Factors Affecting the Global Nursing Shortage

Nursing shortage has increased greatly and rapidly in recent years with well developed hospital systems. However, as considering nursing job satisfaction, commitment, and quality of care as a significant issues for health care organizations, there are high level of turnover rate and staff absenteeism. Nevertheless, satisfied nurses are more commitment; provide high level of performance, and creative. Moreover, several studies have demonstrated the relationship between staff satisfaction, patient satisfaction, and the quality of provided care (AL-Hussami, 2008).

It found that nursing satisfaction is affected by several factors. Higgins (1999) point out, nurses will have a great sense of satisfaction within the job if they work autonomously, and empowered them self. While Chen-chug, Samuels and Judith (2003) indicated that health care policies have an impact on nursing satisfaction as an effective policies will meet the staff needs and be more satisfied. Work related factors such as workload and stress, clinical supervision, salary, leadership style, and motivation are the most related factors related to job satisfaction among the nurses (Bartram, Joiner, and Stanton; AL-Hussami 2008)

Working as a nursing demonstrator at King Abdu Aziz University (KAAU) and acting as a clinical instructor in the university hospital (KAAUH) with regard to nursing management, I have a professional interest to enhancing the quality of nursing care by identifying the associated factors of job dissatisfaction.

Embarking on this fieldwork, the following paper will focus exclusively on the methods of practicing theory-based and acquired nursing knowledge by employing Herzberg job satisfaction theory into the environment of improving the quality of nursing care and to be satisfied with the job in KAAUH. First of all, reflection of my experience by using Carper model will be presented. Secondly, the concept of job satisfaction will be defined. Then a detailed description of Herzberg theory will be discussed. Finally, applying of Herzberg theory in to practice to have a high job satisfaction among nurses will be explained.

Aesthetic:

In this experience I tried to maintain a healthful work environment with a high quality of care by reducing the level of stress and anxiety for both the staff nurse and the patient. Moreover, I was seeking to have an effective communication and relationship with this patient to be more relaxed and satisfied with the provided care. Also, the patient safety is an important issue should be considered in this situation as the nurse was complaining from insufficient knowledge about choosing the appropriate vein and the right skills to insert the cannula. So, I asked her to go for a rest and seek for a help from the other staffs to insert the cannula for several reasons. The nurse can be more relaxed without dealing with this patient in this situation. Moreover, in order to avoid the possibility of conflict. In addition, to maintain the safety for the patient by prevent the occurrence of the complications. So, the patient will be in the safe way, more comfortable and satisfied with the provided care and no more complain can be documented. However, I felt that the nurse was very confused and she had a low self esteem of what she did, but she did not recognized that this is the best action for both of them.

Personal:

As a human being I understand the level of the pain and anxiety that this patient was encountered. I felt and I knew that the patient needs a help from the other health care providers to be survived by avoiding the dealing with this irritated staff. Moreover, I recognised that he was aggressive with the nurse not because she is a nurse, but because of his feeling of pain and high level of anxiety. One of the main issues in this situation was the communication. There was no communication and no trust relationship. As the nurse patient relationship is very important to develop a support and trust between them which is considered as a crucial issue while providing the care. The communication process between the nurse and the patient was brooked down that cause a violent behaviour from the patient.

Ethics:

I think I have managed the situation probably in the right way. The workload and the in appropriate skills could lead to the nursing error which affects on the patient’s outcomes. As with this experience the patient has the possibility of cannula complication. Moreover, the inability to communicate, understands the patient culture, provide a support and the explaining the problem will increase the level of anxiety and reduce the quality of care. In addition, to understand the nursing profession and their roles is very important concern to enhance the communication and the nurse patient relationship. I think to avoid looking to the nursing job as a terrible job is very important to the nurse to practice and provide the care with high level of confident. Moreover, I am as a nurse needs more attention from the hospital organization and from my nurse manager to develop my career by increasing the level of knowledge. Furthermore, reduce the work overload by suitable staff allocation is an essential. As it is known that the emergency department has crowded patients with different symptoms. In this situation I feel that the nurse manager should allocate two qualified staff in each observational room to decrease the workload possibility.

Empirics:

Quality in the health care is defined as performing, practicing and providing the care directed to the patients in the appropriate time and way to achieve the excellence and have a best patient’s outcomes. It noticed that the hospitals with satisfied nurses and low rate of nurses’ turnover are providing a high quality of care and this could be result in patient satisfaction with the giving care.

Nurse staffing has a major role on the patient’s safety and their outcomes. Evidence based practice reviewed 26 studies of nursing staffing and the patient’s outcomes. It has reported that the low nurse staff the more clients adverse affects such as pressure sore. Furthermore, it found that there are several factors contributing to the low staff nurses in the hospitals. Workload in the ward with few staff nurses can lead to many effects such as work stress which is identified as the main obstacle of providing a high quality of care. Stress among nursing staff could be result from many different reasons. According to Ditzel.E.M stress is duo to the workload, long hour shifts and the type of the task or procedure. Moreover, nursing participation in the patient care plan is a significant issue to provide a high quality of care. It has demonstrated that a good contribution will result a good outcomes. In addition, the high quality of care can be performed with a high level of knowledge. So, the staff development and continuing education is very crucial in any hospital to produce high qualified and satisfied nurses.

At the end of the reflection, it acknowledged that job satisfaction is identified as concept that will be clearly defined and stated in the next section based on evidence.

Concept

In all hospitals throughout the world, it seems that the main concern of the patient is to receive a good quality of nursing care and to be treated properly. Moreover, nurses are demonstrating their knowledge and skills while giving the care, and make the patients to feel more comfortable through providing the appropriate support for them as a human being ( ). In addition, the quality of care is known as practicing accurately, at the correct time and way for the appropriate person to achieve an excellent result by providing safety, efficiently, timely and focused on patients (Wisconsin Hospital Association 2009). Therefore, to provide a high quality of nursing care through the hospital organizations, the nurses should be satisfied with their job which is considered as a significant issue for the patients, hospitals and for themselves (policy, 2008). Nursing care has been examined, explained, and defined through the literature during the past few decades by a number of researchers. However, numerous studies have demonstrated that there is a connection between the nursing satisfaction and the quality of provided care. To some extent, dissatisfied nurses with their job will lead to higher rate of patient’s harmful outcomes (Stanton, 2004). As it found that nursing satisfaction is creating a chain, high level of nursing satisfaction lead to high quality of care and this can result in patient satisfaction within the care (Weiss, 2002). Complementing these studies the other studies have evident that low job satisfaction will affect on the quality of care and raise the plan to leave the career among nurses. Moreover, this issue is considered as a challenge which facing the health care organizations (Buchan and Aiken, 2008). Therefore, define job satisfaction defined as:

“A pleasurable emotional state resulting from the appraisal of one’s job, an affective reaction to one’s job, and an attitude towards one’s job”(Weiss, 2002).

It revealed that nursing satisfaction is associated with many several factors that could affect on the quality of care. As a numerous studies have discovered that work related factors play an important role in nursing satisfaction. Al-ahmadi,H conducted a study to find out the reasons of job dissatisfaction among Saudi nurses, and she found that the job performance and the organizational commitment are strongly affect on the level of job satisfaction. In 2009, Ditzel.E demonstrated that the workload is identified as essential factor which reduce the level of job satisfaction among the nurses and lead to increase the job stress which result in harmful outcomes. Furthermore, based on the review of nine articles Comber and Barriball (2007) have reported that the contributing factors related to the work environment are important with nursing turnover more than the demographic factors. Nurse’s salary is identified as one of the essential factors of nursing satisfaction. However, some finding claimed that nurse’s salary do not affect on their work, While other studies have shown the connection between the salary and level of job satisfaction among the nurses. Trembly et al., have argued that the in adequate salary could be a main reason for some nurses and let them to quit. Staff development and continuing education has a significant impact on nursing ability to produce high quality of care. Educational programs which are offered by the health care organizations will increase the level of the knowledge to produce a high quality of care and eliminate the possibility of nursing errors. Although previous researchers have identified that nurses’ careers have various stages, a few papers have recognized that nursing job required different programs to respond to their need(Chang, Chou and Cheng, 2007).

Considering the Patient safety it seems that it is the major source of dissatisfaction to most of the nurses. The nurses were unconfident and felt guilty as they were unable to provide the appropriate care (Stanton, 2004). Consequently, the concept of job satisfaction is very crucial as it will affect on their level of performance.

Herzberg theory overview

In this section Herzberg’s theory of motivation is identified as the most appropriate theory that can increase the level of nursing satisfaction, and to provide the patient safety . To effectively apply Herzberg theory in to practice, one needs to fully establish an understanding of the concept and the theory. So, Herzberg’s theory of job satisfaction and its feasibility will be clearly described.

Frederick Herzberg’s is a psychologist who creates the theory of motivation in the late of 1959s and it is known as two factor theory (Marquis and Huston, 2003). In this theory, Herzberg used Maslow’s general theory of motivation particularly in work motivation (Huber, 2006). The theory was developed after interviewing two groups of employees to identify the main reasons of job satisfaction and dissatisfaction. From this interview Herzberg elucidates the contributing factors that motivate the staffs throughout categorizing their individual requirements. Herzberg wrote a phrase which is said “We can expand … by stating that the job satisfiers deal with the factors involved in doing the job, whereas the job dissatisfies deal with the factors which define the job context.” (Herzberg, 1959).

Herzberg states that the job satisfaction and dissatisfaction are two different phenomenons (Sullivan and Decker, 2005). Furthermore, the theory developed through two dimensions to job satisfaction. It is based on the concept that motivation can be divided into hygiene factors and motivation factors.  Moreover, the theory concludes that there are two type of motivation (Syptak, Marsland and Ulmer 1999).

According to Herzberg (1959), Hygiene Factors are not motivates the employees, but these factors can affect on the level of dissatisfaction; in other word, this factors will decrease the dissatisfaction among the staffs. Hygiene factors incorporate supervision, interpersonal relations, physical working conditions, and salary. Hence, these factors are related to the environment and lead to dissatisfaction. On the other hands, the motivator factors seems to be the factors that can motivate the employee by gratifying the individuals’ requirements and needs for personal development as they are associated to the job itself. Motivator factors include achievement, advancement, recognition and responsibility.

It appears that with the adequate hygiene factors, the staffs would be not dissatisfied and enough motivators need to be existing to enhance the level of job satisfaction (Huber, 2006). It is important to notice that the opposite of dissatisfaction could not be satisfaction as well as the lack of motivators does not lead to dissatisfaction (Marquis and Huston, 2003). For example, if the hygiene factors are at low level, the staffs will be unsatisfied, and when the hygiene factors are at high level the staffs are not dissatisfies, but they are not motivated for higher performance. Conversely, when the motivators are at high level the staffs will be satisfied and provide a high level of quality (Manisera, Dusseldrop and Kooij, 2005).

Critical analysis

Herzberg’s theory is adequate; he completely addressed his theory. This theory of motivation is clear and understandable as it makes the others to understand the nature of the job satisfaction by introducing these two factors of motivation. Herzberg developed his theory by using the study of Maslow, but he focused exclusively on the work structure. However, he did not define the concept of job satisfaction, but he identified and states the two factors that affect on the job satisfaction. Herzberg recognized the two main factors which are the main component of his theory. Motivator and hygiene factors are simply described and explained by Herzberg. This theory is widely applicable and being used in restructuring and designing the work in many organizations, as Herzberg identified the significant needs for the staff to be motivated and to increase the level of productivity. Based on the two factors of Herzberg’s theory, Bare (2004) demonstrates that the nurse managers are deliberating the motivation factors when they prepare and apply the policies to recruit and retain the nurses for a long period of time. In addition, the managers may also take into consideration the hygiene factors such as salary, as the very well paid is normally the answer for long term problems.

There are nemoures studies have supported herzberg’s theory. Lundberg ,Gudmundson and andersson (2009) have tested Herzberg’s theory in hospitality and tourism management. They found that this theory has been used widely in several contexts. For instance, a study of Parsons and Broadbride’s (2006) cited by Lundberg, Gudmundson and andersson (2009), they applied herzberg’s classification of intrinsic factors sauch as responsibility, work itself and recognition, and extrinsic factors as working conditions and salary. The significant results reported that there is a high level of satisfaction with intrinsic factors, and low level of satisfaction with extrinsic factors which indicates the agreement with herzberg’s theor. Furthermore, a conducted study of Furnham, Forde and Ferrari’s (1999) gave an example of herzberg’s theory application in a study of personality and work motivation, they concluded that motivation factors are significant in the workplace, while heygiene factors are more critical in selecting a job. Beside these studies, herzberg’s two factor theory was applied in a study of nurses satisfaction within nursing crare and work in psychatric units (swedish study), it revealed that this theory support the purpose of clinical supervision which had a convinced effect on nursing satisfaction (Rask and Levander, 2002). Friedlander’s (1963) carried out a study that show the agreement with herzberg’s theory. In 1963 Friedlander’s examined a 17 item questionnaire which evaluate the value of each item as a cause of employee satisfaction. In his result he found that there are three factors, two of these factors were matched with herzberg’s two factors hyiegene and motivation, on the other hand the third factor derived from both hyegiene and motivation factors. Moreover, a further study reveald that the results were supported to herzberg’s theory was conducted by Halpern (1966). Halpern had 93 subject and they were asked regarding the aspect of liked job on a 7 item scale. In the results he discovered that there are two points, which are satisfaction with the work itself and achievments opportunities, are reported as the best concerns in a liked job. In addition, he added that all of his subjects were satisfied with herzberg’s two factors hyiegene and motivation similarly.

However, this theory resulted in much controversy in the work place. Part of the argument was due to present the salary as a factor that does not play a role in job satisfaction (Manisera et al., 2005), while Trembly et al., argued that the in adequate salary could be a main reason for some staff for let them to quit. Moreover, some critics do not recognize the clarity between the intrinsic and extrinsic motivation (Huber, 2006; Marquis and Huston, 2003; Manisera et al., 2005). Nevertheless, it appeared that part of the doubt around Herzberg theory was in Herzberg methodology and the lack of identifying the relationship between the two variables. Basically, Herzberg was collected his data by interviewing and questioning the employee with two situations related to their job experience. Firstly, they asked to think of time that they feel satisfied and dissatisfied with the job. Secondly, they asked to discuss their situations and identify the factors associated to their satisfaction and dissatisfaction with the job. Lindsay, Marks and Gorlow (1967) have examined the Herzberg methodology. They reported that Herzberg did not control the number of situations form a given employee, or either the number of the associated factors of their job. They argued that this theory did not state the relation and the effects between these two variables which are hygiene and motivator factors to the job satisfaction and dissatisfaction. Furthermore, it found that according to Herzberg distinction in his methodology, he will gain different results (Furnham et al., 1999). it is important to notice that the literature have demonestrated other studies that showed the disagreement with herzberg theory. Lindsay et al., (1967) revealed that the results of their study have shown that the staff will be satisfied with their success on a job even if there is a lack in the organization policies, or if there are inadequate environments around the job. However, workers who do not experience as if they have a great achievement on their job will be dissatisfied even if the environments around the job are helpful. Therefore, these results are obviously inconsistent with Herzberg’s argument that there is no relation between the two factors. In addition, several studies evident that motivator factors are very significant more than hygiene factors in relation to satisfaction, while Herzberg did not refer to this point in his theory. Furnham et al., (1999) indicate that how can this theory used within the organisations without state the difference of person’s gender, culture and age group. However, three main studies demonstrated that their results were supportive with Herzberg’s result that hyiegne factors lead to dissatisfaction, and motivator factors lead to satisfaction (Mayers 1964; Saleh 1964; Schewartz, Jenusaitis and Stark, 1963). Moreover, the theory is still valid, applicable, and useful to applied in any management organisation (Furnham, et al., 1999; Lundberg et al., 2009).

To sum up, it believed that Herzberg’s theory is being used in various management contexts such as nursing satisfaction, hospitality and tourism management, and in a personality and motivation study. Despite of that fact that this theory is useful, it found that there are a limitation within this theory within the methodology and the relation between these two factors where few studies state that there is a relation.

Theory into practice:

Basically, using Herzberg theory in any health care organization will motivate the staff and increase their level of satisfaction. Considering the two factors theory, the organizations will be noticed a plenty of changes among their staff on various levels (Byrne, 2006).

Herzberg’s theory is widely used in the management and nursing organizations. For instance, this theory is used to increase nursing satisfaction in psychiatric unit. Applying Herzberg theory in King Abdul Aziz University Hospital (KAAUH) to increase the level of satisfaction will be as following:

Hygiene factors:

Despite the fact that hygiene factors (policy, supervision, interpersonal relation, work environment, and salary) are not considering as the source of the job satisfaction, it is important to treat these factors effectively in KAAUH to generate a good environment with satisfied staff and high quality of care.

The health care policy is essential in any health care organization. Moreover, the purpose of the policy is to provide a plan of action or instructions to guide decisions and achieve the organization outcomes, increase the quality of care, and staff satisfaction (Huber 2006). However, the nurses’ involvement in the health policy at KAAUH is very important as it affects on the nurses care and the profession itself. Nurses’ participation in the health policy as policy makers will make significant changes in the nursing practice, education, responsibilities and roles. It found that the nursing practice has an impact on health care policy (Finkelman 2006; McCloskey, 2004). As a result, the contribution of nurses in health policy is significant in order to raise the level of job satisfaction.

Although nursing involvement in the health policy is crucial, the health care policies can be a source of dissatisfaction among the staff nurses (Syptak et al., 1999). However, the policy at KAUH should be clear, easy and should be followed. Moreover, it is important that the policy should be applicable, and easy to access for all the staff by having manual copies in each word. Furthermore, the policies must be updated and depend on the evidence based researchers to enhance the quality of care and patients safety.

With regard to clinical supervision, it seems that it strongly affect on job satisfaction, turnover, and the quality of care ( Kristiina, Kaija and Riina, 2006). In the terms of increase the job satisfaction among new qualified nurses at KAUH, a mentorship program can be applied effectively to reduce the turnover rate and increase the level of performance. Mentorship is known as supportive relationship recognized between the mentor and the mentee, where the knowledge, skills, and experiences are shared through the supervision role (Curtis, 2003). Consequently, Mentors play a critical role in supporting, teaching and assessing the practice which lead to increase nursing satisfaction and improve the quality of care and patient’s safety (ButtelWorth, 1995). In order to provide an adequate supervision in the clinical area, there are some responsibilities for the supervision. The supervisor at KAAUH should give a clear and positive feedback to make the staffs feel that they can trust their supervisor. Furthermore, the reliable and fairly approach to evaluate the staff performance is very significant issue to consider in this hospital. In addition, this role required leadership skills to treat with all staff equally (ButtelWorth, 1995; Syptak et al., 1999).

Considering the interpersonal relation at KAAUH, it can be observed through the process of socializing. With the important role of the nurse manager, there will be an interpersonal interaction between the staff to convey knowledge, value, and supporting each other to achieve their goals (Huber2006). Furthermore, it is important to notice that socializing is very essential process in particular with the new qualified nurses, to have a successful work transition, and reduce the risk of getting shock at KAAUH (Huber 2006). Therefore, the staffs can cultivate their teamwork by their socializing (Syptak et al., 1999).

It is important to notice that the working environment has an impact on the level of quality care and patient safety (Rashotte, 2008). Therefore, the health care organization at KAAUH should provide a healthy work environment for the nurses to be satisfied with the level of giving care and enhance the quality. Moreover, all the facilities, and required equipments are important to be available with an appropriate allocation of the personnel and adequate nurse patient ratio to avoid the possibility of overload. In addition, beside the physical environment, it is important that the organization at KAUH should motivate the staff to believe that their role is very critical in providing the care to increase their confidence and self esteem. It can be seen that through the staff’s contribution in to practice, and good relationship with the other health care professions to work as teamwork, will resulted in a positive outcomes and high quality of care for the patients (Boughton, 2009; Rashotte, 2008; Syptak et al., 1999).

Salary is considered as a controversial topic among the nurses and the health care organizations. The staff at KAAUH wants to be paid equally and fairly and not depend on the nationalities as the Indian and Filipino’s salary are less that Saudi’s salary. In addition, if the staffs are not well paid they will not be satisfied with their work (swansburg. J and swansburg. C, 1999).

2. Motivator factors:

Motivation factors ( responsibility, achievement, rewarding) are significant factors to be satisfied with the staff performance. However, the staff can be pleased with these factors only when the staff starts to the work, in contrast to hygiene factors which do not recognized how much the hard work is.

One way of increasing the level of job satisfaction and motivate staff nurses in KAAUH is by giving them the freedom and the power to perform their tasks. Therefore, they will feel that they are capable and responsible within the quality of the care. Generally, as they become advance in their work they will add more responsibility. However, the added responsibility should be meaningful and exciting and not in sequence of overload. For example, the nurse manger can motivate their staff in the terms of increasing the accountability through the delegation process to develop new skills (Syptak et al., 1999).

Achievement is the staff’s aspect within the work and in the beginning of their career to be succeeded. To assist them in KAAUH, it is very important that the employees are allocated in the right position, so they can practice their skills, knowledge, and avoid the risk of work overload. Moreover, goals, policies, and standards at KAAUH should be clear for the staff nurses to follow. Furthermore, the staffs must be given a frequent, timely feedback on how they are doing within the work. Therefore, when the individuals have a success and achievement with the work at KAAUH, they need to be recognized for their achievement. Recognition of job performance is essential to staff nurse confidence and self esteem. It seems that acknowledgement and praise nurses achievement for a good handling of the situations are very significant issue to be considered by the nurse manager at KAAUH (Syptak et al., 1999; Coughlin, 2000).

In terms of rewarding the staff for their achievement, it appeared as a good motivator to raise the level of their satisfaction at KAUH. However, there are different types of rewarding the staff nurses. The rewards can be financial and non-financial. Financial is monetary while the non-financial is a psychological rewards. Rewarding staff in KAAUH by giving the opportunity of continuing education is one type in relation to the advancement. According to Gieter et al., (2006) they demonstrated that the non-financial and psychological rewards are more important than the financial rewards. It can be evident that with the development of clinical advancement department in KAAUH, participating of education department and the role of the nurse managers to reward their staff in the hospital, the nurses will have the opportunity to advance their level of practice through several courses or conferences, knowledge, and the chance to conduct nursing research by supporting them as a reward for their achievement.

To conclude, applying Herzberg’s theory into KAAUH seems to experience some difficulties. Through this organization it is difficult to maintain a socializing between the staff. As a result of nursing shortage, there is no time for the staff to be socialized even though it is hard for the nurse manager to make an arrangement for it. Moreover, it appeared that rewarding system or department is not existed in this hospital, which requires an administrative support to develop it. However, while applying this theory, it seems that there is a considerable relation between hygiene and motivator factors which is not mentioned by Herzberg. Nevertheless, it is useful and applicable with salary, supervision, working environment, policy, and resposibility to provide a high productivity level.

Conclusion:

Nursing satisfaction is considered as the main concern for the all health care organizations in order to reduce the turnover rate. This paper suggests that through the concept definition of job satisfaction, high level of job satisfaction will improve the quality of nursing care, and lead to patient satisfaction. Moreover, Herzberg has identified two main factors that can be applied by many organizations to increase the level of staff satisfaction. Hygiene factors is related to job dissatisfaction, while motivation factors leading to job satisfaction. This theory has been used in several studies, nursing studies as well as management studies. Nursing studies applied Herzberg theory to increase their satisfaction in several aspects such as clinical supervision, rewarding and achievements, where as this paper attempted to apply the two factors theory (motivation and hygiene) in KAAUH to increase the satisfaction and enhance nursing care. It evident that Herzberg’s theory is clear, adequate, consistent, and it has been widely used effectively. However, the debate of this theory was in the methodology, and the inability to recognize the relationship between these two variables (Lindsay, Marks and Gorlow 1967). Furthermore, the inability to differentiate between the intrinsic and extrinsic motivation is reported as a critique of this theory (Huber. D 2006, Marquis. B, Huston. C 2003, Manisera. M et al., 2005). It should be noted that applying thi