Nurse staffing is undoubtedly a pressing challenge in healthcare. Nailing it requires a well-balanced symphony of forecasting, budgeting, recruiting, hiring, and onboarding processes. As you undoubtedly know as a healthcare leader, trends in the nursing labor market make it difficult to hone these processes and balance staffing costs, patient needs, and available nurses.

A recent surge in nurse turnover spurred by a combination of burnout after two years of service during the pandemic, early retirements, and higher paying travel nurse opportunities have added to an already dire nurse staffing situation.  

Prior to the pandemic, we faced a nursing shortage driven by an aging nursing population (more than 1 million of the nation’s 3.9 million nurses are over 50) and a scarcity of nursing educators to train new nurses to replace retiring Baby Boomers. In 2018, the United States Registered Nurse Workforce Report Card and Shortage Forecast: A Revisit ¹ predicted a shortage of 510,394 RNs by 2030. The effects of the pandemic have only worsened this trend. Today, the Bureau of Labor Statistics projects that U.S. healthcare organizations will have to fill almost 200,000 open nursing positions annually until 2030².  

The result of this shortage has—unsurprisingly—been chronic short staffing. In 2023, studies showed that the turnover rate for staff RNs increased by 8.4% and currently stands at 27.1%³. This mismatch of supply and demand has innumerable ripple effects on patients, hospitals, and nurses. To name a few, remaining nurses are overburdened, short-staffed units strain patient care quality, and filling staffing holes with contingent labor solutions places pressure on hospital budgets.  

In this piece, we will delve into the effects of short-staffing and strategies you can employ to reduce short-staffing in your organization.

Table of Contents

• Why Does Short Staffing Happen in Nursing?
• The Effects of Short Staffing in Nursing
• How to Improve Short Staffing in Nursing
• Reduce Short Staffing with Trusted Works

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Why Does Short Staffing Happen in Nursing?

Supply vs. Demand

The supply-demand mismatch is the overall force driving short staffing. As demand for healthcare is rising due to factors such as an aging population and patient surges from events such as the COVID-19 pandemic, supply is dropping as nurses exit the profession because of retirement and burnout, some of which can be attributed to violence in the workplace⁴. At the same time, organizations are struggling to fill positions. According to a report from NSI Nursing Solutions, Inc., the average time to fill an RN vacancy is 87 days⁵. Unfortunately, this is projected to remain high.

Unexpected Causes

Day-to-day causes of short staffing include nurses calling off work, needs of new staff members, hours worked by staff on call, laws and regulations, and unexpected care demands. 

Health-related Reasons

Nurses may call off because they are sick or because a child or another family member is ill. Given the current level of job stress, some simply decide to take a “mental health” day. Whatever the reason, the nurse leader is left with a staffing hole. In some cases, staff may have to be shifted from one unit to another unit that has a substantial staffing gap, which may end up with both units understaffed. 

New staff will ultimately ease staffing woes, but first they require preceptors, who in the initial phase of orientation should not take patient care assignments. 

Regulatory Reasons

Nurses on call who must work many hours are not safe to work until they have adequate rest time, which can result in an unexpected gap in staffing levels. A report from the Institute of Medicine (now the National Academy of Medicine) recommended that work hours for nurses be limited to 12 hours in any 24-hour work period and 60 hours per 7-day work period⁶.

As of March 2022, 16 states have regulations or laws related to nurse staffing in hospitals, such as nurse to patient ratios⁷. Other states prohibit mandatory overtime; for example, New York prohibits overtime except in a patient care emergency⁸. These laws and regulations are designed to protect patients, but also result in short staffing situations. 

Patient Surges

Finally, unexpected patient surges, such those caused by pandemics and natural disasters, can spur demand for care, leading to staff shortages.

Short staffing is not simply a numbers game about having enough RNs. Call offs by nursing assistants, for example, can seriously impact patient care. In addition, it’s important to have the right skill mix, considering factors such as role (RN, LPN/LVN, nursing assistant), experience, and employer (the organization vs. contractor). 

The Effects of Short Staffing in Nursing

Overcoming short staffing is a complex and necessary undertaking to foster a healthy work environment that increases nurse retention, patient safety, and optimizes resource expenditures. These are just a few ways nurse short staffing causes issues in hospitals across the country:  

Increased Nurse Turnover and Burnout

Short staffing leads to a toxic cycle. Understaffed units have higher rates of nurse burnout, which causes nurses to leave their jobs, which means the same amount of work falls to even fewer nurses. This further exacerbates the stress on already short-staffed nursing teams and leads to—you guessed it—more short staffing issues. In fact, more than half of nurses say short staffing is the primary reason for wanting to leave their position⁹. One study showed that nurses with a greater than 1:4 nurse-to-patient ratio have a higher risk of burnout, and that the risk rises 23% with each additional patient.  

Impacts on Patient Safety

The perpetual cycle is not only damaging to your nurses’ well-being; it is downright dangerous to your hospital’s patients. Tired and overworked nurses struggle with patient interactions, sustaining focus, and making careful decisions, all of which can lead to increased medical errors. Data shows that patients in understaffed facilities face a higher risk of infection, a rise in postoperative complications, a greater number of falls, and an increased rate of in-hospital mortality⁹. These issues not only impact patient safety, but they may also impact your hospital’s ratings, reputation, and potential exposure to litigation¹⁰.

Compound Costs of Overtime, Turnover, and Travel Labor

According to the Advisory Board, the median healthcare organization spent 5.6% of their total payroll expense on agency labor in 2021—double the rate in 2020, and the highest rate reported since 2014¹¹. Hospital clinical labor costs increased by 8% per day (about $17 million in additional annual labor expenses) since the onset of the pandemic¹². This rise in costs can be correlated directly to the increased need for agency staff, temporary labor, and overtime hours. Additionally, the average cost of turnover for a bedside RN is $40,038, which adds up to $3.6 million to $6.5 million per year per hospital. Considering it takes an average of 89 days (about 3 months) to fill a single specialty nurse role, the accumulated costs of filling frequent schedule holes—whether with a temporary or permanent solution—can be exorbitant.  

How to Improve Short Staffing in Nursing

So, what is a hospital plagued with nurse short-staffing issues to do?

1. Rethink Staffing Models

Many of today's established methods for nurse staffing and scheduling (e.g., rigid contracts and 12-hour shift requirements) fail nurses, patients, and hospitals. We suggest meeting the modern nursing workforce where it is (and where it is accelerating to in the future) by trading the traditional employer-centric nurse staffing approach for a more flexible talent-centric approach. This shift will resonate with today’s top nursing talent and position your hospital to develop a more robust and resilient nurse workforce.

The transition toward talent-centric staffing begins with treating nurses as dynamic, individual professionals. It continues with taking each nurse’s unique skills, availability, and career preferences into consideration in your staff planning. The more you know about a nurse’s preferences and motivations, the more you can provide them with fulfilling career opportunities. More fulfilled nurses equates to less nurse turnover and less short staffing.  

Based on nurses' preferences, consider unique schedule options that push the boundaries of the long accepted 12-hour shift model. In practice, this may look like offering more part-time roles (e.g., nights, weekends, or just a few days a week) and variable roles (e.g., enabling nurses to work in different units throughout your organization). This may require embracing technology to help you see how all these variable roles add up to full schedules for your organization.

By implementing more talent-centric models, you will not only enrich your existing team, but you will also build a healthy pipeline of nurses who genuinely want to work with your organization.

2. Level-Up your Staff Forecasting and Scheduling Tools

No doubt, the task of building a staff and schedule to prevent short staffing issues is a lot to ask of any leader—especially one armed only with limited census data, outmoded timekeeping and scheduling tools, and an Excel spreadsheet  

For decades, nurse schedules have been based on averages that do not paint a complete picture of fluctuating staffing needs. This leads to both under and over-staffing. The issue is that traditional staff forecasting approaches are hamstrung by a narrow focus and long runway projections that not only fail to consider variables that can (and should) affect schedule building but also risk limiting a hospital’s ability to respond to those variables.  

Historically, healthcare staffing prediction models and staff scheduling tools have been highly manual and unreliable, restricted by limited access to data and analytics. Rather than proactively building a recruitment pipeline and staying ahead of predictable needs, hospitals have been forced to spend valuable resources on time-consuming and imperfect recruiting and scheduling processes.  

Today, technology makes it possible to forecast staffing needs more accurately by analyzing past data trends and more holistically viewing all available labor sources. Leveraging data, your organization can build a comprehensive workforce strategy. We suggest using a forecasting tool that considers several years of data to examine averages of paid and unpaid leaves each month, turnover percentages, and seasonal trends (like tourism, holidays, or typical flu spikes). Based on a deeper understanding of true staffing needs, you can build a more proactive and agile staffing plan.

3. Empower Nurses ‍

Building a work environment that encourages and validates nurse voices will improve nurse engagement and, in turn, reduce turnover that leads to short staffing. Giving nurses a voice in the scheduling process breaks down perceptions of leader (or hospital) vs. nurses and gives nurses the opportunity to take part in designing solutions to short-staffing issues.  

Start by checking in with nurses about their individual goals and what is working and not working about your staffing model. Responding to their feedback and catering to their goals and interests can help not only with nurse retention, but also with building a more diverse workforce for your hospital. For example, you may discover a nurse is interested in working in another unit. Perhaps an ICU nurse might welcome a few shifts in the Cath lab? Perhaps a nurse in the Cath lab would welcome some mentoring from an ICU nurse? By finding unique ways to tap into nurses’ individual skills and interests, you are increasingly likely to fill diverse needs in the schedule with internal resources.  

To augment this, we suggest working toward a nurse scheduling tool that allows nurses to indicate which shifts they are available for and interested in, so they are in the driver’s seat of their careers, and you match the best-fit nurse with the best-fit shifts.  

4. Think Creatively About your Internal Workforce

There are several ways you can improve nurse retention and reduce short staffing by leveraging your internal resources. We’ve touched on a couple—offering more flexible work arrangements and empowering nurses. Additionally, you might consider investing in upskilling and cross-training staff to work in more areas of your organization. Another strategy is to consider incentivizing internal nurses who sign up for less popular shifts. However, if incentivization and rewards come at risk of overworking your nurses, skip that option altogether. Instead, consider quantifying what the hospital stands to lose by way of nurse burnout, overtime, and turnover and then use that projected spend to hire an additional nurse for a flexible work arrangement you’ve established up front.  

One example: Hiring a nurse at 0.6 FTE who would be willing to work 0.9 FTE during seasonal peaks and adjust down to 0.3 FTW during lower demand periods would keep the hospital’s financial investment and nurse’s overall income the same but would enable the team to meet demand where it’s needed. The bonus for the incoming nurse: Quality of life via the up-front establishment of forecasted downtime they can plan for and use to pursue rest or personal interests.

5. Build Your Own Internal Agency/ Flexible Resource Pool

Another strategy to reduce short staffing is to build your own internal agency or flexible resource pool. This can benefit both single-site healthcare organizations and larger organizations with multiple facilities within the same (or multiple) market(s). Today, technology makes it possible for healthcare leaders to track rapid changes in staff needs and launch creative workforce strategies that bring more agility to staffing. Leveraging data, you can now track and centralize all your shift needs and available resources (and the budget implications of hiring each resource) in one place to optimize resource allocation. In the past, this was cost and time prohibitive. However, with data science and AI, a new staffing world is here—a world that eliminates the staff agency middleman and puts power in the hands of healthcare organizations and clinicians themselves.  

By self-managing your own contingent labor, you build a strategic and flexible source of staff that you can flex to fill needs across your enterprise in line with emerging demand. Doing so effectively requires that you break silos and view your workforce needs and resources enterprise wide. Self-management of your contingent workforce is only efficient with technology that allows you to easily categorize and understand the variety of resources who may be available for any shift—whether it is a per diem, contract, or local or regional float provider. A holistic view empowers you to work nimbly, own your contingent labor database, and understand the operational impacts of, for example, bringing in a local float nurse as opposed to a per diem nurse to fill a given shift.  

Reduce Short Staffing with Works

From contract labor to internal float pools, Works powers labor mix optimization, and end-to-end workforce coordination—all in one system. Works not only empowers you to view your scheduling resources more holistically—expanding your resource pool—it also enables nurses to proactively share their interests.

Our revolutionary shift matching technology allows you to easily identify the best match for any given shift, connecting your staffing needs with credentialed providers who are set up to be paid and ready to fill workforce gaps. Schedule a demo to learn more!

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Works Cited

¹ https://pubmed.ncbi.nlm.nih.gov/29183169/

² https://www.bls.gov/ooh/healthcare/registered-nurses.htm#tab-6

³ https://www.advisory.com/daily-briefing/2022/03/09/hospital-turnover-survey

⁴https://www.ncbi.nlm.nih.gov/books/NBK493175/

⁵ https://www.nsinursingsolutions.com/Documents/Library/NSI_National_Health_Care_Retention_Report.pdf

⁶ https://www.cdc.gov/niosh/work-hour-training-for-nurses/longhours/mod5/07.html

⁷ https://www.nursingworld.org/practice-policy/nurse-staffing/nurse-staffing-advocacy/

⁸ https://dol.ny.gov/system/files/documents/2021/03/mandatory-nurse-overtime-powerpoint.pdf

⁹ https://online.emich.edu/articles/rnbsn/nurse-staffing-affects-patient-safety-satisfaction.aspx

¹⁰ www.nejm.org/doi/full/10.1056/NEJMsa1001025

¹¹ https://www.advisory.com/daily-briefing/2022/03/09/hospital-turnover-survey

¹² https://www.healthcarefinancenews.com/news/hospitals-paying-24-billion-more-labor-during-covid-19-pandemic

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