CONTEMPORARY NURSING ISSUES

QUESTION

Task description

This individual assessment item provides students with an opportunity to research and critique one Contemporary Nursing issue as identified in an interview with a newly registered nurse graduate in a clinical health setting.  Students will use the standard interview guide provided, to develop a more detailed interview plan.  In this essay students will demonstrate their ability to gather information from a number of relevant sources, integrate them and apply theoretical approaches using one Contemporary Nursing issue.  The process of undertaking a structured interview with a graduate nurse will facilitate students’ ability to identify and further explore areas of personal interest.

Practical application

Part A – Interview (refer to Structured Interview Guide below)

• Use the Structured Interview Guide provided to develop more detailed and specific interview questions, add these questions to your interview guide to assist you with the interview process.
• During your clinical placement, interview a newly graduated registered nurse (within one year of graduation) using the Structured Interview Guide with your specifically developed questions (which should be attached to your submitted essay).
• Based on information gathered during the interview, identify one contemporary nursing issue that the graduate nurse highlights to discuss in more detail
• Analyse the influence of this issue on nursing practice, nurses and the nursing profession.

Part B – Essay (refer to Essay Marking Criteria below)

• Clearly identify the contemporary nursing issue you have chosen and the pertinent topics surrounding it.
• Discuss the historical, social, political and/or economic factors that have contributed to and/or impact this issue.
• Analyse the impact the issue has on contemporary nursing practice, from a personal, organisational, societal and/or world perspective.
• Identify opinions and recommendations from the literature surrounding the issue.

SOLUTION

Nurses comprise of the largest section of health professionals across the world. They provide health care to the people across their lifespan. The nurses provide holistic care to the people, promoting good health and preventing illness. Nursing in Australia is similar in many ways to the nursing in other countries, like the United Kingdom, Canada, etc. In Australia, the three categories for nurses are registered nurses, enrolled nurses and nurse practitioners. The ANC (Australian Nursing council) develops and maintains standards for the registered and enrolled nurses and also for nurses immigrating from abroad. In Australia, the career opportunities with nursing are superb. Moreover, it is not just fun, but challenging and exciting, as well.

Nurses can be found almost anywhere where people are found. They act as a guide, mentor, facilitator of health care, etc. However, there are a lot of issues surrounding the profession of nursing. These can be of varied types like staffing problems, workload, taking care of the patient without risking one’s own health, etc. Almost all nurses, at varying levels of practice experience these ethical issues during their day to day work, which require immediate and focused attention by the health service managers. The contemporary problem chosen to be described for the purpose of this assignment is “staff shortage and workload”.

Nursing shortage refers to a situation when the need for nursing professionals greatly exceeds the number of nurses present. This means that the demand is greater than the supply. Due to the shortage in the working staff, the workload on the existing nurses exceeds the limits. Heavy workloads leads to job strain and long term health costs (Baumann et.al., 2001, cited in Nursing Now, 2003). . Also, according to the ANF (Australian Nursing Federation), Australia faces a severe nurse crisis. The main reasons for the shortage of professional nurses are the workforce moving into the less stressful roles, less students into the nursing programme due to faculty shortage, etc. there have also been deceasing enrolments evident for quite some time (Tang et. al., 1999).
The nurses experience higher workloads due to four major reasons. These are increased demand for nurses, inadequate supply, reduced staffing and reduction in patient length of stay (Carayon and Gurses).According to Keenan and Kennedy, the reasons for shortage of nurses are increased demand due to population aging, other career options, wages, workload and work environment, etc.

The main criterion associated with nursing shortage is the “Nursing resource Intensity”. It is a measure of the nursing resources used, in terms of the total amount of time spent with a patient and the level of care provided. There are many factors which affect the nursing workload and affect the final output. These are nursing and/ or medical condition of the client, nursing interventions used, environment, characteristics of the care provider (O’Brien- Pallas et.al., 1997).It is not possible to quantify all resources and problems. There are some issues which need to be taken care of and come all of a sudden. These are unfamiliarity with the work setting, multidimensional responsibilities, unanticipated events, interruptions, etc. Workload and work environment are two of the most important factors contributing to the nursing shortage.

Nursing workload can have serious consequences. These are patient safety, negative job satisfaction, non professional tasks, etc.(Carayon and Gurses). The nursing workload can be mainly divided into four categories. These are workload at unit level, job level, patient level and situation level.
Workload at the unit level is depicted through a small nurse to patient ratio. This can be due to two reasons, which are decreased number of nurses or an  increased number of patients.
Workload at the job level depends on the type of nursing job or specialty. There may be a shortage of nurses in one specialty as compared to the other. There can be a condition in which there are ample number of nurses of one specialization and scarcity of the nurses of some other specialization.
Workload at the patient level is justified by the clinical condition of the patient. A particular patient may require more attention and care than the other patients.
The situation level workload depicts the system set up. Some particular situations may require more and focused attention as compared to the other situations.

Nursing workload is a major problem and needs to be urgently addressed by the health professionals. It can have serious consequences like reduced patient satisfaction, patient safety, etc. Concern for the safety of the patient is the top most priority of the health care professionals. For this, nurses are responsible 24 x 7. the workload also affects the time a nurse can devote to a patient. Under heavy workload conditions, the nurses may not have enough time for interacting with the patient or spending time as required. Moreover, it may also hinder the nurses’ act of talking and discussing with the physician. This may seriously impact the quality of work. Workload can also be the reason for stress in nurses. Nurses experiencing stress and burnout may not be able to perform efficiently and effectively because their physical and cognitive resources may be reduced; this suboptimal performance may affect patient care and its safety.
Nurses with heavy workloads may not have sufficient time to perform tasks, apply safe practices, or monitor patients. They may be dissatisfied with their job, affecting their high quality performance. They experience stress and burnout which can have an negative impact on their performance. High cognitive workloads can lead to errors, such as slips and lapses, etc. It may make it more difficult for nurses to follow the rules and guidelines.

Historically, the medical profession has not been very supportive of the nursing ethics. Although, now it has been recognized as a distinctive field in its own way, nursing still lacks the authority they need to match their responsibilities as responsible, ethical practitioners. Nurses still do not feel respected or valued by their medical practitioners.
Nurses are an important part of the organizations they work in. Their issues must be respected. When the nurses are made to account for their moral/ immoral actions, they must be supported by the organization in all possible ways. It is very important that the work environment is supportive of the ethical nursing practice and as termed by Curtin (1993), the nurses must be provided with “moral space”.

There can be a number of varied strategies for addressing the problem of reduced staffing and hence, workload. Many experts recognize the need to increase funding for nursing education, directed toward nursing faculty as well as students. The training programs for nurses should be subsidized. Moreover, the training needs to be revised for accepting changes and challenges in the profession. The training should be included at all stages of the career and wages be revised. The nurses should be encouraged to talk out their problems more freely, such that action can be taken on time.
The institutions and organizations must actively support the nurses in dealing with ethical issues. These can be done in the following ways; An organizational code of ethics should be set and no diversions should be made, repeated, regular and effective communication should be done and the ethical issues should be discussed at a safe place, outside the usual hierarchy of power

The work system factors contributing to nursing workload should be identified. According to the Balance Theory of Carayon and Smith: (1) eliminating the source of the excessive workload, or (2) compensating or balancing out the workload are two solutions for the problem. The Balance Theory proposes an alternative approach aimed at compensating for or balancing out the negative aspects of work.
The work system is a key concept for defining workload. Any change in one element of the work system can affect other elements of the work system in negative and/or positive ways (Smith MJ, Carayon-Sainfort P, 1989).For example, For instance, work hour limits for physicians affect the nurse schedules. Nurses are often required to work increased overtime to compensate for reduced physician hours.
To resolve the problem of workload, the following strategies should be adopted. The situational workload should be measured. The work factors contributing to the workload should be identified and worked upon. The situational workload impacts on the final outcomes should be carefully observed and analyzed. Strategies should be devised for the the problem of situation workload. The barriers for improving nurses’ work systems should be improved.

Another important aspect of dealing with the problem of reduced staffing and thereby workload is the development of “Workload management system”. The main aspects of a workload management system are as follows:
•    telling senior colleagues about unacceptable standards
•    reporting circumstances in the environment which could jeopardize standards of practice;
•    Being aware of new codes, charters and registration body guidelines;
•    Making sure that local procedures are in place, challenged and/or changed;
•    Keeping accurate records; and when necessary, getting guidance on how to present information to management.

Nurse Managers should be given the opportunity to shape risk-management policies in their organizations. They can help to ensure that staff understand local  incident reporting procedures, and are confident about using them.
The patient needs assessment is a complex process the key factors of which are direct care workload in a ward or unit, indirect care ward, skill mix to meet the patients’ needs and the availability of budget for staff nursing.

In the state of Victoria, the nurse to patient ratio has become mandatory after the year 2000. This legislation was supported by the Victorian Branch of Australian nurses federation. The issue of work staffing and workload came up during the 1990’s as the result of budget cuts in the public health system and amidst allegations that managers were relying on computerized patient dependency systems to calculate workload and staffing levels instead of paying attention to nurses’ professional judgment.

The basic approaches to deal with the problem can be categorized into Top down approach, bottom up approach, determining Nursing hours per patient/nurses per occupied bed, Dependency-activity based methods, Using care plans, benchmarking, etc.
The top down approach is done on the basis of calculating the health needs of a population. It may be done on the basis of calculating the health needs of a population, or by calculating the satisfactory levels of service needs.
The Bottom up approach consultative approaches; activity based regression methods and various bottom-up workload assessment systems. The Telford consultative approach developed in 1979, in which Telford proposed a three step solution. According to this, the ward staff should set safe and acceptable levels of staff for each shift on each day. These should be documented. Secondly, numerical assessments should be transposed into grades of staff and whole time equivalents. Thirdly, appropriate allowances for trained and permanent staff should be allocated based on the grades. The activity based regression methods assesses the activity of direct care as a whole rather than as an aggregate of a number of tasks.
The calculation of Nursing hours per patient/nurses per occupied bed is a method to calculate the desired number of nurses to the actual number of nurses per person. The use of occupied beds as a measure of workload is regarded with disfavor by some nurses, because it ignores the severity of the condition of individual.
The Dependency-activity based methods are designed to balance the available
nursing hours in the ward with the required nursing hours. The purpose is to match nurse staffing to the peaks and troughs in ward activity. It is used to deploy the staff when the needs of the patients are the greatest.
The individual care plans may also be used as a way to assess the workloads. According to Bell et al. these systems rose in popularity very quickly in the UK in the early 1990s, but their popularity declined when it was discovered that there was a considerable amount of work associated with setting them up and little published research about the accuracy of workload calculated in this manner.
Benchmarking is a comparatively new way to assess the requirement of nurse staffing. Databases are available which enable comparisons between the budgeted staff establishments and levels of staff employed in similar hospitals.

Another new strategy devised is “Skill Mix”. In this, the staff is a mix of trained and untrained, qualified and unqualified and supervisory and advisory staff. While cost effectiveness and efficiency are the two concerns, this idea is still in the developmental phase.

Nursing workload is affected by staffing levels and the patients’ conditions, but also by the design of the nurses’ work system. There are many factors and ideas which need to be developed for the purpose of reducing the workload, as it is very important and urgent. Strategies need to be devised according to the situation and the conditions. The nurses and nurse managers should be considered important and included in the decision making procedures. The work system factors should be considered and management systems developed for the solution to the problem of workload. Nursing resource intensity is also an important criterion for determining the staffing problems. Whatever way, the final aim has to be the solution to the problem of workload as it is not only a nuisance for the patients and the nurses, but the society as well.
In Australia, the number of nurses being lost is more than the number which can be replaced. All this and the continuous increasing demands lead to patient error and the implications are overwhelming. At a time of increased patient complexity and acuity, health care facilities need to be excellent, rather than putting forward the problem of staff shortage and workload.

References:

American Nurses Association (1999) Nursing-sensitivequality indicators for acute care settings and ANA’s safety& quality initiative. Nursing Facts from the ANA
(viewed on 13/10/2011) from http://www.nursingworld.org/readroom/fssafe99.htm)

Baumann, A. O’brien Pallas,l. Armstrong Strasser, M. Blythe, J. Bourbannais, R. Cameron, S., et.al., 2001, Commitment and Care: The benefits of a healthy workplace for nurses, their patients and the system, Ottawa: Canadian Health Services Research Foundation.

Bell,A.M., Price, J. and Roberts, J.M. (2000) Innovations in nformation systems for nurse staffing. In Fralic, M. (ed.) Staffing Management and Methods, Jossey-Bass, San
Francisco, pp. 165 – 209.

Carayon P, Gurses AP, Hundt AS, et al. Performance obstacles and facilitators of healthcare providers. In: Korunka C, Hoffmann P, eds. Change and quality in human service work. Vol. 4. Munchen, Germany: Hampp Publishers; 2005. p. 257-76.

Carayon P, Gurses A. Nursing workload and patient safety in intensive care units: a human factors engineering evaluation of the literature. Intensive Crit
Care Nurs 2005;21: 284-301.

Freeman T, O’Brien-Pallas LL. Factors influencing job satisfaction on specialty nursing units. Canadian J Nurs Adm, 1998;11(3):25-51.

Keene AR, Cullen DJ. Therapeutic intervention scoring system: update 1983. Crit Care Med. 1983;11(1):1–3.

O’Brien-Pallas L, Baumann A, Donner G, Tomblin Murphy G, Lochhaas Gerlach J, & Luba M 2001b,‘Forecasting models for human resources in health care’, Journal of Advanced Nursing, vol 33, pp 120-129.

Tang KC, Duffield C, Choucair S, Chen J, Creegan R, Mak C & Lesley G 1999, ‘Nursing as a career choiceperceptions of school students speaking Arabic, Serbo-Croatian, Spanish, Turkish or Vietnamese at home’,Australian Health Review, vol 22, no 9, pp 107-121.

Telford,W.A. (1979) Determining nursing establishments.Health Service Manpower Review, 5 (4).

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