Abstract
Background
Healthcare systems globally are experiencing a shortage of nursing personnel. The nurses comprise a critical portion of the healthcare workforce. It can be argued that within the healthcare industry, nursing is the largest profession whose roles in achieving patient wellbeing are critical. In any industry, an imbalance between the demand and supply of labour can be detrimental to the productivity of the personnel. Adult care can be defined as that part of healthcare services focusing on elderly patients above the age of 65 years. Some scholars have revealed that this group of patients is particularly vulnerable and should be handled with greater care. The conditions of these patients can accelerate from minor to chronic depending on the type and quality of care offered.
Methods
This research is in the form of an extended literature review. This is a methodology that is increasingly becoming common in the field of nursing. The review is presented as a full paper in which case it is used to offer a thorough and comprehensive analysis of the mentioned research topic. The focus will be on examining the empirical evidence of the relationships between the shortage of nurses and the quality of care offered to patients.
Findings
The findings have been presented in the form of five themes where each theme analyses how nurse shortage affects the quality of care. With the selected definition of quality of care, two themes, namely patient safety and satisfaction have been selected. However, the review acknowledges that the relationships are not direct and that the immediate effects of nurse shortage include burnout, workloads, and nursing performance. The inclusion of these three themes has helped offer a more comprehensive picture of all the implications of the problem of scarcity and the interplay between the core variables. The findings have helped reach a general conclusion that there is a correlation between the scarcity of nursing personnel and the quality of care.
Conclusion
The lack of materials directly addressing the concept of the nursing shortage and its implication for adult care has led to inferences being made from those studies examining related themes. It can be concluded that few registered nurses in hospitals negatively affect the quality of healthcare offered to patients. Additionally, the shortage has been seen as the result of burnout and heavy workloads in a highly stressful working environment which causes turnover and the intentions to leave the profession. However, these elements are also the causes of poor nurse performance, which is reflected through the safety and satisfaction of the patients.
Introduction
Nurses comprise a significant portion of the overall healthcare workforce. However, they also represent the main area where acute shortages are experienced in the entire healthcare system. The primary objective of this extended literature review is to examine how the shortage of nurses affects the quality of adult care in hospitals. Research on the general subject of nursing shortages and its implications has been studied extensively across the world.
However, there is a need to examine the specific context of adult care in hospitals because the needs of these patients differ from other groups. Elderly patients tend to experience health difficulties when admitted to hospitals. Those with minor problems may eventually undergo a steep decline in health. The focus on the elderly also emanated from the fact that they are hospitalized three times more often than the younger populations (Mattison, 2020, para. 1). Therefore, it emerges that adult care is one of the most demanding tasks for nurses.
The extended literature review will focus on the degree to which adult patients’ needs get the attention of nurses. The review considers adult care in hospitals to be the practice of taking care of elderly people, preferably over 65 years admitted in hospitals for various illnesses. Such is the definition adopted or upheld by several scholars and publications (Porcel-Gálvez et al., 2020, p. 1; Bakerjan, 2020, para. 1; Morrow and Nicholson, 2016, p. 301; Shewasinad and Sayih, 2018, p. 5). The definition does not consider the nature of the care needed or the amount of time that a patient is hospitalized.
The most important concept in this extended literature review will be the quality of care. According to Sfantou et al. (2017, p. 2), the term quality of care can be defined as the high probability of attaining the expected health outcomes. The six features of high-quality care are effectiveness, safety, reliability, efficiency, patient-oriented, and equitable. This idea of the quality of care can also be inferred from multiple publications (Sloane et al., 2018, p. 1005; Aiken et al., 2017, p. 560; Woo, Lee, and Tam, 2017, p. 5; Guirardello, 2017, p. 6; Gishu et al., 2019, p. 1). Other aspects such as satisfaction with nursing care can be used as major nursing outcomes.
In this case, the extended literature review would consider those studies examining patient satisfaction. However, this may become a challenging aspect because the individual interactions between nurses and patients mostly determine the level of satisfaction. In such a case, therefore, an effort will be made to determine the relationship between the nursing shortage and patient satisfaction. The determinants of satisfaction can be explored alongside the dimensions or features of quality of care.
The effects of the nursing shortage, as will be shown in the sections below, is a broad subject examined in the general context rather than specific nursing specializations such as adult care. They can, however, be inferred for any context and application of nursing practice. The argument is that the basic role of the nurses is to take care of patients regardless of their demographic characteristics. The extended literature review will examine such general applications and use the findings to discuss the effects of nurse shortage on the quality of adult care.
Background
The shortage of nurses is a global problem that has been studied extensively. Nurses, according to Muabbar and Alsharqi (2021, p. 35), comprise a critical portion of the healthcare workforce experiencing a scarcity of qualified personnel who can deliver dignified, passionate, and safe care. In countries such as the United States and Iran, nursing is the largest profession in healthcare and nurses’ roles in care delivery are critical as they serve a wide range of responsibilities (Zhang et al., 2018, p. 229; Poorchangizi et al., 2017, p. 1).
Therefore, a nation should ensure that there are adequate personnel to fill all the positions across the entire hospital system. The importance of nurses in the industry cannot be underestimated considering that they are responsible for supporting and educating the patients regarding their health issues. According to Muabbar and Alsharqi (2021, p. 35), nurses are also tasked with providing health promotion and psychological services, including referral, health education, assessments, and counselling. Appreciating the role of the nurses, therefore, helps understand the extent to which their shortage affects the system.
Though a historical phenomenon, the nursing shortage is a problem that persists in the future. A simple forecast by Zhang et al. (2018, p. 229) reveals that the United States will experience a shortage estimated at 154,018 registered nurses by 2020. These figures will reach 510,394 by the year 2030 (Zhang et al., 2018, p. 229). An article published in the Amerian Association of Colleges of Nursing presents a similar observation by highlighting that a shortage is expected between 2016 and 2030 (Rosseter, 2020, para. 1).
Other researchers estimate that by 2030, the shortage will be about 918,232 with the western region of the country being the most affected (Juraschek et al., 2019, p. 474). Regardless of the estimates, the point to note is that the entire healthcare system faces a critical challenge that could reduce the functioning of the industry. As a global phenomenon, no country can hope that domestic deficiencies can be replenished through labour importation. Therefore, the studies on the nursing shortage, its causes, consequences, and mitigating factors become crucial.
To better understand the situation, the starting point is to understand the root causes of the problem. Many scholars have presented different opinions on why the world is experiencing nursing shortages. The first cause as explained by multiple surveys is the nurses leaving the profession (Goodare, 2017, p. 50; Sandler, 2018, p. 23; Pélissier et al., 2018, p. 1; Kronsberg et al., 2018, p. 51). The studies reveal that the working environment for most nurses is not considered fulfilling. Workplace justice and other problems such as bullying have been cited among the factors most likely to affect leaving or the intention to leave the nursing profession (Chin et al., 2019, p. 307; Wilson, 2016, p. 303).
In other studies, it has been established that the act of nurses quitting their job is a result of burnout resulting from the heavy workload (Heijden, Mahoney, and Xu, 2019, p. 1). Leaving the profession is, therefore, a serious risk factor faced by the healthcare system and one which should be addressed promptly. A country spends massive resources on nursing development, meaning quitting causes not only nursing shortage but also losses in terms of critical resources.
Nurses leaving their jobs could also be the result of other factors that further complicate the problem. Retirement, for example, leaves vacant positions that have to be filled (Beitz, 2019, p. 403). This means that the education system has to be effective in developing new professionals as replacements. However, many recruits have been known to leave the development courses for multiple reasons before they can become professionals (Beitz, 2019, p. 403).
The effect these events include that the personnel retiring or leaving is less than the new ones entering the profession. Training nursing professionals can be time-consuming and a demanding task for both the students and trainers. Some studies have established that about a third of qualified students discontinue the development programs (Fagan and Coffey, 2019, p. 427). The clinical education is considered imperative in the development of competent and safe new nurses. However, the discontinuation of students tends to put a dent in it. This is in addition to the observation that qualified nurses often leave their jobs to become faculty members in clinical education institutions (McPherson, 2019, p. 201). The educational institutions are another area that is suffering the same shortage challenges.
From the information regarding the causes of the nursing shortage, it can be surmised that the deficiency of the nursing personnel is the result of more professionals leaving the jobs than those new entrants occupying the vacant positions. With this background, therefore, it can be understood that there is an imbalance in the demand and supply of nursing professionals. While the next step in the analysis of the problem would be to examine the mitigating factors, this extended literature review pays greater attention to the consequences of such an imbalance. Several hypotheses can be developed drawing links between the nursing scarcity and outcomes. Such outcomes have been defined in the previous section to include the various features of quality care and the determinants of patient satisfaction (Gishu et al., 2019, p. 1; Eyasu et al., 2016, p. 1). The hypotheses will form the basis on which the literature review is undertaken.
First, it can be hypothesized that the shortage of nurses reduces the quality of adult care. The assumption is that fewer employees result in inadequate attention for patients. As such, the patients requiring extensive and constant care will be deprived of the precious time they need to spend with the nurses due to commitments elsewhere.
The problem becomes more complicated because the adult patient patients have unique needs that, if not met, can adversely affect their level of satisfaction. This hypothesis is also linked with the determinants of satisfaction whereby the shortage is also directly linked to declining levels of patient satisfaction. The argument, as will be shown in the findings section, is that inadequate time with an adult patient leaves them unhappy as their overall health needs may not be met. Quality of care is a broad subject and the analysis of this hypothesis may require attention to the specific features of quality care.
A second hypothesis for this extended literature review could focus on other aspects that affect the productivity of the nurses. It will be argued that the shortage leads to heavier workloads per available nurses. Research linking workload and productivity can be used to support this position (Umansky and Rantanen, 2016, p. 551; Mersin, İpçioğlu, and Koca, 2018, p. 238). Huge workloads are considered to be mentally taxing and result in a lot of pressure to perform various tasks in short amounts of time. Such pressure means that nurses will be prone to making errors as they rush procedures, processes, and protocols.
Lastly, it can be hypothesized that the shortage and the resulting workload cause burnout among the available nursing personnel. Several studies have established a relationship between nursing burnout and various determinants of patient satisfaction and characteristics of quality care. One aspect which has been extensively studied is patient safety where several studies reveal that burnout negatively affects it (Garcia et al., 2019, p. 1; Hall et al., 2016, p. 2; Aghjayan, 2019, para. 1).
In addition to safety, other healthcare outcomes are negatively affected by nursing burnout as will be discussed in the findings section. From these potential hypotheses, it is apparent that the nursing shortage triggers a chain reaction which is felt across the system. Among the immediate effects is the growing workload for nurses which in turn reduces the amount of time dedicated to patients. The workload also has the effect of causing exhaustion and burnout which consequently reduces patient safety and other healthcare outcomes. Even though these are general applications, it is important to emphasize that the specific contexts, including adult care, are affected similarly by the scarcity of healthcare personnel.
Methodology
The methodology adopted in this paper is an extended literature review. Many disciplines, including healthcare and nursing, have used different approaches of conducting literature reviews as explained by Snyder (2019, p. 334). In nursing, literature reviews have become particularly popular as a means of synthesizing information and evidence relevant to the profession (Aveyard & Bradbury-Jones, 2019, p. 2; Davis, 2016, p. 60). The reviews can be presented as full papers as it will be the case here. In such circumstances, the aim is usually to offer a thorough and comprehensive analysis of a topic (Nakano and Muniz, 2018, p. 2).
Lastly, literature reviews provide the foundation for academic inquiries as expressed by Xiao and Watson (2019, p. 93). The use of this methodology in this research presents an opportunity to synthesize evidence regarding the subject of global concern. The researcher acknowledges that the problem of nursing shortage has a long history and has received adequate attention among practitioners, policymakers, and scholars. However, the exploration of a specific context, such as adult care, has been limited meaning that this literature review should form the basis for future empirical inquiry.
Before explaining the process that will be adopted in conducting a literature review, it is important to acknowledge the various types of this methodology. According to Snyder (2019, p. 334), there are three major types of literature review. The first one is the systematic literature review, which has often been used in medicine to synthesize research findings in a reproducible manner. Such an approach could involve the application of various forms of analyses, include meta-analyses which use statistical methods to combine results from multiple studies. A qualitative systematic review, however, is simply a means of comparing the findings from qualitative or other studies without the use of statistical tools.
The second type is the semi-systematic literature review which is also known as a narrative review approach. It is designed for subjects that have different conceptualizations across multiple disciplines, a characteristic that hinders a full systematic review process. Several methods of analysis can be used with this method, including content and thematic analysis (Snyder, 2019, p. 335).
In this literature review, a semi-systematic literature review will be adopted where several themes will be generated and supported by evidence from several previous studies. The third type is the integrated review, which is closely related to the semi-systematic approach. In this methodology, the review can be used to critique, assess, and synthesize literature regarding a topic (Snyder, 2019, p. 335). The basic idea behind a literature review as a research method, therefore, is that no new empirical inquiry is made and only previous studies are examined.
In this literature review, the process will involve multiple phases and steps. The phases discussed by Snyder (2019, p. 336) will also be considered for this study because they present a blueprint upon which any literature review can be conducted. As a semi-systematic literature review, however, steps similar to a systematic review as described by Xiao and Watson (2019, p. 103) will be used. The table presented below summarized the various phases and the aspects to take into account for each:
Table 1: Phases of literature review as adapted from Snyder (2019, p. 336)
The first phase of the literature review is planning where the need and contributions of the exploration are communicated. The introduction and background sections have discussed why the topic is important. The purpose has been described as to examine the effects of nursing shortage on the quality of adult care. As a semi-structured literature review, a thematic analysis will be the selected methods. The search strategy will include the use of keywords built around the three potential hypotheses discussed in the background.
For each of the hypotheses, the inclusion criteria include relevance where the materials address the topic and currency where the sources are less than five years old. Screening for the inclusion and exclusion will be done by examining the contents of the abstracts. The rationale is that the general overview of a peer-reviewed work is summarized in the abstract, which helps determine the relevance of the source. It is important to emphasize that that relevance will be assessed in terms of the degree to which each source addresses the specific hypotheses or the major themes of the literature review.
In the second phase, an actual search for the materials takes place following the plan which is considered adequate. The practical plan, however, entails the utilization of online databases and repositories in the search for the relevant materials. Reputable online platforms such as NCBI, PubMed, and BMC journals will be searched for the peer-reviewed articles on the subject. The documentation of the search process will not be highlighted and the quality assessment of the sources will be done using the inclusion criteria selected in the planning phase.
The analysis is the most important phase because it determines the overall quality of the research process. As explained earlier on, a thematic analysis will be used where the major themes are listed and literature regarding them synthesized. The analysis phased will be reflected in the findings section where all the data are summarized and explained. In the phase, this extended literature review document is written as a research report explaining the need and motivation for the inquiry. The results are presented in the findings section and an explanation for them offered in the discussion section. Aspects such as adequacy of the information and the quality of the extended literature review will also be elaborated in the discussion section, whereas a quality assessment will feature in the strengths and weaknesses section.
Findings
As explained in the background, the research on the effects of the nursing shortage on the quality of adult care is limited. A search on “the effects of nursing shortage on the quality of adult care” or simplified keywords such as “nursing shortage and adult care” did not yield materials that meet the selected criteria. These keywords were, therefore, discarded and others which yield better results used.
To make it possible to find materials which can directly address the research topic, some simplifications were made to the concept of quality of adult care and a more general subject included. In other words, the characteristics of quality care were used in which case a deviation from adult care was made. It has been explained that the generalized results from studies examining the general concept of quality care can be used to make inferences in specific contexts such as adult care. Therefore, one characteristic of quality care, patient safety, and used alongside the concept of patient satisfaction as the two aspects representing the quality of care.
As explained in the background, several aspects of a nursing career are affected by the shortage and the consequences of the scarcity tend to reflect in the quality of care. With such an assumption, other effects of nursing shortage which have a direct implication on the quality of care are examined, including the effects on workload, nursing burnout, and performance. Therefore, five themes have been generated in the search process as enumerated below:
- The effects of the nursing shortage on patient safety
- The effects of the nursing shortage on patient satisfaction
- The effects of the nursing shortage on nurse burnout
- The effects of the nursing shortage on nurse workload
- Effects of nursing shortage on nurse performance.
The interrelationships between these themes will be discussed in detail in the discussion section which offers a detailed explanation of the findings presented here. In this section, a summary and a brief synthesis of the results on each theme are presented. The focus is to show that there is evidence that the current and future shortages of nursing professionals adversely affect the quality of care offered in hospitals.
Patient Safety
Three studies were chosen using the selection criteria developed in the planning phase. These studies have all expressed that nursing shortage either directly or indirectly affects the safety of patients. An important point to note, however, is that some researchers are not directly exploring the effect of nursing shortage on patient safety. Only one study by Rosenberg (2019, p. 1) directly expresses the relationship between the nursing shortage and patient safety.
The study makes two broad conclusions: first, that lower levels of registered nurse staffing cause higher risks of death during the hospital stay, and second, that increasing nursing assistants does not compensate for the shortages. With such conclusions, it is possible to ascertain that fewer available nurses in any hospital will limit the time and attention given to a patient, which will ultimately lead to certain errors that are detrimental to patient safety.
The other two sources which fall under this theme make an indirect inference to the topic. The study by Moss and Jackson (2019, p. 151), for example, examines how new graduate nurses can be mentored. The need for such efforts is explained through making inferences to the fact that “there is a critical shortage of neonatal practitioners (NNPs) in the United States” (Moss and Jackson, 2019, p. 151). Additionally, the authors express that the deficiency of nursing personnel causes an increase in the workloads which affects job satisfaction and ultimately causes a decline in patient safety. To increase patient safety, Moss and Jackson (2019, p. 151) express that new nurses need to be encouraged to enter the profession. Additionally, those already in it have to be made satisfied with their jobs to raise their intentions to stay. In other words, reducing the nursing shortage increases patient safety.
The third source also makes an indirect approach to the topic. Research by Fagerström, Kinnunen, and Saarela (2018, p. 1) explores the implications of increasing workload per nurse on patient safety incidents and observes that presence of more nurses improves nursing outcomes. Higher staffing, it is argued here, means having adequate nursing personnel in a hospital or having no shortage. This allows a hospital to offer adequate attention to patients and reduce workloads on each nurse.
Patient Satisfaction
Patient satisfaction can be an indicator of quality care meaning that perceived satisfaction of patients is a reliable metric with which to measure the quality of care. Several studies have met the inclusion criteria that make both direct and indirect links between nursing shortage and patient satisfaction. Winter, Schreyögg, and Thiel (2020, p. 380) examine environmental and organizational factors causing the staff shortage and their implications on the level of patient satisfaction. The main finding is that hospital staff shortages have a direct correlation with patient satisfaction.
The presence of adequate nursing personnel can directly influence health outcomes of the patients. A study by Hockenberry and Becker (2016, p. 890) presents a hypothesis that hospitals with more non-registered nurses (RN) nursing hours have lower average patient satisfaction. This is a statement that indicates that the amount of time a registered nurse spends with a patient directly translates into the level of patient satisfaction.
Inadequate non-RN nursing hours, it is argued, is a result of shortages in which case the researchers confirm that the shortage of nursing personnel reduces patient satisfaction. Even though Hockenberry and Becker (2016, p. 890) focus on staffing strategies as opposed to the nursing shortage, their findings support the observation that fewer nurses affect patient satisfaction. Other studies that find a similar relationship between nursing shortage and patient satisfaction are summarised in a table.
Nursing Burnout
A few studies have met the inclusion criteria for this theme. Those examined have directly or indirectly linked nurse burnout to nursing shortage globally. Research by Mudallal et al. (2017, p. 1) explores nursing burnout and contributing factors. The authors express that the nursing shortage is becoming a global crisis because it affects the efforts to offer quality care. The scarcity of the personnel causes personal and work conditions such as unrealistic job expectations, work demands exceeding resources, higher work hazards, and poor work environment. Burnout is also a major result of the shortage and the excess workload per nurse.
The feelings of burnout and dissatisfaction have an adverse effect on the quality of life of the professionals which ultimately reflect in the quality of care. Another study by MacPhee, Dahinten, and Havaei (2017, p. 1) reveals that nursing shortage results in higher workloads and consequently nursing burnout. Burnout could result in a challenge such as tasks left undone and patients unattended. The result of such a scenario is that both the quality of care and safety of the patient is compromised.
Burnout is a complex subject which has been studied in multiple contexts. However, the links between burnout and nursing shortage works in two ways whereby shortage increases chances of burnout and burnout may raise the intentions to leave. Intention to leave, it should be understood, is perceived as a major indicator and cause for the nursing shortage. A case study of Malaysia has been presented by Permarupan et al. (2020, p. 1) which explains that nursing work is physically and emotionally intense, characteristics which cause burnout. Shortage of personnel increases this intensity which could see the nurses leave the profession or deliver low quality healthcare outcomes.
Nurse Workload
The main argument in this theme is that with fewer nurses per hospital, the available nurses are forced to take up more tasks which could otherwise be shared across more individuals. Huge workloads have many effects, which include burnout, as explained in the previous theme and supported by several studies. According to MacPhee, Dahinten, and Havaei (2017, p. 3), the heavy workload has several healthcare outcomes, including tasks left undone, emotional exhaustion, task-level disruptions of workflow, and several cases of reported nursing errors. The argument is that with multiple jobs for a single nurse and the time restrictions, a nurse can easily get overwhelmed and exhausted, factors that will lead to errors and unaccomplished duties. As explained before, these results of heavy workloads are directly associated with the quality of care afforded to a patient. This is because unattended patients and medical, for example, could cause deteriorated health outcomes for a client.
Different approaches to the same theme are adopted by various authors. Oppel, Winter, and Schreyogg (2017, p. 53), for example, examine the need for adequate staffing where the researchers argue that reducing nurse-patient ratio, which is equivalent to reducing shortage, reduces burnout and job dissatisfaction. As a result, better health outcomes for the patient can be achieved. Oppel, Winter, and Schreyogg (2017, p. 53) argue that staffing below the desired levels can be a proxy for nursing shortage. Additionally, a lower nurse-patient ratio can have the effect of adverse patient events, mortality rates, and poor perception of care quality by the patients.
Lastly, Hockenberry and Becker (2016, p. 890) express that workloads for the nurses directly affect patient satisfaction and acknowledge that the research on the staffing levels and nursing outcomes is relatively undeveloped. However, it is important to acknowledge that these researchers focus on the staffing levels, which could be an indication of nursing shortage or a deliberate decision by the human resource management. Whichever the cause of staffing level adopted by a hospital, the key implication is on the quality of care.
Nurse Performance
This theme is based on the notion that nurse performances have an implication on patient outcomes, meaning the quality of care as manifested by safety and satisfaction among other indicators. As with other themes explored above, nurse performance is a broad subject where various researchers focus on different aspects. An exploration by Wazqar et al. (2017, p. 418) explains that nursing is a high-stress occupation. In contexts such as oncology, the problem is made more complex by the fact that cancer patients are increasing while the professionals are declining. The resulting workloads, job strains, and declining ability to cope all reduce the performance of nurses. Even though the study is set in Saudi Arabia, it can be inferred that general shortages of nursing personnel have similar effects on their performance.
The theme of nurse performance can be controversial because of the different ways in which the term ‘performance’ can be defined. For a nurse, the major duty is taking care of patients and, therefore, performing such a job means meeting the desired outcomes.
The patient outcomes, on the other hand, can be positive or negative, and this could be an indication of good or bad performance. The quality of care and patient satisfaction can also be used as indicators of performance meaning that studies on the effect of nurse shortage on quality and satisfaction can be used to explain performance. Nursing shortage, as explained in a study by Haegdorens et al. (2019, p. 2), affects patient outcomes in surgical wards. These outcomes are in the form of patient mortality where adequate staffing increases success levels. From this perspective, therefore, nurse performance is measured in terms of their output in terms of whether or not the patient care succeeds.
Discussion
Quality of adult care is a critical subject under the current scenario where the healthcare system is experiencing a shortage of nurses. Their roles in ensuring patient satisfaction are crucial, especially for elderly patients who have a higher risk of deteriorating their health. The findings section has managed to present a general correlation between the shortage of nurses and the quality of care even though no content was found specifying the context of adult care. The adequacy of these results and the broad implications practice and further research can be examined critically.
The five themes have been used to prove that there exists a direct correlation between nurse staffing in hospitals and the health outcomes of patients. Most importantly, they have helped to present an understanding of the complexity of the issue and its implications on the patients. The two themes with a direct reference to the subject are patient safety and patient satisfaction. Regarding patient safety, it has been established that fewer nursing personnel are associated with higher mortality rates.
Such studies as Rosenberg (2019, p. 1) specify that the scarcity of registered nurses has greater effects and adds that assistant nurses do not compensate for the shortages. Taking this point critically, it emerges that the registered nurses are a critical part of the healthcare system. Their training and qualifications are a major resource that can directly and significantly influence the health outcomes of patients. When discussing the problem of nurse shortage across the globe, therefore, it is important to emphasize that the most important personnel are the registered nurses.
The studies on nursing shortage have hardly specified the types of nurses considered scarce. Apart from the study by Rosenberg (2019, p. 1) that shows how critical registered nurses are, many studies examining patient safety have simply stated the shortage of nurses. It is important to appreciate, however, that these studies have helped explain the seriousness of the problem. Moss and Jackson (2019, p. 151) propose a solution that nursing students should be mentored.
Their study is accepted for this review because it states precisely that nursing shortage threatens patient safety and the answer to the problem is getting more students to graduate and pursue the profession. The context for this study is neonatal care, another sensitive practice due to the high risks involved with the type of patients. The question of how safety is affected by the shortage of nursing has been explained by Fagerström, Kinnunen, and Saarela (2018, p. 1) who state that fewer nurses causes heavier workloads and increases the chances of medical errors and other accidents. Regardless of the context, it is argued that this can be the situation across all practices, including adult care.
Patient satisfaction is an important indicator of quality care because the experiences of patients are also critical in healthcare. This theme uses studies that have explored the relationship between the nursing shortage and the perceptions of patients regarding their satisfaction. Another case for registered nurses has been made by Hockenberry and Becker (2016, p. 890) who observes that hospitals with fewer RNs experience lower patient satisfaction levels.
However, it is important to acknowledge that the form of shortage referred to by these researchers is not the global scarcity of personnel but the staffing strategies used by hospitals. However, the most important point derived from the research in that fewer nursing personnel is detrimental to patient satisfaction. The shortage itself should have the same effect in which case the hospitals will be experiencing a deficiency in the nursing personnel.
The issues of nursing turnover and intention to leave the profession have emerged multiple times throughout this review. Many of the studies used to explore the theme of patient satisfaction indicate that these two events have a direct and significant effect on patient satisfaction. These two concepts imply that the nurses have already been employed and after working for some time they decide to leave.
Several reasons cause these decisions and it is argued that burnout and workload, two themes that make the working conditions unbearable for nurses, are among the key decision factors. The inclusion of burnout and heavy workloads as viable themes in this review, therefore, is based on the notion that the nursing shortage is caused by a combination of nurses quitting and fewer employees entering the profession. While such an argument explains the turnover and intention to leave, the focus of this review is about what happens next on that personnel left in the industry. The issues of workload and burnout become worse and the effects include poor patient care.
Studies linking nursing shortage and burnout are perfect for this review, but only a few were found. However, the researcher deems them sufficient to explain the tertiary link between the shortage of nurses and the quality of care. Researchers such as Mudallal et al. (2017, p. 1), for example, explain the global scarcity of nurses affects their efforts and ability to deliver quality care. They argue that fewer workers in a hospital cause work and personal conditions which include high work demands and hazards, as well as poor working conditions. Such factors make it impossible for a nurse to deliver quality and satisfactory care for a patient.
They also tend to increase the chances of burnout which in turn will cause human errors which can be detrimental to the safety of the patients. Such situations can be magnified in adult care because this population is relatively more vulnerable than others. Therefore, small mistakes could result in heavy consequences for both the patient and the hospital.
Burnout is a serious problem in nursing and it has been studied extensively. For this review, a study by MacPhee, Dahinten, and Havaei (2017, p. 3) is used to explain how burnout causes dissatisfaction among the nurses which further raises the intentions to leave. Before deciding to leave, however, it can be argued that the nurses will have experienced lower levels of output and their commitment and motivation will have declined.
Considering the heavy consequences of serious nursing mistakes, quitting becomes one of the best options for those who cannot handle burnout any more. However, the major criticism of these sources is that they offer only a faint idea of the relationships between the variables used for this review. The lack of adequate materials that offer a better view of these associations means that the researcher has to use them. Therefore, future empirical studies should attempt to fill these gaps and offer a better view of the interplay between nursing shortage and quality of patient care.
The theme of workload is explored similarly to than of burnout. The main argument is that while the heavy workload could be a reason for nurses to quit, the fewer left in the industry will experience even greater workloads and diminishing patient satisfaction. The consensus among several scholars, including Wazqar et al. (2017, p. 418), is that nursing is a high-stress environment. This the result of the demanding working conditions and high standards that must be maintained. Therefore, increasing the workload for nurses who are already feeling the stresses of the job will likely result in one of two outcomes. First, the personnel will quit when they reach their tolerance limits which increases the chances of greater workloads for those left. Second, the work performance of the individual nurses will dwindle which will be manifested in the quality of care offered to patients.
Many of the studies examining the relationships between workload and quality of care are founded on the notion that human resource management in hospitals is responsible for the staffing decisions. There are optimal levels of staffing below which researchers such as Oppel, Winter, and Schreyogg (2017, p. 53) indicate that cause burnout and dissatisfaction and ultimately declined quality of care. Such studies not necessarily address the problem of the nursing shortage and this review assumes that inadequate staffing will create an effect similar to the shortage. In other words, the shortage and inadequate staffing create a scenario where the personnel catering for patients are inadequate. Whether shortage or insufficient staff, scholars such as Hockenberry and Becker (2016, p. 890) establish that workloads for the nurses directly affect patient satisfaction. The ultimate solution, therefore, is to increase the numberof registered nurses.
Nursing performance has also been included as a major theme because nursing outcomes are directly related to patient outcomes. Poor performance means poor patient care and, therefore, there was a need to examine the presence of a correlation between nursing shortage and nurse performance. However, a closer examination of the five themes shows that there are multiple ways in which the shortage of nurses can affect the quality of care. The interrelationships between these variables are complex and it can be argued that the correlation between the quality of care and shortage of nurses is not direct. The shortage affects other aspects of the nursing job which in turn affects how patients are served in hospitals. Burnout and heavy workload are the major causes and consequences of nursing shortage across the world.
The general observations across multiple studies only manage to offer a glimpse of how shortage related to the quality of care. The findings, however, fail to directly address the context of adult care due to the lack of relevant research materials. Therefore, the findings are based on the assumption that all practices of nursing are affected in the same way when the demand for personnel in hospitals exceeds the supply. The major implications for research, therefore, is that field of adult care requires further examination. It has been severally mentioned that the elderly patients are particularly vulnerable and their conditions could quickly deteriorate when hospitalized.
The lack of current exploration in this area should be a concern not only among the scholars but also among the practitioners. If the empirical evidence shows that care for the elderly is highly sensitive, then the hospitals should make better staffing decisions to make sure that this department is optimally staffed.
The implications for practice are vast considering that the problem is global and current solutions do not seem to be working. As explained above, the studies examined in this review are divided between the nursing shortage and inadequate staffing. The human resource management in hospitals should be concerned with such findings, which can be interpreted to mean that their recruitment practices have a direct impact on the patient outcomes.
For human resource managers, their primary goal is to make sure the hospitals are staffed adequately without redundancies which cost the healthcare institutions. Achieving this balance can be a sensitive matter, especially in those departments where the patients need more care. Additionally, the managers may be held responsible for the working conditions of the nurses because they decide the nursing workloads and related consequences such as burnout and the intention to leave. Adopting better human resources practices could help ease the challenges faced by nurses and even aid in addressing the shortage of nurses by motivating nurses to stay.
The implications for nursing practice as a whole are quite different because the major concern is how it can be made more tolerable, satisfying, and comfortable for the nurses. The turnover and intention to leave are the direct results of the stresses caused by the job. It can be reiterated here that nursing is a high-stress occupation (Wazqar et al., 2017, p. 418). The main question, therefore, is how the career can be made more fulfilling for the nurses.
The nurses are a critical part of the healthcare workforce and, thus, an area in which the industry should invest heavily. The problem is complicated further by the fact that the intention to leave does not only apply to the nurses in the industry but also students undertaking nursing courses. The practice can and should be made more appealing to attract more personnel and the current global shortage problem can be addressed. Short term solutions may not work and, therefore, the industry needs to start considering long term solutions.
Strengths and Limitations
A literature review as a research methodology has several strengths and limitations. As explained in the methodology, a literature review can be used to offer a thorough and comprehensive analysis of a topic (Nakano and Muniz, 2018, p. 2). For this reason, it can be argued that the major strength of this research is that it has made it possible to thoroughly explore a problem that has received little attention among researchers. Using the inclusion criteria discussed in the methodology, it is apparent that the review sought to examine what has been explored recently regarding the subject. The sources found can explain a huge gap in research.
For example, the inclusion criterion of recency limited the materials to five years and the inadequate materials on the subject reveals that no recent effort to address nursing shortage despite the problem persisting. Such a criteria may have presented the researcher with several limitations. However, the most important point is that nursing shortage is a huge current and future concern and should, therefore, receive more scholarly attention.
Another point that can also be considered a strength is the fact that even without materials directly addressing the research topic the review managed to find credible scholarly to serve the purpose. This may also have been a strength in that it reveals another gap that may not have captured to the attention of practitioners and researchers. The topic of adult care and how it has been affected by the nursing shortage has not been studied recently.
For all the five themes, the review found that the only means by which to achieve the objective of the review was to use generalizations from other studies. While could be a weakness, the assumption that the effects of the nursing shortage are similar across all nursing practices is solid. The generalization is made possible because, in any labour force, the demand and supply of the workforce have similar implications across industries. In other words, few nurses limit the productivity of a firm, meaning that scarcity of nurses limits their output measured in terms quality of care.
Lastly, the topic of adult care is relatively sensitive considering the demographic changes across the world. Caring for the elderly in hospitals may be different from other patients because elderly patients tend to experience a harder time when admitted in hospitals. The literature review raises the awareness that the hospitals cannot allow extreme shortages in nursing personnel caring for ageing patients as these may be the most sensitive. Most of them may be having chronic illnesses, severe conditions, or even nearing the end of their lives. The amount of time that is dedicated to each patient is greater than other patients meaning once a nurse is allocated, they may end up remaining committed to a single client for prolonged periods. Regardless of the illness, the point being made is that few nurses mean inadequate care, reduced patient safety and satisfaction. The literature review should inform the need not only for further exploration of the subject, but also for policymakers to find feasible solutions to the problem.
On the other hand, however, the literature review has serious limitations which include partially addressing the topic. As mentioned in the introduction, the focus of the review was the adult care and how it is affected by the shortage of nurses. However, the inclusion criterion of recency allows only the most recent materials which lead to an exclusion of any scholarly efforts more than five years old. The limitations from this criterion hare apparent in the findings section where inferences from previous studies have been used as opposed to materials directly exploring the topic. The review has been based on an assumption that all practices in nursing are affected similarly by the shortage of nurses. Such a presumption has been made despite acknowledging the adult patients are particularly vulnerable and that minor issues could cause a steep deterioration in health. Therefore, one of the basic limitations is the partial examination of the original topic.
It should be acknowledged, however, that the topic of adult care has not received much attention and the lack of direct materials is not necessarily the result of the inclusion criterion. A search on the effects of nursing shortage on quality of adult care yield extremely few sources and none could be used for this review. As expressed above, this could be counted as a strength of the review in that it helps to shed light on a subject that has been ignored despite the critical implications.
Conclusion
The nursing shortage is a global phenomenon and studies can show how this scenario affects the quality of care. Among the adult patients, there is a lack of current studies linking the shortage with the quality of care. This review defines the quality of care as the high probability of attaining the expected health outcomes. Of the six characteristics of quality care outlined, patient safety has been selected for review as it is among the common themes in nursing studies. The concept of patient satisfaction has also been used because satisfaction is a measure of how the patient perceives their wellbeing after being nursed. However, a direct relationship between nursing shortage and these two aspects of quality care it difficult to determine. Therefore, the themes of burnout, workloads, and nursing performance have been used because these can directly be related to nursing outcomes.
Even though the main of the review was to examine the effects of nursing shortage on the quality of adult care, the lack of materials addressing this topic means only inferences could be made. An assumption that the inadequate demand for personnel is detrimental to the quality of care across all departments has been made. The studies used, however, have presented adequate proof that shortage negatively affects patient outcomes. The materials used for the review are scientific and credible meaning that generalizations could be made. Therefore, their application in the context of adult care does not undermine the credibility of this review. The major conclusion that can be derived from the research is that turnover and intention to leave are the major causes of the nursing shortage. Additionally, the major effects of this phenomenon are reflected in the quality of care afforded to the patients.
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