Striving Towards Better Care:

Healthy Workplaces, Healthy Nurses, Safer Patients

Long-term and acute care settings are facing important challenges regarding patient safety. Ongoing research demonstrates that significant factors in nurses’ professional practice environments can influence positive patient care outcomes.

Changes over the last two decades have led to a deterioration of the long-term care work environment. Funding has not kept up with inflation. The proportion of the population that can no longer live independently, and is unable to receive familial help, is increasing. The well-being of fragile or elderly individuals requiring support may deteriorate, if home assistance is not available or accessible. Older people who arrive in a hospital as a result of a serious medical crisis or chronic neglect of a medical condition are left in acute care far too long because of shortages of long-term care beds in several provinces.

Long-term and chronic care providers need to prepare for the significant increase in senior care required in the coming decades by ensuring that registered nurses (RNs) play an important part in that preparation. In 1996, seniors made up more than 12% of the Canadian population. By 2041, they will make up more than 22%.

Concerns and Challenges

Without a strong long-term care system in place to meet the rising demand for resources and services, the increasing workload may quickly become unmanageable. For example, in Ontario nursing homes, RNs are often responsible for 60 residents during the day and sometimes over 100 on a night shift. The nursing leadership working in geriatric care units argue that more gerontology-certified RNs are needed in all facilities.

Long-term care facilities and home care organizations cannot afford to lose any more RNs and cannot operate without them. RNs are knowledge workers who conduct in-depth assessments of residents’ needs, set goals with the residents and/or family members and implement individual care plans with other staff. When implementing the care plans, RNs determine the patient needs and assign the appropriate nursing staff. They also oversee dayto- day operations of one or more units, interact with other health care providers, and meet with and support families.

The Canadian Nurses Association (CNA) is recommending ways in which health care providers can improve patient health and safety by improving working conditions so that they will be able to recruit and retain productive RNs to provide care to their patients. Research shows that a healthier, safer workplace for nurses means a safer environment and better health outcomes for patients. “If better patient outcomes are to be attained, governments, employers, educators and nurses must work together to create a healthy nursing work environment.”

The Canadian book, How to Evaluate and Select a Nursing Home, suggests that patients and their loved ones who are looking into long-term care should ask some hard questions: “Is the nursing supervisor a registered nurse? In many homes, direct patient care is generally given by other personnel, but a large RN contingent is definitely a good sign.” A higher proportion of RN staff has been linked to “lower 30-day mortality...in non-urban hospitals” and in some community settings but little research is available in long-term care settings. Workplace Issues

Why are there RN shortages in the long-term care sector? As more RN positions change and tasks are assumed by other health care providers, RNs are re-evaluating the role that they are required to play in this sector. In hospital settings, nurses report that the number of RNs is inadequate to allow them to provide safe and effective care.

In addition, RNs are concerned about the well-being of their patients as well as their own while they are at work. Several areas of concern have been identified, many caused by having too few qualified staff on duty. “Nurses are working harder, caring for more individuals, and spending less time with each person. What has shrunk in this changing environment is the amount of time they have to assess, monitor and provide appropriate nursing care as well as be teachers, comforters and communicators.”

Several studies have revealed relevant findings about the link between staffing practices and the outcomes for patients:

• Increasing the numbers of RN staff will lead to a decrease in patient mortality rates, and
• The increase in one hour worked by RNs per patient day was associated with an 8.9% decrease in the odds of getting pneumonia.

There are safety risks that nurses face as well. Nurses suffer a very high rate of strains and sprains, sometimes from moving patients without adequate assistance. Other injuries are a result of punctures from needles or other medical instruments. A worker can only maintain an extremely high level of stress for so long, and many nurses, if they haven’t been physically injured, are forced to take leave from their jobs to recover psychologically. “In hospitals with high patient-to-nurse ratios…nurses are more likely to experience burnout and job dissatisfaction.”

Understandably, patients can react to a strained environment. The strain they sense may increase agitation, confusion, delirium, etc. This may then result in physical assault and aggressive acts towards care providers. Unfortunately, nurses are usually in the line of fire when frustration becomes too much. “Nurses are more likely to be attacked at work than prison guards or police officers.”

When nurses are trying to provide patient care in a workplace that is unhealthy, it becomes very difficult for nurses to function and provide optimum care. The CNA Code of Ethics for Registered Nurses states: “Nurses value the ability to provide safe, competent and ethical care that allows them to fulfill their ethical and professional obligations to the people they serve.”

Recruitment and Retention

RNs are essential for the smooth operation of a long-term care facility or home care service. The Canadian Gerontological Nursing Association (CGNA) is an active national group whose mission is to address the health concerns of older Canadians and the nurses who participate with them in health care. CGNA has developed standards of practice for RNs and has participated with CNA to initiate certification exams. However, nurses certified in gerontology are becoming increasingly difficult to recruit for jobs in long-term care; many working in long-term care are experiencing high levels of work and ethical stress.

The nursing shortage needs urgent attention. According to a CNA study, Canada will see a projected shortfall of 78,000 RNs by the year 2011, increasing to 113,000 by 2016. “Among the employment sectors, the most severe losses are expected in the long-term care sector, where the equivalent of 19% of the 2001 workforce could be lost to retirement or death by 2006... The implementation of successful retention incentives could significantly reduce expected losses of RNs due to retirement.” Also, with fewer nursing seats in universities than 25 years ago, not enough nurses are entering the profession to replace those leaving.

Additionally, heavy work loads, long shifts, removal of nursing leadership positions and a perceived lack of control all result in a very high level of stress in the health care workplace for nurses and other health care workers. Many nurses are leaving the profession and others are absent for short and long periods due to stressful working environments. RNs working full-time have a rate of absence due to illness and injury that is 80% higher than the rate found among the overall full-time labour force (8.1% compared with 4.5%). Absentee wage costs amount to an estimated $325 to $440 million per year. Replacement costs could be significantly reduced if the rate of nurses’ illness and injury could be brought in line with other Canadian workers; these savings could be used for additional staffing needs.

“You cannot separate out staff well-being from client/patient satisfaction” stated the CEO of a large health care organization. RNs would add ... “and safety, too”. In terms of business or financial goals, workplace health translates into improved cost and productivity performance, and enhanced competitiveness. In a period of escalating concern over skill shortages, it can also help an organization become a preferred employer, improving its ability to recruit and retain employees.

Some Solutions

How can nurses be recruited to long-term care positions where they are desperately needed? RNs have made it clear: they will choose positions with a better quality professional practice environment, even over higher pay.

CNA has been working in collaboration with the Canadian Council on Health Services Accreditation (CCHSA) to ensure that nurses have an impact on improving health care work environments in Canada. The CCHSA is a national, non-profit independent organization and the national accreditation body for health services in Canada, including more than 1,000 long-term care facilities. The CCHSA voluntary accreditation program is called “Achieving Improved Measurement” (AIM) and requires a global evaluation of each organization, including management and professional practices. There is a self-assessment and an independent review of the organization seeking accreditation.

CNA has partnered with CCHSA to advance the use of quality of work life indicators in the CCHSA accreditation process. These indicators, developed in consultation with the national nursing community, include measuring full-time nursing positions, absentee rates, overtime rates, professional development opportunities and grievances. “These indicators are currently being tested for validity and reliability.”

This partnership continues to promote the importance of using work life indicators as a means to improve the health care workplace in Canada. By bringing this issue to the attention of the health care sector, and through collaboration with the CCHSA accreditation program to rectify the situation, RNs are working to create a better, stronger Canadian health care system.

According to Commitment and Care, a healthy workplace benefits nurses, their patients and the system. For example, less absenteeism means better continuity in nursing care for patients. Less stress, less fatigue and more professional support mean that nurses will be less likely to cut corners, miss important patient cues, or be rushed into making errors. A nurse who feels in control and validated for her/his work, will be happier and perform better. Addressing the work environment for nurses is an essential element in the maintenance of a sound Canadian health care system. Long-term care and home care owners and managers who receive AIM accreditation, through a positive work life assessment and other factors, can anticipate better retention and successful recruitment opportunities, as a result of the recognition that they offer a quality workplace environment.

As well, RNs have developed many strategies to move the patient safety agenda forward, within their national, provincial and territorial associations, as well as within nursing specialty groups. Advocacy, political action, partnerships with stakeholders, participation in high-level research and public policy – these are areas where nurses and nurse leaders are involved in shaping primary health care renewal. Health system reforms will require judicious financial investment and political commitment, but in the long term, will lead to efficient use of public funding.

With better places to practice, RNs will be supported as they strive for an optimum level of patient care. Healthy workplaces lead to healthy nurses, safer patients and better care.