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Relationship of RN Role Responsibilities to Job Satisfaction
This study tested a delivery of care model that maximizes the role of the registered nurse in rehabilitation by providing care based on the scope of practice exclusive to the registered nurse and supplementing that practice with licensed and non-licensed support personnel. The model of care was developed as a response to the nursing shortage. The model attempts to best utilize the limited resource of registered nurse staffing. The nursing shortage is a national and global public health problem that is expected to intensify as the nursing population ages. The hypothesis was that when the rehabilitation registered nurse is allowed to function in areas for which they are exclusively trained, job satisfaction will significantly improve as long as there is sufficient support staff to provide for non-essential functions. The conceptual model for the study is based on Donabedian’s model which demonstrates the relationship between satisfaction and patient outcomes. Results indicated that after an initial stage of discomfort resulting from a change in role expectations nurse satisfaction improved when registered nurses functioned within their exclusive scope of practice.
The nursing shortage is a national and global public health problem, which is expected to intensify as the nursing population ages. In 2005, 19 states introduced legislation to hold hospitals accountable for the development and implementation of valid and reliable nurse staffing plans to ensure adequate nurse staffing levels. Combinations of legislated nurse-patient ratios, an aging nursing population, demand for nurses, and the shrinking number of nurses make it imperative that rehabilitation facilities closely define the role of the registered nurse (RN) and complement their role with optimally effective and efficient delivery of care models. A key rationale is that rehabilitation nursing is a specialty area with a high touch and functional focus that requires a staff mix much different than the acute care setting. Therefore rehabilitation nurses must define the most appropriate model of care that meets the demands of the rehabilitation environment and also addresses the shortage of RNs.
Scope of the Shortage
According to projections released in February 2004 from the Bureau of Labor Statistics, RNs top the list of the 10 occupations with the largest projected job growth in the years 2002–2012. The total job openings, which include both job growth and the net replacement of nurses, will be more than 1.1 million. If the nursing shortage goes unchecked, the deficit of RNs is expected to grow to 2.8 million by 2020 (American Nurses Association, 2005). Rehabilitation facilities must carefully but aggressively find ways to define the role of the RN in the rehabilitation setting and identify effective ways to complement their role with efficient delivery of care models, while preserving or improving the quality of patient care. This article offers an interim model so that patient care can be accomplished by maximizing the limited RNs available during this particular nursing shortage cycle.
The study, conducted at Madonna Rehabilitation Hospital, tested a delivery of care model that maximizes the role of the RN in rehabilitation by providing care based on the scope of practice exclusive to the RN and supplementing that practice with licensed and nonlicensed support personnel. There is an assumption that when the rehabilitation RN is allowed to function in areas for which they are exclusively trained, job satisfaction significantly improves as long as there is sufficient support staff to perform nonessential functions. The conceptual model for the study was based on Donabedian’s (Burde, 2002) model that demonstrated the interaction between satisfaction and patient outcomes. Stratton (2002) further demonstrated the effect of nurse satisfaction on patient outcomes, (i.e., nurse satisfaction), which may explain more than 20% of the variance in specific patient outcomes.
A breakout of the RN activities and job satisfaction was completed to assist in the examination of the role of the rehabilitation RN using the scope of practice as a framework to define the nurse’s role. Implementation of a professional partnership model of rehabilitation nursing delineates the RNs role to those activities that are exclusive to the RN. This delineation is based on the scope of practice for RNs. It was hypothesized that the change in nursing care model would be associated with RNs performing essential functions to a greater extent and improvements in RNs’ satisfaction. Essential functions were defined as those elements exclusively within the Nurse Practice Act for RNs that includes assessment, planning, education, and overall direction of patient care activities.
According to a study of 43,000 nurses in several countries (Aiken, Clarke, Sloane, Sochalski, & Silber 2002) over 40% of U.S. nurses acknowledged dissatisfaction with their jobs. Among additional findings of the study were that only about one-third of respondents felt that their settings had sufficient RNs to produce high-quality work, fewer than half of the respondents felt that they had sufficient support services to do their jobs adequately, and only about three of every ten respondents felt that administrators listened and responded to their concerns. Additional factors that affect nurses’ dissatisfaction included (Aiken et al.): unfulfilling professional working environments and relationships with non-nursing coworkers; excessive patient to nurse ratios; mandatory overtime; unsafe, and at times abusive, working environments; limited availability of advanced technology that could help improve accuracy and efficiency; and inadequate compensation (Aiken et al.).
Nurses’ Response to Work Redesign
In one recent study, nursing responses to the process of work setting redesign indicated that there were significant stressors associated with the nursing process (Mee & Robinson, 2003). Data were collected through focus groups from two hospitals to explore nurses’ perceptions and reactions to organizational changes occurring in nursing processes. Responses, collected via open-ended queries, were examined for common themes. Although data suggested that some adaptive adjustment had begun, the investigators found emotional distress to be fairly pervasive during the change processes that unfolded over a number of months, including stress, feelings of loss, anger, despair, and abandonment. Staff morale was described as lower than ever in the past, and mistrust of the administration was mentioned in more than one group (Ingersoll, Fisher, Ross, Soja, & Kidd, 2001).
Philosophy of the RN as a Scarce Resource
Given the shortage of RNs, they should be considered a scarce resource. This philosophy at Madonna Rehabilitation Hospital goes further to change the focus from recruitment of nurses to retention of nurses. The rationale here is that there are limited numbers of nurses not only at the community level but at the regional, national, and international level. Retention efforts focused on a variety of factors including nurse satisfaction. By focusing on the RNs’ professional expertise, as defined by the state’s Nurse Practice Act, nurses were encouraged to exercise their professional potential in planning, directing, and critical thinking in an enhanced autonomous role. To utilize the professional expertise of the RN in the most efficient and effective manner possible, a nursing model was developed based on roles that are mutually exclusive to the scope of practice of the RN. Nursing functions and tasks that are within the scope of practice of licensed practical nurses are delegated under the direction of the proficient RN. Likewise, duties that do not require a licensed scope of practice are delegated to unlicensed assistive personnel. Because of some of the labor-intensive or hands-on attributes of rehabilitation nursing, this model provides a logical fit for the rehabilitation practice environment.
Focus groups held during implementation indicated that initially the nursing staff at Madonna Rehabilitation Hospital showed distress with the change in the delivery-of-care model, consistent with the findings previously cited by Ingersoll. After an RN became more comfortable with his or her new role he or she expressed satisfaction with the change in the delivery-of-care model.
RNs’ Influence on Patient Outcomes
Finally, the seriousness of the nursing shortage is by no means simply limited to the physical and emotional quality of life and satisfaction or dissatisfaction of those in the nursing profession. The impact on patient outcomes has been clearly demonstrated in several recent studies. For example, in a recent study commissioned by the U.S. Department of Health and Human Services, incorporating data from almost 800 hospitals in 11 different states, patient length of stay and the incidence of urinary tract infections, gastrointestinal bleeding, shock, and pneumonia were all found to be correlated with nursing staffing levels. Higher rates of patient death were also related to staffing levels for patients with shock, deep vein thrombosis, pneumonia, sepsis, gastrointestinal bleeding, and pulmonary emboli (Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002). In another recent, large-scale study focusing on post surgical patients, investigators found that, after controlling for certain covariates, for each additional patient assigned to a nurse there was an approximately 7% increase in the likelihood of patient death within 30 days of admission and a 7% increase in the odds of failure to rescue (Aiken et al. 2002). These investigators also found that, for each additional patient per nurse, there was a 23% increase in the odds of burnout and a 15% increase in the odds of job-related dissatisfaction (Aiken et al.).
The focus of the study at Madonna Rehabilitation Hospital was the implementation of a change in the role of the rehabilitation RN and nursing delivery-of-care model. Delivery-of-care models have evolved over the years. Previous models were summarized in a recent article produced by the Kaiser Permanente Institute for Health Policy, based on an extensive review of the pertinent literature (Neisner & Brian, 2002). The authors described the process of evolution of several models over the past several decades, including
More recently, different models have been developed, as described in the Kaiser report:
The authors of the Kaiser report cite both positive and more equivocal findings among the studies that have examined the effect of different models on both nursing satisfaction and patient outcomes, including patient satisfaction. The authors suggested that the following elements be considered as new nursing models are tested and refined:
Professional-Partnership Model of Care
The implemented rehabilitation delivery-of-care model (Figure 1) is a professional partnership model that is closely related to the differentiated model-of-care delivery, but is tailored specifically to the meet the needs of the rehabilitation nursing environment. Rehabilitation nursing care is coordinated by a nurse that is an expert in rehabilitation care and would be expected to be a Certified Rehabilitation RN (CRRN®) with several years of rehabilitation nursing experience. The expert nurse provides direction to another RN who may be at a proficient or expert level of care. Differentiation of expert and proficient are extracted from Benner’s model (Benner, 1982). In this case, the expert nurse has significant bedside experience in rehabilitation nursing, an understanding of the conceptual framework of rehabilitation nursing, and is a CRRN. Even at the proficient level, the nurse is expected to have significant bedside experience in rehabilitation nursing and an understanding of the conceptual framework of rehabilitation nursing. The rest of the model functions as a team model; however, there is a high degree of flexibility depending on unit census, acuity, and available staff for how to mix and match personnel. Rehabilitation patient care is labor intensive; therefore, the use of certified nursing assistants is economically and clinically sound. The advantage of the model is that it maximizes the expertise of the RN. RN hours actually decreased after implementation of the model while total hours per patient day increased slightly at over 8 hours per patient day. Cost per patient day remained the same. The purpose of the model is not to reduce cost, but to answer the challenge of a shortage of RNs and still provide quality care.
The study conducted at Madonna Rehabilitation Hospital provided additional research on this topic. The objective of the study was to develop and test a model that most efficiently and effectively utilized the specialized skills of the rehabilitation RN. The model was based on a specific and limited role definition for the rehabilitation RN who is supported by adequate ancillary personnel. Nurse satisfaction scores were utilized for outcome measures, because nurse satisfaction and patient outcomes were shown in the literature to be correlated. The study consists of two parts applied prior to introducing a new delivery of care model and repeated post-model implementation. A baseline of current practices and level of satisfaction was achieved with a pre-model study.
Part I of the facility study was an RN activity study. Activity by RNs in a pre-determined group of functions was randomly observed in three 1-week observation periods. Repeating the observation three times allowed analysis for variations within the weeks and provided validation of the RN activity. Consistency in data collectors and the data collection forms was identified as an essential component to ensure a valid study. Data collectors were trained in data collection processes and use of forms. Additional training was provided in a simulated data collection environment for return demonstration skills. Real-time data collection was validated through trainer duplication of data collection to confirm accurate data results. Data collectors were trained by Lynn Schafer, RN. The data collectors included RNs, licensed practical nurses, and nurse aides. Seventeen activities were observed during the RN activity study: patient activities of daily living, assessments, care planning, documentation, IV therapy, medication administration, locating equipment/supplies, performing patient education, staff performance reviews/discipline, physician call/orders, reporting/communicating, supervision/delegation, staff education, staff assignments, patient transfers/repositioning/ambulation, performing treatments, and collecting vital signs data.
From the above activities, eight were determined to be essential functions of the RN: assessments, care planning, documentation, IV therapy, patient education, reporting/communicating, staff education, and supervision/delegation. A frequency occurrence was used to score the RN activity observations.
Part II of the facility study used the Index of Work Satisfaction (IWS) to measure nurse satisfaction (Stamps, 1997). The IWS is a result of an extensive literature review, interviews with nurses, and 10 years of statistical testing for both reliability and validity. The IWS, like the RN activity study, was completed pre- and post-delivery of care model implementation. Consents were obtained from the RNs who participated. Approximately 45 minutes of RN time was required to complete the survey.
The IWS is a two-part measurement tool that is designed to assess nurses’ level of satisfaction with their work by measuring six components of satisfaction. One of the unique features of the IWS is that it weighs each component based on its importance in providing satisfaction. The six components used are pay, autonomy, task requirements, organizational policies, professional status, and interaction.
Both components of the study—Part I, the RN activity observations and Part II, nursing satisfaction—served as the central outcome measurement for the study.
Figure 2 indicates nurses performed essential functions 38% of the time pre-implementation and 45% of the time post-implementation. This translates to a 7% increase in RN activity (or resource) without any increase in RN staff. Because the RN is the highest paid nursing clinician, this is an economically sound and efficient model for the utilization of the RN as a scarce resource.
Table 1 indicates that nurses’ perception of autonomy, professional status, interaction, and overall satisfaction increased as determined by the post- implementation measures. Interestingly perceptions of organizational policies decreased. Informal feedback from involved nursing staff indicated this was related to some role confusion because their role was redesigned to a more limited scope defined by essential RN functions.
Study Relevance to Rehabilitation Nursing Practice
Analysis of the role of the RN has been focused in the acute care setting. It is critical that research is conducted in the rehabilitation setting to evaluate the role and impact of the RN. The rehabilitation setting is vulnerable for several reasons. First, where there are mandated nurse-patient ratios, the studies supporting the ratios have been completed in acute care settings. There has been no specific analysis addressing the needs of rehabilitation nursing as a specialty area. Secondly, the issues that surround the controversy with the 75% Rule and patient access to inpatient rehabilitation services could put rehabilitation nursing jobs at risk. Legislated nurse-patient ratios may push rehabilitation facilities to eliminate certified nursing assistants, forcing nursing to revert back to primary care delivery models, which may result in decreased nursing satisfaction and inappropriate utilization of scarce registered nursing resources. The Rehabilitation Professional-Partnership Model focuses on the professional nurse performing essential functions and supplementing that role with appropriate support personnel.
The study indicates that the Rehabilitation Professional-Partnership Model can be used as an effective method to more efficiently utilize RNs, which are a scarce resource. By narrowing the scope of practice of the RN to essential functions, fewer RNs are required to provide care as long as the RN has adequate support staff to carry on nonessential functions. The results of the study also indicate that when the RN is practicing within a scope of practice focused on essential functions, job satisfaction improves. Areas of essential functions at which RNs should be performing at a high percentage rate can be identified from each state’s nursing practice act.
Collecting data prior to introducing a new delivery of care model is key to completing full analysis of the RN study, thus allowing for a baseline of information to assist in formulating research conclusions.
Informal queries with direct care staff indicated they did experience unrest as the change in the model of care was being implemented because of confusion of expectations and fear of role changes and competence. Allowing a minimum of 6–12 months after implementation of a new delivery of care model— before repeating the study—was essential in order to provide staff sufficient time to become accustomed to their roles. Outcomes of both studies should be further analyzed to identify areas that affect ability of RNs to perform essential functions, affect job satisfaction, identify opportunities for additional research, and recognize potential for continued improvement in delivery of care.
About the Authors
Paul Nathenson, MPA BSN RN CRRN, is vice president of patient care at Madonna Rehabilitation Hospital. Address correspondence to him at 5401 South Street, Lincoln, NE 68506 or firstname.lastname@example.org.
Lynn Schafer, RN, has recently retired as director of nursing informatics at Madonna Rehabilitation Hospital, Lincoln, NE.
Jackie Anderson, CRRN, is director of nursing at Madonna Rehabilitation Hospital, Lincoln, NE.
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