With the worldwide shortage of registered nurses, it is becoming more difficult for hospitals to provide the effective and safe care that the public both needs and demands. The problem of a nursing shortage is correlated with the high workloads found in many hospitals and emergency rooms. Burnout is common among health care workers, but the rate of burnout is significantly higher for hospital nurses. Nurses, on the average, experience levels of burnout at a 40 percent rate (Aiken, Clarke, Sloane, Sochalski, and Silber, 2002). According to Aiken, (2002), the job dissatisfaction is four times greater among nurses than it is among other employees in the health care field.
The problem is significant with one in five hospital nurses telling researchers that they plan on leaving their jobs within the year (Aiken, 2002). With the crisis of maintaining care for the patients, the state of California recently passed legislation to mandate a patient-to-nurse ratio in its hospitals to maintain a safe environment due to the nursing shortage. On the hospital surgical units, the ratio was 3 to 10 patients per registered nurse (Aiken, 2002). Studies have shown that there is a correlation between the patient-to-nurse ration and rates of patient mortality.
Studies show that hospitals that have high patient-to-nurse ratios have patients that are at risk with failure to rescue rates. These hospitals tend to have more nurses with burnout and job satisfaction issues. These nurses experience emotional exhaustion which has an impact on the care a patient receives under these conditions (Aiken, 2002).
Studies show that when a nurse on the floor is assigned one extra patient, burnout hits levels of 23 percent, and job satisfaction reaches 15 percent in the field (Aiken, 2002). The nurses who claim burnout and job dissatisfaction claim they will leave their jobs in the coming year. Forty-three percent of the registered nurses claim they suffer from burnout (Aiken, 2002).
Therefore, the problem of nurse retention is a problem not just for hospital administrators, or nurses, but also for patients who expect good healthcare. This paper examines the problem of nursing shortages, and suggestions for alleviating the worldwide problem.
Historical Context
At one point in time, women grew up believing that they were limited in their careers to the field of education or nursing. This is not the case today. Women have many career options, and may choose to be a physician rather than nurse. Keeping this in mind, many of the nurses who have kept the hospitals running over the years are reaching retirement age. With less people entering the nursing field, a critical workforce shortage has developed (Laschinger, Leiter, Day and Gilin, 2009).
According to Laschinger (2009), a 2006 World Health Organization survey recognized a 4.3 million shortage of healthcare workers. This number is expected to increase by 20 percent in the next 20 years. One of the major reasons for the turnover in the nursing field has to do with incivility of the workplace and job dissatisfaction (Laschinger, 2009). Over the years, nursing attitudes regarding work environments have contributed to the problem of retention. When job satisfaction is down, researchers see considerable impact upon retention (Cowin, Johnson, Craven and Walsh, 2008).
The global nursing shortage is threatening to damage healthcare delivery throughout. Many hospitals face the downward retention of nurses in spite of vigorous attempts at retention. Scholars indicate that new ideas must provide new answers in the quest to retain good nurses in a profession already suffering in numbers.
The Reality of Nursing Shortages
When hospitals have increased the number of nurses on duty, an improved mortality rate has been noted. Nurse surveillance is one key factor that helps maintain a patient’s recovery. Nurse surveillance depends on the amount of staff available to monitor the patients on a regular basis. Studies indicate that a lower mortality rate results from increased staff (Aiken, 2002).
Surveillance leads to early detection of problems with patients and the timely intervention to prevent serious injury. An increase in a hospital’s staff could alleviate the turnover rate and reduce job dissatisfaction and career burnout. It is clear that hospital staffing increases could prevent patient deaths and retain good nurses in the profession (Aiken, 2002).
There are four generations now working in the field of nursing. Retention programs must create a work environment to meet the needs of each group. For instance, Generation X, 27-40, may respond to input into hospital decision, or personal attention. Older nurses may need work hours shortened, and physical demands decreased. The answer may lay in making nursing a positive career choice (Wieck, Dols, Landrum, 2010)
With more than half of the nurses working in the field today retiring in the next 10 years, hospitals continue to examine methods of retaining nursing staff (Wieck, 2010).
A factor in turnover is lack of workplace satisfaction. A method to increase the individual’s work environment is by providing empowerment strategies. Such strategies provide the employee with some control over their job, and in the process, build organizational commitment and job satisfaction (Laschinger, 2009).
According to Laschinger, (2009), the worker has four empowerment needs. They are as follows: access to information about the organization, access to assistance, access to job resources, and the chance to grow with the company. An environment that promotes the empowerment needs is more likely to have low levels of burnout, and civility among the workers of the organization.
Summary of Conceptual Articles
The problem of keeping good nurses is made worse by nurse-on-nurse bullying. Victims of bullying often maintain silence and do not know how to combat the problem. Often, bullying results in nurses leaving their chosen profession to avoid the humiliation they experience while on the job.
According to Rocker (2008), the problem of bullying has nothing to do with gender or race, but is a sign of emotional strain. When the supervisory personnel do not act upon the problem, the victim becomes helpless and often is chronically absent from the job. This absenteeism eventually results in the victim resigning from the job, thus adding to the serious problem of nursing shortages.
What creates the practice of bullying? Rocker (2008), indicates that bullying may begin with the individual and his or her environment. However, studies show that bullying is a behavior learned by others. Nurses who are targeted by the bullies are often labeled as stupid or incompetent. The victim then becomes the focus of attention in the workplace, while no one notices the bully. The abuse becomes normalized because of the established power structure that the bully embraces.
In Rocker’s article “Addressing nurse-to-nurse bullying to promote nurse retention,” (2008), she discusses how the victim of the bully fears attending work and often suffers from Post Traumatic Stress Disorder, alcoholism, depression, insomnia, anxiety, weight loss, headache and nausea. It is not unusual to have workplace bullying lead to suicide or violence.
Rocker recommends that strategies be implemented to avoid bullying to retain nurses. She suggests nurses’ work together in hospitals to design an effective anti-bullying program (2008).
“Investigating the effect of nurse-team communication on nurse turnover: Relationships among communication processes,” by J. Apker, K. Propp, and W. Ford, discusses the rising turnover rate among nurses and its effects on mortality rates within the hospitals. Apker, (2009), says that reduced staffing levels within the hospitals effect both mortality rates and failure to rescue complication rates. Hospitals that do not have qualified nurses to care for patients run a serious risk of losing them.
Hospitals experience serious financial losses due to the loss of a nurse. It is estimated that the cost is $42,000 to replace a registered nurse in the surgical unit. It costs an estimated $64,000 to replace a nurse in intensive care. This cost is passed along from the hospital to the patients (Apker, 2009).
The usually tools for retention, such as monetary incentives, do not always keep the nurses in their jobs as it does not address working conditions. Burnout among nurses results from poor communication. Those nurses who have support from supervisors and co-workers tend to have less burnout. According to Apker, (2009), support from both superiors and peer groups builds an attachment to the organization, or hospital, and reduces staff turnover. Nurse-team communication builds identification and retention by increasing team synergy. Nurses tend not to leave their positions if they are a part of patient-care teams where they engage in synergistic communication. In addition, analysis indicates that there is a relationship between synergistic team communication and organizational identification. The attachment to the organization mediates any attempt by the nurse to leave his or her job.
Apker, (2009), also suggests that mentoring is important to the success of the nurse building greater job satisfaction and higher productivity levels. The author states that to retain nurses leadership must communicate so that organizational identification is fostered. She recommended orientation programs and recruitment events.
The maintenance of nurses in rural communities is related to more than just job satisfaction. According to Roberge, (2009), other personal issues may help determine whether a nurse stays in a rural setting and works. However, if a rural nurse does not want to remain in her job, she is more likely to leave than a nurse in the city. A Canadian survey indicated that stress, and low job satisfaction is the main reasons nurses leave the rural setting.
Researchers recently compared nurses in urban and rural New York and found that there was less job satisfaction in the rural environment. Rural nurses were more apt to leave their job in the next year, while city nurses indicated they were more likely to leave their posts within the next five years. The findings show that nurses, who stay at their job in a rural setting for more than a few years, were influenced by other factors besides job satisfaction (Roberge, 2009).
Roberge (2009) said that nurses with high levels of education, management, or held educational roles, were more likely to stay on the job. Those nurses who held part-time positions were the most likely to leave their jobs. There was a correlation between professional autonomy and job satisfaction and pay, task requirements, and organizational commitments.
Scholars indicate that to survive the shortage of nurses, rural hospitals must prevent turnover. In British Columbia, the Ministry of Health in 2006 created rural nursing strategies for retention. The strategies emphasized more education, tuition reimbursements, management opportunities, and mentoring programs, improve shift scheduling and professional development (Roberge, 2009).
Evidence-Based Articles
Organizational support for nurses and adequate staffing are important in the improvement of patient care and in the retention of quality nurses in the hospital system. Adequate staffing also helps to eliminate burnout, and job dissatisfaction. Currently, 18 percent of Americans and British say their last stay in the hospital was poor or fair. Canadian consumers also addressed a serious problem with adequate healthcare (Aiken, Clarke, Sloan, 2002).
“Hospital staffing organization, and quality of care: cross-national findings,” (2002), is a detailed study of 10, 319 nurses in 303 hospitals with the objective of examining the effects of nurse staffing and hospital support on job satisfaction. Researchers found that it was a common concern of the nurses that low staffing could have a negative effect on patient health. Also, noted was the high incidence of job dissatisfaction and burnout.
The study showed that when there is organizational support for staffing, nurses see it as a concern for quality of care. The study found that a decreased quality of care was three times as likely to occur in a facility that lacked appropriate staffing (Aiken, 2002).
“Rounding for outcomes. An evidence based tool to improve nurse retention, patient safety, and quality of care,” by Baker and McGown, (2010), asked specific questions in three areas to get the information necessary to improve quality of care. The goal of the study was to identify areas that need improvement, learn what works, build relationships, and make sure staff has the equipment to do the job.
To build satisfaction in nursing, researchers did “rounding on staff.” Specific questions were asked that gave the nurse an opportunity to express their concerns. According to Baker, (2010), the rounding process creates a sense of loyalty among nurses, provides a feeling of importance, while making them feel as though they make a difference. The idea of rounding on staff has to do with building good relationships between employees and their supervisors. The main reason employees quip their job has to do with their relationship with their boss. Building a relationship helps to retain workers and improve working conditions.
Also important is the idea of leader rounding on patients. The idea to make sure the hospital is providing safe, quality care to all patients. Rounding on patients helps to show that workers are doing what they are asked to do to make the experience of the patient more than just satisfactory (Baker, 2010).
To reduce patient anxiety and increase confidence in the system, the reception area is also an area of questioning. The idea is to tell patients that it is okay to wait and not to leave without being seen by a doctor. According to studies the emergency room loses approximately two percent of all patients who leave without seeing the doctor. Researchers claim that if they could keep some of these billable people and have them seen by the doctor, more money would go into the hospital budget (Baker, 2010).
With the nursing shortage as serious as it is, researchers in New South Wales examined the importance of job satisfaction and professional identity on the retention of nurses. There were 2000 nurses who participated in the study, with only 528 participating at a time. They were asked to fill out a questionnaire that measured the nurse retention index, index of work satisfaction and self-concept (Cowin, Johnson, Craven, and Walsh, 2008).
Many interventions were suggested as a result of the study. For instance to improve self-concept, counseling was recommended. It was also suggested that supportive working environments be created between supervisor and worker. In addition, it was deemed necessary to improve the management of nurses’ clinical ladder as well as pay program. The study emphasized that the most important factor leading to retention is the improvement of the professional status of the individual (Cowin, 2008).
Forecast for the Future
As more and more nurses leave the profession, it is important to craft a policy that will attract new nurses, while maintaining those with experience. The cost of replacing one nurse in the intensive care unit amounts to $64,000 (Apker, 2009). It is clear that the healthcare system cannot continue to absorb continuing losses and must begin to put money into retention programs that work.
There must be a change in the way nurses are managed. Most individuals leave their jobs because of conflict with their supervisor. A nurse-team program should be instituted to enhance worker communication with each other and with the supervisor. Nurse teams work to alleviate burnout and improve working conditions. A mentoring system must be instituted to build trust between employees and help to eliminate the problem of bullying. Empowerment programs must be instituted to make employees feel more engaged in the hospital process.
Money must be invested into the healthcare system to increase nurse-to-patient ratio to protect and safeguard patients. An increased staff helps to maintain worker satisfaction and decrease the problem of burnout. As the workload for the average nurse decreases, shifts must be redesigned to alleviate the stress and strain of the average nurse.
Money must also be spent on safety programs for the nursing staff. Forty percent in a recent study of nurses indicated that they felt their safety was at risk each day on the job (Wieck, Dols, Landrum, 2010). In addition, the career ladder salary system must be redesigned to provide more incentives for nurses to remain in their jobs. Higher pay scale for nurses with experience will help to improve self-perception and professional identification.
Hospitals must be family friendly, not only for the patients, but for the nursing staff. Day-care centers on the hospital grounds would create a positive environment for the nurses who have children. Knowing that one can check on their children on break adds to the positive work environment.
All of the above is necessary if hospitals globally are going to decrease the number of nurses leaving the profession. It will cost money to retain employees, but it cost more money to continue the process of turnover. Turnover rates can be reduced if the above methods are implemented.
References
Aiken, L., Clarke, S., Sloane, D., Sochalski, J., Silber, J. (2002). Hospital nurse staffing and patient mortality: nurse burnout and job dissatisfaction, Journal of the American Medical Association, 288, (16)
Aiken, L., Clarke, S., Sloane, D. (2002). Hospital staffing organization and quality of care: cross-national findings, International Journal for Quality Healthcare, 14, (1), 5-13
Apker, J., Propp, K., Ford, W. (2009). Investigating the effect of nurse-team communication on nurse turnover: relationships among communication processes, identification and intent to leave, Health Communication, 24, 106-114
Baker, S., McGowen, N. (2010). Rounding for outcomes: An evidence based tool to improve nurse retention, patient safety, and quality of care. Journal of Emergency Nursing, 36, (2)
Cowin, L., Johnson, M., Craven, R., Walsh, H. (2008). Casual modeling of self-concept, job satisfaction, and retention of nurses, International Journal of Nursing Studies, 45, 1449-1459
Laschinger, H., Leiter, M., Day, A., Gila, D. (2009). Workplace empowerment, incivility, and burnout: impact on staff nurse recruitment and retention outcome. Journal of Nursing Management, 17, 302-311
Roberge, C. (2009). Who stays in rural nursing practice? An international review of literature on factors influencing rural nurse retention, Online Journal of Rural Nursing and Healthcare, 9, (1)
Rocker, C. (2008). Addressing nurse-to-nurse bullying to promote nurse retention, Online Journal of Nursing, 13, (3).
Wieck, K., Dols, J., Landrum, P. (2010). Retention priorities for the intergenerational nurse workforce, Nursing Forum, 45, (1)
