Boston-Leary, Katie PhD, MBA, MHA, RN, NEA-BC; Stone, Bobbie
The nursing profession has been greatly impacted by what has been coined as the Great Resignation and Great Attrition.1 Demand for competitive compensation, better work environments, safe nurse staffing, moral leadership, a politically charged healthcare consumer base, and high acuity for complex care demands in a politically charged environment is “nursing's tsunami.”1 Nurses have more options than ever before and they are exercising those options.2 This mounting unrest has simmered in a pot of paradigm shifts and is boiling over. The nurse staffing crisis is increasingly being viewed as a public health crisis garnering national and global attention.
The COVID-19 pandemic has forced immediate changes—and hopefully for the better. The navigation through this new world of care delivery warrants developing new maps to reach a new and acceptable normal. The forced and rapid evolution of healthcare and nursing has resulted in experimentation and innovation.3 Providing efficient high-quality care is our collective vision, but there is growing discourse on how these goals can be achieved in a complex and challenging environment with diverse needs and priorities.4 It is time to establish the vision and chart the course for nursing's new world order. This article outlines urgent issues and necessary steps for measurable change for nurses, in nursing practice and work environments by 2030.
Current issues
The nursing shortage
The US is inarguably in the midst of a critical nurse staffing crisis that is expected at the time of this writing to continue through 2030.5 Furthermore, nursing shortages are being documented around the globe, with a recent report from the World Health Organization noting that the world may be short 5.7 million nurses by 2030.6 According to the US Bureau of Labor Statistics' Employment Projections 2019-2029, RNs are listed among the top occupations in terms of job growth through 2029.5 The Bureau also projected 175,900 openings for RNs each year through 2029 in a 2018 report.5 The US has experienced periodical and cyclical nursing shortages since the early 1900s due to world wars, natural disasters, dissatisfaction with the work environment, aging demographics, recessions, and supply and demand for healthcare.7 Moreover, the magnitude and breadth of this nurse staffing crisis are unlike one we have ever seen, particularly in modern history.8
Nurses' mental health
In a 2022 survey of 12,694 nurses conducted by the American Nurses Foundation, results indicated that nurses felt stressed, frustrated, exhausted, overwhelmed, anxious, and overworked during the COVID-19 pandemic.9 Most nurses reported difficulty sleeping, overeating, difficulty in relationships, and increased suicidal ideation over two surveys completed within 6 months in 2021 and 2022.9 Decades ago, it was believed that Florence Nightingale engaged in self-imposed seclusion to protest and to protect herself from a “less than nurturing society” while managing moral injury from treating soldiers.10 The compounding of traumatic events, the whiplash of stressors from COVID-19 infection and hospitalization surges, and abuse over a protracted and lengthy crisis has undoubtedly led to maladaptation for nurses, particularly those in the US.11 Maladaptation is also due to the lack of a systemic and sustained approach to address nurses' mental health along with organizations' inabilities to address the main evil root cause of nurses' feeling burned out—the lack of staffing.
Attrition, resignations, and turnover
Based on current research at the time of this writing, large numbers of nurses are not quitting the profession.12 However, nurses are making necessary adjustments within their nursing careers.The phenomenon of unsafe nurse staffing is the main reason that nurses consider leaving their jobs. This is an epic negative feedback loop: poor staffing causes nurse attrition, and nurse attrition sustains poor staffing.13 Nurse turnover is a historically used metric to measure the movement of nurses outside of organizations where they are employed.14 Attention needs to be paid to every aspect of movement and mobility such as intradepartmental shift changes, interdepartmental transfers, setting attrition from acute to less acute or ambulatory, specialty changes, movement within and outside communities, and geographical location movements. Attrition may also occur from levels of hourly commitment to organizations whether full-time, part-time, per diem, or contingency. The 2021 national RN vacancy rate was alarmingly high at 9.9%, almost a full point higher than in 2020.15,16 A high vacancy rate directly impacts quality outcomes and the patient experience. It also leads to excess labor costs such as overtime and travel or agency usage.6
Cyclical biological threats
The pandemic has painfully illuminated unresolved problems and issues in nursing, such as poor staffing, mental well-being challenges, and supply chain vulnerabilities. A never-ending public health crisis from a novel virus continues to produce variants that cause societal disruptions. A public that was once very supportive is now inducing a vicious cycle of surges creating unsafe environments for nurses and healthcare providers. Isolating, quarantining, vaccines, and mask mandates were not consistently adhered to or welcomed by the general public. Sicker patients, either with COVID-19 or without, are presenting at healthcare facilities after delaying care, increasing the need for critical care while acute care nurses are experiencing relatively higher levels of stress and suicidal ideation compared with other nursing specialties.4
Vision for 2030
If the past is a good predictor of future events, 2030 may optimistically be a year of recovery and planning. Nevertheless, the prevailing theme here is that “Rome is burning” and it is high time to look beyond the current crisis state and crack the door open to a positive future for the nursing workforce with a list of daring declarations and manifestations for improvement.
Mental health support
Mental health and wellness are antidotes to the collective harm caused by being in a prolonged state of emergency. Mental illness, along with moral and stress injuries, has been deemed by some experts as the silent, invisible, and growing pandemic overlapping the COVID-19 pandemic.17 The evidence is quite clear that employee assistance programs are not trusted by nurses nor are they considered to be adequate to provide the support that nurses need.18 Nurses experience traumas due to the nature of the work with exposure to grief as they render care or insufficient resources, such as staffing, supplies, knowledge, and expertise to provide quality care.19 The stigma associated with nurses seeking help, placing care for others above their own, and their preference for nurse-led programs presents many challenges with the sustained success of peer recovery programs.20
It is the authors' hope that healthcare institutions will offer systemized programs that provide ongoing assessment for immediate support and access to resources in real time. Critically, the “it's ok to not be ok” philosophy must be systemized, incorporated structurally, evident to prospective hires, and taught on an ongoing basis. Mental health programs should be embedded in occupational health departments rather than human resources departments. In the same manner that nurses were upskilled during the pandemic, healthcare leaders and teams should be upskilled in mental health first aid to develop an awareness of warning signs for early intervention and to properly guide their teams when they are in distress on individual or departmental levels. Mental health initiatives will be perennial, evergreen, and a required social contract between organizations and teams. Mental health programs are to be included in organizational strategic plans with regular reporting with meaningful and measurable statistics versus feel-good and anecdotal process reports versus outcomes. Investments are to be made to include clear and concise resources for staff to seek assistance versus contacting a random 1-800 number. Mental health days should be normalized by setting the tone early and often while adding “mental health” sick codes and time to payroll systems for nurses to use when needed.
Wellness at work integration
Gallup has also provided a “wellbeing at work framework,” which is an evidence-based, holistic, and comprehensive approach to caring for members of their team. This framework invites leaders to understand five tenets of well-being (Career, Social, Financial, Physical, and Community) to boost productivity and key performance indicators.21 Career well-being is about liking what you do every day; social well-being refers to maintaining meaningful relationships; financial well-being concerns the appropriate management of financial resources; physical well-being is the energy to accomplish goals, and community well-being means feeling safe and engaging with the community and surroundings where one lives.20 Employee engagement and safety culture surveys provide temporal and unilateral perspectives and do not necessarily indicate an earnest interest in fully embracing the importance of nurses' well-being while at work.
By 2030, holistic and comprehensive wellness programs are incorporated during nurses' shifts in a nondisruptive but caring manner. Shared governance programs should include a wellness council where nurses provide insight on how this can be done effectively. Similar investments and attention paid and made to improving patient satisfaction should be directed toward nurse satisfaction. Similarly, investments in understanding the community from a case management perspective—where people live, pray, and play—should be applied to the teams within organizations. These approaches will strive directly at the heart of presenteeism, which entails physically showing up at work but not being fully engaged or functioning.22 Presenteeism is increasingly important to understand given the impact on patient experience, outcomes, and cost.22
Staffing and care delivery models
Innovative care delivery models are largely missing and needed.23 The traditional models of care delivery, such as total patient care, functional, team, and primary nursing have been unsustainable for years.23 A wide tent and progressive approach to staffing and developing models are necessary to positively disrupt and solve the nurse staffing crisis. Nurses and nurse leaders will need to conduct an inventory of all potential additional roles of licensed and unlicensed caregivers, such as certified unlicensed assistive personnel, emergency medical technicians, LPNs, and medical technologists, and how they can deliver care safely and within regulatory scopes of practice standards.24 It is essential to engage members of patient and family advisory councils in planning efforts.
By 2030, education and mentoring structures will be a standard for success and sustainment in addition to implementing a disciplined approach to establishing measures of success, such as hospital-acquired infections, adverse events, safety hotline reporting, and patient satisfaction for baseline and postintervention assessments. Literature and evidence will also bolster and support execution strategies and garner support within leadership structures. Partnership with academic nursing institutions and community leaders will be a standard as it is necessary to establish pipelines for a continuous supply of top nursing talent and stronger affiliations for clinical exposure and development. Staffing models will be reviewed and adjusted regularly based on internal needs and external suppliers to meet those needs. Considerations for the development of institution-based grant programs also offer opportunities for lower-paid organizational incumbents and nursing aspirants to obtain better-paying positions to achieve financial well-being. Employers will reflect a paradigm shift, evolving from the traditional employment arrangement and showcase models to embrace nurses' needs to explore other specialties and remove feelings of guilt associated with nurses' increasing desires for change and mobility. Innovative and effective care delivery models with evidence of positive and measurable outcomes will be reviewed, published, and shared at nursing conferences to build interest and spark innovation.
Documentation improvements
Nurses are the largest group of health information technology users but are the most dissatisfied with these products. Electronic health records (EHRs) were supposed to provide an efficient means of documentation while improving records' legibility, data mining, security, and portability of patient records. A study about nurses' perceptions of their EHR indicated that nurses held negative perceptions of navigation, functionality, system performance, response time, and documentation workload.25 EHRs tend to be one of the most prevalent pain points for nurses in the acute care setting. A study by Melnick et al.26 indicated that nurses rated the usability of their current EHR in the low marginal range of acceptability and found a strong association between usability and nurses' burnout.
By 2030, strategic and measured efforts for trended improvement of EHRs usability will be a priority for organizations and systems. Systems utilized for physiologic monitoring and lab data will be integrated into documentation processes to eliminate additional steps and reduce transposition errors or missed entries. Transcription, voice-enabled documentation technology, or scribes with nursing students or medical assistants will be provided during patient admission or initial transfer assessments to improve focus on the patient. There will be organizational discipline to resist adding more steps, layers, and processes as action items with quality improvement. Nurses' EHR usability and satisfaction will be measured and addressed on an ongoing basis with an urgency to manage nurses' burnout. Efforts to reduce the documentation burden will be a recruitment tool for prospective talent. Nurses will be able to balance being high-tech and high-touch.
Revenue vs. cost center
Nurses' services are invisible in the inpatient billing system since it is embedded in a line item for room and board which doesn't adjust or account for patient acuity or intensity of nursing care during hospitalization.27 Nursing services should be measured for value and submitted for billing as a separate line item. Legislative action and advocacy are necessary at the state level for these changes to occur.
In 2030, organizations will partner with nurses to understand the importance of capturing this charge and collaborate on state advocacy efforts. A singular message will be adopted by all nurses which supports efforts for strong and effective advocacy. This can spark the political might and muscle of nurses to rally collectively on one major issue, such as those shown during the efforts of the suffrage movement of 1873.
Diversity, equity, inclusion, and belonging
Nursing is not diverse enough to mimic the diversity in the population that the profession serves. There has been a significant movement after the death of George Floyd in 2020; however, substantive improvements with the hiring of diverse leaders and initiation of Diversity, Equity, Inclusion, and Belonging (DEIB) programs in healthcare have yet to be determined. Recent findings from a study link Black women's positions in the healthcare labor force to the historical legacies of sexism and racism which date back to the division of care work in slavery, domestic service, and limited opportunities in the most specialized care in hospitals.28 Social determinants of health are most effectively addressed with a diverse nursing workforce at the highest levels of nursing leadership and specialization.
By 2030, DEIB efforts will intensify as organizations partner with nurses to engage in community events at schools and colleges in diverse and impoverished neighborhoods to offer nursing as a rewarding career for people of color. Men in nursing will also profile the profession to young male students and serve as role models. Lesbian, gay, bisexual, transgender, queer (or questioning), asexual (or allied), and intersex (LGBTQAI) nurses will also be profiled and elevated to eliminate any stigma. DEIB efforts will be measured and reported regularly for improvement and reported with transparency to the community and the board. Organizational boards of directors will include more nurses and nurses of color to impact decisions and financial investments. Education and training on cultural humility will be offered regularly to support efforts for inclusion and less forced acclimation and assimilation.
Abuse and workplace violence
According to the 2019-2020 American Nurses Association's Healthy Nurse, Health Nation Survey29 of 6,000 nurses, violence and bullying at work are the top two hazards that nurses experience. All types of abuse and workplace violence toward nurses and healthcare professionals have no place in healthcare.30 By 2030, healthcare institutions will have clear definitions of workplace violence, visible processes and policies for employees, patients, and visitors, and advocate on nurses' behalf for proper legislation to be passed to deter these behaviors. Security and security systems will be improved with nurses having the ability to immediately call for assistance. De-escalation training will be provided to all employees. Nurses will also be protected to be able to serve as witnesses when these cases are prosecuted. Nurses will advocate with their employers at the state level to develop policies to address and deter workplace violence.
Philanthropy and community investments
Fundraising and philanthropy are key to financial viability to execute and sustain programs and innovative projects in nursing and healthcare. Nurses should be included and educated on philanthropy efforts that will fuel participation. Grateful patients tend to honor nurses that supported them through challenging experiences and many opportunities are missed.31 During a time of shrinking budget margins, the revenue pool can be expanded with nurses understanding that “the ability to express gratitude in a meaningful way seems to aid in a patient's recovery process with stronger immune systems, lower blood pressure, improved ability to heal, less loneliness, and more joy, optimism, and happiness.”31 Nurses also need to be aware of the importance and benefits of these efforts to understand how fundraising can impact patient outcomes.
By 2030, there will be improved alignment and coordination between foundational and philanthropic departments and strategies codeveloped to drive engagement. Nurses will utilize their “thinking outside of the box” skill sets to adjust strategies for effectiveness. Nurse leaders who have an interest in philanthropy are assessing their educational qualifications and can become more acquainted with philanthropy by going back to school to obtain a bachelor's or master's degree in Philanthropic Studies, a master's degree in Philanthropy, or Non-Profit Management Certified Fundraising Executive certification. Some organizations are combining job descriptions in philanthropy and nursing to include prospect research, communications, digital marketing, stewardship, and grant writing.
Conclusion
It is time to address the root causes of nurses' burnout and frustrations. The COVID-19 pandemic has created a strong desire and demand for improvement as today's workforce has rejected the “nature of the beast” arguments for the tough environments that nurses practice within. It is important to note that this is not an exhaustive list of all the issues that warrant immediate attention and improvement to drive nurses' engagement. The biggest question of all is: What are organizations and leaders willing to do to recruit and retain nurses who are no longer willing to accept the status quo?
There is a clear demand for these issues to be addressed now as there has been a paradigm shift in accepting the environments where nursing care is delivered. The innovation dial needs to be turned up now and will need to continue to move in the right direction to recruit and retain top nursing talent. Nurses most likely will be interested in exploring and leveraging additional skills they may possess outside of nursing to support efforts to improve if they feel valued and are appropriately compensated.
Nursing is here to stay but in a different way. Changes need to be made now leading up to work that is required for future years for nursing care that is diverse, different, and desirable and will pay positive dividends for all stakeholders. The time to act is now. Measurable improvements will come much later.
REFERENCES
1. Boston-Fleischhauer C. Reversing the Great Resignation in Nursing: more things to consider. J Nurs Adm. 2022;52(6):324–326. doi:10.1097/NNA.0000000000001155.
Cited Here
2. Keith AC, Warshawsky N, Talbert S. Factors that influence millennial generation nurses' intention to stay: an integrated literature review. J Nurs Adm. 2021;51(4):220–226. doi:10.1097/NNA.0000000000001001.
Cited Here
3. Kagan O, Littlejohn J, Nadel H, Leary M. Evolution of nurse-led hackathons, incubators, and accelerators from an innovation ecosystem perspective. OJIN: The Online Journal of Issues in Nursing. 2021;26(3):3.
Cited Here
4. Poindexter K. The Great Resignation in health care and academia: rebuilding the postpandemic nursing workforce. Nurs Educ Perspect. 2022;43(4):207–208. doi:10.1097/01.NEP.0000000000001003.
Cited Here
5. World Health Organization. Nursing and midwifery. www.who.int/news-room/fact-sheets/detail/nursing-and-midwifery. Accessed March 2, 2022.
Cited Here
6. Bureau of Labor Statistics. U.S. Bureau of Labor Statistics' Employment Projections 2019-2029. www.bls.gov/news.release/archives/ecopro_09012020.pdf. Accessed February 5, 2022.
Cited Here
7. Mackenzie B. World may be short 5.7M nurses by 2030: 4 report takeaways. Becker's Hospital Review. www.beckershospitalreview.com/nursing/world-may-be-short-5-7m-nurses-by-2030-4-report-takeaways.html. Accessed March 15, 2022.
Cited Here
8. University of St. Augustine for Health Sciences. The 2021 American nursing shortage: a data study. 2021. www.usa.edu/blog/nursing-shortage/. Accessed July 20, 2022.
Cited Here
9. American Nurses Foundation. COVID-19 Impact Assessment Survey - The Second Year. nursingworld.org. Accessed March 10, 2022.
Cited Here
10. Bae SH. Noneconomic and economic impacts of nurse turnover in hospitals: a systematic review. Int Nurs Rev. 2022;69(3):392–404.
Cited Here
11. Lesley M. Psychoanalytic perspectives on moral injury in nurses on the frontlines of the COVID-19 pandemic. J Am Psychiatr Nurses Assoc. 2021;27(1):72–76.
Cited Here
12. Delgado S. Nurse staffing: a reason to leave and a reason to stay. www.aacn.org/blog/nurse-staffing-a-reason-to-leave-and-a-reason-to-stay. Accessed February 3, 2022.
Cited Here
13. Gee PM, Weston MJ, Harshman T, Kelly LA. Beyond burnout and resilience: the disillusionment phase of COVID-19. AACN Adv Crit Care. 2022;33(2):134–142.
Cited Here
14. Solutions N. N. Inc. 2019 National Healthcare Retention & RN Staffing Report. NSI Nursing Solutions, Inc.; 2019.
Cited Here
15. NSI Nursing Solutions. 2022 NSI National Health Care Retention & RN Staffing Report. www.nsinursingsolutions.com/Documents/Library/NSI_National_Health_Care_Retention_Report.pdf. Accessed March 1, 2022.
Cited Here
16. Raso R, Fitzpatrick JJ, Masick K. Nurses' intent to leave their position and the profession during the COVID-19 pandemic. J Nurs Adm. 2021;51(10):488–494. doi:10.1097/NNA.0000000000001052.
Cited Here
17. Byon HD, Sagherian K, Kim Y, Lipscomb J, Crandall M, Steege L. Nurses' experience with type II workplace violence and underreporting during the COVID-19 pandemic. Workplace Health Saf. 2021;21650799211031233.
Cited Here
18. Foli KJ, Forster A, Cheng C, Zhang L, Chiu YC. Voices from the COVID-19 frontline: nurses' trauma and coping. J Adv Nurs. 2021;77(9):3853–3866.
Cited Here
19. American Nurses Association. Nurses in the workforce. 2022. www.nursingworld.org/practice-policy/workforce/.
Cited Here
20. Clifton J, Harter J. Wellbeing at Work. Gallup Press; 2021. ISBN 9781595622419.
Cited Here
21. Hemp P. Presenteeism: at work—but out of it. Harv Bus Rev. 2004;82(10):49–58.
Cited Here
22. Rainbow JG. Presenteeism: nurse perceptions and consequences. J Nurs Manag. 2019;27(7):1530–1537. doi:10.1111/jonm.12839.
Cited Here
23. Prentice D, Moore J, Desai Y. Nursing care delivery models and outcomes: a literature review. Nurs Forum. 2021;56(4):971–979. doi:10.1111/nuf.12640.
Cited Here
24. AACN, ANA, HFMA, IHI & AONL. Nurse Staffing Think Tank: priority topics and recommendations. 2022. www.nursingworld.org/~49940b/globalassets/practiceandpolicy/nurse-staffing/nurse-staffing-think-tank-recommendation.pdf.
Cited Here
25. Strudwick G, Hall LM, Nagle L, Trbovich P. Acute care nurses' perceptions of electronic health record use: a mixed method study. Nurs Open. 2018;5(4):491–500.
Cited Here
26. Melnick ER, West CP, Nath B, et al. The association between perceived electronic health record usability and professional burnout among US nurses. J Am Med Inform Assoc. 2021;28(8):1632–1641. doi:10.1093/jamia/ocab059.
Cited Here
27. Lasater KB. Invisible economics of nursing: analysis of a hospital bill through a Foucauldian perspective. Nurs Philos. 2014;15(3):221–224. doi:10.1111/nup.12040
Cited Here
28. Dill J, Duffy M. Structural racism and black women's employment in the US health care sector. Health Aff. 2022;41(2):265–272.
Cited Here
29. ANA. Covid-19 impact assessment survey - the second year. www.nursingworld.org/practice-policy/work-environment/health-safety/disaster-preparedness/coronavirus/what-you-need-to-know/covid-19-impact-assessment-survey—the-second-year/.
Cited Here
30. Stand L, Francis R, Bickford CJ, Boston-Leary K. Zero tolerance starts now: making nurses' safety a priority. Nurs Manage. 2021;52(11):18–22. doi:10.1097/01.NUMA.0000795588.86737.9a
Cited Here
31. Dorrill A. Funding academic and clinical nurse strategiesthrough joint fund-raising initiatives and grateful patient engagement. Nurs Adm Q. 2018;42(4):311–317. doi:10.1097/NAQ.0000000000000316.
Cited Here