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Our Take

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

20 Minute Read

Concerns about an imbalance in supply and demand in the nursing workforce have been around for years. The number of nursing professionals nationally may be healthy, but many nurses are not in the local areas, sites of care, or roles where they're needed most. And many of today's nurses don't have the specialized skills they need, widening the existing gap between nurse experience and job complexity. As a result, gaping holes in staffing rosters, prolonged vacancies, unstable turnover rates, and unchecked use of premium labor are now common.

Health care leaders need to confront today's challenges in the nursing workforce differently than past cyclical shortages. In this report, we present six hard truths about the nursing workforce. Then, we detail tactics for how leaders can successfully address these challenges—stabilizing the nursing workforce in the short term and preparing it for the future.

 

The conventional wisdom

It’s easy to blame the Covid-19 pandemic for the current nursing shortage. But while the pandemic has certainly intensified many aspects of the staffing challenge, several factors were at play prior to the pandemic.

Heading into 2020, hospitals and health systems faced the experience-complexity gap, a new kind of nursing labor shortage. It wasn't a shortage of nursing FTEs, it was a shortage of nursing experience. As retirement-age nurses exited the workforce at rapid rates, there was an influx of new graduate RNs. The net effect was a decline in the overall experience of the nursing workforce. Simultaneously, as the collective experience of the nursing workforce declined, care complexity continued to rise. The result was a more novice workforce delivering increasingly complex care.

With that backdrop of a gap between nurse experience and care complexity, the Covid-19 pandemic further aggravated nursing supply and demand issues. Today, RN vacancies are hitting an all-time high in many localities amid an acute shortage of RNs. Health care leaders report an increase in the time to fill nursing vacancies and are struggling to maintain adequate staffing levels. Many organizations are relying heavily on premium nurse labor. And in most markets, institutions can’t compete without offering large sign-on bonuses to newly hired nurses. Tenured staff, frustrated that they aren’t eligible for such bonuses, are burned out from the relentless workload. This contributes to rising turnover rates, which leads to more vacancies, and so on.

 

Our take

Organizations cannot simply return to the nursing recruitment, retention, and staffing strategies used before the Covid-19 pandemic. In addition to exposing staffing shortfalls, Covid-19 accelerated changes to the nursing workforce that will make it more challenging to staff as organizations once did. Pre-pandemic staffing solutions are insufficient in today's environment due to three main factors:

  1. Unresolved structural issues: A 2021 survey of nurses found that 22% of nurses intend to leave their jobs within the next year. The top reasons nurses cited for their intention to leave were related to long-term challenges within the work environment, including the following:
    • Insufficient staffing levels and demanding nature/intensity of workload
    • Emotional toll of the job and not feeling listened to or supported at work
    • Insufficient compensation
  2. Burnout: Workforce burnout is a long-standing challenge for the nursing workforce. Mental health struggles among health care workers are not new—they existed long before the pandemic began. But when Covid-19 emerged, the problems grew as the workforce simultaneously managed their own health concerns, an added workload, and emotional distress brought on by the pandemic.
  3. Changing workforce needs and expectations: In the United States, 96% of workers want more flexibility at work. Many industries are giving workers more flexibility, and nurses want that too. For example, during the pandemic, parents struggled to cover childcare and other home obligations while working. Some organizations offered short-term solutions to meet these needs, but the needs will continue even once the pandemic abates. Many nurses are seeking flexible roles outside of acute care—or outside of the nursing profession entirely—that better accommodate their personal lives. This trend will continue if organizations can’t meet their workers’ needs.

As a result of these three factors, many nurses are leaving the profession or choosing to retire early. And as nurses leave the workforce, most vacancies created by those departures are filled by new graduates, further widening the experience-complexity gap.

Leaders must acknowledge that the current RN shortage requires a different approach than previous cyclical workforce supply-demand imbalances. It is time to confront hard truths regarding what it will take to stem the exodus of RNs from hospital-based care. Beyond budgetary impact, failing to invest now will affect quality and safety while eroding the organization’s capacity to achieve growth and expand market share.

 

Six hard truths about the nursing workforce

The nursing shortage is a strategic health care challenge and as such requires the commitment of the entire C-suite, not just the CNO and/or CHRO. This report outlines six hard truths that are foundational for all C-suite executives to understand and accept. Accompanying each hard truth is a mindset shift for how executives can adapt to the current landscape.

  • Hard truth

    Waning organizational loyalty has eroded bedside RN longevity

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  • Hard truth

    Staff need work-life-balance and won't stay without it

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  • Hard truth

    Care models that rely disproportionately on RNs are no longer sustainable

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  • Hard truth

    Assistive personnel can't be overlooked anymore—they are critical to team-based care

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  • Hard truth

    Overreliance on contract labor is unsustainable

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  • Hard truth

    Staffing is a zero-sum game, and everyone is your competitor for nursing talent

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Parting thoughts

Confronting the hard truths about changes in the nursing workforce and implementing tactics to address these changes is critical for the long term. But for short-term tactics to stabilize the workforce today and stem the exodus of nurses from the inpatient setting, consider the list of ideas below. It includes practical solutions to address pipeline problems, retention pain points, and structural barriers to nursing practice.

Recruitment strategies:

  • Run an alumnus return campaign.
  • Confront the bonus conundrum by demonstrating ROI.
  • Grow the entry-level pipeline.
  • Build a sustainable entry-level workforce strategy.

Retention strategies:

  • Hardwire ongoing tactics for workforce resiliency, emotional support, and recovery.
  • Ensure RNs are safe and feel safe at work.
  • Revitalize professional development.
  • Practice routine, meaningful recognition.
  • Position nurse managers as chief retention officers.
  • Elevate "stay interviews" to the executive level.

Structural dissatisfiers:

  • Offer flexible schedule and role options.
  • Commit to team-based staffing models.
  • Redesign RN total rewards.
  • Innovate care delivery to reduce reliance on RNs.
  • Augment staffing with virtual care technology.
  • Confirm and market the inpatient nursing value proposition.

Addressing the hard truths detailed above and making progress on these tactics will require buy-in from more than just nursing and HR leadership. The ramifications of the nursing shortage go beyond the nursing department. This is a strategic health system challenge and as such requires the commitment of the entire C-suite. Failing to invest in the nursing workforce beyond band-aid solutions will cost health systems greatly and delay progress on workforce recovery efforts. Organizations will either need to invest in their nursing workforce now or pay dearly for it.

“The current and future nursing shortage is potentially an existential crisis for hospitals and health systems. In general, hospitals and the nursing profession change incrementally. But this shortage will require hospitals to take some big leaps—drastic changes will be needed.”
- EVP and CFO of a large, multi-state health care system

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