Nurse Understaffing in Healthcare

Problem Statement and Proposed Solution

The ultimate goal of healthcare is to provide quality care based on a patient’s needs and recent evidence. The quality of care depends upon many factors, including the level of staffing among frontline care providers. According to Martsolf et al. (2016), nurse staffing level positively influences patients’ experience during the hospital stay. Moreover, adequate staffing facilitates effective transitioning from hospital to home or other settings (Martsolf et al., 2016). Therefore, keeping an optimal number of nurses to bed ratio is a crucial task for human resource managers.

Nurse understaffing is a significant bother for healthcare managers, as the shortage of frontline employees can be associated with a decrease in the quality of care. According to Metcalf, Wang, and Habermann (2018), a high level of understaffing in healthcare settings is linked to the number of missed treatments in hospital settings. In other words, insufficient staffing of nurses leads to an increased number of scheduled procedures to be overlooked. Additionally, understaffing is associated with an increased turnover rate of nurses, which can be related to a raised cost of care due to the need to replace employees (Wendsche, Hacker, & Wegge, 2017). Therefore, nurse understaffing is an urgent issue that needs to be addressed to improve the quality of care.

The present paper proposes to utilize Lewin’s organizational change theory to address insufficient staffing by hiring more male employees and offering additional benefits to improve retention rates. Lewin’s change includes three steps, which are unfreezing, or arousing dissatisfaction with current situations, moving, or creating and implementing an action plan, and refreezing or revising the current guidelines for the continuity of change (Batras, Duff, & Smith, 2016). Accordingly, the solution for the stated problem also consists of three parts: spreading the knowledge about the consequences of understaffing (unfreezing), utilizing effective hiring strategies of male nurses (moving), and improving retention rates among men (refreezing). The proposed approach requires extensive research to acquire recent evidence through a literature review.

Literature Review

Theoretical Framework

An organizational change is to be directed by a theoretical framework to assure its efficiency and effectiveness. In the article “Organizational change theory: Implications for health promotion practice” by Batras et al. (2016), the authors provide a comprehensive review of the majority of the theoretical frameworks for organizational changes. The design of the study is a systematic review with no clearly defined methods. The article provides an in-depth insight into organizational change theories, including Lewin’s change theory, diffusion theory, organizational learning theories, organizational culture theories, and receptive contexts for change.

The authors also address strategies for facilitating the application of the reviewed theories to improve the quality of organizational changes. Batras et al. (2016) conclude that researchers need to identify targets for change, and their choice is to be theory-informed. The article is relevant for the project, as it allows understanding of key features of theoretical approaches and helps to choose an optimal theoretical framework for the proposed change. As the strategy for addressing understaffing suggested in the present paper is based upon Lewin’s organizational change theory, the further literature review will be divided into three categories to support the three steps described by the theory.

Unfreezing: Literature Concerning Nurse Understaffing

In the article “An examination of hospital nurse staffing and patient experience with care: Differences between cross-sectional and longitudinal estimates” by Martsolf et al., the author’s study associations between nurse staffing and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores. They conduct a retrospective study using cross-sectional and longitudinal designs and compare the results of the two approaches. As for methods, the authors utilized electronic databases to access hospital-level information about staffing, patient satisfaction, and hospital characteristics for 341 hospitals. They used HCAHPS scores to measure patient experiences, as it is a common method to describe the matter. The conducted research confirmed the hypothesis that the staffing level of nurses is positively associated with patient satisfaction. The findings are relevant for the present project, as it is recent evidence concerning the impact of nurse understaffing. The dissemination of the findings is beneficial for the “unfreezing” stage, as it would arouse dissatisfaction among managers with the current staffing situation.

In the article “Hospital unit understaffing and missed treatments: Primary evidence,” Metcalf et al. (2018) examine how understaffing in respiratory care leads to increased error rates. The authors utilize correlational research design by juxtaposing the results acquired from a survey about understaffing and teamwork and the missed treatment rates. As for methods, Metcalf et al. (2018) distributed the elaborated survey among 105 respiratory care managers and accessed national databases to acquire characteristics of participating hospitals. After the acquisition of the results, multiple regression was used to test the hypothesis. The authors concluded that understaffing leads to an increased number of missed treatments. Even though the research does not address nursing directly, it is relevant for the present project, as nurses are frontline care providers. Therefore, it may be concluded that nurse understaffing leads to an increased level of missed treatments.

The article “The relationship between understaffing of nurses and patient safety in hospitals—A literature review with thematic analysis” by Glette, Aase, and Wiig (2017) performs a thematic analysis of literature to study the correlations between nurse understaffing and the number of adverse events on hospital grounds. The research design is a literature review, and the method for information extraction is a previously elaborated form that includes study design, quality, objectives, data material and participants, main findings, and the location of the study (Glette et al., 2017). The data was gathered from Cinahl, Medline, Isi Web of Science, Cochrane Library, and Academic Search Premier databases (Glette et al., 2017). The article provides significant insights on the correlations between direct and indirect consequences of nurse understaffing, including patient harm, increased mortality, poor quality of basic care, and errors in medication administration. The researchers conclude that understaffing of nurses can negatively affect patient safety. The research is relevant for the project as it provides significant insights on the effects of inadequate nurse staffing, which is vital for the “unfreezing” stage.

The article “Recruitment, advising, and retention programs — Challenges and solutions to the international problem of poor nursing student retention: A narrative literature review” by Mooring (2016) gives a thorough overview of hiring and retention strategies for nurse students. The author conducts a literature review to identify problems with nursing student retention and recruitment. As for the method, Mooring (2016) uses five steps to address the matter that includes problem identification, literature search, data analysis, theme emergence, and information synthesis. The author proposes that the primary reason for nurses dropping nursing schools is the lack of necessary intervention by faculty. Mooring (2016) suggests that changes in recruitment and academic advising can improve the situation. Even though the article does not describe an intervention that can be used to address understaffing, it provides a deeper understanding of why there are not enough nurses graduating from universities. Therefore, the appreciation of the reasons for nurse student retention is vital for the present project.

Moving: Literature Concerning Hiring male Nurses

In their article “The male of the species: A profile of men in nursing,” Stanley et al. (2016) aimed at characterizing the perception of men in nursing. They utilized a non-experimental, comparative, descriptive research design to conduct a quantitative study. Stanley et al. (2016) elaborated an online survey and asked certified nurses to complete it. The researchers state that “decisions to recruit more men into nursing should be based on an understanding of men’s concept of nursing and the challenges faced by men who enter nursing” (Stanley et al., 2016, p. 1156). They conclude that men’s recruitment strategies are to include delivering the right message while hiring. Additionally, career opportunities should be described, and the picture of nursing as a feminine job should be addressed. The study is of most importance to the present project, as it provides recommendations about hiring strategies for men, which is crucial for the “moving” stage of the proposed change.

The article “Development, validation, and implementation of a clinic nurse staffing guideline” by Deeken et al. (2017) describes a nurse hiring guideline that can improve the situation with understaffing. They conducted experimental research with randomized control trial design. As for methods, Deeken et al. (2017) proposed the Clinic Technical Skills Permission List (CTSPL) that could be used for staffing decisions in the University of Missouri Healthcare. The hypothesis was that CTSPL could improve the situation about the nurse professional roles and staffing. The researchers concluded that the elaborated guide could be helpful for enhancing recruitment decisions, as it provides a comprehensive framework for what skills should be looked for in the candidates. The results of the research are beneficial for stage two of the present project, as hiring nurses with a predetermined skill set can help to address understaffing. The researchers provide an excellent guide that could be used for elaborating a comprehensive hiring strategy.

In the article “Are you man enough to be a nurse? The impact of ambivalent sexism and role congruity on perceptions of men and women in nursing advertisements,” Clow, Ricciardelli, and Bartfay (2015) describe how male nurses are discriminated against in the hospital settings. The authors utilized a correlational quantitative research design to study associations between masculinity and perceived role incongruity. Clow et al. (2015) utilized the method of surveying psychology students, asking them to rate the pictures of male and female nurses according to the student’s perception of the nurses’ professionalism. The study concluded that pictures of men with more masculine appearances provoked the feeling of greater role inappropriateness. Therefore, promoting manliness is not a viable strategy for hiring more male nurses. The research by Claw et al. (2015) is relevant as it reviews strategies to recruit more men in nursing, which is one of the goals of the present project. Therefore, the findings from the study will be useful for the “moving” stage of the plan.

Refreezing: Literature Concerning Retention of Male Nurses

In the article “Subtle perceptions of male sexual orientation influence occupational opportunities,” Rule, Bjornsdottir, Tskhay, and Ambady (2016) describe the connections between a man’s profession and his occupation. The design utilized for the research is descriptive correlational. As for methods, the researchers conducted five surveys using pictures of gay and straight men and asking the respondents to tell how likely people on these pictures will get a job in nursing or engineering. The results show that male facial appearance may play a role in his occupational success, as gay men are more likely to get a job as a nurse. This perception may be the problem with gender misbalance in nurse staffing, as straight men may be perceived as gay and are discriminated against while working as a nurse. The study is relevant for the present project, as it provides significant insights on the reasons for nurse retention. Sexism and discrimination in the workplace is a critical issue for nurse turnover. Therefore, for the “refreezing” stage, it would be vital to design measures to fight the matter.

The article “Understaffing and registered nurses’ turnover: The moderating role of regular rest breaks” by Wendsche et al. (2017) examines how the regularity of organized rest breaks affects the turnover rate in nurses. The researchers used a cross-sectional, multi-method, quantitative study design to assess the variables and come to a conclusion. Regarding the method, the information about understaffing, the regularity of rest breaks, turnover rate, and control variables from 80 nursing teams were gathered and analyzed. For data accumulation, Wendsche et al. (2017) accessed online databases and conducted online surveys. The results of the research show that there are positive correlations between nurse retention and regular rest breaks. Therefore, the organization of regular rest breaks is vital for preventing further staff shortages. The study is relevant for the third stage of the present project, as it suggests a viable strategy to address understaffing and reduce turnover rates.

Action Item Checklist

The literature review provides considerable insights into the matters that are to be addressed in the course of the capstone project. As suggested by the utilized theoretical framework, there will be the major steps in the implementation of the project: unfreezing, moving, and refreezing. However, before the implementation of the project, some preliminary work should be accomplished. Below is the proposed action item checklist with approximate dates for the completion of each stage.

  • Step 1: Choosing the Settings. During the first stage, different hospitals and other acute care providers are to be contacted with the offer to organize an intervention concerning nurse understaffing. One hospital is to be chosen for the project’s implementation. Estimated completion date: May 15, 2019.
  • Step 2: Analyzing the Care Provider. During the second stage, the chosen hospital is to be evaluated in terms of turnover rates, the number of male and female nurses, and hiring strategies. The results of the analysis with proposed interventions and expected results supported by recent evidence are to be handed to the hospital head. Estimated completion date: June 3, 2019.
  • Step 3: Revising Hiring Strategies. During the third stage, the assessment of the hospital’s hiring strategies will be improved to focus on males. The human resource managers will be offered to focus on career opportunities and delivering the message about the misconception of the nurse profession being feminine. Estimated completion date: June 18, 2019.
  • Step 4: Addressing Turnover. During the fourth stage, measures that address workplace sex discrimination will be offered and implemented. Additionally, the hospital heads will be provided to alter the regularity of rest breaks if necessary. Estimated completion date: July 1, 2019.
  • Step 5: Interpreting the Results. During the last stage, the results of the intervention will be acquired and analyzed. The conclusions will be shared with the hospital head to disseminate the knowledge. Estimated completion date: September 1, 2019.


Batras, D., Duff, C., & Smith, B. J. (2016). Organizational change theory: Implications for health promotion practice. Health Promotion International, 31(1), 231-241.

Clow, K. A., Ricciardelli, R., & Bartfay, W. J. (2015). Are you man enough to be a nurse? The impact of ambivalent sexism and role congruity on perceptions of men and women in nursing advertisements. Sex Roles, 72(7-8), 363-376.

Deeken, D. J., Wakefield, D., Kite, C., Linebaugh, J., Mitchell, B., Parkinson, D., & Misra, M. (2017). Development, validation, and implementation of a clinic nurse staffing guideline. JONA: The Journal of Nursing Administration, 47(10), 515–521. Web.

Glette, M.K., Aase, K. and Wiig, S. (2017). The relationship between understaffing of nurses and patient safety in hospitals—A literature review with thematic analysis. Open Journal of Nursing, 7, 1387-1429. Web.

Martsolf, G. R., Gibson, T. B., Benevent, R., Jiang, H. J., Stocks, C., Ehrlich, E. D., … Auerbach, D. I. (2016). An examination of hospital nurse staffing and patient experience with care: Differences between cross-sectional and longitudinal estimates. Health Services Research, 51(6), 2221-2241. Web.

Metcalf, A., Wang, Y., & Habermann, M. (2018). Hospital unit understaffing and missed treatments: Primary evidence. Management Decision, 56(10), 2273-2286. Web.

Mooring, Q. (2016). Recruitment, advising, and retention programs — Challenges and solutions to the international problem of poor nursing student retention: A narrative literature review. Nurse Education Today, 40, 204-208. Web.

Rule, N., Bjornsdottir, R., Tskhay, K., & Ambady, N. (2016). Subtle perceptions of male sexual orientation influence occupational opportunities. Journal of Applied Psychology, 101(12), 1687-1704. Web.

Stanley, D., Beament, T., Falconer, D., Haigh, M., Saunders, R., Stanley, K., … Nielson, S. (2016). The male of the species: A profile of men in nursing. Journal of Advanced Nursing, 72(5), 1155–1168. Web.

Wendsche, J., Hacker, W., & Wegge, J. (2017). Understaffing and registered nurses’ turnover: The moderating role of regular rest breaks. German Journal of Human Resource Management, 31(3), 238-259.