Nursing Staff Shortages in the Health Care System

Jessenia Castro

West Coast University

Capstone 401

Professors Thomas

October 9, 2022

Abstract

The shortage of nurses is a global health issue that negatively affects healthcare delivery, and the problem is expected to worsen with the increasing demand for healthcare providers caused by the aging population. To goal of this paper is threefold. Firstly, the paper seeks to uncover the causes of nurse shortages. Secondly, the paper aims to uncover the adverse effects of nurse shortages. Lastly, the paper aims to uncover practical solutions for minimizing nurse shortages in healthcare facilities. The most common causes of nurse shortages include low income, poor funding for nursing education, low expenditures on healthcare, nurse burnout, low levels of income, reduced supply of nurses, poor recruitment plans, ineffective planning, improper use of the available nursing resources, and lack of cultural competence and cultural diversity. Effects of nurse shortages include sleep deprivation, which negatively affects nurses central nervous and cardiovascular systems. Nurse shortages also cause in-hospital deaths, HAIs, medication errors, increased medical costs, reduced job satisfaction, burnout, and moral distress. Possible solutions to minimize nurse shortages include improving nurses’ job satisfaction, increasing healthcare expenditure, increasing funds for nursing education to make it affordable for students to pursue a career in this field, and establishing laws that promote retention of nurses. Minimizing nurse shortages will help improve the patient outcome and quality of life.

Nursing Staff Shortages in the Health Care System

Introduction

Nursing is an integral part of the healthcare system and accounts for about 56% of any hospital’s staff (Shamsi & Peyravi, 2020). Nurses are renowned for being proponents of healthcare promotion, training patients and the society about how to avoid diseases and injuries, taking part in rehabilitation, and offering assistance and care. Despite the important roles played by nurses, healthcare facilities today face an increasing challenge of nurse shortage. Supporting this statement, Shamsi and Peyravi (2020) claim that nursing staff shortage is a significant and multifaceted problem and has reached a warning threshold. It is also expected that the issue of nurse shortage will continue to worsen due to increasing demand for healthcare providers caused by the aging population (Stokes & Iskander, 2021). It is approximated that by 2029, there will likely be 73% more Americans over the age of 65, which will increase the demand for healthcare practitioners to provide medical services. This paper provides a comprehensive understanding of the issue of nursing staff shortages in health care system. Specifically, it also illustrates the causes of nurse shortages, the effects of nurse shortages, and the possible solutions to this problem. The purpose of pursuing this topic is to reduce the negative effects of nursing shortages in the health care system. This goal is realistic when the government works together with the health facilities to achieve it.

To help with research and understand the causes, effects, and possible solutions of the issue of nurse shortages, various research questions from different perspectives of inquiry have been used. The different perspectives of inquiry include scientific, analytical, ethical, and cultural perspectives of inquiry. For each perspective of inquiry, one Level 1 and one Level 2 questions were selected. For the scientific perspective of inquiry, the chosen level 1 research question is “Which body systems are affected?” while the formulated level 2 research question is “What are the effects of nursing staff shortages on the patient outcome?” On the other hand, the level 1 research question from the analytical perspective is “What are the economic issues involved?” while the level 2 research question under this type of inquiry is “what are the causes of nursing staff shortages, and how can this problem be solved?”. Furthermore, the chosen Level 1 question from the ethical perspective of inquiry is “What laws pertain to the issue?” while the formulated level 2 question from this perspective is “What are the ethical implications of nursing staff shortages?”. The chosen level 1 question from the cultural perspective of inquiry is “Which cultural values influence the issue?” and the corresponding level 2 question is “How does cultural diversity affect nurse shortage?” The answers to these questions have been combined to develop the paper.

Causes of Nurse Shortages

In order to define practical solutions to a problem, it is important to first understand the cause of the problem. Therefore, it is important to explore the factors which contribute to the nursing staff shortage. Nursing shortages are caused by a number of reasons. One of them is the fact that the nurses are growing old and need to retire (Mac et al., 2019). They however lack people to replace them and some of them are forced to continue working even during old age. This mostly brings about inefficient work. Another cause of nurse shortage is nurse burnout. This is mainly caused by the availability of few nurses who are forced to work overtime (Manyisa & Aswegen, 2017). Other causes of nurse burnout include low shifts, high workloads, and low staffing (Dall’Ora et al., 2020). When nurses experience burnout, fewer nurses are left to attend to patients; thus, a healthcare facility may experience a nursing staff shortage. Additionally, since most of the nurses are females, they are forced to leave the profession to go and bear children and take care of their families. In some American states, the number of nurses is high compared to others. This results to shortages in states that have few nurses. This is also due to the fact that nurses will prefer to work in regions that are good for settling with their families (Haddad et al., 2022). Some nurses complain of emotional and physical abuse caused by the stressful hospital environment.

Another cause of nurse shortages is lower income levels. Drennan and Ross (2019) reveal that low-income countries experience nurse shortages since nurses move to low-income countries to seek employment. On the same note, Fawaz et al. (2018) reveal that relatively low pay contributes significantly to the nurses’ deficit. Based on the classic economic theory, income level is a major factor in pushing or attracting people from one job to another as well as from one market to the other (Drennan & Ross, 2019). Also, the lack of funding to support nursing education contributes to the nurse shortage. Supporting this point, Drennan and Ross (2019) argue that the nursing staff shortage is high due to the poor funding for nursing education. Lastly, underfunding of the healthcare system contributes to nurse shortages. Marć et al. (2019) claim that low healthcare expenditures translate into nurses’ low salaries. Consequently, this results in nurses quitting their job and hence the problem of nurse shortage. In relation to the economic effects of nursing staff shortages, Haddad et al. (2022) reveal that nurse shortages lead to medical errors. These medical errors may lead to patients’ prolonged stay in the hospital, which increases the cost incurred in the hospital.

Furthermore, lack of cultural competence also causes nurse shortages. Notably, cultural competence is recognized as one of the cultural values that influence the issue of nurse shortages. Cultural competence is the set of values, practices, behaviors, and attitudes within an organization system or even individuals, which allows them to work effectively across different cultures. Cultural competence influences nurse shortages because when nurses are not culturally competent, they tend to get stressed, which results in nursing burnout. Another cultural value that influences nurse shortages is cultural diversity. Cultural diversity is the existence of many cultures in the same society. Nurses must be well prepared to serve culturally diverse patients. Unless nurses are culturally competent, they cannot be in a position to provide quality care to patients. When nurses cannot provide quality care, they get stressed and end up quitting their jobs. The last cultural value that influences nurse shortage is cultural awareness. Nurses’ cultural awareness is their comprehension of differences between themselves and patients from other cultural backgrounds. Similar to cultural competence, a lack of cultural awareness may result in nurse shortages.

Lastly, cultural diversity causes nurse shortage. Research reveals that nurses without a firm understanding of cultural differences may experience frustrations and stress when dealing with culturally diverse patients (Balante et al., 2021). Consequently, this may result in nurse burnout. Burnout is one of the leading causes of nurse shortages. Thus, it can be concluded that nurses’ lack of cultural competence indirectly results in nurse shortages. On the contrary, cultural competence allows nurses to provide inclusive healthcare service, improves nurses’ job satisfaction, and facilitates patient satisfaction. When nurses are satisfied with their job, they tend to retain their profession. Consequently, this minimizes nurse shortages.

Impacts of Nurse Shortages

Nurse shortages cause a huge negative impact on the health care systems today. One of these impacts include, increase in patient deaths. This is because patients will be sent home to be taken care of by care givers rather than nursing professionals. Another impact is the increase of medication errors (Haddad et al., 2022). Studies have shown that 46.8% of nurses have committed errors in the last one year. These errors include giving medication to wrong patient, omission of medication, mistaken medication and giving a patient medication twice instead of once. Lastly, nursing shortages increase overcrowding in emergency rooms. This is because the nurse-to-patient ratio is uneven. By solving the nurse shortage problems, these negative impacts will be reduced.

Furthermore, the shortage of nurses indirectly affects the nurses’ body system, where it causes sleep deprivation. Nurse shortages force nurses to work overtime. The long working hours put nurses at an increased risk of short sleep duration, sleep disturbances, and fatigue. Sleep deprivation and fatigue affect the nurse’s central nervous system making their brain not to function correctly. Also, research reveals that lack of sleep among nurses may lead to psychological issues such as memory loss, serious thought retardation, stress, anxiety, and depressive symptoms (Deng et al., 2020). Sleep deprivation due to long working hours also affects nurses’ cardiovascular system. This is because sleep affects processes that affect blood pressure and body sugar levels. Research reveals that sleep deprivation causes severe cardiovascular diseases such as heart attack and stroke (Ahmad & Didia, (2020). On the same note, Liew and Aung (2021) reveal that sleep deprivation causes high blood pressure, a leading risk factor for stroke. It also makes it easier for blockages to occur in arteries causing strokes.

Also, nurse shortage is shown to affect patient outcome. Ghafoor et al. (2021) reveal that the shortage of nurses adversely affects patient care leading to health decline in the nation at large. On the same note, Haegdorens et al. (2019) reveal that lack of sufficient nurse staffing in healthcare facilities is associated with negative events such as hospital-acquired infections (HAIs), patient falls, in-hospital mortality, and medication errors. Also, nurse shortages result in rationing time to care, increasing the risk of missed care. This translates to poor patient care delivery. According to Janatolmakan and Khatony (2022), missed nursing care results in patient dissatisfaction, psychological and physical complications, and even death. Missed care may also result in delayed treatment and medication.

Nurse shortage leads to the medical errors in the process of service delivery and the data entries. The medical errors are caused by the overworking conditions of the working nurses that may make them exhausted to deliver the approved quality services (Haddad et al., 2022). Hospitals with high patient to nurse ratio are characterized by the nurse experiencing of the burnout, dissatisfaction. As such the dissatisfaction creates a mechanism where the nurse may unknowingly error in medical service delivery. The error in service delivery henceforth causes the higher mortality of the patients and failure to rescue the ailing patients

Furthermore, persistent nurse shortages across the world challenge the values and beliefs of this profession and result in various ethical implications. One of these ethical implications is poor patient care. One of the ethical obligations that nurses must fulfill during their line of duty is ensuring that patients are protected from harm (Haahr et al., 2020). However, nurse shortages make it challenging for the nurses to fulfill this obligation as the hospitals assign them to cater for many patients. Since chronically ill patients require holistic care, inadequate staffing denies nurses an opportunity to provide such care to these patients, resulting in poor patient care. Another ethical implication of nursing staff shortages is nurses’ reduced job satisfaction. Usually, ethics assist nurses in making the right decisions guided by their morals. However, nurse shortages leave nurses dissatisfied with their jobs because they do not have sufficient time to communicate with their patients and provide holistic care. Moral distress is another ethical implication of nursing staff shortages. Nurses who serve in healthcare facilities with shortage of nursing staff experience moral distress since they feel that they are compromising their ethical obligation of ensuring patients are protected from harm by providing inadequate patient care (Bayat et al., 2019). Also, nurses who work in health care facilities facing the issue of nurse shortage may suffer moral distress because they feel that they would have rendered better patient care if they were not assigned many patients. Lastly, burnout is another ethical implication of nurse shortages. According to Mullen et al. (2017), increased ethical conflict at work may result in emotional stress and mental burnout. Consequently, this may result to nurses quitting their profession, leading to nurse shortage.

Possible Solutions to Nurse Shortages

The best-known solution is increase in nurse salaries and incentives. This will make more people consider the nursing field. It will also make them feel motivated especially for the nurses who work in the unfriendly areas (Haddad et al., 2022). The male gender is also highly encouraged to join the nursing field so as to enable women to have maternity leaves and go take care of their families when need be. Male patients feel more understood when they are taken care of by male nurses. Health care institutions should also provide training and counseling to their staff. These will enable nurses to speak about the issues they face at work, prompting the management to find the solutions to the issues hence decrease in nurse turnover (Manyisa & Aswegen, 2017). In the event of pandemics or flu, the management of health institutions should hire temporary nurses to help the permanent ones. This will reduce chances of nurses getting burnout. Another solution is having policies that make health centers carry out effective nurse staffing which will increase job satisfaction and nurse retention rates therefore reducing nurse turnover (Holmberg et al., 2018). Nursing programs can also help reduce nurse shortages by increasing wages for nursing educators and therefore motivating them. The nurse students can also receive scholarships which will encourage them to start and finish the nursing courses without financial problems (Marc et al., 2019). Having nursing online classes will motivate more people to take up the nursing career since they do not have to travel to access institutions of higher learning.

Additionally, concerning how nurse shortages can be minimized, research reveals that policy attention is needed in all elements of human healthcare resources and to avoid policy-making that relies overly on oversimplified linear thinking (Drennan & Ross, 2019). For instance, policymakers should not only focus on increasing the number of individuals who enter nursing training but should also make policies that seek to increase the numbers entering the workplace and increase burses retention. Also, improving nurses’ job satisfaction can help reduce nursing staff shortages. This can be achieved through improving role transitions and orientations. According to Lockhart (2020), transition programs for new graduates improve job satisfaction and increase nurse retention. Other ways of improving nurses’ job satisfaction identified by Lockhart (2020) include nursing mentorship programs and improving the workplace environment. Increasing the salaries of nurses may also improve their job satisfaction.

Also, nurse shortages can be minimized by implementing rules and regulations. Since different countries have different laws that pertain to this healthcare issue, the focus of this paper will be on the US laws that pertain to the issue of nursing staff shortages. One of these laws is the Nurse Reinvestment Act, P.L. 107-205. The 107th Congress passed the Nurse Reinvestment Act on July 22, 2002. Congress had been significantly engaged since the 1960s with the goal of providing the US with sufficient nurse manpower. The Act was later signed into law by President George W. Bush on August 1, 2002. The Nurse Reinvestment Act pertains to the issue of nursing staff shortages because Title I and Title II pertain to nurses’ recruitment and retention, respectively. Title 1 of the Act provides two ways of boosting nurses’ recruitment. The first initiative is the development and broadcasting of grant-based funding of local and state public service announcements to promote and advertise the nursing profession. During broadcasting, the rewards ad advantages of the nursing profession should be highlighted, and people are persuaded to enter into this profession. The second initiative entails the revision of provisions of the National Nurse Service Corps (NNSC) related to items such as scholarships, loan repayment, funding, and reporting and eligibility requirements. Boosting nurses’ recruitment helps in addressing the main health care issue selected, which is nurse shortages. Title II of the Nurse Reinvestment Act presents policies intended to improve the retention of nurses. The provisions of Title II relate to areas such as creating career ladders and retaining high-quality nurses through retention grants and nurse education, developing and funding comprehensive geriatric education, and creating and running a nurse faculty loan program to improve the number of qualified nursing faculty. Title II of the Act helps address the issue of nurse shortages by ensuring nurses do not quit their profession. Another law that pertains to the issue of nursing staff shortage in the US is the Nurse Training and Retention Act of 2007, S.2064. The 110th Congress passed this Act on September 18, 2007. This Act aims to ensure comprehensive programs are funded to facilitate a sufficient supply of nurses. Increasing the supply of nurses helps deal with the selected healthcare issue, nursing staff shortage.

Investing in the long term-training of the nurses to enhance the professional development has enabled the healthcare organization to mitigate the detriment of the nurse staff shortages. Medical institutions should create a lifelong learning for nurses through the promotion to innovative and management positions (Challinor et al., 2020). The conditions for the promotions get based on knowledge provision and skills through distance learning, on-site classes, and the self-tutorials by the employers. Notably, avoiding the expensive and immediate training can get achieved by the organizations through the adoption of the fun training for the senior nurses.

Another approach of reducing the nurse shortage by the healthcare organization is the conversion of the current nurses into compensate for the referrals and the recruiters. The conversion will enable the nurses to communicate in one language hence creating a framework of delivering the quality services through limiting the time w3astyage in service delivery. The act of cp0nvertiong the nurses to compensate for the referral and he recruiters get achieved through monetary compensation to encourage the nurses in their duty delivery hence creating a position of recruiting other nurses to the organizations.

Moreover, offering the altered schedules for the accommodation of the professional and the personal needs of nurses remains an initiative of addressing the nurse shortage in the healthcare organization. However, maintaining and achieving professional and personal life balance sometimes becomes difficult for the nurses. As such, the immediate improvement strategies that should be achieved by the nurse leaders get based on offering the altered schedules for the nurses to accommodate the professional and personal needs like offering the special mum shifts for the busy mothers who may have opted to take a leave (Buchan & Aiken, 2008). Also, the ability of the organization to create a part time shift in service delivery accommodate the personal and the professional needs of the nurses hence are creating a framework of choosing the options that fits the personal obligations. Choosing the fit shift makes nurses happy with the service delivery hereby enhance the work balance and promoting the satisfaction and wellness within the organization.

Furthermore, the use of the onboard programs to make new recruited nurses feel welcomed in the service delivery creates the group cohesion hence effective and efficient service delivery which bridges the gap of the nurse shortage and encourages their retention. Also, good onboarding program eases new recruits into the job market hence reduce overwhelming at the first few days at the new job (Challinor et al., 2020). As such, the organization and the management should avoid assigning nurses to the new patients immediately after recruitment. The onboarding program continues to involve the use of new mechanisms that enable the new nurses to know the current nurses for the sense of community encouragements. As a result, the nurses tat feel part of the nursing community are likely to retain their jobs and bring along the qualified friends. Nurse residency program continues to characterize the onboarding program through provision of accommodation that make the nurse feel easier to transit from being the student nurse to handling the nurse responsibilities. The initiative creates a mentorship program through combination of the new nurses with the experienced nurses to create a comprehensive knowledge of caring for the patients.

Conclusion

Overall, the nursing unit forms an integral part of the healthcare system. As such, the increasing challenge of nursing staff shortages poses an increased risk to the health outcome of patients. The main causes of nurse shortages include low income, poor funding for nursing education, and low expenditures on healthcare. Other causes of nurse shortages include nurse burnout, low levels of income, reduced supply of nurses, poor recruitment plans, ineffective planning, and improper use of the available nursing resources. Lack of cultural competence and cultural diversity also cause nurse shortages. It has been established that nurses’ body systems, including the central nervous and cardiovascular systems, are indirectly affected by this healthcare issue. Usually, nurse shortages cause sleep deprivation, thus negatively affecting the aforementioned systems. Also, nurse shortage has shown to impact patient outcome, where the issue results in missed care, in-hospital deaths, HAIs, and medication errors. Furthermore, shortage of nurses is associated with increased medical costs, which are associated with prolonged stays in hospitals. Other effects of nurse shortages include reduced job satisfaction, burnout, and moral distress. Nursing shortages can be improved by improving nurses’ job satisfaction. This can be achieved by launching nursing mentorship programs and improving the workplace environment. Also, increasing healthcare expenditure may increase nurse satisfaction since they will receive higher pay. Increasing nurses’ salary will also make more people to consider pursuing a career in this field. Another solution to reduce nurse shortage is increasing funds for nursing education to make it affordable for students to pursue a career in this field. Also, laws such as Nurse Reinvestment Act, P.L. 107-205, and the Nurse Training and Retention Act of 2007, S.2064 help minimize the problem of nurse shortages. Notably, the Nurse Reinvestment Act pertains to the issue of nursing staff shortages because Title I and Title II pertain to nurses’ recruitment and retention, respectively. On the other hand, the Nurse Training and Retention Act of 2007 aims to ensure comprehensive programs are funded to facilitate a sufficient supply of nurses.

References

Act, N. R. PL 107-205 (2002). Washington, DC: US Government Printing Office.

Ahmad, A., & Didia, S. C. (2020). Effects of sleep duration on cardiovascular events. Current Cardiology Reports, 22(4), 1-5. https://doi.org/10.1007/s11886-020-1271-0Balante, J., van den Broek, D., & White, K. (2021). How does culture influence work experience in a foreign country? An umbrella review of the cultural challenges faced by internationally educated nurses. International Journal of Nursing Studies, 118, 103930. https://doi.org/10.1016/j.ijnurstu.2021.103930Bayat, M., Shahriari, M., & Keshvari, M. (2019). The relationship between moral distress in nurses and ethical climate in selected hospitals of the Iranian social security organization. Journal of Medical Ethics and History of Medicine, 12 (8), 1–16. https://doi.org/10.18502%2Fjmehm.v12i8.1339Buchan, J., & Aiken, L. (2008). Solving nursing shortages: a common priority. Journal of clinical nursing, 17(24), 3262-3268. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2702.2008.02636.xChallinor, J. M., Alqudimat, M. R., Teixeira, T. O., & Oldenmenger, W. H. (2020). Oncology nursing workforce: challenges, solutions, and future strategies. The Lancet Oncology, 21(12), e564-e574. https://www.sciencedirect.com/science/article/pii/S1470204520306057Dall’Ora, C., Ball, J., Reinius, M., & Griffiths, P. (2020). Burnout in nursing: a theoretical review. Human resources for health, 18(1), 1-17. https://doi.org/10.1186/s12960-020-00469-9Deng, X., Liu, X., & Fang, R. (2020). Evaluation of the correlation between job stress and sleep quality in community nurses. Medicine, 99(4), 1-7. https://doi.org/10.1097%2FMD.0000000000018822Drennan, V. M., & Ross, F. (2019). Global nurse shortages: The facts, the impact, and action for change. British medical bulletin, 130(1), 25-37.

Fawaz, M. A., Hamdan-Mansour, A. M., & Tassi, A. (2018). Challenges facing nursing education in the advanced healthcare environment. International Journal of Africa nursing sciences, 9, 105-110. https://doi.org/10.1016/j.ijans.2018.10.005Ghafoor, Y., Yaqoob, M. A., Bilal, M. A., & Ghafoor, M. S. (2021). Impact of nurse shortage on patient care. Saudi J Nurs Heal Care, 4(4), 114-9. https://10.36348/sjnhc.2021.v04i04.003Haahr, A., Norlyk, A., Martinsen, B., & Dreyer, P. (2020). Nurses experiences of ethical dilemmas: A review. Nursing ethics, 27(1), 258-272. https://doi.org/10.1177/0969733019832941Haddad, L. M., Annamaraju, P., & Toney-Butler, T. J. (2022). Nursing shortage. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK493175/Haegdorens, F., Van Bogaert, P., De Meester, K., & Monsieurs, K. G. (2019). The impact of nurse staffing levels and nurse’s education on patient mortality in medical and surgical wards: an observational multicentre study. BMC health services research, 19(1), 1-9. https://doi.org/10.1186/s12913-019-4688-7Haddad, L. M., Annamaraju, P., & Toney-Butler, T. J. (2022). Nursing shortage. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK493175/Holmberg, C., Caro, J., & Sobis, I. (2018). Job satisfaction among Swedish mental health nursing personnel: Revisiting the two‐factor theory. International journal of mental health nursing, 27(2), 581-592. https://www.researchgate.net/profile/Christopher-Holmberg/publication/315839805_Job_satisfaction_among_Swedish_mental_health_nursing_personnel_Revisiting_the_two-factor_theory/links/59e245eb458515393d57efca/Job-satisfaction-among-Swedish-mental-health-nursing-personnel-Revisiting-the-two-factor-theory.pdfJanatolmakan, M., & Khatony, A. (2022). Explaining the consequences of missed nursing care from the perspective of nurses: a qualitative descriptive study in Iran. BMC nursing, 21(1), 1-7. https://doi.org/10.1186/s12912-022-00839-9Liew, S. C., & Aung, T. (2021). Sleep deprivation and its association with diseases-a review. Sleep medicine, 77, 192-204. https://doi.org/10.1016/j.sleep.2020.07.048Lockhart, L. (2020). Strategies to reduce nursing turnover. Nursing Made Incredibly Easy, 18(2), 56.https://doi.org/10.1097/01.NME.0000653196.16629.2eManyisa, Z. M., & van Aswegen, E. J. (2017). Factors affecting working conditions in public hospitals: A literature review. International journal of Africa nursing sciences, 6, 28-38. https://reader.elsevier.com/reader/sd/pii/S2214139117300082?token=D0CC165AE5A35F826306E23E28CB281D82200AAFCC97C33F86A9FDD45EBDC8DBD687E104BD2018A858094210B8B55CDA&originRegion=eu-west-1&originCreation=20220824134123Marć, M., Bartosiewicz, A., Burzyńska, J., Chmiel, Z., & Januszewicz, P. (2019). A nursing shortage–a prospect of global and local policies. International nursing review, 66(1), 9-16. https://doi.org/10.1111/inr.12473Mullen, P. R., Morris, C., & Lord, M. (2017). The experience of ethical dilemmas, burnout, and stress among practicing counselors. Counseling and Values, 62(1), 37-56. https://doi.org/10.1002/cvj.12048Shamsi, A., & Peyravi, H. (2020). Nursing shortage, a different challenge in Iran: A systematic review. Medical journal of the Islamic Republic of Iran, 34 (8), 1-9. https://doi.org/10.34171%2Fmjiri.34.8Stokes, F., & Iskander, R. (2021). Human rights and bioethical considerations of global nurse migration. Journal of bioethical inquiry, 18(3), 429-439. https://doi.org/10.1007%2Fs11673-021-10110-6