The Real Issues Driving the Nursing Crisis

Health care leaders face a daunting set of challenges — rising costs, the transition to digital health, and shifting payment models, to name just a few. But according to a recent survey from the American College of Healthcare Executives, the No. 1 problem hospital CEOs face is staff shortages and burnout.1 Ninety percent of the CEOs surveyed cited nursing shortages as a particularly acute pain point.

In 2021, the total number of registered nurses working in the U.S. dropped by the largest amount in 40 years, with younger nurses leading the exodus.2 By 2025, the U.S. health care system could suffer a shortfall of up to 450,000 nurses, or 20% fewer than the nursing workforce required for patient care.3

High levels of job dissatisfaction and burnout are driving nurses from the profession. The COVID-19 pandemic placed tremendous pressure on all health care workers, but dissatisfaction and burnout among nurses have not improved since the pandemic ended. And by some measures, it might be getting worse: In 2021, nearly two-thirds of registered nurses would have encouraged others to become a nurse, but only half said they would recommend nursing as a profession two years later.4

One of the richest sources of insight on dissatisfaction among nurses is how they describe their job, in their own words, on employment sites like Indeed and Glassdoor. This information is voluminous but difficult to synthesize because most of it takes the form of unstructured free text. To understand the challenges nurses face, we analyzed how 150,000 of them had described their employers in Glassdoor reviews since the beginning of the pandemic. (See “The Research.”) In this article, we share key insights from that analysis and offer advice to health care leaders about how they can address nurses’ most pressing issues.

Health Care Leaders Are Out of Touch

Nurses view their managers as out of touch with the daily realities of patient care. We categorized their comments about managers into nearly 50 leadership traits. The second most frequently cited trait described managers as being unaware of the challenges that nurses struggle with in the workplace. When nurses discussed how managers understood life at the bedside, their comments were negative 9 times out of 10.

The Truth Behind the Nursing Crisis

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Nurses are particularly critical of members of the senior executive team for their disconnectedness. The top team was 10 times more likely than front-line supervisors and middle managers to be criticized for being out of touch. Our results reinforce a separate survey in which nearly half of hospital nurses said they believe management does not listen to their concerns.5

To address dissatisfaction and burnout, health care leaders must first understand what’s happening at the bedside. This can be challenging, particularly in large health care systems with thousands of nurses working across multiple sites and specialties.

Historically, leaders have struggled to systematically analyze the gold mine of insights into nurses’ frustrations that can be gleaned from their comments in employee surveys or external reviews. Reading, understanding, and analyzing huge volumes of unstructured textual data has simply not been practical. However, recent advances in artificial intelligence make it possible to identify deep patterns in large bodies of text and understand feedback at scale. Leaders can now mine free text to gain a nuanced understanding of the issues driving dissatisfaction and burnout among nurses and use that insight to improve life at work for their nursing staffs. (See “Getting Started With Text Analytics.”)

Identify Relative Strengths and Opportunities Through Benchmarking

Nursing satisfaction varies widely across employers. We identified 200 of the largest health care employers in the United States, including hospitals and health care systems, home health care providers, operators of senior living facilities, and staffing agencies. For each employer, we calculated how highly nurses rated the organization and senior leadership on Glassdoor from the beginning of the COVID-19 pandemic through June 2023.6

Among large employers, nurses’ Glassdoor ratings ran the gamut from poor (2.6) to nearly perfect (4.9) on a 5-point scale. Nurses’ assessments of how well senior leadership has performed during and after the pandemic were even more varied, ranging from 2.1 to 4.9 on the same 5-point scale. The wide variance in Glassdoor ratings is consistent with a separate survey in which the percentage of dissatisfied nurses ranged from 2% to 48% across 60 U.S. hospitals.7

Employees of the 200 large health care organizations can use our interactive tool to see how their organization ranks against others. The index is sortable by nurses’ overall ratings, their assessments of the top leadership, and the four most powerful predictors of nurses’ satisfaction: compensation, workload, organizational support, and toxic culture.

Nurses who work for staffing agencies (who are sometimes referred to as travel nurses) are, on average, much more satisfied than other nurses. The five highest-ranked employers in our sample (and six of the top 10) are staffing agencies.

Higher compensation, of course, accounts for part of this difference, but not all of it. We compared how positively nurses working with staffing agencies spoke about 200 topics compared with their counterparts employed by hospitals and health care systems. (See “Staffing Agencies Rate Better on Many Key Factors.”) While compensation was viewed more favorably by agency nurses, issues around solving nurses’ problems and open, honest communication had a larger sentiment gap between the two groups. By focusing on nurses as clients, staffing agencies excel at practices that improve satisfaction beyond simply paying higher wages. Other health care leaders can learn from their example, and we’ll make some concrete recommendations below.

Prioritize Drivers of Job Satisfaction

To understand the drivers of job satisfaction among nurses, we analyzed the free text of all reviews that had been written by the nurses in our sample since the beginning of the COVID-19 pandemic and classified the text into nearly 200 topics.8 We then clustered topics into two dozen broader themes and used those themes to predict nurses’ overall ratings of their employers. We then compared each theme’s relative importance in predicting ratings. (See “Top and Bottom Predictors of Nurses’ Job Satisfaction.”)

Compensation was the top predictor of satisfaction among nurses reviewing their current employer, which is not surprising, given that inflation eroded the purchasing power of take-home pay during the period we analyzed. The importance of workload, the second-most-important driver, jibes with findings from a separate large-scale survey that found insufficient staffing was the strongest predictor of nurses’ job dissatisfaction, burnout, and intent to quit.9

Workload and compensation are root causes of the nursing crisis that must be addressed, but they are not the only factors influencing nurses’ job satisfaction. Our analysis surfaced other aspects of the work environment, including toxic culture, organizational support, work schedules, communication, and learning and development opportunities, that leaders can focus on to improve nurses’ work lives.

This analysis also highlights areas that are unlikely to move the needle in improving the workplace experience for nurses. Perks are nice, but they will not compensate for a punishing workload or wages that fail to keep pace with inflation. Highlighting the corporate mission to promote patient health won’t help much either. Nurses already know that their job serves a higher purpose; that’s why most of them became nurses in the first place.

Mine Free Text for Actionable Insights

Many health care organizations rely on annual employee surveys, with dozens of items rated on a 5-point scale and a few open-ended questions tacked on as an afterthought. Faced with a long list of multiple-choice questions, employees are prone to switching to autopilot and assigning similar scores to very different items. The choice of questions constrains what employees can discuss, and there is seldom room to expand on why they chose a particular numeric response.

Open-ended, free-text feedback provides a rich source of nuanced and actionable insights. When nurses can decide which topics to write about, they use their freedom to discuss what matters most to them. Open-ended questions provide nurses with the space to expand on their concerns in their own words, offer crucial context, and propose concrete and actionable fixes to the problems they face. Individual free-text responses can be aggregated into broader themes to prioritize where leaders could focus their attention and limited resources to achieve the largest improvements in nurses’ satisfaction.

While organizational averages are useful, it is important to remember that distinctive subcultures can coexist within the same organization. This is particularly true among large health care systems that have grown through mergers and acquisitions. One national hospital chain, for example, has ratings that range from 1.9 to 3.9 across nearly 50 sites. Rather than relying on organizational averages alone, health care leaders must measure and analyze differences across locations, departments, functions, teams, and individual leaders.

Women, underrepresented minorities, and older employees can also experience organizational culture very differently from other employees.10 It’s crucial to understand the drivers of job satisfaction and burnout across diverse employee populations.

Leaders can mine the free text for detailed insights about the most critical pain points for specific groups and tailor their interventions accordingly. Schedules, for example, have a significant impact on nurses’ job satisfaction, but which aspects of scheduling matter most will depend on the specific position. Flexibility in scheduling shifts and the ability to take uninterrupted work breaks is very important for nurses in hospitals and primary care practices, while home health care nurses place a premium on predictable schedules.11

Nurses’ comments provide a treasure trove of practical suggestions to improve the workplace and patient care. The Glassdoor reviews we studied, for example, include dozens of actionable suggestions for how employers can improve scheduling. Some are easy-to-implement actions, such as using an app to make it easier to pick up or swap shifts, or paying a $20 to $50 bonus to nurses who pick up shifts at the last minute. Others are more systemic changes, like including nurses on a committee established to set schedules or ensuring that employees who receive tuition assistance are able to schedule work around their classes.

Listen to Nurses Who Leave Your Organization

Most organizations limit their surveys to current employees. Exit interviews are administered haphazardly, if at all, and the feedback from former employees is too often dismissed as the rantings of malcontents. But ignoring feedback from former employees is a big mistake.

Interviewing or surveying former employees can surface the reasons for their departure and pinpoint the most effective actions to retain talent. Free of the threat of retaliation, nurses who are leaving (or have left) an organization are more likely to provide candid feedback, even about taboo issues that current employees are reluctant to discuss. By collecting feedback from those who have left, organizations can uncover potential blind spots.

More than one-third of the Glassdoor reviews in our sample were written by former employees and provide insights on what mattered most to nurses who voted with their feet.12 The bars on the left side of the figure “Top and Bottom Predictors of Nurses’ Job Satisfaction” rank the factors that predict how nurses who quit rank their former employers, and it sheds light on a critical reason nurses might head for the exits.

In an earlier article, we argued that five behavioral attributes — disrespectful, noninclusive, unethical, cutthroat, and abusive — mark an organizational culture as toxic.13 Among nurses who quit, toxic culture is more than twice as predictive of their overall satisfaction than compensation or workload. The importance of toxic workplaces among nurses who quit is consistent with earlier research that found toxicity to be the strongest predictor of industry-adjusted attrition during the first six months of the Great Resignation.14

Toxic culture has become more important for nurses in the post-pandemic era. When we compared which factors best predict how nurses rated their employer before and after the pandemic, toxic culture experienced the largest gain in relative importance post-COVID-19 (followed by workload, well-being, and compensation). If your organization suffers from cultural toxicity, another article of ours, “How to Fix a Toxic Culture,” presents several evidence-based interventions health care leaders can use to detox their own organization.

Learn From Staffing Agency Practices

As the figure “Staffing Agencies Rate Better on Many Key Factors” shows, nurses are very positive about the processes staffing agencies have in place to resolve problems quickly and efficiently. Of nurses who mentioned the efficiency of staffing agencies’ processes, 75% were positive, compared with 23% expressing positive sentiment for health care systems. For travel nurses, common process issues include onboarding, obtaining required credentials and licenses, contract negotiation, and reimbursement. The best staffing agencies listen to feedback, develop a deep understanding of the typical problems travel nurses face, and optimize their work processes to address these issues.

Many of the pain points encountered by staff nurses will differ from those of agency nurses. Health care systems, home health agencies, and long-term care providers could, however, adopt a similar approach to capture and analyze nurses’ feedback, prioritize the most common and frustrating challenges they face, and work with staff members to address these issues.

Consistently listening to and acting on feedback can also build trust with the nursing staff. Staffing agency nurses are more positive about having the psychological safety to speak up about difficult issues and be heard than are nurses working in hospitals and health care systems.

The benefits of psychological safety are blunted, however, if management is slow to respond to issues that nurses raise. Nurses speak highly of how quickly staffing agencies respond to their questions and concerns. In contrast, nurses frequently complain that other types of employers are slow to respond to emails raising issues, if they get a reply at all. Nurses also place a high value on having multiple channels of communication with their supervisors, including text, email, Facebook, Jabber, and a 24/7 hotline.

Another insight from our research is that nurses value honesty and transparency. They understand the challenges health care faces as well as anyone, and they expect honest communication about what is happening in the organization, how it affects them, and why decisions were made. Triage, a staffing agency and the fourth most highly rated large employer we studied, places honest communication at the center of its value proposition: “We tell it like it is so you won’t be surprised by how it goes.”15

Health care systems can learn from staffing agencies, but they can also leverage their own distinctive advantages to attract and retain nurses. Nurses in full-time staff positions rate hospitals and health care systems higher than staffing agencies on three important aspects of organizational life: learning and development (including promotion opportunities and reimbursement for training), benefits, and colleagues. Those three factors are among the top 10 predictors of how nurses rate their employers. Health care systems should invest in their comparative advantages and emphasize them when communicating their value proposition to potential and current employees.

Translate Feedback Into Action to Build Trust

It’s one thing to collect employee feedback, but it’s another to consistently act on those insights. Employees are less likely to surface issues or propose potential solutions if they believe that managers will not act.16 Worse yet, employees are more likely to quit if they believe that management lacks the power, resources, or interest to make changes based on their suggestions.17 Nearly half of nurses believe that management will not fix problems that clinical staff members bring to their attention.18

Organizations need to put in place structures to consistently act on employee feedback. One well-known example is Kaiser Permanente’s unit-based teams (UBTs), which consist of clinical staff members and managers who regularly work together in a specific unit or department.19 The teams, which meet at least once per month, are responsible for their unit’s performance and are co-led by a manager, a labor representative, and, typically, a clinical staff member.

The UBTs identify opportunities to improve along four dimensions: quality (including patient outcomes), patient service, affordability, and employee experience. The teams use employee feedback to identify and prioritize improvement opportunities. Next, the teams develop and test solutions using best practices and evidence-based methods. Once a solution has been deemed effective, it is implemented across the unit, department, or, in some cases, the entire organization. The UBTs then monitor the impact of these changes in terms of patient outcomes, employee satisfaction, and cost reduction.

Our study of 150,000 reviews written by U.S. nurses since the onset of COVID-19 reveals wide variation in how nurses rate their employers as a whole, and specifically in terms of compensation, workload, toxic culture, and organizational support — the four factors that most shape nurses’ job satisfaction. In our view, this variation offers a message of hope. Despite the structural challenges that all health care organizations face, it is possible to provide an environment where nurses look forward to going to work every day.

Many organizations, including some of the largest employers of nurses, have significant room for improvement. These rankings are not designed to “name and shame” but rather to make health care leaders aware of the magnitude of the gap between their organization’s performance and what is possible when it comes to providing a healthy workplace for nurses. We also hope that the objective data on how health care organizations rank on factors that matter most to nurses can provide their leaders with the impetus to make improvements and the evidence to convince all stakeholders of the urgent need for change.

What leaders should not do is ask nurses to work harder and endure more frustration and stress while failing to understand and address the organizational factors that make life miserable for many of them. Leaders who continue business as usual should not be surprised when staff members quit, workers unionize, and state and federal legislators dictate regulations to protect the interests of nurses.

To improve the work lives of nurses, and indeed all health care workers, leaders must collect and act on their feedback, recognizing that different parts of the organization and different populations will face distinctive challenges and issues. Listening to nurses demonstrates that there are meaningful steps health care leaders can take to fix the nursing crisis. The single most important step is to listen to them in the first place.