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.