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Hallmarks of the Professional Nursing Practice Environment

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The work environment for the practice of nursing has long been cited as one of the most demanding across all types of work settings. Nurses provide the vast majority of patient care in hospitals, nursing homes, ambulatory care sites, and other health care settings (AONE, 2000). The first objective of the professional practice environment for nurses is to put the patient first. Nurses and health care organizations must focus on patient safety and care quality and always ask the question, "What is best for our patients?"

In recent years a variety of factors have converged to challenge the work environments of contemporary nurses. Rapid advances in biomedical science, improved disease prevention and management, integration of new clinical care technologies, and shifts in care delivery to a broad array of clinical sites have contributed to the rapidly increasing need for well-educated, experienced nurses. Additionally, population demographics are changing as the public ages in growing numbers and becomes increasingly diverse in culture and language.
The charge of this AACN task force was to identify those environmental characteristics or "hallmarks" of the practice setting that best support professional nursing practice and allow baccalaureate- and higher degree-prepared nurses to practice to their full potential. These "hallmarks" may inform students and new graduates, nurse educators, executives, and practicing nurses about key characteristics of health care settings that promote professional nursing practice.


Background

Current Environment for the Practice of Nursing
Health care delivery has changed dramatically and rapidly. The Board of the American Hospital Association's Society for Healthcare Human Resources believes that the attractiveness of careers in health care, especially hospital care, is markedly different than twenty years ago. "In a single generation, health care has moved from a favored to a less favored employment sector" (AHA, 2001). Significant drivers of this change have been economic constraints resulting from changes in reimbursement for care, rapid advances in clinical technologies and care modalities, and corporatism of health care systems. Hospitals and health systems have been forced to focus on cost control and restructuring of operations to achieve maximum efficiencies. Many cost savings in health care have been realized at the expense of direct caregivers, including downsizing of the professional nursing workforce, restructuring of nursing services, changes in staffing mix, rapid movement of patients to alternative care settings, and decreased support services for patient care. Furthermore, poor collaboration among health care providers hampers efforts to provide quality care in today's health systems. Many nurses describe the current work environment as highly stressful and professionally unfulfilling (Josiah Macy Foundation, 2000).
Exacerbating the challenges to the work environment for nursing practice is the nationwide shortage of nurses and other allied health professionals. Key government agencies and professional nursing organizations have reported on issues related to the national nursing workforce. Evidence suggests that, if left unchecked, current shortages of nurses will escalate into a national health care crisis by the year 2010. Multiple factors of demand, supply, and the aging workforce have contributed to the problem of insufficient numbers of nurses available to care for the rising needs of the American public. Although the actual supply of nurses has continued to grow; it has not kept up with the significant increase in demand for nurses.
 
Increasing Demand
  • Demand for nurses has exceeded supply in certain types of patient care specialties, such as critical care, cardiac, neonatal, and perioperative nursing (ANA, 2000).
  • Demand is particularly great in some geographical regions due in part to a maldistribution of nurses throughout the United States, e.g., Massachusetts has twice the number of nurses per capita as California.
  • Demand has intensified for more baccalaureate-prepared nurses with skills in critical thinking, case management, and health promotion skills across a variety of inpatient and outpatient settings (Goode, et al., 2001).
  • Demand has increased for more culturally competent nurses with knowledge of gerontology and long-term care because of rapidly changing population demographics (President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry, 1998).
Slow Growth in Supply
  • Supply of new nurses has decreased with declining numbers of new students and declining applications to schools of nursing (NACNEP, 1996; AACN, 1999b; AACN, 2001).
  • Supply of nurses is adversely impacted by faculty shortages in schools of nursing making it difficult to increase the number of students across the country (AACN, 1999a).
  • Supply of nurses is affected by a highly competitive labor market that attracts the best candidates away from health professions careers (AHA, 2001).
  • Supply of nurses is negatively influenced by the inaccurate media images of nursing, decreasing the selection of nursing career options by young people (William Mercer, Inc., 1999).
Aging of the Nursing Workforce
  • The current nursing workforce is estimated to be nearly 2.7 million, with the average age of nurses at 45.2 years. Of these, only 82% or 2.2 million are employed either full- or part-time in nursing with an average age of 43.3 years. (U.S. Department of Health & Human Services, Bureau of Health Professions, Division of Nursing, 2001).
  • The largest cohort of currently practicing nurses will be in their 50s or 60s in the next decade, with many of these nurses retiring or decreasing their work time (Buerhaus, Staiger & Auerbach, 2000).
  • The average age of nurses is increasing at more than twice the rate of all other occupations in the U.S. workforce, with the number of nurses under age 30 decreasing by 41 percent from 1983 to 1998 (Needleman, et al., 2001).
The impact of increasing demand and decreasing supply of registered nurses and rapid aging of the nursing workforce means that by the year 2020 there will be a 20 percent shortage in the number of nurses needed in the U.S. health care system. This translates into an unprecedented shortage of more than 400,000 registered nurses (Buerhaus, Staiger & Auerbach, 2000).


Work Environments that Support Professional Nursing Practice

Magnet Hospital Recognition
In 1983, with the publication of the original Magnet Hospital study, nursing leaders began to have a greater understanding of factors that helped to attract and retain professional nurses in the nation's health care system (McClure, et al., 1983). The American Academy of Nursing of the American Nurses Association initiated a nationwide investigation of hospitals known for successful nurse recruitment and retention. In this original study, 41 hospitals were identified that met selection criteria for "best practices" supporting nursing practice.
Follow-up studies of these hospitals through the 1980s and 1990s contributed important evidence to support those factors that earned these hospitals a reputation for excellence in nursing practice (Kramer & Schmalenberg, 1988; Kramer & Hafner, 1989; Aiken, Smith & Lake, 1994; Aiken, Sochalski & Lake, 1997; Havens & Aiken, 1999). By 1993, the American Nurses Association through the American Nurses Credentialing Center established the Magnet Hospital Recognition Program to identify excellence in the provision of nursing services. This program recognized those health care institutions that acted as a "magnet" for professional nurses by creating a work environment that rewarded quality nursing services. The name of the program was changed in 1996 to the Magnet Nursing Services Recognition Program for Excellence in Nursing Services. The program was expanded in 1998 to include long-term care facilities. Today, the Magnet Nursing Services designation is a four-year recognition and the highest level of reward that can be accorded to organized nursing services in health care organizations (ANCC, 2001).
The foundation for the Magnet Nursing Services program is the Scope and Standards for Nurse Administrators (ANA, 1995). The program provides a framework to recognize excellence in:
1) nursing services management, philosophy, and practices;
2) adherence to standards for improving the quality of patient care;
3) leadership of the chief nurse executive and competence of nursing staff; and
4) attention to the cultural and ethnic diversity of patients, their significant others, and the care providers in the health care system.
Nurse scientists have continued to evaluate magnet hospitals. Recent studies have substantiated improved patient outcomes within organizational environments that support professional nursing practice. The Magnet Nursing Services designation remains a valid marker of excellence in nursing care (Aiken, Havens & Sloane, 2000).
Preceptorships and Residencies
With the increased complexity of health care environments, there has been an identified need to provide clinical experiences that assist students and graduates to make the transition to the work setting with more realistic expectations and maximal preparation (Mills, Jenkins & Waltz, 2000). One approach has been for education and service to partner to create summer internships, externships, and senior capstone preceptored experiences. Students working closely with staff nurses have the opportunity for role socialization as well as increasing clinical skills, knowledge, competence, and confidence (Letizia & Jennrich, 1998; Mills, Jenkins & Waltz, 2000; Nordgren, Richardson & Laurella, 1998). In addition, extended preceptorships have proven to be excellent recruitment devices, often decreasing the cost of lengthy orientation programs and reducing turnover rates (Mills, Jenkins & Waltz, 2000; Woodtli, Hazzard & Rusch, 1988).
 
Post-graduate residencies or internships are another mechanism being developed to more effectively transition the new graduate into the practice arena. Residencies are usually described as formal contracts between the employer and the new graduate defining clinical activities to be performed by the new nurse in exchange for additional educational offerings and experiences to further the new graduate's professional development (NLN, 1983). In a University HealthSystem Consortium survey of chief nursing officers (2000), 85 percent of responding CNOs reported having an extended program of orientation for new graduates. Mentoring of the new graduate by experienced professional nurses can be a key component in producing beneficial outcomes for both the mentor and mentee (Talarczyk & Milbrandt, 1988). Overall, residencies have been shown to facilitate recruitment, increase retention, and increase commitment (Currie, Vierke & Greer, 2000; Hunter, Pollman & Moore, 1990; Kasprisin & Young, 1985).
 
Differentiated Nursing Practice
Differentiated practice models are models of clinical nursing practice that are defined or differentiated by level of education, expected clinical skills or competencies, job descriptions, pay scales, and participation in decision making (AACN, AONE & N-OADN, 1995: Bellack & Loquist, 1999; Moritz, 1991; Pitts-Wilhelm, Nicolai & Koerner, 1991). Differentiated practice models have been implemented in acute care inpatient settings, rural community nursing centers, and acute care operating rooms (Anderko, Robertson & Lewis, 1999; Hutchens, 1994; Anderko, Uscian & Robertson, 1999; Graff, Roberts & Thornton, 1999; Malloch, Milton & Jobes, 1990; Milton, et al., 1992).
 
Evidence indicates that differentiated practice models foster positive outcomes for job satisfaction, staffing costs, nurse turnover rates, adverse events (i.e., patient falls and medication errors), nursing roles, and patient interventions and outcomes (Anderko, Robertson & Lewis, 1999; Anderko, Uscian & Robertson, 1999; Hutchens, 1994; Malloch, Milton & Jobes, 1990). Differentiated practice outcomes include the opportunity for healthcare delivery organizations to capitalize on the education and experience provided by varied educational programs leading to RN licensure. The registered nurse has the opportunity to practice to his or her potential, taking full advantage of educational preparation. Often, differentiated models of practice are supported by a clinical "ladder" or defined steps for advancement within the organization based on experience in nursing, additional education, specialty certification, or other indicators of professional excellence.
 
Interdisciplinary Collaboration
In 1999, the Institute of Medicine (IOM) issued a comprehensive report, To Err is Human: Building a Safer Health System, summarizing problems of patient safety in the U.S. health system (IOM, 1999). One important recommendation was to create improved safety systems inside health care through implementation of safe practices at the delivery level, including interdisciplinary clinical practice among health professionals. Interdisciplinary practice or collaboration is defined as a joint decision-making and communication process among health care providers with the goal of satisfying the needs of the patient while respecting the unique abilities of each professional involved in the care (Colluccio & McGuire, 1983). Attributes of interdisciplinary collaboration include trust, knowledge, mutual respect, good communication, cooperation, coordination, shared responsibility, and optimism (Arcangelo, et al., 1996).
Many professional education programs for medical, nursing, and allied health students now require curricula that support interdisciplinary practice in a variety of clinical settings. These programs should emphasize teamwork, conflict resolution, and the use of informatics to promote collaboration in patient care planning and implementation (Wakefield & O'Grady, 2000). Today's best integrated health delivery systems are evolving toward a model of care in which interdisciplinary teams of providers manage the care of complex patients. Studies of environments that support collaboration among physicians, nurses and allied health professionals have shown evidence of improved outcomes for both acutely and chronically ill patients (Pew Health Professions Commission, 1998).
 
Recommendations
In this era of increasing health care workforce shortages, there is an ever expanding need for high-quality professional nursing care due largely to changes in the socio-demographics of the population and in the health care system itself. There is a critical need to fully utilize the knowledge and skills of professional nurses and to ensure their retention in the profession as well as attract an increased number of individuals into the discipline. The hallmarks of the practice setting that support and optimize professional nursing practice and allow the baccalaureate- and higher degree-prepared nurse to practice to their full potential are identified.
 
Clinical practice refers to all direct and indirect patient care activities undertaken to provide nursing care to individuals, families, or groups. Practice sites encompass a wide array of settings, including acute care facilities, extended care institutions, clinics, homes, and other community venues (AACN, 1999a). These hallmarks are intended to apply to all professional practice settings and all types of nursing practice. The hallmarks may be useful to new graduates, practicing nurses, students, faculty, nurse executives and managers, and employers across all nursing practice settings. AACN has developed this list of hallmarks, with accompanying specific questions in Appendix A, to assist nursing students educated at the baccalaureate level and above in making the best decision on where to practice following graduation.


Hallmarks of the Professional Nursing Practice Environment

Hallmarks are characteristics of the practice setting that best support professional nursing practice and allow baccalaureate and higher degree nurses to practice to their full potential. These Hallmarks are present in health care systems, hospitals, organizations, or practice environments that:
 
1. Manifest a philosophy of clinical care emphasizing quality, safety, interdisciplinary collaboration, continuity of care, and professional accountability, for example:
  • The organization has a philosophy and mission statement that reflects these criteria;
  • Nursing staff have meaningful input into policy development and operational management of issues related to clinical quality, safety, and clinical outcomes evaluation;
  • Nurse staffing patterns have an adequate number of qualified nurses to meet patients' needs, including consideration of the complexity of patient care;
  • Nursing is represented on the organization's staff committees that govern policy and operations;
  • The organization has a formal program of performance improvement that includes a focus on nursing practice, safety, continuity of care, and outcomes; and
  • Nursing staff assume responsibility and accountability for their own nursing practice.
2. Recognize contributions of nurses' knowledge and expertise to clinical care quality and patient outcomes, for example:
  • The organization differentiates the practice roles of nurses based on educational preparation, certification, and advanced preparation;
  • The organization has a compensation and reward system that recognizes role distinctions among staff nurses and other expert nurses, e.g. based on clinical expertise, reflective of nursing practice, education, or advanced credentialing;
  • The organization's performance improvement program has criteria to evaluate whether nursing care practices are based on the most current research evidence;
  • Professional and educational credentials of all disciplines, including nurses, are recognized by title on nametags and reports;
  • Nurses and other disciplines participate in media events, public relations announcements, marketing of clinical services, and strategic planning;
  • Nurses are encouraged to be mentors to less experienced colleagues and to share their enthusiasm about professional nursing within the organization and the community; and
  • Advanced nursing roles, including clinical nurse specialists, nurse practitioners, scientists, educators, and other advanced practice roles, are utilized in the organization to support and enhance nursing care.
3. Promote executive level nursing leadership, for example:
  • Nurse executive participates on the governing body;
  • Nurse executive reports to highest level operations or corporate officer;
  • Nurse executive has the authority and accountability for all nursing or patient care delivery, financial resources, and personnel; and
  • Nurse executive is supported by adequate managerial and support staff.
4. Empower nurses' participation in clinical decision-making and organization of clinical care systems, for example:
  • Decentralized, unit-based program or team organizational structure for decision making;
  • Organization or system-wide committee and communication structures include nurses;
  • Demonstrated leadership role for nurses in performance improvement of clinical care and the organization of clinical care systems;
  • Utilization review system for nursing analysis and correction of clinical care errors and patient safety concerns; and
  • Staff nurses have the authority to develop and execute nursing care orders and actions and to control their practice.
5. Maintain clinical advancement programs based on education, certification, and advanced preparation, for example:
  • Financial rewards available for clinical advancement and education;
  • Opportunities for promotion and longevity related to education, clinical expertise and professional contributions;
  • Peer review, patient, collegial, and managerial input available for performance evaluation on annual or routine basis; and
  • Individuals in nursing leadership/management positions have appropriate education and credentials aligned with their role and responsibilities.
6. Demonstrate professional development support for nurses, for example:
  • Professional continuing education opportunities available and supported;
  • Resource support for advanced education in nursing, including RN-to-BSN completion programs and graduate degree programs;
  • Preceptorships, organized orientation programs, re-tooling or refresher programs, residency programs, internships, or other educational programs available and encouraged;
  • Incentive programs for registered nursing education for interested licensed practical nurses and non-nurse health care personnel;
  • Long-term career support program targeted to specific populations of nurses, such as older individuals, home care or operating room nurses, or nurses from diverse ethnic backgrounds;
  • Specialty certification and advanced credentials are encouraged, promoted, and recognized;
  • APNs, nurse researchers, and nurse educators are employed and utilized in leadership roles to support clinical nursing practice; and
  • Linkages are developed between health care institutions and baccalaureate/graduate schools of nursing to provide support for continuing education, collaborative research, and clinical educational affiliations.
7. Create collaborative relationships among members of the health care provider team, for example:
  • Professional nurses, physicians, and other health care professionals practice collaboratively and participate in standing organizational committees, bioethics committees, the governing structure, and the institutional review processes;
  • Professional nurses have appropriate oversight and supervisory authority of unlicensed members of the nursing care team; and
  • Interdisciplinary team peer review process is used, especially in the review of patient care errors.
8. Utilize technological advances in clinical care and information systems, for example:
  • Documentation is supported through appropriate application of technology to the patient care process;
  • Appropriate equipment, supplies, and technology is available to optimize the efficient delivery of quality nursing care; and
  • Resource requirements are quantified and monitored to ensure appropriate resource allocation.
AACN Task Force on Hallmarks of the Professional Practice Setting
Karen L. Miller, PhD, RN, FAAN, Task Force Chair
Dean, School of Nursing
University of Kansas
Carol Bradley, MSN, RN
Consultant, CAREforce Consulting Group
Rebecca Jones, DNSc, RN, CNAA
Provost, Concordia University and West Suburban College of Nursing
Maureen P. McCausland, DNSc, RN, FAAN
Chief Nursing Executive, University of Pennsylvania Health System and
Associate Dean for Nursing Practice and Professor of Nursing Administration, School of Nursing, University of Pennsylvania
Kathleen Potempa, DNSc, RN, FAAN
Dean, School of Nursing
Oregon Health and Science University
Diane Rendon, EdD, RN
Director, Hunter-Bellevue School of Nursing
Hunter College of CUNY
Joan Stanley, PhD, RN, CRNP, Staff Liaison
Director of Education Policy
American Association of Colleges of Nursing

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APPENDIX A

 
Suggested Questions for Interview for a Professional Nursing Practice Position
1. Manifest a philosophy of clinical care emphasizing quality, safety, interdisciplinary collaboration, continuity of care, and professional accountability.
  • Does the organization have a written philosophy and mission statement that reflect an emphasis on quality, safety, interdisciplinary collaboration, continuity of care, and professional nursing accountability?
  • Does the organization have committees with nursing representation that provide input into policy development and operational management of issues related to quality of care, safety, continuity of care, patient-staff ratios, and clinical outcomes?
  • Does the organization have a formal mechanism for quality assurance that includes criteria to assess whether nursing practice is based on the most current research evidence?
  • What is the nurse-to-patient ratio? What support staff are available on the unit to assist nurses?
2. Recognize the contributions of nurses' knowledge and expertise to clinical care quality and patient outcomes.
  • Request a copy of the job description(s) of the registered nurse.
  • How does the organization hold professional nurses accountable for high quality practice?
  • Does the annual performance evaluation have explicit criteria related to level of practice expertise?
  • Are there differentiated practice levels or roles for nursing congruent with differences in educational preparation, certification, and other advanced preparation in nursing (i.e. continuing education)?
  • Does the organization have differentiated pay scales that recognize role distinctions and educational preparation among staff nurses?
  • Does the organization recognize professional role distinctions among all disciplines by title on nametags, etc?
  • Does the organization utilize clinical nurse specialists, nurse practitioners, nurse scientists and/or educators to support and enhance the work of staff nurses in clinical care?
3. Promote executive level nursing leadership.
  • What are the key responsibilities/accountabilities of the top nurse executive? (Request a copy of the job description.)
  • Request a copy of the organizational chart of the governing body and hospital structure to determine:
- Where is the top nursing voice in the organizational chart?
- Where are nurses represented in key committees and activities of governance?
  • Request a copy of the organizational chart of the patient care/nursing services:
- What is the chain of command?
- What resources and functions fall under the domain of the nurse executive?
- What professional development, educational, and research functions are included in nursing services?
4. Empower nurses' participation in clinical decision-making and organization of clinical care systems.
  • Do nurses control decisions directly related to nursing practice and delivery of nursing care, such as staffing, nursing quality improvement, and peer review?
  • Do nurses have input into the systems, equipment, and environment of care?
  • How is nurse staffing addressed in the hospital plan of care? (Request a copy of the hospital plan of care.)
  • Request a copy of the unit/department plan of care to determine:
- What is the specific patient population and nature of nursing care on this unit?
- What issues are evident in the performance improvement plans for this department?
- What role is defined for nursing staff in the unit plan?
  • Request a copy of the policy/procedure regarding the patient classification system to determine:
- How are nurses involved in establishing and monitoring the workload measurement
system?
- How does this system influence daily staffing?
  • Request a copy of the hospital performance improvement plan to determine:
- Is the role of nursing evident?
- What are the key issues reflected in this overall hospital plan?

5. Maintain clinical advancement programs based on education, certification, and advanced preparation.
  • Are bachelor's prepared graduates distinguished from other nursing personnel in terms of:

    - Employment responsibilities?
    - Opportunities for advancement and promotion?
    - Initial pay schedule or salary? If yes, what are the differences?
  • What rewards based on educational preparation are available?
  • How are clinical competencies and professional contributions evaluated?
  • How does this evaluation relate to the promotion process?
  • Does the evaluation of clinical advancement, competencies, and professional contributions include consideration of:

    - Patient satisfaction?
    - Self-initiated education?
    - Dissemination of clinical information, e.g. nursing rounds, case presentations, articles?
    - Improvement of clinical outcomes and efficiency?
    - Evidence-based practice?
    - Ability to delegate to and guide non-bachelor's prepared nursing staff?
    - Serving as mentor, consultant, or preceptor to students and recent graduates?
    - Demonstrated ability to work in an interdisciplinary context?
    - Leadership role in institutional self-governance and practice committees?
 
  • How are nurses recognized for meeting the professional practice criteria listed above, e.g. public acknowledgement, salary increases, time release, additional education, support to attend conferences, etc.?
  • How do peers, patients, and supervisors provide input into the review process?
  • Request a copy of procedures or information regarding the performance evaluation process and any clinical advancement system:

    - Is peer review included in this process?
    - What are salary increases based on?
6. Demonstrate professional development support for nurses.
  • What resources are committed to the ongoing professional development of nurses, i.e. tuition, continuing education, and certification?
  • How much is budgeted annually per staff nurse for attendance at professional development activities?
  • Do you provide tuition reimbursement for nursing course work completed towards obtaining the next higher degree?
  • Is there an internship or its equivalent in your institution for bachelor's degree nursing students?
  • Is there an internship or mentorship program to prepare nurses for clinical leadership positions?
  • Do the graduates who have completed an internship program in your institution as students start at a higher pay scale/salary than those who have not?
  • What are the opportunities for promotion within the clinical practice model?
  • What types of incentive programs exist for licensed practical nurses and other non-nurse health care personnel who wish to pursue registered nurse education?
  • Do you use case managers or their equivalent in your institution and what is the minimal nursing education required for that role?
  • What are the opportunities for my own professional growth? What can I learn here and how would employment here facilitate my career goals?
7. Create collaborative relationships among members of the health care provider team.
  • How is the quality of patient care and safety reviewed?
  • Who is involved in this process? Is it a peer review process?
  • Do nursing units or departments of the practice setting have interdisciplinary or shared leadership models?
  • Does the practice setting have interdisciplinary standing committees for peer review, patient safety, quality care, or disease state management?
  • Does an interdisciplinary team participate in the process for quality improvement and review of patient care errors?
  • Does the practice setting offer clinical practice privileges to advanced practice nurses and other health care providers as part of the medical staff bylaws and credentialing system?
  • Are nursing units or departments of the practice setting organized from a discipline-centered perspective or from a patient-centered perspective?
  • Do nurses from the practice setting refer to other members of the patient care team when discussing their role or work?
  • Do nursing units or departments of the practice setting hold routine interdisciplinary care planning sessions?
  • What collaborative, interdisciplinary articles, books or research reports have been published by clinicians from the practice setting?
8. Utilize technological advances in clinical care and information systems.
  • Does this institution utilize an electronic patient care documentation system? If yes, who has
    access to this system and who inputs information? If a patient goes to a unit/department
    outside of this building, do the staff in that unit/department have access to the system?
  • Do nurses have electronic access to clinical nursing and health care knowledge and research results, including Web access? Is this access available on nursing units or departments of the practice setting?
  • Does the practice setting allocate budgeted resources for new equipment and patient care technology? Do clinical care providers have routine opportunities to provide input to the budget planning process?
  • What clinical information system, including patient care documentation, does the practice setting use? Is the system integrated throughout all or most clinical departments?
  • Do nurses feel that their practice is supported by up-to-date clinical care technology?
  • What continuing nursing education programs are in place to help nurses and other providers assimilate new technologies and information systems?

Other key statistics and information that should be requested:
 
  • RN vacancy rate and RN turnover rate
  • Patient satisfaction scores (preferably percentile ranking)
  • Employee satisfaction scores
  • Average tenure of nursing staff
  • Education mix of nursing staff
  • Percentage of registry/travelers used