When we tabulated the results of our first nationwide nursing survey almost two years ago, we were surprised to see such a high reported likelihood of nurses planning to leave their jobs—and we did not expect this trend to persist for such an extended period of time.
But that is what has happened in the wake of the COVID-19 pandemic. In fact, we have seen some of this reported anticipated turnover actually occur, as well as a decrease in the overall active nursing workforce. And there is still cause for concern: today, 31 percent of nurses still say they may leave their current direct patient care jobs in the next year, according to our most recent survey. That said, we are cautiously optimistic that some of the practices implemented by healthcare organizations to improve the experience of nurses are bearing fruit.
In this article, we share the latest data from our September 2022 frontline nursing survey of 368 frontline nurses providing direct patient care in the United States (see sidebar, “About the research”). We offer these insights as resources for organizations as they continue their journeys of attracting, supporting, and retaining a vibrant workforce, as well as promoting longer-term workforce stability.
What’s been happening in the nursing workforce
Nursing turnover continues to be a substantial challenge for healthcare organizations as the number of individuals with the intent to leave their jobs remains high. In our most recent nursing survey, 31 percent of respondents indicated they were likely to leave their current role in direct patient care, a figure that has stabilized over the past six to 12 months yet is still higher than the 22 percent rate observed in our first survey in February 2021 (Exhibit 1). Our research further shows that the intent to leave varies across settings. For example, inpatient registered nurses (RNs) have consistently reported a higher intent to leave than the average of all surveyed RNs. In our most recent pulse survey of inpatient RNs, we saw intent to leave rise again, from 35 percent in fall 2022 to over 40 percent in March 2023.
Recent analysis of studies comparing intent to leave to actual turnover show that both jumped meaningfully over the course of 2021. A study from Nursing Solutions Inc. (NSI) showed that actual reported hospital and staff RN turnover increased from 18 percent in fiscal year 2020 to 27 percent in fiscal year 2021; the same March 2022 study reported that the workforce lost about 2.5 percent of RNs in 2021. In the latest NSI report (March 2023), turnover reduced to 23 percent in fiscal year 2022 but still remains elevated compared with prepandemic levels. A Health Affairs study published in April 2022 found that the RN workforce fell by about 100,000 by the end of 2021, which is a “far greater drop than ever observed over the past four decades.” This decline was particularly pronounced among midtenure nurses (aged 35 to 49). In terms of where they are going, nurses are both leaving the profession entirely as well as simply changing employers or roles. About 35 percent of respondents to our most recent survey who indicated they were likely to leave said they would remain in direct patient care (that is, at a different employer or role). The remainder said they intended to leave the bedside for nondirect patient care roles to pursue different career paths or education or to exit the workforce entirely.
With this persistently high turnover and the corresponding gathering storm in US healthcare, it is more important than ever for healthcare organizations to design and deploy initiatives that respond to and address workforce needs. Most healthcare organizations have learned that attracting and retaining nursing talent in the postpandemic era will require a more nuanced understanding of what nurses are looking for in a profession and an employer.
Our four frontline nursing surveys over the past two years have enabled us to glean insights into factors contributing to both attrition and retention. Frontline nursing respondents have consistently ranked elements of flexibility, meaning, and balance as the most important factors affecting their decision to stay in direct patient care (Exhibit 2). Recognition, open lines of communication, and embedding breaks into the operating model (for example, during shifts, between shifts, and formal paid time off) have consistently been rated as the top initiatives to support well-being.
The nursing workforce has evolved over the course of the pandemic, and the strategies aimed at attracting and retaining tomorrow’s workforce have evolved as well. To start, structural solutions that help to ensure a manageable workload—for example, consistent support staff, a safe environment, reduced documentation and administrative requirements, predictability of schedule, and ability to take paid time off—continue to be critical. Surveyed nurses who left a direct patient care role in the past 18 months indicated that not being valued, unmanageable workloads, and inadequate compensation were the top factors in their decision to exit (Exhibit 3). There are no one-size-fits-all solutions, but many healthcare organizations have adapted their approaches and carried out interventions that appear to be yielding results.
What stakeholders can do in the short term
Our most recent survey found that 75 percent of nurses who left a job in the past 18 months reported that not being valued by their organization was a factor in their decision. In addition, 56 percent of total respondents reported that appropriately recognizing nurses for their contributions was the most effective initiative to support well-being. Surveyed nurses suggested various ways to respond to the recognition gap, including simple acknowledgement, appreciation of excellence, and reinforcement through broader workplace culture and support in the field.
Many healthcare systems have found ways to implement the nurses’ suggestions. While more research is needed to understand the full impact of these efforts, they may be helpful short-term starting points in the attempt to show support for the workforce.
At the Orlando VA Medical Center, “Employee Well-Being Centers” were set up to address the burnout and stress caused by the pandemic. Setting up a dedicated quiet space with amenities like virtual-reality headsets, aroma therapy, and sound machines, as well as snacks and beverages, resulted in a measurable positive impact on Employee Whole Health engagement scores and decreased feelings of burnout, higher retention, and increased overall well-being. As a result of these improvements, the program has expanded to more than ten medical centers across the Veterans Health Administration network.
Some health systems have employed digital tools to ensure that tailored recognition can be delivered in a timely and meaningful way. For example, nurse managers at the Orange Coast Medical Center in Fountain Valley, California, were using sticky notes, mining emails, spreadsheets, and other manual processes to remind them which nurses did what to deserve recognition or to schedule meetings to help other nurses improve their work. While meaningful, these recognition processes were time-consuming for nurse managers.
To sustain both this type of in-the-moment recognition and to reward bigger milestones, Orange Coast implemented the Laudio technology platform, which enables frontline leaders to monitor and manage team activity and performance. Use of this system has shown that one meaningful, or high quality, interaction per team member per month can reduce turnover by 36 percent. In addition to keeping track of events and alerting managers about matters to engage in with specific nurses, Laudio can send digital cards and notes to nurses to acknowledge high performance.
Safety is also increasingly top of mind for nurses, as troubling incidents involving visitors and patients have risen. In our most recent survey, 42 percent of nurses indicated that not having a safe working environment was an extremely or very important factor affecting their decision to leave direct patient care, up from 24 percent in March 2022.
To address safety concerns and incivility, UMass Memorial Medical Center in Worcester, Massachusetts, developed a patient and visitor code of conduct. At the entrances to facilities, visitors are asked to sign an agreement to adhere to a code of conduct that formalizes parameters and expectations of behavior. In addition, UMass created talking points for employees to use to respond to and de-escalate contentious situations. In just over a month of piloting the program, the hospital collected 56,000 signed agreements and only asked four visitors to leave the premises.
In addition to deploying more effective strategies to support and retain employees, healthcare executives can look at ways to better attract talent in the near term. To recruit staff, health systems should ensure that their value proposition is aligned to the workplace elements that nurses consider most important—especially when differentiating on compensation is less feasible. Aya Healthcare, a healthcare-talent software and staffing company, found that hospitals seen as a great place to work paid less to secure talent throughout the pandemic. In fact, hospitals seen as great places to work had labor compensation rates 11 percent lower than those without this advantage.
What stakeholders can do in the medium term
In the medium term, finding ways to incorporate flexibility into work schedules is an initiative that 63 percent of surveyed nurses ranked as the most effective for their well-being. We saw similar responses regarding nurses’ decision to stay in their current position: 86 percent cited a flexible work schedule as the reason, which ranked second after “doing meaningful work.” The nature of nurses’ work—typically specialized and always in demand—may make providing schedule flexibility seem daunting. But health systems have pursued several creative ways to address the issue.
For example, the Mercy health system launched Mercy Works on Demand, a systemwide on-demand platform that allows its full- and part-time nurses as well as other experienced nurses to select when they work. Through the platform, Mercy has hired about 1,100 individuals they are calling gig nurses and have improved overall fill rates by two percentage points. But flexibility means different things to different people, which has increased complexity for employers. Charting a path forward will require a nuanced understanding of the employee value proposition as well as what options resonate with the workforce.
Job flexibility is at the center of many health systems’ strategies to not only attract new talent but also to welcome back nurses who left during the pandemic. Henry Ford Health has been able to bring back 25 percent of the nurses who left by offering flexible opportunities. Nursing leaders 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 virtual) or to work only on weekends. The health system also created fixed-term positions for nurses who didn’t want full-time permanent jobs, with the option to transition to permanent roles once their term was up.
As in other industries, the flexibility to work remotely has become increasingly important to some nurses. Trinity Health launched a virtual-care model, allowing more experienced nurses to continue providing patient care but away from the bedside. The new virtual model opens the door to nurses who may be physically tired from the demands of in-person care and to those who prefer to work from home. In addition, this program has enabled the virtual nurses to provide support to teams at the bedside and to improve patient experience by giving them more chances to interact with a nurse. The program is being rolled out across Trinity’s 88 hospitals nationwide.
What stakeholders can do in the long term
As health systems look beyond retaining the current workforce and meeting the expected demand for nursing talent, they could have a role to play in building a longer-term pipeline through investing in new-graduate nurses and in the infrastructure required to ensure successful onboarding into the profession.
For example, Dignity Health has invested heavily in longer-term pipeline building through a joint venture between Dignity Health Global Education and Global University Systems. The partnership offers online academic degrees to further the education, training, and development of the healthcare workforce. The joint venture spans technical, professional, executive, and leadership training and provides a range of flexible, accessible, and affordable education opportunities for healthcare workers to advance their careers. It also has a scholarship fund to remove financial barriers for education and to increase equity in healthcare. Dignity Health Global Education now has one of the most comprehensive nursing residency programs, available in 21 states.
The commitment to building a longer-term talent pipeline has expanded beyond individual health systems. Many city and regional partnerships have developed across the United States, bringing together critical stakeholders across the healthcare ecosystem to train and upskill unemployed and underemployed job seekers into healthcare occupations. For example, the Birmingham Region Health Partnership, the result of close collaboration among government, healthcare employers, and other community partners, including Birmingham Business Alliance and Innovate Birmingham, won a $10.8 million grant from the Good Jobs Challenge to train and place over 1,000 jobseekers in the region. Similar collaborative partnerships exist in Chicago, Baltimore, Philadelphia, among others, to build a pipeline of healthcare workers and to create meaningful career opportunities for historically excluded job seekers.
Other stakeholders are taking action at a national level. In 2022, the US Department of Labor budgeted $80 million to encourage not-for-profit organizations, 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 nursing careers. 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 longer-term talent pipeline will be critical to meeting the projected shortfall in registered nurses. There isn’t one answer to the challenges confronting healthcare organizations, and indeed, they have begun taking steps to address nurses’ stated needs through short-, medium-, and longer-term strategies that attract, strengthen, and grow a vibrant nurse workforce. There is more to be done, especially in taking account of the voices of the front line and addressing the core drivers behind why nurses are planning to leave. We are optimistic that the issues facing the nursing profession can be addressed, but this will require consistent and dedicated attention from many parties.