There is a persistent crisis in the recruitment and retention of nurses in the USA, where I’ve practiced as a nurse for over 40 years, including 34 years as a flight nurse, 20 years of in-hospital experience, and over two decades as a clinical educator. Indeed, the problem is repeated around the world. This crisis, exacerbated and highlighted by the Covid-19 pandemic, involves many interrelated issues requiring a multifaceted solution.

A tight squeeze

Nursing schools are facing a shortage of nursing faculty and training facilities as well as a lack of clinical placement sites

In fact, the nursing pipeline is being squeezed at both ends and throughout the middle. On one end, nursing schools are struggling to expand their capacity to meet the growing need for nursing care globally due to an aging population and an increased prevalence of chronic illnesses. For instance, in the USA, according to the American Association of Colleges of Nursing annual survey, nursing schools are facing a shortage of nursing faculty and training facilities as well as a lack of clinical placement sites, resulting in a massive 65,766 qualified applications being turned away at nursing schools nationwide in 2023 alone.

On the other end, accelerated retirement rates for nurses are dealing a double blow as the most experienced nurses are leaving the profession. And at all points in between, despite their call to care, nurses are understandably abandoning their bedside roles due to decreased job satisfaction fueled by untenable staffing and workplace conditions, as well as poor management, including lack of support and talent development, and insufficient recognition and compensation. The lack of diversity in nursing school faculty and the underrepresentation of males and minority groups in most nursing school student bodies – paired with a lack of diversity among bedside nurses and nurse leaders – is further dampening the flow of new and more seasoned talent.

From sickness to wellness

In the longer term, shifting away from the current sick care model toward a wellness healthcare model will reduce the need for nursing services across all demographics. Fully recognizing and embracing nursing as STEM (science, technology, engineering and mathematics, aka STEMM, with the second ‘M’ for medicine) will open significant funding avenues and inspire more young people to explore the profession for generations to come. In the near term, there are steps that healthcare providers, educational institutions, insurers, governments, professional organizations, and even individual healthcare professionals can take and advocate for
right now.

First, getting more nursing students enrolled is crucial. In the USA, individual states are best positioned to hold stakeholder summits to brainstorm creative local solutions to address the backlog of waiting students. For nursing programs attended by underserved populations, incentives to support new student recruitment would keep those programs on their diversification trajectories.

To grow the ranks of nursing school faculties, states and locales might consider offering incentives and competitive salaries to retiring nurses to work a part-time or flexible teaching schedule or serve as adjuncts to other clinical educators. Financial assistance for hospitals and clinics to offer clinical training opportunities for students would both increase the training space and boost their recruiting prospects. Local, state and federal STEMM and nursing-specific grants for assisting with facility acquisition and faculty expansion could in part be used to acquire the high volume of unused commercial office space existing in most cities, which would be ideal for teaching and training needs.

To stem the tide of nurses leaving the profession or retiring early, it’s time to follow the path laid out by research for developing healthy workplace environments and equipping supervisors to lead. Adoption of the American Association of Critical-Care Nurses Standards for Establishing and Sustaining Healthy Work Environments, with incentives and accountability for adherence, offers a ready-made place to start. This proven framework focuses on six standards: skilled communication, true collaboration, appropriate staffing, effective decision-making, meaningful recognition, and authentic leadership.

To stem the tide of nurses leaving the profession or retiring early, it’s time to follow the path laid out by research for developing healthy workplace environments and equipping supervisors to lead

Flexible work hours, a zero-tolerance policy for abusive behavior or workplace violence, and fair pay and adequate benefits packages that include free access to mental and physical wellness services are must-haves. For the sake of nurse wellbeing and patient safety, nurses, state legislatures and healthcare administrators must come together to reach specialty- and locale-specific consensuses on safe staffing levels and patient loads.

At the individual nurse level, having visible clinical and professional development pathways and ample opportunities for advancement increases engagement and empowerment, and can be an antidote to burnout. As much as nurses want fair pay, they want to be prepared and competent on the job. Research out of the UK points to the success of robust preceptorship training for recruiting and retaining new emergency department (ED) nurses.

We know from research conducted by the BCEN that when nurses pursue specialty certification – where employer support can be ‘make or break’ – nurses who are empowered with advanced knowledge are more confident, have greater job satisfaction, are natural leaders, and they deliver safer, more technically proficient and more ethical care. One of BCEN’s 2024 National Certification Champion Award winners – which were all selected based on their exceptional commitment to support their nurses’ professional development – reported a remarkable 99.1% annual retention rate in their adult ED. All of the winners reported an increased ability to attract top talent.

Focusing on HEMS staffing requires commitment

In the air medical community, a keen focus on professional development is part and parcel of our just/safety culture and a documented contributor to transport nurse success and satisfaction. To promote recruitment and retention among nurses working in the pre-hospital environment, providing comprehensive financial and ongoing education support for rural and urban pre-hospital providers and ambulance services, and developing and expanding community paramedicine programs are impactful. In the USA, legislating the expected day of payment with associated penalties for insurers will give the No Surprises Act teeth, while also increasing Medicare and Medicaid rates to near actual cost would mean that transport programs can safely and sustainably deliver vital public healthcare in their service areas.

Repairing the nursing workforce crisis, including resolving the nursing school bottleneck, will take teamwork, coordination, action right now, and persistence over time

Artificial intelligence (AI) is destined to be part of the solution as well. While the use of AI to make charting more efficient and effective and offload certain non-nursing tasks is being explored, AI offers immediate promise to streamline the hiring process. Applicants can be screened against basic requirements without bias, instantly, and quickly moved along for deeper vetting. This will help tremendously with the delay in getting new nurses into the system. Non-qualified applicants can be given instant feedback on ways to improve their suitability for the job.

Repairing the nursing workforce crisis, including resolving the nursing school bottleneck, will take teamwork, coordination, action right now, and persistence over time. Commensurate pay, safe and supportive work environments, clear professional development and advancement pathways, and smart use of technology will make the nursing profession more appealing, more accessible, more diverse and inclusive, and more sustainable for all who are called to care.