Nursing

Practice Alerts & Guidelines

Results of the September 2002 Survey of Registered Professional Nurses, Volume II

Summary:

In September 2003, the State Education Department (SED) presented the Board of Regents with the first of a two-part presentation providing analysis of a comprehensive survey of New York State registered nurses (RNs). The survey, sent to over 31,000 RNs in September 2002, was conducted as an outcome of the recommendations of the Regents Blue Ribbon Task Force on the Future of Nursing. Its primary purpose is to serve as a centralized source of data upon which employers, policymakers, educators, researchers, and legislators may base public policy and resource allocation decisions. The large-scale randomized survey was designed during the summer of 2002 through a partnership with the Department's Fiscal Analysis and Research Unit, the Office of the Professions and other key stakeholders.

This month we present findings of Volume II of the 2002 Survey of New York State Registered Nurses. This volume provides important information on different types of employment climate factors affecting nurses, the impact of these factors on staff turnover, and nurses' support for a variety of common reform initiatives. Since the majority of these findings relate to the employment conditions of practicing nurses, the Department will share these data with our partners whose leadership may impact the environments in which nurses practice. Certain aspects of these findings may also help inform the regulatory process.

Volume I of the survey results, presented in September 2003, reported on basic demographic characteristics, education, employment status, salary, and the supply of registered nurses in New York State. Emphasis was directed at the aging of nurses, in general, nursing faculty, in particular, and the negative effect of insufficient faculty on recruitment of students. Based on the survey results:

• The Regents recommended support for Regents Priority Legislation that would provide 100 awards of $15,000 annually, to students seeking a master's degree in nursing or doctoral study who agree to work in an area of nursing education in New York State upon completion of the degree program, for a period of time determined by the Commissioner. If enacted by the legislature and the Governor, awards would be provided for three to five years to nurse applicants who are residents of New York State, demonstrate academic merit, have previous nursing experience, and meet specific admission criteria.
  
  
• Additionally, data presented in Volume I of the survey results, have already proven to be useful to the field. For example, Senator Schumer recently used the results of the Department study to launch a proposal urging Congress to provide $50 million in scholarships to nursing students who work in health care facilities with critical nursing shortages.

Volume II: Major Findings

Stress in the Workplace

• Workload-induced stress is substantial according to survey respondents. Eight of every ten nurses report they have to work very hard in their jobs. Close to two-thirds also say they have to work very fast at their jobs.
• When questioned about the frequency of experiencing "great stress" on their jobs, nearly one third of RNs indicated that they felt under great stress almost every day; another fifth reported feeling under great stress several days a week. (See Figure1)
  
  
  
  
  
• RNs in nursing homes and inpatient hospital-based settings reported the highest levels of both workload stress and stress-frequency. Almost two thirds of these RNs reported experiencing great stress on a daily basis or several days each week. Nursing staff in emergency, medical/surgical, geriatric and intensive care units reported experiencing the highest levels of stress.
• Among RNs working in direct care who spend more than two thirds of their workday on paperwork, 76 percent felt they lacked sufficient time to do their job. Among those spending less than one third of their time on paperwork, this percent dropped to 52 percent.
• Resource-adequacy stress refers to having access to supplies or the room and equipment to do one's job well. Three or four of every ten RNs agreed that resources or equipment were inadequate or not easily accessible.

Autonomy

• Nurses' perceptions of the degree of autonomy they have within their jobs were measured by their responses to such questions as "how much freedom do you have as to how your job is done" and "how much say do you have over what happens on your job." The data indicated that many younger nurses, new to the profession, feel they have too much autonomy, which in turn increases their stress levels. More experienced nurses and managers, however, placed a higher value on autonomy within their jobs, and for these more seasoned nurses greater job autonomy has a substantial positive relationship with greater job satisfaction.
• Autonomy varied substantially by job setting. RNs in private practice and educational settings reported the highest levels of autonomy. The average autonomy scale score of nursing home staff was in the mid-range, and inpatient hospital staff nurses reported the least job autonomy.
• Higher levels of formal education credentials generally equated to greater autonomy in the job. RNs educated at the doctoral level reported significantly greater job autonomy, on average, than RNs educated at the master's level and, likewise, master's level RNs reported significantly greater job autonomy than RNs with bachelor's degrees, associate's degrees or diplomas.

Satisfaction with Pay

• Nurses' average level of satisfaction with pay was the lowest of all the job climate satisfaction scale means. About 45 percent disagreed or strongly disagreed with the statement, "My present salary is satisfactory". In contrast, about 20 percent agreed or strongly agreed with this view (the remaining 35.9 percent expressed relatively neutral feelings). The same pattern characterized RNs' views regarding the adequacy of their pay increases. These relatively low compensation satisfaction ratings were generally consistent across settings and titles. Slightly higher than average pay satisfaction ratings, however, were reported by RNs working for HMOs, insurers, business or industry, and by RNs working in physician's offices. The three job titles associated with the lowest levels of pay satisfaction were public/community health nurse, in-service director/instructor, and staff nurse.
• Satisfaction with salary is greater among New York City and rural New York nurses than it is with their upstate urban/suburban and downstate suburban counterparts.

Promotional Opportunity

• Although 35 percent of the RNs working in New York State agree that "there is opportunity for advancement" in their job, over 40 percent either strongly disagree or disagree with that proposition. Similarly, 37.4 percent agree or strongly agree with the proposition that "I am in a dead-end job".

Instrumental Communication

• "Instrumental communication" refers to the extent to which an organization communicates to its members key job-related information. Between 50 and 55 percent of RNs felt they were kept well informed, or very well informed, about what needed to be done on the job, what they needed to know to do the job well, and what were the job priorities. Only 12 to 13 percent felt their organizations did a poor job of informing them about this information. These generally positive ratings contrasted with RNs' ratings of how well they were kept informed about "how well the job is done." Only 36.5 percent felt they were kept well informed about how well the job was done, and 29 percent felt they were poorly informed on that issue.

Nurse-Nurse and Nurse-Physician Interaction

• Nurses indicate overall mildly positive attitudes regarding the quality of nurse-nurse interactions within their work units. Nursing home and inpatient hospital nurses have the lowest scores on these measures.
• Nurse-physician interactions yield less positive assessments: the average score on this scale is just marginally higher than neutral. Inpatient hospital RNs are the least satisfied with the quality of nurse-physician relations in their work setting.

Analysis of Job/Career Satisfaction and Organizational Commitment

Global Job Satisfaction

Nurses in New York are fairly satisfied with their jobs. The average global satisfaction scale score of 3.47 statewide, (reflecting the composite of all seven measures), is midway between the neutral and positive (but not strongly positive) values. For example:

• More than 55 percent of nurses surveyed agreed or strongly agreed that they were "all in all, very satisfied" with their current jobs; and 65 percent agreed or strongly agreed that they were "fairly well satisfied" with their job.
• RNs in nursing homes and hospital inpatient units, however, evidenced the lowest global job satisfaction ratings, while nurses in education, private practice and physicians' offices were among the most satisfied. Those in direct patient care capacities were typically less satisfied with their jobs than RNs working in management, education or other roles.
• Among direct care nurses, job satisfaction is higher among RNs who report spending higher percentages of their day on direct patient care. Conversely, the higher the percentage of their workday they report spending on paperwork, the less satisfied direct care nurses are with their jobs.
• Older nurses report higher levels of job satisfaction than younger nurses. Correspondingly, more experienced nurses report higher levels of job satisfaction than do less experienced RNs.

Career Satisfaction

• Nurses are more satisfied with their careers than with their current jobs: just under two-thirds of respondents agree or strongly agree with the statement that, as they look over their careers to date, they have been "very satisfied" with their careers.
• The degree of commitment nurses feel toward their organizations is less positive than their satisfaction with their jobs and careers. The statewide mean of 3.21 on this five-point scale indicates that the average level of organizational commitment is just marginally higher than a neutral response.

Intentions to Leave, Timing to Exit and Job Seeking

Job Seeking Behavior and Leave Intentions

• Job search behavior increases with the extent to which the overtime worked by nurses is mandatory. Among nurses who work overtime, but never on a mandatory basis, only 19.9 percent report a high level of job search behavior. Among nurses who report that some of their overtime is mandatory, 25.1 percent report a high level of job search behavior. Among nurses who report that all of their overtime work is mandatory, 34.1 percent report a high level of job search behavior. (See Figure 2)
  
  
  
  
  
• Five years from now, one half of New York State nurses expect that they will still be working in the same job setting, and slightly more than three quarters expect that they will still be working in the nursing profession.
• Nurses working within inpatient hospital settings expressed the intention to leave their current job (not the nursing profession) within the next five years with far greater frequency (27.6 percent) than the average rate of job-leaving for nurses working in all other settings (22.9 percent).
• A survey finding of concern is the pronounced job-changing and career-changing intentions of young RNs currently working in New York State. Among RNs 19 to 30 years of age, 50 percent expect to leave their current jobs (but remain in nursing) within the next five years. In contrast, the percentages of nurses between 31 and 60 years of age planning to leave their current jobs within five years averages around 30 percent. Fifteen percent of RNs aged 19 to 30 intend to leave the nursing profession within five years compared to 13 percent of RNs in their 30s and 40s.

Willingness to Recommend Nursing as a Career

• Only one-quarter of RNs currently working in New York State say that they would "strongly recommend" nursing as a career to their friends; slightly more than a third would tell their friends that nursing is an "OK" career, while just under a quarter would recommend to friends that they choose a different career. A select 5.4 percent would advise their friends not to choose nursing "under any circumstances".
• The degree of enthusiasm with which RNs would recommend a career in nursing is highly affected by their own career satisfaction. Among those who would not recommend the profession under any circumstances, the average global satisfaction scores were only 2.25 on a five-point scale. Those RNs who would strongly recommend the profession to others as a career averaged 4.24 on the same scale.

Nurses at Risk for Leaving the Profession

The responses of all RN respondents currently working in nursing in New York State were partitioned into five distinct groups at different levels of risk for leaving the profession. These five "risk groups" were defined by both age - less than 52 years of age or 52 years and older - and by intended timing for leaving the nursing profession.

• Among RNs of all ages working in NYS planning to leave the nursing profession within the next 12 months, "retirement" was most frequently cited (37 percent) as the #1 reason for leaving nursing.
• The average age of RNs citing "retirement" as their #1 reason for leaving the nursing profession within 12 months was 62 years. The average age of RNs citing any reason except retirement as their #1 reason for leaving was 47 years. In other words, RNs leaving nursing for reasons other than retirement are, on average, 15 years younger than RNs who are planning to retire. (See Figure 3)
  
  
  
  
  
  
• When the analysis is broadened to include the three top reported reasons for leaving given by each RN, a different pattern emerges. "Stress" is among the top three reasons for leaving the profession more frequently than any other reason. In fact, a majority (58.6 percent) of RNs intending to leave the profession within the next 12 months cite "stress" as a primary reason for leaving. Half (49.9 percent) of these RNs leaving nursing in the next twelve months point to "retirement" as a primary reason, which is followed next in frequency of citation by "salary" (43.9 percent). Other prominent reasons frequently cited were: lack of recognition (33 percent), shift/hours (24.9 percent) and career change (24.2 percent).
• Frequency of experiencing great stress on the job is the most potent predictor of job dissatisfaction for all RNs under the age of 52 years working in New York State. The effect of stress frequency on the reported level of job dissatisfaction for the relatively young risk group of RNs leaving the profession within 12 months is three times stronger than it is for other RNs under the age of 52 working in New York State.
• RNs motivated to leave nursing primarily because of "stress" have the lowest average job satisfaction ratings and the highest levels of workload and stress frequency. More than one-third of this "stress-leaver" cohort was less than 43 years of age; thus their nursing careers are shortened by roughly 20 years.
• For two of nine employment setting categories (ambulatory care and hospitals) "stress" and not "retirement" was the top-ranked reason for leaving the nursing profession. Among RNs working in ambulatory care settings almost 4 of every 10 nurses listed "stress" as their primary reason for leaving. For hospital nurses, 3 out of every 10 indicated that stress was their primary reason for leaving. Moreover, this group of RNs leaving the profession because of stress was the youngest (average age = 48.8 years); had the shortest average length of career experience (21.3 years); and experienced the highest frequency of stress as well as the highest measures of workload-related job stress.
• Satisfaction with pay has a much stronger relationship with job satisfaction for the group of RNs under 52 years of age planning to leave nursing within 12 months than it does for other RNs. For this group "salary" is the second most frequently cited reason for leaving the profession - 54 percent of this group cite "salary" as among their three primary reasons for leaving the nursing profession.

What Nurses Want (and Don't Want)

• Nurses under 30 and over 70 report compensation as being less important to job satisfaction than nurses 40 to 49; nurses under 30 value autonomy the least, while older RNs in their 50s and 60s value it the most; nurses over 60 years of age claim technology has a greater impact on their job satisfaction than younger nurses; retired nurses report compensation as being less important to their job satisfaction than RNs currently working.
• Valuing compensation is related to lower job satisfaction and valuing autonomy is related to higher job satisfaction. Correspondingly, valuing compensation correlates with not recommending nursing as a career option to friends.
• The greater the educational level of nurses, the more value they place on autonomy and the less value they place on compensation and technology.
• Nurses who reported their ethnicity as something other than "White/Caucasian" and nurses born outside of the US value recognition more than other RNs - they value recognition even more than they value compensation and autonomy.
• Across job titles, "autonomy" is the mean policy preference score which varies the most: nursing home and inpatient hospital staff nurses value autonomy far less than nurses in other titles and settings.

Support for Proposed Reforms and Incentives

Respondents to this statewide survey were asked to rate the potential effectiveness of 19 different reform initiatives for recruiting and retaining high quality nurses in the profession. The initiatives included two educational loan and scholarship initiatives, eleven "generic" reforms ranging from health-safety and workplace-security reform proposals to a variety of financial reform incentives, and six reforms targeted to the hospital sector.

• Incentive proposals were all very strongly endorsed. These included: preferential state tax treatment for nurses; portable pensions/retirement benefits; reimbursement for childcare and affordable day care on the work site; and tuition assistance for continuing education, paid by one's employer. These proposals were each endorsed by 95 percent or more of those sampled.
• Hospital and nursing home reform proposals - including reducing the maximum number of patients under the care of a single nurse, and giving nurses more control over, and more stable work schedules - received exceptionally high levels of support by RNs working in those settings, even stronger levels of support than were given to financial incentives. These six initiatives also included "no float staffing policies", restrictions on mandatory overtime, and "maximum hourly shift lengths." All six of these proposals received the top endorsement rating, "highly effective," more frequently than any of the other twelve proposals.
• Among this same hospital and nursing home based respondent group, the reduction of nurse caseloads was the most strongly supported policy of all. It was an initiative supported by a remarkable 98.3 percent of respondents, and almost universally rated as potentially "highly effective" for recruiting and retaining good nurses.
• The two educational reform initiatives (one involving work commitments in under-served areas in exchange for scholarship funding, and the other actual loan forgiveness for similar work commitments) were both strongly endorsed. Over 85 percent of respondents indicated that these proposals would "probably help" or "definitely help" in attracting good candidates to the nursing profession.
• Reforms given moderate to strong endorsement, but less strong than financial incentives, included: security against workplace violence and blood-borne or bodily fluid infectious exposure; peer and senior mentoring; the application of ergonomic standards to the workplace; and the availability of public transit vouchers and assistance. These incentives were viewed favorably as effective or very effective by about three quarters of respondents, on average.
• Finally, minority RNs born and/or educated outside of the U.S. and those working in New York City had a different policy preference profile than the majority of other RNs. They were substantially more concerned about workplace violence and infectious disease controls than their non-minority, U.S. born and/or educated counterparts. Also, unlike the majority of RNs, these nurses supported the proposal for more stringent licensing requirements. Ethnic minority RNs, working inside or outside of New York City, also more strongly supported proposals for educational loans and scholarships than did other RNs.

Survey Results Reinforce Recommendations of the Regents Taskforce on the Future of Nursing

Survey respondents provided a number of diverse opportunities to support the nursing profession and address the nursing shortage that reinforced recommendations of the Regents Blue Ribbon Panel on Future of Nursing. RN respondents strongly endorsed 18 of 19 reform and incentive proposals related to initiatives to recruit or retain quality RNs. Additionally, hundreds of survey respondents provided written recommendations and anecdotal comments.

Task Force Recommendation: Education - Provide additional academic and financial support systems to increase the pool of nursing school graduates and create career ladders.

Tuition Assistance

• Survey respondents strongly supported the proposal that greater tuition assistance be available for continuing education for RNs. Almost 95 percent of respondents felt such assistance would help to retain good nurses within the profession.

Support Baccalaureate Education

• Baccalaureate degree recipients now make up increasingly smaller "shares" of the basic nursing preparation degree pool, as associate degrees have grown in popularity in recent years. Furthermore, since the average associate degree recipient defers the timing of her/his basic education training until the early thirties while the baccalaureate recipient typically completes her/his degree around 27 years of age, these timing differences suggest that baccalaureate degree recipients have potentially greater career longevity than holders of associates degrees. More importantly, based on our findings, baccalaureate degree recipients are more likely to extend their educational training to the master's or doctoral level than their associate-degree counterparts. These discrete educational strands suggest that especially aggressive efforts must be made at the high school level to attract and recruit prospective baccalaureate candidates for the nursing profession. Promising high school candidates must be apprised of the growing variety of scholarship, loan-forgiveness, and other financial incentives that are increasingly available to such candidates.

Task Force Recommendation: Retention - Support initiatives to retain current nursing workforce, including pursuit of best practice principles.

Workload

• The reform proposal given almost universal endorsement, and the strongest level of endorsement, by the survey respondents was the proposal to reduce the maximum number of patients under the care of a single nurse.
• Nurses also emphatically supported the proposal to place restrictions on mandatory overtime work. The greater the extent to which respondents reported that they were required to work mandatory overtime, the less satisfied they were with their jobs, the more frequently they experienced great stress at work, and the more frequently they reported seeking other employment.

Financial Incentives

• Increasing salary and benefit compensation packages for nursing staff should be considered a priority.
• Nurses say that efforts to enhance their pensions and retirement benefits and proposals to make those benefits more portable are important to them.
• RNs recommend legislation that would give preferential State tax treatment to nurses.

Family Friendly Employment Practices

• Over 96 percent of respondents agreed that reimbursement for childcare expenses would help to retain RNs within the nursing profession.
• Over 96 percent of respondents agreed that having affordable daycare available at the site of employment would help to retain quality RNs. Inpatient hospital RNs have children living at home with them, especially children under six years of age, with greater frequency than RNs working in other job settings. "Inpatient hospital" is the job setting in which a greater percentage of nurses plan to leave within the next five years (to work as nurses in a different setting) than any other job setting. Inpatient hospitals would probably benefit more than other settings by providing affordable daycare on site.

Flexible scheduling options, greater stability in their schedules, and greater control over schedules.

• Over 95 percent of our respondents agreed that these measures would help to retain RNs within the profession. Many letters sent to the State Board for Nursing along with the returned surveys described how the incompatibility of respondents' work schedules and their family obligations forced them to leave their careers in nursing.

Overtime

• Overtime practices, particularly mandatory overtime, are a major source of nurses' job dissatisfaction and add further stress to an already highly stressful work environment. Nurses say that these practices should be restricted or eliminated. They are not the solution to the shortage problem and may in fact exacerbate it insofar as overtime contributes to attrition.

Autonomy

Volume II findings demonstrated that autonomy is among the job dimensions most highly valued by nurses.

• Over 95 percent of respondents supported the proposal for "no-float" staffing policies within hospitals and nursing homes. Being "floated out" to units in which they have insufficient experience or expertise leaves RNs in the position of being substantially less at ease with making autonomous decisions.
• Survey respondents recommended greater recognition of, and support for, the clinical expertise of RNs, especially of highly experienced and credentialed RNs.
• Nurses surveyed suggested that more RNs be active members of governing bodies of health care related institutions and organizations.

Enhance Administrative and Supervisory Communication

• Survey respondents recommend concentrated efforts to improve informational delivery systems and active listening strategies in health care organizations.
• Reward and recognition strategies may be effective for highlighting individual and group success.

Workplace Safety

The majority of survey respondents agreed that enhanced workplace safety proposals would help to retain quality RNs. Support for these proposals was by far the strongest among ethnic minority RNs and nurses born and/or educated outside of the U.S., especially those working in New York City.

• Survey respondents recommend providing greater protection against blood-borne or bodily fluid infectious exposure.
• RNs suggest providing a higher level of security against workplace violence.

In-Service Training to Foster Awareness and Reduction of Job Stress

• In addition to reducing the sources of job stress, in-service training was recommended by RNs in nursing homes and hospitals as a potential strategy for teaching nurses a variety of stress management techniques.

Technology

• Survey respondents recommend strategies to reduce paperwork. Findings presented in this Volume demonstrated that a major contributor to the high levels of workload job stress experienced by many RNs working in direct patient care is the amount of time they are required to spend completing paperwork (on average, almost one third of their workday). The higher the percentage of their time these RNs report having to spend on paperwork, the more frequently they report not having adequate time to care for their patients. In effect, high paperwork demands contributes not only to workload stress - but to diminished nurse/patient ratios critical to high-quality care.
• RNs suggest exploring new technologies to reduce paperwork. Technology-driven strategies such as the use of standardized software for clinical assessment, readily accessible laptop computers, voice-recognition transcription systems, etc. should be more fully exploited to minimize clinical time lost to paperwork requirements and, consequently, to alleviate the stress induced by exorbitant paperwork. Nurses report needing more time to provide direct nursing care to their patients.
• Survey respondents recommend more consistent application of ergonomic standards to the work setting. RNs also called for equipment and technology to lessen the potentially damaging physical demands of their direct patient care responsibilities. This reform proposal was supported by most RN respondents, but was endorsed with the greatest enthusiasm by older nurses. As the RN workforce continues to age, the provision of equipment and technologies that lessen the physical demands of nursing will be increasingly important for nurse retention.
• Nurses surveyed recommend expanding distance learning opportunities to provide access to degree programs. Distance learning and teleconferencing approaches to completion of approved credit-bearing coursework toward a bachelor's degree should be more fully exploited. Technology-driven strategies enabling nurses on site flexible access to such training are likely to both increase staff participation and garner employer support.

Task Force Recommendation: Data Collection - Develop a reliable central source of data on the future need for nurses in the workforce upon which employers, policy makers, futurists, researchers and legislators may base public policy and resource allocations.

• Survey respondents indicated the need for periodic surveys to inform decisions about nursing and health care in New York State. Just as the trend analyses presented in this report rested upon previous surveys, ongoing efforts to monitor the nursing supply and issues of concern to nurses will depend upon the continuing collection of data. For example, if resources permit, another data collection initiative in 2010 might be considered to help stakeholders understand and respond to the needs arising from future changes in the nursing workforce and workplace.

Conclusion:

This summary has provided highlights of the Department's 2002 survey of registered professional nurses. The survey results revealed a number of opportunities for future action that reinforce the recommendations of the Regents Blue Ribbon Task Force. Addressing the nursing shortage will require continued collaboration and commitment from government leaders, association representatives, employers, educators, nurses, and all members of the health care community.