Executive summary
The problem of nurse retention intensified by the COVID-19 pandemic may be regarded as crucial not only in Canada but all over the world. The purpose of this report is to summarize the main aspects of the research dedicated to nurse retention and the efficiency of solutions provided by Health Canada and other organizations. The study applies the case study research as its research methodology and collects data from articles dedicated to the factors of nurse shortages and official reports. On the basis of an in-depth analysis of existing literature, the study discovers the presence of a complex problem related to nurse retention and nurse shortage in Canada determined by various factors, including stressful working conditions, a lack of management support and leadership in medical facilities, inappropriate recruitment, work overloads, and associated exhaustion and burnout that lead to low self-esteem, job dissatisfaction, a lack of motivation, and poor performance. Moreover, additional stressors were introduced during the pandemic, and Canadian organizations have elaborated on efficient recommendations dedicated to nurse retention. In turn, Health Canada demonstrates the increase of nurses in the country. However, this tendency is not supported by reliable and time-sensitive data. It is recommended that Health Canada use the existing experience and provide efficient policies. All in all, the results of this research may be used by the managers of medical facilities to raise their awareness in relation to the factors that limit nurse retention and potential solutions dedicated to this issue.
Introduction
Over the past few years, the healthcare industry has faced significant difficulties in terms of nurse retention. Meanwhile, these difficulties became more critical with the beginning of the pandemic when nurses faced unprecedented workloads. Therefore, the understaffing problem, which was previously reported by various organizations in Canada, was exacerbated, and the lack of mechanisms of coping with stress caused by the increased number of patients was critical for this result (Registered Nurses’ Association of Ontario, 2021). In turn, the measures implemented by the government to eliminate accompanying risks to people’s health status do not necessarily correlate with those adopted by organizations.
Within the field, Health Canada may be regarded as one of the most significant participants. As the Government of Canada’s department, Health Canada is responsible for control over national health policy. Being federally funded, it is still entirely independent in its reporting system (Canadian Institute for Health Information, 2019). It goes without saying that public authorities are aware of the issue related to nurse retention and the negative consequences of its lack. Thus, the activities of Health Canada are included in the annual publications, and they are oriented towards the recent shifts, which were promoted by the organization.
This fact allows us to suggest that the actions aimed at eliminating critical risks in the field are given, but their precision with regard to other participants seems dubious. At the same time, analyzing the shifts is impossible without comparing credible data (Stewart, 2022; Cnockaert, 2022). In this way, the evidence from articles devoted to nursing problems leading to their intention to quit should be compared to the information from Health Canada in order to determine what actions mitigate the challenge.
The purpose of this research is to evaluate the process of developing measures to guarantee nurses retention during the ongoing crisis in Canada by Health Canada and the government in general and their outcomes. It aims to investigate the effectiveness of the nurses’ retention policies currently in place in Health Canada to overcome the turnover crisis caused by the COVID-19 pandemic. First of all, this research will provide additional details that will support numbers provided by Health Canada and justify the expediency of its actions. In addition, the performance of this task will help identify the common ideas promoted by authorities in the field of health care and use the findings for further quantitative analysis of similar approaches to determine their effectiveness. Finally, from the analysis, recommendations will be made to Health Canada to implement support actions to improve the nursing staff retention levels.
The research includes several major sections: after the introduction that outlines the problem and the necessity of its solution along with the study’s purpose, the literature review contains the description of theories and frameworks that may be applied to the issue, nurse retention in the health care system, and how it is suggested to be addressed within the framework of post-pandemic retention crisis. Subsequently, the study provides research methodology and techniques for data collection and analysis. On the basis of it, an in-depth analysis of cases and authorities’ policies related to nurse retention was made. Finally, implications and recommendations dedicated to how the results of the research may be applied in order to benefit nurses, managers, and the health care system, in general, were presented.
Review of Theories and Frameworks
Human Capital Theory and Resource-Based Theory
The Human Capital Theory and the Resource-Based Theory will be used as the theoretical framework for the research. Initially, the Human Capital Theory had no connection with health care – it was developed by Adam Smith in the 18th century and then extended by economists Gary Becker and Theodore Schultz in the 1960s (Health Assured team, 2021). This theory mainly implies that education and training are proper investments in human productivity, leading to increased productivity. In its basis, it suggests investing in human capital in the same way as in technology or machinery to receive profit from it through staff’s improved skills, abilities, and values (Health Assured team, 2021). Human capital includes people’s tangible qualities, such as education, problem-solving and communication skills, workplace training, people management, and emotional, mental, and physical well-being (Health Assured team, 2021). While people were previously regarded as commodities, the requirement for mass training and education appeared with the overwhelming growth of production and decreasing demand in the physical working force.
The Human Capital Theory has a considerable impact on the human resource management of any organization as a well-functioning workforce provides benefits and ensures its efficient performance. All in all, the human resource departments were established to perform tasks aimed at improving the quality of the human capital by introducing multiple developmental strategies and practices, such as goal setting, coaching, education, training, and constructive feedback. Thus, human capital management allows to oversee employees’ performance rates and provide training if necessary, set achievable goals for workers, and deliver constructive feedback in order to ensure improvement (Health Assured team, 2021). While the theory’s critiques suggest that it does not presuppose concise measures for skills and talents to be fully objective, it is impossible to deny its significance for leaders who realize the significance of guidance to help subordinates enhance their skills, display their talents, and fulfil their potential to retain and work productively.
In turn, the Resource-Based Theory suggests that an organization should have strategic resources in order to be competitive with its rivals. However, the resources are seen as a strategic advantage if they are valuable, rare, difficult to imitate, and non-substitutable (Carter, 2019). Having resources with the listed characteristics, companies and organizations gain a competitive advantage over other market players, but only given that the enterprise is organized to capture value from these resources. In turn, people’s tangible qualities, including knowledge and skills, become a company’s intangible resources (Pressbooks, 2020). Along with other sources and strategies, it may create a combination that will provide an organization’s strategic resource (Pressbooks, 2020). In general, its evaluation may be presented in the following VRIO framework decision tree:
Staff Retention in Health Care
Staff retention is a phenomenon when employees prefer to continue working with their employers rather than change jobs. In most organizations, staff retention is one of the top priorities for HR departments. Therefore, HR managers develop and implement strategies and practices focused on staff retention in all industries, public and private services. In healthcare, nurse retention is traditionally regarded as a highly important international workforce issue that substantially impacts the quality of healthcare delivery in almost any country across the globe (Efendi et al., 2019). In general, workforce is the health care system’s strategic resource that determines its functioning. However, according to the World Health Organization, while a global shortage of almost 14.5 million nurses, doctors, and midwives has already been estimated, by 2030, the shortage of the nursing workforce might reach 7.6 million specialists (Efendi et al., 2019). That is why multiple studies are dedicated to nurse retention, especially to the factors that contribute to it and help avoid nurse shortages.
In general, nurse retention is closely connected with work conditions in medical settings and the general state of the health care system. According to Efendi et al. (2019), global nursing shortages are caused by an aging workforce and population in general, nurse burnout, a lack of balance between family responsibilities and competing careers, violence in medical settings, and emergent environmental and geographic situations that impact health and health care delivery. At the same time, the authors emphasize that addressing the factors of nurse shortages does not imply improved nurse retention (Efendi et al., 2019). In turn, nurse retention should be improved through particular retention efforts, including employee health initiatives, selective recruitment, and the reduction of health care providers and the system’s inefficiency associated with “ghost” workers and absenteeism.
The concept of nurse retention was thoroughly analysed with the use of various approaches for the detection of reliable factors that contribute to its enhancement. For instance, using the Walker and Avant approach, Efendi et al. (2019), identify four major attributes of retention that include attachment to work; individual decision, intention, and motivation; geographical context; and intervention and strategy. In turn, Hughes (2017) underlines the ultimate significance of leadership for the improvement of nurses’ trust, loyalty, appreciation, security, and support essential for retention within the framework of comfortable working conditions. The importance of authentic leadership’s promotion and leaders’ commitment to their organizational duties for subordinates’ motivation is supported by Collard, Scammell, and Tee (2020). In addition, they state that nurse retention may be developed and promoted within undergraduate education (Collard, Scammell and Tee, 2020). As a considerable number of newly qualified nurses quit due to disappointed expectations, resilience-building training should be included in nurses’ education in order to help them cope with the physical and emotional impact of their profession in the future.
However, decreased nurse retention and associated nurse shortage may be regarded as a global issue. In particular, the Organisation for Economic Co-operation and Development (OECD) countries, including Canada, the United Kingdom, and Australia, are experiencing high turnover and shortages of staff along with the instability of nursing labour markets (Lavoie-Tremblay et al., 2022). In addition, the pandemic has subsequently worsened the whole situation. Thus, according to a survey of Ontario’s registered nurses (RNs) conducted by the Registered Nurses’ Association of Ontario (RNAO), in Canada where the health care system had already faced nurse shortages, an increased number of nurses in their mid-20s to mid-30s reported that that they considered leaving their profession due to high levels of stress and a lack of employer support (Work and wellbeing survey results, 2021). The same situation may be observed in the United Kingdom – the Care Quality Commission’s State of Care report indicated the shortage of approximately 40,000 full-time equivalent nurses in NHS medical facilities (Macdonald and Baker, 2020). Nevertheless, both countries undertake all efforts to minimize shortages through the increase of nurse retention.
Nursing Staff Retention in the Face of Post-Pandemic Retention Crisis
The particular trends in nursing staff and post-pandemic retention could be seen throughout the current research trends. Gunawan et al. (2022) note that e-health practices can be used to improve nursing staff retention and lower the tensions that were caused by the dangers of pandemic and severe work overloads. The scholars state that the technology has great potential in nursing staff retention, as it can relieve workloads and enhance patient service practices.
Then, von Eiff et al. (2022) report that post-pandemic nursing management should utilize the models of leadership. This approach is handy for aligning the chaotic processes in healthcare procurement of “system-critical medical products and pharmaceuticals” (von Eiff et al., 2022, p. 157). The scholars distinguish the factors of working conditions, motivation to work, and satisfaction with incentive systems as critical for staff retention. The value-based leadership model is suggested as a navigator for making the right decisions to overcome the nursing staff retention crisis.
Avgar et al. (2020) discuss technological innovation and change, which will positively impact the roles of healthcare managers. Then, Van Housen (2022) claims that post-pandemic recovery suggests the need for nursing workforce development, applying the Human Capital Theory. The scholar discusses the potential of academic cooperation in overcoming the post-pandemic crisis. Developing new talents, in their opinion, will help to solve the problem of the growing demand for nurses.
Research Methodology
Research Methodology
The case study research was chosen as a research methodology as it allows to understand and explore complex issues within a particular context and on the basis of past studies. In general case studies investigate real-life phenomena through an in-depth analysis of conditions, events, and relationships between them (Schoch, 2020). In addition, the research is focused on the staff retention strategies and practices in the healthcare industry. The organizations, including Health Canada, the Canadian Nurses Association, and the royal Society of Canada, for further detailed analysis were chosen based on their efficiency in introducing the nursing staff retention practices in the face of the post-pandemic crisis. The larger Canadian organizations were given preference as the data will subsequently be compared with data presented in reports by Health Canada to identify common themes and points of intersection.
Based on these intersections, the recommendations will be developed for Health Canada on developing guidelines and policies for post-pandemic nursing staff retention. The healthcare industry may have various specializations in terms of areas of work. Despite this, the services of all clinics are based on the successful performance of duties by nurses, the quality of which is significantly reduced if organizations fail to ensure nursing staff retention.
Data Collection and Analysis
The data for further analysis were collected from the cases studied, most of which were subsequently used to come up with conclusions and recommendations. Selected secondary sources have been included to form the basis for further discussion of overcoming the post-pandemic nursing staff retention crisis by Health Canada. The cases related to nurse retention-associated practices were presented in journal articles by Lopez et al. (2022), Boamah et al. (2021) and Lavoie-Tremblay et al. (2021). No less important, the latest reports by Health Canada were used to broaden the perspective. In particular, the reports from the Canadian Institute for Health Information (2018) and the Canadian Institute for Health Information (2019), financed by Health Canada, were utilized. This cross-organizational analysis allowed for a better understanding of practices of nursing staff retention throughout the country and its healthcare industry.
To analyse the selected data, the Porter’s Generic Strategies tool was applied. This tool suggests that businesses may use three types of strategies to gain a competitive advantage. These are cost leadership, differentiation, and focus strategies, among which the first is focused on incentives and bonuses to maintain the value of the service or good but decrease its price to retain customers (Kabeyi, 2018). The second strategy of differentiation implies developing individualized products or services for customers to get their attention and preferences (Kabeyi, 2018). The third strategy uses both cost leadership and differentiation, but in the niche markets to reach the most loyal customers.
Porter’s Generic Strategies were initially developed to achieve competitive advantage by companies and organizations. Nonetheless, this tool can be applied to analyse the best practices in nursing staff retention, demonstrated by the organizations from the cases. In particular, healthcare institutions use strategies in nursing staff retention, which could be classified according to Porter’s three types of customer retention strategies. Some organizations focus on diversified individualized practices appealing to the emotional well-being of the nurses, while others use incentives and reimbursement to enhance motivation or develop niche-specific practices.
Presentation of findings
Analysing the data
The analysis of data demonstrates the presence of a complex problem related to nurse retention and nurse shortage in Canada and across the globe determined by various factors, including stressful working conditions and a lack of management support in all aspects as major ones. At the same time, the issue of nurse retention and its lack in particular is regarded as more deep and complex. Thus, according to Boamah et al. (2021), nursing faculty shortage leads to nurse shortage in medical facilities and decreased nurse retention in Canada as nursing faculty is responsible for the promotion of leadership in the health care system and preparing nurses for practice. However, it currently faces an aging workforce along with an absence of doctorally prepared nurses due to various factors, including stressful work environments, a lack of leaders’ support, and faculty’s impending retirement (Boamah et al., 2021). This issue requires context-specific solutions and a multidimensional approach that implies the creation of a solid foundation for nursing faculty retention that will contribute to the retention of health care providers in clinical settings.
In addition, data shows that the pandemic caused by a global spread of COVID-19 not only exacerbated the existing problem but introduced new stressors that impacted nurse shortage. In general, the pandemic is associated with a severe burden on healthcare providers and healthcare systems in general due to a highly increased number of patients within an extremely short period of time, new requirements, and rapidly changing protocols (Lopez et al., 2022). That is why the emotional well-being of working nurses was considerably affected by additional patient load, the necessity to combine nursing practice with studying dedicated to the peculiarities of new COVID-19-related circumstances, and a fear of getting infected. Thus, while the pandemic required nurses’ increased recruitment and retention, more and more qualified and experienced healthcare providers decided to leave nursing due to emotional stress, burnout, and mental health issues along with inappropriate working conditions.
The analysis of data demonstrates the significance of addressing COVID-related aspects of nursing practice in order to prevent nurse turnover. According to Lavoie-Tremblay et al. (2021), healthcare delivery for COVID-19 patients influences nurses’ performance, job satisfaction, leadership, and turnover intention. All in all, the necessity to provide care for an increased number of people on a daily basis facing the risk of intention leads to chronic fatigue exhaustion, and burnout that worsen the quality of care and lead to nurses’ poor performance, job dissatisfaction, a lack of motivation, and quit. In addition, during the pandemic, the impact of nursing faculty shortage on the retention of nurses in clinical settings nay be indirectly observed. As nursing faculty retention affects the quality of nurses’ competence, it inevitably leads to nurse retention in medical facilities essential especially in challenging situation. Thus, the study conducted by Lavoie-Tremblay et al. (2021) demonstrated that poorly prepared nurses had considerably lower retention rates in comparison with properly qualified colleagues. That is why the data indicates the necessity of multidimensional approach to the issue of nurse retention as its factors are interconnected.
A plethora of factors that lead to the increase of nurse turnover was discovered as well. Among them were a lack of employer support, massive workloads, inappropriate interprofessional relationships, low job satisfaction, and multiple health issues caused by exhaustion (Lopez et al., 2022). According to the study that covered more than 40 organizations with almost 30,000 participants involved, 43% of individuals reported suffering from work overload, 38% from them mentioned depression, and anxiety, 49% had burnout, and more than 60% expressed fear of infection (Lopez et al., 2022). As the latter was a new factor that, in turn, determined nurse retention, authorities from all over the world started to pay particular attention to nurses’ equipment in order to prevent COVID-19 transmission and exposure and provide workers’ more stable emotional well-being.
At the same time, reports financed by Health Canada demonstrate the increase of nurse workforce. Thus, according to reports from the Canadian Institute for Health Information (2018) and the Canadian Institute for Health Information (2019), the number of regulated nurses increased by 1.9% between 2018 and 2019: 431,769 health care providers in 2018 against 439,975 individuals in 2019. At the same time, according to the analysis of Health Canada’s reports dedicated to nurse retention, this issue was properly addressed only in 2000 by Nursing Strategy for Canada, prepared by the Advisory Committee on Health Human Resources (2000). According to it, Health Canada was responsible for support of federal and local health care authorities that had to elaborate on efficient strategies of nurse retention on the basis of nurses’ demands in their regions. All in all, according to the Porter’s Generic Strategies, health care providers were attracted by individual conditions that aimed to improve their working conditions and the quality of work life. Although it is possible to connect the increase of nurse workforce in 2018-2019 with the results of Nursing Strategy for Canada, Health Canada still lacks essential policies that would target the current crisis associated with the pandemic’s conditions.
At the same time, other organizations developed solutions for nurse retention. Thus, the Canadian Nurses Association and the Royal Society of Canada emphasizes the significance of coordinated actions and the involvement of registered nurses, professional associations, unions, and local and federal authorities for the prevention of nurse shortage and the increase of nurse retention on the basis of the following directions:
- The elimination of non-nursing tasks to reduce workloads;
- The provision of necessary equipment and staff support through the improvement of leadership skills in medical settings;
- The provision of interprofessional training for nurses and additional personalized opportunities for their commitment and competence in relation to resilience;
- The improvement of nurse retention during education through the presence of campus counsellors, additional resilience-dedicated programs, improved teaching methods, and students’ financial support;
- Data related to nurse retention and factors that may impact it should be constantly collected and analysed for the implementation of new efficient responsive strategies if necessary.
- The government should provide the financial support of policies that aim to increase nurse retention (Canadian Nurses Association, no date; An RSC Policy Briefing, 2022).
Reflections on findings
The efficient solution of any problem requires the analysis of factors that led to its occurrence. According to the results of this research, nurse retention and its lack is affected by multiple factors, and additional ones were added by the pandemic. Thus, its improvement is in need of a complex approach that should address factors that lead to nurse shortage, including work overloads, a lack of support, poor communication, a lack of necessary equipment, and nurses’ emotional exhaustion caused by stressful work environments and a fear of infection. For me as for a health care provider, it is essential to be aware of factors that may contribute to my decision to leave work. On the basis of information provided in the research, it is possible to elaborate on the algorithm of actions depending on the reason of this decision – either it derives from personal motives or determined by working conditions. In addition, for any health care specialist, it is highly essential to know how nursing-related issues are addressed by authorities. For the organization, it is also important to discover stressors that may lead to nurse shortage in order to apply strategies to prevent it and raise nurse commitment and retention. Finally, the health care system may benefit from the study’s results as well as the awareness of retention-related factors and existing policies will help improve regulations and prepare for upcoming health challenges. In this case, a potential occurrence of another pandemic may cause less devastating consequences.
Implications and Recommendations
In general, the results of the research coincide with previous studies and the articles of other authors that address the issue of nurse retention. Nurse workforce and human capital is regarded as the health care system’s major strategic resource that determine its performance represented in the quality of health care delivery, and this resource becomes more valuable in the periods of crises, such as pandemics. At the same time, the results support the existence of a complex problem related to nurse retention caused by multiple factors the majority of which are associated with working conditions. The research indicates the presence of stressors, such as nurse burnout due to stressful working environments and work overloads, a lack of employer support and efficient communication, poor preparedness for nursing practice, and a lack of resilience and motivation, that have been already mentioned in existing literature.
At the same time, in relation to potential solutions, the results of this research and other studies emphasize the significance of leadership skills for the increase of nurse retention. When nurses feel that they are valued and respected and their interests and demands are considered, their intention to leave will be determined by exclusively personal motives. Moreover, the advantage of this study lies in its effort to connect the existing researches dedicated to the factors of nurse shortage and retention with policies developed by authorities as potential solutions, At the same time, in comparison with reviewed literature, it does not address unique strategies that may be applied locally, such as the se of modern technologies for nurse retention.
As there are multiple solutions provided by Canadian organizations in order to reduce nurse shortage, especially in the post-pandemic period, it is recommended for Health Canada to update their policies related to this issue on the basis of existing materials and scientific evidence. For this, it is recommended to organize a full-scale data collection and survey to evaluate the situation with nurse shortage and retention after the pandemic and assess the main reasons of nurses’ intention to leave in order to compare it with existing materials and prove their validity. Subsequently, Health Canada may cooperate with other organizations I order to share experience and update existing recommendations to present them officially. In this case, Health Canada will positively contribute to its reputation as an organization that pays particular attention to the well-being and appropriate working conditions of the country’s health care providers.
In the present day, while the organization’s reports demonstrate the increase in nurse workforce in the country, there is a lack of time-sensitive data from it that would justify this tendency. In addition, as a negative impact of the pandemic on nurse retention is impossible to deny, it is essential for Health Canada to use the existing experience and provide efficient policies. In turn, the potential solutions provided by other organizations and authorities may be beneficial for managers in medical facilities. In general, all solutions address factors that lead to nurse turnover, including stressful working conditions, workloads, inappropriate preparedness, a lack of leadership and opportunities for professional and personal development, and inflated expectations concerning nursing practice.
Thus, medical facilities may assess the factors that lead to the decrease of nurse retention and apply strategies on the basis of their unique situation. Managers may apply the results of this research in order to assess the scope of the problem and realize the necessity of efficient responsive measures. Moreover, they may organize the process of monitoring in their medical facilities to evaluate nurses’ current state, their motivation, job satisfaction, and job commitment. If health care providers have the intention to quit, the reasons of this intention should be addressed as well to detect the working environment-related problems that lead to nurse turnover. In this case, mangers may apply information reflected in this study to elaborate on strategies for improvement.
In addition, this research may benefit other industries as well – first of all, it demonstrates the necessity of an in-depth analysis of factors that lead to an issue for its efficient solutions. In addition, the quality of health care impact people’s physical and mental health. Thus, it affects the quality of human capital that may be regarded as a strategic resource in other industries as well.)
Conclusion
This research was dedicated to the issue of nurse shortage in Canada and the assessment of the efficiency of developed measures to guarantee nurses retention during the ongoing crisis by Health Canada and the government in general. On the basis of an in-depth analysis of existing literature, the study discovers the presence of a complex problem related to nurse retention and nurse shortage in Canada determined by various factors, including stressful working conditions, a lack of management support and leadership in medical facilities, inappropriate recruitment, work overloads, and associated exhaustion and burnout that lead to low self-esteem, job dissatisfaction, a lack of motivation, and poor performance. In turn, the results demonstrate that the pandemic caused by a global spread of COVID-19 not only exacerbated the existing problem but introduced new stressors that impacted nurse shortage.
Canadian organizations, including the Canadian Nurses Association, presented recommendations and potential solutions dedicated to the problem of nurse shortage in the country. Their efficiency may be justified by the fact that they are based on major factors that cause nurse shortages. In turn, Health Canada demonstrates the increase of nurses in the country. However, this tendency is not supported by reliable and time-sensitive data. It is recommended that Health Canada to use the existing experience and provide efficient policies. At the same time, the results of policies’ application and their efficiency in practice remain unreviewed. From a personal perspective, the acquisition of reliable results requires time as the post-pandemic period has just begun.
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