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End Notes

  1. Thompson quote is from U.S. Department of Health and Human Services (2002, February 22).
  2. Data are from Buerhaus, Staiger and Auerbach (2000, June 14), Buerhaus (2002), p. 5 and Spratley, Johnson, Sochalski, Fritz and Spencer (2001), p. 7.
  3. Author's calculations based on Spratley et al. (2001), Table 34, p. 72.
  4. Nursing Executive Center (2000), p. 10–11.
  5. Blegen (1993).
  6. Aiken et al. (2002).
  7. American Nurses Association (2001). Respondents were allowed to check all that applied.
  8. American Nurses Association (2001).
  9. Norris (2002, April 8).
  10. First Consulting Group (2001), p. 16.
  11. RNs experienced strong yearly growth in inflation-adjusted hourly wages through 1990 (averaging 2.7 percent per year), but wage growth leveled off between 1990 and 1994 and then fell 1.5 percent annually over the next 3 years. Buerhaus and Staiger (1999), p. 216. See also U.S. General Accounting Office (2001, July 10), p. 10–11 and Spratley et al. (2001), chart 9, p. 20.
  12. Foundation for Healthy Communities (2001), p. 2.
  13. American Nurses Association (2001), Appendix.
  14. U.S. General Accounting Office (2001, June 27), p. 5.
  15. American Nurses Association (2001), Appendix.
  16. "Massachusetts Nurses Association" (1997) and Molly O'Connor, interview with Gordon Lafer, August 2002.
  17. United Nurses Associations of California/ Union of Health Care Professionals, National Union of Hospital and Health Care Employees, American Federation of State, County and Municipal Employees (UNAC/UHCP), www.afscme.org/una. (CA Health and Safety §1276.65(b)).
  18. American Federation of Teachers/Federation of Nurses and Health Profesionals (2001), Mandatory Overtime, p. 27.
  19. Among recent strikes over mandatory overtime are those at McLaren Hospital in Flint, Michigan (AFSCME Local 875), Altoona General Hospital in Pennsylvania (AFSCME Local 3156) and Trumbell Memorial Hospital in Ohio (AFSCME Local 74).
  20. AFT/FNHP (2001), The Nurse Shortage.
  21. See for example, Sparks, Cooper, Fried and Shirom (1997) and Fenwick and Tausig (2001). The National Institute for Occupational Safety and Health (NIOSH) recognizes stress as an occupational hazard. "Job stress can lead to poor health and even injury" National Institute of Occupational Safety and Health (1999), p. 5.
  22. O'Leary (2002), p. 3.
  23. American Hospital Association, Hospital Statistics, Chicago, 1999, cited in Kohn, Corrigan, and Donaldson (2000).
  24. Berens (2000, September 10).
  25. ANA survey results reported in Foley (2002, March 7).
  26. Needleman, Buerhaus, Mattke, Stewart and Zelevinsky (2001).
  27. Grady (2002, May 30).
  28. Needleman, et al. (2001), p. 137.
  29. California Nurses Association (n.d.), quoting American Journal of Critical Care.
  30. Seago and Ash (2002). The analysis controlled for number of beds, AMI-related discharges, cardiac services, staff hours and wages.
  31. Seago and Ash (2002), p. 150.
  32. U.S. Department of Health and Human Services (2002, February 22).
  33. Quoted in Nursing Executive Center (2001), p. 11.
  34. American Hospital Association. Commission on Workforce for Hospitals and Health Systems (2002), p. 2.
  35. Quoted in Murray (2002).
  36. Data is from American Hospital Association. Commission on Workforce for Hospitals and Health Systems (2002), p. 6.
  37. American Hospital Association. Commission on Workforce for Hospitals and Health Systems (2002), p. 11. 68 percent of hospitals said recruiting became more difficult for Imaging Technicians; 53 percent for Pharmacists; 46 percent for Lab Technicians; 40 percent for LPNs and for Billers/Coders; 34 percent for Nursing Assistants; 20 percent for Housekeeping; and 13 percent for Information Technologists.
  38. Nursing Executive Center (2001), p. 4. Asked to rank various issues from 1 ("very satisfied") to 5 ("very dissatisfied"), the availability of qualified nurses was ranked 3.1, the lowest ranking of any issue reported.
  39. Spratley (2001), Table 33, p. 71.
  40. Spratley (2001), Table 13, p. 51.
  41. American Organization of Nurse Executives (2002). The AONE rate is based on a survey of 693 acute care hospitals conducted in July-August 2001. The overall hospital turnover rate is for all nurses, including administrative, supervisory and outpatient nurses in addition to inpatient staff nurses. As shown in the table, vacancy rates for ER, critical care and medical/surgical nurses are higher than the hospital-wide average. A vacancy rate is defined as the average percentage of all budgeted positions which are unfilled at any given point during the year.
  42. American Hospital Association. Commission on Workforce for Hospitals and Health Systems. (2002), p. 7. The AHA calculation is based on vacancies for all nurses in a hospital, including outpatient, diagnostic, and long-term care.
  43. The 126,000 figure, which is widely cited, comes from an AHA survey of 715 member hospitals and is reported in "The Hospital Workforce Shortage" (2001, July). O'Leary (2002), p.1, also uses the 126,000 estimate. First Consulting Group (2001), Appendix, p. 29, estimates total vacancies of 153,000, based on a total hospital RN count of 1,022,093 and 13 percent vacancy rate.
  44. First Consulting Group (2001), p. 4, 14, 15.
  45. First Consulting Group (2001), p. 16.
  46. Nursing Executive Center (2000), p. 9, 45. The report projects a total RN turnover rate of 12–16 percent in 2000 and 16–25 percent in 2005.
  47. First Consulting Group (2001).
  48. State rates reported in U.S. General Accounting Office (2001, July 10), p. 4.
  49. "Health Workforce" (2002, April 24), p. 487.
  50. Data that follows are from American Organization of Nurse Executives (2002), p. 11, based on AONE's survey of 693 hospitals; and from First Consulting Group (2001), p. 24–25, based on a survey of 1,100 hospitals carried out in August and September, 2001.
  51. Spratley (2001), p. 5.
  52. American Organization of Nurse Executives (2000), p. 28, 41.
  53. Data are from Buerhaus, Staiger and Auerbach (2000 June 14); Buerhaus (2002), p. 5; and Spratley (2000), p. 7.
  54. American Hospital Association. Commission on Workforce for Hospitals and Health Systems (2002), p. 9.
  55. Data is from Populations Projections Program, Population Division, U.S. Census Bureau, reproduced in American Hospital Association (2002), p. 9.
  56. Buerhaus (2002), p. 5.
  57. American Organization of Nurse Executives (2000), p. 59, projects a 20 percent gap in 2020 and presents figures that show it to be approximately 300,000 RNs. The projected 20 percent gap in 2020 is also reported by Nursing Executive Center (2001), p. 11. JCAHO president Dennis O'Leary, O'Leary 2002 p. 1, projects that by 2020 "there will be at least 400,000 fewer nurses than will be needed."
  58. O'Leary (2002), p. 3.
  59. O'Leary (2002), p. 7.
  60. Buerhaus (2002). Buerhaus, a respected authority on issues of nursing economics, is the Senior Associate Dean for Research at the Vanderbilt University School of Nursing, Nashville, TN.
  61. U.S. General Accounting Office (2001 July 10), p. 6, and Buerhaus and Staiger (2000).
  62. O'Leary (2002), p. 1.
  63. American Organization of Nurse Executives (2000), p. 6.
  64. Spratley (2001), Table 33, p. 71. Respondents were allowed to cite more than one reason, so percentages sum to more than 100 percent. 17.4 percent of nurses working as non-nurses stated that their nursing skills were out of date; 7 percent cited a disability or illness that prevented them from working as nurses, and 24.9 percent said they were taking care of home and family. Since more than one reason can be given, it is impossible to say that any single reason was determinative for all those who cited it as one of their reasons. However, given that all these people are currently employed in some occupation, it seems that the need to care for family is not something that would prevent one from working as a nurse, unless combined with other reasons such as relative convenience of hours.
  65. Author's calculations based on Spratley (2001), Table 34, p. 72.
  66. California Nurses Association (n.d.), Ratios.
  67. American Organization of Nurse Executives (2002), p. 9.
  68. First Consulting Group (2001), p. 28.
  69. First Consulting Group (2001), p. 29.
  70. First Consulting Group (2001), p. 5, 22. Foundation for Healthy Communities (2001) reports that New Hampshire hospitals paid as much as $80 per hour for agency nurses, or roughly three times the compensation package offered regular staff nurses.
  71. First Consulting Group (2001), p. 22.
  72. Nursing Executive Center (2000), p. 10–11.
  73. Nursing Executive Center (2000), p. 12.
  74. Reported in California Nurses Association (n.d.).
  75. Assuming the AONE's estimate of average direct turnover costs of $10,000 per RN, and assuming that direct costs are 21 percent, or roughly 1/5 of total costs.
  76. Spratley (2001), p. 30–31.
  77. National Opinion Research Center, General Social Survey, Data Information and Retrieval System (1999, March 15) .
  78. Nursing Executive Center (2000), p. 14.
  79. Spratley (2001), p. 30–31.
  80. Blegen (1993).
  81. Nursing Executive Center (2000), p. 14.
  82. Data that follows is from Nursing Executive Center (2000), p. 15. Numbers include those who stated they were either "somewhat" or "very dissatisfied" with their jobs.
  83. Nursing Executive Center (2000), p. 15.
  84. On this point, see Irvine and Evans (1995); Blegen (1993); Hinshaw and Atwood (1984); McCloskey (1990); and Stratton, Dunkin, Juhl and Geller (1995).
  85. Nursing Executive Center (2000), p. 19. 42 percent reported 0–3 yrs; 32 percent said 4–10 yrs, and 26 percent said more than 10 years.
  86. Krantz and Lee (2000). The authors based the survey on workplace environment, income, future prospects, physical demands, job security, job stress, wages, length of work-day and hiring trends.
  87. Data is from NY State Nurses Association Survey of RNs, March 1999, in "RNs at Work: Here are the Facts," Report: The Official Newsletter of the New York State Nurses Association, June 1999; reported in Nursing Executive Center (2000), p. 19.
  88. AFT/FNHP (2001). Similar findings were reported by Fletcher (2001). This study was conducted by mail and the population consisted of 5,192 RNs employed by 10 hospitals in Southern Michigan. Of these, 1,780 were usable. No hard numbers were given on whether nurses would recommend nursing as a career choice, but the following statements were quoted: "I actively discourage my children from entering a health profession." "If I had it to do all over again, I would never in my life choose nursing." "We tell the student nurses to run for their lives, as nurses now are stretched beyond any limits they might have."
  89. American Nurses Association (2001). In December 2000 and January 2001, nearly 7,300 nurses filled out an ANA survey posted at http://www.nursingworld.com/. Question 10 asked RNs to rank their willingness to recommend the profession on a scale of 1–10, with 1 being "highly recommend" and 10 being "highly discourage." 55 percent of respondents gave rankings between 6–10.
  90. Aiken et al. (2001). The Aiken et al. study involved a survey of over 43,000 nurses from the United States, Canada, England, Scotland and Germany. The U.S. sample consisted of 13,471 nurses from Pennsylvania; all hospitals in the state were studied, and 50 percent of RNs living in the state were sampled. The authors examined the effects of nurse staffing and work environment issues on patient outcomes and nurse satisfaction. Data were gathered regarding nurse perceptions of burnout, work climate, managerial support, non-nursing task workload, and patient quality of care. Four of the five countries reported that 30–40 percent of nurses had higher burnout scores than other medical workers.
  91. Aiken et al. (2001), p. 46.
  92. Aiken et al. (2001), p. 46, Exhibit 1. Aiken used the Maslach Burnout Inventory.
  93. Aiken et al. (2001), p. 46.
  94. This measure, termed the "Aon Performance Pyramid," is described in Aon Loyalty Institute, Healthcare@Work, Ann Arbor, Michigan, 2001. The pyramid consists of a tiered list of employee needs that may or may not be met. The most basic need is "Safety/Security," denoting both physical and psychic security. Then "Rewards," meaning wages and benefits. Following this is "Affiliation," denoting the extent to which employees are treated with respect and incorporated into decision-making processes. Following this is "Growth" — opportunities for upward mobility. And finally, "Work/Life Harmony," which is explained by noting that "similar to the idea of individual self-actualization, employees want to reach their potential both on the job and in other facets of life." The Aon system is described in American Hospital Association (2002), p. 28–29.
  95. American Nurses Association (2001). Respondents were allowed to check all that applied.
  96. Risher and Appelbaum (2002). 7,600 nurses were randomly selected from a national database, and were given the option of answering from a paper survey or via the internet. 4,108 completed the survey.
  97. Nursing Executive Center (2000), p. 54–55.
  98. Nursing Executive Center (2000), p. 54. No matter which subgroup was polled, the ranking of critical job attributes was the same. It is worth noting that this survey, like others, did not offer nurses a choice to identify "having more nurses per patient," or a similar direct reference to staffing levels, as the key factor. The fact that management-designed surveys may refer to "intensity of work" rather than staffing levels may obscure the centrality of staffing ratios. However, factors such as "scheduling options," "intensity of work," "competence of clinical staff," and others are directly related to the adequacy of hospital staffing patterns.
  99. Foundation for Healthy Communities (2001). The full study has not yet been published. Information is from the Executive Summary, p. 2.
  100. Foundation for Healthy Communities (2001). The full study has not yet been published. Information is from the Executive Summary.
  101. Foundation for Healthy Communities (2001). The full study has not yet been published, Information is from the Executive Summary.
  102. Spratley et al. (2001), Table 33, p. 71.
  103. RNs experienced strong yearly growth in inflation-adjusted hourly wages through 1990 (averaging 2.7 percent per year), but wage growth leveled off between 1990 and 1994 and then fell 1.5 percent annually over the next 3 years. Buerhaus and Staiger (1999), p. 216. See also U.S. GAO (2001 July 10), p. 10–11; Spratley et al. (2001), chart 9, p. 20. Average real earnings increased from 1980–1984 and 1988–1992, but fell in the mid-1990s and ended the decade more or less where they began.
  104. American Organization of Nurse Executives (2002).
  105. Buerhaus (2002).
  106. Aiken et al. (2001), p. 48.
  107. Foundation for Healthy Communities (2001). The full study has not yet been published. Information is from the Executive Summary.
  108. U.S. GAO (2001 July 10), p. 10.
  109. Buerhaus (1998); Buerhaus (1995).
  110. Pindus and Grenier (1997). p. 9.
  111. American Nurses Association (2001), Appendix.
  112. Buerhaus (2002).
  113. U.S. General Accounting Office (2001 June 27).
  114. AFT/FNHP (2001), p. 8, 17.
  115. Risher and Appelbaum (2002).
  116. The survey was conducted among 400 nurses attending AFSCME's 8th National Nurses Congress. Reported in "Staffing Shortages and Lack of Respect Cited as Top Concerns in AFSCME Nurses Survey," Press Release, April 24, 2001, http://www.afscme.org/.
  117. Aiken et al. (2001), p. 47, Exhibit 2.
  118. Aiken et al. (2001), p. 47, Exhibit 2.
  119. Aiken et al. (2001), p. 49, Exhibit 4.
  120. Aiken et al. (2001), p. 49, Exhibit 4.
  121. Greiner (1996), p. 13.
  122. American Nurses Association (2001), Appendix.
  123. American Nurses Association (2001), Appendix.
  124. Buerhaus, Donelan, DesRoches, Lamkin and Mallory (2001).
  125. Buerhaus et al. (2001), p. 208.
  126. Nursing Executive Center (2000), p. 83.
  127. Allen (1999).
  128. Allen (1999).
  129. Cited in O'Leary (2002), p. 5.
  130. AFT/FNHP (2001) The Nurse Shortage, p. 8, 17.
  131. Steinbrook (2002).
  132. O'Leary (2002), p. 3.
  133. Hinshaw (2001).
  134. McCranie et al. (1987); Robinson, Roth, Keim, Levenson, Flentje and Bashor (1991); Jackson (1988); Dugan, Lauer, Bougquot, Dutro, Smith and Widmeyer (1996).
  135. O'Leary (2002), p. 8.
  136. O'Leary (2002), p. 9.
  137. O'Leary (2002), p. 3.
  138. Bush (1988).
  139. Laschinger and Havens (1996).
  140. Laschinger, Finegan and Shamian (April 1999).
  141. American Hospital Association. Commission on Workforce for Hospitals and Health Systems (2002), p. 5.
  142. Laschinger, Shamian and Thomson (2001), p. 218.
  143. Survey is described in American Federation of State, County and Municipal Employees (2001, April 24).
  144. AFT/FNHP (2001), p. 20. 21 percent of the 700 RNs surveyed (147) are considering leaving their job. Of the potential leavers, 71 percent indicated that the most enjoyable part of their job is helping patients and families. Of all current nurses, 62 percent agreed with this statement.
  145. Risher and Appelbaum (2002), p. 67.
  146. AFT/FNHP (2001), p. 24. Other items getting between 44 percent and 56 percent are: refresher courses, more aides/support staff, summer leave option, mentor new hires, continuing education time off, orientation for new hires, better retirement, more paid time off, on-premises childcare, and performance based salaries.
  147. American Organization of Nurse Executives (2002), p. 67.
  148. O'Leary (2002), p. 6.
  149. American Hospital Association. Commission on Workforce for Hospitals and Health Systems (2002), p. 18.
  150. Data is from Doreen Frusti, "Magnet Status: A New Approach to the Nursing Shortage," presentation to Minnesota Organization of Leaders in Nursing (MOLN) Conference, Fall 2001, cited in Minnesota Department of Health (2001).
  151. Laschinger, Shamian and Thomson (2001), p. 210. On this point, see also L. Aiken, et al. (2000). When researchers compared the job satisfaction of nurses at current magnet hospitals with those at otherwise similar non-magnet hospitals, they found that nurses rated magnet hospitals significantly higher on nurse autonomy, control and nurse-physician relations. Aiken, et al. (1997), p. NS11.
  152. Data is from 21 magnet hospitals, collected in July 2002. National averages are for hospitals with 350 or more beds (the average of the 21 hospitals in this sample was 513 beds), as reported in American Organization of Nurse Executives (2002).
  153. Concentration of nurse shortages in medical-surgical and ICU units is reported in American Organization of Nurse Executives (2000), p. 23.
  154. There are five hospitals with vacancy rates of 4 percent or lower: Catawba Valley (med-surg staffing of 1:6), Childrens Memorial (1:3), Fox Chase Cancer Center (1:4), Hackensack University Medical Center (1:5), and St. Mary's (1:6).
  155. Comment of Kathy Smith, University of Colorado Hospital, interview with Helen Moss, July 2002.
  156. American Academy of Nursing (1983), p. 90.
  157. American Academy of Nursing (1983), p. 18, 21.
  158. American Academy of Nursing (1983), p. 21.
  159. American Academy of Nursing (1983), p. 41.
  160. American Academy of Nursing (1983), p. 89.
  161. American Academy of Nursing (1983), p. 81.
  162. American Academy of Nursing (1983), p. 89–90.
  163. Nursing Executive Center (2000), p. 61.
  164. Nursing Executive Center (2000), p. 131.
  165. Collective bargaining agreement between United Nurses of Pennsylvania/NUHHCE/AFSCME and North Philadelphia Health Systems, October 8, 2000 – September 30, 2004, Article 10, Section 7.
  166. First Consulting Group (2001), p. 18.
  167. Peterson (2001), p. 3.
  168. Roberts (2000).
  169. Quoted in Steinbrook (2002).
  170. O'Leary (2002), p. 4.
  171. "Massachusetts Nurses Association" (1997); Molly O'Connor, interview with Gordon Lafer, August 2002.
  172. Nursing Executive Center (2001), p. 131.
  173. Richmond (2002, February 19).
  174. Laschinger, et al. (2001), p. 209.
  175. Julie Pinkham, Executive Director, Massachusetts Nursing Association, interview with Gordon Lafer, August 2002.
  176. Quoted on http://www.unac-ca.org/.
  177. http://www.unac-ca.org/
  178. Seago (2002), p. 48. AB 394 was passed in 1999, which directs the DHS to establish and implement, by January 2002, "minimum, specific, and numerical licensed nurse-to-patient ratios by licensed nurse classification and by hospital unit." The exact staffing levels to be set by the state government were a source of controversy. Seago (2002), p. 50, notes that the California Healthcare Association (employer group) called for a 1:10 ratio in med/surg. UC Medical Centers recommended 1:6. SEIU, UNAC and Kaiser agreed to 1:4, and C.N.A recommended 1:3. Seago's (2002, p. 52) own survey found that on average California hospitals had 6.7 RNs per patient in med/surg units in rural hospitals, and 5.9:1 in urban areas. This means that the state legislation mandates, at 1:6, might not be that different from current reality. The law also requires hospitals to continue using patient classification systems (PCS) in order to determine optimal staffing levels, and to staff higher than the minimum legislated ratios if that's what their PCS indicates. One commonly cited problem is that there is no standard formula for determining a PCS. Each hospital makes up its own, they're often different from unit to unit within a hospital, and often are developed more as budget-control tools for hospital management rather than based on objective patient care requirements. According to Seago (2002), p. 53, "there is widespread distrust of virtually any PCS that is currently being used." C.N.A. calls the current use of PCS "acuity fraud." Seago (2002) reports that "they claim that the staffing matrices that are linked to the PCS are determined by the hospital budget, not by the needs of the patients or the competency of the nursing staff. The argument has merit, because all PCS are designed to measure nurse workload but also to fit within the hospital budget. The California law prohibits the use of persons employed to provide maintenance services, including food preparation, housekeeping and laundry, from providing nursing care or being counted in determining the required nurse-to-patient ratios (CA Health and Safety §1276.65(b)).
  179. Institute for Health & Socio-Economic Policy (2001), p. 9–10.
  180. Seago (2002).
  181. Needleman et al. (2001), p. 55–56.
  182. Seago (2002), p. 54–55.
  183. American Academy of Nursing (1983), p. 44.
  184. American Academy of Nursing (1983), p. 44.
  185. Interview with UNAC President Kathy Sackman, November 2002.
  186. Interview with Eleanor Chavez, Director, National Union of Hospital and Health Care Employees (NUHHCE), District 1199 New Mexico, November 2002. NUHHCE is an affiliate of AFSCME.
  187. American Hospital Association (2002), p. 20.
  188. Reported in Steinbrook (2002); ONA communication with Helen Moss, July 2002.
  189. LERC research and interviews with union staff, 2002.
  190. American Academy of Nursing (1983), p. 53.
  191. American Academy of Nursing (1983), p. 22.
  192. American Hospital Association (2002), p. 19.
  193. Collective bargaining agreement between Taylor Hospital, a division of Crozier-Chester Medical Center, and the United Nurses of Pennsylvania/NUHHCE/AFSCME, April 1, 2002–March 31, 2005, Article 31, p. 48–50.
  194. Aiken et al. (2001).
  195. Foundation for Healthy Communities (2001).
  196. Nevidjon (2001), p. 4.
  197. Peterson (2001), p. 3.
  198. American Academy of Nursing (1983), p. 70.
  199. American Academy of Nursing (1983), p. 72–73. The $1,000 figure is as of 1982. At that time, approximately 30 percent of RNs took advantage of this offer.
  200. American Academy of Nursing (1983), p. 35–36.
  201. American Academy of Nursing (1983), p. 104.
  202. American Hospital Association (2002), p. 30.
  203. Aiken, Sochalski and Lake (1997).
  204. Laschinger, et al. (2001).
  205. The NWI was first developed in Kramer and Hafner (1989).
  206. Laschinger, et al. (2001).
  207. American Academy of Nursing (1983), p. 15.
  208. American Academy of Nursing (1983), p. 20.
  209. Aiken et al. (1997), p. 51.
  210. American Academy of Nursing (1983), p. 49–50.
  211. American Organization of Nurse Executives (1988).
  212. Scott, Sochalski and Aiken (1999), p. 5.
  213. American Hospital Association (2002), p. 19.
  214. Scott et al. (1999), p. 6.
  215. American Academy of Nursing (1983), p. 26.
  216. American Academy of Nursing (1983), p. 59.
  217. Norris (2002, April 8), p. 1.
  218. Reported in Buerhaus (2002), p. 5.
  219. U.S. Department of Health and Human Services (2002, February 22).
  220. Foundation for Healthy Communities (2001).
  221. Nursing Executive Center (2000), p. 17.
  222. Quoted in First Consulting Group (2001), p. 16.
  223. American Hospital Association (2002), p. 27, 11.
  224. Buerhaus (2002), p. 4.
  225. American Hospital Association (2002), p. 56.
  226. Buerhaus (2002), p. 6.
  227. American Hospital Association (2002), p. 23.
  228. Nursing Executive Center (2000), p. 92, 102.
  229. Nursing Executive Center (2000), p. 46–47.
  230. American Nurses Association (2001).
  231. AFSCME (2001, April 24).
  232. AFT/FNHP (2001), Mandatory Overtime Survey, p. 27. FNHP did a mandatory overtime survey in March 2001, asking the readers of the magazine Healthwire to either mail in the survey in Healthwire or to answer the questions online. The survey was open to all healthcare workers, but 89 percent of the 615 respondents were RNs. Most respondents came from the New York/New Jersey area (58.2 percent). The majority worked in acute care hospitals (58.3 percent). Of those working in acute care hospitals, most worked in hospitals with 250–400 beds and most worked on medical/surgical floors. 68.5 percent of the respondents have seen an increase in their overtime hours in the past two years. 134 of the respondents stated that their overtime hours had increased on the average between 6–10 hours. 75 percent of those surveyed reported that they regularly worked overtime (464 respondents), and of those that worked overtime, 49 percent had been mandated to work overtime some of the hours (229 respondents). 147 respondents reported working overtime because they felt "they had to stay," whether they were mandated or not.
  233. Bosek (2001), p. 99–102. This is an article in the JONA's Law, Ethics and Regulations section. It advises RNs about "professional duty" in the overtime situation.
  234. This is the conclusion of the AFT/FNHP (2001), Stopping the Clock, p. 5, which notes that "there has been no scientific research to date that has studied the effect of forced overtime on health care workers."
  235. Seago (2002), p. 49.
  236. The NIOSH study surveyed 1,049 RNs and LPNs and was carried out in 1978. Cited in Alward and Monk (1993).
  237. Alward and Monk (1993).
  238. Study surveyed 593 female RNs and 42 female LPNs, carried out in Boston in 1992, reported by Alward and Monk (1993). A further study of work schedules suggests that employees who experience sudden shift increases of more than three hours beyond their normal shift court increased risk of heart attack. Sokejima and Kagamimori (1998), p. 775.
  239. Worthington (2001).
  240. Sparks, et al. (1997); Spurgeon, Harrington and Cooper (1997); Martens, Nijhuis, Van Boxtel, and Knottnerus (1999); Barnett, Gareis and Brennan (1999); Shields (1999); Fenwick and Tausig (2001). The National Institute for Occupational Safety and Health (NIOSH) recognizes stress as an occupational hazard. National Institute for Occupational Safety and Health (1999).
  241. Golden and Jorgensen (2002), p. 3.
  242. Cheng, Kawachi, Coakley, Schwartz and Colditz (2000) cited in AFT/FNHP (2001), Stopping the Clock, p. 5.
  243. Kawachi et al. 1995).
  244. Fenwick and Tausig (2001).
  245. Fenwick and Tausig (2001), p. 1194. High significance was defined as probability of .01.
  246. Strikes over mandatory overtime have taken place at McLaren hospital in Flint, Michigan (AFSCME Local 875); Altoona General Hospital in Altoona, Pa. (AFSCME Local 3156); and Trumbell Memorial Hospital in Warren, OH (AFSCME Local 74).
  247. In AFT/FNHP (2001), The Nurse Shortage, 22 percent of the 50 percent of current nurses (total number of current nurses surveyed was 700) who have considered leaving for non-retirement reasons state they have considered leaving for a more predictable schedule (p. 8). Among former direct care nurses, 28 percent (207) stated the main reason they left the field was for a job with regular work hours and a more predictable schedule (p. 9). In Spratley, et al. (2001), Table 33, p. 69 shows that one of the predominant reasons that RNs in 2000 cited for working in non-nursing was the other positions' scheduled hours were more convenient. Of 1,630 in the sample, 731 gave "hours are more convenient in other position" as a reason for other occupation. The AONE survey, (Risher and Appelbaum (2002)) included both staff nurses and managers, which could affect the response to this issue. However, when asked for the reason for resignation, 19 percent (133) of the 693 respondents checked "other." Of these, 45 percent provided answers related to "better hours/schedules." These were unprompted answers.
  248. O'Leary (2002), p. 3.
  249. American Organization of Nurse Executives (2002), p. 67. AONE surveyed HR directors of chief nurses in 693 acute care hospitals in July-August, 2001.
  250. "Health Workforce" (2002, April 24), p. 487. Responses are from a survey of 59 member hospitals of the Greater New York Hospital Association.
  251. American Academy of Nursing (1983).
  252. Sherrill Cronin, Jewish Hospital (Louisville, KY), interview with Helen Moss, July 2002.
  253. Christine Baker, St. Mary's Hospital and Medical Center, interview with Helen Moss, July 2002.
  254. American Hospital Association, Hospital Statistics, AHA, Chicago, 1999, cited in Kohn, et al. (2000).
  255. Mortality figures from Centers for Disease Control and Prevention, National Center for Health Statistics, Deaths: Final Data for 1997, CDC National Vital Statistics Reports, 47(19):27, 1999; cited in Kohn, et al. (2000).
  256. Bates et al. (1997).
  257. Kohn, et al. (2000), p. 60.
  258. Kohn, et al. (2000), p. 79–80.
  259. Kohn, et al. (2000), p. 170.
  260. Rep. Tracy (Democrat, Rome), quoted in Maine Legislative Record, House of Representatives, May 9, 2001. 
  261. Rep. Smith (Democrat, Van Buren), quoted in Maine Legislative Record, House of Representatives, May 9, 2001. 
  262. Berens (2000, September 10).
  263. Golden and Jorgensen (2002).
  264. Kogi (1991).
  265. Baker and Morisseau (1994).
  266. Schuster and Rhodes (1985).
  267. Gander, Merry, Millar and Weller (2000).
  268. Proctor, White, Robins, Echeverria and Rocskay (1996).
  269. Aakerstedt (1994); Duchon, Keran and Smith (1994); Rosa (1995); Smith (1996).
  270. Hanecke, Tiedemann, Nachreiner and Grzech-Sukalo (1998).
  271. Schuster and Rhodes (1985).
  272. Pilcher and Huffcutt (1996).
  273. Williamson and Feyer (2000), cited in Golden and Jorgensen (2002), p. 4.
  274. Gander et al. (2000).
  275. Boodman (2001, March 27).
  276. Arnow, et al. (1982) and Russell, Ehrenkranz, Hyams and Gribble (1983), cited in Golden and Jorgensen (2002), p. 9.
  277. MNA Labor Cabinet (2000, October/November).
  278. Foley (2002, March 7).
  279. Rep. Tracy (Democrat, Rome), quoted in Maine Legislative Record, House of Representatives, May 9, 2001. 
  280. Legislation would establish (2001, January 31).
  281. Rep. R. R. Menard (Democrat, District 58), quoted in Legislation would establish (2001, January 31).
  282. The following examples are all taken from AFT/FNHP (2001), Stopping the Clock, p. 10–16.
  283. Mattick (1999, August).
  284. This text is from the Justification section of AB 7127, An Act to amend the labor law and the education law, in relation to limiting consecutive hours of work by nurses, New York State Assembly, 2001–2002 Regular Sessions, p.2.
  285. Julie Pinkham, Executive Director, Massachusetts Nurses Association, interview with Gordon Lafer, August 2002.
  286. Martin Taylor, Oregon Nurses Association, interview with Gordon Lafer, August 2002.
  287. AFT/FNHP (2000), p. 29.
  288. Connecticut Health Care Associates (CHCA) and The Waterbury Hospital, Overtime Agreement, August 28, 2001.
  289. Contract language is described in AFT/FNHP (2001), Stopping the Clock, p. 29.
  290. Contract language is described in AFT/FNHP (2001), Stopping the Clock, p. 30.
  291. Contract language is described in AFT/FNHP (2001), Stopping the Clock, p. 30.
  292. Harvard researcher Jack Needleman, quoted in Grady (2002, May 30).
  293. ANA survey results reported in Foley (2002).
  294. Aiken et al. (2001), p. 50, Exhibit 5.
  295. Aiken et al. (2001), p. 50, Exhibit 5.
  296. American Organization of Nurse Executives (2000); MMI Companies, "Changes in the nursing environment create new liability exposures," Advisory, (15)3, Sept. 1999
  297. American Organization of Nurse Executives (2000), p. 63.
  298. Quoted in Foley (2002, March 7).
  299. O'Leary (2002), p. 1.
  300. Needleman et al. (2001). HHS funded this study after a 1993 congressional hearing that focused national attention on the delivery of nursing care in hospitals and its effect on patient care.
  301. Needleman, et al. (2002).
  302. Grady (2002, May 30).
  303. Seago (2002), p. 50.
  304. American Nurses Association (1997). Based on data from 483 hospitals in New York and California.
  305. Blegan, Goode and Reed (1998).
  306. Blegan and Vaughn (1998).
  307. Clarke, Sloane and Aiken (2002).
  308. Wunderlich, Sloan and Davis (1996).
  309. Laschinger, Shamian and Thomson (2001), p. 212; Aiken, Smith and Lake (1994).
  310. Laschinger, Shamian and Thomson (2001), p. 211; Leiter, Harvie and Frizzell (1998).
  311. Following findings are from American Hospital Association (2002), p. 18; Aiken et al. (2000). Comparison is based on a cohort of 195 comparable non-magnet hospitals.
  312. Aiken, Sochalski and Lake (1997). While the authors did find that magnet hospitals provided superior service, in this case it was not due to staffing levels. They tested for the impact of staffing and a host of other factors, and in this case staffing was not the factor that created the superior service; it was something else, harder to quantify, in the operation of the magnet hospitals. Aiken has stated elsewhere that it is a combination of adequate staffing levels and other management reforms that are needed to improve nurse recruitment and retention and guarantee quality care for patients.
  313. Scott, Sochalski and Aiken (1999), p. 12.
  314. Research in the late 1980s and early 1990s compared fully staffed units with short-staffed units; in both cases the clinical complications were higher on the short-staffed units. Both studies also concluded that the long-term costs were higher for the short-staffed units because of longer stays and more expensive treatments for complications. Flood and Diers (1988); Behner et al. (1990).
  315. Havens (2001), p. 265.
  316. Havens (2001), p. 265.
  317. Havens (2001), p. 263. More than 50 percent of magnet CNEs reported that "there is enough time and opportunity to discuss patient care problems with other nurses," whereas about 16 percent of comparison CNEs say this. More than 70 percent say "There is a lot of teamwork between doctors and nurses," vs. 42 percent at comparisons. 95 percent say "Nursing controls its own practice," vs. 72 percent at comparisons. 32 percent say "Assignments foster continuity of care," vs. 17 percent at comparisons.
  318. Havens (2001), p. 261.
  319. Havens (2001), p. 264.
  320. Needleman et al. (2001), p. 137.
  321. California Nurses Association (n.d.), "Improved RN."
  322. California Nurses Association (n.d.), "Frequently asked questions."
  323. California Nurses Association (n.d.), "Frequently asked questions." The study is being carried out by James Bramble of Creighton University.
  324. This seems to be what the American Hospital Association (2002) is advocating, p. 76–78. The report promotes a "Strategic Recommendation" that "regulations that govern specific practices of individual occupations should not impede the delivery of the right care, at the right time, by the right person, in the right setting." The authors then call for a national research project to "develop new practice acts that reflect the education, skills, and competencies of today's caregivers," and argue that "hospitals should develop new models of accountability for measuring and documenting worker competencies that can be used to work with regulators toward regulatory improvements." Perhaps similar is another "Strategic Recommendation" that "education in the health professions and allied health professions needs to emphasize interdisciplinary training to facilitate team-based approaches to patient care."
  325. Seago and Ash (2002). The analysis controlled for number of beds, AMI-related discharges, cardiac services, staff hours and wages.
  326. Seago and Ash (2002), p. 150.