Jin Kim, a nurse at St. Joseph's Hospital of Atlanta, scans the bar code on a patient's armband to verify that the drug she administers is the correct one.

Workplace advocacy - an umbrella term for programs designed to create a supportive, safe and healthy working environment - is a top agenda item of national nursing organizations these days.

"With good reason," said Debbie Hatmaker, Ph.D., RN, SANE-A, GNA, and chief programs office and president of the Center for American Nurses. "We recognize that health care is going through some difficult changes that are greatly impacting the workplace. Nurses are working harder."

"Patients in the hospital are sicker, and with the population aging, there are more of them," she said. Hospital stays are shorter, meaning that nurses are caring for patients at the same time that they are educating them before being discharged. Ancillary services like nursing assistants and clerical help have been cut back.

"With the staffing and nursing shortages, nurses are having to make do with less," Hatmaker said.

Many programs have addressed the national nursing shortage from a recruitment perspective, resulting in most nursing schools attracting more applicants than they have spaces.

Now, it's time to work on the more complicated issue of retention, Hatmaker said. "We want to put in place programs and services that will improve the workplace, so that nurses will want to stay in the profession for many years to come."

That was a goal of the American Nurses Association in the 1980s, when it established the magnet designation for hospitals. A major factor in nursing recruitment and retention, magnet designation recognizes health care systems that have outstanding nursing staffs. It appreciates how their leadership and professional practice standards translate to better patient care and services.

There are about a 100 hospitals in the United States with magnet designation, and there's been a surge of new hospitals working to achieve that status.

Shared governance
St. Joseph's Hospital of Atlanta, a 346-bed, adult, acute tertiary care facility, was one of the first to be recognized.

Kim scans the barcode on some medication. The hospital's electronic record-keeping system helps nurses keep track of a patient's treatment history.

"We implemented a nursing shared governance model in 1980. That has shaped the professional character, structure and behavior of our nursing organization and it was the foundation for our becoming a magnet hospital," said Kim Sharkey, RN, MBA, CNAA, division director for inpatient nursing.

The model empowers nurses at every level. They make decisions related to their practice, patient care and professional development through five nursing counsels. "When everyone has a part in the decision making, the staff satisfaction is very high," Sharkey said. Shared governance has established a variety of programs that attract and retain nurses at St. Joseph's.

"Our clinical levels program allows us to encourage older and experienced nurses - who are the brain trust of the organization - to stay involved in bedside care," Sharkey said. They can become preceptors to younger nurses, advance through additional education or certification, or go through the Nursing Leadership Academy, with compensation levels rising accordingly.

A recent staff survey raised the concern of nurses who need help lifting patients - a concern addressed on the national level by the ANA's Handle with Care initiative. The nursing profession has the second-highest incidence of workplace back injuries, according to Hatmaker. Incorrect lifting techniques put both the nurse and patient at risk. St. Joseph's asked each unit to assess its own needs and provided the appropriate lifting equipment.

The hospital continues to perfect an electronic recordkeeping system, which doctors, nurses and staff can easily and simultaneously access. A flexible scheduling policy (with some nurses working full time on weekends only), helps nurses balance career and families.

The People in Progress Center allows all staff to increase education levels and gain skills (while being paid) in order to advance their careers. It helps entry-level staff learn basic math, science or English skills, prepare for the GED test or prepare for a college program in the health sciences. Nurses can review or learn new skills through the Pearls Review Program online.

"We walk the talk here because we value our employees and want them to have a good quality of work and life," Sharkey said.

Becky McKee-Waddle, MSN-FNP, shows new nurse Rebecca Pihera, RN, BSN, how to use a machine to perform continous renal replacement therapy. Nurse clinical specialists at Emory Crawford Long Hospital train new nurses and those re-rentering the field in eight specialty areas.

'A steady journey'
St. Joseph's/Candler in Savannah, a magnet hospital with 636 beds and 860 full-time registered nurses, has been on "a steady journey to nursing excellence," said Susan Howell, EdD, RN, AOCN, director of professional practice. "We adopted a shared governance model in 2002 and the voice of nursing is heard everywhere in our system. Our CNO sits on the board and staff nurses are involved at the counsel level."

Last year, the hospital hired a health care consulting company to show staff better ways to recruit and retain top nursing talent.

"We now have a nurse who serves as a retention coordinator - a neutral person to hear concerns. People change and grow and, sometimes, they just need to be challenged or move to a different unit to be happier on the job," Howell said. Two registered nurses now serve as nursing recruiters.

A Nursing Bridge to Excellence Clinical Advancement Ladder allows nurses to grow within their practice and receive more pay.

"A lot of ladders look at community activities," Howell said. "We wanted to focus on nursing delivery/ practice and the reception has been very positive."

Nurses have opportunities for education, leadership training and tuition reimbursement and there are bonuses for national certification.

Fifty-two nurses are participating in the new Center for Frontline Nursing Leadership program at St. Joseph's/Candler. They'll work as teams on unit-improvement projects. Other examples of nursing support include streamlined documentation and a Patient Control Analysis drug administration system, which identifies parameters of usage as an extra safety net.

"Nursing has changed so much. The acuity of patients is higher and the technology is much more demanding," Howell said. "We need to put in place every possible program that encourages people to come into the field and supports them once they're here."

'A good environment'
That includes changing the physical and emotional environment in the workplace, said Alice Vautier, RN, Ed.D., association administrator for patient services and CNO for Emory Hospitals. She is the 2004 Georgia Hospital Association's Workforce Leadership Award winner for her commitment to workplace advocacy.

Emory Hospitals have used computer simulations to redesign patient units, so there is less physical work for the staff.

"Nurses walk a lot. Having things placed efficiently cuts down on the number of steps they have to take and makes the job a little less demanding," Vautier said. "It sounds simple, but it helps to have ergonomically-sound chairs in nursing stations and the walls painted pleasing colors. A good environment affects how people feel and work."

To eliminate competition after the merging of Emory University Hospital and Emory Crawford Long Hospital, nursing leadership is organized by clinical areas. Both emergency rooms operate under the same nursing director, patient protocols and policies, for example.

Emory also has made it easy for former nurses to re-enter the work force. They're paid as employees while they take 4 to 6 weeks of classes, then work with a preceptor and mentor on the floor.

Nurse clinical specialists teach residency programs (six weeks to six months) in eight specialty areas. The gerontology residency program is one of the first in the country to train LPNs to work with elderly patients.

"Residency programs allow new nurses to gain experience in an area of specialty and seasoned staff to transfer to a new practice area," Vautier said. Continuing education programs are ongoing.

"Emory is an educational facility and we take the education emphasis seriously," Vautier said.

Low nurse/patient ratios and no mandatory overtime also make Emory Hospitals a more pleasant workplace for staff and a safer place for patients.

"Nursing is a physically demanding profession. We've tried to be proactive about making this a better place to work," Vautier said.