The Impact of the Early COVID-19 Pandemic on Registered Nurses' Intent to Stay in Nursing.

The COVID-19 pandemic has been difficult for registered nurses. Media reports, most of them anecdotal, have reported upticks in nurse resignations, and plans to resign and/or leave nursing due to COVID-19. This article reports findings from an online anonymous 95-item survey completed by about 1,600 nurses from a New York City metropolitan area health system's (HS) four hospitals and ambulatory care centers about their COVID-19 experience in the spring of 2020, their intent to stay at the HS, and their intent to stay working as a nurse. Conducted early in the pandemic, this survey addresses a major gap in the literature, as there was no timely evaluation of nurses' intent to leave during the "Great Attrition" wave or to stay during the "Great Attraction" trend. Among those nurses completing the survey, 85.7% reported that they planned to work as a nurse one year later and 77.9% reported that they planned to work at the HS one year later. Those nurses who obtained a master's or doctoral degree as their first professional degree in nursing, or had a high level of mastery, were less likely to report an intent to stay at the HS. Those with no children, those who thought the HS was more supportive, and those who thought that registered nurse-medical doctor relations were higher were more likely to intend to stay at the HS. Those nurses who reported worse communication with their nurse manager were less likely to report an intent to stay in nursing. Those who reported lower stress, who were unmarried and had no children were more likely to intend to work as nurses. Our findings on nurses' intent to leave their organization and their intent to leave nursing are much lower than reports in the popular press. Our data were collected early in the pandemic and it may not reflect the accumulated stress nurses experienced from witnessing the death of so many patients.

A comparison of scheduling, work hours, overtime, and work preferences across four cohorts of newly licensed Registered Nurses.

AIMS: To conduct a comparative analysis of four cohorts of newly licensed Registered Nurses and their work schedule, daily shift length, weekly work hours, second job, and weekly overtime hours. Nurses also reported their preferences regarding work schedule and daily shift length. DESIGN: We used a retrospective, comparative design analysing four cross-sectional surveys from new nurses first licensed between 2004-2015. METHODS: Using state licensure lists, nurses who were first licensed between 1 August 2004 and 31 July 2005 were randomly sampled using a nested design in 23 geographical areas in 13 states and Washington, DC. The same sampling strategy was conducted for subsequent cohorts in January 2009, 2012, and 2016. We sent a mailed survey measuring demographics, education, work attributes, and attitudes to participants with a $5 incentive, following methods by Dillman. RESULTS: There were no statistically significant differences in average weekly work hours (39.4 hrs) or holding more than one job for pay (11.6-14.6% across all cohorts). There were statistically significant differences in overtime across cohorts and shift length by unit type. The preferred shift length was 12 hrs and day shift was the preferred work schedule. CONCLUSION: New nurses are predominantly scheduled for 12-hrs shifts and nearly half work weekly overtime, trends that have remained relatively stable over the past 10 years. Nurse managers, policy-makers, and researchers should pay attention to new nurses' schedule and shift preferences and guard against mandatory overtime hours.

Common predictors of nurse-reported quality of care and patient safety.

BACKGROUND: In the era of the Patient Protection and Affordable Care Act, quality of care and patient safety in health care have never been more visible to patients or providers. Registered nurses (nurses) are key players not only in providing direct patient care but also in evaluating the quality and safety of care provided to patients and families. PURPOSE: We had the opportunity to study a unique cohort of nurses to understand more about the common predictors of nurse-reported quality of care and patient safety across acute care settings. APPROACH: We analyzed cross-sectional survey data that were collected in 2015 from 731 nurses, as part of a national 10-year panel study of nurses. Variables selected for inclusion in regression analyses were chosen based on the Systems Engineering Initiative for Patient Safety model, which is composed of work system or structure, process, and outcomes. RESULTS: Our findings indicate that factors from three components of the Systems Engineering Initiative for Patient Safety model-Work System (person, environment, and organization) are predictive of quality of care and patient safety as reported by nurses. The main results from our multiple linear and logistic regression models suggest that significant predictors common to both quality and safety were job satisfaction and organizational constraints. In addition, unit type and procedural justice were associated with patient safety, whereas better nurse-physician relations were associated with quality of care. CONCLUSION: Increasing nurses' job satisfaction and reducing organizational constraints may be areas to focus on to improve quality of care and patient safety. PRACTICAL IMPLICATIONS: Our results provide direction for hospitals and nurse managers as to how to allocate finite resources to achieve improvements in quality of care and patient safety alike.

Diversity and education of the nursing workforce 2006-2016.

BACKGROUND: The Institute of Medicine (IOM) report, The Future of Nursing, included recommendations to increase nurse diversity, the percent of nurses obtaining a bachelor's degree, and inter-professional education. PURPOSE: The purpose of this paper is to report the progress toward achievement of these recommendations. METHODS: We used a longitudinal, multi-state data from four cohorts of nurses newly licensed in 2004 to 2005, 2007 to 2008, 2010 to 2011, and 2014 to 2015 to examine and compare the trends. FINDING: The percentage of males who became licensed increased, from 8.8% in 2004 to 2005 cohort to 13.6% in the 2014 to 2015 cohort. The percentage of white-non-Hispanic nurses who were licensed decreased from 78.9% in 2007 to 2008 to 73.8% in 2014 to 2015. These differences primarily reflect an increase in white-Hispanic nurses. More nurses are obtaining a bachelor's degree as their first professional degree, from 36.6% in 2004 to 2005 cohort to 48.5% in 2014 to 2015 cohort. About 40% of the 2014 to 2015 cohort reported that they learned to work in inter-professional teams. Collegial nurse-physician relations had an upward positive trajectory over time increasing almost 7%. DISCUSSION: The diversity and education of new nurses have increased, but are short of meeting the IOM recommendations.

Challenges and Resources for Nurses Participating in a Hurricane Sandy Hospital Evacuation.

PURPOSE: Weather-related disasters have increased dramatically in recent years. In 2012, severe flooding as a result of Hurricane Sandy necessitated the mid-storm patient evacuation of New York University Langone Medical Center. The purpose of this study was to explore, from the nurses' perspective, what the challenges and resources were to carrying out their responsibilities, and what the implications are for nursing education and preparation for disaster. DESIGN: This mixed-methods study included qualitative interviews with a purposive sample of nurses and an online survey of nurses who participated in the evacuation. METHODS: The interviews explored prior disaster experience and training, communication, personal experience during the evacuation, and lessons learned. The cross-sectional survey assessed social demographic factors, nursing education and experience, as well as potential challenges and resources in carrying out their disaster roles. FINDINGS: Qualitative interviews provided important contextual information about the specific challenges nurses experienced and their ability to respond effectively. Survey data identified important resources that helped nurses to carry out their roles, including support from coworkers, providing support to others, personal resourcefulness, and leadership. Nurses experienced considerable challenges in responding to this disaster due to limited prior disaster experience, training, and education, but drew on their personal resourcefulness, support from colleagues, and leadership to adapt to those challenges. CONCLUSIONS: Disaster preparedness education in schools of nursing and practice settings should include more hands-on disaster preparation exercises, more "low-tech" options to address power loss, and specific policies on nurses' disaster roles. CLINICAL RELEVANCE: Nurses play a critical role in responding to disasters. Learning from their disaster experience can inform approaches to nursing education and preparation.

Enabling a Disaster-Resilient Workforce: Attending to Individual Stress and Collective Trauma.

PURPOSE: Superstorm Sandy forced the evacuation and extended shutdown of New York University Langone Medical Center. This investigation explored how nurses were impacted by the disasters and how they can best be supported in their nursing responsibilities. DESIGN: Sequential mixed methods were used to explore the psychosocial issues nurses experienced throughout the course of this natural disaster and its lingering aftermath. METHODS: In-depth interviews were conducted from April to June 2013 with a subsample of nurses who participated in the evacuation deployment (n = 16). An anonymous, Internet-based cross-sectional survey sent to all registered nurses employed at the hospital at the time of the storm explored storm impact and recovery. Between July and September 2013, 528 surveys were completed. FINDINGS: The qualitative data revealed challenges in balancing professional obligations and personal concerns. Accounts described dealing in the immediate recovery period with unexpected job changes and resultant work uncertainty. The storm's lingering aftermath did not signify restoration of their predisaster lifestyle for some, but necessitated coping with this massive storm's long-lasting impact on their personal lives and communal loss. CONCLUSIONS: Nurses working under the rapidly changing, uncontrolled, and potentially dangerous circumstances of a weather-related disaster are also experiencing concerns about their families' welfare and worries about personal loss. These multiple issues increase the psychosocial toll on nurses during a disaster response and impending recovery. CLINICAL RELEVANCE: Awareness of concerns and competing demands nurses experience in a disaster and aftermath can inform education and services to enable nurses to perform their critical functions while minimizing risk to patients and themselves.

Nurses Improve Their Communities' Health Where They Live, Learn, Work, and Play.

Nurses are often recognized for their volunteer efforts following disasters and international humanitarian crises. However, little attention is paid to the activities of nurses who promote a culture of health in their communities through local volunteer work. In this article, we describe nurses' perceptions of how they promote health in their communities through formal and informal volunteer work. Using 315 written responses to an open-ended question included in a 2016 survey of the career patterns of nurses in the U.S., we utilized conventional content analysis methods to code and thematically synthesize responses. Two broad categories of nurse involvement in volunteer activities arose from the participants' responses to the open-ended question, "Please tell us what you have done in the past year to improve the health of your community": 17% identified job-related activities, and 74% identified non-job-related activities. 9% of respondents indicated they do not participate in volunteer work. Job-related activities included patient education, educating colleagues, and "other" job-related activities. Non-job-related activities included health-related community volunteering, volunteering related to a specific population or disease, family-related volunteering, church activities, health fairs, raising or donating money, and travelling abroad for volunteer work. Nurses are committed to promoting a culture of health in their communities both at work and in their daily lives. Leveraging nurses' interest in volunteer work could improve the way nurses engage with their communities, expand the role of nurses as public health professionals, and foster the social desirability of healthful living.

All nurses need to be research nurses.

INTRODUCTION: Nurses are critical to the research enterprise. However all nurses are not prepared to participate as members of the research team since education and training in clinical research nursing and nurse-specific Good Clinical Practice are not consistently included in nursing curricula. The lack of nurse education and training in clinical research and Good Clinical Practice leaves research participants vulnerable with a nursing workforce that is not prepared to balance fidelity to protocol and patient quality care and safety. METHODS: A collaborative network of nurses within Clinical and Translational Science Awards and beyond was established to address this education and training need. Over a 2-year period, using expert opinion, Delphi methods, and measures of validity and reliability the team constructed curriculum and knowledge test items. RESULTS: A pilot modular electronic curriculum, including knowledge pretest and post-tests, in clinical research nursing and nurse-specific Good Clinical Practice competencies was developed. CONCLUSIONS: As the scope and setting of clinical research changes, it is likely that all practicing nurses, regardless of their practice setting or specialty, will care for patients on research protocol, making all nurses, in essence, clinical research nurses. The curriculum developed by this protocol will address that workforce education and training need.

Barriers and facilitators of nurses' use of clinical practice guidelines: An integrative review.

BACKGROUND: Preventable harm continues to be one of the leading causes of patient death. Each year about 400,000 patients die from sepsis, hospital acquired infections, venous thromboembolism, and pulmonary embolism. However, as shown in the recent reduction in hospital acquired infections, the number of deaths could be reduced if healthcare providers used evidence-based therapies, which are often included in clinical practice guidelines (CPGs). PURPOSE: The purpose of this integrative review is to appraise and synthesize the current literature on barriers to and facilitators in the use of clinical practice guidelines (CPGs) by registered nurses. DESIGN: Whittemore and Knafl integrative review methodology was used. Primary quantitative and qualitative studies about the nurses' use of CPGs and published in peer-reviewed journals between January 2000 and August 2015 were included. METHODS: The Critical Skills Appraisal Program (CASP) was used to critically appraise the quality of sixteen selected quantitative and qualitative studies. RESULTS: Internal factors were attitudes, perceptions, and knowledge whereas format and usability of CPGs, resources, leadership, and organizational culture were external factors influencing CPG use. CONCLUSION: Given each barrier and facilitator, interventions and policies can be designed to increase nurses' use of CPGs to deliver more evidence based therapy. In order to improve the use of CPGs and to ensure high quality care for all patients, nurses must actively participate in development, implementation, and maintenance of CPGs.

Estimating and preventing hospital internal turnover of newly licensed nurses: A panel survey.

BACKGROUND: Registered nurse job turnover is an ongoing problem in the USA resulting in significant financial costs to both organizations and society. Most research has focused on organizational turnover with few studies about internal or unit-level turnover. Turnover of new nurses in hospitals has particular importance as almost 80% of new nurses work in hospitals and have higher turnover rates when compared to experienced nurses. This paper focuses on new nurses' unit-level turnover rates in hospitals. OBJECTIVES: The purpose of this study is to: (1) identify factors that predict new nurses staying in the same units, positions, and job titles to inform unit-level retention strategies, and (2) examine the changes in work environment perceptions over time between nurses who remain in the same unit, position, and title to those who changed unit, position and/or title. STUDY DESIGN: A panel survey design was used to analyze changes over time. PARTICIPANTS: Participants were newly licensed registered nurses who were licensed for the first time between August 1st, 2004 and July 31st, 2005. The nurses came from metropolitan statistical areas or rural areas that were nested to reflect a nationally representative USA sample (58% response rate). The analytic sample for this study was 1335. DATA SOURCES: Data were collected in January 2006 and 2007 following the Dillman total design approach. All potential respondents received paper surveys and non-responders received repeated mailings. RESULTS: Using multinomial regression the five variables with the largest effects on unit retention were (1) variety (positive), (2) having another job for pay (negative), (3) first basic degree (having a bachelors or higher degree increased the probability of staying), (4) negative affectivity (positive), and (5) job satisfaction (positive). Nurses who changed unit, and/or position, and/or title reported more positive change scores on a variety of work attitudes. DISCUSSION: Almost 30% of new nurses working in hospitals leave their unit, and/or position, and/or title during their first year of work. Our results point to the variables on which managers can focus to improve unit-level retention of new nurses. Although participants were from a nationally representative sample of nurses who were newly licensed in 2004-2005, with the geographical shifts in the USA population in the last 10 years the sample may not be geographically representative of new nurses who graduated in 2015.

Impact of transformational leadership on nurse work outcomes.

AIMS: To examine the effect of transformational leadership on early career nurses' intent to stay, job satisfaction and organizational commitment. BACKGROUND: Lack of leadership support is one of the top reasons staff nurses leave. Current studies reported mixed results about the impact of transformational leadership on key nurse outcomes. However, little is known whether leadership directly or indirectly affects satisfaction, organizational commitment and intent to stay. DESIGN: This study was a cross-sectional study of nurses who had been licensed for 7·5-8·5 years which was part of a 10-year longitudinal panel design. METHODS: The analytic sample was 1037 nationally representative newly licensed Registered Nurses. Data were collected from January-March 2013. We used a probit model to model the relationship between transformational leadership and intent to stay, organizational commitment and job satisfaction. RESULTS: Transformational leadership did not have a significant impact on intent to stay and job satisfaction, but significantly associated with organizational commitment. Organizational commitment, job satisfaction, mentor support, promotional opportunities and age were positively associated with intent to stay, while ethnicity, non-local job opportunities and work settings were negatively associated with intent to stay. CONCLUSIONS: Transformational leadership had no direct relationship with intent to stay and job satisfaction and had a small direct positive effect on organizational commitment. Transformational leadership has potential to slow attrition and retain nurses by creating a positive work environment that supports nurses. Any improvement in job satisfaction and organizational commitment would positively increase the change in probability for intent to stay.

Scheduling and shift work characteristics associated with risk for occupational injury in newly licensed registered nurses: An observational study.

BACKGROUND: Registered nurses across the globe bear a heavy injury burden. Every shift, nurses are exposed to a variety of hazards that can jeopardize their health, which negatively impacts their ability to provide high-quality patient care. Previous research suggests that inexperienced, or newly licensed nurses, may have an increased risk for certain occupational injuries. However, the current knowledge base is insufficient to fully understand how work hours influence newly licensed nurses' occupational injury, given the significant variation in hospital organization and work characteristics. OBJECTIVE: To describe newly licensed nurses' shift work characteristics and determine the association between shift type and scheduling characteristics and nurse injury, before and after adjusting for individual and combined effects of demographics, external context, organizational context, and work context, following the Organization of Work model. DESIGN: This study is a secondary analysis of a nationally representative survey of newly licensed registered nurses using a cross-sectional design. PARTICIPANTS: The analytic sample includes 1744 newly licensed registered nurses from 34 states and the District of Columbia who reported working in a hospital and were within 6-18 months of passing their state licensure exam at the time of survey administration. METHODS: Descriptive statistics were calculated, followed by bivariate and multivariate Poisson regression models to assess the relationship between shift type and scheduling characteristics and nurse injury. Lastly, full models with the addition of demographics, external context, organizational context, and work context variables were calculated. RESULTS: The majority (79%) of newly licensed nurses worked 12-h shifts, a near majority worked night shift (44%), and over half (61%) worked overtime (mandatory or voluntary) weekly. Nurses working weekly overtime were associated with a 32% [incidence rate ratio (IRR) 1.32, CI 1.07-1.62] increase in the risk of a needle stick and nurses working night shift were associated with a 16% [IRR 1.16, CI 1.02-1.33] increase in the risk of a sprain or strain injury. CONCLUSIONS: Overtime and night shift work were significantly associated with increased injury risk in newly licensed nurses independent of other work factors and demographic characteristics. The findings warrant further study given the long-term consequences of these injuries, costs associated with treatment, and loss of worker productivity.

A structural equation model of turnover for a longitudinal survey among early career registered nurses.

BACKGROUND: Key predictors of early career nurses' turnover are job satisfaction, organizational commitment, job search, intent to stay, and shock (back injuries) based on the literature review and our previous research. Existing research has often omitted one of these key predictors. OBJECTIVES: The purpose of this study in a sample of early career nurses was to compare predictors of turnover to nurses' actual turnover at two time points in their careers. DESIGN: A multi-state longitudinal panel survey of early career nurses was used to compare a turnover model across two time periods. The sample has been surveyed five times. PARTICIPANTS: The sample was selected using a two-stage sample of registered nurses nested in 51 metropolitan areas and nine non-metropolitan, rural areas in 34 states and the District of Columbia. METHODS: The associations between key predictors of turnover were tested using structural equation modeling and data from the earliest and latest panels in our study. We used predictors from the respondents who replied to the Wave-1 survey in 2006 and their turnover status from Wave 2 in 2007 (N=2386). We compared these results to the remaining respondents' predictors from Wave 4 in 2011 and their turnover status in Wave 5 in 2013 (N=1073). We tested and found no effect for missingness from Wave 1-5 and little evidence of attrition bias. RESULTS: Strong support was found for the relationships hypothesized among job satisfaction, organizational commitment, intent to stay, and turnover, with some support for shock and search in the Wave 1-2 sample. However, for Wave 4-5 sample (n=1073), none of the paths through search were significant, nor was the path from shock to turnover. CONCLUSIONS: Nurses in the second analysis who had matured longer in their career did not have a significant response to search or shock (back injuries), which may indicate how easily experienced registered nurses find new jobs and/or accommodation to jobs requiring significant physicality. Nurse turnover is a major concern for healthcare organizations because of its costs and related outcomes. The relevant strength and relationships of these key turnover predictors will be informative to employers for prioritizing strategies to retain their registered nurse workforce. We need more research on programs that implement changes in the work environment that impact these two outcomes, as well as research that focuses on the relevant strength or impact to help administrators prioritize translation of results.

Educational gaps and solutions for early-career nurse managers' education and participation in quality improvement.

OBJECTIVE: The objective of this study was to examine early-career frontline nurse managers' (FLNMs') reported educational preparedness and participation in quality improvement (QI). BACKGROUND: Frontline nurse managers are vitally important for leading QI. However, it is not well known if they have adequate knowledge and skills to lead this important function. METHODS: We examined cross-sectional survey data from 42 FLNMs using descriptive statistics. RESULTS: About 30% of FLNMs reported being very prepared across 12 measured QI skills by schools or employers and 35% reported participating in a specific clinical effort to improve patient care on their unit more than once a month. More than 50% reported having good organizational support for QI, but only about 30% reported being rewarded for their contributions to QI. CONCLUSION: Our study highlights opportunities for development in QI for FLNMs and offers some solutions for nurse executives that can bridge the educational gaps.

What does nurse turnover rate mean and what is the rate?

Registered nurse turnover is an important indicator of the nurse job market. Despite its wide use as a measure for health-care system analysis, there is a lack of consistency in the definition of turnover. Some definitions include any nurse leaving an organization; others may include involuntary and voluntary leaving. These inconsistent definitions also result in various turnover rates. The RN Work Project is a 10-year panel study of new nurses. Data were collected from the new nurses, rather than from a specific organization. About 17.5% of new nurses leave their first job within 1 year of starting their jobs. Consistent and accurate measurement of turnover is an important step in addressing organizational work environments and policies about the nursing workforce.

Challenges of nurses' deployment to other New York City hospitals in the aftermath of Hurricane Sandy.

On October 29, 2012, a 12-ft storm surge generated by Hurricane Sandy necessitated evacuation and temporary closure of three New York City hospitals including NYU Langone Medical Center (NYULMC). NYULMC nurses participated in the evacuation, and 71 % were subsequently deployed to area hospitals to address patient surge for periods from a few days up to 2 months when NYULMC reopened. This mixed methods study explored nurses' experience in the immediate disaster and the subsequent deployment. More than 50 % of deployed nurse participants reported the experience to be extremely or very stressful. Deployed nurses encountered practice challenges related to working in an unfamiliar environment, limited orientation, legal concerns about clinical assignments. They experienced psychosocial challenges associated with the intense experience of the evacuation, uncertainty about future employment, and the increased demands of managing the deployment. Findings provide data to inform national and regional policies to support nurses in future deployments.

Exploring direct and indirect influences of physical work environment on job satisfaction for early-career registered nurses employed in hospitals.

We explored direct and indirect influences of physical work environment on job satisfaction in a nationally representative sample of 1,141 early-career registered nurses. In the fully specified model, physical work environment had a non-significant direct effect on job satisfaction. The path analysis used to test multiple indirect effects showed that physical work environment had a positive indirect effect (p < .05) on job satisfaction through ten variables: negative affectivity, variety, workgroup cohesion, nurse-physician relations, quantitative workload, organizational constraints, distributive justice, promotional opportunity, local and non-local job opportunities. The findings make important contributions to the understanding of the relationship between physical work environment and job satisfaction. The results can inform health care leaders' insight about how physical work environment influences nurses' job satisfaction.