Classification of nursing staff needs into five levels
By Charles Bilodeau & Elisabeth Laughrea
March 6, 2023
An uncertain future for the next generation of nurses
According to the chief executive of the International Council of Nurses, we could have a potential shortage of 14 million nurses by 2030, which is equivalent to half of the current nursing workforce, in particular because of the COVID-19 effect. He also asserted that “the health of the nursing workforce could be the greatest determinant of the health of the world’s population over the next decade” (Ford, 2021). It therefore seems essential to seek to actively meet the needs of the next generation of nurses in order to ensure a sustainable future in the profession. This is how the idea of a pyramid detailing the needs of the next generation of nurses came to us.
Development of a pyramid detailing the needs of the next generation of nurses
In 1943, Abraham Maslow published the book A Theory of Human Motivation, in which he suggested that a person’s motivations result from the dissatisfaction of certain needs. His work led to the design of the now-famous Maslow’s pyramid, which ranks a person’s needs in order of importance according to five levels. Although this theory has been challenged many times, it remains a staple in the field of psychology for its simplicity and convenience.
Like Maslow’s pyramid, the proposed pyramid detailing the needs of the next generation of nurses presents five levels of needs corresponding to those that nurses at the start of their career seek to meet in order to develop their professional practice and identity. However, unlike Maslow, who believed that once the need is met, it disappears, and the person moves on to the next one, this modified pyramid proposes needs that overlap and coexist throughout the nurse’s career. This pyramid, which is focused on clinical practice, stems from our personal and professional experiences as nurses, as well as our many interactions with early-career nurses and others involved with them. The recommendations it contains primarily concern organizations that will be hiring the next generation of nurses, but it also considers the needs of the next generation of nurses themselves.
Figure 1. Pyramid of the needs of the next generation of nurses
Level 1: Basic needs
At the first level, the needs are directly related to “survival” within the nursing profession and the organization that employs the nursing staff. To ensure that these needs remain met, organizations are encouraged to offer work schedules that allow for a good work-life balance and enough free time for leisure. To this end, as mentioned on numerous occasions in the literature, compulsory overtime should be avoided and should only be considered as a last resort. The experience of many Magnet hospitals clearly indicates that the use of compulsory overtime can be greatly reduced, if not eliminated, by adopting different methods of staff management, such as 12-hour shifts, rotating positions, self-management of schedules, participation of management staff in clinical activities and reduction of the use of private agencies.
In Maslow’s pyramid, the basic needs include the actions of drinking and eating. Although it may seem trivial, several nurses, many of whom are novices, report that they often cannot take breaks from work because of the heavy workload. This phenomenon, which has been described in the literature for many years, contributes significantly to the exhaustion of nursing staff and reduces the safety of patient care (CNA, 2010).
Unfortunately, this situation is too often normalized or even sometimes justified by attributing it to the lack of efficiency of novice nurses. This long-standing culture of “failed breaks” implies that organizations are doing nothing to ensure that nurses can take their breaks and be replaced as needed during this time (CNA, 2010). Internal policies must be in place to ensure adequate resting places in the workplace for nursing staff on all shifts and to recognize the importance of taking breaks.
Level 2: Need for security
At the second level, the next generation of nurses seeks security. As part of their work, they may frequently be exposed to situations that endanger their physical or psychological safety, especially in the context of a global pandemic. The COVID-19 pandemic will have reminded us, at our expense, how essential access to adequate and sufficient personal protective equipment is to ensure the physical safety of nursing staff.
Psychologically, the repercussions of the COVID-19 pandemic are even more disturbing. A recent meta-analysis on the incidence of COVID-19 among the populations most affected by the pandemic showed that rates of post-traumatic stress have increased by 22 per cent, depression by 16 per cent, anxiety by 15 per cent and distress by 13 per cent (Cénat et al., 2021). Added to these results is a 24-per-cent increase in the rate of insomnia. Indeed, among health-care professionals, rates of insomnia are up to twice as high as in the rest of the population.
Among the proposed solutions, let us mention the need for managers to actively monitor, using sensitive indicators, the psychological well-being of their staff and the impact of changes in workload. Organizations must also be able to provide quick access to formal treatment for those who need it (e.g., employee assistance programs).
Finally, some staff should receive training in active listening or peer support since these strategies have proven to be particularly beneficial in supporting other types of workers exposed to trauma, such as firefighters, police officers or soldiers (Greenberg et al., 2021). These interventions would promote the development of a culture of awareness of the mental health problems experienced by nurses. To ensure its sustainability, various actions must be taken, including official recognition by the government of the burnout of nursing personnel, which should be viewed as a national issue to ensure the safety and quality of care being offered to the population.
Moreover, the mental health of nurses should be among the quality indicators of the Quebec health-care system; this would help ensure that health-care employers abide by such standards.
Safety also requires a workplace free of violence and intimidation. Nurses are the health-care professionals most likely to be victims of physical and psychological violence in the workplace (CNA & CFNU, 2014). A 2012 U.S. study found that nearly 73 per cent of novice nurses had experienced bullying in the previous month (Berry, Gillespie, Gates, & Schafer, 2012). Despite the absence of provincial laws governing the management of these problematic situations, it is essential for victims and institutions not to normalize them. At the individual level, the nurse must not tolerate any intimidation, must point out that the behaviour will be denounced, must put the facts in writing in order to report them to a superior, and must not hesitate to consult the union and the resource department (Côté & St-Pierre, 2012).
As for employers, they must “establish and promote explicit policies against psychological harassment in the nursing environment, and clarify the complaint procedure. Training can also be offered to managers to help them recognize harassment, so as to prevent or put an end to negative behaviour” [translation] (Trépanier, 2013). A clear position regarding zero tolerance for violence and intimidation must be conveyed and valued in order to generate a safe and healthy work environment (RNAO, 2019).
It is important to properly equip and supervise the practice of managers because their actions and attitude toward a situation of violence or intimidation will have a great influence on the experience of victims (Morken, Johansen, & Alsaker, 2015). As Margot Phaneuf (2016, p. 11) pointed out: “While the organization of the care establishment is not necessarily the cause of psychological health problems at work, it is always part of the solutions” [translation].
An adequate onboarding and orientation period will also contribute to the feeling of security of nurses from the next generation, such as being able to quickly and easily consult a colleague (assistant head nurse, preceptor, mentor, health-care advisor, etc.). The feeling of security is also dependent on confidence in their own practice. This confidence is built through progressive exposure to complex care situations and a type of position adapted to the skills of the nurse at the start of practice.
To this end, nursing internship or residency programs, adapted over periods that can vary between six and 12 months depending on the clinical setting, would not only make it possible to optimize the integration of new nursing staff into their establishment, retention rate and skills development, but also to reduce their level of psychological distress (Kim, Lee, Eudey, Lounsbury, & Wede, 2015).
Level 3: Need to belong
At the third level is the need to belong. This feeling first develops within the work team. To do this, a clear and precise integration plan, combined with a stable position at the start of the nurse’s career, is a winning strategy. In addition, a supervised mentoring program, support from experienced nursing staff members, and the presence of on-the-spot management contribute significantly to the successful onboarding of new nursing staff members into their workplace, as well as their sense of belonging to it.
Subsequently, the emphasis can be placed on the sense of belonging to the organization by calling on the committees dedicated to the next generation that already exist in many establishments. These committees offer young nurses the opportunity to take an active part in the search for solutions to the specific problems that affect their care settings. They can also help facilitate the professional integration of new nurses at the start of their employment by participating in onboarding and preceptorship programs, as well as their evaluation.
Finally, belonging to the nursing profession is an important source of pride. To acquire a sense of belonging to the profession, nurses of the next generation are invited to participate in the many activities implemented by their organization or various professional associations, such as the Canadian Nurses Association (CNA). These recruits can also find out about the opportunities for participation available to them within these different organizations.
Level 4: Need for esteem
At the fourth level, the next generation of nurses needs to be seen as professionals. This esteem can be drawn from different sources — namely from users, colleagues, organizations and regulators.
In particular, it is important to emphasize the importance of the collaborative relationship between nurses and the physicians with whom they work. The quality of this relationship can have a direct impact on a nurse’s patient care behaviours and, consequently, on the quality of care (Kenaszchuk et al., 2010; Siedlecki & Hixson, 2015).
An effective strategy to strengthen this relationship is to hold interdisciplinary rounds, such as those found in many critical care units. A recent systematic review confirmed that these rounds improve interprofessional communication and therefore team spirit between participating nurses, physicians and other professionals (Heip, Van Hecke, Malfait, Van Biesen, & Eeckloo, 2022).
Other simple strategies can be used to meet the need for esteem, in particular the holding of organizational events highlighting nursing expertise and the projects resulting from it, recognition awards given in the workplace, using a board to display successes, and holding regular meetings to mention them verbally.
Organizations must also listen to the next generation of nurses and take their ideas into account when resolving clinical, organizational or ethical issues. The development of strong self-esteem in the next generation of nurses will be beneficial for organizations; this is because nurses who consider themselves integrated into the organizational culture are able to communicate their opinions effectively, engage in interpersonal relationships of mutual aid, and build a good capacity for resilience (Doré, 2017).
Level 5: Need for accomplishment
At the fifth and final level, the next generation of nurses seeks to fulfil themselves professionally and perfect their professional identity by aiming to achieve the objectives of their professional development plan and their career plan. The various parties involved in the development of the next generations of nurses are encouraged to put in place conditions conducive to the achievement of these objectives, in particular by allowing the next generation to use the knowledge and expertise acquired in university and through continuing education.
Organizations must also recognize individual potential and capitalize on human capital by targeting the talents and interests of nurses. For example, they can identify potential candidates for management positions and specialized clinical practice positions, as well as future specialized nurse practitioners. By supporting the development of skills and best clinical guidelines, organizations can contribute to meeting both their own evolving needs and the need for nurses’ accomplishment while promoting full occupation of their field of practice.
For many nurses, an important form of professional accomplishment involves contributing to the development of their colleagues. Offering these professionals the opportunity to participate in the training and orientation of new recruits can therefore be a winning strategy to contribute to their development.
The COVID-19 pandemic has had the effect of weakening the nursing workforce in Quebec, particularly the next generation of nurses, who already had to deal with many issues associated with their integration into the profession. It is therefore important to take an interest in their needs and develop effective strategies to meet them. The recommendations made in this article are part of this perspective.
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Charles Bilodeau is a clinical nurse in intensive care and a doctoral candidate in health sciences research at the Université de Sherbrooke in Quebec. He also acts as a lecturer at the School of Nursing at the Université de Sherbrooke.
Elisabeth Laughrea is an advisor for the implementation of the Magnet hospital program and coordinator of clinical activities at the Jewish General Hospital of the CIUSSS de l’Ouest-de-l’Île-de-Montréal, in addition to being president of the executive committee of the council of nurses of her institution.