quantitative research nursing shortage

NCSBN Research Projects Significant Nursing Workforce Shortages and Crisis

CHICAGO – Today, NCSBN unveiled its research, titled “Examining the Impact of the COVID-19 Pandemic on Burnout & Stress Among U.S. Nurses,” in a panel titled “Nursing at the Crossroads: A Call to Action” in Washington, D.C. at the National Press Club at 9:30 am EST.

For the first time, the research findings reveal how the nursing workforce was impacted by the pandemic and how many left the workforce in this period, and forecast how many nurses in the U.S. have an intent to leave the workforce. The research also examined the personal and professional characteristics of nurses experiencing heightened workplace burnout and stress due to the COVID-19 pandemic.

The study is considered to be the most comprehensive and only research in existence, uncovering the alarming data points which have far reaching implications for the health care system at large and for patient populations. The research was gathered as part of a biennial nursing workforce study conducted by NCSBN and the National Forum of State Nursing Workforce Centers.

Key findings include:

• Approximately 100,000 registered nurses (RNs) left the workforce during the COVID-19 pandemic in the past two years due to stress, burnout and retirements.
• Another 610,388 RNs reported an “intent to leave” the workforce by 2027 due to stress, burnout and retirement.
• 188,962 additional RNs younger than 40 years old reported similar intentions.
• Altogether, about one-fifth of RNs nationally are projected to leave the health care workforce.
• 62% of the sample reported an increase in their workload during the pandemic.
• A quarter to half of nurses reported feeling emotionally drained (50.8%), used up (56.4%), fatigued (49.7%), burned out (45.1%), or at the end of the rope (29.4%) “a few times a week” or “every day.”
• These issues were most pronounced with nurses with 10 or fewer years of experience, driving an overall 3.3% decline in the U.S. nursing workforce in the past two years.
• Licensed practical/vocational nurses, who generally work in long-term care settings caring for the most vulnerable populations, have seen their ranks decline by 33,811 since the beginning of the pandemic. This trend continues.

Research also suggested that nurses’ workloads and unprecedented levels of burnout during the COVID-19 pandemic played key roles in accelerating these workforce trends and threatening the future of the U.S. nursing workforce, particularly for younger, less experienced RNs. Further, high levels of turnover were seen with the potential for even further declines in a post-pandemic nursing workplace as disruptions in prelicensure nursing programs have also raised concerns about the supply and clinical preparedness of new nurse graduates. Early career data for new entrants into the profession suggest decreased practice and assessment proficiency. Coupled with large declines among nursing support staff, NCSBN calls for significant action to foster a more resilient and safe U.S. nursing workforce moving forward.

“The data is clear: the future of nursing and of the U.S. health care ecosystem is at an urgent crossroads,” said Maryann Alexander, PhD, RN, FAAN, NCSBN Chief Officer of Nursing Regulation. “The pandemic has stressed nurses to leave the workforce and has expedited an intent to leave in the near future, which will become a greater crisis and threaten patient populations if solutions are not enacted immediately. There is an urgent opportunity today for health care systems, policymakers, regulators and academic leaders to coalesce and enact solutions that will spur positive systemic evolution to address these challenges and maximize patient protection in care into the future.”

The research findings and proposed solutions were presented in a panel discussion today at the National Press Club in Washington, D.C.

Panelists included:

• Antonia Villarruel, Dean of Nursing at University of Pennsylvania
• Gay Landstrom, Senior Vice President and Chief Nursing Officer at Trinity Health System
• Congresswoman Lisa Blunt Rochester, U.S. Representative of Delaware
• Robyn Begley, CEO of the American Organization for Nursing Leadership and CNO/Sr. VP for the American Hospital Association
• Rayna M. Letourneau, Board of Directors, National Forum for State Workforce Centers

A recording of the panel discussion is available on ncsbn.org .

To request interviews with NCSBN or view the entire research, please contact [email protected] or visit ncsbn.org .

Research Methodology: The study examines a subset of the 2022 National Nursing Workforce Study for analysis. Reported trends represent population-based estimates. There were 29,472 registered nurses (including advanced registered nurses [APRN]) and 24,061 licensed practical nurses/vocational nurses across 45 states included.

About NCSBN Empowering and supporting nursing regulators across the world in their mandate to protect the public, NCSBN is an independent, not-for-profit organization. As a global leader in regulatory excellence, NCSBN champions regulatory solutions to borderless health care delivery, agile regulatory systems and nurses practicing to the full scope of their education, experience and expertise. A world leader in test development and administration, NCSBN’s NCLEX® Exams are internationally recognized as the preeminent nursing examinations.

NCSBN’s membership is comprised of the nursing regulatory bodies (NRBs) in the 50 states, the District of Columbia and four U.S. territories. There are five exam user members and 25 associate members that are either NRBs or empowered regulatory authorities from other countries or territories.

The statements and opinions expressed are those of NCSBN and not individual members.

What’s Really Behind the Nursing Shortage? 1,500 Nurses Share Their Stories

• Survey Results
• What Is the Nursing Shortage?
• Reasons Nurses Quit
• Hope For the Future
• What Nurses Need Now
• How to Take Action

Winner of the Gold Award for the Digital Health Awards, Best Media/Publications Article, Spring 2022

Update 10/10/2022

The findings of  Nurse.org's 2021 State of Nursing Survey revealed some harsh truths about the profession but also spoke to the strength, perseverance, and passion that nurses have for their work. Nurse.org has relaunched the State of Nursing survey in 2022 with the aim to capture a complete picture of the true state of the profession - from how nurses feel about work, how nurses are being treated, how nurses feel about the future of nursing, nurse's mental wellbeing and what nurses think needs to change within the profession. Take the survey now (it takes less than 10 minutes.)

>> Take Nurse.org's NEW 2022 "State of Nursing Survey" and let your voice be heard about issues in nursing that matter most. 

January 26, 2022

If the past two years have taught the world anything, it's that nurses are NOT okay. The truth is that despite the 7 pm cheers, the commercials thanking nurses for their dedication and selflessness, and the free food from major retailers – the overwhelming majority of nurses are burnt out, underpaid, overworked, and underappreciated.  

With millions of nurses worldwide, Nurse.org wanted to truly understand the current state of nursing and give nurses a voice to share their thoughts, feelings, and apprehensions about the nursing profession. We surveyed nearly 1,500 nurses to find out how they felt about the past year and get to the real reasons behind the nursing shortage . The responses were heartbreaking, but not without hope.  

Nurse.org teamed up with nurse-centric companies to give away 100s of prizes during the month of May. Subscribe to our newsletter to learn more!

What We Found: Nurses Are Struggling

Nurses are struggling. Regardless of practice specialty, age, or state of practice – the answers were all the same. Nurses, NPs, and APRNs are all struggling and need help.  

Only 12% of the nurses surveyed are happy where they are and interestingly, 36% would like to stay in their current positions but changes would need to be made for that to happen. Nurses report wanting safe staffing, safer patient ratio assignments, and increased pay in order to stay in their current roles.  

Nurses didn’t hold back when discussing their feelings regarding the current state of nursing:  

• 87% feel burnt out 
• 84% are frustrated with administrators 
• 84% feel they are underpaid 
• 83% feel their mental health has suffered 
• 77% feel unsupported at work 
• 61% feel unappreciated 
• 60% have felt uncomfortable having to work outside of their comfort zone in the past year 
• 58% of nurses have felt frustrated with their patients 
• 58% of nurses have felt unsafe at work in the past year 

The numbers don’t lie. It’s astounding that a profession continually recognized for its compassion, strength, and resilience is suffering . And the suffering is universal.  

One nurse responded with the following, “I have been an RN for 34 years and in my specialty of nursing for 31 years and I am burned out.” 

What Is the Nursing Shortage and Why is it Happening?

You’ve likely heard about the nursing shortage, but what does that mean and why is it happening? 

According to the U.S. Bureau of Labor Statistics (BLS) , the employment of registered nurses is projected to grow 9% from 2020 to 2030.  Approximately 194,500 openings for registered nurses are projected each year, on average, over the decade. However, this number was projected prior to the pandemic, and before the mass exodus of bedside clinical nurses. As a result, it’s likely substantially lower than what the real demand for nurses will look like.

The American Nurses Association (ANA) reports that the increased need for nurses spans beyond the current pandemic. In fact, they sent a letter to the U.S. Department of Health and Human Services (HHS) on September 1, 2021, urging the country to declare the current and unsustainable nurse staffing shortage to be a national crisis. 

The ANA attributes the needs for thousands of nurses to the following:  

• The Affordable Care Act made access to health care services possible for more people
• Increased focus “primary care, prevention, wellness, and chronic disease management” 
• Aging baby-boomer population
• Growing interest in community-based care

Why Are Nurses Really Leaving The Bedside? 

However, those stats don’t address some of the systemic issues nurses face every day, particularly in the midst of a pandemic. That’s why we asked nurses why they are really leaving the bedside.

What we heard is that, overwhelmingly, the number one reason nurses want to leave the bedside is because of unsafe staffing ratios. This leads to a never-ending cycle of shortages: nurses face unsafe staffing ratios so they decide to leave the bedside, this results in even fewer nurses available to care for patients, so the downward cycle continues.

Essentially, nurses are dealing with an increased workload with fewer resources. Typically, pre-covid ICU nurses would experience a 1:1 or 2:1 patient-to-nurse ratio. Now ICU nurses throughout the country are experiencing a 3:1 or 4:1 patient-to-nurse ratio which exacerbates staff burnout and unsafe nursing practices.  

One nurse reported, “With increased patient census, staffing ratios are very unsafe especially with high acuity patients. Having 4+ critically ill patients not only puts licenses at risk but the patients do not benefit at all. We’re just running around doing tasks, not providing adequate care.”

Unsafe Staffing Ratios Are Just Part of the Problem

While a big piece of the puzzle, unsafe staffing issues are, unfortunately, one part of a long list of issues plaguing nurses today. 

 Nurses are leaving the bedside because of issues like: 

• Inadequate staffing ratios 
• Not getting equal pay for equal experience 
• Not receiving hazard pay during a pandemic 
• Not having adequate back up 
• An inability to take breaks, sick days, or even turn down extra shifts 

To learn more about the nursing shortage and learn ways you can get involved, check out the full report here . 

Despite All This, Nurses Still Have Hope

70% of nurses still think that nursing is a great career and 64% still think that new nurses should join the profession. 

“If you’re a student considering becoming a nurse, please know that you are not walking into a doomed profession. You will never meet anyone who is more determined, more resourceful, or more ready to jump in and lend a helping hand than a nurse." 

--– Nurse Alice Benjamin, MSN, APRN, ACNS-BC, FNP-C, CCRN, CEN, CV-BC, Chief Nursing Officer and Correspondent at Nurse.org

If you’re a nurse, you know that nursing isn’t just a profession, it’s a calling. It’s devastating to see that so many nurses are suffering in their quest to heal and give care, but it’s heartening to know they are not without hope. 

What Nurses Need Now 

If you’re a nurse, know that your job is simply to put yourself first. If we want to solve the nursing shortage (and we do!), it can't happen without nurses recognizing that they are NOT the problem. 

"The problem is not with nurses or nursing; the problem is that nurses have been so busy taking care of others that no one has taken care of them. And we’re here to change that--and by entering the nursing profession, you will be part of the solution too”

 – Nurse Alice Benjamin, MSN, APRN, ACNS-BC, FNP-C, CCRN, CEN, CV-BC, Chief Nursing Officer and Correspondent at Nurse.org 

The truth is nurses need a lot more to be incentivized to stay practicing clinically at the bedside. Nurses reported needing:  

• Higher pay 
• Safe nurse-to-patient ratios 
• Hazard pay 
• REAL mental health resources 
• Adequate staff support 
• Support programs for new nurses

4 Ways to Support Nurses and Take Action

While we may not be able to make this change at an individual level, collectively, we can amplify the voice of nurses and shed some light on the issues that they are facing every day. Together, we have the power to create meaningful, lasting change for current and future nurses.  Here's how to get involved: 

1. Sign the Pledge

Sign the pledge seen below and encourage your friends & colleagues to do the same. While you’re at it, print it out and post it in your break room. 

2. Spread the Word 

Change can’t happen unless we get the word out about what’s really going on. Share what you’ve heard and what you’ve experienced, and encourage others to do the same. 

3. Contact Your Elected Officials 

It’s time for elected officials to stand up for nurses. Write them a letter. Call their office. Demand change for nurses. Click here to get the contact information for your local and state Officials. 

4. Download and Share the Report

Get even more in-depth insights into what’s going on with the state of nursing and the issues that nurses face today, click here to download the full State of Nursing report or read about the best and worst specialties for nurses during COVID . 

“If you are a current nurse considering leaving the profession, be assured that you are not alone in your struggles. If all you’ve had the energy for is keeping your head down and getting through your shifts, sleeping, and getting up to do it all over again, know that you are doing enough. It’s not your responsibility to solve the nursing shortage.” 

– Nurse Alice Benjamin, MSN, APRN, ACNS-BC, FNP-C, CCRN, CEN, CV-BC, Chief Nursing Officer and Correspondent at Nurse.org 

Find Nursing Programs

Kathleen Gaines (nee Colduvell) is a nationally published writer turned Pediatric ICU nurse from Philadelphia with over 13 years of ICU experience. She has an extensive ICU background having formerly worked in the CICU and NICU at several major hospitals in the Philadelphia region. After earning her MSN in Education from Loyola University of New Orleans, she currently also teaches for several prominent Universities making sure the next generation is ready for the bedside. As a certified breastfeeding counselor and trauma certified nurse, she is always ready for the next nursing challenge.

Plus, get exclusive access to discounts for nurses, stay informed on the latest nurse news, and learn how to take the next steps in your career.

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• Introduction
• Conclusions
• Article Information

A, Total direct care staffing hours each week (registered nurses [RNs], licensed practical nurses [LPNs], and certified nursing assistants [CNAs]) at participant facilities and compared with national trends. B, Hours per resident-day for total direct care staff (RNs, LPNs, and CNAs) at participant facilities and compared with national trends.

A, Use of an agency for direct care staff including registered nurses (RNs) (A), licensed practical nurses (LPNs) (B), and certified nursing assistants (CNAs) (C).

eMethods. Interview Guides 1 and 4

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Brazier JF , Geng F , Meehan A, et al. Examination of Staffing Shortages at US Nursing Homes During the COVID-19 Pandemic. JAMA Netw Open. 2023;6(7):e2325993. doi:10.1001/jamanetworkopen.2023.25993

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Examination of Staffing Shortages at US Nursing Homes During the COVID-19 Pandemic

• 1 Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
• 2 Student, PhD Program in Health Policy, Harvard University, Cambridge Massachusetts
• 3 Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
• 4 Division of Geriatrics and Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York

Question   Do nursing home administrator perspectives on staffing in US nursing homes during the COVID-19 pandemic provide context for conflicting staffing data reports?

Findings   In this study, qualitative and quantitative data from 40 US nursing homes were integrated to assess staffing levels during the pandemic. Short-term compensatory strategies were used by administrators to comply with minimum staffing regulations and offset staffing shortages.

Meaning   Findings from this study suggest that staffing shortages during the COVID-19 pandemic placed strain on nursing homes.

Importance   Staffing shortages have been widely reported in US nursing homes during the COVID-19 pandemic, but traditional quantitative research analyses have found mixed evidence of staffing shortfalls.

Objective   To examine whether nursing home administrator perspectives can provide context for conflicting aggregate staffing reports in US nursing homes during the COVID-19 pandemic.

Design, Setting, and Participants   In a qualitative study, convergent mixed-methods analysis integrating qualitative and quantitative data sets was used. Semistructured qualitative interviews were conducted between July 14, 2020, and December 16, 2021. Publicly available national Payroll Based Journal data were retrieved from January 1, 2020, to September 30, 2022, on 40 US nursing homes in 8 health care markets that varied by region and nursing home use patterns. Staffing and resident measures were derived from Payroll Based Journal data and compared with national trends for 15 436 US nursing homes. Nursing home administrators were recruited for interviews. Of the 40 administrators who consented to participate, 4 were lost to follow-up.

Exposure   Four repeated, semistructured qualitative interviews with participants were conducted. Interview questions focused on the changes noted during the COVID-19 pandemic in nursing homes.

Main Outcomes and Measures   Thematic description of nursing home administrator compensatory strategies to provide context for quantitative analyses on nursing home staffing levels during the COVID-19 pandemic.

Results   A total of 156 interviews were completed with 40 nursing home administrators. Administrators reported experiencing staff shortages during the COVID-19 pandemic and using compensatory strategies, such as overtime, cross-training, staff-to-resident ratio adjustments, use of agency staff, and curtailing admissions, to maintain operations and comply with minimum staffing regulations. Payroll Based Journal data measures graphed from January 1, 2020, to September 30, 2022, supported administrator reports showing that study facilities had reductions in staff hours, increased use of agency staff, and decreased resident census. Findings were similar to national trends.

Conclusions and Relevance   In this qualitative, convergent mixed-methods study, nursing home administrators reported the major staffing strain they experienced at their facilities and the strategies they used to offset staffing shortages. Their experiences provide context to quantitative analyses on aggregate nursing home census data. The short-term compensatory measures administrators used to comply with regulations and maintain operations may be detrimental to the long-term stability of this workforce.

The COVID-19 pandemic has put tremendous strain on the US nursing home workforce. 1 - 3 Burnout, 4 , 5 low wages, 6 poor work conditions, 7 and the increased burden of caring for vulnerable residents during a health crisis 3 , 8 have contributed to a 13.3% decrease in nursing home sector employment since the start of the pandemic. 9 Nursing homes currently employ 1.37 million workers (roughly 10% below projected demand) 9 and continue to face staff shortages. 10 , 11 Administrators have responded to ongoing staff shortages by increasing staff workloads, 12 , 13 halting or decreasing new admissions, 14 - 16 and offering substantial wage raises 10 , 17 and other incentives to retain staff. 18 Despite these efforts, only 2% of all nursing homes in the US reported being fully staffed in 2022. 19 , 20

Although staff shortages at nursing homes have been widely reported, 12 , 18 , 19 , 21 quantitative studies have found mixed evidence of staffing shortfalls. One study found no decrease in staffing levels during the early part of the pandemic after accounting for a decreased census. 22 The Kaiser Family Foundation reported that nursing home staffing shortages coincided with COVID-19 variant surges, varied widely by state, and peaked in January 2022 at 34%. 11 In contrast, an analysis that used detailed employee-level payroll data found staffing patterns consistent with reports of nursing homes experiencing major staffing challenges during severe COVID-19 outbreaks and for extended periods of time after the outbreak. 23

This study conducted a qualitative assessment of nursing home administrator experiences during the pandemic and integrated qualitative findings with quantitative analysis of national payroll staffing data. The objective was to provide context to conflicting aggregated data on nursing home staffing levels during the COVID-19 pandemic.

This convergent mixed-methods study 24 - 26 used semistructured qualitative interviews with nursing home administrators and merged thematic results with quantitative analyses of publicly available facility-level staffing data. This project followed the Consolidated Criteria for Reporting Qualitative Research ( COREQ ) reporting guideline for qualitative research and was approved by the Brown University Institutional Review Board, which determined it to not be human research. Verbal consent was obtained prior to audiorecording interviews. The nursing home administrators received compensation for participation.

Using the Hospital Referral Region table from the Centers for Medicare & Medicaid Services Geographic Variation Public Use file, 8 health care markets were identified. 27 Markets varied based on US region and nursing home use patterns. Using purposive sampling, 5 nursing homes that varied by 5-star rating, size, payer mix, and profit status were selected in each market. 28 Administrators were recruited by email and telephone to participate in semistructured interviews. Interviews were repeated at 3-month intervals from July 14, 2020, to December 16, 2021, to understand the outcomes associated with COVID-19 in US nursing homes over time.

Interview protocol development and testing consisted of 3 cognitive interviews with the immediate research team and 3 pilot interviews with nursing home administrators, after which final revisions to the interview guide were made. The interview guide included open-ended questions and subsequent probes about COVID-19 at nursing homes and was used as a baseline across all 4 interviews, with modifications to add or discontinue questions as needed. Interview guides for interviews 2 and 3 included follow-up questions specific to the facility’s previous interview. A summary report detailing preliminary findings and emerging themes was sent to participants before their third interview. During the third interview, targeted questions were asked to solicit feedback on the summary report, confirm preliminary findings, and refine emerging themes. The interview guide for interview 4 was further modified to include questions designed to look back on administrator experiences over the 1-year interview time frame (eMethods in Supplement 1 ).

Four qualitative research team members (J.F.B., A.M., R.R.S., and E.A.G.) conducted the interviews. All were women with 5 to 35 years of experience in conducting qualitative research. They included 2 PhD-level faculty members and 2 Master’s-level research staff. The researchers did not know the interview participants before the first interview. The purpose of the research was shared with interview participants during recruitment and at the start of each interview.

Interviews were conducted virtually or by telephone depending on participant preference and lasted approximately 60 minutes. Two qualitative research team members participated in each interview: one conducted the interview while the other took detailed notes to flag questions for follow-up and record emergent themes.

Interviews were recorded, professionally transcribed verbatim, deidentified, and reviewed for accuracy. Transcripts were not shared with participants. Using modified grounded theory, 29 an initial coding scheme was developed based on the interview guide (a priori codes) and on emerging data from interviews (de novo codes). The coding tree was adjusted iteratively, such that codes were added and refined throughout data collection and analysis. Four researchers (J.F.B., A.M., R.R.S., and E.A.G.) double-coded 102 interview transcripts in coding teams of 2. Teams rotated to ensure rigor and prevent drift in code definition understanding. Preliminary emerging themes were identified and noted in an audit trail. Once high coding agreement was reached, 54 transcripts were coded by individual researchers. Coded transcript data were entered into the qualitative software package NVivo, version 12 Plus (QSR International) to facilitate comparative analyses across themes.

Once all interview transcripts were coded, reports were generated that collected all the quotations assigned to the same code and related to an identified preliminary theme. Using the 6 steps devised by Braun and Clarke for thematic analysis, 30 the code reports related to a theme were examined together and reanalyzed to identify quotations that were both supportive of and in contrast to the identified themes and identify additional themes. It was determined that saturation was achieved. 31 During analysis, a comprehensive audit trail 32 was kept to record team decisions, questions and comments, code definitions, and emerging themes.

Daily facility-level staffing data for January 1, 2020, to September 30, 2022, were obtained from the publicly available Centers for Medicare & Medicaid Services Long-term Care Facility Staffing Payroll Based Journal (PBJ) data. 33 All Medicare- or Medicaid-certified nursing homes are required to submit daily staffing data, which includes hours worked by staff type and contract type (ie, agency vs direct employee) and resident census. To construct national averages for comparison, data for the 40 sample nursing homes and all 15 436 nursing homes in the US were obtained.

The PBJ data were used to construct 4 measures between January 2020 and September 2022. Measure 1: the mean total daily direct care staff including registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs) in any given week; measure 2: the mean daily resident census in any given week; measure 3: direct care hours per resident-day, calculated by dividing total hours by patient census on that day 34 ; and measure 4: the share of agency worker hours (rather than direct care employees) that provide temporary staffing to offset potential shortages of RNs, LPNs, and CNAs. The staffing measures provide insights into the adequacy of staffing levels and quality of care during the study period. The share of agency worker hours measure is an indicator of staffing stability and may reflect challenges in recruiting and retaining direct care employees.

Weekly means for the 4 measures for the 40 participating nursing homes and 15 436 nursing homes nationally were calculated. These averages were graphed over time to examine temporal trends in the study sample and compared with national trends for the same time period. To construct the national average for each measure, data were weighted by the size of the nursing home, as measured by the number of residents. To ensure the accuracy of our analyses, any data points with either the resident census or the total staffing reported as 0 for a facility on any given day were excluded.

Qualitative and quantitative data sets were integrated to answer the question, Do nursing home administrator perspectives on staffing in US nursing homes during the COVID-19 pandemic provide context for conflicting staffing data reports? The 3 themes generated by qualitative analysis prompted the development of 4 analytic measures to statistically evaluate facility-level data for the study sample. Qualitative themes were compared with quantitative measures to assess whether administrator experiences with nursing home staffing levels were supported by facility-level data and whether administrator perspectives provided an explanation for how staffing challenges were addressed.

This mixed-methods study included 156 total interviews with 40 nursing home administrators in 8 markets across the US. Although specific demographic information was not gathered, participants were licensed nursing home administrators who self-reported a range of education levels and backgrounds, including nursing, social work, business administration, health care administration, public administration, finance, and marketing. Experience in nursing homes ranged from several months to more than 30 years. Nursing home characteristics are presented in Table 1 .

Using modified grounded theory 29 and thematic analysis, 30 3 major themes that reflect administrator perspectives on nursing home staffing from July 14, 2020, to December 16, 2021, were identified. In theme 1, administrators report on the substantial staffing shortages they experienced during the pandemic. Themes 2 and 3 present major strategies administrators used to offset immediate staffing shortages including hiring agency staff (theme 2) and operating at a reduced resident census (theme 3). Embedded within each theme are concepts that support the theme. Themes, concepts, and illustrative quotations are summarized in Table 2 .

Quantitative analysis of facility-level staffing data assessed changes found in the study sample of nursing homes from January 1, 2020, to September 30, 2022. In measure 1, study nursing homes experienced large reductions in total direct care staff hours throughout the study period ( Figure 1 A). Measure 2 showed that study nursing homes experienced reductions in direct care staff hours per resident-day throughout the study period ( Figure 1 B). Measure 3 indicated that the census at study nursing homes decreased substantially from March 1, 2020, to January 1, 2021 ( Figure 2 ). Measure 4 analyses showed that study nursing homes increased their use of agency staff for all levels of direct care throughout the study period ( Figure 3 ). As a validity check, quantitative results for measures 1 through 4 were compared with the same measures developed for the national sample of 15 436 nursing homes. Changes found for measures 1 to 4 in the study sample of nursing homes were comparable to national changes ( Figure 1 , Figure 2 , and Figure 3 ).

Thematic results from qualitative analysis were merged and compared with the quantitative results of facility-level staffing data measures. Theme 1 results were evaluated against measures 1 and 2 findings, theme 2 was assessed by measure 4 findings, and theme 3 was evaluated by measure 3 for evidence of agreement.

One administrator reflected on the challenge of finding staff throughout the pandemic: “With that many staff members out [due to COVID-19 infection], we had an extreme staffing crisis. There was nobody to help.” (S5N1.3, March 2021). Administrators described an ongoing struggle to maintain safe staff-to-resident ratios, “be in compliance when it comes to staffing” (S6N4.3, June 2021), and provide “good customer service” (S2N4.4, August 2021). Since nursing homes are required to maintain compliance with state and federal regulations around safe staff-to-patient ratios, administrators used compensatory strategies, such as overtime, cross-training, and increasing staff-to-resident ratios to balance regulatory requirements with staffing shortfalls at their facilities. Table 2 , theme 1, provides representative quotations.

Using PBJ data to assess staff hours per resident-day per week, our analyses substantiate the qualitative findings indicating that nursing homes faced staffing challenges during the COVID-19 pandemic (theme 1). In support of theme 1, our analyses showed a decrease in total direct care staffing hours for study sample nursing homes throughout the study period (July 14, 2020, to December 16, 2021) (measure 1). As noted in theme 1, administrators used various strategies to compensate for staff shortages and remain in regulatory compliance. Measure 2 analyses of staff hours per resident-day support administrator reports and show an increase of staff hours per resident-day at the outset of the pandemic. The impact of staff shortages extended beyond a facility-wide COVID-19 outbreak with staff hours per resident-day decreasing over time. This was evident at the facilities composing our study sample which, although slightly higher than the national trend, followed the national trend trajectory through December 2021. We continued our analyses through 2022 and found the facilities in our study sample followed national trends but at a higher rate ( Figure 1 A, B).

To compensate for staffing shortages, many nursing home administrators brought in agency staff to maintain facility functionality and meet regulatory compliance requirements. As one administrator noted: “We’re still utilizing agency, and all of that to be able to keep the building staffed according to the guidelines” (S6N4.4, September 2021). For some administrators, it was the first time (S2N4.2, February 2021) they had ever needed to rely on agency staff. Hiring agency staff proved problematic during the pandemic as the demand for agency staff soared due to competition with hospitals and other health care settings. As a result, administrators found that agencies could demand high payments for service that was often unreliable. Administrators expressed concerns about the prioritization by agency staff of monetary reward, which negatively impacted existing staff morale and resident care. Table 2 , theme 2 presents representative quotations.

Our quantitative analyses using PBJ data support our qualitative findings that nursing home administrators hired agency staff to manage staffing shortages at all levels of patient care (measure 3). Quantitative analyses showed a corresponding change of increasing agency use in both our sample of 40 nursing homes and nationally throughout the study period (July 14, 2020, to December 16, 2021), and continuing in 2022. Additionally, our analyses reflect the increase in agency use by nursing homes for all levels of nursing staff: RNs, LPNs, and CNAs. For our study sample, agency RNs were increasingly used over the course of the study period but at a lower rate than the national average; LPN and CNA agency staff, however, were used at rates higher than national averages by the 40 nursing homes in our study ( Figure 2 ).

A longer-term impact of staff shortages was nursing homes being unable to increase their admissions and census. As one administrator noted: “Yeah, the only restraint on us getting a little bit higher census is staffing issues. We’re running into staffing issues” (S5N2.4, July 2021). For many administrators, low staffing levels impacted their ability to increase their resident census. Thus, curtailing admissions was their only recourse until additional staff could be hired. Table 2 , theme 3, presents representative quotations.

Analyses of PBJ data substantiated administrator reports of a decrease in resident census (theme 3). Our analyses (measure 3) found that the number of nursing home residents in our study sample decreased substantially in March 2020 and continued to decrease through January 2021—a trend also found nationally. As nursing home administrators reported, resident census increased through 2022 but, at the time of the study, had not yet reached prepandemic levels ( Figure 3 ).

This study of nursing home administrator perspectives and facility-level staffing data aimed to address a critical gap in understanding how nursing homes met minimum staffing levels and remained operational while experiencing substantial staffing shortages. Using both quantitative and qualitative data, this study may help illuminate crucial ways nursing homes have dealt with the pandemic with 3 important findings.

First, while aggregate staffing and resident census data suggest that resident-to-staff ratios remained stable in the earlier part of the pandemic as a result of the decreasing resident census, our qualitative data provide an important explanatory context not shown by these analyses. Administrators used crisis management compensatory strategies to meet regulatory staffing minimums and maintain operations. As administrators noted, increasing resident-to-staff ratios, hiring agency staff, and reducing resident census enabled them to comply with regulations and continue to care for residents.

Second, although the compensatory strategies administrators used addressed an immediate staffing crisis created by the pandemic, these measures came with a financial cost. Increased staff overtime pay, the high cost of agency staff, and the decreased revenue from new resident admissions has had major financial influences on nursing homes already coping with high operational costs due to the pandemic. 35 - 37

Third, the stop-gap compensatory mechanisms administrators used to maintain operations have only exacerbated staff burnout. Not only have staff had to manage higher caseloads, they have had the additional burden of supervising and training temporary agency staff unfamiliar with facility protocols. This raises concerns for quality of care at nursing homes as staff burnout and high turnover 38 , 39 have been reported to be associated with poor resident outcomes. 40 - 42

Staffing ratios alone are an incomplete picture of the staffing environment in nursing homes, particularly in the midst of a public health crisis. It took an immense effort with substantial financial and staff costs for nursing homes to maintain minimally adequate staffing ratios and remain operational during the pandemic. The long-term consequences of these compensatory strategies will likely greatly affect the stability of an already strained workforce. 9

This study has several limitations. First, although our sample size of 40 nursing home administrators in 8 health care markets is robust for qualitative research, our findings may not be generalizable to all US markets and all nursing homes. Our quantitative analyses for facilities participating in this study, however, showed trends that were consistent with national trends. Second, while quantitative analyses continued through September 2022 and show trends continuing, our interviews were conducted between July 14, 2020, and December 16, 2021. Although we were able to capture administrator perspectives close to the beginning of the pandemic, we were not able to explore administrator perspectives into 2022. Third, our interviews focused on nursing home administrator perspectives, which may not represent staff perceptions as they responded to the loss of colleagues and patients, increased workloads, and the influx of agency help.

Findings from this qualitative mixed-methods study may have implications for future research and policy. The dual approach of quantitative and qualitative analyses provides depth and context to our understanding of complex topics such as staffing and nursing home care. It remains unclear how long the crisis adaptation techniques nursing home administrators used can persist without major effects on staff and resident safety. More mixed-methods research is needed to better understand the long-term outcomes of the COVID-19 pandemic associated with nursing home staffing and how policies and regulations around staffing during a crisis, such as a pandemic, have aided or limited the efficacy of administrator responses to maintain quality care for their residents. Policymakers should consider reviewing current nursing home regulations around staffing and work with nursing home administrators to create policies that more nimbly adjust to crisis management.

Accepted for Publication: June 15, 2023.

Published: July 27, 2023. doi:10.1001/jamanetworkopen.2023.25993

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Brazier JF et al. JAMA Network Open .

Corresponding Author: Joan F. Brazier, MS, Brown University School of Public Health, 121 S Main St, Box 6, Providence, RI 02903 ( [email protected] ).

Author Contributions: Ms Brazier and Dr Gadbois had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Brazier, Meehan, White, McGarry, Shield, Rahman, Gadbois.

Acquisition, analysis, or interpretation of data: Brazier, Geng, Meehan, McGarry, Shield, Grabowski, Rahman, Santostefano, Gadbois.

Drafting of the manuscript: Brazier, Meehan, Rahman.

Critical review of the manuscript for important intellectual content: Meehan.

Statistical analysis: Geng, McGarry, Santostefano, Gadbois.

Obtained funding: Rahman.

Administrative, technical, or material support: Brazier, Meehan, McGarry, Rahman, Santostefano, Gadbois.

Supervision: Shield, Grabowski, Rahman, Gadbois.

Conflict of Interest Disclosures: Dr Grabowski reported receiving personal fees from the AARP, Analysis Group, GRAIL LLC, and Medicare Payment Advisory Commission outside the submitted work. No other disclosures were reported.

Funding/Support: This work was supported by the Warren Alpert Foundation (D.C.G. and M.R.).

Role of the Funder/Sponsor: The Warren Alpert Foundation had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2 .

Additional Contributions: Aseel Rafat (Brown University), provided substantial editorial contributions to this article; no financial compensation was provided.

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• Published: 23 February 2022

Keeping nurses in nursing: a qualitative study of German nurses’ perceptions of push and pull factors to leave or stay in the profession

• Catharina Roth 1 ,
• Michel Wensing 1 ,
• Amanda Breckner 1 ,
• Cornelia Mahler 2 ,
• Katja Krug 1 &
• Sarah Berger 3  

BMC Nursing volume  21 , Article number:  48 ( 2022 ) Cite this article

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The increasing nursing shortages worldwide has focused attention on the need to find more effective ways to recruit and retain nurses. The aim of this study was to gain understanding of factors that keep German nurses in nursing and explore their perceptions of factors that contribute to nurses leaving or staying in the profession.

An explorative qualitative study was undertaken at four different hospitals (two university hospitals and two public hospitals) in Baden-Wuerttemberg, a state in South Germany. Semi-structured face-to-face or telephone interviews were conducted with 21 state-qualified nurses who had graduated from a German nursing program. Each interview was pseudonymized and transcribed. Transcripts were coded according to Qualitative Content Analysis with data structured into themes and subthemes. The study was reported according to the Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist for qualitative research.

Two themes emerged from the analysis and each theme had several subthemes: a) PUSH FACTORS i.e. factors that may push nurses to consider leaving the profession included limited career prospects, generational barriers, poor public image of nursing, and workplace pressures; b) PULL FACTORS i.e. factors that nurses wished for and could keep them in the profession included professional pride, improved remuneration, recognition of nursing, professionalisation, and improving the image of nursing as a profession.

The decision to leave or stay in nursing is influenced by a complex range of dynamic push and pull factors. Nurse Managers responsible for stabilizing the workforce and maintaining their health system will continue to have to navigate challenges until working conditions, appropriate wages and career development opportunities are addressed. A key to tackling nursing shortages may be focusing on pull factors and nurse managers listening in particular to the perspectives of junior nurses directly involved in patient care, as giving them opportunity to further develop professionally, reinforcing a strong and supportive workplace relationships, paying an appropriate salary, and improving the public image of nursing profession.

Registration number

The study has been prospectively registered (27 June 2019) at the German Clinical Trial Register ( DRKS00017465 ).

Peer Review reports

Health systems globally are facing a crisis of workforce shortages [ 1 , 2 ]. According to the World Health Organisation (WHO), the International Council of Nurses (ICN), and Nursing Now (global campaign run in collaboration with the International Council of Nurses and the World Health Organization) there is a global nursing shortage of 5.9 million nurses, with the greatest need of qualified nurses in South East Asia and Africa [ 3 , 4 ]. In the European Region, around 7.3 million nurses and midwives are currently employed, however, this number is not adequate to meet current and future needs [ 5 ]. Although Germany has the highest number (13.9 nurses) of nurses per 1000 inhabitants in the European Union (OECD (2021)), it has been struggling also to address the increasing need for qualified nurses [ 6 ]. A study by the Prognos AG [ 7 ], for example, predicted a nursing shortage of 520,000 full-time nurses in Germany in 2030.

The shortage of nurses can be viewed in terms of real nursing shortage and pseudo-shortage. The latter refers to a sufficient availability of qualified nurses, but low willingness to work under present conditions, which results in the decision to leave practice or the profession [ 2 ]. Nursing shortages differ by specialty, country, healthcare sector, healthcare service, and organisation [ 2 ]. Primary contributing factors are the increased demand for nurses and decreased supply worldwide. Factors linked to increased demand include an aging population, globalization and a growing private sector, and increased social mobility [ 2 ]. Unsatisfactory working conditions (e.g., high workloads, inadequate support staff, work-related stress, and workforce burnout) [ 8 ], insufficient remuneration, lack of participation in decision making, lack of leadership support, and changes in health human resources approaches are factors associated with a decreased supply of qualified nurses [ 2 , 9 , 10 ]. The demographic changes, particularly in Europe [ 11 , 12 ], the high prevalence of chronic diseases [ 13 ], the fact that more and more qualified nurses are close to retirement [ 12 , 14 ], and a decreasing number of student nurses puts an increased pressure on the healthcare system [ 2 , 12 ]. In addition, the shortage of nurses is exacerbated by an aging nursing workforce [ 12 , 15 ]. Studies have shown that nursing workforce shortages increase the risk of adverse events, nurse-sensitive outcomes e.g. pneumonia or falls, and mortality [ 12 , 16 , 17 , 18 ], which all have direct impact on the quality of patients care and patient safety [ 16 ].

Internationally, several strategies to address the nursing workforce shortage have been undertaken. This includes measures to improve working conditions, expand the recruitment base, and target qualified nurses who have left the nursing profession to return, recruitment of internationally trained nurses, and improved remuneration [ 19 , 20 ]. However, previous studies have shown that financial incentives are only one of many drivers of nursing shortage [ 21 ]; the underlying causes of the global nursing shortages are complex [ 22 ]. Strategies that have been applied to date internationally to tackle the increasing nursing workforce shortage seem to be inadequate. Many countries are not able maintain supply of qualified nurses including Germany [ 6 ]. The shortage of qualified nurses has been becoming increasingly acute due to increased demand especially in developed countries with aging populations and an aging workforce. The demand for healthcare will continue to increase, while the supply of qualified healthcare staff to meet those needs is going to be limited [ 6 ]. The urgent need for newly qualified nurses and also the retention of experienced nurses [ 23 ] requires immediate attention. Measures to address these issues need to be implemented in a concerted manner. Improved understanding of factors that keep nurses in nursing may be a key to improving recruitment and retention. In the light of an aging nursing workforce and fewer student nurses, further evidence is needed to identify what attracts young Germans to enter the nursing profession, and what keeps them nursing.

To date, research on turnover and nursing workforce shortages in Germany have mainly focused on assessing factors that influence intention to leave workplace. Few studies have examined factors that keep nurses in nursing, attract young Germans to entering nursing profession, and what the wish for in order to stay. Gaining a better understanding of perceptions of factors that contribute to nurses leaving or staying in the profession in Germany by qualified nurses directly involved in patient care is key to development of successful strategies for future recruitment and retention.

The aim of this study was to advance understanding of factors that keep German nurses in nursing and explore their perceptions of factors that contribute to nurses leaving or staying in the profession.

Study design

The research presented in this manuscript is part of a larger research project (the Nurse Migration Project) , conducted by the Department of General Practice and Health Services Research of the University Hospital Heidelberg, Germany. The main aim of the research project Nurse Migration was to explore the integration process of internationally trained nurses into the German nursing workforce from the perspective of German trained nurses (GTN) and internationally trained nurses (ITN). Another aim was to gain more in-depth knowledge regarding the experiences of GTN and ITN in the workplace.

The present study reports the findings from a qualitative interview study with GTN with data collected by semi-structured face to face or telephone interviews.

Study setting

Four German hospitals were invited to participate in this study:

Centre 1 (University Hospital) has 57 specialized clinical departments with 1.600 beds in total. These services provide high-quality inpatient treatment with best practice medical and nursing standards. Currently, 2601 nurses are employed at Centre 1.

Centre 2 is (with 310 beds in total) one of the largest lung care clinics in Europe and currently employs more than 200 nurses.

The Centre 3 works closely with the Centre 1 and has six different departments with around 200 beds in total and employs more than 200 nurses.

The Centre 4 is a public acute hospital (with 234 beds) which provides basic and standard medical care and currently employs around 280 nurses.

Participants

Nurses were eligible to participate in this interview study if they were at least 18 years old and were employed in one of the involved hospitals. Other healthcare professionals (e.g., physicians, physiotherapies, nurse aides), as well as student nurses and nurses who did not consent to participate were excluded from the present interview study. No minimum employment working hours was set. All nurses gave their written informed consent to participate in the study prior to the start of the interview.

Sampling and recruitment process

The nursing leaders of the four hospitals were initially informed about the purpose of the study and the recruitment process by a member of the research team via email and by phone. All hospitals decided to participate in the research project. Different sampling and recruitment methods were applied at the four remaining hospitals.

At Centre 1, a key contact person was appointed by the Director of Nursing management. The key contact person was responsible for informing the ward managers about the nature and the purpose of this study. At Centre 2, all ward nurse managers were informed during a meeting with a member of the research team, that was organized by the nursing management. At Centre 1 and Centre 2 the ward nurse managers were responsible for the distribution of the study material. Each nurse received an envelope with information resources including an invitation letter to take part in the study, an information leaflet, an informed consent form, and a reply envelope for return in the internal mail system. The information leaflet included contact details of the research team. Nurses who decided to take part were requested to contact the research team directly.

At Centre 3 and Centre 4 nursing management informed ward nurse managers about the study. Ward managers then informed their nursing teams and decided together with their teams who was eligible and was willing to participate. They then informed the research team about the interested nurses. Those nurses also received information resources including an invitation letter to take part in the study, an information leaflet, an informed consent form, and a reply envelope via the internal mail system. Together with the interested nurses, the ward nurse manager and a member of the research team arrange interview appointments.

Four weeks and six weeks after the first distribution of the study material reminders were sent to the nursing management and ward managers of each hospital to increase the respondent’s rate. Ward managers were asked to make the survey public at regular team meetings. In addition, nurses who took part in an interview were asked to invite their peers in all four hospitals.

Data collection

Semi-structured individual face-to-face or telephone interviews were conducted between September 2019 to August 2020 by a female health services researcher with a background in nursing and public health (CR). The interview guide was initially developed by CR (female health services researcher with a background in nursing and public health) and discussed in a qualitative research colloquium at the Department of General Practice and Health Services Research, Heidelberg University Hospital. Adjustments were made according to recommendations by the participants of the colloquium. The interview questions were open-ended and based on an extensive literature search. Interview questions addressed experiences and perceptions regarding workplace experiences. The data collection process was interrupted by the SARS-CoV-2 pandemic in 2020 and was therefore prolonged. Face-to-face interviews were conducted in a separate and quiet room on the ward. All interviews were digitally recorded, pseudonymized and transcribed verbatim. Each transcript was reviewed whilst listening to the digital recording to ensure accuracy. Data gathering was finalized when saturation was reached. Information such as sociodemographic data, work experience, and place of work were collected in addition to the interviews. No additional field notes were taken during or after the interview. Interviews were not repeated. Transcripts were not returned to participants for verification or feedback. Only the participants and the researcher were present during the interview.

Data analysis

Data was analysed according to Qualitative Content Analysis [ 24 ] to structure collected data into themes and subthemes using an inductive approach. In a first step, two female researchers (CR and AB) familiarised themselves with the whole data set. They coded the first three interviews independently. The results were discussed, and a coding system was developed by consensus. The transcripts were then coded line-by-line by CR (health services researcher with background in nursing) and AB (health services researcher). The coded transcripts were compared against the coding system in further discussions. Disagreements regarding codes were resolved in discussions with CR, AB and SB (health services researcher with background in nursing). All transcripts were analysed using the same method by the two coders. Moreover, the final coding system including themes and subthemes and illustrative quotes were discussed between CR, AB and SB in order to ensure consensus as part of the quality management process for qualitative data analysis. Interview data was analysed using MAXQDA, version 2020.1.0 [ 25 ], a computer-assisted qualitative data management software.

Quotations presented in this paper were translated into English and slightly adapted to maintain meaning by CR (fluent in German and English) and checked for accuracy by SB (a native English speaker fluent in German).

Ethical considerations

The study was approved by the Medical Ethics Committee of the Medical Faculty of Heidelberg University (S-367/2019). In addition, the staff council of each hospitals approved the study. Written informed consent was provided prior commitment to interviews by participants. Research conducted in this study was performed in accordance with the Declaration of Helsinki [ 26 ]. The study was reported according to the Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist for qualitative research [ 27 ].

Management of data quality

Rigorous procedures were implemented to enhance the credibility of findings: (a) using more than one data coder during data analysis, (b) peer debriefing (qualitative research colloquium), (c) consensus discussion between the two coders and if necessary, a senior researcher, and (d) member checking/ respondent validation with a senior researcher. In addition, an audit trail of the research process was developed to document the research process [ 28 ].

Twenty-one interviews with German trained nurses were conducted. The majority of nurses were employed at Centre 1. The mean age was 40.4 years (SD 11.4), with the youngest participating nurse being 22 years old and the oldest being 60 years old. More than three-quarters of the total sample identified as female (81.0%). They had work experience of 19.5 years on average. Participants were employed in a variety of different departments. The majority worked on inpatient wards with a small number of nurses from on an intensive care unit (Table  1 ). Mean interview duration was 17.25 min (range 8.14–23.41).

Two main themes emerged from qualitative content analyses in relation to nursing workforce shortage: a) Push Factors and b) Pull Factors (Table 2 ). Each theme included subthemes. Exemplar quotations were used to illustrate meaning and themes emerging from the considerable data set that was generated from the study. Exemplar quotes were anonymised to protect the identity of participants.

Theme 1: push factors

This theme included factors that may push nurses to consider leaving the profession as demotivators from the perspective of nurses trained in Germany.

Limited career prospects

Some nurses indicated that a lack of opportunities for professional advancement may be demotivating and thus contribute to nursing shortages in Germany. Participants emphasized the limited opportunities for professional advancement.

I think it would be more lucrative. Because then people would also come in and say: "Well, I studied” […] and maybe I can develop a bit more diversely […] to study nursing science or nursing management would perhaps be a bit better, I hope, if you do it for a year longer. (Nurse_26, Age 29)

However, it was also acknowledged that just the higher qualification alone would not always be enough and that there was no easy answer.

It's just difficult to get promoted, although I also have to say: Well, in the past there was no university degree for nursing. As I said, I see it critically. I don't know... I think at the management level it is good, it's okay if someone has a university degree [...] and then maybe also a degree in business administration, but whether or not a ward manager necessarily has to have an advanced training course or a university degree, I honestly don't know. (Nurse_24, Age 48)

Generational barriers

Some participants described perceived differences between the younger and the older generation of nurses, which involved divergent values and motivations. Some younger nurses highlighted that they wished to have the chance to influence their workplace and have a voice, but they felt their group was too small to initiate change. They had the impression that older nurses have a different mindset and that it was sometimes challenging to find common ground between the two generations, which could be demotivating at work.

And that is not in the minds of the nurses, that is mainly a generational problem. It works better with the younger ones [younger nurses], it's easy to get them on board, but my generation or my level of education is not yet in a position to perceive it at all. Very few people are, that's my experience. And I think that... they are... Many of them [older nurses] just want to do their work in peace, […] they want to do their work in the best possible way in the area where they feel comfortable. I think that's the difficulty, to get the generations together a bit. (Nurse_22, Age 40)

Poor public image

Participants reported that perceptions in German society had of the nursing profession such as the stereotypical picture of nurses given in the media contributed to a poor public image. They highlighted that many people did not realise the range of professional skills nursing required to provide patient care and how demanding the nursing job really was and that this had a demotivating effect.

[...] because the nursing profession has been dragged through the mud and degraded, […] we support and remove natural needs from the human being. That's nothing bad and nothing disgusting in my eyes, but one should just, because that was put in the foreground, yes, just the nurse was degraded to the rear cleaner and that's what society has now and it's just yes: "Give food, a bit of washing and yes and therefore they still get too little money for that." (Nurse_31, Age 36)

Personally speaking, I think it would be much more beneficial for the nursing profession if we showed a certain amount of transparency. It is... I notice that in my patients, there are many who have no idea about what we actually do here. All the hospital series like "Grey's Anatomy" and I don't know what else, we have already been asked whether we really have relationships with our physicians. Yes, so you have to listen to things like that. Of course, it is completely misrepresented, even if you watch private channels like SWR or ARD and all the others, that this is not the job or the day of a nurse. There are very few nurses who stand up and say: "No, we do much more than just supporting patients with personal hygiene. We do much more than just prophylaxis." (Nurse_26, Age 29)

Participants described the nursing profession as a highly specialised field that has a wide spectrum of responsibilities and wide range of competencies. Participants stressed that they felt a need to show for society to better understand what nurses do and what they are capable of in order to increase the attractiveness of the profession.

[…] because many people think: "The doctors are always there", but especially at an intensive care unit, the physicians are usually not at patient’s bedside, [..] the nursing staff actually do everything, they are responsible for the ventilation of patient and things like that […] You also have a lot of responsibility for it, so I think that's more appealing somehow if people would know that […]. (Nurse_18, Age 30)

Workplace pressure

The workplace pressures linked to inadequate staffing were not going to improve if even gaining entry to nursing training was perceived as a barrier for some. Participants indicated that some nursing schools required a secondary school certificate to be able to enrol in nursing school, which could be a barrier for some otherwise suitable candidates for the nursing profession. Participants described the negative impact on their motivation to work due to inflexible rostering choices. They suggested a more family-friendly roster.

[…] more flexible working hours, more possibilities, everything is still too rigid. (Nurse_22, Age 40)

Participants described workplace pressure that had a demotivating effect included inadequate staffing levels, constant time pressure during patient care, physical stress, inflexible rostering choices, the impact of political decisions, and managing the physical and emotional work.

And this time pressure that we have here because we learn to give everything for our patients during nursing training, this and that, hygiene also needs a certain amount of time, yes, and we also need time for conversations, but it is not possible, because otherwise you simply won't get through and won't get any further, yes, that is very difficult. […] We work with people and very often we forget that, because there is simply pressure from above and that is just a pity, because that is not what we have learned in this profession, […] and at some point, after the time I say: "I can't do any more." Yes, I cannot spend 24 hours here doing what I do. I just have to do the bare minimum and that's not why I'm a nurse. (Nurse_25, Age 30)

Theme 2: pull factors

This theme included factors that could keep nurses in the profession or factors that nurses wished for in order to stay as motivator from the perspective of nurses trained in Germany.

Professional pride

Participants emphasized the importance of a sense of pride for their profession. These nurses described their feelings of pride, and that nursing work was meaningful and contributed to society.

To be proud of what we have learned and what we are doing as nursing profession, […]. (Nurse_24, Age 48)

And that's where I say, "Ok we are nurses, we just have to learn to be happy with it." [...] Of course more money is great; of course, more recognition is great. But […] it just helps me to say: "Hey, I'm proud of my profession it is not just a job, it's a vocation". (Nurse_26, Age 29)

Improved remuneration

Participating nurses discussed factors related to remuneration or salary as a pull factor for staying in the workforce. They highlighted that higher payment could raise the status of the profession. In addition, improved remuneration would show nurses that they were valued and that their work was appreciated.

In order to address the shortage of skilled workers in nursing, I see above all an attractive salary that expresses a certain appreciation for nursing staff and that should definitely become apparent, which will perhaps be a factor for many to return to the nursing profession. (Nurse_10, Age 29)

However, some participants indicated that a better salary alone was not enough to increase the attractiveness of the nursing profession.

I think that more money alone doesn't make it [nursing] more attractive, at least not in the long term. (Nurse_29, Age 42)

Yes, and I mean payment is always quite nice and good, but I think the work has to be fun. Of course, you have to be able to make a living from it, but it also has to be fun […]. (Nurse_24, Age 48)

Recognition of nursing

Participants stressed that the recognition of nursing started with how they sew themselves but also how other healthcare professionals and society saw them. They indicated that in order to be recognised as a profession they had to show the world what it meant to be a nurse and what the world would be like without nurses. Factors participants thought that positively impacted on the image of nursing were a strong social standing, being proud of being a nurse, and a professional association that worked towards maintaining high status of the nursing profession.

I think that it is a shame and I have a lot of criticism for the society in general, but especially now with nursing, it starts with us, so if someone young were to ask me, a young woman who is perhaps thinking about becoming a nurse, I would advise her to (Nurse_8, Age 56)

Participant were in favour of collaborating with other healthcare professionals to find best practice solutions. They highlighted the desire to improve collaboration and increase recognition of nursing by other professions.

I think it would help if we worked more in an interdisciplinary team, I personally suffer from the hierarchical structures and sometimes I think I've been working as nurse for so long and I'm always here, but I'm just not allowed to have a say in ward decisions […] I find really bad, and that's also something that probably won't change in the time I'm there, but for the future I hope that there will be more equality [...]. (Nurse_8, Age 56)

Another factor mentioned in relation to g the image or recognition of nursing was how nurses talk about their profession themselves. Some participants were concerned that other nursing colleagues had sometimes discouraged young people to choose nursing as profession and wished that their colleagues acted differently.

It starts with us, so if someone young were to ask me, a young woman who is perhaps thinking of becoming a nurse, I would advise her to do so, well, I would, for example, I've really had good experiences all my life, I've learned a lot for myself, I've managed to raise three children at the same time and I also find that it's always manageable with shift work and with sometimes more and sometimes less work. […] And besides, I think that there are a lot of people working there who are very open-minded and social, good colleagues and I would advise, but I also find that there are a lot of people who say 'Oh, don't do that, don't do that' because of the shift work, so I don't think it's that bad. (Nurse_8, Age 56)

Professionalisation

The advancement of the profession with transition to university qualification was an important pull factor for sustaining the workforce. The majority of participants perceived the opportunity to get a university degree in nursing as important, nevertheless indicating that it would be important to generate jobs including an adequate salary for nurses with a university degree, not only for academics but also for those in clinical practice.

I also think it is important to build up a mix of qualifications, because I think the professionalisation of nursing is relatively important. In my opinion, this does not have to happen extensively, because perhaps it is not important for everyone, but the possibility of getting a university degree in nursing should exist, and it should then also result in appropriate jobs with appropriate remuneration - that's it. (Nurse_10, Age 29)

[…] That's something, you have to get the two fields together, then I think professionalisation has a better chance. If you could get it closer to practice. Most people are moving away from practice, as far as that's concerned, and.... because there are no fields. That's also the thing with... You have to take fields of activity, for example in the clinic, and that's what's still missing. If you don't manage to do that, then I think the nursing profession will develop into the blue-collar sector and the academic sector, and then we'll have a gap that I don't think is really good. (Nurse_22, Age 40)

Nevertheless, participants stressed that transition to university qualification could not be the only way. They wished that nurses without a university degree also received recognition and appreciation.

And I see that as a huge problem, so you would have to create something, so professionalisation on the one hand, but on the other hand I would have to create something where I have people who are professionally qualified [without a university degree], where I know they will stay in nursing […]. (Nurse_24, Age 48)

Some participants indicated that professionalisation could enhance the image of the nursing profession and contribute to workforce retention.

I think it has to be about a status. With the new Nursing Reform Act, we are perhaps on the right path towards having clearly defined tasks, reserved tasks and no longer being regarded as an auxiliary profession, but as a profession in its own rigth. Of course, it will take a few more years for this to become established, but I think that this is actually a good way forward, as is this university degree, that we are becoming more professional. What I think is important is that we get a skills-mix on the wards, i.e. students with different qualification [pathways e.g. hospital and university training programs] but also support roles such as healthcare assistant, ward secretary, […] Yes, so that a qualified nurse or also a ward nurse manager can then also pursue their activities accordingly, namely the planning, control and organisation of a patient's care needs and control and is involved. (Nurse_29, Age 42)

Finally, participants highlighted the need for effective advertising and marketing campaigns targeting young people, improving the image of the different hospitals, job information day at schools, showing presence at job fairs, and increasing positive media presence as another pull factor to attract young people into the workforce.

Yes, I don't know about job information days at schools or so. I've never actually had nursing anywhere or at these job fairs, yes at Jobs4Future they are, or presentations at the job centre or so, where I used to go nursing was not present, at least I hadn't seen any nurses […], maybe with practical exercises and so, I think you can catch the people. (Nurse_16, Age 22)

Key findings highlighted that primary push factors for nurses questioning whether to stay in nursing were workplace pressures and poor public image followed by limited career prospects and generational barriers. Moreover, pull factors such as improved remuneration, professionalisation, professional pride, effective marketing and increased social recognition were all factors that could attract young people into nursing and motivate them to stay in nursing as a satisfying and meaningful profession.

Limited career prospects, not having a voice, and not being able to influence ones working environment have been recognised in other studies [ 29 , 30 , 31 , 32 , 33 ]. Flinkman et al. [ 29 ], conducted a qualitative case study with young registered nurses in Finland and explored why they intended to leave the nursing profession. Lack of career advancement and the fear of being stuck at one place without being able to further develop were factors that contributed to their decision to change their career. Clendon et al. [ 30 ] found that for young nurses in New Zealand career progression (e.g. completing master’s degrees) was important and a factor in retention. Hasselhorn et al. [ 32 ] found that nurses in Europe with an intention to leave the profession were usually young, highly qualified and looking for a way to professionally develop. Lynn et al. [ 33 ] explored solutions to the nursing shortage from the point of view of nurses working in eight different states in the USA. Career progression and educational opportunities were key motivators to stay in the profession [ 33 ]. In addition, studies conducted in the USA suggested that giving nurses a voice to influence their work environment resulted in increased satisfaction and retention [ 34 , 35 ]. In light of an aging nursing workforce, the loss of highly motivated and qualified (young) nurses due to limited career prospects and lack of new challenges is unacceptable.

Nurses in our study, particularly the younger generation, indicated that the opportunity to obtain a university degree was important to them for realising their professional potential. In addition, limited career prospects were perceived as a push factors for considering leaving the profession. The commitment and wish to gain experience and skills is typical for millennial generation nurses [ 36 ]. Shields et al. [ 37 ], examined the impact of job satisfaction of British nurses on intention to quit and found that dissatisfaction with promotion and training opportunities are found to have a stronger impact than workload or insufficient remuneration. A study conducted in Ethiopia found that nurses with a bachelor or a master degree scored higher on the motivation score compared to nurses with less education [ 38 ]. Watts et al. [ 39 ], found that the intention to leave was lower in certified nurses than in non-certified nurses.

Differences between younger generations and the older generations of nurses are also an important consideration. Particularly, the younger generation of nurses participating in our study were enthusiastic and excited about their chosen career. They highlighted their desire to shape their workplace and further develop professionally but felt held back by those from an older generation. These results reflect the findings by Clendon et al. [ 30 ] and Dols et al. [ 40 ]. Retention strategies that enabled young nurses to be heard and have an opportunity to advance in their career through for example professional development or project work are necessary. However, these strategies will only be effective in the long term if nurses are paid accordingly and have sufficient time and resources needed to do their work [ 30 ].

In our study nurses, described stereotypical portrayals of nurses in the media that contributed to poor public image. They felt that the nursing profession was undervalued by other professions and society in general in Germany. These findings are supported by the work of other researchers [ 29 , 41 , 42 ]. Historically, the nursing profession has been a female profession and has been associated with stereotypical attributes such as being the submissive handmaids of dominant physicians with little responsibility [ 42 , 43 , 44 ]. Particularly, young nurses in our study did not identify with this picture. They rather saw themselves as highly skilled and ambitious professionals. This is consistent with findings by Flinkman et al. [ 29 ] and Takase et al [ 41 ]. .Takase et al. [ 41 ], conducted a study investigating the impact of the perceived public image of nursing on nurses’ work behaviour in Australia and found that the poor public image can decrease self-esteem and lead to job turnover.

Previous research has already established that workplace demands have a significant impact on the physical and emotional health of nurses and their intention to leave the nursing profession [ 22 ]. Findings in our study highlighted that high workplace demands and poor practice environment were reasons for intention to leave, which is consistent with those by Huntington et al. [ 45 ], Haywards et al. [ 46 ], and Flinkman et al. [ 29 ]. In a multi-national study with nurses working in New Zealand, Australia, and the United Kingdom high workload, constant pressure, and staff shortages had a negative impact on the job satisfaction of nurses and increased intention to leave [ 45 ]. Flinkman et al. [ 29 ], also identified workplace pressure as a major driver for young nurses to leave the nursing profession especially those linked to insufficient practice environment and nurse-patient ration. In an Canadian study [ 46 ], factors that influenced experienced nurses’ decision to leave their profession included increased workload due to a higher number of acutely ill and sicker patients.

Not being able to provide a high standard of patient care and the ensuing moral distress was a reason for some nurses in our study to think about leaving the profession. Nurses experiencing emotional and physical exhaustion due to the inability to provide a reasonable level of care over time leads to moral distress that in turn prompts nurses to consider leaving their profession [ 29 , 45 , 46 , 47 ]. There are growing demands of the nursing profession as patient acuity increases linked to longer lifespans of people with long-term conditions and multimorbidity. Nurses need to be able to fulfil the requirements of modern patient care by applying evidence-based interventions. However, in order for nurses to be willing to stay in nursing, workplace conditions need to be such that they have the ability to provide patient care without experiencing chronic emotional and physical exhaustion.

Given the challenges face by nurses in contemporary clinical practice, which threaten further losses to an already dwindling workforce, a clear understanding of factors that keep nurses in nursing is essential. In our study positive workplace relationships contributed to a positive feeling and increased job satisfaction, which has also been reported elsewhere [ 45 , 46 ]. Fair and appropriate remuneration is another strong motivating factor. Nurses in a Swedish study [ 31 ] indicated, that an unsatisfactory salary was the main reason for leaving the nursing profession. Flinkman et al. [ 29 ] found that nurses thought their salary was not adequate, and that a higher salary would improve attractiveness of nursing [ 29 ]. However, improved remuneration alone does not compensate if other factors are unsatisfactory. Cox et al. [ 48 ], reported that moral distress and poor interpersonal relations were the primary mediating factor for turnover rather than pay. Improved remuneration alone is not a solution to nursing workforce shortages but are part of a bundle of strategies needed to improve the image of nursing and increase nurse satisfaction, so they stay in nursing.

Similar to findings in our study, Hayward et al. [ 46 ], described the lack of respect in their working relationships with physicians contributed to nurses decision to leave their jobs. Rosenstein et al [ 49 ], .conducted a survey in the USA investigating the effect of nurse-physician relationship on nurse satisfaction and intention to leave. Disruptive behaviour from physicians increased work-related stress and frustration [ 49 ]. This behaviour was not only experienced in physicians-nurse relationships but also in nurses-nurse relationships [ 49 ]. Our findings also indicated that the way nurses talk with each other particularly about their own profession may have a negative impact on retention or recruitment. Rosenstein et al. [ 49 ] showed that the prevalence of disruptive behaviour resulted in nurses resigning [ 49 ]. Nurses seek to be recognized and wish for positive workplace relationships not only with their peers but also other healthcare professionals. Improving collaborative interprofessional teamwork may be another key to improved interprofessional relationships and thus enhance the recognition of the nursing profession. Integration of interprofessional education into the education of different healthcare professionals may be a strategy to address this issue.

The decision to leave or stay in nursing is influenced by a complex range of dynamic push and pull factors. Nurse Managers responsible for stabilizing the workforce and maintaining their health system will continue to have to navigate challenges until working conditions, appropriate wages and career development opportunities are addressed.

Implications for practice

A global undersupply of nursing and attrition rates that continue to climb means that nurse managers and policymakers need clear understanding of a range of financial, professional, and personal factors that keep nurses in nursing. Particularly, young nurses globally are looking for opportunities to develop professionally. It is important to them to have the opportunity to qualify at a university and gain increased autonomy. Strong and supportive workplace relationships seem to be one of the key factors to keep nurses in nursing not only in Germany but globally. Inadequate remuneration and the poor public image of the nursing profession seem to contribute to the intention to leave nursing profession. In addition, not being able to provide adequate patient care seem to be one of the main factors globally that leads to nurse turnover, particularly in young nurses. In order to address the nursing shortages, further research is needed to explore what young nurses are looking for, what motivates them to choose nursing, and what keeps them nursing worldwide.

Strengths and limitations

This study explored on factors that may push nurses to consider leaving the profession and pull factors that may keep them in nursing. In contrast to previous studies, which mostly focused on factors that contributed to intention to leave the nursing profession, this study provided a perspective on factors that kept nurses in nursing. Qualitative interviews are an important research tool to gain in-depth knowledge on the research subject and understanding of perspectives of targeted groups and was therefore considered as appropriate research method. Data analysis was guided by adequate methodological strategies aiming to minimize bias and reduce the risk of losing relevant content. Reporting of the qualitative findings was guided by the recommendation of the COREQ checklist [ 27 ].

Some limitations must be acknowledged. Although the qualitative design allowed an in-depth exploration of the nurses’ perceptions on push and pull factors, findings of this study cannot be generalized beyond the study population. In addition, as the study was conducted in South Germany in two university hospitals and two smaller public hospitals, specific national and regional factors might have influenced the results. A similar study conducted elsewhere might get different results due to context. Even though data saturation was reached, higher number of nurses from different hospitals may have led to more diverse results. Although perceptions and experiences were relatively consistent within the study sample, these experiences may not be shared by all nurses. In addition, nurses who voluntary participated might have different perceptions and experiences compared nurses that choose not to participate. Social desirability in answers cannot be excluded. Quotes were translated from German into English; it is therefore possible that the meaning in translated quotes subtlely differed from the original meaning in German quotes. The results of the study must be interpreted with caution in terms of generalization and representativeness.

Availability of data and materials

The dataset that was generated and analysed during the study will not be made publicly available due to German data protection law but may be made available by the corresponding author on reasonable request.

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Acknowledgements

We would like to thank the nursing management and ward managers of the hospitals who supported this study, and all nurses who participated in this research.

Open Access funding enabled and organized by Projekt DEAL. This study received funding from the B. BRAUN-STIFTUNG.

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CR and MW conceived the study. CR and SB developed the study protocol. MW was the principal investigator of the study. CR conducted the interviews, CR, AB and SB analysed the data. CR wrote the first draft manuscript. MW, SB, AB, KK, and CM provided critical input at every stage of the development of the manuscript. All authors provided substantial comments and approved the final version of the manuscript.

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The study was approved by the Medical Ethics Committee of the Medical Faculty of Heidelberg University (S-367/2019) prior to the start of the study. The staff council of each hospitals approved the study. Informed consent was provided prior to the interviews by all participants. Research conducted in this study was performed in accordance with the Declaration of Helsinki.

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Roth, C., Wensing, M., Breckner, A. et al. Keeping nurses in nursing: a qualitative study of German nurses’ perceptions of push and pull factors to leave or stay in the profession. BMC Nurs 21 , 48 (2022). https://doi.org/10.1186/s12912-022-00822-4

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Data Spotlight: Insights on the Nursing Faculty Shortage

Registered Nurses (RNs) are one of the fastest growing groups of health professionals, with projected growth of 7 percent from 2019 to 2029 according to the Bureau of Labor Statistics . To keep up with this growth, more nursing faculty will be needed to educate new nurses. However, the United States is facing a persistent nursing faculty shortage according to survey data from the American Association of Colleges of Nursing (AACN). Data collected from the 2020 AACN Faculty Vacancy Survey revealed that there were approximately 1,492 vacant positions in 2020. While the national vacancy rate has decreased slightly from 2016 to 2020, the vacancy rate in the southern region of the U.S has remained relatively stagnant, with little improvement (Figure 1). In 2020 and in previous years, the West had the highest regional vacancy rate, particularly due to Alaska and Wyoming (Figure 2). Figure 2 shows that Alaska and Wyoming had the highest faculty vacancy rates in the U.S, with 30 and 20.8 percent respectively. 

Although the national faculty vacancy rate has declined slightly, a looming faculty shortage persists. Results from the 2020 AACN Annual Survey revealed that nursing schools rejected 66,274 nursing applications for entry into a generic baccalaureate program. Nursing programs in western and southern states have the highest rejection rates for these qualified applications. The top reason for not offering admission to all applicants was insufficient clinical sites (n=254). However, in 2020, almost half of generic baccalaureate nursing programs reported rejecting qualified applications due to an insufficient number of faculty. Of these programs, about 72 percent report being unable to hire additional faculty due to insufficient funds (Figure 3). This shortage of nursing faculty continues to be a top concern, as it contributes to the loss of qualified nursing talent. 

For more information on the nursing shortage and the faculty shortage, click here . 

Figure 1. Trends in Nursing Faculty Vacancies (2016-2020)

Figure 2. U.S Map of 2020 Nursing Faculty Vacancy Rates, By State

Figure 3. Top Reasons for Insufficient Faculty in Generic Baccalaureate Programs (2020)

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May 7, 2024

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How the nursing shortage is affecting the Canadian health care system, patients and nurses themselves

by Lisa McKendrick Calder, Leanne Topola and Tanya Heuver, The Conversation

If you worry that there are not enough health care providers to meet health needs, you are not alone. Seventy percent of Canadians worry about access to care. One factor affecting health-care access is a global nursing shortage .

The increasing demand for nursing services in Canada far exceeds the current supply. Statistics Canada reported in 2021-22 nursing had higher job vacancies than any other occupation, and nurses worked over 26 million hours of overtime.

In honor of National Nursing Week 2024 (May 6–12), we ask all Canadians to consider asking a nurse they know about the realities of the nurses' working lives.

A short-staffed health system

Forecasting models predicted a shortage of 60,000 nurses nationwide by 2022, and further predicted that would almost double to more than 117,000 by 2030.

Responding to shortages has led to changes in staffing models , with fewer registered nurses, more licensed practical nurses and substantially more health-care aides. But even with these, there is a significant shortage, making it essential to retain existing nurses who have the required education and expertise.

In 2024 the Canadian Federation of Nursing Unions (CFNU), conducted a survey of 5,595 nurses. Thirty percent reported dissatisfaction with their career and 40 percent intend to leave nursing or retire.

Early career nurses were even more unhappy with 35 percent reporting dissatisfaction. This is due to occupational disappointment , which is a feeling of disheartenment with career choice.

Job dissatisfaction in nursing

The majority of CFNU survey respondents attributed this disappointment to high workload and insufficient staffing. One cause of increased workload is caring for more patients than the bed capacity is funded or staffed for. Seventy percent of nurses reported their workplace regularly operated over capacity.

Even when care areas are understaffed, patient needs do not change and fewer nurses must meet these needs. Nurses are also influenced by shortages in other health professions such as physiotherapy by picking up extra duties to meet patient needs.

Insufficient staffing increases nurse workload to above normal demands and can threaten patient safety. When there is insufficient staff, nurses from other areas may be displaced to cover. For example, a nurse scheduled on an orthopedic unit might be displaced to neurology.

Forty two percent of nurses in the CFNU survey were displaced within the last year and 40 percent of them felt inadequately trained for the care area they were sent to.

Insufficient staffing can also lead to missed care where patient needs are unmet. Common examples include delay or failure to answer patient call bells or assist with personal care. Recently neonatal intensive care units highlighted they were functioning at 102 percent capacity and babies were not able to be fed as frequently.

Nurses' concerns with substandard care impact job retention as they may experience moral distress . Moral distress is highly correlated with increased intent to leave a job , or the profession .

Safety and safeguards

When short staffed, nurses can be mandated to work beyond their eight- or 12-hour scheduled shifts. Under the Registered Nurse Code of Ethics, the nurse has a duty to provide care to assigned patients until they are transferred to another appropriate care provider. Failure to do so is considered abandonment.

While off duty, nurses can be called in for mandatory overtime. The CFNU policy statement advocates against the use of mandatory overtime except in exceptional circumstances such as disasters. Despite this, in 2023 Manitoba nurses worked over one million hours of mandatory overtime. This is shocking, especially considering Manitoba has legislation limiting mandatory overtime usage.

From a safety perspective however, restricting overtime is not a solution, as it could leave patients at risk and nurses even more overburdened.

Not all overtime is mandatory. Many nurses receive frequent calls to pick up extra hours , which leaves them unable to properly recover between shifts . Declining overtime can cause guilt or a sense of letting colleagues down. In the CNFU survey, 62 percent of respondents worked overtime in the last month out of obligation.

The impact of the nurse shortage

Work hour factors impact patient safety . The CFNU study "Safe hours saves lives" reported extended shifts led to deficits in patient care with nurses reporting decreased physical strength, focus, and ability to be compassionate. Fatigue contributes to medication errors.

Fatigue is correlated with drowsiness and difficulty staying awake both on shift and when driving home . This presents a danger to patients, nurses, and all Canadians on the roads.

Persistent fatigue has been found to impact nurses health. This influences work attendance which further worsens the shortage. Canadian nurses missed an average of 19 days of work for illness or leave in 2022, up from 14.7 days in 2021. This is more than double the sick time taken by government and private sector employees.

Many factors identified in this article contribute to nurse burnout. Canadian nurses have increasing rates of burnout. Ninety three percent of CFNU survey respondents reported symptoms of burnout . Burnout has been linked with depression, anxiety, and post-traumatic stress disorder.

Why a shortage of nurses matters

All Canadians ought to worry about the nursing shortage. Without addressing it, Canadian's ability to access safe, compassionate care will be compromised. When looking at the complex ways that the shortage impacts nurses and their work demands, it is no wonder why they experience occupational disappointment.

Work is underway by nurses alongside Canada's Chief Nursing Officer . The Nurse Retention Toolbox provides guidance. The work to address nursing retention cannot be done by nurses alone. All Canadians need to advocate for conditions that support the well-being of nurses and other health care providers. This is essential for a safe, sustainable health system for us all.

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Innovative Solutions to Maximize Oncology Nurse Staffing During a Nursing Shortage

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Amid the growing number of patients with cancer, ongoing nursing shortages, high staff turnover rates, and nurses’ general desire for more flexible and balanced work, innovative oncology nurse managers are turning to technology and data as creative—even critical—tools for effective staff scheduling.

Acuity-Based Staffing Models

ONS member Patrick Evans, RN, BSN, MBA , senior nurse manager in the hematology and hematological malignancies department at Fred Hutchinson Cancer Center in Seattle, WA, managed the ambulatory hematologic malignancies department during the COVID-19 pandemic. Like many of his peers around the world at the time, he struggled with challenges with a growing department to meet the need for ambulatory options for immunocompromised patients, nurses becoming burned out, and ultimately recruiting to fill both gaps. In an effort to understand why many staff were leaving the profession or looking for different roles, Evans led an initiative to identify better ways to equip the team, serve patients, and support nurses.

Evans said that the patient population at Fred Hutch is complex and requires varying levels of expertise and time based on individual patients. The provider group covers six different hematologic diseases and malignancies with varying acuity levels. Nurses were expected to care for patients in all disease states, although physicians are more specialized. Evans and his team proposed positioning nurses into groups similar to their physician model “so they could also become experts and really well-versed and well-rounded in their education for those disease groups,” Evans said. “Categorizing nurses into specialties within the hematology group was really important.”

Evans partnered with the Fred Hutch nurse education department to conduct literature searches and research acuity models, but most of the examples they found were from infusion centers rather than holistic clinical settings like theirs.

“Our nurses are not actively engaged in putting IVs in, doing hydration, and administering chemotherapy. They’re focused on the global scope of care—partnerships with physicians, advanced practice providers, and schedulers. They are doing more of a holistic approach, answering supportive care needs, and coordinating all of our efforts for the patient. They are incredibly busy, but they’re not doing that physical, hands-on care,” he said. “There weren’t acuity models based on that.”

With no blueprint to follow, the team conducted interviews and analyzed patient volume. Ultimately, Evans and team decided that, instead of looking at the number of physicians per nurse or the number of patients per physician, they would determine the appropriate nurse-to-patient ratio. “We were able to create nurse assignments by total volume of patients on individual panels,” he said.

Incorporating both qualitative and quantitative measures of acuity from their electronic health record’s (EHR’s) in-basket usage, telephone calls, scheduled nurse visits, provider clinical support, coordination of treatment for urgent add-ons, admissions, emergency department use, and total nurse-patient panel size, they used 100 “active” (e.g., acute care) patients and another 100 “inactive” (e.g., surveillance) patients per nurse to identify patient panel limitations. Evans’s team continuously monitors the data and flags any numbers that vary by 25% to reassess and evaluate the need for additional changes.

After establishing those requirements, Evans and his team noticed that “we were short-staffed to be able to meet our own standard we had just created.” They pivoted and developed a business plan to request several nursing positions to meet the level set.

Their request was granted, but Evans said it would not have been possible without a supportive executive leadership group. His advice to others in a similar situation? “One of the key pieces is that you can do all the work, but engaging with your stakeholders and having a group of stakeholders that care that much is extremely beneficial.”

Fred Hutch’s new system allowed Evans’s team to move to 10-hour shifts, four-day workweeks, and a one-day-a-week work-from-home option. In a two-year follow-up analysis, Evans reported that his institution reduced its number of travel nurses from eight or nine to none. He also reported that their current turnover is very low, with the exception of nurses growing their roles within the department, and a “new to specialty” nursing role that has provided attractive recruitment opportunities for nurses to learn more and advance their skills within oncology.

iQueue and Other AI Nurse Scheduling Tools

Artificial intelligence (AI) is influencing all areas of society, including nurse scheduling, with several tools on the market. Valerie Quigley, RN, BSN, OCN®, HN-BC, infusion manager at the Valley Hospital in Ridgewood, NJ, recently helped her organization to implement LeanTaaS ’s iQueue and Nurse Allocation tools.

Like Evans’s model, iQueue centers on acuity levels, which are critical in Quigley’s busy community-based cancer center that has a limited number of chairs but a variety of treatments. Per day, the Valley team treats about 75–80 patients with an average of 12 nurses. About half of the patients are receiving chemotherapy, with the remainder receiving blood transfusions, hydration, other medication infusions, and injections. Although their number of patients continues to grow, the center is not able to increase beyond its 24 chairs. Using those chairs efficiently is critical.

Quigley said that iQueue and Nurse Allocation has optimized both space (i.e., patient scheduling) and staffing (i.e., care hours).

“ Nurses are used to counting patients and not looking at patient care hours,” Quigley said. “The nursing allocation takes nursing care hours into consideration.”

Valley Hospital uses the Meditech EHR, which integrates with iQueue to assess patient volume and appointment types over the previous year and then builds appointment types for future scheduling. Patients are scheduled in specific slots of 30–60 minutes, 61–90 minutes, 91–120 minutes, and 240+ minutes.

iQueue’s embedded Nurse Allocation tool uses the patient schedule to identify nurses’ schedules. First, the manager enters the nurses for the day with their start and end times (based on whether they work 8-, 10- or 12-hour schedules). Then, the manager can simply “Run Allocation” to let the system balance the schedule.

Valley Hospital worked with its nurses and the vendor to customize the system to meet their needs. For example, they were able to color-code new patients who may require extra time. They also enabled staffing managers to view patients’ names in one view and appointment times in another, which allows the charge nurse to move patients in the allocation if needed. As the manager, Quigley can look ahead to identify staffing needs or determine if they can accommodate another patient. The charge nurse can look at the allocation to see the best time and staff available.

Implementing the tool did require some trial and error. “You need to give it a little time,” Quigley said. “We needed to frequently review our data and adjust our chair times accordingly.”

Getting nurses to buy into the process was the biggest challenge, Quigley said, mostly because everyone was learning the new system and how it worked. For example, “assignments were definitely challenging in the beginning until we knew what we knew,” Quigley said. “We learned that the less we manipulated our assignments, the better they were balanced.”

Vendor staff worked with the center’s nurses to address concerns and adjust the tools based on feedback. They also conducted pre- and postimplementation surveys, which found overall satisfaction and some areas for additional improvement.

“AI does have limitations,” Quigley said. “For example, you can’t take into account if a patient had a previous reaction or needs additional time. This is when you would have to manually move patients.”

Quigley said that patients also needed time to adjust to the new system. For example, they may have been used to coming at a specific time that was no longer available. To address this, Quigley developed a script for schedulers to explain why the changes were being made and how they would enable them to provide the best care to patients.

Quigley acknowledged that LeanTaas is costly; however, she said that the efficiencies gained both in terms of patient and chair turnover and scheduling compliance helped justify the costs. Quigley’s team identified and shared metrics that demonstrated those efficiencies, which helped them uncover things like bottlenecks, overall wait times, and wait times for pharmacy services. Managers could see which providers run behind on appointments to determine how long to allow between provider and infusion appointment times.

For others interested in incorporating AI into their scheduling, “staffing up at the beginning would be helpful, if at all possible,” Quigley advised. “Nurses also need to be involved in the planning and continued use of the product. They are the front line and have great input.”

She added that without proper programming, AI can’t take into account if a patient requests a specific nurse, has reacted frequently, or requires a new treatment. “You have to work with it, not against it,” she said.

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Research Article

Registered nurses’ perceptions on the factors affecting nursing shortage in the Republic of Vanuatu Hospitals: A qualitative study

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing

Affiliation Vanuatu College of Nursing Education, Ministry of Health, Port Vila, Vanuatu

Roles Conceptualization, Formal analysis, Methodology, Supervision, Validation, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation School of Public Health and Primary Care, Fiji National University, Suva, Fiji

Roles Conceptualization, Supervision

• Adel Tutuo Tamata, 
• Masoud Mohammadnezhad, 
• Ledua Tamani

• Published: May 20, 2021
• https://doi.org/10.1371/journal.pone.0251890
• Reader Comments

Registered nurse has a vital role in delivering healthcare services to individual, family and community. One of the main challenges that health system facing globally is the shortage of nursing workforce. Vanuatu as a Pacific county is also facing the shortage issue and the impact on the registered nurses’ performance.

A qualitative study was used to collect data from 25 registered nurses in three randomly selected hospitals in Vanuatu between 4 th to 14 th September, 2020. A semi-structured open-ended questionnaire was used to collect data using face-to-face in-depth interviews. The data were transcribed and analyzed using thematic analysis process.

Four themes were identified including; Difficult working conditions, Reinforcing factors and Perceived risks. Sub themes for difficult working condition were heavy workload, lack of workforce and unusual working hours. Sub themes for reinforcing factors were lack of support, lack of opportunities and advancement in nursing practice. Sub themes for perceived risks were stress, physical and mental risk, and social and family risks.

This study has identify factors affected shortage of current nursing workforce and the impact it has on registered nurses. Broad themes and sub-themes were identified which highlighted the impact of nursing shortage to registered nurses and the effects on their performance which includes stress or moral distress from work overload and lengthy hours shift which impact the nurses’ physical, psychological, social, and family relationship, and lack of leadership support. The findings can be helpful to policy makers at the decision-making level to resolve the nursing workforce shortage and its effects in the future by refining and developing relevant policies that will address and strengthen the nursing workforce to meet the demand and improve delivery of quality health services to all individual.

Citation: Tamata AT, Mohammadnezhad M, Tamani L (2021) Registered nurses’ perceptions on the factors affecting nursing shortage in the Republic of Vanuatu Hospitals: A qualitative study. PLoS ONE 16(5): e0251890. https://doi.org/10.1371/journal.pone.0251890

Editor: Kingston Rajiah, International Medical University, MALAYSIA

Received: February 25, 2021; Accepted: May 4, 2021; Published: May 20, 2021

Copyright: © 2021 Tamata et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Data can be found at the Open Science Framework (OSF): Factors affecting nursing shortage in Vanuatu (Mohammadnezhad, 2021) (DOI: 10.17605/OSF.IO/W7G8E ).

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Registered Nurses (RNs) are valued professionals and constitute the largest proportion of nursing population. They play a very significant role to ensure that effective quality care is provided in improving the health system [ 1 ]. In order to improve the health coverage and achievements of health targets, adequate nurses are crucial as the effectiveness of the patient care depend on the availability of more nurses [ 2 , 3 ].

While the world has acknowledged nursing profession as vital in delivering healthcare services, one of the main challenges faced today globally is the shortage of nursing workforce which has major impact on nurses and causes severe effects on the nurses’ performance to provide quality of health care services and improving well-being of the global population [ 3 – 5 ]. The nursing shortage caused severe stress or burned out which aggravate the problems on nurses to leave their job [ 1 ].

According to the World Health Organization (WHO), it was estimated that there will be a shortage of 7.2 million health workers to deliver healthcare services worldwide and by 2035 the demand of nursing will reach 12.9 million [ 6 ]. The inadequate supply of nurses has notably created many negative impacts not only on RNs but also on patient health-related outcome as well as challenges to fight diseases and improving health, which causes increase workload on nurses and later results in decreasing the quality of nursing care [ 7 , 8 ].

There are many factors affecting the healthcare system as a result of shortage of nursing workforce. These include decreased number of student nurse’s enrolment in nursing program and increase number of early retirement due to health problem [ 3 , 9 ]. However, one of the main factors reported in many countries is inadequate policies and workforce planning [ 10 , 11 ].

In the Pacific Island Countries (PICs), the shortage in nursing workforce is becoming a common problem [ 9 ]. In Solomon Islands, Papua New Guinea and Vanuatu, the health worker density per 1,000 populations (mainly nurses and midwives) is far below the minimum threshold density (4.45 per 1,000 populations) to sustain basic health services [ 12 ]. In countries such as Tonga, Samoa and Fiji, the main factors that trigger shortage of nursing staff includes very high rate of nurses’ migration to other countries, especially to Australia and New Zealand for better working conditions and for other potential opportunities. This has created challenges and gaps that needed to be identified to better explore the extent of the nursing shortage and to address it promptly and efficiently [ 13 ].

In Vanuatu, nurses constitute only 58% or 12.0 per 10,000 populations, which is below the WHO recommended ratio of 45 nurses per 10,000 populations [ 14 ]. According to the Vanuatu Ministry of Health (MoH) Annual Report (2018), the number of retiree nurses in the next 10 years will continue to rise but will be disproportionate to the qualified nurses graduated from the Vanuatu College of Nursing Education (VCNE) which becoming a major problem for Vanuatu MoH to fill the vacant positions. This will create more workload for nurses which will impact their performance. This study sets out to explore RNs’ perceptions on the impact of nursing shortage of nurses and their performance in providing quality care in Republic of Vanuatu in 2020.

Methodology

Study design and setting.

A qualitative study was used to gather information using face-to-face in-depth interviews from RNs in three hospitals in Vanuatu between 4 th to 14 th September, 2020. The three hospitals were randomly selected among six hospitals that included Vila Central Hospital (VCH) in Shefa Province, Northern Provincial Hospital (NPH) in Sanma Province and Lenakel hospital in Tafea Province. In-depth interviews are very powerful methods to allow participants to express their view freely regarding their detailed personal experiences [ 15 , 16 ].

Study population and sample

All RNs in Vanuatu were considered as the study population and those who were currently working at the three selected hospitals with at least 6 months’ work experience were included in this study. Those who were not willing to participate in the study were non-respondent. A purposive sampling was used to choose study participants. The RNs were interviewed using face-to-face, in-depth interviews until data saturation is reached. A total of 25 RNs were involved in this study.

Data collection tool

In-depth face-to-face interviews was conducted using a semi-structured open-ended questionnaire to probe elicit information from the identified participants from both the target populations. Open-ended questions aimed for participants to express their personal experience freely [ 17 ]. The interview questions developed is based on relevant literatures and research studies that will fulfill the aim and the research question of the study. Seven questions were prepared and asked during in-depth interview to enable the participants to explain or discuss their perceptions about the research topic.

The demographic information form was also used to collect demographic characteristics regarding their gender, age, marital status, education level, work station and years of experience. The interview questions were checked by 3 experts in the relevant filed and also by 3 RNs to make sure they are understandable and are in line with the research questions before conducting the interviews.

Study procedures

Following the ethic approvals, all potential RNs in three selected hospitals were informed about the aim of study and were invited to participate. An information sheet was used to inform the participants about the purpose, procedure and nature of the study; duration of interview; the right to participate; benefits and risks of the study; notification for decline or withdrawal at any time from participating; informed consent and the interview procedure. They were informed that their information will be confidential and they are allowed to leave the study at any time. Those who met the study criteria and were willing to participate were asked to sign a consent form. An arrangement was made about the date, time and venue of the interview. A trained bi-lingual interviewer who signed a consent form was employed to conduct interviews. Participants were asked about their preferred language to do interview before the interview. Those who preferred to speak in local language were interviewed in Bislama language otherwise the English language was chosen for the interviews. All interviews were audio-taped for transcription later.

Data management and analysis

Cross translation was applied for translating the interviews that were in Bislama to English. All the interviews were transcribed by the main researcher and were checked by the research assistant to make sure they are transcribed accurately. The data were manually analyzed using thematic analysis process to identify the final themes. Thematic analysis is a method which involves identifying, analyzing, and reporting patterns of data and is widely used for analyzing qualitative research [ 18 ]. The participants’ answers were read and re-read closely by the main researcher to divide into key words or phrases into their similar meanings and create codes. The transcribed results were later transferred to A4 paper. Then the coded data were sorted into themes and sub-themes based on the similar issues which formed the result of the study.

Ethics approval

Before proceeding to data collection, ethic approvals were obtained from the College Health Research Ethics Committee (CHREC) in Fiji National University (FNU) and from the Research Ethics Committee in Vanuatu MoH. All participate were provided a consent form and the information sheet. The participants were informed about the purpose of the study and ensures that their identities are anonymous and the participants ‘data and any other information would be kept confidential and protected.

Demographic characteristics of participants

Twenty-five participants were involved in the in-depth interview (12 males and 13 females). With respect of age, 14 with age range <40 and 6 of the participant with the age range from 40–49, and 5 age ≥50, and 18 of them were married. Their educational level, 21 of them had their undergraduate qualification and 4 had their highest qualification as post graduate level which includes post graduate diploma ( Table 1 ).

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https://doi.org/10.1371/journal.pone.0251890.t001

Themes and sub-themes

The thematic analysis found three major themes emerging; 1) Difficult working condition, 2) Reinforcing Factors, and 3) Perceived risks. Each theme had several sub-themes ( Table 2 ). The participants’ reflection for each theme and sub-theme are further expanded and compared with other published studies. In this section, participants are presented with a “P” and cardinal number like P1, P2.

https://doi.org/10.1371/journal.pone.0251890.t002

Difficult working conditions

The nurses believe that the conditions where nurses’ work can have a major influence on their performance and the quality of care provided to patients include “heavy workload”, “lack of workforce” and “unusual working hours”.

1. Heavy workload.

All the participants (25) working in the hospitals have confirmed that workload has been a challenge when there are extremely limited nurses to manage the patients on each shift. P3 stated that shortage of nursing and workload is seen throughout the hospital wards which exceed the number of nurses working per shift.

“Shortage of nursing is seen throughout the hospital wards and is a long-term issue where workload exceeds the number of nurses working in one shift” .P3 (a 56-year-old female RN).

All the participants (25) also reported that the workload is increasing because of the high number of patients’ admitted. P16 compared the population in the past with the current and stated that when the population increased, diseases also increased that caused workload on nurses.

“In the past , the population was less but now the population increases due to the high number of disease cases that causes more patients’ admission and more workload to us nurses” .P16 (a 32-year-old male RN)

Some of the participants (15) reported an inadequate number of nurses working in each shift also create challenges due to workload when other nurses on sick calls or annual leave. P6 expressed the workload when only one nurse worked to cover for nurses who were on various leaves.

“Workload is too much as most of the time only two nurses working in each shift is not enough , if one staff on sick leave or annual leave then we must double the shift” . P6 (a 34-year-old male RN)

Four participants stressed the ratio of nurses to patients admitted in the hospital in Vanuatu as a huge difference which affects nurses’ performance compared to the other countries. P14 stated:

“Uh… . when we look at the ratio of nurses to patients in Vanuatu which is 1 : 10 or 1 : 15 compared to other countries of which they have 1 : 4 , there is a huge difference . One ward receives on average of 20 to 30 patients at one time but only 2 to 3 nurses work on one shift which is too much for one nurse to perform his or her duty effectively” .P14 (a 33-year-old male RN)

Twenty participants have the same responses due to the nursing shortage they experienced in their workstation, that they neglected a lot of their duties and responsibilities as a registered nurse. P8 reported that the impact of shortage prevents him to perform his duties and responsibilities such as home visits and other bedside nursing care which also affects the quality of care the patients required.

“Impact of shortage prevents me from performing some of my duties and responsibilities such as home visits and follow-up care to patients with chronic illnesses . Bedside nursing and wound care or wound management are also not done regularly , which can have a great impact on patients’ health” . P8 (a 43-year-old male RN)

2. Lack of workforce.

Increased workload compared to less number of nurses working in the hospitals causes nurses’ physical exhaustion leading to job dissatisfaction as expressed by all 25 participants. P11 expressed the result of lack of workforce to his well-being.

“Workload is too much in the hospital wards and we cannot do all our work at one time……I normally experienced tiredness and exhaustion and not interested to work due to incomplete jobs seen each day” . P11 (a 37-year-old male RN)

Thirteen of the participants responded that the increased workload does not correspond with the number of nursing staff in the health facilities especially with increased number of patients admitted and less number of nurses working. P8 stated that the number of workforce does not match with the number of workload from increased admission.

“Few nurses do not match with the increased workload today . For example , increased number of admissions with only 2 staff working per shift is a great challenge to us” .P8 (a 43-year-old male RN)

Other participant added:

“Shortage in my ward with only 2 nurses in one shift is not enough compared to the number of patients admitted especially when we have the critical patients that need close supervision in the ward” . P22 (a 53-year-old female RN).

Furthermore, eight participants stated that training and enrolment have significant effects to the shortage on the nursing workforce due to a single nursing college in the country with limited number of student nurses’ enrolment. P6 said that lack of workforce is due to inadequate enrolment from the nursing college each year.

“ One nursing college is not enough to train more nurses to have an adequate number of nurses in the workforce . Furthermore , the decreased number of intakes to only 30 per year is not enough” . P6 (a 34-year-old male RN)

Conversely, seven participants stated that lack of nursing workforce is due to irregular nursing enrollment in the nursing college in the past.

“The reason for having a shortage of nurses frequently is due to uhm……no regular nursing intake from the VCNE each year . In the past 15 years , nursing college always have regular intakes each year even if the number of intakes is less , we still have continuous graduation of nurses each year with a good supply of nurses in the hospital to work and provide care . Nowadays , the intake occur every 2 or 3 years . P20 (a 33-year-old female RN)

Few of the participants (4), reported that the other reasons for lack of workforce is nurse turnover. P24 stated that the workforce is affected especially when nurses leave their profession and look for other jobs elsewhere due to too much pressure from work.

“Workforce is affected when nurses leave their profession and look for other jobs elsewhere . They left due to too much work load and not enough time to rest” . P24 (a 42-year-old female RN).

3. Unusual working hours.

Working long shift hours up to 12 to 16 hours or double the shift due to not enough staff to do shift work especially when staff on sick leave or on annual leave causes physical and emotional exhaustion and also affects quality patients’ care. P21 expressed the reasons for long hours shift and its impact to the nurses and to the patient.

“Most of the time we spend long shift hours of work e . g . 12 to 16 hours or we double the shift due to not enough staff in the ward to do shift work when we don’t have enough staff and when staff are on sick leave . It is so tiring and causes a lot of stress to most of us who work long hours which also affect the quality care provided to patient” .P21 (a 42-year-old female RN)

Fifteen of the participants who normally work shift stated that they used to work double shift especially during the night where only few nurses were working. P17, an experienced nurse expressed that double shifts especially at night is common in the hospital wards when nurses on duty unexpectedly on sick leave which significantly affect the nurses’ physical well-being.

“Double shift is a common practice in the wards especially when there are not enough nurses to work or when a working colleague is on sick leave . This causes much stress to us nurses due to tiredness” . P17 (a 64-year-old female RN)

Five senior nurses responded that occasionally they work 24 hours to assist nurses in the ward when more critical patients are admitted or during an epidemic. P3 stated that as a senior in charge nurse, they committed to work 24 hours when lack of nurses to take care of increased patient admission

“It is our duty as senior nurses to assist the nurses in the wards when more critical patients are admitted or during disease outbreak and work for 24 hours . It is quite tiring but we have no choice because it is part of our responsibilities” . P3 (a 56-year-old male RN)

Three participants responded that during natural disasters, where a lot of nurses are unable to attend work and more patients admitted, they have to work extra hours during the day and during the night. P22 expressed her experience during natural disasters where she has to work on unusual hours to care for the casualties and assist nurses in the wards.

I have experienced spending all day and night for one whole week during tropical cyclones to look after patients as more nurses were unable to come to work” . P22 (a 53-year-old female RN).

Reinforcing factors

The nurses quoted during the interviews that “lack of support” and “lack of development opportunities and advancement in nursing practice” were reasons for low motivations in their performance and job retention.

1. Lack of support.

Most respondents (13) reported that lack of support from the leaders causes low working morale and low motivation. P15 stated that the leaders in the hospital management haven’t provide much support to the nurses.

“We always confront our nursing managers or clinical supervisors concerning problems in our work place such as poor working equipment needing replacement and poor working environment but they always give excuses and no action taken seriously which affects our morale of work ….” P15 (a 35-year-old male RN)

Another participant added:

“We hardly see the managers or supervisors doing regular visitation to support nursing staff and to assess nurses work performance , this causes low staff motivation” . P14 (a 33-year-old male RN)

All nurses (25) responded that lack of family support is common due to working overtime and coming home late from work. One participant (P21) reported that they don’t receive any support from the family especially when they came home late from work

“When I came home very late from work my family got angry with me . I don’t receive any support from my family . They even forced me to quit my job due to coming home late from work every day” . P21 (a 42-year-old female RN)

“Even my family don’t want to give me food due to frustration of continuously coming home late from work . ” P16 (a 32-year-old male RN)

Most of the participants (15) have expressed their frustration due to lack of financial support from the MoH especially special allowance for working overtime and others. P1 stressed that she has been working for more than 20 years but she hasn’t received any financial support concerning their overtime package or other allowance or incentives apart from their normal wages which affect their motivation to perform duty effectively.

“I work for many years but I don’t receive any financial support from the health authorities apart from my little salary regarding extra responsibility allowances or overtime allowances or any incentives” . P1 (a 56-year-old female RN)

“Even our working status is on contract bases for so long due to positions not budgeted for which affects our benefits and job insecurity” . P11 (a 37-year-old male RN)

2. Lack of development opportunities and advancement in nursing practice.

All participants (25) stated that lack of development opportunities to advance in nursing practices and career pathways are common problems that cause disappointment within the working environment. P24 expressed her disappointment that she works for quite a long time in the hospital but chances to advance in her knowledge is very slim and don’t have the opportunity to expand her knowledge and skills in nursing practice.

“I am very disappointed because I worked in the hospital for many years doing the same routine job as usual and I still remain the same usual nurse… . I don’t receive any promotion because I don’t have any opportunities to advance in knowledge and skills in nursing practices” . P24 (a 42-year-old female RN)

“I haven’t seen any effective career pathway for nurses developed by managers for further trainings to upgrade nurses’ knowledge and skills for advancement in our clinical practice” . P4 (a 34-year-old male RN)

All the participants stated that most of them don’t have any chances for professional development. P18 responded that most nurses perused their training from the Vanuatu nursing college with a diploma level and haven’t had any chances to upgrade to a higher level of qualification.

“ Most of us nurses graduated from the nursing college with a diploma of nursing but we don’t have changes to upgrade to a higher level of qualification or to up skill our-selves” . P18 (a 30-year-old female RN)

“Our skills in nursing practice need to be upgraded in order for us to advance with our clinical practices . It is very good to have regular in-service training but it never happens on regular bases , in order to keep us updated with our nursing practice skills ”. P2 (a 34-year-old male RN)

Other nurses reported that specialty training is also necessary to up skill nurses and advance in their clinical practice in the speciality area but only few nurses had given the chances in the past to attend those training.

“Vanuatu needs more specialized nurses to provide quality care to different types of patients however , only few nurses had been given the chances to take up those training which is still needed for more nurses to take specialize training to provide effective and quality care needed” . P3 (a 56-year-old female RN)

Perceived risk

The nurses quoted during interviews that “stress” and “physical and medical risks” were reasons that affect nurses and increased the chances to quit their profession.

Majority of the participants (20) have worked in the hospital for more than 5 years and reported that they have experienced the impact of shortage of nursing personally. P5 reported that stress causes a major effect on nurses due to workload and also threatens her job.

“I experienced tiredness , stress and not satisfied with my job each day due to work overload . I normally go home late due to long hours of work and no time for my family which affects my family relationship . Even my family asked me to look for another health facility to work which has less workload” . P5 (a 31-year-old female RN)

Four of the participants stressed the effects of work overload and overtime due to nursing shortage causes stress and frustration and violence at home.

“Work overload and work for long hours causes a lot of stress and frustration where I don’t have enough rest , no time to relax , and not enough quality time for my family which causes frustration and violence in my home” . P23 (a 53-year-old female RN)

O ther participants (12) added:

“Stress is the result of tiredness and not enough rest especially when the ward is full and less nurses working and you have to double the shift” . P12 (a 40-year-old female RN)

2. Physical and mental risks.

Some participants (6) stated that work overload and work for long hours causes more physical and medical risks

“Shortage of nurses affects our physical body very badly . We experienced back pain and back injury for trolleying patients to the theatre and to other diagnostic units……and we felt tired and cannot provide the best quality nursing care to our patients” . P20 (a 33-year-old female RN)

Other physical risks which was reported by all participants (25) is when they don’t have enough time to rest and eat or drink due to too much work load and limited nurses. P24 expressed that they don’t have enough time to rest and eat during busy times which affect her physical body and her health.

“Most of the time our ward is busy and those times I don’t have enough time to rest and eat or even drink which affects my physical health” . P24 (a 42-year-old female RN)

Workload with only few nurses causes a lot of medical risks on nurses’ health and clinical performance which leads to early retirement or were granted early retirement due to medical reasons. One participant stated:

“A lot of nurses in our hospital leave their job and most of them were granted early retirement due to medical health reasons which prevent them to continue with their job” . P11 (a 37-year-old-female)

“I worked almost 20 years now and I have medical issues which affect both my lower extremities and I have requested to take my early retirement because I won’t be able to work with the current health conditions . My health conditions will not only affect my well-being but will also affect my clinical nursing performance” . P7 (40-year-old-female RN)

Most nurses (15) reported that high job demands increase physical and mental health problems. P9 mentioned the impact of stress to physical and mental problem on nurses

“Stress affects our mental health when we are exhausted due to work overload which prevents us to think properly which also increases the chances to make mistakes” . P9 (a 56-year-old female RN)

“When we have too many patients and lack of skills especially for us inexperienced nurses , it affects us psychologically as well which can affect our performance” . P5 (a 31-year-old male RN)

3. Medical risk.

One of the respondents stated that medical errors are one of the common risks that occur due to stress from working long hours or work overload.

“I have experienced the result of stress that causes high chances of errors in our work station which threaten the lives of the patient . Some prevented errors are the result of work overload and long hours of work which prevent nurses from perform their duties effectively and increase the chances to make mistakes” . P2 (a 34-year-old male RN)

Four participants reported that medical errors were seen in their work station due to physical and psychological stress where they gave incorrect medication to the patients.

“Few times I gave incorrect medication to patients because I can’t think properly due to tiredness and exhaustion or sometimes I gave the correct medication but I don’t explain it well to the patient especially the dose , time and route of administration” . P4 (a 34-year-old male)

“Most of the time due to frustration and too much workload I don’t practice infection control rules and regulations which cause more medical risk to my patients” . P11 (a 37-year-old male RN)

4. Social and family risk.

Nurses experienced social and family risks when they have high volume of pressure and when patients are not receiving services immediately, they cause mischief to nurses and their families. P12 expressed his fear when patient and relatives were frustrated due to patients’ not receiving care or service immediately and threaten her family.

“I experienced most times especially when we have less nurses working in one shift in the emergency department when I and even my family were threatened when patients’ relatives got angry with me for not attending to them immediately or not treating them well as expected . Sometimes they threatened me and my family as well” . P12 (a 40-year-old female RN)

“Occasionally I get frustrated from work due to pressure and when I bring frustration to my home , it causes domestic violence in my home . This causes much risk to my family” . P6 (a 34-year-old male RN)

Prompted by the findings from the RNs in Vanuatu on the nursing shortage, it impacted the health service delivery throughout the Vanuatu population [ 14 ]. Although the Vanuatu MoH has been implementing strategies in the past to address the issues, the shortage of nursing is still evident with the current nursing workforce shortage of more than 400 where Vanuatu MoH is still unable to fill the shortage gaps [ 14 ]. The current study findings have reported the impact of nursing shortage on the nurses and their performance in providing quality care.

The working conditions for nurses have major influence on the nurse’s performance and the quality of care provided to patients due to job dissatisfaction. The findings emerged with the condition which includes workload due to high patients’ admission, lack of workforce and unusual working hours. Several studies have shown that job dissatisfaction always emerged along with poor working conditions due to workload and lack of workforce [ 19 , 20 ].

It is obvious that the workload in the health facilities within the MoH health system has been a long-term issue and become a challenge when few or limited number of nurses who care for the large number of patients admitted, and workload exceeds the number of nurses working in each shift. The maximum number of nurses working per shift is 2 to 3 nurses according to the findings, which is not effective to provide a quality care needed for nurses and patient’s safety. Although the managers within the hospital setting are aware of the workload issues, they have no better solutions to address the workforce shortage as it become a major challenge across the country that needs effective planning and policy directions from the policy makers at the government level. Studies stressed that work load is becoming a major factor when there are inadequate number of nurses working compared to the demand [ 21 , 22 ]. Other studies from other developed countries also reported that inadequate policy direction and planning has huge impact on nursing population including nurses’ workload [ 5 , 23 ]. The difference is that our study participants have experienced shortage and its impact while working in the hospital and might have limited knowledge about the policy and planning direction of Vanuatu MoH.

With few number of nursing staff compared to high workload, causes a lot of pressure and physical exhaustion to nurses. There are factors that contributed to lack of workforce identified by participants who include low student nurse enrolment or irregular training provided by the nursing college. Although the nursing college enrolled nurses continuously for the last 30 years, the number of output is so limited and does not match with the increased demand. Other health leaders also supported the fact that low enrolment in the nursing college is becoming obvious when looking at the current increase number of aging population of nurse within the MoH. Studies from other countries stated that low enrolment have significantly contributed to lack of workforce which affect nursing and their profession in the future [ 4 , 24 ]. The shortage were identified by the participants from the low number of nurses distributed and work in each of the hospital.

In this study it was found that most of the nurses working in the hospital had experienced long shift hours up to 12 to 16 hours or double the shift due to not enough staff to do shift work or when other nursing staff on sick calls or annual leave. The nurses stated that long working hours is very stressful which affects their work performance and as well as their social and family relationship. The nursing managers and senior clinical supervisors aware that nurses normally work on unusual hours when not enough staff to do shift work, and have noticed moral distress on nurses which affects nurses’ motivation to perform the job effectively. In other industrialized countries, one third of the nursing workforce has irregular or unusual working hours which significantly affects the nurses’ health and patient outcome [ 25 ]. Furthermore, pressure of working long hours contributed to nurses leaving their profession from job dissatisfaction and poor working environment. Study have shown that nurses leave their job due dissatisfaction with working condition in a stressed environment such as irregular working hours [ 26 , 27 ].

Findings shows that lack of support and lack of development opportunities and advancement in nursing practice were reasons for low motivations which affects nurses’ performance.

Most nurses reported that lack of support from the managers and supervisors causes low working morale and low motivation to perform duties effectively. Although the nursing managers and senior clinical staff are experienced in their position, nurses still haven’t received full support for the leaders. This includes no regular visits and no actions to nursing staff complaints or grievance. It is evident due to areas that yet to be resolved and need urgent actions from the managers. Studies show that nurses needed attention from the managers and supervisors to identify areas that needs urgent or serious attention or early detection of any problems that might occur among nurses and their work performance [ 20 , 28 ].

Most of the nurses stated that lack of development opportunities to advance in nursing practices is one of the common issues that create disappointment on nursing staff within their working environments. Nurses believed that when opportunities to advance is left too long or no attention from their superiors, it causes low motivation that leads to low performance that will certainly allow nurses to leave their job. Although the HR at the national level develop career pathway for nurses, most nurses are not given any chances to advance in their profession or capacity building as part of their professional development, which is also reflected on the level of Education on demographic information where the highest level for most nurses is diploma of nursing. A study in Iran has shown that lack of opportunities to advance in nursing and lack of professional vision towards nursing, cause discrimination among nurses and dissatisfaction which causes nurses intended to leave their profession [ 21 ]. According to the RNs personal characteristics, more than 50% have completed undergraduate studies with diploma of nursing as their highest level of nursing which reflect lack of professional vision to upgrade nurses to higher level which might results to low motivation in the workplace.

The findings perceived that stress and medical risks impact nurses that increase the chances to quit nursing profession.

Stress has major effect on nurses not only with physical exhausted but also has an effect on social and family relationship. Stress affected nurses due to workload and overwork which significantly affect the quality of care provided to patients as well. Majority of the RNs who work in the hospital might experience the impact of shortage of nursing personally because they have worked for more than five years. If stress was managed promptly, it will prevent burnout, job satisfaction and improve patients’ quality care. Although studies have shown that stress affect all nurses due to worldwide nursing shortage, the nursing managers and leaders in Vanuatu, who have in contact with nurses regularly must have better understanding of stress and its relationship and also its symptoms in order to manage stress effectively [ 29 , 30 ]. It is important for Vanuatu MoH to adopt stress management process by other countries in order to identify and management stress among nurses effectively.

Findings have shown that work overload and long hours’ work causes serious threats to nurse’s physical health. Furthermore, finding shows that nurses experienced injuries and other medical conditions while performing service. Furthermore, majority of the RNs have been granted early retirement due to medical reasons that might be due to work overload or poor working conditions. The challenges of having nurses gone on early retirement is when not enough nurses for replacement, however nurses with medical reasons need to leave their profession as they will negatively impact patient’s care and also their well-being. Studies supported that mental and physical health of nurses has significant effects on the quality of care provided to the patient [ 30 , 31 ]. On the other hand, other studies supported that senior nurses leave their profession before their retirement age due to medical reason and is necessary for patients’ safety to decrease mortality [ 32 , 33 ].

Furthermore, stress associated with nursing shortage has a significant impact on patients’ care in the hospital which causes much health risks and increase the risk of medical errors and lack of quality care up to a required standard. Findings show that, Vanuatu nurses were able to work under pressure, but medical errors can still be experienced at the workplace. Studies confirmed that medical errors are associated with nurses’ psychological stress and other health risks due to work overload [ 8 , 31 ].

Study strengths

The study is a high quality study and the first study that was conducted in the Republic of Vanuatu among the registered nurses. The study rigors was followed from conducting the study, data collection and data analysis. The study will benefit the Vanuatu ministry of health by enabling the policy makers to refine and develop relevant policies to address and strengthen the nursing workforce to meet the demand and improve delivery of quality health services to all individuals in both urban and rural settings.

Study limitations

There were some logistic limitations in terms of conducting interviews or reach the study participants easily due to was unable to Covid-19 pandemic. It was not possible to study other hospitals in Vanuatu to extract more information due to time limitation.

This study has identified many key factors that contributed to the shortage current nursing workforce and the impact it has on RNs which needs to be addressed promptly to resolve the shortage of nursing workforce Vanuatu in the coming years. Broad themes and sub-themes were identified which highlighted the impact of nursing shortage to RNs and the effects on their performance. The studies showed that stress or moral distress from work overload and lengthy hours shift impact the nurses’ physical, psychological, social, and family relationship.

The recommendation to assist the Vanuatu government through the Ministry of health to address chronic shortage of nurses is, the government should invest on establishing a much bigger nursing college to increase its yearly intake in nursing, to have interim plan to address the current shortage of nurses and review the whole nursing situation and nurses distribution, and to promote nursing in all the secondary levels of education.

Acknowledgments

We would like to thank all the study participants and those who were very supportive for their valuable time and participation in the interview.

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• 6. World Health Organization (WHO). Global health workforce shortage to reach 12.9 million in coming decades. 2013; Available on: http://www.who.int/mediacentre/news/releases/2013/health-workforce-shortage/en/
• 11. Amadi E. Healthcare leaders’ perceptions about the nursing shortage: A qualitative collective case study available from Dissertations & Theses @ University of Phoenix. 2015; Retrieved from https://search.proquest.com/docview/1747438477
• 14. Ministry of Health (MOH). Workforce Development Plan 2019–2025. Building capability and leadership. 2019; Port Vila, Vanuatu.
• 32. Uthaman T, Chua TL, Ang SY. Older nurses: A literature review on challenges, factors in early retirement and workforce retention. London, England: SAGE Publications. 2016; https://doi.org/10.1177/2010105815610138

International Nurses Day: New research addresses UK’s nursing shortage

Tactics from around the world to encourage school leavers into nursing have been examined by the University of Southampton, with a view to helping fill the tens of thousands of vacancies in the UK.

It coincides with International Nurses Day which celebrates the contribution that nurses make to society, on Sunday 12 May – the anniversary of Florence Nightingale’s birth.

The study  says better links between universities and schools, as well as access to nursing work experience, are needed to attract more school leavers to study nursing.

Young people’s preconceptions around low pay, poor working conditions, and nursing being for women, must also be addressed if the thousands of vacant nursing posts in the UK are to be filled.

In 2021-2022 there were 46,000 vacant NHS nursing posts in England. The Health Foundation has predicted that, without intervention, there could be 140,600 empty nursing jobs by 2030 .

A project by Clinical and Health Research master’s student Emily Clipstone and Dr Leire Ambrosio, Lecturer in Adult Nursing at the University of Southampton, has found school leavers are overlooked when it comes to nursing recruitment. In 2021, 7,105  university places to study nursing were taken up by school leavers, compared to 17,415 places taken by mature students.

The project brings together, for the first time, educational strategies used in different countries to increase the numbers of school leavers going on to study nursing.

Emily said: “Nursing is seen by school leavers as a comparatively low-paid job choice, and one that is traditionally female. Through examining strategies used around the world, we’ve looked at how these engrained ideas could be challenged in the UK to boost recruitment into nursing.”

Successful tactics used in other countries to boost teenagers’ interest in nursing include clinical simulation sessions (in Bahrain), nursing open days at universities (in Italy), pre-nursing scholarships with a week’s residential experience (in Scotland), six-week internships in clinical settings (in the United States), and a health club in school with visits from nurses and voluntary nursing work in the community (in the United States).

Dr Ambrosio explained: “From analysing the outcomes of these initiatives in other countries, it’s clear that exposing young people to the settings of studying and working in nursing – giving them real life experience in the profession – makes a huge difference to piquing their interest in pursuing a nursing career.”

The project paper recommends further research over an extended period to assess how successful these practical recruitment strategies are at turning school leavers’ interest in nursing into studying nursing at university.

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