Ethical Issues in Healthcare

Management
Health care in the 21st century is governed by a confusing array of rules, regulations, laws and
ethical standards. Issues that involve confidentiality, informed consent and patient relationships can
appear out of nowhere, even when health care workers have the best of intentions. What’s legal today
might not be considered ethical, and there is the ever-present threat of being sued for negligence and
malpractice. There are unresolved issues around doctor assisted dying that have yet to be worked out,
while medical procedures considered ethical for adults might not be seen as ethical for minors.

Here are the top five ethical issues that health care managers of today and tomorrow will be facing in
the course of delivering responsible and compassionate patient care.

1. Patient Confidentiality
Information about a patient’s medical condition is considered private. Violating a patient’s
confidentiality can hurt the patient and have legal and ethical consequences for the health care
worker. The Health Insurance Portability and Accounting Act (HIPAA) has drawn up specific laws
that govern the release of a patient’s medical information. These laws state clearly the type of patient
information that can be released to third parties and which information must be kept confidential.
The laws also set forth who can see the information and who cannot. Although these laws appear
straightforward, there are grey areas such as when withholding information about a patient’s
condition would be unethical because it could harm the patient or someone else.

2. Patient Relationships
Health care providers are ethically prohibited from entering into personal relationships with patients
in the course of providing treatment. Violating this policy, especially if it involves a sexual
relationship, can result in losing a license to practice, in being sued and in being forbidden to provide
any kind of healthcare services in the future. Entering into a sexual relationship with a patient is
considered a serious violation of that patient’s rights and an act of misconduct and abuse of power on
the part of the health care worker. When under medical care, a patient is considered vulnerable and
unable to defend or protect themselves. Even the appearance of a sexual relationship with a patient
can have serious consequences for a health care practitioner.

3. Malpractice And Negligence

Health care providers are always at risk for being charged with malpractice and negligence. A patient
who is harmed by defective medical equipment or products, injured in the course of a medical
treatment or placed in danger because of medication errors can sue to recover their losses. Patients
can also sue when health care providers fail to provide a critically needed treatment or service. Due
to the ever-present threat of litigation, health care providers must carefully cover all the bases in the
course of providing patient care.

4. Informed Consent
In order for any medical treatment to be considered legal, the patient must first provide the health
care worker with an informed consent. Unless a patient provides informed consent for a procedure,
that procedure can considered an assault or even a homicide if the patient were to die as a result of
treatment. Informed consent means that a patient has had all of their questions answered and freely
agrees to a treatment or procedure with full knowledge of the risks, benefits and possible
consequences. Informed consent also means that patients are informed about other options as well as
about the option of doing nothing.

5. Issues Related To Physician Assisted Suicide

(PAD)
Most health care professionals are aware that physician assisted dying is already legal in states like
California and Oregon. Support for PAD is growing in momentum as the baby boom generation gets
older. Surveys show that roughly 50 percent of doctors now support some form of physician assisted
dying. These days, physicians are broadening the concept of “Do no harm” to include providing
relief for those who are dying and suffering as a result of a fatal illness.

We are moving into an era that will provide increasing options for medical care. Innovative
technologies, cutting-edge medical procedures and state-of-the-art treatments are designed to give
people longer and more productive lives. But as we move forward, concerns about the future of
medical care and its effect on the patients it was designed to treat will become increasingly
important.

The importance of nurse staffing to the delivery of high-quality patient care was a principal
finding in the landmark report of the Institute of Medicine’s (IOM) Committee on the Adequacy
of Nurse Staffing in Hospitals and Nursing Homes: “Nursing is a critical factor in determining
the quality of care in hospitals and the nature of patient outcomes”1 (p. 92). Nurse staffing is a
crucial health policy issue on which there is a great deal of consensus on an abstract level (that
nurses are an important component of the health care delivery system and that nurse staffing has
impacts on safety), much less agreement on exactly what research data have and have not
established, and active disagreement about the appropriate policy directions to protect public
safety.
The purpose of this chapter is to summarize and discuss the state of the science examining the
impact of nurse staffing in hospitals and other health care organizations on patient care quality,
as well as safety-focused outcomes. To address some of the inconsistencies and limitations in
existing studies, design issues and limitations of current methods and measures will be presented.
The chapter concludes with a discussion of implications for future research, the management of
patient care and public policy.
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Background
For several decades, health services researchers have reported associations between nurse
staffing and the outcomes of hospital care.2–4 However, in many of these studies, nursing care and
nurse staffing were primarily background variables and not the primary focus of study.5 In the
1990s, the National Center for Nursing Research, the precursor to the National Institute of
Nursing Research, convened an invitational conference on patient outcomes research from the
perspective of the effectiveness of nursing practice.6 It was hoped that as methods for capturing
the quality of patient care quantitatively became more sophisticated, evidence linking the
structure of nurse staffing (i.e., hours of care, skill mix) to patient care quality and safety would
grow. However, 5 years later, the 1996 IOM report articulating the importance of nurses and
nurse staffing on outcomes concluded that, at that time, there was essentially no evidence that
staffing exerted an effect on acute care hospital patients’ outcomes and limited evidence of its
impact on long-term care outcomes.1
There has been remarkable growth in this body of literature since the 1996 IOM report. Over the
course of the last decade, hospital restructuring, spurred in part by a move to managed care
payment structures and development of market competition among health care delivery
organizations, led to aggressive cost cutting. Human resources, historically a major cost center
for hospitals, and nurse staffing in particular, were often the focus of work redesign and
workforce reduction efforts. Cuts in nursing staff led to heavier workloads, which heightened
concern about the adequacy of staffing levels in hospitals.7, 8 Concurrently, public and
professional concerns regarding the quality and safety of patient care were sparked by research
and policy reports (among them, the IOM’s To Err is Human9), and then fueled by the popular
media. A few years ago, reports began documenting a new, unprecedented shortage of nurses
linked to growing demand for services, as well as drops in both graduations from prelicensure
nursing education programs and workforce participation by licensed nurses, linked by at least
some researchers to deteriorating working conditions in hospitals.10, 11 These converging health
care finance, labor market, and professional and public policy forces stimulated a new focus of
study within health services research examining the impact of nurse staffing on the quality and
safety of patient care. An expected deepening of the shortage in coming years12 has increased the
urgency of understanding the staffing-outcomes relationship and offering nurses and health care
leaders evidence about the impacts of providing care under variable nurse staffing conditions.
This chapter includes a review of related literature from early 2007.
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Identifying Nurse-Sensitive Outcomes

The availability of data on measures of quality that can be reasonably attributed to nurses,
nursing care, and the environments in which care is delivered has constrained research studying
the link between staffing and outcomes. While nurse leaders have been discussing the need to
measure outcomes sensitive to nursing practice back to at least the 1960s, widespread use of the
terms “nurse/nursing-sensitive outcomes” and “patient outcomes potentially sensitive to nursing”
is a relatively recent development. Nurse-sensitive measures have been defined as “processes
and outcomes that are affected, provided, and/or influenced by nursing personnel, but for which
nursing is not exclusively responsible.”13, 14 While some scholars feel the term “nurse-sensitive
measure” is fundamentally incorrect because patient outcomes are influenced by so many
factors, health care is practiced in a multidisciplinary context, and few aspects of patient care are
the sole purview of nurses, there is a broad recognition that some outcomes reflect differences in
the quality of nursing care patients receive and therefore presumably respond to the
characteristics of the environments in which care is provided (including staffing levels).
No matter what label these measures are given, measures that have conceptual and clinical links
to the practice of nursing and are sensitive to variations in the structure and processes of nursing
care are an essential ingredient in this area of research. Data sources from which to construct
these measures must be identified, and exact definitions indicating how measures are to be
calculated must be drafted. This is particularly critical if different individuals or groups are
involved in compiling quality measures. There have been calls for standardization of measures of
the quality of health care for some time,1, 15 along with outcome measures related to the quality of
nursing care. Inconsistent definitions have slowed progress in research and interfered with
comparability of results across studies. A paper, now under review, examines and compares
common measures of adult, acute care nurse staffing, including unit-level hospital-generated data
gleaned from the California Nursing Outcomes dataset, hospital-level payroll accounting data
obtained from the California Office of Statewide Health Planning and Development, hospital-
level personnel data submitted to the American Hospital Association, and investigator research
data obtained from the California Workforce Initiative Survey. Findings reveal important
differences between measures that may explain at least some inconsistencies in results across the
literature (Spetz, Donaldson, Aydin, personal communication February, 2007).
Efforts to address the standardization imperative began with the American Nurses Association’s
(ANA) first national nursing quality report card initiative. This initiative began with a literature
search to identify potential nurse-sensitive quality indicators. Next, expert reviewers examined
and validated a smaller, selected group of indicators and measures from among these.16 The ANA
then funded six initial nursing quality report card indicator feasibility studies, which developed
and refined these first sets of measures, documenting the quality of nursing care in acute care
settings. The California Nursing Outcomes Coalition (CalNOC) was among the first State-based
feasibility projects conducted by the ANA that ultimately served as the basis for the National
Database for Nursing Quality Indicators (NDNQI) established in 1997. Maintaining an informal
collaboration with the NDNQI, CalNOC continues to function as a regional nursing quality
database, and more recently, CalNOC methods have been adapted by both the emerging Military
Nursing Outcomes Database and VA Nursing Outcomes Database projects. All four groups
currently collect and analyze unit-level data related to the associations between nurse staffing
and the quality and safety of patient care. Together, they have formed an unofficial collaborative
of nursing quality database projects.17–21
The most recent initiative in standardizing staffing and outcomes measures for quality
improvement and research purposes was undertaken by the National Quality Forum (NQF). The
mission of the NQF is to improve American health care through consensus-based standards for
quality measurement and public reporting related to whether health care services are safe, timely,
beneficial, patient centered, equitable, and efficient. To advance standardization of nurse-
sensitive quality measures and respond to authoritative recommendations from multiple IOM and
Federal reports,9, 15, 22 the NQF convened an expert panel and established a rigorous consensus
process to generate the Nation’s first panel of nursing-sensitive measures for public reporting.
The aim of the expert panel was to explicate and endorse national voluntary consensus standards
as a framework for measuring nursing-sensitive care and to inform related research. Potential
nursing-sensitive performance measures were subjected to a rigorous and systematic vetting
under the terms of the NQF Consensus Development Process, which included a thorough
examination of evidence substantiating each measure’s sensitivity to nursing factors, alignment
with existing requirements being made of providers, and validation/recommendations of
advisory bodies to Federal agencies. As illustrated in Figure 1, the resulting first 15 NQF
nursing-sensitive measurement standards were informed by earlier work by the NDNQI and
CalNOC, as well as measures arising from formal research studies.

Figure 1
Standardizing Nursing’s Quality Indicators Notes: CMS = Centers for Medicare and Medicaid
Services; EHR = electronic health record; JCAHO = Joint Commission on Accreditation of
Healthcare Organizations, now known as the Joint Commission; OMB = (more...)
These measures represent a first (but by no means final) attempt to make nurse-sensitive
outcomes visible to the broader community of payers and policymakers. The first 15 voluntary
consensus standards for nursing-sensitive care intended for use in public reporting and policy
initiatives included23
1. Failure to rescue
2. Pressure ulcer prevalence
3. Falls
4. Falls with injury
5. Restraint (vest and limb) prevalence
6. Urinary catheter-associated urinary tract infections (intensive care unit, ICU)
7. Central line catheter-associated bloodstream infections (ICU)
8. Ventilator-associated pneumonia (ICU)
9. Smoking cessation counseling for acute myocardial infarction
10. Smoking cessation counseling for pneumonia
11. Smoking cessation counseling for heart failure
12. Skill mix
13. Nursing hours per patient day
14. Practice Environment Scale-Nursing Work Index
15. Voluntary turnover
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A Framework Relating Nurse Staffing to Patient Care Quality and Safety

Figure 2 illustrates a set of conceptual relationships between the key variables in this review,
including influences on staffing levels and factors influencing outcomes. These relationships
form a set of interrelated pathways that link nurse staffing to patient care quality, safety, and
outcomes. Notable is that each of the elements enclosed in a box—specifically administrative
decisions, quality of nursing care, care needs, and safety and clinical outcomes—is influenced by
a host of factors that are not detailed in the diagram and could each be the subject of its own
literature review.

Figure 2
Nurse Staffing, Quality of Care, and Outcomes
 Staffing levels are set by administrators and are affected by forces that include budgetary
considerations and features of local nurse labor markets. Administrative practices result
in a structure of the nursing staff of an agency (nature of supervision) and staff or staff
hours assigned to different subunits in a facility. These practices also affect the mix and
characteristics of the nurse workforce, the model of care used in assigning staff and in
providing care, and a wide range of workplace environments that affect how nurses
practice. Other characteristics of the workplace environments noted in the literature
included the physical environment, communication systems and collaboration,
information systems, and relevant support services. All of these factors ultimately
influence the “dose” or quantity of nursing time, as well as the quality of nursing care.
 Variables included in the category of care needs of the patient include the acuity and
complexity of the patient’s health status, as well as the patient’s comorbid medical
conditions, functional status, family needs/resources, and capacity for self-care. The
vulnerabilities of patients for adverse events varies and changes over the course of a
hospital stay or episode of care.
 The quality of nursing care relates to the appropriate execution of assessments and
interventions intended to optimize patient outcomes and prevent adverse events. For
example, the extent to which nurses assess the risk for falls in hospital patients upon
admission, implement evidence-based fall-prevention protocols, and sustain such
preventive interventions could each be developed into measures of nursing care quality.
The quality of nursing care also includes attention to safety issues, for example, the
accuracy of medication administration. Safe care also entails consistent monitoring
tailored to patients’ conditions to guarantee early recognition of patient deterioration and,
if problems are identified, benefit from a rapid, appropriate interdisciplinary team
response to these issues.24
The quality of care that nurses provide is influenced by individual nurse characteristics such as
knowledge and experience, as well as human factors such as fatigue. The quality of care is also
influenced by the systems nurses work in, which involve not only staffing levels, but also the
needs of all the patients a nurse or nursing staff is responsible for, the availability and
organization of other staff and support services, and the climate and culture created by leaders in
…………………………………………………………………………..
………………………………………………….
that setting. The same nurse may provide care of differing quality to patients with similar needs
under variable staffing conditions and in different work environments.
 Safety outcomes include rates of errors in care as well as potentially preventable
complications in at-risk patients. Safe practices that avoid errors and foreseeable
complications of care can be thought of as either a basic element of or a precondition for
delivering high-quality care, but are generally thought of as only one component of
quality.
 Clinical outcomes (endpoints) of importance vary from patient to patient or by clinical
population and include mortality, length of stay, self-care ability, adherence to treatment
plans, and maintenance or improvement in functional status. Serious errors or
complications often lead to poor clinical outcomes. So far, very few positive clinical
outcomes have been studied by staffing-outcomes researchers, probably because of
limited measures and data sources.
The sheer number of variables and myriad linkages depicted suggest why precise evidence-based
formulas for deploying nursing staff to ensure safe, high-quality patient care are impossible
based on the knowledge on hand. In fact, such prescriptions may never be possible. Certainly,
evidence-based guidelines for allocating resources to ensure optimal outcomes in acute care and
other health care settings cannot be offered until working environments, staffing (beyond head
counts and skill mix), patient needs, processes, and outcomes of care can be measured with
precision.
Research investigating links between hospital nurse staffing and patient outcomes began with
studies examining patient mortality. Reviews now include research examining a broad range of
outcomes, including specific adverse events other than mortality. Although many studies support
a link between lower nurse staffing and higher rates of negative nurse-sensitive safety
outcomes,25–27 reviews of two decades of research revealed inconsistent results across studies.25–30
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State of Science on the Relationship Between Nurse Staffing and Patient

Outcomes
Before examining the state of the scientific literature on the relationship between nurse staffing
and clinical outcomes, it is important to consider common challenges of research in this arena.
Investigators face at least two fundamental problems when designing staffing-outcomes studies:
first, finding suitable data sources and measures for staffing and patient outcomes, and second,
linking the two types of variables to reach valid conclusions. As noted earlier in this chapter,
because of limitations in measures, data sources, and analytic methods, researchers generally ask
a different question in their studies (Is there a correlation between staffing and patient care
outcomes?) than the questions that are of primary concern to patients, clinicians, managers, and
policymakers (What staffing levels are safe under a specific set of
circumstances?).31 Nonetheless, researchers in this field deserve a great deal of credit for making
creative use of a variety of data sources not originally developed for research (or research on
staffing and outcomes) to generate a great deal of evidence that has fueled discussion in the
practice, management, and policy communities.

Data Sources, Measures, and Challenges

As clinical trials or controlled experiments are difficult if not impossible to conduct in this area,
observational designs must be optimized as much as possible. When outcomes are compared
across hospitals or other health care organizations as a whole or their clinical units or
microsystems, frequently the research design that results from data linkages and analyses is
cross-sectional and correlational in nature. Staffing levels and patient outcomes from
approximately the same time are analyzed to determine whether a correlation exists between the
two. As all students of research methods know, correlational designs are more limited than
experiments for determining the extent to which causal links exist between staffing levels and
outcomes. Factors other than nurse staffing can vary alongside staffing levels, so whether or not
certain different staffing levels directly lead to better or worse outcomes cannot be determined
with certainty from correlational designs. Such factors include other aspects of the environment
in which care is provided (for example the availability of supplies, quality of physician care
and/or other services and supports). Statistical methods can control for obvious factors that
influence or are otherwise associated with staffing levels (such as hospital size, academic
affiliation, or rural-urban location). Nonetheless, it is impossible to measure and account for all
possible confounding variables (or competing explanations for findings) in the typical designs of
these studies. Maximizing returns on correlational research designs involving staffing requires
careful selection of variables and clearly articulating the theoretical and/or empirical bases for
choosing them.
Tables 1 and 2 provide brief overviews of types of measures and the questions consumers of
staffing outcomes research might consider in appraising individual studies. The discussion that
follows is intended to emphasize a few fundamental points before turning to the findings in the
literature itself.

Table 1
A Typology of Measures in the Staffing-Outcomes Literature
Table 2
Major Methodological Considerations in This Literature

Staffing
Staffing levels can be reported or calculated for an entire health care organization or for an
operational level within an organization (a specific unit, department, or division). Specific time
frames (at the shift level and as a daily, weekly, or yearly average) must be identified to ensure
common meaning among collectors of the data, those analyzing it, and individuals attempting to
interpret results of analyses.
In many cases, staffing measures are calculated for entire hospitals over a 1-year period. It is
fairly common to average (or aggregate) staffing across all shifts, for instance, or across all day
shifts in a month, quarter, or year and sometimes also across all the units of hospitals. The
resulting measures, while giving an imprecise idea of what specific conditions nurses and
patients experienced at particular points, are general indicators of facilities’ investments in
staffing. However, staffing levels on different units reflect differences in patient populations and
illness severity (the most striking of which are seen between general care and critical care units).
Furthermore, in practice, staffing is managed on a unit-by-unit, day-by-day, and shift-by-shift
basis, with budgeting obviously done on a longer time horizon. For these reasons, some
researchers argue that at least some research should be conducted where staffing is measured on
a shift-specific and unit-specific basis instead of on a yearly, hospitalwide basis. A distinct, but
growing, group of studies examined staffing conditions in subunits or microsystems of
organizations (such as nursing units within hospitals) over shorter periods of time (for example,
monthly or quarterly).17, 32–34
In addition to three sources of staffing data, there are also two basic types of staffing measures or
variables. The first type divides a volume of nurses or nursing services by a quantity of patient
care services. Common examples include patient-to-nurse ratios, hours of nursing care delivered
by various subtypes of personnel per patient day (HPPD), and full-time equivalent (FTE)
positions worked in relation to average patient census (ADC) over a particular time period.
Patient-to-nurse ratios, HPPD figures, or FTE:ADC measures have the potential to both
systematically overestimate or underestimate nurse workloads and the attention given to specific
patients in relation to those patients’ needs, conditions, and clinical trajectories across units or
institutions or over time.31
The second major type of measure examines the credentials or qualifications of those staff
members and expresses them as a proportion of staff with more versus less training (or vice-
versa). Commonly, the composition of the nursing staff employed on a unit or in a hospital in
terms of unlicensed personnel, practical or vocational nurses, and registered nurses (RNs) is
calculated. The specific types of educational preparation held by RNs (baccalaureate degrees
versus associate degrees and diplomas) have also begun to be studied. Additional staffing-related
characteristics studied include years of experience and professional certification. The incidence
of voluntary turnover and the extent to which contract or agency staff provide care have also
been studied. As will be discussed, the majority of the evidence related to hospital nurse staffing
focuses on RNs rather than other types of personnel.
For the most common measures, ratios and skill-mix, determining which staff members should
be included in the calculations is important, given the diversity of staffing models in hospitals.
Most researchers feel these statistics should reflect personnel who deliver direct care relevant to
the patient outcomes studied. Whether or not to count charge nurses, nurse educators involved in
bedside care, and nurses not assigned a patient load (but who nevertheless deliver important
clinical services) can present problems, if not in principle, then in the reality of data that
institutions actually collect. Outcomes research examining the use of advanced practice nurses in
acute care—for instance, nurse practitioners and nurse anesthetists—to provide types of care
traditionally delivered by medical staff and medical trainees has been done in a different tradition
(analyzing the experiences of individual patients cared for by specific providers) and does not
tend to focus on outcomes relevant to staff nurse practice; therefore these studies are not
reviewed here. No studies were found that examined advanced practice nurse-to-patient ratios or
skill mix in predicting acute care patient outcomes. There have been calls to examine advanced
practice nurses supporting frontline nurses in resource roles (for instance, clinical nurse
specialists who consult and assist in daily nursing care, staff development, and quality assurance)
and their potential impact on patient outcomes. No empirical evidence of this type was found.

Outcomes
Clearly, capturing data about patient outcomes prospectively (i.e., as care is delivered) is the best
option for obtaining precise, comprehensive, consistently collected data. This approach is the
most challenging because of practical, ethical, and financial considerations. However,
researchers can sometimes capitalize on prospective data collections already in progress. For
instance, hospital-associated pressure ulcer prevalence surveys and patient falls incidence are
commonly collected as part of standard patient care quality and safety activities at the level of
individual nursing units in many institutions.18, 32 Many, but by no means all, studies in this area
use secondary data not specifically intended for research purposes, such as patient medical
records. Outcomes researchers often use condensed or abstracted versions of hospital patients’
records in the form of discharge abstracts, which contain data extracted from health care records
about clinical diagnoses, comorbidities, procedures, and the disposition of patients at
discharge.35 As there are concerns that the quality and reliability of clinical documentation varies
widely,35 one author suggested that only a form of electronic medical record that forces
contemporaneous recording of assessment data and interventions will permit true performance
measurement in health care.36 Wider application of information technology in health care
settings, anticipated to facilitate care delivery and improve quality and safety, is also expected to
provide richer, higher-quality data sources for strategic performance improvement that can be
leveraged by outcomes researchers.
Patients are not all at equal risk of experiencing negative outcomes. Elderly, chronically ill, and
physiologically unstable patients, as well as those undergoing lengthy or complex treatment, are
at much greater risk of experiencing various types of adverse events in care. For instance, data on
falls may be consistently collected for all hospitalized patients but may not be particularly
meaningful for obstetrical patients. Accurately interpreting differences in rates across health care
settings or over time requires understanding the baseline risks patients have for various negative
outcomes that are beyond the control of the health care providers. Ultimately this understanding
is incorporated into research and evaluation efforts through risk adjustment methods, usually in
two phases: (1) carefully defining the patient populations at risk—the denominator in rates; and
(2) gathering reliable and valid data about baseline risk factors and analyzing them. Without
sound risk adjustment, any associations between staffing and outcomes may be spurious; what
may appear to be favorable or unfavorable rates of outcomes in different institutions may no
longer seem so once the complexity or frailty of the patients being treated is considered.35
The focus of this review is on staffing and safety outcomes. However, as was noted earlier,
quality of care and clinical outcomes (and by extension, the larger domain of nursing-sensitive
outcomes) include not only processes and outcomes related to avoiding negative health states,
but also a broad category of positive impacts of sound nursing care. Knowledge about positive
outcomes of care that are less likely to occur under low staffing conditions (or are more likely
under higher levels) is extremely limited. The findings linking functional status, psychosocial
adaptation to illness, and self-care capacities in acute care patients are at a very early stage37 but
eventually will become an important part of this literature and the business case for investments
in nurse staffing and care environments.

Linkage
In staffing-outcomes studies, researchers must match information from data sources about the
conditions under which patients were cared for with clinical outcomes data on a patient-by-
patient basis or in the form of an event rate for an organization or organizational subunit during a
specific period of time. Ideally, errors or omissions in care would be observed and accurately
tracked to a particular unit on a particular shift for which staffing data were also available. Most,
but not all, large-scale studies have been hospital-level analyses of staffing and outcomes on an
annual basis and have used large public data sources.
Linkages of staffing with outcomes data involve both a temporal (time) component and a
departmental or unit component. Many outcomes (endpoints) examined by staffing researchers
are believed to reflect compounded errors and/or omissions over time across different
departments of an institutions. These include some types of complications as well as patient
deaths. Attribution of outcomes is complicated by the reality that patients are often exposed to
more than one area of a hospital. For instance, they are sometimes initially treated in the
emergency department, undergo surgery, and either experience postanesthesia care on a
specialized unit or stay in an intensive care unit before receiving care on a general unit. If such a
patient develops a pressure ulcer, at what point did low staffing and/or poor care lead to the
pressure ulcer? Unfortunately, in hospital-level datasets, it is impossible to pinpoint the times
and locations of the errors or omissions most responsible for a clinical endpoint. In the end, if
outcomes information is available only for the hospital as a whole (which is the case in discharge
abstracts, for instance), data linkage can happen only at the hospital level, even if staffing data
were available for each unit in a facility. Similarly, if staffing data are available only as yearly
averages, linkage can be done only on an annual basis, even if outcomes data are available daily
or weekly. Linkages can be done only at the broadest levels (on the least-detailed basis or at the
highest level of the organization) available in a dataset. Many patient outcomes measures (such
as potentially preventable mortality) may actually be more meaningful if studied at the hospital
level, while others (such as falls) may be appropriately examined at the unit level.
One should recognize that common mismatches between the precision of staffing measures and
the precision of outcome measures (i.e., the staffing across an entire year across all units in a
hospital used as a predictor of outcomes for a patient treated for a short time in only a fraction of
these units) compromise the likelihood that valid statistically significant associations will be
found. This finding is particularly relevant when staffing statistics span a long time frame and
therefore contain a great deal of noise—information about times other than the ones during
which particular patients were being treated. High-quality staffing data, as well as patient
assessment and intervention data—all of which are accurately date-stamped and available for
many patients, units, and hospitals—will be necessary to overcome these linkage problems. Such
advances may come in the next decades with increased automation of staffing functions and the
evolution of the electronic medical record.
Recent prospective unit-level analyses, now possible with datasets developed and maintained by
the NDNQI, CalNOC, and the military hospital systems, make it possible to overcome some of
these issues. These databases, although not risk adjusted, stratify data by unit type and hospital
size and have adopted standardized measures of nurse staffing and quality of care. The resulting
datasets provide opportunities to study how variations in unit-level staffing characteristics over
time can influence patient outcomes (for instance, pressure ulcers and falls, as discussed later).
As data sources do not exist for all types of staffing and outcomes measures at all levels of
hospital organization (nor will they ever), research at both the unit level and the hospital level
will continue, and both types of studies have the potential to inform understanding of the
staffing-outcomes relationship.
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Research Evidence
Perhaps staffing and outcomes research has such importance and relevance for clinicians and
educators as well as for managers and policymakers, staffing-outcomes research is a frequently
reviewed area of literature. As was just detailed, a diversity of study designs, data sources, and
operational definitions of the key variables is characteristic of this literature, which makes
synthesis of results challenging. Many judgments must be made about which studies are
comparable, which findings (if any) contribute significantly to a conclusion about what this
literature says, and perhaps regarding how to transform similar measures collected differently so
they can be read side by side. The review of evidence here builds on a series of recent systematic
reviews with well-defined search criteria.25, 27, 30, 38 At least one group of researchers conducted a
formal meta-analysis that integrated the bulk of empirical findings in the hospital staffing
literature and summarized effect sizes for specific staffing measures, outcomes, and clinical
populations.30 This review was the most up-to-date identified within this search.

Evidence Related to Acute Care Hospitals

 Many researchers have identified higher levels of adverse patient events (mortality and
complications, for instance) and negative nurse job outcomes (such as burnout) under poorer
staffing conditions (specifically, thinner staffing coverage or fewer nurses per unit of patient care
and, somewhat less commonly in these studies, lower skill mix/education level of staff). These
findings have appeared in studies conducted using a variety of designs and examining hospital
care in different geographical areas and over different time periods. On the whole, while some
researchers have identified effects of 20 percent and greater reductions in negative outcomes
associated with increased/improved (or the most generous) staffing, most studies in this literature
show much smaller reductions in negative outcomes (under 10 percent and often much smaller
ones) associated with the most favorable staffing conditions they observe.30 Given the relative
rarity of some outcomes, these are subtle enough changes in outcomes to require observing many
thousands, if not hundreds of thousands, of patients to identify staffing effects on the reduction
of negative patient outcomes. Again, because of the tremendous number of factors involved in
staffing decisions and their effects on patient care, and limitations in assessing patient
characteristics, the specific staffing thresholds applicable to managers’ decisionmaking below
which outcomes are demonstrably worse cannot be identified using this literature—a point
emphasized in many reviews.24, 26
The evidence table summarizes four major systematic reviews of the literature, approaches, and
conclusions regarding the state of the evidence for specific outcomes or outcome types. In these
papers, reviewers identify specific measurement types and established criteria for study inclusion
in terms of design and reporting and examined a relatively complete group of the studies one by
one to provide an overview of the state of findings as an integrated whole.
A persistent shortage of nursing staff across the United States challenges the belief and
values of this profession. Many nurses may find it difficult to carry out their ethical obligations
to patients due to the insufficiency in staffing. Because of this shortage, many nurses
complain that they experience emotional distress and job dissatisfaction and end up not
providing quality care to their patients. Such nurses end up in an ethical dilemma, whereby
they must choose between caring for their own welfare or the needs of their patients.

Poor Patient Care

1. One ethical obligation nurses must fulfill during their daily duties involves ensuring
they protect patients from any harm. However, due to staffing shortages, nurses find
this challenging because the hospital where they work assigns them to care for
several patients. In so doing, the hospital sets unrealistic goals, especially if these
patients need specialized care due to terminal illnesses. For example, if a hospital
assigns six cancer patients undergoing chemotherapy to a single nurse, the nurse
might fail to adequately meet all the other patients’ needs. Chronically ill patients
require holistic care and a lot of emotional support. Inappropriate staffing levels deny
nurses a chance to provide proper patient care despite their training and experience.
According to the Online Journal of Issues in Nursing, this inadequate nursing shortage
increases patient mortality because they fail to receive the necessary care during
hospital stays.
 Decrease in Job Satisfaction
1. Ethics help nurses make the right decisions under the guidance of their morals.
However, due to acute staffing shortages, nurses may feel constantly dissatisfied with
their jobs. Most hospitals respond to the increasing patient demands by providing
overtime pay for nurses. In so doing, the hospital emphasizes only the technical
aspect of nursing care and forgets about the ethics of care, a personal value that most
nurses cherish. Job dissatisfaction results from finding an inappropriate working
environment whereby nurses lack the time to communicate with the patients and
provide meaningful nursing care. According to the Journal of Nursing Ethics, many
nurses view providing support to patients and comfort care as a vital aspect that
reflects professional values and ethics.

Moral Distress
1. Nurses working in health care settings with inadequate staff may suffer from moral
distress because they feel that they compromise their ethical responsibility of
protecting patients from harm by providing inadequate patient care. When hospitals
assign several patients to a nurse, it also interferes with the principle of doing good to
protect patients from harm. For instance, a nurse may decide to only give the basic
mandatory care to a patient, such as injections or medicine, but lack the time to give
them a back rub or take them out for a walk. In worse circumstances, nurses might
end up making a medical error that leads to the death of a patient simply because the
hospital overwhelms them with too many responsibilities. Such nurses may suffer from
mental anguish because they believe that they would have provided better care to
patients were it not for the multiple duties.

Burnout
1. Constant ethical conflicts at work may lead to emotional stress and physical
and mental burnout. Nurses working around the clock to attend to all the
patients the hospital assigns to them suffer from physical exhaustion. In
addition, they end up working overtime to cater to the rising patient demands
while at the same time compromising the quality of nursing care. In the long
run, such nurses suffer from physical exhaustion and mental distress and may
consider quitting their profession.

Legal Implications
1. The public is aware about the problem of understaffing and view it as a major
fundamental issue in health care centers. According to plaintiff counsels, the
public can readily access the data about the inadequate staffing levels in health
care settings and use it to trigger lawsuits even in the absence of other
systematic problems. For example, the Federal Office of Inspector General
 announced that it would treat failure of care resulting from inadequate nursing
levels as grounds for criminal and civil prosecution using the Federal Civil False
Claims Act. Moreover, in the past few years, health care facilities have
continued to receive lawsuits relating to low staffing levels. Matters relating to
these lawsuits touch on poor nursing care leading to injuries, bedsores,
residents wandering and even death. In most of the cases, the jury awards
large settlements to the victims’ families, making it an expensive affair for the
health care providers.

ursing workload and its effects on the quality of nursing care is a major concern for nurse
managers. Factors which mediate the relationship between workload and the quality of nursing
care have not been extensively studied. This study aimed to investigate the mediating role of
implicit rationing of nursing care, job satisfaction and emotional exhaustion in the relationship
between workload and quality of nursing care.

Methods
In this cross-sectional study, 311 nurses from four different hospitals in center of Iran were
selected by convenience sampling method. Six self-reported questionnaires were completed by
the nurses. The data were analyzed by SPSS version 16. Structural equation modeling was used
to determine the relationships between the components using Stata 14 software.

Results
Except direct and mutual relationship between workload and quality of nursing care (P ≥ 0.05),
the relationship between other variables was statistically significant (P < 0.05). The hypothesized
model fitted the empirical data and confirmed the mediating role of implicit rationing of nursing
care, job satisfaction and emotional exhaustion in the relationship between workload and the
quality of nursing care (TLI, CFI > 0.9 and RMSEA < 0.08 and χ2/df < 3).

Conclusion
Workload affects the quality of the provided nursing care by affecting implicit rationing of
nursing care, job satisfaction and emotional exhaustion. Nurse managers need to acknowledge
the importance of quality of nursing care and its related factors. Regular supervision of these
factors and provision of best related strategies, will ultimately lead to improve the quality of
nursing care.

Peer Review reports

Background
Care is the core of the nursing profession and the main factor which distinguishes nursing from
other health-related professions [1, 2]. High-quality nursing care means the provision of easy and
accessible care by competent qualified nurses [3]. Nowadays, the maintenance and improvement
of the quality of nursing care is the most important challenge for nursing care systems around the
world [4]. The first step in improving the quality of nursing care is to evaluate and analyze the
quality of provided care and examine the factors affecting on it [5].

Various variables can affect the quality of nursing care [6,7,8]; one of which is workload. Zuniga
et al. (2015) indicated in Switzerland that increased workload and, subsequently, increased stress
could reduce the quality of nursing care [9]. However, there are contradictory findings in this
regard. It was shown in another study that there was a high level of nursing care quality despite
the high workload and inadequate human resources and equipment [6]. In another study, the
workload was measured by total direct nursing hours. The results showed a significant
correlation between total direct nursing hours and some indicators of nursing care quality such as
incidence of patient restraint, and mortality rate. Nevertheless, there was no significant
correlation with other indicators of nursing care quality like incidence density of pressure sores,
the incidence of falls, the incidence of tube self-extraction, and incidence density of infection
[10].

In addition to the correlation between workload and the quality of nursing care, a number of
other factors can also be involved in this relationship. For example, workload can lead to implicit
rationing of nursing care, thereby can affect the quality of care. In a study conducted in Lebanon,
the level of perceived workload in all shifts had a positive relationship with the level of rationing
of nursing care [11]. Because of many reasons such as high workload, nurses may find
themselves in situations where they are forced to omit the necessary cares, do them briefly or
with delay [11, 12]. Nurses are unable to provide comprehensive care in accordance with
professional standards, and it can affect the quality of nursing care [13]. A study conducted in
China showed that the nurses who had a higher score in rationing of nursing care, had a lower
score of the quality of nursing care [14]. Moreover, while increased rationing in rehabilitation,
care, supervision and social care in nursing homes, decreases the quality of nursing care,
increased rationing in the field of documentation increases the quality of nursing care [9].

Job satisfaction seems to be another factor mediating the relationship between workload and the
quality of nursing care. Inegbedion et al. (2020) indicated that increased workload could be
associated with decreased job satisfaction among nurses [15]. Workload as a strong stressor can
negatively affect the job satisfaction of nurses [16]. Job satisfaction is a multidimensional
emotional concept which reflects the interaction between nurses' expectations and values, their
environment and personal characteristics [17]. Perception of the significance of nurses' job
satisfaction and its improvement is essential in providing high-quality care with optimal clinical
outcomes. In the study of Aron et al. (2015), 87.6% of nurses believed that the quality of care
provided by nurses was affected by their job satisfaction [18]. According to another study, job
satisfaction was a significant predictor of the quality of nursing care [19].

Workload may also affect the quality of nursing care by causing emotional exhaustion in nurses.
The results of a study revealed that 55.4% of Canadian nurses suffered from emotional
exhaustion. The high workload in this study was a predictor of emotional exhaustion and there
was a positive and significant correlation between workload and emotional exhaustion [20].
Additionally, the findings of Nantsupawat et al. (2016) were indicative of the effect of emotional
exhaustion on the quality of nursing care. While increased emotional exhaustion of nurses in
their study increased the incidence of medication errors and infections, it decreased the quality of
nursing care [21]. Findings of another study showed that among the components of job burnout,
emotional exhaustion had the strongest relationship with the quality of nursing care [22].

Previous studies have mainly investigated the relationship of one or two variables with the
quality of nursing care and the simultaneous effect of several mediating variables on the quality
of nursing care has not been examined [23,24,25]. Many of these studies have not used a
comprehensive questionnaire to assess all aspects of the quality of nursing care or have been
conducted in other settings except hospital units [6, 9, 26, 27]. Assessing the quality of nursing
care with an incomplete questionnaire or with only one question does not cover all dimensions of
quality of nursing care such as the care-related activities, nursing care environment, nursing
process, and strategies that empower patients and will provide incomplete findings [28, 29].

Accordingly, to improve the quality of nursing care, we need to determine these variables and
their mediating roles, in order to better control them through applying effective interventions.
Using Structural Equation Modeling (SEM) is one powerful tool for mediation analysis [30, 31],
this study was conducted to investigate the mediating role of implicit rationing of nursing care,
job satisfaction, and emotional exhaustion in the relationship between workload and the quality
of nursing care in Iran.

Hypotheses
The theoretical model in this study was developed by reviewing the related literature (Fig. 1) to
test three hypotheses:

Fig. 1

Hypothesized model
 Full size image

H1: Implicit rationing of nursing care plays a mediating role in the relationship between
workload and the quality of nursing care.

H2: Job satisfaction plays a mediating role in the relationship between workload and the quality
of nursing care.

H3: Emotional exhaustion plays a mediating role in the relationship between workload and the
quality of nursing care.

Methods
Study design and participants
This cross-sectional study was conducted from October to December 2020 in inpatient units of
four selected hospitals in central Iran, Kashan city. According to the guidelines of structural
equation modeling, the study required at least 300 participants [32]. As such, 311 employed
nurses participated in the study by using the convenience sampling method. Inclusion criteria
were as follows: willingness to participate in the study, having at least six months of work
experience, having experience of direct clinical care of patients, and having at least a bachelor's
degree in nursing. Exclusion criteria were failure to complete the questionnaire and decline to
answer the questionnaires in the process of the study.

Instrumentation
Six tools were used to collect data and analyze the variables of this study:

1. 1.

Nurse's demographic information questionnaire which contains questions about age,

gender, marital status, current workplace unit, employment status, nursing work
experience, duration of working in the current unit, having overtime, average salary per
month, being a nurse as a second job, having a second job beside nursing and the level of
interest in the nursing.

2. 2.

The NASA Task Load Index (NASA-TLX) includes six areas of mental demand,
physical demand, temporal demand, performance, effort and, frustration. The final score
is calculated to be between zero and 100, where scores higher than 50 are indicative of a
high overall subjective workload [33]. Using Cronbach's alpha coefficient, the reliability
of this questionnaire has been reported to be above 0.8 in previous studies [34, 35].

3. 3.
 Basel Extend of Rationing of Nursing Care (BERNCA) questionnaire which has 20 items
based on a 4-point Likert scale. In this questionnaire, nurses assess themselves how many
times in the past month they have not been able to perform the listed care activities and
have been forced to ration them. The total mean score of rationing is 0–3, and the higher
the score, the more will be the care that has been rationed. Cronbach's alpha coefficient
was calculated to be 0.93 [36]. The reliability coefficient was calculated at 0.91 in the
present study.

4. 4.

The Minnesota Satisfaction Questionnaire (MSQ) which was designed by Weiss et al.
(1967) and has two long and short versions [37]. In this study, the short version of the
questionnaire was used. This 18-item questionnaire is based on a 5-point Likert scale and
higher scores are indicative of better job satisfaction. The reliability and validity of this
questionnaire was determined in Iran [38]. Using Cronbach's alpha, the reliability of this
questionnaire was calculated at 0.77 in the present study.

5. 5.

The emotional exhaustion subscale of the Maslach Burnout Inventory (MBI), includes
nine items and is based on a 7-point Likert scale. Higher scores indicate higher emotional
exhaustion [39]. The validity and reliability of this scale were examined in Iran and
Cronbach's alpha coefficient was reported to be 0.88 [40]. Cronbach's alpha coefficient
was calculated to be 0.90 in the study of Maslach et al. (1996) and 0.89 in the present
study.

6. 6.

The Good Nursing Care Scale (GNCS) is a comprehensive questionnaire that examines
all aspects of the quality of nursing care. It has two parallel versions for the nurse and the
patient and the nurse's version was used in the present study. This questionnaire has 40
items and seven dimensions include nurses’ characteristics in providing care ( such as
type of interaction with the patient, and accuracy), care-related activities (such as patient
education, and emotional support), care preconditions (such as nurse’s knowledge, skill,
and experience), nursing care environment (such as infection control, maintain patient
safety, and patient privacy protection), nursing process (conditions related to patient’s
admission, treatment and, discharge), patient empowerment strategies in coping with the
disease (such as paying attention to the patient’s level of knowledge, answering the
questions), and collaboration with the patient's family and relatives (such as providing
sufficient information to the family, and family participation in treatment process). The
scale is based on a 5-point Likert scale and the higher the obtained score, the more will be
the quality of provided care [28, 29]. This scale has been psychometrically evaluated and
used in different countries and Cronbach's alpha coefficient for the scale has been in the
range of 0.80 to 0.94 in various studies [6, 41,42,43]. Cronbach's alpha coefficient was
calculated to be 0.93 in the present study.
Data collection
All six questionnaires were filled out by the participants based on their work performance in the
past month. After obtaining the informed written and oral consent of the eligible nurses, they
were explained how to complete the questionnaires. It order to prevent the nurses’ fatigue, the
questionnaires were prepared in both online and paper format. The researcher asked each of the
participants if they wanted to fill out the questionnaires online or on paper format. If the
participants chose the paper format, the questionnaires were delivered to them and were collected
at the appointed time. All of the questionnaires have been assessed immediately after the
response of the participants and any missing data have been filled by them. But if the participants
selected the online version, the link to the questionnaires was sent to their cellphone. This link
was designed in such a way that a person could answer only once through the link of the
questionnaire and until all the questions were answered, the questionnaire was not sent.
Accordingly, there were no missing data. All data collection process was done by a researcher
(first author).

Data analysis
Data were analyzed using SPSS version 16 and Stata version 14. Categorical data were described
by frequencies and percentages, and quantitative continuous data by mean and standard deviation
(SD). The correlation between the variables was determined by the Pearson correlation
coefficient test. Structural equation modeling was used to capture the structure of relationships
among a web of latent and observed components. To understand the relationships between the
variables, according to the theoretical model of the study, all variables were analyzed using Stata
software and the structural model was developed. In this study, three types of absolute,
comparative and, parsimony fit indices were examined. The Root Mean Square Error of
Approximation (RMSEA), the Comparative Fit Index (CFI) Tucker-Lewis Index (TLI), and the
ratio of chi-square to the degrees of freedom (χ2 / df) were considered for the good fit of the
model. A model is considered to have good fit if the (χ2 / df) value is lower than 3, CFI and TLI
are 0.90 or greater, and the RMSEA value is less than 0.08 [44, 45]

Results
Participants’ characteristics
All of 311 distributed questionnaires were completed and analyzed. The mean age of the nurses
participating in the study was 32.68 ± 6.73 years. The majority of the participants were female
(86.5%) and married (76.2%). The complete demographic information of the participants can be
seen in Table 1.

Table 1 The characteristics of the participants (n = 311)

Full size table

Bivariate analysis
According to the scoring of the questionnaires, the workload of the nurses was at a high level,
implicit rationing of nursing care happened rarely, the job satisfaction of nurses was at a
moderate level and emotional exhaustion was at a low level. Moreover, the quality of the
provided nursing care was at a good level (Table 2).

Table 2 Mean and standard deviation, minimum and maximum scores of the research
variables

Full size table

According to the result of Pearson correlation coefficient, there was a statistically significant
correlation between the various variables of the study (except workload and quality of nursing
care) (Table 3).

Table 3 Correlation of the research variables

Full size table

Structural equation model

Based on the results of this study, the direct effect of workload on implicit rationing of nursing
care, job satisfaction and emotional exhaustion was statistically significant (p < 0.05). Moreover,
implicit rationing of nursing care, job satisfaction, and emotional exhaustion had an indirect
statistically significant effect on the relationship between workload and quality of nursing care
(p < 0.05) (Table 4).

Table 4 Direct and indirect effect of variables

Full size table

The obtained good fit indices confirmed the mediating role of implicit rationing of nursing care
(TLI = 0.94; CFI = 0.95; RMSEA = 0.05), job satisfaction (TLI = 1; CFI = 1; RMSEA = 0.01) and
emotional exhaustion (TLI = 0.96; CFI = 0.95; RMSEA = 0.01) in the relationship between
workload and the quality of nursing care.

As shown in Fig. 2, the model fit the data well and was consistent with the hypothesized model.
By putting together the three variables of implicit rationing of nursing care, job satisfaction, and
emotional exhaustion as mediators in the model, a good fit was obtained (TLI = 0.95; χ2/df = 2.3;
CFI = 0.96; and RMSEA = 0.05).

Fig. 2
The final model

Full size image

Discussion
The results of this study supported the proposed hypothesized model. The findings shown in this
structural equation model provided strong support for the study hypotheses.

Based on the findings, implicit rationing of nursing care played a mediating role in the
relationship between workload and the quality of nursing care. Therefore, the H1 hypothesis was
supported. When the nurses’ workload is high and they are responsible for caring for a large
number of patients, they are inevitably forced to ration some important interventions which, in
turn, can reduce the quality of nursing care [12, 13]. An earlier study showed that implicit
rationing of nursing care functions as a mediator between predictive variables such as workload
and patient-related outcomes such as medication error and patients’ falling. These adverse events
can reduce the quality of nursing care [20]. In other words, workload has an indirect effect on
patient-related outcomes through care rationing and affecting the ability of nurses in completing
their main tasks. In another study, nurse-to-patient ratio, as an important indicator in the
workload of nurses, affected the quality of care and the incidence of adverse events through
rationing of care. In other words, poor nurse staffing levels leads to the rationing of nursing care
and, thereby, hinders the provision of high quality care [14]. Some other studies also referred to
the mediating role of rationing of nursing care in the relationship between workload and patient
safety [46] as well as in the relationship between workload and patients’ falling [47].
Accordingly, implicit rationing of nursing care seems to play a key role in the relationship
between workload and the quality of nursing care.

In the present study, nurses’ job satisfaction was the second variable that mediated the
relationship between workload and quality of nursing care. Hence, the H2 hypothesis was
supported. When the workload is increased, nurses cannot meet some of the needs of patients
despite the effort they make. So, nurses do not have a positive attitude toward their
performances, leading to less job satisfaction [23, 48]. In these circumstances, nurses do not have
the necessary peace of mind and precision in the workplace which may negatively affect their
efficiency and performance, decreasing the quality of the provided care [49]. Job satisfaction is
an important variable that mediates the relationship between workload and other variables such
as intention to leave the job and position [50, 51]. Therefore, this is affecting the quality of
nursing care indirectly. However, more research is required to investigate the mediating role of
job satisfaction.

Emotional exhaustion was another mediating variable in the relationship between workload and
quality of nursing care in this study. Therefore, the H3 hypothesis was supported. Emotional
exhaustion is considered to be the most important component of job burnout and nurses who
experience high levels of emotional exhaustion will suffer from job burnout and have a lower
ability and tendency to provide high-quality care [39, 52]. According to Van Bogaert et al.
(2009), emotional exhaustion plays a mediating role in the relationship between nurses’
workplace conditions and the quality of nursing care [53]. Liu et al. (2018) also indicated that
emotional exhaustion mediates the relationship between workload and patient safety. When
nurses are constantly exposed to stressful work environments, their reactions become more
chronic and serious, and they need more time to recover [46]. Additionally, because of high
workload and regular attendance at the hospital, nurses do not have much opportunity to rest and
regain their energy and, thus, will experience a perpetual emotional exhaustion [54].

It is noticed from this study that there was no significant correlation between workload and
quality of nursing care. This finding is interesting and in line with an earlier study in which
despite the high levels of workload and insufficiency of human resources and equipment, the
quality of nursing care was at a high level [6]. Considering that both the nurse’s workload and
the quality of nursing care have been investigated from the nurse's point of view, more reliable
results have been obtained in this study. It should be noted that the final model in this study is a
full mediation model, as the three variables (rationing of nursing care, job satisfaction, and
emotional exhaustion) fully mediate the effect of workload on the quality of nursing care. So,
after controlling for this mediation effect, there is no direct effect of workload on quality of
nursing care [55].

Also, it seems that experience of high levels of workload for a long period of time and fall into
the habit of these conditions lead to nurses can manage difficult situations. According to this
finding, it is suggested that temporary or permanent high nursing workload should be taken into
consideration in the next researches. Also, social desirability bias which is the tendency to
respond in a pleasing way, in answering the questions related to quality of nursing care may also
have been influential.

2. Abstract: It is crucial to comprehend factors associated to job dissatisfaction among healthcare

workers (HCWs) in Malaysia’s primary health clinics, especially those working in ‘Type 2 Health
Clinics’ which cater for populations of >50,000 and a daily average number of patients between
500 and 800. It is essential to ensure that effective strategies can be proposed to promote job
satisfaction. A total of 314 HCWs from ‘Type 2 Health Clinics’ in north-eastern Malaysia
consented to participate in this cross-sectional study, conducted between October 2020 and
December 2021. The Job Satisfaction Survey was used to assess job dissatisfaction. The
prevalence of job dissatisfaction was 35.7%. The significant factors associated with job
dissatisfaction were younger age and those who were dissatisfied with their yearly performance
mark. Targeted interventional activities for young HCWs and for those who are dissatisfied with
their yearly performance mark are recommended to improve job satisfaction. Keywords: job
dissatisfaction; primary health clinic; factor associated; north-eastern Malaysia 1. Introduction
Job dissatisfaction consists of one’s cognitive, emotional, and behavioral response to their job
[1]. It was discovered that agreeableness (the traits of cooperation and likeableness),
extraversions (the traits of being assertive, enthusiastic, and energetic), and conscientiousness
(the traits of high level of organization, hard work, and goal persuasion) are related to job
satisfaction, whereas neuroticism (the traits of lack of emotional stability and lack of positive
psychological adjustment) and lack of openness to experience (the trait of unconventionality)
are related to job dissatisfaction [2]. Apart from that, job dissatisfaction also has been linked to
workers’ level of autonomy in how they act, given their skill set and work expectations. It also
has to do with employees’ psychological challenges in carrying out their duties [3]. Job
dissatisfaction can have a negative impact on both the organization and the people receiving the
services. It can jeopardize patients’ safety and treatment, being related to poor job performance
and absenteeism amongst healthcare workers (HCWs) [4]. Hence, it is important to determine
job dissatisfaction, especially among HCWs. In Malaysia, the primary health clinic is an important
structure in the public healthcare system as it provides curative, promotive, and rehabilitative
care services. However, there is a noticeable shortage of HCWs in primary health clinics, as most
of them leave for the private sector or leave the healthcare system entirely [5]. This can lead to
an imbalance between those who provide healthcare services and those who require healthcare
services, which contributes to occupational stress and leads to job dissatisfaction, which later
leads to quitting [6,7]. Apart from that, poor job performance may jeopardize patients’ safety
and care [4]. Hence, it is important to determine the prevalence of job dissatisfaction and to
identify its predictors among HCWs in Malaysia. Int. J. Environ. Res. Public Health 2022, 19,
16106. https://doi.org/10.3390/ijerph192316106 https://www.mdpi.com/journal/ijerph Int. J.
Environ. Res. Public Health 2022, 19, 16106 2 of 13 2. Literature Review 2.1. Job Dissatisfaction
and Healthcare Workers Internationally, two studies conducted in Ethiopia found that the
prevalence of job dissatisfaction was around 46% [8,9]. However, Behmann et al. (2012) found
that the prevalence of job dissatisfaction among primary care physicians in Germany was slightly
lower at 36% [10]. In a local Malaysian context, Manan et al. (2015) reported that 48% of
pharmacists in Negeri Sembilan, Selangor, and Perak were unsatisfied with their job, and found
that HCWs aged 35 and older and who had worked more than seven years’ experience are more
likely to be satisfied with their jobs [11]. Aidalina M. (2015), who studied the brain drain
phenomenon of physicians in the public and private sector in Selangor and Kuala Lumpur, found
that 35.6% were dissatisfied with their work and 55% of those respondents felt neutral about
public-sector job satisfaction, driving them to leave the public sector to work in the private
sector [12]. Numerous factors can contribute to job dissatisfaction, such as co-workers,
supervisors, work, and promotion [13]. Job dissatisfaction was found to be associated with age
when being both a young and an old worker (near retirement age) [11,14]. Interestingly, looking
at the years of employment, it was noted that the longer the worker’s work experience, the
more satisfied they were with their job [14,15]. However, it was also found that those who work
for more than ten years are less satisfied than young workers [10]. Other than that, gender
dominance is subjected to conflicting studies in regards to job dissatisfaction. There were
studies that found no gender difference with job dissatisfaction [10,11,14] and studies that also
found that females were more prone to job dissatisfaction than males [12,16]. One of the
elements that influenced job satisfaction for public servants in Malaysia was satisfaction with
their yearly performance mark, which is an annual assessment report, often known as ‘Laporan
Nilaian Prestasi Tahunan’ (LNPT). LNPT, according to Malaysia’s Public Service Department, aims
to improve employee motivation and performance and identify employee potential, and can be
used for employee promotion, training, and placement, as well as to effect salary increment.
The supervisor evaluated the workers once a year as a means of providing feedback in which
they try to identify their subordinates’ areas for improvement, assist them with further training,
and help them learn new skills to accomplish their job [17]. A study in Indonesia discovered a
high link between perceived supervisor support and job satisfaction, indicating a meaningful
association [18]. Aside from reducing worker burnout and increasing job happiness, excellent
support also helps employees feel more secure in achieving their work goals [19]. Apart from
that, job-related factors also contributed to job dissatisfaction [20]. In depth, they can be
divided into intrinsic variables of co-workers, supervision, and work itself, and extrinsic variables
of salary and advancement [13]. Working environment plays an important role as an
unfavorable working environment contributes to job dissatisfaction [10,16]. Aside from that,
those working under appropriate and supportive supervision and colleagues are more pleased
with their job compared to those who do not [9,21]. In a local context, job-related factors also
play a role in job dissatisfaction as a study involving Malaysia’s family physicians in 2016 found
that Malaysian family physicians were dissatisfied with their salary, recognition, and their
working conditions [22]. 2.2. Primary Health Clinic in Malaysia According to the Family Health
Development Unit, Ministry of Health, Malaysia under the Primer Infrastructure Development
Sector, a health clinic can be divided into seven types depending on its catchment population
and daily average number of patients. It provides services such as the out-patient department,
accident and emergency, maternal and child health, dental, rehabilitation, radiography,
laboratories, and pharmacy [23]. Table 1 shows the types of primary health clinic in Malaysia Int.
J. Environ. Res. Public Health 2022, 19, 16106 3 of 13 Table 1. Primary health clinic types in
Malaysia. Health Clinic Type Catchment Population Average Number of Patients/Day Service
Provided Type 1 Health Clinic >50,000 >800 Out-patient department, accident and emergency,
maternal and child health, dental, rehab, X-ray, laboratory, and pharmacy Type 2 Health Clinic
>50,000 500–800 Type 3 Health Clinic >30,000–50,000 300–500 Type 4 Health Clinic >20,000–
30,000 150–300 Out-patient department, accident and emergency, maternal and child health,
dental, rehab, X-ray, laboratory, pharmacy, ABC (alternative birth center) (optional), sick bay
(optional) Type 5 Health Clinic >10,000–20,000 100–150 Out-patient department, accident and
emergency, maternal and child health, dental, mini laboratory, pharmacy, ABC (alternative birth
center) (optional), sick bay (optional) Type 6 Health Clinic >5000–10,000 50–100 Out-patient
department, accident and emergency, maternal and child health, mini laboratory, pharmacy,
ABC (alternative birth Type 7 Health Clinic 50,000 and their daily average number of patients
was between 500 and 800 [23]. Using a twoproportion formula, with a 95% confidence interval,
5% precision, and allowing a 10% non-response rate or data entry error, the required sample
size was 335 (p = 0.63) [24]. All available HCWs were included in the study as the required
sample size exceeded the number of the workers in those clinics. 3.2. Data Collection and
Research Tool A proforma as attached in Appendix A was designed to gather sociodemographic
data such as age, education level, and years of employment. The Job Satisfaction Survey (JSS)
was used to assess job satisfaction among the respondents. The JSS was developed by Paul E.
Spector in 1985 and is commonly used in many fields, including healthcare services. It has nine
facets and a 36-item scale to evaluate employee attitudes toward their job and its various
aspects. The facets were pay, promotion, contingent rewards, operating procedures,
supervision, nature of work, fringe benefits, communication, and co-workers. Each item had six
options, varying from “strongly disagree” to “strongly agree” [25]. In this study, the JSS scored
the Likert scale of minimum and maximum score as satisfied (144–216) and dissatisfied (36–
143). Based on a systemic review conducted in 2003, it was found that the JSS has adequate
validity and reliability. The discriminant validity was 0.19–0.59 and convergent validity was 0.61–
0.80, whereas the internal consistency was 0.91 and test–retest was 0.71 [26]. The Malay
language version was translated by Tan Soo Luan in 2010 with reported similar internal
consistency of Cronbach’s α 0.84 when compared to its English version [27]. Permission to use
the questionnaire was obtained before conducting the study. In this study, a HCW was defined
as a person whose work involves contact with a patient or with blood or other body fluids from
a patient in a healthcare, laboratory, or public safety situation at a health clinic [28]. We
included all ‘Type 2 Health Clinics’ HCWs aged 18 and above who had worked for at least three
months in the current clinic’s working system. Those who did not complete at least 80% of the
questionnaire data were excluded. Int. J. Environ. Res. Public Health 2022, 19, 16106 4 of 13 3.3.
Procedure The questionnaire was distributed to all HCWs working in all ‘Type 2 Health Clinics’ in
north-eastern Malaysia. Initially, the selected health clinics were informed through a letter that
was sent through the ‘Kelantan State Health Department’ explaining the study that will be
conducted to the clinic’s manager, who will convey the information to all HCWs at their clinic.
The research team then scheduled a face-to-face session with the help of the clinic’s manager
with their respective HCWs. The session explained the research objectives and procedures,
voluntariness, and anonymity. They were then given enough time to consider their participation,
signed the consent form, and answered the questionnaire given. Any questions that arose were
entertained by the research team during the session. 3.4. Data Analyses For data entry and
analysis, IBM SPSS version 26.0 was used. Data were checked and cleaned once they were
entered. In descriptive analyses, data were analyzed and presented as frequency (n) and
percentage (%). Simple and multiple logistic regression was used to find the predictor of job
dissatisfaction as the outcome was categorical and binary of either job dissatisfaction or job
satisfaction. Forward LR and Backward LR were used to compare and identify the final model of
factors associated with job dissatisfaction. It was then checked for multicollinearity, interaction,
and the model’s fitness. The final model was presented as a p-value and adjusted OR. A p-value
of less than 0.05 was set as the level of significance. 3.5. Ethical Consideration Ethical approval
for this study was obtained from the Medical Research and Ethics Committee (MREC), Ministry
of Health, Malaysia, with identification number NMRR-20- 2574-57270 (IIR). Ethical approval
was also obtained from the Human Research Ethics Committee (JEPeM), Universiti Sains
Malaysia (USM), (USM/JEPeM/2 0110577). Written consent was obtained from participants
prior to the study. Only the researcher can access the data and participant anonymity was
applied to ensure the confidentiality of the data. 4. Results The respond rate was 84.9%
(314/370). The mean (SD) age of the HCWs was 40.6 (7.81) years old, and duration of
employment was 15.7 (7.58) years. A total of 219 (69.7%) of them completed tertiary education
and 284 (90.4%) were satisfied with their yearly performance mark. Table 2 shows the
 sociodemographic characteristics of the respondents. Table 2. Sociodemographic characteristics
of the healthcare workers in ‘Type 2 Health Clinics’ in north-eastern Malaysia (n = 314).
Variables n (%) Mean (SD) Age (year) 40.6 (7.81) Gender Male 82 (26.1) Female 232 (73.9) Race
Malay 309 (98.4) Non-Malay 5 (1.6) Marital status Single/divorced 34 (10.8) Married 280 (89.2)
Education level Tertiary 219 (69.7) Secondary 95 (30.3) Int. J. Environ. Res. Public Health 2022,
19, 16106 5 of 13 Table 2. Cont. Variables n (%) Mean (SD) Health clinic’s working system Non-
shift 142 (45.2) Shift 172 (54.8) Number of children 2.6 (1.74) Monthly income (RM) 4213.7
(1891.95) Employment (year) 15.7 (7.58) Yearly performance mark Satisfied 284 (90.4)
Dissatisfied 30 (9.6) A total of 69 (22.0%) of the HCWs in the shift clinics’ working system and 43
(13.7%) in the non-shift clinics’ working system in ‘Type 2 Health Clinics’ in north-eastern
Malaysia were dissatisfied with their job. Table 3 provides the details. Table 3. Proportion of job
dissatisfaction among healthcare workers working in different health clinics’ working systems (n
= 314). Variable Proportion Job Satisfaction (%) Job Dissatisfaction (%) Health clinic’s working
system Shift 103 (32.8) 69 (22.0) Non-shift 99 (31.5) 43 (13.7) The top two job dissatisfaction
factors among HCWs in ‘Type 2 Health Clinics’ in north-eastern Malaysia according to JSS facets
were related to operating conditions (61.8%) and benefits (55.4%). Table 4 provides the details.
Table 4. Proportion of various levels of satisfaction towards job-related factors among
healthcare workers in ‘Type 2 Health Clinics’ (n = 314). Job-Related Factors No. of Dissatisfied
(%) No. of Satisfied (%) Pay 94 (29.9) 220 (70.1) Promotion 148 (47.1) 166 (52.9) Supervision 53
(16.9) 261 (83.1) Benefits 174 (55.4) 140 (44.6) Rewards 134 (42.7) 180 (57.3) Operating
conditions 194 (61.8) 120 (38.2) Co-workers 48 (15.3) 266 (84.7) Nature of work 27 (8.6) 287
(91.4) Communication 110 (35.0) 204 (65.0) The variables from simple logistic regression with a
p-value less than 0.25, which were age, gender, race, monthly income, and yearly performance
mark, were selected and further analyzed using multiple logistic regression to determine the
associated factors. Multiple logistic regression shows that age in years (Adj. OR 0.91; 95% CI:
0.83,0.99, p = 0.037) and dissatisfaction with yearly performance mark (Adj. OR 14.80; 95% CI:
3.43,63.763, p < 0.001) predicts job dissatisfaction. It can be interpretated as the HCWs working
in ‘Type 2 Health Clinics’ in north-eastern Malaysia had 9.4% lower odds of job dissatisfaction as
they got older, and those dissatisfied with their yearly performance mark were 14.8 times more
likely to develop job dissatisfaction after being adjusted for age. Table 5 shows the details for
both simple and multiple logistic regressions. Int. J. Environ. Res. Public Health 2022, 19, 16106 6
of 13 Table 5. Simple and multiple logistic regression analysis for factors associated with job
dissatisfaction among healthcare workers working in ‘Type 2 Health Clinics’ in north-eastern
Malaysia. Variables Crude OR a (95% CI) p-Value a Adjusted OR b (95% CI) p-Value b Age (year)
0.953 (0.882, 1.029) 0.214 0.906 (0.826, 0.994) 0.037 Gender Male 1 Female 4.603 (0.585,
36.226) 0.147 Race Malay 1 Non-Malay 5.528 (0.534, 57.211) 0.152 Marital status
Single/divorced 1 Married 1.392 (0.172, 11.250) 0.756 Education level Tertiary 1 Secondary
0.842 (0.249, 2.845) 0.782 Health clinic’s working system Non-shift 1 Shift 0.824 (0.268, 2.537)
0.736 Number of children 0.860 (0.612, 1.208) 0.384 Monthly income (RM) 1.000 (0.999, 1.000)
0.139 Employment (year) 0.963 (0.891, 1.040) 0.337 Yearly performance mark Satisfied 1 1
Dissatisfied 7.792 (2.266, 26.789) 0.001 14.795 (3.433, 63.759).

Registered nursing is one of the top professions for growth. If you’re interested
in advancing your nursing career, or are considering joining the profession, it’s
important to understand what’s behind the nursing shortage and what opportunities this
shortage might create for you.
The nationwide nursing shortage is not a new topic. The American Nurses Association
(ANA) estimates an 11% growth rate through 2022. Meanwhile, the U.S. Bureau of
Labor Statistics estimates there will be 175,000 positions for registered nurses each
year through 2029.

When you hear nursing shortage, you may think of practicing nurses. But there’s also a
shortage of nurse educators. Nationwide nursing faculty shortages limit nursing program
student capacity, making it impossible to keep up with the demands of the nursing
shortage (AACN PDF source). The problem has been discussed in a language such as
“in the next 20 years.” But now that 2026 is just 5 years away, this poses a significant
concern to the healthcare system.

The American Association of Colleges of Nursing (AACN), the ANA and

the Institute of Medicine have reported the importance of addressing the nursing
shortage for more than a decade. A shortage occurs when the demand for nurses
available outweighs the number of nurses available to work. As the current nursing
shortage deepens, the pressure will intensify for nursing programs to increase the
enrollment capacity to fill these vacancies. 

The healthcare industry worldwide is undergoing radical transformation based on

recommendations from the Institute of Medicine and Quality and Safety Education for
Nurses (QSEN) initiatives. The nursing profession is at the forefront of this
transformation, but the nursing shortage must be addressed. 

What is Causing the Nursing Shortage? 

There are four main contributors to the nursing shortage:

1. Retiring nurses or those choosing to leave the profession

2. The aging population necessitates increasing the level of care patients require
3. A nursing faculty shortage capping pre-licensure admission capacity
4. Nursing burnout

According to AACN, the average age of the nursing workforce is 50 years old.

Whereas this is not retirement age, today’s healthcare with emerging technologies (i.e.,
computerized charting, barcode medication administration) coupled with the rising
acuity of patients increases the mental and physical demands required of practicing
nurses today impacting a nurse’s decision to retire at an earlier age than other
professions. The notable increase in nurses taking early retirement reduces an already
depleted nursing workforce. 

Nursing is a knowledge-intensive profession built upon years of experiences, on-the-job

training and invaluable clinical reasoning skills. The ANA estimates that 1 million
nurses will retire between now and 2030. Not only is the profession expected to lose a
large number of nurses, but when experienced nurses leave, healthcare organizations
are left to mitigate the threat of lost knowledge. Nurses will leave with the critical nursing
experience and knowledge they have accumulated. This leaves enormous shoes for
new graduate nurses to fill. 

A second cause impacting the nursing shortage is that people are living longer due to
advancing medical science. The U.S. has the largest number of Americans over the
age of 65. As the population ages, the number of health conditions, chronic illnesses
and co-morbidities requiring healthcare services grow. These increasing healthcare
needs require healthcare organizations to increase nursing staff to provide quality care
safely. 

A third contributor is the pre-licensure nursing education capacity. There is a direct link
between the nursing shortage and nursing education. According to the AACN, nursing
schools in the United States turned away approximately 80,000 qualified
applicants due to an inadequate number of faculty, clinical sites, academic space and
budget. According to the Higher Ed Jobs, to date, there are currently over 1,000 open
nurse educator positions with 500 of these vacancies at the associate degree level. 

A final contributor crucial to highlight is nurse burnout. With the nursing shortage and
the complexity of healthcare needs, many nurses are overworked and emotionally
exhausted. Nurses are choosing to leave the profession. If the nursing shortage is not
addressed, nurses will continue to leave the profession due to burnout. If nurse burnout
is not addressed, the United States will continue to deal with a nursing shortage. It is a
cycle that needs to be broken. Many statewide initiatives are taking place to address
practicing nurse and nurse educator shortages as they are linked and cannot resolve
without the other. 

Is There a Nursing Shortage Worldwide? 

The nursing shortage is not just an issue in the United States, but also a global problem.
Globally, nurses comprise half the healthcare workforce. It is estimated that there will be
a nurse shortage of 7 million globally by 2030 (Centre for Health & Social Care
Research PDF source). Just as mentioned above, the same causes are impacting the
profession of nursing worldwide. 

When Did the Nursing Shortage Begin?

According to the World Health Organization (WHO), the nursing profession has dealt
with periodic nursing shortages; however, shortages have always been resolved until
the past decade. With many nurses near retirement age, the increasing number of older
adults with chronic disease, and the inability to train nurses fast enough, the nursing
shortage will only grow. Healthcare organizations and academic nursing programs must
align in order to address the nursing shortage.

What States Have a Nursing Shortage?

Not every state is experiencing a nursing shortage. Nurses tend to work in urban areas,
leaving rural areas facing more significant shortages. Additionally, the COVID-19
pandemic has demonstrated the shortage of specialized nurses around the country.
Healthcare systems are overwhelmed with the acute needs of patients ill with COVID-
19, and nurses with specialized skillsets are in high demand. While there is a nursing
shortage nationwide, it is interesting to see the differences between states. You might
think that it could be rural vs. Urban areas, but that is not the case. According to a
Supply and Demand Summary by the Center on Education and the Workforce at
Georgetown University, North Dakota, Washington D.C. and Rhode Island have the
highest concentration of nurses (Georgetown University PDF source).

In contrast, California, Georgia and Nevada have the lowest. California, Texas and New
York are reported to have the highest number of nurse vacancies.

What Types of Nurses are Most in Demand? 

According to a quick search via Indeed®, there are vacancies in every unit, department
and specialty across the nursing industry. The important takeaway is that not only is
there a shortage of practicing nurses in all fields, but also a shortage of academic
nurses. According to the NLN Biennial Survey, 43% of pre-licensure nursing programs
report the number one reason for the inability to expand enrollment is a lack of nursing
faculty (NLN PDF source). To practice as a nurse educator, a nurse must have a
graduate degree in nursing. Just as a pre-licensure nursing programs have difficulty
increasing capacity due to limited faculty, graduate nursing programs have the same
issue.

Where Are Most Nursing Jobs Located? 

As mentioned above, there are numerous nursing vacancies within every state across
America. The nursing shortage has allowed nurses to be employed nearly anywhere, in
their specialty of choice. In a strategic move, the National Licensure of State Board of
Nursing (NCSBN) has introduced the National Compact License (NLC), which allows
nurses in a compact state to practice physically or remotely in any other compact state
without having to apply for another license. 

The NCSBN reports that approximately 2 million nurses live in a compact state and can
practice in other NLC states. Currently, 34 states have elected to partake in the NLC.
This is a huge step forward in helping close the nursing shortage gap for both practicing
nurses and nurse educators as this allows nurses to cross state lines, participate in
telemedicine outside of their state and teach as a nurse educator via distance learning. 

What Does This Mean for You? 

Nurses make up the largest sector of all healthcare professions and have a seat at the
table to shape healthcare delivery. As the current nursing shortage deepens, the
demand for versatile, competent nurses will continue to rise. With that being said, there
is not a better profession to join than the nursing profession. Johnson & Johnson, an
advocate for the advancement of the nursing profession, believe that nurses are
uniquely positioned to change the trajectory of healthcare. 

Nursing is a career in which your ideas can change the lives of others, and even
healthcare itself. With more than 90 nursing specialties, nurses have choices,
challenges and numerous opportunities to take on more responsibilities, and the salary
is commensurate with education and experience. With an advanced degree, nurses can
also become independent healthcare providers, such as a nurse practitioner or a nurse
anesthetist, or leaders in their field as clinical nurse leaders, nurse administrators and
nurse educators. There are many options for nurses looking for a more advanced role
within their profession. These are exciting times and with an advancing profession, the
best time to be a nurse.  

Dr. Crissy Hunter, DNP, RN, CHSE, CNE has been a nurse for over 20 years. She has
taught undergraduate and graduate nursing full time for the past 12 years. Currently,
she serves as course coordinator for the Master of Science in Nursing nurse educator
core courses (Teaching and Learning, Assessment and Evaluation and Curriculum
Design). Additionally, Dr. Hunter is the coordinator, advisor and faculty for the nurse
educator capstone experience with students and preceptors. Dr. Hunter holds a
Doctorate in Nursing Practice from American Sentinel University and multiple specialty
certifications in nursing education.

The need for healthcare within the United States is growing as the Baby Boomers grow
older. Compounding this problem is the fact that nurses in the Baby Boomers
generation are starting to retire. According to the Bureau of Labor Statistics, the number
of available nursing jobs is expected to grow by about 16% by 2024. With the number of
nurses expected to leave the workforce in the next few years, it’s projected that there
will be more than 1 million unfilled job openings for nurses by 2024.

For nurse executives, the nursing shortage is a worrisome trend. The shortage makes it
difficult to run a profitable medical facility while balancing patient care and creating a
good work culture that encourages employee retention. Many of the macro trends and
solutions for the nursing shortage, such as increasing financial aid for nursing students,
and addressing legal barriers that prevent phased retirement, are outside of the control
of today’s nurse leaders. However, there are creative solutions that can be employed to
help hospitals recruit and retain their nurses. Here’s a look at some creative solutions
that nurse leaders can begin using to address today’s nursing shortage.

 
Solution #1 – Use an Onboarding Program to Make
New Nurses Feel Welcome
Studies and surveys show that community, group cohesion, and nurse autonomy reduce
employee turnover among nurses, and nurses who feel they have a sense of community
at work report higher levels of job satisfaction. When hospitals bring in new nurses,
making these nurses feel welcome with an onboarding program can help encourage
employee retention. A good onboarding program can ease new nurses into the job so
they’re less overwhelmed in the first few weeks at a new job. A good example is to avoid
assigning new nurses to problem patients right away. Another example is to consider
events that help new nurses get to know current nurses to encourage a sense of
community. Nurses that feel like they are welcome and part of a community not only
stick with the job, they’re more likely to bring along their friends.

For new nurses who are also new graduates, a nurse residency program may prove
helpful, making it easier for new graduates to transition from being a student nurse to
dealing with the responsibilities of being a nurse. This offers mentorship for new
graduates by combining new nurses with experienced nurses so they spend time caring
for patients together before being release to practice alone. This helps to reduce
turnover rates among first-year nurses and also provides an atmosphere in which
valuable peer groups are formed.

Solution #2 – Incentivize Behaviors You Want from

Your Nurses
Provide incentives to encourage behaviors you want to see from your nurses. For
example, consider having a points system that gives points for picking up bad shifts,
taking extra shifts, or learning new skills. Points could be used to buy special prizes or
they could be used to help nurses increase their pay scale over time. This makes it easier
to staff even the unpopular shifts in a way that keeps nurses happy. However, while
offering incentives for the behaviors you want to see can aid in employee
retention. Strategies for Nurse Managers notes that it’s important to avoid incentivizing
unhealthy behavior. Perfect attendance incentives, for example, may make nurses come
in on days they are sick or not fit to work, compromising patient care.

 
Solution #3 – Invest in Long-term Training and
Professional Development
Medical facilities that want to keep nurses on staff should invest in long-term training
and professional development for nurses. A recent publication by the Robert Wood
Johnson Foundation suggests that institutions should commit to lifelong learning in
nurses. As nurses are promoted into innovative and managerial positions, they’ll require
new knowledge and skills, and employers can provide nurses with training through
distance learning, self-tutorials, on-site classes, and more. However, instead of front
loading all the training within the first few months after employment, which can be a
waste if a nurse leaves, spreading out the training and saving more expensive training
endeavors and fun training for senior nurses can save money and boost retention.

Solution #4 – Convert Current Nurses into Recruiters

and Compensate for Referrals
In an interview with Career Builder, the vice president of executive recruitment and
talent selection for Mercy mentioned converting current nurses into talent scouts and
recruiters. Nurses speak the language of nurses, and they know what issues are most
important to other nurses. Offering incentives for referrals, such as monetary
compensation, can encourage current nurses in your work force to bring in other nurses.

Solution #5 – Offer Altered Schedules to Accommodate

the Personal and Professional Needs of Nurses
Achieving and maintaining a personal and professional life balance is often difficult for
nurses, and nurse leaders can improve nurse recruitment and retention by offering
altered schedules for nurses that better accommodate both their personal and
professional needs. For example, for busy mothers who want to spend as much time as
possible with their children, hospitals like Cleveland Clinic are offering special “mom
shifts,” which run from 9 a.m. to 2 p.m., and in some cases, nurses’ positions are made
available that offer summers off when mothers can be with their children. Offering
nurses the ability to choose part-time shifts, eight-hour shifts, and 12-hour shifts can
better accommodate the unique needs of nurses. More flexibility in shift lengths and
start times can give nurses the flexibility to choose options best for their personal
obligations ensures they’re happier with their work life balance, promoting greater
satisfaction and wellness.

Although drastic policy changes and developments are needed on a large scale to deal
with the continuing nursing shortage, facilities can begin adopting unique and
innovative approaches to recruitment and retention to find workable solutions to this
problem. Nursing leaders can lead the way by instituting initiatives and programs that
can stall the shortage momentum, reducing the effects of shortages on patient care and
facility profits.

The alarming nursing shortage

All sectors of the nursing workforce—telephone nursing, virtual nursing, in-
person nursing—are facing the same staffing fiasco. The supply of
registered nurses is shrinking as demand is growing. Patient care, patient
safety, and positive patient outcomes are at risk—and something must be
done about it.

There are many reasons for the current nurse staffing crisis. To list just a few:

 An aging nursing workforce.

 COVID-19 pandemic fatigue.

 Job dissatisfaction and nurse burnout.

 Fears about personal safety.

 Fewer new nursing students at nursing schools.

 Poor nursing administration.

Some nurses simply want better job opportunities: careers with less stress
and higher pay. Many newer nurses, after just a year or two of practice, leave
the nursing profession forever.

The supply of registered nurses in the United States is insufficient to meet the
health needs of the aging baby boomer generation, the chronically ill, and
high-risk patients. According to the American Nurses Association, the United
States is short over 1.1 million RNs—and this number will only continue to
grow over the next 20 years if action isn't taken.

Because of the current red-hot job market—a market in which many industries
are desperate for workers—nurses who are disengaged or ambivalent in their
current roles have powerful motivation to leave for greener pastures. 

This is even with skyrocketing sign-on bonuses and fierce recruitment tactics
from C-Suite health executives, who stay awake at night fretting about
staffing. The nursing shortages threaten care quality, patient outcomes, and
the American healthcare system as a whole.

The impact of the nursing shortage on

patient care & health
The nurse staffing shortages have frightening implications for patient safety.
Which is why increasing nurse staffing levels is at the core of most providers’
strategic goals.

Nursing shortages, if not addressed, risk the health of America's aging

population, of nursing home residents, and of critically ill patients. The nursing
shortage will also affect the patient experience of healthy young people who,
when they go to the doctor's office or hospital, will experience long wait times
and lower care quality.

Solving the nursing shortage isn't just the job of the Chief Nurse Executive or
the American Nurses Association. It is the job of the entire healthcare C-Suite,
who must commit the brain power and resources needed to increase nurse
staffing levels.

Solutions to the nurse staffing crisis

Achieving appropriate staffing levels will require effort, resources,
and creativity. Below I’ve listed 14 ways that hospitals, providers, and
practices can reach safe staffing ratios.
#1: Recruit to retain

You should hire nurses with the greatest potential to succeed in the role.
Nurses who are deeply devoted to patient care, patient satisfaction, and
positive patient outcomes. Nurses who love the healthcare industry. Nurses
who will be loyal to your organization for years to come.

#2: Recruit deliberately

When recruiting new nurses, look for certain traits:

 The ability to actively listen to patients.

 Personal experiences/anecdotes that required critical thinking.

 Time management and flexibility.

Use behavioral-based interview questions that assess the

prospect's communication style, empathy, and problem solving skills. They
should also demonstrate a commitment to putting patient care first.

Be upfront about job requirements and expectations. Nurse triage is often a

24/7/365 operation, so make the duties crystal-clear from the start to ensure
there's no misunderstandings down the line. Tell the nurse if they will need to
work on weekends, on holidays, or be on call. Don't leave out any details,
even if those details aren't appealing.

Being upfront from the get-go ensures safe staffing and lowers the risk of
nurse burnout. Nurses who aren't informed about the job requirements going
in are usually the quickest ones to go out.

#3: Consult with current staff

Talk with seasoned nurses and other health professionals about the potential
new hires, who are investments in the success of every healthcare
organization. They can make or break health services, so it is essential to
ensure—before hiring—that they will get along with other staff.
#4: Automate or offload tedious tasks

To keep the telehealth machine running, nurses often must navigate laborious

processes. These administrative tasks exhaust and aggravate nurses, who’d
much prefer to focus entirely on patient care.

Organizations that view registered nurses as professionals have greater

success with recruitment and retention. Role expectations that allow RNs to
practice at the top of their licensure demonstrate respect and value.
Unappealing duties should be reassigned to unlicensed support staff—and the
importance of teamwork should be emphasized. 

Most organizations know they must support their lawyers, doctors, and other
highly-skilled workers with robust support technology and support staff. This
same mindset needs to be applied to nurses. Fortunately, there now
exists cutting-edge triage and call support software that automates many
burdensome tasks, freeing nurses to perform at top-of-license. In turn, they
are happier and more effective employees.

Organizations should incorporate technology and automation, whenever

possible, into nurse workflows:

 Use cell phones to communicate in real-time so nurses don’t need to

make constant trips to the nursing station for a call. 

 Have support staff wear a tracking device. When an RN needs help, she
then knows who is where and whether or not they are available.
 
 Provide electronic teaching materials—and discharge instructions—that
can be easily accessed and printed.

If you’d like to read more about the current state of technology in nursing,
check out my blog: “Nurse Triage & Telehealth Technology: A Symbiotic
Relationship.”

#5: Consider registered nurses with restricted

licenses
I worked with a Midwestern academic medical center that was committed to
the recovery of employees who suffer with substance abuse. In collaboration
with Human Resources and the Board of Nursing, we created a program
where compromised staff nurses were given the opportunity to return to work
as registered nurses in my Nurse on Call department—and they were paid
accordingly.

#6: Broadcast the contributions of front-line triage

nurses

 Publicize data, loudly and relentlessly, revealing the number of

unnecessary and expensive emergency department visits that nurse
triage call lines diverted to more appropriate and less costly sites of
care.
 
 Emphasize that patients need nurses for clinical care—and that
patients have come to rely on nurses for remote care.

 Quantify the savings accrued thanks to triage nursing.

 Advertise that more than 50% of patient encounters with triage nurses

require no further action. It is one call and done.

 Elevate nurse triage and critical care nurses to a place of importance

within the organization or hospital.

#7: Commit to communication

To empower nurses, nurse staffing managers and the nursing administration

should ask their staff what they want out of their job duties. They should listen
to any complaints/suggestions, and make changes accordingly.

It's critical for nurse leaders to inform the nursing staff about anything that may
impact their job. No one likes workplace surprises or feeling left out.

On day one, give new nurses an orientation schedule and agenda. This
demonstrates that you honor their time and respect their need for a work-life
balance.
#8: Make compensation more than fair

Numerous studies have shown RN turnover rates continue to rise upwards of

17% (NSI, 2016), costing US hospitals over $17 billion annually and
contributing to the current staffing crisis. The cost of replacing a single RN is
$36k - $54k. In some expensive locales, it is $85k - 100k.

This staff leakage has severe consequences for hospitals and health
providers:

 Temporary replacement expenses.

 Costs for recruiting and hiring new nurses.

 Lost productivity.

 Inadequate medical care, which can lead to poor patient outcomes.

Of the healthcare workforce, nurses are by far the largest discipline. They are
also voted, year-after-year, as the #1 most trusted profession in the world.

And yet the compensation American nurses receive is not commensurate with
the impact they have on patient care, hospitals, and the US health system as
a whole.

What happens when compensation is low, or even just average? 

 Nurse turnover increases.

 You are forced to hire someone at a higher salary.

 The knowledge and training you invested in disappears.

 It will take months of interviews, hiring, and training just to get back to
baseline.

I recall being the Administrator of a 100+ RN nurse triage practice. I attended

a leadership retreat, and I was told, by a non-nurse, that money is not a
motivator for nurses. 
If that is the case, why has the popularity and reliance on travel nurses and
agency nurses skyrocketed? 

Why are nurses leaving permanent hospital jobs for 13-week travel nursing
assignments?

To stop the nursing shortage, nurses must be paid a wage commensurate to

the high-value jobs that they perform.

#9: Reward longevity & excellence

Your most loyal and successful nurses need to know that they’re valued. Any
turnover is unfortunate, but it’s especially important to hang onto employees
who have faithfully served your organization or hospital for years or even
decades.

Long-term employees crave recognition, so don’t hesitate to highlight

milestones with special gifts. Better yet, throw full-blown parties or awards
banquets to recognize major achievements. 

Regular raises and increased allowances for time-off are equally important—
or nurses may seek higher-paying positions outside of health.

Any effort to retain the most talented and passionate nurses will eventually be
repaid tenfold. Let hard-working nurses know they matter. The stakes are too
high for anything less than stellar treatment.

COVID-19 embittered many nurses, who grew frustrated that they were not
given hazard pay for putting their lives at risk. Health organizations with
aggressive retention strategies have since implemented quantifiable rewards
and incentives for staff—which is a step in the right direction.

Current nurses have seen increases in pay and bonuses, and many new
nurses receive incentives when they accept the position. Hospitals that offer
incentives for nurses who work overtime—and for nurses who take on more
responsibilities—can reduce turnover rates.
To retain and attract more nurses, additional incentives include:

 Tuition assistance for nursing school.

 Tuition reimbursement for nursing school.

 Sending nurses to seminars and conferences.

 Offering internal training opportunities.

 Offering CE programs onsite.

#10: Utilize career ladder model for rapid, attainable

advancements and wage increases

The American Nurses Association recommends the following nurse staffing

ladder:

 Level 1: Entry-level RN.

 Level 2: An RN who practices independently and can function as a

charge nurse, or as a preceptor to new nurses and students.

 Level 3: An RN who demonstrates high-level capability aligned with the

organization's professional practice model.

#11: Create a community

To achieve safe staffing levels, the health organization, hospital, or medical

practice needs to build a positive relationship with the nursing staff—which
means creating a friendly and healthy work environment. 

This can be accomplished by building a "we're in this together" teamwork

culture—and through community events such as holiday parties. The work
culture should feel like a family environment; an environment where everyone
belongs, and where everyone's input is valued.

#12: Trust nurses to do their jobs

Rectifying the nursing shortage crisis will require giving nurses sufficient
autonomy over their practice in all settings. This means trusting the nurse's
skills.

Hospitals and health organizations should make an effort to keep their aging
nurse workforce in active and direct care roles. This means redesigning
certain job duties so that they can be successfully performed by older nurses.

The American health system must stop taking nurses for granted. It
contributes to a toxic work environment, and it makes nurses feel
unappreciated and undervalued.

Like any professional in any industry, nurses want to know their employer
cares about them and their needs. Employers must be advocates for nurses.

#13: Work-life balance

It's imperative that nurses, given their high-stress job, have an excellent work-
life balance. Ask your nurses what would be an appealing augment to hourly
compensation, whether that be a gym membership, a weekly yoga class,
doggy daycare, or after-work happy hours.

These perks help nurses achieve a healthy work-life balance, which in turn
makes them happier and more effective employees in the long-run.

Introducing greater flexibility into what is often a rigid work structure/schedule

can also improve morale.

#14: Recycle talent

Reach out to your health organization's pool of recent nurse retirees. Provide
hands-on training for these nurses, so that they are confident when they
reenter the workforce.

Offer unique, age-specific benefits and perks such as fitness classes or tickets
to local plays/exhibits.
Older nurses are likely to have a diverse range of skills and advanced practice
or specialist qualifications. They all have irreplaceable experience. Policies
need to be in place to enable these nurses to be active members of the health
workforce. These policies include:

 Understand the workforce profile and employment needs of older

nurses by conducting surveys, focus groups, and nurse labor market
analysis.
 
 Create flexible work opportunities that are specifically designed for older
nurses.

 Ensure that older nurses have equal access to relevant learning and

career opportunities.
 
 Redesign job duties to relieve heavy workloads and stress.

 Provide job enrichment opportunities that will optimize the contributions

of older nurses.

 Offer a pay and benefits system that meets older nurses’ needs—and
that rewards their experience.

 Utilize older nurses in specialist roles, in mentorship roles, and in

preceptor roles.
 
 Maintain succession planning, which enables knowledge transfer and
leadership development.

 Support retirement planning options, and, when appropriate, flexible

pension provision.

The nurse staffing crisis is curable

The staffing conundrum has been brewing for years—but it wasn’t until Covid-
19 hit that it exploded into a full-blown calamity.

Thankfully, the nursing shortage is solvable. It simply requires willpower,

resources, and imagination. Technological innovations, such as AI-powered
triage software, will also play a crucial role in rectifying the situation. 
The nursing crisis affects us all. Every American needs, or will need, health
services. It’s imperative we solve this problem before it’s too late.

Posted By

Gina Tabone
Gina Tabone, MSN, has 25+ years of experience in telehealth. She has consulted for physicians,
health systems, call centers, & other healthcare entities.