Managing Chhanges During Clinical Staff Shortages - Assignment Example

Running Head: MANAGING CHHANGES DURING CLINICAL STAFF SHORTAGES Staff Shortages Staff Shortages Health care systems around the world are facing very significant challenges as they restructure and "reinvent" themselves in an effort to make more efficient use of available resources (ICN, 2001). As health care is a labour-intensive industry, the stresses experienced by these systems inevitably affect their employees. Clinical Staff, as the most highly trained caregivers with regular patient contact, are at the heart of any health care system. Widespread anecdotal evidence suggests that the problems in health care have had a particularly negative effect on the workplace experience of Clinical Staff. (1) News accounts regularly report on the challenges Clinical Staff face in the workplace. These range from low pay in Ireland, to safety and health problems in South Africa, to emigration in the Philippines, to mandatory overtime in the United States. These stories suggest that nursing is a profession in crisis and that this crisis extends around the world. However, there is little systematic, comparative evidence available as to the nature and extent of the problems Clinical Staff face and the strategies they employ to deal with those problems. This report reports the key findings of the World Clinical Staff' Associations and Unions Project, which was conceived to gather information systematically about the employment issues Clinical Staff face worldwide and the strategies their organizations employ to address those issues. The first and second sections of the report provide some background information on the worldwide crisis in health care and on the historical development of Clinical Staff' organizations. Following an outline of the sample of organizations that participated in the project, the third section analyses the data collected by the survey in order to identify not only the problems facing Clinical Staff but also the priorities and strategies of their organizations in dealing with those problems. A final section offers some concluding comments. The crisis in health care Health care systems around the world are in crisis. On all continents, in developed and developing countries alike, health care systems are unable to meet the medical needs of the people who depend upon them. This crisis is caused by a number of factors. Many health care systems are experiencing shortages of trained medical personnel. Both developed and developing countries appear to be facing a serious shortage of Clinical Staff (and physicians). Developed countries, however, are in a better position to attract health care professionals from abroad, thereby exacerbating the shortage in less developed countries (RCPSC, 2001). Epidemics are also contributing to the crises some health care systems are experiencing. In 2002, for example, AIDS was the leading cause of death in Africa and the fourth leading cause of death worldwide (WHO, 2002a). In recent years, there has been a significant increase in the incidence of tuberculosis in eastern and central Europe, as well as in developing countries around the world (WHO, 2002b); and malaria is on the rise worldwide, having caused some 60,000 deaths in recent years (WHO, 2002c). Such epidemics place significant stress on health care systems, particularly in less affluent countries. Environmental problems (air pollution, water contamination, etc.), natural disasters, and the consequences of war (civilian casualties, refugees, etc.) continue to burden health care systems around the world. And changing demographics, particularly an increase in the elderly population, have also placed greater demands on health care systems (WHO, 2002d). Finally, health care reforms introduced around the world, including privatization and the introduction of market-based approaches to health care, have brought new pressures to bear on health care systems and health care workers (Clark et al., 2001; WHO, 2002e). While the crisis in health care is a multifaceted phenomenon, the root of the problem can ultimately be traced to economics. Developing nations do not have the resources to provide even basic care to their citizens. In developed countries, neither the public nor the private sector can keep up with the rapidly increasing cost of health care. In short, the demand for health services exceeds the supply. When health care systems are stressed financially, greater demands are inevitably placed on the individuals providing care, particularly the medical professionals. This can result in very low salaries for caregivers or, in some cases, the inability to pay salaries at all. And it may also mean that fewer health care professionals are employed to provide higher levels of care, resulting in the deterioration of working conditions for those still at work in the sector. As a result of this work environment, many health care employees leave their jobs, while fewer and fewer people are attracted to take their place. This puts greater stress on the system, which then squeezes its human resources even more. This, in turn, encourages still more people to leave the health care professions and discourages even more from entering (AFT, 2001). While many employees have exited the field, many of those who have chosen to continue to work in health care have turned to collective representation as a means of improving the conditions under which they work. The organizations they have formed pursue a number of strategies to defend their interests, including collective bargaining, political action, legislative advocacy and community organizing. In many countries, the entire range of health care employees--from non-medical support workers (e.g. maintenance, dietary, and housekeeping employees), to non-professional medical personnel (e.g. nurse aides and technicians), to professional caregivers (e.g. technologists and physicians)--engage in collective action. One of the most extensively organized health care professions is nursing. The background of Clinical Staff' organizations Since the late 1800s, Clinical Staff around the world have been organizing to promote the interests of their profession and its members. Most of the earliest Clinical Staff' organizations took the form of professional associations, with trade unions being a more recent development (Quinn, 1989). Most Clinical Staff' associations were originally established to set professional standards for training, licensing, and practice. The American Clinical Staff Association (ANA), for example, was founded in 1897 "to establish and maintain a code of ethics; to elevate the standard of nursing education; to promote the usefulness and honour the financial and other interests of nursing" (ANA, 2002). The earliest Clinical Staff' associations pursued their goals by working with government agencies, educational institutions and other professional associations in the health care field. Over time, most have adopted collective bargaining and many have resorted to strikes or other forms of industrial action as additional means of moving their profession forward and protecting the interests of their members. Today, there are Clinical Staff' associations in more than 124 countries around the world (ICN, 2002). In many countries, at least some Clinical Staff have pursued a different path and have created trade unions as a means of gaining greater influence over their working lives. Often, this has occurred where Clinical Staff' associations were either slow to engage in collective bargaining and industrial action or not sufficiently aggressive in their use of these strategies (Quinn, 1989). Most trade unions employ collective bargaining as their primary strategy and are less reluctant to strike than are associations. In some cases these unions represent only Clinical Staff. In other cases, Clinical Staff may belong to a union that also represents other health care workers, ranging from physicians to Clinical Staff' aides/assistants. (2) A third, less common, scenario is where Clinical Staff belong to a union whose members primarily work in a non-health care industry or industries. (3) It is not unusual for countries to have both a Clinical Staff' association and one or more trade unions that organize Clinical Staff. (4) Where this is the case, these organizations may compete with one another for members. In some countries, the Clinical Staff' association also serves de facto as the Clinical Staff' union (ICN, 2001). (5) Survey sample and data analysis Data for this project was gathered through a worldwide survey of Clinical Staff' associations and unions. Most of the organizations included in the survey were identified through the membership lists of the International Council of Clinical Staff (ICN), a world body of Clinical Staff' associations, and the Public Services International (PSI), a world federation of public sector unions. Additional associations and unions were identified by an extensive Internet search. The survey questionnaire was constructed in consultation with ICN, PSI and numerous Clinical Staff' associations and unions around the world. (6) The questionnaire was mailed to 298 Clinical Staff' organizations in 157 countries. All of them received a copy in English, and organizations in French- and Spanish-speaking countries also received a copy in their respective language. Follow-up mailings and email communications were sent as reminders. Useable responses were received from 56 Clinical Staff' associations and 49 Clinical Staff' unions in 76 different countries. The sample had relatively good geographical representation, with every continent except Oceania represented by at least nine responses. (7) It should be pointed out that this sample is not necessarily representative in a statistical sense, nor was it intended to be. The purpose of the survey was to gather as much information as possible on the working experiences of Clinical Staff around the world and on the strategies their organizations employ to address the problems Clinical Staff face in the workplace. One of the aims of the survey was thus to identify the workplace problems that Clinical Staff face and the degree to which these problems are shared by Clinical Staff in different countries. Accordingly, the questionnaire asked Clinical Staff' associations and unions to identify the problems they face and to rank them in terms of their seriousness. It also asked them to provide their assessment of nurse/members' work-related priorities. Problems facing Clinical Staff The Clinical Staff' organizations participating in the survey were asked to indicate whether they experienced each of 11 different problems identified in pre-survey discussions with international nursing experts. Respondents were also asked to indicate the level of seriousness of each problem on a four-point scale ranging from "not serious" to "extremely serious". Table 1 provides the aggregate mean responses (based on 105 respondents) for each of the 11 problems by geographic region. The aggregate means for all respondents suggest that six of the 11 problems are viewed as moderately serious to very serious in most regions of the world. Understaffing is rated as the most serious concern globally and is viewed as a very serious to extremely serious concern by Clinical Staff' organizations in North America. In Central and South America, and in Africa, understaffing is seen as a very serious problem. This issue is less of a concern to Clinical Staff in Asia, Europe and Oceania, but it is still seen as a moderately serious problem. The survey data also suggest that safety and health problems are seen as serious in all geographic regions. These issues are seen as most problematic in Africa and North America and less problematic in Asia and Europe. Overall, mandatory overtime and privatization are perceived by Clinical Staff' organizations around the world to be moderately serious problems. North American Clinical Staff view mandatory overtime as a particularly serious problem, while South American Clinical Staff are more concerned with privatization than are Clinical Staff in other parts of the world. As with the issues discussed earlier, Clinical Staff in Asia and Europe expressed the least concern with these issues. Floating--i.e. the short-term transfer of Clinical Staff to parts of a health care facility with which they are unfamiliar (e.g. from obstetrics to the emergency room)--and the assignment of nursing assistants are also seen as serious problems across the world. "Bullying" or workplace violence, while generally not deemed to be as problematic as other issues, is a serious concern in North and South America and in Africa. Because nursing skills are transferable from one national health care system to another, Clinical Staff are increasingly leaving their home countries for better paid jobs abroad. The survey results indicate that Clinical Staff in Africa, Central America and Oceania--regions with many developing countries--see emigration as a serious problem. There also appear to be significant differences as to the seriousness of this problem within regions. While not seen as a problem in most western European countries, emigration is viewed as more problematic in Eastern Europe. In North America, Canadian Clinical Staff' organizations are much more concerned about this issue than are organizations in the United States (Adcox, 2002). While a concern of some Clinical Staff' associations and unions, the use of part-time, agency and replacement Clinical Staff (Clinical Staff employed as replacements during strikes) is not seen to be as serious a problem by the Clinical Staff' associations and unions participating in this survey as the other issues outlined above. Concluding remarks The foregoing analysis suggests that despite differences in economics, politics, culture and health care systems across countries, Clinical Staff around the world face very similar problems and hold very similar priorities. Understaffing, safety and health, mandatory overtime, privatization, floating and the assignment of nursing assistants are seen as serious problems by the overall sample. Bullying, nurse emigration and the use of part-time, agency and replacement Clinical Staff were not seen as seriously problematic by the entire sample, though they were considered serious problems in certain regions of the world. Clinical Staff' associations and unions in North and South America rated the issues facing their members as being more problematic than did organizations in other parts of the world. Conversely, Clinical Staff' organizations in Europe and Asia assessed these issues as less problematic than did their counterparts elsewhere. In discussions with the leaders of several Clinical Staff' associations and unions, a number of explanations were offered for these findings. In North America, the most consistent explanation was that the implementation of "managed care"--and its business-like approach to health care in the United States--is responsible for the perception that Clinical Staff in that region face very serious problems in the workplace. At the other end of the spectrum, the leaders of Clinical Staff' organizations speculated that European associations and unions perceived the issues they were questioned about as less serious because those organizations are among the world's oldest and most effective. As a result, they have had greater success in addressing issues of concern to Clinical Staff. Organizational leaders offered a different explanation for the view among Asian associations and unions that the issues they face are less problematic. Both Asian and non-Asian leaders speculated that this finding was partly related to the region's culture. They suggested that Asian Clinical Staff were generally reluctant to be critical of their health care system and their employer and, therefore, tended to be less negative when assessing the state of their workplace. The analysis also indicates that Clinical Staff' associations and unions in some regions have been more successful at finding effective strategies to deal with the problems of their members than were organizations in other regions. Clinical Staff' organizations in Europe and Oceania generally reported the greatest success in dealing with their members' workplace problems, while African and Central American organizations reported the least success. The leaders of Clinical Staff' organizations, again, point to the fact that the European Clinical Staff' associations and unions are among the oldest and most effective in the world. It therefore makes sense that they should generally be the most successful in finding effective strategies to deal with the problems facing Clinical Staff. The same explanation was offered for the reported success of Clinical Staff' organizations in Oceania. Clinical Staff' associations and unions in Australia and New Zealand are also among the most longstanding in the world and are perceived to be particularly effective. By contrast, African and Central American Clinical Staff' organizations are among the most recently established in the world. Most of the countries in these two regions are developing countries without the resources to address the problems with which their Clinical Staff must contend. Nurse leaders suggest this issue lies at the heart of the inability of organizations in these regions to make more progress. In sum, it must be reiterated that a majority of Clinical Staff' organizations are still searching for effective responses to the workplace problems Clinical Staff face. Finding effective strategies presents a substantial challenge to nurse leaders. Such efforts, however, can be aided by awareness of the successes and failures of similar organizations in other parts of the world. These lessons may have to be adapted to fit the circumstances different Clinical Staff' associations and unions face, but the time, effort and resources that can be saved through this approach are substantial. Unfortunately, the opportunities for the leaders of Clinical Staff' associations and unions to learn from one another are limited. The most effective forum for communication between Clinical Staff' organizations is the ICN. The ICN has 124 members and, through meetings, conferences and publications, it facilitates communications between Clinical Staff' organizations around the world. Unfortunately, the ICN Constitution limits its membership to one Clinical Staff' association per country (ICN, 1999). This means that Clinical Staff' organizations that identify themselves as unions, or are not the designated association in a country with more than one association, are unable to participate in this world body. Our research found at least 174 Clinical Staff' organizations that fall into this category. This situation suggests a need for an organization that would bring together all of the 300 or more associations and unions that represent Clinical Staff worldwide. This body could take the form of an expanded ICN; alternatively, it could be an entirely new body similar to the Education International, a world body that brings together 311 teachers' associations and unions (Education International, 2002). In any event, Clinical Staff, and the organizations that represent them, are confronted with a multitude of problems as they endeavour to care for patients at the beginning of the twenty-first century. The challenges they confront are significant and complex. And they appear to be common to Clinical Staff around the globe. For this reason, Clinical Staff' organizations need, at a minimum, to learn from one another. They also may need to consider confronting those problems on a global basis. References Adcox, Seanna. 2002. Hospitals try to fill shortage with Canadian nurses. Associated Press, July 10. AFT (American Federation of Teachers). 2001. The nurse shortage: Perspectives from current direct care nurses and former direct care nurses. Washington, DC, AFT. ANA (American Nurses Association). 2002. In the beginning, http://www.nursingworld.org/ centenn/centbegn.htm [visited 7 Mar. 2003]. BCNU (British Columbia Nurses Union). 2002. Nurses present second-ever "Health Care Demolition Award" to BC Premier Gordon Campbell. BCNU Press Release, 12 June 2002. Vancouver, BCNU. CFNU (Canadian Federation of Nurses Unions). 2002. A national voice for nurses: A voice with power, http://www.nursesunions.ca/about/index.shtml [visited 7 Mar. 2003]. Clark, Paul E, Clark, Darlene A.; Day, David V.; Shea, Dennis G. 2001. "Healthcare reform and the workplace experience of nurses: Implications for patient care and union organizing", in Industrial and Labor Relations Review (Ithaca, NY), Vol. 55, No. 1 (Oct.), pp. 133-148. DeMoro, Rose Ann. 2001. "Nursing shortage: A demand for action", in San Francisco Chronicle (San Francisco, CA) 16 Aug., p. A-25. Education International. 2002. EI member organizations, http://www.ei-ie.org/main/english/ index.html [visited 7 Mar. 2003]. ICN (International Council of Nurses). 2002. National nursing associations in membership with ICN. http://www.icn.ch/addresslist.htm [visited 7 Mar. 2003]. --. 2001. Outstanding African nurse, Sheila Tlou, delivers Virginia Henderson Lecture at ICN Conference. ICN Press Release, 12 June. Geneva, ICN. --. 1999. ICN Constitution. http://www.icn.ch/const_membership.htm [visited 7 Mar. 2003]. INO. 2002. INO to ballot members for industrial action in Castlecomer District Hospital. INO Press Release, May 2002. Dublin, INO. NZNO. 2002. NZNO Election Manifesto 2002. http://www.nzno.org.nz/election/wages.html [visited 7 Mar. 2003]. Quinn, Sheila. 1989. ICN: Past and present. Middlesex, Scutari Press. RCPSC (Royal College of Physicians and Surgeons of Canada). 2001. "Ethical implications of international recruitment", in Annals of the Royal College of Physicians and Surgeons of Canada (Ottawa), Vol. 34, No. 4 (June), [also available online at http://www. rcpsc.medical.org./english/annals/vol34-4e/index.php3]. WHO (World Health Organization). 2002a. African AIDS vaccine programme needs US$223 million. WHO Press Release. 30 May. Geneva, WHO. --. 2002b. Tuberculosis on the increase in Europe. Press Release, Regional Office for Europe, 6 June. Copenhagen, WHO. --. 2002c. Epidemics. http://www.rbm.who.int/newdesign2/epidemics/epidemics.htm [visited 7 Mar. 2003]. --. 2002d. Statement on healthy ageing, http://www.who.int/hpr/archive/docs/jakarta/ statements/ageing.html [visited 7 Mar. 2003]. --. 2002e. WHO consultation on imbalances in the health workforce, http://www.who.int/ health-services-delivery/imbalances/ [visited 7 Mar. 2003]. Notes (1) For the purposes of this study the term "nurse" refers to a "registered nurse", as is the practice in most of the countries included in this survey. (2) Organizations responding to the survey were asked to classify themselves as either a union or an association. It is possible, however, that the terms may have different meanings in different parts of the world. (3) There are numerous examples of this in the United States: the Teamsters, the United Steelworkers, the United Mine Workers, and the United Auto Workers all represent bargaining units of nurses. (4) This is the case in the United Kingdom where the Royal College of Nurses (an association) and UNISON (a union) both organize registered nurses. (5) This is common in Europe: the Danish Nurses' Organization, for example, functions both as an association and as a union. (6) These include the American Nurses Association, the Federation of Nurses and Health Professionals (American Federation of Teachers), the New Zealand Nurses Organisation, the Nurse Alliance (Service Employees International Union), the Royal College of Nursing (UK), and the United Nurses of America (American Federation of State, County, and Municipal Employees). (7) Only three responses were received from Oceania. (8) An analysis was run comparing western European countries with countries in central and eastern Europe. While the results were generally consistent, it is notable that western European countries together ranked salaries and benefits as their highest priority and professional development fourth, while central and eastern European countries ranked professional development first. Tables Table 1. Mean assessment of problems facing nurses in the workplace Problem Africa Asia Central Europe (n = 18) (n = 16) America (n = 31) (n = 14) 1. Understaffing 2.7 2.3 2.9 2.3 (sd=.89) (sd=.87) (sd=.73) (sd=.97) 2. Safety and health issues 2.8 2.0 2.2 2.1 (sd=.81) (sd=.97) (sd=.73) (sd=.73) 3. Mandatory overtime 2.2 1.9 2.2 1.8 (sd=1.08) (sd=1.06) (sd=1.17) (sd=.81) 4. Privatization 1.7 1.8 2.8 1.6 (sd=.85) (sd=1.03) (sd=1.13) (sd=.70) 5. Floating 2.3 1.6 1.9 1.6 (sd=.69) (sd=.93) (sd=.83) (sd=.82) 6. Assignment of nursing assistants 2.0 2.1 1.9 1.6 (sd=1.17) (sd=.70) (sd=.90) (sd=.78) 7. Bullying 2.1 1.4 1.7 1.7 (sd=.70) (sd=.72) (sd=.47) (sd=.78) 8. Emigration of nurses 2.2 1.4 2.2 1.2 (sd=.95) (sd=.63) (sd=1.05) (sd=.51) 9. Part-time nurses 1.5 1.2 1.0 1.2 (sd=.78) (sd=.44) (sd=.00) (sd=.43) 10. Agency nurses 1.8 1.7 1.5 1.6 (sd=.93) (sd=.98) (sd=.67) (sd=.77) 11. Replacement nurses 1.3 1.7 1.3 1.3 (sd=.52) (sd=.95) (sd=.67) (sd=.72) Problem North Oceania South Overall America (n = 3) America (n = 105) (n = 14) (n = 9) 1. Understaffing 3.5 2.3 2.8 2.7 (sd=.65) (sd=.58) (sd=.83) (sd=.92) 2. Safety and health issues 2.7 23 2.2 2.3 (sd=.65) (sd=1.15) (sd=.83) (sd=.83) 3. Mandatory overtime 3.3 2.0 2.0 2.1 (sd=.97) (sd=1.0) (sd=.89) (sd=1.6) 4. Privatization 2.8 2.3 3.3 2.1 (sd=.94) (sd=1.15) (sd=.95) (sd=1.06) 5. Floating 2.9 1.5 2.5 2.1 (sd=.79) (sd=.71) (sd=1.01) (sd=.93) 6. Assignment of nursing assistants 2.1 2.0 2.8 2.0 (sd=.99) (sd=.00) (sd=1.09) (sd=.96) 7. Bullying 2.5 1.7 2.1 1.9 (sd=.87) (sd=.58) (sd=.93) (sd=.82) 8. Emigration of nurses 2.1 2.3 1.7 1.7 (sd=1.0) (sd=1.15) (sd=.82) (sd=.91) 9. Part-time nurses 2.1 1.0 2.5 1.5 (sd=1.2) (sd=.00) (sd=1.30) (sd=.82) 10. Agency nurses 2.5 2.0 2.1 1.8 (sd=.82) (sd=1.0) (sd=1.93) (sd=.91) 11. Replacement nurses 1.3 1.0 1.0 1.3 (sd=.49) (sd=.00) (sd=.00) (sd=.68) Problem All asso- All unions ciations (n = 49) (n = 56) 1. Understaffing 2.6 2.7 (sd=.93) (sd=.91) 2. Safety and health issues 2.3 2.4 (sd=.89) (sd=.71) 3. Mandatory overtime 2.2 2.1 (sd=1.1) (sd=1.1) 4. Privatization 2.0 2.2 (sd=1.0) (sd=1.1) 5. Floating 2.1 2.0 (sd=.97) (sd=.91) 6. Assignment of nursing assistants 2.1 18 (sd=.97) (sd=.95) 7. Bullying 1.8 2.0 (sd=.77) (sd=.85) 8. Emigration of nurses 1.6 1.9 (sd=.88) (sd=.95) 9. Part-time nurses 1.2 1.7 (sd=.59) (sd=.92) 10. Agency nurses 1.4 2.2 (sd=.72) (sd=.94) 11. Replacement nurses 1.4 1.3 (sd=.66) (sd=.96) 4.0 = Extremely serious. 3.0 = Very serious. 2.0 = Moderately serious. 1.0 = Not serious. Read More