Why are so many nurses dissatisfied on the job, and what can be done to improve things?

There are 3.9 million registered and licensed practical nurses in the United States.

Not all of them, however, are happy in their work.

A 2014 survey of more than 3,300 nurses found that they were stressed, overworked, underappreciated, and underutilized.

Of those nurses surveyed by the Vickie Milazzo Institute in Houston, 64 percent said they rarely get seven to eight hours of sleep per night. Another 31 percent said they get enough sleep just two to three nights a week.

And despite being in the health industry, 77 percent of nurses said they regularly do not eat well.

They may also have long shifts and on call availability that make them more likely to pull 24- or 36-hour shifts.

The survey also found that 75 percent of nurses do not feel they have enough authority. And 89 percent said they cannot work effectively due to apathetic superiors and a lack of support staff.

Nick Angelis, a nurse anesthetist from Florida, said that nurses are put in a difficult position because of standardized methods of care and the need to avoid being denied reimbursement by health insurance companies.

“Instead of critical thinking and deciding what’s best for the individual patient, the nurse’s workload instead depends on inflexible protocols and avoiding institutional penalties,” Angelis said.

During one shift, a patient’s nose began to bleed profusely. The nurses could not reach a doctor, so in the meantime, Angelis suggested treating the patient with one of two remedies until a doctor was available.

“They were aghast and reminded me that unlike nurse anesthetists, bachelor-prepared nurses weren’t supposed to come up with pharmaceutical solutions,” he recalled. “They were right … but they should have still been thinking of ways to fix the problem in case a physician never came through to save the patient.”

Beth Anne Schwamberger quit working a few years ago as a pediatric nurse for similar reasons.

“Most nights on the job, I felt unable to provide my patients the high-quality care that they deserved because of being short-staffed and having access to undertrained residents as our primary point of contact,” she said. During a night shift, one patient didn’t get the diagnostic test needed, and another was not placed in intensive care due to a lack of space.

Schwamberger, from Pittsburgh, said a system in which another physician could be reached in an emergency — without pushback — would have helped. Also, having a process in place to handle increased patient acuity and numbers would have improved her experience and the patients’ outcomes, too.

“As nurses, we spend so much of our time just advocating and arguing in favor of our patients. We shouldn’t have such an uphill struggle just to get our patients the treatment that they deserve,” she said.

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Underfunded hospitals and low wages are another significant burden for nurses.

Only 16 percent of the nurses surveyed said they are fairly paid.

Of all the respondents, 40 percent said they are not fairly paid, and 44 percent said they are fairly paid but could use extra compensation. PayScale.com reports that nurses make about $55,203 per year on average.

According to a study this year by WalletHub, Washington was ranked the best state for nurses to work in, followed by Illinois, Texas, and Oregon. Louisiana ranked last among the states, and Washington, D.C., was at the bottom.

Many people are stressed on the job, but poor working conditions and sparse budgets for nurses can impact patient care. A 2013 study in the Journal of Patient Safety estimates that between 210,000 and 440,000 patients die at hospitals each year as a result of medical errors. Those can happen when a nurse is exhausted or not given the authority to make critical decisions.

A 2011 survey taken by about 95,000 nurses found that 36 percent of nurses in hospitals, and 47 percent of nurses in nursing homes providing direct patient care, said their workload caused them to miss changes in their patients’ conditions.

“Our underfunded hospital did not provide for float pool nurses for our floor. The most we could do was to beg a manager to come in and help, and this was unsuccessful 95 percent of the time. We were just told to do our best,” Schwamberger said. “When your best means that your patients are at high risk of not being treated appropriately, many nurses choose to just walk away rather than risk our license for having to provide care in such a risky environment.”

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In Angelis’ case, the patient with the bloody nose might have received better care if Angelis had an expanded scope of practice. “Scope of practice” refers to the legal restrictions governing what nurses and doctors can and cannot do.

Matthew McHugh, a nursing outcomes and policy researcher, and a professor at the University of Pennsylvania, said there’s room for legislative action to expand scope of practice, especially for advance practice nurses with more education.

A lot of issues can be resolved internally if management is attentive, he said.

For example, many nurses are responsible for urinary catheter installation, removal, and monitoring. If left in too long, however, catheters can cause infections, which would fall under a doctor’s scope of practice.

In some medical facilities, the management has enacted a protocol that lets nurses decide if a catheter should be removed without having to consult a doctor. This can prevent complications for the patient, as it can sometimes take time to get approval from a physician.

“There are lots of things that don’t require policy change,” McHugh said.

In the case of catheters, that’s the kind of decision that can have a huge impact on a patient’s outcome and happiness, as well as the nurse’s job satisfaction. All of those factors can be “hindered,” McHugh said, by having to go through red tape.

Pegge Bell, director of the Eleanor Mann School of Nursing at the University of Arkansas, said nurses are leading the way to improve workplace operations.

For example, the rush to get Medicare patients home within a 30-day period under the Affordable Care Act (ACA) gives nurses less time to help patients better manage their long-term treatment.

“I think that [patients] are being discharged before they are ready to totally manage things,” she said. “When they don’t know what else to do they just come back to the emergency room.”

Nurses — or “front-line soldiers,” as Bell calls them — are taking a leadership role by bringing up these concerns. With responsive managers, they’re “very much making positive change.”

Using advanced practice nurses, such as certified nurse practitioners or certified nurse midwives, can also give nurses more decision-making power. In some states these nurses function independently. And in others they work collaboratively with a physician or patient care team. Many institutions have tried this approach to improve nurse satisfaction and patient outcomes in light of a shortage of doctors.

McHugh said much of the debate about expanding scope of practice applies to advanced practice nurses, not to all registered nurses.

A 2010 Institute of Medicine report urged state lawmakers to remove barriers in nurses’ scope of practice, and a 2012 National Governor’s Association called on states to think about changing their scope of practice legislation to allow nurse practitioners to provide primary care.

The American Association of Nurse Practitioners (AANP) reports that 19 states and Washington allow nurse practitioners to diagnose and treat patients without involving a doctor — something known as full practice. Other states allow reduced or restricted practice.

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Just giving nurses more authority, though, isn’t enough to improve their working conditions. Susan Sepples, an associate professor of nursing at the University of Southern Maine, has said publicly that nurses’ concerns are taken seriously when there is a threat of unionization, but that an “us vs. them” mentality doesn’t create a positive work environment.

McHugh added that unions can be beneficial for nurses, but automatically being part of one hasn’t remedied all the issues nurses face at work.

With unions come the issue of dues — many nurses pay them yet conditions do not improve. Recently, the Supreme Court ruled that home healthcare workers are not eligible to be public employees, so they don’t have to contribute money to fund an employee union.

The Supreme Court case concerned Illinois resident Pam Harris who cares for her physically disabled son using government disability benefits. Her wages are paid through Medicaid and the state considered workers like Harris public employees able to collectively bargain with the state.

Harris wasn’t a member of a union-represented unit, but she sued on behalf of those who have to pay “fair share” contributions to help fund employee unions. Anti-union organizations who supported the suit said that fair share fees given to a public sector union are political payments because the union can negotiate with the government as an employer.

If unions are not a cure-all, what is? According to the Vickie Milazzo Institute survey, hospitals can do several things to help nurses. Hospitals must set realistic work hours, give nurses the authority to take charge in an emergency, give veteran nurses a voice at management meetings, offer healthy meals and snacks, and cultivate a culture of trust and respect.

If the situation does not improve, hospitals could be impacted too. If nurses are under pressure, that’s likely to show up in patient surveys as part of the Hospital Consumer Assessment of Healthcare Providers and Systems, which affects how much the government reimburses hospitals for care they provide.

“Burnout and dissatisfaction is always a risk in any human services,” McHugh said. “That translates into poor patient experience.”

In his research, McHugh has found that nurses care more about working conditions than pay. Management can change this, similar to the way Fortune 500 companies enact positive corporate strategies. Nurses’ concerns and solutions should be taken into account when coming up with improvements, McHugh said.

Improved working conditions can prevent nurse turnover and absenteeism, which also raises costs. The American Nurses Credentialing Center’s Magnet Recognition Program is a good example of a model that fosters a better work environment for nurses, and thus, enhanced patient care.

“It’s a quality of care issue,” McHugh said. “That ultimately is the business of healthcare.”

Editor’s Note: This story was originally published on July 7, 2014, and was updated on September 27, 2016.