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Mary L. Fisher is a professor and associate vice chancellor for academic affairs at Indiana University-Purdue University, Indianapolis, Indiana. When this article was written, she was professor and chair of Environments for Health, Indiana University School of Nursing, Indianapolis.
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.
To learn more about healthy work environments, read "Types of Intensive Care Units With the Healthiest, Most Productive Work Environments" by Claudia Schmalenberg and Marlene Kramer in the
American Journal of Critical Care, 2007;16:458–468.
Now that you’ve read the article, create or contribute to an online discussion about this topic using eLetters. Just visit http://ccn.aacnjournals.org and click "Respond to This Article" in either the full-text or PDF view of the article.
None reported.
Corresponding author: Maria R. Shirey, RN, MS, MBA, NEA-BC, 10700 Coach Light Dr, Evansville, IN 47725 (e-mail: mrs{at}mail2maria.com).
Although reports of the changing conditions in the health care work environment have been extensively documented in the general nursing literature,4–7 and changes in the work environment are linked to patient safety,8 limited formal studies before the AACN national critical care survey9,10 (hereafter referred to as the National Survey) have been undertaken to provide an empirical assessment of the health care work environment at the facility and unit level in critical care. As reported by Kirchhoff and Dahl,9 the National Survey offers the first glimpses of issues specific to acute and critical care units and the more than 500 000 nurses who work in these units.11 The aim of the National Survey was to provide important national averages to which hospitals can compare their institutions and critical care units. The significance of the National Survey is that it offers new insights into critical care units and nurses from the standpoint of unit-specific rather than aggregate data.
Of note, although the data from the National Survey9 may provide early comparative data that were not previously available on critical care units, these data are not "benchmarks" because they do not constitute best demonstrated practices. Additional studies are needed to evaluate how these early data compare with performance standards and outcomes in Magnet facilities and units that have received the AACN Beacon Award, both designations recognized for excellence.2,3 The low facility response rate (18.2%) in this study of 120 (of 658 eligible) facilities and 300 (of 576 solicited) units should be considered. With Web-based surveys such as the National Survey, a 60% response rate is considered acceptable.12 Dillman,13 a pioneer in Internet survey methods, encourages closer to an 80% response rate while acknowledging that achieving such high response rates is difficult.
Five percent of the responding hospitals in the National Survey9 had been designated as Magnet hospitals by the American Nurses Credentialing Center (no reference was made to AACN Beacon unit status). Nationally, only 3.6% (209 Magnet hospitals among 5759 hospitals in the United States) of all US hospitals are Magnet hospitals. This observation indicates that the hospitals in this study may overrepresent Magnet institutions and thus may not be fully representative of other facilities throughout the United States. At best, findings from the Magnet organizations may show more favorable outcomes than do those of other facilities. Thus, the snapshot of critical care units generated from the National Survey may be rosier than reality and points to the need for further work on behalf of critical care units and their respective nursing practice environments.
Purpose
The purpose of this article is to present a secondary analysis of the AACN National Survey published in the January 2006 issue of the American Journal of Critical Care9 and the 2004 National Critical Care Survey Findings Report10 to determine their implications for nursing administrators. The findings are then related to evidence and best-demonstrated practice where those practices exist. Finally, administrative strategies for change are recommended.
Analysis
Two nurses with advanced degrees and experience in critical care nursing, nursing administration practice, and research utilization conducted the secondary analysis. After independently examining the study findings, the reviewers came to agreement on themes that emerged from the findings. Four major themes were specifically relevant to nursing administration practice: leadership, practice environment, staffing, and professional advancement and recognition. Elements of the 4 themes were amenable to intervention. In the following sections, we discuss each of these vital themes. Table 1
provides a summary of the National Survey findings to support each of the identified themes. This table complements commentary for each theme within the following "Discussion" section.
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Leadership
Leadership Overview.
Nursing administration practice involves both leadership and management functions, although leadership and management are 2 separate and distinct concepts.14 Ideally, leadership and management expertise should exist simultaneously in the same person. Understanding the distinction between leadership and management is essential because both are needed to move organizations forward.
For purposes of distinguishing between leadership and management, leadership involves "mobilizing the interest, energy, and commitment of all people at all levels of the organization."15 Leadership addresses effectiveness (are we doing the right thing?) and focuses on what needs to be done and why. Leadership is transformational and places great emphasis on vision and innovation for the future. Importantly, leadership is about people and about relationships. Conversely, management is defined as "a process of coordinating actions and allocating resources to achieve organizational goals."14 Management addresses efficiency (how can we do this better and faster?) and focuses on understanding processes with more of an emphasis on the status quo and bottom-line results. Management is more transactional and thus is driven by problems emerging in random order and requiring immediate operational actions.14
In the National Survey, more attention was given to management structures (unit function and operations) than to leadership functions (influence and vision). Learning about the state of both leadership and management in critical care settings helps leaders create more positive environments for practice. Understanding the current leadership and management state of today’s practice settings also helps heed the warnings of prominent leaders who suggest organizations in the United States have for too long been over-managed and underled.15,16
References to Leadership.
The unit governance structure is a distinct area mentioned in the National Survey that directly addresses both leadership and management functions. Although the results suggest that 55% of the units have shared governance, a collaborative management structure17 requiring the manager to serve as coach, mentor, and facilitator, the findings do not shed extensive light on the current leadership art and science practiced in today’s critical care work environment. Although the purpose of the National Survey was to provide a comprehensive view of hospitals and critical care units, it may have benefitted from a more detailed assessment of the state of current leadership in critical care. A separate study that uses staff nurse respondents to report on the conditions of the work environment and the perceived state of leadership within those environments would provide an even richer assessment to complement the National Survey. It is well known that staff nurses identify leaders’ empowering behaviors (inclusive of support) as important requirements of the desirable practice environment18 needed for nurse retention.19 Accordingly, addressing the extent to which authentic leadership, an essential element of the healthy work environment, is evident (or not) in today’s critical care practice settings is crucial for a fuller assessment of work environments. Because authentic leadership is an empowering leadership style and one that has been identified as "the glue" that holds together a healthy work environment,20 additional studies are needed to document the state of the leadership in today’s critical care units. Understanding the current state will help determine the necessary interventions required to bridge existing leadership and management gaps and propel movement toward the more desirable authentic leadership practices needed to promote healthy work environments.21
The National Survey makes reference to critical care managers spending considerable time (number of hours per day are not specified) in the staffing function. This finding is consistent with the findings of qualitative studies that the amount of nurse manager time and energy taken with staffing the managers’ units is extraordinary.22 Although staffing is an important function, excessive time spent on this short-term aspect of the role precludes the manager’s ability to be visible and to build the necessary long-term relationships with staff that translate to engaged, committed, and retained employees for the future.
The National Survey’s full findings report10 alludes to span of control. About three-fourths of the nurse managers surveyed reported having responsibility for 1 or 2 units; 1 in 5 nurse managers had responsibility for more than 2 units. On average, nurse managers had accountability for 71 staff members and 28 beds per unit. This nurse manager span of control appears to be higher than the 16 to 54 nurse manager direct reports noted in the most recent comparative study23 of acute care hospitals with 50 to more than 350 beds, respectively. The span of control figure in the National Survey is also far greater than the maximum 15 employees advocated by some experts.24 That the nurse manager’s plate may be too full is an understatement. Excessive managerial span of control is an important issue, particularly because recent research25 indicates an inverse relationship between nurse manager span of control and employee engagement. Research findings further suggest that "it is not humanly possible to consistently provide positive leadership to a very large number of staff while at the same time ensuring the effective and efficient operation of a large unit on a daily basis."26(piv)
Practice Environment Workforce.
The respondents to the National Survey were nurse managers whose demographics suggest a homogeneous group in terms of race/ ethnicity (82% white, 7% African American, 1% Hispanic), age (mean, 45 years), and sex (90% female). This profile mimics the national nursing demographics for the variables of race/ethnicity (88.4% white, 4.6% African American, 1.8% Hispanic), age (mean, 46.8 years), and sex (94.3% female) as reported in the national sample survey of US registered nurses.11 The demographic profile for both the National Survey and the national sample of US registered nurses, however, does not match the overall US demographic profile27 for the same variables (race/ethnicity, 75.1% white, 12.3% African American, 12.5% Hispanic; mean age, 35.3 years; sex, 50.9% female). This observation highlights the need to strengthen nursing leadership through further efforts to achieve workforce diversity in keeping with US and community demographic profiles.
The findings of the National Survey suggest that the current nursing shortage and the increasing complexity of patient care have been felt in the critical care work environment. A total of 25% of nurse respondents perceived that staffing does not currently match patients’ needs to nurses’ skill level or mix. Lack of staffing, overwork, and stress have been reported8 and raise important implications for patient safety and considerations for adverse health outcomes in nurses.
Despite reporting increases in acuity of critical care patients in the past 12 months, respondents to the National Survey indicated that no concurrent increases in budgeted positions for registered nurses (RNs) had occurred. This finding suggests that nurses are currently working harder and thus may be more at risk for physical and emotional exhaustion. Some evidence28–30 suggests that increasing acuity of patients combined with inadequate staffing (which is discussed later) may lead to fatigue and burnout among nurses, which in turn may interfere with the nurse vigilance system and threaten patient safety. Of concern was the predominant pattern (used by at least 70% of units) of calling in regular staff RNs on their days off. Although this practice may serve to fill an immediate staffing void, the previous hours worked by critical care nurses may not be considered. This National Survey finding is alarming because of the known adverse effects of longer work hours for critical care nurses on nursing vigilance and patient safety.6
The reported use of contract staff (including travelers and local external agencies) by 34% of the units in the National Survey also may have to do with both the current nursing shortage (unfilled positions in 60% of units in the survey) and the flexible scheduling requirements (desired control over personal schedules and work-life balance) of those critical care nurses still practicing at the bedside.
Wages for experienced nurses with 10 years of experience were $27/h, compared with $21/h for entry-level nurses. These findings suggest that wages for beginning nurses may be competitive, but wage compression is evident among experienced nurses. The salaries for these experienced nurses averaged 22% higher than for beginning nurses (that percentage reflects a 2.2% increase per year of experience). Of course, this wage pattern does not keep up with inflation, which has averaged 2.84% per year since 1998,31 let alone recognize a nurse for seasoned, professional expertise. Wage compression manifested by wage growth early in a nurse’s career and low wage growth for experienced nurses is an unresolved phenomenon32 common in the nursing profession.33,34 Increasingly, wage compression contributes to experienced nurses’ leaving patient care for careers outside nursing or away from direct patient care.35 If the goal is to retain experienced and proficient nurses, an analysis of wages may be necessary to identify areas for future equity considerations and better retention of more qualified nurses.36
The unit-level mean staff vacancy rate reported in the National Survey was 11.8%. This figure compares favorably with the national mean staff vacancy rate in critical care units of 14.6% reported in the most recent comparative study.23 Unit-level nurse turnover varied significantly within the sample: progressive care units, 13.3%; intensive care units (ICUs), 11.2%; postanesthesia care units (PACUs), 6.5%. Evidence suggests that a desirable organizational climate is an important determinant of intent to leave among ICU nurses, and increased pay alone without attention to organizational climate is most likely insufficient to reduce nurse turnover.37 Because differences in organizational climate were not specifically addressed, further research to establish a correlation between organizational climate and nurse turnover may help to explain the turnover variability in these settings.
The wages paid for nurses working in all 3 areas were the same. The mean time to fill vacant positions, however, varied; 90 days were required for progressive care units, 62 days for ICUs, and 33 days for PACUs. Without supporting data about reasons for these variations, we can only speculate that the greater ease in filling the PACU positions may have to do with the apparent desirability of working in smaller units, the seemingly more flexible systems reported in the PACU environment (care seems to be more routine and predictable), and the more desirable work hours of the PACU.
Advanced Practice Nurse Support.
Advanced practice nurses (APNs) such as clinical nurse specialists (CNSs) and nurse practitioners do not appear to be abundant in the critical care work setting. Of the 300 units surveyed, 53% had no CNSs, and 73% had no nurse practitioners. Forty-two percent of critical care units had hospital-employed CNSs and of these, most were employed in ICUs; fewer were employed in progressive care units and even fewer in PACUs. Far fewer units (16%) employed nurse practitioners. Despite extensive evidence to suggest that APNs contribute to strengthening nursing staff partnerships,38 enhancing patient outcomes,39,40 improving quality of care,41,42 decreasing hospital costs,43 promoting interdisciplinary collaboration,44 and advancing evidence-based nursing practice,45 use of APNs in hospitals (especially in community hospitals) does not seem adequate. With the strong evidence to support the value of APNs, it is counterintuitive not to see APN practice in critical care settings maximized.
That 44% of the facilities in the National Survey were seeking Magnet designation within the next 3 years is consistent with national trends. What is not consistent, however, is that such a large percentage of Magnet-aspiring facilities were apparently not tapping into the valuable consultation services and professional expertise that APNs offer and Magnet designation requires. In fact, the availability of consultation support from a variety of knowledgeable experts including APNs is an essential element required to meet Magnet criteria.46 Specifically, the eighth force,47 consultation and resources, within the 14 required Forces of Magnetism48,49 requires that "health care organizations must provide adequate resources, support, and opportunities for the utilization of experts, particularly advanced practice nurses."47
Because of the high percentage of newly licensed RNs (85% in ICUs and 89% in progressive care units) being hired into critical care units after graduation,9,10 tapping into CNSs (recognized as expert clinical practitioners) more aggressively to mentor new, inexperienced nurses in the RN role seems prudent. New nurses report that the first 3 to 6 months of professional practice are the most stressful.50,51 Although having a mentor is not commonly regarded as an integral component of nursing organizations,52 having such a practice in place is known to enhance retention of new nurses and enhance the nurses’ confidence and competence to increase patient safety.53 The need for the presence and guidance of CNSs becomes even more compelling in the setting of inconsistent peer mentors that results from the growing number of transient workers (34% of units using contract staff ) and an increasing trend in experienced nurses opting for part-time employment.
Governance.
Fifty-five percent of the units surveyed had formalized shared governance structures. The presence of shared governance structures compares favorably with best-demonstrated practices that "legitimize the nurse’s decision making control over professional practice."46 Although 55% of units having a shared governance structure may sound like a great start, of note, 100% of all Magnet-designated facilities have some form of shared decision making for nurses, and shared governance is the most common structure reported.46 Involving nurses in effective decision making through use of shared governance structures also meets a crucial requirement of the AACN standards for healthy work environments.1 The effectiveness of the shared governance models, a crucial step to linking these models to effective decision making, was not evaluated in the National Survey.
Performance Improvement.
Results of the National Survey indicate that many practices in the critical care work environment lack standardization and thus performance improvement efforts are needed. For example, evidence from the National Survey suggests that performance improvement initiatives are needed for end-of-life care, visitation policies, and information systems.
About 1 in 4 critical care units reported using some type of protocol for end-of-life care. Among the 3 comfort care policies cited, policies varied considerably by type of unit. The lack of standardization in end-of-life care implies an important quality void. Although consensus papers and articles on end-of-life care in the ICU exist, evidence on which to base best-demonstrated practices for providing high-quality, end-of-life care in critical care settings still appears to be limited.54 Partnering with an internal hospice program well recognized for expertise in palliative care55 could help facilities to promote unique practices for end-of-life care that have long been needed for critical care patients. Further adoption of the AACN recently released end-of-life collaborative findings with the Chest Foundation and the Critical Care Family Assistance Program56 would be most beneficial. Addressing the barriers to providing a "good death" in the ICU is also necessary. These barriers include nursing time constraints, inflexible staffing patterns, communication challenges,57 lack of expert critical care nursing practice at the end of life,58,59 and restrictions on family presence in the ICU.60
Family visitation policies vary considerably by unit type and size. Although critical care nurses have long debated the topic of visitation policies in the ICU,61 limited consensus62 and lack of an evidence-based practice still prevails. Improved efforts to translate existing research into practice are needed; family visits are an important area for satisfaction of patients and their families with critical care.63–65
Although critical care nurses practice in the information age, the finding that only 42% of critical care units surveyed used electronic documentation systems suggests that critical care units may still be lagging in technology. Does the fact that more than three-quarters of units did not provide readmission data reflect a lack of information systems, or does it reflect a knowledge void in financial management or in how to use those systems? Are critical care nurse managers educated about the linkages between quality and financial data needed to provide evidence-based leadership? Are the majority of the nurses in the National Survey who reported they have Internet access (83%) at work using their electronic access to enhance patient care processes and evidence-based nursing practice or is the available technology not being used to its fullest?
Staffing
Sixty-two percent of respondents did not report the mean number of days needed to fill an RN position. It is uncertain whether the data were not collected or were not known to the person completing the survey. Among those who responded to the item, the number of days varied from less than 30 to more than 120 days (mean, 59 days). National benchmarks suggest that critical care and emergency department positions take the longest to fill; only 51% of these positions are filled in 60 days, and 22% take more than 90 days to fill.66
Only 42% of respondents used acuity systems, and acuity systems were more prevalent in hospitals with more than 500 beds and in hospitals in urban settings. Data on days to fill a vacancy and the use of acuity systems are important information needed for staffing in acute care units. In the National Survey, lack of consistent reporting about days to fill a vacancy and the use of acuity systems by less than half of the units raised concerns among reviewers that many units are operating on less than the optimal information needed to provide evidence-based leadership related to staffing. Data on days required to fill a vacancy and use of acuity systems along with nursing productivity/utilization metrics (measure of how hard nurses have to work and what resources nurses need to meet the workload demands of patient care)67 are essential for evidence-based leadership decision making related to staffing. The information is vital for determining the exact nature and reasons for turnover, if leaders hope to intervene and correct the contributory deficiencies. Therefore, using standardized administrative data sets such as the Nursing Management Minimum Data Set (NMMDS) may be the best way to begin analyzing these phenomena. The NMMDS is the research-based management data set used by nurse executives to gather nursing management data for accurate and reliable decision making.68 The NMMDS represents the seminal work of Huber, Schumacher, and Delaney,68 work that has been improved over time69 and continues to be relevant today.70
In the National Survey, staffing decisions differed according to unit size. Smaller units (up to 29 beds) were more likely than larger units (operationally defined as having =30 beds) to take into account the need for specialized skills (balloon pumps, dialysis) when making staffing decisions. Does this finding imply that larger units have more universally prepared staff or that smaller units are more conscious of the specialized needs of their patients? More research is needed in this critical area of decision making.
With 88% of respondents indicating that patient census is the major factor they consider when making staffing decisions, and acuity systems being the least used factor, clearly most participating units do their staffing with patient needs receiving less emphasis than the patient head count in the decision making. Lack of careful consideration for matching the right caregiver to each patient is inconsistent with evidence-based standards for staffing,67 the AACN staffing blueprint,71 and The AACN Synergy Model for Patient Care.72
The bottom line for staffing issues is that the majority of respondents thought that the staffing had not been optimal up to 25% of the time. Nine percent had closed beds for more than 30 days because of the lack of sufficient RN staffing. This finding is similar to results of other national research70 in which 75% of 7324 nurses studied thought that the quality of care has declined. In the survey conducted by the American Nurses Association,70 92% of the respondents who reported a decline in quality of care attributed the decline to inadequate staffing. To what extent are pressures to keep beds open in the face of inadequate staffing influencing patient outcomes? What policies are needed to ensure a proper balance between open beds and safe staffing? To what extent are hospitals and leaders heeding the Institute of Medicine’s8 evidence-based leadership recommendation of providing ongoing vigilance in balancing efficiency and safety?
Kramer and Schmalenberg73 recommend use of an instrument to measure "perception of adequacy of staffing" to monitor acceptable staffing levels. Hospitals seeking Magnet status must address nurses’ perceptions of staffing effectiveness, and such an instrument might be one way to begin those measures that could lead to comparisons for benchmarking best practice in the future and linking the perceptions of RN staff to patient outcomes. The perception of staffing adequacy is so important for nurses that a recent Canadian74 study of 8597 hospital-based nurses documented a direct path (negatively weighted) from perceived staffing to emotional exhaustion.
In the AACN Standards for Establishing and Sustaining Healthy Work Environments,1 staffing is 1 of the 6 essential standards indispensable for quality care in the critical care environment. Staffing (especially if inadequate) is "one of the most harmful threats to patient safety and to the well-being of nurses."1 The goal of staffing is to match the needs of patients to nurses’ skills and workload over worked hours67 so that the dynamic changes that occur in critical care patients can be quickly recognized and responded to by an alert staff. Formal evaluation processes must be in place to determine the effects of staffing decisions on patient outcomes and to analyze the dynamics associated with failures in this area that needs continuous improvement.
The Joint Commission75 now assesses hospital staffing and measurements for monitoring its effectiveness.76 Two human resource measures for evaluating staffing effectiveness must be monitored for each institution.75,77 According to Ritter-Teitel,76 RN hours worked per patient day are a stronger predictor of nurse-sensitive outcomes for patients than are the usual hours worked per patient day. The latter measure reveals all levels of direct care-givers and does not specify the caregiver mix, whereas RN hours worked per patient day specifically addresses RN hours and is a significant factor in predicting patient outcomes.78 Much research is still needed to determine best practice in evaluating staffing models and numbers.
Professional Advancement and Recognition
Although the National Survey did not specify an operational definition for professional advancement and recognition, assessment measures were reported for each. Professional advancement included organizational financial support for continuing education and availability of orientation programs for nurses. Although orientation is typically considered a foundational requirement for all new employees rather than a form of advancement, orientation was still addressed in the category of professional advancement.9,10 Recognition identified ways that units and facilities acknowledged the contributions of critical care nurses inclusive of support for certification, association membership, research/scholarly activities, volunteer activities, and years of service to the facility.
Investment in professional advancement and recognition of achievement are key strategies for organizations to retain both employees and volunteers.79 Employees may achieve better performance through the motivation provided by recognition. It is thus not surprising that "people who are recognized have higher self-esteem, more confidence, and are willing to take on new challenges and contribute new ideas."79
Overall, the results of the National Survey9 outline a generally positive picture for professional advancement and recognition. Forty-four percent of participating units had professional development and advancement programs in place, and an additional 12% had such programs in process. More than 80% of participating units provided tuition reimbursement, continuing education support, and recognition for nurses. The extent of educational opportunities available did vary according to clinical unit. Evidence that progressive care units were less likely than ICUs or PACUs to receive support for continuing education indicates a lack of a uniform strategy for investing in employee education. The rapid growth in new knowledge and technology mandates the need for all employees to benefit from planned educational opportunities to enhance competency, job satisfaction, and retention.
Although a "standardized" orientation program was not operationally defined in the National Survey, it was reported in nearly 90% of responding units. An area of variability was the length of orientation for newly licensed and newly hired experienced RNs, which ranged from less than 30 to more than 120 days and tended to be longer in larger facilities. Preceptors were assigned in 94% to 96% of units. No indication was given as to alternative models to use of preceptors in the remaining 4% to 6% of units. However, the quality of the orientation and new employee outcomes were not addressed. More data are needed to evaluate the impact of standardized orientation programs on RN retention. The need for this evaluation becomes more compelling in light of the literature that focuses on creating the "right onboarding" experience for new employees.80 Onboarding, defined as a holistic approach that combines people, process, and technology to optimize the impact of a new hire to the organization, requires more than just an orientation; it also requires long-term employee support and follow-up.81 Providing new employees with the skills and tools to succeed in their new roles better engages and aligns the employees with the organizational mission to achieve excellence and sustainable value.82 Success stories must be evaluated and shared with the larger nursing community so that data-based standards of orientation practice can be established and validated. Both efficiency and effectiveness of orientation efforts must be evaluated.
In the National Survey,9 nearly three-quarters of units indicated some reward for national certification; 42% gave public acknowledgment (no indication is given about the form of this public acknowledgment), 25% gave a bonus, and 27% gave a plaque, letter, or gift. Rewards for certification were in place for about three-quarters of the reporting units, but only 8% of units required specialty nursing certification. Almost 50% of nurse managers held no specialty certification. Nurse leaders are an important force in driving cultures of certification.83 Although certification in a clinical specialty may not be the most appropriate certification for a nurse manager, having clinical specialty certification may make a nurse manager a better role model for certification than having no certification at all. The recently announced AACN collaboration with the American Organization of Nurse Executives84 to develop a certification examination designed exclusively for nurse managers may help modify the percentage of certified nurse managers in future studies.
Years of service were more universally recognized (97%), but recognizing membership in professional associations received less support (65% reported no recognition).9 Although the reported level of professional advancement and recognition in the National Survey appears positive, careful consideration must be given to staff members’ perceptions about the adequacy and meaningfulness of these efforts. Examining staff members’ perceptions may be necessary, especially in light of the various generational needs of the current nursing workforce. In determining the type and timing of rewards for performance, Hu et al85 suggest that differences exist between generational groups and the groups’ employment demands and needs for orientation, training, advancement, benefits, perks, and retirement options. In other words, what may be meaningful to one person may not be meaningful to another. Therein lies the challenge of deciphering meaningful recognition for the individual respondent and understanding its meaning as a survey item.
The data on professional advancement and recognition bring several questions to mind for future research: What types of recognition are most meaningful to critical care nurses? How do critical care nurses perceive the effectiveness of the recognition they receive? What impact has nurse recognition had on the productivity, satisfaction, and retention of nurses?
The finding in the National Survey that 65% of facilities did not recognize association membership is concerning because it reflects a lack of support for involvement in external organizations. Without support for external development and networking, organizations may not be able to systematically ensure a common staff awareness of industry trends and issues that promote optimal patient care. This void raises the long-term questions: To what extent are nurse managers able and willing to cultivate their employees through managerial support of external organizational involvement and planned professional growth and development? To what extent are organizations allowing nurse managers to lead when the nature of the nurses’ current work is so bogged down in daily workplace complexities?
Conclusion
Our intent in this article is to evaluate the administrative implications of the AACN National Survey.9,10 Nursing administration recommendations based on a review of the survey findings9,10 are summarized in Table 2. Although much work remains to be done, Table 2 highlights 12 practical recommendations that nurse leaders can begin to address immediately.
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PRIME POINTS
Strategies for building healthy work environments:
References
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