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‘The unique function of the nurse is to give nursing care. To this function both nursing management and nurse education are in a service relationship. Their excellence can only be judged by the excellence of nursing care which they enable’

Jean McFarlane (1970, p. 11)

These words from Jean McFarlane are as pertinent for today’s nurse as they were when first penned 40 years ago. Globally, health challenges are shifting; populations are living longer, becoming more diverse, with a shift from acute to long-term health-care needs for conditions such as cardiovascular disease, arthritis, hypertension and diabetes and mental health conditions. Alongside this increasing complexity of health-care delivery, effective workforce planning and strategies to promote the recruitment, retention and sustainability of appropriately qualified nurses in the global workforce are urgently needed.

The current global economic crisis has intensified the existing problems of allocative efficiency concerning the distribution of resources between competing areas of health interventions and technical efficiency in the use and allocation of health-care resources (Mills 1997, Retzlaff-Roberts et al. 2004). At the same time, health policy makers face an escalating global demand for nurses. Previous international recruitment, and supported migration of nurses from developing countries to meet nursing shortages in developed countries, left source countries with insufficient nursing staff to meet their own health-care needs (Nichols et al. 2010). Buchan (2002) comments on global nursing shortages as a symptom of wider health system or societal ailment still holds strongly today. In their interim report, from the forthcoming Royal College of Nursing Labour Market Review (LRM) 2011, Buchan and Seccombe (2011), claim that ‘the challenges facing nursing and the nursing workforce across the UK in 2011 are the greatest for a generation’. They point out that the nursing workforce is highly vulnerable to policy change especially with regard to the number of education places being commissioned and the number of nurses retiring.

This global financial crisis also brings emerging opportunities for nurses to challenge current practice, to cease ineffective work and to show how they can focus their work to have a real impact on providing innovative, cost-effective and efficient health care for patients. As suggested by McSherry and Douglas (2011), Bettencourt (2010) and Gibson and Kelly (2010), such innovation in practice in leading and contributing to widespread and meaningful change, requires an organizational culture and working environment with clear vision and values, including robust structures and systems for sharing and communicating ideas, to meet emerging demands for quality, safer, personal and affordable care.

Providers of health care are discovering new ways to deliver effective patient and family-centred care, and increasingly care is delivered closer to home. Adapting to these changes and meeting the quality and affordability challenges posed requires a fundamental rethinking of the roles of many health-care professionals, including nurses (Institute of Medicine 2010). As stated by Christine Beasley, Chief Nursing Officer UK, this:

‘Gives us (nurses) the opportunity and the challenge to articulate what we do, it means being able to apply tested tools and change techniques in order to show the impact and outcome of nursing care. It means thinking about and telling the story of the nurse’s role and the impact it has on the experience, safety and effectiveness in everything we do.’

(DoH 2010a)

The DoH ‘Nursing Road Map for Quality’ (2010a) reaffirms the importance placed on quality in nursing. That is, by providing a sign-posting reference guide for nurses, categorizing the resources and tools that are currently available that aim to raise quality of care, to reduce waste and remove unnecessary repetition. This renewed focus on quality follows the DoH (2008) publication of ‘High Quality Care for All’, which set out a vision for ‘an NHS with quality at its heart’. A critical element in taking the quality agenda forward is ensuring the optimum number of nurses worldwide that have the appropriate attitude, values, skills and knowledge.

The challenges for workforce planners

  1. Top of page
  2. The challenges for workforce planners
  3. Future potential: liberating the nursing workforce through education and new roles to transform health-care systems
  4. Organizational culture and working environment: associations between work conditions, workplace bullying, employee turnover and nurses’ reported levels of stress
  5. Impact of workplace bullying practices
  6. Factors influencing job satisfaction
  7. Policy issues
  8. Rethinking of nursing roles
  9. Conclusion
  10. References

The association between the number of nursing staff deployed and the quality and safety of care delivered, and on patient outcomes is now widely recognized (Royal College of Nursing 2010). Nurses currently work throughout the entirety of health care, from health promotion and disease prevention to early diagnosis to prevent or limit disability (Institute of Medicine 2010). Nurses practice in many settings, including homes, health clinics, schools, hospitals and long-term care facilities; others are involved in conducting research and scientific study.

The health workforce is highly influenced by policy drivers (Segal & Bolton 2009). It is now generally accepted that poor work environments, lack of job satisfaction and nurses’ intention to migrate are all factors that adversely affecting health-care delivery (Kohi et al. 2010). Short staffing compromises care and results in increased staff stress, reduced staff well-being, high levels of burnout, more staff leaving and lower job satisfaction (Royal College of Nursing 2010).

Over the past decade, an emerging body of academic studies have mapped the association, and has sought to make explicit, the positive associations between higher nurse staffing levels and better patient outcomes (Aiken et al. 2008, Rafferty et al. 2007). Lankshear et al.’s (2005) systematic review looked at relationships between nurse staffing and patient outcomes, and reported that ‘high nurse staffing and richer skill mix are associated with improved patient outcomes, although the effect size cannot be estimated reliably’. Similarly, in a 2007 meta-analysis, Kane et al. (2007) reported an association between increased RN staffing, lower rates of hospital related mortality and adverse patient events. Although there is no overall agreement on what constitutes ‘understaffing’ many high-profile cases of failure in care provision are recurrent themes where staffing levels have been found to be unable to sustain adequate health-care standards. As stated by the Royal College of Nursing in ‘Guidance on Safe Nurse Staffing Levels in the UK’:

‘Whilst research on how and why this (safe staffing) works may be complex, but as with a parachute, evidence of its effectiveness becomes abundantly clear when it is not there.’

(Royal College of Nursing 2010, p. 15)

Future potential: liberating the nursing workforce through education and new roles to transform health-care systems

  1. Top of page
  2. The challenges for workforce planners
  3. Future potential: liberating the nursing workforce through education and new roles to transform health-care systems
  4. Organizational culture and working environment: associations between work conditions, workplace bullying, employee turnover and nurses’ reported levels of stress
  5. Impact of workplace bullying practices
  6. Factors influencing job satisfaction
  7. Policy issues
  8. Rethinking of nursing roles
  9. Conclusion
  10. References

The recent DoH (2010b)‘Liberating the NHS: Developing the Healthcare Workforce (England)’ sets out a new system for the planning, commissioning and delivery of health-care education. Within this paper, the aspiration of the first objective is ‘security of supply, having people with the right skills in the right place at the right time’. The paper put forward the objective that this will be part of a service model that delivers value for money, and widens participation, while delivering high-quality education and training that supports safe, high-quality patient care which is responsive to patient need. Similarly, the Institute of Medicine (2010)has called for an emphasis on developing higher levels of education and training of nurses to address deficits and challenges to health care in the USA. Key messages from the report are that ‘nurses should practice to the full extent of their education and training; nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression; and nurses should be full partners with physicians and other health-care professionals in redesigning health care in the US’.

These are high ideals to aim for. Visionary leaders need to champion development of effective advanced clinical career roles and provide the structures, support and vision to empower nurses to stretch and expand their scope of practice. Nurses need targeted education and support to develop new competencies such as critical thinking, leadership, knowledge of health policy, quality and performance improvement, nursing metrics, research and evidence-based practice and team-work as well as competency in specific content areas, including community and public health (Moffa et al. 2010, Foulkes 2011). In expanding their roles to collaborate and coordinate care across teams of health professionals, future nurses need to be able to master technological tools and use relevant information management systems (Institute of Medicine 2010). Alongside this, organizational, cultural and legislative barriers that hinder and limit the ability of nurses to practice to the full extent of their competence need to be challenged. Effective clinical leaders need to work together, be committed to the vision, share responsibility and play an active part in dealing with front-line challenges for this future of nursing to be realized.

Organizational culture and working environment: associations between work conditions, workplace bullying, employee turnover and nurses’ reported levels of stress

  1. Top of page
  2. The challenges for workforce planners
  3. Future potential: liberating the nursing workforce through education and new roles to transform health-care systems
  4. Organizational culture and working environment: associations between work conditions, workplace bullying, employee turnover and nurses’ reported levels of stress
  5. Impact of workplace bullying practices
  6. Factors influencing job satisfaction
  7. Policy issues
  8. Rethinking of nursing roles
  9. Conclusion
  10. References

Within this issue of the Journal of Nursing Management, the importance of workforce planning and educational support is highlighted along with devising strategies and policies for supporting nurses in daily activities. Bae in presenting a synthesis of current literature on working conditions and their association with patient outcomes concludes that although general reviews support the positive link between work conditions and patient outcomes, definitive evidence remains inconclusive and that further longitudinal and interventional research in various settings is needed to advance our knowledge on this important topic.

The next three papers address the impact of role stress on different groups of nurses and caregivers. Purcell and colleagues present a descriptive correlation study using self-reported data to explore the relationship between nurses’ stress and nurse staffing factors in a large teaching hospital in the south-eastern USA. They conclude that patient workload and day of the week worked are important factors affecting nurses’ stress levels. In their study, younger nurses reported higher stress levels, leading the authors to speculate that this may be caused by activities outside of their working environment, especially when working weekends. Older nurses cared for a greater number of patients than younger nurses yet reported lower stress levels, these differences were not statistically significant. Riahi presents us with a model representing the concept of role stress developed through ‘careful consideration of the attributes, consequences, antecedents and empirical referents of role stress’. The author states that it is essential for nurses to be educated on the concept of role stress to heighten their awareness regarding coping strategies and consequences. In the third of this set of papers, Engstrom et al. explored the working life and stress symptoms among caregivers in elderly care settings in Sweden with formal and no formal competence. They report that stress symptoms were increased for those staff that had no formal competence and suggest that self-determination, impact and opportunities need to be improved to promote job satisfaction for these staff groups.

Impact of workplace bullying practices

  1. Top of page
  2. The challenges for workforce planners
  3. Future potential: liberating the nursing workforce through education and new roles to transform health-care systems
  4. Organizational culture and working environment: associations between work conditions, workplace bullying, employee turnover and nurses’ reported levels of stress
  5. Impact of workplace bullying practices
  6. Factors influencing job satisfaction
  7. Policy issues
  8. Rethinking of nursing roles
  9. Conclusion
  10. References

The relationship between bullying practices in the workplace and increased employee turnover is addressed in the next two papers. Hogh, Hoel et al. in a three-wave prospective cohort study of Danish health-care workers with training as health-care helpers, set out to measure the actual rate of employee turnover in relation to bullying. They conclude that a relationship exists and, furthermore, suggest that the risk of turnover increases with the frequency of exposure to bullying. The results of this study show that workplace bullying in an organization has substantive costs for both the individual and the organization. The authors recommend that to protect against such detrimental impacts organizations need to regularly monitor the psychosocial work environment and to develop, implement and evaluate policies and procedures to prevent and manage bullying. Ortega et al. report on a 1-year prospective questionnaire study, in the elderly-care sector in 36 Danish municipalities, which explored the effect of both frequent and occasional workplace bullying on long-term sickness absence among health-care employees. The authors report that the risk of long-term sickness absence was 92% higher for those exposed to frequent bullying even after adjusting for psychosocial work characteristics. Both these papers add to knowledge in regard to the links between bullying and turnover, and adds support to the already clear imperative for managers to act to reduce bullying.

Factors influencing job satisfaction

  1. Top of page
  2. The challenges for workforce planners
  3. Future potential: liberating the nursing workforce through education and new roles to transform health-care systems
  4. Organizational culture and working environment: associations between work conditions, workplace bullying, employee turnover and nurses’ reported levels of stress
  5. Impact of workplace bullying practices
  6. Factors influencing job satisfaction
  7. Policy issues
  8. Rethinking of nursing roles
  9. Conclusion
  10. References

The next three papers present some international perspectives on job satisfaction. Nabirye et al. bring our attention to the severe situation in Sub-Saharan Africa where the nursing shortage means one nurse/midwife for every 3.065 people or one nurse to 100 patients. In a country where life expectancy is low, infant mortality is high and the situation is further compounded by the HIV/AIDS, pandemic it is no wonder that, as the authors explain, the current situation ‘poses a risk of continuous loss of nurses, either because of stress-related diseases or attrition as a result of a lack of job satisfaction’. On a similar note, Chang and colleagues in their exploration of personality traits in relation to depression among hospital nurses in Taiwan report that 52.5% of the nurses in the study indicated mild-to-moderate levels of depressive symptoms. The authors make the recommendation that nurse managers need to pay immediate attention to this issue by incorporating ‘empowerment’ techniques such as coaching, participation and mentoring, and cognitive behavioural stress management training workshops to into their management strategies. Wells et al. consider important issues, including quality work environments, change processes and improved care delivery, in their report on nurse-related outcomes associated with change to a total patient care delivery model within a regional health authority in Newfoundland and Labrador, Canada. The authors conclude that this change in practice did not bring any improvement in nurses’ reported level of job satisfaction; however, respondents reported that they perceived that client care was more effective than in the previous care delivery model.

Policy issues

  1. Top of page
  2. The challenges for workforce planners
  3. Future potential: liberating the nursing workforce through education and new roles to transform health-care systems
  4. Organizational culture and working environment: associations between work conditions, workplace bullying, employee turnover and nurses’ reported levels of stress
  5. Impact of workplace bullying practices
  6. Factors influencing job satisfaction
  7. Policy issues
  8. Rethinking of nursing roles
  9. Conclusion
  10. References

Attree and colleagues in their review of nursing workforce policies identify two common policy themes across five European countries. These are, first, improving retention through effective human resource management, improving the practice environment and nurses working lives. Second, improving recruitment through attracting more new recruits and registered nurses (RNs) back to practice. The authors conclude that health-care systems and organizations need to identify and implement effective policies to promote the retention of RNs in the workforce or risk the threat to patient care quality, safety and even sustainability of the system. Stone et al. conducted a literature search and analysis of recent Nursing and Midwifery Council activity to examine the evidence of how poorly performing nurses and midwives are managed in the UK. Their scoping work highlights the general lack of empirical data on this important topic, and identifies that inexperienced, poorly trained or poorly supported managers are using suspension inappropriately. The authors conclude that data is inadequate and point to the need for better data reporting requirements such as recording of reason, length and outcome. Pöder et al. in their comparative questionnaire study sought to identify staff opinions about, and their use of, an evidence-based standard care plan and quality standard for the care of patients experiencing a stroke. They report that staff-perceived knowledge about evidence-based guidelines increased after implementation and staff reported increased knowledge about care and treatment in stroke care.

Rethinking of nursing roles

  1. Top of page
  2. The challenges for workforce planners
  3. Future potential: liberating the nursing workforce through education and new roles to transform health-care systems
  4. Organizational culture and working environment: associations between work conditions, workplace bullying, employee turnover and nurses’ reported levels of stress
  5. Impact of workplace bullying practices
  6. Factors influencing job satisfaction
  7. Policy issues
  8. Rethinking of nursing roles
  9. Conclusion
  10. References

To meet future health-care delivery challenges, nurses and midwives need to be able to challenge current practice, be leaders of change, and show how they have a real impact on health care for patients. In the final paper in this issue, Mullen and colleagues provide an insightful evaluation of the non-medical consultant role in the North West of England. They confirm that while still small in number, the role is evolving to meet service need. Strategic thinking, thinking differently and innovatively, and being flexible and responsive to change were identified by respondents as the skills and behaviours most necessary to succeed. Interestingly, the evaluation found that although the non-medical consultant role forms the highest clinical-level post, only 54% of participants intended to stay in role. Forty-six per cent reported that they intended to leave within the next 4 years. The authors conclude that the role provides organizations with clinical leaders at a strategic and operational level but that succession planning remains poor, which is a threat to its effectiveness and sustainability.

Conclusion

  1. Top of page
  2. The challenges for workforce planners
  3. Future potential: liberating the nursing workforce through education and new roles to transform health-care systems
  4. Organizational culture and working environment: associations between work conditions, workplace bullying, employee turnover and nurses’ reported levels of stress
  5. Impact of workplace bullying practices
  6. Factors influencing job satisfaction
  7. Policy issues
  8. Rethinking of nursing roles
  9. Conclusion
  10. References

Countries across the world have the opportunity and the economic necessity to transform health-care systems to better meet the emerging needs of their populations now and in the future. Nurses have the opportunity to be fully involved in this transformation. Working together with policy makers, government leaders, managers, executives, educational institutions and especially with patients and their carers, today’s nurse leaders and operational and clinical managers need to grasp the opportunity to ensure that they are actively leading these changes and ensuring that health-care systems are ‘fit for purpose’, accessible to all and that they deliver quality care, and improved health and well-being to present and future populations.

Finally, the editor would like to thank and acknowledge all the contributors to this journal issue. The editor strongly urges nurse leaders and managers to take note of the messages within these papers and make plans immediately to take action to address future challenges, while taking up the opportunities, to make nursing as relevant in future health-care provision as it has been to date. Are we ready for the challenge?

References

  1. Top of page
  2. The challenges for workforce planners
  3. Future potential: liberating the nursing workforce through education and new roles to transform health-care systems
  4. Organizational culture and working environment: associations between work conditions, workplace bullying, employee turnover and nurses’ reported levels of stress
  5. Impact of workplace bullying practices
  6. Factors influencing job satisfaction
  7. Policy issues
  8. Rethinking of nursing roles
  9. Conclusion
  10. References
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  • Department of Health (2008) High Quality Care for All: NHS Next Stage Review. The Stationary Office, London.
  • Department of Health (2010a) The Nursing Roadmap for Quality: a Signposting Map for Nursing. HMSO, London.
  • Department of Health (2010b) Liberating the NHS: Developing the Healthcare Workforce (England). HMSO, London.
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  • Segal L. & Bolton T. (2009) Issues facing the future health care workforce: the importance of demand modelling. Australia and New Zealand Health Policy 6 (12), 612.