title: Nurse staffing issues are just the tip of the iceberg: a qualitative study about nurses' perceptions of nurse staffing.
abstract: OBJECTIVE
  To obtain in-depth insight into the perceptions of nurses in the Netherlands regarding current nurse staffing levels and use of nurse-to-patient-ratios (NPR) and patient classification systems (PCS).
  
  
  BACKGROUND
  In response to rising health care demands due to ageing of the patient population and increasing complexity of healthcare, hospital boards have been implementing NPRs and PCSs. However, many nurses at the unit level believe that staffing levels have become critically low, endangering the quality and safety of their patient care.
  
  
  METHODS
  This descriptive phenomenological qualitative study was conducted in a 1000-bed Dutch university hospital among 24 wards of four specialties (surgery, internal medicine, neurology, gynaecology & obstetrics and paediatric care). Data were collected from September until December 2012. To collect data four focus groups (n=44 nurses) were organized. Additionally, a total of 27 interviews (20 head nurses, 4 nurse directors and 3 quality advisors) were conducted using purposive sampling. The focus groups and interviews were audiotaped, transcribed and subjected to thematic analysis.
  
  
  RESULTS
  Nurse staffing issues appear to be merely the 'tip of the iceberg'. Below the surface three underlying main themes became clear - nursing behaviour, authority, and autonomy - which are linked by one overall theme: nurses' position. In general, nurses' behaviour, way of thinking, decision-making and communication of thoughts or information differs from other healthcare disciplines, e.g. physicians and quality advisors. This results in a perceived and actual lack of authority and autonomy. This in turn hinders them to plead for adequate nurse staffing in order to achieve the common goal of safe and high-quality patient care. Nurses desired a valid nursing care intensity system as an interdisciplinary and objective communication tool that makes nursing care visible and creates possibilities for better positioning of nurses in hospitals and further professionalization in terms of enhanced authority and autonomy.
  
  
  CONCLUSIONS
  The perceived subservient position of nurses in the hospital appears to be the root cause of nurse staffing problems. It is yet unknown whether an objective PCS to measure nursing care intensity would help them communicate effectively and credibly, thereby improving their own position.
authors.affiliation: Department of Quality Assurance & Process Innovation, Academic Medical Centre, P.O. Box 22700, 1100 DE Amsterdam, The Netherlands; Department of Surgery, Academic Medical Centre, P.O. Box 22700, 1100 DE Amsterdam, The Netherlands. Electronic address: c.j.vanoostveen@amc.nl.
authors.forename: Catharina J
authors.initials: CJ
authors.lastname: van Oostveen
authors.affiliation: Department of Quality Assurance & Process Innovation, Academic Medical Centre, P.O. Box 22700, 1100 DE Amsterdam, The Netherlands; Clinical Health Sciences, Faculty of Medicine, Utrecht University, P.O. Box 85500, 3584 CG Utrecht, The Netherlands.
authors.forename: Elke
authors.initials: E
authors.lastname: Mathijssen
authors.affiliation: Department of Quality Assurance & Process Innovation, Academic Medical Centre, P.O. Box 22700, 1100 DE Amsterdam, The Netherlands; Department of Surgery, Academic Medical Centre, P.O. Box 22700, 1100 DE Amsterdam, The Netherlands; Amsterdam School of Health Professions, University of Amsterdam, P.O. Box 22700, 1100 DE Amsterdam, The Netherlands.
authors.forename: Hester
authors.initials: H
authors.lastname: Vermeulen
mesh_terms: D001291:Attitude of Health Personnel; D017144:Focus Groups; D009740:Nursing Staff / Q000523:psychology; D010561:Personnel Staffing and Scheduling
keywords: Inter-professional relationships; Nurse staff hospital/organization & administration; Personnel staffing and scheduling; Personnel staffing and scheduling information system/classification; Professional autonomy; Professional practice; Qualitative research; Quality of healthcare; Safety; Workload