Staffing Shortages in Nursing Are a Consequence

Staffing shortages in nursing are a consequence of poor nurse retention and nurse satisfaction. Being a nurse requires a lot of dedication, patience, and ability to keep updated in a constantly evolving world. When hospitals and other medical facilities have staffing shortages or shortages in qualified nurses, the healthcare delivery of that particular place dwindles. Nurses are the backbone of any healthcare facility.

Especially in recent times, nurses provide prescriptions, treatment protocols, and diagnosis when doctors are away or busy. This literature review is meant to explain such a phenomena and how it relates directly to nurse satisfaction and nursing retention. From here, the connection crosses over to nursing care and healthcare delivery as standards of practice. Things like arrhythmias will be viewed to understand how nursing shortages attribute to lower quality of care. Utilizing Polk's theory of Resilience, this review will allow a look into performance improvement concerns and practice through a particular lens.

Nursing Shortages and its Repercussions on Patient Care

In an article analyzing the turnout rate of oncology nurses, the study believed nurses within the oncology department of a chosen hospital expressed job dissatisfaction due to stress and burnout. "…it appears that oncology RNs who worked in substandard staffing units often express job dissatisfaction, stress and burnout, which prompt them to seek new employment out of the oncology specialty" (Toh, Ang & Devi, 2012, p. 126). Nursing is a demanding field that requires constant attention to detail and no mistakes. With nurses taking on the role of doctors and caregivers, it may sometimes be too much for a person to handle. Organizations hiring nurses for patient care must understand the toll being a nurse entails. They have to develop better retention strategies to keep quality nurses from leaving.

Recruitment also plays a vital role. "This entails a pressing need for organisations to ensure sufficient staffing in oncology/haematology settings, in order to ensure that quality patient care is provided" (Toh, Ang & Devi, 2012, p. 126). Quality nurses must be found on a regular basis to ensure hospitals retain an adequate number of staff to avoid placing too much burden on any single nurse. The stress that the nurses in the study experienced came directly from a large workload and overextending themselves in their job duties. Departments like oncology demand extra from nurses in that most of the patients assigned to the oncology department are chronically ill and/or terminal. These things must be taken into consideration when applying strategies to improve nurse retention.

Chronic illness is a big issue for nursing. Nurses must deal on a daily basis with chronically ill patients. Chronically ill patients make up a large portion of nursing care and make the role of nursing that much more vital for quality health care as doctors are often too busy to handle individual cases consistently, letting nurses take over with prescription refills, referrals and so outpatient care protocols. Another study dealing with palliative care clinics, speaks of the negative consequences of staffing shortage with some practices having staffing shortages that resulted in longer wait times for new patient appointments and 24/7 care. "Eleven practices noted a staffing shortage and 8 had a wait time of a week or more for a new patient appointment. Only 12 practices provide 24/7 coverage" (Smith et al., 2013, p. 661).

When patients must wait for care especially in the palliative care clinic setting, this means the quality of patient care suffers. A staffing shortage in this scenario greatly affects how patients perceive and receive healthcare. This study provides data on active clinics and the negative effects of a nurse shortage. Funding is often another reason why staffing shortages in healthcare facilities exist. Besides nurse dissatisfaction rates, funding also adds to the nursing shortage epidemic. "Most practices described starting because inpatient palliative providers perceived poor quality outpatient care in the outpatient setting. The most common challenges included: funding for staffing and being overwhelmed with referrals" (Smith et al., 2013, p. 661).

Attempts at Reducing Need for Nurses

Solutions for Nurse Shortages

In a study performed this year, researchers attempted to see if nurse aides could provide the same quality care as nurses. The results were mixed.

The 76% RNs group made fewer medication errors than the 100% RNs group; the 76% and 92% RNs groups had a higher rate of urinary tract infections; the 92% RNs group had a lower rate of bloodstream infections; the 76% RNs group had a lower rate of ventilator weaning; and the 76% and 92% RNs groups incurred higher nursing costs."

Although nurse aids contributed to the accuracy of test results and essentially similar rates of infection as RNs, the cost was not lessened, making the introduction of nurse aides ineffective. The main problem of nursing shortages revolves around lack of job satisfaction brought on by heavy caseloads. Researchers attribute heavy caseloads to staffing shortages that are caused by lack of funding. If nurse aids do not provide a decrease in expenses then they are not useful in decreasing staffing shortages.

In order for hospitals to avoid such a risk, hospitals and other healthcare facilities must train and employ their own nurse aides and nurses revolving around education materials and adequate training to avoid the expense seen in the study. "Use of different nursing staffing models that substitute nurse aides for RNs may negatively affect patient safety and quality of care and increase nursing costs." (Yang, Hung & Chen, 2015, p. 1). Proper training avoids additional expenses because less mistakes are made. Furthermore, nurses and nurse aides learn to use less materials when they know which standards of practice are effective for each case.

Everything in the healthcare world revolves around effective use of resources. Quality care from the patient perspective means fast wait times, fast referrals, and minimum healthcare expense. With proper training nurses and nurse-aids may be able to diagnose, treat, and help patients in a faster time allowing for more patients per day and higher profits. However if medical staff are not properly trained, this may result in misuse of resources by adding unnecessary exams and tests, and mishandling of patient records and issues, resulting in more appointments and wasted time assessing and interacting with patients. Everything must be examined when looking at the nursing shortage dilemma.

In a prospective observational study, Wise et al., compared mortality and length of stay or (LOS) of medical ICU patients. Either hospitalists or intensivists led the teams caring for them. The results showed intensivist-led teams produced better results showing that nurses in these areas are most needed when it came to mortality and LOS. "Mechanically ventilated patients with intermediate illness severity showed improved LOS and a trend towards improved mortality when cared for by an intensivist-led ICU teaching team."(Wise et al., 2011, p. 183). Although nurse shortages run through several areas within nursing, the hardest hit and the most needed are in critical areas like palliative care, ICU, and oncology. These areas require the most from nurses in order to provide high quality patient care.

The results from a quantitative study demonstrated a strong correlation between nursing group outcomes and job satisfaction. "Moderately strong and strong significant correlations (P < 0.003) were found between job satisfaction and nursing group outcome attainment capability (intrinsic satisfaction r = 0.800; extrinsic satisfaction r = 0.650; total satisfaction r = 0.770)" (GIANFERMI & BUCHHOLZ, 2011, p. 1012). As earlier mentioned, nurses in the previously detailed studies expressed dissatisfaction from handling referrals and heavy caseloads. Nursing administrators play a part in how much work and training a nurse receives or handles throughout any given day. If in order to improve job satisfaction, some of the workload must be lessened, the nurse administrator must then strategize to develop ways for nurses to handle less referrals and focus more on patient care.

The study continues to explain that fulfilling goals can also provide relief and higher rates of job satisfaction for nurses and nurse administrators. "To increase job satisfaction, it is important that nurse administrators have the power to achieve their professional goals" (GIANFERMI & BUCHHOLZ, 2011, p. 1012). When nurses and nurse administrators attain their daily or weekly goals, this may improve morale and motivation. Therefore, assigning goals that are not too hard to achieve, but also challenge the nurse or nurse administrator may be applicable. Job satisfaction comes from a complex set of actions and reactions. Studies like these help to shed light on what hospitals and other medical facilities may use in order to improve job satisfaction and improve nurse retention rates.

There are other ways to optimize job responsibilities and improve or alleviate nurse shortage. Cross-training is one such model explored by researchers to see if it is effective for nurse workforce planning. In the end, operating at minimum cost while not sacrificing quality of care remains the favorable outcome for any tested model. Cross-training offers benefits such as reduction in costs as well as maintenance of quality care standards.

We demonstrate the benefits of cross-training in terms of a reduction in the total number of nurses required to satisfy demand across multiple departments as well as from an economic (i.e. overall cost savings) perspective, while simultaneously meeting the hospitals service and quality of care requirements. In particular, the results indicate that cross-training strategies could help with optimal utilization of constrained nursing resources and thereby limit the negative implications of the growing nurse shortage crisis (Paul & MacDonald, 2014, p. 83).

Cross-training works by correctly utilizing nursing resources through efficient allocation. With less work for nurses and more resources allocated to staffing and training, cross-training may be an effective solution for nursing shortages in both the long-term and the short-term. These among other avenues worthwhile to explore will help to preserve the quality of care patients need as well as proper execution of practice standards. These practice standards in high mortality areas like heart-related conditions, will be examined briefly in the next section.

"Paroxysmal supraventricular tachycardia (SVT) is a common dysrhythmia treated in the prehospital setting" (Minhas et al., 2015, p. 1).

Asystole

Asystole means when a patient flatlines or the heart stops. It is a state of no cardiac electrical activity. Therefore, no cardiac blood flow or output remains present or contractions of the myocardium. Typically, asystole happens in those with coronary artery disease, presenting in 60% of asystole cases. Standard practices for asystole or cardiac arrest in the last five years state a need for integral management, speed, and quality of care. "…when a malign arrhythmia that leads to cardiac arrest presents itself, the outcomes are directly related to the speed and quality with which cardiopulmonary resuscitation maneuvers are put into effect, and to the integral management of the clinical condition that is post-cardiac arrest syndrome" (Ricardo-Navarro Vargas, Matiz-Camacho & Osorio-Esquivel, 2015, p. 9).

The standard of care within the last five years to treat asystole in patients revolves around achieving consistency in reporting, definitions, care structure, as well as care process. This is because heart disease and cardiac arrest lend to a high-acuity, highly complex, and high-stress care situation and clinical event that relies heavily on the formation of reliable systems to achieve favorable outcomes for high-risk patients such as these. The main objectives of post-cardiac arrest care comprise of optimizing vital organ perfusion and cardiopulmonary function, transportation of patient to a suitable hospital in addition to a wide-ranging asystole treatment system of care that includes neurological care, acute coronary interventions, hypothermia, and goal-directed critical care. Attempting to diagnose and treat precipitating causes of the event and prevention of any recurrent cardiac arrests is another of the main objectives that nurses are often the most responsible for, when it comes to patient care.

Unlike before, the main difference in practice within the last five years involves prevention and focus on comprehensive care. Prior standards of practice did not feature or highlight the importance of periodic assessment and lifestyle change. Most often than not, patients were given a list of instructions to follow. However, the focus was not on developing healthy habits to prevent another cardiac event, but rather treating the acute problem. Outpatient care was not really allotted. Now nurses step in to not only give a lifestyle protocol for patients, but to also monitor their vitals periodically in the days, months, and even years after the cardiac arrest helping to increase successful prevention of cardiac arrests.

Supraventricular Tachycardia

Another heart condition, supraventricular tachycardia, occurs in as many as 200,000 to 3,000,000 cases per year. The condition signifies a faster than normal heart rate starting above the heart's two lower chambers. People suffering from this condition may have pain in their chest, feelings of lightheadedness, fatigue, or fainting. Standard treatment involves medications like Cardizem (channel blocker) by mouth or injections like Nexterone. Some patients may need a cardioversion or an electric shock to the heart, even ablation to slow down the heart.

Recent practices involves the T + R protocol which was assessed a study by Minhas et al. In the study, researchers found that by applying the protocol, a "significant proportion of patients presenting to EMS with SVT. Risk of re-presentation following T + R was low, and paramedic protocol adherence was reasonable. T + R appears to be a viable option for uncomplicated SVT in the prehospital setting" (Minhas et al., 2015, p. 1). T + R frequently involves periodic assessment of a patient's condition after the cardiac event followed by medication and patient education. Getting an adequate patient history helps in understanding the circumstances which may have resulted in a patient developing SVT.

Nurses become essential in these protocols because they are the ones that often carry out patient education and follow up appointments. Without their intervention, patients would not get the critical attention they need to understand their condition and what to do to prevent it from reoccurring. Patients often do not have the knowledge to handle conditions like this without being acquainted with terminology and possible risks brought on by lifestyle choices. Although doctors are a vital aspect of healthcare, they more commonly then not, do not have the time to spend with a patient. Therefore, nurses assume the primary role are healthcare practitioner.

A nurse shortage within this area of healthcare is detrimental as so many cases of SVT are reported in the United States alone, each year. Job satisfaction and effective training and resource allocation becomes extremely important in properly understanding and assessing patient needs. Nurses deal primarily with heart disease and other heart related problems. Awareness of this need will propel people to implement effective strategies to improve nurse retention rates.

Atrial Fibrillation: Stable vs. Unstable

Nurses play a vital role in other aspects of heart disease such as patient stability when it comes to atrial fibrillation. Atrial fibrillation or AF is an abnormal heart rhythm categorized by irregular and rapid beating. At first patients experiencing AF have brief periods of abnormal beating. After a certain amount of time, the irregular beating may become constant although most episodes usually do not show symptoms. When patients have AF, their risk of dementia, stroke, and heart failure increase.

In a study by Bosch et al., researchers examined stable vs. unstable patients.

The rate of stable patients was 43.4%. In the multivariate model male gender, history of stroke, and permanent (vs. persistent) AF were associated with stable disease. Conversely, the factors chronic heart failure, impaired left ventricular function, rhythm-control (vs. other), OAC and antiplatelet therapy were significantly correlated with unstable disease (Bosch et al., 2013, p. 750).

The results showed certain criteria enabled stable disease such as history of stroke. Antiplatelet therapy correlated with unstable disease.

Lifestyle change alone with treatments such as antiplatelet therapy create positive outcomes for those that suffer from AF leading to a decreased occurrence of dementia and other related illnesses. Nurses are most often responsible for patient education. That means they are the ones typically responsible for improvement of a patient's condition in the long-term as they are the ones that spend the most time with a patient, assess their vitals, and administer intravenous therapies that assist in recuperation.

Polk's Theory of Resilience and BSN Student Achievement

Polk (1997) synthesized four patterns of resilience derived from individual resilience literature and they are:

Dispositional Pattern or the dispositional pattern- how it relates to ego-related and physical psychosocial characteristics that encourage or stimulate resilience. These involve those facets of an individual that stimulate a resilient temperament towards life stressors, and may include a sense of independence or self-reliance- a sense of rudimentary self-worth, good physical health as well as good physical appearance.

Relational Pattern concerns an individual's parts in society including his/her relationships/associations with others. These relationships and roles can range from close and friendly relationships to those containing the wider societal system.

Situational Pattern addresses those features involving a joining between an individual and a demanding situation. This may include an individual's dilemma solving aptitude, the capability to assess situations and responses, along with the ability to take action in reaction to a situation (Polk, 1997).

Philosophical Pattern denotes to an individual's life paradigm or worldview. This might include numerous beliefs that encourage resilience, such as the confidence that an individual can find positive meaning in all experiences, the belief that self-development is significant, the belief that life is decisive.

When applying this to BSN student achievement, students can then apply their learned resilience to the workloads and expenses of school. Much like nurses have to gain resilience to deal with the difficult demands of their job, students must gain resilience to cope with the stresses of school life. Student loans, hard assignments, team work, all these things contribute to student life and student achievement.

For any student to succeed and earn their degrees in university, they must do well in their classes. Getting good grades often involves dedication. Students at times procrastinate and fail to do their assignments on time. This may result in failure. However, if students learn to be independent and address problems and situations as they arise, they will succeed.

It is often hard to understand how to improve one's self and continue improving as this is an important fundamental to Polk's theory of resilience. Constant improvement means individuals will possess the skills and capacity needed to take on challenges. If this lens is then applied to nurses, and nurse administrators, training and assessment can then be seen as a step toward continual improvement. Aspects like independence and individual assessment become integral to a resilience model for nursing.

Without resilience, nurses will not stay in their jobs. If they stay in their jobs due to a hard economy, they may not have the motivation or energy to perform adequately their job functions. When nurses underperform, the error rate rises along with a lowering of the quality of patient care. Patients need nurses performing to their best of their ability every time.

Resilience then becomes key in developing such a level of quality care. Any strategies aimed at enabling higher retention rates should allow resilience to be a key way to improve performance. Teaching how to increase resilience will improve any situation from student life to nursing. It promotes that ability to understand things in global perspective. It promotes growth and reasoning skills and increases a person's ability to handle stress and grow independent and knowledgeable.

Resilience in Nursing

Resilience, job satisfaction and staffing shortage are all connected. Although funding, a topic covered briefly earlier, plays a part in the nursing shortage, resilience, especially in today's tough economy plays an even greater role. Hudgins explains in an article discussing resilience in nursing, how the connection between anticipated turnover and resilience are a close and fundamental one. "There are significant relationships between resilience, job satisfaction and anticipated turnover. Additionally, it was found that the variables of job satisfaction and anticipated turnover significantly overlapped in their meaning and created a new construct of intent to remain (ITR) that has a statistically significant relationship with resilience" (Hudgins, 2015, p. 1). If nurses and nurse administrators are to handle their job duties and perform to the best of their abilities, they must incorporate methods that increase resilience. Organizational theories that promote creativity and autonomy in nurses may help improve resilience as nurses become more and more confident in their own abilities and thus gain independence. Additional training may help as well.