Invest in nursing: the backbone of health care systems : JBI Evidence Synthesis

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Invest in nursing: the backbone of health care systems

Salmond, Susan Warner1,2; Macdonald, Marilyn3,4

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JBI Evidence Synthesis 19(4):p 741-744, April 2021. | DOI: 10.11124/JBIES-21-00089
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This issue of JBI Evidence Synthesis coincides with International Nurses Day—an opportunity to honor those at the forefront of patient care delivery, providing nursing across the care continuum and across the lifespan to people across the globe. This year and last, COVID-19 has brought to light the extraordinary nature of what nurses do—despite facing unique stressors related to the pandemic—in the provision of innovative, person-centered care with expertise, courage, compassion, and dedication.

The pandemic has exposed weaknesses in health care systems that nurses and nursing science have long been reporting. This issue of JBI Evidence Synthesis is organized around the theme of workforce/workplace issues critical to optimizing the contribution of the nursing profession to quality patient care. The well-being of nurses is integrally tied to the health systems in which they work and to the strength of the profession in advocating for conditions that promote quality care.

Staffing and its relation to patient and nurse outcomes

Complementing a strong body of research, mostly from the United States and European countries,1-8 the systematic review by Assaye et al.9 on the impact of nurse staffing on patient and nurse workforce outcomes in acute care settings specifically includes studies from low- and middle-income countries. Within this context, the findings reinforce the critical link between staffing and patient safety. The authors conclude that the higher the nurse workload, the higher the rates of in-hospital mortality, hospital-acquired infections, and medication errors. The importance of the science that has linked staffing with patient safety must be examined in relation to the number of unavoidable deaths. In the United States, the third-leading cause of death is medical errors,10 a rate much higher than in comparable countries that illustrates the importance of this area of study. The Lancet Global Health Commission's study on health care quality in low- and middle-income countries estimated 5 million deaths per year because of poor-quality health care.11

In addition to affecting patient outcomes, there is strong science that inadequate staffing also influences nurse outcomes. The review by Assaye and colleagues9 found that lower nurse-to-patient ratios and higher nurse workloads were linked to high levels of burnout, needlestick and sharps injuries, absenteeism, and intention to leave the job. This is similar to other studies that have linked staffing to burnout,5-8 job dissatisfaction,7,8 and intent to leave.8 These outcomes read like symptoms, and if so, what is the malady or maladies? Science points to the work environment. A supportive and empowering work environment improves nurse retention and job performance, and reduces burnout.

Addressing the nursing shortage with tailored recruitment and retention strategies

As nurses and midwives make up more than one-half the health care workforce worldwide, and the World Health Organization estimates a shortage of nearly 9 million nurses,12 it is critical that we examine workplace issues affecting the recruitment, retention, and engagement of nurses. There is no one-size-fits-all approach, and we must turn to the evidence to guide us in tailored approaches appropriate to the population and context. Two scoping review protocols in this issue aim to do this: “Retention strategies and barriers for millennial nurses”13 and “International nursing students’ and new graduates’ experiences of transition to the nursing workforce.”14 Both populations have unique strengths, interests, and needs. Millennial nurses have higher levels of burnout and exhaustion compared with other generations,13 and more than 50% leave the workforce within two years. Millennials comprise about one-third of the nursing workforce15; finding retention strategies that meet their needs will be an important strategy in addressing the shortage and ensuring adequate staffing. International nursing students who subsequently transition into the nursing workforce in the countries where they are trained also have unique needs. For all new graduates, this transition is “stressful and challenging and the new graduate often feels insecure about their competence and ability to step into working life.”16(p.418) For the international nursing student, the transition is potentially even more challenging due to language and communication issues, lack of strong personal supports, and, in some cases, discrimination and prejudice in the workforce. By addressing the unique needs of these groups and tailoring orientation and retention approaches, there is a greater chance of promoting job satisfaction and retention.16

Unleashing the potential of advanced practice nurses

Increasing primary care capacity globally is a bridge to greater access. Shifting population demographics, complex chronic care needs, prioritization of preventive care, and ongoing health care financial concerns have increased demands on primary care systems.17 Harnessing the potential of nursing the world to health requires unleashing the potential of advanced practice nurses (APNs).18 With global shortages of primary care providers and strong evidence19-21 showing that primary care delivered by nurse practitioners is of equal or better quality at a lower cost, expanding the advanced practice nursing role is key.

Seventy-eight countries have advanced practice nursing roles for nurses, some long-standing and some emerging. Understanding the scope of these roles and the competencies required will assist in ongoing role development and APN role utilization. Two protocols in this issue will advance this understanding. “Advanced practice nursing roles in Arab countries in the Eastern Mediterranean region”22 examines the APN role in 21 countries in this region and provides insight on how the roles have been developed and implemented, the role regulations and titles used, the educational requirements, and any outcomes related to APN roles in the region. “Competencies and scope of practice of nurse practitioners in primary health care”23 examines the scope of practice, work-related activities performed by nurse practitioners (NPs), areas of responsibility, and core competences. A clear understanding of NP skills and competencies can help practice managers and administrators understand which factors in the practice setting increase job satisfaction and decrease intent to leave, and enable them to devise ways to improve the practice environment.

The completed scoping review “Advanced practice nurse professional advancement programs”24 highlights that the lack of opportunity for professional advancement is a cause of APN job dissatisfaction, burnout, and turnover. The review describes career ladder or advancement programs specific to NP practice. Although these programs are limited in number, the advancement programs provided the opportunity to showcase APNs’ contributions, gain recognition, and participate in activities that fostered professional growth—all factors associated with greater job satisfaction and retention.

Informatics: a core competency of professional health practice

The workplace for registered nurses and APNs has experienced a rapidly expanding use of information and communication technologies. As a result, nursing roles are becoming increasingly reliant and intertwined with digital health tools, such as electronic records, mobile computing devices, point-of-care technologies, telehealth, and robotics.25 The rapid pace of change can leave health care staff feeling insecure and lacking the competencies to maximize the benefit of the technology. Professional competency is linked with empowerment and quality patient care. The scoping review “Approaches for defining and assessing nursing informatics competencies”25 concludes that nursing informatics is no longer viewed as a specialization restricted to nurse informaticians, but rather a core competency of professional health practice. Both general nursing informatics competencies and role-specific competencies (eg, for nurse leaders and NPs) are key to effective use of technology in digitally enabled environments.

Racism and health disparities

Another critical issue facing the nursing profession is the predictable differences in health outcomes among nations and among population groups within nations. These disparities are tied to socially and economically disadvantaged populations, and over the past several years, there has been increasing awareness of the role of social determinants in predicting health outcomes. A component of attending to these inequities is the dismantling of social systems that produce injustice, such as racism.26 The protocol “African Canadian nurses in the nursing profession in Canada”27 highlights the long-standing structural racism that was and continues to exist. Structural racism has been and continues to be a cause of persistent health disparities in the United States as well as in Canada. The epidemiology of the COVID-19 pandemic and the police killings of people of color are ongoing reminders that structural racism persists. Nurses, guided by the Code of Ethics, need to be at the forefront of advocacy and unite to fight against systemic racism and bias. Ensuring diversity in the nursing workforce is a key strategy to achieving these goals. In the words of Dr Beverly Malone, president and CEO of the National League for Nursing in the United States, “without diversity, there is no excellence.”28(p.226)

Expert commentaries on these issues

Accompanying the articles in this issue are written and video commentaries by global experts addressing the professional issues of safe staffing; workplace environments that promote recruitment, retention, and engagement of nurses at all levels; advancing informatics competencies in the rapidly changing digital environment; advanced practice nursing—a contributor to global health; racism in nursing; and a look at the 2021 International Council of Nurses’ theme for International Nurses Day on May 12, 2021: “Nurses: a voice to lead—a vision for future health care.”

We invite you to examine this issue of JBI Evidence Synthesis and the commentaries that accompany it to inspire you to advocate for an investment in nursing, the backbone of health care systems globally.


1. Aiken LH, Sloane DM, Bruyneel L, Van den Heede K, Griffiths P, Busse R, et al. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet 2014; 383:1824–1830.
2. Aiken LH, Sermeus W, Van den Heede K, Sloane DM, Busse R, McKee M, et al. Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ 2012; 344:e1717.
3. Lasater KB, Sloane DM, McHugh MD, Cimiotti JP, Riman KA, Martin B, et al. Evaluation of hospital nurse-to-patient staffing ratios and sepsis bundles on patient outcomes. Am J Infect Control 2020; S0196-6553(20)31038-5. Online ahead of print.
4. Kruk ME, Gage AD, Joseph NT, Danaei G, García-Saisó S, Salomon JA. Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries. Lancet 2018; 392:2203–2212.
5. Kutney-Lee A, Germack H, Hatfield L, Kelly MS, Maguire MP, Dierkes A, et al. Nurse engagement in shared governance and patient and nurse outcomes. J Nurs Adm 2016; 46:605.
6. Cimiotti JP, Aiken LH, Sloane DM, Wu ES. Nurse staffing, burnout, and health care–associated infection. Am J Infect Control 2012; 40:486–490.
7. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA 2002; 288:1987–1993.
8. Shin S, Park JH, Bae SH. Nurse staffing and nurse outcomes: a systematic review and meta-analysis. Nurs Outlook 2018; 66:273–282.
9. Assaye AM, Wiechula R, Schultz TJ, Feo R. Impact of nurse staffing on patient and nurse workforce outcomes in acute care settings in low- and middle-income countries: a systematic review. JBI Evid Synth 2021; 19 (4):751–793.
10. Makary MA, Daniel M. Medical error—the third leading cause of death in the US. BMJ 2016; 353:i2139.
11. Kruk ME, Gage AD, Arsenault C, Jordan K, Leslie HH, Roder-DeWan S, et al. High-quality health systems in the Sustainable Development Goals era: time for a revolution. Lancet Glob Health 2018; 6:e1196–e1252.
12. World Health Organization. State of the world's nursing report—2020 [internet]. [cited 2021 Mar 09]. Available from:
13. McClain AR, Arnold A, Palokas M, Christian R. Retention strategies and barriers for millennial nurses: a scoping review protocol. JBI Evid Synth 2021; 19 (4):867–873.
14. McKitterick DJ, Peters MDJ, Corsini N, Chiarella M, Eckert M. International nursing students’ and new graduates’ experiences of transition to the nursing workforce: a scoping review protocol. JBI Evid Synth 2021; 19 (4):874–882.
15. O’Hara M, Burke D, Ditomassi M, Palan Lopez R. Assessment of millennial nurses’ job satisfaction and professional practice environment. J Nurs Adm 2019; 49:411–417.
16. Keepnews DM, Brewer CS, Kovner CT, Shin JH. Generational differences among newly licensed registered nurses. Nurs Outlook 2010; 58:155–163.
17. Salmond SW, Echevarria M. Health care transformation and changing roles for nursing. Orthop Nurs 2017; 36:12–25.
18. International Council of Nurses. Nurses: a voice to lead nursing the world to health [internet]. 2020 [cited 2021 Mar 09]. Available from:
19. MacDonald JA, Herbert R, Thibeault C. Advanced practice nursing: unification through a common identity. J Prof Nurs 2006; 22:172–179.
20. Newhouse RP, Stanik-Hutt J, White KM, Johantgen M, Bass EB, Zangaro G, et al. Advanced practice nurse outcomes 1990–2008: a systematic review. Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [internet]. 2011 [cited 2021 Mar 09]. Available from:
21. Swan M, Ferguson S, Chang A, Larson E, Smaldone A. Quality of primary care by advanced practice nurses: a systematic review. Int J Qual Health care 2015; 27:396–404.
22. Almukhaini S, Martin-Misener R, Weeks LE, Macdonald M, Hussain H, Macdonald D, et al. Advanced practice nursing roles in Arab countries in the Eastern Mediterranean region: a scoping review protocol. JBI Evid Synth 2021; 19 (4):891–898.
23. Schlunegger MC, Aeschilimann S, Palm R, Zumstein-Shaha M. Competencies and scope of practice of nurse practitioners in primary health care: a scoping review protocol. JBI Evid Synth 2021; 19 (4):899–905.
24. Hankins A, Palokas M, Christian R. Advanced practice nurse professional advancement programs: a scoping review. JBI Evid Synth 2021; 19 (4):842–866.
25. Kleib M, Chauvette A, Furlong K, Nagle L, Slater L, McCloskey R. Approaches for defining and assessing nursing informatics competencies: a scoping review. JBI Evid Synth 2021; 19 (4):794–841.
26. Thomas SB, Quinn SC, Butler J, Fryer CS, Garza MA. Toward a fourth generation of disparities research to achieve health equity. Annu Rev Public Health 2011; 32:399–416.
27. Jefferies K, Martin-Misener R, Murphy GT, Helwig M, Bernard WT, Gahagan J. African Canadian nurses in the nursing profession in Canada: a scoping review protocol. JBI Evid Synth 2021; 19 (4):883–890.
28. Malone B. Without diversity, there is no excellence. Nurs Sci Q 2020; 33:226–228.
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