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Illustration by Malcolm Garris/PhotoDisc c
By Charlotte Huff
{ctober 23, 1997c

Ô
 CLINICIANS at the bedside can translate into high turnover, unhappy
patients, and lower quality of care. But the solution may lie less in pay and perks than
in redefining the control and influence that nurses and other clinicians wield in their
daily work, according to researchers and managers. c

Words such as aontrol, aollaboration , influenae , autonomy, and respeat are

frequently mentioned in job satisfaction discussions, said Anna Gilmore-Hall, RN,
director of labor relations and workplace advocacy for the American Nurses
Association. When dissatisfied nurses turn to a union for help, they are most often
worried about patient care, Gilmore -Hall said. "They say that if they had increased
control over how they performed their work, it would increase their job satisfaction." c

But, she added, "the employers are reacting to a very competitive marketplace." As
employers work to reduce costs, in many cases "job satisfaction for RNs really isn¶t
high on their list of priorities." c

Ignoring nurse job satisfaction will only be detrimental to health care and the
managers responsible for it, said Steve Strasser, PhD, president of HealthCare
Research Systems, a market research company in Columbus, {hio. Research,
Strasser said, has demonstrated that nursing care is the primary factor in how
patients view their hospital stay. "The issue is that the more satisfied patients are with
nurses, the more satisfied they are with their s tay." His company is working with a
hospital that cut too deeply into its nursing work force and is rehiring nurses after
patient satisfaction scores slid. c

Patient satisfaction is no small matter as hospitals battle to keep beds full, said Linda
Aiken, PhD, RN, director of the Center for Health Services and Policy Research at
the University of Pennsylvania School of Nursing in Philadelphia. And unhappy
nurses have ample opportunity to pass their concerns along if they choose, Strasser
said. "They are the closest point of service. They are the ones who get the pain meds
there on time and so on." c
Some facilities have begun to address morale with focus groups and surveys. At
Memorial Healthcare System in Houston, Margaret Loper, RN, started meeting with
clusters of RNs and LVNs two years ago. Helping people, she learned, was what
they enjoyed most about their work. "What made them feel really good was at the
end of the day, they had given quali ty care²that they had done the very best for their
patients."c

But in today¶s healthcare climate, with sicker patients and leaner staffs, some nurses
feel overwhelmed, Loper said. They may collapse at home after a long stressful day,
only to realize they had never returned, as promised, to talk to a particular patient.
Memorial, which includes nine hospitals, is making changes, including increasing
staff on one unit and considering more flexible staffing on another, Loper said. "They
would like to have control over the work day," Loper said, and she thinks that¶s a
reasonable request. "They are adults ²give them parameters and let them operate
within those parameters." c

Nurses prefer a decentralized management structure, in which more decisions are

made on the unit level, and they can work more efficiently in that structure, Aiken
said. Aiken¶s research involves about 40 hospitals designated as magnet facilities by
the American Academy of Nursing for providing a good working environment. c

Allowing clinicians to make more bedside decisions, she said, can actually be more
cost-effective. "My basic position is clinicians know best how to invest resources to
get the best possible patient outcomes." c

Health care also can be improved when nurses have more opportunities t o
collaborate with physicians, according to Judith Gedney Baggs, PhD, RN, an
assistant professor in the University of Rochester School of Nursing in New York. In
her study of nurse-physician collaboration on transferring patients out of the ICU,
Baggs found that collaboration increased satisfaction among nurses more than
among physicians. The study was published in the 

  

in September. "If the nurse believes there has been collaboration, she believes
a better decision-making process is going on," Baggs said. c

A chain-of-command system was developed at Presbyterian Hospital in Dallas after

nurses said they lacked sufficient recourse if they disagreed with a physician¶s
decision, according to Mike Evans, PhD, RN, vice president fo r nursing. Now a nurse
can first appeal to the charge nurse, and if the charge nurse agrees, the concern will
be passed up through channels, along with follow -up consultations with the
physician. "It has the full support of the medical leadership," Evans s aid.c

Evans is no newcomer to the issue of nursing satisfaction; he did his dissertation on

it. "Nurses are the heart of health care," he said. "And if they are satisfied, it¶s going
to have positive repercussions down the line" on quality of care. c

Presbyterian has made several changes since 1995, when it began surveying about
500 nurses annually to address a turnover rate of 22 percent. Pay was not the issue.
"No hospital can afford not to be within the market range on salaries, benefits," Evans
said, adding that Presbyterian¶s pay was above average. The survey revealed
frustration with what was seen as a lack of control on the job, as well as no
recognition from supervisors. c

Since then, Presbyterian has expanded the nursing service¶s governing council to
ensure that a nurse is elected from each unit, Evans said. By the end of the fiscal
year in September, turnover fell to 10 percent. Key quality measures, including
medication errors, hospital-acquired infections, and bedsores, have also improved. c

Time and logistical constraints always impede organizations¶ efforts to boost clinician
satisfaction, Baggs said. However, even minor changes in routine procedures can
drive home the message that the bedside clinician¶s voice really matters. Nurses, for
example, can join physicians on rounds and in continuing education classes when
the course work overlaps. Nurses and physicians can begin routinely jotting their
notes in the same area of the patient¶s chart so they can benefit from each other¶s
perspective. c

Getting nurses more involved from the start, Baggs said, can frequently pay off over
the long haul by reducing aggravation and improving quality of care. c