Nursing Post Pandemic: The Path Forward

As we move into 2023, we are, I hope, moving into a brave new future. COVID-19, while still evolving and highly prevalent, is moving into more of an endemic, flu-like state as opposed to a pandemic presentation. The health care system, to include the nursing profession, however, has been left in a shambles. The reality, as we all know, is that the health care system was teetering on the edge of disaster prior to the onset of the pandemic. COVID-19 was essentially the “straw that broke the camel's back.” This statement is particularly true for the nursing profession.

The nursing profession, and thus health care as we know it, is on the brink of implosion. Nurses of all ages are leaving at record numbers. Many are retiring, and taking decades of experience with them. Many newer nurses, however, are leaving the bedside within a year to two years of hire; some to advance their education and move out of the acute care setting, but many are leaving the profession entirely. The number of nursing students in the pipeline is in no way sufficient to fill the gap, and current nurse retention strategies are inadequate and outdated. The nursing profession, and particularly the future of health care in the acute care setting, is at a tipping point. If we, as the nursing profession, do not take the lead in staving off disaster, someone else will fix it for us, and we will likely not be happy with the results. Nurses, as a profession, must find a new path forward.

The numbers as they currently stand are not pretty, yet, not surprising. A Becker's report published in October of 2022 reported some disturbing statistics:

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  Regional RN turnover percent rate changes from 2020 to 2021 ranged from 3.2% to 12.2%.
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  The overall nursing turnover rate in 2021 was 27.1%, up 8.4% over the previous year.
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  RN turnover rates in step down units, emergency departments, behavioral health, and telemetry increased from 101.3% to 111.4% over the last five years.
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  Average turnover cost for a nurse is $46,100.00, up 15%.
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  60% of survey respondents reported an RN vacancy rate of 15%.
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  It now takes an average of 3 months to recruit an experienced RN.

A 2022 survey of physicians, registered nurses, and advanced practice providers showed that 25% of respondents were considering switching careers. To no surprise, 89% of those considering leaving the profession cited burnout as the primary reason. These statistics confirm what is now common knowledge: clinician burnout is a real threat to the stability of the US health care system. Wellbeing is also commonly acknowledged as the antithesis to that burnout. Yet how we define wellbeing, and how we enhance nursing wellbeing, is in need of some clarity and consensus building.

Wellbeing has many components: personal, spiritual, physical, mental, financial, etc, but what does well-being mean for the nurse? A recent concept analysis defined nurse wellbeing as “being the best “you” that you can be, and bringing the best “you” to your work, to your team, unit, and/or organization.” On face value, this definition implies a personal perspective or ownership. It is “your” responsibility to attain wellbeing. Many nursing leaders and national nursing organizations have fallen victim to this attitude….if one only took better care of themselves, took time for meditation, attended wellness classes, etc, then the nurse could attain that ever elusive goal of wellbeing. The reality, however, is that nurse wellbeing cannot be obtained through individual pursuit. Nurse wellbeing is primarily a consequence of work environment issues, of having one's basic human needs met in the work environment (Figure 1).

Nurse wellbeing emanates from a work environment in which one is adequately paid, protected, and supported. An environment where one's workload is manageable and the nurse is able to provide the nursing care that the patient requires. An environment where the nurse can take a break without interruption, where the nurse has control of their schedule, where they are respected and have a sense of belonging, and where they feel protected and safe from harm.Nurses do not need wellbeing officers and classes. The evidence clearly supports that nurses are looking to be treated and supported as professionals….as the guardians of safe, quality health care. A work environment must be created in which nurse wellbeing can flourish. The work environment must support the basic needs of nurses. Nurse burnout does not result from an individual's failure to pursue wellbeing; nurse burnout is a result of a failed health care system.

In my opinion, the first step down the pathway to a new nursing reality is in the recognition of the significant impact of nursing care that we provide impacts patient outcomes. This work begins in the C-suite. Nursing must no longer be considered as the primary cost center in the hospital. The care that nursing provides must no longer be wrapped up in the bed charge. Nursing must be recognized for what we are, the major revenue generator for the hospital. Without a nurse, there is not a hospital bed. The one and only reason that a patient is admitted to the hospital is because they require 24/7 nursing care. If a patient does not require 24 hour nursing care, then they can be managed via services in an outpatient setting. Nursing leaders and nursing administrators must own this power and make their voice known in the boardroom. They must support the bedside nurses they lead and no longer cave to pressures to “cut costs” in the nursing department. The nursing department is the center to which all other departments connect. We are the core that holds the acute care setting together. Nursing must own our positive impact on safe, quality patient outcomes and be reimbursed accordingly. Might this mean that nursing should be held accountable for critical nurse-sensitive quality measures? Yes. But this also means that nursing must be supported with adequate resources to deliver quality nursing care. Might nursing care delivery models need to be restructured to provide cost-effective care delivery at the bedside? Yes. Must federal policy and reimbursement structures be modified to reflect the criticality of nursing care to safe, patient care delivery? ABSOLUTELY!

The path forward to a new nursing reality will not be easy. It will not be without wrong turns, but we must traverse this long and difficult journey together. The new reality, the new future of nursing, will require significant changes in approaches to nursing leadership, nursing education, and the individual nurse's approach to patient care. Nothing, and I mean nothing, will be the same as before the pandemic, but with hard work and collaboration, a new future can be obtained.