The Professional Nurse: Four Decades of Immense Change.

As one of the world's oldest occupations, nursing has seen, inspired, and innovated a host of changes. The evolution has been especially evident for the last 39 years. Since the 1980s, a growing focus on autonomy, research, and evidence-based practice has transformed nursing from a job to a profession. Concepts such as shared governance, interprofessional collaboration, and frontline engagement have transformed nurses from doctors' assistants to empowered and independent clinicians directly impacting patient outcomes and the healthcare environment. As the 30th anniversary of the American Nurses Credentialing Center comes to an end and the original Magnet® research celebrates a 39th birthday, we take a closer look at how the Magnet framework reflects these changes and how Magnet-designated organizations continue to advance nursing practice with innovation, knowledge, and leadership.

Confronting the Workforce Tsunami: Nonnegotiable Tactics to Reverse the Exodus of RNs.

The sobering facts are clear: hospitals and health systems are facing a severe nursing shortage, with safe inpatient staffing approaching near-crisis levels. Safely staffing inpatient care is challenging. Stopping the exodus of nurses from acute care must be prioritized by the entire C-suite, with the chief nurse executive at the center of all decisions. Beyond aggressive retention strategies, different in-kind solutions to address the practice environment are nonnegotiable and help address nursing concerns about continued hospital employment.

Changes in proportion of bachelor's nurses associated with improvements in patient outcomes.

This study uses data from two cross-sections in time (2006, 2016) to determine whether changes over time in hospital employment of bachelor's of science in nursing (BSN) nurses is associated with changes in patient outcomes. Data sources include nurse survey data, American Hospital Association Annual Survey data, and patient administrative claims data from state agencies in California, Florida, New Jersey, and Pennsylvania. The study sample included general surgical patients aged 18-99 years admitted to one of the 519 study hospitals. Multilevel logistic regression and truncated negative binomial models were used to estimate the cross-sectional and longitudinal effects of the proportion of hospital BSN nurses on patient outcomes (i.e., in-hospital mortality, 7- and 30-day readmissions, length of stay). Between 2006 and 2016, the average proportion of BSN nurses in hospitals increased from 41% to 56%. Patients in hospitals that increased their proportion of BSN nurses over time had significantly reduced odds of risk-adjusted mortality (odds ratio [OR]: 0.95, 95% confidence interval [CI]: 0.92-0.98), 7-day readmission (OR: 0.96, 95% CI: 0.94-0.99) and 30-day readmission (OR: 0.98, 95% CI: 0.95-1.00), and shorter lengths of stay (incident rate ratio [IRR]: 0.98, 95% CI: 0.97-0.99). Longitudinal findings of an association between increased proportions of BSN nurses and improvements in patient outcomes corroborate previous cross-sectional research, suggesting that a better educated nurse workforce may add value to hospitals and patients.

The Future of Nursing: Creating A Culture of Equity.

As development of the Future of Nursing 2020-30 Report by the National Academy of Medicine is underway, the nursing profession is positioned to continue positively impacting health and health equity in the United States. Progress to date engenders hope that nurses will continue to take a significant role in reducing health disparities. The work to create a culture of health aligns with the Christian imperative to "love your neighbor as yourself."

Artificial Intelligence and Nursing: The Future Is Now.

As systems evolve over time, their natural tendency is to become increasingly more complex. Studies in the field of complex systems have generated new perspectives on the application of management strategies in health systems. Much of this research appears as a natural extension of the cross-disciplinary field of systems theory. Since writing my 1st article for Managing Organizational Complexity in 2004, much has happened to further our understanding of complexity in healthcare systems. The growth of new computational methods in the fields of data science and data analytics has allowed scientists to identify signals or patterns in large complex data sets (big data) that in the past were seemingly hidden. Rather than relying on historical statistical methods to infer outcomes, these advanced methods combined with increased computer processing power allow machines to learn the structure of data and create artificial intelligence (AI). In our ongoing efforts to find solutions for complex healthcare problems, AI is becoming more and more an accepted method. The purpose of this edition of Managing Organizational Complexity is to define AI and machine learning, discuss the recent resurgence of AI, and then provide examples of how AI can provide value to healthcare with an emphasis on nursing.

Involvement in health policy and political efficacy among hospital nurses in Jordan: A descriptive survey.

AIM: The aims of this study were to (a) examine the levels of nurses' political efficacy and involvement in health policy; and (b) explore the relationships between political efficacy, involvement in health policy and participants' background variables. BACKGROUND: Nurses as citizens and health care providers have the right to express their opinions and beliefs in regard to issues that are concerned with the health care system or the public health domain. METHODS: A descriptive, cross-sectional design using was utilized. A self-administered questionnaire (Political Efficacy Scale & Involvement in Health Policy Scale) was completed by a convenience sample of 302 nurses. RESULTS: The results of this study showed low levels of involvement in health policy and political efficacy, and a positive weak correlation between political efficacy and involvement in health policy. The perceived level of political efficacy was associated positively with nurses' age and experience. CONCLUSIONS: Nurse administrators and managers may empower, support and encourage nurses to enhance their involvement in health policy. IMPLICATIONS FOR NURSING MANAGEMENT: The findings have implications for nursing leaders and administrators to design appropriate strategies to enhance nurses' involvement in health policy development.

The indicators of human capital for hospital-based nursing workforce in Taiwan.

AIM: To develop a hospital-based nursing human capital model for Taiwan. BACKGROUND: Effective nursing management only becomes possible when nurse managers are able to manage and maintain the right equilibrium among human capital components. METHOD: We developed an analytic hierarchy process (AHP) model with 8 dimensions and 31 indicators based on extensive literature review and experts' perceptual assessment. We used expert and purposive sampling and invited 82 nursing professionals to rate the importance of these dimensions and indicators. The AHP process was performed to identify the weightage and prioritize the dimensions and indicators of the nursing human capital. RESULTS: Our analysis showed that, for nursing human capital, health was the most important factor (weight: 34.8%), followed by employee protection (20.4%), work attitude (13.7%), employee stability (10.8%), general nursing training (6.3%), competencies (5.8%), advanced nursing training (4.3%) and clinical nursing experience (3.9%). CONCLUSION AND IMPLICATION FOR NURSING MANAGEMENT: The model would be most useful for nurse administrators in long-range strategic management. Specifically, the model can be used as a reference to form a rating system to analyse nursing human capital. Health promotion programs and employee protection measures targeting nurses could improve nursing human capital in hospitals.

The side effects of service changes: exploring the longitudinal impact of participation in a randomised controlled trial (DOORWAYS) on staff perceptions of barriers to change.

BACKGROUND: Staff and service users have expressed concerns that service improvements in British mental health wards have been slow or transient. It is possible that certain changes are positive for some (e.g. service users), but negative for others (e.g. staff), which may affect implementation success. In this study, we explore whether a programme of change to improve the therapeutic milieu on mental health wards influenced staff perceptions of barriers to change, 12 months after implementation. METHOD: A cluster randomised controlled trial called DOORWAYS was conducted on eight British, inner-city acute mental health wards. Randomisation was achieved using a list randomly generated by a computer. A psychologist trained ward staff (mainly nurses) to deliver evidence-based groups and supported their initial implementation. The impact of these changes was measured over 12 months (when 4 wards were randomised), according to nurses' perceptions of barriers to change (VOCALISE), using unstructured multivariate linear regression models. This innovative analysis method allows maximum use of data in randomised controlled trials with reduced sample sizes due to substantial drop out rates. The contextual influences of occupational status (staff) and of workplace setting (ward) were also considered. RESULTS: Staff who participated in the intervention had significantly worse perceptions of barriers to change at follow up. The perceptions of staff in the control group did not change over time. In both groups (N = 120), direct care staff had more negative perceptions of barriers to change, and perceptions varied according to ward. Across time, direct care staff in the intervention group became more negative than those in the control group. CONCLUSION: Participation in this program of change, worsened staff perceptions of barriers to change. In addition, occupational status (being from the direct care group) had a negative effect on perceptions of barriers to change, an effect that continued across time and was worse in the intervention group. Those providing direct care should be offered extra support when changes are introduced and through the implementation process. More effort should be placed around reducing the perceived burden of innovation for staff in mental health wards. TRIAL REGISTRATION: ISRCTN, ISRCTN 06545047. Registered 29/04/2010, https://www.isrctn.com/search?q=06545047.

Cultural and Generational Considerations in RN Retention.

OBJECTIVE: The aim of this study was to identify evolving cultural and generational factors influencing nurse retention. BACKGROUND: Multigenerational/culturally diverse workforces challenge the nurse leader's understanding of nurse satisfaction. METHODS: A survey was designed to identify the RN's career intentions, desired leadership traits, and practice environment appraisal. RESULTS: While generally satisfied with their current position, generational differences in the average number of years nurses intend to stay at their current employer exist with Millennials anticipating staying 3.03 years; Generation X, 5.83 years; and Boomers, 8.25 years. Perceived inability to meet patient needs, which varied by generation, was significantly related to nurse satisfaction (P < .01). Factors identified by the nurses that may improve retention, regardless of generation, were pay, staffing, and nursing leadership support. Preferred leader traits varied by generation and ethnicity. Hispanic nurses value hardworking, honest leaders, whereas non-Hispanic nurses value dependability. CONCLUSION: Nurse leaders must individualize efforts to retain an ethnically diverse and multigenerational nursing workforce.

Travel Nurse Onboarding: Current Trends and Identified Needs.

OBJECTIVE: The purpose of this study was to describe current practices for onboarding travel nurses (TRNs) and identify TRNs' specific onboarding needs. BACKGROUND: Onboarding must be streamlined and organized for TRNs to provide safe patient care. METHODS: Cross-sectional descriptive survey was used with 306 TRNs throughout United States who were recruited electronically from a closed social media group page. RESULTS: The TRNs identified critical information, including unit patient ratios, onboarding schedule 7 to 14 days before travel assignment start, and login IDs/accesses on day 1. Travel nurse onboarding and competency assessment checklists should be specific to the unit/facility where they will work. CONCLUSION: Findings from this study have the potential to support hospitals in the development of streamlined and tailored TRN onboarding to support regulatory compliance and patient safety as well as realize significant cost savings for TRN onboarding.

National trends and variation in nurse staffing on inpatient psychiatric units.

The purpose of this study was to examine national trends and variation in nurse staffing on inpatient psychiatric units in US general hospitals from 2005-2017. The National Database of Nursing Quality Indicators® provided data on nurse staffing from 1,143 psychiatric units in 610 US hospitals. A weighted linear mixed model was fitted for each of two staffing measures: Registered nurse (RN) hours per patient day (HPPD) and non-RN HPPD. Monthly staffing levels were modeled as a function of study year, unit type, and hospital bed size, teaching status, government ownership, for-profit status, metropolitan location, and US census division. Very gradual upward trends in staffing were observed. Compared with adult units, child/adolescent units had lower RN staffing and higher non-RN staffing. Levels of both types of staffing were lower in for-profit facilities. The Pacific census division had higher RN staffing than every other census division by an estimated margin of 0.52-1.54 HPPD, and census divisions with the lowest levels of RN staffing had the highest levels of non-RN staffing. Despite concerns expressed over the past 15 years about patient violence, staffing levels, and use of seclusion and restraint on psychiatric units, average staffing levels have apparently increased only modestly since 2005, and increases in RN staffing on psychiatric units have not kept pace with increases in general care units. Marked regional differences in staffing merit further investigation.

Systematic review: Association between the patient-nurse ratio and nurse outcomes in acute care hospitals.

AIMS: To evaluate and summarize current evidence on the relationship between the patient-nurse ratio staffing method and nurse employee outcomes. BACKGROUND: Evidence-based decision-making linking nurse staffing with staff-related outcomes is a much needed research area. Although multiple studies have investigated this phenomenon, the evidence is mixed and fragmented. EVALUATION: A systematic literature search was conducted using PubMed, Embase, Web of Science, Cinahl, Cochrane Library and the ERIC databases. Thirty studies were identified, analysing eight selected key nurse outcomes. KEY ISSUE(S): Future research should focus on unit-level data, incorporate other methodologies and aim for comparability between different types of clinical settings as well as different health care systems. CONCLUSION: A relationship between the patient-nurse ratio and specific staff-related outcomes is confirmed by various studies. However, apart from the patient-nurse ratio other variables have to be taken into consideration to ensure quality of care (e.g., skill mix, the work environment and patient acuity). IMPLICATIONS FOR NURSING MANAGEMENT: Hospital management should pursue the access and use of reliable data so that the validity and generalizability of evidence-based research can be assessed, which in turn can be converted into policy guidelines.

Recent Trends in Baccalaureate-Prepared Registered Nurses in U.S. Acute Care Hospital Units, 2004-2013: A Longitudinal Study.

PURPOSE: To examine the trends in baccalaureate (bachelor of science in nursing)-prepared registered nurses (BSN RNs) in U.S. acute care hospital units and to project the growth in the number of BSN RNs by 2020. DESIGN: This is a longitudinal study using the Registered Nurse Education Indicators data (2004-2013) from the National Database of Nursing Quality Indicators. METHODS: The level of BSN RNs in each unit was operationalized as the proportion of nurses holding a baccalaureate degree or higher among all the nurses in a unit. Our sample included 12,194 unit-years from 2,126 units of six cohorts in 377 U.S. acute care hospitals. A hierarchical linear regression model was used to examine the trends in BSN RNs and to project future growth in the number of BSN RNs when controlling for hospital and unit characteristics and considering repeated measures in units over time and clustering of units within hospitals. RESULTS: The proportion of BSN RNs in U.S. acute care hospital units increased from 44% in 2004 to 57% in 2013 (a 30% increase); when combining all cohorts, this rate increased from 44% in 2009 to 51% in 2013. On average, the proportion of BSN RNs in a unit increased by 1.3% annually before 2010 and by 1.9% each year from 2010 on. The percentage of units having at least 80% of their nurses with a baccalaureate degree or higher increased from 3% in 2009 to 7% in 2013. Based on the current trends, 64% of the nurses working in a hospital unit will have a baccalaureate degree by 2020, and 22% of the units will reach the 80% goal by 2020. CONCLUSIONS: There was a significant increase in the proportion of BSN RNs in U.S. acute care hospital units over the past decade, particularly after 2010. However, given the current trends, it is unlikely that the goal of 80% nurses with a baccalaureate degree will be achieved by 2020. CLINICAL RELEVANCE: The U.S. nursing workforce is under educational transformation in order to meet the increasing healthcare needs. To help accelerate this transformation, further advocacy, commitment, and investment are needed from all healthcare stakeholders (e.g., policymakers, executives and managers of healthcare facilities, nursing schools, etc.).

Reflections on the Emotional Hazards of Pediatric Oncology Nursing: Four Decades of Perspectives and Potential.

THEORETICAL PRINCIPLES: Pediatric oncology nurses are particularly vulnerable to emotional distress. Responsible for the oversight of a child's care, these nurses sustain close interactions with multiple patients and families over time, many of whom are coping with life-limiting diagnoses. The world of pediatric oncology nurses is one where tragedy is routinely witnessed thus demanding self-care and healing across a continuum. PHENOMENON ADDRESSED: The aim of this article is to outline and review the emotional sequelae of pediatric oncology nurses' work and to suggest interventions to support well-being in light of prolonged caregiving. Three major categories that are addressed include the aspects of clinical practice that influence caregiving, the risks of burnout, compassion fatigue, moral distress and grief, and interventions to counteract these phenomena. RESEARCH LINKAGES: Future-nursing research should focus upon the development of validated, psychometrically sound measurement tools to assess nurse-specific variants of burnout, compassion fatigue, moral distress, and nurse grief. Qualitative research should investigate the relationship between personal variables, workplace and team characteristics, age and experience, and their influence on the predominance of burnout, compassion fatigue, moral distress, and nurse grief. Lastly, the phenomena of resiliency demands further study.

Stages of Adoption Concern and Technology Acceptance in a Critical Care Nursing Unit.

OBJECTIVE: The aim of this study is to examine the stages of concern (self, task, and impact) and usability (trust, perceived usefulness, and ease of use) shifts experienced by nurses adopting new technology. BACKGROUND: Patient care processes in critical care units can be disrupted with the incorporation of information technology. New users of technology typically transition through stages of concern and experience shifts in acceptance during assimilation. METHODS: Critical care nurses (N = 41) were surveyed twice: (1) pre, immediately after training, and (2) post, 3 months after implementation of technology. RESULTS: From presurvey to postsurvey, self-concerns decreased 14%, whereas impact concerns increased 22%. Furthermore, there was a 30% increase in trust and a 17% increase in perceived usefulness, even with a 27% decrease in ease of use. CONCLUSION: Adoption of new technology requires critical care nurses to adapt current practices, which may improve trust and perceived usefulness yet decrease perceptions of ease of use.

Wage Inequity: Within-Market Comparative Analysis of Salary for Public Health Nurses and Hospital Nurses.

The labor market perspective focuses on supply and demand for registered nurses (RNs) as employees. This perspective contrasts with beliefs in the public health sector that RNs working in local health departments (LHD) as public health nurses (PHNs) accept lower wages because of factors other than market demand. This study sought to describe the extent to which hourly wages of RNs working in LHDs are competitive with hospital RN wages within the same county market. A repeated measures survey design was used in collecting 2010 and 2014 data. The unit of analysis was the county, as an RN labor market for LHDs and hospitals. Survey questions captured factors common in human resources benefits and wage packages, such as differential pay, hourly rate pay based on years of experience, components of benefit packages (eg, sick and vacation leave), and reimbursement for education. Within each county, the LHD and all hospitals constituted a "market," yielding a potential 12 markets in our study sample. Human resources representatives from each of the 12 LHDs and from all hospitals within those 12 counties were invited to participate. We conducted comparisons with survey data using t test of mean differences on mean RN wages across years of experience. On average, LHDs paid significantly less than hospitals in their markets, at all levels of RN experience, and this gap increased with RN experience in the sample markets. Salary compression was evident in 2010 and worsened for PHNs in 2014, when compared with hospital RNs. In 2014, 100% of the sample LHDs offered reimbursements for continuing education for PHNs compared with 89% of hospitals providing this benefit. This study contributes to our understanding of the human resources challenges faced by LHDs and provides evidence elucidating resources issues that need to be addressed in order to improve recruitment and retention of PHNs.

Trends in the geographic distribution of nursing staff before and after the Great East Japan Earthquake: a longitudinal study.

BACKGROUND: Medical care systems in Iwate, Miyagi and Fukushima prefectures were greatly damaged by the Great East Japan Earthquake (GEJE), which struck on 11 March 2011. The shortage of nurses in this area was concerning; however, temporal trends have not been investigated. This study aimed to investigate the trends in the geographic distribution of total nursing staff per population in the secondary medical areas (SMAs) of these prefectures before and after the GEJE. We also aimed to qualify the above trends. METHODS: We conducted a longitudinal study at four time points (July 2007, 2010, 2011 and 2013) over 6 years using reports of basic hospitalization charges from all hospitals within Iwate, Miyagi and Fukushima prefectures that experienced severe damage from the GEJE. We calculated the number of total nursing staff per population in the SMAs and compiled descriptive statistics. Changes from 2010 to 2013 were qualified and mapped. RESULTS: In coastal SMAs, the ratios of total nursing staff per population decreased immediately after the GEJE. In most SMAs in 2013, the ratios increased and exceeded the pre-GEJE level. However, the changes in total nursing staff per population from 2010 to 2013 were negative in Ryouban (-4.0%), Ishinomaki-Tome-Kesennuma (-1.9%), Sousou (-47.7%) and Iwaki (-1.9%). In Sousou, which is closest to the Fukushima Daiichi Nuclear Power Plant, the changes in total nursing staff per population qualified by job role were -33.7% for nurses, -57.7% for associate nurses and -63.2% for nursing aides. CONCLUSIONS: Our study indicated that the temporal trends in the number of total nursing staff per population due to the GEJE differed between the physically damaged areas and those affected by radiation. We also found the difference in the trend by qualifications: the reduction in total nursing staff per population was larger in Sousou, the area most affected by radiation, than in any other SMAs. Moreover, the number of nursing aides was most affected among the three types of staff. To promote the post-GEJE reconstruction of medical care systems, it might be necessary to develop policies to secure both nurses and nursing aides after nuclear disasters.

Transitioning to Excellence in Nurse Staffing: A Statewide Initiative to Leverage the Evidence.

Successful transitions require leadership, focus, and tenacity. Substantive change rarely comes easily. Leaders are frequently challenged to determine when change is needed and how to best accomplish it. This month we will shine the spotlight on a statewide initiative in Wisconsin to transition the nurse staffing decision process, in every practice setting, from largely opinion based to evidence based. This leadership initiative capitalized on the leadership potential of a professional association and the power of consensus and a well-executed strategy.

Optimizing All Licensed Staff: Magnet Standards Require an All-BSN/RN Staff in Hospital Settings by 2020: Truth or Myth?

This column, presented by the executive vice president and chief officer of the American Nurses Credentialing Center, Linda Lewis, MSA, RN, NEA-BC, FACHE, discusses a topic of interest to nurse executives as they develop plans for the nursing workforce. Ms Lewis addresses the direction of the Magnet Recognition Program® with regard to requirements for staffing mix.