Reimagining the nursing workload: Finding time to close the workforce gap (2024)

(9 pages)

US healthcare organizations continue to grapple with the impacts of the nursing shortage—scaling back of health services, increasing staff burnout and mental-health challenges, and rising labor costs. While several health systems have had some success in rebuilding their nursing workforces in recent months, estimates still suggest a potential shortage of 200,000 to 450,000 nurses in the United States, with acute-care settings likely to be most affected.1Gretchen Berlin, Meredith Lapointe, Mhoire Murphy, and Joanna Wexler, “Assessing the lingering impact of COVID-19 on the nursing workforce,” McKinsey, May 11, 2022. Identifying opportunities to close this gap remains a priority in the healthcare industry. This article highlights research conducted by McKinsey in collaboration with the ANA Enterprise on how nurses are actually spending their time during their shifts and how they would ideally distribute their time if given the chance. The research findings underpin insights that can help organizations identify new approaches to address the nursing shortage and create more sustainable and meaningful careers for nurses.

Over the past three years, McKinsey has been reporting on trends within the nursing workforce, collecting longitudinal data on nurses’ self-reported likelihood to leave their jobs and factors driving nurses’ intent to leave.2“Nursing in 2023: How hospitals are confronting shortages,” McKinsey, May 5, 2023. As of March 2023, 45 percent of inpatient nurses (who make up about 2.0 million of the 4.2 million nurses in the United States3Nursing fact sheet, American Association of Colleges of Nursing, updated September 2022.) reported they are likely to leave their role in the next six months. Among those who reported an intent to leave, the top two reasons cited were not feeling valued by their organization and not having a manageable workload. In fact, nurses have consistently reported increasing workload burden as a main factor behind their intent to leave.

About the research

We conducted a survey of 310 registered nurses across the United States from February 8 to March 22, 2023. Our goal was to understand nurses’ perception of time spent throughout the course of a shift and to identify existing and desired resources to help nurses provide high-quality care. Our sample focused on nurses in roles that predominantly provide direct patient care in the intensive-care unit, step-down, general medical surgical, or emergency department settings. Insights were weighted by length of shift (the minimum shift time included was six hours).

For questions related to intent to leave nursing, all nurses from any care setting (including home care and long-term care facilities) were included. Our survey questions on intent to leave have been kept consistent to collect longitudinal data on nurses’ intent. Our last survey, of 368 frontline direct-care nurses, was conducted in September 2022.

In our new survey, nurses provided a breakdown of the average time spent during a typical shift across 69 activities (see sidebar “About the research”). They also reported their views on the ideal amount of time they would like to spend on these same activities. In looking at ways to redesign care activities, we found the potential to free up to 15 percent of nurses’ time through tech enablement, or automation, and improved delegation of tasks (Exhibit 1). Leveraging delegation and tech enablement could reduce and redistribute activities that nurses report being predominantly responsible for. The subsequent reduction in time savings could improve nursing workload and their ability to manage more complex patients. When we translate the net amount of time freed up to the projected amount of nursing time needed, we estimate the potential to close the workforce gap by up to 300,000 nurses.

Nurses report a desire to spend more time with their patients, coach fellow nurses, and participate in professional-growth activities

In our survey, we explored where nurses wanted to spend more of their time (Exhibit 2). The responses fall into the following three categories.

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Reimagining the nursing workload: Finding time to close the workforce gap (2)

Direct patient care

Nurses report spending the majority of their shift—54 percent, or about seven hours of a 12-hour shift—providing direct patient care and creating personal connections with patients (direct patient care includes patient education, medication administration, and support of daily-living activities). The survey reveals that nurses wish to spend even more time in these activities.

Spending sufficient time on patient-care activities promotes both nursing satisfaction and quality of patient care.4Terry L. Jones, Patti Hamilton, and Nicole Murry, “Unfinished nursing care, missed care, and implicitly rationed care: State of the science review,” International Journal of Nursing Studies, June 2015, Volume 52, Issue 6. Furthermore, rushing care and not having sufficient time to meet patients’ needs can contribute to moral distress and burnout.

Teaching and training for new nurses and peers

Nurses report spending on average about 2 percent of their shift teaching peers and students (excluding shifts when nurses are in a dedicated teaching or “precepting” role), an activity they say they want to spend double the amount of time on. Peer-to-peer teaching is an important component of building workplace cohesiveness, improving patient outcomes, and preparing new generations of nurses. In our survey, nurses report that they often lack the time to engage in coaching new nurses. As a result, important informal teaching, which is critical to build confidence and to support skill development for newer nurses, is often missed.

Involvement in professional-growth activities

Similar to educating other nurses, nurses report wanting to spend more than double the amount of time on growth and development activities (about 7 percent of an ideal shift). These activities include participating in shared governance, reviewing and reading work emails, and completing annual requirements and continuing education hours.

Freeing up nursing time to support organizational initiatives and further professional development may contribute to a nursing staff that is more engaged, feels valued, and has a strong connection to their departments.

Nurses desire to spend less time on documentation, hunting and gathering, and administrative and support tasks

Charting and documentation

Documentation continues to greatly contribute to nurses’ workloads, making up 15 percent of a nurse’s shift. The most time-consuming documentation tasks are head-to-toe assessments, admissions intakes, and vitals charting, which account for the majority of documenting time (70 percent). Nurses say that ideally, documenting should make up only about 13 percent of their shift. But without realistic and effective alternatives (for example, nursing scribes, device integration, reduction in documentation requirements, and AI to aid with documentation), it is unlikely that nurses’ documentation burden can be fully alleviated.

Hunting and gathering

For nurses, hunting and gathering means searching for individuals, equipment, supplies, medications, or information. Nurses report that they spend about 6 percent of a 12-hour shift on hunting and gathering—tasks they would spend approximately 3 percent of their shift on in an ideal shift.

Activities best delegated to support staff

Nurses report spending nearly 5 percent of their shift on tasks that do not use the fullest extent of their license and training. For example, they say they spend nearly an hour on nutrition and daily-living activities, such as toileting, bathing, and providing meals and water. In an ideal shift, nurses say they would spend about 3 percent of their time on these activities.

Redesigning care models: Adjusting how nurses spend their time

As we consider how to alleviate nursing workforce challenges, one area of intervention could be evaluating how current care models can be redesigned to better align nursing time to what has the most impact on patient care. Performing below-top-of-license or non-value-adding activities can create inefficiencies that lead to higher healthcare costs and nurse dissatisfaction. Rigorously evaluating whether tasks can be improved with technology or delegated to allow nurses to spend time on activities they find more valuable could help to reduce the time pressures felt by nurses.5“National guidelines for nursing delegation,” a joint statement by the NCSBN and American Nurses Association, April 1, 2019. In our analysis, we reviewed the activities nurses say they would ideally spend less time on and considered whether delegation and tech enablement of such tasks could free up nurses’ time.

Delegation

Based on our analysis, we estimate that full or partial delegation of activities to roles including technicians, nursing assistants, patient-care technicians, food services, ancillary services, and other support staff, could reduce net nursing time by 5 to 10 percent during a 12-hour shift (Exhibit 3).

While nurses report wanting to spend more time overall on direct patient care, there are specific tasks that could be delegated both vertically and horizontally to ensure that the work nurses perform is at the top of their license and promotes professional satisfaction. Appropriate delegation requires training support staff and upskilling where appropriate, as well as evaluating systemwide resources that can be used where needed. For example, within direct patient care, nearly an hour could potentially be freed up by delegating tasks such as patient ambulation, drawing labs and starting IVs, transferring patients, and supporting patient procedures.

Full or partial delegation of activities to roles such as technicians and other support staff could reduce net nursing time by 5 to 10 percent during a 12-hour shift.

Tasks that are evaluated for redistribution to other clinical and non-clinical staff can also be considered as part of broader care-model redesign. Upskilling support staff across clinical and nonclinical roles can often result in overall better use of resources already in place across a health system.

Tech enablement

Based on our assessment, we estimate that a net 10 to 20 percent of time spent during a 12-hour shift is spent on activities that could be optimized through tech enablement. Investing in digital approaches that automate tasks (either completely or partially), rather than simply redistributing workload, could potentially free up valuable time for nurses (Exhibit 4).

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Reimagining the nursing workload: Finding time to close the workforce gap (4)

Examples of tech enablement and delegation in practice

To determine the amount of time that could potentially be freed up over the course of a nurse’s shift, we used estimations based on best-in-class care delivery models from practice, innovative emerging technology from industry, and how easy it would be for health systems to implement the intervention (for example, cost and technological requirements).

Tech-enablement

  • Robotic automatic-guided vehicles (AGVs) deliver equipment, food, and supplies throughout a hospital.1“Robots help nurses get the job done–with smiles and beeps,” Cedars Sinai, November 29, 2021.
  • Robotic pill-picker machines select and deliver medicines throughout a hospital.2Jay Kiew, “The digital surgery: Humber River Hospital reinvents itself with AI & robotics,” Change Leadership, June 16, 2018.
  • Virtual nurses monitor patients remotely, working alongside a bedside-care team comprising a bedside RN, bedside licensed vocational nurse, and virtual RN.3Giles Bruce, “Trinity Health plans to institute virtual nurses across its 88 hospitals in 26 states,” Becker’s Health IT, January 13, 2023.
  • Ambient intelligence (that is, passive, contactless sensors embedded in a clinical setting to recognize movement or speech) reduces documentation workload and can continuously monitor patients.4Albert Haque, Arnold Milstein, and Li Fei-Fei, “Illuminating the dark spaces of healthcare with ambient intelligence,” Nature, September 9, 2020.

Delegation

  • Centralized training for roles such as transporters that can then be utilized in all areas of the hospital.
  • Upskilling employees and modifying staffing models allow nurses to work in units where they are needed most (for example, non-critical-care nurses in critical-care departments).

For example, nurses spend 3 percent of their shifts on patient turning and repositioning. This task could be optimized through innovative “smart” hospital-bed technology, including bed-exit alarms, advanced therapy for redistributing pressure, integrated scales and measurements, and remote information on patient conditions. Voice-automated devices and smart beds can also equip patients with control and autonomy over their rooms and preferences (for example, shades, television, and lighting) without nurse intervention (see sidebar “Examples of tech enablement and delegation in practice”).

These interventions, however, can be costly and may not be appropriate solutions in every system. Healthcare organizations will need to assess the specific needs of nurses and patients to determine which interventions will have the most impact.

Healthcare organizations could also consider continuously evaluating the digital approaches they have implemented to ensure that the technology itself does not create redundancies or rework, introduce delays, or adversely increase workload. For example, 37 percent of nurses report that they do not have access to vital signs or telemetry machines that are integrated with electronic medical records for automatic documentation. This could explain why nurses say they could spend less time—about 30 percent less—documenting vital signs. Technology like scanners and automated vitals machines have been an effective way to streamline documentation. But nurses still report spending nearly 10 percent of their shift scanning medications into the patient record, documenting vitals and completed patient education, and drafting progress notes.

Nurse time saved through care-model changes and innovations can benefit patients and nurses—and contribute to building sustainable careers in healthcare

The impact of care-model redesign could range from improving workload sustainability to addressing a substantial portion of the projected 200,000 to 450,000 nursing gap. Our analysis finds a potential net time savings of 15 to 30 percent of a 12-hour shift, based on estimating the possible range of time reduced through delegation6“ANAs principles for delegation,” American Nurses Association, 2012. or tech enablement.7Mari Kangasniemi, Suyen Karki, Noriyo Colley, and Ari Voutilainen, “The use of robots and other automated devices in nurses' work: An integrative review,” International Journal of Nursing Practice, August 2019, Volume 25, Issue 4.

In our conservative estimate, there would be no additional opportunity to alleviate the potential nursing shortage, as health systems would reallocate the saved time to their current nursing staff for activities they say they would spend more time on, including time with patients, teaching peers, and investing in their growth and development (Exhibit 5). However, this reallocation of time could improve the sustainability of nursing careers in acute-care practice.

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Reimagining the nursing workload: Finding time to close the workforce gap (5)

In our optimistic estimate, after reallocating time back to nurses, health systems could free up a 15 percent net time savings, which could translate to closing the nursing workforce gap by up to 300,000 inpatient nurses. Achieving this may require health systems to invest heavily in technology, change management, and workflow redesign.

Realizing these changes will require bold departures from healthcare organizations’ current state of processes. It will be critical for hospitals to bring both discipline and creativity to redesigning care delivery in order to effectively scale change and see meaningful time savings. Close collaboration beyond nursing is also paramount to ensure alignment across the care team and hospital functions including administration, IT, informatics, facilities, and operations. A comprehensive evaluation of redesign requirements can enable health systems to understand what is limiting care-model change (for example, policies, skill development, education). Investment in education and additional onboarding may be needed to upskill and train staff on expectations as work is shifted across roles. Partnering with tech companies and industry vendors in areas such as electronic-health-record platforms can accelerate innovation and implementation to build off existing tools and reduce implementation risks. Although the idea of change may be daunting, incorporating innovations in healthcare delivery could be a strategy for building a sustainable workload that could attract and retain nursing talent by allowing them to do more of what matters to them most: taking care of patients and one another.

Gretchen Berlin, RN, is a senior partner in McKinsey’s Washington, DC, office; Ani Bilazarian, RN, is a consultant in the New York office; Joyce Chang, RN, is an associate partner in the Bay Area office; and Stephanie Hammer, RN, is a consultant in the Denver office.

The authors wish to thank Katie Boston-Leary, RN, and the ANA Enterprise for their contributions to this article. The authors also wish to acknowledge and thank the entire healthcare workforce, including all of those on the front line.

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