Sherilynn Quist (00:00): Turnover is down and vacancies are improving, and that's really meaningful progress. But what we see on the ground is that better staffing on paper doesn't always translate to an easier day-to-day. Abby Burns (00:13): From Advisory Board, we're bringing you a Radio Advisory, your weekly download on how to untangle healthcare's most pressing challenges. I'm Abby Burns. Today we're talking about the healthcare workforce. Specifically, I want to understand the state of the nursing workforce. I've said it before, nurses are the lifeblood of care delivery. There are more than four times as many nurses in the US as there are physicians. They make up the largest swath of the health system workforce, and of course the labor budget. (00:43): This all means that the state of a health system's nursing workforce is an important indicator for the health of the overall system. So where does that stand today, and what should health system leaders, not only nursing leaders, by the way, do today to get stronger? To help us answer those questions, I've invited advisory board nursing expert, Ali Knight, and Optum Consulting expert, Sherilynn Quist, to join me. Hey Ali. Hey Sherilynn. Welcome back to Radio Advisory. Ali Knight (01:12): Hey, Abby. It's great to be here. Sherilynn Quist (01:13): Happy to be here, Abby. Abby Burns (01:16): So we are recording this conversation on Wednesday, May 6th. So first things first Ali, happy Nurses Day. Ali Knight (01:24): Thank you. What an honor to be here to kick off Nurses Week essentially with all of you and happy Nurses Day to all of the nurses out there. Abby Burns (01:34): Our conversation is very timely because we are here today to talk about nurses and nursing more broadly. And if I think about the tone that leaders have used when talking about workforce, and nursing workforce specifically over the past few years, some of the words that come to mind for me are panic, crisis, maybe hair on fire. That tone seems to have calmed down at least on the surface, but Ali, you have actually put some numbers to this in your research this year. Sherilynn, you've been out in the market at the hip of chief nursing officers. So to start our conversation, give us a pulse. How would you describe the state of the nursing workforce right now in spring of 2026? Ali Knight (02:18): I would describe the state of the nursing workforce right now as relatively stable. We are seeing decreases really back down to pre-pandemic levels in measures like turnover, vacancy, and time to fill. And most organizations I talk with seem like they are making progress in all of their major nursing initiatives. Abby Burns (02:42): And can you just help us put some numbers to, when we say return to pre-pandemic levels, what do turnover, vacancy, and time to fill look like these days? Ali Knight (02:50): So the latest data that we've seen shows about an 18% nursing turnover. So up a little bit from what we saw in 2024, and actually a tiny little bit up from pre-pandemic levels. But much improved from the peak of 27% turnover that we saw in 2021. Abby Burns (03:07): Oh my gosh. 27%. Ali Knight (03:09): Yes. Think about that. In 2021, almost a third of our nurses were turning over. Abby Burns (03:14): So we're down from that level, although I think a lot of folks would say, pre-pandemic, if we think 2019 wasn't necessarily the picture of a stable nursing workforce. Ali Knight (03:24): No. I usually do call out that, even though we've returned to that 2019 level, it's not necessarily a target we're recommending you strive for. Because those of us that have been around healthcare long enough, remember that we were still experiencing challenges in 2019 as well. Abby Burns (03:40): Yeah. What about vacancy and time to fill? Ali Knight (03:44): RN vacancy in 2026 was at 9%. So up just a percentage point from where we were in 2019. And time to fill has dropped actually below pre-pandemic levels. Last data point I saw was 78 days for time to fill. Abby Burns (04:02): Wow. Okay. So that means we're evening back out a little bit from pandemic level highs. Ali Knight (04:08): Yes. And I just want to take a moment, especially on Nurses Week, to call out the amount of work that has gone into seeing the improvements we have over the last five years. So thank you to all of you out there who have worked tirelessly to make the gains that we have. Abby Burns (04:25): Yes, absolutely. I couldn't agree more. We don't get to numbers like the ones that you just shared without really hard, complex work and leadership from nursing leaders. At the same time, I'm always wary of relying too heavily on sort of a small set of numbers to tell me a story about people. So these standard benchmarks are one lens to look at what is the state of the nursing workforce. What aren't they telling us? Ali Knight (04:53): So what we're not seeing is this bubble that we're sitting on right now where RN intent to leave is increasing. So we ran a survey at Advisory Board last year that showed about half of the nurses currently working at the bedside were planning to leave the bedside in the next three years. Abby Burns (05:11): Wow. That's a concerning number. Ali Knight (05:14): That's a concerning number. And the National Nursing Workforce Survey showed a pretty similar result in that almost 40% of nurses intended to leave nursing within the next five years. Abby Burns (05:28): Leave nursing altogether. Sherilynn, how does that compare to what you're seeing? Sherilynn Quist (05:32): Yeah, the data's real. I mean, turnover is down and vacancies are improving, and that's really meaningful progress. But what we see on the ground is that better staffing on paper doesn't always translate to an easier day-to-day. So there's still a lot of variability in experience, higher patient acuity, and seems like more packed into each shift. So while fewer nurses may be leaving, many are still working in a system that requires constant adjustment. What we're hearing isn't out, it's, "I can't keep doing this." And that's really the next layer of work that we have to address. Abby Burns (06:12): And when we think about who should be accountable for doing and leading this work, it strikes me most people listening to this conversation are probably not nursing leaders actually. And they therefore might hear these indicators that we're talking about this work to be done and think, man, that sounds hard. I wonder what my nurse leader is going to do about it. And I think that you would argue this is not just a problem for nurse leaders to solve on their own. Which other leaders should have this on their short list of priorities? Sherilynn Quist (06:44): I think the not my problem mindset is a real risk. Because when the nursing force is strained, it doesn't stay contained within nursing. It shows up all across the entire system. So operations leaders feel it first because it impacts throughput, length of stay, day-to-day flow. CFOs really should care because this is a cost issue. Turnover is very expensive. You've got average cost of turnover is 60 to $70,000. However, inefficiency in the workforce is also expensive because you've got premium labor showing up. Abby Burns (07:24): Which other leaders should we be thinking about here? Sherilynn Quist (07:28): I would say CNIOs and CIOs. There's a big push towards tech-enabled solutions right now. But if those tools aren't aligned to clinical workflows, they can actually be a burden instead of reducing workflows. And in addition, physician leaders. This directly affects how care teams function. At the end of the day, it's not a nursing problem to solve in isolation. It's really a shared responsibility across anybody shaping how care gets delivered. Abby Burns (08:03): You mentioned the CNIO role, and this is one that frankly I keep hearing more and more about. I'm curious, how common is it that hospitals or health systems have a CNIO position? Sherilynn Quist (08:15): I think it's becoming more common, just simply because tech enablement is at the forefront of workforce efficiency. What people are really trying to realize and understand now is what do I have and what can I utilize to become more efficient? There's all these bells and whistles out there, and you need that person to shift the mindset and keep everybody moving forward on what they have. Abby Burns (08:45): Yeah. As we think about hospitals and health systems deploying AI, what we're seeing right now, again, spring 2026, is a lot of hospitals have not been able to point to measurable demonstrable ROI for many AI investments. There are exceptions, ambient listening is an exception. But having a CNIO position, having nurse leadership involved in designing how are we going to roll out AI enablement at our organization? Sherilynn Quist (09:13): I'm not sure about the CNIO role per se, but nursing needs to be at the table when you're talking about tech. 100%. Yeah. Abby Burns (09:21): So whether it's a suite role or whether it is nurses having a seat at the table as you're designing your AI enablement, tech enabled workflows, things like that. Sherilynn Quist (09:28): Absolutely. Ali Knight (09:30): I just want to jump in. The other role that is really critical to this, but we have not mentioned yet, is the role of human resources, and their ability to help with recruitment, retention, compensation, all of these things, even new role creation, that may help offset some of the challenges that we're experiencing. Abby Burns (09:51): Yeah, that's a great call out because we think, okay, these are a lot of challenges to solve. Nurse workforce related challenges can be really sort of sticky and intertwined. We should be thinking about who are our potential teammates that have expertise to bring to the table to start to chip away at these problems. That's a really good call out. With that, Ali, you mentioned this bubble of discontent that the nursing workforce is sort of sitting on. What are some of the root causes of this underlying instability in the nursing workforce? Ali Knight (10:20): So through our research, we've identified five primary drivers of the discontent. It is workplace violence. It's a culture of bullying and incivility. As Sherilynn alluded to earlier, it's workload, and workloads that are unsustainable. It's work-life balance. The very last thing is career growth and identifying career paths across the different tenures of a nurse's career. Abby Burns (10:50): Which is a topic that we talked about on the podcast a few months ago with our colleague, Miles Cottier. So would encourage anyone who is interested in nurse careerpathing to go back and listen to that conversation. (11:00): I want to dig in deeper on two of those in particular, workplace violence, and the sort of staffing and workload of it all. Both because they are incredibly important topics, and because frankly, they are the issues I hear come up most frequently in association with efforts to unionize. And we're not here to take sides on the issue of unions, but we are seeing an increase in organizing activities. We see more union elections being held. Work stoppages happening every six weeks or so this year on average, compared to every four months historically. So it's certainly worth digging into the factors that are driving some of these actions. (11:40): Let's start with workplace violence, Ali, where you started us off because this is on the rise. It's also an area where I think for a lot of us we see headlines. We certainly have a human reaction. But we aren't all that well informed about the scale of the problem and how organizations are responding. Ali, give us a lay of the land. How common is workplace violence for nurses? Ali Knight (12:04): So workplace violence for nurses is actually pretty common. I've seen a variety of different reports ranging from 46% of nurses experiencing violence up to 78%. Abby Burns (12:15): Wow. Ali Knight (12:17): Yeah. It's common. It has become part of the day-to-day fabric of life in a hospital. And the nurses we are hearing, they are telling us, that they need to feel safe. They need to feel a sense of security when they're at work and they need to know that their organization is taking steps to protect them. Abby Burns (12:39): Yeah. I did not realize that the numbers were that high. I have to imagine that that plays into some of the numbers you were talking about around intent to leave, specifically intent to leave bedside roles. Ali Knight (12:50): Yes. 32% of nurses have considered leaving nursing altogether as a result of workplace violence. Sherilynn Quist (12:58): I mean, interestingly enough, workplace violence also is driving increased cost in staffing. Abby Burns (13:04): Say more. Sherilynn Quist (13:05): Because hospitals are investing more in training for workplace violence, but they're also investing more in people, security, and sitters, and things like that. So there's a cost that comes with this increased workplace violence too that hospitals have to balance between making sure that their employees feel safe and ensuring that, from a financial standpoint, they're doing the right things. Abby Burns (13:36): What are some of the things that health systems are doing that are particularly effective in supporting their nurses in the face of workplace violence? Ali Knight (13:45): So one of the tactics that I have heard actually come up quite frequently is a little to no cost solution, and that is having the security team do purposeful rounding throughout the organization. Abby Burns (13:58): Rounding, like patient bedside rounding? Ali Knight (14:00): Actually rounding just on the units with their colleagues. So going floor to floor, talking with the nursing team, understanding maybe what patients might have a potential of escalating, or even just taking the time to get to know the staff. When you have that invested relationship, and the nurses feel like security knows them and they know who security is, just that that added relationship helps to improve the perception and the actual safety. (14:28): Additionally, when security knows that there's a likelihood of a patient escalating, they will be that much more apt to respond, or they can round more frequently, making themselves readily available in the event something begins to change. The biggest takeaway I would have related to workplace violence is to make sure that you are talking with your staff, understanding where their primary concerns are related to workplace violence, and then engaging them in identifying the right solutions for your organization. Abby Burns (15:01): Sherilynn, I see you nodding along with that. Sherilynn Quist (15:03): Absolutely. You've got to get the staff involved, and that's with every process improvement initiative or safety initiative. That's change management right there. Things aren't going to happen unless you hear from the staff and have them engaged. Abby Burns (15:16): There's probably also something to the signal value of having those conversations. It could easily feel like I feel unsafe at work and is my organization doing anything to counter that, if the nurses are not actively engaged in problem solving. Ali Knight (15:31): I was chatting with a nurse leader a couple weeks ago who called out that it's important to continue to talk about these things that we're doing, and to keep them at the forefront, even when they've been implemented. Because it can be really easy to have these initiatives fade into the background, and to forget all of the great work that is actually happening on an ongoing basis. Abby Burns (16:46): If workplace violence is the area where maybe our listeners are least well-informed, let's go to the other end of the spectrum. I want to talk about staffing and workload because this one is huge. So give us a sense for sort of the state of play around nurse staffing in 2026. Sherilynn Quist (17:04): On staffing and workload, I'd say the state of play is more nuanced than just there's not enough nurses. We absolutely hear concerns about understaffing and workload. But sometimes what's showing up is less about the headcount and more about the workflow, the experience mix, the support resources, and the complexity of the environment. So you can have units that are staffed to benchmark and still have nurses feeling overwhelmed. Part of the challenge is helping leaders and staff distinguish between workload strain and unsafe staffing. Those aren't always the same thing. Many hospitals are providing safe patient care at staffing levels compared to peers, but nursing is not always feeling that. Abby Burns (17:55): Yeah. And I think this point of nurses aren't always feeling that, I think we can even quantify that. Is that right? Ali Knight (18:01): 40% of nurses worry that their patients' needs may go unmet due to understaffing. And 88% voice concerns about the detrimental effects of staffing shortages on patient care. Abby Burns (18:16): So not just that the patient need will go unaddressed, but that will then have an impact on their quality of care, their care outcomes. Ali Knight (18:24): Yes. Abby Burns (18:24): I totally understand why this is directly related to nurse engagement because that's why our nurse is at the bedside every day, they're there for patients, right? Sherilynn Quist (18:32): 100%. And it's really important that you understand why they are feeling the way they are. This is that nurse engagement piece, and making sure that any process improvement, any staffing initiative, anything that you're going to do to improve the workforce includes those nurses in those discussions. Because oftentimes what they'll describe is not what a manager understands is the problem. Abby Burns (18:59): Yes, Sherilynn, this is exactly where I wanted to go, which is the difference between how it feels on the floor, and how it might feel from a nurse manager perspective. Ali Knight (19:08): Yeah. So I can tell you that when I was a nurse manager, I could look at the staffing sheets and think that things were spot on for the day. The nurse to placement ratios looked exactly right for what they should be, number of patients we had. But what I was missing was all of the other things that rolled into that assignment that I didn't see on paper. I didn't know who we couldn't get a follow-up appointment for, who maybe had a lot of complexities in their care today that didn't show in headcount. And even sometimes the experience of the care team that was working that day could shift the assignments. So I learned very quickly that what appeared on paper didn't always translate exactly to the day-to-day reality. Sherilynn Quist (19:53): And again, you have to go down to the level of what is the concern. Is it that they don't have enough support staff? Is it that they are training new nurses and have a lot of orientation? Is it that you've got less experienced caregivers? Is it that you don't have appropriate sitters or virtual sitting capability for those patients that need an extra eye? Abby Burns (20:20): So this gap exists. We need to understand it. Ali, what did we do about it? Ali Knight (20:24): Some of it comes down to just having the conversation. Just because there's a difference in perception of staffing doesn't necessarily mean that we're staffed inappropriately. It might be that we have workflow issues that are leading to challenges. It might be that we have experience issues or inefficiencies that we need to work on together. So starting a conversation and kind of root causing what's leading to that feeling of being short is important. (20:57): And the other reality that we have to face as healthcare leaders is that we just don't have enough people to continue to throw at the situation. So even if people were going to be the final answer, there are very real times that we can't recruit enough of them to even do so. So we have to look at what else? How else can we be more efficient? Are there things that we are doing today that we don't need to do anymore, but we never stopped doing because it's just the way we've always done them. And not to say that we'll never add people, but people should never be the only solution that you look at when you're evaluating your workforce. Sherilynn Quist (21:38): That is the work that we do at Optum Advisory when we go on site. We sit down with leaders and map it all out, try and understand where they can be more efficient, where communication is stalled, where supplies are in the wrong place. Abby Burns (21:59): Sherilynn, I want to ask about a little bit of the elephant in the room, which is the flip side of adding people, which I think there is this perception that, okay, if we're engaging a third party to help us evaluate our workforce, is, quote, unquote, "evaluating our workforce" code for cutting staff? Sherilynn Quist (22:15): Not at all. And I'll give you an example. We walked into an organization in Missouri, and they asked us to do an overall workforce assessment with their organization where we looked across workforce tools, premium labor, span of control, everything like that. Oftentimes people think nursing is my biggest, most expensive workforce, and that's where I'm going to find all of my savings opportunity. Abby Burns (22:42): Cross reduction target. Yeah. Sherilynn Quist (22:44): Yeah, absolutely. This organization was absolutely so efficient in running their nursing units. And so I had a conversation with the CFO to let him know, listen, here's what's happening, here's what we see in the units, and you've got some opportunity in terms of technology, but these other units are where you need to actually focus. Abby Burns (23:10): Sherilynn, you mentioned technology, and I don't want to let that ball go by. Is technology going to solve our workforce problems for us? It's a little bit of a hyperbolic question. Sherilynn Quist (23:20): It is not. So technology is a helper. I think the mistake that organizations are making today is they see all the bright, shiny things, and are excited to think that this new bright, shiny thing is going to solve all of my problems. When the current challenges are you've got technology that you're using in your hospital that might not be enabled. (23:44): So the first thing that I recommend when I walk into hospitals is understand the technology that you have today, what is turned on, what you're using and what you could be using more efficiently. Is there a better workflow that you could build utilizing the technology that you currently have? So it's a support for the workforce, but it is not an end all be all. Ali Knight (24:07): I think the other thing with technology I would just add, is being really clear on what problem that you are looking to technology to solve. Because to Sherilynn's point, it can be really easy to be distracted by the latest and greatest, and you may end up solving for something that isn't actually your primary root cause. Abby Burns (24:24): Can you give me a sense, how are we using tech enablement to support the nursing workforce today? Ali Knight (24:31): So we're seeing tech supporting the nursing workload in a variety of ways. We're seeing some organizations use virtual nursing to help soften the experience complexity gap and provide some virtual support for less experienced nurses. We are seeing virtual nursing be used for things like throughput and discharge planning to get patients moving out the door faster and freeing up both bed and staffing capacity. We're seeing the use of robotics to even do things like basic supply delivery or running specimens down to labs. Stuff that just takes the time and the physical burden off of our care teams. Abby Burns (25:11): Yes. So nurses don't have to walk literally miles per day moving things around the hospital. Ali Knight (25:15): Yes. Sherilynn Quist (25:16): One of the other things, Ali, we're doing a project in the Northeast, and they're using virtual technology for sitters and sitter utilization. Utilization of sitters has increased so much over the last couple of years because of your population. We're seeing increased age, more dementia, more delirium within hospitals. And so using those virtual sitters really can support the workforce. Abby Burns (25:45): When we think about the momentum and the activity that we're seeing around AI deployment in hospitals and health systems right now, a lot of focus has been on backend administrative functions. When we think about clinical applications, there's been more focus on supporting physicians. I'm wondering how you see the conversation around using AI to support nurses in particular, and how you would evaluate the momentum there. Ali Knight (26:09): We are seeing more organizations beginning to pilot ambient listening for nurses. It's so early on that we have not necessarily have a good handle on the impact for that, but really does highlight the burden that documentation is placing on the nursing colleagues. So organizations are looking to technology to offload some of that work from the day-to-day. Sherilynn Quist (26:36): AI and nursing is such an interesting topic because, when you think about it, AI is built into the technologies that people are using. Your EMR. You've got all these companies like your EHR or your EMR companies, they are using AI to make their systems better as well. On top of what Ali mentioned in terms of ambient listening, the AI that I think about is really just built into the technology that they're already using today. Abby Burns (27:08): Yeah. It doesn't need to be something new, flashy, entirely different or separate. Ali, Sherilynn, as we wind down our time and we think about the collaboration that it's going to take between nurse leaders and their peers to address, hopefully pop the bubble of discontent in a productive way that is affecting our nursing workforce right now, what action steps do you want to leave our listeners with? Sherilynn Quist (27:33): I think where this works well is when finance, nursing, and operations are truly partnered. So it's not the historical finance setting targets in isolation. It's really a shared view of what it takes to deliver care. Abby Burns (27:49): What does that look like in practice? Ali Knight (27:52): In practice, this is the CFO asking questions about what it means to run a nursing unit. From the converse side of that, it's the nursing leaders understanding their financials, understanding the organization's budget, and trying to work together in a give and take situation to come up with strategies, actions, that not only keep the department operations running, but can do so in a way that helps achieve the financial targets and the margins that are necessary to continue the mission. And I think if there's one key thing I want you to remember to do, it is engage your frontline in the process. They often see things that we as leaders don't always see because they're the ones doing the work on the day-to-day basis. Sherilynn Quist (28:37): They're also the ones that are going to move the work forward. Ali Knight (28:40): Yes. Sherilynn Quist (28:40): You can't have a successful team unless you've got your frontline staff involved and engaged. Abby Burns (28:48): Well, Ali, Sherilynn, thank you for coming on Radio Advisory. Sherilynn Quist (28:52): Thanks so much Abby. Ali Knight (28:53): Thanks for having us. Abby Burns (28:58): I said at the start of this episode that the state of the nursing workforce is an indicator for the health of the overall system. And while some indicators have gotten better here, I'll bring back what Ali said at the beginning of our conversation. The nursing workforce as a whole is sitting on a bubble of discontent. And this is not just a nursing leader issue to solve. Nursing, ops, finance, HR leaders need to work together to sustainably strengthen the nursing workforce. This is a place where Advisory Board has a wealth of research, including recent webinars on the five trends Ali talked about in our conversation today, and where Sherilynn's team at Optum can plug in for more on the ground support if that's what you need. Because remember, as always, we're here to help. (30:10): New episodes drop every Tuesday. If you like Radio Advisory, please share it with your networks, subscribe wherever you get your podcasts, and leave a rating and a review. Radio Advisory is a production of Advisory Board. This episode was produced by Atticus Raasch, Ellie Berman, Rae Woods, Chloe Bakst, and me, Abby Burns. The episode was edited by Katy Anderson with technical support provided by Dan Tayag, Chris Phelps, and Joe Shrum. Additional support was provided by Leanne Elston and Erin Collins. Special thanks to Allyson Paiewonsky, Monica Westhead, and Miles Cottier. We'll see you next week.