From the caring value to the bottom line: the impact of health care reform on nursing.

How do staff nurses view the complex changes that have resulted from health care reform? What has been the impact of changes in care delivery on job satisfaction and career commitment? W A qualitative research study was completed with the purpose of seeing these changes through the eyes of a group of staff nurses. Personal experiences of nurses who have witnessed recent transitions can lead to a greater understanding of the dynamics of change and the effects on the nursing profession. It should be noted that four months after the completion of this research, the obstetrics/gynecology unit in the large, urban teaching hospital where this study was conducted was closed due to hospital restructuring. Some of the nurses who participated in this study lost their jobs as a result of the transition. How the System Has Changed Health care reform and the need to reduce the costs of care have created changes in the health care delivery system. Widespread hiring of unlicensed assistants who lack standards of competency for nursing tasks has led to transformations in responsibility, authority, and accountability for nursing functions. Economic and political restructuring has led to the integration of many hospitals into multi-institutional health care corporations. New reimbursement regulations have led to downsizing and hospital closings. These profound changes, which involve all aspects of health care in this country, have dramatically affected nursing and created a need for innovative models for nursing practice in the future. The Study Ten staff RNs were interviewed individually about current working conditions. Cluster and factor analyses were used to analyze the data. Clarification of the obtained information was reviewed with a nursing professor to minimize bias and validate the perceptions during the data analysis process. The findings suggest that transformations in health care delivery have had a significant impact on the nurses interviewed for the study and their perceptions of their work environment, their job satisfaction, and their commitment to the nursing profession. Participants were significantly affected by changes made to contain costs and increase productivity. Nine of the ten nurses alluded to role confusion, poor management of time, increased responsibilities, and ambiguous expectations. As one respondent stated, "The organization and everybody ... knowing what their job is ... what's expected of each person, as far as nurses and CSAs (clinical support associates or unlicensed personnel) ... people expect certain things that other people don't, and there's just ... confusion." Another nurse stated, "I feel like they're trying to lump us together... and they're not making the distinction between a registered nurse and a CSA." Nine of the nurses expressed skepticism or negativism related to their work lives. Four spoke of the significance of caring for others, while seven alluded to self-preservation. As one nurse stated, "I think everybody has to look out for themselves now." Personal enthusiasm toward work as a nurse may not necessarily be related to working conditions. It may be more an attitude of conscious choice in spite of the surrounding environment. A nurse who spoke of frustration, disillusionment, and exhaustion with her job also stated, "I love being a nurse . …