Clarifying workforce flexibility from a division of labor perspective: a mixed methods study of an emergency department team.

BACKGROUND: The need for greater flexibility is often used to justify reforms that redistribute tasks through the workforce. However, "flexibility" is never defined or empirically examined. This study explores the nature of flexibility in a team of emergency doctors, nurse practitioners (NPs), and registered nurses (RNs), with the aim of clarifying the concept of workforce flexibility. Taking a holistic perspective on the team's division of labor, it measures task distribution to establish the extent of multiskilling and role overlap, and explores the behaviors and organizational conditions that drive flexibly. METHODS: The explanatory sequential mixed methods study was set in the Fast Track area of a metropolitan emergency department (ED) in Sydney, Australia. In phase 1, an observational time study measured the tasks undertaken by each role (151 h), compared as a proportion of time (Kruskal Wallis, Mann-Whitney U), and frequency (Pearson chi-square). The time study was augmented with qualitative field notes. In phase 2, 19 semi-structured interviews sought to explain the phase 1 observations and were analyzed thematically. RESULTS: The roles were occupationally specialized: "Assessment and Diagnosis" tasks consumed the largest proportion of doctors' (51.1%) and NPs' (38.1%) time, and "Organization of Care" tasks for RNs (27.6%). However, all three roles were also multiskilled, which created an overlap in the tasks they performed. The team used this role overlap to work flexibly in response to patients' needs and adapt to changing demands. Flexibility was driven by the urgent and unpredictable workload in the ED and enabled by the stability provided by a core group of experienced doctors and nurses. CONCLUSION: Not every healthcare team requires the type of flexibility found in this study since that was shaped by patient needs and the specific organizational conditions of the ED. The roles, tasks, and teamwork that a team requires to "be flexible" (i.e., responsive and adaptable) are highly context dependent. Workforce flexibility therefore cannot be defined as a particular type of reform or role; rather, it should be understood as the capacity of a team to respond and adapt to patients' needs within its organizational context. The study's findings suggest that solutions for a more flexible workforce may lay in the organization of healthcare work.

The rate and cost of nurse turnover in Australia.

Nurse turnover is a critical issue facing workforce planners across the globe, particularly in light of protracted and continuing workforce shortages. An ageing population coupled with the rise in complex and chronic diseases, have contributed to increased demands placed on the health system and importantly, nurses who themselves are ageing. Costs associated with nurse turnover are attracting more attention; however, existing measurements of turnover show inconsistent findings, which can be attributed to differences in study design, metrics used to calculate turnover and variations in definitions for turnover. This paper will report the rates and costs of nurse turnover across three States in Australia.

Methodological integrative review of the work sampling technique used in nursing workload research.

AIM: To critically review the work sampling technique used in nursing workload research. BACKGROUND: Work sampling is a technique frequently used by researchers and managers to explore and measure nursing activities. However, work sampling methods used are diverse making comparisons of results between studies difficult. DESIGN: Methodological integrative review. DATA SOURCES: Four electronic databases were systematically searched for peer-reviewed articles published between 2002-2012. Manual scanning of reference lists and Rich Site Summary feeds from contemporary nursing journals were other sources of data. REVIEW METHODS: Articles published in the English language between 2002-2012 reporting on research which used work sampling to examine nursing workload. RESULTS: Eighteen articles were reviewed. The review identified that the work sampling technique lacks a standardized approach, which may have an impact on the sharing or comparison of results. Specific areas needing a shared understanding included the training of observers and subjects who self-report, standardization of the techniques used to assess observer inter-rater reliability, sampling methods and reporting of outcomes. CONCLUSION: Work sampling is a technique that can be used to explore the many facets of nursing work. Standardized reporting measures would enable greater comparison between studies and contribute to knowledge more effectively. Author suggestions for the reporting of results may act as guidelines for researchers considering work sampling as a research method.

A comparative review of nurse turnover rates and costs across countries.

AIMS: To compare nurse turnover rates and costs from four studies in four countries (US, Canada, Australia, New Zealand) that have used the same costing methodology; the original Nursing Turnover Cost Calculation Methodology. BACKGROUND: Measuring and comparing the costs and rates of turnover is difficult because of differences in definitions and methodologies. DESIGN: Comparative review. DATA SOURCES: Searches were carried out within CINAHL, Business Source Complete and Medline for studies that used the original Nursing Turnover Cost Calculation Methodology and reported on both costs and rates of nurse turnover, published from 2014 and prior. METHODS: A comparative review of turnover data was conducted using four studies that employed the original Nursing Turnover Cost Calculation Methodology. Costing data items were converted to percentages, while total turnover costs were converted to US 2014 dollars and adjusted according to inflation rates, to permit cross-country comparisons. RESULTS: Despite using the same methodology, Australia reported significantly higher turnover costs ($48,790) due to higher termination (~50% of indirect costs) and temporary replacement costs (~90% of direct costs). Costs were almost 50% lower in the US ($20,561), Canada ($26,652) and New Zealand ($23,711). Turnover rates also varied significantly across countries with the highest rate reported in New Zealand (44·3%) followed by the US (26·8%), Canada (19·9%) and Australia (15·1%). CONCLUSION: A significant proportion of turnover costs are attributed to temporary replacement, highlighting the importance of nurse retention. The authors suggest a minimum dataset is also required to eliminate potential variability across countries, states, hospitals and departments.

Nursing churn and turnover in Australian hospitals: nurses perceptions and suggestions for supportive strategies.

BACKGROUND: This study aimed to reveal nurses' experiences and perceptions of turnover in Australian hospitals and identify strategies to improve retention, performance and job satisfaction. Nursing turnover is a serious issue that can compromise patient safety, increase health care costs and impact on staff morale. A qualitative design was used to analyze responses from 362 nurses collected from a national survey of nurses from medical and surgical nursing units across 3 Australian States/Territories. METHOD: A qualitative design was used to analyze responses from 362 nurses collected from a national survey of nurses from medical and surgical nursing units across 3 Australian States/Territories. RESULTS: Key factors affecting nursing turnover were limited career opportunities; poor support; a lack of recognition; and negative staff attitudes. The nursing working environment is characterised by inappropriate skill-mix and inadequate patient-staff ratios; a lack of overseas qualified nurses with appropriate skills; low involvement in decision-making processes; and increased patient demands. These issues impacted upon heavy workloads and stress levels with nurses feeling undervalued and disempowered. Nurses described supportive strategies: improving performance appraisals, responsive preceptorship and flexible employment options. CONCLUSION: Nursing turnover is influenced by the experiences of nurses. Positive steps can be made towards improving workplace conditions and ensuring nurse retention. Improving performance management and work design are strategies that nurse managers could harness to reduce turnover.

Nurse/midwife-to-patient ratios: A scoping review.

BACKGROUND: A significant body of work has linked high nurse or midwife workload to negative patient outcomes. Anecdotal reports suggest that mandated ratio models enhance patient care and improve nurse job satisfaction. However, there is limited focused research. OBJECTIVE: To identify key outcomes, implementation processes, and research needs regarding nurse/midwife-to-patient ratios in the Australian healthcare context. DESIGN: Scoping review. METHODS: Data sources were CINAHL, Open Dissertations, Medline, and Scopus. 289 articles screened, and 53 full text documents independently assessed against criteria by two reviewers and conflicts resolved by a third reviewer, using Covidence™. Three studies were included in this review. RESULTS: Studies focused on nurse (job satisfaction, burnout), patient (mortality, readmission, length of stay) and system (costs) outcomes with limited information on implementation processes and no midwifery research. CONCLUSIONS: Ratios provide benefits for patients, nurses, and hospitals although there is limited research in Australia. Implementation was poorly reported..

Vicarious Trauma and Health Outcomes in Forensic Mental Health Nurses.

BACKGROUND: Nurses working in forensic mental health settings are at risk of vicarious trauma because of their exposure to traumatized patients and distressing material such as the aversive details of patient crimes. AIM: The aim of this study was to determine the incidence of vicarious trauma and explore its impact on health and absence from work. METHODS: A cross-sectional descriptive correlational study was undertaken. All 205 forensic mental health nurses working in a high-security inpatient facility were invited to participate. An online survey included the Vicarious Trauma Scale and the SF-36v2 to measure mental and physical health. Absence from work was also explored. RESULTS: Sixty-seven respondents completed the survey. Almost half of respondents had a moderate level of vicarious trauma, and only over one-quarter experienced high levels. Higher levels of vicarious trauma were associated with poorer mental health (r = -0.59, p < 0.000) and absence from work (r = 0.27, p < 0.010). CONCLUSIONS: Forensic mental health nurses are at a greater risk of vicarious trauma than nurses working in mainstream mental health services, given their exposure to aversive details of patients' violent crimes. Adverse mental health consequences of vicarious trauma, and other forms of workplace trauma experienced by forensic mental health nurses, are likely to include trauma-related symptoms, depression, and anxiety. Forensic mental health nurses experiencing vicarious trauma may use sick leave as time away from work to care for their own mental health or a coping mechanism for workplace-induced psychological distress.

Impact of the Practice Environment on Oncology and Hematology Nurses: A Scoping Review.

BACKGROUND: Practice environments have a significant impact on nurses' practice and their retention within the oncology and hematology specialty. Understanding how specific elements of the practice environment impact nurse outcomes is important for creating supportive and safe practice environments. OBJECTIVE: To evaluate the impact of the practice environment on oncology and hematology nurses. METHODS: A scoping review was conducted according to the PRISMA-ScR Statement Guidelines. Electronic databases (MEDLINE, CINAHL, PsychINFO, Google Scholar, and Scopus) were searched using key terms. Articles were assessed according to the eligibility criteria. Data extraction was conducted with results explained through descriptive analysis. RESULTS: One thousand seventy-eight publications were screened with 32 publications meeting the inclusion criteria. The 6 elements of the practice environment (workload, leadership, collegial relations, participation, foundations, and resources) were found to significantly impact nurses' job satisfaction, psychological well-being, levels of burnout, and intention to leave. Negative practice environment elements were linked to increased levels of job dissatisfaction, higher levels of burnout, greater prevalence of psychological distress, and greater intention to leave both oncology and hematology nursing and the nursing profession. CONCLUSIONS: The practice environment has a significant impact on nurses, their job satisfaction, well-being, and intention to stay. This review will inform future research and forthcoming practice change to provide oncology and hematology nurses with practice environments that are safe and lead to positive nurse outcomes. IMPLICATIONS FOR PRACTICE: This review provides a foundation upon which to develop and implement tailored interventions that best support oncology and hematology nurses to remain in practice and provide high-quality care.

Violence on the Job: The Experiences of Nurses and Midwives with Violence from Patients and Their Friends and Relatives.

Violence in healthcare is recognised as a significant workplace issue worldwide, with nurses recognised as the profession at greatest risk. The purpose of this study was to explore nurses' and midwives' experiences of violence in different clinical areas, work sectors and geographical regions. A cross-sectional design was employed to survey the membership of the New South Wales Nurses and Midwives' Association about their experiences with violence from patients and/or their friends and relatives in their workplace. A total of 3416 participants returned a completed questionnaire and more than three-quarters of had experienced an episode of violence in the preceding six months. Participants working in the public health sector reported significantly more physically violent behaviours than their colleagues in the private sector. No statistically significant difference between the rates of violence (overall) was identified between different geographical areas. Violent behaviours were reported across all clinical settings, with emergency departments, mental health and drug and alcohol settings reporting the highest proportion of episodes. The results of this large study highlight the high levels of violence that nurses and midwives experience in the workplace across all sectors of employment, geographical regions and clinical settings.

Workforce flexibility - in defence of professional healthcare work.

Purpose The desirability of having a more flexible workforce is emphasised across many health systems yet this goal is as ambiguous as it is ubiquitous. In the absence of empirical studies in healthcare that have defined flexibility as an outcome, the purpose of this paper is to draw on classic management and sociological theory to reduce this ambiguity. Design/methodology/approach The paper uses the Weberian tool of "ideal types". Key workforce reforms are held against Atkinson's model of functional flexibility which aims to increase responsiveness and adaptability through multiskilling, autonomy and teams; and Taylorism which seeks stability and reduced costs through specialisation, fragmentation and management control. Findings Appeals to an amorphous goal of increasing workforce flexibility make an assumption that any reform will increase flexibility. However, this paper finds that the work of healthcare professionals already displays most of the essential features of functional flexibility but many widespread reforms are shifting healthcare work in a Taylorist direction. This contradiction is symptomatic of a failure to confront inevitable trade-offs in reform: between the benefits of specialisation and the costs of fragmentation; and between management control and professional autonomy. Originality/value The paper questions the conventional conception of "the problem" of workforce reform as primarily one of professional control over tasks. Holding reforms against the ideal types of Taylorism and functional flexibility is a simple, effective way the costs and benefits of workforce reform can be revealed.