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The Nursing Shortage and Suggestions for Improving Nursing Care

Nursing professionals remain a critical component in the delivery of quality health care in America and other parts of the world. In fact, nurses constitute a substantial proportion of the health workforce thereby meaning there is a need for immediate considerations of their welfare in order to achieve efficiency in healthcare delivery. The nursing shortage has become one of the major challenges facing almost all countries, especially the United States. Poor working environment coupled with ineffective recruitment and largely retention strategies has compounded the nursing shortage hence resulting in poor health outcomes. More importantly, the introduction of magnet status in hospitals is aimed to encourage healthcare institutions to recruit enough nurses hence meeting the recommended ratio of nurses to patients. In this essay, the cycles and factors contributing to the shortage in the nursing workforce together with the economic impact of recruitment, retention and nurses turnover will be discussed. In addition, the paper will discuss the impacts of effective recruitment and retention programs coupled with attainment of magnet status on the overall nursing professional staffing.

The nursing shortage has become a cyclic phenomenon that is dependent on several factors on the economic and social fronts. The first shortage was felt in mid-1960,s with several instances occurring in the last few decades. Although the reasons behind the shortage remain different in the various episodes, the issue of disincentives plays a crucial role in the shortages. In addition, the boom and bust cycles experienced in nursing employment with regard to the broadening and diversification in career opportunities for women have not only dissuaded women but also men from joining the noble profession. In 1964, an acute shortage of nurses was experienced at a time when the government was trying to entice as many students to join the profession. Although significant steps have taken place in the nursing field that has eventually shaped the profession, the shortage still persists The fact that more than 80% of the nurses were trained through hospital-based programs led to a massive supply of diploma nurses thereby resulting in high demand for graduate nurses. Government policy in the early 1980s resulted in more workload for the nursing workforce taking into the length of stay of patients in the wards was significantly increased after the introduction of the Medicare reimbursement formula (Donley & Flaherty, 2002, p. 8). Increase in paperwork, utilization of advanced technology and high intensity in providing nursing care resulted in significant declines in the overall enrolment of nurses since the profession was regarded as too demanding and unrewarding. Cycles of shortages have remained a norm with exception of 1990-1992 when a slight surplus was experienced. However, the shortage is expected to remain a short time due to the changes in the demographics coupled with the rising population of the elderly and economic prosperity. In fact, the shortage is expected to reach alarming levels in the next two decade4s in the face of high demand and retirement of the current workforce (Andrews, 2004).

The issue of nursing shortage has proved a national disaster for the United States with its effect to lower the overall quality of healthcare despite increased spending on health and improvement in technology and infrastructure. Lack of incentives has remained the major reason behind the disaster. In addition, the rate at which the nursing workforce is growing older has surpassed the number of graduates joining the profession at the entry-level. The inadequacy in the training of nurses coupled with lack of motivation to work as nurses has also compounded the problem making the shortage reach alarming levels in the recent past (NJ RNs Working Together, 2010). Moreover, weak leadership in terms of miscalculated policy papers coupled with weak management styles in the majority of health care institutions has resulted in the withdrawal of nurses from the profession thereby leaving a wide gap in human resources. The withdrawal has also been influenced by the increased pressures occasioned by the additional workloads in the routine activities of the nurses. The fact that nurses are required to work overtime has demoralized a wide section of married nurses making them opt out of the profession (Forsyth & McKenzie, 2006). In addition, the exposition in the career opportunities especially for women has dissuaded them from joining the demanding nursing profession. The nature of the nurse’s work fails to attract a sizeable proportion of men, despite the fact that unemployment rates amongst them are relatively high compared to the women. The nursing shortage is also brought about by the ever-growing demand for qualified nurses particularly in alternative health settings that offer palliative or residential care for elderly persons. In addition to the above reasons, frustration and discontent in the overall work environment have also contributed significantly to the shortage. For instance, strict regulations with regard to visas have limited the power of institutions in the hiring of qualified nurses from outside the United States.

Although concerted efforts are usually put in place to address the shortages in health settings, various problems still occur. The acute shortage has created major gaps in the continuum of care when taking into consideration the destabilizing effect occasioned by disparities in salary compensation between the various sectors. Better working conditions especially in the hospital sectors have resulted in a mass exodus of nurses from nurse-dependent settings such as home and the popular long-term care sectors. Acute nurse shortage in these centers leads to a breakdown in the delivery of palliative and residential care to this special category of individuals thereby lowering their quality of life. In addition, the nurses who remain behind in the residential nurses are overwhelmed with the workload thereby leading to a sharp decline in morale that subsequently results in poor execution of responsibilities. In addition, the disaster has affected the mortality rates in the hospitals with slight increases recorded owing to a lack of dedicated workforce to cater to the ever-rising number of patients especially in critical and emergency departments. In fact, about a quarter of deaths and injuries have been linked to the low nurse population in hospitals. Qualified nurses are believed to improve the overall patient outcomes thereby ensuring increased access to better and safe care (Forsyth & McKenzie, 2006). Moreover, shortages in the number of registered nurses within hospitals have remained a hindrance in the achievement of care goals brought up by the institute of medicine. There is also an increased chance of death particularly for any additional surgical patient, brought under the care of the nurse, above the recommended nurse workload (Stone et al, 2004, p. 1984). More importantly, it is even costly to run health facilities with fewer nurses owing to the high costs associated with the replacement process and catering for the patients exhibiting poor outcomes (American Association of Colleges of Nursing (AACN), 2010)

Various efforts have been implemented to curtail the unfavorable impacts occasioned by the nurses’ shortages. Of particular importance is the introduction of mandatory overtime for the exiting staff while ensuring adequate compensation is guaranteed. Mandatory overtime ranging from two to six hours introduced to cover for the shortfall recorded positive impacts in overall patient outcomes although slight cases of burnouts were reported by the nurses (American Association of Colleges of Nursing (AACN), 2010). In addition, federal legislation requiring hospitals to observe a certain minimum standard of nurse to patient ratio at all times has ensured adequate care is provided to all patients. The involvement of representatives of the registered nurses in the overall staffing plans is crucial in understanding the needs and priorities in the various departments. In addition, the development of whistle-blower protection that gives the nurses the absolute right to refuse any task that violates the various nursing acts has lowered the instances of overburdening of nurses. The introduction of reverse bidding that allows for flexibility in filling of vacancies in the open by utilization of web-based system has proved effective in increasing efficiency in distributing labor. The utilization of free agency to carry out the staffing not only ensures timely bidding for shifts but also provides the required labor at the right time. More importantly, the availability of travel nursing companies has helped cushion several hospitals from acute shortage of nurses in the last few years, especially taking into account the disparities in the nurse population in the various states (NJ RNs Working Together, 2010).

The failure in the overall recruitment and retention system in almost all hospitals has created ballooning costs and expenses that are curtailing the performance and efficiency in service delivery. Although the hospitals may have retrenched a proportion of the nurses as a cost-cutting measure, they might also have committed their institutions to unexpected expenses that are related to the nursing shortage (Finkler, Kovner & Jones, 2007, p. 12). In fact, the actual cost of the registered nurse’s vacancies is determined through expenses incurred when hiring new nurses and payments to the hiring agency. In addition, the costs are also affected by the compensation payable to the traveling nurses who indulge in excessive overtime and the inefficiencies occasioned by the operational costs brought about by the acute nursing shortage (American Association of Colleges of Nursing (AACN), 2010). Variations in the measures used in determining the direct costs related to the registered nurses turnover exist with conservative estimates showing that a hospital usually spends about $10000 to cater for direct recruitment costs for a new nursing vacancy. It is estimated that a facility boasting a nurse workforce of 400 will spend slightly above $800000 annually to recruit and train about an additional 80 registered nurses (Lafer, 2003). The direct recruitment costs represent a small portion of the added costs brought about by inefficiencies in workforce management. In fact, the failure to attract qualified personnel and subsequent retention have led to skyrocketing expenses not only for the agency but also traveling nurses. A study commissioned by the regulators of nursing practice asserted that doubling in the number of hospitals paying out sign-in bonuses during the recruitment process. The share increased from a marginal 19% to slightly above 40% in a span of two years with the total bonuses estimated at slightly above $80 million in 2001. More importantly, the study noted an unusual increase in the reliance on traveling and agency nurses with more than half the hospital utilizing this approach. A substantial proportion of the hospitals pay about 20% more with regard to the wages and the accompanying benefits package to secure the temporary services (Mitchell, 2003, p. 224). More importantly, the expenses of utilizing agency nurses not only result in higher compensation costs but also a wide range of related costs in terms of lower productivity and lowering the overall quality of healthcare. The fact that agency nurses lack the basic understanding of the hospital policies and standards leads to an additional cost burden in familiarizing them with the protocols. The cost of nursing turnover is better understood by comparing the visible costs with the associated hidden costs. Visible costs represent the cost incurred due to lack of enough nurses and recruitment process while the hidden costs relate to the lost productivity occasioned by inadequate staffing. The out-of-pocket costs for turnover represent more than 21% of the actual costs with more than three quarters accounting for the hidden costs. Turnover estimates from $10000 to $11500 depending on the specialty and training of the nurses with moderate estimates denoting that about 24 % and 18% of the total costs represent visible costs in the medical and special categories of nurses respectively. It is thus estimated that the turnover costs range from about $47000 to slightly above $85000 (Lafer, 2003, para. 3). The national nursing workforce is slightly above 1.5 million with the turnover rate averaging about 15%. A whopping $9.75b is spent annually on the overall process of replacing the nurses, thus representing colossal amounts that could have been saved if proper and timely recruitment and retention strategies were put in place (Finkler, Kovner & Jones, 2007, p. 12).

Faced with the cyclical nursing shortage, the various stakeholders in the US decided to come up with concrete plans to address the contributing factors. Inadequacy in the recruitment and retention systems was targeted with mixed success occurring in the last few years. In order to enhance the overall image of the nursing profession, realignment in the advertisement strategy has to be formulated to encourage young students to take up training while also endearing graduates to join hospitals across all states. Media campaigns in form of target focus groups coupled with televised public services have helped polish the image of the nursing profession (Employee Retention and Talent Management Resources, 2010). Downloadable pamphlets from the websites have served to promote the uptake of careers in the nursing field. In addition, the mailing of brochures detailing the benefits and requirements for the nursing profession is currently occurring thereby resulting in students’ early exposure to the profession. To support all these efforts, the nurse investment act that was signed into law in 2002 provides for larger benefits for graduate nurses. Provision for scholarship money coupled with a loan cancellation program aimed at eliminating the financial barriers that hinder enrolment in faculty careers is expected to encourage more people into the profession (Wieck, 2003). In addition, availing funding to enhance the provision of best practices in care has led to an overall improvement in working conditions and patient outcomes. Integration of retention programs in the overall hospital strategy also plays a crucial role in minimizing recruitment costs. With this regard, taking into consideration the needs of career-focused nurses is imperative in retaining their services (Maxwell, 2004, p. 86). Ensuring adequate professional advancement opportunities while also supporting them with technology will enhance furthering of studies hence resulting in the achievement of evidence-based nursing practice. The introduction of these opportunities also improves the reputation of the facilities hence endearing them to future graduates. Flexibility in the work environment in terms of working hours especially for working mothers and better compensation for services rendered is among the successful retention programs in many hospitals. Giving special considerations to the varying needs of the different generations of nurses has promoted diversity in the workforce and improved job satisfaction. Moreover, focusing on workplace improvement strategies such as patient education enhances performance and overall job satisfaction. Promoting value independence in the millennial workforce is also imperative in retaining the nurses in health care settings (Employee Retention and Talent Management Resources, 2010).

Magnet status has become a visible accreditation tool for hospitals with regard to the available nursing services. The American Nurses Credentialing Center’s main aim was to promote excellence in the nursing services based on a set of quality indicators and best standards developed in conjunction with the American Nurses Association (American Nurses Credentialing Center (ANCC), (2010). Magnet hospital status implies that an institution has quality nursing leadership coupled with effective managerial style and hierarchical structure. In addition, professionalism, high levels of autonomy, positive relationships among the health professionals and quality care form the core of the institution. Magnet status is imperative since it guarantees positive impacts to the nursing staff. Not only does magnet status bring about a positive workplace but also creates a sense of pride among the nursing professionals. Magnet hospitals have continually recorded high nurse satisfaction that subsequently results in enhanced rates of staff retention. The institutions enjoy higher ratings with regard to the degree of teamwork while nurses identify them as the ideal workplace environment. The services offered help improve the reputation of the nurses owing to the enhanced ratings by patients in terms of quality care (American Nurses Credentialing Center (ANCC) (2010).

The nursing shortage has proved the major impediment in the delivery of quality care around the world. In fact, it has proved a national disaster for the United States with its effect to lower the overall quality of healthcare despite increased spending on health and improvement in technology and infrastructure. Inadequacy in incentives has perpetuated the cycles of nursing shortage over the last few decades thereby resulting in declining standards and quality in nursing care that subsequently lead to poor patient outcomes. Increased risk of dying and unacceptable palliative care is among the negative impacts of the nursing shortage. The ballooning costs occasioned by the high turnover coupled with frequent recruitments have made the relevant stakeholders implement favorable recruitment strategies and retention principles aimed at ensuring the achievement of magnet status. In view of the current and expected shortages, it is imperative to move with speed in boosting the training and recruitment initiatives to guarantee financial savings, high nurse satisfaction and improvement in the delivery of quality care.

Reference list

American Association of Colleges of Nursing (AACN) (2010). Nursing Shortage Fact Sheet. Web.

American Nurses Credentialing Center (ANCC) (2010). ANCC Magnet Recognition Program. Web.

Andrews, D.R. (2004). The NRA: The impact of governmental and nongovernmental administrative tools. Journal of Professional Nursing, 20(4), 260-269.

Donley, R., & Flaherty, M.J. (2002). Re-visiting the American Nurse Association’s first position on education for nurses. Online Journal of Issues in Nursing, 7(2). Web.

Employee Retention and Talent Management Resources (2010). Nursing and Staff Retention: Nursing shortage. Web.

Finkler, S.A., Kovner, C.T. & Jones, C.B. (2007). Financial management for nurse managers and executives (3rd ed.). St. Louis, Missouri: Saunders Elsevier.

Forsyth, S. & McKenzie, H. (2006). A comparative analysis of contemporary nurses’ discontents. Journal of Advanced Nursing, 56(2), 209-216.

Lafer, G. (2003). Solving the nursing shortage: The cost of failure. Pittsburgh, Pennsylvania: American Healthcare Solutions LLC. Web.

Maxwell, M. (2004). Recruitment realities: Building an HR/nursing relationship. Nursing Economics, 22(2), 86-87.

Mitchell, G. J. (2003). Nursing shortage or nursing famine: Looking beyond numbers? Nursing Science Quarterly, 16(3), 219-24.

NJ RNs Working Together (2010). Solving the Nursing Shortage and Improving the Delivery of Safe, Quality Care. Web.

Stone, P. W., Clarke S., Cimiotti J., & Correa-de-Araujo, R. (2004). Nurses’ working conditions: implications for infectious disease. Emerging Infectious Diseases, 10(11), 1984-9.

Wieck, K. L. (2003). Faculty for the millennium: changes needed to attract the emerging workforce into nursing. Journal of Nursing Education, 42(4), 151-8.

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