August 2007 - Volume 1, Issue 4

NURSING SHORTAGE, CAUSES AND POSSIBLE SOLUTIONS

Dr. Mariam Elmobasher MsN, PhD Psychology, HA-AD, PP&R, CME/CPD Section

ABSTRACT In this paper the writer tries to examine the nursing shortage by identifying the factors that lead to it. Nevertheless, highlighting the causes that escalate the international problem of nursing shortage will not solve it, but indeed it might drive concerned people to adopt certain strategies that will contribute toeffectively solving it. However, a collaborative approach by all stakeholders, communities and nurses themselves, should be the best advocate for their profession. These efforts are pointed out by many authors, in regard to minimizing the magnitude of this vital problem. The mass media has a very important role in public awareness and change of perception of the nursing profession, which might reflect positively in improving its image. The paper will recommend some solutions and actions that should be taken seriously and adopted by decision makers to overcome this problem. Hopefully in the near future the profession will attract many young females as well as males to join it. Furthermore existing nurses will be motivated and less likely to leave the profession.

INTRODUCTION

Massive literature addresses the problem of nursing shortage and its adverse effects on the health care systems and their outcome. Nursing shortage is a serious problem that needs urgent solutions. Some honorable nursing societies like, the Honor Society of Nursing, Sigma Theta Tau International recognizes the nursing shortage as a major threat to the future of the world's health care system.

In this paper I intend to participate in highlighting this international problem and trying to identify some of its causes as well as recommending some possible workable solutions, which might contribute in minifying it. NURSES SHORTAGE - IS IT REAL?

Yes, is the answer to the above question, as there is a consensus in the literature dealing with the topic of nursing shortages. Today's nursing shortage is very real and is a common problem worldwide. Currently the nursing shortage is evidenced by fewer nurses entering the profession, and by the increasing demand for nurses. There is a noticeable shortage of nurses who are appropriately prepared and qualified to meet patients'/clients' needs and provide safe nursing care in a changing health care environment. Lassey et.al (1997) stated that in the USA the increased cost of well-trained nurses led the hospitals to employ less trained nurses or even nurse aids to lower the cost.[6]

On the other hand, there are many nurses who leave nursing and follow another profession. This shortfall will grow more serious over the next 20 years and it is expected to become a serious problem. This prediction is also supported by a report from the California Health Care Foundation, which states that "everyone agrees that the problem of shortage in nursing is going to get worse by 2020."[2]

Therefore, by 2020 the number of nurses will fall nearly 20% below requirement.[1]

It is quite essential to identify the causes that impacted on the enrollment of students in nursing programs as well as the increasing number of nurses who leave the profession. Remedial actions are acutely needed to solve this critical problem.
WHAT ARE THE CAUSES AND POSSIBLE SOLUTIONS?

Nursing shortage as a worldwide common problem, is being dealt with by the media in many countries with emphasis on its causes, but unfortunately the efforts to tackle the identified causes and prevent the occurrence of future ones are less noticeable. This notion is also indicated by some authors in the literature as well as the media, for instance it is stated that, currently causes of nursing shortage and its magnitude are being discussed widely in the press. However, solutions for this problem have been quite few.[10]

A list of the causes of fewer students joining nursing schools are identified in the ACCESS NURSES Website as "professional alternatives" which means many young women tend to choose other careers rather than nursing which is considered by many nurses as a highly demanding and stressful profession.

Another cause indicated in the above article is the declining enrollment of student nurses and nurse educators, as recently new admissions into nursing schools have dropped dramatically and consistently.[1]

In 1977 China put more emphasis on nursing education, but still sufficient training programs are not available to meet the national requirements.[6]

This decline in student nurses' numbers might also be due to the above stated causes. Another market that needs to be pursued is males. Increasing the number of male nurses in the profession will backup the shortfall.

Further more nurses' role is unlimited in providing direct patient care but is continuously extended to include other non-nursing activities. This might be due to lack of other support staff e.g. unit clerks, porters. The expanding nurses' role and its resulting constraints on hospital resources have made the nursing profession an increasingly over demanding, and stressful occupation and even less desirable. [1]

The American Nurses Association (ANA) believes that a major contributing factor to the current and emerging nursing shortage is dissatisfaction with the work environment.9 Dissatisfaction and occupational stress can lead to burnout which might lead to nurse turnover.

There are various factors that can cause nurses' negative reaction, which might lead to burnout. Tappen (2001), listed factors she considered as contributing to such negative reactions in healthcare professionals including nurses, such as low pay; long hours; too much paperwork; client losses; lack of appreciation and understanding; lack of support; unresponsiveness to client needs by the healthcare system which conflicts with the professional ideals; powerlessness; discrimination; inadequate advancement opportunities.[11]

Thus, different strategies and approaches are needed to address varying needs among nurses, which in turn will contribute to the resolution of the problem.

Recently it is found that nurses need recognition for a job well done. It is a right of the nurse to be appreciated and recognized for being competent and doing a good job, which is not the case most of the time, although, nurses provide most of the care needed by their patients/clients as they spend more time with them, as indicated by Kathy Quan who mentions that nurses are shifting into an ever expanding role of health educators, as well as providing more direct care to the patients.[5] However, the nurse is the last to get credits and recognition in the case of positive patients'/clients' outcomes. Hence, respect, recognition and acknowledgment of nurses' contribution to patient care is a strong factor that might assist in retaining them.

On the other hand, the area that needs to be addressed most critically is nurses' work environments.[4] Nurses work in distressing environments. Therefore, the difficult working conditions push many female nurses to leave the profession, and some of them migrate to other countries, especially the USA, looking for higher payment and better working settings.

Nursing shortage is highly reported in Sweden because, trained nurses leave the profession to join more satisfying occupations.

Moreover, nurses' salaries should be proportionate to their skills, education, and experience. Many nurses are paid less than what they should be, especially in the developing countries, despite the fact that their profession is over demanding and distressing, as well as less rewarding. In Japan nursing shortage is mainly due to low status and pay of nurses compared to physicians.[6]

Lack of equity and respect can be very distressing and de-motivating for nurses. Nurses need to be treated fairly and respectfully by their managers, not only that, they should be treated well by their senior colleagues as well as senior-level leaders.

Nurses' schedules have to be flexible as nurses have to do shifts which might disrupt the nurse's family and social life, as nurses might work for long hours as well as evenings and nights, especially in hospitals.[6] That's why many nurses don't recommend their children to enter the profession. A result of a survey conducted by the American Nurses Association (The ANA Staffing Survey), shows that over 54 percent of nurse respondents would not recommend their profession to their children or their friends.[8]

Nursing shortage is not only addressed by the Western countries (e.g. USA, Germany), but also in places like Eastern Europe (e.g. Czechoslovakia, Hungary), the Middle East, Africa, and even the Gulf Region has started to highlight the problem of shortage of nurses in the health care settings, especially local nurses. There are various studies done to find ways or strategies to overcome this problem by trying to make the nursing profession an attractive one.

For example,e there are two studies conducted in the United Arab Emirates by Emarati nurses as part of the requirement of Leadership For Change (LFC) Program. The first study was conducted in 2005 by Salma Al Nuaimi and colleagues. The main question asked by the study is "Why Emarati Students are Not Entering the Nursing Profession". The target group was the public secondary school female students. It is important to mention some of the study suggestions and recommendations which are, to change nurses' uniform "as the nurses uniform is not accepted culturally"; and more lectures to be conducted to encourage students/parents - this recommendation is essentially needed to increase their awareness of nursing; use of the media to orient the community to a positive nursing image, and highlighting the importance and value of nursing. Another recommendation is to increase nurses' salaries.[13]

The second study was conducted by Almustafa et al 2006 (unpublished), it is about how to increase the number of Emarati Women Enrolled in Nursing Programs. The study was designed to answer a question: "Why Do Emarati Women Not Join The Nursing Profession?" They studied a group of 56 grade 12 students from the government schools. They used a quantitative and qualitative questionnaire. A pre and post questionnaire was distributed to participants. The pre questionnaire identified the barriers for students from becoming nurses, which is mainly related to the image of nursing as not culturally valued and shift work. The pre-questionnaire analysis shows that 89% of participants have limited understanding of nursing as a profession. The results also identified that the barriers for students to become nurses are quite similar to the previously mentioned study, for example, the community view of nursing as "low image"; limited understanding of the nursing profession; nursing being a tiring job; and low salary. The researchers suggested a future plan to increase the level of perception of the students and community, that is to increase awareness; and to transfer the ownership of the recommendations to higher authorities.[14]

The image of nursing is one of the major causes that influence negatively the enrollment of students into nursing, especially in the Gulf region due to cultural regards. Low image of nursing is a common phenomenon, which faces nurses even in the so-called developed countries. As mentioned in the literature, in Russia hospital nursing does not have much prestige.[6]

Nursing image has to be changed. This can be started through reaching school children at an early age. It is recommended by educators that students often have their minds made up by fifth grade regarding their desirable and undesirable careers. Thus an early positive image of nursing should be emphasized. 1 Megan Malugani who is one of a Monster Contributing Writer, in her article "A New Image for Nursing" reported that:

"with a major nursing shortage on the horizon, healthcare and nursing organizations are giving the profession a dramatic makeover in hopes of attracting a new, diverse generation of RNs to the workforce".[3]

Furthermore, "A Call to the Nursing Profession" - was sponsored by the American Nurses Association and the Nursing Organization Liaison Forum.[4]

Creating Cultures of Retention, as identified in the literature [1] is another strategy to be adopted to overcome nursing shortage. To retain nurses is not that easy, it needs a collaborative effort from nursing leaders, practitioners, health care executives, government, and the media.[10]
Moreover, effective administrative structure; quality patient care; and investment in professional development of nurses could reflect positively in nurses' retention. Nonetheless, nursing staff must be involved in defining and developing the practice of care in the organization since they are the closest to the patient. This includes participation in the financial management of their units.[10] All of the above mentioned are important factors that might help in nurse retention, and boost their morale.

Nevertheless, Strengthening the Infrastructure is an initiative in the USA that aimed to promote people to enter and remain in nursing careers, which will eventually reduce the continuous shortage. The Nursing Reinvestment Act was signed by President Bush in 2002 to address the problem of USA nursing shortage. That initiative establishes scholarships, loan repayments, public service announcements, retention grants, career ladders, and grants for a nursing faculty.1 If the US initiative is adopted by countries in which nursing shortage is a major problem it might be of great help in overcoming the problem.

Retaining nurses and encouraging students to join nursing might also be accomplished if nurses are encouraged and supported to develop their knowledge and skills. Also it is high time that nursing, as in many other professions has to encourage nurses to be specialized, as most of the nurses are generalists. This in turn will weaken the profession. Currently, there are critical needs for experienced nurses in areas such as the operating rooms, critical care, and neonatal care arenas. Therefore, hospitals should reintroduce intensive training programs for nurses in these specialties, which in turn will help to retain nurses who are looking for a transfer opportunity as well as to recruit new staff. It also builds a career development path for staff, which is not the current case as careers in nursing have been constrained by limited opportunities for advancement, as discussed by Lassey and his colleagues.[6] Unless nurses are provided with chances to develop their subsidiary status, they will never be able to change and grow.

It is worth mentioning that the government of Japan in 1993 attempted vigorously to increase student nurse enrollment in nursing schools by providing services such as providing loans to students, subsidizing private nursing schools, and providing supportive services, for example, day care, in hospitals.[6]

Internship programs are another area that has to be considered, as it is very important for newly graduated nurses to bridge the theory practice gap which might lead to reality shock as identified by Kramer since 1974. Reality shock might have a negative effect on novice nurses which might cause some of them to leave the profession early, and be a negative influence on student nurses as well as other potential students. CONCLUSION

Nursing shortage as a major universal problem cannot be solved easily by writing papers. Joint efforts and genuine intentions of decision makers as well as nurses themselves can be a magical tool to solve the problem.

Various studies have analyzed the problem and have identified many causes and reasons that create and escalate it.

Realizing the seriousness of the problem and recognizing its causes, might be an effective tool that can be used in adopting specific strategies to keep nurses in the profession and attract both genders to enter it, particularly: improved work conditions with less stressors, recognition, appropriate rewards and better payment, can be motivating and will enhance nurses' job satisfaction. All of these factors and others will of course share in solving the nursing shortage problem.

Nurses have a major role to play. They must become more of a voice in the press[11]. This phrase should provoke nurses to make their voices heard. They should be advocates for their profession and try to smarten it, and draw public attention to its advantages as emphasizing the fact that:

"As a career, nursing offers a unique combination of job security and adrenaline-pumping excitement. There are also plenty of opportunities for career advancement, from high-paying nurse executive and nurse practitioner positions to prestigious research positions as nurse scientists."[7]

1. ACCESS NURSES - The Source for Healthcare Professionals. Nursing Shortage Page 2. Causes of the Nursing Shortage
   Available at: http://www.accessnurses.com/nursingshortage/causes/
2. Report Identifies Positive Impact Technology Can Have on Nurse Productivity
   and Satisfaction. California HealthCare Foundation and First Consulting
   Group explore technology benefits to nursing shortage, June 27, 2002
   Available at: http://www.chcf.org/press/view.cfm?itemID=19801
   
3. Megan Malugani, A New Image for Nursing, by Monster Contributing
   Writer monster Feature Reports http://featuredreports.lycos.monster.com/nursing/image/
   
4. Nurse shortage needs immediate action. RNABC NEWS. Nursing BC, Feb 2003
   Available at: http://findarticles.com/p/articles/mi_qa3916/is_200302/ai_n9181072
   
5. Kathy Quan, Your Guide to Nursing.
   
6. Lassey, L. Marie, Lassey, R. William, Jinks, J. Marten. (1997) Health Care Systems Around The World - Health Characteristics, Issues, Reforms. Prentice-Hall International (UK) Limited, London
   
7. Minority Nurse.com: Recruiting Men into Nursing School
   Available at: http://www.minoritynurse.com/features/men/03-21-06e.html
   
8. ANA AMERICAN NURSES ASSOCIATION. Remarks of Mary Foley, MS, RN
   President, American Nurses Association. ANA Staffing Survey Press Conference
   National Press Club, Washington, DC February 6, 2001
   Available at: http://www.nursingworld.org/pressrel/2001/pr0207b.htm
   
9. American Nurses Association Applauds Introduction of Nurse Retention and Quality of Care Act 2001
   Available at: www.nursingworld.org/pressrel/2001/pr1105.htm
   
10. Brenda Nevidjon, Jeanette Ives Erickson. THE NURSING SHORTAGE: Solutions for the Short and Long Term. ? 2001 Online Journal of Issues in Nursing Article published January 31, 2001
    Available at: http://www.nursingworld.org/ojin/topic14_4.htm
    
11. Nursing Shortage Serious For Seniors. As the population ages the impact of the nursing shortage will be even greater.
    Available at: http://seniorhealth.about.com/cs/prevention/a/nurse_shortage.htm#
12. Tappen, M. Ruth (2001), Nursing Leadership and Management - Concepts and Practice, 4th edition. F.A. Davis Company. Philadelphia, P.P 509 - 510.
    
13. Al Nuaimi, Salma (2005). Awareness of Emiratization about Nursing at Al-Ain Government Secondary School (Girls). Unpublished study.
14. Almustafa, S. et.al, 2006. Increase The Number Of Emarati Women Enrolled In Nursing Programs. Unpublished study.