Nursing workforce: A special issue

Available online at www.sciencedirect.com International Journal of Nursing Studies 46 (2009) 875–878 www.elsevier.com/ijns Editorial Nursing workforce: A special issue Keywords: Nursing workforce; Work environment; Patient outcomes 1. Introduction The aim of this editorial is to consider the questions raised by the papers presented in this special issue of the International Journal of Nursing Studies (IJNS) in the context of where the field of workforce research is heading, as well as to pull out and discuss some of their implications for policy and practice. The papers presented reflect the prevailing preoccupations of the field, focussing on the size and composition of the nurse workforce, the impact of the work environments for nurses in various settings and the nature of the relationship between staffing levels and outcomes. Three key messages emerge from the findings. The first is a remarkable consistency in the evidence base across countries and clinical settings, noted in landmark papers such as Aiken et al. (2001). The second is the need to protect and reward the existing talent pool as well as invest in new nurses. The third relates to modifiable factors within the environments in which nurses practise, those factors over which leaders in the profession can exercise some discretion and control to improve outcomes and wellbeing of patients and workers. But first a word about methods. In this issue, some of these leitmotifs are explored using new methods, but more often they are revisited in new settings. Methods used in the papers reveal a preference for observational studies; surveys (panel, longitudinal and cohort designs), correlational as well as case studies and systematic reviews of the literature. Analysis of secondary datasets on staffing remains a popular choice. Researchers remain fixed on cross-sectional analyses and rarely make the leap from assessing intentions to leave to studying actual turnover. Given that the costs of nursing labour can be so heavy, remarkably few studies here or in the workforce literature at large include an economic component. As a result, we have a distressingly meagre evidence base for defending, especially as we confront major downward pressure on costs as the global economy takes a major downturn. Economic modelling, evaluations and Randomised Controlled Trials of different skill mix models in 0020-7489/$ – see front matter # 2009 Published by Elsevier Ltd. doi:10.1016/j.ijnurstu.2009.04.012 different settings present methodological and budgetary challenges but can help to inform the cost/quality trade-offs and titrations of staff numbers and staff qualifications which at least some institutions, regions and countries will inevitably have to make. 2. Workforce quality Papers by Massey et al. (2009), Wray et al. (2009), Takase et al. (2009) and Gillespie et al. (2009) in this special issue, consider the quality and composition of the nursing and midwifery workforce. It is vital that we understand the labour market dynamics and flows of the workforce for planning at the local, regional and national levels. Massey et al. (2009) describe the employment practices of bank and agency staff in an acute care Trust in Wales and the need to focus on how best to reconcile fluctuating demand with a fixed resource. Flexible working and self-rostering are advocated as solutions to modulate staffing inputs and minimise staffing levels and sickness. Understanding the employment experience of an ageing workforce is an important component of this. Older nurses are significant not only in terms of their prominence within the workforce but because they have a major role to play in socialising the next generation and sustaining the quality of the work environment. Wray et al. (2009) urge us to reward and support experienced staff. They reveal that older nurses have not had access to some of the benefits, notably continuing professional development (CPD), enjoyed by younger colleagues. Furthermore, they warn us that demographic differences within this age group militate against treating this group as a monolith. Black and minority ethnic colleagues reported higher levels of mental wellbeing, while those with a disability reported less psychological morbidity but lower quality of life. While Wray et al. (2009) explore cohort effects and differences in the employment experiences and needs of different age groups in Wales, Takase 876 Editorial / International Journal of Nursing Studies 46 (2009) 875–878 et al. (2009) explores the question of generational differences in Japan. This further underlines the diversity of the workforce and differences in motivations, attitudes and priorities that different generations assign to different work benefits and values. Takase et al. (2009) found that nurses born after 1960 tended to value economic return and job security more highly compared to those born between 1946 and 1959. Those born between 1960 and 1974 embraced higher needs and values in professional privilege such as autonomy and recognition compared to subsequent generations. Gillespie et al. (2009) suggest that we should examine the factors which keep some nurses at work in the healthcare system for long periods. In their survey of operating room nurses (OR) they found experience of OR nursing rather than age per se was the key correlate of resilience and longevity. Support was identified as the crucial ingredient of success and provided this is available to younger nurses they will thrive. In their cohort analysis of predictors of intent to work and work decisions in the US, Brewer et al. (2009) highlight work/life balance and work-family conflict as important variables influencing retention as well as salaries and other benefits. 3. Work environment All of these factors relate to the quality of the work environment and the presence of modifiable variables within the control of employers. Gunnarsdóttir et al. (2009) demonstrate the predictors of job outcomes and nurses’ ratings of quality of care in Iceland. Consistent with findings from other studies, relations with managers and doctors as well as perceptions of staffing adequacy were associated with enhanced job satisfaction and likelihood of retention as well as perceptions of the quality of care for patients. A further point of continuity with the evidence is noted by Poghosyan et al. (2009) in their international comparative analysis of burnout. They argue for the validity of the Maslach Burnout Inventory as a tool to map burnout across different healthcare jurisdictions and, in particular, how sensitive a barometer it is for capturing the effects of reduced length of stay and productivity. Rechel et al. (2009) remind us that the work environment of nurses includes the design (including architectural) features of the built environment. They review literature that indicates that many traditionally designed health facilities do not facilitate the health of healthcare workers and indeed impact negatively upon their well-being. They argue for the inclusion of the needs of healthcare workers at the design stage to inform outcomes. Employee engagement is the latest in a long line of concepts to capture the imagination of management gurus and policy makers. Echoing Gillespie et al.’s (2009) work in this issue, Simpson’s (2009) review of the engagement literature pinpoints organisational factors rather than personal characteristics as the main drivers of commitment and personal investment. The danger with concepts like engagement is that they can become unwieldy, fuzzily-defined terms invoked as panaceas for the dilemmas of workforce management. Simpson (2009) reminds us that conceptual clarity and definitional precision around measurement of engagement and its organisational outcomes are imperative. 4. Staffing and outcomes The precise nature of the association of nurse staffing with nurse and patient outcomes remains hotly contested. Methodological challenges with data quality and complex setting-specific contextual factors join the complexity of the relationship itself in limiting the strength of the conclusions that can be drawn from the body of studies, and highly polarized political interests tend to take opposing interpretations of its findings. Although an accumulating body of evidence points to a positive linkage between nurse staffing and patient outcomes, West et al. (2009) in their systematic review of the literature on nursing resources and patient outcomes in intensive care units noted that nursing resources were more consistently linked to adverse patient events than mortality. Shuldham et al. (2009) in a high dependency critical care context demonstrated that among a number of outcomes investigated only the rate of sepsis was significantly reduced as the ratio of staff hours available to patients increased. Future research will need to explore the sensitivity of sepsis to nursing organisational factors, as well as the observed levels of variation in conditions to help explain why associations in lower dependency areas were weak. Significantly, Van den Heede et al. (2009) did not find any associations between staffing and patient outcomes in a sample of Belgian hospitals, despite examining a similar patient population to that used by Rafferty et al. (2007) and Aiken et al. (2002) in earlier work. Differences in staffing measures, units of analysis and study design may in part account for null findings and although studies have grown in sophistication over time, theoretical models and measurement tools have, in general, not. This is all the more reason that Schubert et al.’s (2009) paper is to be welcomed. Even low levels of rationing were associated with impact on patient outcomes, suggesting that patient outcomes may be sensitive to the rationing of nursing resources measured by proxies such as nurses’ reports leaving tasks undone. Economic research in this area, as noted above, remains woefully neglected, and so Mincsovics’s (2009) contribution is a welcome addition to a barren field. 5. Policy and practice Making decisions about staffing more transparent will enable policy makers, managers, professionals and patients to take more informed decisions about resource allocation in the cost/quality offsets outlined by Aiken (2008) in her Editorial / International Journal of Nursing Studies 46 (2009) 875–878 analysis of the economics of nursing. In North America, questions linger regarding accountability, transparency and regulation of staffing conditions in practice. A number of American states have adopted regulations requiring hospitals to submit staffing plans for inspection, or to publish data on staffing, outcome measures or both for public scrutiny. No other states have yet gone the way of California and the Australian state of Victoria in legislatively mandating minimum staffing levels (Gordon et al., 2008). The economic downturn is likely to reduce latitude in determining staffing levels and the anticipated shortage of nurses may put a premium on recruiting and retaining the best nurses (Clarke and Donaldson, 2008). This could well provide a pretext for rooting out and trimming nurses and nursing personnel who do not meet performance criteria in a tighter labour market in the attempt to raise the quality bar of the workforce. Equally, it could also set a premium on the quality of the work environment in order to retain and challenge a high quality workforce. In such circumstances we may see a new compact emerging between employers, policy makers and trade unions and professional associations to promote and protect quality work in a quality work environment. Economic conditions and financial exigencies could further deepen disparities between hospitals within the same jurisdictions in terms of working conditions, nurse credentials and, ultimately, patient outcomes. Researchers, policy makers and employers are alert to the fact that the demand side needs as much attention as the supply side of the workforce calculus. One of the challenges ahead is how to reshape the size and scope of the nursing workforce to the changing patterns of care-giving at local, national and international levels. We need better scenario planning and modelling to better contextualise nursing within labour market dynamics and enhance our forecasting capability for effective workforce planning at all levels. Research has an important role to play here not only in refining the evidence base but in challenging our thinking and helping us to scenario plan and to imagine new and intelligent solutions to emergent as well as enduring problems. This is one of the areas where the evidence base is weak and where we need to focus if we are to shift from supply side to demand led models of care for the future. 6. Future directions Continued attention to methods for drawing forth the best from an ageing workforce will be welcome (and vital) in the light of the global shortfall in nurses and need to retain older nurses. In many western countries, in recent years, experienced nurses have had unprecedented high workforce participation rates that have staved off the worst effects of the shortage thus far. By the end of the next decade, many will seek employment away from direct care delivery in hospitals and similar settings, or, equally likely, they will retire, and so are unlikely to sustain health care delivery this way in the 877 future. More data about these nurses and their experiences is needed. What are the characteristics of those nurses who have survived the system? Why do some nurses, to use a phrase from Trevor Clay, former General Secretary of the Royal College of Nursing in the UK ‘burn’ for nursing while others burn out? We need renewable energy sources for the profession. Creating these sources will make significant demands on us as educators, managers and policy makers. Not only do we need to craft innovative solutions to recruiting the best and target our efforts at changing generational needs and expectations of the post-Baby Boomers generations (X and Y), but deploy staff creatively and develop new models of delivery that cross traditional boundaries of caregiving settings. New roles which enable nurses to work across organisational and geographical boundaries will need to be forged and these, in turn, will need to be evaluated. This is already proving particularly challenging for educators in schools of nursing in particular, a heavily-segmented and rapidly ageing group in the equation, who play a key role in workforce supply. Nurse educators operate under a variety of increasingly severe demands and constraints, but they and their work have been minimally studied, despite the apparent role of an undersupply of educators as a barrier to the recruitment and preparation of a critical mass of new nurses, notably in the US and Canada. The educational workforce therefore needs to be part of the research agenda for the future. If trends in recent decades are any indication, healthcare work in the future will make greater and greater demands upon the cognitive skills of workers and require a well educated workforce. This is no time for ‘‘dumbing down’’ the profession, especially when a growing evidence base supports better outcomes from more highly educated nurse workforces in hospitals. But a better educated workforce is likely to make higher demands on the work environment and have higher expectations of the workplace. So will the graduates of Generation Y, the footloose and fancy free, be able to retain a value set which reflected job tenure practices derived from the long boom of the 1990s? Will this still make sense as unemployment rates begin to rise? The hard economic times ahead are likely to make greater demands upon the creative energies and ingenuity of clinicians, managers, employers and policy makers and at times pressure them to make choices that appear more expedient in the short-term even if they have deleterious effects over the long haul. A number of the contributions to this issue reflect the vibrancy of work environment concept in nursing and ongoing interest in the magnet hospital movement. Significantly, the magnet concept shares many of the features of job quality identified by the Work Foundation; task discretion and autonomy, sense of control, strong relationships at work with colleagues and managers and job security (Coats and Lehki, 2008). How will these play out in the years ahead while the threat of an economic ice age remains a cause for speculation. 878 Editorial / International Journal of Nursing Studies 46 (2009) 875–878 As Clarke and Donaldson (2008) note in their review of the state of the science in outcomes research we need more robust measurement tools and theoretical models to capture variation in outcomes that are sensitive to process variables as well as nuances of staffing. Clearly in research terms more of the same will not serve us well for the future. This is no time for what Thomas Kuhn (1962) calls ‘normal science’ in which we refine an established paradigm. We need to build on existing work while pushing back boundaries, thinking out of the box by formulating new questions regarding the nurse workforce, its composition and management, paying attention to the anomalies in the evidence base, and perhaps most importantly, taking some theoretical, intellectual – and political – risks. While the future may be hazy, we as a profession need to shape our own destiny. The challenges are great but the consequences are heavy – not only for nurses employed across a variety of roles and the continuum of care, but for the societies we serve. We and our research colleagues in this field clearly have our work cut out for us in more ways than one! References Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J.A., 2001. Nurses’ reports of hospital quality of care and working conditions in five countries. Health Affairs 20, 43–53. Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J., Silber, J.H., 2002. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. The Journal of the American Medical Association 288 (16), 1987–1993. Aiken, L.H., 2008. Economics of nursing. Policy, Politics and Nursing Practice 9, 73–79. Brewer, C.S., Kovner, C.T., Greene, W., Cheng, Y., 2009. 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Rafferty, A.M., Clarke, S.P., Coles, J., Ball, J., James, P., McKee, M., 2007. Outcomes of variation in hospital nurse staffing in English hospitals: cross-sectional analysis of survey data and discharge records. International Journal of Nursing Studies 44 (2), 175– 182. Rechel, B., Buchan, J., McKee, M., 2009. The impact of health facilities on healthcare workers’ well-being and performance: a literature review. International Journal of Nursing Studies 46 (7), 1025–1034. Schubert, M., Sean, P.C., Tracy, R.G., Bianca, S., De Geest, S., 2009. Identifying thresholds for relationships between impacts of rationing of nursing care and nurse- and patient-reported outcomes in Swiss hospitals: a correlational study. International Journal of Nursing Studies 46 (7), 884–893. Shuldham, C., Parkin, C., Firouzi, A., Roughton, M., Lau-Walker, M., 2009. The relationship between nurse staffing and patient outcomes: a case study. International Journal of Nursing Studies 46 (7), 986–992. Simpson, M.R., 2009. Engagement at work: a review of the literature. International Journal of Nursing Studies 46 (7), 1012–1024. Takase, M., Oba, K., Yamashita, N., 2009. Generational differences in factors influencing job turnover among Japanese nurses: an exploratory comparative design. International Journal of Nursing Studies 46 (7), 957–967. Van den Heede, K., Sermeus, W., Diya, L., Clarke, S.P., Lesaffre, E., Vleugels, A., Aiken, L.H., 2009. Nurse staffing and patient outcomes in Belgian acute hospitals: cross-sectional analysis of administrative data. International Journal of Nursing Studies 46 (7), 928–939. West, E., Mays, N., Marie Rafferty, A.M., Rowan, K., Sanderson, C., 2009. Nursing resources and patient outcomes in intensive care: a systematic review of the literature. International Journal of Nursing Studies 46 (7), 993–1011. Wray, J., Aspland, J., Gibson, H., Stimpson, A., Watson, R., 2009. ‘‘A wealth of knowledge’’: a survey of the employment experiences of older nurses and midwives in the NHS. International Journal of Nursing Studies 46 (7), 977–985. Anne Marie Rafferty CBE* Florence Nightingale School of Nursing and Midwifery, King’s College London, UK Sean P. Clarke Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Canada *Corresponding author E-mail addresses: [email protected] (A.M. Rafferty) [email protected] (S.P. Clarke)