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MeaningfulRecognition 1
LiteratureReviewonMeaningfulRecognitioninNursingPsychologicalAssociatesandDAISYFoundation
Copyright Psychological Associates [2009]
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MeaningfulRecognition 2
TABLEOFCONTENTSAbstract..Page3
LiteratureReviewonMeaningfulRecognitioninNursing.Page4
PositiveOutcomesWhenRecognitionisPresent...Page8
NegativeOutcomesWhenRecognitionisAbsent..Page11
SuccessofMeaningfulRecognitionPrograms..Page17
ReferencesPage23
Table1:CriticalElementsofMeaningfulRecognitionasOutlinedinthe
AACNStandardsforaHealthyWork
Environment..................Page29
Table2:AComparisonofNursesPerceptionsofTheirWork
EnvironmentsinanAACN2006SurveytoaFollowupAACNSurveyin
2008.Page30
Figure1:AbrahamMaslowshumanneedstheory...Page31
AboutPsychologicalAssociatesPage32
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MeaningfulRecognition 3
Abstract
MeaningfulrecognitioncontributestohealthyworkenvironmentsandhasbeendelineatedbytheAmerican
AssociationofCriticalCareNurses(2005)asoneofthekeystoestablishingandmaintaininghealthywork
environmentsfornurses.Thisliteraturereviewrevealsthatmeaningfulrecognitionhasbeenlinkedtosuch
positiveoutcomesasjobsatisfaction,organizationalandcareercommitment,cohesionandcollaboration,and
perceivedorganizationalsupport.Alackofmeaningfulrecognitionhasbeenlinkedtonegativeoutcomessuch
asabsenteeismandturnover,stressandburnout,anddecreasedqualityofpatientcare.Researchonhowto
bestconductrecognitionprogramsisprovided.Oneexampleisoffered,theDAISYAwardforExtraordinary
Nurses.Moreresearchisneededonthelinkbetweenrecognitionandnursesjobsatisfaction.
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MeaningfulRecognition 4
LiteratureReviewonMeaningfulRecognitioninNursing
Itprobablywouldnttakefancyresultsofformal,scientificresearchtosellnursesontheideathat
they,andtheircolleagues,appreciatebeingrecognizedwhentheydoagoodjob.Itmightalsoseemintuitive
thatreceivingrecognitionforworkinghardcanhelpincreasejobsatisfaction.Yetformanynurses,italso
doesnttakelongtothinkofexampleswhentheirorganizationseitherdidntrealizethis,oriftheydid,they
didnttakethetimeormaketheeffort.Theresearchdoesexistthough,andwithoutadoubtitshowsthat
recognitioncontributesdirectlytojobsatisfaction(Cronin&Becherer,1999;Lu,While,&Barriball,2005).Yet
asintuitiveasthismayseem,theAmericanAssociationofCriticalCareNurses(AACN)stillfelttheneedin
2005tospecifythatmeaningfulrecognitionisoneofthesix,keystandardsnecessarytoestablishandsustaina
healthyworkingenvironment(Shirey,2006).Thisservesasagiantcluethattoomanynursesstillmusttolerate
unhealthyworkenvironmentsandtoolittlemeaningfulrecognition(Bylone,2008).Theshortageofnursesis
criticalandisaworldwideproblem(Tourangeau&Cranley,2006).Jobsatisfactionisstronglyassociatedwith
intentiontoremainattheorganization(Larrabee,Janney,Ostrow,Withrow,Hobbs,&Burant,2003;Sourdif,
2004).Thisliteraturereviewwillreciteandrevealtheresearchshowingthatmeaningfulrecognitioninhealthy
workenvironmentswillproduceremarkableoutcomesfornurses,andperhapsmostimportantly,fortheir
patients.
TheAACNfeltthattherewasenoughevidencetoshowthatunhealthyworkenvironmentscontribute
tomedicalerrors,conflictandstressamonghealthprofessionals,andineffectivedeliveryofpatientcare.
Effortswereneededtospellouthowhealthyworkenvironmentscouldbecreatedandsustained.They
delineatedsixessentialstandardsincluding:skilledcommunication,truecollaboration,effectivedecision
making,appropriatestaffing,meaningfulrecognition,andauthenticleadership(AmericanAssociationof
CriticalCareNurses,2005).Regardingthemeaningfulrecognitionstandard,theAACN(2005)defineditasan
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MeaningfulRecognition 5
acknowledgmentprocessthat:isongoingandbuildsonitself,isrelevanttothepersonbeingrecognized,is
congruentwiththepersonscontributions,anddoesntoccurautomaticallybutisaresponsetothevaluethey
add.TheAACN(2005)wrotethatrecognitionofthevalueandmeaningfulnessofonescontributiontoan
organizationsworkisafundamentalhumanneedandanessentialrequisitetopersonalandprofessional
development.Peoplewhoarenotrecognizedfeelinvisible,undervalued,unmotivated,anddisrespected(p.
32).ThecriticalelementsofmeaningfulrecognitionasdelineatedbytheAACNarelistedinTable1.
Otherresearchershavedefinedrecognitionaswell.ForinstanceBlegen,Goode,Johnson,Maas,
McCloskey,andMoorhead(1992)definedrecognitionasheadnursebehaviorsthatacknowledge,withashow
ofappreciation,staffnurseperformanceandachievement.TheAmericanOrganizationofNurseExecutives
(AONE)alsorealizedtheimportanceofahealthfulworkenvironment,andin2004,indicatedthatnine
elementssupportit.Ofthenineelements,twospecificallyaddressrecognition(i.e.,Element8Recognitionof
theValueofNursingsContribution,andElement9RecognitionbyNursesforTheirMeaningfulContribution
toPractice)(AmericanOrganizationofNurseExecutives,2004).
Recognitionisimportantbecauseitservesasaformoffeedback.Feedbackhelpsinformemployeesof
howwelltheyareperforming.Researchhasdemonstratedthatthevalueoffeedbackissoimportantto
individualsthattheywillactivelymonitorandseekfeedbackinformationfromtheirenvironment,especially
whentheyarentformallyreceivingit(Ashford&Cummings,1983).Organizationsneedtocreateperformance
managementsystemsthatplaceastrongemphasisonprovidingandsolicitingfeedback(Piskurich,2006;Prue
&Fairbank,1981).Feedbackseekinghasbeenfoundtobenecessaryforaccurateselfassessment(Fletcher,
1999).Receivingpositivefeedbackcanincreaseanemployeesselfesteem;andhavingapositiveselfidentitycanleadtosatisfactionatwork.Brook(1991)reportedthatselfidentity(operationalizedasthedistancebetweentheactualselfandidealself)hadamoderatingroleinhowindividualsperceivedtheirsuccessand
attitudestowardslife.Specifically,theyshowedthatpositiveselfevaluation(lowactualselfvs.idealself
discrepancy)wasverystronglyassociatedwithpaidemploymentthatwasseenasvaried,challenging,andgoal
oriented.Thoseindividualswithhighselfesteemreportedthattheywerehappywiththeirperformanceinlife.
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MeaningfulRecognition 6
Blegenetal.(1992)wrotejobsatisfactionisthoughttobearesultofneedfulfillmentandrecognitionis
thoughttosatisfybymeetinghigherorderneedsforselfesteem(p.58).
Humanbeingshavebasicneedsthatrequirefulfillmentandwhentheirneedsarenotmet,thereisa
senseoffrustrationthatoccurs(Latham,2007).Oneofthemostinfluentialtheoriesofhumanneedsisthe
HierarchyofNeedsasintroducedbyAbrahamMaslow.Maslowproposedthattherewerefivehumanneeds
arrangedinahierarchy.Eachneedrequiresfulfillmentandattendingtoupperlevelneedscanbefrustratedby
notachievingthelowerlevelneedsfirst(Maslow,1970).Twooftheseneedsareimportantwithregardsto
receivingrecognition.ThefirstiscalledSocial(Belonging)andtheotherisEgo(Esteem).Thetheoryisshownin
Figure1(UniversityofTasmania,2009).Social(Belonging)indicatesourneedtobelongtoagroupandhave
acceptanceandagiveandtakewithothers.Humansneedtobeneeded.ThesecondisEgo(Esteem)which
indicatesourneedtobecompetentandachievemasteryofourtasks,aswellasourneedforattentionand
praiseoncewehaveattainedoursenseofcompetency.Fulfillingbothofthesehigherlevelneedsiscriticalin
orderforapersontoattainthehighestlevel,whichisSelfActualization.SelfActualizationindicatesourneed
tomaximizeourpotential,bepeacefulwithourselvesandoursurroundings,andknowthatwearegood.
Achievingasenseofselffulfillmentisrewardingandwillleadtotruesatisfactionwithbothcareersandlife
(Maslow,1970).
Anunderstandingthatapersonhasachievedcompetency(andsubsequentlyselfactualization)
requiresselfawarenesswhichisprovidedbyfeedbackandrecognition.McCarthyandGaravan(1999)
reportedthattheconceptofselfawarenessplaysavitalroleinthecontextofcareerdevelopment.Asmart
nursingmanagerwillprovidefeedbackrecognitionandincludestaffnursesinacollaborativeeffort.Thisis
importantbecausecollaborativeleadershipstylesdirectlyaffectstaffnursesatisfaction(Lucas,1991).Lucas
(1991)reportedthatof505staffnurseswhoweresurveyed,mostwereexperiencinganauthoritativestyleof
leadershipbuthighlydesiredaparticipativemanagementstylewithmoretwowaycommunicationand
cooperation.Authoritativeleadersmayrequest,and/orprovide,smalleramountsoffeedback.Management
stylewasstronglyrelatedtojobsatisfactionwithacorrelationofr=.61.Interestingly,nurseswithgreater
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tenurereportedmoreparticipativestylesandhencemoresatisfactionthannewerhires,butitwasclearthat
theoldernursesweregivenmorecommunicationandmoredecisionauthorityduetotheirexperience.
Communication,especiallyaboutperformanceandachievement,wasimportant.McNeeseSmith(1997)
reportedthatinsemistructuredinterviewswith30nurses,themostappreciatedleadershipbehavior
managerscoulddemonstratewasrecognitionofajobwelldone.Managersupportwascitedasareasonfor
bothperceivedjobsatisfactionandorganizationalcommitment.Thenursesreportedthatjobsatisfactionwas
mostinfluencedbythemanagergivingpraise,recognition,andthanks.Inthediscussionoftheresults,
McNeeseSmith(1997)indicatedthatnurseleadersneedtocreateandfindeasywaystothankthenurses
undertheirsupervision.
ChanandMorrison(2000)reportedinasurveyof113nurses,thatcollegialcooperationand
recognitionwereamongthefactorsthatleddirectlytotheirdecisiontostayversusleavetheorganization.
Nearly80%reportedthatrecognitionwasafactorindecidingtostay,butover70%oftherespondents
reportedthattheyhadreceivednorecognitionfortheworktheyhaddone!
Ulrich,Lavandero,Hart,Woods,Leggett,Friedman,DAurizio,andEdwards(2009)reportedonresults
ofa2008surveyof5,562nursesconductedbytheAACNandcomparedtheresultstoasimilarsurveythe
AACNconductedin2006.Nursesatbothsurveyadministrationsratedthehealthoftheirindividualworkunits
higherthanthehealthoftheirorganizationasawhole.TheeffortsoftheAACNtopromotehealthywork
environmentsmaybehelpingthough.AscanbeseeninTable2,theamountofmeaningfulrecognitionthat
nursesperceivedasoccurringhasincreasedslightlyfrom2006to2008.However,Ulrichetal.(2009)also
wrotealthoughthehugemajorityoftheresponseswerepositive,someRNswithvariouslengthsofpractice
saidthattheyhadneverreceivedmeaningfulrecognitionfromtheirorganizations(p.98). ShireyandFisher
(2008)reportedinanationalsurveyofnursesthat65%reportedreceivingnorecognitionforgaining
membershipinprofessionalnursingassociations.Obviouslyrecognitionisimportant,andhighlydesiredby
nurses,yetmanynursesstillperceivetheyarentgettingitatwork.
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PositiveOutcomesWhenRecognitionisPresent
Thenumberonepositiveoutcomeofincreasedrecognitionofnursesperformanceisthatit
contributesdirectlytohigherjobsatisfaction(Blegen,1993;Gelsema,vanderDoef,Maes,Akerboom,&
Verhoeven,2005;Goode&Blege,1993;Hampton&Hampton,2004;Hurst,Croker,&Bell,1994;Luetal.,
2005;Mills&Blaesing,2000;Tourangeau&Cranley,2006;Qaseem,Shea,Connor,&Casarett,2007).Tettand
Meyer(1993)definedjobsatisfactionasanaffectiveattachmenttoajobthatcanbeviewedasanoverall,
globalperception,oritcanbeviewedinregardstoparticularaspectsorfacetsofthejob.Aninvestigationof
theliteratureshowsthatthereisastrongrelationshipbetweenjobsatisfactionandtheamountofrecognition
onereceives. Forinstance,Gelsemaetal.(2005)reportedontheresultsofasurveyof807nursesinthe
Netherlandsthatshowedtherelationshipbetweensupportfromtheirsupervisorandjobsatisfactionwas
significantlycorrelatedatr=.38andtherelationshipbetweensupportfromtheircolleaguesandsatisfaction
wassignificantlycorrelatedatr=.27.Multipleregressionanalysisalsoshowedthatthesupportshownfroma
supervisorwasasignificantpredictorofjobsatisfaction( =.12).Hierarchicalregressionanalysisshowedthat
rewardwasasignificantpredictorofjobsatisfaction( =.23).
SchmalenbergandKramer(2007)reportedonsurveyresultsfrom698nursesworkinginintensivecare
unitsandfoundthatthenursesinneonatalintensivecareunitsscoredsignificantlyhigherinprofessionaljob
satisfactionthanothertypesofintensivecareunitsandneonatalintensivecareunitsalsoscoredsignificantly
higheronthecomponentsofahealthyworkenvironmentthantheothertypes.Interestingly,thesewerethe
samegroupofnurseswhohadthehighestnurseassessedqualityofpatientcare,whichsuggeststhepositive
linkbetweensatisfactionandjobperformance.
MillsandBlaesing(2000)reportedonresultsfromasurveyconductedduringthelastnursingshortage
in1989.Thesurveyof3298Missourinursesshowedaseriousproblemthenbetweenhowmuchsupportthey
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receivedfrommanagersversustheircareersatisfaction.Apparently20yearsagosupportandrecognitionwas
asimportanttonursesasitistoday,yetresearcherstodaymuststillinculcatethismessagetogetitheard.
Notonlyhavequantitativestudiesclearlyshownthestrongrelationshipbetweenrecognitionandjob
satisfaction,qualitativestudiestoohaveshownthisrelationship.Qaseemetal.(2007)reportedthatan
analysisofthethemesthatemergedfromsemistructuredinterviewsshowedthatofthe22themesthat
emerged,nineofthesehadtodowithworkingrelationshipsandsupport.Themessuchasrespectfromothers,
feelingvaluedaspartoftheteam,emotionalsupportfromcoworkers,andfeedbackonperformanceclearly
showedhowimportantrecognitionwastothenurseswhowereinterviewed.
TourangeauandCranley(2006)reportedontheresultsofasurveyof8456nursesthatshowedthe
importanceofpraiseandrecognition.Theobviousimportanceofrecognitionintheirstudywassoapparent
thattheauthorswrotepriorityshouldbeplacedonimplementationofstrategiesthatpromotesatisfactionin
theareasofpraiseandrecognition,relationshipswithcoworkers,andwithsocialinteractionopportunities
(p.505).Jobsatisfactionisjustonepositiveoutcomefrommeaningfulrecognition.Anotherpositiveoutcome
iscommitment.Luetal.(2005)reviewedtheresearchonnursesjobsatisfactionandindicatedthatin
summary,bothorganizationalcommitmentandcareercommitmentwerehighlyrelatedtojobsatisfaction.
MeyerandAllen(1991)demonstratedthreeformsofcommitment(affective,normative,andcontinuance).Of
thethreetypesdefinedbyMeyerandAllen(1991),theonemostlikelytoberelatedtomeaningfulrecognition
isaffectivecommitment,anditisdefinedasthestrengthofapersonsinvolvementandidentificationwith
theirorganization.TettandMeyer(1993)foundthatjobsatisfactionandcommitmentwerenotthesame
construct,buttheywererelated,andeachcontributeduniquelytoturnoverintention.
RusbultandFarrell(1983)reportedresultsofasurveyofnursesthatshowedthatrewards(which
includedfeedbackandcoworkerrelations)weresignificantlyrelatedtobothjobsatisfactionandcommitment.
Whatwasinterestinginthisstudyisthatitwasconductedasalongitudinalstudyanditcomparedtheresults
ofemployeeswhostayedintheorganizationwiththosewholeft.Theresultsshowedthattherelationship
betweenrewardsandjobsatisfactionforthoseemployeeswhostayedrangedbetweenr=.76and.85
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betweentime1andtime4.Furthermore,theresultsshowedthatcorrelationsbetweenrewardsandjob
commitmentforthoseemployeeswhostayedrangedbetweenr=.53and.62betweentime1andtime4.Job
rewardsexertedinfluenceonsatisfactionandcommitmentfromthebeginningandcontinuedtobeimportant
goingforward.Thoseemployeeswholeftthejobreportedperceivingrewardsasbeinglower.Forthose
employeeswholeftthejob,thecorrelationswerereportedaslower,anddecreasingovertime.Thissupportsa
processwheredecliningrewardsdistinguishbetweenthosewhostayandthosewholeave.Perceptionsof
decliningrewardsseemedtoleadtodecliningcommitmentanddecliningjobsatisfaction.
Anotherpositiveoutcomefromnursesbeingsatisfiedwiththeirjobisworkgroupcohesionand
collaboration.TourangeauandCranley(2006)reportedthatthelevelofteamwork,whichtheyusedasan
indicatorforcollaborationandworkgroupcohesion,wasasignificantpredictorofintentiontoremain
employed.Ingersoll,Olsan,DrewCates,DeVinney,andDavies(2002)reportedthatinasurveyof1853nurses
therelationshipbetweenjobsatisfactionandsatisfactionwiththeirinteractionwithpeerswasr=.81.
Furthermore,thenurseswhointendedtostayattheirorganizationreportedsignificantlyhigherlevelsof
satisfactionwiththeirgroupinteractionthanthosewhoindicatedtheyweregoingtoleave.
Larrabeeetal.(2003)reportedthatjobsatisfactionwassignificantlyrelatedtogroupcohesionr=.35.
Finally,Sourdif(2004)reportedinasurveyof108nursesfromMontrealthatorganizationalcommitmentwas
relatedtosatisfactionwithadministration(r=.60)andsatisfactionwiththeirjob(r=.43).Workgroup
cohesionwasrelatedtosatisfactionwithadministration(r=.51),satisfactionwiththeirjob(r=.39),and
organizationalcommitment(r=.49).Eachofthesecorrelationswassignificantatthe.01level(twotailed).
Pastresearchhasalsomadethelinkbetweenperceivedorganizationalsupportandsatisfaction.
ODriscollandRandall(1999)reportedthatperceivedorganizationalsupportandsatisfactionwithrewards
appearedtobestrongpredictorsofjobinvolvementandemployeesaffectiveattachmenttotheorganization.
Employeeswhofelttheirorganizationsupportedthemweremorelikelytoscorehighonaffective
commitment.Perceivedorganizationalsupportwasdefinedasthebeliefthattheirorganizationvaluestheir
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contribution,considerstheirgoalsandinterests,makeshelpavailabletosolveproblems,andcaresabouttheir
worksatisfaction.
Itisinterestingtoseethattheresearchisveryclearthatorganizationsthatsupporttheiremployees
cangarnermanyimportantoutcomessuchasjobsatisfaction,commitment,andaworkforcethatis
collaborativeandcohesive.Onewaytodemonstratesupportistogivepraiseandrecognition.Organizations
thatmaketheefforttoprovidemeaningfulrecognitionshouldenjoythesepositiveoutcomes;however
organizationsthatdonotprovidepraiseandrecognitionmayalsoreapmanynegativeoutcomesthatcanbe
detrimentaltoachievingtheirgoalsandmission.
NegativeOutcomesWhenRecognitionisAbsent
Thenumberonenegativeoutcomewhenrecognitionforjobperformanceisnotgivenisdysfunctional
jobturnover(Cartledge,2001;Contino,2002;Hayes,OBrienPallas,Duffield,Shamian,Buchan,Hughes,
Laschinger,North,&Stone,2006;Hausknecht,Rodda,&Howard,2009;Ingersolletal.2002;Janney,
Horstman,&Bane,2001;Larrabeeetal.2003;Luetal.2005;Rusbult&Farrell,1983;Takase,Maude,&
Manias,2005;Tourangeau&Cranley,2006;Sourdif,2004).Contino(2002)reportedthatsomeorganizations
reportnursingturnoverratesashighas40%.Shereportedthatwhilenoquickfixesexisted,targetedeffortsat
creatingcultureswithtwowaycommunicationandinstillingaclearunderstandingofexpectationscouldmake
adifference.Contino(2002)wrotetocreateinnovativeprogramstoretainstaff,leadersmustbeableto
identifytheiremployeesbestqualitiesandexaltthem(p.13).Shealsoreportedthatorganizationshaveto
measurethecostsinvolvedinturnoverincluding:separationandvacancycosts,recruitmentcosts,and
educationcosts.Onceprogramsareimplementedtoreduceturnover(suchasimprovedfeedbackand
recognitionprograms)theefficacyoftheprogramscanbeclearlycomputedbycomparingthecostof
implementingtheprogramversusthesavingsrealizedinreducedturnover,thusprovidingchieffinancial
officerswithquantifiableproofoftheprogramsefficacy.
Someturnovercanbefunctionalandrevitalizeanorganization(Larrabeeetal.,2003).Forinstance,
nurseswhoretiremayhavealongtenureandthereforehighersalariesthantheirnewlygraduated
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replacements.Furthermore,someturnovermayincludenurseswhowerenotsatisfiedwiththeorganization
ortheircommute,andfreshfacescanbringfreshideasandnewenergy.Highvoluntaryturnovercanquickly
havenegativeconsequencesandbecomedysfunctionalincluding:recruitmentandneworientationcosts,loss
ofexperiencednurses,periodsofovertimeduetoshortageofstaff,useoftemporaryagencynurseswhomay
beunfamiliarwiththeorganization,andthepotentialforadversepatientoutcomes(Larrabee,2003).Hayeset
al.(2006)reviewed130articlesonnursingturnoverandindicatedthatoverandoverthebiggestpredictorof
turnoverwasjobdissatisfaction.Hayesetal.(2006)reportedthatturnoverislargelyaresultoflowjob
satisfactionandcommitment,andthatpraiseandrecognitionwasonesatisfactionfactor,aswasjob
embeddedness.TheJobembeddednessconstructfocusesontheaccumulatedreasonswhyapersonstaysina
job.Oneofthelargestcontributorstodissatisfactionwasnursesreportedfeelingsofbeingundervalued
(Hayesetal.,2006).
TourangeauandCranley(2006)reportedthatjobsatisfactionwasadirectpredictorofnurseturnover,
andnursemanagersupportwasanindirectpredictor,inthatsupportmediatedtherelationshipbetweenjob
satisfactionandintenttoremain.TourangeauandCranley(2006)wrotenurseswhoweremoresatisfiedwith
thepraiseandrecognitiontheyreceivedatworkweremorelikelytoremainemployedattheircurrent
hospitals(p.504).Sourdif(2004)reportedthatsatisfactionatworkwasthevariablethatexplainedthemost
intenttostayanditaccountedforover22%ofthevariance.
Takaseetal.(2005)usedpersonenvironmentfittheoriestoinvestigatenursebehaviorsandturnover
intention.Theauthorsusedpolynomialregressiontoanalyzetheresultsof346questionnaires.Theauthors
wereabletoshowthatduetohighlevelsofprofessionalism,nursesworkhardtoprovidequalitycareevenin
environmentswheretheyreceivelittlesupport;yetthesenegativeenvironmentsdirectlyimpactedtheir
intentiontoquit.Takaseetal.(2005)wrotewhilenursesjobperformancewasexplainedbyacurvilinear
relationshipwiththeirperceptionoftheenvironmentalcharacteristics,theresultsshowedthatnurses
intentiontoquittheirjobswaslinearlyrelatedtotheirperceivedenvironmentalcharacteristics(p.895).This
articleundertookaqualitativestudyaswellasaquantitativestudybyconductingfocusgroups.Oneofthe
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themesthatemergedfromthequalitativeanalysissupportedthequantitativeresults.Morespecifically,dueto
professionalismthenursestriedtocontinuetoprovidequalitycare,butlackofsupportandrecognitionledto
anintentiontoleave.
Takaseetal.(2005)reportedthisexchangefromoneofthefocusgroups:
[firstfocusgroupmember]Ithinkthereismoreeffectonjobsatisfactionifyoureinanenvironment
whereyourenotgettingsupportandyourejustnotbeingpraisedoryourenotbeingrecognized,
overallthejobsatisfactionisdecreasedbutnotperformance[secondfocusgroupmember]yes,if
youdohaveanawfulworkplace,youmayeventuallyleave.(p.896)
Janneyetal.(2001)reportedononeorganizationseffortstoincreasenursesatisfactionandretention.Oneof
themainfactorsthatwasreportedduringfocusgroupswastherespectandrecognitionthatnursingmanagers
provided.Aseriesofretreatswereconductedtogetfeedbackfromthestaffnurses.Basedonthefeedback
received,aprogramwasimplementedthatincludedlisteningtostaffnurses,gettingfeedbackondecisions,
andimplementingformalandinformalrecognitionprograms.Theauthorsreportedthattheorganization
realizedaturnoverdropfrom12%to6.2%,aswellasa75%decreaseinovertime.Cartledge(2001)reported
onresultsofaqualitativestudytoinvestigatereasonsforturnoverofintensivecarenursesintheUK.She
reportedthatfourthemesemergedfrominterviewsregardingreasonsforturnoverincluding:stress,
professionaldevelopment,recognitionandtherespectofothers,andtheimplicationsofshiftwork.Thelackof
recognitionledtothenursesfeelingundervaluedandnotrecognizedforthecontributionstheyweremaking.
Finally,BradySchwartz(2005)reportedthattheMagnetRecognitionProgram,whichrecognizes
excellenceinlongtermoracutecarenursingfacilities,contributestojobsatisfactionandthisisrelatedtoa
decreaseinturnover.Inasurveyof470RNscomparingnonMagnetdesignatedhospitals(n=297)toMagnet
designatedhospitals(n=173),nursesfromMagnetfacilitiesreportedsignificantlyhigheroveralljob
satisfactionscoresandwerealsomorelikelytostayintheircurrentposition.Lacey,Cox,Lorfing,Teasley,
Carroll,andSexton(2007)alsoreportedthatinasurveyof3,337registerednurses,thosefromsitesthathad
achievedMagnetstatus(aswellthosenursesfromMagnetaspiringsites)weremoresatisfiedwiththeirjobs
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andtheyweremorecommittedtotheirorganizationthannursesfromnonMagnetsites.Intheprocessof
achievingMagnetstatus,nursingsupportfeaturesareputinplaceandthesefeaturesappeareffectivein
influencingsatisfactionandcommitment,whichinturnaffectstheirintenttostay.InordertogainMagnet
status,afacilitymustdemonstratetheirabilitytocreateahealthyworkenvironment.Nurseswanttocontinue
theiremploymentinthesehealthyworkenvironments.
Decreasingturnoverisimportantbecauselargeratesofturnoverareespeciallyproblematicgiventhe
concurrentnursingshortage.Whatisbecomingapparentisthatsomeoftherecentturnoverincludesthe
nurseswhohavethemostexperience.Ingersolletal.(2002)reportedresultsfrom1,853nurseswho
completedquestionnaires.Overallsatisfactionwiththeirjobwassignificantlyhigherfornurseswhointended
tostayatthesameemployerinthesamejobcomparedtonurseswhointendedtostayatthesameemployer
butchangejobs,andnurseswhointendedtochangeemployerscompletelyF(5,1851)=16.4,p
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MeaningfulRecognition 15
hourlyworkersincludedadvancementopportunitiesandorganizationalprestige,whereasthereasonsgivenby
lowperformersandhourlyemployeesmostoftenincludedextrinsicrewards.Thisshowsthatifthegoalisto
retainhighperformingemployees,humanresourcemanagementpracticesshouldattempttotargetwhatis
valuedmostbythishighperforminggroup.Turnoverisonlyonenegativeoutcomeseeninorganizationsthat
dontrecognizeemployees;anotherisabsenteeism.Luetal.(2005)reportedthatjobsatisfactionwasrelated
toabsenteeism.
Demerouti,Bakker,Nachreiner,andSchaufeli(2000)reportedthathavingtoofewresources(which
includedperformancefeedback,jobcontrol,taskvariety,supportfromsupervisors,rewards,andparticipation
indecisionmaking)ledtodisengagementfromwork.Theytestedtheresultsofsurveysfrom109German
nursesusingstructuralequationmodeling.Thefinalmodelthattheytestedshowednominallyacceptablefit
indicesincluding:2(80,N=109)=100.67,p=.059,andaGFI=.88,AGFI=.83,RMR=.05,NFI=.78,andCFI=
.94.Havingtoofewresourcescontributedtodisengagementbecauseofstressandburnout.Stressand
burnoutisanotherpossiblenegativeoutcomefromlackofsupportandrecognition.
Demeroutietal.(2000)reportedthathighjobdemandsalonedidnotpredictstressamongnurses,but
stressandburnoutwasfoundamongnurseswhowereexposedtoademandingworkenvironmentwithtoo
fewjobresourcestocombatthedemands.Luetal.(2005)reportedthatjobsatisfactionwasrelatedtostress
withastrong,negativecorrelationreportedintheliterature(r= .61).Gelsemaetal.(2005)reportedthat
rewardsareimportantinthestressprocess.Rewardscanactasabufferbycompensatingforhigheffort.In
particular,socialsupportofsupervisorsisimportant.
Thefinalnegativeoutcomethatoccurswhensupportandmeaningfulrecognitionareabsentcan
potentiallyaffecteveryone,especiallythosepeoplemostdependentonnursesperformance,theirpatients.
Researchhasclearlyshownthatthequalityofpatientcarecanbejeopardizedbyunhealthywork
environments(Hayesetal.,2006;Lacey,Teasley,Henion,Cox,Bonura,&Brown,2008).Hurstetal.(1994)
proposedthatifstaffmembersweresatisfiedwiththeirorganizationandtheamountofrecognitiontheywere
receiving,theyshouldbebetterabletofocustheirenergyonincreasingthequalityofpatientcare.McDaniel
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andPatrick(1992)reportedthatlevelsofnursingturnoverwashighlyrelatedtopatientsperceptionof
satisfaction(r= .98).HamptonandHampton(2004)reportedthatrewardsweremorehighlyrelatedto
professionalismthantojobsatisfactionintheirmodel,supportingtheirhypothesisthatprofessionalismcanbe
enhancedbyarewardsystemthatreinforcesprofessionalbehavior.Itisimportanttorealizethatthereare
significantandpositiverelationsbetweenrewards,professionalism,andmarketorientationofnurses.Hayes
etal.(2006)reportedintheirreviewoftheliteraturethatpatientsatisfactionwaslinkedtonursesjob
satisfactionandmostimportantly,managerandorganizationalsupportfornurseswasrelatedtonurses
assessmentsofqualitycare.Leiter,Harvie,&Frizzell(1998)wrote:
Patientsonunitswherenursesfoundtheirworkmeaningfulweremoresatisfiedwithallaspectsof
theirhospitalstay.Patientswhostayedonunitswherenursingstafffeltmoreexhaustedormore
frequentlyexpressedtheintentiontoquitwerelesssatisfiedwiththevariouscomponentsoftheir
care.(p.1611)
Thequalityofpatientcarehasadirectimpactofthewellnessofpatients.Zimmerman,GruberBaldini,Hebel,
Sloane,andMagaziner(2002)reportedthatturnoverratesofnurseswererelatedtotheinfectionand
hospitalizationratesofresidentsinnursinghomes. Theauthorsusedasampleof2,285residentsfroma
stratified,randomsampleof59nursinghomesinMarylandbetween1992and1995.Theauthorsreported
thatwitheachproportionatelossofanurse(afulltimenursingemployee/100beds)theriskofinfection
increasedalmost30%andtheriskofhospitalizationincreasedmorethan80%.Someofthereasonsgivenfor
therelationshipbetweennurseturnoverandinfectionincludedthatturnover:makesitmoredifficultto
establishandmaintaineffectivecontrolpolicies,mayreducethefamiliaritybetweenstaffandresidentmaking
achangeinresidentstatusanddetectionofhealthchangeshardertodetect,mayleadtoinconsistent
supervisionandtrainingofstaff,andmayaffecttheclimateofcollaborationandprofessionalnursingcare.The
dataalsoindicatedthathighratesofhospitalizationforinfectionwereassociatedwithlackofadministrative
emphasisonstaffsatisfaction.
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MeaningfulRecognition 17
Takaseetal.(2005)indicated,ascitedearlier,thatnurseswillstrivetomaintainprofessionalismand
patientcare,evenintoxicenvironments,butthatturnoverwasdirectlyaffected.Itcouldwellbethatthe
nurseswhoremaintryhardtocontinuetoprovidequalitycare,butwhenpoorjobsatisfactiondrivesnursesto
findabetterenvironmenttoworkin,patientcareisaffectedbyshortstaffandpossiblyburnoutamongthe
remainingnurses.Theliteratureisclearthateffortstocreatehealthyworkenvironmentswithsuchprograms
asmeaningfulrecognitionareimportantandhavevaluetobothnursesandtheirpatients.Therearemany
greatexamplesofsuchprogramsthathavebeenimplemented.
SuccessofMeaningfulRecognitionPrograms
Asreviewedabove,loweredturnoverratesandhigherjobsatisfactionfornursescanbeachievedwith
meaningfulrecognition.Beforeimplementingretentionprogramsthoughitisimportanttounderstandwhat
nurseswant.Lacey(2003)reportedthatsurveysofnursesin87hospitalsinNorthCarolinashowedthat
positivecollegialenvironmentandrecognitionprogramswerementionedby11%ofthenurseswho
responded.Thenumberonefactorinretentionmentionedbythenurseswascompetitivewages(24%),
followedbyflexibleschedules(16%),opportunityfordecisionmakinginput(15%),comprehensivebenefits
(12%),professionaldevelopmentopportunities(11%),collegialenvironment(6%),recognitionprograms(5%),
bonusprograms(5%),adequatestaffing(4%),andahostofotherreasonsmentionedwithsmallfrequency.
Blegenetal.(1992)surveyed341nursesregardingthemeaningfulnessofrecognitionbehaviorsandwrote:
Itismoreimportantforheadnursestorecognizeoutstandingperformancethancompetent
performanceorachievement.Themostmeaningfulrecognitionthatheadnursescanprovideissalary
increasescommensuratewithperformancelevels,privateverbalfeedbacktothestaffnurses,and
writtenacknowledgmentofthestaffnursescontributions.(p.63)
Hensinger,Parry,Calarco,andFuhrmann(2008)reportedonasurveyof727RNsregardingwhichNurses
Weekcelebrationsandawardsaremostmeaningful.Theresultsshowthatnursesidentifyrecognitionand
acknowledgmentasfundamentaltoNursesWeek.Providingeducationaleventsandopportunitieswere
consideredthemostmeaningfultypesofrecognition.
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MeaningfulRecognition 18
CroninandBecherer(1999)proposedthatrewardprogramsshouldhavecostsavingsdueto:
improvedrecruitment,decreasedturnover,increasedjobsatisfaction,andincreasedmotivation(whichshould
leadtobetterperformance).Whiletheirstudydidnotspecificallyassessthereturnoninvestmentfor
recognitionprograms,CroninandBecherer(1999)didreportaninterestingfindingfromtheirsurveyof287
staffnursesand55nursemanagers.Inthesurvey,nursingmanagersbelievedthatstaffnurseswouldmost
highlyvaluerecognitionfrommanagersandsupervisors;howeverstaffnursesactuallyrankedrecognition
frompatientsandfamiliesasthehighestsourceofrecognition.Staffnursesalsoratedrecognitionfrom
coworkersassecondhighest.Recognitionfrommanagersandsupervisorswasonlyrankedthird.Ulrichetal.
(2009)reportedthatintheirfollowupsurvey,mostofthemeaningfulrecognitioncamefrompatientsand
families(48.9%)andfromotherRNs(27.0%),whereasnurseadministratorswereless,only(8.5%),aswere
frontlinenursemanagers(7.7%),physicians(4.6%),andotherhealthcarecolleagues(3.3%).
Itisimportantthatemployeesrealizethatrecognitionisgivenasaspecialrewardforexemplary
serviceandperformance.Ifemployeesseerecognitionprogramsasanormalpartoftheorganizationssystem,
orarequirementofmanagers,recognitioncanbecomeanentitlementinsteadofanextragestureof
appreciation(Graham&Unruh,1990;McConnell,1997).Furthermore,communicationregardingwhythe
recognitionwasgivenshouldbecleartoall.McConnell(1997)wrotewhenemployeesseeapeerrecognized,
theyneedtobeabletothink:ifIachievethesamekindsofresults,Icanbesimilarlyhonored(p.90).Thiscan
increaseeveryonesperformanceandcontributetotheorganizationssuccess.
Hurstetal.(1994)citedliteraturethatreportedsavingsfrompublicpostingrecognitionprograms
rangingfrom$600to$105,000peryear.Returnoninvestmentwillbeeasiertoachievewithcheaper
recognitionprograms.Programsdonothavetobeexpensivethough.GrahamandUnruh(1990)reportedina
surveyof175medicaltechnologiststhatamanagergivingverbalpraisewasthetopratedmotivation
technique,withwrittenpraiseaclosesecondandpublicrecognitionalsonearthetop.Bylone(2008)reported
onthesuccessofasimplesolutionwhereabulletinboardwashungwithnotesthatnurseshadreceivedfrom
patientsandfamiliesthankingastaffmemberforgoingtheextramile.Blanknotecardswerealsoplacednext
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MeaningfulRecognition 19
tothebulletinboardsothatpatientsandfamiliescouldwriteandpostthankyounotes.Thearticlementioned
sometouchingnotesthathadbeenleft.Webb,Tour,Hurt,andvanKammen(1992)reportedonthesuccessof
arecognitionprogramwhereduringeachquarterthereisaweekdesignedasratingsweekwhereentireunits
canberecognizedfortheirexcellence.Theprogramconsistsofanengravedbrasstrophywhichispresentedto
thewinnerbythepreviouswinner.BreakfastanddinnerpartiesarealsoheldwithremarksbytheMedical
CenterDirectorandChiefofStaff.Photographsaretakenandadisplayispreparedbythepublicrelations
office.Theprogramhasbeencreditedwithimprovingproductivityanddecreasingturnover.Theauthorsmake
averyvalidpoint;recognitionshouldtakeplacemorethanjustonceperyear.
Keyes(1994)reportedthatacareerladderprogramhadbeenimplementedwithlittlesuccess.Career
ladderprogramsrewardnurseswhoachievesometypeofprofessionaldevelopmentbyincreasingtheircareer
progressionrate.Thestaffnursesindicatedthattherewereseveralprobablereasonsforthefailureofthe
careerladderprogramincluding:thosewhoparticipatedwerenotnecessarilytheoutstandingnurses,those
whoparticipatedweremostlydrivenbythepotentialforsalaryincreases,oneofthecriteriaforbeing
rewardedrequiredextracurricularworkandcommitteeworkwhichcausedthosenursestoleavethefloor,the
heavypaperworkfortheprogramtooktimeawayfromthenursesworkingwithpatients,onceawardedinthe
careerladderprogramannualrenewalwasassured,animositydevelopedandanegativeaurabeganto
surroundtheprogramsothatwinnershidordownplayedreceivingtherewardbecauseofnegativefeelings
frompeers.Withlessthan10%ofthenursesparticipating,theprogramwasscrappedandanewrecognition
programwasimplemented.Thenewprogramsdevelopmentutilizedsignificantinvolvementandinputfrom
thestaffnursesinitsdesign,itrequiredunitspecificpeerassessmentwherethenursesthemselvesparticipate
intheselectionofthewinners,andtheprogramrankorderedthenursesintheunittoensurethatthebest
nurseswerebeingrewarded.Thenewsystemhasbeensuccessful.Keyes(1994)reportedthattwoyearsinto
theprogram75%ofthestaffnursesparticipated,approximately25%ofthenursesarebeingrecognized,
nursesarenowproudoftheaward,unitsfeelempoweredtomakechangestotheprogramwhenneeded,and
thereisneveranydifficultyfindingmemberstoparticipateinthecommittee.
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MeaningfulRecognition 22
AONEreportingthatmeaningfulrecognitionisimportanttomaintaininghealthyworkenvironments,an
improvedunderstandingoftheoutcomesofmeaningfulrecognitionisneeded.Daehlen(2008)wroteakey
areaforfurtherresearchonnursesjobretentionseemstobetherelationshipsbetweentheirreasonsfor
leavingtheworkforce,jobsatisfactionandthedeterminantsofjobsatisfaction(p.1798).Whilemeaningful
recognitionshouldimprovenursesjobsatisfaction,moreresearchisneededonthelink.Giventheprojected
shortageofnurses,andtheimportancethatnursesmaketosociety,thisresearchshouldbedeemedcritical.
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MeaningfulRecognition 23
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Table1CriticalElementsofMeaningfulRecognitionasOutlinedintheAACNStandards
foraHealthyWorkEnvironment
CriticalElementsThehealthcareorganizationhasacomprehensivesysteminplacethatincludesformalprocessesand
structuredforumsthatensureasustainablefocusonrecognizingallteammembersfortheircontributionsand
thevaluetheybringtotheworkoftheorganization.
Thehealthcareorganizationestablishesasystematicprocessforallteammemberstolearnaboutthe
institutionsrecognitionsystemandhowtoparticipatebyrecognizingthecontributionsofcolleaguesandthevaluetheybringtotheorganization.
Thehealthcareorganizationsrecognitionsystemreachesfromthebedsidetotheboardtable,ensuringthat
individualsreceiverecognitionconsistentwiththeirpersonaldefinitionofmeaning,fulfillment,development,
andadvancementateverystageoftheirprofessionalcareer.
Thehealthcareorganizationsrecognitionsystemincludesprocesseswhichvalidatethatrecognitionis
meaningfultothosebeingacknowledged.
Teammembersunderstandthateveryoneisresponsibleforplayinganactiveroleintheorganizations
recognitionprogramandmeaningfullyrecognizingcontributions.
Thehealthcareorganizationregularlyandcomprehensivelyevaluatesitsrecognitionsystem,ensuringeffective
programsthathelpmovetheorganizationtowardasustainablecultureofexcellencethatvaluesmeaningful
recognition.
TakenfromAmericanAssociationofCriticalCareNurses(2005)
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Table2AComparisonofNursesPerceptionsofTheirWorkEnvironmentsinanAACN2006
SurveytoaFollowupAACNSurveyin2008
Statement1:RNsarerecognizedforthevalueeachbringstotheorganization:
StronglyAgree Agree Disagree StronglyDisagree
IntheRNsorganization,2006 10.8 46.2 32.5 10.5
IntheRNsorganization,2008 10.9 48.6 32.1 8.3
IntheRNsworkunit,2006 17.8 46.9 25.6 9.7
IntheRNsworkunit,2008 18.3 48.1 25.9 7.7
Statement2:RNsrecognizeothersforthevaluetheybringtotheworkoftheorganization:
StronglyAgree Agree Disagree StronglyDisagree
IntheRNsorganization,2006 8.2 58.5 28.7 4.6
IntheRNsorganization,2008 9.7 60.0 26.4 3.8
IntheRNsworkunit,2006 15.8 57.9 22.0 4.3
IntheRNsworkunit,2008 17.6 58.2 20.7 3.4
TakenfromUlrichetal.(2009)
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Figure1.AbrahamMaslowshumanneedstheory.
Takenfromhttp://www.ruralhealth.utas.edu.au/commlead/leadership/maslowdiagram.htm
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MeaningfulRecognition 32
ABOUTPSYCHOLOGICALASSOCIATESPsychologicalAssociatesisafirmofbehavioralscientistswhoapplybehavioralscienceprinciplestothework
placetoimprovestaffperformance. Theirfiftyyearsofexperiencehasproventhatincreasingsynergy,
collaboration,candor,andtrusttobusinesspractices/strategiesleadstobetterbusinessoutcomes. Intheir
healthcarepractice,PAoffersavarietyofservicestocreateandsustainahealthyworkenvironment. They
helphealthcareexecutiveshonethepeopleskillsthatcontributedirectlytosuccessfuloutcomes.They
transformnursesintonurseleadersequippedtomeetchallengesinhealthcaretodayleaderswhocan
focustheenergyandenthusiasmofothersonthemissionandvisionofanorganization.Theydevelopleaders
fromthebedsidetotheboardroom. PAshealthcareteammembershaveworkedinhospitalsformany
yearsasphysicians,nursesandleaders. Aseachmemberhaswalkedintheshoesofahealthcareprovider,
theyknowwhatworksandwhatwillnot.
ThisliteraturereviewwasconductedforTheDAISYFoundationasadonationfromPAtohelpusunderstand
theimpactrecognitionhasonnursesworkplaceandcommitmenttotheirworkandcolleagues. Ourprofound
gratitudetoDr.CindyLefton,RN,PhD,andRickBreugger,M.A.fortheirfinework.
FormoreinformationaboutPA,pleasevisitwww.q4solutions.com
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