# NATIONAL COUNCIL OF NURSING EXECUTIVE SUMMARY 

##### OF THE 1998 IHS NURSE SURVEY

# Introduction

The National Council of Nursing (NCON) is a nationwide consortium made
up of nurse leaders from the 12 Areas of Indian Health. These
representatives are area and national nurse consultants, nurse
recruiters, advanced practice nurses, urban nurses, and officers of the
National Council of Nurse Administrators (NCONA) from Indian Health
Service/Tribal/Urban (I/T/U) programs. NCON provides leadership and
advocacy for comprehensive health care delivery responsive to present
and future health care needs of American Indian and Alaska Native
people. NCON also discusses issues, resolves problems, recommends action
for change and keeps abreast of current trends in nursing and health
care.

# Background

In 1981 the Indian Health Service initiated a Nurse Retention Study.
This study, which included identified problems and issues, was presented
to the National Council of Nursing. In response, the NCON developed an
Action Plan in 1982 to address and improve some of the problems
identified. The following deficiencies were identified:

1.  Quality of supervision and management changing in staffing patterns.

2.  The use of patient classification systems.

3.  Alternative work schedule.

4.  Autonomy through use of clarification of role definition and
    responsibilities.

5.  Recognition and awards.

6.  Development of the Nursing Education Center for Indians (NECI).

7.  Housing and safety precautions.

NCON implemented several positive changes during the early 1980's,
however the severe nursing shortage present in the US at that time
definitely impacted Indian Country also. In an effort to determine the
effectiveness of the 1982 Action Plan, a national survey was completed
in 1984. After the survey was completed, the original Action Plan for
Nurse Recruitment & Retention that was established by the NCON was
expanded and then implemented.

Other activities and programs have been reviewed, updated and adjusted
continually since then to improve nurse satisfaction, recruitment and
retention:

1.  A special pay rate was implemented in 1991.

2.  Nursing school recruitment and retention grants were developed
    (Section 112).

3.  Specialty training programs were developed and offered in OB,
    perioperative, wound care and ostomy care, leadership, etc.

4.  National nurse recruiter positions were established.

5.  Loan Repayment Program was established.

6.  Budget and facility expansion to increase nurse staffing.

As a result, the IHS has been able to decrease the vacancy and turnover
rates.

# Methodology

# During the 1990's, tremendous changes have impacted health care delivery in the US and the administration of IHS. To determine the impact of these changes, and to prepare for the predicted new and even more severe nursing shortage in the next few years, IHS Nursing determined it was necessary to repeat and update the original survey of 1984 again in 1998.

# The 1984 survey was designed to determine what factors influence nurses to either remain with or leave IHS and what factors associated with both the living and work environments were perceived as satisfying or dissatisfying. With only minor changes the questionnaire used in the 1998 survey was the same as in 1984.

The purpose of the 1998 survey is a comparative study to determine any
and all changes that have occurred in policy and nursing practices since
the "Registered Nurse Recruitment and Retention Survey" that was
completed in 1984. In addition, the survey was intended to determine
what improvements have been made, what changes need to be made to
continue to attract and retain nurses, and what changes should be made
to meet the future patient care needs of Indian people.

# In August of 1984, 1,690 registered nurses in the Indian Health Service (IHS) were surveyed to determine what factors influenced them to either remain in or leave the IHS. Of 1,690 registered nurses surveyed, 1,339 or 79.2% returned the questionnaire. The questionnaire was designed to profile registered nurses currently employed by the IHS. 

In October of 1998, 2,554 registered nurses in the IHS were mailed
questionnaires. Of the 2,554 surveyed, 1,103 or 43.2% returned the
questionnaire. Respondents included hospital or ambulatory care based
registered nurses who provide either direct or specialized services, and
public health nurses who provide care in the community setting. The 1998
Survey questionnaire which included 214 questions was different than the
one used in 1984 in the following ways:

-   The term Indian Health Service/Tribal/Urban (I/T/U) replaced IHS
    throughout the questionnaire

-   Identification of type of scholarship for payback

-   Type of facility in which the nurse is working was expanded to
    include non applicable, advanced practice nurses and nurse
    specialists

-   "Advanced Practice Nurse" was added to the choices for functional
    titles (CNP, CNM, CRNA, CNC). Community Health Nurse was also
    changed to Public Health Nurse

-   The 40 hour work week category was expanded to include 12 hours per
    day in addition to 10 hours per day

-   Identification of assigned Service Unit was deleted

-   Tribal and Urban were added as employment status options

-   A section was added to examine the impacts of changes which have and
    continue to take place in I/T/U since 1984

Due to the changes in Indian Health Service and Office of Management and
Budget clearance requirements, the 1998 Survey did not go out to the
majority of tribal and urban programs until the end of 1998 and early
1999. Therefore the results contained here are more reflective of IHS
nurses. As soon as the results are compiled from the tribal and urban
nurses they will be figured into the Executive summary and tables.

Since this survey instrument is essentially the same and the primary
purpose is a comparison to the 1984 results, the basic data analysis
techniques are the same as those utilized in 1984. In order to better
interpret the responses elicited, responses were often broken down and
examined by: 1) the IHS Area and 2) position (nurse specialty).

**Significant Findings -- 1998 Nurse Survey**

It was hoped that the 1998 survey would evaluate the outcome of actions
implemented from the 1984 study with respect to recruitment and
retention and also identify new problems. Issues specifically identified
in the 98 survey were lack of:

1.  Local administrative support.

2.  Adequate time for supervisory clinical nurses to perform
    administrative activities.

3.  Opportunities to improve skills and knowledge through continuing
    nursing education.

4.  Expectations placed on nursing administrators by facility
    administration.

5.  Opportunity for career advancement.

6.  Security precautions at work.

Based on the findings mentioned above and contained in the results of
the surveys, the following issues were identified in 1984 and continue
to still be present in 1998.

**The following table is a comparison between the 1984 and 1998 Nurse
Surveys, looking at professional experience and identified issues that
still persist as major dissatisfactions.**

+----------------------------+--------------------+--------------------+
| # Identified Issue         | #  1984 Survey     | #  1998 Survey     |
|                            |                    |                    |
|                            | ##                 | ###  **D           |
|                            |  Dissatisfaction % | issatisfaction %** |
+----------------------------+--------------------+--------------------+
| Local Administrative       | 39%                | 45%                |
| Support                    |                    |                    |
+----------------------------+--------------------+--------------------+
| Adequate time for nursing  | 41%                | 41%                |
| administrative activities  |                    |                    |
+----------------------------+--------------------+--------------------+
| Opportunities to improve   | 39%                | 40%                |
| skills and knowledge       |                    |                    |
| through continuing         |                    |                    |
|                            |                    |                    |
| Nursing education.         |                    |                    |
+----------------------------+--------------------+--------------------+
| Opportunities to maintain  | 34%                | 36%                |
| skills and knowledge       |                    |                    |
| through continuing         |                    |                    |
| nursing.                   |                    |                    |
|                            |                    |                    |
| Education                  |                    |                    |
+----------------------------+--------------------+--------------------+
| Expectations placed on     | 28%                | 35%                |
| nursing by facility        |                    |                    |
| administration             |                    |                    |
+----------------------------+--------------------+--------------------+
| Perform tasks outside      | 65%                | 65%                |
| nursing scope of practice  |                    |                    |
+----------------------------+--------------------+--------------------+
| Additional work with no    | 49%                | 54%                |
| compensation               |                    |                    |
+----------------------------+--------------------+--------------------+
| Unpredictable work         | 62%                | 62%                |
| schedules                  |                    |                    |
+----------------------------+--------------------+--------------------+
| Staffing (Inadequate)      | 62%                | 62%                |
+----------------------------+--------------------+--------------------+
| Immediate supervisor       | 30%                | 33%                |
| performance:               |                    |                    |
|                            | 29%                | 30%                |
| -   Recognition for        |                    |                    |
|     clinical nursing       | 30%                | 30%                |
|     skills                 |                    |                    |
|                            |                    |                    |
| -   Staff self-esteem      |                    |                    |
|     enhancement            |                    |                    |
|                            |                    |                    |
| -   Leadership and problem |                    |                    |
|     solving                |                    |                    |
+----------------------------+--------------------+--------------------+

The average respondent has been in IHS for 9 years, compared to 6.75
years in 1984 Survey. Sixty-five percent of RNs now employed intend to
remain in their current positions. The average age of RNs is 45.9 years.
Eighty three percent are civil servants, 13% are commissioned officers,
0.8% work in tribal facilities and 0.5% work in urban facilities. Forty
two percent graduated from an associate degree program in the 1984
Survey with similar results in 1998; while 32% in the 1984 Survey
graduated from a bachelors degree program as compared to 41% in the 1998
Survey.

Respondents were queried with regard to the impact of changes since 1984
that included such factors as restructuring, I/T/U redesign,
self-governance, and managed care. "Your ability to do your job" was
viewed by a higher percentage of respondents as having a positive
influence rather than a negative influence. Three of the top seven top
factors influencing 82% of RNs to join the IHS were economic reasons
such as salary, fringe benefits, and job security.

Respondents were well satisfied with several aspects of their
professional work experience and their area of nursing. These include
rapport with patients, quality of nursing care provided, and specific
area of nursing in which they worked. Overall, the respondents expressed
satisfaction with their immediate supervisor's performance, being open
to nursing staff, fair evaluations, and being prepared for supervisory
functions and responsibilities.

A few of the most satisfying factors included climate, acceptance as
member of the community, and outdoor recreational activities. Of
interest, another satisfying factor included housing and the
availability of housing.

Dissatisfactions were in the area of recognition of clinical nursing,
self-esteem enhancement, and leadership in problem solving. Respondents
indicated that staffing was inadequate to provide quality-nursing care.
Of significance, there was probably less satisfaction expressed
regarding management than any other factor in the survey. Non-Indian
registered nurses stated that the Indian Preference regulation is a
barrier to career advancement.

There was overall satisfaction with security in the workplace, however
there are alarming concerns that need to be addressed. Thirty nine
percent stated that they were verbally abused by the client to the point
of creating fear for their own safety or someone they know and 15% of
nurse respondents stated clients physically assaulted them at the
workplace.

Salary and fringe benefits were the most frequent factor indicated as a
positive influence to remain with I/T/U and was the second most frequent
comment area in regards to improving nurse retention in I/T/U. The
comments centered on increasing pay and benefits, keeping/bringing back
retention and incentive bonuses, increased job security, and higher GS
levels for specialty nurses.

## Below, you will find two tables listing the top twenty Satisfiers (influences to stay with I/T/U) and the top twenty Dissatisfiers (influences to leave I/T/U). Each table lists factors in the rank of importance respondents gave in both the 1984 and the 1998 Surveys. Recommendations given by respondents are also listed.

####  Table One -- Satisfiers

+------------------+---+---+-------------------+---------------------+
| **Factor**       | * | * | **Survey          | **Survey respondent |
|                  | * | * | respondents       | recommendations**   |
|                  | 9 | 8 | comments of       |                     |
|                  | 8 | 4 | satisfaction**    |                     |
|                  | * | R |                   |                     |
|                  | * | a |                   |                     |
|                  |   | n |                   |                     |
|                  | * | k |                   |                     |
|                  | * | o |                   |                     |
|                  | R | r |                   |                     |
|                  | a | d |                   |                     |
|                  | n | e |                   |                     |
|                  | k | r |                   |                     |
|                  | o | o |                   |                     |
|                  | r | f |                   |                     |
|                  | d | f |                   |                     |
|                  | e | a |                   |                     |
|                  | r | c |                   |                     |
|                  | o | t |                   |                     |
|                  | f | o |                   |                     |
|                  | f | r |                   |                     |
|                  | a | s |                   |                     |
|                  | c | * |                   |                     |
|                  | t | * |                   |                     |
|                  | o |   |                   |                     |
|                  | r |   |                   |                     |
|                  | s |   |                   |                     |
|                  | * |   |                   |                     |
|                  | * |   |                   |                     |
+------------------+---+---+-------------------+---------------------+
| Salary and       | 1 | 1 | Salary & fringe   | Continue process    |
| fringe benefits  |   |   | benefits were the | the IHS Executive   |
|                  |   |   | most frequent     | Leadership Group    |
|                  |   |   | factor indicated  | has begun to obtain |
|                  |   |   | as a positive     | and implement       |
|                  |   |   | influence to      | increase in special |
|                  |   |   | remain with       | pay. Make           |
|                  |   |   | I/T/Us. This was  | information         |
|                  |   |   | true for nurses   | available to tribes |
|                  |   |   | in all roles but  | about comparable    |
|                  |   |   | especially for    | salaries in the     |
|                  |   |   | supervisory       | non-Indian private  |
|                  |   |   | nurses. Sited as  | sectors.            |
|                  |   |   | a tool that could |                     |
|                  |   |   | be used for       |                     |
|                  |   |   | retention of      |                     |
|                  |   |   | nurses paired     |                     |
|                  |   |   | with other        |                     |
|                  |   |   | incentives.       |                     |
+------------------+---+---+-------------------+---------------------+
| Geographic       | 2 | 2 | Location          | Make exerted effort |
| location of your |   |   | influences both   | to match potential  |
| present          |   |   | joining and       | employee with their |
| assignment       |   |   | staying at ITU    | desired location.   |
|                  |   |   | site. Expressed   | Explain employment  |
|                  |   |   | satisfaction with | options for nursing |
|                  |   |   | available         | thru direct tribal  |
|                  |   |   | housing.          | hire, the Civil     |
|                  |   |   |                   | Service System,     |
|                  |   |   |                   | and/or Commissioned |
|                  |   |   |                   | Corp. Encourage HQs |
|                  |   |   |                   | to maintain some    |
|                  |   |   |                   | resources in        |
|                  |   |   |                   | short-term training |
|                  |   |   |                   | funds that would    |
|                  |   |   |                   | allow temporary     |
|                  |   |   |                   | staff to fill       |
|                  |   |   |                   | position of a FTE   |
|                  |   |   |                   | nurse to attend     |
|                  |   |   |                   | training. Develop   |
|                  |   |   |                   | pa                  |
|                  |   |   |                   | rtnerships/liaisons |
|                  |   |   |                   | with universities.  |
+------------------+---+---+-------------------+---------------------+
| Work Hours       | 3 | 1 | Highest level of  | Continue to         |
|                  |   | 4 | satisfaction      | compensate for      |
|                  |   |   | among outpatient  | extra hours worked. |
|                  |   |   | and ER clinical   |                     |
|                  |   |   | nurses. 69%       |                     |
|                  |   |   | preferred         |                     |
|                  |   |   | compressed        |                     |
|                  |   |   | workweek.         |                     |
+------------------+---+---+-------------------+---------------------+
| Acceptance of    | 4 | 4 | General           | Connect potential   |
| your children by |   |   | satisfaction with | employee with       |
| their peers in   |   |   | acceptance in the | community agencies  |
| the community    |   |   | community and of  | and resources.      |
|                  |   |   | the family.       |                     |
+------------------+---+---+-------------------+---------------------+
| **Factor**       | * | * | **Survey          | **Survey            |
|                  | * | * | respondents       | respondents         |
|                  | 9 | 8 | comments of       | recommendations**   |
|                  | 8 | 4 | satisfaction**    |                     |
|                  | * | R |                   |                     |
|                  | * | a |                   |                     |
|                  |   | n |                   |                     |
|                  | * | k |                   |                     |
|                  | * | o |                   |                     |
|                  | R | r |                   |                     |
|                  | a | d |                   |                     |
|                  | n | e |                   |                     |
|                  | k | r |                   |                     |
|                  | o | o |                   |                     |
|                  | r | f |                   |                     |
|                  | d | f |                   |                     |
|                  | e | a |                   |                     |
|                  | r | c |                   |                     |
|                  | o | t |                   |                     |
|                  | f | o |                   |                     |
|                  | f | r |                   |                     |
|                  | a | s |                   |                     |
|                  | c | * |                   |                     |
|                  | t | * |                   |                     |
|                  | o |   |                   |                     |
|                  | r |   |                   |                     |
|                  | s |   |                   |                     |
|                  | * |   |                   |                     |
|                  | * |   |                   |                     |
+------------------+---+---+-------------------+---------------------+
| Health care of   | 5 | 5 | General           | Assist and          |
| your children    |   |   | satisfaction in   | establish contacts  |
|                  |   |   | spite of limited  | with local          |
|                  |   |   | availability of   | providers of        |
|                  |   |   | specialists and   | choice.             |
|                  |   |   | preferred access  |                     |
|                  |   |   | to care for       |                     |
|                  |   |   | American Indians. |                     |
+------------------+---+---+-------------------+---------------------+
| Environment in   | 6 | 3 | 59% overall       | The environment     |
| which to raise   |   |   | influenced to     | that staff is       |
| your children    |   |   | remain in I/T/Us; | offered to raise    |
|                  |   |   | 74% influenced to | dependent children  |
|                  |   |   | stay in Alaska.   | often influences    |
|                  |   |   |                   | them to stay.       |
|                  |   |   |                   | Therefore it is     |
|                  |   |   |                   | important that the  |
|                  |   |   |                   | local               |
|                  |   |   |                   | administration work |
|                  |   |   |                   | with the tribal     |
|                  |   |   |                   | government &        |
|                  |   |   |                   | adjacent            |
|                  |   |   |                   | communities to      |
|                  |   |   |                   | improve the         |
|                  |   |   |                   | environmental       |
|                  |   |   |                   | conditions.         |
+------------------+---+---+-------------------+---------------------+
| Quality of the   | 7 | 6 | High regard for   | Maintain high       |
| nursing staff    |   |   | the quality of    | professional        |
|                  |   |   | staff             | standards. Maintain |
|                  |   |   |                   | and increase        |
|                  |   |   |                   | development of      |
|                  |   |   |                   | cross training      |
|                  |   |   |                   | programs so nurses  |
|                  |   |   |                   | feel competent in   |
|                  |   |   |                   | floating and        |
|                  |   |   |                   | increase specialty  |
|                  |   |   |                   | training            |
|                  |   |   |                   | opportunities.      |
+------------------+---+---+-------------------+---------------------+
| Work schedules   | 8 | 1 | Only inpatient    | Continue to be      |
|                  |   | 7 | nurses, and 24%   | flexible and open   |
|                  |   |   | of them, were     | to creative         |
|                  |   |   | influenced to     | staffing patterns.  |
|                  |   |   | leave. 3% PHNs    |                     |
|                  |   |   | were influenced   |                     |
|                  |   |   | to leave while    |                     |
|                  |   |   | all the rest      |                     |
|                  |   |   | stayed in ITU\'s. |                     |
+------------------+---+---+-------------------+---------------------+
| Learning about   | 9 | 8 | Positive          | Use as a            |
| and serving      |   |   | influence to      | recruitment tool to |
| another ethnic   |   |   | decision to join  | bring native nurses |
| group            |   |   | and remain in     | home and attract    |
|                  |   |   | ITU.              | and interest        |
|                  |   |   |                   | non-native nurses.  |
+------------------+---+---+-------------------+---------------------+
| Expressed        | 1 | 1 | PHNs, more than   | Continue to allow   |
| appreciation by  | 0 | 5 | any other         | more direct         |
| patients and the |   |   | specialty, were   | interaction between |
| community.       |   |   | satisfied with    | clients and staff.  |
|                  |   |   | appreciation      |                     |
|                  |   |   | expressed.        |                     |
+------------------+---+---+-------------------+---------------------+
| Climate          | 1 | 1 | Majority (76%)    | Make exerted effort |
|                  | 1 | 0 | satisfied with    | to match potential  |
|                  |   |   | the climate where | employee with their |
|                  |   |   | they are working  | desired location.   |
|                  |   |   | and living.       | Explain employment  |
|                  |   |   |                   | options for nursing |
|                  |   |   |                   | thru direct tribal  |
|                  |   |   |                   | hire, the Civil     |
|                  |   |   |                   | Service System,     |
|                  |   |   |                   | and/or Commissioned |
|                  |   |   |                   | Corp.               |
+------------------+---+---+-------------------+---------------------+
| Ability to       | 1 | 1 | A clear majority  | Optimize current    |
| provide          | 2 | 1 | of nurses are     | staffing. Continue  |
| quality-nursing  |   |   | satisfied with    | to nurture and      |
| care.            |   |   | the quality of    | maximize the team   |
|                  |   |   | nursing care they | approach. Encourage |
|                  |   |   | provide. Their    | opportunities for   |
|                  |   |   | ability to        | career progression  |
|                  |   |   | provide quality   | and advancement.    |
|                  |   |   | care with         | Focus on retaining  |
|                  |   |   | available staff & | versus recruiting   |
|                  |   |   | with the          | new nurses.         |
|                  |   |   | available         |                     |
|                  |   |   | equipment and     |                     |
|                  |   |   | supplies in a     |                     |
|                  |   |   | majority of       |                     |
|                  |   |   | responses         |                     |
|                  |   |   | positively        |                     |
|                  |   |   | influenced them   |                     |
|                  |   |   | to stay.          |                     |
+------------------+---+---+-------------------+---------------------+
| Recreational     | 1 | 9 | Varies with area; | Connect employees   |
| activities for   | 4 |   | Alaska 91%        | with community      |
| your children    |   |   | satisfied,        | agencies and        |
|                  |   |   | Nashville 25%     | resources.          |
|                  |   |   | satisfied.        |                     |
+------------------+---+---+-------------------+---------------------+
| Ability to       | 1 | 1 | 50% satisfied.    | Continue to support |
| provide quality  | 5 | 1 |                   | the purchase of     |
| nursing care     |   |   |                   | equipment and       |
|                  |   |   |                   | supplies allowing   |
|                  |   |   |                   | nursing staff to do |
|                  |   |   |                   | the jobs.           |
+------------------+---+---+-------------------+---------------------+
| Available        | 1 | 1 | 75% satisfied in  | Connect employee    |
| outdoor          | 6 | 6 | Alaska, which     | with community      |
| recreational     |   |   | represents        | agencies and        |
| activities.      |   |   | highest level of  | resources.          |
|                  |   |   | satisfaction.     |                     |
+------------------+---+---+-------------------+---------------------+
| Quality of       | 1 | 7 | Educational       | Inform and educate  |
| education        | 7 |   | facilities at ITU | employee as to what |
| available in the |   |   | assignments may   | is available either |
| community        |   |   | be better than    | in the broader      |
|                  |   |   | those in larger   | community or the    |
|                  |   |   | urban areas.      | local Indian        |
|                  |   |   |                   | community.          |
+------------------+---+---+-------------------+---------------------+
| **Factor**       | * | * | **Survey          | **Survey            |
|                  | * | * | respondents       | respondents         |
|                  | 9 | 8 | comments of       | recommendations**   |
|                  | 8 | 4 | satisfaction**    |                     |
|                  | * | R |                   |                     |
|                  | * | a |                   |                     |
|                  |   | n |                   |                     |
|                  | * | k |                   |                     |
|                  | * | o |                   |                     |
|                  | R | r |                   |                     |
|                  | a | d |                   |                     |
|                  | n | e |                   |                     |
|                  | k | r |                   |                     |
|                  | o | o |                   |                     |
|                  | r | f |                   |                     |
|                  | d | f |                   |                     |
|                  | e | a |                   |                     |
|                  | r | c |                   |                     |
|                  | o | t |                   |                     |
|                  | f | o |                   |                     |
|                  | f | r |                   |                     |
|                  | a | s |                   |                     |
|                  | c | * |                   |                     |
|                  | t | * |                   |                     |
|                  | o |   |                   |                     |
|                  | r |   |                   |                     |
|                  | s |   |                   |                     |
|                  | * |   |                   |                     |
|                  | * |   |                   |                     |
+------------------+---+---+-------------------+---------------------+
| Expectations     | 1 | 2 | 68% satisfied     | Continue to allow   |
| placed on your   | 8 | 0 | with              | more direct         |
| patient          |   |   | expectations.     | interactions        |
|                  |   |   |                   | between staff and   |
|                  |   |   |                   | clients.            |
+------------------+---+---+-------------------+---------------------+
| Patient Load     | 1 | 2 | 65% described     | Prioritize nursing  |
|                  | 9 | 5 | workload          | responsibilities to |
|                  |   |   | extremely heavy,  | maximize available  |
|                  |   |   | 31% just right,   | nursing time for    |
|                  |   |   | and 4% extremely  | client care.        |
|                  |   |   | light.            |                     |
+------------------+---+---+-------------------+---------------------+
| Physical         | 2 | 2 | Tribal members    | Continue to         |
| condition of     | 0 | 1 | are aware of the  | maintain and        |
| medical facility |   |   | condition of the  | restore our         |
|                  |   |   | facilities and    | facilities.         |
|                  |   |   | often work with   |                     |
|                  |   |   | the tribal        |                     |
|                  |   |   | government and    |                     |
|                  |   |   | HIS to restore,   |                     |
|                  |   |   | maintain, and/or  |                     |
|                  |   |   | build.            |                     |
+------------------+---+---+-------------------+---------------------+

Table Two - Dissatisfiers

+-------------------+---+---+-------------------+--------------------+
| **Factor**        | * | * | **Survey          | **Survey           |
|                   | * | * | respondents       | respondents        |
|                   | 9 | 8 | comments of       | recommendations**  |
|                   | 8 | 4 | dissatisfaction** |                    |
|                   | * | R |                   |                    |
|                   | * | a |                   |                    |
|                   |   | n |                   |                    |
|                   | * | k |                   |                    |
|                   | * | o |                   |                    |
|                   | R | r |                   |                    |
|                   | a | d |                   |                    |
|                   | n | e |                   |                    |
|                   | k | r |                   |                    |
|                   | o | o |                   |                    |
|                   | r | f |                   |                    |
|                   | d | f |                   |                    |
|                   | e | a |                   |                    |
|                   | r | c |                   |                    |
|                   | o | t |                   |                    |
|                   | f | o |                   |                    |
|                   | f | r |                   |                    |
|                   | a | s |                   |                    |
|                   | c | * |                   |                    |
|                   | t | * |                   |                    |
|                   | o |   |                   |                    |
|                   | r |   |                   |                    |
|                   | s |   |                   |                    |
|                   | * |   |                   |                    |
|                   | * |   |                   |                    |
+-------------------+---+---+-------------------+--------------------+
| Equality of       | 1 | 1 | Highest level     | Educate staff      |
| opportunity for   |   |   | expressed by      | regarding Indian   |
| advancement       |   |   | Nashville,        | preference         |
|                   |   |   | Oklahoma area &   | according to laws  |
|                   |   |   | inpatient &       | and HIS mandates.  |
|                   |   |   | ambulatory        | Support and        |
|                   |   |   |                   | increase           |
|                   |   |   |                   | educational        |
|                   |   |   |                   | opportunities to   |
|                   |   |   |                   | achieve and        |
|                   |   |   |                   | enhance            |
|                   |   |   |                   | qualifications and |
|                   |   |   |                   | skills.            |
+-------------------+---+---+-------------------+--------------------+
| Quality of        | 2 | 4 | Administration    | Provide more       |
| Administrative    |   |   | needs to be more  | qualified,         |
| staff             |   |   | accountable &     | competent          |
|                   |   |   | they are not      | administrators who |
|                   |   |   | effective in      | understand the     |
|                   |   |   | promotion of job  | Indian Health Team |
|                   |   |   | satisfaction.     | approach.          |
|                   |   |   |                   | Administrators     |
|                   |   |   |                   | who: treat         |
|                   |   |   |                   | everyone           |
|                   |   |   |                   | equitably, provide |
|                   |   |   |                   | support to nurses  |
|                   |   |   |                   | and a positive     |
|                   |   |   |                   | working            |
|                   |   |   |                   | environment.       |
+-------------------+---+---+-------------------+--------------------+
| Awards,           | 3 | 6 | Suggest bonus     | Form employee      |
| Recognition for   |   |   | pay, cash awards, | recognition teams  |
| service           |   |   | time-off and      | at every level .   |
|                   |   |   | simply pat on the | Educate            |
|                   |   |   | back              | supervisors on     |
|                   |   |   |                   | awards process for |
|                   |   |   |                   | federal employees  |
|                   |   |   |                   | and tribal         |
|                   |   |   |                   | programs.          |
|                   |   |   |                   | (Reference         |
|                   |   |   |                   | Circular 10-97 for |
|                   |   |   |                   | civil service      |
|                   |   |   |                   | staff). Look at    |
|                   |   |   |                   | overtime process   |
|                   |   |   |                   | and see what can   |
|                   |   |   |                   | be done within     |
|                   |   |   |                   | regulations to     |
|                   |   |   |                   | compensate OT.     |
|                   |   |   |                   | Educate            |
|                   |   |   |                   | administrators in  |
|                   |   |   |                   | ways to recognize  |
|                   |   |   |                   | their staff        |
|                   |   |   |                   | formally &         |
|                   |   |   |                   | informally.        |
|                   |   |   |                   | Develop formal HQs |
|                   |   |   |                   | Nursing Morale     |
|                   |   |   |                   | Boosting/Team      |
|                   |   |   |                   | Building           |
|                   |   |   |                   | Initiative.        |
+-------------------+---+---+-------------------+--------------------+
| Indian preference | 4 | 3 | #1 factor         | Educate staff      |
| policies of ITU   |   |   | influencing       | regarding Indian   |
|                   |   |   | inpatient         | preference         |
|                   |   |   | supervisors and   | according to laws  |
|                   |   |   | APNs to leave     | and IHS mandates.  |
|                   |   |   |                   | Support and        |
|                   |   |   |                   | increase           |
|                   |   |   |                   | educational        |
|                   |   |   |                   | opportunities to   |
|                   |   |   |                   | achieve and        |
|                   |   |   |                   | enhance            |
|                   |   |   |                   | qualifications and |
|                   |   |   |                   | skills.            |
+-------------------+---+---+-------------------+--------------------+
| **Factor**        | * | * | **Survey          | **Survey           |
|                   | * | * | respondents       | respondents        |
|                   | 9 | 8 | comments of       | recommendations**  |
|                   | 8 | 4 | dissatisfaction** |                    |
|                   | * | R |                   |                    |
|                   | * | a |                   |                    |
|                   |   | n |                   |                    |
|                   | * | k |                   |                    |
|                   | * | o |                   |                    |
|                   | R | r |                   |                    |
|                   | a | d |                   |                    |
|                   | n | e |                   |                    |
|                   | k | r |                   |                    |
|                   | o | o |                   |                    |
|                   | r | f |                   |                    |
|                   | d | f |                   |                    |
|                   | e | a |                   |                    |
|                   | r | c |                   |                    |
|                   | o | t |                   |                    |
|                   | f | o |                   |                    |
|                   | f | r |                   |                    |
|                   | a | s |                   |                    |
|                   | c | * |                   |                    |
|                   | t | * |                   |                    |
|                   | o |   |                   |                    |
|                   | r |   |                   |                    |
|                   | s |   |                   |                    |
|                   | * |   |                   |                    |
|                   | * |   |                   |                    |
+-------------------+---+---+-------------------+--------------------+
| Training and      | 5 | 2 | In general,       | Inform employees   |
| career            |   |   | registered nurses | on distance        |
| development       |   |   | are not as        | educational        |
| opportunities     |   |   | satisfied with    | opportunities on   |
|                   |   |   | opportunities to  | Internet and       |
|                   |   |   | maintain or       | through satellite. |
|                   |   |   | improve their     |                    |
|                   |   |   | skills and        | Bring training to  |
|                   |   |   | training through  | the local service  |
|                   |   |   | continuing        | areas so that it   |
|                   |   |   | education as they | is more readily    |
|                   |   |   | are with the      | available to       |
|                   |   |   | other aspects of  | staff. Develop new |
|                   |   |   | their             | tracks so that     |
|                   |   |   | professional work | staff can stay in  |
|                   |   |   | environment.      | direct client care |
|                   |   |   |                   | and still be       |
|                   |   |   |                   | promoted. Educate  |
|                   |   |   |                   | facility and       |
|                   |   |   |                   | tribal leaders on  |
|                   |   |   |                   | importance of      |
|                   |   |   |                   | educated           |
|                   |   |   |                   | workforce.         |
+-------------------+---+---+-------------------+--------------------+
| Professional      | 6 | 5 | Dissatisfaction   | Administrators at  |
| recognition and   |   |   | centered on the   | all levels will    |
| status            |   |   | lack of           | promote            |
|                   |   |   | recognition,      | recognition of     |
|                   |   |   | respect, and      | nursing            |
|                   |   |   | support for       | achievement and    |
|                   |   |   | nursing as a      | contributions to   |
|                   |   |   | profession.       | the facility and   |
|                   |   |   | Nurses felt there | the community.     |
|                   |   |   | should be more    | Make starting      |
|                   |   |   | value of          | salaries more      |
|                   |   |   | nursing's         | comparable with    |
|                   |   |   | contributions to  | local public or    |
|                   |   |   | the overall       | private sector pay |
|                   |   |   | health care       | scales. Provide    |
|                   |   |   | process, without  | clear, concise     |
|                   |   |   | which no health   | policies that are  |
|                   |   |   | facility could    | enforceable and    |
|                   |   |   | function.         | realistic.         |
+-------------------+---+---+-------------------+--------------------+
| Quality of        | 7 | 7 | Lack of:          | Assure potential   |
| nursing           |   |   | recognition of    | and current        |
| supervision       |   |   | nursing skills,   | nursing obtains    |
|                   |   |   | enhancement of    | formal training to |
|                   |   |   | self-esteem,      | effective          |
|                   |   |   | leadership and    | leadership skills  |
|                   |   |   | problem solving.  | (specifically      |
|                   |   |   |                   | Indian Health      |
|                   |   |   |                   | ELDP).             |
|                   |   |   |                   | Administration     |
|                   |   |   |                   | must listen to     |
|                   |   |   |                   | comments and input |
|                   |   |   |                   | offered by staff   |
|                   |   |   |                   | and incorporates   |
|                   |   |   |                   | feedback into      |
|                   |   |   |                   | positive solutions |
|                   |   |   |                   | and actions.       |
+-------------------+---+---+-------------------+--------------------+
| Expectations      | 8 | 1 | 25% were          | Assist             |
| placed on you by  |   | 4 | dissatisfied with | administration in  |
| administration    |   |   | expectations of   | including staff in |
|                   |   |   | immediate         | planning scope of  |
|                   |   |   | supervisors.      | work and assigning |
|                   |   |   |                   | responsibilities   |
|                   |   |   |                   | and being more     |
|                   |   |   |                   | involved in the    |
|                   |   |   |                   | bigger picture of  |
|                   |   |   |                   | Indian Health      |
|                   |   |   |                   | (Strategic, GPRA)  |
+-------------------+---+---+-------------------+--------------------+
| Relationship with | 9 | 2 | Only slight       | Aggressively       |
| ITU nursing       |   | 0 | variation among   | peruse open and    |
| management        |   |   | areas and         | timely             |
|                   |   |   | specialties.      | communication and  |
|                   |   |   |                   | sharing of         |
|                   |   |   |                   | information and    |
|                   |   |   |                   | resources.         |
+-------------------+---+---+-------------------+--------------------+
| Quality of        | 1 | 1 | Due to some       | Education and      |
| education         | 0 | 9 | remote locations, | inform new and     |
| available in the  |   |   | opportunities     | current staff      |
| community for     |   |   | limited.          | regarding          |
| your children     |   |   |                   | resources          |
|                   |   |   |                   | available in the   |
|                   |   |   |                   | context of the     |
|                   |   |   |                   | Indian community.  |
+-------------------+---+---+-------------------+--------------------+
| Available support | 1 | 8 | The opportunity   | Opportunities to   |
| for in-services,  | 1 |   | to improve skills | maintain or        |
| continuing        |   |   | and knowledge was | improve skills     |
| education         |   |   | the third         | must be made       |
|                   |   |   | dissatisfiers     | available. Provide |
|                   |   |   | among factors     | support for        |
|                   |   |   | presented that    | nursing to utilize |
|                   |   |   | influences nurses | their training     |
|                   |   |   | to leave.         | monies and         |
|                   |   |   |                   | educational leave. |
|                   |   |   |                   | Be creative in     |
|                   |   |   |                   | assisting staff to |
|                   |   |   |                   | obtain continuing  |
|                   |   |   |                   | education.         |
+-------------------+---+---+-------------------+--------------------+
| Availability of   | 1 | 1 | Highest level of  | Educate staff      |
| child day care    | 2 | 6 | dissatisfaction   | regarding          |
| centers           |   |   | in Navajo &       | availability of    |
|                   |   |   | Aberdeen          | services in the    |
|                   |   |   |                   | community.         |
+-------------------+---+---+-------------------+--------------------+
| Overall program   | 1 | 1 | 23% influenced to | Standardize        |
| policies and      | 3 | 2 | leave             | policies and       |
| priorities        |   |   |                   | enforce them       |
|                   |   |   |                   | consistently. Have |
|                   |   |   |                   | nurses participate |
|                   |   |   |                   | in establishing    |
|                   |   |   |                   | priorities.        |
+-------------------+---+---+-------------------+--------------------+
| **Factor**        | * | * | **Survey          | **Survey           |
|                   | * | * | respondents       | respondents        |
|                   | 9 | 8 | comments of       | recommendations**  |
|                   | 8 | 4 | dissatisfaction** |                    |
|                   | * | R |                   |                    |
|                   | * | a |                   |                    |
|                   |   | n |                   |                    |
|                   | * | k |                   |                    |
|                   | * | o |                   |                    |
|                   | R | r |                   |                    |
|                   | a | d |                   |                    |
|                   | n | e |                   |                    |
|                   | k | r |                   |                    |
|                   | o | o |                   |                    |
|                   | r | f |                   |                    |
|                   | d | f |                   |                    |
|                   | e | a |                   |                    |
|                   | r | c |                   |                    |
|                   | o | t |                   |                    |
|                   | f | o |                   |                    |
|                   | f | r |                   |                    |
|                   | a | s |                   |                    |
|                   | c | * |                   |                    |
|                   | t | * |                   |                    |
|                   | o |   |                   |                    |
|                   | r |   |                   |                    |
|                   | s |   |                   |                    |
|                   | * |   |                   |                    |
|                   | * |   |                   |                    |
+-------------------+---+---+-------------------+--------------------+
| Quality of        | 1 | 1 | 22% were          | Be clear in skill  |
| support staff     | 4 | 5 | influenced to     | level and          |
|                   |   |   | leave.            | expectations of    |
|                   |   |   |                   | support.           |
+-------------------+---+---+-------------------+--------------------+
| Opportunities in  | 1 | 1 | Concerns          | Provide cross      |
| nursing           | 5 | 7 | regarding Indian  | training into      |
| administration    |   |   | Preference and    | specialty areas.   |
|                   |   |   | continuing        | Maximize           |
|                   |   |   | education         | educational        |
|                   |   |   | opportunities     | funding            |
|                   |   |   |                   | opportunities      |
|                   |   |   |                   | available to       |
|                   |   |   |                   | nursing            |
|                   |   |   |                   | administrators.    |
+-------------------+---+---+-------------------+--------------------+
| Professional      | 1 | 1 | Because of        | Expand the Indian  |
| isolation         | 6 | 0 | remoteness nurses | Health network,    |
|                   |   |   | feel outside the  |                    |
|                   |   |   | world of nursing. | communications     |
|                   |   |   |                   | between            |
|                   |   |   |                   | organizations, and |
|                   |   |   |                   | opportunities to   |
|                   |   |   |                   | attend regional    |
|                   |   |   |                   | meetings.          |
+-------------------+---+---+-------------------+--------------------+
| Requirement to    | 1 | 9 | Required to do    | Educate and        |
| perform nursing   | 7 |   | non-nursing       | demonstrate the    |
| tasks that        |   |   | duties,           | nursing scope of   |
| underutilize      |   |   | preventing        | practice to        |
| skills and        |   |   | fullest extent of | reflect the need   |
| knowledge         |   |   | training.         | for nursing to     |
|                   |   |   |                   | concentrate on own |
|                   |   |   |                   | position           |
|                   |   |   |                   | description.       |
+-------------------+---+---+-------------------+--------------------+
| Recreational      | 1 | 2 | Aberdeen Area had | Educate all        |
| activities for    | 8 | 4 | a 20%             | employees about    |
| your children     |   |   | dissatisfaction   | organizational and |
|                   |   |   | rate with this    | community          |
|                   |   |   | factor.           | resources.         |
+-------------------+---+---+-------------------+--------------------+
| Ability to        | 1 | 1 | Nurses often      | Maximize available |
| provide quality   | 9 | 3 | brought up        | nursing staff by   |
| nursing care with |   |   | inadequate        | utilizing the      |
| available staff   |   |   | staffing and its  | concept of cross   |
|                   |   |   | negative impact   | training,          |
|                   |   |   | on nursing cares. | decreasing         |
|                   |   |   | Need to improve   | non-nursing        |
|                   |   |   | the patient/staff | duties, and        |
|                   |   |   | ratio to improve  | maximizing the use |
|                   |   |   | optimum nursing   | of support staff.  |
|                   |   |   | care.             |                    |
+-------------------+---+---+-------------------+--------------------+
| Environment in    | 2 | 2 | Over 20% of       | Educate all        |
| which to raise    | 0 | 6 | nurses in the     | employees about    |
| your children     |   |   | more remote areas | organizational and |
|                   |   |   | were dissatisfied | community          |
|                   |   |   | with the adequacy | resources. Promote |
|                   |   |   | of housing for    | and assist all     |
|                   |   |   | their dependent   | staff and families |
|                   |   |   | children.         | to use these       |
|                   |   |   |                   | resources.         |
+-------------------+---+---+-------------------+--------------------+

## 

## Summary 

Nursing represents the largest workforce in the Indian Health Care
System and plays a critical role in the delivery of health care. Current
nursing statistics reveal that we are already feeling the effects of the
predicted nursing shortage. It is imperative that we act now to improve
nursing recruitment and retention efforts. Statistics show that
two-thirds of the 2,500 nurses currently working for Indian Health
Service will be retired or at retirement age in ten years. The IHS
vacancy rate for nurses' ranges from 8-12% while the national average is
6-8%.

The average age of RN's nationally is 44.5 years and more than half of
the nation's 2.5 million RNs will reach retirement age within the next
15 years. According to the American Association Of College of Nursing
(AACN), if the current trends continue, rising demand for nurses will
outstrip the supply beginning in 2010. They are predicting 114,000 jobs
for full-time RNs to go unfilled nationwide. Over the past four years,
there has been a 5.5% yearly decline in nursing school enrollments. The
AACN feels this has been due in part to headlines several years ago of
hospital downsizing and RN layoffs in various markets, which created
lasting but outdated perceptions in many potential students.

For the past several years there has been a national shortage of
experienced nurses, especially in ICU, OR, ER, and Labor & Delivery so
that many agencies have used sign-on bonuses ranging from \$1,000 to
\$10,000 nation wide. Many hospitals are now offering new graduates
sign-on bonuses to get them into their own training programs. Nursing
shortages are cyclic and occur about every ten years but this one is
predicted to be one of the "worst" as it is difficult to predict the
shortage compounded with the "aging of the population and aging of the
nurse population" and the demands this is placing on the health care
industry. The I/T/U is already feeling the nursing shortage in specialty
nursing areas.

Salaries and benefits continue to be a positive factor in the retention
of nurses. The current salaries are now at the lower end of the national
average nurse salary range. Advanced practice salaries are not
competitive and fall up to 35% below the national average. The American
Association of Nurse Midwifes states that beginning salaries for
advanced practice nurses directly out of school is \$65,000 nation wide
compared to \$43,170 as a GS 9 in IHS. After one year's experience these
salaries increase to \$48,320 in IHS, which is still 26% below national
average. Nursing salaries need to be made a priority. They must remain
competitive in order to continue our ability to recruit and retain
qualified nursing staff.

The survey shows that overall, the RN's responding to the survey are a
highly motivated and satisfied group. Based on the results of the
survey, management at Headquarters, Area offices, and at the local
service area must make an effort and commitment to address and improve
in many areas. These areas include:

-   Continuing education availability

-   Equality of opportunity for career advancement

-   Management that values input of nursing staff

-   Minimizing non-nursing functions

-   Improving the quality of supervision

-   Improved communication at all levels so all nurses will have input

Throughout this process, communication and timely dissemination of
information is essential to achieving retention; as is the need to pay
attention and be aware of the upcoming national trends affecting nursing
both in and outside of Indian country. We must look closely at what
nurses currently working for I/T/U are saying in the 1998 IHS Survey
about recruitment and retention. Administrators need to start planning
now for the future and have an effective plan to meet the supply and
demand of nurses needed to effectively deliver healthcare in Indian
country.

This Executive Summary was presented and approved by the NCON and NCONA
at their June 2000 meetings. This Executive Summary will also be
presented by the NCON Chair, Pat Smith, to the IHS Executive Leadership
Group (ELG) by August of 2000. The NCON Strategic Plan is currently
addressing recruitment and retention issues in several of their
identified goals.

The complete "Factors Influencing Recruitment and Retention Of
Registered Nurse: A Survey of Registered Nurses in the Indian Health
Care System -- 1998" is available for review at each area and soon will
be available on the IHS Web Site. Recruitment and Retention is such a
broad and complex issue that it must be addressed at all levels. This
means that it is strongly recommended that Recruitment and Retention
Committees and Initiatives be established at the National, Area, and
Service Areas.