The turnover rate for registered nurses, especially those new to the profession, presents a serious challenge for healthcare systems across the globe. Shockingly, up to 83% of hospital turnover involves these newcomers.

Nurses today find themselves in a demanding environment where patient needs are complex, staffing ratios are too tight, and ongoing technological advancements require constant training. This daunting mix can discourage even the most committed professionals.

To tackle this issue, healthcare organizations must recognize and actively respond to these challenges with targeted improvements. This article proposes that a robust, efficient onboarding process can boost operational effectiveness and dramatically increase nurse retention rates.

Understanding the Nurse Shortage

A 2023 survey by nurse.org revealed that 60% of nurses still felt passionate about their profession. However, 62% were concerned about their future in the field.

Despite some improvements since 2021, a significant number of nurses continued to face severe burnout, mental health challenges, and a lack of support. About 39% were unhappy with their current jobs, with this sentiment varying based on their educational background and specialty.

Persistent staffing issues and a deepening nursing shortage remained major challenges for the U.S. healthcare workforce. An overwhelming 91% of those surveyed believed the situation was getting worse, citing burnout, poor working conditions, and low pay as the primary reasons.

Moreover, 79% of nurses reported that their units were understaffed, and 71% thought that improving staffing ratios would significantly help alleviate the shortage. Understandably, there were loud calls for better compensation—55% had received a pay raise in the previous year, yet 75% still felt underpaid, and 52% perceived a lack of pay equity for similar levels of experience at their hospitals.

As of 2024, the outlook was bleak: a survey by AMN Healthcare earlier in the year showed that 80% of nurses did not anticipate any improvement in their working conditions. Specifically, 42% foresaw no changes from the previous year, 38% predicted conditions would worsen, and only 20% were hopeful for enhancements.

Disturbingly, more than one-third (35%) of nurses found it extremely likely that they would switch jobs within the year. Additionally, 55% viewed it as very or somewhat likely they would seek new employment opportunities.

Furthermore, 35% were highly likely to change their work hours or schedules that year, with 58% seeing such a change as somewhat or very likely.

Projected RN Shortages

The geographical landscape presents a complex picture as well: while some states face severe nurse shortages, others are navigating surpluses that complicate workforce management and resource allocation. This imbalance underscores significant challenges and opportunities within the healthcare system, reflecting broader demographic shifts, economic fluctuations, and policy influences.

California is facing a staggering shortage of registered nurses, with an estimated deficit of 44,500, nearly triple that of the next most affected state. Texas, New Jersey, and South Carolina are also expecting shortages, each needing over 10,000 more nurses. Alaska, Georgia, and South Dakota will find themselves several thousand nurses short as well.

Conversely, Florida is grappling with an abundance of registered nurses, expecting an excess of 53,700. Ohio is not far behind, with a surplus of 49,100 nurses. Virginia, New York, Missouri, and North Carolina will also have more than 15,000 extra RNs than needed.

Alaska is notably impacted, with a shortfall of 5,400 nurses, which represents over 22% of its required 23,800 RN workforce. South Carolina and South Dakota are each missing about 15% of their needed nurses, with California and New Jersey not far behind, each lacking around 11%.

Wyoming faces the largest surplus percentage-wise, with projections showing 8,300 nurses for only 5,500 positions. New Mexico will have a 45% surplus, with 31,300 nurses to fill just 21,600 positions. States like Ohio, Vermont, Kansas, and Nevada are expected to exceed their nursing needs by more than 30%.

By 2030, the U.S. anticipates adding 795,700 new RN positions to meet growing healthcare demands.

California is set to introduce 110,500 new RN roles by 2030, followed closely by Texas, which plans to add 88,800. Despite these additions, neither state is likely to fully resolve their nursing deficits. Florida, in contrast, is poised to create an additional 69,400 nursing positions, likely leading to a surplus of over 50,000 nurses.

South Carolina is on track for substantial growth, planning to increase its nursing workforce by 26,600, boosting its current numbers by an impressive 69.4%. Hawaii is also set to see significant growth, with a planned addition of 5,600 new nurses to its current workforce of 10,600.

Nebraska, on the other hand, will see minimal growth, adding just 900 new RN positions to its existing workforce of 20,300, marking a 4.4% increase. Ohio and New York are facing slow growth rates of 8.1% and 12.1% respectively, yet both are expected to experience notable nursing surpluses as the supply outpaces the demand.

10 Factors Contributing to Nurse Deficits

Some of the critical factors that are intensifying the struggle to maintain adequate nursing staff levels are:

• Aging Population: As the baby boomer generation, one of the largest age groups, continues to age, the demand for complex healthcare services is on the rise. By 2030, all baby boomers will be 65 or older, significantly increasing the need for specialized nursing care.

• Aging Workforce: The nursing workforce is aging alongside the population it serves. With an estimated one million RNs expected to retire by 2030, the healthcare industry faces the daunting prospect of a significant drop in experienced nurses within the next decade.

• Increased Burnout: Nurses are facing burnout at levels never seen before, fueled by high-stress environments, long working hours, and the emotional demands of their roles. This intense pressure is causing a decrease in job satisfaction, a rise in absenteeism, and a growing number of nurses leaving the profession.

• Nurses Leaving Bedside Positions: More nurses are moving away from high-stress bedside roles to other positions within healthcare or even different industries. Key reasons include burnout, unsafe staffing levels, lack of support, inadequate pay, and insufficient mental health resources. As reported by the National Library of Medicine in February 2023, nursing turnover rates vary widely from 8.8% to 37%, depending on location and specialty.

• Faculty Shortage: In 2021, nursing schools were unable to admit nearly 92,000 qualified applicants due to a lack of resources such as clinical sites, classroom space, and faculty. This was the highest number in decades, exacerbated by non-competitive salaries for faculty positions, as highlighted by the American Association of Colleges of Nursing.

• Impact of the Affordable Care Act (ACA): The expansion of healthcare coverage under the ACA has increased the demand for medical services, adding more pressure on the nursing workforce to cater to a larger patient base.

• Growing Interest in Community-Based Care: There is a shifting preference towards community-based care models, which require more nurses outside of traditional hospital settings and strain the already limited nursing resources.

• Economic Incentives in Other Fields: Nurses are often drawn away by the lure of better pay and less stressful conditions in other sectors, reducing the inflow of new talent into the nursing field.

• Violence in Healthcare Settings: The rise in physical and emotional abuse within healthcare environments contributes to the stress and danger of nursing jobs. Healthcare workers face a much higher risk of injury from workplace violence compared to other professions, making the nursing role less appealing.

• Physician Shortage: The expected shortage of 37,800 to 124,000 physicians by 2034 will further strain the healthcare system, as noted by the Association of American Medical Colleges. This shortage will place additional responsibilities on nurses, increasing the demand for these professionals, especially in primary care settings.

These factors collectively contribute to the ongoing challenges in staffing sufficient, skilled nurses, which impacts the overall quality of healthcare services.

Enhancing Nurse Retention through Effective Onboarding

The financial repercussions of losing and subsequently replacing home health nurses can be profound, costing twice as much as the nurse's salary due to lost productivity and other turnover-associated expenses. Alarmingly, the majority of nurses who resign from their positions do so within the first three to twelve months of employment.

Surveys indicate a general satisfaction among nurses with their careers—two-thirds are content, and 80% are committed to staying in the healthcare sector. However, recent data from a Jarrard survey highlights significant opportunities for improvement, particularly in onboarding and career development practices.

Onboarding effectiveness seems mediocre at best, with nurses rating their programs between 6 and 7 out of 10. Less than two-thirds feel their organization equips new nurses with the necessary resources for success, and those with more tenure perceive even less support.

Just over 60% of respondents believe that during the orientation and onboarding phase, new nurses and Advanced Practice Registered Nurses (APRNs) receive adequate information, tools, and resources to succeed long-term. A similar proportion feel supported by their managers and supervisors in their critical first 90 days.

The transition for new nursing graduates into the field is increasingly challenging. They face complex patient care needs, high nurse-to-patient ratios, and must keep up with rapid technological advancements requiring continuous education.

Effective onboarding programs aim to reduce costs, cut down on errors made by new nurses, ensure high-quality care, and foster professional identity development. These programs are crucial not only for building clinical skills but also for helping new hires integrate into their workplace community, fostering a sense of belonging and enhancing retention.

Despite being relatively less costly on the pay scale than their more experienced peers, onboarding a new nursing graduate is no small feat. Research indicates it takes at least six weeks to onboard a new nurse, and about 140 days before they become fully productive, with costs ranging from $15,000 to $20,000 per hire. Yet, the demand for new nursing graduates continues to exceed supply, with employment rates at 93% within four to six months after graduation.

Given the current 22% high turnover rate, which translates to an annual cost of approximately $4.4 million for a workforce of 1,000 nurses, healthcare organizations are keen to fill vacancies with new graduates.

To maintain a stable flow of new nursing graduates who stay longer in their positions, it's imperative for nurse leaders to proactively manage both the onboarding and retention of these new entrants. In today’s resource-limited and competitive healthcare landscape, new nurses are invaluable assets, especially since the enrollment in entry-level baccalaureate nursing programs saw a decline of 1.4% in 2022, marking the end of two decades of growth.

Best Practices for Nurse Onboarding

The transition period can be fraught with personal challenges for new nurses, including lack of confidence, heavy workloads, and overwhelming situations, which can negatively impact both patient care and job satisfaction.

Well-structured orientation programs are proven to boost new nurses' competence and confidence, enhance patient safety and outcomes, and improve retention rates. Effective retention of new nurses not only saves on the recurring costs and time of recruitment but also boosts staff morale and helps achieve hospital performance targets.

Evaluating Your Onboarding Process

To enhance the onboarding of new nursing graduates, begin with a detailed evaluation of your existing processes. Employing quality improvement methods to map out these processes will highlight your strengths and expose any weaknesses. This insight allows you to craft an improved onboarding strategy that better meets the needs of your organization.

If your current approach is reactive—merely filling vacancies as they arise—you're likely increasing stress among your staff and incurring unnecessary costs. A shift towards a predictive hiring model, utilizing predictive analytics, can forecast your needs for new graduates more accurately, enabling a more strategic approach to hiring.

Centralizing the onboarding process can relieve your nurse managers from the heavy burden of managing recruitment and training. By establishing a dedicated onboarding unit, you can more efficiently distribute resources across supporting departments such as Human Resources, Workforce Development, IT, and Training. This unit can also make effective use of shared facilities like simulation labs and automated learning platforms.

Such centralization not only enhances the training process but also speeds up the preparation of new graduates for practical work. Drawing inspiration from academia, you can employ seasoned nurses to mentor new hires, assessing their skills and guiding them through initial training phases to ensure they are well-prepared for their roles.

Using evidence-based resources and comprehensive training tools can significantly improve the effectiveness of your training programs. These resources help close skill gaps and support the mentoring process, even if the addition of dedicated training faculty isn't feasible. Standardizing training materials across your organization is crucial to reduce costs and streamline the onboarding experience.

Implementing Quality Improvement Methods

Adopting methodologies like Lean can streamline both hiring and onboarding processes for new nurses by eliminating inefficiencies and focusing on activities that deliver the most value to nurse leaders and newcomers.

Onboarding a new nurse typically unfolds over a four to six-month period. During the initial 14 weeks—minus the two weeks a departing nurse may still be working—the vacant position is often filled by a mix of float pool nurses, overtime shifts, or travel nurses, all of which come with a higher cost.

The financial impact of this vacancy period can be steep. When you factor in the salary of a new nurse and the additional costs to cover the role until they are fully productive, the financial strain becomes clear. Nationally, the average cost related to turnover for one staff RN rose by 13.5% from 2021 to 2022, landing somewhere between $40,200 and $64,500.

Moreover, each percentage increase in RN turnover can potentially cost—or save—an average hospital around $380,600 annually. Interestingly, if a hospital can reduce its use of agency RNs by just 20, it might save upwards of $3.1 million each year, though this calculation doesn’t account for the potential impact on patient care and outcomes.

Centralize the onboarding process

Switching to a centralized hiring process for new graduates significantly eases the workload on nurse managers, freeing them up to concentrate on interviews and daily unit operations. This shift not only lightens their load but also allows them to adopt a more strategic and proactive stance toward hiring.

Leverage historical data to establish a baseline for hiring

By analyzing historical data, healthcare facilities can establish a hiring baseline, identifying trends and predicting both the attrition rate and the cost of hiring per nurse. This information is invaluable for supporting budget proposals and tailoring the orientation process to better meet actual needs.

From this data, our teams can gauge how many new hires are needed each month to effectively address ongoing vacancies. To calculate this, we divide the average number of departures by the average number of employees over a typical 12-month period, then multiply by 100 to derive the attrition rate.

Determining the cost per hire in a centralized model involves summing up all recruitment expenses—both internal and external—and then dividing by the total number of hires within a specific timeframe.

Once senior management signs off, our centralized hiring unit can set up a continuous requisition for new graduate positions. This approach eliminates the redundancy of opening new requisitions for each vacancy, ensures a consistent influx of candidates, and aligns hiring volumes with the organization’s typical attrition rate. This method not only streamlines the recruitment process but also allows us to proactively plan for workforce needs by monitoring application trends and adjusting hiring practices accordingly.

Comprehensive Training and Credentialing Programs

Healthcare facilities can significantly enhance their retention rates by creating robust training and continuous education programs that engage nurses throughout their first year and beyond. By providing clear roadmaps for clinical growth, such as investing in certification programs and training for managing high-acuity patients, facilities can foster skill development and career advancement for their nursing staff.

• Focusing on Mentorship and Learning Styles

Allocating time for seasoned staff to mentor new hires is crucial. These field educators play a vital role in equipping new nurses with the necessary skills for success. Additionally, offering both synchronous and asynchronous learning—combining in-person, classroom instruction with online and self-paced studies—caters to the diverse learning preferences of new nurses, enhancing their educational experience.

• Setting Realistic Goals and Ensuring Documentation Accuracy

It's important to establish realistic timelines for new nurses to reach full productivity. Accurate documentation practices are also critical; setting up systems to ensure precision and addressing any gaps in training can prevent future issues. Moreover, implementing robust systems to track compliance with educational requirements set by accrediting bodies like OSHA or CMS is essential for maintaining standards.

• Empowering Nurses Beyond Salary

While competitive pay is important, empowering nurses goes beyond financial incentives. Ensuring that nurses have a voice in their career paths and access to opportunities for advancement is crucial for long-term retention.

How Medical Credentialing Software Facilitates Efficient Onboarding

Efficient credentialing significantly shortens the onboarding period, allowing nurses to start their assignments much sooner. A quick and seamless onboarding experience enhances job satisfaction by minimizing the common frustrations associated with bureaucratic delays. This not only helps in retaining skilled nursing staff but also supports a more focused and motivated workforce, ultimately leading to better patient outcomes, and the best way to do it is through automation.

Credentialing software automates the verification of a nurse's qualifications, such as nursing licenses, certifications, and educational background. By reducing the reliance on manual processes, these systems can deliver credentialing results 78% faster, turning what used to take weeks into mere days. This acceleration is crucial for quickly addressing staffing needs and reducing the gaps in nurse availability.

The software enhances background checks by integrating with databases that provide information on sanctions or malpractice histories, ensuring thorough vetting. It also keeps track of compliance statuses and upcoming renewals, ensuring that nurses meet all regulatory and institutional requirements without any lapses that could affect their employment or the quality of care they provide.

Conclusion

The persistent nurse shortage poses a complex challenge, requiring a strategic and comprehensive response to improve operational efficiency and nurse retention. By integrating efficient onboarding processes, including advanced credentialing software, healthcare organizations can significantly reduce the time it takes for new nurses to become fully operational.

However, addressing the underlying causes of the nurse shortage is equally important. With the projected increase in nurse demand, driven by an aging population, burnout, and evolving healthcare needs, adopting a multifaceted strategy that includes better workplace conditions, competitive compensation, and enhanced support systems is essential.

These strategies not only mitigate high turnover rates, particularly among new nurses, but also build a more stable and satisfied workforce. By cultivating a supportive and efficient environment from the start, healthcare facilities can effectively respond to the challenges of nurse staffing shortages, thereby improving the overall quality of care and the effectiveness of the healthcare system.