The State of Workforce Engagement: Meeting the Needs of Bedside Caregivers

Added on Dec 12, 2019

Health care professionals whose jobs involve direct patient care are less engaged in their work than those not on the front lines of care, according to the findings of a recent white paper on the state of workforce engagement in health care. As Part II of our blog series designed to deconstruct some of the key findings of the report, this post focuses on how understanding barriers to direct patient care is crucial in defining best practices for bedside caregivers. Part I in the series looked at generational differences in engagement and offered recommendations for bridging generation gaps.

blonde nurse next to bedNurses understand that administrative responsibilities, such as charting and care coordination, are necessary to providing safe, high-quality, patient-centered care. However, as nurse shortages and limited resources continue to plague hospital systems across the nation, the buildup of these behind-the-scenes tasks that fall on nurses can feel like an insurmountable burden. Although operational transformation does not occur overnight, daily support for bedside nurses facing growing demands inside and outside the patient room starts by understanding what nurses need to feel valued and valuable.

For those entering the nursing sector of the health care workforce, the high degree of direct patient interaction is almost always a motivating factor for their career choice. Yet, data from the recently published Press Ganey white paper, Health Care Workforce Special Report: The State of Engagement, indicate that many of the job categories on the lower end of the engagement scale involve direct patient care, while those on the higher end do not. More specifically, among the nursing roles overall, registered nurses (RNs) with at least 50% direct patient care responsibilities had the lowest mean engagement score, at 4.04, while RNs with less than 50% direct patient care responsibilities had higher mean engagement, at 4.10. Caregivers in nursing assistant-type roles, such as licensed practical nurses (LPNs), vocational nurses, and certified nursing assistants (CNAs), referred to in the report as “Not RNs,” with more than 50% direct patient care responsibilities had considerably higher engagement, at 4.15. Those with less than 50% direct patient care responsibilities had the highest engagement, at 4.27.

Considering that nurses make up the largest segment of the health care workforce and have the most direct patient care responsibilities, improving nurse engagement has the potential to boost overall workforce engagement and, by so doing, improve performance on measures of safety, quality, and experience of care, as research has shown these to be highly interdependent.

Anne Freeman, RN, an engagement consultant for Press Ganey, attributes this finding to inherent differences in the roles of nurses and nursing assistants. The latter, she explained, tend to have fewer external responsibilities pulling them away from the bedside, and therefore have more abundant opportunities for face-to-face contact with patients.

In contrast, RNs who spend at least half of their shifts directly with patients have a multitude of other responsibilities that go above and beyond their primary role at the bedside, such as charting, managing physician conversations, relaying information, and coordinating care, Freeman continued, adding that when these tasks overwhelm bedside RNs, they can diminish RNs’ primary source of fulfilment: connecting with patients.

These routine responsibilities are compounded with ongoing changes in health care, such as the integration of technology in almost all aspects of care delivery. The result? A seemingly constant state of competing priorities: Nurses need to attend to their external responsibilities because they are important, but they also want to be with the patient, Freeman noted.

To dig deeper into this engagement finding for RNs specifically, Press Ganey collected data around activation, defined as the degree to which individuals connect to their work, and decompression, defined as the ability to disconnect from work. Mean response scores for resilience, decompression, and activation for RNs with at least 50% direct patient care responsibilities and RNs with less than 50% direct patient care responsibilities were only slightly different. Specifically, in both groups, RNs had a high degree of activation and a lower degree of decompression.

“The phenomenon I see, particularly with nurses, is that the higher their level of activation, the more committed they are to doing the best they can for their patients, to the detriment of their own well-being,” explained Freeman. “Ten years ago nurses were able to spend more face-to-face time with their patients. Now the amount of time spent at the bedside is less and less, and more goes on behind the scenes. They are not able to give the same type of quality interaction.”

This is where the ability to decompress comes in.

“When the burden of indirect patient care tasks competes with meaningful face-to-face engagement, nurses go home feeling like they didn’t do enough for their patients,” explained Freeman. After a while, this high level of activation and low level of decompression amounts to a feeling of caregiver guilt—I should have done more, I could have done more—and ultimately, burnout, she said.

According to Freeman, traditional solutions in health care to combat this negative cycle, such as using computers on wheels and conducting bedside shift reports, are sufficient but have not done enough to bridge the growing gap between bedside caregiver and patient interaction. The fact is, health care is constantly being driven in different directions. Improvement efforts must be grounded in the ability to adapt and respond to these changes.

“We have to start with what we can control,” Freeman stated. “In the health care workplace, there is a system of inherent and added rewards and stressors that tip the balance toward engagement or disengagement. Leaders, along with their teams, should strive to amplify inherent rewards while addressing added stressors.”

Put simply, magnify the “humanness” of the workplace. By recognizing where there are human factors in care delivery, such as teamwork, communication, and trust, leaders can improve existing processes and relieve some of the burden nurses shoulder in today’s health care environment, Freeman suggested. “Unfortunately, the guilt nurses feel about not being able to spend enough time with patients is not going away anytime soon,” she said. “But added stressors such as bullying, incivility, and poor team coordination further inhibit RNs from getting their work done safely, with quality, and with the patient at the center. Most of these stressors are totally avoidable.”

To identify where there are added stressors in the bedside nurse workload, Freeman gave a simple piece of advice to nurse leaders: “Walk in the shoes of a bedside caregiver. Decisions about care at the bedside cannot be made away from the front lines of caregiving.” Once leaders understand the obstacles their teams regularly face, they can approach improvement efforts with a new perspective. Furthermore, evidence of leadership commitment to meeting the needs of front-line caregivers goes a long way toward building trust, she explained.

In today’s rapidly advancing health care landscape, organizations must ensure that growing demands in the care process do not fall disproportionately on one sector of their workforce. Understanding the specific obstacles that nurses face daily is critical to tailoring a realistic improvement plan that fosters teamwork and acknowledges the critical importance, and limitations, of bedside caregivers in delivering on an organization’s care promise.