WORKPLACE
ADVOCACY AND WORKPLACE ISSUES
Workforce advocacy is a pro-active, energetic,
constructive and comprehensive approach for registered nurses to improve their:
·
capacities to advocate
for quality patient care
·
workplace and learning
environments
·
abilities to practice to
their full legal and professional scope
·
relationships with
colleagues and coworkers
·
satisfaction with nursing
and their workplace positions
·
state healthcare network
Workforce advocacy
encompasses:
·
an understanding of the
internal factors that contribute to work satisfaction
·
an appreciation of the
external social, technological, economic, environmental and political factors
which impact practice (STEEP)
·
a mindset that says, “I am a registered nurse who believes I should work
for quality patient care and my abilities to practice as a professional.”
·
tools, resources and
education to support RNs in these efforts
·
collaboration with
appropriate individuals, associations and boards
·
lifelong learning
·
competence in the area of
practice, education, administration or research in which one is involved
Assumptions that underpin
a strong workforce advocacy program:
·
Consumers/patients/clients
are an integral part of the healthcare system and need to be included in
problem identification/resolution and healthcare improvement.
·
Healthcare is provided by
a team effort; in which registered nurses are an integral part.
·
Each discipline and each
person within a healthcare system deserves to be valued, respected and trusted.
·
Each person, discipline
and position within a system brings creativity, knowledge, skills and expertise
to enhance patient care and improve work environments.
·
Each person has a
responsibility to contribute to continuous quality improvement both in
healthcare for our citizens and in workplace environments.
·
No one of us as an
individual or a group can assume to know what another individual needs or
wants.
·
Opening
communication/dialogue/negotiation among people will increase understanding of
their expertise, needs and wants.
·
Diversity of values, life
views, perspectives, knowledge, skills, wants and needs enriches healthcare and
the opportunity for improving its quality and satisfaction to all participants.
·
The role of advocacy
encompasses diverse approaches that can be utilized to respond to problems that
arise in the workplace.
Words are powerful tools for advocates of
personal rights. Abraham Lincoln and Martin Luther King, Jr., are examples of
people who used them well-by making their words clear to everyone; their
messages became effective tools for change."If
words are not carefully chosen or well understood, their message holds little
meaning to very few. As the noise regarding workplace issues rises to a
mind-numbing din, nurses need clear, meaningful messages," says Anna Atteberry, MSN-S, BSN, RN, a member of the South Dakota
Nurses Association and a staff nurse at the Gregory Healthcare Center in
Gregory, South Dakota. "Before determining how workplace advocacy
strategies can be used by nurses, we must be clear about what these words
mean."
Atteberry,
who sits on the ANA's Commission on Workplace Advocacy, says workplace advocacy
empowers nurses to solve issues in their own practice settings. In addition to
addressing issues such as practice and occupational health and safety, advocacy
can be applied to education, professional development, and legal concerns.
"I can't stress enough the importance of using workplace advocacy
strategies in professional nursing practice," says Atteberry.
"Often these activities include the resources and strength of a national
professional association like the ANA and its 54 constituent member
associations."
Violence, ethical dilemmas, mandatory overtime,
and environmental and ergonomic risks also concern other professions. By
forming new alliances and partnerships, a larger pool of strategies can be
created to address these issues.
A NEW NEGOTIATING TOOL
A strong economy, technological advances, and
workplace restructuring have changed how employers and employees negotiate. For
example, many rights that were previously only available to unionized employees
are now found in nonunion zed work settings.
In July 2000, the National Labor Relations Board
(NLRB) decided to expand such a right. In its decision, entitled Epilepsy
Foundation of Northeast Ohio (331 NLRB 92 [2000]), the NLRB reversed a
longstanding precedent by determining that employees not represented by a union
have the right to have a coworker present at an investigatory interview that
the employee reasonably believes could result in disciplinary action.
The decision came as a result of a charge of
unlawful dismissal brought in front of the NLRB by Arnis
Borgs and Ashrafel Hasan against their former employer, the Epilepsy
Foundation of Northeast Ohio. Borgs and Hasan, who worked together on a school-to-work transition
program for teens with epilepsy, had ongoing problems with their supervisor.
Together, they penned a letter to him, sending a copy to the executive director
of the agency, stating they no longer required his supervision. Days later, in
a memo addressed directly to the executive director, the two criticized the
supervisor's involvement in the program and cited examples in which he had
acted inappropriately. Soon after the memos were written, the supervisor and
executive director requested a meeting with Borgs. He
asked that Hasan attend this meeting, but the request
was denied. When he continued to express his opposition to meeting alone with
the supervisor and executive director, Borgs was sent
home and fired the next day for gross insubordination. (Hasan
was terminated nearly two months later.)
Borgs appealed to
the NLRB. The judge who heard the case found that Borgs
had been discharged for "his persistent refusal to comply with [the
executive director's] directive to meet alone with her and [the
supervisor]." The judge noted that under the U.S. Supreme Court's 1975
case NLRB v. J. Weingarten (420 U.S. 251), employees in unionized work settings
are entitled to representation in an investigatory interview that the employee
reasonably believes could result in disciplinary action, but under NLRB
precedent, employees in nonunionized workplaces didn't have the same right.
Accordingly, the judge found that Borgs had no
statutory right to condition his attendance at the meeting on the presence of Hasan.
After considering the case, however, the NLRB reversed the judge and
overruled its precedent, finding that the employer's termination of Borgs for his attempts to have a coworker present at the
meeting was unlawful. The NLRB's decision recognized that "the right to
the presence of a representative is grounded in the rationale that the
[National Labor Relations] Act generally affords employees the opportunity to
act together to address the issue of an employer's practice of imposing unjust
punishment on employees."
The NLRB held that "the ability to avail oneself of this protection
doesn't depend on whether the employees are represented by a union." This
decision is consistent with the growing trend of recognizing and acknowledging
individual rights in the work setting.
USING THE LAW
Workplace protections for nurses also exist at the state level. For
example, Texas has both a state whistleblower law and a whistleblower clause in
the state nurse practice act. These provided the legal defense for emergency
department nurse Stephanie Hohman, RN. Her employer,
the University of Texas Medical Branch, retaliated against her when she
witnessed the trauma team forcing unnecessary treatments on patients and
reported her concerns to the Board of Nurse Examiners. During her trial, the
Texas Nurses Association (TNA) testified to an RN's duty to report potential
harm to patients as well as to her rights under the whistleblower laws. As a
result of this support, and because Hohman documented
her acts and subsequent treatment, she won the case and received back wages,
compensatory damages, and coverage of incurred legal fees.
Sometimes, legislation doesn't need to become law
to be used as an effective workplace advocacy strategy. For example, in New
Jersey, mandatory overtime legislation "brought agreement among a number
of health care groups that are often opposing or competing with each
other," according to Andrea Aughenbaugh, RN, CS,
CAE, chief executive officer of the New Jersey State Nurses Association
(NJSNA). "The NJSNA, the Patient First coalition (consisting of health
care worker unions), the Organization of Nurse Executives of New Jersey, and
the New Jersey Hospital Association all agreed that a safety issue existed and
needed to be addressed by the government. Further, the publicity regarding this
legislation and the governor's conditional veto prompted facilities to
voluntarily examine their policies and make changes."
PARTNERSHIP POWER
The examples in Texas and New Jersey illustrate a
key strategy in workplace advocacy-using the power of nursing organizations and
broad coalitions to maximize workplace protections.
"Membership in your state nurses association
supports the creation of meaningful advocacy strategies, for you, the nurse,
and ultimately the consumers, our patients," notes Clair Jordan, MSN, RN,
executive director of the TNA and chair of the ANA's Commission on Workplace
Advocacy.
"To make workplace advocacy work for you and to secure a better
workplace, learn more about the growing treasure trove of resources in your
state and enjoy a ready-made source of professional partners."
The following are rules that govern employees'
right to bring a representative with them into investigatory meetings:
The right arises only when the employee requests
the presence of a coworker.
If the employee requests representation, the employer can't insist on
questioning the employee without a coworker present. Moreover, the employer
can't discipline the employee for making the request or for refusing to
participate in the interview without the presence of the coworker. If an
employee is discharged or otherwise disciplined for asserting his or her
rights, the employer can be ordered to reinstate the employee and provide back
pay.
Employees can request representation only in
situations they reasonably believe will result in disciplinary action.
The employer has no obligation to justify its
refusal to allow representation at the interview. Employers are free to carry
on their inquiry without meeting with the employee.
Employees can't insist on coworker representatives
who are absent at the time of the meeting and can't bring in attorneys or
nonemployees. As long as there is another coworker available to accompany the
employee, the meeting need not be postponed.
Representatives can't engage in a debate with investigators
or tell the employee not to answer a question.
Workplace Advocacy and Workplace
Issues
•
Workplace advocacy to improve the
quality of health care
•
Issues affecting professional nursing
practice
•
Resources to assist in improving the
workplace
•
Advocating for safe and effective
workplace environments
•
Internal and external workplace
strategies for quality patient care
•
Nurses are struggling to deliver
patient care against many barriers
•
Commitment to quality care and
advocacy may place nurse in direct conflict with administrators
Professional Practice Advocacy
•
Umbrella of activities to promote a
professional practice environment:
–
Workplace advocacy
–
Collective bargaining
•
Activities supportive of:
–
Patient advocacy
–
Professional practice
self-determination
–
Employment rights and
responsibilities
Professional Practice Advocacy Examples
•
Promoting occupational safety and
health
•
Using political processes to
influence and protect nurses and patients’ rights
•
Developing public reactions and
conflict resolution skills
•
Building coalitions and support
groups
Workplace Advocacy
•
Activities initiated to address
workplace challenges
•
Safe and effective workplaces are
promoted by knowing where to seek information
•
American Nurses Association’s (ANA’s)
Commission on Workplace Advocacy supports workplace advocacy
Workplace Advocacy Examples
•
Develop conflict resolution models to
address patient care concerns
•
Identify mechanisms for RNs to affect
institutional policies
•
Seek legislative solutions for
workplace problems
•
Develop legal centers for legal
support and decision-making advice
Workplace Issues
•
Nursing shortage
•
Appropriate staffing
•
Patient safety
•
Workplace safety
Nursing Shortage Overview
•
Managed care influenced cyclic
shortages in the late 1990s and in early 2000
•
Current shortage is more complex and
long lasting
•
Nursing employment opportunities will
grow more rapidly than all other U.S. occupations through 2008
•
Planning for an adequate nursing
workforce will be a critical challenge
Nursing Shortage Issues
•
Health care is no longer a favored
employer
•
Decline in nursing school enrollments
•
Increasing demands for nurses with
specific education and skills
•
Faculty shortage
Nursing Shortage Issues—cont’d
•
Nurse retention
•
Aging workforce
•
Foreign nurse recruitment
•
Compensation
•
Work environment
Appropriate Staffing
•
Factors contributing to inadequate
nurse staffing:
–
Nursing shortage
–
Cost-cutting initiatives related to
managed care
•
Absence of data to quantify effect of
staffing on safety and quality
Mandatory Overtime
•
Mandatory overtime/mandatory on-call
requirements have increased
•
Mandatory overtime studies:
–
Increased time lost to absenteeism
–
Increased injuries
–
Required 3 hours of work to produce
an additional 2 hours of productivity
Mandatory Overtime Issues
•
May alleviate the employer’s sense of
urgency to proactively find more appropriate staffing
•
Nurses may feel resentment to bear
the personal, professional, and legal burden for the staffing problem
Floating
•
Nurses increasingly required to float
to other patient care units
•
Floating issues include:
–
Questions regarding knowledge,
expertise, and experience needed to work in the area
–
Time for orientation and training
–
Availability of support from
experienced nurses
Shared Governance
•
Gives nurses an active role in
decision making
•
Attributes include independence,
accountability, and autonomy over nursing practice
•
Results in increased job satisfaction
and efficiency and better patient outcomes
•
Goes beyond participatory management
through creation of structures to govern nursing practice
Patient Advocacy and Safety
•
Patient advocacy is the cornerstone
of nursing
•
Complex systems and complicated
technology lead to errors and adverse events
•
Nursing must assert its powerful
voice to promote safer health care systems
Errors in Health Care
•
Two major studies indicate that
errors in health care delivery kill 44,000 to 98,000 people in U.S. hospitals
annually
•
Nursing organizations are attempting
to demonstrate the link between nurse staffing and patient adverse events
Whistleblower Protection
•
Protects nurses who speak out about
unsafe situations through appropriate channels
•
Advocated for at the federal level
and has passed in some states
•
Major changes
in care and staffing are occurring with few data to justify the effects on
safety and quality
•
Professional
organizations are working to collect and publicize data to link nurse staffing
mix with patient outcomes
ANA’s Nursing-Sensitive Indicators
•
Mix of RNs,
licensed practical nurses (LPNs), and unlicensed staff caring for patients
•
Total
nursing care hours provided per patient day
•
Pressure
ulcers
•
Patient
falls
•
Patient
satisfaction with pain management
ANA’s Nursing-Sensitive Indicators—cont’d
•
Patient
satisfaction with educational information
•
Patient
satisfaction with overall care
•
Patient
satisfaction with nursing care
•
Nosocomial
infection rate
•
Nurse staff
satisfaction
Workplace Safety
•
Needlesticks
–
U.S. health
care workers experience 800,000 needlesticks annually
–
Legislation
is being passed to protect workers
•
Ergonomic
injuries
–
Back
injuries affect 38% of all nurses
•
Workplace
violence
–
Major
societal issue
Advocating to Prevent Workplace Violence
•
Organizational
assessments to identify high-risk environments, psychological conditions, and
populations that threaten safety
•
Staff
education to address the identification and response to high-risk behaviors
that can lead to violence
ANA's Workplace Advocacy Program
•
Advocates
for administrative controls:
–
Adequate
staffing
–
Health and
safety committees
–
Engineering
controls such as ventilation and safer needle-stick devices
–
Personal
protective equipment such as respirators and synthetic gloves
Workplace Advocacy: A
Professional Strategy of Advocating for Excellence
Professional nurses have a long
history of struggling to deliver patient care against multiple barriers,
including dwindling resources. As we speed into the current century, the
struggle is increasing in complexity. This struggle affects not only individual
nurses, but also patients, organizations, and the nursing profession. Nurses’
strong commitment to patient care and their role as patient advocates often
places them in direct conflict with administrators of health care
organizations. How nurses react to this conflict, how they continue to advocate
for patients in this environment, and what resources they have available to improve
patient care has become an increasingly important focus of the nursing
profession and the health care industry. A recent report by the Institute of
Medicine (IOM) (2004) entitled "Keeping Patients Safe:
Transforming the Work Environment of Nurses" highlights the important role
nurses provide in our complex health care system and provides recommendations
for improving the workplace partnership between nurses and employing
organizations. The ability of nurses and organizations to improve the workplace
partnership is vital to the future success of health care.
It is
important to the future of health care that ample strategies be identified to
provide support for nurses as they take on the challenges of the new century.
One organizational strategy that has long been stressed as a mechanism by which
nurses can advocate for and manage their professional role is that of shared
governance (SG) strategy that promotes power bases that afford nurses optimal
work environments is work place advocacy (WPA). This article attempts to
identify common denominators that are part of both SG and WPA.
Work Place Advocacy operates at the
organizational, local, state, and/or national levels to equip nurses to
skillfully use a range of external (macro) and internal (micro) strategies that
are complementary in nature.
These strategies focus on strengthening
nursing’s voice and ensuring nurse involvement in workplace decisions that
affect nursing care (Green &
Jordan, 2002). Developing an effective WPA strategy or program is a
complex, multifaceted task involving both individual nurses and professional
organizations, such as national and state nurses associations.
Macro level
strategies would likely focus on either local, state, or federal policies that
are capable of directly impacting professional nursing practice. These types of
policy initiatives are usually begun by state or national professional nursing
organizations, although they may also be initiated by other stakeholder groups,
such as the American Hospital Association. Examples of such initiatives that
have resulted in legislation of health policy include: state-regulated,
mandatory safe staffing rules and national workplace safety initiatives, such
as protection of confidentiality in reporting of workplace injury or illnesses.
Individual nurses have a professional obligation to participate in macro level
activities, via membership in state or national professional nursing
organizations, to improve nursing practice environments and patient care
delivery systems.
Advocating
for the nursing profession and/or professional practice has been a priority of
professional nursing organizations for many years. In particular, the American
Nurses Association (ANA) has long been working to define the programs and
services intended to promote and support professional practice standards in the
workplace. These activities support nurses’ advocacy for their patients,
professional practice self-determination, and the exercise of nurses’
employment rights and responsibilities.
In 2000, the ANA committed to
supporting the profession through WPA with the formation of the Commission on
Workplace Advocacy (CWPA). That commitment was further refined in 2003 by
structural changes within ANA resulting in the creation of the Center for
American Nurses (CAN),
formerly the Center for Work Place Advocacy (CWPA). Information about the CAN can be found atwww.centerforamericannurses.org.
The CAN is an
independent, national professional association affiliated with the American
Nurses Association that was designed to form a partnership between the
thirty-eight participating state nurses associations and the practicing
registered nurse. Most of the remaining states not involved in the CAN prefer
to utilize collective bargaining as their primary strategy for impacting the
workplace. The goal of the CAN is to develop cutting-edge strategies, including
products and programs that will help nurses to optimize their value in the
workplace. As the American workforce changes in the 21st century, nurses will desire new and
diverse opportunities to influence their workplace and the CAN will provide the
pathways needed to achieve this empowerment.
The CAN has
identified many approaches to optimize the voice of the practicing nurse in
health care settings. Many of these approaches parallel SG in that they bring
the nurse to the decision table. Nurses’ success at that
table will be a function of individual nurse’s skills and abilities, as well as
employers’ reasons for wanting the nurse present at this table. Nurses
can empower themselves by seeking guidance and assistance from the CAN as they
strive to strengthen their positions in health care organizations through the
use of SG and WPA strategies.
Micro level
CAN activities occur at the organizational level where the nurse is employed.
Examples of micro level WPA strategies are: advocating for appropriate staffing
levels within the organization and developing organizational level workplace
safety programs to prevent ergonomic injuries. These improvements occur when
individual nurses take leadership in implementing WPA awareness within their
organizational settings.
Common
Denominators in Shared Governance and Work Place Advocacy
Common
Denominators in Shared Governance and Work Place Advocacy include:
accountability, empowerment, conflict resolution, and patient advocacy. Each of
these denominators will be discussed below.