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February 16, 2022

The nursing shortage, discussed: A conversation with Advisory Board's top nursing experts

Daily Briefing
    Andrew Mohama

    I spend every day reading and writing about health care. Over the past two years, every health care challenge has been filtered through the lens of the Covid-19 pandemic. And that should come as no surprise—the health care world is a radically different place today. Many of these challenges ebb and flow with the pandemic, like a rollercoaster ride that just never seems to end.

    But there is one issue that has been on a worsening trajectory for far too long, stemming from even before pandemic times. Seen as a national, if not a global crisis, it could be the most pressing problem in health care today: the nurse staffing shortage.

    Covid-19 exposed deep and painful gaps in all realms of health care, with an especially damaging impact on delivery and operations, and all clinical staff have paid high consequences. Nurses are among the hardest hit.

    It's worth questioning: As Covid-19 stabilizes, will the nursing shortage subside?

    After plenty of conversations with leading experts on the matter, I'm here to tell you the hard and fast truth: it won't. The longer we fail to acknowledge this reality, the more difficult it will be to address—both from an individual health system perspective and from the larger national level.

    I wanted to speak directly with two of Advisory Board's top experts on nursing and the clinical workforce, Carol Boston-Fleischhauer and Monica Westhead. We dissect everything from how chief nursing executives see the current staffing environment to reasons why this shortage is so different.

    One big takeaway? We should be prepared for the nursing shortage long haul.

    An edited and condensed transcript of the conversation follows below.

    Participants:

    Today's nursing challenge, discussed

    Question: We are more than two years into the Covid-19 pandemic. Covid-19 has ebb and flowed, but we know the nursing shortage has unfortunately been constant and even gotten worse. Can you help paint the picture of just how serious this shortage really is today?

    Carol Boston-Fleischhauer: I have spoken with plenty of health care executives, and here's the thing: No one is saying that this nurse staffing shortage is turning around. Everyone seems to be in the trenches trying to figure out what to do. I am truly not hearing one story from any executive that this crisis is getting better. And the data supports this too, with C-suite concern increasing. The new ACHE survey found that hospital CEOs' top concern is personnel shortages, with 94% of CEOs saying that a lack of RNs was the most pressing staffing issue.

    Monica Westhead: I echo what Carol said. It is important to clarify that today's situation is much different than historical shortages. It goes beyond burn out and fatigue. Staffing numbers are so low that executives are acknowledging this is not just a nursing and HR problem—it is a problem for any CEO or other provider executive who wants to keep their operations going.

    Q: Carol, you've had a wide-reaching career and have been a prominent leader in the nursing field for some time. How does this nursing shortage compare to others you've observed throughout your career?

    Boston-Fleischhauer: I've gone through many nursing shortages in my career. I can't definitively say this is the worst; however, it is unequivocally very different. There are absolutely no signs of reversal, which is different from other shortages I have observed. We typically see shortages run their course over time, but that is not the case here. This one will require different in-kind solutions. We must ask the question: Are all industry stakeholders ready to support the depth of solutions required here?

    Insights from executive level conversations

    Q: You've spoken with countless executives about the nursing shortage, you've presented multiple webinars on the topic, and you've had a seat at the table of this issue for years. What are some stories, takeaways, and reflections you have observed from these conversations?

    Boston-Fleischhauer: As i said, it's clear that executives recognize the gravity of the problem; but what is not clear is how prepared executive teams are to implement aggressive solutions that will have long term impact. Short term fixes will not be enough. It's clear to me that more and more executives are addressing the root causes and structural problems of the today's challenges. But what is also clear is that the organizations focusing only on one piece of the puzzle will not make a large dent.

    Westhead: I agree. We don't have to convince any of these leaders that this is different and severe. But there may be a gap in the understanding of what needs to be done. I believe it is possible to get leaders on board with the long-term solutions necessary here, but it will take largescale efforts and a true reckoning with the root causes.

    Q: I would love to dive into some of those solutions soon, but I first want to ask about the conversations you are having with C-suites. It seems like we are really talking about a systemic shift in what the future of nursing and workforce support looks like. But not every leader is willing or even ready to adopt that mindset yet. Considering that, let me ask: Have you spoken with executives who are thinking about this in the right way? And how are those conversations different?

    Boston-Fleischhauer: Let me use an operational example related to staffing model changes to answer part of that question. Several health care organizations are being extraordinarily creative, working in partnership with their staff to determine how to use limited resources in a way to support the overall mission of the organization. These leaders who were flexible during the harshest moments of Covid-19 are doubling down and continuing to be flexible in the peri- and post-pandemic environment. And what is special about these organizations is that the staff are actually willing to take this trip in partnership with the executives—that is very powerful. For across-the-board impact, this partnership dynamic must be the norm versus the exception.

    Westhead: And I will add that in some cases we hear reports of frontline nurses not feeling valued by leadership. When nursing staff observe travel nurses getting paid astronomical amounts of money for the same work, frustration and confusion arise. They think: why aren't you investing in me?

    Boston-Fleischhauer: And again, some leaders may still be embracing the faulty feelings of this all blowing over as the pandemic subsides. It simply will not, and I think we are still facing an uphill battle here. Many C-suites wish we could go back to how nursing was pre-Covid-19, but that wasn't healthy either. We need a systemic shift moving forward.

    Looking forward—solutions and speculations

    Q: Let's dive into what this shift moving forward will entail. We've discussed just how different this nursing shortage is and how different the solutions will need to be. Can you discuss what a few of these solutions may be?

    Boston-Fleischhauer: As you know, we've written extensively about why nurses are leaving and what can be done about it. And before we discuss the solutions, I want to clarify the specific reasons why this shortage is different. It comes down to four key factors: There are structural problems related to the complexity of patient care that were not addressed during Covid-19, we have an increasingly battered workforce, early retirement is up, and employees are voicing new and expansive expectations. The organizations making the most headway are those addressing what nurses say needs to be fixed in the work environment. For example, this involves investing in professional development and recognition while getting as creative as possible with competitive compensation models. Said differently, adjusting the hourly rate for a nurse by a dollar an hour is not enough.

    Let's not underestimate the power of dramatically shifting how we pay our nurses as well making sure our permanent nurses understand what the total compensation program actually includes—such as paid time off, health care, tuition reimbursement, childcare, and more. This is as important as ever in the era of travel nursing pay that has skyrocketed. Beyond all the clinical value they add, nurses are deeply valuable to the bottom line of health care organizations. So, what should we do? It starts with paying nurses more for their work. And ultimately, these are a few pieces of the puzzle. The long-term solution revolves around a holistic and wide-reaching approach.

    Westhead: I also think we need to dissect what it means to be a nurse today. There are plenty of settings in which they can work, and each of them offers a different value proposition that might appeal to different nurses. Leaders should be asking: What are the available nursing roles, where are they, and how can we use the diversity of the opportunities we can offer to our nurses to help match their needs to the needs of the system? A nurse who is looking for a 9-5 role could work in a clinic, or one who is interested in more autonomy could transition to the home health setting; a SNF could offer a team leadership opportunity while keeping the bedside RN role. For this to work, we also need to tackle the feelings of stigma associated with working in different care settings or units. This shortage is not the same for every nurse or every care setting. It is a multidimensional, complex issue. ICUs and nursing homes are hurting much more than most outpatient clinics.

    Boston-Fleischhauer: The pandemic has also brought a lot more interest in the non-direct bedside care roles for nurses. And for the first time, nurses are realizing how expansive their careers can be. Employers need to understand what their nurses want out of their careers and help them achieve that.

    And even further, as organizations work to meet employees' requests for flexibility and new arrangements, RNs themselves are challenged to embrace the various approaches to changing work and staffing models. Amid a supply and demand imbalance, I believe the best path forward is one where employees and employers work together and recognize the power in moving with collaborative solutions—a genuine partnership.

    And let's be very clear: reversing the exodus of RNs from inpatient care is not just the job of the chief nurse executive; it is the job of the entire C-suite to ensure commitment of the brain power and the resources needed. If organizations have not already taken an all hands-on-deck approach, now is the time.

    Q: It's hard to feel positive about much these days, but I want to hear your thoughts. What are you optimistic about? Does anything give you hope about the future nursing shortage right now?

    Westhead: Sometimes you have to get to a breaking point in order to see real change. We are at the breaking point, and while there has been ample suffering in the process, health care leaders have an opportunity to lean in and embrace today's reality. They must reckon with it and employ legitimate solutions.

    Boston-Fleischhauer: I agree. This challenge is getting the attention it deserves at levels other than within the profession itself, and it is the subject matter of an overwhelming majority of my conversations these days. Everyone is paying attention to this crisis, from board members to the media to specific communities and to even the government. I am optimistic because of all the attention that this shortage is receiving; let's hope for solutions that match the serious gravity of the shortage.

    And the last thing I will say is the need to rekindle the collective why for entering the nursing workforce. We cannot forget why nurses pursued this career in the first place. This work is a calling and a passion for many people, and if we can reignite the passion and joy that many nurses had in the beginning, I am optimistic about the future. It will take deep efforts and sustainable partnerships with nurses and leaders, but I know we can make it happen.

    Parting thoughts

    Let's be honest: working in health care today can be exhausting. And for the clinical workforce, exhaustion can feel like an understatement. But this is also true: We don't have to accept exhaustion as an inevitable experience in health care. It will take robust and collective action, and health care organizations need to act now. But I know it is possible.

    And perhaps for now, even if just for the moment you are reading this, I encourage you to simply marvel at our collective ability to move through the hardest of times—as if we were made precisely for this. I have hope for a better future of the clinical workforce, but we must move together and with unwavering conviction.

    I've listed a few of our resources intended to guide your efforts in supporting, retaining, and recruiting your nursing care teams. Here are our latest insights to help:

    Review our more comprehensive list of resources on boosting your capacity here.

    The Advisory Board's Nurse Executive Center stands ready to further consult executives on these and other here-and-now tactics to address the nursing shortage, including a critique of your current workforce plan's strengths and vulnerabilities. We can be reached at AskAdvisory@advisory.com

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