The Danger of Nursing Shortage

Literature Review

The researcher conducted a comprehensive search of the literature published between 2015 and 2020. Keywords used to conduct the search included nurse staffing, quality of care, nurses’ perceptions, nursing shortage, patient safety, nurse-patient ratios, Donebedian, Donebedian’s structure, process, outcomes, Donebedian’s framework.

Nurse Staffing

Nurse staffing can be defined as the total nursing care hours per patient day or staff mix (ANA, 2014). The American nurses association defines staff mix as the percentage of registered nursing care hours among the total of all nursing care hours including RNs, and LPNs (ANA, 2014).

Total nursing hours per patient day is defined as the total number of productive hours worked by all nursing staff with direct patient care responsibilities in a patient day (ANA, 2014). Fallatalah et al. predicted that there would be a nationwide registered nurse job vacancy of 1.2 million nurses by the year 2020 (Fallatah & Laschinger, 2017). This forecast indicates that nurse staffing will continue to pose a complex issue for hospitals in Canada.

Perceived safe staffing

For the aim of this literature review, the theme of safe nurse staffing refers to a balance between the demand to meet patient needs and the availability of nursing staff. Moreover, safe nurse staffing includes nurses that are competent in the care that they provide. For the sake of this literature review, the term ‘nurse’ will constitute only registered nurses (RN) and all other nursing personnel will be recognized by their role or tasks.

Numerous studies have described nurses’ perception of safe and adequate staffing. One study revealed that there is a significant association between increased nursing skill mix (or prevalence of total nursing stuff who were registered nurses) and perceptions of adequate staffing. However, there was a perception of less adequate staffing associated with increased nurse workload and large unit size. Patient acuity level (extent of illness, and sum of nursing care needed to care for the patient) was significantly linked with nurse perceptions of less adequate staffing levels. Kalisch et al, surveyed ninety-two nurses on surgical, intermediate and rehabilitation units in eleven hospitals and revealed that nurses perceived adequate staffing on units with higher proportions of nurses with BSN (Bachelor of Science in Nursing) degrees or above. They also perceived lower staffing adequacy with units that had inadequate assistive personnel (Kalisch et al., 2011).

Gaps in literature

There have been several attempts to correct the safe staffing issues, varying from federal legislation to healthcare facility budget adjustments. There has been a universal dilemma regarding strain from competing healthcare dollars and labour costs. Most healthcare facilities within the provinces base their ratios on policies set forth by nurse union contracts and by the institution. To date there is no federal legislation enacted in Ontario for mandating specific nurse to patient ratios (Hall et al., 2006). Within the United States, the only state that has enacted minimum nurse staffing ratios is California (Serratt et al, 2011). The influence of legislative and federal policies on safe nurse staffing are set by the provinces however the level of staffing differs based on organizational structure. Harrington et al (2012) examines the standards of nurse staffing in a multitude of nursing homes across several countries.

The study looks at staffing regulations and policies in Canada, England, Germany, the U.S, Sweden and Norway, that indicates standards set forth without mandated nurse patient ratios were not congruent with actual staffing. Actual staffing ratios relied on the size of nursing facilities (number of patient beds), number of residents and whether or not the facility was for profit (Harrington et al., 2012). The battle between cost benefit and cost effectiveness is a reoccurring problem that causes healthcare organizations to weigh the advantages of safe staffing with the risks of increased healthcare dollars. According to an article by Thungjaroenkul et al (2007), results show that nurse to patient ratio of 8:1 was considered the most cost effects however it was associated with the highest level of patient mortality. In addition, as the nurse to patient ratio went down per increment, labour cost increased while patient mortality also declined. This is an excellent example of the struggle between health care spending and patient safety. Where should priorities and limits be set?

Inadequate nurse to patient ratios has proven to pose significant challenges on healthcare spending, as well overall satisfaction of nursing staff. In a study that examines the importance of emotional distress and ethical conflicts, nurses admit that both these factors contribute to work stress and physical and emotional burnout that force many nurses to work absence and intent to leave (Guadine & Thorne, 2012).

Theoretical Framework

The framework that guided this research study is the PESTEL (political, economic, sociocultural, technological, environment, and legal) analysis framework. Business leaders use this framework to address two basic features. The first feature enables the examination of the environment in which the healthcare facility operates. And the second basic feature provides information and data that will allow the company to predict circumstances and situations that it might potentially encounter the future (Issa et al., 2010). The PESTEL framework was utilized to develop strategies that healthcare leaders can use to determine tackle staffing shortages (Mehdaova, 2017).

In conclusion, to safeguard against nurses’ inability to successfully promote maintenance of health and restoration, interventions for safe staffing should support safe working conditions. This study should offer further insight into nurse’s experiences regarding unsafe staffing patterns and should address the problem statement and research questions.

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