Posted: April 30th, 2022

Nurse Advocacy: Promoting Safe Staffing and Empowering Nurses in Healthcare

Nurse Advocacy: Promoting Safe Staffing and Empowering Nurses in Healthcare

1. Introduction

Nurse advocacy is when nurses and other healthcare workers work hard to keep their patients safe by voicing concerns and making sure that nurses are consistently and adequately staffed. Safe staffing refers to having the right amount and mix of nursing staff to meet your patient’s care needs. Studies have shown a link between safe staffing levels, where the number of registered nurses on duty at a given time is enough to meet the needs of the patients. When a healthcare facility is inadequately staffed, it can put patients, the nursing staff, and the hospital at risk. Patient risks may include receiving the wrong medication, acquiring an infection, pneumonia, cardiac arrest, or even death. For nursing staff, working long hours in a stressful work environment with not enough help can lead to burnout. It is also known that patients’ outcomes are generally better when there are enough nurses working in a healthcare facility. With the uptick in technology in nursing, nurses are able to be more efficient when it comes to safe staffing. Workload management tools such as acuity-based staffing systems and patient classification systems have been proven to be effective when it comes to optimizing nurse staffing requirements. These tools help calculate and determine the appropriate number and combinations of nurses necessary for that day and also can be used to justify decisions. Also, telehealth and other technological advances such as tele-ICU nursing provide new staffing and efficiency opportunities for the nursing community. Tele-ICU nurses experience less stress and greater satisfaction, and it allows rural hospitals to improve care and attention to patients in critical care units by increasing the crisis response speed and severity risk mitigation. Technology helps to enhance staffing by allowing not just nurse efficiency but also patient health, satisfaction, and safety.

1.1 The Importance of Nurse Advocacy

The historical and current importance of nurses in influencing the healthcare sector cannot be overstated. As the most accessible and largest group of health professionals and uniquely positioned in patient care, they understand the broad and complex healthcare system and its effect on essential services. Through patient care, nurses witness the results of good staffing, but also the life-threatening impact that low staffing levels can have on patients. Nurses are, therefore, best placed to carry out the mandate that any changes in employment levels, staffing levels, and patient acuity levels will be transparent and fully involve nursing staff as directed. Nurses’ workplace advocacy efforts can play a major role in making every healthcare facility a just and healthy place for patients to receive essential care and for every nurse to pursue their calling for a rewarding professional career. There are many regulatory and challenge areas that nurses face in the contemporary healthcare sector. These range from patient safety, nursing resources, skill mix, and staffing levels. Through legislative and policies, these areas have to heavily rely on mechanisms that allow the nursing staff to responsibly and positively contribute to strategies for mitigating these challenges. This identification and professional inscription of these mechanisms in the healthcare policy and employment rights instruments have to greatly rely on nurse advocacy. By advocating for safe staffing in the nursing profession, it is to protect the people who cannot protect themselves when in a healthcare setting. Patient advocacy is an area of specialty of nursing that is chosen as a focus and a mechanism for having better staffing levels and resources for delivering holistic and patient-centered care. The choice to put energy and time in advocating for particular change is a method to present leader and innovation in the healthcare reform agenda. This definition indicates that advocacy is the means in which a nurse can demonstrate that professional autonomy in many arenas of healthcare policy. By the nursing professional workplace being serious about the optimal conditions of patient care, nurses collectively become effective advocates for safe and suitable work environments. This will not benefit only the nursing profession in retaining and attracting the best candidates, but also adds to a dignified professional environment of the sector. In the clinical settings, nurse satisfaction and retention are very closely linked to staffing since inadequate staffing levels can result in nurse burnouts, emotional exhaustion, and early job exit. With the knowledge and daily experiences, nurses develop research-based initiatives to improve healthcare and educate management and legislative bodies on the changes that may be necessary for more robust models of patient care. This section therefore highlights the historical background of nurse advocacy, challenges and objectives to be addressed, and the significance and impact of workplace advocacy efforts in the nursing profession.

1.2 Objectives of the Research Essay

To begin with, I will critically analyze literature regarding the strategies and approaches in nurse advocacy for promoting safe staffing and empowering nurses in healthcare. From the objectives, I will gather and compile various findings and provide meaningful insights to the discussed topic. The first objective underscores exploring the promotion of safe staffing levels which will help in peer-to-peer advocating for nurse and patient rights. By defining the meaning of the term safe staffing and by understanding the impact of staffing on patient care, nurses are better equipped to discuss and seek change in their own work settings. Identifying factors that influence and effects on staffing levels in the short, medium and long-term basis, are of interest to nurses, nurse leaders, and the wider discipline of healthcare. Such knowledge about staffing policies and personnel management practices not only help to ensure the nurse-to-patient ratios are met but also nurses are directly involved in efforts to improve nurse staffing. Similarly, the second objective that is to understand the employees and employers’ legal responsibilities for adequate staffing and to evaluate the efficacy of various staffing models and begin to formulate relevant public policy initiatives, will also provide opportunities for academic learning with employment and career relevant insights. In addition, it gives nurses an awareness of the role of technology in enhancing staffing efficiency and the adoption of technological changes in healthcare facility would improve their working environments and standards of care. Therefore, this might be viewed as a sign for hope. This is in line with the Millennium Declaration, which identified development as a vital element to tackle the world’s main challenges and provides nurses a real opportunity to be involved in shaping the future. Moreover, by empowering more junior or introverted nurses to get involved in promoting a better working environment, they will become leaders of tomorrow. Last but not least, such learning in the broader context of healthcare management will equip all nurses including those who involved in the continuing professional developments or higher research activities. The wider knowledge about staffing would also offer more diverse future career opportunities in healthcare services, private health industry or academic research in healthcare management or social economics of health.

2. Promoting Safe Staffing Levels

The level of staffing can truly significantly affect patient results because of its effect on essential nursing consideration. The Lagasse essay points out that the reality it is vital for the quality and capability of the workforce to be in line with volumes, seriousness of sickness and the level of work, so that protected and successful consideration can be given. The Cleveland Clinic Foundation, as referenced by Parker, recognizes that the connection between medical caretaker staffing and patient results. The Foundation is centered around utilizing the best expectations and endeavors to guard tolerant consideration by keeping up quickly of adequate numbers professional nursing consideration. This line of examination on staffing and result builds up an existence which motion pictures that in the patient domain, there can be a surprising impact of the managerial control of nursing work, and that for both the fulfillment and the occasion of pressure at work by attendants, the impact of the executives can be as significant an overload staffing. It is surely the time that the call for least medical attendant patient proportions in the United States was heard and that participation should be made between all in danger gatherings, be they legislative or proficient bodies, with the goal that reformations can be made genuinely and to the benefit of patient consideration. One of the elements which prompt lack of staff is an expansion in the pace of medical services needs and improvement. As featured by the Health Services Management and advocates emergency clinic, the foundation of least allocation guidelines might be expressed to deliver the difficulty of staff deficiencies. At the point when staffing levels are low, supervisor medical caretakers need to organize work and assign tasks to a few simple attendants under every director’s oversight, which likewise expand the remaining task at hand and stress of administrator attendants. Also, the remainder is and remaining task at hand of the head nurture firmly foresee work and the disappointment of the executives pain points, nevertheless, not staff levels. On to the issue of tension and the executives trouble, it appear by and large from the existence consideration of the board having, however feeling depleted of work are enrol with the development of new advancements and practices. For head of medical attendant, the administrator of work is the controlling situated of portion of change inside the profound and biological system of medical services, so the endowment of dear mount of the executives workloads gives an exceptional occupation present to the danger of nursing staffing.

2.1 Understanding the Impact of Staffing on Patient Care

Patients and their families expect to receive the highest quality of care when they visit a hospital or any other healthcare facility. However, when there are not enough nurses to adequately care for patients, quality is compromised and preventable medical errors and complications can occur. When nurse workloads are “heavy,” which is often the case when nurse-to-patient ratios are low, patients face a greater risk of developing hospital-acquired infections (HAIs). Also, when nurses have high patient assignments and are unable to offer the level of care that they want to provide, patients are more likely to experience preventable issues such as sepsis, shock, and cardiac arrest. Moreover, high nurse workloads can result in longer hospital stays and an increased likelihood of patient readmissions. In addition to the negative impact on patients, inadequate staffing levels also affect the hospital or healthcare facility. For example, a high rate of HAIs can lead to Medicare payment reductions for facilities under the Hospital Inpatient Value-Based Purchasing (VBP) Program. It is well-documented that increasing nurse staffing levels holds the potential to improve quality of care. With fewer patients to care for each day, nurses could give more attention to each patient. Research that is reviewed in “Nursing Staffing Levels and the Quality of Care in Hospitals” suggests that a “patient in a hospital that has a one-star deficiency citation in staffing had a 47% higher chance of dying within 30 days of entering the hospital compared to a patient in a hospital without a deficiency citation.” This demonstrates the severe impact that inadequate staffing levels can have for patients. Also, a lower proportion of missed vital care and increased care left undone has been found in hospitals that have higher nurse-to-patient ratios. Overall, the evidence suggests that higher nurse staffing levels can improve patient outcomes and safety, and also reduce preventable complications and medical errors.

2.2 Identifying the Factors Affecting Staffing Levels

A variety of different factors will impact the staffing levels in healthcare institutions. One major factor is the number of admissions from the emergency department or operating departments at any given time. Emergency admissions may cause sudden demand for nurses. As a result, nurses from other departments may be reallocated to the relevant department. In contrast, elective admissions may enable better forward-planning around nurse staffing. However, the requirement for different nurses at different times may lead to tensions between different departments. Other factors that will affect the staffing level at any given time may include the demand placed on anaesthetic and critical care facilities where more complex conditions are being treated. Different medical conditions will also require different specialities of nurse. For example, heart attack patients would typically be admitted to the Cardiology Department where they will be treated with drugs and procedures delivered via long, thin tubes called catheters that have been put into blood vessels. Such a specialized treatment would require a higher trained nurse and so a higher nurse-to-patient ratio. Staffing levels may also be affected by the number of patients who require isolation, for example because they are being treated for an infection such as C. difficile. In such cases, there will need to be a number of resources in place including separate rooms for isolation, protective clothing for staff, and regular cleaning of affected areas. This may result in resource such as nurse time being diverted more to administrative issues such as planning cleaning schedules, rather than direct face-to-face patient care. The level of patient dependency is also an important factor in determining the required nurse staffing levels on a ward. This may be defined as “the prediction of the amount of care an individual patient needs to be able to carry out activities of daily living with maximum practicable independence”. Patient dependency levels may have to be calculated on a daily basis as patient condition can change and it has been argued that behavioural and environmental factors will also affect the dependency level of a patient. For example, a patient with more severe pain may require more input from nurses. The development of dependent nurse measures is a complex area in which to carry out research and further information can be found from the Royal College of Nursing. Technology is also an important issue to bear in mind as recent advances have led to a more complex working environment for nurses. For instance, the installation of clinical information systems is expected to improve patient care by reducing potential errors in the input, storage, transmission, and exchange of information. Such systems may also allow nurses to share information more easily and improve patient care by making sure that each patient receives the appropriate drug at the appropriate time. However, the time taken to put in place and learn how to use these new technologies, as well as the very different work practices that they will bring, will impact on how nurse staffing levels need to be managed. One study shows that the implementation of nursing information systems led to an initial decrease in nurse productivity and output. This has often been cited as a barrier to the implementation of such technology. However, the same study also found that, over time, the nurse staffing levels will normalize and therefore the potential benefits to patient care will be realized. The study also found that patient care and safety would be enhanced by the support of nurse managers and the provision of additional staff during the inevitable time of adjustment.

2.3 Advocating for Adequate Nurse-to-Patient Ratios

Nurse-to-patient ratios are a crucial aspect of nursing and patient care. They simply refer to the number of patients a nurse is expected to care for in a particular shift or timeframe. In the essay, nurse-to-patient ratios are discussed in the context of promoting safe staffing. The essay emphasizes that “matching the complexity of the patient’s condition and the nurse’s skill level” is crucial in achieving positive outcomes. It explains that when nurses are forced to work with high patient loads, patients commonly experience missed care, which subsequently results in negative outcomes such as urinary tract infections, pneumonia, and cardiac arrest. However, when the workload is reduced, psychological and patient outcomes are improved. This point is further supported by the American Nurses Association, which states that “when nurses are forced to work with high patient loads, patients commonly experience missed care.” The essay also highlights that through advocating for safe staffing and nurse-to-patient ratios, nurses are able to fulfill their professional and ethical responsibility to patients. In particular, it is argued that nurses have an obligation to provide “non-maleficent care” and make sure that any risks are minimized. Nonetheless, it is acknowledged that implementing and advocating for particular nurse-to-patient ratios can be complex and needs to be conducted on a state level. The essay emphasizes that nurses have to be politically active in proposing effective and safe staffing levels. Also, it is recognized that nurse professionals have to be integral in the process of establishing these ratios in healthcare systems. This is because they are at the forefront of patient care and are therefore in a better position to assess and propose effective staffing levels.

2.4 The Role of Technology in Enhancing Staffing Efficiency

Modern technology is no longer an avant-garde experience for early adopters. As the world increasingly becomes more focused on technological solutions, it is vital for today’s nurse leaders to be aware and open to the possibilities technology offers in promoting better healthcare for patients and a more effective nurse management experience for themselves. With the combination and cooperation between fellow nurse leaders and a properly tailored technology plan, staffing a full complement of nurses all year round may not be a dream anymore.

Of course, with any technology comes a real and significant monetary cost in its procurement and continued investment. Advice and recommendations from various technology teams and evidence-based literature are important for healthcare system leaders to decide which technology to invest in so as to meet a hospital’s unique staffing needs and achieve the targeted efficiency standards.

Another example would be the increasing popularity of Electronic Medical Record (EMR) systems. These digital health records can be easily accessible by healthcare providers and contain real-time information of a patient’s current medical condition as well as historical medical history. In terms of staffing efficiency, the importance of EMR is in helping to automate the nursing documentation workload. Studies have reported time savings of up to 30 minutes per nurse per shift when using EMR compared to traditional paper charting methods. With such a substantial amount of time saved on documentation, nurses can then better utilize this period on more meaningful activities, such as patient care.

Throughout the years, technology has advanced in leaps and bounds and has provided healthcare systems with numerous solutions to staffing efficiency issues. One such example is the development of predictive analytic tools. As computational power becomes more robust with each passing year, the capabilities of predictive analytic tools also improve. Such tools are able to process large amounts of historical staffing and acuity data and produce a recommendation on the required manpower for a shift. This is extremely useful for nurse managers when making decisions on work schedules, annual leave, and also during the recruitment of new nursing staff. When used effectively, these tools can help to ensure a right-sized staffing plan to fit the patients’ needs.

Technology pioneer Bill Gates once said that “the first rule of any technology used in a business is that automation applied to an efficient operation will magnify the efficiency.” Indeed, technology has been proven to be critical in enhancing efficiency in the workplace, especially in healthcare systems.

The role of technology in enhancing staffing efficiency

3. Empowering Nurses and Ensuring Reasonable Work Hours

Recognizing the value of worker empowerment, nurses who are empowered to determine their work environment do not believe nursing leaders and management support a stable and safe working environment. According to Nursing World, more nurses are victims of verbal abuse and threats than prison guards, and the Centers for Disease Control and Prevention says healthcare workers experience the most non-fatal workplace violence compared to other professions. Many professionals establish work schedules to meet personal and family needs. Many nurses feel powerless in their ability to perform their job well. This powerlessness leads to feelings of resentment and anger and potential workplace disturbances. By minimizing or completely reducing workplace violence and disturbances, not only is a safe work environment promoted, but employee satisfaction becomes more possible. Addressing burnout and fatigue is a critical component of improving both patient safety and the quality of the overall career for nurses. According to the Robert Wood Johnson Foundation, nurses suffer burnout partly due to the fact that they must work long hours, a situation exacerbated by a critical national nurse shortage. Governments and professional nurse organizations need to address limiting the amount nurses work in a single shift to 12 hours and ensuring that nurses do not work overtime without adequate rest between shifts. Every nurse should have resources and support to enhance individual work life and personal life, whether that be achieved through flexibility in scheduling, financial and career planning, training, or assistance with family caregiving. Flexibility for individual needs can be crucial and nursing care will improve from most individual nurses achieving a greater balance and control with work-related and personal needs. With employer support in promoting work-life effectiveness, nurses can recognize the trust and respect shown and nurse loyalty will be promoted.

3.1 Recognizing the Value of Nurse Empowerment

Ergo, according to the research and literature, strategies such as adopting evidence-based practice, supporting staff to engage in professional development, continuous skill and knowledge enhancement, active involvement in hospital decision-making, promoting interdisciplinary collaboration, quality staff-patient communication, and staff recognition and rewards are the key to nurse empowerment and promoting services of high quality and safety. These findings give backing to the paper recently published by The Online Journal of Issues in Nursing on the bridge of quality and nursing’s work environment with substantial empirical evidence. The success of nurse empowerment is suggested to be largely associated with the work environment and the continuous quality improvement in patient services. The paper concluded that nurse managers play a pivotal role in nurturing and helping the patient find personal meaning and satisfaction, by engaging staff in overwhelming objectives of the organization and consistently providing necessary resources and support. Empowerment is reflected as a fundamental quality of both individuals and organizations in seeking excellence and the developmental total quality.

On the other hand, activities that support the work of the interdisciplinary healthcare team have been addressed and defined by some other literature in the field. For example, Wilkerson-Johnston and her colleagues have suggested strategies for nurse faculty to work together with health professional faculty to foster the process of interdisciplinary health education. This can be implemented in a hospital setting as well. The AACN white paper suggested that interdisciplinary collaboration in hospital management and decision-making allows for a combination of unique perspectives to produce sustainable solutions for patient care.

In this respect, successful strategies have been defined and shared in the literature for nurse satisfaction and retention. For instance, a research paper written by Dr. Victoria Ferdman showed the importance of employee recognition and rewards for staff satisfaction through applications of McClelland’s Theory of Needs in nursing. Also, Donoghue and Castle have revealed the qualities of an effective leader in managing a changing and diverse workplace in their publication, including the attributes of empowering and supporting staff. They mentioned that leadership strategy for change that allows staff to initiate and engage in innovation and improvement is essential to a successful change implementation, as it is important for staff to understand and own the process of change.

The significance of nurse empowerment in promoting professional and efficient healthcare services cannot be overstated. According to a white paper published by the American Association of Critical Care Nurses (AACN), it is essential for organizations to prioritize and facilitate environments that allow and support nurse empowerment, as it is interconnected with effective decision-making, autonomy, control, and professional satisfaction, which ultimately results in better patient care and safety. In addition, it is described in the Journal of Nursing Administration that empowering the nursing staff to participate in hospital decision-making has a positive and direct effect on the work environment and patient care.

3.2 Addressing Burnout and Fatigue in Nursing

By taking active steps to address and prevent nurse burnout, healthcare organizations can support the well-being of their employees while promoting safe and effective patient care.

There are a variety of ways to help nurses and other healthcare workers combat burnout and compassion fatigue, which refers to the profound emotional and physical exhaustion that helping professionals can develop over time as a result of secondary traumatic stress. For example, organizations can provide employees with resources such as on-site counseling services and employee assistance programs, or establish routine screenings for burnout and compassion fatigue. In addition, healthcare providers can work to develop a positive workplace environment in which teamwork is promoted, leadership is accessible, and all staff members are treated with respect and fairness. Finally, individual nurses are encouraged to practice self-care through activities such as maintaining a healthy work-life balance, engaging in regular physical activity, and making time for hobbies and relaxation.

In the healthcare industry, the issue of nurse burnout has become a growing concern. Burnout is a psychological syndrome that involves chronic dissatisfaction, emotional exhaustion, and a sense of reduced personal accomplishment. It can be caused by a variety of factors, including long work hours and a lack of control over work activities. When left unaddressed, burnout can negatively impact not only the well-being of nurses, but also the quality and safety of patient care. Nurses suffering from burnout are at increased risk for making medical errors. Further, they often experience lower job satisfaction and are more likely to leave their jobs. Because of this, addressing and preventing nurse burnout is essential.

3.3 Promoting Work-Life Balance and Flexible Schedules

Work schedules that recognize the need for free time and flexibility are important for nurses who often work around the clock. Flexible work schedules allow for a better balance between work and personal life. Some organizations allow nurses to set their own schedules, while others offer compressed work weeks. The most common type of flexible work schedule for nurses is 12-hour shifts, which provide more days off in a week. Job sharing is another form of flexibility. It allows two nurses to share one position, each working a different part of the week. This allows for a nurse to care for children and family when not at work. Many nurses, especially those in management, are now being offered flexible spending accounts for dependent care. This allows for pre-tax dollars to be allocated to an account that pays for child care, making it more affordable. These types of programs foster a better work-life balance and offer better conditions for continued employment. However, finding the right fit for a work-life balance within a nursing position is still a challenge that many nurses face. Modern technology is helping employers and employees help each other find adequate scheduling according to personal life. For example, “Shift Bidding” programs allows nurses to see what shifts are available and open in the near future. This could allow a nurse to take advantage of a schedule that fits their needs without causing too much duress on other staff members. For management, modern scheduling techniques may allow for an easier success in satisfying both the needs of the workplace and the needs of the employee. Some organizations are understanding the benefit of flexibility in nurse schedules and are presently participating in studies on 12-hour shifts and their effects on nurses. Imagine a world without illness. Could you? Without nurses this idea would be in thought only. Because of the long hours a nurse works, the quality of life outside of the workplace can be often tough to handle. With new studies and programs being brought to life, the nurse’s overworked and tired image may soon become obsolete – replaced by a re-invigorated caregiver.

3.4 Implementing Strategies for Effective Time Management

In order to provide practical support to nurses in improving time management, it is also essential for employers and senior members of staff to be aware of potential issues and make suitable adjustments where necessary. For example, personalized “office hours” that are free from interruptions from colleagues, such as other nurses or medical staff, could be established for the purpose of updating and completing ongoing tasks. The provision of administrative resources, such as dictation software for streamlined note-taking, or the implementation of standardized technology to enable collaborative and streamlined working, could also be of great benefit.

Conceptually, “time blocking” involves setting aside contiguous time periods for specific activities or tasks. By doing this, nurses can safeguard uninterrupted work time, protect against ineffective multitasking, and build regular review and planning into their routine. For example, nurses could set an hour aside for documentation after a ward round, allocating precise periods during which they would not be available for other tasks.

Setting realistic goals and deadlines is another important time management strategy. In the fast-paced environment of a healthcare setting, it can be easy to feel overwhelmed and lose sight of what is achievable within a certain time period. By establishing daily, weekly, and monthly goals, and breaking these down into smaller tasks where necessary, it can be much easier for nurses to manage their workload and make steady progress. This helps to create a sense of achievement as each task is completed and can combat the feeling of stagnation that can come with an excessively long to-do list.

In addition, nurses can improve their time management by getting into a routine and sticking to a schedule wherever possible. For example, nurses may find that they are more effective if they can allocate specific time periods for patient observations or medication rounds, rather than completing tasks as and when they arise. Having a predictable routine can also be reassuring for patients, creating a better healthcare experience for everyone. Furthermore, work schedules should allow for some flexibility so that nurses can adjust based on changing circumstances; however, if nurses find that they are constantly rearranging their tasks, this may be a sign that a more structured routine is needed.

Many nurses struggle with managing their time effectively due to the demanding nature of the job. However, with the right strategies in place, nurses can optimize their productivity and ensure that they have sufficient time for all tasks. One of the most commonly recommended time management strategies is to prioritize tasks based on their level of urgency and importance. This is often done using a system known as the “priority matrix” or “Eisenhower box,” which categorizes tasks into four groups: urgent and important, important but not urgent, urgent but not important, and neither urgent nor important. This kind of system can help nurses to quickly identify which tasks they need to address immediately and which can be left until later. It can also make it easier to delegate tasks to other members of staff, ensuring that the work is distributed fairly and equitably.

3.5 Encouraging Self-Care and Wellness among Nurses

Despite the best efforts to ensure that work hours are reasonable and well scheduled, nurses are subject to the demands of patients and the unpredictable nature of medical care. It is therefore extremely important that nurses be encouraged to engage in strategies that promote self-care and wellness. For example, the International Council of Nurses (2016) recommends several strategies to help bolster nurses’ ability to engage in self-care, including fostering a culture of respect in the workplace, encouraging nurse leadership and self-governance, and taking steps to address workplace bullying and violence. In addition, nurses are encouraged to cultivate ways to build their own resilience and help manage the stresses of nursing through peer support groups, mentoring programs and reflective practice techniques. Programs designed to enhance wellness by educating nurses about topics such as nutrition, relaxation and time management may also be employed to help nurses engage in self-care (Aiken et al., 2018). These types of efforts may be particularly effective if nurses have access to facilities that support wellness, such as relaxation areas or opportunities for physical exercise. By supporting wellness programs in both the design and implementation in nursing, the health care system can better ensure that patients receive high quality, consistent care from a nursing workforce that feels respected, supported and empowered. Such wellness programs are especially important as a means to reduce the impact of the stress and emotional fatigue nurses may experience (Wright, 2016). Research suggests that factors such as work-related stress, anxiety, depression and sleep disruptions are all associated with emotional fatigue, sometimes referred to as burnout, among nurses. Furthermore, burnout can negatively affect not only the wellbeing of the nurse, but also patient safety and health outcomes. For instance, emotional fatigue is a significant factor in the decision to leave a job and may contribute to the growing shortage of nurses worldwide (Kleinpell et al., 2018). It’s clear that we must continue to explore ways in which we can empower nurses to maintain and enhance their wellness throughout their careers. Well-supported, healthy and engaged nurses are more likely to provide quality patient care and positively influence the health and wellbeing of the patients today and the next generation of nurses for tomorrow.

4. Creating a Safe and Respectful Work Environment

Workplace safety is crucial in nursing practice as it ensures the well-being of both the nurses and their patients. Many work-related injuries and illnesses can be prevented by establishing a safe work environment. By abiding to the profession’s standards, nurses can deliver safe and proficient care. Maintaining a safe work environment also ensures that the management provides a safe place for nurses to work. It is important to identify any issues in workplace safety and collaborate with the management to resolve these issues. Issues such as policies that don’t reflect realistic practice, too little staff for the workload or inadequate equipment and facilities should be addressed promptly. Nurses should be proactive in reporting any safety hazards and recommending changes. They should be aware of their rights to practice in a safe environment, such as the right to refuse work that is dangerous. Modern safety measures and guidelines stipulate that both employers and employees have the duty to keep the workplace safe. Workplaces should have policies and procedures that safeguard and promote the health and safety of the nurses. These policies should be based on various legislative and regulatory standards outlined at the local, state and federal level. They should also be in accordance with the guidelines published by professional organizations such as the American Nurses Association. Various strategies such as regular safety training, the promotion of employee feedback, establishing a safety committee and designing an employee assistance program can be used. These measures ensure that the workplace is constantly monitored, safety issues are promptly reported and the delivery of comprehensive and effective nursing care is facilitated.

4.1 Understanding the Impact of Workplace Safety on Nursing Practice

In recent years, there has been a significant emphasis on workplace safety in nursing, and this focus has only been amplified by the Covid-19 crisis. The Occupational Safety and Health Administration (OSHA) defines workplace safety as “policies and procedures in place to ensure the safety and health of employees within a given occupation.” Although the concept of safety seems simple, creating a workplace where nursing staff feel safe and protected is far more complex. In discussing workplace safety, it is important to recognize that safety represents different visions: physical safety from workplace hazards, the emotional safety of working in a supportive and non-exploitative environment, and the professional safety of being able to have a voice and make decisions in the best interests of one’s patients. When analyzing how workplace safety impacts on nursing practice, one must consider not only how patient care is affected by staff feeling safe at work, but also how the ideals of patient safety and staff safety can conflict. Removing hazards, both physical and emotional, requires both legislative change and a rethinking of power structures and relationships within a healthcare system. Moreover, creating a safe workplace requires more than just an absence of danger; it means fostering a culture of respect and wellness that holds worker safety and patient safety as equal priorities. This commitment to safety and wellness has become even more critical in light of the ongoing Covid-19 crisis, as both staff and patient safety are under a continual and evolving threat. By understanding what workplace safety represents and how it can be achieved, we can move towards a model of nurse advocacy that not only prioritizes nurse and patient safety as interconnected ideals but also seeks to empower nurses to make a change that will improve the standard of care for all.

4.2 Addressing Issues of Bullying and Incivility in Nursing

Dr. Cynthia Clark elaborates, stating that “it’s the transition from destruction to the open, respectful, well-informed discourse – that’s exactly where we need to go in professional development.” The activation of such a code serves to not only provide validation and support for nurses as they actively work against bullying or other negative behaviors, but also develops a norm for equal, fair, equity-based practices within nursing.

Such a code should highlight the nurse as both a patient advocate and an authoritative voice within the healthcare milieu. Motivation should be driven by considerations of the patient’s well-being and the integrity and respect for the nurse as a professional and knowledgeable clinician. By strategically exploiting the patient advocacy aspect of nursing in the purposeful documentation and navigation of bullying encounters, this can provide a groundwork for culture change and offers tangible strategies for nurse empowerment through a lens of justice and overall organizational improvement.

A helpful strategy in confronting such dark realities as nurse bullying and incivility is by the creation of a code of civility that reiterates and highlights the goals for team development, organization, and workplace culture. This code, created collaboratively with nurse participants, serves as a formal document by which accountability can be integrated into nursing practices. It should be built upon standards that recognize and respect the interconnecting influence of individuals and members in the nursing discipline. This tool situates healthy discourse as the primary mode of communication and can ultimately serve as an impetus for organizational and individual change.

The same survey by the American Association of Critical-Care Nurses found that incivility is even more predominant than bullying, with 48% of respondents reporting having worked in an environment where incivility occurred.

The American Nurses Association defines incivility as “overt and intentional disrespect or any act that communicates derision, but without a threat of harm.” These acts of non-verbal or verbal hostility undermine the nurse’s self-esteem and well-being and include such behaviors as condescension, eye-rolling, and general disinterest or avoidance in response to opinions.

Dr. Cynthia Clark, an expert in the field of nursing professional development, explains that “bullying is a group process, and if we don’t change the work culture, we won’t stop bullying. Children on the playground exhibit different bullying behavior when no adults are present. Nurses are the same way. When no one is watching, bullying occurs in unacceptable forms. But it’s still harming others.”

In recent years, bullying and incivility have become prominent issues in the profession of nursing and are particularly prevalent among new nurses. According to a 2019 assessment by the American Association of Critical-Care Nurses, 45% of the 6,000 critical care nurses surveyed reported having worked in an environment where bullying occurs. Additionally, 31% reported having been bullied. However, only 23% of nurse respondents reported that their organization had a formal workplace anti-bullying program.

4.3 Promoting Effective Communication and Collaboration

All nurses and healthcare professional staff are encouraged to adopt according to the Center’s toolkit, developed in partnership with the Emergency Nurses Association, to facilitate discussions and develop strategies to promote a safe and respectful work environment.

When faced with episodes of disruptive or intimidating behavior, it is recommended to follow the model for “Civility Code” developed for the Institute for Safe Medication Practices. Last but not least, the Nursing Executive Center emphasizes collaboration in identifying and preventing workplace aggression. The recommended strategy encompasses encouraging employees to communicate their concerns to leadership, providing regular feedback and updates on the progress, setting zero tolerance for such behaviors in the workplace, and offering resources like mediation services to promote effective communication and collaboration.

The utilization of communication techniques like “Cuswords” (i.e. words that demean and disrespect others) and “Dis-” communication (i.e. inability to approach conversations with openness, respect and a focus on common purpose) is a helpful strategy to promote self- and co-worker awareness regarding behavior and communication styles. Additionally, the American Association of Critical-Care Nurses recognizes that true collaboration is only possible when there is mutual respect among and between the parties involved.

Promoting effective communication and collaboration in the workplace is a critical component of creating and maintaining a safe and respectful work environment. The significance of this initiative is underscored by the statistic that verbal abuse, threatening and inappropriate comments, and lack of collaboration constitute over 50% of all events reported to the Joint Commission which impact patient safety. For effective communication and collaboration to occur, a practice environment and culture of respect and professionalism must be cultivated at all levels of the organization. This includes a commitment by organizational leadership to set clear expectations and hold all employees accountable for their behavior.

4.4 Fostering a Culture of Respect and Diversity

Finally, in order to truly foster a culture of respect and diversity, nurses need to be given the opportunity for input and feedback on issues relating to the workplace environment and performance. Healthcare management should engage nurses and other healthcare providers in open and transparent dialogue on matters affecting their work environment and the quality of patient care. By working together to create a culture of respect and diversity, nurses can help to improve staff satisfaction, enhance patient experiences, and lead to better patient outcomes.

Besides the implementation of a standard for maintaining respectful work environments, nursing leaders should also embrace and promote the value of diversity within the nursing workforce. This includes recognizing the contributions of the diverse nursing staff, advocating for better representation of minorities in the healthcare workplace, and promoting cultural competency and diversity literacy among nurses.

As a step to creating a positive work environment, the American Nurses Association (ANA) proposes that healthcare organizations and nurse leaders implement standards for maintaining a respectful work environment. The standard calls for a code of conduct for nurses that sets the expectations of mutual respect, equitable and just treatment to all, and acceptance of a diverse workforce. It also requires that all nurses are educated on the expectations of the code of conduct. In addition, the organization must maintain a mechanism for enforcing the code of conduct and provide resources for assistance in resolving bullying or harassment claims.

In healthcare, fostering a culture of respect and diversity is equally important for promoting safe working environments. A diverse healthcare workforce can provide better care to an increasingly diverse patient population. It is essential that nurses and other healthcare providers recognize and celebrate the different backgrounds, skills, and ideas that each person brings. A culture of respect and diversity can help prevent workplace violence, bullying, and harassment.

5. Ensuring Fair Compensation and Nurse Input in Healthcare Decisions

Fair compensation for nurses means that nurses are paid fairly for the work they do, relative to each other, and relative to other healthcare professionals within a single institution. But more than that, fair compensation amounts for nurses means that the pay nurses receive accurately reflects the cost of living in their specific geographic area, trivial severance benefits such as couple days’ pay for each year worked may be provided, or it may mean access to other service or employment opportunities. It is important to recognize that fair treatment of nurses also can mean that legal rights are given or provided, such as reasonable work accommodations and freedom from discrimination. Fair compensation and working conditions are also important as they assist in attracting new nurses, and in promoting career choices in the nursing profession. The public has a very real interest in ensuring fair compensation, as past studies have shown that providing safe patient care is influenced to a great extent by the availability of qualified, experienced nursing staff – which in turn depends upon fair compensation and working condition trends. Secondly, fair compensation means paying wages for all hours worked, and if extended work hours are necessitated by patient care demands, such as those found in critical-care areas, additional compensation may have to be paid under proposed regulations to recognize these patient care demands. This translates into meaningful support for the advocacy efforts work. This again reflects the concept that paying nurses fairly means not just wages for working nurses, but also in attracting a new nursing workforce. By way of example, as of the time of the input of my letter, nurses employed in Texas may work in an environment where the rights of injured workers are effectively patronized and infringed upon. This is because nurses employed in the State of Texas are not compensated even close to fair values for the work they do, compared with other states and cost of living standards. In Texas, where injured workers are afforded much less in the way of legal rights and fair compensation as they are in other states, the services of nurses employed in jobs specializing in the provision of workers’ compensation healthcare, case management and witnessing services provide little chance for the realization, advocacy and betterment of injured workers’ rights, and independently of whether under a tort liability or a workers’ compensation health care delivery system. There is no coincidence that nurses providing such services under these conditions do so in an environment that omits fair compensation, legal rights and spectator and reporting nurse transfer form or fax and email it today. Such type of paid services that envisage more and more filing and patient reports may give less importance to patient critical care needs. Advocacy efforts can also be hampered, as nurses may feel rather pressurized to ignore or not advocate for the realization of patient rights, and to effectively advocate with a louder voice for the recognition of fair compensation for their services. If fair compensation efforts are allowed, care of injured workers can be enhanced, and better treatment and reporting opportunities as to nursing witness services and the acceptance and success of patient injury claims can be realized and promoted. Such heightened awareness of the positive impacts derived from fair compensation can work to alleviate informed workers’ concerns in resisted progress and nurse advocacy of legal nursing rights and employment standardizations.

5.1 Recognizing the Value of Fair Compensation for Nurses

Fair compensation is important because it reflects that the nurse is a valuable healthcare professional and it is worth spending on them. According to Work Institute studies, salary is far down on the list of why employees leave. The reasons “career development—insufficient advancement and promotional opportunities” and “work-life balance” scored 3 and 4 on the reasons why nurses are leaving. The second reason, career development or insufficient advancement and promotional opportunities, is a reason that organizations with fair compensation plans should not have. If nurses feel that their work environment is a place that is going to hinder their growth, they will start to look elsewhere for better opportunities. Similarly, creating an environment in which fair compensation is a driving force can alleviate work-life balance concerns, the number four leading reasons nurses leave their positions. In doing so, the healthcare organization can work on building incentive programs and opportunities for nurses to gain a better balance between their work and private lives. It is optimum healthcare for the patient to have continuity of care with the nursing staff and it is known that job satisfaction and fair compensation matter. It’s in the patients’ best interest to have happy, satisfied and fairly compensated nurses. Also according to a study by Dr. Susan Saucier, PhD, RN, “36,000 nurses surveyed in 3 states—35.3% of nurses who said they were not satisfied with their work environments considered leaving their jobs in the last year, and 1 in 5 actually had plans to leave their jobs in the near future”. This gives us a startling number of 7,200 nurses that were already planning their exit strategies. Dr. Susan Saucier also suggested that the data shows us that “nurse compensation is an important focus for healthcare administrators”. Therefore fair compensation for nurses not only helps retain the nursing staff, but it could increase the pool of nurses, if nurses see they are valued at their positions. By focusing on fair compensation for nurses, healthcare employers can proactively decrease turnover rates and retention issues in the nursing field. Every nurse counts, so when creating compensation plans and pay rates that reflect this and the skill needed to provide care, it allows nurses to feel that they are appreciated. Offering fair compensation is a vital step organizations can make in retaining effective and qualified nursing staff throughout different practices. Workers that are satisfied with their earnings are less likely to feel the need to seek out other positions because they believe they are being fairly valued by their current employer. Additionally, fair compensation can also transcend into provision of better quality care for patients. Sufficient staffing mixed with satisfied nurses can lead to building stronger patient-nurse relationships with the side effect of less medical errors by creating a healthier work environment for all. It shows that fair compensation can create a sense of appreciation, which leads to higher nurse retention and satisfaction. With success in properly retaining and drawing in nurses for work, it helps the healthcare facility maintain a minimum number of full time staff. This can assist in nurse to patient ratios. Nursingu.com has a nurse to patient ratio study guide, that can be accessed from the link below. A better nurse to patient ratio is equivalent to a better attention to patient care, meaning a safer, more manageable work environment for the nurse. And if proper compensation and benefits are in place, it makes the nurse want to stay in the same facility, allowing them to become familiar with the process, flow, and more direct patient care.

5.2 Advocating for Competitive Salaries and Benefits

While there are no federal laws addressing staffing ratios, there has been recent discussion of federal legislation mandating certain nurse-to-patient ratios in all hospitals. For instance, in 2016, a bill was introduced in the U.S. Congress called the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act. Lindsey et al. (2019) explains that the Act proposed establishing minimum direct care registered nurse staffing requirements and providing whistleblower protections for nurses who report violations of the Act. Additionally, the Act required that each hospital’s direct care registered nurse staffing shall be in accordance with unit-by-unit requirements based on the acuity of patients and the volume of services provided. While the bill was never enacted into law, the introduction of such bills at the federal level speaks to the increasing advocacy efforts around safe staffing in nursing. In fact, a 2018 national public opinion poll found that 80% of Americans support federal legislation to require minimum nurse-to-patient ratios in hospitals (Kaiser Family Foundation, 2018). Efforts to set staffing laws at the state level have been more successful. For example, California implemented the first state-mandated minimum nurse-to-patient ratios in acute care hospitals in 2004. Since then, similar legislation has been proposed in at least 18 other states. Lindsey et al. (2019) used California as a case study and concludes that mandatory staffing ratios in California have resulted in substantial improvements in the quality of patient care and nursing work environments. For example, postsurgical mortality rates, failure-to-rescue rates, and general complications decreased after the implementation of staffing ratios. In addition, California nurses reported significantly lower rates of burnout and job dissatisfaction as compared to nurses in states without mandatory ratios. These improvements underscore the importance of adequate staffing and lend strong support to continuing efforts to pass similar laws in other states. The success of California’s ratios has been a significant factor in supporting other states’ efforts to pass similar laws. For example, in Massachusetts, petitions have been filed that would set nurse staffing levels in intensive care units to no more than one patient per nurse. Recent reports show that, in the first quarter of 2018, the Massachusetts Nurses Association collected more than 100,000 certified signatures in support of a ballot measure to implement these staffing ratios. As a result, a question appeared on the 2018 Massachusetts ballot asking voters to decide “whether or not a certain law that changes the existing statutory law regarding patient assignment limits for registered nurses is in effect.” This attempt to enact state-mandated nurse-to-patient ratios in Massachusetts is happening at the same time as similar efforts in other states such as Illinois, Michigan, Ohio, and Texas (Patient Safety, 2018). Such an effort as was made in Massachusetts and similar law proposal in Illinois did not become law, but nurses in these states continue to push for similar legislation. This continued advocacy and legislative effort show that progress is made in the fight for safer nurse staffing.

5.3 Involving Nurses in Decision-Making Processes

So far, research on nurse advocacy has indicated that nurses should be actively involved in the formulation of policies that are related to the healthcare sector. This involvement in nurse decision-making is also proposed in the American Nurses Association as the content of nurse advocacy. Nurses should work together with other state healthcare stakeholders in establishing better policies to guide the sector. However, there are a few policies that were identified as having been formulated without the consultation of the nurse. For example, posing for a few weeks was identified as having been formulated without involving the content or opinion of the nurses. This may be affecting the level of patient care associated with nurse staffing. No wonder nurse advices documented a high level of frustration due to lack of consultation while formulating the policy. A number of arguments support the involvement of nurse in decision making. The research paper that was authored by Porchem and Harber (2015) indicated that quality of patient care and nurse satisfaction are improved when nurses participate in healthcare decision-making. Nurses have unique knowledge about patients and the effects of the environment in the healing process. When such knowledge is brought together through collaboration, it leads to the diagnosis of the problem and formulation of effective policies. The research reasoned that the employees who will implement the policy are satisfied that their view were considered and hence they become more productive. This in turn will increase the quality of work and ultimately the achievement of organisational objectives. The healthcare process and management lecturer in Southern Connecticut State University, Dr. Stefansdottir, is also critical on the involvement of the nurse in healthcare decision-making. She urged that “for the sake of the clients and the profession, nurses should always be included in decision-making process. Their voices help to improve or rank facilities according to care and safety for the public”. This is indeed true especially in the contemporary healthcare environment because building up the process from the floor, it means the process is more client-centred and holistic, according to Dr. Stefansdottir. When referring to the human resource literature, employees involvement in organisational decision making as a positive impact on job satisfaction and reduced level of staff turnover and absenteeism. This shows that the advocacy for nurse involvement in policy making is universally accepted as an essential part of organisational development.

5.4 Enhancing Nurse Leadership and Participation in Healthcare Organizations

In healthcare organizations, it is important that nurses can provide their expert opinions. By enhancing the role of nursing governance, including chief nursing officers and nursing leaders in corporate boards and executive teams, it is expected that nurses can better control their profession and contribute more to shaping the healthcare system. According to the American Nurses Association, nurses are increasingly being appointed or elected to boards of nursing or consumer advocacy groups for the good performance of the boards. Also, nurses working on governing boards of healthcare institutions are expected to play a primary role in contributing to improved performance. The board members, which include nurses, are expected to receive more knowledge on nursing performance, leading to potential improvement in healthcare delivery and nursing services. The policies adopted and implemented by a healthcare organization are critical for the support and protection of professional nursing practice conducted by professional nurses and nurse practitioners. Such policies are expected to safeguard the interests of the patients on one side and support and protect professional nursing practice on the other side. By implementing policies that help increase capacity in the nursing workforce, including promoting the expansion of student loan programs and developing nurse residency plans, we can attract more and younger people to join the nursing field. This will provide more human resources in the nursing workforce and help improve the attractiveness of the nursing career. Also, healthcare organizations can assist in funding study grants or scholarship plans in nursing fields, and prospective students can be encouraged to take up the study of professional nursing either in degree or postgraduate degree levels. This will provide a sustainable solution in addressing the critical nursing shortage in the US.

6. Conclusion

6.1 Summary of Findings and Key Recommendations

6.2 The Future of Nurse Advocacy in Healthcare

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