The Importance Of Teamwork In Nursing
The nursing shortage is an issue that affects health care systems worldwide along with the quality of care that is provided for patients. In this paper, the nursing shortage will be analyzed from a sociocultural, political, and economic perspective to better understand how the different viewpoints are affected and/or contribute to the issue. After analysis, the barriers to resolving this issue will be identified and the strategies to resolution will be provided along with the rationale behind each of these strategies.
In paper one, the factors that contribute to the nursing shortage were discussed. The issue is that high turnover rates and difficulty recruiting and retaining nurses was the ultimate result from an aging workforce, inadequate number of nursing faculty, and job dissatisfaction due to burnout and poor quality of practice environment.
Social Cultural Perspective
Most experts agree that culture includes cognitive beliefs, behaviours, practices and interactions, assumptions and attitudes that are shared within a workplace and between members (Braithwaite, Herkes, Ludlow, Testa, & Lamprell, 2017). These shared ways of thinking and behaving is then normalized and is seen as acceptable and legitimate (Braithwaite et al., 2017). The sociocultural factors that contribute to the high turnover rate of nurses is mainly due to the workplace culture of the practice environment. This means that within the practice environment, there is workplace violence such as horizontal and vertical bullying, lack of teamwork/cooperation, and difficulties with interpersonal communication (Yoshiyuki, 2018). These factors are related to burnout which contribute to nurses’ intent to leave and turnover (Yoshiyuki, 2018).
Turnover not only affects nurses, but also new nursing graduates (Yang, Lv, Zhou, Liu, & Mi, 2017). With the nursing shortage being a global concern, there are many young, nursing graduates who are considering leaving their job and/or profession (Flinkman, Isopahkala-Bouret, & Salantera, 2013). The youngest generation of nurses are the most willing to leave the profession as they are more vulnerable to early career burnout which is associated with intention to leaving the profession (Flinkman et al., 2013). The factors that contribute to this are high psychological demands, an imbalance between effort and reward, and higher job strain (Flinkman et al., 2013). There is also a higher incidence of bullying against newly licensed nurses (licensed for less than three years) (Gillespie, Grubb, Brown, Boesch, & Ulrich, 2017). In Iran, the highest rate of nurse turnover is among nurses who have three years or less of work experience (Ashghaly Farahani, Oskouie, & Ghaffari, 2016). The idiom “Nurses Eat Their Young” refers to bullying behaviours that are experienced by new nurses (Gillespie et al., 2017). These behaviours can include withholding information, spreading rumours, ignoring/excluding targets, intimidating others, etc (Gillespie et al., 2017). This affects not only the nurses who are the victims of bullying, but ultimately affecting the patients as well (Gillespie et al., 2017). The result for nurses would be poorer mental health, decreased collaboration and teamwork with team members, ineffective communication, reduced work productivity, and poor job commitment (Gillespie et al., 2017). This means that the quality of care that these nurses provide for patients would also decrease which could result in serious consequences from medication errors to patient death (Gillespie et al., 2017).
In a study done by Lavoie-Tremblay et al., young graduates (24 and younger) who experience poor work environment were more likely to consider leaving the profession (Flinkman et al., 2013). In Sweden, 10-20% of new graduates have considered leaving the profession and in the United States, more RN graduates left their first nursing job than the nursing profession during the first two years of their career (Flinkman et al., 2013). This shows that the culture of the practice environment is a significant factor in turnover rates and the retention of new nurses. New nursing graduates require social support from peers as they highly value the level of support they receive from colleagues and supervisors along with organizational support which can reduce burnout and thus increasing commitment to the job and profession (Yoshiyuki, 2018). They also need stability, flexible schedules and shifts, recognition, opportunities for professional development, and adequate supervision (Lavoie-Tremblay, Leclerc, Marchonni, & Drevniok, 2010).
Although the nursing shortage causes many issues, there are some benefits. Due to the shortage of nurses, nursing may be one of the few careers that is practically recession-proof (Purdue University Global, 2015). With the significant amount of the aging workforce reaching retirement age, there would be hundreds of thousands of replacement positions available (Purdue University Global, 2015). This results in a vast amount of career options for nurses as many different positions in different settings will need to be filled (Purdue University Global, 2015). Outside of the hospital department, nurses can work in home health care, doctors’ offices, extended care facilities, and government positions (Purdue University Global, 2015). There are also non-clinical roles that nurses can work in such as, researchers, recruiters, and nurse educators. Nursing is one of the few careers that has consistent part-time or per diem opportunities (Purdue University Global, 2015). There is also increased recognition of the nursing profession as it becomes more visible in times of scarcity. In the past 30+ years, professional recognition has slowly grown as healthcare leaders reward frontline caregivers and managers for their hard work by increasing salary wages and creating clinical ladders, flexible staffing systems, and advanced practice roles (Gelinas, 2017). Finally, the nursing shortage will increase the spotlight on the remaining staff. This means that more attention will be paid to staff who do not perform to expectations and standards of care. As a result, the staff members who performs inadequately, sometimes called marginal performers, will increase the workload on other members of the team which contributes to burnout and turnover (Gelinas, 2017).
Every nurse has the opportunity to make a positive impact through day-to-day advocacy for nurses and the nursing profession (Tomajan, 2012). Advocacy is defined as the act or process in supporting a cause or proposal (Tomajan, 2012). The set of skills required for advocacy include problem solving, communication, influence, and collaboration (Tomajan, 2012). Nurses advocate for themselves and this shown by thousands of nurses rallying for safe patient ratios in Pennsylvania (Hamburg, 2019), New York (Good, 2018), Washington D.C. (Nitzky, 2018) and many other regions. These nurses stated that appropriate limits on nurse-to-patient ratio is necessary so that nurses can provide safe, excellent care for patients as they are getting burned out and overwhelmed at the number of patients that they are assigned to (Hamburg, 2019). As burnout is a contributing factor to turnover and the shortage of nurses, providing appropriate nurse to patient ratios will not only benefit nurses by improving quality of the practice environment but also the quality of care that nurses provide for the patients. A healthier workplace culture is believed to improve patient outcomes, such as reduced mortality rate and length of stay, increased quality of life and decreased pain level (Braithwaite et al., 2017).
The nursing shortage that results from nurse turnover is costly for health care organizations. There are direct and indirect costs. Direct costs are considered those that are clearly and readily attributable to a specific activity which makes it obvious and tangible (e.g. advertising and recruitment) while indirect costs are those that may be hidden and are not readily assigned to a specific activity (e.g. loss of productivity) (Jones & Gates, 2007). The costs of turnover include orientation and training, termination, potential errors, poor work environment and culture, additional turnover, and vacancy costs (e.g. overtime and paying agency nurses) (Jones & Gates, 2007) while the retention of nurses will reduce overall costs on all of these areas. The cost of turnover per nurse ranges from $25,000 to $60,000 (Jones & Gates, 2007). In addition to the costs of replacing staff members, there is also financial costs on the remaining colleagues who are left behind (McIntyre, Tomlinson, & McDonald, 2019). These colleagues are vulnerable to decreased job satisfaction and mental health challenges as there is low morale and decreased productivity due to the extra burden (McIntyre et al., 2019). On the contrary, there are benefits to turnover such as, reductions in salaries and benefits of new hired nurses versus departing nurses, savings from bonuses that are not paid to outgoing nurses, elimination of poor performers, and replacement nurses bringing creativity, new ideas, and knowledge of competitors (Jones & Gates, 2007).
In times of a nursing shortage, managers at hospitals and other facilities face difficulty in recruiting and retaining nurses and thus often use nurses from temporary employment agencies to fill vacant positions (Seo & Spetz, 2014). These temporary agency nurses can be both short-term daily (per diem) nurses and longer term traveling nurses (Seo & Spetz, 2014). By filling vacancies with temporary nurses, hospital services may improve by allowing shorter waiting periods for admission while ensuring appropriate nurse to patient ratios are met (Seo & Spetz, 2014). The temporary staff is cost-effective and relatively inexpensive for hospitals (Seo & Spetz, 2014). Although the hourly rate for agency nurses are higher than the baseline wages of in-house staff, there would be no need to pay agency nurses for unneeded hours of work and the high fixed costs of employee benefits (Seo & Spetz, 2014). In 2012, the U.S. government funded $230 million for nursing workforce programs to expand nurse supply (Seo & Spetz, 2014).
Barriers to Resolution
Identifying barriers is one of the most important strategies to bring an issue toward resolution (McIntyre et al., 2019, p. 323). Once the barriers are identified, the chances of resolving the issue through mediation, collaboration, and negotiation increases (McIntyre et al., 2019, p. 323).
The biggest barrier to this issue is the way that it has been understood and conceptualized (McIntyre et al., 2019, p. 323). Typically, the nursing shortage has been seen as short-term problems and simply a numbers issue (McIntyre et al., 2019, p. 323). It is usually temporarily solved by recruiting international nurses or by educating more nurses (McIntyre et al., 2019, p. 323). Secondly, the lack of legislation regarding nurse-to-patient ratios can increase burnout and turnover. In the United States, only 14 states have currently addressed the staffing ratio in hospitals (American Nurses Association [ANA], 2015). California is the only state that stipulates in law and regulation a required minimum nurse-to-patient ratios to be maintained at all times (ANA, 2015). Finally, a poor workplace culture and/or poor quality of practice environment will continue to result in nurse turnover which contributes to the nursing shortage. Although there is a lack of shortage in the number of nurses, there is also a pseudo-shortage (McIntyre et al., 2019, p. 317). This means that there are enough nurses but not enough who are willing to work under the conditions that are available (McIntyre et al., 2019, p. 317). Simply increasing the amount of new graduates without addressing the working conditions will result in the same current situation (McIntyre et al., 2019, p. 317).
Strategies for Resolution
Long-term strategies are the most important in resolving the nursing shortage (McIntyre et al., 2019, p. 324). Based on the sociocultural analysis and the way that the nursing shortage is conceptualized, it is important to raise awareness of the factors associating to the nursing shortage such as, burnout, workplace violence, and high nurse-to-patient ratios as they contribute to nurse turnover. The goal is to improve working conditions and workplace culture. Actions that can be taken against bullying include educating nurses about bullying, fostering positive interprofessional relationships, using cognitive rehearsal to learn to professionally defend oneself, de-escalation strategies, and self-awareness for preference of managing conflict (Gillespie et al., 2017). This is important because by eradicating bullying, it will not only improve work productivity and mental health of nurses, it will also potentially improve patient care by yielding fewer errors (Gillespie et al., 2017). It will also result in less turnover as nurses will go wherever they are respected, rewarded for their competencies, and given opportunities for professional and personal development (McIntyre et al., 2019, p. 324). Working conditions can be improved by having laws and regulation on the nurse-to-patient ratios. In California where ratios are implemented, the quality of care turned out to be higher with significant lower levels of patient mortality and the nurses reported greater job satisfaction and lower levels of burnout compared to other states such as, New Jersey and Pennsylvania (Manitoba Nurses Union [MNU], 2012).
Another strategy for resolution is for health care organizations to invest in providing training, offering and funding for extra certification programs for new nursing graduates. There are many nursing specialties that require extra certifications to qualify for specific positions. The nursing shortage is not simply lacking the number of nurses but also the amount of qualified nurses for certain positions. By offering and funding for these programs, new nursing graduates will be able to quickly qualify for many positions in combination with additional training.
The nursing shortage is a worldwide recurring issue that is typically viewed as a short-term problem that is temporarily solved by recruiting temporary nurses to fill vacancies. However, the factors contributing to the shortage is not simply a matter of supply and demand. The nursing shortage has become a cycle where a lack of nurses puts more pressure on the remaining nurses which causes overwhelming stress that eventually leads to job dissatisfaction and in turn contributes to high turnover rates. This will result in a poor workplace culture and practice environment due to low morale and decreased work productivity. The overwhelming workload results in burned out nurses and often times workplace bullying develops. By solving the factors that contribute to burnout and turnover, the nursing shortage will slowly decline and nurses will be able to provide ongoing safe, excellent care for patients.
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