Just imagine you or a loved one were admitted to the hospital and had to wait an extended period to receive the care desperately needed. Would that sit right with you?
It has been stated time and time again that there is a nationwide shortage of nurses, but is that the problem?
Nursing, the largest healthcare profession within the U.S. with over 5 million active registered nurses, still needs to improve to maintain safe staffing ratios to improve patient care. There is not a shortage of nurses, but a shortage of nurses willing to work in stressful and unsafe conditions.
The daunting physical, mental, and emotional stress experienced by those in the nursing profession leads to decreased work satisfaction and extreme burnout. This is a primary driving force for those quitting their jobs or leaving the profession.
Safe staffing is essential to reported nurse satisfaction and contributes significantly to improving patient outcomes, minimizing on-the-job injuries, and decreasing medication errors. All of these factors can cost patients their lives!
As an Intensive Care Unit nurse, I love what I do. Nursing can be a gratifying career, but success depends on the support and resources available. Working during COVID-19, I saw firsthand how patient conditions can suffer when staffing is inadequate.
Currently, 16 states have addressed nurse staffing through regulations and laws, but only two have addressed and mandated nurse-to-patient ratios. In May of 2021, a bill was introduced to the Senate and House of Representatives regarding federally mandated safe nursing standards, which dictate hospitals’ responsibilities and expectations, nurse-to-patient ratios, and unsafe working conditions to which nurses may object. Unfortunately, that seems to be where it ended – an introduction. There has been no movement on this bill since May 13, 2021. In April of 2023, this bill was reintroduced to the House of Representatives and the Senate. However, as of March 2023, it remains an introduction, and no further action has been taken.
We MUST do more! Given this “post-COVID Surge Era,” in which many nurses have either left the bedside or retired early due to working conditions, we must put increased pressure on our state and federal legislators to create more ironclad state regulations and ultimately “end all, be all” federal laws.
This can be done by writing to state representatives and urging them to vote in favor of bills H.R. 2530 and S.1113, currently active in Congress. These bills, which outline clear and safe nurse staffing ratios, were introduced to the House of Representatives and the Senate.
Remember, these individuals are not nurses and may not understand how significant these bills are to improving patient outcomes. It is up to us to continue bringing this concern to the forefront. Increasing awareness will bring change, and this change will lead to a safer and happier healthcare system.
In a unique effort to jump-start young people into healthcare professions, including nursing, one philanthropy will provide $250 million to create special high schools to prepare students for healthcare careers.
In January, Bloomberg Philanthropies announced an initiative to pair public education systems and hospitals in ten communities nationwide, ranging from Boston, MA, to Demopolis, AL. “By combining classroom learning with hands-on experience, these specialized healthcare high schools will prepare students for careers with opportunities for growth and advancement,” says Michael R. Bloomberg, founder of Bloomberg Philanthropies and 108th mayor of New York City, in a press release.
According to Bloomberg Philanthropies, each school, whether newly established through this initiative or a revamp of an existing school, will offer students robust academic programming, specialized healthcare classes, work-based learning at the partner health system, and the opportunity to earn credentials and certifications.
Immediately upon graduation, a press release notes that students can enter healthcare jobs within the partner healthcare system or advance their healthcare career through post-secondary education. As part of this initiative, all health system partners have committed to providing job opportunities for students who complete the graduation requirements of their programs.
Memorial HermannStaff Teach Alongside High School Teachers
At Houston-based Memorial Hermann Health System, the initiative can help address the nursing shortage, according to Bryan Sisk, DNP, RN, chief nursing executive at the system. “The pressure is on to be innovative and look at unique ways to solve this,” he says.
Bryan Sisk, DNP, RN, chief nursing executive at Houston-based Memorial Hermann Health System
An initial $31 million investment from Bloomberg Philanthropies will enable Memorial Hermann and the Aldine Independent School District to build the Health Education and Learning High School or HEAL High School. Specifically, according to Sisk, the program will refurbish the existing ninth-grade campus at Nimitz High School, creating a mock hospital environment. What students see in their daily interactions at school with the exam rooms “will be the same specification they’ll see when they start their work-based learning programs,” he says.
“The idea behind this partnership is to immerse them,” said Sisk in an interview. Students will start with a summer program before they enter ninth grade and continue it every summer, including the summer after graduating high school. They will participate in job shadowing and rotate through the hospital to see five different career pathways, including nursing, imaging, rehabilitation (physical and occupational therapy), pharmacy, and non-clinical administration.
Starting in ninth grade, Memorial Hermann staff members will teach alongside the high school teachers. “We will create a four-year relationship with these individuals so that we can make sure they have the tools to be successful,” Sisk explains. When students turn 16, usually in the 11th grade, they’ll have an opportunity to start their work experience at Memorial Hermann, according to Sisk.
Sisk hopes this program will excite students about nursing and eventually help stem the tide of nurses leaving the profession. “I think we can turn that tide because these individuals will be immersed in healthcare and nursing over a four-year window. They’ll have nurses working directly with them. They’ll get to know nurses; they’ll get to see what the job entails.” What’s more, after they graduate from high school, they’ll be followed for a year to maintain a connection and help them be successful, notes Sisk.
A side benefit of the program involves promoting health equity. “If you’re truly going to tackle health equity, there’s no better way to do that than to go and get individuals who live in that community, who are invested in that community, and get them on a career track where they can earn a living wage,” Sisk says. They can then, he notes, “encourage future generations to go down this pathway.”
Sisk stresses that the effort is a partnership involving the leaders of Memorial Hermann, Aldine ISD, and the community. “It is something that everybody’s rallying around,” he says. “I think this is going to turn into something that we can do on a much larger scale in Houston,” Sisk says.
Concerns of a nationwide nursing shortage have loomed for decades, and the COVID-19 pandemic only fast-tracked the profession toward crisis.
Nursing is integral to safe healthcare delivery, and the threat of a nursing shortage should concern everyone.
When it comes to patient safety, nurses are the nervous system of a hospital. They sense, perceive, connect, communicate, and solve. Critical to patient safety, appropriately staffed nursing staff protects patients through decreased mortality rates, reduced duration of hospitalization, and decreased preventable errors, such as falls or infection [1].
Despite being the country’s largest healthcare profession[2], nurses overwhelmingly feel undervalued, understaffed, and underappreciated. And after Covid-19, they’re walking away from the bedside.
This Mayo Clinic study from 2021 surveyed the pandemic’s impact on clinicians. They found that 1/3 of surveyed physicians and nurses planned to reduce work hours within a year, and approximately 40% of nurses planned to leave their current jobs within two years [3]. Why? Stress, burnout, and heavy workload.
Nurses who are leaving the bedside aren’t retirement age. Analysis from 2022 found that the total number of registered nurses decreased by more than 100,000 between 2020 and 2021–the most significant observed drop in the past 40 years. Many were under 35 and employed in hospitals [4].
The nurses who should be the profession’s future are leaving it behind.
The threat of a shortage existed before Covid-19. The pandemic poured salt in the profession’s wounds. This American Association of Colleges of Nursing (AACN) reviewed a nursing workplace survey from 2022. It indicated that the median age of a registered nurse is 46 and estimated that a quarter of nurses plan to retire or leave the profession over the next five years [5].
By 2030, there will be an estimated exodus of one million nurses into retirement [6].
This is detrimental to patient safety. Experienced nurses leaving the bedside leave a large and dangerous void. New nurses and physicians rely on the knowledge, expertise, and intuition of experienced nurses. These intangibles, combined with their ability to lead, mentor, and educate, are challenging to quantify and replicate.
While nurses continue to retire from or leave the bedside, the demand for quality healthcare only increases. Modern medicine means longer life expectancies, resulting in increased hospitalization utilization and geriatric care.
According to the U.S. Census Bureau, as baby boomers age, they will outnumber children for the first time in the country’s history, and by 2034, there will be 77 million people who are 65 years old or older [7].
As baby boomer nurses leave the bedside, they’ll find themselves as patients in an overwhelmed, understaffed healthcare system.
There is no straightforward answer to this imminent shortage. You might think, can’t hospitals hire more nurses? Unfortunately, it isn’t as simple as that.
Demand for Nurses is Growing Faster Than Supply
According to the AACN, nursing school enrollment can’t meet anticipated demand [5]. Nursing college programs and their resources are finite.
The AACN’s report showed that schools often reject qualified applications due to inadequate faculty, professors, clinical sites, clinical preceptors, and budget constraints [5]. This means that even with increased interest in nursing education, nursing programs cannot churn out new graduate nurses quickly enough to fill job openings.
Still, new nurse recruitment isn’t practical if you can’t retain them.
Early in the pandemic, nurses pushed their fears aside to care for patients under immense pressure and uncertainty. Nurses are at the patient’s side more than any other clinician, assuming the highest burden of risk for disease transmission. Still, nurses answered the call and remained dedicated to the profession.
Supply shortages left frontline healthcare workers lacking basic personal protective equipment (PPE), like masks, gloves, and gowns. In 2020, the World Health Organization called for a 40% increase in production in response to dangerously low supplies of PPE, putting frontline workers’ health in jeopardy [8].
Nurses found themselves understaffed, overworked, and under-appreciated. Insufficient nurse staffing negatively impacts both patients and nurses. Staffing concerns during the pandemic plagued the profession, raising stress and decreasing morale.
A study published in Nursing Outlook examined the impact of insufficient staffing and higher nurse-to-patient ratios. As seen in the pandemic, higher nurse-to-patient ratios contribute to a higher degree of burnout, increased job dissatisfaction, and higher intent to leave [9].
This 2022 COVID-19 impact survey released by the American Nurses Foundation and the American Nurses Association showed that 52% of nurses are considering leaving their current roles. Why?
Insufficient staffing
Work negatively impacting health and well-being
Inability to deliver quality care
A staggering 6 out of 10 nurses report feeling burnt out, and three out of 4 nurses report feeling stressed, frustrated, and exhausted [10].
These aren’t the concerns of a small minority. This is endemic to the profession.
Unsurprisingly, the pandemic prompted many nurses to explore opportunities beyond traditional bedside nursing. The profession provides many opportunities: ambulatory centers, outpatient departments, school nursing, aesthetic nursing, administrative nursing, and telehealth and remote work.
As more appealing nursing positions pull nurses away from the bedside, urgent healthcare executive action and governmental involvement are necessary to keep hospitals functioning.
The AACN is currently focused on solutions to the impending shortage through such measures as:
Advocacy for federal legislation and increased funding for nursing education
Applying innovation in nursing programs, such as accelerated education pathways like BSN and MSN programs
Working with organizational partners to encourage interest in the career [2]
As we approach this crisis, certain regions will feel the shortage’s impact more directly. These predictions are partly due to population data showing an aging population that will outnumber the nursing supply. This study shows 37 out of 50 states will experience significant shortages [11]. This will negatively impact safe and quality patient care and nursing morale.
For nurses, the professional outlook is a double-edged sword.
You’ll almost definitely be hired, but there’s no guarantee that your job won’t push you out of the profession.
At a time of significant instability and uncertainty in 21st-century healthcare, holding onto valuable nursing staff could not be a smarter focus for organizations that want to stay ahead of the game. If nurse attrition is an arch-enemy of high-quality patient care, how can prudent facilities ensure their nurses stick around?
It’s Not About Pizza and Tote Bags
According to the 2023 NSI National Health Care Retention & RN Staffing Report published by NSI Nursing Solutions, a hospital-based RN turnover rate of 22.5% is our reality, with nurses employed in pediatrics, surgical services, and women’s health showing the lowest rate of attrition, and those working in telemetry, step down, and med-surg being the most likely to leave.
“In a competitive market where nurses can easily become well-paid travelers or find a better compensation package and more positive workplace culture down the street or across state lines, healthcare organizations can’t be lazy,” states Sharon M. Weinstein, MS, BSN, RN, CRNI-R, CVP, CSP, FACW, FAAN, a certified coach, speaking professional, and consultant to healthcare organizations. “Nurses are valuable, and those employers that reflect their knowledge of that value will be much more likely to reap the rewards of nurse retention.”
If the average cost of turning over an RN position is $52,350, as NSI reports, inspiring nurses’ sense of workplace loyalty should be top of mind for healthcare administrators, managers, and executives who are watching their profit margins shrink. A constantly revolving door isn’t healthy for any unit, let alone the facility of which it’s a part.
While free pizza, a tote bag, or a new thermal coffee cup can provide a few feel-good moments and a full stomach for a hard-working nurse, these initiatives fall flat when it comes to long-term nurse retention. Pizza and coffee cups don’t put money in nurses’ pockets or decrease their workload, so these shallow band-aids are not central to any retention strategy.
What Will Make Them Stick Around?
When considering the need to create a workplace environment where nurse retention is a direct result, we’ve already established that pizza and tote bags should not be your go-to. So, where do we look beyond such simplistic would-be incentives?
According to Weinstein, things have changed. “The pandemic brought a perfect storm of challenges for healthcare providers with a disruptive impact on practice and process; one thing that did not change was our commitment to the profession.”
“This is the time for wellbeing to prevail as a core retention strategy,” Weinstein admonishes healthcare leaders. “We must be attuned to nurses’ needs for active listening, respect for their mental health, and the constant threat of burnout. We must offer a stress-free, psychologically safe work environment and reinforce that there is joy in the journey. We want their place of work to be the focus of that joy.”
Compensation: Nurses want and deserve proper compensation, and they’ll vote with their feet when they know certain facilities or employers pay more. Sign-on bonuses, money for relocation, tuition reimbursement, childcare, generous health insurance, and other benefits are all incentives for nurses to come on board and remain loyal.
Positive work environment/workplace culture:Flowery words on the company website are nice, but creating a positive workplace culture takes work. Work-life balance initiatives, zero tolerance for bullying and incivility, a culture of appreciation and camaraderie, and an atmosphere encouraging kindness and rejecting negative behaviors don’t just happen organically. There must be a commitment from the top. When it comes to a positive workplace environment, safe staffing is at the top of most nurses’ agendas — we can’t practice safely if we’re asked to do too much in too little time with too few resources.
Professional growth and development: Generous tuition reimbursement (as mentioned above) is a good start. Ongoing in-house training and educational opportunities are essential, as are pathways for career advancement. Nurses interested in professional growth should be aware of a leadership funnel and/or clinical ladder in which they can participate. Mentorship programs can also be part of a culture that encourages professional growth. A culture of learning is a dynamic and healthy culture.
Engage staff in the organization’s life: Weinstein suggests employers can engage their staff in organizational development. “Offer diagnostic design thinking to your teams in small group workshops, and have them think differently about themselves, their roles, and their futures.” These experiences can enhance a sense of “ownership” of the process by both staff and leaders.
Recognition and rewards: Like any other strategy, employee recognition programs are just one of many ways to give back to hard-working staff. Performance-based rewards, promotions, financial incentives for specific achievements, and celebrating professional milestones can all contribute to employee satisfaction. From her experience as a consultant, Weinstein knows what works: “Offer meaningful recognition — recognize and reward your nurses.”
Flexible scheduling: Flexible work schedules must also include understanding and consideration for the needs of nurses and their families. Smart employers make allowances for employees with young children and disabled or elderly family members to care for. “Nurses have lives beyond the clinical space,” states Weinstein, “and they need to engage in flexible scheduling and comprehensive benefits packages to get a life and enjoy it!”
Health and wellness benefits: Employee Assistance Programs (EAPs) and anonymous mental health and counseling services for employees are a must in this day and age. Stress management programs, financial wellness support, and other programs that show employees that they’re cared about make nurses feel appreciated and seen.
No Silver Bullet
There is no silver bullet in nurse retention, but organizations that approach this crucial issue with a thoughtful, intelligent, and well-planned strategy will engender more loyalty and positive regard from their nursing staff than organizations that rely on the tired pizza-and-tote-bag approach. Nurses are valuable, and those employers that reflect their knowledge of that value will be much more likely to reap the rewards of nurse retention.
“Turning attrition to attraction begins with the relationship you build with your team, concludes Weinstein. “An organization with top talent can navigate change, mitigate uncertainty, exceed staff and patient expectations, and soar to success. It can create loyalty and reignite passion, even in unprecedented times.”
Burnout and high turnover have been taking a toll on nurse clinicians, resulting in a staffing deficit that will only worsen. According to McKinsey & Company, the U.S. will be short 200,000 to 450,00 registered nurses for direct patient care by 2025. Research from NCSBN further reports almost 900,000 RNs intend to leave the workforce by 2027.
With this in mind, leaders from our company wanted to examine what could be done to mitigate this growing crisis, one already impacting nearly every healthcare facility daily. So, we surveyed our traveling clinicians to find out what motivates and keeps them in the industry. Analysis of the data revealed the benefits that matter, what they appreciate in a facility, and perhaps more importantly, why they continue taking travel assignments and remain in the profession. Here are a few of the highlights.
Control Leads to Satisfaction
Over three-quarters of respondents surveyed said they were satisfied with their most recent travel job, whereas only half felt the same about their last permanent staff post. Burnout was a significant factor for staff clinicians due to problematic patient-to-staff ratios, lengthy shifts, and hospital politics. These issues were major influences in prompting clinicians to pursue traveling opportunities.
Not surprisingly, higher compensation and the ability to meet financial goals were the foremost reasons nurses seek traveling opportunities, cited by 84% of respondents. Other motivators included freedom and flexibility at 71%, followed by a sense of adventure (39%), work-life balance (28%), and an “ability to focus on the patient, not hospital politics” at 22%.
Top 5 Motivators for Seeking a Travel Position
Having experienced the freedom and flexibility afforded by traveling, 41% of respondents said they would never return to a staff position. Additionally, after completing their first assignment, data showed work-life balance increased in value by 4%, as did the chance to focus more on patients, not politics.
Traveling Nurses: The Value of Pay, Place, and Perks
Pay was the top motivator when selecting a travel assignment at 26%, followed closely by location at 20%. This is supported by what we see internally as many clinicians begin their searches filtering by city and state. Shift structures and the facility came in at 11%, with contract length (10%) and start date (8%).
Travel clinicians are particularly adept at negotiating monetary benefits. That said, we asked them to rank the compensation package features they find most important. The top responses were: Pay rate guarantees (18%), housing stipends (14%), travel reimbursement (12%), paid time off between assignments (8%), licensing and certification reimbursement (7%), affordable healthcare (7%), retirement contributions/401k matching (5%), support while on assignment (5%), scrubs reimbursement (4%), housing coordination and support (4%), and continuing education unit (CEU) reimbursement (3%).
As the data shows, pay, place, and perks are a few of the best ways to retain and attract these talented nurses.
Flexibility and Safety
Every healthcare facility has its processes and systems, ranging from unique float parameters to the type of electronic medical records (EMR) software it uses. When evaluating offers from a specific facility, traveling clinicians cared most about flexible scheduling (14%) and staff-to-patient ratios (13%).
Yet, while patient safety and support are critical, other factors have an impact, including facility reputation (9%), floating frequency (8%), charting systems (7%), opportunity for overtime shifts (7%), ability to request time off (RTO – 7%), thorough onboarding (7%), parking (7%), float parameters (6%), number of unit clinicians (6%), and lunch breaks (5%).
Interestingly, after completing their first assignment, responses showed some changes in value. “Work-life balance” grew by another four points, as did the ability to focus on the patient, “not the politics.” While still overwhelmingly important, money became somewhat less of a motivator for repeat travelers, dropping eight points.
Top 5 Motivators for Seeing a Travel Position
We also included a body of allied health professionals in our survey, those providing various diagnostic, technical, therapeutic, and support services. Topping their list of essential factors is thorough onboarding (12%), followed closely by the number of clinicians per unit. These healthcare professionals, on the whole, tend to be newer to traveling, likely explaining why they emphasize onboarding and ratios at a facility when considering offers. On a related note, Staffing Industry Analysts project continued growth in this space, with allied health travel jobs increasing by 5% in 2023 and 2024.
Satisfaction Guarantees?
The NCSBN study noted that more than 60% of nurses experienced workload increases during the pandemic. This left many feeling exhausted, emotionally drained, and disillusioned. With healthcare workforce shortages showing no signs of stopping and every indication they will continue to climb, the nursing profession must focus on rebuilding, or tragic consequences may follow.
Retaining talented, tenured RNs and attracting new talent are essential. The traveling nurses in our study have provided vital feedback related to job satisfaction. While there are no guarantees, their insights are important to consider across the industry as we work together to position healthcare for a healthier future.
The COVID-19 pandemic transformed the healthcare industry, including how health systems coped with the ongoing shortage of qualified registered nurses. Dramatic surges in patient volumes led to hospitals bringing in travel nurses at unprecedented rates, hiking the demand for contract nurses by at least 35% over pre-pandemic levels.
Health systems had to take quick action to cover the gaps. Many hired travel nurses, but it wasn’t the ideal solution to the problem. The salary disparities were unsustainable and inflammatory for health systems, drawing sharp criticism from employed nurses doing the same jobs for significantly less money.
The resentment affected both employed and contracted nurses, further eroded morale in a challenging time, and even prompted some employed nurses to leave their positions and take up more lucrative travel spots, perpetuating the cycle of staffing shortfalls.
Now that the Public Health Emergency has ended, reimbursement and demand have returned to more realistic levels, leaving travel nurses feeling burned out, expendable, and unsure of what comes next in their careers – while leaving health systems still lacking the nurses they need to provide safe, high-quality patient care.
Healthcare organizations need a different solution to the nursing shortage that doesn’t rely on flying in professionals in response to sudden spikes in need. Virtual nursing is that solution.
In addition to providing an attractive career alternative for travel nurses looking for a new role, virtual nurses offer the best of both worlds for health systems: they are available when and where they’re needed, yet they aren’t strangers to the organization or a perceived threat to employed nursing staff.
Instead, virtual nurses utilize advanced telehealth technology to provide expert assistance with complex clinical tasks, such as care in the ICU or emergency room, and more routine needs, like giving discharge instructions and answering questions from patients or caregivers.
Nurses are brought into the environment via wall screens or telehealth carts with high-definition audio/visual equipment. In addition, some nursing stations in the virtual care center (such as Critical Care ICU) are connected to telemetry feeds and other data streams to enable off-site nurses to watch patients and their vital signs continuously.
This frees on-site staff to focus on building relationships and delivering hands-on care – all while knowing their remote colleagues have their back if they need extra support.
The result is an environment less likely to breed burnout and more likely to help all nurses feel as if they are maximizing their skills and working together as a coordinated team. It represents the start of creating an organizational culture that minimizes turnover and supports safe and effective patient care.
Virtual nursing won’t be able to solve the massive shortage of RNs completely. Still, the strategy offers a more sustainable and potentially less controversial alternative to relying too heavily on travel nurses.
As health systems seek innovative ways to trim unnecessary spending while supporting optimal patient care, virtual command centers could improve patient care and sustain workforce morale without breaking the bank.
