In this essay, I would like to Cover my experience in regard of Staff Shortage and its impact on patients safety & quality of care and factors contributing to shortage and its consequences on Nurses, as a Paediatric Oncology haematology and BMT nurse for 14 years in tertiary care setting in Middle East, and how this topic will explain my professional career. The organization provides the highest level of specialized healthcare in an integrated educational and research setting. The setup have 34 bed capacities designated to Paediatric Haematology, Oncology, Immunology and Bone Marrow transplant, as the services shows it is high dependency and well demand facility and nursing staffing play crucial roles in such aptitude.
Nursing: Nursing is a profession, where nurses utilize their acquired knowledge and skills for the benefits of other individual to help them to go through smoothly during health issues and well-being. Florence Nightingale (1860) defined nursing as “The act of utilizing the environment of the patient to assist him in his recovery”.
Shortage: Oxford English dictionaries (2018) define shortage as noun that “A state or situation in which something needed cannot be obtained in sufficient amounts”. Nursing makes the largest body of employees in health care system. Nurses are a fundamental part of healthcare and make up the major section of the health profession. Nursing staff shortage is not something new; the issue has affected global public from decades. According to the World Health Statistics Report (2013), there are approximately 29 million nurses and midwives in the world, with 3.9 million of those individuals in the United States. Estimates of upwards of one million additional nurses will be needed by 2020. According to Bureau of Labour statistics from monthly labor review (United State department of labor 2015), Healthcare support occupations and healthcare practitioners and technical occupations are projected to be the two fastest growing occupational groups, adding a combined 2.3 million jobs. The combined share of employment for these two groups is projected to increase from 8.3 percent of all jobs in 2014 to 9.2 percent of all jobs in 2024. ANA estimated by 2022, there will be extreme registered nurse jobs existing than any other profession, at more than 100,000 per year. With more than 500,000 seasoned RNs anticipated to retire by 2022, the U.S. Bureau of Labor Statistics projects the need for 1.1 million new RNs for expansion and replacement of retirees, and to avoid a nursing shortage. The report released from, The United Kingdom (UK) nursing Labour Market review (2018), indicated the warning that nursing shortage to be continues as nursing and Midwifery Council showing that more people are exiting than joining Nursing register.
This is driven by ‘perfect storm ‘inter related issues affecting recruitment and retention. Staffing Industry Analysts (SIA) reported in (January, 2018), Nursing staff are in high demand in European countries with the high number of job vacancies increasing for the UK, Netherlands, Germany, France and Belgium, from 2016 to 2017. The data showed that the UK has a shortage of nurses with 790 nurses per 100,000 inhabitants, the lowest number of the five countries surveyed. This is compared to 990 nurses per 100,000 inhabitants in France, 1,050 for the Netherlands, 1,080 for Belgium and 1,330 for Germany. Further records from Job feed revealed that the increase in nurse vacancies between 2015 and 2017 has grown for all five countries surveyed. Germany showed the biggest increase at 26.2%, followed by Belgium (18.0%), UK (17.2%), Netherlands (16.9%) and France (2.9%). In Netherland, Dutch hospitals force themselves to briefly stop patient entry due to lack of staffing. Providing quality health care involves a secure and suitable supply of health-care professionals. Throughout my professional career so far, I witnessed nursing staff struggling due to insufficient work force available as per patients’ demand, as there are many contributing factors associated to this shortage. Recently on (03 Nov 2018) there was news aired about one of the biggest NHS trusts (King George hospital, London) will cease providing chemotherapy, from 12 November because four of its nurses have quit and two others have gone on maternity leave, left few specialist cancer nurses to staff the unit.
Impact on patient care: There have been many studies on the effect of under staffed nursing units and departments; here is the overview of some of the findings. The influence is on safe patient care, caused by prolonged hospital stays, high numbers of readmission rates, rising morbidity and mortality rates, increased infections, as compared to sufficient amount of qualified nurses where such consequences may be less. Moreover, with population growth worldwide and increasing number of health concerns when left to lower number of qualified personnel’s may result task not done, it may lead to dissatisfied customers, poor quality of life and possibly serious outcomes.
Infections: Several multicenter studies using large records showed linked between understaffing and high incidences of nosocomial infections. Some opinions says that if there’s lack of qualified nurses the work burden may increased which chances using short cuts rather than following evidence based practices as per organization policies, for example, hand washing may not be practised or done improper way may lead to increase nosocomial infections. Studies identified some common infections like, Pneumonia, Urinary tract infections. Infections added to long course of antibiotics which leads to prolong hospitalization, contributed to risks of acquired infections and greater the cost. Staffing is a key element of healthcare-associated infection in critically ill patients. Assuming causality, a significant proportion of all infections could be avoided if nurse staffing were to be maintained at a higher level. Consequently, cross-transmission rate might be sensitive to compliance to infection control measures and to workload.
Failure to Rescue: Some evidences found in relation of lower nurse staffing can influence failure to rescue, which probably caused of complications and chances of deaths increased. Although not as strong, some evidence exists regarding the impact of nurse staffing levels on failure to rescue (death within 30 days among patients who had complications) and mortality. A study using administrative data from 799 hospitals in 11 States revealed that a higher number of hours of RN care per day was associated with lower failure to rescue rates.13 In a study of 168 nonfederal adult general hospitals in Pennsylvania, Aiken and colleagues10 found that each additional patient per nurse was associated with a 7 percent increase in the likelihood of mortality within 30 days of admission and in the likelihood of failure to rescue. An earlier study found that hospitals that had more RNs per admission had lower mortality rates.
Medication Errors: Nurses plays final role in preventing wrong medications administration to the patients. When responsibility done under stress due to workload, nurse may avoid performing right direction it might cause of error. Attentive nurses are often step between the patient receiving the wrong medication or incorrect dose prescribed by a physician and pharmacist. One report stated that extra shift work and work under stress contributed to nursing related medication administration errors.
Patient outcome: There is strong evidence in the literature that nurse staffing levels significantly affect several nursing-sensitive patient outcomes. Several studies have been performed to investigate the association between staffing issues or increased workload and health-care-associated adverse events, such as mortality, patient length of stay, costs postoperative complications, medication errors, decubitus ulcers, delayed weaning from mechanical ventilation. In addition to that if patient queries not answered in specific time frame, or left unanswered due to short staff, therefore paid to dissatisfied customers and organizations may lose customer trust.
Contributing factors of nursing staff shortage: Nursing shortages can ignite a wide range of challenges for healthcare organizations, solving the problems of nurse shortages and high vacancy rates can be difficult for most healthcare organizations. From the review of literature the reasons are identified for shortage as categorized staff related factors and organization and customers’ related factors. Customers related factors are Population Growth, Ageing, expectations, demand and level of understanding. In addition, today's consumer is more informed, and with the cost of health care rising, the consumer has greater expectations of the health care delivery system's ability to provide high-quality, compassionate, and professional health care. While organization elements are ageing faculty/nurses, limited resources, cost of nursing schools, lack of job based motivation, less support system, behavior of the leaders’ lack of opportunities of professional development, work environment and deficient incentives. However personal issues like; job dissatisfaction, work related fatigue and exhaustion, work and family balance, work place safety, seek for betterment and immigration etc. might put nursing staffing in vulnerable edges.
Every efforts needs to be done to save the profession in general in terms of measurement of workload, Identification of work system factors that contribute to workload, Evaluation of the impact of workload on outcomes, development of strategies for reducing workload, Evaluation of barriers to improving nurses’ work system.
Impacts on Nurses: While the nursing shortage presents opportunities for nurses, there are potential negative implications, too. Having the right number of appropriately qualified, competent and experienced nurses protects both the public and the nursing profession. Nurses often need to work long hours under stressful conditions, which can result in fatigue, injury, and job dissatisfaction. Through increased pressure, nurses practicing in these environments are more predisposed to making mistakes and errors, with patient quality care suffering. For these reasons and more, ANA is dedicated to improving the workplace safety for all nurses.
Job Dissatisfaction: Many studies conducted have shown relationship between nurses’ working conditions, such as high workload and job dissatisfaction. Lack of satisfaction can lead to low self-esteem, absenteeism, turnover, poor job performance and potentially threaten patient care quality /safety and organizational effectiveness. Job dissatisfaction can start when nurses are expected to perform non-professional tasks such as delivering and retrieving food trays; housekeeping and maintenance duties; transporting patients; and ordering, coordinating, or performing auxiliary services. Nurses' professional job dissatisfaction remains correlated to organizational issues such as inadequate staffing, increased use of overtime, inadequate support system, and salary compression. Other factors like; Work environment and design also contribute to job strain and emotional stresses.
Exhaustion: which interfere with the essence of nursing, a heavy nursing workload can lead to distress (e.g., doubt, anger, and emotional exhaustion) and burnout. Nurses experiencing stress and burnout may not be able to perform efficiently and effectively because their physical and cognitive resources may be reduced; this suboptimal performance may affect patient care and its safety. One of the survey done by Royal Collage of Nursing (2017), one of the older people’s nurse saying “I work hard to provide a high standard of care; however, when I can’t do my job due to staffing issues, I feel my profession is being undervalued. I expect to provide exceptional care every day, not just sometimes. All my patients deserve the best care I can provide; unfortunately this is not always the case, which is something I struggle with.” Not able to meet patient required amount of care demotivate nurses which increase stress level end up to emotionally and physically ill staffing further create negative impacts.
A more stable nursing workforce will reduce the direct and indirect costs associated with staff turnover. Reduced nurse staffing levels have been linked to poorer outcomes for hospital patients, when compared with higher levels of nurse staffing. These poorer outcomes are measured via an increase in mortality rate, infection rates, length of hospital stay, drug error rates and accident rates. Therefore an increase in nurse retention rates will increase staffing levels, reduce the rates of poorer health outcomes for consumers and reduce the costs associated with staff turnover. As a potential solution to the skilled nurse’s shortage, many countries are recruiting immigrants. The nurses’ turnover may be attributed to their dissatisfaction with the quality of care rendered in an institution; autonomy; type of supervision; professional interpersonal relationships; salary; workplace safety; staffing; career development opportunities; hours of work/shift work; mission and purposes of the institution; availability of workplace resources and location of the facility (rural or urban). Today's competitive health care environment has heightened the importance of achieving positive patient outcomes and excellent customer satisfaction. To remain competitive and fiscally responsible, health care organizations must adapt quickly to ever-changing regulatory requirements, quality improvement initiatives, and customer expectations.
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