The state of the clinical workforce

The clinical workforce is at a crisis point across virtually all direct care roles. Organizations are struggling to fill vacancies. Turnover is at record highs. According to Advisory Board’s 2021 hospital staff turnover and vacancy survey, turnover of full-time and part-time staff is the highest we’ve recorded in 16 years of benchmarking. Median turnover (excluding PRN, per diem, and casual staff) rose to 18.8% in 2021, up from 15.5% in 2020.

As of November 2022, healthcare employment remained below pre-pandemic levels, with the number of workers down by 1.1%, or 176,000, compared to February 2020, per the U.S. Bureau of Labor Statistics.

Typically, the labor market evolves slowly, or at least slowly enough for employers to plan for. But that has not been the case since 2020, as the pandemic rocked the foundations of workers’ professional and personal lives. Burnout associated with the pandemic has exacerbated existing tensions in the workforce, and many clinicians are weighing whether to remain at the bedside or not—or in some cases exit healthcare altogether.

At the same time, we’ve witnessed a shift in the labor market. Current labor market conditions are not only making job movement possible, they also actively incentivize turnover. Demand for jobs, particularly for clinicians—but also in other sectors—has made it easier for people to leave their roles.

There are misconceptions that clinical workforce challenges occur on a cyclical basis and this will abate over time, and that these challenges fall under the purview of nursing and HR departments. But this is a new-in-kind, strategic challenge that will require the commitment of the entire C-suite.

Drivers of clinician turnover include:

• Burnout: Staff experience chronic workplace stress exacerbated by the pandemic and inadequate staffing.
• Feelings of disrespect: Staff voice ongoing concerns about pay, treatment, work-life balance.
• Concerns about workplace safety: Staff live with the threat of workplace violence and harassment from patients and families.

Clinician turnover often creates a vicious cycle. Staff leave due to their working environment, which puts an enormous strain on the workers who are left behind. Those left behind then leave due to the working environment, restarting the cycle. This cycle leaves facilities understaffed and forced to rely on short-term fixes like travel nursing expenditures to fill in the gaps. These short-term fixes are expensive and leave no money to invest in underlying workforce issues, further perpetuating cycle shown below.

Key clinical roles of concern

There are significant areas of supply and demand imbalances across many roles in the delivery system. The table below outlines turnover and the status of the pipeline for future staff.

Provider organizations face rising costs and budget concerns

The healthcare industry is dominated by increasing costs and tightening margins. Even before the pandemic, labor costs typically made up more than 50% of hospitals' total expenses. Staffing shortages and an increased reliance on contract labor have caused labor expenses to jump sharply. Labor expenses per adjusted discharge increased by more than one-third from pre-pandemic levels through March 2022, while contract labor as a percentage of total labor expenses increased more than five times the rate from pre-pandemic levels.

With these expenses on top of other rising costs, such as supply and energy costs, providers are struggling to keep their margins positive. This forces organizations to make tough decisions including service rationalization, layoffs, leadership changes, and even closures. Providers are also seeking higher reimbursement rates from commercial payers, which will in turn show up in higher premiums charged to patients.

An understaffed workforce negatively impacts care quality and patient safety

A shortage of healthcare professionals limits patient access to healthcare. Patients experience longer wait times and delays in care, which may potentially worsen patients' health outcomes.

In addition to reducing access, clinician shortages also negatively impact care delivery. Due to understaffing, clinicians are responsible for a larger number of patients, which can increase clinician burnout and lead to an increase in medical errors, higher morbidity, and higher mortality rates. Researchers are already quantifying the current shortages’ negative impacts on care quality and patient safety. One study from the U.S. Centers for Disease Control found that healthcare-associated infections increased significantly in 2020 after years of decline. Researchers attribute this increase to labor shortages and patient volumes, which limited hospitals’ ability to follow standard infection control practices.

Staff who look to change jobs are trying to improve their circumstances, whether it’s a better employer, better staffing, or better pay. There are real opportunities for non-provider employers to attract talent. Non-provider employers of healthcare workers include life sciences organizations, health plans, and tech companies. These players have more flexibility to accommodate the pay, hours, and benefit needs current clinicians are asking for. This positions non-provider organizations to be even more competitive in attracting new employees.

However, non-provider stakeholders that partner with provider organizations in any way must recognize that the acute nature of the workforce crisis trumps any strategic initiative or partnership opportunity they are trying to forge. As health providers continue to deal with clinician shortages, non-provider organizations must understand how their customers’ priorities are changing—and what that means for their customer engagement, evidence generation, and communication strategies.

Providers will likely experience clinician shortages for years—but these shortages will not be evenly felt across all employers.

Skilled nursing facilities (SNFs) and acute care hospitals are losing talent due to the long hours, high patient load, low compensation, and physically demanding work that characterizes these sites of care. Post-acute employers cannot afford to pay as much as other providers, and the taxing nature of working in a SNF makes it a less attractive option to candidates. In contrast, payers and ambulatory care sites can offer higher compensation and better hours, which positions these employers to gain talent in today’s market.

It’s a complex situation: attracting workers away from healthcare organizations in one setting will result in staffing difficulties in another. For example, if a SNF experiencing staffing shortages is unable to accept transfers from a hospital, that hospital is left full of patients who cannot be discharged to subacute care. See the table below for more details on the impact of clinician shortages on provider organizations.