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Nurse Recruitment and Retention
Imperatives of imagining the future and taking a proactive stance
Megan-Jane Johnstone
Professor of Nursing; Director of Research, Division of Nursing and Midwifery, RMIT University, Bundoora West Campus, Melbourne VIC
Article Text
The need to imagine, examine, study, take a proactive stance in regard to and make a steadfast commitment to the future of nursing has never been more imperative. As Bezold et al (1999: 4) persuasively argue, the nursing profession (and others) have
never had a greater need to understand the future, to envision a preferred future, and to develop strategies to create the preferred future than it does today. Vision and commitment are needed more than ever.
The reasons for this are twofold. First, the nursing profession world-wide is facing a crisis in recruitment and retention. This crisis, widely recognised as involving 'the worst nursing shortage in the last 50 years' (Hodges et al 2002), is having a significant and negative impact on health care and the capacities of the health care systems around the world (including the Australian health care system) to respond appropriately, safely, and effectively to the health needs of the individuals, groups and communities they serve. There is a critical need for stakeholders to collectively and creatively 'think and work' their way out of this crisis.
A second key reason is that the health, welfare and well-being of both current and future generations depends on the access, equity, quality and viability of professional nursing services. The accessibility and sustainability of quality nursing services, in turn, depend on nursing futures work and the capacity of this work to 'confront the will to act' in regard to the realisation of a preferred healthier future for all (Bezold et al 1999: 4). In sum, the future of nursing is imperative because:
Nursing's future is inextricably, and rightly so, bound to society's future and the future of health care (Bezold et al 1999:8).
Australian health care crisis
Few would disagree that Australian health care is in a crisis. Despite policies that advocate access and equity to Australia's health care services, thousands of Australians do not have timely access to appropriate and effective health care. Furthermore, as is the case in the United States of America, in Australia:
- health care costs are increasing, in spite of efforts to contain costs;
- quality of care is decreasing in spite of increasing regulations to enhance quality care; and
- the existing health care system is reactive rather than proactive (Jardin 2001:615).
A key contributor to the present crisis in Australian health care is the local and global shortage of registered nurses (Duffield and O'Brien-Pallas 2003; Preston 2006). This shortage is not only affecting patient care delivery, but also the education of nurses on account of their being a commensurate decline in the nurse educator workforce - a problem that has not yet been formally recognised or strategically addressed in Australia.
In Australia, nurses constitute the largest group of health care professionals, with 30% being employed in the health care sector (National Review of Nursing Education 2001: 10). Nurses provide care across the continuum of care and work within a wide range of models of service 'which are constantly evolving due to advances in science and technology, consumer expectations, an aging population and the drive to find efficiencies in an industry where expenditure continues to increase' (National Review of Nursing Education 2001: 10).
The current nursing shortage is serious. Not only does the shortage of nurses threaten the quality and safety of patient care (Duffield and O'Brien-Pallas 2003), but also 'the economic viability of the hospitals and other health care agencies where [nurses] are employed' (Hodges et al 2001: 15). As the Key Performance Indicators (KPIs) of most Australian hospitals currently demonstrate, when there are insufficient numbers of registered nurses available, beds have to be closed, wait times in emergency departments increase, ambulance by-pass rates increase, delays are experienced in elective surgery as well as emergency surgery, intensive care admissions, and general medical-surgical admissions - all of which have a significant (negative) effect on a health care facility's funding entitlements and overall economic performance. As Hodges et al (2001: 15), writing from the cultural context of North America, observe:
The inadequate supply of registered nurses can directly affect the hospital or health care facility's bottom line, forcing closure of medical-surgical beds, entire hospital wings, or other patient care services. Inadequate staffing also places the agency at risk for lawsuits due to medical and nursing errors and poor patient outcomes. Ultimately, the inability to provide needed health care services negatively affects a community's economic base and the state's tax base, and dims the prospects of relocation or expansion of industry into a locale.
Conversely, as overseas research has shown, adequate registered nurse staffing levels can have a significant impact on reducing such adverse events as: wound infection, urinary tract infection, falls, drug errors, and unexpected readmissions (Aiken et al 1994, 2001, 2003; Duffield and O'Brien-Pallas; Henneman and Gawlinksi 2004; Needleman et al 2001, 2002; Page 2004; Schindul-Rothschild et al 1996, 1997; Stone et al 2004; Woods and Doan-Johnson 2002). In a 2001 study conducted by the Harvard School of Public Health, involving a national sample of 799 hospitals and the analysis of data from more than 5 million patient discharges, strong and consistent correlations were found between adequate registered nurse staffing levels and a reduction in: urinary tract infection, pneumonia, length of stay, logarithm of stay, upper gastrointestinal bleeding, and shock (Needleman et al 2001, 2002). These and other studies are consistently demonstrating the importance of nurses to the provision of quality care and patient health outcomes.
Nurses have long been recognised as the backbone of the health care system; as put succinctly by the Chief Executive of the Royal College of Nursing, Australia (RCNA), Rosemary Bryant (2002: 7), 'Without nurses there can be no health system.' Thus, if we are to preserve our health care system - and, more to the point, ensure its accessibility, quality, relevance, viability and sustainability - action needs to be taken now to stop the loss of nurses from the system and from the profession itself. Effective action, however, requires consideration of the possible and probable causes of the nursing recruitment and retention crisis, and the development of creative 'futuristic' solutions and strategies to ameliorate the status quo.
In Australia, the shortage of registered nurses has prompted focussed attention on the future of nursing, and how the current and escalating shortage of registered nurses can be best addressed in order to prevent the looming health care crisis that is facing Australia and to protect the public interest (see, in particular, the Council of Deans of Nursing and Midwifery (Australia and New Zealand) 2006 report on Nurse Workforce Futures (Preston 2006)). While needed attention has been give to examining the future of nursing with a particular emphasis on the recruitment and retention of future registered nurses to meet health care sector demands, with the notable exception of the International Council of Nurses (see in particular its Guidebook for Nurse Futurists) little attention has been given to exploring and advancing a futurist perspective of nursing and health care. While it is conceded that we can't predict the future, we can nevertheless envisage a preferred future depicting our highest aspirations. We can also choose to shape our future according to our highest aspirations as opposed to merely allowing ourselves to be at the mercy of outside forces and circumstances, and to lose the capacity and energy to change and construct the world in which we desire to live and work.
In this special issue of Contemporary Nurse, attention is given to considering a 'futurist' approach to the nursing and associated health care crisis, and imaginative strategies for overcoming this crisis. In considering the present nursing crisis three key questions are considered: What can be done? What choices do stakeholders have? How might we proceed and succeed in improving the status quo?
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