The Nursing Shortage and Work Expectations Are in Critical Condition: Is Anyone Listening?

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Annette M. Bourgault; The Nursing Shortage and Work Expectations Are in Critical Condition: Is Anyone Listening?. Crit Care Nurse 1 April 2022; 42 (2): 8–11. doi: https://doi.org/10.4037/ccn2022909

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Working conditions have worsened for many nurses and health care professionals across the globe during the COVID-19 pandemic. 1 – 3   During the Omicron wave, the US Department of Health and Human Services has reported critical staffing shortages in 24% of US hospitals, 4   and military medical personnel have been deployed to assist hospitals in at least 8 states. 5   As I write this editorial in January 2022, health care workers have also been asked to return to the work setting 5 days after testing positive for COVID-19. Consequently, many nurses are working 12-hour shifts with an increased patient load, increased patient acuity, and, for some, added mandatory overtime while recovering from illness. These expectations are not reasonable.

  • The Reality

Nurses and other health care workers have been saddled with the burden of the pandemic by first being asked to work in unsafe conditions without proper protective personal equipment and then asked to work in crisis mode after crisis mode, as the various waves of the pandemic hit. 6   And the pandemic is not over. How much more can nurses and other health care professionals be asked to take on? I speak mostly about nurses because this journal is Critical Care Nurse , yet I recognize that nurse leaders, physicians, and other allied health providers are also exhausted and working in crisis mode.

In late January 2022, the incidence of Omicron in US communities is beginning to fall, yet many hospital systems remain burdened by unprecedented high patient volumes and COVID-19–related deaths. Hospital-acquired infections, pressure injuries, and patient falls have increased since the pandemic began. 7   These adverse outcomes are a consequence of the current work environment—a health system issue. Some nurses who may have cared for 2 critically ill patients in the past are now being asked to care for 3 or 4 critically ill patients. Anyone who has worked at the bedside in critical care knows these high staffing ratios are a recipe for failure. 8 , 9   Nurses cannot provide optimal care if they are assigned to too many patients. Some patients may not receive all of the necessary elements of evidence-based care, and some patient needs will not be attended to. This situation is not the fault of the nurse—it is a system failure.

The ideal nurse-to-patient ratio can change instantly, especially in critical care. Patients in the intensive care unit (ICU) have fluctuating requirements; they need a nurse who has flexibility in their assignment and is available to run to their room when they have a critical need. The American Association of Critical-Care Nurses (AACN) developed the Synergy Model to illustrate the importance for patient needs to drive nurse competencies. 10   Appropriate staffing is much more than just a number.

Consider a nurse who may have 3 critically ill patients. This situation can be difficult to manage even if all 3 patients remain stable. What happens if one patient’s blood pressure becomes unstable? This scenario is common in critical care and can involve a large amount of nursing time to assess the cause, alert other health care providers, determine the appropriate interventions, and perform or assist with diagnostic testing and/or interventions to monitor and stabilize the patient. This sudden change in workload takes a lot of time and energy. While the nurse is busy stabilizing this patient, who is looking after the other 2 patients? If every nurse has a high patient load, who has flexibility to assist other patients or other nurses during times of critical need? In health care, we may have little or no control over the timing of critical needs or adverse patient events.

Not all patient needs are critical, but they are all important. For example, a patient who is intubated and ventilated may be scared and anxious. Leaving this patient in a room by themselves for extended periods of time without someone there to reassure them that everything will be OK—is that the kind of health care environment we want? There is little flexibility in the system when nurses are overassigned. This situation can be incredibly stressful for the nurses and extremely unsafe for the patients. Natasha Williams, an emergency department nurse in New York City, said she felt like she was “being pulled in too many directions at once.” These constant interruptions may also lead to unsafe work environments. 11  

Insufficient staffing levels were associated with poor outcomes before the pandemic. 8 , 9   A study of 422 730 surgical patients in 9 European countries showed that patients were more likely to die within 30 days of admission when the nurses’ workload was increased by 1 patient. 12   This study included hospitalized patients with common surgical diagnoses and did not appear to include ICU staffing. If 1 extra patient per nurse on a medical/surgical unit can affect mortality, imagine the implications of adding 1 or 2 patients to the assignment of an ICU nurse.

Global health care staffing costs are projected to reach $47.8 billion by 2026. 13   Some hospitals have started cutting nursing hours to save money, but excellent health care costs money. I am not just referring to the cost of nurses’ salaries, but the cost of adequate and safe staffing levels. We should not allow our institutions to use terminology such as nonproductive time to refer to the valuable time spent by nurses obtaining professional development such as learning how to use a new medical device or working on collaborative evidence-based practices. 14   Just because the nurse is not physically touching a patient, it does not mean that their work is not important. Thinking and educational time is valuable. Nurses need to make critical lifesaving decisions. The public and our health care institutions must be prepared to spend the money necessary to obtain the kind of health care that is expected and desired. No one wants to be on a discount budget plan when they are a patient in the ICU. An inadequate staffing budget can lead only to poor outcomes.

Many nurses are angry and leaving the profession early. Jessica Fink left ICU nursing to focus more on preventative, primary care. 15   She said, “I worry for America’s nurses, and I am angry. The problems they face are inflicting a deep and lasting wound.” 15   As the public gets angry about pandemic issues such as delayed elective surgeries, they need to realize that these delays are caused by systems in crisis. Hospitals in almost half of the US states postponed surgeries during the Omicron wave. 16   If customers are angry about long waiting times for hospital admission or delayed and canceled surgeries, they should also be upset and angry about the type of work environments that nurses are currently working in. If our customers want to receive excellent health care for themselves and their loved ones, they need to support changes to the nursing work environment, such as safe and flexible nurse-to-patient ratios and healthy work environments. I think customers expect safe and appropriate staffing in health care.

Prepandemic research identified 2 major reasons for understaffing of nursing care: (1) poor workplace conditions and (2) inadequate staffing models and flexibility. 17   Dr Linda Aiken, a top researcher on nursing workforce issues, blames inadequate staffing on lack of government legislation, especially at the state level 17   ; she believes that states can assist by mandating staffing ratios. Dr Mary Ann Fuchs, president of the American Organization for Nursing Leadership, says that decisions around flexible staffing should be driven by professional nursing judgment. 18   According to Dr Fuchs, 18   “To truly commit to patient safety—always the number one priority— nurses[,] not legislators[,] need to be empowered with flexibility to determine appropriate staffing for the needs of their patients.” Dr Aiken also highlights the importance of nurses and says that “health care leaders must fund enough positions for nurses and create reasonable working conditions so that nurses will be there to care for us all.” 17  

Policies must be in place to help safely manage nurse-to-patient ratios. It is one thing to say that health care systems can adjust staffing as needed during times of crisis, but when the crisis continues 2 years after the start of the COVID-19 pandemic, enough is enough. Nurses and other health care professionals are human. As they have cared for all of us, many nurses have fallen ill with COVID-19 and too many nurses have died. Some of the nurses are still recovering. We tell nurses to look after themselves to maintain health and resiliency, but how can they do that when their scheduled days off are canceled due to mandatory overtime or they are begged to come into work on their days off? Nurses cannot authentically engage in self-care if they feel guilty about saying no to working when their colleagues are short staffed and overworked. Many nurses are exhausted and our system is failing them. We cannot afford to lose or harm more nurses. Action needs to happen and it needs to happen soon because our health care system is in crisis.

  • Is Anyone Listening?

The answer is Yes! Although I have written about some of the deplorable realities of the current work conditions for many nurses around the globe, I feel hopeful that meaningful and substantive changes will be made to nurse staffing and healthy work environments. We have seen positive changes during the pandemic such as enhanced, interdisciplinary teamwork and expansion of the scope of practice for advanced practice nurses. 1   AACN and other organizations such as the American Nurses Association (ANA), American Organization for Nursing Leadership, Healthcare Financial Management Association, and the Institute for Healthcare Improvement are collaborating to develop strategies for positive change in the health care environment. 19   These organizations will work hard to push for action in a timely manner.

Hopefully, by the time you read this editorial, many nurses will have joined ANA’s initiative to send a strong message to state representatives in Congress. 20   The ANA letter states that “… it’s time for Congress and the Administration to take concrete steps towards finally addressing the nursing shortage to ensure that we have a robust workforce now and in the future.” 20   Nurses can personalize their message to describe the difficult work situations they have been enduring.

We need to create an environment in which nurses can autonomously use their nursing skills at the highest level. We need to create a system where nurses want to work and feel proud about the excellent care that they can deliver. Great health care costs money, and that money should be spent where it is most needed, at the bedside.

Nurses, if you are asked what you would like for Nurses Week in May, I suggest asking one of your hospital administrators to shadow a critical care nurse for a day. This exercise may lead to administrators gaining a greater understanding of the nursing role and the extraordinary demands being placed on nurses.

We have an opportunity to create change, so let us make it happen and soon—before we lose or harm more nurses and other health care professionals. As AACN president Beth Wathen 21   says, “The future of nursing starts now.”

To purchase electronic and print reprints, contact the American Association of Critical-Care Nurses, 27071 Aliso Creek Rd, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; email, [email protected] .

The statements and opinions contained in this editorial are solely those of the Editor.

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The nursing shortage in the United States of America: an integrative review of the literature

Affiliation.

  • 1 School of Nursing, Capital University, Columbus, OH 43209, USA. [email protected]
  • PMID: 12887349
  • DOI: 10.1046/j.1365-2648.2003.02722_1.x

Aim: The aims of this paper are to review the literature to determine what factors are contributing to the nursing shortage in the United States of America (USA) and discuss possible solutions to this current and future nursing shortage.

Background: The need for nurses is often depicted as cyclical in nature. Throughout history, the USA has experienced a series of nursing surpluses and shortages. However, the current shortage has been characterized as being unlike those experienced in the past. Trends of an ageing Registered Nurse (RN) workforce and limited supply to fill the impending vacancies are some of the unique aspects that bring a new dimension to an old problem. Today's nursing shortage will not be resolved by simply returning to the solutions of yesteryear, and strategies to reduce its impact will have to be more creative and focus on the long-term.

Methods: Integrative literature review of published literature on the current nursing shortage in the USA from 1999 to 2001.

Discussion: Four main areas were identified as the major contributors to the nursing shortage in the USA: the ageing RN workforce; declining enrollment; the changing work climate; and the poor image of nursing. Solutions to the shortage followed similar themes to the contributing factors and encompassed four main areas: exploring recruitment efforts; exploring retainment efforts; improving the image of nursing; and supporting legislation that helps to rectify the shortage.

Conclusion: There is firm evidence that the USA amidst a nursing shortage. Much is known about the many contributing factors but now nurses need to become proactive to help secure the future of their workforce. By forming partnerships within the profession and with other influential parties, nurses can be in the forefront of resolving their workforce issues.

Publication types

  • Delivery of Health Care / organization & administration
  • Education, Nursing / methods
  • Nurses / supply & distribution*
  • Nursing / organization & administration*
  • Personnel Selection / methods
  • Population Dynamics*
  • United States

Welcome to American Journal of Biomedical Science & Research

Article Citation

Manana Machitidze. Impact of The Nurses Education and Shortage on The Patients Care Outcomes-Literature Review. Am J Biomed Sci & Res. 2022 - 15(4). AJBSR.MS.ID.002135. DOI: 10.34297/AJBSR.2022.15.002135.

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Biomedical Science and Research

Impact of The Nurses Education and Shortage on The Patients Care Outcomes-Literature Review

Manana machitidze.

*Corresponding author: Manana Machitidze, School of Health Sciences, University of Georgia, Georgia.

Received: January 23, 2022; Published: February 25, 2022

DOI: 10.34297/AJBSR.2022.15.002135

Aim/Objective: The reasons for the shortage of nurses and the factors affecting it varies according to the development of the countries. However, the Covid-19 pandemic has exacerbated the problem globally. The aim of this article is to analyze the problem and its triggers, as well as the consequences.

Background: Qualified nurses are needed to ensure proper care for patients and the general population. Therefore, the lack of well-trained and educated nurses is a rather big problem, especially if the deficit is widespread. The shortage of nurses has reached a critical level for healthcare services, both locally and globally. The global shortage of nurses has been further exacerbated by the impact of the Covid-19 pandemic. Lack of human resources and professional nurses affects patient care outcomes. With sufficient human resources, qualified nurses are needed. The quality of patient care can only be ameliorated if there is sufficient nursing staff in the hospital. Lack of nurses hinders the implementation of nursing education, as there is a shortage in this area. Shortage of teachers limits the number of students admitted to nursing programs.

Design and Methods: The article is based on secondary research and limited to descriptive analysis. The article is based on the analysis of publications and analysis of international organizations (WHO, the International Council of Nurses (ICN)), as well as a review on the shortage of nurses and COVID -19 pandemic impact on Nurses shortage (SCOPUS, PubMed).

Results and Conclusions: Nursing shortages are worrisome, because effects the safety of both-the nurse and the patient. Nurses are busier, more stressed, and less focused on the details during working. The result of this is less communication to patients/ colleagues, making mistakes during working, which increases risks for errors and unsafety during patient care, treatment, and recovery processes. The global shortage of nurses has been further exacerbated by the impact of the Covid-19 pandemic.

Keywords: Nurse, Education, Nursing Shortage, Triggers; Well-Trained; Human Resources; Ameliorated; Communication; Stressed; International Organizations

Abbreviations: IRF - Idiopathic retroperitoneal fibrosis; RPF- retroperitoneal fibrosis; CT - computed tomography; KUB - kidney, ureter and bladder; AMA - anti-smooth muscle antibody; ANA - antinuclear antibody; RF - rheumatoid factor; Anti-TPO - antithioperoxides; ESR - erythrocyte sedimentation rate; Ig4-RD - immunoglobulin 4 related disease; MRI - magnetic resonance imaging; IVU - intravenous program

The nursing shortage is a critical issue not only in Georgia but in different parts of the world. For instance, in the United States, the shortage of nurses in the hospitals happens to cause serious problems since it affects the overall quality of patient care [1]. What’s more, as early research demonstrates, the lack of nursing staff is directly linked to patient complications and even death [2]. Several organizations in the United States, including the IOM, AHRQ and CMS focus on improving the standards and safety of patient care on a national scale. These organizations understand that to reach this goal, they need to first work on increasing the quantity of highly qualified nursing workforce in the hospitals [1]. In other words, the quality of patient care can only be ameliorated if there is sufficient nursing staff in the hospital (ibid).

Moreover, Hassmiller and Cozine [3] explore different ways to address the nurse shortage. By taking the Robert Wood Johnson Foundation’s (RWJF’s) example of supporting nurses, the authors outline how crucial it is to invest in the nursing programs, including leadership and mentoring programs for nurses. It is equally important to change the working processes for nurses-instead of spending more time on administrative tasks, the nurses should focus on the patient and improve care in their units. Furthermore, Hassmiller and Cozine emphasize the role of investing in research. In the case of RWJF, the foundation supported new studies at New York University and the University of Buffalo by tracking the career paths of newly graduated nurses over four years and identifying the factors impacting their work decisions. It is important to note that the problem with the nursing shortage should be addressed by bothprivate and public organizations and invest in the qualified nursing workforce at local and national levels (ibid). Correspondingly, Hahn and Truman’s [6] study describes the importance of public health interventions through educational programs and policies.

While it is important to look at the implications of the shortage of highly qualified nursing staff, it is equally crucial to examine the reasons behind this problem. The nursing shortage is both-a local and a global multifaceted problem. Based on the World Health Organization (WHO) report, 7.2 million healthcare workers are in shortage regarding the existing health needs. This problem, which is becoming more and more serious in Europe, Asia, and North America, might regulate the future world health policy [8]. It’s important to note that population aging and changes in global demographics become one of the factors standing behind the global undersupply of nursing staff. According to the UN, there will be a double quantity of people aged 60 and over, increasing up to 2.1 billion seniors by 2050 [9]. Aside from the demographic reasons, there is also a strong factor of migration involved in the processes. For instance, as Poland became part of the EU, highly qualified nurses started to move to different countries to ameliorate their living conditions. Economic migration of qualified nurses is not only the source of undersupplied nursing staff in Poland but in various countries [8]. It is evident, that to avoid further shortage of the nursing staff in the future, the healthcare system needs to develop better employment conditions for nurses, implement programs oriented on their professional growth and regulate their salary system (ibid). As there is increasing number of nurses leaving their profession [7] it is crucial to urgently address the problem through governmental and non-governmental interventions.

The shortage of nurses became particularly acute at the onset of the Covid-19 pandemic. The current situation has exacerbated the problem. The statistics are disturbing. According to the State of the World’s Nursing (SOWN) report, there was a global deficit of almost 6 million nurses before the pandemic, with the majority (89%) concentrated in low-and low-middle-income countries. Added to this is the fact that for the next 10 years, one in six nurses in the world is expected to retire. This means that 4.7 million new nurses will have to replace them; The migration of nurses puts at risk some country’s health requirements. By the same report, every eighth nurse is in migration. [7]. Countries should seriously consider maintaining nursing attractiveness as a profession. It is important for them to be provided with pay and working conditions, career prospects, continuing postgraduate education. Which will help ensure that the periodic and long-term supply of new nurses will not be delayed.

According to the American Nurses Association (ANA), by 2022 there will be available more registered nurses working than in other professions. According to an article in the Nursing Times, based on a study by the U.S. Bureau of Labor Statistics, 11 million additional nurses are needed to prevent deficits in the future. It is also expected that from 2016 to 2026, the employment of nurses will grow at a faster rate (15%) than in other professions. (NCBI, 2020).

The global shortage of nurses has been further exacerbated by the impact of the Covid-19 pandemic. It is likely that in countries where the impact of different waves of pandemics was significant and severe, it also affected nursing staff. Because nurses ‘’burned out’’, infected, and ‘’post-COVID’’ disability helped to isolate them from work for a short or long period of time. 90% of NNAs report inadequate busy work schedules and a lack of human resources due to pandemics. Low pay, fatigue, stress, and busy work schedules are the major determinants that make nurses think to leave working during pandemics. ICN member NNAs 20% indicates that in 2020 the number of nurses who left the job increased. 70% of associations says their countries are ready to increase the number of nursing students, but still be an interval of few years before new graduate nurses are ready to enter the workforce. It is unfortunate that due to the lack of nurses, the aging of staff, and pandemic result, the ICN estimates that up to 13 million nurses will be needed to fill the global shortage of nurses in the future. (International Council of Nurses, 2021). The data is really alarming.

Addressing the problem of lack of nurses is important for improving the treatment outcomes of patients. Much research is still needed to explore, analyze, and better determine the relationship between nursing care and patient outcomes. When talking about the shortage of nurses, it is interesting to have a consistent analysis of where the shortage of nurses begins. Where is the shortage of nurses coming from-lack of nursing students or graduates? While there is a shortage of nurses in the country, how easy is it for a graduate to get a job? Why do nurses leave their jobs? Is the nursing faculty ready to accept students and ensure a quality teaching process? What is the distribution of this deficit in the different specializations of nursing, can we equate the shortage/deficit with the number of primary care workers and the number of nurses in the clinical sector? Consequently, the factors that contribute to the shortage of nurses are different, not only globally, but also nationwide, and therefore, effective strategies to eliminate the shortage must be different. Unfortunately, due to the lack of nursing staff for a variety of reasons, the nursing profession continues to be in short supply. This is due to the lack of potential nursing educators/mentors, unequal distribution of labor, and migration. Nursing shortages are worrisome because effects the safety of both-the nurse and the patient. Nurses are busier, more stressed, and less focused on the details during working. The result of this is less communication to patients/colleagues, making mistakes during working, which increases risks for errors and unsafety during patient care, treatment, and recovery processes.

I thank the International organizations and the authors for their work whose research findings were used in the article.

Biomedical Science &, Research

Table 1: The cause of the wound must be identified before the initiation of treatment so that it can be controlled accordingly. There are different causes of the wound which are listed.

Biomedical Science &, Research

Figure 1: Homeostasis is the first response generated within minutes. Platelets play their role in clotting. The period of 1-4 days of injury is Inflammation. during this period neutrophils and macrophages remove cell debris and involve in the process of phagocytosis. Proliferation is the period of the 4th-21st day of injury. Proliferation involves the re-establishment of skin function and different cells (Macrophages, Lymphocytes, Fibroblasts, Neurocytes, and Angiocytes) perform their function to re-establish the function of the skin.

nursing shortage literature review

Consanguinity Worldwide

  • Peter I Buerhaus, Karen Donelan, Beth T Ulrich, Linda Norman, Mamie Williams, et al. (2005) Hospital RNs' and CNOs' perceptions of the impact of the nursing shortage on the quality of care. Nurs Econ 23(5): 214-221 .
  • Jack Needleman, Peter Buerhaus (2003) Nurse staffing and patient safety: Current knowledge and implications for action. Int J Qual Health Care 15(4): 275-277.
  • Susan B Hassmiller, Maureen Cozine (2006) Addressing the nurse shortage to improve the quality of patient care. Health Affairs 25(1): 268-274.
  • Anita Atwal, Kay Caldwell (2006) Nurses' perceptions of multidisciplinary team work in acute health-care. Int J Nurs Pract 12(6): 359-365.
  • Lisa M Haddad, Pavan Annamaraju, Tammy J Toney-Butler (2020) Nursing Shortage. Stat Pearls [Internet].
  • Robert A Hahn, Benedict I Truman, (2015) Education improves public health and promotes health equity. Int J Health Serv 45(4): 657-678.
  • International Council of Nurses (2020) COVID-19 and The International Supply of Nurses. Report For The International Council of Nurses.
  • Marć M, Bartosiewicz A, Burzyńska J, Chmiel Z, Januszewicz P (2018) A nursing shortage - a prospect of global and local policies. Int Nurs Rev 66(1): 9-16.
  • United Nations (2015) World Population Prospects: The 2015 Revision.
  • World Health Organization (2013) A Universal Truth: No Health Without a Workforce.

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Reimagining the nursing workload: Finding time to close the workforce gap

US healthcare organizations continue to grapple with the impacts of the nursing shortage—scaling back of health services, increasing staff burnout and mental-health challenges, and rising labor costs. While several health systems have had some success in rebuilding their nursing workforces   in recent months, estimates still suggest a potential shortage of 200,000 to 450,000 nurses in the United States, with acute-care settings likely to be most affected. 1 Gretchen Berlin, Meredith Lapointe, Mhoire Murphy, and Joanna Wexler, “ Assessing the lingering impact of COVID-19 on the nursing workforce ,” McKinsey, May 11, 2022. Identifying opportunities to close this gap remains a priority in the healthcare industry. This article highlights research conducted by McKinsey in collaboration with the ANA Enterprise on how nurses are actually spending their time during their shifts and how they would ideally distribute their time if given the chance. The research findings underpin insights that can help organizations identify new approaches to address the nursing shortage and create more sustainable and meaningful careers for nurses.

Over the past three years, McKinsey has been reporting on trends within the nursing workforce , collecting longitudinal data on nurses’ self-reported likelihood to leave their jobs and factors driving nurses’ intent to leave. 2 “ Nursing in 2023: How hospitals are confronting shortages ,” McKinsey, May 5, 2023. As of March 2023, 45 percent of inpatient nurses (who make up about 2.0 million of the 4.2 million nurses in the United States 3 Nursing fact sheet, American Association of Colleges of Nursing, updated September 2022. ) reported they are likely to leave their role in the next six months. Among those who reported an intent to leave, the top two reasons cited were not feeling valued by their organization and not having a manageable workload. In fact, nurses have consistently reported increasing workload burden as a main factor behind their intent to leave.

About the research

We conducted a survey of 310 registered nurses across the United States from February 8 to March 22, 2023. Our goal was to understand nurses’ perception of time spent throughout the course of a shift and to identify existing and desired resources to help nurses provide high-quality care. Our sample focused on nurses in roles that predominantly provide direct patient care in the intensive-care unit, step-down, general medical surgical, or emergency department settings. Insights were weighted by length of shift (the minimum shift time included was six hours).

For questions related to intent to leave nursing, all nurses from any care setting (including home care and long-term care facilities) were included. Our survey questions on intent to leave have been kept consistent to collect longitudinal data on nurses’ intent. Our last survey, of 368 frontline direct-care nurses, was conducted in September 2022.

In our new survey, nurses provided a breakdown of the average time spent during a typical shift across 69 activities (see sidebar “About the research”). They also reported their views on the ideal amount of time they would like to spend on these same activities. In looking at ways to redesign care activities, we found the potential to free up to 15 percent of nurses’ time through tech enablement, or automation, and improved delegation of tasks (Exhibit 1). Leveraging delegation and tech enablement could reduce and redistribute activities that nurses report being predominantly responsible for. The subsequent reduction in time savings could improve nursing workload and their ability to manage more complex patients. When we translate the net amount of time freed up to the projected amount of nursing time needed, we estimate the potential to close the workforce gap by up to 300,000 nurses.

Nurses report a desire to spend more time with their patients, coach fellow nurses, and participate in professional-growth activities

In our survey, we explored where nurses wanted to spend more of their time (Exhibit 2). The responses fall into the following three categories.

Direct patient care

Nurses report spending the majority of their shift—54 percent, or about seven hours of a 12-hour shift—providing direct patient care and creating personal connections with patients (direct patient care includes patient education, medication administration, and support of daily-living activities). The survey reveals that nurses wish to spend even more time in these activities.

Spending sufficient time on patient-care activities promotes both nursing satisfaction and quality of patient care. 4 Terry L. Jones, Patti Hamilton, and Nicole Murry, “Unfinished nursing care, missed care, and implicitly rationed care: State of the science review,” International Journal of Nursing Studies , June 2015, Volume 52, Issue 6. Furthermore, rushing care and not having sufficient time to meet patients’ needs can contribute to moral distress and burnout.

Teaching and training for new nurses and peers

Nurses report spending on average about 2 percent of their shift teaching peers and students (excluding shifts when nurses are in a dedicated teaching or “precepting” role), an activity they say they want to spend double the amount of time on. Peer-to-peer teaching is an important component of building workplace cohesiveness, improving patient outcomes, and preparing new generations of nurses. In our survey, nurses report that they often lack the time to engage in coaching new nurses. As a result, important informal teaching, which is critical to build confidence and to support skill development for newer nurses, is often missed.

Involvement in professional-growth activities

Similar to educating other nurses, nurses report wanting to spend more than double the amount of time on growth and development activities (about 7 percent of an ideal shift). These activities include participating in shared governance, reviewing and reading work emails, and completing annual requirements and continuing education hours.

Freeing up nursing time to support organizational initiatives and further professional development may contribute to a nursing staff that is more engaged, feels valued, and has a strong connection to their departments.

Nurses desire to spend less time on documentation, hunting and gathering, and administrative and support tasks

Charting and documentation.

Documentation continues to greatly contribute to nurses’ workloads, making up 15 percent of a nurse’s shift. The most time-consuming documentation tasks are head-to-toe assessments, admissions intakes, and vitals charting, which account for the majority of documenting time (70 percent). Nurses say that ideally, documenting should make up only about 13 percent of their shift. But without realistic and effective alternatives (for example, nursing scribes, device integration, reduction in documentation requirements, and AI to aid with documentation), it is unlikely that nurses’ documentation burden can be fully alleviated.

Hunting and gathering

For nurses, hunting and gathering means searching for individuals, equipment, supplies, medications, or information. Nurses report that they spend about 6 percent of a 12-hour shift on hunting and gathering—tasks they would spend approximately 3 percent of their shift on in an ideal shift.

Activities best delegated to support staff

Nurses report spending nearly 5 percent of their shift on tasks that do not use the fullest extent of their license and training. For example, they say they spend nearly an hour on nutrition and daily-living activities, such as toileting, bathing, and providing meals and water. In an ideal shift, nurses say they would spend about 3 percent of their time on these activities.

Redesigning care models: Adjusting how nurses spend their time

As we consider how to alleviate nursing workforce challenges, one area of intervention could be evaluating how current care models can be redesigned to better align nursing time to what has the most impact on patient care. Performing below-top-of-license or non-value-adding activities can create inefficiencies that lead to higher healthcare costs and nurse dissatisfaction. Rigorously evaluating whether tasks can be improved with technology or delegated to allow nurses to spend time on activities they find more valuable could help to reduce the time pressures felt by nurses. 5 “National guidelines for nursing delegation,” a joint statement by the NCSBN and American Nurses Association, April 1, 2019. In our analysis, we reviewed the activities nurses say they would ideally spend less time on and considered whether delegation and tech enablement of such tasks could free up nurses’ time.

Based on our analysis, we estimate that full or partial delegation of activities to roles including technicians, nursing assistants, patient-care technicians, food services, ancillary services, and other support staff, could reduce net nursing time by 5 to 10 percent during a 12-hour shift (Exhibit 3).

While nurses report wanting to spend more time overall on direct patient care, there are specific tasks that could be delegated both vertically and horizontally to ensure that the work nurses perform is at the top of their license and promotes professional satisfaction. Appropriate delegation requires training support staff and upskilling where appropriate, as well as evaluating systemwide resources that can be used where needed. For example, within direct patient care, nearly an hour could potentially be freed up by delegating tasks such as patient ambulation, drawing labs and starting IVs, transferring patients, and supporting patient procedures.

Full or partial delegation of activities to roles such as technicians and other support staff could reduce net nursing time by 5 to 10 percent during a 12-hour shift.

Tasks that are evaluated for redistribution to other clinical and non-clinical staff can also be considered as part of broader care-model redesign. Upskilling support staff across clinical and nonclinical roles can often result in overall better use of resources already in place across a health system.

Tech enablement

Based on our assessment, we estimate that a net 10 to 20 percent of time spent during a 12-hour shift is spent on activities that could be optimized through tech enablement. Investing in digital approaches that automate tasks (either completely or partially), rather than simply redistributing workload, could potentially free up valuable time for nurses (Exhibit 4).

Examples of tech enablement and delegation in practice

To determine the amount of time that could potentially be freed up over the course of a nurse’s shift, we used estimations based on best-in-class care delivery models from practice, innovative emerging technology from industry, and how easy it would be for health systems to implement the intervention (for example, cost and technological requirements).

Tech-enablement

  • Robotic automatic-guided vehicles (AGVs) deliver equipment, food, and supplies throughout a hospital. 1 “Robots help nurses get the job done–with smiles and beeps,” Cedars Sinai, November 29, 2021.
  • Robotic pill-picker machines select and deliver medicines throughout a hospital. 2 Jay Kiew, “The digital surgery: Humber River Hospital reinvents itself with AI & robotics,” Change Leadership, June 16, 2018.
  • Virtual nurses monitor patients remotely, working alongside a bedside-care team comprising a bedside RN, bedside licensed vocational nurse, and virtual RN. 3 Giles Bruce, “Trinity Health plans to institute virtual nurses across its 88 hospitals in 26 states,” Becker’s Health IT, January 13, 2023.
  • Ambient intelligence (that is, passive, contactless sensors embedded in a clinical setting to recognize movement or speech) reduces documentation workload and can continuously monitor patients. 4 Albert Haque, Arnold Milstein, and Li Fei-Fei, “Illuminating the dark spaces of healthcare with ambient intelligence,” Nature , September 9, 2020.
  • Centralized training for roles such as transporters that can then be utilized in all areas of the hospital.
  • Upskilling employees and modifying staffing models allow nurses to work in units where they are needed most (for example, non-critical-care nurses in critical-care departments).

For example, nurses spend 3 percent of their shifts on patient turning and repositioning. This task could be optimized through innovative “smart” hospital-bed technology, including bed-exit alarms, advanced therapy for redistributing pressure, integrated scales and measurements, and remote information on patient conditions. Voice-automated devices and smart beds can also equip patients with control and autonomy over their rooms and preferences (for example, shades, television, and lighting) without nurse intervention (see sidebar “Examples of tech enablement and delegation in practice”).

These interventions, however, can be costly and may not be appropriate solutions in every system. Healthcare organizations will need to assess the specific needs of nurses and patients to determine which interventions will have the most impact.

Healthcare organizations could also consider continuously evaluating the digital approaches they have implemented to ensure that the technology itself does not create redundancies or rework, introduce delays, or adversely increase workload. For example, 37 percent of nurses report that they do not have access to vital signs or telemetry machines that are integrated with electronic medical records for automatic documentation. This could explain why nurses say they could spend less time—about 30 percent less—documenting vital signs. Technology like scanners and automated vitals machines have been an effective way to streamline documentation. But nurses still report spending nearly 10 percent of their shift scanning medications into the patient record, documenting vitals and completed patient education, and drafting progress notes.

Nurse time saved through care-model changes and innovations can benefit patients and nurses—and contribute to building sustainable careers in healthcare

The impact of care-model redesign could range from improving workload sustainability to addressing a substantial portion of the projected 200,000 to 450,000 nursing gap. Our analysis finds a potential net time savings of 15 to 30 percent of a 12-hour shift, based on estimating the possible range of time reduced through delegation 6 “ANAs principles for delegation,” American Nurses Association, 2012. or tech enablement. 7 Mari Kangasniemi, Suyen Karki, Noriyo Colley, and Ari Voutilainen, “The use of robots and other automated devices in nurses' work: An integrative review,” International Journal of Nursing Practice , August 2019, Volume 25, Issue 4.

In our conservative estimate, there would be no additional opportunity to alleviate the potential nursing shortage, as health systems would reallocate the saved time to their current nursing staff for activities they say they would spend more time on, including time with patients, teaching peers, and investing in their growth and development (Exhibit 5). However, this reallocation of time could improve the sustainability of nursing careers in acute-care practice.

In our optimistic estimate, after reallocating time back to nurses, health systems could free up a 15 percent net time savings, which could translate to closing the nursing workforce gap by up to 300,000 inpatient nurses. Achieving this may require health systems to invest heavily in technology, change management, and workflow redesign.

Realizing these changes will require bold departures from healthcare organizations’ current state of processes. It will be critical for hospitals to bring both discipline and creativity to redesigning care delivery in order to effectively scale change and see meaningful time savings. Close collaboration beyond nursing is also paramount to ensure alignment across the care team and hospital functions including administration, IT, informatics, facilities, and operations. A comprehensive evaluation of redesign requirements can enable health systems to understand what is limiting care-model change (for example, policies, skill development, education). Investment in education and additional onboarding may be needed to upskill and train staff on expectations as work is shifted across roles. Partnering with tech companies and industry vendors in areas such as electronic-health-record platforms can accelerate innovation and implementation to build off existing tools and reduce implementation risks. Although the idea of change may be daunting, incorporating innovations in healthcare delivery could be a strategy for building a sustainable workload that could attract and retain nursing talent by allowing them to do more of what matters to them most: taking care of patients and one another.

Gretchen Berlin, RN , is a senior partner in McKinsey’s Washington, DC, office; Ani Bilazarian, RN , is a consultant in the New York office; Joyce Chang, RN , is an associate partner in the Bay Area office; and Stephanie Hammer, RN , is a consultant in the Denver office.

The authors wish to thank Katie Boston-Leary, RN, and the ANA Enterprise for their contributions to this article. The authors also wish to acknowledge and thank the entire healthcare workforce, including all of those on the front line.

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Nursing shortage, a different challenge in Iran: A systematic review

Aziz shamsi.

1 Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran

Hamid Peyravi

2 Department of Critical Care Nursing, Iran University of Medical Sciences, Tehran, Iran

Background: Nursing shortage is an important and multifaceted challenge in the health systems and has reached a warning threshold. The factors associated with nursing shortage vary from country to country. Therefore, this study compared the causes of nursing shortage and suggested strategies to help resolve this concern both in Iran and in the world.

Methods: To conduct this systematic review, search was done in English and Persian databases from 2000 to 2016. In the preliminary review, 537 articles were included in the study. After reviewing the titles, abstracts, objectives, and results of articles, 32 studies were finalized.

Results: The important causes of nursing shortage in the world included aging of the nursing workforce, inadequate admission and training of nurses, aging population, and job abandonment. However, the leading causes in Iran were unwillingness and lack of desire to enter and remain in the nursing field, job abandonment, inadequate salaries, low social status, and negative perception of nursing. Proposed strategies in the world are increasing the salaries, redesigning the work environment, improving the public’s perspective, retaining the existing nursing workforce, and flexible work schedules. In Iran, these strategies include increasing salaries and recruitment, enhancing the public’s perception of nursing, and supporting nursing organizations.

Conclusion: Nursing shortage is a multifaceted concept with varying magnitudes in different countries. Therefore, the strategies to resolve nursing shortage should be based on the unique conditions of each country. The most important strategies to overcome nursing shortage in Iran are focused on the improving the retention of existing nursing workforce.

↑ What is “already known” in this topic:

Previous studies on nursing shortage have suggested some of the causes of nursing shortage and presented some strategies to address this problem.

→ What this article adds:

In this study, the causes and strategies for addressing nursing shortage in the world and Iran were prioritized according to their importance. Having compared the causes of nursing shortage and the corresponding strategies, it became clear that increased age of nursing staff was the main cause of nursing shortage in the world, but unwillingness to enter and remain in the nursing profession was the main cause of nursing shortage in Iran. Nevertheless, the main strategy to overcome nursing shortage in Iran and the world is to increase nurses' salaries and rights.

Introduction

The importance of human health resources and their key role in maintaining and improving the health of the community is agreed upon by health care providers ( 1 ). The main problems of the hospitals, as the main provider of health care services, are rooted in the lack of manpower or its inappropriate distribution ( 2 ). Meanwhile, a nursing team is a vital part of the health care system, and comprises about 56% of any hospital’s staff ( 3 ). Thus, its shortage can reduce the quality of health care services ( 4 ).

Assuring the quality of patient care is the basis of nursing practice ( 5 ). Therefore, any defect in persistent provision of nurses to respond to care needs is a serious threat that can threaten the quality of care ( 6 ). Quality nursing care can decrease hospital infection, length of hospital stay, mortality rate, cardiac arrest incidence, and other complications ( 7 ). Various studies have pointed to a shortage of nurses as an obstacle against the efficiency and quality of care ( 8 - 10 ).

Nursing shortage is a major challenge to health care systems and has reached a warning threshold ( 11 ). This shortage becomes evident when there are not enough nurses to provide a certain level of care or to fill vacant positions and budget allocations ( 12 ). Nursing shortage is an international problem in progress. According to the World Health Statistics 2013, it is estimated that 1 million additional nurses will be needed by 2020 ( 13 ). Also, health workforce shortage is estimated to be 7 million, and is expected to reach 12.9 million by 2035 ( 14 ).

Nursing shortage is a complex phenomenon associated with many factors ( 15 ). One study identified several factors for nursing shortage: low salaries; bad working conditions; poor management; weakness of the authorities in employing work force prioritizing women for nursing profession; and preferring African, Spanish, and Latin nurses ( 16 ). Nursing shortage is the consequence of reduced university student admissions, elderly workforce, competition for employing skilled workforce ( 17 ), increased demand due to aging population and customer needs, rapid technological development ( 18 ), globalization of the labor market, and increased inclination of nurses for alternative jobs ( 19 ).

Nursing shortage problemis a multifaceted problem ( 20 ) and its associated factors vary from one country to another ( 21 ). The main causes of nursing shortage in the world are insufficient university student admissions, lack of faculty members, aging of nurses and their early retirement, aging of the society, and the need for more care, inadequate employment, increase of stress, low job satisfaction, and willingness to leave the job ( 22 ). However, in Iran, the main factors associated with nursing shortage include low social status, work-related injuries, early retirement, immigration, and willingness to abandon the current job, employment in other professions, housekeeping, low employment rates, and the increase of hospital beds ( 1 ). Due to the economic dependence of the health and medical centers on the government in Iran, these canters need to obtain the necessary credentials for employment of nurses, which can pose a restriction against nurse recruitment or university student admission ( 23 ). In Iran, currently the shortage of nurses is about 130 000. There are about 1.3 nursesper 1000 population, and it is anticipated that in 2020, there will be a shortage of 200 000 nurses ( 24 ). There is still a shortage of nurses in the United States although they have about 10 nursesper 1000 ( 20 ). Therefore, the concept of nursing shortage depends on the scope of practice for nurses, the geographic area of activity, and the balance of supply and demand in that community ( 24 ). In Iran, the problem of nursing shortage is recognized as the most important challenge in the field of nursing and it is in contrast with its global concept, requiring unique strategies ( 21 ).

Different studies have examined different aspects of nursing shortage and there is no comprehensive view on this issue. In addition, due to the differences in the concept of nursing shortage with respect to the context and considering the differences in the proposed strategies, this study aimed to identify and compare the causes of nursing shortage and the strategies used to solve this problem in Iran and in the world using a systematic review of the related studies.

In this systematic review, PubMed, Google Scholar, Science Direct, Ovid, and Scopus were explored to obtain related articles in English and SID, ISC, Magiran, Iranmedex, Medlib, and Google Scholar were reviewed to find related articles in Persian. The search strategy and the method of selecting articles were agreed upon by the researchers. For data extraction, a form was developed by the researchers which included the name of the authors, publication year, causes of nursing shortage, and the suggested strategies. According to Medical Subject Headings (MeSH), the keywords of "medically underserved area", "shortage", and "nurse" were used individually and in combination to search. Only papers published from early 2000 to the end of 2016 were included in the study. To avoid bias, the search was performed by 2 researchers independently and by using a data collection form. Agreement was reached about controversial cases through scientific discussion. The inclusion criteria were having research standards based on PRISMA checklist, being relevant, and having structure. The exclusion criterion was the lack of access to the full-text or the required data. The studies were reviewed and selected in 3 stages. First, the title was reviewed, and unrelated articles were excluded. In the second stage, having read the abstract, the related articles were selected. In the third stage, all included articles were quickly reviewed and duplicate studies removed (24 articles). In case of lack of access to full-texts, an email was sent to the corresponding author requesting the full-text of the article. Studies with insufficient data or without text (5 papers) were excluded from the study. Then, the texts and documents collected by each researcher were carefully examined during a discussion. According to the defined inclusion and exclusion criteria, 32 articles were selected and analyzed, which included descriptive studies, systematic reviews, and qualitative studies. The search stages are shown in Figure 1 .

An external file that holds a picture, illustration, etc.
Object name is mjiri-34-8-g001.jpg

Flow diagram showing the different phases involved in searching for relevant publication

In the initial search, 537 articles were found. Having reviewed the titles, 263 articles were selected. After studying the abstracts, 148 out of 263 articles were included. By assessing the full-texts, objectives, and findings of the selected articles, 25 related papers in the world and 7 related papers in Iran were finally selected for analysis. The results on the causes of nursing shortage in the world and Iran are presented in Table 1 .

After extracting, assessing, and analyzing the findings of the included studies, the researchers assigned the causes of nursing shortage into 6 categories of organizational factors, sociocultural factors, demographic characteristics, work-related factors, education-related factors, and job abandonment and grouped strategies into 3 main categories of increase in supply and decrease in demand, retention improvement, and reduction in job abandonment). In Table 2 , the causes of nursing shortage in the world and in Iran are highlighted in order of priority and importance. Furthermore, the most important suggested strategies in order of priority and importance are presented in Table 3 .

The most important cause of nursing shortage in the world is aging of nurses. With regards to the phenomenon of increased baby boom between 1946 and 1964 ( 27 ), part of this generation who chose nursing have been either retired or will be retired in the next few years. Therefore, despite the entering of young nurses in the profession, the shortage of nurses is not over ( 50 ). The mean age of the registered nurses (RN) is about 46 years and a large number of them will be retired in the next 10 to 15 years ( 51 ). Nevertheless, the mean age of nurses in Iran is 35-38 years and this factor cannot lead to shortage of nurses in Iran ( 23 ).

One of the main causes of nursing shortage in Iran is the unwillingness and lack of desire to enter and stay in nursing or willingness to leave the job. The rate of job abandonment, the unwillingness of nurses to stay in their job, and comparing nursing with other occupations are highly important ( 52 ), such that the rate of job abandonment among nurses is 20% in the United States and it is estimated to reach 36% by 2020 ( 53 ). The high rates of job abandonment and lack of interest may be due to the fact that nursing is considered as a worthless profession for women in most countries ( 54 ). Although there are no statistics on the causes of lack of interest and willingness to stay in nursing in Iran ( 28 ), it seems that its low salary and benefits and low social level are influential factors contributing to this issue. In a study aimed at examining the process of Iranian nurses' job abandonment, it was found that dissatisfaction with the profession, management weakness, and inappropriate social status of nursing were the main causes of job abandonment of nurses in Iran ( 28 ).

The second leading cause of nursing shortage in the world is the inadequate nursing education associated with financial issues and academic shortcomings. In the United States, in 2012, nearly 80 000 applications to enroll for undergraduate or postgraduate degrees were dropped due to inadequate faculty members, clinical environments, and classroom space ( 55 ). In Iran, inadequate nursing education is not the main cause of nursing shortage and it is ranked as the sixth reason. The low rank of this reason in Iran may be due to an effort made by relevant organizations to increase student admissions. In this regard, Abbaszadeh and Abdi quoted from the head of Iranian Nursing Organization that “the student admission capacity has increased from 7000 to 10 000 in 2011.” ( 24 )

The third leading cause of shortage of nurses in the world is an increase in the elderly population and the need for further care, resulting in increased demand and exacerbated nursing shortages. According to the UN report, from 2015 to 2030, the population over the age of 60 is projected to increase from 901 million to 1.4 billion ( 56 ), and the need for care and nursing will be increased subsequently ( 26 ). This is not the cause of nursing shortage in Iran, because the average age in Iran is 28.3 years ( 56 ). However, due to the increase in the population of the elderly, this problem will worsen the shortage of nursing in the coming years.

Insufficient nursing salary compared to that of other professions is the third leading cause of shortage of nurses in Iran. High salaries and benefits are one of the ways to attract and retain workforce ( 19 , 39 ). This is the seventh cause of a shortage of nurses in the world, reflecting the low level of Iranian nurses' salary. In this regard, experts believe that to make sustainable changes, reforms should be developed in politics, laws, and public’s perspective ( 57 ). Therefore, one of the reforms in the field of policies and laws can be the implementation of a tariff plan for nursing services to increase the salaries of nurses.

Nurses' inadequate employment causes stress, low job satisfaction, and a desire to leave the profession ( 22 ). This factor is one of the important causes of the shortage of nurses in the world and in Iran, with almost the same significance. In Iran, most health centers are economically nongovernmental and government-dependent and have limitations for workforce recruitment ( 23 ). In addition, many studies highlighted the low employment rates due to financial constraints in the world and considered it as one of the major causes of nursing shortage ( 20 , 22 , 26 , 31 , 32 ).

Insufficient managerial support is one of the major causes of nursing shortage in the world and in Iran, with almost the same importance. Many studies pointed to the effective role of managers in the retention of the nurses and the reduction of job abandonment ( 20 , 33 , 36 ). One of the management's efforts to retain human resources is to create job satisfaction and prevent employees’ dissatisfaction ( 58 ).

Other cause of nursing shortage in Iran is immigration nurses from Iran to improve their economic status and quality of life, although the exact statistics are not available ( 24 ). Developed countries compensate their nursing shortages by resorting to the recruitment of nurses from poor and developing countries ( 59 ).

Nursing shortage strategies have been categorized into 3 categories: (1) supply increase and demand decrease, (2) retention improvement, and (3) decrease of job abandonment. Moreover, the improvement of salaries and benefits has been the main proposed strategy to overcome nursing shortages in the world and in Iran. Since manpower is the main source of production and service delivery in organizations and the most important factor contributing to the survival and success of organizations ( 60 ), retention of existing staff can be achieved by offering financial incentives ( 19 , 39 ).

Given that work-related factors are the most important causes of nursing shortage in the world, optimization and improvement of the work environment is the second proposed strategy ( 19 , 22 , 32 , 33 , 36 , 61 , 62 ). A better work environment for nurses is associated with reduced job dissatisfaction and job abandonment, which can successfully resolve nursing shortages ( 63 ). Therefore, nursing shortage cannot be solved with increasing student admissions, but long-term nurse workforce growth and retention can be achieved by providing a safe and supportive work environment for the nurses ( 19 ). In Iran, improving the work environment should be among the priorities for the resolution of nursing shortage, although this is not a priority among the proposed strategies.

The second strategy to solve this problem in Iran is increase in recruitment. In Iran, due to the centralized management system, the recruitment process is subject to limitations ( 23 ). Due to such limitations, researchers consider the support of the Nursing Organization as one of the strategies to deal with nursing shortage problem, as the Nursing Organization tries to create better nursing work conditions by reaching out to the Islamic Consultative Assembly and other responsible organizations ( 21 ). However, studies conducted in different countries around the world have indicated that one strategy to recruit greater number of workforce is by providing nursing admission and recruitment for men, minorities, and different cultural groups ( 44 , 46 ).

The third proposed strategy in Iran and the world is improving the public’s view of nursing. In Iran, the social perception is one of the main reasons for nurses' dissatisfaction ( 64 ). Therefore, through promoting the public’s view of nursing and familiarizing the society with the important role of a nurse using public media, the retention of existing nurses and recruitment of new workforce can be achieved.

Another important strategy used worldwide is improving the existing nurses’ retention. The average of registered job abandonment among the nurses was about 17.2% in 2014 ( 65 ). However, the retention of the existing nurses can be increased and nurses’ job abandonment can be reduced by improving salaries and benefits, improving the work environment, developing independence and professional power, supporting the existing workforce by the management team, and creating a flexible work schedule ( 19 ). Most researchers agree that retention of existing nurses is a priority ( 66 ). In Iran, various studies have also contributed to improving the retention of the existing nurses by providing strategies such as increasing salaries and benefits, optimizing the work environment, using nurses in other positions, improving the quality of professional life, transferring nursing staff among different hospital wards, and improving the employment status of nursing workforce ( 21 , 24 , 29 , 30 ). Increasing the number of nursing students’ admissions and the nursing faculties has been highlighted as an important strategy both in Iran and in the world. Admission of nursing students has been doubled in Iran in the previous years ( 64 ). Another strategy proposed in different countries around the world is to increase the recruitment of foreign nurses. Many studies conducted in the US have highlighted the importance of this strategy; thus, the NHS has asked the government to consider nursing in the list of occupation shortages and allow foreign nurses to enter the country without visa due to nursing shortage ( 67 ). In Iran, a reverse strategy should be used and necessary measures should be taken to prevent the migration of nurses from the country and develop conditions for their retention. However, this strategy has not been suggested in studies conducted in Iran.

One of the proposed strategies in Iran which is not done in other countries is to gain the support of the Nursing Organization and scientific associations. The suggestion of this strategy may be due to important role of the Nursing Organization in nursing-related policies ( 21 ). Therefore, nurses’ retention, job satisfaction, social status, and recruitment can be achieved by supporting the Nursing Organization and improving the working conditions, benefits, and salaries of nurses.

To improve the retention of the existing nursing workforce, it is necessary to increase the salaries and benefits in proportion to workload and other professions, improve the work environment, value nursing profession, gain managers’ support, use nurses in diverse positions, develop flexible work schedules in accordance with personal life, and create employment opportunities for newly graduated nurses. The public's view of the nursing profession should be improved through familiarizing people from childhood with the vital role of nurses in the health system, improving the community's familiarity with the scientific position of the nurses in the hospital, and using the public media to show the important role of the nurses in hospitals. Nursing shortage can be overcome by increasing the admissions of nursing students at universities, taking into account the necessary requirements, and recruiting larger number of graduated nurses in accordance with needs of health care system.

Conflict of Interests

The authors declare that they have no competing interests.

Cite this article as: Shamsi A, Peyravi H. Nursing shortage, a different challenge in Iran: A systematic review. Med J Islam Repub Iran . 2020 (19 Feb);34:8. https://doi.org/10.34171/mjiri.34.8

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  19. A systematic review study on the factors affecting shortage of nursing

    To investigate the nursing shortage in Saudi Arabia healthcare workforce. Nurses in Saudi Arabia from 1993 to 2013: reviewing literature on the nursing shortage - Nursing supply depends on expatriate workforce - Lack of training in local nurses. 2: Abhicharttibutra et al., 2017. Thailand

  20. Factors Affecting Nurses' Shortage

    The results of this systematic review can be used as a rubric for the design and development of strategies to end the nursing faculty shortage and expand global nursing capacity. View Show abstract

  21. Beyond ratios

    In an extensive literature review we found no evidence to determine the cost effectiveness of different ways to use such tools to guide staffing decisions (Griffiths et al., 2020a). In our previous study, we used a simulation model to compare a standard staffing plan, following Safer Nursing Care Tool recommendations, where baseline staffing ...

  22. PDF Literature review: Why do we continue to lose our nurses?

    thought necessary to begin the review of reasons broadly before delving into the most commonly identified issues detailed by the authors. Chan et al (2013) performed a systematic literature review of the shortage in the nursing profession and why members had the intention to leave. Chan et al (2013) highlighted two major

  23. Solutions to close the nursing shortage gap

    US healthcare organizations continue to grapple with the impacts of the nursing shortage—scaling back of health services, increasing staff burnout and mental-health challenges, and rising labor costs. While several health systems have had some success in rebuilding their nursing workforces in recent months, estimates still suggest a potential shortage of 200,000 to 450,000 nurses in the ...

  24. Nursing shortage, a different challenge in Iran: A systematic review

    Nursing shortage is the consequence of reduced university student admissions, elderly workforce, competition for employing skilled workforce ... Duvall JJ, Andrews DR. Using a structured review of the literature to identify key factors associated with the current nursing shortage. J Prof Nurs. 2010; 26 (5):309-17. [Google Scholar]