The Future of Nursing

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The Future of Nursing

Resolving Nursing Leadership’s Top Challenges & Solutions

Today’s nurse leaders are juggling competing priorities, all of which can impact patient satisfaction and outcomes, care quality, and ultimately, the hospital’s bottom line. Staffing issues reign as the priority concern as healthcare organizations attempt to optimize care delivery within a framework of higher demand for services and higher-acuity patient populations. Nurse leaders must also design strategies to successfully navigate the continuous influx of new technologies disrupting workflows1 and an ever-changing regulatory climate to ensure nurses feel supported and are productive and engaged.

A recent survey of nurse leaders conducted at the Elsevier Nursing Leadership Forum ahead of the American Organization of Nurse Executives (AONE) 2019 Annual Meeting identified recruitment and retention as the top challenge confronting hospital leadership today. Succession planning and the leadership gap, along with minimizing disruptions when adopting and implementing innovative technology, rounded out the top three.

Recruitment and Retention

That fact that recruitment and retention was top-of-mind should come as no surprise. Nurse leaders are dealing with the perfect storm of high turnover, a worsening nurse shortage, and conflicting generational work styles and expectations. According to the Bureau of Labor and Statistics, the U.S. will need more than 1 million Registered Nurses (RNs) by 20242 thanks to the ongoing shortage and the projected retirement of more than 500,000 RNs by 2022.3

Retaining nurses is an equally complex undertaking. The 1-year turnover rate among newly licensed RNs is 17.5%, jumping to 33.5% at the 2-year mark. Meanwhile, 43% of newly licensed hospital-based nurses leave their first job within three years.4 The retention challenge is heightened by the fact that today’s nursing workforce consists of five distinct generations—Silent, Baby Boomers, GenX, Millennial and GenZ—each of which thinks, responds and is motivated differently.5 If not managed properly, the differences can be a significant source of discord.

The first step to identifying recruitment and retention solutions is understanding the breadth of the problem. One nurse leader noted that his organization is on the verge of losing 60% of its nursing staff to retirement— taking with it years of invaluable experiential knowledge.

Nurse leaders at the Elsevier Nursing Leadership Forum identified several solutions designed to attract and retain new and experienced nurses, each focused in some way on enhancing nurses’ personal or professional lives. Some were reminders that many nurses find work-life incentives appealing, such as onsite perks like childcare and gym memberships. Others acknowledged that supporting nurses with the tools and resources needed to do their jobs effectively and efficiently plays in bettering engagement.

Most solutions, however, were focused on advancement. For example, ranking high on the list was the creation of a personalized career ladder enabling each nurse to follow the path that most interests them. This could be anything from access to advanced certifications to the creation of opportunities for nurses to move more quickly into various specialties.

Along those same lines, career-minded nurses respond well to innovative continuing education (CE) programs—offerings that can also help bridge the generation gaps. For example, the integration of virtual simulation technology or blended learning techniques has been shown to boost retention of information shared within CE programs as well as exam scores. These models are particularly appealing to millennials and GenZ nurses.

“Instead of ladders, we talked about career pathways so that people engage and embrace what they want in different areas. Then they can move through that as fast as they want. We [also] talked about careers without boarders... It’s really an opportunity to recruit and sell these things, the simulation labs, the things that really engage that millennial population and really create the control and the fun.”
– Elsevier Nursing Leadership Forum Participant

Helping to instill a sense of pride in their work is also key to improving retention. For example, “rebranding” acute care to reflect that it includes multiple specialties and/or creating a path for nurses to move more quickly into clinical practice and also to get involved in other activities that help guide organizational strategies. This can go a long way toward instilling a sense of ownership in organizational success. This ensures that nurses are engaged from the outset by giving them a voice and a path to make a real difference. It also provides an opportunity to have contributions recognized by hospital leadership.

“We have to build pride into what they do… It’s [about] getting the staff to be engaged and appreciate and understand their value. Once you have that, then you can retain [nurses], although there are still going to be the aspirations to [attain] higher degrees.”
– Elsevier Nursing Leadership Forum Participant

Succession Planning and the Leadership Gap

Statistics suggest that 73% of nurses in the Baby Boom generation who have indicated an intent to retire will do so within three years. Consequently, the nursing profession is facing a significant loss of institutional knowledge, one that calls for immediate and effective succession planning to ensure leadership is prepared to pick up the reins. Yet despite indicating that more nurse leaders are needed, 61% of nurses who responded to an AMN Healthcare survey said they had no interest in taking on the role themselves6 —a situation exacerbated by the 1.2 million RN vacancies that are expected by 2022.7

The answer lies in the development of leadership programs encompassing educational offerings, certificates or advanced degrees. These programs must be engaging enough to overcome nurses’ reluctance to step into leadership roles and effective enough to combat the potentially devastating loss of skills and experience as older nurses retire.

Elsevier Nursing Leadership Forum participants offered several solutions centered around leveraging the experience of nurses who are planning to retire or already have done so. Ideas included bringing retired nurses back to impart their wisdom to younger generations through residency and fellowship programs. Also recommended were mentoring programs featuring an “experience download” component where younger nurses partner with retiring nurses who share career experience, top lessons learned, and best practices.

Soon-to-be-retired nurses are another valuable source of knowledge for leadership programs. Nurse leaders recommended encouraging them to transition from bedside practice into newly created roles in non-clinical areas where they can use their experience to educate the next generation of nurse leaders.

“We need to urgently create roles for [older] nurses… [Have] retired nurses lead fellowship programs and be the experts; imparting their expertise during their fellowship and residency programs. And then [establish] mentorships.”
– Elsevier Nursing Leadership Forum Participant

Adopting, Implementing Innovative Technology

Healthcare technology is not going away, as hospitals shift their focus from implementing electronic health record (EHR) systems to improving or replacing them. Nearly a quarter of hospital executives are already conducting major system upgrades and 21% are replacing their EHRs. Further, approximately 40% of Chief Information Officers plan to invest in optimization projects within the year.8

The potential for workflow disruptions and costly end user-resistance puts nurse leaders in the unenviable position of having to engage reluctant staff in the adoption of new technologies. The goal of their actions should be ensuring that new implementations enhance, rather than delay, workflows and improve productivity at the bedside. This is critical, because in many healthcare organizations, nurses represent the largest technology user group—one whose acceptance is crucial to successful implementation.

A study by the BDO Center for Healthcare Excellence & Innovation and the University of Pennsylvania School of Nursing found that hospital leadership has been slow to encourage and optimize nurses’ skills in bringing together clinical innovation and technology and envisioning process change. Just 31% of participants said they have a designated nurse leader responsible primarily for innovation, and less than half (46%) said they specifically include individuals with nursing backgrounds in C-level positions.

As discouraging as the current reality is, the study also found that things are rapidly changing. Most (81%) of the clinical leaders surveyed said they are looking at ways to include nurses on strategic planning teams and 57% noted that they were intrigued by the advanced leadership skills nurse innovators can offer.9

While today’s nurses are generally proficient in the use of healthcare technology and have adopted a more positive view of its role in their workflow, there are barriers to full utilization that nurse leaders must address. Among these are behavioral issues related to perceptions of and satisfaction with technology and doubts among older nurses about working in a technology-rich environment.10

“My passion is around voice recognition. We were talking about having some sort of microphone pinned to our lapel and doing a head-to-toe assessment on our patient [while] talking about what we see. Not only does the patient hear it...but it’s going right into the electronic health record as we’re documenting it. All we have to do is verify it at the end of the day, so we’re returning the nurse to the bedside.”

– Elsevier Nursing Leadership Forum Participant

To overcome these barriers and lay the foundation for successful implementations, Nursing Leadership Forum participants recommended improving education and communications around the technology’s capabilities and how it will benefit both clinical workflows and patient care. Leadership should also push for technologies that match workflows rather than forcing nurses to change up their established practice patterns to accommodate new systems. This will help ensure the new solution will enhance nurses’ engagement at the bedside, where it can support and advance the practice of evidence-based medicine.

It’s also important to avoid duplication of efforts, especially documentation, by ensuring any new systems or optimization solutions integrate with existing technology. Similarly, nurse leaders must demand creation of EHR-standardized workflows. The impact can be significant, as demonstrated by one study that found a standardized EHR documentation template for patient observation can ensure regulatory compliance, comprehensive capture of coding and billing elements, and play a significant role in determining how nursing staffs can deliver safe, effective and efficient care.11 Studies have also shown that EHR-standardized workflows can improve nurses’ productivity and communications during patient transfers.12

Also, in terms of easing documentation burdens, nurse leaders suggested hospitals make broader use of voice technologies and other forms of artificial intelligence (AI) at the bedside. AI holds great promise for reducing “cognitive clutter” and streamlining the process of entering data into, and extracting it from, EHRs,13 thereby creating efficiencies and allowing for documentation in near-real time.

Finally, ensure that a comprehensive data governance plan has been put in place—ideally with input from nurses. These plans dictate how patient information is collected, stored, accessed and otherwise managed to ensure data integrity and availability. Governance also creates a single source of truth for data used across multiple platforms, supports standardization in reporting and creates accountability while promoting a greater understanding of the value of data.14

A Positive Impact

Healthcare is undergoing a transformation that is driving change in nearly every aspect of patient care and organizational operations. Effective nurse leaders recognize how these changes impact their nursing staff and take proactive steps to ensure the experience is positive. At the same time, they look for ways to minimize the impact of the contracting workforce to avoid the loss of institutional knowledge while closing the looming leadership gap.

The key is to get nurses engaged in decision-making and provide them with the tools needed to work more effectively and efficiently while delivering high-quality patient care—and to achieve both personal and professional goals and objectives.

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    x. Cassano, C. The Right Balance –Technology and Patient Care. Online Journal of Nursing Informatics. (October 2014) (Accessed May 27, 2019)

    xi. Noah, C. and Thomas, L. Using an Electronic Health Record to Standardize Documentation in an Emergency Observation Unit. Online Journal of Nursing Informatics. (February 2017), (Accessed May 27, 2019)

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