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MANAGEMENT: NURSING SHORTAGES
associated with higher rates of infection, gastrointestinal
bleeding, pneumonia, cardiac arrest and death from these and
other causes (Needleman et al., 2002). In caring for patients,
nurses are indispensable to our safety.
Berens (2000) in his article in the Chicago Tribune stated
‘Nursing mistakes kill thousands annually’. This article
reported that the results of an analysis of records from the
United States’ Food and Drug Administration and other
Department of Health and Human Services agencies, federal
and state files of annual hospital surveys and complaint
investigations, court and private health care files, and nurse
disciplinary records for every state. The analysis detected
1,720 deaths and 9,584 injuries among hospital patients
resulting from the action or inactions of RNs over a five-year
period.
Peterson (2001) stated that numerous factors influence the
shortages of nurses such as retention, recruitment, increase in
age of working nurses and core compensation. However,
developing countries have some other factors related to
turnover and such under-developed countries like Pakistan
where the population is deprived of many health facilities,
now face a further challenge where they are deprived of good
nursing care in quality driven institutions and turnover
impacts on safety of the patients.
Relationship of nursing turnover to cost of care
The nursing shortage is a critical problem as it increases the
cost of care and may compromise the quality of care. The
hospital administrators, nursing organisations, and nursing
schools are well aware that nurses are working in other fields
everywhere; they just refuse to work in hospitals. Health is the
responsibility of the people within the health care system of
Pakistan. Insurance for health coverage is not available,
therefore patients requiring health services in private health
care institutions have to pay the cost of care from their own
pockets. On the other hand, nurses, while they are attracted
by the high nursing wages paid in the developed countries, do
not think that Pakistani hospitals cannot pay such high wages
as an increase in their salary will directly impact on the cost of
care.
Role of AKUH in nursing retention
To overcome the nursing migration issue, the management of
AKUH formulated a task force in 1998, which recommended
37 strategies to improve nursing recruitment and retention
(see Figure 4). Of these strategies, around 84% were
implemented between 1999 and 2000, but no impact was
observed on turnover. From 1998 to 2003, three research
studies were conducted to further explore the reasons of
nursing turnover and retention. They were: Job Satisfaction
and Nurses’ Intent to Stay in a Private University Hospital in
Karachi, Pakistan (Salma Jaffer, 2003); RN Perception of Work
Satisfaction at Tertiary Care University Hospital, (Dr Khurshid
Khowaja, 2004); and Turnover and Retention of Nurses, (Dr
Khurshid Khowaja, 1998).
In early 2002, the same task force was re-activated to reassess
the issue of nursing shortages. This task force has
implemented 27 recruitment and retention strategies (see
Figure 5) in order to control nursing turnover rates.
48, 10%
86, 19%
86, 19%
91, 20%
147, 32%
0 - 1 year 1 - 2 years 2 - 3 years
3 - 4 years > 4 years
Figure 2: Turnover rate according to years
of experience 2000–2003
36, 6%
75, 12%
26, 4%
40, 7%
31, 5%
395, 66%
Migration Marriage Back to hometown within Pakistan
Higher education Set resignation Other
Figure 3: Reasons for turnover
Mathews and Campbell (2001) and Aiken (2001) reported
that an improvement in the degree of job satisfaction resulted
in successful nurse retention and therefore decreased staff
turnover. However, the nursing task force has revealed that
despite many interventions implemented at AKUH the
impact on turnover rate has not been achieved and in fact the
turnover rate related to migration has increased from 45% in
year 2002 to 66% in year 2004, in particular migration to the
United Kingdom which in 2003 and 2004 was 70%.
The task force whilst implementing these strategies raised
many queries:
➜ Will AKUH ever be successful in retaining nurses to
provide quality care to its customers, while nursing
recruiters from the United Kingdom and the United
States are working hard to recruit nurses internationally as
part of their business?
➜ Who is responsible for putting the extra burden on Asian
hospitals mentally as well as financially?
➜ What is the role of the many world health organisations,
which are well-aware that shortage of nurses will reduce
the standards of practice in clinical settings in such
20 | World Hospitals and Health Services | Vol. 40 No. 4