What's missing from discussions on the nursing shortage? 9 CNOs weigh in

When it comes to the nursing shortage, much of the national rhetoric is focused on nurses who have left the bedside, or projections on how many more are planning an exit. But there is a need for more emphasis to be placed on the now: How can nursing delivery models change to best support and retain today's nurses while also attracting more individuals to the profession?

No doubt there is a critical need to invest in recruitment and building a pipeline, but "these are far strategies that cannot sustain the transformation needed now," Betty Jo Rocchio, DNP, RN, senior vice president and chief nursing officer at Chesterfield, Mo.-based Mercy, told Becker's. "Reimagining the nursing care delivery model is going to have to be the now/near focus to change the way nurses deliver high-quality care and interact with patients/consumers."

This means recognizing that a bedside role is no longer the only career option for nurses and requires investments in technologies and innovations to support emerging delivery models, such as virtual care, chief nursing officers told Becker's

Becker's recently asked nine CNOs what they think is missing from conversations about combating the nursing shortage, or what they wish CEOs know about efforts to address nurse shortages. Responses are listed in alphabetical order. 

June Altaras, RN. Executive Vice President and Chief Quality, Safety and Nursing Officer at MultiCare Health System (Tacoma, Wash.): Nurses devote their lives to caring for others. It is important that they also feel cared for and supported. What is lost in the national discussion is that the nursing model we have all been following for more than 40 years is no longer working. Focusing only on hiring more nurses won't get us to where we need to be. The challenges of the last few years have seen nurses leaving the profession in droves and taking their knowledge and experience with them. There are national studies that claim we'll need 1.3 million more nurses by 2030. The math just doesn't add up.  

But for real change to happen, CEOs need to be willing to invest in technology and support personnel to allow nurses to do what they were trained to do: care for the patient. Health systems will need to change their primary care model and invest in the technology, tools and support nurses to enable them to work at the top of their license. If we can do that, nurses will feel supported and respected by their hospitals and clinics. We can find long-term solutions to our nursing shortage; we just need the courage to implement them.

April Fox, DNS. Chief Nursing Officer at Baptist Women's Hospital and the Spence and Becky Wilson Baptist Children's Hospital (Memphis, Tenn.): Nursing opportunities have grown tremendously, which makes it a challenge for hospitals to attract nurses immediately after they've graduated from nursing school. Besides working in different capacities as nurses, they can pursue higher degrees as nurse practitioners or certified nurse anesthetics. While it is important to fill all these positions, this can reduce the number of nurses who choose to work at the bedside, where there is a great need. Fortunately, at Baptist Memorial Hospital for Women, our CEO works closely with our nursing team to identify trends and challenges so that we can be proactive and work together to make bedside nursing more attractive for new and veteran nurses.

Wendi Goodson-Celerin, DNP, APRN. Senior Vice President and Chief Nursing Officer at Tampa (Fla.) General Hospital: In my experience, the most important thing any leader can do is to really understand what the nurses at their hospital need. Then, support their personal and professional development. When we connect directly with nursing teams, leaders can better understand how to attract and retain top nursing talent.

At Tampa General, our CEO and our entire leadership team are committed to interacting with all team members. For example, our CEO and board chair have "scrub days" where they work alongside care teams on patient floors. In addition to regularly scheduled town halls, team meetings and surveys, team members are actively encouraged to send emails to the CEO with questions and comments. As a four-time American Nurse Credentialing Center Magnet-designated hospital, we have a layered Shared Governance model with seven council meetings focusing on such areas as healthy work environment, education and professional development, quality, safety, innovation and more. All of this provides opportunities to receive authentic feedback enabling us to better collaborate on creating an environment that supports our teams and puts their well-being first.

Anita Girard, DNP, RN. Chief Nursing Officer Cedars-Sinai Medical Center (Los Angeles): There needs to be a stronger federal statement and support of how we combat the nursing shortage, particularly in the rural areas and at critical access hospitals. With many critical access hospitals closing due to nursing and overall shortages across the country, where will these critically ill patients go? I have heard stories of patients having to drive hours with chest pain to gain access to a cardiologist and a cath lab. What's missing from the conversations is recognition of the critical role that highly skilled and educated nurses provide in the healthcare arena. We need to ask ourselves, without these skilled nurses, who will provide 24/7, 365-day care of our patients in the acute care, ambulatory and at-home settings, [and] where will healthcare be in the future without them?

Michelle Hereford, MSHA, RN. Chief Nursing Executive at University Hospitals (Cleveland): While we know the impact the last several years have had on the nursing shortage, what's missing from many of today's discussions is a recognition that there are numerous roles now available to nurses that did not exist in the past, further increasing the demand. These new roles reflect the changing landscape in healthcare. Beyond serving as valuable direct caregivers at the bedside, nurses are serving in other important roles that positively impact care delivery, finance and quality, among other areas. We see this at University Hospitals, for example, with the role of virtual care in our Hospital@Home program. With 24/7 monitoring by registered nurses using remote patient monitoring, medical providers can assess a patient's vitals, monitor interventions and medical stability, which previously required a patient to stay in the hospital.

When we focus too narrowly on trying to preserve the way things have always been for nurses in our hospitals and don't fully embrace evolving roles, responsibilities and the commitment to service, we can be at risk of overlooking the new needs for healthcare expertise that have been created by us, by the healthcare industry, by the community, by a different kind of demand. Of course, we continue to feel the nursing shortage most keenly at the bedside in the acute care areas. But evolving models such as virtual care also require talented professionals to provide compassionate care to patients.

Our charge is to help create a pipeline of nursing students who want to join our organization in any one of our different roles, as well as striving to create an inclusive, healthy working environment so that nurses who join us will choose to stay. We have several initiatives underway to help make this happen. Our inaugural Future Nurse Academy for high school students just concluded, which we're confident will help build a robust pipeline for years to come. Our Earn to Lean programs support our MAs, PCNAs and LPNs. And our Care Team of Tomorrow model helps nurses operate at the top of their license by enlisting other team members to perform tasks that take advantage of the full extent of their distinct training, license and experience.

Giancarlo Lyle-Edrosolo, DNP,, RN. Vice President and Chief Nursing Officer at Advocate Christ Medical Center (Oak Lawn, Ill.): It will take efforts from a variety of sectors to offset the nursing shortage hospitals across the country continue to face. Our organization is focused on retaining our nurses while also finding innovative ways to build a new generation of nurses.

To retain our existing talent, we ensure our nurses feel supported within our positive work culture by addressing the root causes of burnout. We promote wellness through initiatives like peer support groups, resiliency programs, leadership training and mindfulness resources. Leaders also make sure nurses are part of the decisions that impact their practice and the care they provide to our patients through a commitment to our nursing professional governance structure.

To attract new nurses, we've developed a nursing residency program for new grads that provides structured support and mentoring. We also allow flexibility and opportunity for our current experienced nurses to learn new specialties through fellowship programs. We also partner with area schools and host free events for high school, associate degree and doctoral-level nursing students — all while honoring our commitment to diversity, equity and inclusion.

Denise Mihal, BSN, RN. Executive Vice President and Chief Nursing and Clinical Operations Officer at Novant Health (Winston-Salem, N.C.): There is not one simple answer to solving or combating the nursing shortage. We must be having conversations across industries and with multiple stakeholders to develop a solution that addresses a continuum, including: nursing pipeline, academia, physicians and advanced practice providers, health systems, governance and legislation and payors. We need to also address the increase in workplace violence, a threat across all industries and in our communities.

  • Pipeline development: Building interest in healthcare professions among youth must start early. We can expose high school and middle school students to healthcare fields, their options and career pathways. Vocational tech programs in high schools are critical in offering CNA certifications, allowing students to enter a hospital as a full-time employee upon their high school graduation.
  • Academia: Redesigning traditional classes and clinical structure will result in increased options for students and instructors. We can attract more instructors by increasing salaries. At the same time, increase class sizes and student enrollment to meet demands. We must also meet students where they are and offer convenient child care, classes and clinicals in evenings and weekends.
  • Physicians, advanced practice providers and health systems: At Novant Health, we have implemented numerous options for our nursing team members such as offering flexible shifts, an accredited RN residency program for new graduates, and tuition assistance for those pursuing RN (such as CNAs). We also know competitive wages and benefits are a must. Other options include improving daycare options and extending operation times; tuition forgiveness programs (as done for physicians); and a robust shared governance system for RN input and influence over policy and procedures. Lastly, adopting technology to assist with administrative tasks as possible. Technology alone cannot solve our challenges, but the future of nursing will require us to find ways to use technology to enhance the nurse work environment.
  • Governance and legislation: We should allow advanced practice nurses to practice independently without direct physician supervision, as there is also a physician shortage. Of course, we need  guidelines, competencies, practice oversight and peer review. Independent nurse practitioners will improve patient access (especially in rural communities), improve patient outcomes and stretch the reach of all healthcare providers into our communities. We must also find a way to expedite the visa process for international nurses and prioritize healthcare workers. Novant Health implemented an international nurse program last year but recently learned that visas filed in 2022 will be delayed until 2024 due to a government agency staffing shortage.
  • Payers: Payers must value nursing care. Currently, nursing care is included in the "room charge." Delineating the cost of nursing care will elevate the value the nurse brings to the health system, patient experience and patient outcomes.
  • Social value and respect: The increase in violence, both verbal abuse and physical assault, has escalated within our communities and walls of our hospitals and clinics. Our healthcare providers deserve a safe and violence free workplace. Patients and families come to us at their times of greatest need. The healthcare team is there to meet the needs of their patients; violence is unacceptable and must be taken seriously by police and magistrates to protect our teams.

The nursing shortage is not "owned" or "caused" by nurses. It is a result of our complex and complicated national healthcare system. It must be addressed by nursing leaders, nursing organizations and C-suite, academia, physicians, advanced practice providers, health systems, communities, legislators and payers. 

At all costs, ensure that nurses have a reasonable daily workload that allows for breaks, connecting with patients and families and completing non-patient care activities such as education and email communications. Like in any industry, nurses who experience joy and feel valued at work are more likely to stay with their organization. 

Maddy Pearson, DNP, RN. Senior Vice President of Patient Care Services and Chief Nursing Officer at Brigham and Women's Hospital (Boston): Having a supportive, inclusive culture that fosters a sense of belonging among staff and leaders is crucial to retaining staff. These are challenging times in the healthcare profession with the national capacity crisis and staffing shortages, and it's important for everyone to feel that we are in it together and supporting each other. No one should feel alone during or after a challenging shift. We can all play a role in shaping the experience of our colleagues. Speaking to CEOs in particular, I would advise that it is vital they fully understand the value and contributions of nursing in the broader context of delivering care and that financial and care delivery models should support nurses working at the top of their license.

At Brigham and Women's Hospital, we have a robust program for newly licensed nurses in which they are part of a cohort to share experiences, ask questions and receive support. A culture in which nurses are heard, respected, included and valued is vital to retaining staff and delivering high-quality care, especially during challenging times.

Betty Jo Rocchio, DNP, RN. Senior Vice President and Chief Nursing Officer at Mercy (Chesterfield, Mo.): Flipping the paradigm … rather than continued discussions around the nursing shortage, let's look at changing the nursing care delivery model to support our patient population with the nurses we have. In order to do that, we must ask if we really have a nursing shortage or a failure to design a new nursing care delivery model with our current nursing workforce.

Nurses' value to their organizations became abundantly clear during the pandemic. Nursing is a valuable partner in helping healthcare meet goals across all care settings. And as a partner, nursing needs the right level of investment to ensure its viability and growth. At the C-suite level, the pursuit of quality, patient access and patient experience, co-worker engagement and culture remains a strong focus while bending the cost curve. In nursing, the strategy and early investment in the workforce is often overlooked, inhibiting our ability to achieve our goals. 

According to HRSA (2023), we are not going to be able to generate the number of nurses needed until after 2035. While the usual lanes of nursing pipeline and engagement with our colleges/universities, recruitment and retention will remain, these are far strategies that cannot sustain the transformation needed now. Reimagining the nursing care delivery model is going to have to be the now/near focus to change the way nurses deliver high-quality care and interact with patients/consumers. Just as consumer and patient needs have changed, we too must adapt and focus on two fundamental things to achieve our goal of attracting more nurses into the profession: 

1. Improve workflows by utilizing technology and streamlining documentation to assist the nurse workflow.

2. Optimize the work environment by reducing friction while delivering patientcare. 

To accomplish this, nursing leadership must shift the measurement of nursing care and impact so that the focus is on workload not ratios and fill rate (supply/demand), not productivity as primary drivers in efficient, effective delivery of nursing care.

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