The Issue Of Low Staff Morale In Nursing Settings And Strategies To Change It

Low staff morale in nursing settings has been an increasing concern. Retention, turnover, recruitment, workplace health and safety issues have all been linked to poor nursing morale. Not only researchers, but also politicians, administrators and policymakers have been trying to understand how to fight this issue. Both national and international calls for transformation and reform continue to go forward due to growing uncertainty and increasing mandates for change. If hospitals expect to perform well, they must give great attention to nursing staff morale, as excellent and qualified staff will ensure patient satisfaction and positive health outcomes.

“Morale” is the capacity of people to maintain belief in an institution or a goal, or even in oneself or others, and for them to pull together persistently and consistently in pursuit of a common purpose. It is a crucial element in maintaining a healthy work environment. Although nursing staff is often overlooked when it comes to medical personnel, low nursing staff morale is also concerning and can have great impact on the quality of care. Nursing staff morale has been plummeting, especially recently. In 2005 nursing staff morale reached an all-time high in the United Kingdom, whereas in 2007 there was a significant drop. In the survey, 30% of NHS nurses said they would leave if they could and four out of five said their workload was too heavy and the pay was too low. An increase demand of qualified nursing professionals, along with low retention rates, pose a danger to the nursing sector, as the workload will continue to increase and hospitals will continue to lose staff. This will continue in decrease of morale. Although it is simple to brush off these problems as simply low job satisfaction, morale and job satisfaction are slightly different concepts. Job satisfaction is an individual relationship with the job the employee is doing, whereas morale is related to the collective atmosphere of the workplace and what is happening in the institution itself. In fact, it is not uncommon for employees with high job satisfaction to have low morale.

In the U.K. case, the nurses did not mention that they dislike caring for others. The main reasons were related to low morale – outer factors that reduced the belief in the institution. Certified nursing assistants make up the largest portion of the nursing employees in long-term care and are responsible for 80-90% of the hands-on care that is provided to the residents. In the U.S., Registered nurses represent almost one fourth of the hospital workforce, so nursing personnel are often a target for cost reductions as hospital budgets continue to shrink. It might seem obvious that less nursing staff would mean less expenses, but research suggests that it might be the opposite. It has been reported several times that fewer nurses could cost more – Pronovost and colleagues have previously examined the link between the amount of nursing staff and found that having an ICU nurse-to-patient ratio of less than 1:2 during the day increased mean ICU days by 49%, which increased resource use. Moreover, a 20-hospital study done among AIDS patients in 1999 estimated that one additional nurse per patient-day could reduce the odds of death by more than a half. These results show that it is highly important to have an adequate number of nursing staff, which is why the harm done by low morale, such as absenteeism and turnover, should be treated as an urgent matter. Along with losing nurses, we may lose more patients and residents due to neglect and poor performance. This means that hospitals and nursing homes are not the only ones affected. Losing patients means grieving families, spouses, friends and relatives. It also means poor customer satisfaction and losing future patients to other hospitals and nursing homes.

Resource use is not the only financial cost when it comes to high staff turnover. Whenever employees leave, new staff is needed in order to compensate for the shortage. This leads to additional training and increased cost. According to a meta-analysis by Seavey (2004), the minimum direct cost of turnover is $2,500 per person. Direct costs include not only additional training, but also costs of advertising, temporary agency workers and even increased injuries. Some of the indirect costs were loss of residents to other facilities and using nursing staff inefficiently while training new employees. These expenses all add to the economic impact of turnover. Most importantly, quality of care deteriorates with turnover due to deterioration of staff morale, organizational culture, loss of consistent practices and loss of experienced and knowledgeable workers. The financial impact of losing staff is an important factor, so we may be tempted to choose financial solutions such as increased wages. However, these measures do little to combat low morale, as financial issues do not appear to be the root cause.

In 2008, Squillace et al. published a report along with the U.S. Department of Health, based on the observations of several resources, citing reasons why nursing assistants dislike their job, why they would leave their job, or why they are already leaving their job. It was found that the most common reasons among nursing staff for disliking their jobs were bad relationships with their co-workers and having problems with supervisors, whereas two-thirds of all nursing staff who wanted to stay in their jobs reported liking their co-workers and supervisors as one of the main reasons. Even out of the 24% of employees who were looking for another job, 67% were not likely to leave. 99% of all respondents said they continued to work in their current job, because they enjoyed caring for others. 97% said that they feel good about what they do.

The above study shows, that in order to ensure staff retention and increase productivity, it is more important to focus on the workplace atmosphere instead of just financial means. According to several recent studies, in order to enhance the performance and morale of nursing staff it is important to maximize organizational justice as well. Organizational justice refers to the extent to which employees perceive workplace procedures, interactions and outcomes to be fair in nature. Staff who reported a feeling of high organizational justice also reported higher organizational identification and organizational trust, leading to increased motivation, substantial improvements and boosting morale in general. Organizational commitment was also explained by supervisor trust, laws, codes and benevolence. Another important factor on organizational effectiveness of trust is an environment which enhances perceptions of empowerment. However, organizational justice and a perception of empowerment are not the only environmental factors that influence staff morale – according to The Joint Commission (2008), about 50% of nurses have suffered from bullying and incivility in their workplace and approximately 90% have witnessed abusive behavior in health care settings. This sort of behavior creates a toxic environment and results in nursing staff escaping incivility by leaving their jobs or moving to another clinical unit. Edmondson and Allard reported that 37% of nurses leave their jobs because of incivility in the workplace. Whenever incivility in the workplace is tolerated, nurses are also more likely to leave. Without a doubt, bullying and incivility is completely unacceptable, but many institutions seem to turn a blind eye at this problem. This perpetuates not only low staff morale, but also poor retention rates and staff turnover.

Nurse-clinician relationship also has considerable impact for staff morale – intimidating, confrontational, inappropriate or disruptive behavior among physicians greatly influences not only nursing staff morale itself, but also nurse retention and even patient safety. In perspective, the majority of nursing staff enjoy the work they do on a personal level. They enjoy caring for others and find meaning in the work that they do. However, the biggest problems appear when it comes to the collective level, especially relationships with their co-workers and supervisors. As supervisors and physicians are in positions of leadership when it comes to nurses and assistants, this brings us to the conclusion that poor leadership and poor inter-personal relationships have a very large impact on nursing staff, and especially on their morale. This problem cannot be solved by financial solutions alone – there needs to be a complete change in the models of leadership used in contemporary nursing settings.

When it comes to the concept of leadership, often conversations about leadership focus on project management or strategic decision making. However, the role of the leader is even more challenging than before. A leader in the nursing sector has to manage positive care outcomes, satisfaction and retention rates and meet financial targets. The contemporary leader has to excel not only in organizational management, but also in developing a culture and work environment that helps develop professional models of care. However, a key role of a leader is not only juggling responsibilities, but also getting the most out of the team. Low satisfaction among nursing staff is a sign that supervisors and other personnel that are in leadership positions need to change their leadership model. There must be a shared vision between leaders and followers in what exactly they are trying to accomplish. They should also understand common problems, pressures and challenges. It has been stated in an article published in 2008 that strong clinical leadership can have a great impact to staff morale, and, as a result, have a positive effect on even the most basic outcomes such as fewer drug errors.

There are many modern leadership models that could be used in order to improve staff morale and the overall quality of inter-personal relationships in the workplace. Some of the more common ones that are used in nursing are the visionary leadership style and transformational leadership style. The first article on transformational leadership in nursing was published more than two decades ago, and soon professionals understood how valuable this form of leadership can be in nursing. It quickly became obvious that it is more preferable in a nursing setting due to its ability to inspire others. It is especially successful in boosting nursing staff morale, as it is based on trust and respect. Therefore, a successful leader that uses transformational leadership will achieve great employee motivation. Davidhizar argued that transformational leadership is a modern leadership style, emphasizing charisma as an important feature. Communication and positive attitudes help maintain a healthy work environment for all employees. However, with the nursing environment changing rapidly, transformational leadership might already be outdated in some cases.

In coaching leadership, the main focus is the development of people. In essence, coaching and leadership could be called two sides of the same coin – both are based on a relationship between people. Coaches inspire others by letting hope flourish and succeed, whereas transformational leaders inspire by reminding of the purpose of a goal or organization. Also, coaches are genuine and authentic, whereas transformational leaders act like role models. Although coaching has been covered in a vast amount of literature, little of it addresses coaching as a leadership model, and its outcomes. Despite the lack of literature, coaching leadership style has been included in several important leadership theories. The coaching leadership style model is based on four main questions which are (in no particular order): “what is the goal?”, “what is the situation today?”, “what are the barriers?” and “how can I realize these goals?”. Coaching leadership style is best suited in situations when managers want to help employees build their personal strengths. Coaching the leaders themselves can also bring positive results – leaders who had received coaching were more likely to be relationship oriented, provided more guidance to their followers and had a higher degree of personal development. They demonstrated better relationships with the people they coached.

One of the models of leadership models that could be considered effective in a nursing setting is the servant leader approach. This model focuses not just on leaders, but also on meeting the needs of the followers. Followers are not treated as just a means to an end, but are valued and treated with respect by their leaders. Thus in the servant leadership model the leader is a servant himself, who is fulfilling a desire to serve others and puts others first. As healthcare is an environment which is centered around care and concern for others, these values should not only apply to the patients or residents, but also to the staff. Livesley has stated that if the care of staff is put below the constraints of the service, morale falls. This leads to decreased quality of output, which then leads to loss of trained staff. Many successful hospitals, also called “magnet” hospitals, are not large hospitals that attract staff using prestige. Rather they are hospitals with good retention rate, adequate staffing, supportive management, and are able to attract well qualified nurses through flexible schedules, emphasis on education, and career advancement opportunities. Putting back “caring” into “care”, letting others develop and expressing humanity in an often impersonal environment are some of the positive outcomes of servant leadership that may help less successful hospitals perform better. However, not all staff could agree to this approach, especially if they prefer a more hierarchical system.

There are many leadership styles for a reason – one style is not suitable for all situations, teams and institutions. This is why every institution must choose the model that would be best appropriate to them in order to maximize the strengths of the employees. However, it is important to understand the concept of a care environment, which is based on compassion and empathy. This should also be reflected in the leadership model of the institution as poor leadership will continue to harm the morale of the staff. Whichever model of leadership an institution chooses to implement, a change in the culture of nursing has to be made. Especially with our aging population, the demand for nursing staff will only increase and a quickly evolving medical system will require even more skilled and reliable employees. Modern leadership is more than hierarchy, so leadership models used in nursing also have to evolve along with the profession in order to unlock the potential of each employee. The decision making process has to be more team-based and participatory, and the problems faced by nursing staff cannot be ignored. Although the problems in the nursing sector are often swept under the rug, the industry cannot afford staff shortage, absenteeism, or general indifference. The very basis of nursing doesn’t stop just at care for the patients.