Gege Li
Waner Wang
Jiangfeng Pu
Zhanghao Xie
Yixuan Xu
Tiemei Shen2*
Huigen Huang- 1Department of Nursing, Jinan University, Guangzhou, China
- 2Department of Nursing, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
- 3Department of Nursing, Guangdong Pharmaceutical University, Guangzhou, China
- 4Department of Nursing, Shantou University Medical College, Shantou, China
Objective: To understand the current situation of nursing manpower allocation, explore the factors affecting nurse staffing, improve nurse staffing level, and provide reference for better formulation of nursing human resources staffing standards.
Methods: A descriptive research method was used to conduct semi-structured interviews with 14 nursing managers. The data were analyzed and refined by content analysis. The sample size was subject to content saturation.
Results: Nine themes and twenty sub-themes of influencing factors for nursing staffing were identified across four levels: hospital level, department level, patient level, and nurse level.
Conclusion: Hospital and department managers need to comprehensively consider the factors of affecting nurse staffing. Adopting multidimensional optimization measures, improving relevant systems, optimizing nurse structure, and establishing flexible and mobile nurse database to cope with public emergencies, so as to effectively improve nurse staffing and nursing service quality.
1 Introduction
The global nursing workforce shortage has been a major challenge in the medical field. In 2020, the World Health Organization reported a shortage of 5.7 million nurses and midwives (1). By the end of 2022, the total number of health workers in China was 14.411 million. Among them, the total number of registered nurses is 5.224 million (2). Compared with the 2025 China nursing career planning target, there is still a gap of 276,000 (3). The number of registered nurses in China in 2022 is 3.17 per 1,000 population, which is far lower than the global median density proposed by WHO (4.86 per 1,000 population) (4). In the evolving healthcare sector, ensuring optimal nurse staffing remains a key issue in hospital administration and nursing management (5, 6). Adequate nurse staffing is critical not only to provide high quality patient care, but also to maintain nurse job satisfaction and reduce turnover (7, 8). However, the factors that influence nurse staffing are multifaceted and complex, including a range of variables from institutional policies to the characteristics of individual nurses. At present, researchers mainly focus on quantitative studies on nurse staffing and nursing quality, patient outcomes and nurse outcomes (9, 10). However, there are few qualitative studies on the influencing factors of nurse staffing. Nursing managers play a key role in staffing decisions, pay close attention to day-to-day operational dynamics and challenges, and are uniquely positioned to provide insights into the various factors that affect nurse staffing (11). Therefore, this study aims to explore the influencing factors of nurse staffing through the perspective of nursing managers, and through in-depth interviews and thematic analysis, reveal the human resource challenges and considerations faced by nursing managers in their efforts to ensure appropriate nurse staffing levels. The results of this study will help develop more effective staffing strategies and policies, ultimately improving the quality of care provided to patients and improving the working environment for nurses.
2 Research objectives
This qualitative study explores the influencing factors of nurse staffing. Two nursing managers were selected for pre-interview, and the final interview outline was revised according to the feedback of the pre-interview. See Table 1 for details.
Table 1. Interview outline.
3 Materials and methods
3.1 Participant recruitment
From December 2023 to February 2024, nursing managers in a Grade 3 hospital in Guangdong Province were selected as interview subjects by purpose sampling method. Inclusion criteria: (a) Engaged in clinical work ≥10 years; (b) Engaged in management work ≥3 years; (c) have intermediate or above professional titles; (d) Informed consent and voluntary participation in this study.
3.2 Data collection methods
The development of the interview outline was based on the research objectives and a review of relevant literature, following a systematic process (12). An initial draft of the interview guide was formulated to focus on the research theme. This draft was refined through discussions in project team meetings. Before the formal interviews, two nursing managers were invited to participate in pilot interviews, and since no further revisions were needed, the pilot interview data were included in the subsequent analysis. The qualitative research involved conducting semi-structured, in-depth face-to-face interviews with the participants. Before each interview, one researcher (LGG) obtained informed consent from the interviewees, explaining the purpose, methods, and content of the interview. The interviews were recorded and noted, and were conducted in the interviewee’s office to ensure privacy. To protect the confidentiality of the participants, two researchers (LGG and WWE) were responsible for questioning and recording, respectively, using pseudonyms N1 to N14 instead of real names. The interviews were conducted in easily understandable language, encouraging participants to express their feelings and thoughts fully. Active listening, clarification, and probing techniques were employed, along with noting non-verbal cues. Each interview lasted between 30 and 60 min, with an average duration of 39 min.
3.3 Data analysis methods
Data collection and analysis in this study were conducted simultaneously. Within 48 h after each interview, the recordings were transcribed verbatim, and the non-verbal information recorded during the interviews was integrated into the documents, forming complete interview transcripts. We used thematic analysis to analyze the data (13), organizing the materials with NVivo Plus 11 software. Throughout the analysis process, the two researchers (LGG and WWE) maintained an open and neutral attitude, repeatedly reading the transcripts and non-verbal notes. By continuously comparing and inductively analyzing the data, we extracted themes to gain a deeper understanding of the participants’ actual meanings. Text from individual interviews was divided into meaning units that were condensed and coded. The themes in the table were derived from the initial codes, with similar codes grouped into subcategories and categories, which were then further organized into themes (14). The first author identified the initial codes, while the other authors reviewed the coded interview samples. Any disagreements regarding themes were resolved through discussions among all authors until a consensus was reached.
4 Results
4.1 Sample size
The sample size was by information saturation (15). Finally, a total of 14 participants participated in this study, among which 13 were female and 1 was male, and the average age of all participants was 45.86 years old (33 ~ 52 years old). The average duration of clinical work was 25.57 years (11–23 years) and the average duration of managerial work was 11.21 years (4–16 years). The demographic characteristics of participants are shown in Table 2.
Table 2. General data sheet for participants.
4.2 Hospital level
4.2.1 Imperfect policies and systems
Decisions made by hospital management based on national policies, such as establishing standards for bed-to-nurse ratios in each department, inspection systems, training and promotion mechanisms, significantly impact nurse allocation. However, N12 highlights that for specialized departments like emergency care, there lacks a unified allocation standard in China (16), which complicates nurse allocation levels to some extent. Several respondents in the study noted limitations in current nurse staffing due to rigid adherence to bed-to-nurse ratios that often fall short, thereby compromising adequate staffing levels. Furthermore, the imperfect inspection, promotion, and training systems in the face of a complex and evolving clinical environment constrain nurses’ workload and career advancement opportunities, affecting both stability and quality of nursing care.
4.2.2 Insufficient manpower reserve
The hospital’s human resource reserve directly influences the quantity and quality of nurses, as well as the hospital’s capacity to address staffing shortages, temporary needs, and emergencies. Respondents in the study also noted that due to insufficient or lacking hospital manpower reserves, even submitted personnel demand applications often remain unresolved.
4.3 Department level
4.3.1 Department characteristics
In the rational allocation of nursing human resources, it is necessary to consider a variety of factors, such as the department’s patient conditions, department size, bed turnover, workload, and the need for specialized nursing. For instance, departments like emergency, intensive care, and surgery require nurses with specific professional skills and knowledge to ensure patient safety and effective treatment outcomes.
4.3.2 Cost-effectiveness driven nurse staffing
Reasonable manpower cost control can be in to ensure the quality of care under the premise of optimizing the allocation of resources, improve the efficiency of the cost. Appropriate labor cost control of department, fair and reasonable scheduling system, by ensuring reasonable salary, meet the demand of nurses reasonable help stabilize the nurse team, reduce turnover and maintain the continuity and stability of the nursing work, at the same time maximize the cost-effectiveness of department, ensure quality of nursing service.
4.3.3 Cultural construction of the department
Department culture construction is one of the important factors affecting the allocation of nurses, including good working atmosphere and teamwork, effective communication and mutual understanding, and staff care. A good department culture construction can improve the satisfaction and stability of nurses, and ensure the efficiency and high quality of nursing work. In the study, respondent N1 also said that a good working atmosphere in the department would alleviate the original shortage of manpower.
4.3.4 Multi-level recognition and support
Nurses occupy a large proportion in the department and play an indispensable role. Recognition at the department level, including but not limited to the head nurse and department director, as well as the recognition and support from doctors for the work of nurses, can not only enhance nurses’ job satisfaction and loyalty but also significantly improve the efficiency and quality of nursing care. This influence helps optimize working conditions for nurses.
4.4 Patient level
4.4.1 Patient profile
With the rapid development of social economy, the demand for nursing services is gradually increasing. The basic situation of patients, including the number of patients, the complexity of the disease, the self-care ability of patients and the patient’s needs, which will virtually affect the workload of nurses, and therefore put forward requirements for the staffing of nurses.
4.5 Nurse level
4.5.1 Challenges in nursing human resources
The shortage of nurses is a significant issue in nursing human resource management, profoundly affecting nurse staffing. Insufficient nursing staff can lead to a decline in the quality of nursing services, failing to meet patient care needs, and thereby impacting treatment outcomes and patient satisfaction. Respondents to the study indicated that this shortage is expected to persist in the short term. Currently, nurses face high workloads and pressure, with long-term overwork increasing their physical and psychological burden, reducing work efficiency and quality, and leading to higher turnover rates. This exacerbates the challenges in nurse staffing.
4.5.2 Nursing professional development
The structure of nurses is an important part of human resource management, including the age, work experience, title, comprehensive ability and specialized skills of nurses. Optimizing the structure of nurses can promote the staffing of nurses. Provide continuous professional training and career development opportunities for the nursing team, including advanced studies, promotions, and specialized training. These initiatives will improve nurses’ professional skills and career satisfaction, enhancing their willingness to stay in the department and their overall stability (see Table 3).
Table 3. Influencing factors of nursing staffing.
5 Discussion
For additional requirements for specific article types and further information please refer to “Article types” on every Frontiers journal page. From the perspective of nursing managers, this study discussed the relevant factors affecting nurse staffing, mainly from four levels: hospital, department, patient and nurse level.
The results of this study indicate that nurse staffing is related to the imperfection of hospital policies and systems, the lack or insufficiency of manpower reserves, and the control of nurse manpower costs. The formulation of policies related to nursing human resources can play a crucial role in the number of nurses. On the one hand, although China has formulated many standards, principles and plans for staffing (17–20), but at present, most medical institutions in our country still adopt a single number of beds for human staffing, ignoring the differences of condition, disease, service quantity, etc., which makes it difficult to meet the clinical practical needs of nursing human resources. On the other hand, the participants indicated that the hospital did not reserve talents or had insufficient reserves at present, and the study found that public emergencies would have a certain impact on the staffing of nurses, and the reasonable establishment of a mobile nurse base could make up for the shortage of manpower to a large extent in crisis situations (21).
At present, there is no legislation on nurse staffing in China, but there are a few areas (10, 22, 23), such as Victoria or Queensland in Australia and California in the United States, have made the nurse–patient ratio mandatory, and scientifically found that this measure is beneficial to patients and healthcare systems. Belgium is also reforming its nursing staffing policy and using part of its budget to hire non-nursing staff to alleviate the shortage of nurses, while India is making further efforts to revise the standards of the nurse-to-patient ratio. Yet labor costs dominate hospital budgets. They are easy targets for cuts to offset other expenses (24). The financial budget of a hospital on the cost of nursing manpower will directly affect the number of nurses, resulting in the imbalance of the nurse-to-patient ratio, and increasing the work pressure and load of existing nurses (25). In the future, when developing safe and reasonable nurse staffing, it is necessary to comprehensively consider the control of nurse labor cost and solve the problem of baseline nurse staffing, so as to better cope with the fluctuation of nurse nursing demand among patients (26, 27).
In addition, the shortage of manpower reserve makes it difficult for hospitals to quickly deploy enough nurses in the face of emergencies (such as epidemics, natural disasters, etc.), which affects the timeliness and effectiveness of nursing work. First of all, in order to actively and effectively respond to public emergencies and other emergency events, it is necessary to establish a mobile nurse team. At the same time, it is necessary to strengthen the hospital’s leadership of the nurse team and improve the emergency level of the nurse team. Secondly, the recruitment process of new nurses should be accelerated, and the relevant training mechanism should be optimized to ensure that new nurses can quickly get on the job and adapt to the work needs. Finally, establish reasonable vacation and prepare class arrangements, to ensure that the nurse has enough during the period of vacation or sick leave substitute nurses to fill the gap, to ensure the safety of patients and the high quality nursing service.
The results of this study show that the staffing of nurses is related to the department characteristics, cost-effectiveness driven nurse staffing, department culture construction and multi-level recognition and support. Nurses with affected by the characteristics of the various specialist departments for college work, care needs and technical differences, nurse need to change accordingly, in order to ensure safe and effective nursing service. The control of nurse labor costs varies between departments and hospitals due to differing economic benefits. It is crucial to balance the relationship between existing nurse staffing and costs. A limited department budget can affect the hiring of additional nurses or the ability to increase nurses’ salaries, directly impacting nurse staffing levels. Implementing a fair and reasonable scheduling system ensures that each nurse receives adequate work and rest time, preventing overwork or underwork. This can improve job satisfaction and work efficiency, thereby reducing nurse turnover rates and fatigue (28).
Additionally, fostering a positive departmental culture is also essential. Nurses’ working environment and atmosphere, and leadership style can affect nurses’ turnover intention, thus further affecting the staffing level of nurses and the quality of nursing work by affecting nurses’ turnover intention (29–31). Active teamwork, effective communication, and mutual understanding are crucial factors in optimizing nurse allocation and improving the quality of nursing services. Good teamwork and effective communication streamline workflow, reduce redundant tasks and communication errors, and enhance nursing efficiency (32, 33). Mutual understanding and trust among team members facilitate knowledge and experience sharing, promoting both individual and team skill development. A well-functioning department resembles a warm, supportive family, which requires managers to show concern and care for nurses, focusing on their physical and mental health needs. This helps alleviate work pressure, strengthens colleague relationships, and enhances team stability. Multi-level recognition and support from department directors, head nurses, doctors, and patients serve as key motivators for nurses, reinforcing their commitment and sense of value in their work. However, the lack of necessary material and emotional support increases job burnout and affects nurses’ intention to stay (34, 35). Therefore, in this challenging environment, it is crucial to optimize nurse allocation, enhance the quality of care, and ensure the stability of the nursing team. This can be achieved by improving the working environment and atmosphere, fostering team cooperation, formulating reasonable scheduling plans, and establishing effective communication and feedback mechanisms.
With the accelerated aging of China’s population and the increasing prevalence of chronic diseases, the demand for long-term care and health management has risen significantly. The growing number of patients directly impacts the number of nursing staff needed in departments. A high patient load necessitates more nursing staff to ensure each patient receives adequate care. This situation poses a challenge for managers in nursing staff allocation, requiring flexible adjustments based on patient admissions and discharges to respond to fluctuating peaks and troughs.
Patients with complex conditions require higher levels of nursing skills and more hours of care, necessitating additional specialized nursing staff or more training and support. As patients’ expectations for the quality of nursing care rise, departments need to increase their nursing staff to meet these expectations. A higher level of nursing expertise can improve patient satisfaction, delivering higher quality care and greater value (36). Therefore, when planning nurse allocation, managers should consider the number of patients, the complexity of conditions, and specific nursing needs. By conducting thorough evaluations and making flexible adjustments to the nursing team, managers can effectively address the needs of different patient groups and enhance the quality and efficiency of nursing services.
Nurses are the largest group in the medical and health system, occupying an irreplaceable position, and sufficient nursing staff is the premise and basis of rational allocation of nursing human resources. The shortage of nurses is a serious problem facing the world today (37, 38). The shortage of nurses will lead to the increase of nursing workload and labor intensity, resulting in a high turnover rate of nurses, and turnover intention is a predictive factor of turnover rate (39, 40). The turnover intention of nurses varies significantly among different countries. The turnover intention of nurses in South Korea was 18.8% (41), 22.5% of nurses in European countries expressed their intention to quit (42) and 43% of nurses in Lebanon expressed an intention to leave within one year (43). In China, the turnover intention of nurses in East China is 43% (44) and that of nurses in Guangdong Province is as high as 64.1% (40), which means that the turnover rate of nurses in China remains high, and the gap of nurses will further increase. Attracting and retaining the existing nurse workforce is critical to maintaining high quality patient care (26). Studies have shown that nurses are the foundation of patient safety and nursing quality, and higher nurses’ satisfaction will bring better job performance, nursing quality and employee retention (34, 45). In addition, research shows that with adequate nurse staffing, good working environment and welfare benefits, nurses will have higher job satisfaction and lower turnover intention, thus ensuring the stability of the nurse team and nursing quality (46). With the continuous improvement of medical technology, higher requirements are put forward for the education level and working ability of nurses. Nurses need to constantly enrich their theoretical knowledge and improve their nursing skills in order to meet the growing nursing needs and the speed of high-quality development of hospitals. Therefore, the nurse structure should be considered and further optimized when staffing nurses.
5.1 Limitations
The study has several limitations. First of all, in order to ensure the diversity of the study subjects, we used purpose sampling to sample the head nurses of various departments in the hospital, but the study scope was limited to one hospital, which made it difficult to obtain additional information. Secondly, the interview document data is translated from Chinese to English, and there is a certain risk of translation errors.
6 Conclusion
From the perspective of nursing managers, this study explores the related factors affecting the allocation of nurses through descriptive qualitative research, explores the specific challenges, pressures and needs of nurses in their work, and reveals the deep causes of the shortage of nurses from multiple levels and directions, rather than just stay on the quantity and statistical data. From a nursing manager’s perspective, the results of this qualitative study highlight the multifaceted and interrelated factors that influence nurse staffing. Hospital-level factors are the most critical. Improving and unifying nursing personnel staffing standards is the premise of ensuring the development of high-quality nursing. Nursing managers stressed the importance of a supportive work environment, effective communication, and continuing professional development to mitigate staffing challenges. At the same time, it reveals the influence of humanistic and emotional factors, and captures the importance of humanistic care, emotional support and professional identity experienced by nurses in the work. These factors have an important impact on the job satisfaction and retention rate of nurses, thereby indirectly affecting the staffing of nurses. Addressing these factors through integrated strategies can improve nurse retention, improve the quality of patient care, and foster a more stable and satisfied nursing workforce. This study can provide deep insight and effective strategy suggestions for understanding and solving today’s nurse staffing problems, so as to provide a unique contribution to the continuous development and improvement of the nursing profession.
Data availability statement
The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.
Ethics statement
The studies involving humans were approved by Ethics Review Committee of Guangdong Provincial People’s Hospital. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.
Author contributions
GL: Conceptualization, Data curation, Formal analysis, Investigation, Visualization, Writing – original draft, Writing – review & editing. WW: Conceptualization, Data curation, Formal analysis, Investigation, Writing – review & editing. JP: Conceptualization, Data curation, Writing – review & editing. ZX: Supervision, Writing – review & editing. YX: Methodology, Supervision, Writing – review & editing. TS: Methodology, Project administration, Supervision, Writing – review & editing. HH: Supervision, Writing – review & editing, Funding acquisition, Resources.
Funding
The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. This study was supported by the Nursing Research sub-project of China Health Personnel Training Program (Project number: RCLX2320048).
Acknowledgments
The authors would like to express their sincere gratitude to all the people who participated.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
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Keywords: nurse staffing, nurse manager, semi-structured interviews, influencing factor, human resources
Citation: Li G, Wang W, Pu J, Xie Z, Xu Y, Shen T and Huang H (2024) Relevant factors affecting nurse staffing: a qualitative study from the perspective of nursing managers. Front. Public Health. 12:1448871. doi: 10.3389/fpubh.2024.1448871
Edited by:
Thomas T. H. Wan, University of Central Florida, United StatesReviewed by:
Szymon Szemik, Medical University of Silesia, PolandSu-I Hou, University of Central Florida, United States
Copyright © 2024 Li, Wang, Pu, Xie, Xu, Shen and Huang. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Huigen Huang, MTM4MjIyMjE2MjhAMTYzLmNvbQ==;Tiemei Shen, bWVpcm1laXJzaGVuQDE2My5jb20=