Introduction to nursing shortage: factors influencing nursing shortage by

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Reshmi R. Rodrigues

BA – Criminal Justice, Virginia Commonwealth University, 2006

Submitted to the Graduate Faculty of

Health Policy and Management

Graduate School of Public Health in partial fulfillment

of the requirements for the degree of

Master of Health Administration

University of Pittsburgh



Graduate School of Public Health

This essay is submitted


Reshmi R. Rodrigues


August11th, 2014

and approved by

Essay Advisor:

Nicholas Castle, BA, MHA, PhD _________________________________


Department of Health Policy and Management

Graduate School of Public Health

University of Pittsburgh

Essay Reader:

Robin Grubs, PhD _________________________________


Department of Human Genetics

Graduate School of Public Health

University of Pittsburgh

Copyright © by Reshmi R. Rodrigues


Nicholas Castle, BA, MHA, PH.D

Reshmi R. Rodrigues, MHA

University of Pittsburgh 2014

There are a number of factors that contribute to the nursing shortage: Staffing shortages are impacting the stress level of nurses thus impacting job satisfaction. The change in demographics requires a need for more nurses to care for the aging population. A significant sector of the nursing workforce is approaching retirement age. Even though the causes of nursing shortages are multi-faceted in nature, there is growing evidence of the impact of low staffing levels on health care delivery and outcomes. The public health significance of organizations to retain nurses is twofold: by focusing on nursing leadership styles as a recommendation to alleviate some of the problems that are emerging as a result of nursing shortages and nursing job satisfaction.


INTRODution: NURSING SHORTAGE......…………………………………….….................1


REASONS FOR NURSING SHORTAGE.…………………………………………….……..….4



AGING WORKFORCE……………………………………………………………………....…12

LEADERSHIP STYLES………………………………………………………………...............13

TRANFORMATION LEADERSHIP……………………………………………….…..15

TRANSACTIONAL LEADERSHIP……………………………………………………19





Nursing shortage is defined as an inadequate number of qualified nurses to meet the projected demand for nursing care within healthcare settings. The nursing shortage is not a recent phenomenon; however in the last few years the shortage has begun to have a significant impact on our healthcare systems. In this essay I will explain the causes for the shortage of registered nurses (RN), as well as the role of nursing leadership as a recommendation necessary to improve the quality of work in the nursing profession.

According to the American Nurses Association, a Registered Nurse (RN) requires one to assess, plan and intervene to promote heath, help patients manage illness and prevent diseases. While providing care to patients, their duties include observing, assessing and recording patient symptoms, reactions and progress. RN roles range from direct patient care and case management to establishing nursing practice standards, developing quality assurance procedures, directing complex nursing care systems, conducting clinical research and teaching in nursing programs, as well as practicing in many other invigorating settings. RNs also develop and manage nursing care plans, instruct patients and their families in proper care and help individuals and groups take steps to improve or maintain their health. Their roles range from direct patient care and case management to establishing nursing practice standards, developing quality assurance procedures, directing complex nursing care systems, conducting clinical research and teaching in nursing programs. Although there are many specialties that fall within the realm of nursing such as Critical care, Emergency, Nurse Educator, Hospice care/Palliative care, I am interested in learning more about the nursing shortages that effect in a hospital setting overall.
The current nursing shortage and high turnover is of great concern in the United States because of its impact upon the efficiency and effectiveness of any health care delivery system. Research suggests that the current shortage is the product of several trends including (Cullen 2010):

  • A steep population growth in several states;

  • A diminishing pipeline of new students to nursing;

  • A decline in RN earnings relative to other career options;

  • An aging nursing workforce; and

  • An aging population that will require intense health care services.

While opportunities in health care are expanding, issues within the nursing profession are beginning to emerge as a significant proportion of nurses are retiring. Registered Nurses represent the largest single healthcare profession in the United States. The result of cyclical shortages of nurses in the United States health care system will have a direct effect on the quality of patient care and is a multifaceted and complex issue, with causes stemming from training as well as compensation and retention. In 2000, there were 110,000 open nursing positions, indicating that demand for RNs were 6 percent higher than the available supply. In 2008, according to the American Health Care Association’s report of vacancies in long-term facilities as well as the American Hospital Association’s report of hospital vacancies indicated an even larger shortage of 8.1%. It is predicted by 2025, the shortage of RNs is projected to grow to an estimated 260,000 FTEs, twice as high as any US nursing shortage since the 1960’s (Cullen, 2010). The Nursing Management Aging Workforce Survey found that 55% of registered nurses intend to retire from the nursing profession between 2011 and 2015. Nurses reported high levels of job dissatisfaction due to work scheduling, heavy workloads, mandatory overtime, as well as the lack of responsiveness to concerns from upper level management as major reasons for high turnover and early retirement among RNs (Beauhaus, 2009). According to the American Association of Colleges of Nursing (AACN), nursing leaders play a critical role in helping to give nurses a voice in the development of patient care environments. Leaders can help create a deeply satisfying organizational culture at the unit level by engaging staff in the development of shared values in their work. This demands a pattern shift from a more traditional command-and-control style of staff supervision toward a transformational style of leadership in which leaders enhance the motivation, confidence and performance of their follower groups.


Integrative literature review of published literature was reviewed on the current nursing shortage in the United States as well countries abroad from 1997 to 2011. The literature review conducted for this paper was conducted by looking at journal articles, online books and web articles that addressed the topic of nursing shortages and to provide specific recommendations to address the nursing shortage. In order to further my understanding on this topic, my literature review was also conducted through online research that was obtained through published articles and newspapers. Published literature was identified by searching the following bibliographic databases: with in-process records via PubMed; and CINAHL. The main search concept in conducting this research were: nursing shortages, nursing shortage solutions, job satisfaction, ageing RN workforce, stress, recruitment, retention, image, students, future of nursing, nursing shortages trends, common administrative issues in hospitals.  I then searched within these articles for acute care and ambulatory facilities by entering key words such as ER, ICU, NICU, Urgent Care, Ambulatory Surgical Center, Radiology, Acute Care Facilities, etc. After pulling 36 articles I once again narrowed my search and criteria were limited to nurse staffing that focused primarily on the registered nurses and staff nurses when considering nursing perspectives.

Data collected for the review included surveys, questionnaires and direct interviews. The types of questionnaires and surveys utilized were: Multifactor Leadership Questionnaire, Index of Work Satisfaction Effectives Questionnaire (CQEW) which measured the perceptions of workplace empowerment; Job Activities Scale (JAS) was used to measure nurses’ perception of power in the work setting; the Leader Empowering Scale (LEB) measured the empowering behaviors of their managers and lastly the nurse perception of informal power was measure by the Organizational Relationship Scale (ORS). The Anticipated Turnover Scale (ATS) is an instrument which has been used in research to measure anticipated turnover. I utilized these studies as they were relevant to understanding the reasons for rising concerns of nursing shortages over the last several decades.


The reasons for the nursing shortage are multifaceted in nature, which reflect the changes in population demographics, women’s employment patterns, the healthcare system, and nursing work (Rosseter, 2011). Together, these changes pose significant challenges both in recruiting new RNs and retaining currently employed RNs. There is an increase in the demand for nurses as a result of population aging. Projected shortages should be viewed in the context of expected increases in demand for nursing services (Rosseter, 2011). Between 2000 and 2020, the US population will grow by 18 percent (31 million) overall, but the over-65 population, with more health care needs, will grow by 54 percent (19 million people). Furthermore, there are broad changes in social and employment patterns for women. Women who are born after the 1950s have more career options than their predecessors, and fewer have chosen to enter the nursing profession (Rosseter, 2011).

In response to the rising costs of health care, the growth of managed care in the 1990s created cost pressure, particularly on hospitals, the largest employers of RNs. In the early 1990, areas with higher managed care enrollment had slower wage and employment growth for RNs than areas with lower managed care enrollment. As managed care spread, RN wage and employment growth slowed at the national level by the late 1990 (Rosseter, 2011). These changes followed shifts in hospital payment systems designed to reduce spending, leading to shorter lengths of stay in hospitals. As a result, hospital RNs treat patients who are sicker on average, and their work is thus more intensive. Nurses have been overloaded with work in response to health care cost pressure in the 1990s (Rosseter, 2011). Hospitals reduced staffing and implemented mandatory overtime policies to ensure that RNs would be available to work when the number of patients admitted increased unexpectedly. The workload for RNs increased, and their control over scheduling and flexibility decreased as weekend and night shifts were no longer readily available as preferences to RNs. However, additional workload does not mean increased compensation, but, as mentioned above, RNs wages were flat over this time period, due to the more competitive health care environment. With all the factors prominent in the workforce, it is expected that many individuals are hesitant to enter the nursing profession (Rosseter, 2011).


Staff nurses’ job satisfaction is a key focus of hospitals throughout the U.S. to combat the growing nursing shortage. Since hospitals in the United States are faced with the significant problem of nursing turnover, there are measurable effects of high turnover that include increased cost of recruitment and relocation for new staff, as well as agency fees and overtime (Lewis, 2007). Since costs from all factors can easily exceed $25,000 per nurse recruited, the price tag is enormous for hospitals that turn over several hundred nurses per year (Lewis, 2007). However, hospital administrators may believe that they have no choice but to deal with high nursing turnover. Fortunately, now that the problems are more transparent, I believe that administrators now have more resources to confront this issue and work on solutions to tackle the issue upfront. Turnover rates are heavily dependent on staff morale. Staff morale is influenced by the strength of an institution’s leadership and the degree of empowerment it provides its nurses (Lewis, 2007). If hospital administration can focus on strengthening leadership and empowering nurses, then turnover rates and all its associated costs can be reduced. If hospitals can build the foundation by improving the level of dissatisfaction then their employees will be more satisfied and become empowered in the job environment (Lewis, 2007).

Insufficient staffing is raising the stress level of nurses, impacting job satisfaction, and driving many nurses to leave the profession (Lewis, 2007). In a study published in the April 2010 issue of Health Services Research, Dr. Linda Aiken and colleagues found that lower nurse-patient ratios on medical and surgical units were associated with significantly higher patient mortality rates (McVicara, 2007). In the March-April 2005 issue of Nursing Economics, Dr. Peter Buerhaus and colleagues reported that more than 75% of RNs believe the nursing shortage presents a major problem for the quality of their work life, the quality of patient care, and the amount of time nurses can spend with patients. Dr. Christine T. Kovner and colleagues reported that 13% of newly licensed RNs had changed principal jobs after one year, and 37% reported that they felt ready to change jobs (McVicara, 2007). In March 2005, the Bernard Hodes Group released the results of a national poll of 138 health care recruiters and found that the average RN turnover rate was 13.9%, the vacancy rate was 16.1% and the average RN cost-per-hire was $2,821 (McVicara, 2007).

Research by Carol Brewer and Christine Kovner employed survey methodology to investigate the acute care hospital based staff nurses’ job satisfaction factors (AHRQ, 2007). A nationally representative sample of 553 staff RNs who work in hospitals were tested and as a result developed a model to explain the variables that are related to nursing job satisfaction (AHRQ, 2007).The authors also discussed the work life of nurses. This report was based on a larger study entitled “Factors Associated with Work Satisfaction of Registered Nurses.” Some of the key findings about nursing job satisfaction that was explained by working conditions are as follows (AHRQ, 2007):

  • Work setting explained 38 % of the variability in satisfaction.

  • Demographic variables explained 9 % of the variability in job satisfaction.

  • Wages and benefits were not associated with satisfaction in this study, although previous studies have found a relationship.

  • The perception that rewards are tied to performance was significantly related to higher job satisfaction in this study.

  • The majority of nurse’s surveyed plan to stay in the same position in the next year and would prefer to work the same number of hours per week.

  • Within the next year, three out of four (77%) plan on staying with their organization and slightly more than three out of four (78%) planned on staying in a similar position. Few (3%) planned to work outside of nursing. Although one out of three full-time RNs (33%) worked more hours than they were scheduled, slightly less than two out of three nurses (5%) reported that they preferred to work the same number of hours next year, while about one out of three nurses (30%) preferred to work fewer hours next year and few (5%) preferred to work more hours.

  • Nurses have access to many non-compensatory benefits and report that having these benefits is important to them.

  • Most nurses report having medical insurance (87%), retirement benefits (87%), paid time off (85%), other insurance (81%), unpaid family leave (75%) and formal education benefits (75%). Some nurses have paid family leave (3%), flexible workplace (52%) and child care benefits (2%). More than four-fifths (8%) of nurses surveyed reported that benefits were somewhat or very important to staying in their current position.

  • Injury in the workplace is common for RNs who work in hospital settings. About one third of nurses (30%) reported at least one needle stick injury in the past year with slightly less than two-thirds reporting at least one strain or sprain. Nurses also reported bruises (3%) and cuts (32%) with few reporting head injuries (3%), broken bones (2%) or dislocated joints (1%).

The American Nurses Association conducted a national internet survey that targeted 7300 respondents to study nurses’ opinions of their working conditions (ANA, 2001). 75% of the respondents indicated that the quality of care had declined in their work setting over the past two years due to patient load and decreased ties to provide patient care. 40% to 60% stated they skipped meals and breaks to in order to complete their job duties (ANA, 2001).

A study conducted by McNeese-Smith (1999) investigated staff nurse descriptions of job satisfaction and dissatisfaction (McNeese-Smith, D. (1999). This study collected information from 30 staff nurses through questionnaires and direct interviews. Several categories and themes were identified indicating that job satisfaction was derived from the following categories: patient care, environment, and balanced workload, relations with coworkers, personal factors, salary and benefits, professionalism, cultural background of the nurse and career stage of the nurse. Themes related to patient care, the pace and variety in an acute care environment, relationships with coworkers and meeting personal and family needs were cited as particularly relevant to job satisfaction. Job dissatisfaction was primarily influenced by issues related to patient care; factors that interfere with the job and patient care, feeling overloaded, relations with coworkers, personal factors, organizational factors and the career stage of the nurse. As a result of these findings, administrators will have to consider organizational and individual factors that influence nurses’ feelings about their job and they prepare for future solutions for nursing shortages (McNeese-Smith, D, 1999).

The nursing shortages has forced organizations to re-evaluate its strategies and to determine how to keep nurses within an organization. It’s important to evaluate nurses’ perception of those with manager’s perception of their workplace environment. A study done by Gormley found that the work environment influences staff motivation and behavior (Gormley, 2011). Understanding the managers’ idea of work atmosphere versus a nurse’s view of the organizations workplace could be helpful in determining new strategies to retain nurses (Gormley, 2011). A study was conducted in two hospitals in the Midwest region of the USA. The study was inclusive of full time and part time nurses/nurse managers working in an acute or ambulatory. The survey respondents were asked to complete demographic information such as age, gender, marital status, employment, status role, and years of experience using the Anticipated Turnover Scale (ATS). They were also asked to complete Perceived Nurse Work Environment Scale (PNWE) which utilized a Likert scale of one to five, with one representing strong disagree and five representing strongly agree. The breakdown of the subscale components were: opportunity for advancement; participatory governance; decision making; nursing management; job enjoyment; and nurse-physician collaboration. Gormley revealed that 336 staff responded to the survey of which 88% were staff nurses and 12% were managers. The respondents were also asked about the perception of their job and the quality of care provided to patients was asked on a scale of 1 to 10; 1 being strongly disagree and 10 being strong agree. It is not surprising that Gormley found that nurse managers and staff nurses had different perceptions of the work environment. Nurse Managers viewed their work environment more positive than the staff nurses. Staff nurses regarded nursing management; job satisfaction and quality care as determinants of high turnover rates.

Gormley’s study is instrumental for health care organizations in understanding the importance of the variations of perceptions between staff nurses and nurse managers. The varied perceptions in the workplace clearly shows a disconnect within the organization. Healthcare leaders will have to recognize this disconnect and create governance, policy and education to support and encourage nurse managers in their professional growth and engagement in their workplace (Gormley, 2011).

Another study conducted Tsai and Wu (2010) was to evaluate nursing staff perceptions of leadership communication, job characteristics. The questionnaires were sent out to the nurses in the acute medical center in Taiwan. 79% of respondents were accounted for when evaluating the results. All components utilized a five-point Likert type scale with one representing strongly disagrees and five equaling strongly agree. The study conducted by Tsai and Wu (2010) found that an individual’s behavior influences peers. Work competency was found to be the primary component of job satisfaction and salary was the least influential in job satisfaction. Better working opportunities were the primary reason found to be the intent for leaving their workplace. Based on Tsai and Wu (2010) studies also found that training activities, job enrichment programs and empowerment seminars are areas that an organization must consider in retaining staff nurses (Tsai and Wu, 2010).


Workload, leadership/management style, professional conflict and emotional cost of caring have been the main sources of distress for nurses for many years. Stress can be defined from a demand-perception response perspective (Page, 2004). In studying occupational stress and stress management, the cognitive theory of stress has become one of the most widely applied theories (Page, 2004). According to this theory, stress relates both to the perception of demands being made upon an individual and his/her perception of one’s capabilities to meet those demands. A mismatch will mean that an individual’s stress threshold is exceeded, triggering a stress response. Assessing stress is likely to be difficult in an occupation as diverse and challenging as nursing, yet the effectiveness of organizational interventions to reduce or eliminate sources of stress depends upon a sound understanding of the stress phenomenon for nurses (Page, 2004). As previously stated another contributing factor of insufficient staffing is also raising the stress level of nurses thus impacting job satisfaction, and driving many nurses to leave the profession. In the March-April 2005 issue of Nursing Economics, Dr. Peter Buerhaus and colleagues found that more than 75% of RNs believe the nursing shortage presents a major problem for the quality of their work life, the quality of patient care, and the amount of time nurses can spend with patients. Looking forward, almost all surveyed nurses see the shortage in the future as a catalyst for increasing stress on nurses (98%), lowering patient care quality (93%) and causing nurses to leave the profession (93%) (Page, 2004).

Hart Research Associates (2001) indicated that 56% of nurses that were surveyed considered leaving the patient field in order to find jobs that were less stressful and physically demanding. Many nurses were found to find their current working conditions intolerable (Hart Research Associates). Thus the primary motivator for nurses leaving the profession or job is stressful working conditions and in particular understaffing. As briefly mentioned before, American Nurses Association conducted an online national survey to examine the working conditions of 7300 nurses. Of the respondents nurses, 5340 felt and increase in work pressure; 4258 reported being required to work overtime hours, and 3762 had an illness that was stress related (American Nurses Association, 2001). Fifty six percent of nurses surveyed believed their time spent on direct patient care had decreased. Seventy percent of stress and overwork were among the top health related concerns (American Nurses Association, 2001).


The RNs are the largest group of health professionals in the USA (USA Department of Labor 2002). During the 1960s and 1970s, the nursing field experienced its largest influx of women into the profession however, because of the increase of new career opportunities in the following decades; fewer women have entered the nursing profession since then (USA Department of Labor 2002). The average age of RNs currently employed continues to rise and most middle-aged RNs born during the ‘baby boom’ generation (born between 1946 and 1964) who dominate the nursing workforce will reach retirement between 2005 and 2010 (Gabriel, 2001). This means that the most experienced nurses, mainly middle-aged women, will be leaving the profession at an alarming rate and at a time when demand is highest. In a study by Buerhaus et al. (2000), some troubling results regarding the implications of an ageing RN workforce were found. Based on a retrospective cohort analysis of RN employment trends in the USA between 1973 and 1998, they were able to make a reliable estimation of the future RN workforce. It was forecasted that within the next 10 years the average age of RNs would be ages 45/54 years, with more than 40% older than age 50 years. For example, the average age of nurses in Ohio is 47 (Ohio Hospital Association, 2001). Therefore, based on the data, some states may experience the effects of the ageing RN workforce prior to other areas of the country.


In order to alleviate some of the problems in the nursing profession, the hospital must deal with the lack of satisfaction with leadership in the hospital setting. For registered staff nurses, job satisfaction and positive relationships with nurse managers become imperative in order to meet the demanding, multi-dimensional job requirements found in hospitals (Ramey, 2002). The relationship between nurse manager leadership style and staff nurse job satisfaction in hospitals has been widely studied. Based on a hospital’s structure, each Health Care Organization has to design their preferred leadership style that best suits the needs of the organization (Ramey, 2002). Based on preferred leadership styles that suits the organization, nurse job satisfaction will increase and create lower turnover rates in the nursing profession. The hospital will then significantly decrease the amount of money spent recruiting new nurses and orienting the new employees (Ramey, 2002). This, in turn, will create increased patient satisfaction and will reflect a positive view of the hospital by the community. The hospital will also benefit from the satisfaction of registered staff nurses as seen by an increase in productivity, efficiency, and retention. The relationship of perceived leadership styles of nurse managers and job satisfaction of registered staff nurses will establish a positive, mutually beneficial relationship (Ramey, 2002).

Behavioral and organizational research on work and workforce effectiveness has identified management practices that are consistently associated with successful implementation of change initiatives and achievement of safety in spite of high risk for error. These practices include (Burns, 1978):

(1) Balancing the tension between production efficiency and reliability (safety);

(2) Creating and sustaining trust throughout the organization;

(3) Actively managing the process of change;

(4) Involving workers in decision making pertaining to work design and work flow; and

(5) Using knowledge management practices to establish the organization as a “learning organization.” These five management practices, which are essential to keeping patients safe, are not applied consistently in the work environments of nurses (Burns, 1978).

According to the American Association of Colleges of Nursing (AACN), nursing leadership should always be available because nursing leaders play a critical role in helping to give nurses a voice in the development of patient care environments. Leaders can help create a deeply fulfilling organizational culture at the unit level by engaging staff in the development of shared values in their work (Burns, 1978). Nurse Manager’s use of transformational and transactional leader behaviors is now being studied to the development of organizational commitment. I will further explore the different characteristics of transformational compared to transactional leadership (Burns, 1978).

By examining the current workforce, management personnel in healthcare organizations should consider focusing on the nurse leader's role throughout the organization. More recently, the role of nurse managers and executives has been re-examined to better understand which leader is best positioned in the organization to exert the most positive influence on nursing staff relationships (Burns, 1978). Organizations turn to leaders for solutions to workforce and other resource issues that will help the organization achieve and maintain a competitive advantage. The nurse leader's role is pivotal to achieving these outcomes and to enhancing the trust and respect that staff must have in managers at all levels of the organization. Maintaining a positive work environment and building a team effort are keys to achieving patient safety. Positive environments for health care workers should be maintained in order to preserve the nursing staff and to also attract new employees (Burns, 1978). The current shortage of RNs at the bedside magnifies the importance of having strong, clear, and supportive, leadership across the health care organization. The theory of Transformational and Transactional Leadership offers a framework through which managers can further develop their own knowledge and abilities about leading others and provides a model for shaping staff commitment and the work environment (Burns, 1978).


Transformational leadership is a key ingredient in establishing a nursing environment that has proven to retain highly qualified nurses during serious nursing shortages. James MacGregor Burns first introduced the leadership theory that he called transformational leadership (Weberg, 2010). Transformational leadership occurs when two or more persons engage with others in such a way that the leader and followers raise one another to high levels of motivation and morality. Transformational leadership is effective in turbulent and uncertain environments, such as those found in today’s healthcare organizations (Weberg, 2010). Nurses at all organizations can learn how to use the principles of transformational leadership to support a professional practice environment that results in outstanding patient care. The transformational leadership theory is different from older leadership theories such that this theory proposes that in order to achieve high work performance, the organization must meet the needs of the employees. Maslow described basic human needs as physiological stability, safety, belongingness and love, self-esteem and self-actualization (Weberg, 2010). Based on the hierarchical order, these needs are arranged starting with the need for physiological stability and ending with self-actualization. In general, higher-level needs are not as important until basic needs are fulfilled. For example, most people do not strive for higher-level needs such as self-esteem or self-actualization until their basic physiological needs for food, water and sleep are met (Weberg, 2010).

Further studies by Tichy and Devanna have identified the four components of Transformational Leadership: (a) Intellectual Stimulation – Transformational leaders not only challenge the status quo, they also encourage creativity among followers. The leader encourages followers to explore new ways of doing things and to find new opportunities to learn; (b) Individualized Consideration – Transformational leadership offers support and encouragement to individual followers. In order to foster supportive relationships, transformational leaders keep lines of communication open so that followers feel free to share ideas and so that leaders can offer direct recognition of each follower’s unique contributions; (c) Inspirational Motivation – Transformational leaders have a clear vision that they are able to articulate to followers. These leaders are also able to help followers experience the same passion and motivation to fulfill these goals; (d) Idealized Influence – The transformational leader serves as a role model for followers. Because followers trust and respect the leader, they emulate the leader and internalize his or her ideals (Summers, 1995).

Health care organizations have to develop a culture in which transformational leadership must commence with the chief nursing officers or vice presidents. Nursing managers will then have to communicate the organizations vision for the future to their staff nurses. Nurse Managers typically work closely with patient care staff and hence their leadership style has significant impact on professional nursing practice and drives the quality of patient care (Weberg, 2010). Managers that are interested in a more participative management style, and developing transformational leadership qualities leads to more successful interactions within departmental units. Managers should strive to validate perceptions of their leadership style and look for opportunities for personal development and mentoring to strengthen their transformational leadership qualities (Weberg, 2010).

Based on Nursing research, the understanding of nursing leadership styles and their relationship to staff job satisfaction/retention, quality of patient care have been widely studied. Studies done by Medley and Larochelle, investigated the leadership paradigm of transformational and transactional leadership. The Multifactor Leadership Questionnaire and the Index of Work Satisfaction were completed by 122 staff nurses employed throughout acute care community hospitals in many patient care areas. The authors concluded that these correlations showed a significant positive relationship between those head nurses exhibiting a transformational leadership style and the job satisfaction of their staff nurses (Medley, F., & Larochelle, D, 1995).

Staff Nurse Retention rates are directly correlated to high satisfaction rates (Ribelin, 2003). Research shows the direct relationship between effective leadership styles and retention rates were 11% lower when transformation leadership style was practiced (Kleinnlan, 2004).

Transformation Leadership styles build on interpersonal relationships, mentorship value, and a culture that shares responsibility with staff. Kanter’s Theory of Organizational Empowerment relates employee work behaviors are a direct response to their work conditions and environment not just the manifestations of their personality traits (Kanter, 1977). In order for employees to feel empowered, once needs the access to knowledge and information to successfully perform their job duties (Laschinger, 1996). Needless to say, it is important for leaders to motivate and empower others by sharing the resources by making them available to their staff (Laschinger, Sabiston & Kutzcher, 1997). Employees can carry out their job by having access to resources, lines of support ability to obtain materials to maximize effectiveness in one’s job. Without these fundamental elements, employees experience powerlessness (Laschinger, 1996).

A study done by Laschinger (1999) described the impact of nurse managers’ transformational leadership characteristics on hospital nurses sense of empowerment and job satisfaction. The results revealed that RN’S sense of empowered can be enhanced by transformational leadership behaviors perceived to be displayed by the nurse manager. A cross sectional was designed and used to this the model of Kanter’s work of empowerment theory. The sample included part time, full time and PRN registered nurses who have been employed at two sites of the merged hospital. A random sample of 537 staff registered nurses were distributed questionnaire packets that contained, Effectives Questionnaire (CQEW) which measured the perceptions of workplace empowerment; Job Activities Scale (JAS) was used to measure nurses preceptio of power in the work setting; the Leader Empowering Scale (LEB) measured the empowering behaviors of their managers and lastly the nurse perception of informal power was measure by the Organizational Relationship Scale (ORS). Based on the survey, the study suggests that leadership behaviors are important factors of nurse perceptions in being able to get access to support, resources and opportunities in their job place. Based on the survey a strong relationship between leaders demonstrating this type of leadership provides nurses with the freedom to be independent and demonstrate sound judgment, take risks in their day to day job functions (Laschinger, 1999). The study affirms Kanter’s theory that empowered individuals have control over conditions that make their actions possible resulting in organizational effectiveness.


The transactional style of leadership is the one most often used by managers. It focuses on the basic management process of controlling, organizing, and short-term planning. Transactional leadership involves motivating and directing followers primarily through appealing to their own self-interest (Mcguire, 2006). Unlike Transformational leadership, leaders using the transactional approach are not looking to change the future; they are looking to merely keep things the same. These leaders pay attention to followers' work in order to find faults and deviations. This type of leadership is effective in crisis and emergency situations, as well as when projects need to be carried out in a specific fashion (Hargis, 2001). The power of transactional leaders comes from their formal authority and responsibility in the organization. The main expectation of the follower is to obey the instructions of the leader. The style can also be referred to as a “telling style.” The leader believes in motivating through a system of rewards and punishment. If a subordinate does what is desired, a reward will follow, and if he/she does not abide by the wishes of the leader, a punishment will follow. Here, the exchange between leader and follower takes place to achieve routine performance goals. The four components of transactional leadership are: (a)Contingent Rewards: Transactional leaders link goals to rewards, clarify expectations, provide necessary resources, set mutually agreed upon goals, and provide various kinds of rewards for successful performance; (b) Active Management by Exception: Transactional leaders actively monitor the work of their subordinates, watch for deviations from rules and standards and taking corrective action to prevent mistakes; (c) Passive Management by Exception: Transactional leaders intervene only when standards are not met or when the performance is not as per the expectations. They may even use punishment as a response to unacceptable performance; (d) Rewards and punishment are the things that motivate people. A clear chain of command works best in running an organization. Once employees agree to do a job, they are entirely in the hands of a manager. That is, they cede complete authority to the manager; and once they cede complete authority to a manager, employees must do as told. An employee must comply with the work demands of the management, in return for which he/she are adequately rewarded monetarily (Mcguire, 2006). Transactional leadership is a technique of leading an organization where, through routine transactions such as rewards and punishments, tasks get accomplished. It is entirely based on transactions conducted between the nurse leader and subordinate staff members because it is grounded on the theory that workers are motivated by rewards and discipline. A transactional leader generally does not look ahead in strategically guiding an organization to a position of market leadership; instead, these managers are solely concerned with making sure everything flows smoothly today (Ingram, 2012).

Several transactional theories have been tested extensively and some of them have received considerable empirical support. Path-goal theory investigations focus on exploring the relationships between the behaviors of the leadership and satisfaction of nurse in their workplace. House discovered the introductory support for the claim that situational variables may modify the directive leader behavior, in addition to the behavior of supportive leader, and effectiveness measures such as job satisfaction of the subordinates (House, 1971). Schriesheim and DeNisi (1981) stated that task variables characteristics such as assortment, feedback and social interaction modify the relationship between the behavior of directive leader and satisfaction. Also, according to Indvik (1986), in his meta-analysis of several studies, found support for the basic theory hypothesis, especially with respect to the behavior role of the directive leader, moderated by the task characteristics, on the satisfaction of the employees. This leadership style as mentioned before is highly effective in organizations that focus on day to day operations rather than does not look ahead in strategically guiding an organization to a position of market leadership (Ingram, 2012).


Transactional Leadership:

    • Leaders are aware of the link between the effort and reward.

    • Leadership is responsive and its basic orientation is dealing with present issues. 

    • Leaders rely on standard forms of inducement, reward, punishment and sanction to control followers.

    • Leaders motivate followers by setting goals and promising rewards for desired performance.
    Leadership depends on the leader’s power to reinforce subordinates for their successful completion of the bargain.

Transformational Leadership:

  • Leaders motivate followers to work for goals that go beyond self-interest.

  • Leaders arouse emotions in their followers which motivates them to act beyond the framework of what may be described as exchange relations.

  • Leadership is proactive and forms new expectations in followers. 

  • Leaders are distinguished by their capacity to inspire and provide individualized consideration, intellectual stimulation and idealized influence to their followers.

  • Leaders create learning opportunities for their followers and stimulate followers to solve problems.

  • Leaders possess good visioning, rhetorical and management skills, to develop strong emotional bonds with followers.


As a literature review has shown, there are several factors contributing to the nursing shortage. Job dissatisfaction plays an important role in nurse retention in today’s healthcare market. Today’s nurse executives, nurse managers and unit nursing leaders face the challenge of finding ways to shape changes in healthcare. By focusing on transformational leadership, the preferred leadership style of hospital administration has been shown to motivate nurses to perform beyond expectations. Nurses by their nature are visionary, passionate, committed people who have innovative ideas about how to transform healthcare. Nursing executives, nurse managers and both formal and informal nurse leaders with a transformational leadership style can tap this font of nursing knowledge to move nursing and patient care in a positive direction for the future. Whether the issues impacting the nursing shortages are resolved or improvements are made in the work environment will determine the future for the nurse workforce.

Nursing shortage is one the most important predicaments that we are facing in health care today. Nurses are always in the forefront at a hospital setting taking on the duties are a primary care giver for patients. Unfortunately nurses have to deal with the day to day hardships of working long hours, low staffing levels and have to deal with the day to day relationships with their patients and supervisors. Regardless of all the hardships mentioned earlier, I believe that nursing is a worthy profession as it takes a toll on the employee both physically and mentally. Maya Angelou once said, “As a Nurse you have an opportunity to heal the heart, mind soul and body of our patients, families, and ourselves.” This quote holds value because nurses are usually the primary caregivers to patients as mentioned earlier. The shortage of nursing makes it challenging for them to perform their duties to the best of the ability while delivering quality care to each patient. The purpose of this essay is to shed some light on the issues surrounding the nursing shortage and implement solutions so healthcare administrators and health care organizations as a whole can assist nurses in making a difference in the patient‘s lives.


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