THE HEALTH CARE SYSTEM HAS

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1 SERIES CNE Objectives and Evaluation Form appear on page 330. Peter I. Buerhaus Catherine DesRoches Sandra Applebaum Robert Hess Linda D. Norman Karen Donelan Are Nurses Ready for Health Care Reform? A Decade of Survey Research EXECUTIVE SUMMARY As health care delivery organizations react to the changes brought about by public and private sector reform initiatives, RNs can anticipate that, in addition to intended outcomes, there will be unpredictable pressures and unintended consequences arising from reform. Biennial national surveys of RNs conducted over the past decade have explored various changes in the nursing workforce, quality of the workplace environment, staffing and payment policies, and RNs views of health policy, including their expectations of health reform. The latest survey results offer a picture of RNs capacity to practice successfully in a care delivery environment that, over the current decade, is expected to emphasize teams, care coordination, and become driven increasingly by payment incentives that reward quality, safety, and efficiency. If RNs are provided with strong clinical leadership, participate in developing an achievable vision of the future, and if supported to take risks and innovate to improve the quality and efficiency of care delivery, then the profession is likely to thrive rather than struggle during the health reform years that lie ahead. Increasing the education and preparation of nursing leaders, and particularly unit-level managers, will be increasingly vital for nursing to prosper in the future. THE HEALTH CARE SYSTEM HAS begun a decade of transitions that, for the nursing pro - fession, promise to change the practice of nurses, expand current nursing roles and create new ones, and provide many opportunities for nurses to participate in shaping the future delivery system. With the passage of the Affordable Care Act (ACA) in 2010, care delivery and financing systems are undergoing significant transformations that will accelerate in 2014, when major provisions of the legislation are implemented. Under the ACA, Accoun - table Care Organizations will be developed to align the goals of health care delivery reorganizations, enhance care coordination, and improve patient transitions across the care delivery continuum. Expansion of medical care homes, community health care centers, and enhanced coverage for preventative care services will help to shift the delivery system s current focus on acute care to a greater emphasis on prevention and treatment of chronic care conditions using health care teams and information technology. And, over the decade, changes that capitate provider payments and bundle payments for episodes of care will further increase pressures on efficiency. To be sure, these changes in health care delivery and financing, and many other initiatives contained in the ACA, will be tested when health insurance coverage is expanded to 32 million Americans in 2004 (16 million are expected to receive care in Medicaid programs alone). Even before reforms were enacted under the ACA, the nursing profession was the object of NOTE: Authors biographical information can be found on the following page. STATEMENTS OF DISCLOSURE: Peter Buerhaus disclosed grant/research support from the Johnson & Johnson Campaign for Nursing s Future, Robert Wood Johnson Foundation, and the Gordon & Betty Moore Foundation. He serves on the advisory board of the Johnson & Johnson Campaign for Nursing s Future and the Bipartisan Policy Center. Karen Donelan disclosed grant/research support from the Johnson & Johnson Campaign for Nursing s Future. The other co-authors and all Nursing Economic$ Editorial Board members reported no actual or potential conflict of interest in relation to this continuing nursing education article. 318

2 Are Nurses Ready for Health Care Reform? A Decade of Survey Research major national initiatives aimed at expanding the supply of registered nurses (RNs), enhancing nurses capacity to improve the quality and safety of care delivery, and expanding the reach of advanced practice nurses in both primary and specialty care. Among the four key messages of the 2010 IOM report The Future of Nursing: Leading Change and Advancing Health is a call for nurses to practice to the full extent of their education and training, and for nurses to be full partners, with physicians and other health professionals, in redesigning health care in the United States. Other initiatives, such as the Raise Your Voice Campaign collaboration between AARP and The Robert Wood Johnson Foundation, the infusion of substantial re search and education support by the Gordon & Betty Moore Found - ation, Macy Foundation, John Hartford Foundation, and others, have not only increased the profile of nurses but raised expectations for nurses to lead. And, for a decade, the Johnson & Johnson Campaign for Nursing s Future PETER I. BUERHAUS, PhD, RN, FAAN, is Valere Potter Professor of Nursing, and Director, Center for Interdisciplinary Health Workforce Studies, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN. CATHERINE DesROCHES, DrPH, is a Senior Researcher, Mathematica Policy Research, Princeton, NJ. SANDRA APPLEBAUM, MS, is a Senior Research Manager, Harris Interactive, New York, NY. ROBERT HESS, PhD, RN, FAAN, is Executive Vice President of Global Programming, Gannett Healthcare Group, Voorhees, NJ. LINDA D. NORMAN, DSN, RN, FAAN, is Senior Associate Dean for Academics, Vanderbilt University School of Nursing, Nashville, TN. KAREN DONELAN, ScD, is Senior Scien - tist in Health Policy, Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, MA. (J&J Campaign) has focused on promoting the nursing profession, averting future projected shortages of RNs, raising funds for educating students and supporting faculty, and raising public awareness of the value and importance of nurses. As health care delivery organizations react to the changes brought about by public and private sector reform initiatives, RNs can anticipate that, in addition to intended outcomes, there will be unpredictable pressures and unintended consequences arising from reform. Some of these unintended consequences are likely to impede nurses capacity to assure quality of care and safe conditions for patients. With so many known and unknown changes unfolding, one might question how well the nursing workforce is positioned to contend with, and even thrive, during the decade. Despite so many initiatives that have supported nurses in recent years, should policymakers be concerned about whether the nursing profession is prepared to meet the known and unknown challenges as health reforms unfold? In this article, we attempt to address these questions by highlighting results of biennial national surveys of RNs conducted over the past decade, including key results of the most recent survey conducted in These surveys have explored various changes in the nursing workforce, quality of the workplace environment, staf - fing and payment policies, and RNs views of health policy, including their expectations of health reform. Results of this program of survey research offer a picture of RNs capacity to practice successfully in a care delivery environment that, over the current decade, is expected to emphasize teams, care coordination, and become driven increasingly by payment incentives that reward quality, safety, and efficiency. SERIES DATA AND METHODS The 2010 National Survey of Registered Nurses (NSRN) was conducted by mail from May through August 2010 by the survey research firm Harris Inter - active. A cover letter, eight-page questionnaire, and an incentive for participation were mailed to a random sample of 1,500 RNs. The sample was drawn from a national database of RNs consisting of data from state boards of nursing and maintained by Gannett Healthcare Group. Up to four additional mailings were sent to non-responders to encourage participation. Res - ponse enhancement incentives included 4 months of unlimited online continuing education through Gannett Education and a $10 prepaid check sent to RNs who had not completed the survey after the third mailing. After exclusion of retired RNs or those not working at the time of the survey, a 56% response rate was ob - tained among eligible respondents (AAPOR, RR3). The Partners Healthcare System Institutional Review Board reviewed the project and determined it to be exempt from review. To obtain an understanding of whether certain results found in the 2010 RN survey indicate im - prove ments or deterioration over the decade, we compared results from the 2010 NSRN to the results of earlier surveys administered biennially beginning in Survey Instrument The core research team that developed the 2002, 2004, 2006, and 2008 RN surveys also developed the 2010 NSRN. The survey included many of the core questions contained in prior surveys questions designed to gauge RNs views about shortages, quality of their workplace environment, retention and recruitment initiatives, relationships with other professionals, job and professional satisfaction, overtime hours, un - ion membership, and awareness 319

3 SERIES of the J&J Campaign and its effectiveness and added questions that explored organizations use of health information technology and RNs views of its impact on quality of care, impact of Magnet hospital designation on the workplace, and RNs relationships and experiences with nursing students, new graduate nurses, and nursing educators. Because the ACA had just been enacted and details of the plan were not fully understood at the time the 2010 RN survey was conducted, the survey included questions design - ed to explore RNs general impressions of the health reform legislation. The majority of the 116 questions in the 2010 survey, as in previous surveys, were closed-ended, used response categories such as yes/no and excellent, very good, good, fair, or poor. Unless otherwise noted in the text, the wording of the individual survey questions is shown in the tables and figures presented in the results section. Data Analysis In the 2010 NSRN respondents were included in the analysis if they (a) reported that their current or most recent nursing position was direct patient care and (b) their current or most recent work setting was an acute, specialty, or rehabilitation hospital, or an ambulatory care setting. RNs were categorized as hospitalbased direct patient care if their current or most recent work setting was a hospital (n=327) and as ambulatory direct patient care if their current or most recent work setting was in ambulatory care (n=137). Wherever possible, data were compared across survey years beginning with the 2002 survey using a two-sided z test for differences in proportions. We used chisquare tests to compare hospitalbased RNs to those in ambulatory care within the 2010 sample. All significant differences are noted in the tables. Are Nurses Ready for Health Care Reform? A Decade of Survey Research All surveys are subject to error, including sampling error, questionnaire format, question wording, sample coverage, res - ponse effects due to survey mode, and other factors. Thus, results might differ from what would be obtained if the whole U.S. population of RNs had been surveyed. Sampling error varies with the size of the sample and the size of respondent subgroups within the sample. Possible sources of nonsampling error include nonresponse bias, question wording, and ordering effects. Efforts to minimize non-sampling error included pre-testing all instruments, checks for internal consistency and reliability, review of each instrument by multiple ex - perts, and use of instruments and questions tested previously for other studies RESULTS RN Characteristics To be consistent with results reported in prior publications that focused only on hospital-em - ployed RNs providing direct patient care, Table 1 shows characteristics of this same subsample of RNs in 2010 compared to earlier years. Overall, there are no striking differences among most of the characteristics of hospitalemployed RNs who provided direct patient care in 2010 compared to previous survey results. The majority of RNs are White (78%), female (93%), married (68%), in their mid to late 40s (average age 47), report good health, work less than 4 days per week on average, provide approximately 4 hours of overtime each week, and earn between $50,000 and $100,000 per year. Over the past decade, there has been a slow drift upward in the percentage of RNs reporting an associate degree in nursing as their highest degree received, and an even more noticeable increase among those reporting a master s degree, as 15% of RNs in the 2010 subsample reported a master s degree, triple the percentage in 2002 (5%). Quality of Care and Impact of Health Reform Quality of care. During the past decade a disproportionate amount of efforts aimed at im - proving quality of care has focused on inpatient settings versus ambulatory or other settings. For this reason, the 2010 NSRN excluded ambulatory care RNs when nurses were asked to assess the quality of care in the organizations where they worked (Figure 1). To assess quality, we used the six IOM indicators of the quality of health delivery systems and provided a definition of each indicator (see Figure 1). The survey question asked: How often does your hospital provide high quality of care in the following areas: safe, timely, effective, efficient, equitable, and patient-centered. Across the six IOM quality indicators, the majority of hospital-employed RNs working in patient care positions reported each indicator was being provided either frequently or often in the hospital where they worked (see Figure 1). Ac cording to at least 80% of RNs, hospitals frequently or often provided care that was safe, effective, equitable, and patient centered. Fewer RNs, but still majorities, reported their hospital provided efficient (61%) and timely (70%) care on a frequent or often basis. RNs views of health reform. In the 2008 NSRN, RNs were asked to indicate their perceptions of the most pressing problems facing the country (32% said health care vs. 24% the economy), the most important health care problem facing the country (34% said access to health care and the uninsured vs. 28% indicating the cost and affordability of health care), and to select among three ap - proaches to health care reform they would like to see presidential candidates propose (43% support- 320

4 Are Nurses Ready for Health Care Reform? A Decade of Survey Research SERIES Table 1. Characteristics of Hospital-Employed Registered Nurses Providing Direct Patient Care, N=1,442 RR=55% 2004 N=657 RR=53% 2006 N=617 RR=52% 2008 N=617 RR=37% N=327 RR=56% Gender Female Male Age Mean age Less than 35 years and over Race White Black Asian/Pacific Islander Native American <1 <1 <1 1 1 Mixed racial background Other 1 <1 <1 1 1 Hispanic Marital Status Married * Single, never married Divorced/separated/widowed Living with a partner Highest Degree Received Diploma in nursing 19 1 * Associate degree in nursing * Baccalaureate degree in nursing * Master s degree in nursing 5 2 * 9 15 Doctorate in nursing <1 0 * <1 1 Health (self-report) Excellent Very good Good Fair Poor <1 <1 <1 2 <1 Employment Mean days worked per week * Mean hours worked per week * Mean overtime hours worked per week * Mean hourly wage $27.10 $32.10 $33.30 $35.30 continued on next page 321

5 SERIES Are Nurses Ready for Health Care Reform? A Decade of Survey Research Table 1. (continued) Characteristics of Hospital-Employed Registered Nurses Providing Direct Patient Care, To assess RNs views toward health policies and the presidential candidates, the 2008 survey was fielded in two periods, with the instrument modified between the periods. These adjustments lowered the calculation of the response rate using American Association for Public Opinion Research (AAPOR) guideline 1. *Item not included in survey 2002 N=1,442 RR=55% 2004 N=657 RR=53% 2006 N=617 RR=52% 2008 N=617 RR=37% N=327 RR=56% Days Worked per Week < Income as an RN Less than $25, $25,000-$49, $50,000-$74, $75,000-$99, $100,000-$124, More than $124,000 < Location of Work Setting Urban Suburban Rural ed providing health insurance that would cover all or nearly all of the uninsured vs. 28% for a more limited plan, 15% keep things the same, and 10% don t know) (Buerhaus, Ulrich, Donelan, & DesRoches, 2008). The 2010 NSRN continued to assess nurses views of health reform. However, because the ACA had been enacted only about 1 month before the 2010 RN survey was fielded, questions explored RNs overall im - pressions of health reform legislation on the quality of care versus asking RNs views about specific details of the ACA. The survey asked: Do you think the changes to the health care system that have been enacted by Congress and the Obama administration will make better, make worse, or have no effect on the following aspects of patient care? Table 2 shows that shortly after the enactment of the ACA, Figure 1. Registered Nurses Views about Quality of Care According to the Institute of Medicine s Six Aims for High-Quality Health Care Systems, Safety Frequently or often Timeliness Effectivness Sometimes or never Efficiency Equity Patient Centeredness 322

6 Are Nurses Ready for Health Care Reform? A Decade of Survey Research SERIES Table 2. Registered Nurses Views about the Effect of Health Reform on the Quality of Care Provided in the Hospitals, 2010 Do you think the changes to the health care system that have been enacted by Congress and the Obama administration will make better, make worse, or have no effect on the following aspects of patient care? Safety (avoiding injuries to patients) Hospital-Based RNs n=327 Ambulatory Care Based RNs n=137 Make better 27% 22% Make worse 31% 35% No effect 43% 43% Timeliness (reducing waits and sometimes harmful delays) Make better 23% 21% Make worse 54% 58% No effect 23% 21% Effectiveness (providing services based on scientific knowledge to all who could benefit) Make better 36% 39% Make worse 38% 44% No effect 26% 17% Efficiency (avoiding waste) Make better 41% 38% Make worse 46% 49% No effect 14% 13% Equity (providing care that does not vary in quality because of the personal characteristics of the patient) Make better 42% 38%* Make worse 28% 34% No effect 30% 28% Patient Centeredness (providing care that is respectful of and responsive to individual patient preferences, needs, and values) Make better 33% 33% Make worse 35% 37% No effect 33% 29% *Statistically different from hospital-based RNs at p<0.01. more RNs held pessimistic than positive views of the impact of reform, at least with respect to the six IOM indicators of high-quality delivery systems. Regardless of whether RNs were employed in hospitals or in ambulatory settings, more RNs felt the just passed health reform legislation would make worse or have no effect on five of the six IOM quality indicators (safety, effectiveness, efficiency, patient centered, and timeliness of care) than would make these indicators better. Only in the case of equity of care did more RNs think the ACA would make this aim better than those who felt reform would make equity worse or have no effect. Characteristics of the Work Environment Perceptions of the workplace. In each of the biennial surveys conducted over the past decade, RNs were asked to rate the quality of their workplace environment, including questions addressing their opportunity to influence decisions about the organization of the workplace and opportunities to influence decisions about patient care. Results of the 2010 NSRN suggest some improvements might have occurred in 323

7 SERIES these two workplace dimensions. As shown in Figure 2, results of earlier surveys indicate that less than 20% of hospital-employed RNs providing direct patient care rated the opportunity to influence decisions about the organization of their workplace as excellent or very good. However, in the most recent survey, the percentage increased significantly, from 17% in 2008 and prior years to 25% in 2010 (p<0.05). Similarly, in the surveys conducted before 2010, approximately 25% of RNs rated their opportunity to influence decisions affecting patient care as excellent or very good, whereas in the 2010 survey, fully 33% said they had excellent or very good opportunities. Injuries, discrimination, and hostility. Each of the biennial NSRNs asked RNs to respond to questions about injuries, discrimination, and hostility in the workplace. Data presented in Figure 3 suggest little progress has been made over the past decade. In 2010, substantial proportions of RNs reported that, during the last year in which they worked, they had experienced sexual harassment and a hostile workplace (24%), physical abuse (26%), back or other musculoskeletal injury (38%), and verbal abuse (56%). In addition, discrimination based on gender, age, or race has nearly doubled over the decade, increasing significantly from 13% in 2002 to 25% in Relationships with physicians. Each of the surveys conducted over the past decade assessed RNs relationships with physicians. Results from these prior surveys (see Figure 4), including the 2010 NSRN, indicate no improvement in RNs relationships with physicians over the past 10 years. In fact, over this time period, only about one in ten RNs rated their relationship with physicians as either very good or excellent. Career and job satisfaction. RNs reported satisfaction with their career in nursing and with Are Nurses Ready for Health Care Reform? A Decade of Survey Research Figure 2. Excellent or Very Good Ratings of the Opportunities to Influence Workplace Decisions among Hospital-Employed Registered Nurses Providing Direct Patient Care, * Workplace Organization *2010 statistically different from 2008 at p<0.05. their present job increased substantially over the past decade, reaching their highest levels on both in 2010 (see Table 3). Nearly six in ten RNs (57%) reported being very satisfied with their nursing career in 2010 compared to 35% in Similarly, those saying they were very satisfied with their present job more than tripled, from 13% in 2002 to 40% in When asked about the likelihood of recommending a career in nursing to a qualified high school or college student, RNs were more likely in the past few surveys to indicate they definitely or probably would make such a recommendation (ranging between 72% and 86%), compared to those holding this view in 2002 (59%). Patient Care Policies Affecting Nurses Staffing regulations. In the 2008 and 2010 NSRNs, hospitalemployed RNs were asked to indicate their agreement with the three statements (see Table 4) that most closely describe their attitude toward minimum patient-tonurse staffing ratios. Results of both surveys were nearly identical with 70% or more of all employed RNs (regardless of setting) reporting they support minimum nurse staffing ratios. RNs were nearly evenly split between whether they thought ratios should be mandated by the federal government or by the states. Nearly 30% of RNs in the 2008 and 2010 surveys reported minimum RN staffing ratios should not be mandated and approximately one in ten did not provide a response. To obtain information on the perceived effects of staffing ratios, RNs were asked: In general, what effect do you think minimum RN staffing ratios have on the quality of care provided for patients? Once again, there was very little change during the two surveys in 324

8 Are Nurses Ready for Health Care Reform? A Decade of Survey Research SERIES Figure 3. Perceptions of Physical and Mental Safety in the Workplace among Hospital-Employed Registered Nurses Providing Direct Patient Care, * Back or Other Musculokeletal Injuries* Discrimination Based on Gender, Age, or Race Sexual Harrasment/ Hostile Workplace Episodes of Verbal Abuse (1) Episodes of Physical Abuse (1) (1) Question not asked in 2002 or 2004 survey. *2010 statistically different from 2008 at p<0.05. Figure 4. Registered Nurses Perceptions of the Quality of Relationships with Physicians, % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0 Excellent Very Good Good Fair or poor 10% 30% 35% 21% 11% 34% 34% 18% 8% 31% 37% 22% Hospital-Employed RN Providing Direct Patient Care 5% 33% 39% 23% 9% 32% 37% 22% RNs views of the effect of ratios on quality of care. In both surveys, approximately two-thirds of RNs indicated they thought the effect of staffing ratios would be very or somewhat positive, about onequarter very or somewhat negative, and one in ten said neither a positive nor negative effect on quality of care. CMS hospital payment regulations. On October 1, 2008, the Centers for Medicare and Medicaid Services (CMS) implemented a change in payment policy that eli - minated additional payments for preventable, hospital-acquired con - ditions of which several of these conditions are associated with hospital nurse staffing. RNs were asked to indicate the effect of this policy change on a list of possible effects including staffing, quality improvement initiatives, pay, edu- 325

9 SERIES Are Nurses Ready for Health Care Reform? A Decade of Survey Research Table 3. Career and Job Satisfaction, and Willingness to Recommend Career in Nursing Among Hospital-Employed Registered Nurses Providing Direct Patient Care Positions, *Statistically different at p< N=1, N= N= N= N=327 Independent of your present job, how satisfied are you with being a nurse? Very satisfied Somewhat satisfied On the whole, how satisfied are you with your present job? Very satisfied * Somewhat satisfied Given what you know about the state of health care, how likely would you be to advise a qualified high school or college student to pursue a career in nursing? Definitely would * Probably would * Probably would not * * * Definitely would not * * * 4 3 Table 4. Hospital-Employed Registered Nurses Views about Minimum Patient-to-Nurse Staffing Ratios, 2008 and 2010 Which of the following statements most closely describes your attitude about minimum RN staffing ratios? cation, respect, and workload. As shown in Table 5, many RNs did not perceive the CMS payment change had any effect on many of these dimensions of their work experience. Very few RNs (less than 15%) reported the payment change had led to increases in staffing (either RNs, licensed practical nurses, or nursing assistants), 2008 n= n=327 Should be mandated by the federal government 38% 36% Should be mandated by the states 32% 38%* Should not be mandated 29% 27% In general, what effect do you think minimum RN staffing ratios have on the quality of care provided for patients? Very or somewhat positive 61% 66% Very or somewhat negative 28% 22%* Neither positive nor negative 12% 10% *Statistically different from 2008 at p<0.05. respect for RNs, or increases in RN pay. However, RNs perceived the policy change had led to increases in education and training opportunities (44%) and their workload (61%). Nearly eight in ten RNs (79%) reported an increase in the number of quality improvement initiatives designed to prevent hospital-acquired never conditions. DISCUSSION AND POLICY IMPLICATIONS With the passage of health reform legislation in 2010, the health care delivery and financing systems are undergoing significant transformation that will extend throughout the decade and affect nurses and the environment where they work. This study sought to assess whether there are areas where the nursing profession may not be well positioned to meet the challenges that lie ahead as health reform initiatives unfold. Overall, study results offer a mixed assessment by illuminating aspects of the current work environment in need of improvement; areas where staffing, payment, and health reform policy actions are not aligned with the perceptions of nurses; and still other results that indicate strength and improvement, and from which the nursing profession can build upon in preparing for the future. 326

10 Are Nurses Ready for Health Care Reform? A Decade of Survey Research Table 5. Hospital-Employed Registered Nurses Views of Effect of Hospital Payment Changes Affecting Never Conditions, 2010 In 2008, Medicare stopped paying for treatment of preventable, hospital-acquired conditions (e.g., pressure ulcers, urinary tract infections, blood stream infections, etc.), which are related to hospital nurse staffing. To what extent has this payment change affected each of the following in your hospital? RN Staffing Levels Hospital- Based RNs n=327 Increased 12% Decreased 20% No change 69% LPN Staffing Levels Increased 5% Decreased 29% No change 67% Number of Nursing Assistants Increased 12% Decreased 23% No change 66% Number of Quality Improvement Initiatives Designed to Prevent these Eight Conditions Increased 79% Decreased 5% No change 16% Respect for RNs Increased 13% Decreased 13% No change 75% Pay for RNs Increased 10% Decreased 9% No change 81% Education and Training Opportunities for RN Increased 44% Decreased 9% No change 47% RN Workload Increased 61% Decreased 2% No change 36% SERIES Areas Needing Improvement As they have in previous surveys, more than one-third of RNs working in hospitals continue to report experiencing back and other musculoskeletal injuries. With respect to back injuries, large cohorts of baby boom RNs have now aged into their 50s, and may be at increased risk for physical injury. Efforts to prevent injuries will become increasingly important to hospitals, particularly as nearly one in four working RNs will be over age 50 by 2015 (Buerhaus, Auerbach, & Staiger, 2009). Fortunately, the Veterans Administration (2012) VISON 8 Patent Safety Center in Tampa, FL, has conducted extensive research and evaluation of intervention strategies aimed at preventing injury to nurses and patients, and has developed programs that can be readily adopted by hospitals and included in education curricula. It is well known that health care workers, especially nurses and patient care assistants, experience the highest rates of violence in health care occupations, and studies have described the negative aftermaths that include stress, post-traumatic symptoms, de - creased productivity, and other negative impacts on RNs (see, for example, Gates, Gillespie, & Succop (2011). As found in prior NSRNs conducted over the past decade, one in four RNs surveyed in 2010 reported experiencing physical violence, discrimination, and sexual harassment, and even more (nearly six in ten) had experienced verbal abuse. A study by McGovern and colleagues (2000) determined the cost per case for assaults to RNs amounted to $31,643 (medical expenditures, lost wages, legal fees, insurance administrative costs, etc.) and $17,585 for LPNs. Despite efforts by hospitals to decrease these threats to nurses personal wellbeing, the persistence of these harmful and costly aspects of the 327

11 SERIES work environment suggests a new focus and greater commitment by hospital leadership are required. Misalignments Between Health Policy and Nurses Study results point out at least four areas of misalignment bet - ween recent health policy initiatives and the views of the RN workforce. One disconnect in - volves the generally pessimistic views about the effect of the ACA on the quality of hospital care as more RNs expected that five of the six IOM quality indicators will be made worse by the ACA than made better, regardless of whether RNs were employed in hospitals or ambulatory delivery settings. These findings, however, should be interpreted with caution. For one, the ACA had just been enacted into law shortly before the 2010 NSRN was administered, and thus RNs were unlikely to know the specifics of various proposals, especially since many regulations had not even been drafted. In addition, because nurses political ideology is very similar to the political ideology held by the general voting population (Buerhaus, Ulrich, Donelan, & DesRoches, 2008), RNs assessment of the ACA s effect on quality may reflect a general dissatisfaction with health reform, not unlike the public s views at the time, rather than a specific belief that the ACA will directly affect quality. Neverthe less, despite these caveats, be cause RNs are inseparable from the ability of health care systems to produce high quality, and be cause RNs are highly trusted by the public, advocates of health re form should be alert to these pessimistic RN perceptions and pay attention to how and whether health reform negatively affects the quality of care. Even if the implementation of health reform via the ACA is delayed or halted entirely, the delivery system will still depend Are Nurses Ready for Health Care Reform? A Decade of Survey Research Over the decade, relationships between nurses and physicians have not improved. heavily on the nursing profession to ensure the provision of highquality and safe patient care to an increasing number of people of all ages, ethnic groups, and geographic locations. The 2010 IOM report on The Future of Nursing emphasized the need for the profession to become better prepared, quickly, not only to successfully deal with the challenges imposed by health reform, but for nurses to become more actively involved in leading reform initiatives in the organizations where they work. Yet, results of the 2010 RN survey show that a minority of hospital-employed RNs providing direct patient care perceive they have excellent or very good opportunities to influence decisions affecting the organization of their workplace or decisions that influence patient care. The lack of influence has persisted across all surveys since If the IOM report is to have an impact on promoting the increased involvement of nurses, research is needed to understand why nurses continue to perceive so little opportunity to influence their care environment and pa tient care decisions. Hospital management, physicians, and nurses should jointly develop and evaluate strategies to identify the barriers and remove them whether they are organizational in nature, rooted in professional relationships, poor interpersonal and communication skills, or misplaced expectations. Survey results also uncovered misalignments between the goals and outcomes of public policies and the views of RNs. While in - tended to improve quality by providing hospitals with an incentive to prevent never conditions, the majority of RNs reported CMS s decision to no longer pay hospitals for the extra care required to treat never conditions had in - creased their workload yet had not led to increases in staffing, res - pect, or their pay. RNs also reported an increase in the number of quality improvement initiatives related to never events, which might account for some of the reported increase in workload. Similarly, the study found two-thirds of RNs support mandating patient-to-nurse staffing regulations implemented by the federal or state governments. While believing mandating ratios will improve quality of care, others believe regulating nurse staffing in this manner will create inflexibility, decrease efficiency, and in crease costs (Buerhaus, 2009), which are the opposite outcomes of system-wide policies to reform health care delivery. Therefore, hospitals and policymakers should anticipate the potential for misalignment between the intent of such reforms and the perceived impact on nurses and take steps to reduce misalignments. And, hospital management should attempt to understand the problems motivating those who support regulating nurse staffing and take actions to resolve the problems. As noted previously, the lack of input into decisions affecting the organization of care delivery and decisions influencing patient care are likely areas to begin such an assessment. A final misalignment involves the belief that increased teamwork, communication, and care coordination are vital to reforming and improving health care delivery systems. Yet, how can better teamwork, communication, and care coordination be obtained when less than one in ten hospital 328

12 Are Nurses Ready for Health Care Reform? A Decade of Survey Research RNs report having an excellent relationship with physicians? Over the decade, relationships between nurses and physicians have not improved. Beyond the changes associated with health reform that will affect nurses, physicians will be heavily affected by health reforms intended to change the practice of medicine (through increased adoption of health information technology), how much physicians will be paid (whether Congress continues to link payment to the sustainable growth formula), and whether policy changes succeed in expanding the primary care physician workforce. All of these changes will affect how doctors and nurses interact professionally, and suggest that, for their mutual good in overcoming the challenges both will face in the years ahead, nurses and physicians need to strengthen their professional relationship. Fortunately, there are a number of high-profile initiatives that are underway that, among other things, seek to improve relationships between physicians and nurses, including IOM s Best Prac - tices Innovation Collaborative of the Roundtable on Value & Scien - ce-driven Health Care (co-chaired by a physician and a nurse) that catalyzes joint activities among the health professions for im - provement and innovation in health and health care, focusing on fostering evidence-based best practices, including team care and shared decision making (IOM, n.d., p. 1); and the Josiah Macy Foundation (2010) grants and programs on interprofessional education and teamwork. If resistance to such initiatives is encountered, nurses might support the need for change by referring detractors to reports issued over the past several years by the Medicare Payment Assessment Commission that call for changes in graduate medical education that emphasize team coordination communication and greater community-based education. And, recent research (Tshannen, Keenan, Aebersold, Kocan, Lundy, & Averhart, 2011) provides evidence that bringing physicians and nurses together to address communication issues collaboratively resulted in greater openness and collaboration in study units. Positive Trends The study found several areas of strength and improvement. Strong majorities of hospital-em - ployed RNs report their organizations frequently or often provide care that is safe, effective, equitable, and patient centered, and more than half feel the same for efficient and timely care. These results suggest that, with respect to these indicators of high-quality delivery systems, most RNs perceive high-quality of care is currently being provided on a routine basis. A strong majority of RNs also reported their hospital had increased the number of quality improvement initiatives aimed at preventing the CMS never conditions, and many RNs noted the CMS change in payment policy had increased education and training opportunities. RNs also continue to be satisfied with their jobs and careers in nursing, and most would recommend a nursing career to a qualified high-school or college student. SERIES Conclusion Many foundations and private entities have provided substantial support to strengthen the nursing profession. Time will tell whether these investments pay off. 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