Strategic Planning for a Very Different Nursing Workforce.

The COVID-19 pandemic amplified and intensified dramatic changes already emerging within the nursing workforce. This article examines and extrapolates from current trends to enable nurse leaders to prepare for the future nursing workforce and practice environment. Suggestions for strategic planning including imaging and prioritizing from a set of options for achieving a desired future state are offered. Strategic planning focusing on the wise use of nursing expertise and creating a positive professional practice environment can support the transition from the current crisis to a more resilient health care system supported by the full utilization of the knowledge and skills of registered nurses. 2022 by Elsevier Inc. All rights reserved.

The COVID-19 pandemic amplified existing forces creating a very different nursing workforce.

The future workforce will be increasingly shaped by Generation Y and Z nurses and the disruptive forces of the pandemic.

Strategic planning for a different nursing workforce needs to address the wise use of nursing expertise and creating a positive work environment.

Although staffing and concerns about employee well-being have long been a challenge for nurse managers, the intensity, persistence, and uncertainty of the COVID-19 pandemic exacerbated the situation. From the start of the pandemic, nurse mangers’ work pivoted from engaging and aligning the nursing workforce for the purpose of delivering consistent safe and high-quality patient outcomes to sourcing personal protective equipment, communicating an ever-evolving understanding about the novel virus, and subsequently implementing rapidly changing policies and practices. As the pandemic wore on, the emotional toll on the well-being of staff and relentless demand for staffing became an increasing concern. By July 2021, 75% of nurse leaders identified emotional health and well-being of staff; 61% identified surge staffing, training, and reallocation; and 47% identified staff retention, furloughs, and layoffs as a top challenge. Even more concerning, nurse leaders indicated that their ability to respond to these challenges declined over the past year, with the ability to respond to staff retention, furloughs, and layoffs dropping by 24%.

If anything, since July 2021, forces in the environment may have made these challenges more onerous. Just as vaccination rates were rising and infections were ebbing, the emergence of the delta and omicron variants dispelled hopes of the pandemic dissipating any time soon. The overwhelming and relentless patient care demands are driving a massive upheaval in the nursing workforce as evidenced by increasing nurse burnout, overreliance on the use of travel nurses, early retirements, and mounting resignations. The number of nurses either leaving or considering leaving their positions dramatically increased, driven primarily by insufficient staffing, workload, and emotional toll. In 2020, the turnover rate for staff RNs was 18.7%, an increase of 2.8% from the prior year, with time to fill a position still at 3 months. RN vacancy rates are at 9.9%, increased by a percentage point from the prior year, and a third of hospitals report a vacancy rate exceeding 10%. A recent study of over 100,000 health care employees in the United States found that nearly 30% of registered nurses (RNs) were at risk of leaving their current employer, and nurses younger than 35 at their current job less than 1 year are most likely to leave. Even as nurses are leaving organizations, onboarding of new employees has become more complex. In many colleges and universities, the education of recently graduated nurse rapidly shifted to a virtual platform, and clinical experiences were transitioned to simulations. As graduate nurses entered the most difficult practice environment in several decades, orientation processes and precepted experiences were disrupted. First-year RN turnover remains high, at 23.9%. Burgeoning demand drove the use of travel nurses to increase by more than 200% and, although solving an immediate and critical need, simultaneously exacerbated the problem with unsustainable labor expenditures and fueling frustration with existing staff. ,

Many of these trends were not new. The pandemic highlighted and exacerbated factors and forces that were already emerging in the nursing workforce. As the Baby Boomer generation continues to age, the demand for health care has been increasing as the gap between nurses leaving the profession and people graduating nursing school was expanding. On the supply side, Baby Boomer nurses have been retiring at the rate of about 60,000 per year for the past decade. By 2020, the median age of RNs was 52 years, and 19% were aged 65 or older. At the same time, in 2019, US nursing schools turned away nearly 80,500 qualified applicants due to a lack of faculty, education space, and resources. The exit of mature RNs has resulted and will continue to result in a striking loss of clinical and organizational experience, judgment, leadership, mentorship, relationships with colleagues, and expertise in how to overcome barriers to get things done for patients.

As Baby Boomer nurses retire out of the system, Gen X and Gen Y (Millennial) nurses increasingly fill the entry-level, middle management, and senior leadership roles. Gen Z nurses, born between 1995 and 2012, have been entering the workforce for a number of years. But these nurses enter the workforce underprepared. Even prior to the pandemic, studies demonstrated a continual decline in initial readiness of novice nurses to practice in highly complex and dynamic care environments, failing to demonstrate the competencies required of a nurse.

Beyond the demographics, the experiences of nurses contribute to issues with work, the workforce, and staffing. Burnout rates, now estimated at above 50%, were reported to be as high as 22% to 43% in nurses even prior to the pandemic. Inefficient work processes including those associated with documentation; excessive workloads including working when insufficiently staffed and overtime; organizational climate factors including poor management culture and lack of physician–nurse collaboration; work–home conflicts; and deterioration in control, autonomy, and meaning at work have been associated with burnout in nurses.

Strategic Planning in the Current Environment

Clearly, whether or not the pandemic occurred, nurse leaders needed to attend to changes in the nursing workforce. Equally as clear, this pandemic will have an indelible impact on the workforce for some time. Nurse leaders should anticipate and prepare for a very different nursing workforce and a very different staffing environment. If anything, the pandemic has made the need for thoughtful strategic planning to address the complexity of issues more necessary and more urgent.

As nurse leaders simultaneously manage through the existing crisis and pressures of meeting staffing demands for existing patient care with an already diminished and exhausted nursing workforce, investing time in strategic planning may feel onerous. Two years ago, “Strategic Planning in an Age of Uncertainty: Creating Clarity in Uncertain Times” was published. The article espoused that in today's rapidly evolving health care environment, continuing business as usual or tinkering with existing approaches would be insufficient and advocated that strategic planning may be most important in uncertain and turbulent times. Of course, as the paper was written, none of us had any idea of the turbulence and disruption that would be caused to our health care workplace from the COVID-19 pandemic.

As burdensome as strategic planning may be in the midst of intensity and uncertainty of the pandemic, failing to plan carries more dire consequences. Not only will lack of planning prolong the situation, it fails to position the organization for strong and sufficient nursing care in the future and makes the profession of nursing vulnerable to external forces and individuals who do not understand the complexity and nuances of nurse staffing “solving” the problem for us. Today’s pressures affecting the workforce demand that we step out of the turbulent pressures of daily staffing and prepare for a different nursing workforce.

Strategic planning aligns the energy, resources, and activities of an organization to work toward a common goal—addressing the needs for a future workforce that meets the organization and patient care needs while supporting nurses to thrive. Strategic planning applies a systematic, thoughtful, and disciplined process to understand emerging trends; explore and imagine a desired future; consider alternatives; determine and prioritize viable options for success; and execute on the course of action to attain the desired outcomes.

Understanding the Future

Planning for the future requires both acknowledging the current forces stressing the workforce as well as examining and predicting the future work environment. To begin strategically planning for a very different workforce, nurse leaders will find it helpful to invest some time in understanding the future, outlining the forces that will affect both demand and supply of nurses.

Caring for an aging population, transitioning from the overreliance on acute care to managing population health, achieving health equity, reducing health care’s impact on climate change, and navigating as COVID-19 becomes an endemic infection are all looming and relevant issues in addition to the increasingly pressing concern of a nursing workforce shortage. Although national trends will be informative, gathering data about local community needs and the organization’s projections for the nursing workforce will provide necessary specificity. The critical question is “what does our population need from nursing to deliver optimum care in the future?”

Engaging a wide range of internal stakeholders, such as the planning, finance, and quality departments, can be helpful in outlining demand drivers such as customer needs, societal forces, payer practices, and emerging technologies. Human resource departments can offer support with detailed information about impending retirements, turnover rates, and local data on the availability of new nurses and support staff. Colleagues from other organizations can help to identify emerging trends, market forces, and disruptive innovations to create a robust picture of the future state.

The goal is to understand both the work demands and the changing nature of the workforce now and for the next decade. At this stage, nurse leaders should prepare for a work environment increasing shaped by Gen Y and Z nurses. Understanding the culture and expectations of these generations should help form plans for recruiting, onboarding, developing, and retaining nurses. Although Gen Y nurses grew up in the Internet era, Gen Z has always lived in a “phigital” world where the lines between digital and physical realities have been blurred to the point of irrelevance. Gen Z nurses, growing up during a robust gig economy (with everything from Airbnb to Uber) have fundamentally different expectations about personalization, work–life balance, and work itself. Not surprisingly, this generation took advantage of market forces to fill travel nurse positions that provided them the ability to make a meaningful contribution while having more control over both their work and personal lives. Demands for work–life balance, flexibility in work schedules, and customization in work experiences can only be expected to increase.

Having lived in a world with an explosion of knowledge, younger nurses view education as the key to success. They seek continuous training and expect strong mentorship along with support and intellectual stimulation in the workplace. As nurse leaders consider planning for professional development of the future workforce, they should plan for robust ongoing professional development programs. Strong preceptors need to be prepared to teach both critical thinking and how to manage one’s well-being. In addition, recognizing that Gen X and Y nurses crafted their lives in the digital space and that newly graduated nurses have likely spent some or all of the past 2 years being educated via remote learning, nurse leaders should increasingly consider a hybrid approach to education and training. In addition, Gen Z is culturally diverse, is globally connected, and accepts multiculturalism as a way of life. Nurses from Gen Z will generally bring a more expansive view of and expectation for racial, ethnic, and gender diversity and inclusion as well as concerns for addressing the sustainability of the environment.

In the future, the nursing profession will still be an occupation largely composed of women who typically carry hefty personal responsibilities at home. Particularly during the pandemic, women were disproportionally affected with the burden of domestic responsibilities, caregiving and homeschooling children, and supporting elderly or ill family members. Organizations with the desire to attract and retain younger women must strategically plan to offer support with the demands of personal responsibilities.

And, of course, the nursing workforce of the future will need to process and recover from the intensity of the pandemic. Nurse leaders will need to plan on supporting the mental and emotional health of nurses, particularly younger nurses, who have suffered through the pandemic for some time.

Setting the Direction

Setting the direction fundamentally begins with creating a vision. As hard as it may be to set aside the pressures and anxieties of today’s staffing demands and workforce challenges, changing the trajectory for the future starts with imagining the desired state. Nurse leaders should think boldly, imagining a world where nurses find meaning and joy in their work; have the authority and control to fully apply their knowledge and expertise; enjoy partnership and collaboration with their team; where the system fluidly and fluently manages the onboarding and retirement of nurses and growth in the mastery of their practice in between; and where nurses are able to live their lives whole and wholeheartedly. Organizational and professional goals should be addressed including things such as envisioning a world where nurses understand and contribute to the value proposition of healthcare; craft a collegial professional practice environment; invest in their and their colleagues’ development and well-being, and enthusiastically adapt and innovate to emerging changes and societal needs. All of this is for the purpose of nurses adding their unique value to patient outcomes, the organization, community, and profession. Each organization should start strategic planning by imaging and creating their own unique vison for what “wild success” would look like.

This vision sets the framework for generating alternatives and prioritizing approaches to attain the desired future state. Nurse leaders can consider a variety of options including the wise use of nursing expertise and creating a positive professional practice environment. The wise use of nursing expertise includes garnering sufficient resources, maximizing nurse time on professional practice, and designing care delivery to match patient care needs in a way that creates interesting work for nurses. Creating a positive professional practice environment includes engaging and re-engaging nurses with professional governance; creating a culture of well-being; manage retirements, resignations, recruitment, and onboarding; and investing in nurse leaders.

Wise Use of Nursing Expertise

Garnering Sufficient Resources

As a starting point, nurse leaders must recognize and contend with the economic forces at play in health care today. Hospitals lost an estimated $323 billion in revenue in 2020 and are projected to lose an additional $53 to $122 billion in 2021. Although government support bolstered the health system, demands of the pandemic coupled with a sluggish recovery of patient volumes and increased expenses have resulted in nearly half of America’s hospitals and health systems operating with negative margins. Workforce expenses are a significant factor in the financial challenges that hospitals face. In January 2021, hospitals experienced a 30% increase in labor expenses per adjusted discharge from the same time in the previous year.

In this climate, 1 strategic approach is being a good economic steward of the valuable resource of nurses by ensuring that efficient and effective workforce management practices are in place. Nurse leaders need to ensure that those responsible for nurse staffing are implementing best practices. Skillful attention to using nurses in a cost-effective manner will be critical now and in the future.

Underlying the ability to provide a positive practice environment and to attract and retain a sufficient cadre of engaged nurses is the need for all hospital leaders—from the board to the nurse at the bedside—to recognize the value and subsequently wisely invest in and utilize nurses. Many nurse leaders navigated through historic financial pressures on hospitals and health systems, with downsizing, down-skilling, and external forces affecting nurse staffing. As in the past, those less familiar with the necessary and valuable contribution that nurses make to the quality of patient care outcomes will naturally look to reducing staffing, potentially to the point of adversely affecting patient outcomes.

This requires some work on the part of nurse leaders to educate their colleagues to reset the perceptions of nursing as a cost to one of a value-adding asset. As nurses have long known and as became apparent to many others during the pandemic, the economic and human toll of unstaffed bed—not nursing care—is the real cost to the system. Nurse leaders must change the conceptualization as expenses to revenue and value generators. In addition, nurse leaders must make their work crisper and clearer to others within the system. To do so, nurse leaders must tell the story of what it takes to educate and prepare a nurse, the complexity and skill required to align nurse staffing with the talent to meet patient care demands, and the infrastructure that supports the evolution and application of evidence-based knowledge necessary to adapt to and meet the changing patient and system demands for quality nursing care.

Maximizing Nurse Time on Professional Practice

Both nurses themselves and others within the system need to understand, clarify, and articulate where nurses can contribute their unique value to producing desired patient outcomes. Inherent in strategically pivoting to focus on the value of nursing is for nurses themselves to bring their insights and expertise to identify, reduce and eliminate non-value-added practices and wasteful care. Many of the rapidly implemented practices launched at the height of the pandemic offer insights into opportunities for identifying and eliminating non–value-added work. Building upon the creativity, innovations, and renewed collegiality of the pandemic offers an opportunity to eliminate waste from unnecessary nursing tasks, uncoordinated care activities, ineffective handoffs, and unnecessary administrative complexity.

Nurses desire more time with their patients, but studies show that a significant amount of their time is spent on documentation and non-nursing activities. Nurses spend between 19% and 35% of their time on documentation and that electronic heath record (EHR) usage leads to heightened cognitive workload for nurses. Increases in cognitive workload can result in stronger feelings of exhaustion and burnout. In addition, time motion studies find that nurses spend approximately 10% of their time on delegable and non-nursing activities due to insufficient staffing or inattention by other departments or other nursing support staff such as patient care assistants and unit secretaries.

Nurses need to be engaged to identify those elements of their practice that detract from the intellectual contributions and care, and to eliminate, reduce, or innovate all offer strategic opportunities. A component of reducing the workload for nurses is to investigate or innovate using technology to help. Robots and remote telemonitoring can support and augment nursing care delivery, particularly in high-repetition, low-risk tasks as well as support quality and safety. Service robots powered by artificial intelligence are already being deployed and tested in inpatient care environments to assist with supply delivery and patient mobilization. Asynchronous communication tools can reduce the volumes of interruptions. In addition, new innovations such as redesigning documentation systems or using camera computer vison are being explored to significantly reduce the burden of EHR documentation. At a minimum, streamlining documentation to eliminate unnecessary information and reduce the complexity of data entry and retrieval should be explored. Insights and opportunities for improving the EHR abound by exploring where nurses document the same information in numerous places, documentation order does not match workflow, and there are long and invaluable task lists and frequently ignored alerts.

A component of using nurses wisely is ensuring sufficient supportive personnel. Physicians and nurses only comprise about 20% of the health care workers. A large percentage of those in health care are direct service workers, which include patient care assistants, medical assistants, operating room assistants, environmental services staff, and dietary service workers. A large percentage of direct service workers are women, people of color, and immigrants, amplifying issues of inequality along gender, racial, and class lines. Many of these employees earn minimum wage, live in poverty, and/or rely on some form of public assistance. For this group, the combination of low pay, lack of accessible and affordable childcare, and availability non-health care employment opportunities without the exposure to infectious diseases made either not working or working in another industry more appealing. Nurse leaders have a strategic opportunity to work with their human resource departments to ensure that these positions are attractive within the marketplace and to create roles for direct service workers as the precious and non-easily renewable resource they are. Beyond offering competitive salaries and attractive benefit packages, hospitals can couple the hiring of high-demand, entry-level employees with a plan for with skill development for career advancement. Supporting frontline workers with a pathway for career advancement within the institution can improve recruitment and retention and creates long-term sustainable economic transformation and improved well-being within the community.

Redesign Care Delivery Models

At the height of the pandemic, another area where nurses responded with innovation and creativity was in implementing a variety of care delivery models. Everything from using team-based care to cross-training and cross-utilizing nurses to perform new patient care and support functions were rapidly employed. These innovative models offer insights to reimagining nursing care delivery models and staffing practices with a lens to strategic planning for a different healthcare workforce.

For example, during the pandemic, more than 60% of nurses floated across units, acuity levels, and settings, and about one-third indicate interest in continuing to do so if well cross-trained. In the future, planned cross-training has the opportunity to create interesting professional work, enhance the flexibility of the workforce, and vary the intensity of assignments in a way that could be protective of well-being. Both within the acute care setting and as more care is moved to the digital and outpatient/home environment, nurse leaders can reimagine staffing roles in a way that are not unit or department bound. Coupling the intensity of inpatient care with roles in telehealth, community, and in-home care models may provide a way to diversify and add interest to the work while maximizing the valuable contributions of nurses. As hospitals and health systems increasingly attend to social determinants of health, nurses could toggle—even on a weekly or monthly basis—between working in inpatient and community settings. Health systems could reimagine nursing roles where part of the assignment is in acute inpatient care and other part is in outpatient ambulatory settings. Diversifying the intensity of the work, changing the weekend work expectations, and altering the shift length demands could create interesting work experiences in a way that retains or even enhances clinical expertise at the inpatient bedside. Virtual nursing using videoconferencing technology and hospital-at-home care are other options for utilizing the deep knowledge and expertise in a different practice setting. Already demonstrated to be a clinically feasible and efficacious way of providing high-quality acute-level patient care in a cost-effective manner, increasing access to digitized and mobile medical diagnostics and interventions will likely make hospital-at-home care more common. Acute care nurses could work a combination of full-time and intermittent nursing roles in inpatient, telehealth, virtual, and home settings.

Another source for potential strategic planning were the team-based staffing models with an RN supervising a team of licensed practical nurses (LPNs), aides, technicians, and non-nursing staff used during the pandemic. Many nursing colleagues suggesting relying on LPNs to fill RN vacancies or supplement RN staffing. They share how successful this model was early in their careers and lament the loss of LPN talent to care delivery. Certainly, the loss of nursing personnel overall impacts patient outcomes and yet an abundance of evidence associates RN staffing and skill mix with the quality of patient outcomes. ,

Rather than reverting to a model that offered value in a previous patient care environment, ensuring that new models are driven by future demands can be a valuable outcome of strategic planning. For example, advanced practice registered nurse (APRN)-led acute care staffing models could offer promise. Between 2010 and 2017, the number of NPs in the United States more than doubled, and is projected to more than double again by 2030. Although this added assets for advanced clinical practice, it simultaneously reduced the number of RNs. Although some of this is due to increasing numbers of nurses pursuing higher education with the desire to remain a nurse but move from in-hospital practice, there is an opportunity to reimagine the role of APRNs at the bedside in acute care settings. Team-based nursing care with APRNs as the clinical leader could craft an engaging inpatient role for these nurses in a way that simultaneously delivers and coordinates patient care while also serving as a mentor for novice nurses and guide in implementing evidence-based practices and quality improvements for more experienced colleagues.

Nurse leaders would be wise to be informed by and learn from the past and contemporary evidence while considering and exploring new staffing models. Clarity on licensed capabilities, distinguishing nursing task versus professional responsibilities, coaching, and mentorship are all necessary skills for effective delegation and a collaborative work environment. Delegation skills must be learned, practiced, evaluated, and improved. Building skills in teamwork and collaboration will contribute to long term success. Evidence-informed guidelines for intercollaborative practice are currently scarce and will be needed to ensure that all caregivers are working to optimize their and each other’s scope of practice and to enable the success of any new staffing model.

Creating a Positive Professional Practice Environment

Engage and Re-Engage Nurses With Professional Governance

As nurse leaders look to redesign the work and care delivery models to meet the needs of the future, 1 area where history can be most informative is re-examining the early literature on Magnet® recognition. In the nursing shortage of the 1980s, qualitative research using a positive deviance lens examined those hospitals that were “magnets” for nurses. Hospitals that had waiting lists of applicants despite the shortage were found to have a professional practice environment that enabled nurses to control their practice. Transformational leadership; structural empowerment; new knowledge, innovations, and improvement; and exemplary professional practices all undergird a practice environment that maximizes the contribution of nurses.

Professional governance is the cornerstone of professional practice, providing the structure and process for nurses to actively control their practice through decision making in their areas of accountability. Not surprisingly then, professional governance and a Magnet® work environment are consistently associated with improved nurse satisfaction and patient outcomes. Particularly after the pandemic, rather than allowing the frustrations and moral outrage to devolve into endless suffering, powerlessness, and fear, nurse leaders should harness the collective experience to fuel constructive progress. Fundamentally, actively involving frontline nurses in addressing the challenges and devising the solutions to the issues of nursing and healthcare aligns with the intrinsic and deep-seated desire for autonomy, mastery, and living a life of purpose. As evidenced by the rapidity of practice innovation during the pandemic, nurses themselves have the insights and expertise about how to creatively adapt to meeting complex patient care situations, apply innovative new nursing interventions, craft evidence-based policies, and advance clinical practice. By strengthening and supporting professional governance, nurses can work together to exert their professional autonomy and control over their practice, improving and demonstrating their value, and using their clinical expertise and judgment to address the complex demands of the future.

Culture of Well-Being

Certainly, after the turmoil of the pandemic, a component of strategic planning requires creating a culture of physical, mental, and emotional well-being for nurses and all employees. At the most basic level, nurse leaders must look to implement strategies that reduce the mental, physical, and emotional workload. With all of the talk and efforts aimed at improving resilience of the nursing workforce, nurse leaders must understand and put equal, if not more, effort at creating resilient workplaces. Resilient workplaces are partially created by minimizing the cumulative “pile-up” of external, internal, and employee stressors—in essence, reducing the demand for individuals and the organization to be resilient. This requires learning to moderate the level of demand. Productivity and employee engagement are maximized when the work is interesting, meaningful, and challenging as long as the demands match or slightly exceed resources. Both well-being in the workplace and the quality and quantity of work performed is hindered by strain (too much challenge) as well as boredom (too little challenge).

During periods like the pandemic, when the work demands are excessive, the only solution to not overstretch or at least offer some protection to the adaptive capacity of employees is to lessen work demands and offer protected breaks away from the intensity of patient care. This includes both break time within work shifts as well as days off between shifts. Structures, processes, and practices to ensure that time off—from 30-minute breaks within the shift to uninterrupted days off to planned periodic vacations—should be in place. As tempting as it is, nurse leaders and staffing coordinators should not be interrupting nurses on their days off with relentless requests to work extra shifts. In addition, much like travel nurses have intense 13-week assignments followed by a 2-week mini-vacation before their next assignment, nurse leaders can ensure that full-time staff are planning and regularly using uninterrupted vacation time. Creatively, 13-week rotations—for example, a busy inpatient rotation followed by a telehealth assignment—can create interesting job variability coupled with a differing work intensity that could be very protective of nurse well-being.

Strategically, nurse leaders also need to recognize the difference between building individual nurse resilience and building interventions into the work environment to create a long-term culture of well-being. Self-care and peer support need to be encouraged, valued, normalized, and hardwired within organizations. Creating safety about talking through the difficulty of patient care, reducing stigma and normalizing asking for help, and embedding a process where nurses can openly share and process their experiences can protect nurses from burnout and reinforce collegiality. To process and recover from the moral injury experienced during the pandemic, nurses will need to share their experiences, debrief on the whole event, and process their emotions. In addition, embedding practices for meaningful recognition, from “everyday” patient care activities to significant professional accomplishments, reinforces the valuing of nurses’ unique contributions.

Manage Retirements, Resignations, Recruitment, and Onboarding

In the near term, nurse leaders should prepare for nurses who resigned or traveled who might express interest in returning to the workplace. Strategic options range from making travel nurses “do not hire” so as to not further aggravate those nurses who remained on staff to welcoming all nurses back into the practice setting to rebuild staff expertise. Generosity of spirit and sensitivity to the inordinate pressures that everyone faced during the pandemic can be a helpful guide. Whatever the approach, nurse leaders will want to acknowledge the difficult personal and professional forces—from unemployed family members to inaccessible childcare to overwhelming burnout—that all staff faced and honor the choices that people made. With that lens, nurses can plan for how to best approach and respectfully manage both nurses interested in reentering and nurses who remained.

With the retirement wave of baby boomers escalating over the next decade, nurse leaders should anticipate the need for organized knowledge transfer between soon-to-retire and younger nurses. Every hospital and health system has a cadre of experienced nurses who have both deep clinical expertise and knowledge about how to get things done. Losing long-tenured nurse employees is not only the loss of patient caregivers, but also a loss of experienced guides and mentors for more novice nurses. Understanding the impact of nurses aging out of the system and planning for the hiring and education of replacement nurses in a strategic manner can avoid a continuous stressor of turnover, vacancies, and insufficient staffing.

As nurse leaders prepare for a retirement wave, 1 option is to creatively plan for how to keep the expertise of experienced nurses within the health care system. Exploring the reasons for and goals of retirement or resignations may offer insights and enticing possibilities for redesigning roles, creative work schedules, new practice roles, or mentoring opportunities. Strategically thinking about how to reengage nurses who are considering leaving can take a variety of approaches from “won’t you reconsider” conversations to exploring work alternative to inviting people back after some time off. Historically, these conversations have been managed one-on-one by the employee’s nurse manager. Having an infrastructure that supports or supplements nurse managers in letting nurses know that their contribution is important, and exploring alternatives may be valuable in retaining talent in some capacity.

Of course, the plans for addressing retirements and resignations assumes that there will be a sufficient number of new nurses available. As part of strategic planning, nurse leaders should take a long-view of the pipeline of students interested in entering the profession and take necessary steps to bolster future cadre of nursing students. Once again, this is an area where past experiences can be informative. In the 1990s, hospitals focused on managing expenses by reducing nurse staffing. Nurses appropriately publicly protested, explaining the dire consequences of inadequate staffing. An unintended consequence was that the desirability of nursing as a career was diminished. Nursing school enrollments dropped an average of 5% annually. The Johnson & Johnson Campaign for Nursing’s Future reversed the enrollment trend through positive messages and portrayals of nurses on national media. Today, even as nurses legitimately portray the physical demands and emotional exhaustion of working through the pandemic, nurse leaders need to recognize the possible adverse impact of ongoing negative stories. The initial rise in nursing school applications may be a response to the heroic images and desire to help; but as the relentlessness of the pandemic fatigues everyone, negative depictions about the practice conditions may adversely impact interest in entering the profession and long-term growth of the nursing workforce.

Unfortunately, retirements and nurses leaving the profession result in a loss of nurse expertise that is coupled with declining readiness by newly graduated nurses to practice. Evidence indicates that initial competency of newly graduated nurse has been declining at an alarming rate even prior to the disruption of education and clinical rotations during the COVID-19 pandemic. As a result, strategic preparation for onboarding and support for life-long professional development will be necessary. Transition to practice programs will need to strengthen clinical skill proficiency as well as the critical thinking required to provide safe and effective patient care. Professional skills such as time management, delegation, interpersonal communication, evidence-based practice, leadership, and well-being will also need attention for nurses to be successful in clinical practice.

New approaches will be needed to meet the learning styles and expectations of technologically savvy, digital native new nurses. Hybrids of in-person and virtual learning opportunities, including immersive experiences and competency assessments, can engagingly facilitate a novice nurse’s progress from possessing “textbook knowledge” to applying skills in the clinical setting as well as the higher-order thinking and knowledge work required for today's clinical practice.

Investing in Nurse Leaders

All of this strategic work relies on having nurse leaders who have the skills and demonstrate the behaviors necessary to create a high-performance workplace built on collaboration, commitment, and purpose. Decades of research have demonstrated the pivotal role that nurse leaders play in creating positive work environments and influencing intent to stay. Consistently, studies report a significant positive correlation between transformational, servant, and authentic leadership styles and job satisfaction. Leaders with the ability to promote and support teamwork and to empower employees are able to create work environments with both direct and indirect influence on nurses’ job satisfaction. Transformational leadership requires spending time teaching and coaching nurses, guiding their professional and personal development, and developing and enhancing their strengths. Transformational leaders engage nurses in decision-making, listening to their concerns and doubts, as well as involving them in achieving organizational goals. , All of these leadership behaviors require investing time in developing nurses as leaders, ensuring they understand and can apply the knowledge and behaviors necessary for skilled leadership.

Conclusion

These are complicated times, and pretending that simplistic solutions will resolve nursing workforce issues and challenges would be naive. Yet, the status quo is clearly unsustainable. Nurse leaders need to plan today for the future.

When planning, nurses have a rich history filled with opportunities to learn from our mistakes and apply what we know about the value of nurses and the fundamentals of creating a professional work environment. Much like in past shortages, observing for and amplifying positive deviance can provide a path forward. The pandemic equally demands and enables nurse leaders to be more creative and bolder in crafting the future of the nursing workforce.

Nurse leaders can foster conversations to reimagine nursing roles and care delivery, prioritize actions that will achieve those visions, and execute in a way that creates a stronger and more impactful profession of nursing. With a clear vision and a roadmap, nurses can navigate from where we are today into a more palatable solution—the creation of a future that meets both patient care needs and supports the professional practice of registered nurses in a way that enables them to make a meaningful contribution.