HealthManagement, Volume 11, Issue 1 / 2009

Falling Numbers of Health Workers: Facing the Crisis

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In many European countries, health service managers are facing increasing problems of staff attraction and retention. Especially in the nursing health workforce, turnover rates are high, vacancies remain open and the resulting staff deficits lead to increased workload, burnout and reduce staff commitment.


During the last decade, several European countries took policy measures to increase the inflow in the paramedical professions and the retention of existing cadres, including the creation of new cadres of health workers, the recruitment of nurses from other countries, better remuneration schemes, and the introduction of more flexible working conditions. Far less has been written on how health service managers can develop practices to attract and retain health workers that go beyond offering better financial incentive packages or recruiting health workers from the South.


Several interesting alternatives to deal with staff shortages have been developed elsewhere. First, when major shortages of nurses occurred at hospital level all over the US during the 1980s, some hospitals were found to attract and retain professional nurses [1]. Second, high commitment management is a promising stream in the human resource management literature.


This paper describes the key principles of magnet hospitals and draws lessons from high commitment management that could be useful in the current hospital staff crisis. In essence, we’ll argue that investment in relations and in effective support to health workers may pay off sooner than later.

Principles of Magnet Hospitals

During the 1980s crisis, magnet hospitals stood out in the US hospital landscape because they had a low staff turnover and low vacancy rates despite their location in areas with high competition for staff.


Nurses working within them considered magnet hospitals as good places to practise nursing according to their professional norms. Magnet hospitals were found to share leadership, professional and organisational attributes.

In other words, top management created space and opportunities for mid-level (nursing) managers to develop responsive management practices that were appreciated by nurses.


Table 1 summarises these attributes


Underlying Mechanisms of the Magnet Hospital Approach

The key principles underlying magnet hospital management include:

(1) facilitating professional autonomy for nurses,

(2) participation in decision-making, and

(3) systematic communication [2].


Through such management practices, the professional nursing practice is explicitly or implicitly valued and respected, and nurses are being empowered. Magnet hospital management can, indeed, be considered as empowering nurses [3]. Managers give the nursing staff the means, information and support to optimally carry out their professional duties. Further studies linked empowerment to increased trust in management and to commitment to the organisation and its mission of care [4].

Lessons From High Commitment Management

Management practices that are leading to high commitment of employees have been receiving quite some attention in HRM literature for a few years. Such practices have been shown to lead to better organisational performance, reduced stress and higher productivity [5].


In essence, high commitment management consists of applying complementary bundles of HRM practices. Pfeffer identified 7 key elements:


Selective hiring,

Employment security,

Comparatively high compensation contingent on organisational performance,

Instituting training and development,

Self-managed teams and decentralisation,

Reduction of status differences, and

Information sharing [6].


The main message from the current literature, however, seems to be that the exact composition of the bundles is less important than its internal coherence and external fit. Effective bundles include practices that are congruent (i.e. not cancelling out each other) and fitting well with the tasks the organisation is carrying out.


In American magnet hospitals, the hospital management teams were able to find such bundles. Involving staff nurses on hospitalwide crosscutting task forces and committees, delegation of responsibilities and providing opportunities for further professional development are all strategies that create responsibility and challenge. These in turn increase feelings of respect and recognition among nurses, which contributes to their positive commitment towards the hospital and its mission. This ultimately contributed to increased attraction and retention in such hospitals.


The principles underlying magnet hospital management can be assumed to be important for any professional nurse, and as such, this approach seems promising. In practice, however, management approaches that focus on human relationships on the work floor can be expensive in terms of time and management capacity. Support to mid-level nursing managers is of key importance, and they should be given the opportunity to invest heavily in open communication, meetings and on-the-floor presence.


Second, the issue of staff commitment needs to be better understood. What would staff expect from management in return for their commitment to the organisation? Salary buys indeed time of employees, but other practices ensure their motivation and commitment. Hospital managers will need to find out what their nurses appreciate most and consequently adapt their management practices. Facing shortages and limited possibilities to further increase remuneration, managers need to tap other sources of motivation and commitment. Both magnet hospitals and the high commitment management literature offer interesting options.


Bruno Marchal, MD, MPH, Research

Fellow, Department of Public Health,

Institute of Tropical Medicine,

Antwerp, Belgium

Email: [email protected]

For references please contact:

[email protected]

What is Magnet Status?

Magnet status is an award given by the American Nurses’ Credentialing Center (ANCC), an affiliate of the American Nurses Association, to hospitals that satisfy a set of criteria designed to measure the strength and quality of their nursing. A Magnet hospital is stated to be one where nursing delivers excellent patient outcomes, where nurses have a high level of job satisfaction, and where there is a low staff nurse turnover rate and appropriate grievance resolution. Magnet status is also said to indicate nursing involvement in data collection and decision-making in patient care delivery.


The original Magnet™ research study from 1983 first identified 14 characteristics that differentiated organisations that were best able to recruit and retain nurses during the nursing shortages of the 1970s and 1980s. These characteristics became the ANCC Forces of Magnetism that provide the conceptual framework for the Magnet appraisal process.


The 14 Forces of Magnetism are Quality of Nursing Leadership, Organisational Structure, Management Style, Personnel Policies and Programmes, Quality of Care, Quality Improvement, Consultation and Resources, Autonomy, Community and the Healthcare Organisation, Nurses as Teachers, Image of Nursing, Interdisciplinary Relationships and Professional Development.


The idea is that Magnet nursing leaders value staff nurses, involve them in shaping researchbased nursing practice, and encourage and reward them for advancing in nursing practice. Magnet hospitals are supposed to have open communication between nurses and other members of the healthcare team, and an ap - propriate personnel mix to attain the best patient outcomes and staff work environment.

In many European countries, health service managers are facing increasing problems of staff attraction and retention. Especially in the nursing health wor

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