The Changing Workforce
The whitewater of health care transformation is beginning at the bedside. The 1990s established warning flags for the issues that are currently being experienced within health care today. Changes in reimbursement led to financial belt tightening, mergers and acquisitions, and hospital closures. Employees who believed their jobs and thus their security were ensured found themselves in layoff situations or part of faceless corporations. The further advent of managed care and access to care through gatekeepers accelerated the drive toward efficient as well as effective care processes. Words such as benchmark productivity, skill mix, length of stay, payer mix, and evidence-based care have become part of the lexicon of nurse executive thinking. Hospitals have downsized and the message to nursing focused on cutting costs and restructuring staffing matrixes. Concomitantly, other opportunities began to emerge for young women, who have constituted the majority of the professional licensed nursing community. These alternative careers promise more flexibility and more control over work and career development. The profession of nursing may be perceived as a second-tier career choice, as noted through declining enrollments in schools of nursing over the past several years.
Society is just beginning to notice the impact of past health care business decisions coupled with the impact of the explosion of career choices for young people. One example is the awareness around decreased access to hospitals through the emergency room. National newscasts and local newspapers have presented numerous scenarios of inadequate availability of emergency care. Predictions that there would be a reduced need for acute beds have not been realized. The promise of more effective care delivery through managed care has not produced the expected results. These and other factors are creating demand on hospital beds and skilled nursing facility beds. While the demand for care rises, the primary health caregiver is beginning to retire or is making choices other than working in the acute hospital environment.
The need for staffed acute care beds is resulting in pressure being applied to the way work is perceived and how work is completed. At issue for nurse leaders today is how to create an effective working environment that focuses on respect and value while evaluating the work of nursing and redefining how work is assigned.
In this issue (26:2) of Nursing Administration Quarterly the focus is on the changing workforce. The first two articles explore the dynamics being observed and documented in the workplace. Core concerns around the work itself and the expectations of the work environment are studied. The identified needs to analyze the work of nursing and develop processes that allow nurses to have control over their practice are found to be important. The movement away from a more hierarchical structure to a cooperative problem-solving team approach is also imperative to successful restructure.
The article by Nicci Cosolo relates one institution's struggle with work redefinition and identifies the skill sets required using job mapping. The difficulty in breaking down the task set for each job is further complicated by the concern that nurses feel around delegation and trust that work will be done. Restructuring the work and job mapping made more when jobs are created for which there may not be enough available workers. It is important to assess how these jobs will be filled before rolling out a new plan or the workforce will become more exasperated. In the search to find the necessary workforce, a number of hospitals have chosen to use a strategy of hiring foreign nurse graduates. Davis and Nichols review the challenges and opportunities implicit with this strategy.
The complexity of the changing workforce issues has created an even greater need for consultants to help organizations explore best practices and provide out-of-the-box thinking. Opportunities for nurse executives who may contemplate leaving the daily issues of hospital administration to pursue the role of nurse consultant are increasing as the demand for new thinking escalates. The desire to help create the new workforce initiatives that will be required to assure effective health care delivery can be accomplished both within nursing and in the role of consultant. Jaynelle Stichler's article provides insights into the rewards and the challenges that consulting can offer.
The final article, "Nurse Leader: Heal Thyself, by Mary O'Connor is included as a reminder to all nurse executives that balance and self-care are critical to longevity in the face of multiple expectations. The challenge is to change the care delivery system, manage a greater demand for service, respond to growing regulatory scrutiny, and accept increased accountability for the outcomes of care.
The need for leadership has never been so clear in nursing. The ability of the nurse executive to maintain perspective and support the staff through this difficult transition is critical. Maintaining a sense of humor and spiritual well-being is essential. In times of great concern and worry about the future, skilled leaders will and do emerge. Maintaining perspective, seeing what could be, and plotting a deliberate course to reach the destination requires managerial courage and the ability to keep the complexities of the day in perspective. Collectively, the articles in this issue provide an opportunity to reflect on work environment concerns, strategies to intervene, and the need to assure the health of the leadership while traversing the whitewaters of the workforce transformation.