Unaddressed Challenges Affecting the Nursing Profession in the 21st Century

Nursing before the 21st century had little to do with competence and more to do with your gender and willingness to do the job. The rest would be taken care of as you learned the professional skills on-the-job. Nursing skills were passed on from grandmothers and mothers to their daughters as a family trade centered on empathy. In those days, women were perceived to be an inferior gender, and so was the nursing profession.

Nursing has changed drastically over the years and is now a recognized profession that is held in high regard the world over. In spite of all these positive changes, modern nursing is still plagued by a myriad of challenges that have remained unaddressed over the years. Some are emerging challenges that have arisen due to the changes in the delivery of health services while others are chronically persistent issues that have transcended time and boundaries.  Of most importance are the following:

1.     Endless Litigation

As patients have become increasingly aware of their medical rights, physicians and nurses have found themselves facing more and more litigation charges that have threatened their practice and careers. The number of cases going to court has drastically increased over the years, especially those involving independent nurse practitioners. Nurses are forced to adopt a super cautious approach to their work as they are aware of legal ramifications that may threaten to end their careers at any one time.

Patient negligence is also another issue that may attract litigation charges against a nurse. Negligence means forfeiting to do an activity that should be done or not doing it as it should be done and as a result compromising on the standard of care. For a nurse, this could include: failing to give medication, failing to dress a wound as prescribed, failing to turn a patient, failing to record the care given to a patient and such alike. Actually, almost all tasks performed by a nurse can result in negligence charges should they fail to be performed appropriately. Longer working hours and stressful shifts often result in over stressed nurses who are more prone to negligence. When this happens, the patient can easily pursue legal action against the nurse and this may attract hefty penalties or loss of the nursing licensure.

A nurse is held accountable to the nursing code of ethics, their licensure, scope of practice and the public expectation of the nursing profession. When the nurse falls short of these expectations, they are exposed to litigation risks.

As the nursing profession has advanced in scope and practice, the modern nurse has been exposed to greater responsibility and risks. Nurse practitioners are now forced to pay hefty sums in insurance fees in anticipation of legal ramifications associated with the nature of their work.

2.     Job stagnation

As more nurses continue to diversify their skills, it is becoming increasingly harder by the day to find lucrative nursing positions. Many nurses go back to school with the hope that additional degrees will move them further away from the bedside. This fails to happen many times because there can only be so many nurses in management. Attaining nursing qualifications takes a lot of money, time and dedication. It is therefore frustrating when nurses are not able to get their “dream jobs” after investing so much into their training.

Some nursing specialties such as nurse anesthesia have failed to receive the recognition and approval in the medical fraternity that they deserve. Physician bodies have fought hard to bar nurse anesthetists from exercising their full capabilities in a clinical setting, insisting that they work under the supervision of anesthesiologists. Independent nurse practitioners have also faced similar obstacles with their scope of practice being greatly limited. Nurse practitioners in most states are not allowed to prescribe drugs independently, even when they have assessed a patient and made the right diagnosis. This can be very discouraging to highly trained nurses who have worked and studied for years in order to be able to offer quality care to their patients.

3.     Vague job descriptions

As much as nursing has evolved through the years, nurses are often considered “auxiliary” members in patient care. They are the “on-call” for the patient, doctor, lab person, records office, patient relatives and every other unit present in a hospital setting.  They are expected to handle all aspects of patient care and make everyone else in the team comfortable while at it. Even trained medical personnel sometimes fail to understand the scope of nursing duties. Nurses have at many occasions being forced to handle odd tasks such as cleaning floors that ideally should be handled by other staff. When physicians fail to acknowledge the scope of nursing practice, they may end up over-delegating to nurses who will be unable to handle their own job requirements at the end of the day.

4.     Poor Management.

The nursing division in many hospitals falls under the department of clinical services which is most likely headed by a physician or surgeon. As much as this is appropriate for the hospital, the unique needs and experiences of nurses may not be taken into consideration when formulating policies. The experiences of nurses vary significantly from those of doctors and other clinicians. This means that policies that may favor doctors may not necessarily favor nurses and other clinicians as well.

Nurses have also complained of lacking support from their very own nursing managers. It is as if the managers forget where they have come from once they move away from the bedside. When management is poor, nurses feel demotivated, undervalued and insignificant in the greater scheme of things. Poor management is a leading cause of frustration among nurses and contributes significantly to nurses quitting the profession prematurely.

5.     Low pay

In most developed nations, nurses are mid-level income earners. However, nurses in some countries especially in sub Saharan Africa and Asia are grossly underpaid. This is perhaps due to the out dated mentality that nurses do menial jobs that require no training or specialization. But even in countries where nurses are paid mid-level salaries, nurses still feel underpaid considering the amount of effort and time that they need to put in. Nursing is physically, mentally and emotionally exhausting, with shifts that vary between 12 hours to 16 hours. Nurses have to sacrifice holidays and weekends in order to be available to their patients at all times. As much as nurses are compensated for this, the lost moments with family and loved ones are hard to quantify. Over time, this may result in an overwhelming burn out.

6.     Burn out

Burn out is a state where an individual is no longer able to function optimally because of being too exhausted from over stretching themselves in the past. Burn out is characterized by physical, mental and emotional over exhaustion. Nursing burn out occurs for many reasons, but top on the list is under staffing. Typical working shifts for nurses are long, averaging 12 hours. When nurses are under staffed, they may either be forced to work harder during a shift or work for longer. Over time, the pressure builds up to a boiling point where the nurse is completely unable to function. When burnout occurs, a nurse may contemplate quitting the profession altogether.

Nursing burnout may also occur due to nurses prioritizing the needs of the whole medical team ahead of their own personal needs. For example, a nurse may be having a toothache, but instead of seeking proper treatment they keep taking pain killers so that they do not have to be away from work. With time, they develop another problem which they also push to the sidelines so that they can go on being available for the patient. When such needs are ignored for a long time, the nurse ends up experiencing severe burnout when they can no longer ignore their own personal needs which could be severe at this point.  

Nurses also face burnout because of the nature of environment in which they work. Hospitals are high pressure environments with situations constantly fluctuating between life and death. Many people assume that nurses become immune to pain and death, but this is not the case. Over time, nurses may get overwhelmed by a series of overwhelming emotions that may destabilize them and affect their performance of normal duties.

7.     Workplace Hazards

Nurses are constantly exposed to aggressive behavior from both patients and their relatives. Recent data from the Occupational Health Safety Network reported a total of 10,680 workplace injuries occurring between the years 2012 to 2014. Of this, 2,034 were as the result of patient aggression directed towards medical personnel.

Apart from aggressive behavior towards nurses, nurses are also exposed to a number of hazards while in the work place. Most duties carried out by nurses could potentially result in accidents such as needle stick injuries, exposure to pathogens, back strains from lifting patients, falls, burns and other hospital injuries. Some hospitals fail to provide nurses with the right safety gear for their nature of work.

Nurses are leaving the noble profession

These are among the leading challenges that are affecting nurses in the 21st century. Left unaddressed, these challenges become push factors that end up driving nurses away from the profession. While some nurses opt to travel to other countries to seek better working conditions, other prefer to quit the profession altogether. It is disappointing when nurses have to invest so much in their training only for them to give it all up a few years into practice.

As much as these paints a grim picture of the noble profession, all hope is not lost. A number of measures can be put in place to remedy the situation. They include the following:

  • When it comes to matters litigation, nurses can be trained on how to avoid situations that may predispose them to such. They can be offered legal advice and support should they find themselves facing litigation charges. Lastly, they can also be offered insurance covers for legal issues. Ultimately, improving the workplace and work environment for nurses will result in less burnout and fewer negligence cases against nurses.
  • Simple measures such as availing running water, soap and disinfectants to enforce hand washing techniques can go a long way in protecting the safety of nurses while at the work place. Providing nurses with appropriate uniform that covers their skin, masks, gloves and head gear is beneficial too. Providing adequate equipment for lifting and transporting patients, ensuring hospital floors are not slippery and enforcing infection control is of utmost importance too.
  • Improving staffing ratios in hospitals will help in preventing burnout. A ratio of 1:5 would be ideal for most medical/surgical settings. When the number of patients is limited for each nurse, the task becomes manageable.
  • Nurses need to debrief after every major loss that may have affected them, whether they feel it presently or not. Counselors need to be at the disposal of the nursing team to guide them through debriefing sessions and allow them to work through their emotions to a point where the nurses have adequately coped with the loss.
  • Nurses need to be recognized and promoted when they have achieved something exceptional. This will motivate the nurses to keep carrying out their roles to the best of their abilities. It will also help in curbing the mass exodus from the profession, especially from bedside nursing.
  • Nurses also need to be compensated financially for the amount of sacrifice that they put in. Nurses form a vital part of the health care system and their role is comparable to that of the physicians. Therefore, they should be held in equal regard and esteem and this should reflect in their financial remuneration.

The need for nursing services will keep growing, even as health care keeps advancing and longevity is enhanced. It is therefore imperative that these challenges are addressed speedily so that we have enough hands and brains to take care of the growing geriatric population as well as take care of the other health needs of a modern population.


  • Lippincott Nursing Education Blog (2016): the importance of optimal nurse staffing ratios.
  • American Nurses Association: Scope of Practice.
  • Health Leaders (2010): Nurse Anesthetists Battle Overlooks Rural Doctor Shortage.
  • Canadian Nurse (2011): The Power of Empathy.
  • Nurse Journal: Guide to Become a Registered Nurse.

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