Clinical workforce shortages generally, and RN shortages more specifically, remain the number one issue facing hospital and health system C-suites across the country. Executives must target investments to areas of greatest need. Many investments have been made but unsustainable RN turnover continues.

For this report, Advisory Board conducted a survey in March 2023 of nearly 250 nurse leaders to identify their biggest areas of current concern about the RN workforce. This report was also informed by other recently published literature and studies regarding current workforce challenges. By analyzing multiple data sets, we provide a unique insight on balancing the needs and expectations of staff with organizational and market realities.

This report presents five insights and recommendations for 2023 action and investments to further stabilize the nursing workforce in hospitals and healthcare systems.

Over the past three years, unprecedented workforce challenges have plagued the healthcare industry. Leaders put numerous strategies in place to stem extremely high turnover in all clinical disciplines, especially nursing. Some promising workforce trends are now being reported. In hospitals and healthcare systems, overall employee turnover has decreased by 3.2% and overall RN turnover has decreased by 4.6%. These numbers suggest several retention strategies — such as upping compensation, offering scheduling flexibility, and creating internal staffing agencies — are starting to make a difference.

Despite this welcome news, several RN workforce problems persist. At a time when increased baby boomer retirements are predicted, first-year turnover has increased. Time to fill vacant RN positions in local markets has increased. With competition for RNs being fierce in local markets for RNs and new reports that H1 visas for international nurses have run out, an overwhelming number of hospitals plan on continuing to use travel nurses to fill vacancies — a costly strategy that is unsustainable. At the same time, the academic pipeline for nursing is fragile. New data from the American Association of Colleges of Nursing (AACN) reports that overall nursing student enrollment is down 1.4%, the first time enrollments have decreased in over 20 years. Further complicating this situation is continued clinician burnout, in particular for early-career RNs.

This sobering picture suggests the need to further examine current workforce recruitment and retention strategies to ensure that investments are aligned with 2023 issues. Many surveys have been done to understand the perspective of nurses regarding their employment needs and expectations. However, we must also understand the perspectives of nurse leaders to ensure the most impactful interventions. Since few surveys of nurse leaders exist, Advisory Board conducted its own survey of nurse leaders to identify their current concerns about the RN workforce and their perceived ability to influence those areas. 

The following is a summary of top, moderate, and lesser concerns about the RN workforce as reported by nurse leaders on the Advisory Board survey conducted in March 2023.

• Inadequate numbers of qualified RNs to fill frontline/acute care vacancies
• Abuse (physical, verbal, emotional) directed at RNs by patients, visitors, other team members
• Continued escalation of RN labor costs
• Unresolved clinician burnout
• The academic pipeline not keeping up with projected RN demand
• The ability to recruit unlicensed, frontline workers

• RN disillusionment with finding meaningful work in acute care
• Inpatient RN roles viewed as a short-term career option
• Hospital ability to compete with nontraditional healthcare employers for RN talent

• Union organizing
• The momentum to establish federal staffing standards
• The exodus of early-career RNs for NP programs
• Organizational ability to ensure service access
• Limited technology investments to support RN work and work processes

A comprehensive analysis of data from multiple perspectives can provide the best guidance on priority strategies for the next year, balancing multiple perspectives to advance responsive, responsible workforce solutions. Using our survey as the framework to guide this analysis, we compared our survey results with the results of two other leading surveys. Notably, this analysis revealed how nursing leaders’ priorities align and diverge with the reported needs of the workforce.

Advisory Board’s 2023 nursing leaders survey

In March 2023, we surveyed nurse leaders from hospital organizations in our network across the country. We asked them to rate their level of concern about 22 workforce challenges and their perceived ability to impact those concerns. We also analyzed for any market or positional differences. We received 242 responses to our survey.

2023 NSI National Health Care Retention & RN Staffing Report

We examined the results of the 2023 National Health Care Retention & RN Staffing Report from Nursing Solutions, Inc.(NSI) to gain perspective on our survey results in the context of RN workforce shifts and trends.

ANF Three-Year Annual Assessment survey

We reviewed the American Nurses’ Foundation (ANF) Three-Year Annual Assessment survey to gain perspective on the key issues that RNs report they are facing in the work environment and what type of support they need from employers to stay in their positions.

In addition to analyzing and comparing the results of these surveys, we drew on Advisory Board research to add a qualitative lens to our analysis. Other sources were also added in as needed for additional support.

It's important to note that we specifically looked at hospital-based nurses. While some of the insights apply to RN positions in other settings, our specific focus was on nurses working in the hospital setting. 

Based on our cross-survey analysis, nursing leaders should focus on five priorities to continue stabilizing their workforce in 2023 and beyond.