A systematic review study on the factors affecting shortage of nursing workforce in the hospitals

1Nurses are essential workforce and form the largest professional group, which comprises healthcare workforce within the healthcare system in contributing significantly in delivering quality healthcare services, and assisting in the improvement of health outcomes for individuals, families and communities either through preventative and curative measures (Alameddine et al.,; Drennan & Ross, ). Furthermore, they are profoundly valued professionals and frontline healthcare workers in the world's healthcare system not only in delivering effective quality care but also in improving the efficiency of the health system; therefore, the adequate number of nurses is crucial to strengthen the health system to improve health coverage and achievements of all health targets (Aboshaiqah,; Alameddine et al., ).

2While the world has credibly acknowledged nursing profession as vital in delivering healthcare services, one of the main challenges faced today is the shortage of nursing workforce, which causes severe compromise on the quality of healthcare services, and in improving the well‐being of the global population and in achieving universal health coverage (Adams et al.,; Alameddine et al.,; Kurjenluoma et al.,; Park & Yu,; Yahyaei et al., ). This is due to disproportions between the number of existing nurses and those that are entering the nursing profession compared with the required number of nurses to meet the patient's needs (Hudgins, ). Many studies discovered that there are discrepancies in the supply of nurses to maintain the adequate number of nursing workforce in response to ageing population, retirement along with the new recruitment of nurses as well as in retaining the existing nurses, which made it difficult to respond to the growing demand (Adams et al.,; Alameddine et al.,; Heijden et al.,; Matsuo et al.,; Otto et al.,; Park & Yu,; Yahyaei et al., ). For instance, in the United States of America (USA), there is an extreme shortage of nurses as it will need approximately 3 million nurses to fulfil its nursing gap, a demand that cannot be easily achieved (Yun et al., ) and an estimate of 12.9 million deficit of skilled nurses and midwives by 2035 (Adams et al.,; Yahyaei et al., ). Furthermore, it is estimated that the shortage of nurses may exceed 500,000 by year 2025, while in Europe, 590,000 nursing vacancies are estimated by year 2020 (Valizadeh et al., ). Moreover, in South Korea, the shortage of nursing is very serious that the average number of nurses per 1,000 people is only 6.9 compared with the other organization for Economic Co‐operation and Development (OECD) member countries with 9.2 and above. Heijden et al. added that in most developed countries in European Union and others, the shortage of nurses in the next two decades is likely to worsen in response to the supply of nurses and the demand.

3According to the World Health Organization (WHO) report, it was estimated that there will be a shortage of 7.2 million health workers to deliver healthcare services worldwide, and by 2035, the demand of nursing will reach 12.9 million (Adams et al., ). The impact of nursing workforce shortage is a huge challenge globally and is affecting more than one billion people, especially vulnerable populations such as women and children who badly needed the quality healthcare services (Aluko et al.,; Marć et al., ). The inadequate supply of nurses has notably created many negative impacts on the patient's health‐related outcome as well as challenges to fight diseases and improving health, which causes increased workload and stress levels on nurses and later results in decreasing the quality of nursing care, threatening the safety of patient and increasing the patient's mortality rate (Heijden et al.,; Leineweber et al.,; Matsuo et al.,; Valizadeh et al.,; Varasteh et al.,; Yun et al., ).

4There are many factors affecting the healthcare system as a result of the shortage of nursing workforce. If these factors are not addressed promptly and appropriately, the number of people requiring quality nursing care will continue to be affected and the primary goal to improve and protect the health of the individual will continue to be a challenge (Matsuo et al.,; Valizadeh et al., ). These include the decreased number of student nurse's enrolment in nursing programme due to a lack of proper planning and funding availability and the increased number of early retirement due to health problem (Alameddine et al.,; Alshmemri et al.,; Barnett et al.,; Valizadeh et al., ). In Japan, the declining birth rate and increased population causes the inadequate number of workforce (Matsuo et al., ). Furthermore, in Thailand, the rapid migration of nurses due to poor working environment and conditions is the main cause of nursing shortage in the country (Nantsupawat et al., ). While in Singapore and other developed countries, job dissatisfaction remains the main reason for nurses' migration (Aeschbacher & Addor,; Alshmemri et al.,; Hung & Lam,; Leineweber et al., ). Furthermore, in Lebanon, the nursing workforce suffers due to the high migration rate of new graduating nurses with Bachelor's degree to other countries just few years after their graduation due to brain drain (Alameddine et al., ). However, one of the main factors reported in many countries is inadequate policies and workforce planning (Abhicharttibutra et al.,; Amadi,; Marć et al.,; Mehdaova, ). Frequent shortage of nursing in a healthcare system to provide services may lead to stress and burnout, which will affect nurse's performance and increase the chances of medical errors, especially in patient's treatment, clinical care and laboratory tests (Aboshaiqah,; Hung & Lam,; Matsuo et al.,; Otto et al.,; Park & Yu,; Varasteh et al., ).

5More literatures on the shortage of nursing are from the western studies with only few from the Pacific island countries. It is important to get a better understanding on the specific factors that affect shortage in the region to have a meaningful strategy to resolve the current shortage of nursing workforce. The aim of this review is to explore the key factors that are most affecting the shortage of nursing workforce and to identify areas for future research.

6This systematic review study was conducted using Cochrane library guidelines. Five relevant databases were used to reach studies including Research 4life—PubMed/Medline, Scopus, Embase, CINAHL using search terms applicable to specific databases. “Booleans” operator was also used in the search strategy such as (AND and OR) to acquire best information between the following keywords: “Nursing workforce,” “Nursing staff,” factors, determinants and shortage. These were used to locate relevant studies that explore the factors affecting the shortage of nursing workforce and the issues affecting nurses and patient health outcomes.

7All types of studies (qualitative, quantitative and mixed‐method) globally were considered in this review to extract the relevant articles among nurses in hospital settings and other health facilities. The studies published from 1 January 2010 to 31 August 2021 and in English language were examined and included from peer‐reviewed journals, published books and WHO reports with full text available that were related to the nursing workforce shortage and were suitable to support the current research study.

8Systematic review studies and studies that their full text was not available were excluded. The information on shortage in other disciplines such as nurse aids, physicians and allied professionals are also excluded from this study.

9The selection process begins by checking all the titles and abstracts of the articles to identify pertinent articles. After the abstracts, the full texts on the remaining articles were checked to see whether they are applicable to the current research study. The articles were also checked for duplication articles or studies and only articles that suited the inclusion and exclusion criteria were downloaded and saved for use. The bibliography of all the remained studies was also checked to find some other articles that are published but were not in the selected databases. Moreover, 42 articles altogether were retrieved, which addressed the factors that influence the shortage in nursing workforce, its impact on registered nurses and the recommended interventions and measures to resolve the nursing workforce shortage. All the selected articles were then grouped under the major themes. A Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) Flow Diagram in Figure 1 was adopted and used as a preferred reporting item for systematic reviews (Moher et al., ).

10A data extraction sheet was developed to extract relevant information needed for further analysis and create themes for this study (Table 1).

11All the studies were published during 2010–2022. Table 2 shows that most studies were quantitative studies and most were conducted in Asia, European Countries, the United States of America and the rest from Africa, the Middle East, the United Kingdom and in the South Pacific. Of the total of 48 studies, 21 studies were conducted in Asia/Southern Asia and Western Asia (3 in Thailand, 5 in Saudi Arabia, 4 in China, 2 in Hong Kong, 2 in Malaysia, 1 in India and 2 in Iran, 1 Korea, 1 in Japan and 1 in Taiwan). Seven studies were conducted in the United States of America/Southern, Northern and eastern (1 in the United States, 1 in Southern California, 1 in Hawaii, 1 in Columbia, 1 in Midland, 1 in Washington and 1 in Brazil). Nine studies were conducted in Europe (2 in Germany, 2 in Finland and one each in Switzerland, London, Netherlands, Sweden and Poland). Four studies were conducted in Africa (one each in Kenya, Nigeria, Malawi and South Africa), three studies in the United Kingdom and three from the Pacific Islands (2 in Australia and 1 in Fiji).

12From these 48 studies, the factors were identified to be related to the shortage of nursing workforce and were summarized and categorized into 4 themes: Policy and planning Barriers, Barriers to Training and enrolment, Factors causing staff turnover and Issues that affect nurses and patient health‐related outcomes.

13Ten (20.83%) articles revealed that ineffective policies regulations and strategies, poor policy (Alameddine et al.,; Drennan & Ross,; Seitovirta et al., ), poor planning and human resource planning, inadequate workforce planning and recruitment (Alreshidi et al.,; Aluko et al.,; Batran,; Marć et al.,; Marufu et al.,; Purohit & Vasava, ), incompetent implementation plan and continue change of government officers (Park & Yu,; Yun et al., ) and lack of leadership management (Souza et al., ) were main factors affecting shortage in nursing workforce. Furthermore, 7 (14.6%) articles supported that increased workload (Batran,; Hudgins, ), unattractive working conditions, poor working conditions (Hung & Lam,; Kakemam et al.,; Nantsupawat et al., ) and inadequate support affects nursing shortage and nurses' turnover (Alshmemri et al.,; Chan et al.,; Mehdaova, ). Five articles mentioned that barriers in policy and planning lead to nurses receiving poor salary, low level of job satisfaction, increasing ageing population and nurses to replace them and poor incentives for nurses (Alameddine et al.,; Hudgins,; Sirisub et al.,; Souza et al.,; Uthaman et al., ).

14Five (10.4%) articles revealed that decreasing nurse enrolment and lack of training for new nursing intakes are the main barriers that affect nursing shortage. Some training barriers are not enough spaces for training, special classroom, dormitories and clinical sites for practice (Aeschbacher & Addor,; Alameddine et al.,; Amadi,; Appiagyei et al.,; LeVasseur & Qureshi, ). Two (4.2%) articles revealed that importing nurses from other countries rather than train local nurses also has significant effects on nursing workforce (Aboshaiqah,; Yun et al., ).

15There are factors that cause nurses turnover, which then contributed to the shortage in nursing workforce. 21 (43.8%) articles revealed that professional vision towards nurses, lack of social support, work overload and low‐level job satisfaction are factors that cause staff turnover (Adams et al.,; Aeschbacher & Addor,; Aiyub et al.,; Alameddine et al.,; Alshmemri et al.,; Chan et al.,; Drennan & Ross,; Gray et al.,; Heijden et al.,; Hung & Lam,; Ke & Stocker,; Leineweber et al.,; Liu et al.,; Masenyani et al.,; Nantsupawat et al.,; Purohit & Vasava,; Sirisub et al.,; Uthaman et al.,; Varasteh et al.,; Yahyaei et al.,; Yang et al., ). Another 10 (20.83%) articles confirmed that poor salaries or no changes to salary and poor working conditions are some of the contributing factors to nurses' turnover (Alameddine et al.,; Alreshidi et al.,; Chan et al.,; Hudgins,; Kakemam et al.,; Marufu et al.,; Mehdaova,; Park & Yu,; Sirisub et al.,; Souza et al., ) and four (8.3%) articles confirmed that older nurses left work before their retirement age due to health conditions and limitation on new technology by older nurses are factors causing turnover (Buchan et al.,; Kurjenluoma et al.,; Sirisub et al.,; Uthaman et al., ).

16There are major issues that affect nurses due to nursing workforce shortage, which contributes to nurse and patient health outcome. 14 (29.2%) articles revealed increased stress, burnout and psychosomatic disorders such as back and shoulder pain, anger and worry due to overwork (Aeschbacher & Addor,; Batran,; Bradley et al.,; Guo,; Heijden et al.,; Hung & Lam,; Kakemam et al.,; Matsuo et al.,; Otto et al.,; Purohit & Vasava,; Seitovirta et al.,; Varasteh et al.,; Wazqar,; Yang et al., ). The effects of shortage not only affect the nurses but also their family and social their social relationship as well. These have a significant impact on nurses, which affects the patient due to no early detection of patient complication, insufficient care provided to the patient and patient safety.

17The shortage of the nursing workforce is a chronic issue that needs to be addressed effectively. Prompted by the findings on the nursing shortage, it impacted the health service delivery throughout the population (Ministry of Health (MOH), ). Although strategies have been implemented in the past to address the issues, the shortage of nursing is still evident. The aim of this study is to explore the healthcare professional's perception on factors affecting the shortage of nursing workforce and its impact on registered nurses in hospitals. The current study findings have reported the factors that influence the shortage in the nursing workforce and its impact on the Registered nurses.

18In this systematic review, results show that ineffective policies regulations and strategies, poor policy, poor planning and human resource planning, inadequate workforce planning and recruitment, incompetent implementation plan and continue change of government officers and lack of leadership management were some main factors affecting shortage in nursing workforce (Abhicharttibutra et al.,; Alreshidi et al.,; Amadi,; Buchan et al.,; LeVasseur & Qureshi,; Marć et al.,; Marufu et al.,; Park & Yu,; Yun et al., ). Increased workload, unattractive working conditions, poor working conditions and inadequate support affects nursing shortage as nurses tend to leave their job (Batran,; Hung & Lam,; Kakemam et al.,; Nantsupawat et al.,; Varasteh et al., ). Results also show that barriers in policy and planning lead to nurses receiving poor salary, low level of job satisfaction, increasing ageing population and nurses to replace them and poor incentives for nurses (Alameddine et al.,; Alreshidi et al.,; Amadi,; Buchan et al.,; Hudgins,; Jarrar et al.,; Kakemam et al.,; Marć et al.,; Marufu et al.,; Sirisub et al.,; Souza et al.,; Uthaman et al., ).

19The results for barriers to training and enrolment also found that decreasing nurse enrolment and lack of training for new nursing intakes are the main barriers that affect nursing shortage. Some training barriers are not enough spaces for training, special classroom, dormitories and clinical sites for practice, which results in the decreased number of intakes at a time (Aeschbacher & Addor,; Alameddine et al.,; Appiagyei et al.,; LeVasseur & Qureshi, ). Furthermore, the continuous import of expatriate nurses from other countries rather than training local nurses also has significant effects on nursing workforce (Aboshaiqah, ).

20In this review, results show that professional vision towards nurses, lack of social support, work overload and low‐level job satisfaction are factors that cause nursing staff turnover (Aeschbacher & Addor,; Alameddine et al.,; Alshmemri et al.,; Atefi et al.,; Chan et al.,; Drennan & Ross,; Gray et al.,; Heijden et al.,; Hung & Lam,; Ke & Stocker,; Leineweber et al.,; Liu et al.,; Masenyani et al.,; Nantsupawat et al.,; Purohit & Vasava,; Sirisub et al.,; Uthaman et al.,; Varasteh et al.,; Yang et al., ). Furthermore, results show that poor salaries or no changes to salary and poor working conditions as well as older nurses leave work before their retirement age due to health conditions and limitations on new technology by older nurses, which results in nurses turnover (Adams et al.,; Aeschbacher & Addor,; Alameddine et al.,; Hudgins,; Kakemam et al.,; Mehdaova,; Park & Yu,; Sirisub et al.,; Souza et al.,; Uthaman et al.,; Yahyaei et al., ).

21Furthermore, increased stress, burnout and psychosomatic disorders such as back and shoulder pain, anger and worry due to overwork not only affects nurses but also has an impact on their family and social relationship when nurses have to work for more hours (Aeschbacher & Addor,; Batran,; Guo,; Heijden et al.,; Hung & Lam,; Kakemam et al.,; Matsuo et al.,; Otto et al.,; Purohit & Vasava,; Seitovirta et al.,; Varasteh et al.,; Wazqar,; Yang et al., ). These result in patient health outcomes due to no early detection of patient's complication, insufficient care and patient's safety (Batran,; Kakemam et al.,; Masenyani et al.,; Seitovirta et al.,; Wazqar,; Yang et al., ).

22The worldwide shortage of nursing workforce is one of the obstacles in providing quality healthcare services to the population to improve health and well‐being and to achieve universal coverage. The inadequate supply of nurses has created many negative impacts on patient health‐related outcomes, as well as challenges to fight diseases and improves health. This also causes an increased workload on nurses and later results in decreasing the quality of nursing care, threaten the safety of patients and increase the workforce mental health issues. The study synthesized the findings of forty‐two studies. The reasons for the shortage in nursing workforce and the effects were influenced by many factors that are summarized and categorized into barriers to policy and planning, training and enrolment barriers, nursing staff turnover and the impacts on the nurses and patient health outcomes.

23There are factors that significantly contributed to the nursing shortage worldwide such as barriers in policy and planning, training and enrolment and staff turnover due to workload and job dissatisfaction. Intervention to address these factors promptly and appropriately is crucial or quality nursing care will continue to be affected and the primary goal to improve and protect the health of the individual will continue to be a challenge. The findings of this study can be helpful to key health professionals at the decision‐making level or policymakers to resolve the nursing workforce shortage in the future. Further research is needed to determine the in‐depth effects of nursing workforce shortage on patients and interventions to address it more effectively.

24AT and MM conceived the initial idea of the paper. AT wrote the first draft. MM critically revised the initial drafts. All authors were involved in the revision of the final draft of the paper and approved the final manuscript.

25The authors declare no conflict of interest.

26This systematic review study does not need ethical approval as it retrieved and analysed the previous published studies in which informed consent was obtained by primary investigators.