The Nursing Shortage

Like many hospital CEOs, the two things that keep Michael Hansen, FACHE, CEO of Columbus (Neb.) Community Hospital, awake at night are workforce shortages and financial stability. And as many hospital leaders experienced during the COVID-19 pandemic, those two worries intertwined for Hansen when the facility needed to hire traveling nurses. Though the hospital still has about 22 travelers among its 950-plus positions, Hansen and his leadership team are trying to lower that number, as have most institutions given that a traveling nurse can cost up to three times as much as a staff nurse. 

During the pandemic, the Nebraska Hospital Association was already estimating a shortage of more than 5,400 nurses statewide by the end of 2025. As the disruptions caused by the pandemic hit, including staff burnout and resignations that reverberated throughout healthcare, leaders at Columbus Community Hospital realized they were going to need to build their own workforce, not only for nursing but across the board.

“The shortage is not going to go away,” Hansen says. “You’re going to have to be more innovative and look at ways to build your own pipeline. It’s going to get harder and harder. A lot of organizations are using international nurses. We’ve used people from the Philippines. It is going to be a continuing challenge for sure.”

Although the U.S. healthcare system’s nursing shortage might have improved somewhat since the pandemic, it remains deep and broad enough to impact virtually all of healthcare, with no easy solutions and no end in sight. Leaders in the field are realizing that the Band-Aid solutions organizations have been using for the past several years haven’t solved the issue, and in some cases have been quite costly. Nationally, the American Association of Colleges of Nursing estimates the number of nurses needs to grow from 3.1 million in 2021 to 3.3 million in 2031, with more than 200,000 openings per year.

Analysts and those working directly in healthcare see a range of solutions to help ease the crunch, from developing in-house nursing schools to better onboarding and professional development to flexible staffing and scheduling. The field also needs more licensed practical nurses, certified nursing assistants and technicians to handle tasks that are below the license level of registered nurses.

“It’s not only nursing—this has expanded to techs, to medical assistants, to nurse’s aides across the board, which all affects nursing,” says Diane Smith, RN, a consultant with WittKieffer who focuses on the nursing workforce. “A lot of nurse executives are focusing on recruitment, retention and now adding in resilience. Pre-COVID, we already had a lot of challenges. Post-COVID, a lot of folks are talking about partnering with colleges and universities.”

Smith sees a modest amount of good news on the horizon. Hospitals are starting to reduce some of the travelers, while growing their own nursing staff internally through creative recruitment to hire full-time staff and retention strategies that nurture relationships with current nurses. However, the best path forward for larger, urban academic medical centers or for-profit organizations will differ from what smaller, tertiary and rural hospitals need (see sidebar Advice for Larger, Urban Providers—and Smaller, Rural Hospitals). 

“What we’re seeing from health systems, and then as we get into smaller communities, varies,” she says.

Beyond that, Smith adds, strategies include creating internal travel nurse programs, partnering with nursing schools and colleges to train nurses with the hopes of hiring upon graduation, assessing salaries of current staff and making appropriate adjustments, and using international nurses.

Therese Fitzpatrick, PhD, senior vice president at Kaufman Hall, says the nursing shortage already has hit bottom and begun to modestly improve. “Folks are trying some really interesting innovations, which I think, based on both our client experience and what I’m reading in the literature, are beginning to take hold,” she says. “What we’re seeing is organizations stabilizing turnover. We’ve seen double-digit declines in turnover. Maybe after the pandemic it was in the 20% range. Now it’s almost halved in many organizations.”

Fitzpatrick attributes that result to the aforementioned innovations, such as flexible scheduling with atypical lengths and start times, and “robust new graduate residencies and support systems, which have driven down first-year turnover,” she says. Another important step hospitals have taken is better defining career paths and investing in robust career development, so that, “from day one, a nurse understands where her next position is … and she understands what skills she’ll be developing to be ready for that next position,” she says.

CHI Saint Joseph Health in Lexington, Ky.—an eight-hospital system that’s part of the statewide CommonSpirit Health system with 100 locations in 20 counties—expects a nursing deficit for the next 10 to 15 years, at least, says Anthony Houston, EdD, FACHE, market CEO. “We’re not going to make enough nurses in our state schools to satisfy the need in facilities and in state clinics,” he says. “We know there’s a net deficit.”

Nursing shortages impact any entity needing nursing care, no matter what the specialty and whether it’s a physician clinic or an acute care setting, but especially the latter, says Melissa Bennett, DHA, RN, FACHE, CHI Saint Joseph’s COO and chief nursing executive. CHI Saint Joseph is partnering with Lincoln Memorial University in Harrogate, Tenn., to create a new outpost of the LMU Caylor School of Nursing at Saint Joseph Hospital in Lexington.Nursing shortages affect not just the overall numbers but career pathways, Bennett says. “It used to be you would graduate, enter the workforce, start in the medical-surgical unit, get a year or two of general nursing practice and then specialize, whether in critical care or telemetry or dialysis,” she says. “That doesn’t exist anymore. New graduates are able to go right into those specialty areas. That changes the workforce. They come in with no general knowledge, and you’re having to tackle that as you get them into the cath lab or the OR or women’s services helping to deliver babies. That makes planning very different.”

Building Pipelines

A common longer-term approach has been to boost higher education opportunities, Smith says. One of WittKieffer’s clients, a local community hospital, proposed that a local liberal arts college start a nursing program to be able to grow their own candidates. “At big universities, students come from all over, sometimes globally, and go back to from whence they came,” she says. “The hospital strategically went to a liberal arts college and said, ‘Hey, can we start this?’”

However, such an approach requires addressing a shortage in nursing educators. Smith says that needs to be tackled if enough new nurses are to be minted, noting that she’s heard of waitlists at colleges because they don’t have enough educators. “We’re clearly seeing the demand outpace the supply,” says Vinny Gossain, a consultant at WittKieffer. “That’s not going to change overnight.”

Fitzpatrick has seen an array of longer-term interventions that include partnerships with colleges of nursing—and with high schools—and then intentionally building to the next position once new nurses are hired. “Developing strong pipelines in clinical staff means providing clinical experiences for folks when they’re students,” she says. “I am seeing tremendous flexibility … working around class schedules to give folks part-time jobs within the organizations as a way to help solidify the pipeline.”

Once a new nurse is hired, providers are moving beyond initial orientation to stay in close contact and ensure that the new employee feels supported throughout their first year, Fitzpatrick says. Knowing that millennials and Gen Zers often aren’t staying in jobs for more than a couple of years, the pipeline building continues. “Once the employee hops on board, they’re immediately beginning organizational development in planning for the next step in that individual’s career,” she says.

To that end, Fitzpatrick says organizations are moving away from functionally oriented job descriptions to a concept called position architecture, which spells out the competencies required for a specific job. “When you have mastered these competencies, here are the positions and jobs that might be next in line for you,” she says.

Columbus Community Hospital begins its pipeline through pathway programs at local high schools that expose teens to healthcare occupations. Of those who have continued to college, 76% have chosen a healthcare-related major, Hansen says. “We think getting to them early is very helpful in helping them decide what career path they want,” he says. Students take basic health science courses and upon completion can enroll into a CNA program, he adds.

Columbus also has created a nurse apprenticeship program for college students, who work 24 hours a month in exchange for up to 75% of their tuition, books and other school costs, in addition to a $2,400 stipend per term in their last year, Hansen says. The first cohort in 2022–2023 had 17 students, who are finishing their programs and becoming RNs and BSNs. The second finishes this May. “We’re starting to see the fruits of our labor,” he says, adding that the hospital is funding the program through operations for now but seeking grant opportunities.

In exchange for the financial assistance, Hansen says, students “have to give us a certain amount of service, typically three to four years. That helps build the workforce and retain people.” Columbus also offers externships with 135 hours of clinical experience for nursing students, who are paired up with an RN.

When it comes time to hire nurses, Columbus asks behavioral questions during interviews to ensure candidates would fit with the organization’s culture. Hansen says the hospital tends to hire people with roots in the Midwest, if not necessarily Nebraska, and follow-up interviews are done after 30 days and then 90 days to ensure that they’re progressing. Columbus also offers mentoring programs to help new hires along the way and to answer questions or address concerns.

“We know that we can’t just sit around and wait for people to fall into our lap,” Hansen says. “We have to be proactive and build our own pipeline of healthcare people for the future.”

CHI Saint Joseph Health’s new arrangement with Lincoln Memorial University begins this fall and will provide the opportunity for college-age students to gain a BSN. But the hospital system also is engaging with students even earlier, moving beyond partnering with high schools and connecting with students in middle school and even elementary school, searching for those interested in health science. Bennett says opportunities include spending a day job-shadowing and “trying to help people understand what they can be.”

“As we go back into high schools and middle schools,” Bennett says, “if you think you’re interested in nursing, how do we get you into that technical track?”

The system partnered with Americorps to give high-school-aged students a firsthand look at careers in healthcare, bestowing upon them the title of “ambassadors.” “We’re trying to push them toward nursing,” Bennett says. “But more importantly, how do we help support them going to school and getting an advanced education?”

Many local high schools have healthcare pathways and other STEM-type programs already in place. As a Catholic healthcare institution, CHI Saint Joseph has worked with faith-based community groups as well, Houston says. “We’re excited to see children matriculate,” he says. “We have a plethora of relationships with academic institutions around nursing.”

CHI Saint Joseph focuses on both boosting nursing school enrollment and ensuring there are enough instructors to train the workforce. The hospital system also has expanded its extern program to reach students as early as possible in their educational cycle rather than simply during their last year of nursing school, Bennett says. The system has about 190 externs, and Kentucky requires that students first take the “nursing 101” fundamentals. “We have been much more assertive with getting nursing students as soon as they finish that,” she says. “As soon as they meet that definition, we ask, ‘How do we partner with them?’”

To help guard against burnout, the organization has put together a critical care endorsement program with EMTs in the ED. That enables them to partner with nurses to provide care, which also has reduced the need for high-dollar travel or temporary nurses. 

“During the pandemic, emergency nursing was a hard field to be in,” she says. “All those patients in the ER needed a higher level of care. We were seeing staff leaving—and most often leaving not only that kind of nursing but leaving the field because of physical and mental exhaustion. Adding in the paramedics not only reduced contract labor, but it also has enabled us … to make the workload and work environment much more balanced.”

Culture and Resources

Cultural and governance issues also come into play in recruiting and retaining nursing staff, Smith says. “We’re hearing more around, ‘the culture needs work,’” she says. “Coming out of the pandemic into whatever we call this time period, there is a refocus on that. For a while, nurses were just surviving the day-to-day. We’re seeing a shift. You can go down the street to 
earn more from a nearby provider, but is that the place you want to be?” Shared governance is key, she adds.

WittKieffer’s Gossain, who focuses on physician recruitment and retention, notes that overall organizational structure, as well as whether people are being given adequate resources to do their jobs, also can affect keeping positions filled. “Those have got to be considerations for any CEO thinking about, ‘how do I fix the staffing to remove barriers from our teams?’” he says. “There isn’t any magic wand. But more organizations are open to, ‘how does our structure relate to what’s out there in the market? What do you see that’s been more successful?’”

A corollary to that: Nursing recruitment and retention cannot all be placed in the lap of the nursing executive, Smith says. “It’s all of the senior leadership coming together, even with community leaders, to solve the challenges,” she says. “Everybody is looking at it and getting creative with different care delivery models.”

Organizations that don’t will see patients simply go to the nearest care provider, Gossain says. “Consumers want to be seen efficiently and quickly,” he says. “That’s been a challenge because these are complex organizations. But if you have no staff, you have no ability to provide great service.”

Building a culture that retains talented people also means prioritizing not only physical safety but emotional safety as well, Fitzpatrick says. 

“I literally cannot think of a client that does not have a significant programmatic focus around employee well-being—counseling, mental health support and making sure folks are able to work and making sure employees get their PTO, which was something that we weren’t necessarily able to do during COVID,” she says.

Role, Schedules and Technology

To move beyond the Band-Aid approach to the nursing and overall workforce shortage, Smith sees health systems rethinking roles to ensure everyone is working at the top of their license, including EMTs in the ED, and LPNs, techs, medical assistants and nurse’s aides handling everything they are eligible to do. 

“It’s going to take the pipeline some time,” Gossain says. “Whatever intervention you’re going to do, it’s going to take a couple years to get there.”

For the moment, Gossain says, “how can you use the staff you have in ways that are efficient and patient-centric? In what functions do you need nursing? Where do you need nursing assistants? How do you make sure they feel supported and engaged in that whole conversation?”

Many organizations have turned to flexible scheduling to meet the needs of their recruits, Smith says. Gossain adds that also can help better meet patient demand. “If patients want to come in later in the afternoon or the evening, you’ve got to figure out how to do that with the teams you have,” he says. “Not everybody wants to work 7-to-5.”

Fitzpatrick agrees that flexible scheduling can provide a morale boost to stressed-out nurses and other staff.

“Everything from typical start times to a typical shift length. Various programs have weekend-only shifts,” she says. “There are lots of very interesting things happening around float pools. They are being constructed as ‘internal staffing agencies’ with salary structures that recognize flexibility and clinical expertise. … In larger systems, we’re seeing a migration of folks away from travel contract assignments into a more local version of that with their health system.”

Technology has been top of mind for clients of Kaufman Hall, Fitzpatrick says. “It’s kind of rare, at least in the larger health systems now, where you don’t see robots in the hallways delivering supplies,” she says.

More and more hospitals and health systems are using a virtual nursing model, in which a nurse oversees a unit or two without being on-site but can still admit patients and do discharge planning. 

“Somebody on the unit simply rolls a computer up to the patient’s side, and they interact with the nurse, who does admission, education and helps with documentation,” Fitzpatrick says. She’s seen this at everywhere from a 90-bed, semirural hospital to a 700-bed academic medical center.

CHI Saint Joseph Health has a virtually integrated care program in which virtual nurses augment the team, which “allows you to tap into a workforce that historically would need to work fewer hours or consider retirement because of physical limitations,” Bennett says. “It taps into individuals who love nursing but for family reasons, because they have a sick mother or a sick child—it allows flexibility with that kind of workforce.”

Tackling the Shortage: Results to Date

These various methods of addressing the nursing shortage have begun to pay dividends on myriad fronts, according to consultants and healthcare organizations. Columbus Community Hospital notched an overall patient rating of 87th percentile for 2023 on the Centers for Medicare & Medicaid Services’ Hospital Consumer Assessment of Healthcare Providers and Systems score. 

The hospital expects to have reduced its use of traveling nurses nearly 37% by September from the post-pandemic high point.

Meanwhile, CHI Saint Joseph Health has gone from 50 traveler full-time equivalents in its ED across Kentucky to zero today, Bennett says, and there are no vacancies in five of the seven locations where the system delivers emergency care. “In today’s environment, that’s pretty amazing,” she says. 

Outcomes and patient and employee satisfaction scores there also have improved, Houston says. Among them: Employee engagement rose 4.5% year-over-year from 2022 to 2023 as the nurse extern program grew from summer to year-round and more than doubled in size. 

The system also enjoyed a 54.5% reduction in healthcare-associated infections and a 38.5% reduction in healthcare-associated infections per expected infection. This success has led to various accolades, including CHI St. Joseph being listed as one of the nation’s top 15 health systems in 2023 by PINC AI and reported by Fortune.

“We see more volume,” Houston says. “All of those statistics have improved for us since we started this work. Certainly the way we staff the emergency department, and the culture that comes from that, makes this a place people want to work.”

Bennett adds that fewer than 0.7% of patients leave the ED without being seen, well below the national benchmark of 2%. And time to initial assessment averages 15 minutes, about half the typical 30. “Having a stable workforce allows us, from a leadership standpoint, to focus on efficiencies,” she says. “We don’t want patients to have a bad outcome and leave. We want the percentage of patients leaving to be zero.”

She says the quicker somebody can make contact with a patient, whether it’s an advanced practice person or a physician, and do an initial assessment, the better. “Getting started quickly is key,” she adds.

CHI Saint Joseph also has seen significantly higher nursing satisfaction scores, as well as improvements in quality outcomes like falls and hospital-acquired infections, Bennett says. “What we hear from frontline nurses is, ‘by having access to that virtually integrated care team member, I’m able to focus on my patient. … I go in the room and I’ve gotten so integrated with the virtual nurse, I can put hands on my patients, and I can provide a healing touch. Then I can talk to the virtual nurse, and I don’t have to worry about documenting.’”

This has boosted communications evaluation scores as well, Bennett says. “Often, people can’t come to visit a loved one, mom or dad, until they’re off work. They’ve got some barrier to getting there,” she says. 

“If the doctor is in the room with the nurse and the patient, and they’re talking about what the next 24 hours are going to look like, they’ll call the virtual nurse. Later that night, when the family might be visiting, they can connect with that family and close the loop.”

Ed Finkel is a freelance writer based in Chicago.