Opinion Eight Steps To Combat The Crunch

The looming crisis in nursing workforce is not news. For the past three years there has been a steady litany of studies and reports projecting the growing disconnect between the demand and supply of RNs now and, more critically, over the next decade.


I want to focus on eight things that leaders in the care delivery system can do to begin to address the nursing shortage. These are actions that in the most progressive hospitals across the nation are already underway and will eventually be seen as the benchmarks for those institutions that wield human resources to their strategic advantage.

First, leverage the strategic value of nursing to the core missions of the hospital — quality, safety, and efficiency. Without the understanding that nursing is at the core of each of these values, there will be no progress made. If nurses are treated as a labor commodity, then they will act and perform like commodities, and neither patients nor physicians will like it. Value and invest in nursing, and the returns will become immediately apparent.

Second, develop key strategic external partnerships to address the issues at hand. There are two key collaborations that management can activate. First, the schools of nursing need allies and strong partners. Many of these alliances have been built over the past few years, but they need to increase in number and strength and diversify function. The second partnership is between management and labor. In non-union communities, this means strengthening the voice of the nurse at the boardroom table, just as finance and facility have a voice. In communities where nurses are represented by unions, this will mean new efforts to bring management and labor into alignment over fundamental issues of worker safety, job security, training and development, evaluation of quality, and the overall financial future of the hospital.

Third, improve the high-tech and high-touch qualities of nursing. There are enormous advantages to be gained by investing in new technologies that can support and advance nursing practice. Unfortunately, at the hospital level, most of the investments in new information and clinical technology are not used to create a more effective nursing staff with better performance outcomes. Vast improvements could be made by changing current investment allocation. On the flip side of the coin is high touch. To have a caring patient- and family-centered culture, hospitals need to first care about their nurses. Focusing on their needs as caregivers will return enormous dividends in terms of quality, safety, and satisfaction.

Most of what we need to make these changes real is already recognized by many of the nurses on any given shift in any hospital in America. What we need to do is give nurses a voice by involving them in identifying problems, coming up with creative solutions, and then weighing the investments carefully against what is desired as a return on the investment. The name for this is building a learning organization, but it mainly involves empowering those close to the problems to own the solutions and work together to solve them.

All of this means that we will require more facile and adaptive organizations, teams, work groups, and leadership at all levels in the organization. By investing in organizational skills and training, any hospital can facilitate developing and sustaining an adaptive response to the nursing crisis.

We probably will not get to where we need to be only by improving the existing structures, practice models, and relationships. In many instances, care delivery systems will need to come up with new ways of conducting work. This will mean new practice models for nurses, new physician-nurse relationships, new ways of assessing patient acuity and need, and responding with more variable patterns of nursing care and technology.

All of this sounds great but will work only if we collect and use data on nursing performance against the strategic goals of the hospital. We do not have such systems or dashboards in place, and we will continue to fly blindly until such data is collected and used. Then we will know how effectively a redeployed nursing resource is against the targets of lowering costs, improving quality, and enhancing safety.

Finally, change in nursing should have a mantra-like real estate. I propose reward, reward, reward. Without rewards for nursing professionals’ performance, we will soon revert back to the old patterns we are trying to leave behind. Nursing will make do with what is available, much as it always has, instead of being able to demonstrate what it can achieve for patients, hospitals, and society if it is challenged and rewarded in new ways.

Dr. O’Neil is director of the Center for the Health Professions and professor of Family and Community Medicine and Dental Public Health at the University of California, San Francisco.