Audience Analysis
This paper is directed towards hospital CEOs, hospital administrators, healthcare
leaders, the human resources department for hospitals, and anyone who has the authority and
influence in retaining nurses in the workforce. The content of this paper is in context with the
ongoing nurse shortage in the lens of the work hours and work conditions nurses have been
dealing with in their field. The intentions of this paper is to bring to light organizational issues
as well as issues within the workplace that have yet to be addressed and need to be addressed
in order to find and create permanent solutions to the shortage. While nursing is not in my
field of study, I have done extensive research on the nursing shortage looking at various
perspectives and as an Operations Management and Business Analytics major at the Robert H.
Smith School of Business, I can speak on the business side of the shortage.
There are some notable limitations to this paper which include: limited research
available on organizational practices and relationships to nurses, there is a constant flow of
new information since this is an ongoing crisis which may subject this paper to become dated,
and lastly while nurses have been vocal with issues in their work environment, hospital
administrators and the healthcare industry as a whole has not been directly vocal about its
tribulations regarding this aspect. This paper can grant the industry a chance to develop a
voice where they can express their concerns and both parties (employee and employer) can
have a better understanding of each other in hopes of developing solutions.
1
Nurse shortage
The nurse shortage has been deemed a recent global crisis in light of the Covid-19
pandemic. However research shows that this issue has been prevalent since roughly 2002 with
complexities spanning from policy development and intervention, health sector funding, all the
way to nursing regulation, leadership, and nursing recruitment and retention (Turale &
Nantsupawat, 2021). In 2006, Health Affairs.org discussed how the nurse shortages have been a
cyclical occurrence with the year 2000 containing an estimated “126,000 hospital nursing
positions unfilled” driven by aspects like “recruitment, retention, [...] fewer workers, an aging
workforce, and unsatisfying work environments” ( Hassmiller et al.). While shortages are hard to
unanimously define and vary by region, research generally quantifies a shortage as “ any gap
between the numbers of nurses required (demand) against the future number available to work
(the supply)”(Drennan & Ross, 2019). In 2022, the factors contributing to the nursing shortage
have been more concretely defined on elements relating to the work conditions such as burnout,
staffing to patient ratios, and violence in the healthcare setting. (Haddad et al., 2022).
2
Long Hours
Starting with the work shift, the 12 hour work shift has been industry standard since
the 1970s “as a way of simplifying scheduling and addressing a national nursing shortage.
They made it possible for just two nurses, alternating shifts, to care for a patient around the
clock. And 12-hour shifts remain popular among many nurses'' (Mercer). The 12 hour work
shift was originally viewed as an attractive model because a “relatively short work week can
be a boon to nurses who have caregiving obligations outside of the hospital” (Mercer),
however recent research has showcased the negative effects it has on nurses. Nursing Outlook
mentions that nurses in 12 hour shifts are at risk for “cardiovascular disease, gastrointestinal
and psychological disorders, cancer, type 2 diabetes, injuries, musculoskeletal disorders,
all-cause mortality, adverse reproductive outcomes, and difficulty managing chronic
diseases''(Caruso et al.). Within that same study it showed that “the presence of SWLWH
(Shift Work Long Work Hours) is also related to retention issues, including nurses expressing
intention-to-leave or quitting the job.”(Caruso et al.). Beyond this, The Centers for Disease
Control and Prevention (CDC) reported that over 52% of healthcare night shift workers
reported sleeping six hours or less a day. With this research in mind it is evident that keeping
12 long hour shifts is not the best option as it creates harmful risks to nurses, can increase
turnover rates, and reduces work performance. Even though this is unfortunate, as a business it
may not be possible to reduce shift hours especially since there is not enough staff present due
to the current shortage. This reasoning is why I feel it is best to focus on improving work
conditions within nurses shifts to combat the nurse shortage and retain workers.
3
Work conditions in those hours
One aspect regarding the shortage that is often overlooked as to why it is still ongoing
is the work conditions that nurses face. Within those long 12 hour shifts nurses are dealing
with issues of a change in unequal patient to nurse ratios, workplace violence, and a generally
more stressful work environment due to complications from the Covid-19 pandemic. Research
has determined that “Nurses are experiencing higher workloads than ever before due to four
main reasons: (1) increased demand for nurses, (2) inadequate supply of nurses, (3) reduced
staffing and increased overtime and (4) reduction in patient length of stay.” (Carayon and P.
Gurses). In regards to demand from nurses in hospitals, there have been issues with nurses
trying to keep up with the demand with a smaller ratio of nurses to patients. According to an
Emergency Medicine News article, with regards to the small nurse to patient ratio “each
additional patient per nurse was associated with a seven percent increase in the likelihood of
dying within 30 days and a seven percent increase in the odds of failure to rescue. For
instance, the difference from four to six and from four to eight patients per nurse would be
accompanied by 14 percent and 31 percent increases in mortality, respectively.”(Emergency
Medicine News). In that same article “The researchers also found that each additional patient
per nurse was associated with a 23 percent increase in the odds of burnout and a 15 percent
increase in the odds of job dissatisfaction.”(Emergency Medicine News). Research has
depicted job stressors like what was stated previously to accumulate to burnout and can lead to
an increase in nurses’ turnover intention (Mirzaei et al., 2021). It is clear that hospitals need
to implement staffing methods that reduce stressors of unequal patient to nurse ratios to keep
their retention rate high in the long run. If hospitals do not address this, they risk losing their
current nurse staff. This mirrors what Annette Bourgault, editor of Critical Care Nurse and
4
Nurse Scientist of Orlando Health thinks about the p-n ratios : “ Nurses cannot provide
optimal care if they are assigned to too many patients. Some patients may not receive all of the
necessary elements of evidence-based care, and some patient needs will not be attended to.
This situation is not the fault of the nurse—it is a system failure.”(Bourgault)
Workplace violence
A very important aspect regarding the nurse shortage and why many may leave is the
abundance of violence that is present in the workplace against nurses from their patients.
Workplace violence is unfortunately underreported but there are two research studies that
depict this issue really well. One of the studies reveals that different fields of nursing still dealt
with workplace violence and the second study reveals that in a study of triage nurses
(registered nurses in emergency rooms) were exposed to workplace violence even in smaller
quantities. The first study determined that rates of assault correlate with patient-contact time
and that : “nurses and nursing aides are victimized at the highest rates. In the Minnesota
Nurses’ Study, the annual incidence of verbal and physical assaults was 39% and 13%,
respectively. In another large study, 46% of nurses reported some type of workplace violence
during their five most recent shifts; of these nurses, one third were physically assaulted.
Emergency department nurses reported the highest rates, with 100% reporting verbal assault
and 82.1% reporting physical assault during the previous year” (Phillips). For the second
study, research has unfortunately found that in a concentrated study of 27 nurses in the
emergency department, “Ninety-six percent of triage nurses had suffered an episode of
violence during the previous year. Participants reported that perpetrators of violence were
primarily patients' relatives or friends (62%)”(Ferri et al.). This shows that even with the
miniscule amount of nurses in the study, the fact that out of the 27 nurses, 96 % experienced
5
workplace violence showcases how common this issue is; especially in combination with the
first study. Hospitals need to find ways to report and address this issue to reduce turnover
intentions and ultimately retain its staff.
Industry attempts: What have hospitals been doing?
With all this in mind, what have hospitals done to address the shortage? Hospitals have
been looking at short term solutions to fix the problem, mainly looking at travel nurses as the
option to fill in the gaps of nurses needed in the hospital. Travel nurses are essentially
registered nurses in temporary contractual roles that travel all over the world to work in
hospitals, clinics, and other healthcare facilities that are in desperate need of assistance. Hiring
travel nurses are more expensive, however the reasoning is often that : "Hiring traveling nurses
rather than permanent nurses eliminates the need to pay for benefits such as health insurance,
retirement and paid days off, and also reduces recruiting, training, overtime and payroll
costs."(Cornett).
While this is generally a decent solution as a temporary fix, this method has backfired
on hospitals recently. Since we are in the year 2022, we are still in a pandemic and hospitals
are still trying the temporary solution of hiring travel nurses. After being in this situation for
over two years, many permanent registered nurses have decided to become travel nurses due to
their perks of higher pay and flexibility. An example of this can be seen with Nurse Sara Dean
where she switched to being a travel nurse due to these factors: “the average pay bump last year
for full-time nurses was only marginally more than usual nationwide at roughly 4%. And when
a nurse has gotten used to making $8,000 to $10,000 a week, a one-time bonus of $20,000
doesn't sound quite so generous, says Sara Dean. Which is why she and other pandemic
travelers face such a difficult transition” (Farmer). In that same npr article she discussed the
6
joys of “making the most of her downtime — from spending Christmas with her daughter in
New York City to cheering on her preteen at cheer practice.(Farmer).
Industry attempts: What else have hospitals been doing?
While the solution of travel nurses backfired, what other solutions have hospitals tried?
According to the American College of Healthcare Executives CEO Circle White Paper regarding
the nurse shortage, CEO’s proposed methods like “ financial incentives, either increasing
compensation (mentioned by 77% of respondents) or providing signing bonuses (mentioned by
61% of respondents). Filling positions using contract staff who travel was the second most
frequently mentioned approach to address shortages among registered nurses (after increasing
compensation), reported by 64% of respondents. Offering flexible hours was named by 41% of
respondents”(ache.org).
It seems Hospital CEO’s have missed the memo in regards to pay of permanent staff and
the relationship in correspondence with contract staff or in other words travel nurses. While
CEO’s of this industry seem to have some acknowledgement of the issues of flexible hours and
in essence work-life balance, not many plans have been set forth to truly fix work conditions. It
is evident that leaders of the industry’s minds are geared towards a more quick fix rather than a
long term solution. This is made clear by the amount of CEO’s who are trying more lasting
solutions where for work-life balance only 16 tried flex scheduling, 2 have tried to implement
work life balance, 1 CEO offered guaranteed hours, and only 4 tried adjusting the patient-to-staff
ratio to decrease the workload out of 340 CEOs (ache.org). Given the situation that occurred with
travel nurses and pay, the best solution to tackle the nurse shortage is to focus on the long term
and fixing issues within the work environment. This will make nurses want to stay in the
7
industry.
As previously addressed, the solutions avoid the main problem, the work conditions
nurses go through. Hospitals need to focus on permanent solutions like improving work
conditions to diminish the shortage once and for all, not temporary cost saving solutions like
travel nurses that may eventually backfire. A complex problem requires a complex solution to
be properly addressed and hospitals will struggle to stay afloat if they lose their workforce due
to these factors. A Washington Post article Wonderfully wraps up these sentiments “Hospitals
contribute to the problem by keeping their nursing staff as lean as possible, treating the
nursing workforce like a tap they can turn on and off to maximize profits. At the beginning of
the coronavirus pandemic, hospitals furloughed or laid off nurses when lucrative elective
procedures were suspended, only to frantically try to hire them back as covid-19
hospitalizations rose. Ping-ponging from furloughs and layoffs to cutting hours and then to
mandatory overtime is not a recipe for retention. The understaffing crisis is a circular problem:
Not hiring enough nurses makes working conditions unbearable, leading to more nurses
leaving their jobs.” (DiGregorio)
8
Work cited
Turale, S., & Nantsupawat, A. (2021, March). Clinician Mental Health, nursing
shortages and the COVID-19 pandemic: Crises within crises. International nursing review.
Retrieved March 31, 2022, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8251049/#:~:text=The%20shortage%20was%20
deemed%20a%20global%20nursing%20crisis,leadership%2C%20and%20nursing%20recruitme
nt%20and%20retention%20%28Oulton%202006%29.
Hassmiller, Susan B., et al. “Addressing the Nurse Shortage to Improve the Quality of
Patient Care: Health Affairs Journal.” Health Affairs, 2006,
https://www.healthaffairs.org/doi/full/10.1377/hlthaff.25.1.268.
Drennan, V. M., & Ross, F. (2019, May 13). Global nurse shortages-the facts, the impact
and action for change Global nurse shortages—the facts, the impact and action for change |
British Medical Bulletin | Oxford Academic. OUP Academic. Retrieved March 31, 2022, from
https://academic.oup.com/bmb/article/130/1/25/5487611#136987568
Haddad, L. M., J. Toney-Butler., T., & Annamaraju, P. (2022, February 22). Nursing
shortage. StatPearls . Retrieved March 31, 2022, from
https://www.ncbi.nlm.nih.gov/books/NBK493175/
Mercer, Maile. “It's Time to Rethink the 12-Hour Nursing Shift.” Undark Magazine, 23
Nov. 2021,Retrieved May 3, 2022
https://undark.org/2021/11/25/its-time-to-rethink-the-12-hour-nursing-shift/.
Caruso, Claire C., et al. “Policy Brief: Nurse Fatigue, Sleep, and Health, and Ensuring
Patient and Public Safety.” Nursing Outlook, vol. 67, no. 5, 2019, pp. 615–619.,
https://www.nursingoutlook.org/article/S0029-6554(19)30500-7/fulltext
“Short Sleep Duration among Workers - United States, 2010.” Centers for Disease
Control and Prevention, Centers for Disease Control and Prevention, 27 Apr. 2012, Short Sleep
Duration Among Workers — United States, 2010 (cdc.gov).
Carayon, Pascale, and Ayse P. Gurses. “Patient Safety and Quality: An
Evidence-Based Handbook for Nurses.” National Center for Biotechnology Information, U.S.
National Library of Medicine,
https://www.ncbi.nlm.nih.gov/books/?book=mcb&part=A7315&rendertype=def-item&id=A7
816.
Emergency Medicine News. “High Patient-Nurse Ratios Linked to Patient Deaths :
9
Emergency Medicine News.” LWW, Oct. 2003,
https://journals.lww.com/em-news/fulltext/2003/10000/high_patient_nurse_ratios_linked_to_p
atient_deaths.45.aspx#:~:text=A%20new%20study%20in%20the,that%20can%20lead%20to
%20death.
Mirzaei, A., Rezakhani Moghaddam, H., & Habibi Soola, A. (2021, May 7). Identifying
the predictors of turnover intention based on psychosocial factors of nurses during the
COVID-19 outbreak. Nursing Open. Retrieved April 1, 2022, from
https://onlinelibrary.wiley.com/doi/abs/10.1002/nop2.896
Bourgault, Annette M. “The Nursing Shortage and Work Expectations Are in Critical
Condition: Is Anyone Listening?” Critical Care Nurse, vol. 42, no. 2, 2022, pp. 8–11.,
https://doi.org/10.4037/ccn2022909.
Phillips, James P. “Workplace Violence Against Health Care Workers in the United
States.” New England Journal of Medicine, vol. 374, no. 17, 2016, pp. 1661–1669.,
https://doi.org/10.1056/nejmra1501998.
Ferri, Paola, et al. “Violence against Nurses in the Triage Area: A Mixed-Methods
Study.” Journal of Emergency Nursing, vol. 46, no. 3, May 2020, pp. 384–397.,
https://doi.org/10.1016/j.jen.2020.02.013.
Cornett, J.E. “Why Are Hospitals Hiring Traveling Nurses?” Work, 10 Feb. 2022,
https://work.chron.com/hospitals-hiring-traveling-nurses-22729.html.
Farmer, Blake. “For Travel Nurses, Jobs at Home Can't Come Close to Pay They Get on
the Road.” NPR, NPR, 11 Feb. 2022,
https://www.npr.org/sections/health-shots/2022/02/11/1077687493/for-travel-nurses-jobs-at-hom
e-cant-come-close-to-pay-they-get-on-the-road.
Addressing Personnel Shortages in Hospitals - Ache.org.” www.ache.org, 2020,
2020-ceo-circle-white-paper.pdf (ache.org)
DiGregorio, Sarah. “Perspective | Hospitals Desperately Need Staff. but Capping Travel
Nurses' Pay Won't Help.” The Washington Post, WP Company, 14 Mar. 2022,
https://www.washingtonpost.com/outlook/2022/03/14/travel-nurse-pay-caps/.
10
