Huey-Ming Tzeng
Chang-Yi Yin
Historical Trends in Human
Resource Issues of Hospital
Nursing in the Past Generation
EXECUTIVE SUMMARY
Strategic management of
human resource in health care
is indeed important to deliver-
ing high-quality care.
Despite the fact that the nurs-
ing profession is growing and
becoming more and more
sophisticated, human resource
issues have not changed in a
dramatically significant way in
the past generation.
The aim of this study was to
identify the historical trends in
human resource issues related
to hospital nursing in the past
generation from 1977 to 2006.
A total of 10,691 records were
reviewed, resulting in 1,799
valid records that addressed
human resource issues related
to hospital nursing.
Content analyses were con-
ducted and a typology of
human resource issues was
developed.
Productivity, work content and
flow, and occupational hazards
were the three most often
reported themes.
NURSING ECONOMIC$/January-February 2009/Vol. 27/No. 1
1990s, the importance
I
N THE
of human resource systems
and related strategies sur-
faced. Current human re-
source systems primarily empha-
sized individual human resource
functions (e.g., recruitment, selec-
tion, training, compensation, and
performance appraisals). These
functions have been aligned with
each other and linked to the over-
all strategies of the organization
(Khatri, Wells, McKune, & Brewer,
2006). For example, some recent
studies in health care sectors have
added to our understanding of the
links between nursing staffing lev-
els and mix-to-outcome indicators
(e.g., fall rates, length of stay, mor-
tality) (Aiken, Clarke, & Sloane,
2002; Needleman, Buerhaus,
Mattke, Stewart, & Zelevinsky,
2002).
Strategic management of hu-
man resource in health care is
indeed important to delivering
high-quality care. Buchan (2004)
claimed that research on Magnet®
hospitals has been under way for
HUEY-MING TZENG, PhD, RN, is
Associate Professor, University of
Michigan, School of Nursing, Division of
Nursing Business and Health Systems,
Ann Arbor, MI.
over 20 years. Findings have high-
lighted positive links between
good human resource practices
(e.g., being successful in recruit-
ing, retaining, and motivating
nursing staff), staffing characteris-
tics, and outcomes of care.
However, these studies did not
directly address specific human
resource management interven-
tions.
The American Nurses Cre-
dentialing Center (2007a, 2007b,
2007c, 2007d) first started the
Magnet research study in 1983
and formally established the
Magnet Recognition Program in
1997. This program focused on
advancement toward three goals:
(a) promoting quality in a setting
that supports professional prac-
tice, (b) identifying excellence in
the delivery of nursing services to
patients and residents, and (c) dis-
seminating best practices in nurs-
ing services. The requirements for
designation as a Magnet facility
included 14 Forces of Magnetism,
including (a) quality of nursing
CHANG-YI YIN, MA, is Professor,
Department of History, Chinese Culture
University, Taipei, Taiwan.
19
 leadership, (b) organizational
structure, (c) management style,
(d) personnel policies and pro-
grams, (e) professional models of
care, (f) quality of care, (g) quality
improvement, (h) consultation
and resources, (i) autonomy, (j)
community and the health care
organization, (k) nurses as teach-
ers, (l) image of nursing, (m) inter-
disciplinary relationships, and (n)
professional development. In
other words, Magnet recognition
was meant to acknowledge hospi-
tals with good human resource
practice for nursing services.
On the basis of Donabedian’s
(1966) structure, process, and out-
come model, we further catego-
rized these 14 Forces of Magne-
tism into three orientations: (1) the
structural orientation (forces b, c,
h, and j), (2) the process orienta-
tion related to employers and/or
employees (forces a, c, e, g, i, k, m,
and n), and (3) the outcome orien-
tation (forces f and l). In compari-
son, Buchan (2004) suggested
three groups of human resource-
related indicators for hospitals,
including (a) activity-related indi-
cators (e.g., occupied beds), (b)
staffing-related indicators (e.g., job
satisfaction, absence, overtime, re-
tention, accidents or injuries, as-
saults on staff, vacancy rates, use
of temporary staff), and (c) care-
related indicators (e.g., patient
length of stay, readmission rates,
mortality rates, urinary track in-
fections, pneumonia, pressure
ulcers, cross infections, patient
satisfaction).
It was assumed that human
resource issues at the organiza-
tional level (e.g., organizational
structure, strategic management,
and culture) would have an influ-
ence on human resource manage-
ment practices and effectiveness.
Consequently, strategic manage-
ment in human resource practices
may resolve in different nursing
care-related output.
Purpose of this Study
For policy analyses at the gov-
ernmental and organizational lev-
20
els, there is a need first to recog-
nize the knowledge gap concern-
ing the links between human
resource management inputs and
performance, and then to bridge
the gap through research. As a
result, the aim of this study was to
identify the historical trends in
human resource issues related to
hospital nursing in the past gener-
ation from 1977 to 2006. The three
oldest journals meeting our estab-
lished selection criteria were cho-
sen: American Journal of Nursing,
Nursing Outlook, and Nursing
Research. Development of the his-
torical trends in human resource
issues is essential to allow us to
capture the picture of discoveries,
generalized knowledge, and gaps
in knowledge. This effort would
guide future directions in human
resource management research
related to hospital nursing.
Methods
Design. This study was con-
ducted under the assumption that
scholars who recognized the
importance of emphasizing differ-
ent aspects of human resource
management would include relat-
ed key concepts in the titles of
their scholarly articles. Since this
study used a public database of
nursing-related scholarship and
did not involve any human sub-
jects, the institutional human sub-
ject review was waived.
Data Source
Targeted journals were select-
ed from the journals included in
the 2005 Journal Citation Reports
Social Science Edition or Science
Edition under the subject of nurs-
ing. The selection criteria for tar-
geted journals were that the publi-
cation has been available for at
least 30 years and must start earli-
er than January 1, 1977. The start
year and country of publication of
each journal were obtained from
the PubMed journal database. The
three oldest journals meeting the
selection criteria were chosen:
American Journal of Nursing
(ISSN 0002-936X; published in
NURSING ECONOMIC$/January-February 2009/Vol. 27/No. 1
the United States; start year, 1900),
Nursing Outlook (ISSN 0029-
6554; published in the United
States; start year, 1953), and
Nursing Research (ISSN 0029-
6562; published in the United
States; start year, 1952). American
Journal of Nursing is considered a
general interest nursing journal,
and Nursing Outlook and Nursing
Research are read largely by
researchers and nurse faculty. No
nursing management or nursing
administration journals were select-
ed as none of them met the selec-
tion criteria.
During the period of January
1, 1977, to December 31, 2006,
American Journal of Nursing pub-
lished a total of 6,572 records,
Nursing Outlook had 2,020, and
Nursing Research published
2,099. The author, title, abstract,
journal name, and publication
information of these targeted
records were downloaded from
the PubMed database for analyses.
Process of developing the
typology. The authors recognized
that conducting this search using
only key word searching on the
PubMed database was insufficient
to identify the report focus of each
journal article. As a result, the
content analysis method was
employed to code the primary
human resource subject of each
reviewed article.
To develop a preliminary
typology, the titles of the most
recent 500 records were inde-
pendently analyzed by each
author. Each record was then
assigned a single code to capture
the primary focus of the article.
The differences in code designa-
tion between the two authors were
discussed until both authors
reached agreement. Then, both
authors finished reviewing the
rest of the records based on the
preliminary typology.
Some additional codes were
added in the process, and the pre-
liminary typology was revised.
The results of each author’s
review again were compared and
discussed until agreement was
reached. The typology of these
codes was reconciled at the end of
the analyses. Codes with a similar
nature were grouped into themes.
Analyses. Content analyses on
the titles of the identified articles
were conducted by both authors;
the abstracts or the manuscripts of
these identified articles were ana-
lyzed if needed. This study was
not meant to conduct a meta-
analysis or an extensive review of
the literature.
Using content analyses, each
article was given a primary
numerical code. Microsoft Excel
was used to enter the information
abstracted from the reviewed arti-
cles. The entered data were ana-
lyzed with univariate statistics by
journals, years, identified codes,
and themes. As a study limitation,
all types of articles included in
this study (e.g., original and dis-
course articles) were treated as
equal. The concern whether all
these articles were of equal quali-
ty was not addressed in this
report.
Results
A total of 10,691 records were
reviewed, resulting in 1,799 valid
records (16.8%) that addressed
human resource issues for hospi-
tal nursing. In the years 1981,
1992, 1994, from 1998 to 2001,
and from 2003 to 2006, more than
60 human resource-related articles
were published per year. The
developed typology included a
total of 30 human resource issues,
which were further grouped into
eight themes. The total number of
human resource-related records
for each of these eight themes is
presented in Table 1. Historical
trends of these eight emerged
themes by year are shown in Table
2. Figure 1 illustrates the trends by
themes and years.
Discussion
This study identified the his-
torical human resource issues
related to hospital nursing in the
past 30 years (1977-2006). The
identified eight themes corre-
sponded to Donabedian’s (1966)
structure, process, and outcome
model. Each theme may be catego-
rized into more than one orienta-
tion.
For example, Theme 1 (recruit-
ment and retention), Theme 2 (per-
sonnel), and Theme 6 (work envi-
ronment) involve structure and
process orientations. Theme 3
(staffing and scheduling), Theme
4 (work content and flow), and
Theme 5 (professional develop-
ment) have a process orientation.
Theme 7 (occupational hazards
and staff safety) and Theme 8 (pro-
ductivity: care quality and patient
safety) engage both process and
outcome orientations. In other
words, human resource for hospi-
tal nursing comprised not only
organizational-level issues and
management practices, but also
nursing care-related outputs.
Productivity and patient safe-
ty. According to the study find-
ings, as early as 1993, there was a
dramatic increase in reporting
issues related to monitoring nurs-
ing care quality (code 8.1) and
medical errors, accidents, and
incidents (code 8.2). This can be a
consequence of the Institute of
Medicine’s promotion of the
importance of health care service
research, with an emphasis on
patient outcomes, during this
time.
In 1996 the Institute of Medi-
cine launched a health care quali-
ty initiative focused on assessing
and improving the nation’s quality
of care. From 1996 to 1998 the first
phase focused on understanding
the scope of issues as one of over-
use, misuse, and underuse of
health care services. From 1999 to
2001, the second phase of this ini-
tiative targeted the demands on
the health care system and called
for related policy environment
transformations to close the gap
between what is known to be good
quality care and what actually
existed in practice. The current
phase, begun in 2002, focuses on
reforming three different overlap-
ping levels of the system: the envi-
ronmental level, the level of the
health care organization, and the
interface between clinicians and
patients (Institute of Medicine,
2006). Consequently, in compari-
son, Theme 8 (productivity and
patient safety) was the most
reported human resource theme
with the highest number of
records. From 1993 to 2006, 216
(n=369; 58.5%) Theme 8 articles
were published. During this same
period, 87 records (n=123; 70.7%)
on code 8.2 (medical errors, acci-
dents, and incidents) were
obtained (see Table 2).
Individual human resource
functions. Khatri and colleagues
(2006) claimed that in the 1990s,
strategic human resource issues in
the hospital started to surface. The
current human resource systems
still emphasized individual human
resource functions that have been
linked to delivering high-quality
patient care. However, according
to the information presented in
Table 2, Theme 1 (recruitment and
retention), Theme 2 (personnel),
and Theme 5 (professional devel-
opment) did not show any obvi-
ous historical trends. One excep-
tion was that nurses’ competen-
cies in evidence-based or research-
based practice (code 5.3) became a
trend since 1998 with a special
emphasis during 2004-2006.
The issue of occupational haz-
ards and diseases (code 7.1) has
been discussed sporadically over
time. Since 1999, work safety
(code 7.2) emerged as an impor-
tant issue. In comparison, nurses’
mental health (code 7.3) was dis-
cussed more frequently in the
1980s. It is suggested that occupa-
tional diseases and job-related
mental or physical health prob-
lems should be continuously
monitored as these problems may
be linked to issues such as work-
ers’ compensation and nurse
absenteeism. Promoting healthy
nurse workforces should be one of
the priorities of individual human
resource functions.
Staffing, scheduling, work con-
tent and flow. Theme 4 of work

NURSING ECONOMIC$/January-February 2009/Vol. 27/No. 1 21

 Table 1.
Descriptive Information on the 30 Identified Human Resource Issues and Eight Themes
Total Records American
from the Three Journal of Nursing Nursing
Themes and Corresponding Issues Journals Nursing Outlook Research
1. Recruitment and Retention 150 86 50 14
1.1. Nursing shortage 47 23 24 7
1.2. General recruitment and selection 66 43 16 0
1.3. International recruitment and selection 13 9 4 7
1.4. Staff retention 24 11 6 0
2. Personnel 115 74 26 15
2.1. Staff orientation 4 2 2 0
2.2. Performance appraisal 24 6 7 11
2.3. Salary, benefits, and nonmonetary rewards 32 19 9 4
2.4. Promotion and clinical ladders 5 3 2 0
2.5. Disciplinary action and termination 9 9 0 0
2.6. Licensures and credentials 30 24 6 0
2.7. Nurses’ rightsa 11 11 0 0
3. Staffing and Scheduling 118 94 14 10
3.1. Staffing 84 64 13 7
3.2. Scheduling 34 30 1 3
4. Work Content and Flow 301 220 32 49
4.1. Work analysis and content 201 157 7 37
4.2. Interaction and partnership with physicians and other health 16 11 4 1
care providers
4.3. Workflow 84 52 21 11
5. Professional Development 249 139 70 40
5.1. General nursing competencies 102 54 26 22
5.2. Career development and growth 101 60 25 16
5.3. Evidence-based practice 46 25 19 2
6. Work Environment 243 112 83 48
6.1. Employers’ leadership and managerial skills 67 31 24 12
6.2. Working atmosphere and hospital facility 106 50 34 22
6.3. Gender issuesb 18 8 8 2
6.4. Diversity in nursingc 52 23 17 12
7. Occupational Hazards and Staff Safety 254 210 20 24
7.1. Occupational hazards and diseases 109 95 11 3
7.2. Workplace safety 82 76 3 3
7.3. Nurses’ mental health 54 33 5 16
7.4. Nurses’ physical health 9 6 1 2
8. Productivity: Care Quality and Patient Safety 369 281 41 47
8.1. Monitoring nursing care quality 100 72 3 25
8.2. Medical errors, accidents, and incidents 123 106 10 7
8.3. Professional ethics, dilemmas, and obligations 146 103 28 15
Number of Valid Records 1,799 1,216 336 247
NOTES:
a
For example, Family and Medical Leave Act, Americans with Disabilities Act, protected against discharge without cause, right
to work/HIV-positive nurses, right to be unionized, and right to strike.
b
For example, men in nursing.
c
For example, a culture-sensitive environment for nurses and patients.

22 NURSING ECONOMIC$/January-February 2009/Vol. 27/No. 1

 Table 2.
Descriptive Information on the Eight Identified Themes by Year
Frequency by Theme
1 2 3 4 5 6 7 8
Occupational
Recruitment Staffing and Work Content Professional Work Hazards and
Year and Retention Personnel Scheduling and Flow Development Environment Staff Safety Productivity
1977 0 4 0 7 8 3 4 8
1978 4 6 1 9 15 10 1 7
1979 3 4 3 14 15 10 5 3
1980 4 5 3 6 6 13 7 12
1981 7 6 4 8 7 11 6 17
1982 2 4 3 6 7 7 9 15
1983 8 4 4 5 2 6 8 9
1984 4 6 3 7 4 9 1 10
1985 5 4 0 10 5 5 7 8
1986 5 3 2 9 8 6 7 9
1987 2 1 1 11 8 6 5 11
1988 10 3 4 8 4 4 10 9
1989 8 7 2 6 3 13 5 14
1990 4 3 0 14 7 8 11 6
1991 4 1 2 11 3 6 4 4
1992 2 3 5 11 6 13 15 7
1993 3 1 2 12 4 10 9 12
1994 2 3 2 17 7 9 8 19
1995 5 2 0 9 6 4 4 13
1996 4 2 3 9 4 9 4 14
1997 4 2 4 9 5 11 5 15
1998 2 1 2 9 16 14 7 14
1999 5 8 5 7 8 9 9 17
2000 8 4 7 19 7 6 16 18
2001 3 5 9 6 14 4 11 15
2002 12 2 2 5 10 6 10 11
2003 10 5 9 21 9 4 12 18
2004 6 2 18 12 11 5 11 18
2005 6 2 10 11 17 8 28 21
2006 8 12 8 13 23 14 15 15
Total 150 115 118 301 249 243 254 369
NOTE: For each human resource theme, frequencies greater than 10 are in bold.

content and flow showed an
emphasis over the past 30 years.
Compared to other human resource
issues, the issue of work analysis
and content (code 4.1) was the
most reported human resource sub-
ject (n=201). This finding suggest-
ed that nurses’ functions have been
expanded, and the importance of
nurses’ roles in hospital care teams
has been gradually clarified over
the past 30 years. These phenome-
na showed that the nursing profes-
sion has been growing within.
It should also be noted that
since 2000, staffing (code 3.1) has
emerged as an important human
resource issue. The global shortage
of nurses and the increased empha-
sis on patient safety may have con-
tributed to this trend, such as link-
ing skill mix and nurse-patient
ratios to patient safety and clinical
outcomes.
Conclusions and Implications
This study reviewed a total of
10,691 records from three selected
nursing journals (American Journal
of Nursing, Nursing Outlook, and
Nursing Research), which were
published from 1977 to 2006. This
review acquired 1,799 valid
records that addressed human
resource issues related to hospital
nursing. Despite the fact that the
nursing profession has been grow-
ing, human resource issues have

NURSING ECONOMIC$/January-February 2009/Vol. 27/No. 1 23


30
25
20
Frequency
15
10
5
0
1997 1981
1979 1983
not changed in a dramatically sig-
nificant way in the past 30 years.
In practice, organizational/
structural-level human resource
policies would have an influence
on human resource practices and
effectiveness for nursing services.
These organizational-level matters
are usually uncontrollable by
nursing executives and clinical
nurses (e.g., pay scales and
cost containment-related strategic
management). The effectiveness of
human resource practices may
consequently resolve in different
care-related outputs. These out-
puts may feed back to the organi-
zational-level decisions related to
human resource allocation.
As a result, it is suggested that
human resource management for
hospital nursing should no longer
emphasize only individual human
resource functions. A macro ap-
proach to human resource man-
agement with an emphasis on
24
Figure 1.
Trends by Theme and Year
1985 1989 1993 1997 2001
1987 1991 1995 1999
Year
organizational-level strategic plan-
ning is a must. Nursing leaders in
hospitals must work closely with
hospital leaders in laying out
human resource policies for nurs-
ing services, for the goals of pro-
moting a safe care environment for
patients and a safe practice envi-
ronment for nursing staff.
Nursing leaders and managers
should strategize with an aim to
sustain a balanced nursing work-
force with both short-term and
long-term plans. For example, for
an acute hospital, a nurse turnover
rate of 10% to 15% may be reason-
able (this estimate may vary
depending on the nurse market in
the local and national levels) and
helpful to maintain a productive
workforce. It would be essential
for nursing leaders and mangers to
work with health care economists
and accountants to calculate and
justify (a) the direct cost (e.g.,
nurses’ pay scales), (b) indirect
NURSING ECONOMIC$/January-February 2009/Vol. 27/No. 1
Recruitment
Personnel
Staffing
Work Content
Professional Development
Work Environment
Staff Safety
Productivity
2005
2003
cost (e.g., cost related to recruit-
ment, retention and on-job staff
training, nurse managers’ time in
monitoring work performance and
care quality) and (c) hidden cost
(e.g., risk managers’ time to deal
with adverse events related to
nurses’ physical and mental
health), as associated with human
resources in hospital nursing.
Since human resource policies
often require cost-benefit analyses
to rationalize its possible impact,
consequently, cost-benefit analy-
ses should be conducted for both
short-term and long-term plans.
For example, it is essential to
conduct a review on the nurse
managers’ and clinical nurse spe-
cialists’ job descriptions and task
priorities for, such as, every 6
years. If a modification on the
nurse specialists’ job description
is needed, a cost-benefit analysis
on this change and its impact on
care quality would be required. It
is also essential for nursing lead-
ers and managers to take into con-
sideration the factors related to the
economy in the local and national
levels (e.g., the demand and sup-
ply of nurses in the local area).
As another example, technol-
ogy may or may not be the answer
to most of the current human
resource and nursing workforce-
related challenges. For instance,
adopting the informatics system of
electronic patient records to docu-
ment ambulatory and inpatient
nursing services may seem to be
an excellent solution and strategy
that may lead to better patient out-
comes. In such circumstances, it is
important for nursing leaders and
managers to consider in advance
its impact on the human resource
issues identified in this study
respectively and as a whole (see
Table 1).
In summary, nursing leaders
and managers should always ask:
After adopting a selected plan or
action, what are the immediate
and long-term benefits and
impacts on the quality of nursing
care and the practice environ-
ment? A plan and action can be as
small as an added paper or elec-
tronic-document for nurses to fill
out. If this document is needed,
we should also ask: Can this form
be shortened without compromis-
ing its purpose? It should be
emphasized that nursing leaders
should always address human
resource management issues by
taking a macro approach first.
To equip future and current
nursing leaders and managers
with appropriate capacity to have
macro-level visions, graduate
nurse educators should incorpo-
rate the concepts of organizational
politics and economics in health
care settings in graduate-level
management courses. These con-
cepts are essential to address not
only the structure-oriented human
resource issues, but also process-
oriented and outcome-oriented
ones for hospital nursing services.
For future research, it is recom-
mended repeating this study using
NURSING ECONOMIC$/January-February 2009/Vol. 27/No. 1
nursing management journals as
data sources to validate the devel-
oped typology, even if the time
frame must be different. For fore-
casting future human resource
issues, learning from the past (e.g.,
historical trends of scholarship)
and observing the present are both
critical to project future practice
environments correctly. $
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