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The Problem of Nursing Turnover and Shortages

The clinical environment in contemporary society is complex, which makes the process of implementing change a daunting task (Gale & Schaffer, 2009). As such, it is of the essence to make adequate plans before introducing the change. Varnell, Haas, Duke, and Hudson (2008) have argued that unilateral decisions undermine the progress from the status quo. The involvement of the administrators and nurses in the process will facilitate the formulation of negotiated goals (Pagoto et al., 2007). The administrators will approve the allocation of resources if they understand the objectives and benefits of the project. On the other hand, the nurses will embrace the planned change if they participate actively in all the planning, decision-making, and implementation processes (Gale & Schaffer, 2009).

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The Current Problem

The increasing cases of nursing turnover and shortages are affecting the quality and safety of healthcare in modern society (Hayes et al., 2012). The review of the literature has highlighted multiple consequences of reduced staffing levels. Firstly, Duffin (2012) has found out that the small nurse-patient ratios increase the rates of hospital-related mortalities and morbidities. Gillen (2012) has linked the increasing incidences of the adverse clinical events to heavy workloads, which are caused by nursing shortages. Secondly, the inadequate staffing inherent in the majority of hospital wards and units have undermined the delivery of holistic care (Morgan & Lynn, 2009). According to Garrett (2008), overworked nurses cannot meet the unique needs of every patient under their care.

Health organizations and regulatory bodies have developed the minimum nurse-patient ratios (Duffin, 2012). Conversely, Kendall-Raynor (2011) has argued that the current nursing shortages make it difficult for health facilities to comply with these requirements. Some hospitals have even reduced their capacity because it is costly to establish and maintain an adequate staffing level and mix (Unruh & Ning, 2012). On the other hand, there is no consensus in the literature about the correct patient-nurse ratio. Despite these limitations, all the stakeholders have recognized the effect of adequate staffing on patient outcomes (Karantzas et al., 2012). A need has arisen to increase the current staffing levels. This strategy is essential to reduce the missed opportunities (Rondeau, Williams, & Wagar, 2009).

The Proposed Solution

The proposed solution will entail increasing the number of registered nurses in the health facility. It is imperative to note that a safe nurse-patient ratio will complement other initiatives to enhance the clinical outcomes. The rationale behind this decision is that individual and system factors affect the quality of care besides staffing levels (Gunusen, Ustun, & Gigliotti, 2009). Gillen (2012) has asserted that the sheer increase in the number of nurses does not translate to high-quality and safe patient care automatically. By contrast, Kalisch, Gosselin, and Choi (2012) have argued that an increase in the levels of staffing can only be effective if health facilities address the other issues that affect the quality of care.

The Neuman Systems Model will support the proposed changes because it stresses the importance of holistic care. Neuman’s model consists of four paradigms that affect the patient outcomes: person, health, environment, and nursing. The complex interplay among these variables shapes the coping mechanisms of the nurses during the care process (Gunusen et al., 2009). For instance, heavy workloads cause burnout among the nurses. Consequently, the affected hospitals often report an increase in the cases of absenteeism, staff turnover, dissatisfaction, and depersonalization (Unruh & Ning, 2012). The preceding example illustrates the essentiality of creating appropriate systems and procedures (Kane, Shamilyan, Mueller, Duvall, & Wilt, 2012).

The targeted health institution has been unable to maintain the right mix and number of nurses. The hospital has also recorded a high turnover in the past year, which has reduced the staffing levels significantly. This situation has lowered the hospital’s capacity to meet the demands of its clients. The principal concern is that the inadequate staffing levels are undermining the delivery of safe and quality care. Neuman’s model will address these challenges by identifying new practices, concepts, and ideas that can improve the present scope of nursing care. This theory will assist the nurse leaders and other hospital administrators to handle the issues of burnout, stress, absenteeism, and employee turnover (Gunusen et al., 2009).

The Rationale for the Proposed Solution

The escalating costs of healthcare, coupled with a high staff turnover have lowered the nurse-patient ratios significantly (McGahan, Kucharski, & Coyer, 2012). In the same vein, the healthcare sector has come under immense pressure to enhance the quality and safety of patient care (Unruh & Ning, 2012). The primary concern is that the dwindling nurse-patient ratios are compromising the quality of care (Kalisch et al., 2012). The proposed solution will address these concerns by increasing the current ratio of registered nurses to patients. The rationale underpinning this intervention is that adequate staffing will reduce the underlying risks of medication errors, hospital-acquired infections, and other adverse clinical events (Garrett, 2008). McGahan et al. (2012) have argued that high nurse-patient ratios reduce mortality, morbidity, and readmission rates.

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The Review of the Supporting Literature

The significance of nurse staffing has continued to receive much attention in both health care literature and policy discourses. For example, clinical researchers have been exploring and analyzing the correlation between nurse staffing levels and patient outcomes (Kendall-Raynor, 2011). The Institute of Medicine (IOM) has underscored the critical role that the nursing function plays in enhancing patient outcomes and the quality of care (Garrett, 2008). Rondeau et al. (2009) have identified the adequate nurse-patient ratios as an imperative policy issue that has received widespread consensus and support. In essence, nurses influence the safety and quality of care because they constitute one of the most critical components of the healthcare system (Unruh & Ning, 2012).

The nurse administrators determine the level of staffing based on the demands of the labor market and budgetary considerations. Accordingly, administrative practices influence the nursing staff mix, as well as the allocation of duties and working hours (Kane et al., 2012). Kalisch et al. (2012) have noted that the nurse administrators define the scope of supervision and continuing education programs. These factors also inform the models of care, working environment, and employee satisfaction (Morgan & Lynn, 2009). Interdisciplinary teams, collaboration, and communication play a significant role in the delivery of health care. These factors ultimately affect the quality of nursing care, as well as the quantity of time that nurses dedicate to each patient (Rondeau et al., 2009).

The provision of quality care mandates the nurses to execute assessment and intervention procedures appropriately. The complexity and acuity of each patient’s health status determine their individual outcomes (Kane et al., 2012). The patients’ functional status and co-morbid conditions also affect the quality of care. Thus, the patients’ vulnerabilities vary considerably and can change at any moment during the caring or treatment process (Gillen, 2012). These factors mandate the care provider to monitor every patient to ensure the delivery of the patient-centered care (Duffin, 2012). Nonetheless, the inadequate nurse-patient ratios are causing heavy workloads, prolonged working hours, and constant interruptions. Consequently, the nurses do not provide optimal care (Morgan & Lynn, 2009).

The preceding discussions have illustrated that numerous factors influence the delivery of health care. On the one hand, individual nurse characteristics (experience, skills, knowledge, and fatigue) influence the care process. On the other hand, the systems in which the nurses perform their duties also have a profound impact on the nursing practices (Rondeau et al., 2009). Some of the latter factors include the organizational culture, staffing mix, quality standards and policies, and leadership. According to Gillen (2012), these aspects interact inextricably with staffing levels to influence the quality and safety of nursing care. Kane et al. (2012) have underscored the significance of addressing the system and individual factors concurrently with staffing levels.

The Implementation Logistics

The organization has to mobilize all the required resources in readiness for the implementation of change (Pagoto et al., 2007). Kurt Lewin identified two opposing forces that influence the change process. The driving forces affect the change positively while the restraining forces undermine the process (Haas, 2008). The change can only become meaningful if the former supersedes the latter. Newhouse (2007) has acknowledged the importance of performing a force field analysis to determine the drivers and restraints of the planned change. The principal goal of this appraisal is to develop a strategy that will maximize the driving forces while at the same time minimizing the restraints systematically (Gale & Schaffer, 2009).

There is a growing consensus in the health care system regarding the incorporation of research into clinical practice (Oman, Duran, & Fink, 2008). The majority of the health professionals possess limited knowledge of the evidence-based practice (EBP). The primary challenge is that EBP necessitates a radical transformation of the organizational culture (Eaton & Tipton, 2009). The force field analysis will enhance the drivers of change by building an environment that supports change (Gale & Schaffer, 2009). Both the individual and leadership commitment will question the status quo to create the urgency for change. The transformation of the current culture will require a raft of logistical consideration (Oman et al., 2008).

The health providers will not implement the planned change adequately if they have limited knowledge of EBP. Thus, it is essential to mentor the practicing nurses and other clinicians (Funderburk, 2009). The implementation team will develop clinical supervision programs to strengthen the skills and competencies of the nursing profession. The nurse preceptors and other senior staff will play an integral role in sharing their experiences with their subordinates (Funderburk, 2009). Further, the development of continuing education programs will enhance the nursing practice because they will expose the service providers to new ideas and sophisticated practices (Oman et al., 2008). The providers should also gain an in-depth understanding of the research methods to support the appraisal of evidence (Persaud, 2008).

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The integration of evidence in the current practices represents another logistical challenge. Health care facilities often use predetermined procedures and policies to guide the clinical practice (Persaud, 2008). The evidence-based practice provides an opportunity to infuse the best available scientific evidence into the nursing processes (Oman et al., 2008). Nonetheless, Oman et al. have underlined the complexity inherent in the development of policy guidelines. The implementation team will have to develop a panel of experts to facilitate the policy development and revision processes. These professionals will analyze the existing procedures and processes to identify gaps and opportunities (Eaton & Tipton, 2009).

Resources

An organization cannot implement the evidence-based practice successfully without providing concrete resources. The change agent will appraise the hospital’s current stock of resources (Newhouse, 2007). Firstly, leadership is a critical asset that will foster the cultural transition. Effective clinical leadership will be essential to offer guidance, as well as manage the multidisciplinary team (MacRobert, 2008). Secondly, the staff development resources will ensure the seamless integration of EBP. These materials will include education tools, evaluation tools, research mentors, fellowships, journal clubs, and workshops. The hospital will also require financial resources to train and hire additional nurses (Newhouse, 2007).

The use of technology will provide practical resources and the opportunity for efficient communication. For instance, multimedia tools and computer software will facilitate the dissemination and storage of information respectively (Newhouse, 2007). It is imperative to note that the management of change is a continuous process, and the organization may not have all the resources from the onset. By contrast, the change agent will scale-up the resources as the need arises (Gale & Schaffer, 2009). The most appropriate strategy will be to develop a resource inventory or manual. This document will assist the implementation team to rationalize the use and allocation of funds during the budgeting process (Haas, 2008).

References

Duffin, C. (2012). Nurse-to-patient ratios must increase to improve safety. Nursing Older People, 24(4), 6-7.

Eaton, L. H., & Tipton, J. M. (2009). Putting evidence into practice: Improving oncology patient outcomes. Pittsburgh, PA: Oncology Nursing Society Press.

Funderburk, A. E. (2008). Mentoring: The retention factor in the acute care setting. Journal for Nurses in Staff Development, 24(3), E1–E5.

Gale, B., & Schaffer, M. (2009). Organizational readiness for evidence-based practice. The Journal of Nursing Administration, 39(2), 91–97.

Garrett, C. (2008). The effect of nurse staffing patterns on medical errors and nurse burnout. AORN Journal, 87(6), 1191-1204.

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Gillen, S. (2012). Most nurses are struggling with inadequate staffing, survey shows. Nursing Standard, 26(34), 9.

Gunusen, N. P., Ustun, B., & Gigliotti, E. (2009). Conceptualization of burnout from the perspective of the Neuman systems model. Nursing Science Quarterly, 22(3), 200-204.

Haas, S. (2008). Resourcing evidence-based practice in ambulatory care nursing. Nursing Economics, 26(5), 319–322.

Hayes, L. J., O’Brien-Pallas, L., Duffield, C., Shamian, J., Buchan, J., Hughes, F.,… North, N. (2012). Nurse turnover: A literature review – An update. International Journal of Nursing Studies, (49), 887-905.

Kalisch, B., Gosselin, K., & Choi, S.H. (2012). A comparison of patient care units with high vs. low levels of missed nursing care. Health Care Management Review, 4(31), 320-328.

Kane, R. L., Shamilyan, T. A., Mueller, C., Duvall, S., & Wilt, T. L. (2012). The association of registered nurse staffing levels and patient outcomes. Medical Care, 45, 1195- 1204.

Karantzas, G., Mellor, D., McCabe, M., Davidson, T., Beaton, P., & Mrkic, D. (2012). Intentions to quit work among staff working in the aged care sector. Gerontologist, 52(4), 506-516.

Kendall-Raynor, P. (2011). RCN’s fight for safe staffing levels will go on despite setback in Lords. Nursing Standard, 26(14), 10.

MacRobert, M. (2008). A leadership focus on evidence-based practice: Tools for successful implementation. Professional Case Management, 13(2), 97–101.

McGahan, M., Kucharski, G., & Coyer, F. (2012). Nurse staffing levels and the incidence of mortality and morbidity in the adult intensive care unit: A literature review. Australian Critical Care, 25, 64-77.

Morgan, J. C., & Lynn, M. R. (2009). Satisfaction in nursing in the context of shortage. Journal of Nursing Management, 17(3), 401-410.

Newhouse, R. (2007). Creating infrastructure supportive of evidence-based nursing practice: Leadership strategies. Worldviews on Evidence-Based Nursing, 4(1), 21–29.

Oman, K. S., Duran, C., & Fink, R. M. (2008). Evidence-based policies and procedures: An algorithm for success. Journal of Nursing Administration, 38(1), 47–51.

Pagoto, S., Spring, B., Coups, E., Mulvaney, S., Coutu, M., & Ozakinci, G. (2007). Barriers and facilitators of evidence-based practice perceived by behavioral science health professionals. Journal of Clinical Psychology, 63(7), 695–705.

Persaud, D. (2008). Mentoring the new graduate perioperative nurse: A valuable retention strategy. AORN Journal, 87(6), 1173–1179.

Rondeau, K. V., Williams, E. S., & Wagar, T. H. (2009). Developing human capital: What is the impact on nurse turnover? Journal of Nursing Management, (17), 739-748.

Unruh, L., & Ning, J.Z. (2012). Nurse staffing and patient safety in hospitals: New variable and longitudinal approaches. Nursing Research, 61(1), 3-12.

Varnell, G., Haas, B., Duke, G., & Hudson, K. (2008). Effect of an educational intervention on attitudes toward and implementation of evidence-based practice. Worldviews on Evidence-Based Nursing, 5(4), 172–181.

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