Ten years ago, when the Robert Wood Johnson Foundation and the Institute of Medicine put together the first Future of Nursing report, it was intended to provide a blueprint for the profession’s future. The intent behind the newly released Future of Nursing report is no different, said AFT Health Issues senior director Kelly Trautner during a July 21 webinar to discuss how to use the report to advocate for improved working conditions and patient care.
Unions have several ways to influence and effect policy, said Trautner. But labor is not always at the table when discussions take place, even though unionized healthcare workers are often the people who set standards, especially at the facility level. “New concepts are tried and applied. If they work, they’re replicated elsewhere. Sometimes these things are in our interest. Sometimes they are things that we have to fight. When we sit down at the bargaining table, we must view that work as critical policymaking, because that’s what it is.”
Trautner added that the work that union members do, such as filing grievances or advocating for themselves and their patients by using forms to protest an assignment, is part of setting policy in facilities. “Everything we do is policy setting,” said Trautner. “It’s one of the things that makes employers concerned when we truly harness our power.”
Patricia Pittman, professor in the Department of Health Policy and Management at George Washington University’s Milken Institute of Public Health, agreed. “Unions often are not at the table, and this is an exciting opportunity to understand what the current discourse is and to strategize about ways to insert yourselves in the broader conversation.”
Pittman noted that the first report took a more inward look at the profession, but in contrast, this report is more outward-looking because it makes health equity the ultimate goal, which she says is an important shift.
In addition, the report devotes an entire section to the issue of nurse burnout and working conditions because it is understood that nurses’ well-being and nurses’ working conditions are tied to the objective, which is health equity, said Pittman.
The recommendation that relates to working conditions in this report is that by 2021 nursing education programs, employers, nurse leaders, licensing boards and nursing organizations (including unions) should initiate the implementation of structure systems and evidence-based interventions to promote nurses’ health and well-being, especially as they take on new roles to advance health equity.
“This is really a terrific window of opportunity to talk about something that you all have been concerned about for years,” said Pittman.
Before the pandemic, 35 to 45 percent of nurses reported burnout, according to the report. The consequences of burnout include poor patient outcomes, high turnover rates, increased costs, clinician illness and suicide.
“There’s been a lot of focus on this by employers because the high turnover rate costs hospitals lots of money. It’s very expensive to hire and train new nurses,” said Pittman. “So, nurses’ well-being matters in and of itself, and it also has huge effects on patients and hospitals.”
Pittman took a moment to detail the difference between burnout and moral injury and compassion fatigue. Pittman is the director of the Fitzhugh Mullan Institute for Health Workforce Equity at George Washington University where she heads a research project called Moral Injury Among Nurses, which collects stories to elevate the voices of nurses who experience moral injury. The AFT is a partner.
“Burnout is characterized by three components: emotional exhaustion; depersonalization, for example, cynicism or apathy; and little sense of personal accomplishment at work. Moral injury is different,” she said.
Pittman described moral injury as a violation of one’s moral code. “It’s essentially when in this case, a nurse is not able to do what he or she thinks is right because of the constraints that the systems are imposing on them. So, you could think of moral injury as one cause of burnout.”
She added that compassion fatigue occurs when the nurse's ability to empathize with people is reduced due to repeated exposure to others suffering; this fatigue is also an outcome of burnout.
Several solutions can address nurses’ well-being, including initiatives that allow improved access to mental health. Traditional interventions such as talk therapy can be less effective, Pittman added.
The report concludes that organization-level solutions are critical and this is where there are openings for unions to get involved, said Pittman. Stakeholders from unions to nurse executives and educational institutions should work together to design solutions that can range from improving the culture to facilitating self-care, said Pittman. “There are tremendous opportunities here, but there’s going to be a need to think more systematically about what policy changes are needed.”