LPN, RN, and APRN Self-Reported Perceptions of Health

1. LPN, RN, and APRN Self-Reported Perceptions of Health 2nd Annual Nursing Research and Evidence Based Practice Symposium Burlington, VT November 6, 2010

2. Mary Val Palumbo DNP, APRN Betty Rambur PhD, RN Barbara McIntosh PhD, SPHRVicki McLaughlin MSUniversity of VermontAHEC Nursing Workforce Research, College of Nursing and Health Science School of Business Administrationand University of MA Funding support from: HRSA # D65HP05247-01-00 Nurse Education, Practice and Retention: Career Ladders Grant “Mission Essential: Ladders for a Lifetime” and VT Agency of Human Services “Center for Nursing’ grant.

3. ANA Code of Ethics (2001) #5 “the nurse owes same duty to self as to others….” The Standards of Practice of the American Holistic Nurses Association (AHNA, 2007) identify: “the need for self-care, self responsibility, spirituality, and reflection to be integrated into nurses’ lives” Background

4. Being a healing presence to others requires that nurses care for and nurture themselves (Burkhardt & Nagai-Jacobson, 2001) • At the same time, self care may-be difficult for many nurses, with the work itself having many occupational risks (NIOSH ,2008; Houle 2001) Background

5. Survey mailed to all VT RN’s in 2007 (n = 3,955). Those reporting excellent health mean age 51.5 years versus age 48.7 for lesser health ratings (p<.0001). Younger nurses (30 -39) were the most likely to rate themselves in fair emotional health. (13% versus 7% for all others). 85% of nurses reporting excellent general/emotional health were unlikely to leave their position vs 76% of all other nurses (p<.0001) Background- Nurse health studies Palumbo, MV, Rambur, B, McIntosh, B and Naud , S. (2010)

6. Nurses' ratings of their health and professional work environments. (N = 3,132 - US, multi-states) • Self reported good general health • Stress level is the one consistent predictor of poorer health ratings and work environment ratings. • 50% overweight, 50% met physical activity standards • > 66% reported a history of back/needlestick injuries. • Verbal abuse by colleagues (44%) and patients (62%) Background- Nurse health studies Tucker SJ, Harris MR, Pipe TB, Stevens SR, AAOHN J(2010)

7. Norway (n =71) Descriptive-correlational study examined nurses' satisfaction with psychosocial work environment, their moral sensitivity, and clinical nursing supervision in relation to nurses' well-being Ethical conflicts in nursing are a source of job-related stress and anxiety. Supporting nurses by clinical nursing supervision may have a positive influence on: well-being, physical symptoms, feeling of anxiety, and having a sense of control. Background – Nurse Health Studies Bégat I, Ellefsen B, Severinsson E. (2005)

8. China – (n= 480) Health measured with 5 questionnaires. Most frequently cited workplace stressor was workload, Most commonly used coping strategy was positive reappraisal. Workplace stress, coping strategies, psychological hardiness, and demographic characteristics interact in relationship to each other, and the physical and mental health of Chinese nurses. Background – Nurse Health Studies Lambert VA, Lambert CE, Petrini M, Li XM, Zhang YJ., (2007)

9. Cross-cultural comparison -Japan, Thailand, South Korea, and the USA (Hawaii). Examined workplace stressors, ways of coping, and demographic characteristics as predictors of physical and mental health among hospital nurses. Coping varied, stressors are similar. Educational differences predicted better physical health in the US sample only. • Lambert, et al (2004) Background – Nurse Health Studies

10. So What? Ethical self-care Effective patient care Business case

11. Nurse health studies: RELATIONSHIPS to Turnover • Absenteeism and nurse intention to leave and turnover has been established (Taunton, Krampitz , Woods, 1989, Mobley, 1978; Porter, Steers, 1973, Lucas, Atwood, & Hagaman, 1993. Flinkman, Leino-Kilpi and Salantera ,2010 , Estryn-Behar, van derHeijden, Fry, Hasselhorn, 2010). • Work stress and musculoskeletal injury to absenteeism and turnover has been documented. (Trinkoff, Storr, Lipscomb, 2001; Shamian, Kerr, Laschinger, & Thomson 2001) (Shader, Broome, Broome, West & Nash, 2002) • Employee turnover is costly in terms of lost productivity, opportunity costs, recruitment costs, and new staff training costs (McIntosh, 2001, Gray & Phillips, 1994; Irvine & Evans,1995, Jones 1990, Borkowski, Amann, Song and Weiss 2007). Background

12. Background Cycle of Short Staffing In Long Term Care Eaton, S.C. (2001) Appropriateness of minimum nursing staff ratios in nursing homes. Phase II Final Report, Centers for Medicare and Medicaid Services.

13. Socio-economic realities of health status: • Research shows such a strong association between education and good health (Low, MD, Low, BJ, BaumlerER & Huynh PT, 2005) • This has not been consistent in nurse workforce international studies (Lambert et al, 2004) • Nurses licensure offers a stratified perspective of health by different educational levels. Background

14. A descriptive study of the health status of one state’s nurse workforce was undertaken, with a goal of describing perceived general and emotional health by licensure status. Purpose

15. Design—mail survey • The instrument included the minimum data set recommended by Colleagues in Caring (Cleary & Rice, 2005) for nurse workforce assessment with additional questions from the national Health and Retirement Survey. • Content validity-panel of nurses from a variety of settings • Reliability—not assessed • Data analyses included descriptive statistics plus appropriate parametric and non-parametric tests. Methods

16. Would you say your health is excellent, very good, good, fair or poor? • What about your emotional health – how good you feel or how stressed, anxious, or depressed you feel? Is it excellent, very good, good, fair, or poor? Methods: Additional Questions These replicated questions from National Health and Retirement Survey

17. Survey mailed to all RNs and APRNs registered in the State of Vermont in 2007, and all VT. LPNs in 2010 • Surveys of: 813 LPNs (71% response) 3,955 RNs (51% response), 283 APRNs (73% response) were analyzed (n = 5,051) • Excluded those not working in Vermont and those not answering the health and safety questions Methods and Results: Sample

18. Results – Sample

19. Self-reported general health was significantly different across the groups (p = <0.0001), as was emotional health (p=.003). • 54% of APRNs reported excellent general health compared to 31% (RNs) and 22% (LPNs). • Across all license types, when compared to general health, fewer reported excellent emotional health (31% APRN, 22% RN, 16% LPN). • The APRNs reported the most positive health self-perceptions. Results

22. A closer looker at LPN self-reported health status

23. Factors associated with LPN’s self-rated general and emotional health

24. Factors associated with LPN’s self-rated general and emotional health

25. Factors associated with LPN’s self-rated general and emotional health

26. These data suggest that nurses with different licensure status perceive their health differently. • Can these results be solely attributed to educational level? Not exactly… in this study Setting impacts significantly for LPN health Younger LPNs and RNs report poorer emotional health Discussion

27. This study’s gender differences in emotional health are in contrast to many other studies that suggesting women rate their emotional health lower than men* • This finding may indicate that the male LPNs employed in the nursing home may be an important group for qualitative study regarding their health. • Dissatisfied male nurses more likely to leave profession. (Borkowski, N., Amann, R., Song, S. H., & Weiss, C. 2007). Discussion (*Koopmans, et al., 2010; Needham & Hill, 2010; Seedat, et al., 2009).

28. These results are based on only a limited number of self perceived health questions. • The use of a relicensure survey limits the researcher’s options and a non-response analysis is not possible. At the same time, it provides a census sample. • This is a study of one small rural state which lacks diversity. Limitations

29. Further research: Investigation of etiology of work related stressors for LPNs in LTC settings. Investigation of gender differences in LPN Nurse-to-nurse health promotion interventions need development and testing Implications

30. For Promotion of Nurses Emotional Health: • Awareness of our nurse “vulnerable populations” • Work environments that are attentive to nurse’s job stress factors. Implications based on nurse health studies

31. Questions ?

32. American Holistic Nurses Association. (2007). Holistic Nursing: Scope and Standards of Practice Silver Springs, MD: American Nurses Association. ANA. (2001). Code of Ethics for Nurses with Interpretive Statements. Retrieved from http://www.ananursingethics.org/nursingethics.htm Begat, I., Ellefsen, B., & Severinsson, E. (2005). Nurses' satisfaction with their work environment and the outcomes of clinical nursing supervision on nurses' experiences of well-being -- a Norwegian study. J Nurs Manag, 13(3), 221-230. Borkowski, N., Amann, R., Song, S. H., & Weiss, C. (2007). Nurses' intent to leave the profession: issues related to gender, ethnicity, and educational level. Health Care Manage Rev, 32(2), 160-167. Burkhardt, M. A., & Nagai-Jacobson, M. G. (2001). Nurturing and caring for self. Nurs Clin North Am, 36(1), 23-32. Coomber, B., & Barriball, K. L. (2007). Impact of job satisfaction components on intent to leave and turnover for hospital-based nurses: a review of the research literature. Int J Nurs Stud, 44(2), 297-314. Eaton, S.C. (2001) Appropriateness of minimum nursing staff ratios in nursing homes. Phase II Final Report, Centers for Medicare and Medicaid Services. Estryn-Behar, M., van der Heijden, B. I., Fry, C., & Hasselhorn, H. M. (2010). Longitudinal analysis of personal and work-related factors associated with turnover among nurses. Nurs Res, 59(3), 166-177. Flinkman, M., Leino-Kilpi, H., & Salantera, S. (2010). Nurses' intention to leave the profession: integrative review. J Adv Nurs, 66(7), 1422-1434. Gray, A. M., & Phillips, V. L. (1994). Turnover, age and length of service: a comparison of nurses and other staff in the National Health Service. Journal of Advanced Nursing, 19, 819-827. Houle, J. (2001). NursingWorld.org health & safety survey. 1-32. Retrieved from http://www.nursingworld.org/MainMenuCategories/OccupationalandEnvironmental/occupationalhealth/HealthSafetySurvey.aspx Irvine, D. M., & Evans, M. G. (1995). Job satisfaction and turnover among nurses: Integrating research findings across studies. Nursing Research, 44(4), 246-253. Jones, C. B. (1990). Staff nurse turnover costs: Part II, measurement and results. Journal of Nursing Administration, 20(5), 27-32. Koopmans, P. C., Roelen, C. A., Bultmann, U., Hoedeman, R., van der Klink, J. J., & Groothoff, J. W. (2010). Gender and age differences in the recurrence of sickness absence due to common mental disorders: a longitudinal study. BMC Public Health, 10, 426. Lambert, V. A., Lambert, C. E., Itano, J., Inouye, J., Kim, S., Kuniviktikul, W., et al. (2004). Cross-cultural comparison of workplace stressors, ways of coping and demographic characteristics as predictors of physical and mental health among hospital nurses in Japan, Thailand, South Korea and the USA (Hawaii). Int J Nurs Stud, 41(6), 671-684. Lambert, V. A., Lambert, C. E., Petrini, M., Li, X. M., & Zhang, Y. J. (2007). Workplace and personal factors associated with physical and mental health in hospital nurses in China. Nurs Health Sci, 9(2), 120-126. References

33. Low, M. D., Low, B. J., Baumler, E. R., & Huynh, P. T. (2005). Can education policy be health policy? Implications of research on the social determinants of health. J Health Polit Policy Law, 30(6), 1131-1162. Lucas, M. D., Atwood, J. R., & Hagaman, R. (1993). Replication and validation of anticipated turnover model for urban registered nurses. Nursing Research, 42(1), 29-35. McIntosh, B. (2001). An Employer's Guide to Older Workers: How to Win Them Back and Convince Them to Stay. Washington, D.C.: U.S. Department of Labor, Employment and Training Administration. Mobley, W. H., Horner, S. O., & Hollingsworth, A. T. (1978). An evaluation of precursors of hospital employee turnover. Journal of Applied Psychology, 63, 408-414. Needham, B., & Hill, T. D. (2010). Do gender differences in mental health contribute to gender differences in physical health? Soc Sci Med, 71(8), 1472-1479. NIOSH. (2008). Exposure to Stress: Occupational Hazards in Hospitals. Cincinnati, Ohio. Palumbo, M. V., Rambur, B., McIntosh, B., & Naud, S. (2010). Registered Nurses' Perceptions of Health and Safety Related to Their Intention to Leave. AAOHN J, 95-103. Porter, L. W., & Steers, R. M. (1973). Organizational, work and psychological factors in employee turnover and absenteeism. Psychological Bulletin, 80, 151-176. Seedat, S., Scott, K. M., Angermeyer, M. C., Berglund, P., Bromet, E. J., Brugha, T. S., et al. (2009). Cross-national associations between gender and mental disorders in the World Health Organization World Mental Health Surveys. Arch Gen Psychiatry, 66(7), 785-795. Shader, K., Broome, M. E., Broome, C. D., West, M. E., & Nash, M. (2002). A hospital-level analysis of the work environment and workforce health indicators for registered nurses in Ontario's acute-care hospitals. Can J Nurs Res, 33(4), 35-50. Shamian, J., Kerr, M. S., Laschinger, H. K., & Thomson, D. (2001). Physically demanding work and inadequate sleep, pain medication use, and absenteeism in registered nurses. J Occup Environ Med, 43(4), 355-363. Taunton, R., Krampitz, S., & Woods, C. Q. (1989). Manger impact on retention of hospital staff. JONA, 19(3), 14-19. Trinkoff, A. M., Storr, C. L., & Lipscomb, J. A. (2001). Physically demanding work and inadequate sleep, pain medication use, and absenteeism in registered nurses. J Occup Environ Med, 43(4), 355-363. Tucker, S. J., Harris, M. R., Pipe, T. B., & Stevens, S. R. (2010). Nurses' ratings of their health and professional work environments. AAOHN J, 58(6), 253-267. References