Rutgers College of Nursing

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Greetings From Rutgers University, NJ
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Rutgers College of Nursing

• On-line and Class Room Programs
• RN-BSN Program
• MSN Program
• PhD

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Outline

• I. Work Environment What can we learn from
  hospital-based research?
• II. Work Environment in Home Care What agency
  traits are important?
• III. Impact of Home Care Work Environment on
  Nurse and Patient Outcomes Recent Evidence
• IV. Getting Started Evidence-based Strategies
  for Enhancing the Work Environment in Home Care

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I. Work Environment - So What?
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In early 1980s ANA Noticed That Some Hospitals
Attracted Nurses Despite a Severe National
Nursing Shortage
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ANA Conducted Extensive Focus Groups with Nurses
At These Hospitalsto Determine Why?(McClure,
Poulin, Sovie, Wandelt, 1983)
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3 Categories of Magnetic Work Environment Traits

• Administration
• Professional Practice
• Professional Development
• Traits that support my job satisfaction and my
  professional practice

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I. Administration

• Participatory Governance
• Open Communication
• Strong, Well Qualified, Visible Nursing Leaders
• Managers Supportive to Nursing
• Quality and Quantity of Nursing Staff
• Personnel Policies

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II. Professional Practice

• Autonomy Within Scope of Practice
• Quality Care
• Support for Education
• Good Relationships with Physicians
• Clinical Specialists/Consultants

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III. Professional Development

• Preceptor Orientation
• Inservices Support for Education
• Career Development Opportunities

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Descriptions of Magnetism Similar to
Sociologys Descriptions of Professional Work
Environment
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Organizational Theory Professional or
Bureaucratic Work Environment?

• Staff Autonomy or Rigid Policies?
• Interdisciplinary Collaboration or Segregated
  Tasks?
• Open Communication or Hierarchical Communication?
  
• Managerial Support or Managerial Control?

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When the Workplace Supports Professionalism
Instead of Bureaucracy.
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• Staff are Happier
• Staff are More Effective
• The Organization Has Better Outcomes

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Aikens Conceptual Model Of the Nurse Work
Environment (Aiken, et.al. 2002)
Nurse Outcomes
Administrative Support Resource Adequacy RN/MD
Relationships Nurse Autonomy
Staffing
Patient Outcomes
Surveillance
Process of Care
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Questionnaire Developed to Measure Nurse Work
Environment in Hospitals

• Nursing Work Index
• (Kramer Hafner, 1989)
• Nursing Work Index-Revised
• (Aiken Patrician, 2000)

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Professional Work Environment Superior Nurse
Outcomes

• Significantly Lower Levels of Nurse Burnout
• Aiken Sloane, 1997
• Significantly Lower Levels of Nurse Burnout
  Across Cultures of Origin
• Flynn Aiken, 2001

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Even More Superior Nurse Outcomes!

• Higher Job Satisfaction
• Aiken, Clarke, Sloane, 2002
• Aiken, Havens, Sloane, 2000
• Fewer Needlestick Injuries
• Aiken, Sloane, Kocinski, 1997
• Clarke, Sloane, Aiken, 2002

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Professional Work Environment Superior Patient
Outcomes

• Lower Patient Mortality!
• Aiken, Smith, Lake, 1994
• Aiken, et. al., 1999
• Higher Levels of Patient Satisfaction
• Aiken, Sloane, Lake, 1997
• Aiken, et. al., 1999).
• Higher Levels of Quality of Care
• Aiken, Clarke, Sloane, 2002

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Institute of Medicine Keeping Patients Safe
Transforming the Work Environment of
NursesNational Academies Press2004
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So What? Why Should Home Care Worry About Work
Environment?
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ProblemAs the need for home care is rising
home care is experiencing a nursing shortage
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Severe Nursing Shortages Predicted

• In 2020 US will be short 1 million RNs
• In 2020 home care will need 2x number of home
  care nurses as in 2000
• USDHHS National Center for Health Workforce
  Analysis (2002)

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Nursing ShortagesAn International Problem69
Countries Report Nursing Shortages(2003) ICN,
SEW News, 1
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Reported Nurse Shortfalls

• Canada 113,000 shortfall
• UK 22,000 shortfall
• Denmark 22,000 shortfall
• Germany 13,000 shortfall
• Netherlands 13,000 shortfall
• Switzerland 3,000 shortfall
• (2003) ICN, SEW News, 1.

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But Home Care Nurses Love Their Jobs!.Dont
they?
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Home Care Nurse Dissatisfaction

• 30 of Home Care Nurses Report Dissatisfaction
  with Job (National Sample Survey, 2000)
• 21 Turnover rate Among Home Care Nurses
  Estimated Nationwide
• 18 Vacancy rate Among Home Care Nurse Positions
  Nationwide
• (U.S. General Accounting Office, 2001)

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Home Care Nurses PA

• Survey of 1,251 Home Care Nurses in PA
• 35 Dissatisfied with Job
• 41 Report Quality Has Deteriorated Over Last
  Year
• Center for Health Outcomes Policy Research,
  University of PA (2001). Unpublished Data

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Home Care Nurses NJ

• Survey of 800 Home Care Nurses in 2002
• 28.7 Home Care Nurses Plan to Leave Job within
  Year
• 56 Home Care Nurses Cited Dissatisfaction with
  Working Conditions as Primary Reason
• NJCCN (2003)

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Intent-to-Leave in New Jersey

• Long Term Care 35.6
• Hospitals 31.4
• Home Care 28.7

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Work Environment in Home CareWhat Agency
Traits Are Important to Nurses?
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Research Question

• What Are the Characteristics of Home Care
  Agencies That Home Care Nurses Consider Essential
  to
• Support of Their Professional Practice
• Job Satisfaction

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Focus Group Study

• Funded by grant from Xi Chapter
• Published in Journal of Nursing Scholarship,
  December, 2003

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Sample n 58

• 91 Female 9 Male
• 67 White
• Mean Age 44.75 years
• 50 Worked At Least 7 years in H.C.
• 7 Focus Groups
• 6 Agencies
• 3 East Coast States

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Identify describe those features of home care
agencies that you consider essential to your
professional practice and job satisfaction
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Summary of Valued Traits Home Care

• Extensive, Preceptor-Based Orientation
• Competent Supportive Management
• Organized Supportive Office Environment
• Reasonable Working Conditions
• Patient-Centered Mission Vision

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Traits Not Described By Hospital Nurses

• Real Time Phone Support
• Communication Coordination
• Adequate Clerical Assistance
• Field Security
• Uncompensated Care

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What About Home Care Nurses in the Rest of the US?

• Nationwide Survey Funded by American Nurses
  Foundation and published in Home Healthcare Nurse
  (2003)

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Nationwide Survey

• Open-ended questions asking nurses to list
• agency characteristics most important to
  practice and job satisfaction
• 61 Response Rate (n 403)
• 48 States Represented

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Qualitative Findings
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So What About the NWI-R?How important to home
care nurses are the work environment traits
listed on the NWI-R?
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Aims of Study

• Determine if common set of nurse work
  environment traits similarly valued by hospital,
  home care and district nurses.
• Evaluate the applicability of NWI-R as measure
  of work environment in non-hospital settings.

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Sample Demographics(n 1,329)
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Findings

• 85 of Home Care Nurses
• 86 of District Nurses either agreed or
  strongly agreed on
• 47 of 49 items as important to support of
  their professional practice

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ANOVA
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(No Transcript)
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Conclusions

• There is a CORE set of work environment traits
  similarly important to nurses in home care,
  district nursing, and hospitals
• The NWI-R appears to be a valid measure of the
  nurse work environment in home care and district
  nursing as well as hospitals

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Work Environment in Home CareImpact on Nurses
and Quality Care
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Will Supportive Nurse Work Environment Predict
Positive Nurse and Patient Outcomes in Home Care?
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National Survey of Home Care Nurses (2004)

• Modeled after work of Aiken, et. al.
• Response rate of 52
• Sample 137 RNs from 38 States
• Nurses rated
• Agency work environment (NWI-R)(Organizational
  Support .84)
• Job satisfaction
• Quality of care provided by agency
• Frequency of certain adverse patient events

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Nurses As Key Informants (Aiken, et. al., 2003)
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Sample Demographics

• Average age 50 years old (SD 9.29)
• 50 at current agency for at least 8 years
• 56 had BSN or higher
• 98 female
• 90 Caucasian

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Correlations ( p .01)
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Organizational Support was the ONLY significant
predictor of uncontrolled pain, explaining
11.4 of the variance in uncontrolled pain (B
-.264, p .002)
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Quality of Care ( p .01)
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JOB SATISFACTIONOrganizational Support (B
.186, p .044) Quality of Care (B .265, p
.004)predicted Job Satisfactionexplaining 15
of the variance
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Preliminary Conclusions for Home Care

• Organizational Support associated with
• Higher Job Satisfaction of Home Care Nurses
• Higher Nurse-Assessed Quality of Care
• Lower frequency of Uncontrolled Pain
• Organizational Support trumps Staffing/Workload
  as predictor of positive outcomes

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Current Study

• Grant from RWJF to collect data
• Collaborating with Aiken and team
• Surveying 50 of all nurses in NJ, PA, CA
• Aggregate responses to facility level
• Impact of nurses work environments on multiple
  nurse and patient outcomes in
• HOSPITALS
• HOME CARE
• LONG TERM CARE

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Getting StartedEvidence-based Strategies for
Enhancing the Work Environment in Home Care
Agencies
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Donabedians Quality Model (1980)
Structure
Outcome
Process
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Structure

• Working with clinically competent nurses
• Good orientation program for new hires
• Plan of Care accessible and up-to-date
• Enough RNs on staff to provide quality patient
  care

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Process

• Supervisory staff supportive of nursing
• Nurse managers who are good managers and leaders
• Not placing nurses in position of having to do
  things against better judgment
• Nurses have freedom to make important decisions
• Administration listens and responds to concerns
• Good relationships between nursing other
  departments

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ConclusionA culture of quality and retention
requires evidence-based structure and processes
that create a supportive nursing work
environment
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lflynn_at_rutgers.edu