CHAPTER I
INTRODUCTION
Introduction
Nursing is the process of caring for, or nurturing, for an individual known as the ‘patient’. More specifically, nursing refers to the functions and duties carried out by persons who have had formal education and training in the art and science of nursing. To promote the restoration and maintenance of health in their clients, nurses became more particular in enhancing their knowledge through integrating with health and biological sciences ( 1993).
Nursing is a discipline focused on assisting individuals, families and communities in attaining, re-attaining and maintaining optimal health and functioning. Modern definitions of nursing define it as a science and an art that focuses on quality of life as defined by persons and families. Nursing is not only concerned about health and functioning but with quality of living and dying, lived experience, and universal lived experiences of health (1979).
Like other maturing disciplines, nursing has developed different theories that are aligned with diverging philosophical beliefs and paradigms or worldviews. Nursing theories help nurses to direct their activities in order to accomplish specific goals with people. Nursing is a knowledge based discipline committed to the betterment of humankind (, 1979).
A nurse practices nursing as a profession. There are a number of educational paths to becoming a professional nurse in many countries, and more importantly, nursing practice is regulated by law. Advanced practice nurses include nurses with advanced education, generally at the graduate school level. There also are some nurse researchers who have PhDs in nursing or other fields and study human responses to health and illness in many settings. There are other nurses with PhDs who practice with persons who are changing their health patterns. Nurses help people figure out what they need to go on, what they see as possible, how they want to change, how they can move toward their hopes and dreams (, 1994).
Nurses acknowledge that the nursing profession is an essential part of the society from which it has grown. The authority for the practice of nursing is based upon a social contract that delineates professional rights and responsibilities as well as mechanisms for public accountability. The American Nurses’ Association has defined nursing as “the diagnosis and treatment of human responses to actual or potential health problems.” Just as medical diagnoses help in the planning, implementing, and evaluation of medical care, Nursing diagnoses help in the planning, implementing, and evaluation of nursing care ( 1997).
Nurses practice in a wide range of settings from hospital to visiting people in their homes. Nursing is the most diverse of all healthcare professions. It is a universal phenomenon appearing in some form in every culture (, 1979). Concurrently, the nursing profession faces several issues, which include the increased emphasis on primary health care, new models of collaborative practice, the shift from institutional to community care, new developments in technology, and the supply and demand for various health providers with particular skills. These new trends in the delivery of health care emphasize the need for nurse to expand and broaden their skills. In short, to better meet the changing needs of health care of patients in our modern times, the practice of nursing must continue to develop.
However, there is an incipient inroad to the provision of healthcare which directly relates to nursing as a profession. Apparently, there is a shortage of nurses throughout the nation and this has been considered as a serious issue on the healthcare industry. Some academics have been apprehensive of this predicament in the healthcare industry. Thus, this study intends to look into the implications of this shortage of nurses in the quality of patient care in the United States.
Problem Statement
The study intends to look into the effects of the shortage in the nursing profession on the quality of patient care in the United States. Specifically, the study intends to answer the following questions:
1. What are the causes of the shortage of nurses in the United States?
2. How does the shortage affect the healthcare system of the United States?
3. What are the factors influencing the supply of nurses in the United States?
4. What are the probable causes of action available to address the problem of nurse shortage in the United States?
5. Does the shortage of the nursing personnel significantly affect the quality of patient care in the United States?
Brief Description of Methodology
Type of Research
This study will use the descriptive type of research. To illustrate the descriptive type of research, (1994) will guide the researcher when he stated: Descriptive method of research is to gather information about the present existing condition. The purpose of employing this method is to describe the nature of a situation, as it exists at the time of the study and to explore the cause/s of particular phenomena. The researcher opted to use this kind of research considering the desire of the researcher to obtain first hand data so as to formulate rational and sound conclusions and recommendations for the study.
Secondary Data
The secondary sources of data will come from published articles from social science journals, theses and related studies on healthcare and nursing. Acquiring secondary data are more convenient to use because they are already condensed and organized. Moreover, analysis and interpretation are done more easily.
Primary Data
The primary source of data will come from the data acquired from existing studies on the effects of the nursing shortage as well as interviews conducted by the researcher. The primary data frequently gives the detailed definitions of terms and statistical units used in the survey. These are usually broken down into finer classifications.
Scope and Limitations
The study intends to investigate the effects of the shortage of nurses in the quality of patient care in the United States. For this study, primary research and secondary research will be used. The data will be analyzed and compiled for the correlation of the hypothesis. The data will then be presented by means of graphical representations and illustration and the difference would be highlighted. Through the use of different statistics, the researcher will determine the effects of the shortage of nursing in the healthcare system in general.
Summary Paragraph
This chapter served as an introductory part of the whole proposal. In this chapter, the problem as well as its corresponding background has been presented. This is done to establish the foundations of the whole objective of the study. It presented the existing problems in the nursing profession and its effects on the general welfare of the healthcare system of the United States. Specifically, it stated the intention of the study to look into the effects of the shortage of nurses to the quality of patient care in the US.
Chapter II
REVIEW OF LITERATURE
History of Nursing
The notion of nursing as a discipline and nurses as individuals remain obscure in written histories. (1975) documents a chronological history of critical care units with only a passing mention of nurses. ‘s pediatric nursing textbook (1977: 3-21) gives a history of child care with a list of dates and events of importance, without listing any nursing event or primary sources. Interestingly, by the sixth edition in 1988, the role of the nurse is discussed throughout the section ( 1988: 2-16). Nursing is presumed to exist in the shadow of political events and medical accomplishments.
In the United States, three national nursing organizations have served as the foundation of the current idea of professionalization of the vocation. These organizations include the American Nurses’ Associations, The National League of Nursing Education, and the National Organization for Public Health Nursing. ( 2004) Ethics standards and educational developments were among the contribution that these organizations provided the nursing profession. The American Nurses’ Association, founded in 1896, sought to establish and maintain a code of ethics; to elevate the standard of nurses’ education; to promote the usefulness and honor of nurses; to distribute relief among such nurses as may become ill, disabled or destitute; to disseminate information on the subject of nursing by publications in official periodicals or otherwise; to bring into communication with each other various nurses and associations and federations of nurses throughout the United States. (, 2002)
On the other hand, the National League of Nursing Education promoted the development of educational requirement for the profession since its inception in 1983. (, 2004) The League has given numerous contributions to the profession. To illustrate, it is responsible for the extension of the hospital training course to three years starting 1896. Similarly, the organization also pushed through with the introduction of the compulsory registration of nurses in all of the states. This made the government recognize nursing as a profession. Moreover, they have also created a standard curriculum that is premeditated to guarantee a minimum criterion for all nursing schools in the United States and the rest of the world.
On 1912, alternatively, the National Organization for Public Health Nursing was organized. This organization contributed to the history of nursing through foundation of principles in public health nursing. It also sought to diminish the gap between the laity and the nurses by providing a general understanding regarding the importance of preventive work in public health. (, 2002)
Nurses have also given its services for the country through the provision of health care in times of conflict. They have served in 1940’s World War II, the Korean War in 1950-1953, the Vietnam War in 1960, and the Gulf War in 1991. Presently, a significant crisis has taken place. A national shortage of nurses has come to pass. (, 2004)
Nevertheless, the profession of nursing has developed long after the days of Florence Nightingale in 1836. After have completed her training in 1873, nurses in the United States has molded the future of health care. With the nurse practice acts enacting in four states in 1902, the start of the journey for American nurses have taken ground. Consequently in the 1930s to the early 1940s, the public health orientation of nurses shifted to the hospital-based system of health care. This development allowed the institutionalization of the profession by providing its practitioners an area where they could serve their purpose. (, 2002)
The Nursing Profession
The individual healthcare professional’s ability to do what is proposed with proper competence and skill is, of course, crucial in ensuring safe clinical care. But professional competence is only part of the picture. Good people, with good skills and good intentions, sometimes make mistakes. As part of this professional issue, to be a nurse is to observe a dynamic process of caring based on a theoretical body of knowledge.
The role of the nurse as a vital member of the healthcare team through collaborative professional practice must always give priority through caring its patient. The primary goal of being a nurse is to assist individuals in the achievement of an optimal level of wellness. The focus of nursing practice is on individuals’ specific needs based on their healthcare choices related to physiological, psychological, sociocultural, developmental and spiritual dimensions of individual lifestyles.
As part of professional issues, professional care systems, care orientations are described as specialist-cantered ( 1998) although different types of practitioners are found also in lay care systems. (,1990, , 1994, , 1998, , 2000.) Professional care systems are orientated by a rational, systematic and linear way of thinking. This is seen in applications of general principles to individual situations, or vice versa, subsuming individual cases under general laws for the patients’ wellness.
This is accomplished through the promotion, restoration and maintenance of health, based on the individual’s level of functioning and perceived needs. Through health education, the nurse assists individuals in making informed choices and supports individuals and families in decisions regarding healthcare.
The professional nurse is accountable for providing comprehensive nursing care to individuals, families and groups in a variety of settings. Nurses have always recognized the rights of clients of all ages to be both informed and active participants in care. It is important for patients to understand that the role of the professional nurse is to promote & maintain healthy systems. The process by which a person acquires the knowledge, skills and sense of occupational identity characteristics of a professional involves the internalization of the values and norms of a professional group into one’s own behavior and self-conception.” A major tenet of clinical effectiveness is that it is cantered upon real health care settings. It therefore cannot be limited to scientific explanations, but also requires interpretive practical knowledge. Nurturing and caring for others is a task that or an obligation for almost every, it is similar to parenting and other basic caring that we gain from homes. The professional side of it though is a lot complex but never the less similar. There are many theories and instructions that the Nursing school can give but none of these will be effective if not put into practice.
The current health care arena requires nurses with diverse levels of preparation to provide comprehensive, high quality and cost effective care delivery. Authorities have imposed many changes in order to bring quality service to different individuals who are seeking care regarding their health. These rapid changes in society and the health care system over the past decade have sparked dialogue about how best to conceptualize and label the advanced practice domains of nurses. Initially, debate focused on similarities and differences between these roles of advanced practiced nurses. In light of recent changes to the health care delivery system, advanced practice registered nurses have been placed in the interesting position of witnessing both victory and loss within the progression of their field over the past few years. As managed care places an increased emphasis on the value of primary and preventive care, advanced practice nurses see more and more doors open to welcome them into an environment hungry for quality health care skills at a cost lower than that of physicians. At the same time, varying reimbursement laws and lobbying on the part of physician organizations leave many struggling to operate at a level of autonomy for which they’ve been prepared. The term advanced practice registered nurse describes several different providers (, 1990).
made an article about organ donation. The title of the article was “Spare Parts”. According to her, the supply of the organs that will be used in operations cannot cope to the high demands or increasing needs of transplants. The writer also explained the survey made by . These individuals surveyed the people’s attitude towards organ donation to find out why few have volunteered their organs to be donated after their death and what might change their behavior. More than 2,000 people were asked whether they were aware of organ transplantation, if they would be willing to donate organs and how they felt about different methods of obtaining donations. 69% of the respondents had heard of organ donation, but only 19 percent of these actually carried a donor card, designating which of their organs could be used after their death. Of those who didn’t carry a card, 28 percent said they would be willing to do so and 19 percent said they would not. The rest remained undecided. People were a little more generous with their relatives’ body parts: More than half said they would be willing to donate a relative’s organs. In fact, 44% though next of kin should be allowed to donate relative’s organs, even if they had not signed a donor card. And 71% though that if someone had signed a donor card, relatives should not be allowed to overrule it. Stark also said that other studies have shown that 90% of the population is in favour of continued development in the expensive kidney and heart operations. The logical goal of is to match favourable attitudes concerning organ transplantation with favourable attitude towards organ donation ( 1985).
made an article on the works of a nurse who works as a burn specialist. The name of the nurse was , and was assigned to care for a patient who burned his skin through a fire accident. The work of these nurses is very hard and they must endure the grueling task they are facing everyday. According to these nurses, they get overwhelmed when they with other people’s tragedy, but when they see them to their recovery at least it will make them smile knowing that their patient will recover soon. It is better for them to see the patients smile than hearing them crying out from the pain these patients endure (, 2002)
Nurses in many hospitals are aware when one of their patients meets the criteria to be a potential donor. This statement was according to . He explained that if a patient is has brain injury or a neurological injury, the patient could be a potential organ or tissue donor. But the most important thing is to seek for the family’s decision because it is important to know if they are willing to donate their relative’s organ. Some of the potential donor’s relative refused to donate the organ of the patient. This was because of several reasons like cultural reason or their religion refuses this kind of practices of organ donation. So the doctor’s must really talk to the relatives to finalize the situation (, 2001).
Shortage of Nurses
For well over ten years, there has been immense anxiety involving hospitals and nurses on the subject of how much nurses is considered adequate, what their functions are supposed to be, and how to employ and keep hold of them. Medical institutions, paying attention to the bottom line, exhausted much of the 1990s lessening nursing workers by means of layoffs and attrition. Nurses were anxious that these employment cuts would unfavorably have an effect on the quality and sensitivity of patient care. Actually, numerous nurses currently suppose that hospital staffing levels are not simply derisory but hazardous and worsening. In a newly published academic work, only one third of U.S. nurses accounted that their medical institutions have sufficient registered nurses (RNs) to tender first-class care, and 45% stated that the quality of care in their medical institutions has gotten worse in the precedent year. ( 2001) Physicians maintain the nurses’ appraisal: sixty four percent assessed hospital nursing staff levels as fair or poor. Patients and their families similarly appeared disgruntled with existing nurse staffing. They wish for more, and an escalating number are bringing along their personal nurses. (, 2001)
A 1996 congressionally authorized Institute of Medicine academic work held that evidence-established standards were inadequate to direct hospitals, nurses, and policymakers in setting down hospital nurse staffing. (2001) assisted to fill up this void by generating an evidence base for setting up nurse staffing norms. Their work observed the connection involving nurse-to-patient ratios in the intensive care units (ICUs) of Maryland medical institutions and the danger for complications subsequent to abdominal aortic operation. They found out that patients in medical institutions where ICU nurses care for three or more patients have considerably augmented danger for medical complications corresponding to patients in medical institutions where ICU nurses looks after one to two patients. Of interest, California took on an ICU nurse staffing proportion of 1 nurse to 2 patients twenty years ago; (2001) now offer evidence to authenticate that standard.
The comprehensive literature on the association of differential hospital results constantly presents an inverse relationship between nurse staffing and risk-adjusted mortality. Nonetheless, most academic works have “controlled” for the impact of nurse staffing on results more willingly than concentrating on understanding how nurse staffing have an effect on patient outcomes. This might give explanation the conclusion of the Institute of Medicine’s work on the competence of nurse staffing in medical institutions: that inadequate research was accessible to endow with a rationale for mounting nurse staffing principles or minimum prerequisites. (, 1996) Nurse staffing has the tendency to be described by health services researchers as a structural feature of hospitals, in much the similar way that size and teaching status portray the character of an organization. Nevertheless, nothing like size and teaching status, staffing is a managerial judgment. The organizational ambiance in which care transpires similarly reveals managerial decisions. Therefore, more studies are required on how the adaptable attributes of medical institutions, such as staffing and organizational climate, influence patient outcomes. ’ work is a stride in the correct direction.
Chapter III
METHODOLOGY
Decision Criterion
Type of Research
There are three kinds of research methods, correlational, experimental and descriptive. The correlational kind of research method is used due to ethical problems with experiments. Moreover, it is also used due to practical problems with experiments. Moreover, inferring causality from correlation not actually impossible, but very difficult. This mode of study is widely applicable, cheap, and usually ethical. Nonetheless, there exist some “third variable” issues and measurement problems. The correlational research refers to studies in which the purpose is to discover relationships between variables through the use of correlational statistics (r). The square of a correlation coefficient yields the explained variance (r-squared). A correlational relationship between two variables is occasionally the result of an outside source, so we have to be careful and remember that correlation does not necessarily tell us about cause and effect. If a strong relationship is found between two variables, using an experimental approach can test causality.
On the other hand, the experimental method is the only method that can be used to establish cause-and-effect relationships. ( 1994) That is, it is the only one that can be used to explain the bases of behaviour and mental processes. In this method, the subjects are split into two (or more) groups. One group, called the experimental group gets the treatment that the researcher believes will cause something to happen (this treatment is formally called the independent variable). The experimental and control groups are compared on some variable that is presumed to reflect the effects of the treatment, or outcome. This is formally referred to as the dependent variable.
This study will use the descriptive type of research. To illustrate the descriptive type of research, (1994) will guide the researcher when he stated: Descriptive method of research is to gather information about the present existing condition. The purpose of employing this method is to describe the nature of a situation, as it exists at the time of the study and to explore the cause/s of particular phenomena. The researcher opted to use this kind of research considering the desire of the researcher to obtain first hand data from the respondents so as to formulate rational and sound conclusions and recommendations for the study.
This study also employs qualitative research method, since this research intends to find and build theories that would explain the relationship of one variable with another variable through qualitative elements in research. These qualitative elements does not have standard measures, rather they are behavior, attitudes, opinions, and beliefs.
Meanwhile, the qualitative research method was also utilized because this research also intends to find and to build theories that would explain the relationship of one variable with another variable through qualitative elements in research, which is the purpose of a qualitative research method (, 1990). These qualitative elements do not have standard measures; rather they are behavior, attitudes, opinions, and beliefs. ( 1990) Moreover, the qualitative research is multi-method in focus, involving an interpretative, naturalistic approach to its subject matter. ( 1990) This means that qualitative researchers study things in their natural settings, attempting to make sense of, or interpret phenomena in terms of the meanings people bring to them. ( 1990)
Furthermore, as we define the qualitative research it is multimethod in focus, involving an interpretative, naturalistic approach to its subject matter. This means that qualitative researchers study things in their natural settings, attempting to make sense of, or interpret phenomena in terms of the meanings people bring to them. Accordingly, qualitative researchers deploy a wide range of interconnected methods, hoping always to get a better fix on the subject matter at hand.
Validity of Process
For this research design, the researcher will gather data, collate published studies from different local and foreign universities and articles from social science journals, distribute sampling questionnaires; arrange interviews; and make a content analysis of the collected documentary and verbal material. Afterwards, the researcher will summarize all the information, make a conclusion based on the null hypotheses posited and provide insightful recommendations on the dealing with the effects of the nursing shortage in the United States.
Basically, (2000) believes that qualitative research uses explanatory methods in describing the variables wherein the data, situations, or other facts collected will be explained or correlated with other data. According to them qualitative research methods are useful when conducting a study wherein the data are immeasurable, such as feelings, beliefs, thoughts, and others.
Moreover, (1984) stated that qualitative methods is important to management analysis, organisation studies and even to business development since it assist the researchers who desire to understand complex social phenomena. They are appropriate when seeking knowledge about the fundamental characteristics of a phenomenon being studied before theorising about it. This knowledge often surfaces through close contact with subjects of a study, allowing the researcher to understand their points of view about and experiences with the phenomenon.
Researchers even disagree on the definition of “qualitative.” For example, some researchers use terms such as naturalistic and descriptive, as well as field, product, and case study. Perhaps the best way to clear up some of the confusion about qualitative research is to examine some its most accepted methodologies and characteristics.
On the other hand, (1992) proposes that there are but three general types of data-gathering techniques in qualitative studies: experiencing, enquiring, and examining. These three techniques are used, Wolcott argues, in such diverse qualitative approaches as case studies, non-participant observed studies, interviews, participant observation, phenomenology, ethnomethodology, enography, and ethnology. As (1992) notes, the majority of qualitative research is based on a case study that uses one or several of these qualitative techniques, enabling researchers to immerse themselves within a culture or a context and producing questions to pursue for further research and understanding of phenomena.
As an extension of the qualitative technique of interviewing, (1991) propose that focus groups offer researchers a rich source in which to gather genuine information about participants’ perceptions, experiences, and attitudes which provide a basis from which to build theory. Another variation of interviewing techniques proposed by (1992) is the technique, which can be valuable in gathering data on a subject from a panel of experts.
For researchers who want to learn how to conduct qualitative research, numerous sources are available. (1993) present essays on interviews, focus groups, narrative analysis, critical incidents, and ethnographic analysis; (1987) offers good procedures for participant observations; (1988) describes conversation, narrative, and content analysis; (1988) provides guidelines for focus groups; and (1988) discusses interviews.
Reliability of the Process
There are two factors which stand to achieve from the use of qualitative research inquisition. First, researchers gain not only because of increased ease of use to pre-existing viewpoint and the contextually responsive nature of methodologies such as life history, but also for the reason that qualitative research methodology helps researchers address the “singularity of values” (1993) so ubiquitous in past research efforts and understand the nature of “intercontextual work” (1992, p. 243). According to , (1993) second factor, the researched, benefit from qualitative research inquiry because the inquiry provides for more authentic texts and opportunities for personal empowerment and transformation.
On the other hand, (1991) argues that teacher understanding is a ‘multiplicity of personal, social, cultural and political influences’. Thus, research methods have shifted to reflect new ideas. Inquiry into teaching focuses more on self-images and voices of teachers, rather than the single values of the researcher. “Constructionist” and “interactionist” inquiries, argues , are being used to reflect the sophisticated contexts within which teachers operate. (1991) believes that it is a “process of meaning-making, grounded in the contexts of personal and social history” (p. 191). Apparently, (1987) asserts that qualitative researchers not only rebuff the conception of common context-free oversimplification but that delicate and interpersonal histories are mixed up in teaching and qualitative research is a scrupulous approach to data that is milieu sensitive.
Because of these more sensitive approaches to research, , (1993) believes that such issues as gender, race, political and secular interests which may be part of an everyday language can be explored through qualitative methods. According to the researcher’s values are only pan of the research and need to be reported as such. The voice of the researched offers a second reality. A third reality is offered by the social, cultural, political and economic contexts surrounding the life of the researched. The issue of reporting reality and knowledge in dominant research efforts was addressed by (1993) and was called an issue of “singularity of values”.
According to , dominant research, rooted in “mainstream questions and concerns and ethically normative findings, has communicated a singular ontology (philosophy of reality) and epistemology (philosophy of knowing and relating to the intended known, the other” (pp. 30-31) and has lead to the singularity of values, history and accounts in research efforts. Thus, according to him, qualitative inquiry with its greater emphasis on one to one correspondence and its opposition to a priori thinking leads to a greater diversity and representation of the individual and collective values. No longer are researchers the ultimate authority in qualitative research inquiry, ownership is a negotiation between both researchers and researched. Furthermore, claims that power shifts among those involved in the research, roles become flexible, the boundaries of old blurred and changed which ultimately benefit both researcher and researched.
Because qualitative research inquiry addresses issues of authority, interpretation, and reinterpretation in the construction of accounts, authentic texts which appropriately represent the researched are possible. The voice of the researched is valued and given a central place in qualitative research inquiry. A second benefit is that, contructivist, critical, participatory methodologies such as qualitative research inquiry address issues of adequacy and authenticity of text and potentially empowers, and transforms the researched ( 1993).
With respect to legitimacy and sufficiency and changing roles, a number of researchers ( 1993; 1992) raise additional related issues of ethics, rigor, fidelity, plausibility, and consistency, concealment of research intent and imbalanced researcher /researched perspectives. According to (1993), authentic and adequate accounts demand that researchers: choose newer experimental forms of research, forms which consider problems of interpretation and authority; produce knowledge that is transformative; examine the ethics and morality of their work; write texts that are open-ended and subject to multiple interpretations.
In conclusion, qualitative research methods benefit both the researched and researcher communities in diverse ways, thus this kind of research method is definitely an important factor in organisation, business and management development. The researched become agents of knowledge, co-creators scrutinizing the authenticity of texts, while researchers have a mode of textual and inter-contextual analysis and are privy to processes which have ethical safeguards. Researchers therefore have the opportunity to develop a wider understanding of schooling and individual choices through collaborative research.
Moreover, qualitative research inquiry has the prospective to rid texts of singularity of values and offer textual and inter-contextual analysis of lives, This type of inquiry also has the potential to empower and transform the researched by offering more participatory roles, roles which emphasize greater voice in the collecting, analysis and writing of research. Changing roles of researchers, those researched and texts suggest enriched methods of data collection, of dialogue between researcher and researched and of written accounts of results.
Chapter IV
PRESENTATION AND ANALYSIS OF DATA
FACTORS INFLUENCING THE SUPPLY OF REGISTERED NURSES Work Environment
Among the most important aspects that contribute to the complexity in both recruiting and retaining registered nurses (RNs) is the care background. At the same time as pay rates carries on to be a dilemma, the care setting is a principal motivator for individual registered nurse’s acquisition of employment decisions. Academic works (, 1998) have presented that one of the principal factors for the escalating nurse turnover rate is workload and staffing. In accordance with the (1998) nursing shortage study, nursing managers, registered nurses and licensed practical nurses all referred to inadequate supply of qualified managers and knowledgeable staff as the most likely motivation for the existing or projected shortage. On the contrary, the (1999) study presented that the principal rationale for nurse turnover was augmented market demand. Mercer continues to affirm that in their work they have established that the fundamental foundation of turnover is discontent with the job, the immediate superior, or career prospects. The second most mentioned grounds for turnover was “workload/staffing.” These are deep-seated predicaments that situate separate from the subjects associated to the supply of and demand for nursing services. Unless problems associated to the care setting are tackled, strategies to augment the general supply of nurses are doubtful to be successful.
Retention
Apprehensions concerning the aging of the nursing workforce have been well recognized. The existing standard age of registered nurses is 44.3 years with registered nurses who are below 30 years of age corresponds to merely 10 percent of the whole nurse population. ( 1997) In keeping with The Conference Board (, 1995), an employment and market analysis organization, chronological age is a poor determinant of physical or psychological capacity; turnover rates of elder personnel are inferior than those of young individuals; old workers gain knowledge well as younger people, with the exception of the moment when stress is functional; and bringing up to date skills of existing workforce will be a third as costly as hiring fresh graduates educated in the most recent technologies. Additionally, provided the time required increasing the supply of registered nurses by means of education, nursing and the health care industry have got to build up strategies that will keep hold of the elder, proficient registered nurse within the nursing labor force.
A review of the literature presents that very modest research has been completed, principally within nursing, in relation to the impact of the aging personnel and probable adjustments that may require to be completed with the intention of retaining the experienced nurse. (1995), beamed to the demand for additional investigation and policy deliberations associated to pension accessibility, adult reliant care responsibility, and the professed desirable working situations of persons >55 years of age. continued on to state that provided the massive alterations boomers conveyed to the nursing labor market in the 1970s by their unrelenting labor involvement, it is not
unimaginable that this cluster may fashion new outlines at the conclusion of their careers.
Figure 1. Vacant Nursing Positions across New England*
An interactive work ( 1994) recognized problems associated to menopause that, while not putting out of action, may require to provide accommodation, A number of nurses interviewed for this work similarly articulated anxiety about job security if such problems were presented. In Belgium (, 2000), one approach that was secured through strike action to keep hold of the expert, older nurse is to cut down hours of employment. Nurses who are more than 45 can work 36 hours in seven days, but still earn for 38 hours. In the same way, nurses at 55 can work 32 hours per week and bring in money equivalent to 38 hours.
Education
Whereas nursing shortages are considerably not new, the existing circumstances differ from precedent shortages. Not only is the shortage in figure of nurses, the educational training of nurses is insufficient to satisfy the requirements of today’s health care structure. Employers insist on more baccalaureate instituted nurses for medical institutions and specialty nurses for ICUs, operating rooms, and ERs, and other focused areas of acute care (, 1996; 1999).
Figure 2. Twenty-year Projection of the Nursing Shortage*
Only 60% of California’s nurses perform in medical institutions. These practice settings calls for nurses educated with no less than the baccalaureate for the acquaintance and abilities essential for service in the community. Thus far, just about 70% of nurses in California established their preliminary education at the associate degree level and of these, just 16% revert to school for the bachelor’s degree in nursing (, 1999). Advanced practice nurses for example nurse practitioners, nurse anesthetists, nurse midwives, case managers, and clinical specialists are similarly in demand. These nurses have as a minimum a master’s training and perform in a diversity of settings.
Compensation
As stated in the study of (1998), throughout the 1980′s, registered nursing hourly salary amplified by just about 3 percent each year. Throughout the 1990′s, increase in the registered nursing salary was flat. On the other hand, the 1999 RN Salary Survey (, 1999) did present that hourly salary are once more growing. Approximately, around the clock acute care registered nurses’ instant hourly wage improved by 5 ½ percent ever since the 1997 survey. This salary increase is not revealed in salaried nurses, who are first and foremost those who work in management and administration. The survey presents a 17 percent plunge for salaried nurses ever since 1997.
A review of discussed nursing contracts presents that year-to-date on standard unionized nurses is discussed 3 percent to 5 percent salary increases in 2000. On the other hand, important gains have been completed in a lot of contracts to tackle problems such as compulsory overtime and staffing, both problems that are straightforwardly affecting nurse satisfaction with the care environment.
CHARACTERISTICS OF ORGANIZATIONS AND PERSONNEL IMPACTING STAFFING AND PATIENT OUTCOMES
(1997), who’s attention in nursing care and its connection to patient outcomes develop from their employment in following magnet hospitals, confirmed that nursing attendance, whether calculated as RN ratios or as RN hours compared with other nursing employee hours, is considerably connected to mortality. Aiken et al. established that medical institutions that had positive inpatient mortality results similarly had different organizational distinctiveness.
The Impact of Clinical Interaction on Mortality
Aiken’s conclusions are reinforced by research carried out by researchers testing an ICU projecting instrument ( 1986). In 1986, one of the initial studies connected with APACHE II, a severity adjustment and risk forecast structure for critical care, recognized collaboration as having an imperative constructive effect on patient outcomes in intensive care units. In this work of thirteen medical institutions (all of which had 1:1 staffing in their ICUs), physicians and nurses autonomously accounted their professed level of collaboration with each other. In medical institutions where both the nurses and medical doctors decided that their communication and collaboration were positive, a noteworthy percent of patients lived although the instrument foreseen that they would pass away. Nevertheless, in medical institutions where nurses and medical doctors accounted that there was diminutive communication and collaboration, a considerable percentage (58 percent) of patients whom the instrument predicted would survive, actually expired. The variation in mortality between the hospitals varied from 41 percent less than the forecasted to 58 percent higher than predicted, subsequent to modification for patient case mix and sternness of illness. The background of a number of hospitals evidently was therapeutic, and that of the others just as without a doubt was toxic.
In recent years, numerous other academic works have looked into the correlation that collaborative relationships involving nurses and physicians have on patient effects. A lot of these studies supply strong confirmation that a collaborative method to care has a constructive effect on quality of care, resource consumption, and ICU expenses (, 2002). Furthermore, the “multidisciplinary” method is frequently mentioned as having a constructive and significant effect on such practices as weaning from mechanical ventilation ( , 1998), dropping ventilator-associated pneumonia rates, and declining readmissions to ICU (, 2000). These academic works, among others, maintains (1994) statement that medical institutions which have inferior mortality rates share specific distinct organizational uniqueness; uniqueness that assist in creating a therapeutic atmosphere for patients.
The Impact of Nurse-Patient Ratios
Over and above their research on general hospitals, and her colleagues have taken into consideration nursing organization and patient effects in specialized AIDS divisions ( 1999). They established that at 30 days after admission, mortality tolls were 60 percent lesser in magnet hospitals and 40 percent inferior in specialized AIDS divisions than in traditional scattered bed units. It was deduced that the accessibility of specialized medical doctor services and advanced nurse patient proportions were the foremost factors in explanation of the lower rates. Examinations recommended that an added nurse for every patient day condensed the chances of dying by a half (, 1999). It appears to take very little to generate a therapeutic setting: one additional nurse; smaller number of patients for every nurse; and admission to physician specialists make a life and death disparity.
In the meantime, (2002), whose work established a connection between nursing care and 5 variables, revisited their statistics, and both strengthened and illuminated their original conclusion on the subject of the connection involving poor patient results and low nurse staffing in medical institutions. The mean amount of hours of nursing care for every patient-day was 11.4, of which registered nurses tendered 7.8 hours, licensed practical nurses 1.2 hours, and nurse aides 2.4 hours. Amongst medical patients, a superior ratio of hours of care for every day tendered by registered nurses and a superior absolute figure of hours of care for every day tendered by registered nurses were connected with a shorter extent of stay and lower incidences of both urinary tract infections and upper gastrointestinal bleeding. A superior proportion of hours of care tendered by registered nurses similarly were connected with lower incidence of pneumonia, shock or cardiac arrest, and “failure to rescue,” which was described as passing away from pneumonia, shock or cardiac arrest, upper gastrointestinal bleeding, sepsis, or deep venous thrombosis. Amid surgical patients, a superior amount of care tendered by registered nurses was connected with lower incidence of urinary tract infections, and a higher number of hours of care per day offered by registered nurses were connected with lower incidence of “failure to rescue. A 2003 work by (2003) proved that it is, in actual fact, registered nurse’s hours of care that influence the level of unfavorable events patients encounter, and not skill mix. In keeping with Unruh, licensed nurses’ acuity-attuned patient consignment amplified from 1991 to 1997 and both licensed nurse and total nursing staff diminished from 1994 to 1997. There was a superior occurrence of virtually all unfavorable events in hospitals with a smaller amount of licensed nurses ( 2003).
Turnover and its Relationship to Patient Outcomes
A lot of academic works have recognized the association between staffing load and nurse turnover, and hardly any in point of fact examined the effect of both staffing proportions or hours of care for every patient per day and patient results (, 2002; , 2003; , 2002; and , 2002; l, 2002; 2002). One, at any rate, associates all three, and takes in cost data additionally ( 2002). The accrued savings in condensed length of stay, lesser ICU days, and improved staffing, which approximately at all times is connected with superior retention incidence, is not the least bit unimportant. In this 2001 () research analysis concerning 235 medical institutions, the authors proved that organizations with low turnover accounted shorter patient lengths of stay in general. The academic work divided partaking hospitals into three clusters — low, medium and high turnover — and evaluated important performance determinants. Low turnover organizations had a turnover incidence from four percent to twelve percent. High turnover organizations varied from 21.6 percent to 43.8 percent. The low turnover cluster had a severity-attuned length of stay that was 1.2 days below the high turnover cluster. Evidently, amplified length of stay brings about augmented costs. (2002) concluded that:
- Companies with high turnover incidence had 36 percent higher costs for every release than hospitals with turnover incidence of 12 percent or lower.
- Low turnover medical institutions averaged 23 percent return on assets measure up to a 17 percent return for high turnover ones.
- Low turnover hospitals had lessened risk adjusted mortality rate on top of lower severity-adjusted length of stay weigh against medical institutions with 22 percent or superior turnover incidence.
Furthermore, studies of root cause analysis of unwanted patient results and sentinel events, performed under the direction of the Joint Commission on Accreditation of Healthcare Organizations, designated that 24 percent of unwanted results and sentinel events entailed problems caused by the nursing shortage, as well as exhaustion and miscommunication (, 2001). These sentinel events, in conjunction with those not accounted, correspond to an massive toll in human life — and the possible for considerable malpractice rewards.
The Effects of Nurses’ Education on Patient Outcomes
In current cross-sectional examination ( 2003) of outcomes data for general, orthopedic, and vascular surgery patients released connecting April 1, 1998 and November 30, 1999, academics associated the educational level of staff nurses to patient mortality indicators. The percentage of hospital registered nurses in this study which holds a bachelor’s degree or advanced varied from zero to 77 percent across the medical institutions. The academic work adjusted for both patient distinctiveness and hospital structural character (size, teaching status, level of technology), as well as for nurse staffing, nurse experience, and whether or not the patient’s surgeon was board licensed. A 10 percent enhancement in the ratio of nurses acquiring a bachelor’s degree was connected with a 5 percent decline in both the probability of patients passing away within 30 days of admittance, and the probability of failure to rescue (odds ratio, 0.95; 95 percent confidence interval, 0.91 – 0.99 in both cases).
Chapter V
CONCLUSIONS AND RECOMMENDATION
Conclusions
With the intention for nursing to stay alive and flourish, the recurring swings of the nursing shortage have got to be tackled. At the same time as explanations to this dilemma will be talked about more completely in other studies, the author would tender the subsequent judgment. As previously confirmed, failure to take in hand the work setting will make any approach to attend to general nursing workforce planning and the nursing shortage extremely complicated.
It is time for an intensive exertion to shift nursing workforce planning to the state level by means of the formation of state-founded nursing workforce hubs that could follow, evaluate and make proposals on the nursing workforce within the state. Each of these hubs could bring together analogous information that could notify nursing workforce planning at the nationwide level to concentrate on this problem from a macro level. Additionally, augmented nursing education dollars are required to augment the capability of schools of nursing. To conclude, existing work that is in progress to connect nursing care with patient results is completely indispensable for shaping the demand for nursing services from a patient standpoint. As an accompaniment to this data, structured nursing has to require the Health Care Financing Administration to generate instruments for costing out registered nurse services within Medicare, Medicaid and other reimbursement structures. By recognizing both the demand for nursing services from the patient viewpoint and being familiar with the cost repercussions, nursing can accomplish more suitable and opportune workforce planning.
Recommendations
The recommendations in this study will be based on the overall discussions in this paper. The first recommendation is that salary and benefits should be augmented to be a sign of training and experience for both clinical nurses and nursing faculty. Nurses are salaried on average an inferior salary than national averages. Anchored in this data, individual organizations and education programs can evaluate their wages and benefits in opposition to state and national averages. In addition, repayment from payors is required to be sufficient with the intention of ensuring providers are proficient to tender competitive wages.
The second recommendation is that the number of students accepted to nursing education courses should be amplified and distance learning or alternative programs are supposed to be presented. Most nursing curricula in the United States have newly amplified the number of students registered in their programs and are functioning on mounting the release of distance learning plans.
The third recommendation is that staffing levels should be attuned to permit for more undeviating patient care and a less demanding work setting. Policy repercussions take in examining alternative arrangements such as bendable preparation, appraising the satisfactoriness of staffing levels and probing paperwork prerequisites to get rid of redundancy.
The last recommendation is that recruitment attempts should be improved with the intention of increasing awareness in the nursing turf. Nurses recommended a better recruitment counting job fairs, high school certified nursing assistant agenda, nursing camps for youngsters, capacity testing in high schools, educating career therapists and revealing junior high or younger children to the nursing profession. Repercussions takes in associations and facilities collaborating to prepare career fairs, health career lessons, job shadow agenda and/or excursions and having lessons or volunteer familiarity for high school students in health care services throughout the summer.
BIBLIOGRAPHY
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