Nursing Profession

Nursing profession is defined as the degree to which care needs are met within health services. A nurse’s most important responsibility is to provide patient care that is personal, technical, scientific, and tailored to the individual’s needs. A professional nurse is an autonomous practitioner who identifies the needs of the individual receiving care in light of new research findings, develops a care plan accordingly, and assumes responsibility for the care they provide. In addition to this autonomy, nurses constitute the backbone and the largest group of the health workforce. There is substantial evidence across countries worldwide that inadequate nurse staffing not only reduces the quality of patient care but also contributes to widespread nursing shortages. It is projected that this situation will worsen in the future and that the existing shortage could increase by 20% by 2023. Therefore, accurately determining and employing the nursing workforce remains a current and important issue.

Studies investigating the relationship between the number of nurses and quality of care have demonstrated the impact of nurse staffing on patient safety as well as morbidity and mortality rates (ICN, 2006). A report prepared by the Canadian Nurses Association Federation stated that there is strong empirical evidence linking inadequate nurse staffing to a range of adverse patient outcomes such as pressure ulcers, surgical wound infections, medication errors, falls, failure to rescue, and hospital readmissions (ICN, 2006). Another study found that a decrease in nurse staffing also leads to decreased patient satisfaction. Other studies on the subject have identified a positive relationship between nurse dissatisfaction and insufficient nurse numbers. In addition, it has been reported that shortages in the nursing workforce lead to nurses being unable to update their knowledge, lack of motivation, intense stress, fatigue, and burnout.

Another factor reported in the literature as reducing hospital efficiency is the unbalanced distribution and improper utilization of the nursing workforce. Studies have found that nurses spend more time on indirect care activities—such as obtaining medications and supplies, answering phones, writing recommended prescriptions, and monitoring unit entries and exits—than on direct patient care, and that they spend at least half of their working time on indirect care practices. This affects both the quality of patient care and nurses’ physical and psychological health. Due to unacceptable working conditions, nurses retire early or turn to other professions. On the other hand, in a study by Lankshear, Sheldon, and Maynard (2005), which evaluated findings from 22 studies, it was determined that adequate nurse staffing and well-planned task distribution improve patient outcomes. Care provided by professional nurses has been reported to reduce mortality rates and decrease other adverse events such as urinary infections, upper gastrointestinal bleeding, hospital-acquired pneumonia, shock, and cardiac arrest.

There is an inverse relationship between the number of nurses in hospitals and patients’ length of stay. When the number of nurses in clinics is sufficient, patients’ hospital stays become shorter (Oulton, 2006). Moreover, when nurse staffing levels are adequate for the required level of patient care, a decrease in malpractice rates is also observed (ICN, 2006). Another contribution of employing an appropriate number of nurses in clinics is that nurses can fulfill their professional duties and provide holistic care services, thereby contributing to hospitals in multiple ways (economic, social, etc.) (Cheraghi et al., 2008; Rafii et al., 2008; Hurst, 2009). In the “Healthy Workplaces Save Lives” report published by the International Council of Nurses in 2006, it was emphasized that among the policies developed to close the nursing shortage, effective determination of staff distribution and division of labor is important (ICN, 2006; Cronin et al., 2007). Worldwide, an average of 290 midwives/nurses fall per 100,000 population. According to World Health Organization 2013 data, this figure is 842 in Europe, 724 in upper-income countries, 689 in European Union member countries, 354 in upper-middle-income countries, and 197 in our country. According to December 2013 data, 149,012 nurses are actively working in our country. Based on these data, our country ranks last among all countries in the WHO European region. For Turkey to reach EU standards, it needs 250,000 new nurses, and to reach upper-income country standards, it needs 360,000 new nurses (OECD, 2012; OECD, 2014; Ministry of Health, 2014). In recent years, due to health transformation policies that prioritize curative health services, 83.7% of nurses in our country are employed in hospitals (Health Statistics Yearbook, 2012). In developing countries, a large proportion of health expenditures—around 60–70%—is spent on hospitals (Bahadori et al., 2011). The cost of nursing workforce in hospitals is estimated to be around 55–60% (Bahadori et al., 2012). According to Ministry of Health 2012 data, while the per capita application rate to inpatient treatment institutions (Ministry of Health, university, private) is 4.7, hospital occupancy rates vary between 52% and 77% (Health Statistics Yearbook, 2012). Considering the high cost of curative services provided by hospitals, these data indicate the need to make human resource utilization more efficient. This review aims to draw managers’ attention to the importance of appropriate employment of nurses working in inpatient treatment institutions and to nursing workforce planning methods.

Nursing encompasses care aimed at protecting and improving the health and well-being of individuals of all ages, families, groups, and communities in all settings, and restoring health in cases of illness.

In our country, nurses constitute the largest majority within the healthcare delivery team, with approximately 170,000 individuals. To practice the nursing profession, nurses are trained in 132 Nursing Faculties/Departments with 934 academic staff, and 66,944 nursing students are currently studying in these schools. In addition, nearly 100,000 colleagues are waiting for appointment in order to practice the profession they were trained for. Nursing is a profession regulated by the Nursing Law and the Nursing Regulation issued accordingly, and the definition of the profession as well as the duties, authorities, and responsibilities of its members are secured by this legislation. While approximately 100,000 nurses are waiting for appointment, there are initiatives and demands for other healthcare workers who do not hold nursing diplomas (Operating Room Technicians, Dialysis Technicians, Emergency Medical Technicians, etc.) to practice nursing, claiming that there is a nursing shortage and citing employment problems in these occupational groups. If these initiatives and demands are accepted and individuals without nursing education are given the opportunity to practice this profession, it will negatively affect the provision of qualified healthcare services and may cause irreparable harm in terms of the nursing profession and individual and public health. Indeed, in some past examples, it has been experienced that employing unauthorized individuals as nurses led to serious consequences such as confusion in healthcare delivery, preventing the public from receiving qualified care that should be provided by nurses, and putting patient safety at risk.

When the education and duties of other healthcare workers who are enabled to be employed instead of nurses are examined in different countries, it is seen that these workers receive training for varying durations of 1–2 years after high school; they perform their duties in cooperation with nurses and physicians; and their duties, authorities, responsibilities, and clearly defined boundaries of practice are determined by legal regulations (for example, emergency medical technicians working in air and ground ambulances). In short, it is observed that they do not perform the duties of nurses or other healthcare workers, but rather their own roles.

Nursing education has been clearly defined in legislation prepared by taking into account the views of the World Health Organization and the International Council of Nurses and based on the European Union Sectoral Directive No. 2005/36 related to nursing. Nurses who complete this four-year undergraduate education receive basic medical sciences and professional courses and provide preventive, curative, and rehabilitative care services with a holistic perspective in every setting, from the fetus in the womb to the elderly individual, and from acute problems to chronic diseases.

Specialty nursing (dialysis, emergency, operating room, intensive care, home care nursing, etc.) consists of specialized fields documented with certificates earned after additional training on top of basic undergraduate education, both in our country and worldwide. During their education, many healthcare workers learn some basic concepts related to the care of patients. However, this does not mean that health technicians are competent to perform the duties of nurses or specialty nurses. Assigning healthcare workers to areas that fall within the scope of other health professions and in which they are not competent will put public health at risk.

Moreover, meeting the demands of these healthcare professionals to work in specialized areas such as intensive care units, emergency departments, and schools—despite these not being their fields of practice—will lead to care duties being assigned to non-nursing healthcare workers and will prevent our colleagues who face employment problems from practicing their own profession.

All of these will both prevent citizens from receiving quality and safe healthcare services and cause employment problems and violations of rights for nurses waiting for appointment and nursing candidates who will graduate. In conclusion:

1. As in the rest of the world and as it should be, the nursing profession must be practiced by nurses.

2. Other healthcare workers must not encroach upon the duties, authorities, and responsibilities of nurses.

3. In the employment of a healthcare occupational group, internationally accepted real job descriptions of the profession should be taken as reference, not the number of graduates.

In 2020, the number of nurses per 100,000 people was 342; however, in OECD countries, the number of nurses and midwives per 100,000 people is 938. With the pandemic, nurses have been providing services with long working hours by working continuously for 12 or 24 hours, without being adequately rested. To prevent working more than 8 hours, sufficient numbers of nurses should be employed; necessary meals should be arranged to ensure healthy nutrition; and measures should be taken to allow rest. Noting that burnout and stress during the pandemic have led millions of nurses to consider leaving the profession, the International Council of Nurses has called for better pay to encourage existing staff to remain.

The demands frequently voiced by nurses across all platforms include:

To provide qualified services in the healthcare sector, it is extremely important to employ a sufficient number of nurses with adequate qualifications. As soon as possible, a sufficient number of permanent and secure nursing positions should be provided.

Opening large numbers of nursing schools without any planning should be stopped, and nursing education should be improved. While thousands of nurses are waiting for appointment, our country still ranks near the bottom among OECD countries in terms of nurse numbers.

It is known that heavy workload and long working hours increase burnout. Nurses’ harsh and poor working conditions should be improved.

Insufficient rest areas should be properly arranged.

24/7 childcare facilities should be expanded.

Transportation services should be provided on a 24-hour basis.

All additional payments should be reflected in retirement benefits.

Wages and retirement conditions that are above the poverty line and worthy of human dignity should be ensured.

Nurses are among the occupational groups most exposed to violence in healthcare. Safe working conditions should be ensured for nurses. Regulations that will put an end to violence against healthcare workers should be implemented.

Specialist Nurse Ebru Şahin