Hard truths on the current and future state of the nursing workforce

While previous generations of nurses tended to stay at the bedside for years, making a career in the acute care setting, today’s nurses tend not to do that. Organizations across the country consistently point out how difficult it is to retain bedside RN talent for the long term, especially millennial nurses. Multiple factors have contributed to this decline in bedside RN tenure.

Over the past few decades, the bedside RN role has become more difficult due to an increasingly complex care environment. Sicker patients now spend less time in the hospital, requiring RNs to deliver the same or more advanced care in a shorter time frame. This demanding practice environment—coupled with insufficient staffing levels intensified by the pandemic—has exacerbated nurse burnout. As a result, some RNs have exited the nursing profession entirely amid the stress of pandemic-era patient care and staffing shortages. At the same time, some experienced RNs have opted for early retirement.

Additionally, with myriad opportunities now available to nurses in the health care and broader labor market, many nurses view the acute care bedside role as a stepping-stone, not a destination. RNs are leaving acute care to get advanced practice degrees (e.g., becoming NPs), to work in ambulatory care settings with more flexibility and thus a better work-life balance, and to pursue roles in a different part of health care (e.g., at a payer organization). This is especially prevalent in new graduate RNs who are leaving the bedside after an average of just two years. ¹ Since the start of the pandemic, RNs of all experience levels have left their organizations to pursue lucrative travel contracts that offer better pay and extended time off between assignments.

Ultimately, there are many reasons why nurses choose to leave the bedside role. To compete in the workforce market, leaders must develop a workforce strategy that doesn’t rely on waning nurse loyalty.

Mindset shift 1: Fully leverage the RNs you have, while you have them

Organizations must accept the reality of employees’ increased mobility. A lack of experienced RNs and high bedside RN turnover is the new normal. Executives need to tap their existing RNs and position them to lead, delegate, and care for patients most efficiently.

Revamp clinical ladders to reflect accomplishments, not tenure

In recognition of the loyalty challenges organizations face, leaders need to take a critical look at existing career development programs for RNs and tailor them to meet the reality of decreased bedside longevity.

Organizations can start by redesigning their RN clinical ladder to reflect annual awards and recognition based on performance, rather than gradual or cumulative awards based on tenure. Ensure clinical ladders and professional development opportunities respond to the reality of shorter bedside RN tenure instead of trying to fight it.

Support top-of-license practice to maximize the value of each nursing hour

To fully leverage the contribution of bedside RNs, leaders must include mechanisms to support top-of-license practice. Time spent on care activities that another member of the care team could safely execute prevents RNs from spending their time on responsibilities where they are most needed. In addition, unnecessary time spent on below-license work discourages RNs from working in the acute care setting.

For best practices on elevating the impact of the frontline nurse and to view the eight core attributes of top-of-license practice, see Achieving Top-of-License Nursing Practice.

Use virtual care to scale the impact of RNs

One way to support inexperienced RNs and retain experienced RNs, while simultaneously reducing cost and improving quality, is to provide virtual nursing opportunities. Organizations deploying this technology find that novice nurses benefit from the remote oversight and the clinical expertise of the experienced nurse in virtual roles. Virtual nursing roles allow leaders to retain RNs in a way that meets the organization's needs. In addition, these positions make organizations more competitive with virtual RN roles offered by out-of-industry employers.

Virtual RN roles can be used to scale experience in different care models, including the two models detailed below.

• Virtual expert nurse care model: In the virtual expert nurse staffing model, one virtual expert RN leads a care team that oversees
  10 to 12 patients. ³ The rest of the care team varies but may consist of another RN, a CNA, and a patient care technician. Roles on the care team should be created based on patient acuity, organization preferences, and what staff are available in the local market. By implementing the virtual expert nurse staffing model, hospitals can see a 24% reduction in contract RN labor use and a 35% reduction in RN turnover. ⁴ This model of care also helped CHI Health—a 14-hospital health system headquartered in Omaha, Nebraska—realize labor savings of $4.7 million. For guidance on implementing the virtual expert RN care model, read our case study on How CHI Health Implemented a Virtual Expert Nurse Staffing Model.
• Virtual sitter model: In this model, experienced RNs are used as "virtual sitters." RNs remotely monitor the status of multiple patients, freeing up capacity for other frontline nursing staff and helping to avoid the use of more expensive labor to provide this level of care. For instance, one health system reduced patient fall rates by more than 25% and produced cost savings of $286,230 by using a 6:1 virtual sitter model. To learn more about this model, see how Mission Health significantly reduced patient falls and cut costs with virtual sitters.

In the United States, 96% of professionals want more flexibility at work, and many industries are headed in that direction. The same applies to health care. The pandemic amplified competing priorities for nurses, including finding safe and affordable childcare and elder care for family members and prioritizing work-life balance. These personal and professional obligations heightened the growing need for flexibility in health care roles.

While some organizations have offered short-term solutions to meet this need, these efforts have been insufficient to inflect staff retention. Organizations are losing talent to alternate players in the health care ecosystem—such as health plans, infusion centers, employer clinics, and ambulatory surgical centers—that can offer flexible work arrangements in less demanding practice settings. Therefore, all organizations must be prepared to offer flexible arrangements that work for their organization and meet the expectations of nurses today.

Mindset shift 2: Go big on flexibility

Moving forward, provider organizations need to build a flexible nursing workforce—one that includes diverse RN roles, locations, hours, and responsibilities. Flexibility is an important lever to achieve sufficient staffing with fewer available nurses, while also actively retaining and attracting more nurses to the bedside role.

Historically, staffing focused primarily on the needs of the organization. But now, in a candidate-centric market, staff needs and preferences must be weighted equally.

Detailed below are approaches to support employee and organization needs for flexibility.

• Nontraditional roles and schedules: Flexible roles allow a nurse to work across specialties or settings or to perform certain work remotely, while flexible schedules give nurses the chance to work nontraditional shift structures. Evaluate offerings such as no-weekend shifts, shifts for parents arranged around children’s school calendars, lunchtime coverage, and remote work arrangements. While the majority of the workforce will still work traditional 8- and 12-hour shifts, supplement traditional shifts with shorter options for the subset of experienced nurses for whom such options would help keep them at the bedside for longer.
• Cross-trained roles: Rather than striving solely to recruit the scarce experienced nurses in the market, organizations should cross-specialize the nurses they already employ with similar core clinical skills so they can be redeployed to other units and care sites when needed. Read our case study How to Flex RNs Across Sites of Care Using Blended Roles to learn how two organizations introduced blended roles to help frontline nurses expand their breadth of experience without leaving their roles.
• Self-directed floating: As an alternative to mandatory floating or legacy float pools, offer staff flexibility by reinventing the inpatient float pool. Four options include the following: short-shift float pools, ambulatory float pools, system-wide float pools, and internal travel agencies. Read our take on Reinventing the Inpatient Float Pool for an in-depth look at how organizations can implement these four options to address today’s staffing challenges.
• Internal travel agencies: To meet nurses’ needs for flexibility and compete with agency labor, develop internal travel agencies to allow staff to flex across regions and explore new roles and facilities. One perk that an internal agency can offer—that a traditional agency cannot compete with—is the ability for staff to travel without having to relearn a new way of doing things each time they have a new travel assignment. Offering this type of opportunity helps reduce an organization’s reliance on contract labor, could help retain staff interested in travel opportunities, and ensures that nurses working in the health system are familiar with system protocols and culture.

Today’s care models have served organizations and patients well for decades, helping them achieve high clinical and quality outcomes. But given the growing RN shortage, models like primary and total patient care are no longer sustainable.

As the number of RNs ready and willing to work in acute care continues to lag below levels of demand, nursing leaders need to consider redesigning care models. It’s well documented that a higher RN skill mix results in proportionally improved quality outcomes. But this evidence presumes sufficient RN levels for staffing deployment, which in many cases is not currently possible.

Focusing on RN skill mix in isolation fails to consider other aspects of the current staffing reality within the context of a shortage.

Due to these factors, RN skill mix alone is not a good indicator of care quality.

Today's RN shortage shows no signs of reversal, so nursing leaders need to scale the expertise of the limited number of experienced critical care nurses and adapt team-based nursing as the care model of choice.

Mindset shift 3: Get comfortable with team-based nursing

Clinical leaders need to get comfortable with meaningful care model innovation—specifically embracing team-based nursing. Team-based nursing elevates experienced nurses to the head of the care team supported by less experienced RNs, ancillary staff, and unlicensed roles. Leaders must outline clear role delineation to leverage the knowledge and abilities of the experienced and novice RNs on each care team and ensure all members of the team are practicing at the top of their license. For an example of what one organization did to rightsize the proportion of RNs in the skill mix to enable top-of-license practice, see our case study on How Inova Designed Their Skill Mix for Team-Based Nursing.

Nurse leaders also can no longer afford to opt strictly in favor of BSN-trained nurses at the expense of qualified ADNs and LPNs. During previous cyclical RN shortages, the acute care setting tapped LPN talent when they desperately needed it. But organizations returned to favoring RNs over LPNs because of hypothesized lower quality outcomes with LPNs and their limited scope. But now, the idea that LPNs will only be used in the short term is just not realistic.

Many organizations are hesitant to incorporate LPNs and ADNs due to theorized quality and safety downfalls. However, most research doesn’t focus on the impact of LPNs and ADNs on care quality; it looks solely at BSNs. Organizations shouldn’t point to inconclusive research when excluding LPNs and ADNs from the acute care setting. LPNs and ADNs are a critical component of team-based care.

Magnet® myths debunked

Besides the higher quality outcomes seen with BSNs, many leaders appear hesitant to incorporate LPNs and ADNs because of concerns about potential impact on Magnet accreditation.

Magnet’s structural empowerment section has two criteria regarding the nursing workforce:

• Criterion SE5 states that organizations must have an action plan for RNs obtaining a baccalaureate or higher degree in nursing.
• Criterion SE6EO asks for evidence of the organization progressing toward (or maintaining) 80% of professional RNs who have earned a baccalaureate or higher degree in nursing.

Based on these criteria, many nursing leaders assume that Magnet mandates a predominantly BSN-prepared workforce and discourages the use of LPNs, CNAs, and other assistive personnel.

Magnet asks for organizations to:

• Progress toward an 80% BSN-prepared workforce
• Support ADNs in progressing to BSN (flexibility in schedules, tuition reimbursement, partnering with schools of nursing, etc.)
• Decide rate of progression toward an 80%-BSN prepared workforce and how target rate was established (based on literature, strategic plan, etc.)
• Demonstrate improvement or neutrality across "big 3" indicators: clinical outcomes, patient experience, and nurse engagement

Magnet does not:

• Mandate hospitals hire BSNs exclusively—nor does it preclude hospitals from hiring ADNs, LPNs, and other assistive personnel
• Determine the rate at which organizations must increase their BSN workforce
• Require attainment of 80% BSN-prepared nurses, especially during RN shortages
• Require attainment of 80% BSN-prepared nurses within a predetermined time period, especially during current workforce conditions
• Dictate a specific care model and how hospitals should operationalize it

Magnet provides the framework to support nurses but is not prescriptive in how an organization meets the accreditation requirements. The director of the Magnet program emphasized this point:

“Magnet is not about perfection, it’s about excellence. And there’s a difference.”

Without a stable pipeline of assistive personnel comprised of both licensed and unlicensed professionals, RNs are more likely to take on care responsibilities that could be safely accomplished by another care team member with less training. But finding and retaining qualified entry-level caregivers—such as certified nurse assistants, patient care technicians, and patient care assistants—is difficult.

Assistive personnel roles are labor-intensive and low-paying, contributing to both higher turnover and increased vacancy rates among this cohort. In the wake of Covid-19, the work environment has become increasingly difficult. And while the pay has inched up marginally, many entry-level workers feel the pay is not enough to justify the risks and workload. The result is that they’re moving to other industries. Health care organizations are not only competing with other providers for labor, they are also competing with fast-food chains, shipping warehouses, and big-box retail stores. These out-of-industry competitors are offering pay above minimum wage plus attractive benefits such as paid time off (PTO), 401(k) contributions, and compelling career advancement opportunities.

This staffing challenge impacts organizations’ ability to permanently integrate assistive roles into a team-based staffing model.

Mindset shift 4: Invest in entry-level roles to solidify team-based care

A stable workforce of entry-level roles is essential to position nurses to practice at top-of-license and to consolidate team-based staffing. To accomplish this, organizations must build an entry-level recruitment and retention plan that counteracts legacy challenges plaguing the role, is competitive with other industries in the market, and stabilizes the elevated churn of assistive personnel.

Raise baseline compensation

In 2020, over 50% of hospitals did not pay CNAs $15 per hour. The bottom quartile of CNAs earned only $12.81 per hour. The average hourly wage for CNAs in the upper half was just $14.83. In contrast, the starting hourly wage for entry-level employees at Target and Amazon is $15.

At a minimum, organizations need to meet their market’s compensation floor for assistive personnel. But to compete with out-of-industry players for entry-level talent, health care organizations must make upward compensation adjustments for entry-level workers. The same holds true for the benefits package offered to assistive personnel—a healthy menu of PTO, tuition reimbursement, and 401(k) opportunities are necessary to compete.

Unlike out-of-industry competitors, hospitals can offer significant career progression, opening the door to higher-skilled and compensated clinical and administrative roles. Hospitals should advertise this potential for career advancement as a cornerstone of the organization’s value proposition when looking to fill entry-level roles. Highlighting these opportunities is one way leaders can differentiate their organization from competitors that do not have clinical ladders in place.

(Re)invest in the assistive personnel pipeline

Focus efforts on recruiting talent, both internally and externally, to create a stable workforce of assistive personnel. Potential channels for recruiting include:

• Nursing students
• Non-clinical entry-level employees, such as environmental services or food services
• Career and technical high schools, community colleges
• Hospital-based training programs

When building an assistive personnel pipeline, consider pipeline programs that not only help fill immediate assistive staff vacancies, but also serve as a pathway to RN practice. Nurse leaders should support the professional growth and education of CNAs and PCTs through efforts like mentorship opportunities and tuition reimbursement.

Many health care organizations have relied on premium labor to fill staffing gaps since the start of the Covid-19 pandemic. During the pandemic, 90% of hospital executives hired travel nurses, versus just 60% before Covid-19. Demand for travel nurses has skyrocketed, increasing 284% in 2021 compared to before the pandemic.

While travel nurses are an important short-term resource to meet immediate staffing needs, a chronic overreliance on premium labor is not financially sustainable. Travel RNs are now costing organizations 62.5% more than they did in the beginning of 2020. The annual average cost difference between travel nurses and staff nurses is $154,180 per nurse. Reducing reliance on travel nurses will save money that can be used to invest in permanent staff.

Many organizations currently depend on premium labor in part because they have not provided their own staff with compensation and benefits that align with today’s market demands. According to a November 2021 poll of nursing executives, 55% of respondents said that most bedside RNs leaving their organization do so to go to a travel agency. ⁵ When asked why RNs were leaving for travel nursing, 96% of nursing executives listed compensation as the number one reason. ⁶

Mindset shift 5: View travel agencies as both friend and foe

Today’s competitive labor market necessitates difficult trade-offs on resource allocation. While travel nurses are prudent and unavoidable at times to maintain safe staffing levels, contract labor must be treated as a short-term fix rather than a long-term solution. To reduce reliance on travel nurses and retain permanent talent, leaders must make their organization a more desirable place for staff to work—including offering compensation and benefits that align with local market demands.

Strategic considerations for short-term reliance on premium labor:

• Be transparent with staff about contract labor strategy. Being upfront about the agencies your organization is contracting with and for how long will show incumbents that there are no staffing secrets. Staff should be fully aware that travel nurses are there as a temporary fix to alleviate their workload.
• Clarify your return policy. Make it easy for staff who choose to leave your organization to come back upon completion of their travel contract. Leaders cannot afford to turn nursing talent away because of resentment.
• Treat travelers as a talent pool. Emphasize that your organization aims to convert contract labor to full-time staff. Leaders should treat any travel nurses in their organization as potential nursing candidates if the contract allows. Double down on your organization’s value proposition to stand out as a potential home for travel nurses.

Strategic considerations to reduce reliance on premium labor in the long term:

• Offer benefits that drive recruitment and retention.Providing nurses with a wider selection of benefits—beyond the traditional package of PTO, health insurance, and 401(k) contributions—is one way to demonstrate how valuable they are to the organization’s core operations. For instance, offer childcare assistance and meal services to support nurses in their personal lives. By alleviating some of the personal pressure they face, organizations can make it easier for nurses to stay.
• Adjust baseline compensation to reflect market demands. A standardized compensation package for RNs across settings and specialties is no longer a competitive approach. To fill vacancies, organizations must appropriately reward RNs working the most demanding shifts, specialties, and settings. For example, high-demand specialties or areas with high patient acuity—like ICU and critical care—necessitate higher wages. Tiering compensation based on the scope and depth of responsibilities in each setting is another forward-thinking strategy.
• Perform frequent compensation analyses and adjust pay accordingly. Given the speed at which the labor market is changing, leaders need to collaborate with HR and finance teams at their organizations on a competitive compensation plan. Perform compensation analyses annually, at a minimum. But we recommend that leaders review nursing salaries twice a year or even quarterly to stay competitive. Make sure to examine compensation across all potential competitors both within and, where it makes sense, outside of the industry—from ambulatory surgery centers, to health plans, and beyond.
• Allocate bonuses to prioritize retention over recruitment. While sign-on bonuses have become necessary in many markets, retention bonuses are a better long-term intervention. Organizations are likely better off investing in long-term targeted interventions—such as increasing base compensation or providing recognition bonuses—instead of focusing on short-term tactics like sign-on bonuses. Additionally, provide referral bonuses for incumbent staff. If an organization needs to offer sign-on bonuses, it's best to stagger the payout over an extended period and target bonuses to particularly hard-to-fill roles.

All health care settings are feeling short-staffed when it comes to nursing talent, but the competition isn’t just among hospitals—it’s across the care continuum. The health care industry has lost over 524,000 workers since February 2020, with post-acute providers accounting for about 80% of this loss. All settings are competing for the finite number of nurses available, resulting in staffing challenges across the health care ecosystem.

“Staffing is harder now than I have ever seen in the 11 years I’ve been with the organization. We’ve been hemorrhaging staff.”
- ACNO, East coast, post-acute health care organization

Hospitals have historically been seen as more prestigious employers for nurses compared to other care settings, especially post-acute settings. Covid has changed this dynamic, with more nurses leaving inpatient settings. And while Advisory Board predicts that in the next three years, inpatient growth will decrease and outpatient growth will increase, the decrease in inpatient growth will not balance out the supply-demand gap of nurses in the acute care setting.

As of 2019, RNs were employed in settings at the following rates:

• 61% in hospitals (state, local, and private)
• 18% in ambulatory health care services
• 9% in other
• 7% in nursing and residential care facilities
• 5% in government

Moving forward, it’s unclear at this time exactly what percentage of the nursing workforce will remain in inpatient positions as patients shift to different sites of care.

Mindset shift 6: Address downstream capacity constraints as you stabilize inpatient staffing

This tactic is different than the others discussed in this document because it is an industry-wide issue rather than an individual facility challenge. When acute care leaders staff their hospitals, they need to recognize that they’re accepting a short-term risk. By prioritizing the inpatient setting, acute care leaders accept that other care settings may experience a consequential rise in vacancies. The immediate downstream impact of this decision is capacity constraints such as delayed transfers to post-acute settings and increased boarding in the ED.

Ultimately, the nursing talent pool across clinical settings is intertwined. While addressing inpatient staffing challenges, leaders must also address downstream capacity constraints.

Take a system-wide approach to staffing

Leaders must apply a system-wide lens to workforce planning. If leaders continue looking at staffing from an individual facility standpoint, they’ll inadvertently perpetuate a cycle of competition.

By approaching the nursing shortage from a system-wide standpoint rather than a facility view, leaders can be confident that the changes or investments they’re making in one setting are strategically setting them up for success in another area. Or, leaders can strategically choose to make a trade-off, deciding they will prioritize staff in one setting over another because it’s the best course of action for the organization in the long run. Leaders will inevitably need to make staffing trade-offs within the system, as all sites of care are connected.