There aren’t enough workers to hire, and the challenge is here to stay

While overall hospital RN turnover has decreased since last year, it remains too high. The cost of each RN that turns over has increased by 13% in the last year. Health systems and hospitals across the country are dedicating significant resources to recruiting RNs to fill high vacancy rates. NSI reports that 37% of hospitals plan to increase their recruitment budget and 20% plan to increase recruitment (HR) staff.

At the same time, nearly 70% of hospital organizations intend to increase overall RN positions in 2023. To recruit more RNs, many organizations continue to rely on compensation adjustments. Despite these investments, hiring nurses became more difficult over the past year, with the RN difficulty index (time to fill) increasing from 87 days in 2021 to 95 days in 2022.

Our survey found that nurse leaders across all regions and positions report that “market shortage of qualified RN candidates” is their number one concern. According to AACN, for the first time in 20 years, nursing school enrollment has decreased. Retirements continue to outpace the number of new entrants into the nursing field. Nurse leaders are aware of this and reported “academic pipeline not keeping up with projected RN demand” as another top concern in the Advisory Board survey. 

The ability to recruit unlicensed, frontline workers is also a top concern reported in our survey. Frontline workers such as Certified Nursing Assistants (CNA) are essential to supporting RN work. Despite a small decrease in the past year, CNA turnover is still extremely high. Building up this workforce will require strong, long-tern retention and recruitment strategies

Competition at an all-time high for licensed and unlicensed workers

RNs have a plethora of employment options that offer competitive compensation and appear more conducive to work-life balance than working in a hospital environment. Despite this, nurse leaders reported in our survey only moderate concern about hospital/health system ability to compete with nontraditional healthcare employers for RN talent. Given market shortages, leaders must pay more attention to options for competing with non-hospital healthcare employers. Organizations must understand what non-hospital employers offer to RNs and identify the most effective and feasible options for countering these advantages.

There is also strong competition for unlicensed workers. These workers have a variety of other employment options both within and outside the healthcare industry that offer competitive compensation as well as other benefits. Nurse leaders report “recruitment of unlicensed entry level workers” as a top concern on our survey. It is important to understand what other industries offer these essential employees and determine ways to retain them. 

Continued overreliance on agency labor is financially unsustainable 

As turnover and vacancies increased during the height of the pandemic, hospitals substantially increased their utilization of traveling nurses as an interim staffing solution. Despite the pandemic being stabilized, NSI reports that nearly 80% of hospitals predict the same level of external agency use in 2023 as in 2022. However, this tactic is financially unsustainable. While pay rates for travel nurses have decreased nearly 20% this past year, the average hourly rate for a traveler remains almost double that of a permanent employee. The expenses associated with overreliance on travel nurses further burdens an already strained labor budget and does nothing to address underlying issues that make hiring more difficult.

Retention outweighs recruitment for workforce stability.

In the immediate, access to qualified RNs make ambitious hiring goals difficult. With costs of RN turnover increasing, focus on retaining the nurses you already have. Reallocate more of your investments toward retention at this time. However, maintain current efforts to improve both your current pipeline through innovative recruitment, as well as consider creative ways to cultivate the academic pipeline moving forward.

Overall retention numbers masked increases in early-career turnover

There has been notable progress in overall hospital RN turnover in the past year, which demonstrates that various retention strategies are starting to make a difference. Despite this progress, novice/first-year RN turnover increased. This shows that there are generational issues that need to be addressed.

Transition support isn't the only need

Hospitals currently offer comprehensive support for novice nurses as they transition from academia into practice. For example, extended onboarding, longer residencies, more comprehensive coaching, and mentorship programs have all been implemented to support new graduates as they transition into the profession. While transition strategies are essential, retention of early-career nurses requires equal attention to their unique generational expectations for the work environment.

Early-career RNs have specific expectations of their employers

The ANF Three-Year Annual Assessment survey shows clear generational differences on drivers of workplace satisfaction. Overall, 58% of RNs cite work-life balance as a top driver; that rate increases to 63% for early-career RNs. Younger nurses also cite increased expectations for advancement potential, professional development opportunities, and flexible work schedules as compared to more tenured staff. Hospitals will need to create an employee value propositions that is unique for this workforce segment. Competing with nontraditional healthcare employers can be especially challenging for hospitals, as they may not see easy options for offering work flexibility. Hospitals and health systems will need to develop role, shift, and scheduling alternatives that align with both the work needs of the unit as well as the employment preferences of nurses. The 2022 Survey of Perceived Organizational Support (SPOS) from Statistic Solutions also showed generational differences in nurse satisfaction with their employers. Early-career nurses in the acute-care setting reported the lowest scores among all nurses, illustrating that they do not feel supported and valued by their organizations. Executives need to carefully examine these unique generational expectations and determine responsive solutions.

A retention strategy focused on generational differences with outsized efforts to address the needs of novice and early-career nurses will reduce turnover.

 While overall RN turnover has decreased over the past year, first-year turnover continues to increase. Nurse leaders need to understand what early-career nurses need to feel satisfied and supported. Addressing those needs in creative ways will be essential to stabilizing the RN workforce.

Burnout is worse than ever, but it has always been an issue

The clinical environment is stressful, and burnout has always been a workforce challenge. However, various studies report that RN burnout is at an all-time high, especially among novice staff. The direct correlation between unresolved burnout and turnover is clear. Our survey also reports that nurse leaders are concerned about the impact of burnout on quality, safety, and the patient experience. Hospital leaders have historically viewed burnout as an inability of the individual to cope with the stress of the job. The typical playbook for addressing burnout, including arming employees with self-help and wellness tools, will not be enough to make real progress today. Leaders must also address the work environment itself. Burnout is worse than ever, but it has always been an issue We recommend focusing on three areas to address burnout:

• Address core elements of the work environment that stress RNs. Root out dysfunctional, non-value-added tasks that contribute to burnout, and eliminate or automate this work as much as possible. 
• Examine work incivility at the unit level. This is important along with efforts to decrease violence from patients and families, as well as other facility safety measures. ANF reports that 53% of nurses indicate verbal abuse has increased since the pandemic began. Many RNs don't know how to even report this abuse, let alone manage it. Additionally, our survey found that nurse leaders are very concerned about the level of abuse and violence directed at staff. Employees of all disciplines, including RNs, do not feel safe when work incivility exists. Failure to address this form of abuse will lead to increased burnout.
• Ensure all RNs have the necessary tools and support to cope with the perpetually stressful, emotional work environment. A comprehensive employee assistance program (EAP) is foundational. Other efforts that have been proven to reduce stress include the availability of chaplains, guaranteed break and mealtimes, leadership rounds, and Schwartz rounds. These types of efforts are especially important for early-career staff. Today’s nursing students have greater anxiety, emotional stress, and mental health needs than students before the pandemic. In addition, ANF reports that early-career nurses are struggling more with their emotional health than their more experienced colleagues. Almost a third of early-career staff report not being emotionally healthy compared to just 8% of more tenured nurses. Introduce early-career nurses to self-help and wellness support systems as part of employment orientation and reinforce these options throughout employment. 

Our survey found that nurse managers report their ability to influence burnout at levels far less than system CNEs and site CNOs. Organizations should confirm the root cause of these perceptions because research shows that nurse managers have a strong impact on retention because of their relationship with staff nurses. System CNEs and site CNOs should ensure that nurse managers have the skills, tools, and ability to detect if burnout is increasing on their units. And most importantly, these executives should ensure that nurse managers have time to address burnout at the unit level.

What we can’t control

Even if an organization has the best programs in place to cope with stress and burnout, employers can't control whether RNs use them or not. The stigma associated with turning to one’s employer for emotional or mental health support is decreasing, but it remains. Employers need to consistently inform all clinicians of what tools and support programs are available. And they need to provide managers and leaders with ways to assess RN burnout. There are also larger societal issues at play. Violence has increased in all aspects of society. All organizations should have zero-tolerance policies for patients and families regarding violence and unacceptable behaviors. However, it's important to note that healthcare organizations can't address the societal issue of increased violence on their own.

Be assertive but realistic about the causes of burnout you can eliminate and which ones you can mitigate.

National conversations around burnout in the healthcare industry as well as in many other industries can be discouraging. This has created an environment where burnout may seem inevitable and not influenceable. Don’t let this curtail your efforts. Acknowledge that employee burnout is a multifactorial issue, with various root causes that may be beyond our direct control. Focus on the aspects of burnout that you can control.

Change in care models marked by slow progress

Our survey found that nurse leaders’ top concerns include a lack of available RN applicants in their market, continued escalation of RN labor costs, and unresolved RN burnout. At the same time, NSI reports that top recruitment and retention strategies include asking RNs to volunteer for overtime, authorizing critical staffing pay, flexing part-time or per diem RNs, increasing the RN salary scale, as well as continuing to use travelers — all of which actually add to total labor spend.

Remarkably, NSI reports that only 17% of hospitals have changed their care delivery model as a recruitment and retention strategy. Staffing model innovation should be the rule, not the exception.

Move past pilots

Many organizations have piloted new models for care. But given the scarcity of RNs in local markets and documented pipeline shortages, leaders must move past care model pilots and scale staffing model changes as safely and efficiently as is possible.

ANF reports that many RNs are looking for “meaningful work” from their employer. Care model innovations should include:

• Redesigning the role of the bedside nurse in sync with scope of practice and prioritizing ”meaningful work”
• Addressing dysfunctional operational processes that are burdensome and waste time
• Designing a comprehensive entry-level and unlicensed worker strategy for non-RN roles on the care team
• Evaluating virtual care technology to extend RN bandwidth by assuming select, non-patient facing-tasks and providing immediate support and coaching to novice staff

Optimizing technology is imperative

Many clinical leaders underestimate the potential for clinical technology to support nursing work. In addition to virtual technology, consider options to streamline burdensome administrative work, support clinical decision-making, and provide patients with self-management technology. Staffing model innovation should be part of an organization's technology agenda, not a separate idea.

Nurse leaders must elevate their concerns about limited technology investment allocated to non-physician workflows. Strategic technology discussions between CFOs, CNOs, CIOs, and chief strategy officers are essential to ensure technology investments are allocated to the most pressing workforce needs.

Be courageous — accept ambiguity and early risk

It's not surprising that only 17% of hospitals have changed their care models to help with recruitment--this is difficult work and the payoff won't be felt immediately. But today’s employment market realities demand transformational approaches to care and staffing models. Leaders will need to challenge organizational, professional, and cultural norms. Innovation will also require leaders to tolerate early ambiguity and risk. The need for close monitoring and measurement as changes are put in place cannot be overemphasized.

Likewise, provide authentic opportunities for staff to participate in the design of new care and staffing models. This will help with buy-in, as well as provide the opportunity to address RN concerns about “meaningful work.” Sufficient resources for staff development, training, change management, and ongoing monitoring are all required to accelerate model redesign at the pace needed.

Scaled care model redesign is the only sustainable long-term solution to workforce shortages.

Pilots are important to test alternatives to the status quo but must be quickly scaled once tested. Investments required to scale staffing model innovations are substantial, but they have the potential to stabilize the workforce over the long term.

The pandemic damaged the image of nursing

The nursing profession has historically been recognized by the American public as the most trusted of all healthcare professions. During the height of the pandemic, this image was reinforced by countless demonstrations of communities extending overwhelming gratitude for sacrifices made by all clinicians, including nurses, to care for covid patients, despite incredibly stressful working conditions and threats to personal health. Images of exhausted staff, working long, hard hours, often without adequate supplies and resources to address covid care, were repeatedly broadcast on the national airwaves. In addition, nursing students experienced dramatically compromised clinical rotations; but when allowed to enter the inpatient care environment, students witnessed the work environment challenges faced by permanent employees. Three years later, those images have not been replaced by anything positive. Instead of highlighting the joy and sense of personal value in supporting patients and families in acute care facing significant healthcare challenges, broadcast and social media now report on severe clinician shortages, chronic burnout, and extremely stressful working conditions in the inpatient care environment. For the profession of nursing, the image of a career in acute care has been unfortunately tarnished and is serving as a deterrent to both recruitment as well as retention.

Health system leaders have lost control of the narrative about acute care careers

In the current climate of RN burnout and staffing shortages, there are many sources contributing to the narrative about a professional nursing career in acute care. These sources are both internal and external, and they contribute to RN attitudes about the viability of a long-term career in acute care systems, as well as willingness to abandon acute care employment for other options. Health systems need to regain control of the narrative by mobilizing marketing and communications teams to control the narrative surrounding acute care careers both internally and externally.

Launch an external campaign to restore the image of acute care nursing

Health systems spend millions of dollars annually marketing to consumers and payers to grow market share. While this is understandable, marketing resources must be leveraged to rebuild the image of acute care nursing practice in the minds of the American public. Hospital websites that describe the nursing enterprise and various attributes as well as career opportunities are not enough. Keep in mind there is a generational difference in how information is received. Younger generations rely heavily on social media for communication. Utilize all available venues to broadly communicate externally. These include:

• Social media campaigns
• Media outlets
• Partnering with the chamber of commerce, primary, secondary, trade, and nursing schools
• Participating in advocacy efforts for nursing education and work environment needs at local, state, and federal levels.
• Work with academic partners to explore meaningful communication opportunities with students and partners, including permanent employees regarding careers in acute care

Tailor internal communications about careers to frontline staff concerns

Keep staff fully informed on what you are doing to address their concerns. Be sensitive to other messages being shared.

• Regularly update your staff on efforts to market, recruit, interview, and hire staff.
• Update your staff on steps you are taking to prioritize work-life balance
• Communicate what you are doing to address abuse and violence to ensure the safety of your staff.
• Maintain multiple venues for staff to provide feedback.
• Seek suggestions from RNs for continued improvements and what they need to stay in their positions.
• Ensure that employees at the unit level understand the influence that they have on students doing clinical rotations and use that influence to communicate the value of an acute care career.

Take control of the narrative on acute care employment.

Implement a combination of internal and external communication strategies to repair the image of acute care. Focus on the joy and sense of personal value that nursing offers. Internally, communicate intentionally with your staff and seek their input on ways to address their concerns. Externally, allocate marketing resources to address the public image of acute care employment within the broader community. Make clear within your organization what efforts are being taken externally.