Nursing in 2023: How hospitals are responding to shortages (2023)

when we tabResults of our first national survey of nursingalmost two years ago, we were surprised to see such a high reported likelihood of nurses planning to leave – we did not expect this trend to continue for so long.

But that's what happened after the COVID-19 pandemic. In fact, we've seen some of these reported expected turnover actually happen, as well as a reduction in the overall active nursing workforce. There’s still reason to be concerned: Today, 31% of nurses still say they’re likely to leave their current direct patient care jobs within the next year, according to our recent survey. That said, we're cautiously optimistic that some of the practices healthcare organizations are implementing to improve the nurse experience are bearing fruit.

In this article, we share updated data from a September 2022 Frontline Nursing Survey of 368 frontline nurses providing direct patient care in the United States (see sidebar "About the study"). We provide these insights as a resource for organizations to help them continue to attract, support and retain a dynamic workforce and promote long-term workforce stability.

what happened among the paramedics

Nursing staff turnover remains a significant challenge for healthcare organizations, as intentional turnover remains high. In our most recent Nursing Survey, 31% of respondents indicated that they were likely to leave their current role in direct patient care, a figure that has stabilized over the past 6 to 12 months but remains higher than observed in 2018 A rate of 22%Our first survey in February 2021(Exhibit 1).1 Gretchen Berlin, Meredith Lapointe, and Mhoire Murphy, “Nurses Surveyed Consider Leaving Direct Patient Care at Higher Rates,” McKinsey, February 17, 2022; Gretchen Berlin, Meredith Lapointe, Mhoire Murphy, and Molly Viscardi, “2021 of care: Retaining healthcare workers when we need them most”, McKinsey, 11 May 2021.Our research further shows that intention to leave varies across contexts. For example, resident RNs reported consistently higher turnover intentions than the average for all RNs surveyed. In our recent Pulse survey of resident RNs, we saw the willingness to leave rise again, from 35% in fall 2022 to over 40% by March 2023.

1

A recent analysis of research comparing turnover intentions to actual turnover rates shows meaningful jumps in both during 2021. A study from Nursing Solutions Inc. (NSI) indicated that the actual reported hospital and employee RN turnover rate increased from 18% in FY 2020 to 27% in FY 2021; the same study in March 2022 reported that, The 2021 workforce will lose about 2.5 percent of registered nurses.22022 NSI National Healthcare Retention and RN Staffing Report, NSI Nursing Solutions, March 2022.In the latest NSI report (March 2023), turnover fell to 23% in FY 2022, but remains elevated compared to pre-pandemic levels.32023 NSI National Healthcare Retention and RN Staffing Report, March 2023.A Health Affairs study released in April 2022 found that by the end of 2021, the registered nurse workforce would fall by about 100,000 people, a "significantly greater decline than has been observed at any point in the past 40 years." This decline was particularly pronounced among nurses in the mid-term (ages 35 to 49).4David Auerbach, Peter Buerhaus, Karen Donelan, and Douglas Staiger, “A worrying decline in the number of young nurses,” Health Affairs Forefront, 13 April 2022.In terms of where they go, nurses either leave the profession entirely or simply change employers or roles. About 35% of respondents to our recent survey who indicated they were likely to leave indicated they would continue to provide direct patient care (i.e., in a different employer or role). The remainder said they intended to leave the bedside for indirect patient care work to pursue a different career path or education, or exit the workforce entirely.

With this continued high turnover and correspondingAmerica's health care turmoil continues, it is more important than ever for healthcare organizations to design and deploy programs that respond to and address workforce needs. Most healthcare organizations have learned that attracting and retaining nursing talent in the post-pandemic era requires a more nuanced understanding of what nurses are looking for in their careers and in employers.

The four Frontline Care Surveys we conducted over the past two years have given us insight into the factors driving attrition and retention. Frontline care respondents consistently ranked flexibility, meaning, and balance as the most important factors influencing their decision to continue direct patient care (Exhibit 2). Recognition, open lines of communication, and embedding time off into the operating model (e.g., during shifts, between shifts, and formal paid time off) were consistently rated as top initiatives to support well-being.

2

The nursing workforce has changed during the pandemic, and so have strategies aimed at attracting and retaining the workforce of the future. First, structural solutions that help ensure a manageable workload—for example, consistent support staff, a secure environment, reduced documentation and administrative requirements, predictability of schedules, and the ability to take paid time off— Still crucial. Nurses surveyed who had left a direct patient care role in the past 18 months cited undervalued, unmanageable workloads and inadequate compensation as the top factors in their decision to quit (Exhibit 3). There is no one-size-fits-all solution, but many healthcare organizations have adapted their approaches and implemented interventions that appear to be yielding results.

3

What stakeholders can do in the short term

Our recent survey found that 75% of nurses who left their jobs in the past 18 months said not being valued by their organizations was a factor in their decision. In addition, 56% of respondents indicated that proper recognition of nurses' contributions was the most effective move to support well-being. Nurses surveyed suggested a variety of ways to address perception gaps, including simple acknowledgment, appreciation for excellence, and reinforcement through wider workplace culture and on-site support.

Many healthcare systems have found ways to implement nurse recommendations. While more research is needed to understand the full impact of these efforts, they may serve as a short-term starting point to indicate support for the workforce.

At the Orlando VA Medical Center, an "Employee Benefits Center" was created to address the burnout and stress caused by the pandemic. Setting up a dedicated quiet space with amenities such as virtual reality headsets, aromatherapy and sound generators, as well as snacks and beverages had a measurable positive impact on employees’ overall health engagement scores, with less burnout, higher Increased retention and overall happiness. As a result of these improvements, the program has expanded to more than a dozen medical centers in the Veterans Health Administration's network.5 “Employee Benefits Center and Cart,” VA Diffusion Marketplace, accessed April 2023.

Some health systems have adopted digital tools to ensure that tailored identification can be delivered in a timely and meaningful manner. For example, nurse managers at Orange Coast Medical Center in Fountain Valley, California, use post-it notes, dig into emails, spreadsheets, and other manual processes to remind them which nurses do something worthy of recognition, or to schedule meetings to help other nurses improve theirs. Work. These identification processes, while meaningful, are time-consuming for nurse managers.6 “Frontline nurses are burnt out. This digital health startup is trying to change that,” Laudio, 13 May 2022.

To maintain this instant recognition and reward larger milestones, Orange Coast implemented the Laudio technology platform, which enables frontline leaders to monitor and manage team activity and performance. Use of the system has shown that one meaningful or high-quality interaction per team member per month can reduce attrition by 36%.7 “Frontline Nurses Are Burning Out. This Digital Health Startup Is Trying to Change That,” Laudio, 13 May 2022.In addition to tracking events and reminding managers of things to do with specific nurses, Laudio can also send digital cards and notes to nurses in recognition of their excellence.

As disturbing incidents involving visitors and patients continue to increase, safety is increasingly a top concern for nurses.8Christine Porath and Adrienne Boissy, “Depressed Patients Make Health Care Workers’ Jobs Harder,” Harvard Business Review, May 14, 2021.In our most recent survey, 42% of nurses said not having a safe work environment was an extremely or very important factor in their decision to leave direct patient care, up from 24% in March 2022.

To address safety concerns and incivil behavior, UMass Memorial Medical Center in Worcester, MA has developed a patient and visitor code of conduct. At the entrance to the facility, visitors are asked to sign an agreement to abide by formally stated behavioral parameters and expected codes of conduct. In addition, UMass has created talking points for employees to use in responding and defusing contentious situations. In just over a month of piloting, the hospital collected 56,000 signed agreements and only asked four visitors to leave the hospital.9Christine Porath, “Working on the Front Lines When Everyone’s Angry,” Harvard Business Review, 9 November 2022.

In addition to deploying more effective strategies to support and retain employees, healthcare executives can also look for ways to better attract talent in the short term. To recruit staff, health systems should ensure that their value proposition is aligned with what nurses believe are the most important workplace elements—especially if pay differentiation is less feasible. Aya Healthcare, a healthcare talent software and human resources company, has found that hospitals deemed great places to work are paying less to secure talent throughout the pandemic. In fact, labor compensation rates at hospitals deemed great places to work were 11 percent lower than those without this advantage.10April Hansen, "The value of a good reputation (or the cost of a bad one...)", The Staffing Stream, 8 April 2021.

What stakeholders can do in the medium term

In the medium term, finding ways to incorporate flexibility into work schedules is a move that 63% of nurses surveyed felt would work best for their well-being. We saw a similar response for nurses deciding to stay in their current positions: 86% cited flexible work schedules as a reason, second only to "doing meaningful work." The nature of nursing work—often specialized and always in demand—can make offering schedule flexibility seem daunting. But the health system has taken several creative approaches to address the problem.

For example, Mercy Health System launched Mercy Works on Demand, a system-wide on-demand platform that allows its full-time and part-time nurses, as well as other experienced nurses, to choose their hours. Through the platform, Mercy has hired about 1,100 people they call gig nurses and increased its overall hiring rate by two percentage points.11Kelly Gooch, “How Mercy embraces the mindset of nursing work,” Becker Hospital Review, 5 Dec. 2022.But flexibility means different things to different people, adding to the complexity for employers. Charting a path forward requires a nuanced understanding of the employee value proposition and which options resonate with them.

Work flexibility is at the heart of many health system strategies, not only to attract new talent but also to welcome back nurses who left during the pandemic. By offering flexible work opportunities, Henry Ford Health has been able to recall 25% of its departing nurses. Nursing leadership worked closely with Henry Ford Health's human resources department to design flexible options, such as the ability to work in different settings (for example, inpatient, outpatient, or virtually) or on weekends only. The health system has also created fixed-term positions for nurses who do not want to work full-time on a long-term basis, with the option to convert to permanent positions after their tenure ends.12Mackenzie Bean and Erica Carbajal, “How Henry Ford Rehired 25% of Nurses Who Left During the Pandemic,” Becker’s Hospital Review, February 15, 2023.

As in other professions, the flexibility of remote work is becoming increasingly important to some nurses. Trinity Health has launched a virtual care model that allows more experienced nurses to continue caring for patients, but away from the bedside. The new virtual model opens the door for nurses who may be physically tired from in-person care and those who prefer to work from home. Additionally, the program enables virtual nurses to support bedside teams and improve the patient experience by providing patients with more opportunities to interact with nurses. The program is being rolled out at 88 Trinity hospitals across the country.13Giles Bruce, “Trinity Health Plans to Install Virtual Nurses at 88 of Its Hospitals in 26 States,” Becker Hospital Review, Jan. 13, 2023.

What stakeholders can do in the long run

As health systems look beyond retaining their existing workforce and meeting anticipated demand for nursing talent, they can also play a role in building a long-term pipeline by investing in newly graduated nurses and ensuring the infrastructure needed to successfully enter the profession.

For example, Dignity Health has made significant investments in long-term pipeline building through a joint venture between Dignity Health Global Education and Global University Systems. The partnership offers online degrees to advance the education, training and development of the healthcare workforce. The joint venture covers technical, professional, executive and leadership training, and provides healthcare professionals with a range of flexible, accessible and affordable educational opportunities to advance their careers. It also has a scholarship fund to remove financial barriers to education and increase equity in health care. Dignity Health Global Education now has one of the most comprehensive care residency programs, offered in 21 states.14 “Dignity Health and Global University Systems Announce Joint Venture to Expand Education of Health Professionals Worldwide,” Global University Systems press release, January 30, 2019.

The promise of building a long-term talent pipeline goes beyond personal hygiene systems. Numerous city and regional partnerships have been established across the United States to bring together key stakeholders in the healthcare ecosystem to provide training and upskilling for unemployed and underemployed job seekers to enter the healthcare industry. For example, the Birmingham Regional Health Partnership, the result of close collaboration between government, healthcare employers and other community partners, including the Birmingham Business Alliance and Innovate Birmingham, received a $10.8 million grant from the Good Jobs Challenge, using To train and place more than 1000 job seekers in the area.15 “Birmingham secures $10.8m ‘Good Jobs Challenge’ grant”, Birmingham City Council press release, 3 August 2022.Similar partnerships exist in Chicago, Baltimore, Philadelphia, and more to build healthcare worker pipelines and create meaningful career opportunities for historically excluded job seekers.16BACH Quarterly Newsletter, Baltimore Alliance for Healthcare Professions, Accessed April 2023; "Cutting Ribbon for New West Philly Skills Program Headquarters", University City, March 29, 2023; CHWC Overview and Update - February 2021, Chicagoland Healthcare Workforce Collaborative, updated March 10, 2021.

Other stakeholders are taking action at the national level. With an $80 million budget for 2022, the U.S. Department of Labor encourages nonprofits, educational institutions and tribal organizations to apply for grants of up to $6 million each to train current and former nurses to become nursing educators and frontline healthcare workers to train for the nursing profession.17 “DOL Care Expansion Grant Program: Total Funding Available: Up to $80 Million,” U.S. Department of Labor, Employment and Training Administration, 2022.The program emphasizes increasing workforce diversity and building partnerships with community-based organizations and training institutions.

Retaining the current nursing workforce, while looking ahead to the long-term talent pool, is critical to addressing the projected shortage of registered nurses. There is no single answer to the challenges healthcare organizations face, and in fact they are already beginning to take steps to meet the stated needs of nurses through short-, medium- and long-term strategies to attract, strengthen and develop a vibrant nurse workforce. More work to come Do, especially in terms of considering frontline voices and addressing the core drivers behind nurses' planned departures. We are optimistic that the problems facing the nursing profession can be resolved, but it will require concerted and focused attention from many parties.