As CNOs deal with nursing shortages, it's critical to understand why they are happening.
The National Council of State Boards of Nursing (NCSBN) recently published the latest 2024 National Nursing Workforce Study which surveyed 800,000 nurses about the state of the nursing workforce.
According to the study, there are five main reasons that nurses are leaving, according to the data. According to Phil Dickison, CEO of NCSBN, solving these issues will take thinking differently.
"Every one of those numbers is a voice, it is not simply a number on a page," Dickison said in regard to the survey participants. "My argument is that [as leaders] we need to be better about…listening to these voices of the nurses before we invoke solutions."
Prioritizing nurse wellbeing has an impact on the entire workforce, not just nurses, says this nurse thought leader.
On this episode of HL Shorts, we hear from Diane Sieg, Registered Nurse, Author, Coach, and Creator of the Well-Being Coaching Initiative, about how health systems benefit from prioritizing nurse wellbeing. Tune in to hear her insights.
There are five major reasons why nurses are departing from the workforce, according to this new study.
As CNOs deal with nursing shortages, it's critical to understand why they are happening.
The National Council of State Boards of Nursing (NCSBN) recently published the latest 2024 National Nursing Workforce Study which surveyed 800,000 nurses about the state of the nursing workforce. According to the study, 40% of participants indicated their intention to leave the workforce in the next five years. The study also reported that 138,000 nurses have left the workforce since 2022.
So why is this happening? Let's take a look.
Why nurses are leaving
There are five main reasons that nurses are leaving, according to the data: stress and burnout, workload, understaffing, inadequate salary, and workplace violence. According to Phil Dickison, CEO of NCSBN, solving these issues will take thinking differently.
"Every one of those numbers is a voice, it is not simply a number on a page," Dickison said in regard to the survey participants. "My argument is that [as leaders] we need to be better about…listening to these voices of the nurses before we invoke solutions."
Dickison stated that more data is necessary to determine which nurses are having certain experiences and which ones are having others. For instance, the stress that an ICU nurse faces might be completely different than what a NICU or med surg nurse might experience.
"We need to find this out because we're doing correlations now, but maybe there's better correlations that stress is higher in those areas," Dickison said. "Intuitively…we might believe that, but is it true? And if it is true, then what are the causes of stress in that area?"
Positive outlooks for the industry
Despite what the study suggests about nurses leaving, there are also some positive trends that can be drawn from the data. According to Dickison, one of the positive results has to do with the number of nurses currently in the workforce. The data show that 88% of RNs and 71% of LPN/VNs are actively involved in nursing, which is a sign that employment levels have rebounded since the height of the pandemic.
"We've started to see a rebound in the size or the number of individuals in the workforce," Dickison said. "We started to see that grow in the right direction."
The study also shows that the median age of the nurse workforce went up as experienced nurses begin to return to the workforce. Additionally, 73% of participants hold a baccalaureate degree or higher, which is the highest educational level for nurses that NCSBN has ever documented. The number of Hispanic and Latino nurses has doubled to 7.2% since 2015, and nurses are experiencing a 10-16% increase in median pre-tax income.
A call to action
Dickinson cautions that though these numbers are good, the question remains about whether the workforce is sustainable. While the survey does show moderation for some of these issues, it's critical that the focus remains on solving them.
"I have this fear that because we're showing moderated stress and burnout data that it will somehow become a backburner issue," Dickison said. "Let's not let that happen, because the fact that we moderated it is a good thing, but it is not solved."
Dickison believes CNOs need to continue prioritizing stress, burnout, salary, and workplace violence even though they might be moderated for the time being.
"We need to prioritize that as a moment in time now to go forward and not just talk about solutions, but seek and implement solutions," Dickinson said.
Dickinson also emphasized that these are multifaceted problems, and CNOs alone will not be able to solve these problems.
"What I would argue [for] at this point is somewhat of a call to action within NCSBN and [to] all of our partners, our clinical partners, our practice partners, our education partners, and our policy partners," Dickison said, "because I think this is not a single solution set."
Houston Methodist is now using virtual nursing across eight acute care campuses, and handling some 500 admits and discharges per day. Many of those nurses are even working from home.
While virtual nursing programs typically begin with one or a few specific functions and outcomes, scaling those programs means creating a comprehensive platform that can handle many services.
Houston Methodist, which launched its virtual nursing program in 2022, is now using the platform to facilitate more than 500 admits and discharges a day across eight acute care campuses, says Steve Klahn, the health system's clinical director for virtual medicine. And at its newest location, Houston Methodist Cypress, that experience is much more immersive.
"The team is piloting care delivery in a more comprehensive fashion with remote virtual nurses," Klahn, a participant in the HealthLeaders Virtual Nursing Mastermind program for the second year, said in a recent e-mail exchange. "This pilot includes rotating bedside nurses through a local virtual operations center and supporting bedside nurses' care for their patients by increased remote documentation assistance, multi-disciplinary rounds participation and virtual consenting."
Steve Klahn, clinical director for virtual medicine at Houston Methodist. Photo courtesy Houston Methodist.
As noted in a 2024 story on the program, Houston Methodist is in it for the long run. That means understanding where the platform can evolve and where executives need to take a step back and evaluate their priorities.
"Maintaining flexibility to all the great ideas [that] come in, while being able to remain standardized in the approach so as to not have to re-educate and change workflows too frequently," is crucial to the program's growth, Klahn says. "We also aim to ensure programmatic efficiency with minimization of wait times, while maintaining 24x7 services with safe and fiscally responsible staffing solutions."
One glimpse of the future might be seen in their staffing strategy. Several participants in the Mastermind program have indicated they're looking at enabling nurses to work from home—a key incentive to retaining current nurses and attracting new ones. At Houston Methodist, which now has 50 RN FTEs dedicated to the program, Klahn says the idea is being pushed along out of necessity. Some 70% of the health system's virtual nurses now work from home, and the gaol is to get that number up to 90%.
"We are currently shifting more of our teams to remote work, as space in our virtual operations center is at a premium," he says. "Our strategy remains for direct hire exceptional staff nurses (no-outsourcing to contracted teams), as well as supporting nurses in times of short-term light-duty assignments."
Klahn says the program is gradually integrating new services as well, including dual medication signoffs, remote witnessing of controlled substance wasting, and VTE prevention rounding.
He says the program's success is due to how well it has been received by both patients and nurses.
"We continue to appreciate high levels of satisfaction with patients, bedside nursing teams, physicians/providers and hospital administrators," he says. "The team does an amazing job of ensuring focused high-quality completion of the clinical support they do on a daily basis."
"The biggest surprise to me is how fast the program grew with the strategy our organization acted upon," Klahn adds. "It was amazing to see how quickly the bedside teams embraced this new approach to patient care, and we were able to quickly deliver on the requests for services to each of our hospitals. The future is very bright for VN programs and we look forward to much more growth in the space."
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CNOs must provide career pathways and robust wellbeing support systems to improve nurse retention, say these nurse leaders.
In the latest edition of HealthLeaders' The Winning Edge webinar series, a panel of nurse leaders discussed innovative retention strategies that CNOs can use to foster career growth, prioritize wellbeing, and create a more sustainable work environment.
The discussion included three key takeaways: how to support nurses at every career stage, the importance of providing professional development opportunities, and why it's critical to center nurse wellbeing in retention strategies.
Attendees at this week’s HealthLeaders CFO Exchange are addressing how they confront mounting financial and operational pressures, from labor shortages to unions to recruitment.
CFOs gathered this week at the HealthLeaders CFO Exchange to discuss the pressures shaping the financial landscape of health systems. With margins still squeezed post-pandemic, the tone was less about recovery and more about resilience and planning, particularly around the workforce.
Workforce Headwinds Take Center Stage
As expected, workforce issues are still at the top of the agenda. Nurses and frontline staff are commanding higher wages, while those who rely on costly agency staffing are facing their own financial burdens. Many CFOs expressed the need to develop their workforce in-house, through expanding education platforms.
While turnover is down since COVID, it’s still high. But some CFOs are seeing a silver lining: Some employees are completing short-term or contract work with the health system, then deciding to stay on.
Radiology and Anesthesiology Costs
Some CFOs expressed concern with the rising costs of radiologists and anesthesiologists, including CRNAs, all of whom are commanding higher salaries. The hope here is that AI can be used to bring down those costs, particularly in handling administrative tasks that take up a lot of time.
Nursing
CFOs also have a lot to say about nursing costs. Two top concerns are nurse safety and nurse staffing ratios. Nurse staffing ratios, in particular, are often the first thing incoming nurses ask about when being hired. Nurses want to know that they won’t be overloaded from the get-go, and burnout is certainly still a huge pain point for the industry.
Unions
Exchange members spoke about the process of unionizing non-union hospitals and the challenges with keeping non-union wages up to par. Tough market productivity metrics are also difficult to keep up with, some members said. There’s also a feeling of general unproductivity here because of regulated ratios for unions.
Other members found more periodic experiences with unions that typically manifest on the nursing side. It’s clear the nurses know their value and aren’t afraid to speak up. Exchange members said it’s important to be able to sit down and have thorough talks with the nursing staff. Members also pondered how they can set themselves apart culturally from unions.
RecruitingThe Community
Many exchange members spoke about the importance of showing their support for the communities they serve by partnering and providing opportunities for local medical students.
Many have started partnering with local universities and tech schools, especially for recruiting for ultrasound tech positions. CFOs agreed the main idea here is to “put your money where your mouth is” and ensure the health system is supporting schools and the incoming workforce. Consistent outreach and offering shadowing opportunities are two components in this strategy.
One of the biggest challenges CFOs have found with recruiting is getting the staff that wants to work the second and third shifts, staff who are willing to work nights or in a Level one emergency department. The timing of shifts is more where the challenges are rather than the roles themselves.
The Cleveland Clinic is the latest to partner with a developer of ambulatory surgery centers to take minimally invasive procedures out of the hospital.
Health systems are taking a step toward the hospital of the future by outsourcing minor surgeries.
The latest to do so is the Cleveland Clinic, which announced a partnership this week with Tennessee-based Regent Surgical to build a number of ambulatory surgery centers across the country. These centers are designed to handle minimally invasive procedures, which require little to no hospital stays and shorter recovery times, much of which can be handled at home or in clinics.
As hospitals struggle with workforce shortages and look to reduce costs and their patient census, leadership is looking for alternatives to expensive and resource-intense hospital care, with the idea of saving the hospital for those who need acute care services and will spend several days there.
As a result, the ambulatory surgery market is growing. Fortune Business Insights reports the market size was valued at almost $44 billion in 2022 and projected to grow to more than $75 billion by 2030. There are currently more than 6,000 such centers in the U.S.
Arizona-based Banner Health joined forces with Select Medical in 2018, and now has a network of four private rehabilitation hospitals and outpatient physical therapy programs and services at dozens of Banner Physical Therapy Centers. Mark Garvin, the health system’s SVP of Partnership & Venture Development, says the partnership is part of Banner’s strategy to grow beyond its extensive hospital footprint and provide value-based care where it’s most convenient.
“These are people that wake up every single day and this is what they worry about,” he said in a recent HealthLeaders interview. “They’re experts. They know how to operate. They know how to develop. They know how to grow. It is their wheelhouse.”
Garvin says health systems and hospitals have the advantage over disruptors because of the name brand and the expertise in providing healthcare services.
“We can play in this space differently than the Amazons, differently than other retail organizations, simply because we’ve created these clinically integrated networks,” he says.
Cleveland Clinic, which is internationally known for outsourcing second opinions through The Clinic by Cleveland Clinic, a partnership with telehealth provider Amwell, is banking on new efficiencies with the Regent Medical deal.
“Ambulatory surgery centers provide an important setting for health systems to expand access to surgeries, and to be more efficient in the delivery of services,” Cleveland Clinic CEO and President Tom Mihaljevic, MD, said in a press release. “Regent's capabilities in managing and operating ambulatory surgery centers will enable us to focus on continuing to provide the highest quality care for our patients and will enhance our ability to grow and offer that care to more patients.”
CNOs must be ready to support nurses from the beginning to the end of their careers, and throughout life changes, according to these nurse leaders.
Nurses are multifaceted individuals with needs that must be met both at work and at home. CNOs must take the time to understand each nurse's individual needs and goals. The goal should be to create a space where nurses are not afraid to approach leaders with their needs.
CNOs must provide career pathways and robust wellbeing support systems to improve nurse retention, say these nurse leaders.
Retention is struggle for all leaders in healthcare, including CNOs.
Predictions about the nursing workforce are somewhat grim, with many studies suggesting that nurses plan on leaving the workforce in the near future. That coupled with existing shortages and continuing issues with nurse turnover, does not bode well for the industry.
So, while health systems might have different approaches, there are several creative retention strategies that CNOs should take into consideration.
The panel discussion included three key points about retention strategy.
Support at every career stage
Nurses are multifaceted individuals with needs that must be met both at work and at home. CNOs must take the time to understand each nurse's individual needs and goals. For new-to-practice nurses, many of whom are Gen Z, the panelists recommended that nurse leaders meet with them within the first 30 to 90 days of their employment to discuss their career path. Then, come up with a road map for how they can accomplish those goals.
The goal should be to create a space where nurses are not afraid to approach leaders with their needs. Gen Z nurses in particular appreciate emotional connections with the people they work with, according to the panelists, and they enjoy recognition.
For more tenured nurses, the goal is to create opportunities for them to share their knowledge with the next generation of nurses. This might involve having them enter virtual nursing or telehealth positions. For nurses who have family members to care for at home, the panelists emphasized the importance of flexibility. Leaders must be able to empathize and help their nurses navigate through life changes while they continue to work.
Professional development opportunities
Nursing is a dynamic career with many pathways to success, and CNOs are responsible for equipping nurses with the skills they need to grow and mold their careers. Professional development is not only critical to nurse retention, but it is also the key to succession planning and fostering the next generation of nurse leaders.
According to the panelists, CNOs should focus on building leadership pipelines that help bolster the nurse's career path. Nurses should be able to cross train, participate in leadership development, and obtain certifications for other skillsets.
One key benefit that CNOs should consider is tuition assistance. The panelists explained that for many nurses, the cost of certification or continuing education is the one barrier standing in their way. If health systems are able to cover the initial costs up front, that can help lift financial burdens off of nurses who are ready to advance their careers.
Centering wellbeing
CNOs and other nurse leaders must also prioritize nurse wellbeing to maintain the sustainability of the workforce. This is done by creating a work environment that is as safe, efficient, and barrier-free as possible.
First and foremost, health systems must provide mental health support systems for nurses, through EAP programs and other resources. The panelists recommended mental health counseling and stress first aid, which equips nurse leaders with evidence-based stress response practices for when incidents occur. CNOs can also advocate for physical spaces in the health system where nurses can go to find a moment of relaxation in their day.
More specific strategies can include initiatives to improve individual wellbeing. For instance, promoting sleep schedule recommendations for nurses who work a mixture of days and nights. CNOs should get in touch with their workforce to see what their wellness needs are, and then make sure to provide the kinds of support they need.
AI can help clinicians manage complex conditions and relationships, says the CMIO of Stanford Medicine Children's Health
Pediatric healthcare is a complex undertaking. The doctor-patient experience is far more complicated, involving not just patients of various ages but parents, grandparents, siblings, other caregivers, maybe even a pet or two, real or imaginary. The old standard ‘How are you doing today?’ usually doesn’t do the job in this environment.
“So much of pediatric care is about connection, and about preventative medicine, and about ensuring that you understand the complex interactions between the child, the parent and the provider, and so, so much of that kind of subtle nuance about what is the child doing during the evaluation,” she says. “So much of what we’re assessing is the child’s behaviors [and] the child’s interaction with other people in the room, the child’s body motions. And if you're sitting at a computer and typing the whole time, you're missing all of that very rich data.”
Children’s hospitals have a rich history of embracing innovation, often because the tried-and-true ways of care management for adults don’t necessarily work for kids. Clinicians often have to take new ideas and technology designed for adults and modify them for their own patients.
That’s also true of AI, which, Pageler says, needs to evaluated differently.
Natalie Pageler, MD, CMIO of Stanford Medicine Children's Health. Photo courtesy Stanford Medicine Children's Health.
Take ambient scribes, which are designed to capture the doctor-patient encounter for the medical record.
“We did a rigorous evaluation of how that affected the interaction for children and families, because most of it was developed in the context of a single provider and a single patient,” Pageler says. “Of course, in pediatrics, it's often the patient, a couple parents, a couple kids running around the room screaming. We really wanted to do that evaluation to understand [whether] it could have the same impact for children and families.”
The potential value of these tools for pediatric clinicians is clear. In that busy exam room, a doctor or nurse needs to be attentive to the children as well as the parents, picking up on subtle clues and interactions that could play an important role in diagnosing and treating underlying health concerns.
“We need to make sure they are addressing the true needs of the patient and the family,” Pageler notes.
Just as important, she says, is the connection between the clinician, the patient and the patient’s family, a key dynamic in any healthcare experience but critical to those working with children. Pageler says AI is helping to take the technological barriers out of the exam room and making children and their parents feel more comfortable.
“We’ve had several patients walk out of the room and say, ‘Wow, my provider looked at me the whole time and we got to really talk about this complex challenge I'm having with my child's behavioral issue,’” she says.
Pageler says some doctors have even decided to use AI instead of having a scribe in the room or listening to the conversation from another location. In some cases, she says, Ai is less intrusive to parents and children who want to talk about personal issues and don’t want another person listening to that conversation.
Aside from ambient listening opportunities, Pageler says AI can be a valuable support tool for doctors who are treating patients as young as infants and as old as teens. Different ages often call for different treatments, and the technology can help clinicians gather the information they need to guide their conversations with children, adolescents, parents and other caregivers.
“The relationships are so complex,” she notes. Clinicians have to be “extremely thoughtful” in how they share information with different patients and family members.
Pageler expects clinician decision support to be the next wave of AI innovation, helping clinicians find and use the right data to improve care management and coordination. That’s especially true as healthcare organizations set their sights on health and wellness and prevention opportunities.
As she sums up the value of AI in the pediatric care space, Pageler says the technology enables doctors and nurses to interact with patients, their families and others without the intrusive presence of computers and scribes.
“AI should make care more human, not less,” she says. It will “allow for more humanity” in care management.
