Nurses and the Great Attrition

Many nurses are reevaluating their commitment to direct patient care given the demands of the coronavirus. Now, during a time of unprecedented need, what can health systems and other employers of nurses do to prevent losing this backbone of the healthcare workforce to the Great Attrition? Hear from Gretchen Berlin, a registered nurse (RN) and McKinsey senior partner, on the state of nurses and on specific suggestions to improve their work experience, practically and emotionally. After, McKinsey associate partner David Baboolall joins us to discuss the recent findings of the McKinsey Quarterly article “Being transgender at work.” An edited version of the conversations follow.

The McKinsey Podcast is hosted by Roberta Fusaro and Lucia Rahilly.

Segment one: Nurses are under great strain

Lucia Rahilly: Today, we have Gretchen Berlin on the show, a registered nurse and senior partner in our healthcare practice. Gretchen, welcome to the podcast.

Gretchen Berlin: Thank you.

Lucia Rahilly: It’s great to have you here. Nurses have been on the front lines of the COVID-19 crisis for nearly two years now. Infection rates are surging. What are you hearing on the ground about how nurses are feeling now?

Gretchen Berlin: Nurses are not a monolithic group, and it varies quite significantly across the country. In general, demands on nurses were high even before COVID-19. Across the country and across the world, we have an aging population. We have a population that’s getting sicker and needs more care.

Now, fast-forward to today: a lot of those nurses are tired. In any crisis situation, you’re running on adrenaline and trying to get through to the other side. What has become clearer as the months have gone by—with Delta and now Omicron—is that there may not be a magical end of the tunnel, and that is a very different world to be facing.

It’s a lot of pressure, a lot of day-to-day, and then month-to-month, demands and potentially not a lot of relief in the near-term future.

A few factors driving nurse fatigue

Lucia Rahilly: And we see resignation generally in the zeitgeist in the wake of the pandemic. Quitting is up across the board in different industries, and McKinsey’s own “Great Attrition” research shows that the intent to quit continues to be heightened. How do nurses stand in that area? Are there factors that are specifically driving nurses out the door?

Gretchen Berlin: Nurses are no exception to our research on the likelihood of people leaving their professions. We ran a survey in early 2021 that showed about 20 percent of folks were looking to leave. [Editor’s note: This figure rose to 32 percent in a McKinsey survey conducted in November and December of 2021.]

What we’ve seen in the healthcare market in recent months is massive competition through things such as retention bonuses, attraction bonuses for new hires; frankly, in a way, that is largely unsustainable.

I think the more troubling piece is that nurses are exiting the profession altogether. It’s not just a challenge that the US is facing; we hear it from health systems around the world.

To answer your question as to what drives them to leave: we see a lot around compensation, and, yes, we need to pay nurses adequately for the services and value that they’re delivering. But at the end of the day, a lot of it comes down to the support and recognition that they feel in their workplace, from their leaders, their managers, their team, and through ensuring there’s sufficient staffing, sufficient respite, and gratitude.

Lucia Rahilly: Presumably, there’s variability in care settings, but are you seeing extremities of workload, insufficient staffing, or an emotional toll on nurses right now as the pandemic drags on?

Gretchen Berlin: Yes, you can almost draw a timeline of the pandemic. It started at this crisis moment where many health systems were flexing staff in a variety of ways. You had nurses who were historically nurses in the OR [operating room] becoming ICU [intensive-care unit] nurses or nurses who were accustomed to running ventilators moving over onto COVID-19 units.

You had nurses in the outpatient settings moving into inpatient. We had nurses crossing state lines and operating in health systems they had never operated in before. All of that was happening, with most non-COVID-19 care being delayed.

Health systems have been doing everything they can to ensure sufficient staffing, but it has been a challenge to meet the need, to say the least. It’s had to be met by contract labor and additional support, which is extremely expensive and can often be challenging to integrate into the regular care team.

Because of those staffing challenges or the variability in the workload, we haven’t yet hit a new normal in the health system. We continue to see reports coming out about the impact of delayed care, and that still hasn’t fully run its course through the system.

We have done surveys of health systems every quarter, and they’re still projecting that surgical backlogs and preventative backlogs are not yet through the system.

The mental health of nurses

Lucia Rahilly: It feels like nurses have always been required to be incredibly resilient. They are expected to behave heroically, but nurses are also human beings, and we’re seeing a rise in clinician burnout across the board.

Is mental health a new issue for nurses, or have they been suffering under the radar for longer than many of us might have suspected?

Gretchen Berlin: I don’t think mental health is a new issue in nursing at all. In general, mental health is an underappreciated, underdiscussed issue in the entire population, and nurses are no exception to that.

Many parts of care have provided support and respite for clinical teams. For example, pediatric hospitals will allow rotations between cardiac ICU step-down units and outpatient settings, allowing nurses to avoid being in the most critical, upsetting care settings day in, day out, in perpetuity.

We haven’t really built in that decompression space for a lot of healthcare. And it’s interesting that you use the word “burnout”—there are a lot of sensitivities around that word in healthcare. And rightly so, as some believe that it implies that the clinicians themselves aren’t resilient enough to deal with what is happening. When, in reality, what is happening is an untenable situation for anyone to individually survive in, let alone thrive in.

We, as a society, need to lift up these professions. In the last two years, we’ve had probably ten different parades for different professional sports teams who have won championships. And, yes, these events bring great joy to society. But where is that kind of support and recognition at the community level for what our frontline heroes are doing day in and day out?

Lucia Rahilly: Right, it’s a really good point. I live in New York City, and at the beginning of the pandemic, we used to stop what we were doing and clap at seven in the evening for the essential workers. And it was such an amazing outpouring of gratitude.

But now, lo these many months later, that appreciation may reside in all of us, but it’s much less visible.

Gretchen Berlin: Exactly. The nurses and clinicians have not stopped seeing the patients, the firefighters and police have not stopped answering the calls for patients in respiratory distress that may or may not have COVID-19. The level of stress that individuals are dealing with is going to have massive implications on everyone’s well-being, which then will put more strain back on the healthcare system through mental-health needs, cardiac needs, et cetera.

Lucia Rahilly: Seems also that since family members are not allowed to visit bedside in many healthcare settings, this could add to the emotional work of nurses?

Gretchen Berlin: I think that’s absolutely right. Nurses are dealing with a lot at the bedside, in terms of helping patients die and helping families. To your point, many patients, especially at the start of this, had only the nurses with them for those final moments, and I’m not sure that we’ve provided the decompression space for what that does to an individual who has to see that and support people through that over and over again.

How to improve nurse working conditions

Lucia Rahilly: Let’s talk about what we should be doing to make this better. You’ve written that we should move away from thinking about a rebuild and shift instead toward an entirely new build of our nursing workforce. And specifically, Gretchen, you mentioned several areas: workforce health, workforce flexibility, reimagining care-delivery models, and strengthening talent pipelines.

Let’s start with workforce health and well-being, both of which feel exigent right now. How can those areas be improved?

Gretchen Berlin: I think the areas of workforce health and well-being can be improved in a couple of ways. Some of it is societal recognition and celebration. When you hear that someone is an astronaut, the reaction often is, “That is so cool; tell me about that.” How do we make that be the narrative for our frontline caregivers?

The second form of recognition in our society often comes financially through compensation for the role that nursing plays.

There’s other financial recognition that can be provided, too, and has happened over time in terms of loan forgiveness from states, from the federal government, from various nonprofits in support of these roles, which different parts of the community can get involved in.

And then I think there’s recognition in the workplace. A lot of health systems do it in spades, but genuinely doing it means doubling down on the basics of leadership recognition, being on the floor with nurses to understand the simple and the complicated fixes to make their lives easier—things such as making sure supplies are there on time, and eliminating unnecessary documentation so that they can spend more time at the bedside.

Lucia Rahilly: What about workforce flexibility? Many nurses must already work shifts. What does workforce flexibility look like in the nursing context?

Gretchen Berlin: Workforce flexibility takes a few flavors. Some of it is flexibility in the care setting. So, a bit of what we discussed earlier: allowing folks the ability to have the intense experience in the ICU when they want it, but also to have the ability to go elsewhere to get different experiences—obviously all within appropriate licensure and clinical standards—depending on what’s going on with them individually or with the rest of their lives.

Health systems are often doing this through regional float pools or other team-based models, but more and more of this can and should happen.

Lucia Rahilly: The pandemic obviously accelerated digital adoption in all kinds of areas, including telehealth. How might telehealth affect future care delivery and nurses’ roles in it?

Gretchen Berlin: Well, I think telehealth is an example of flexibility, and more nurses now say that they would like to continue to participate in telehealth.

The other thing that happened during the pandemic that was interesting was the more digital ways of providing patient monitoring and care. Many facilities moved a lot of the patient monitors out into the hallway to avoid unnecessary donning of PPE [personal protective equipment] and going into the room. And that actually allows for more patient monitoring at any one time.

So how do you translate that into a new model? Some parts of patient care you’re never going to get rid of—for example, the human interaction. You need to do physical assessments. You need to administer medications. But how do we take what worked in a moment of crisis and institutionalize it further in our systems and in our technology?

Lucia Rahilly: Is there a possibility of hybrid work for nurses? And if so, what would that look like?

Gretchen Berlin: I think there is the option of hybrid working for nurses in the future.

Often when we think of telemedicine, we think of a parent at home worried about their kid’s fever, and if they should bring them in or not, and getting a telemedicine visit. But telemedicine and teleconsultations are used for a lot more complex things. Especially in rural hospitals—for example, if you have a patient coming in with a stroke, they’ll have more of a virtual consultation, with higher specialty service elsewhere.

We’re doing that for tele-ICU, et cetera. And individuals could operate across these care settings. Again, of course, all within license requirements, to provide flexibility. And we are seeing that nurses are more interested in doing telemedicine going forward.

Lucia Rahilly: It’s interesting to think of telehealth not just as a convenience but also as potentially a model that improves the cadence and the quality of care through more frequent monitoring or monitoring for folks in rural settings who might not otherwise make it all the way into the doctor on a more routine basis.

Gretchen Berlin: I think it can be very effective, especially for more rural settings.

The promise of technology

Lucia Rahilly: You talked about fungibility in care settings and regional float pools and so forth. Gretchen, you yourself went to nursing school. Are the skills that nurses need to do their jobs successfully changing?

Gretchen Berlin: We continue to ride the curve of technology.

In the past 20–25 years, there has been a lot of technology adoption in care delivery. A lot of these technologies often don’t fully replace how something is done, which adds to nurses’ workloads. How do you then use technology to declutter what a nurse does and help get the signal through the noise of all of the alarms and all of the vitals and all of the documentation to actually help clinicians practice at the top of their license and focus on what truly matters?

I think that is very exciting, and that is the promise of redefining how the clinical workforce can go into the future. There are longer-term systemic things we can and should do in terms of strengthening the talent pipeline: encouraging students to engage in science, engage in medicine.

It will also require expanding schools and clinical-training spots. And we see health systems doing that directly because they recognize the need and aren’t willing to wait for others in the ecosystem to do it. And these things are all needed to rebuild our talent pipelines and skills for the workforce of the future.

But in the meantime, we need to flip the operating models that we have for our workforce now, so that we’re able to bridge the gap. Otherwise, I worry, we’re going to have more than a decade of pretty turbulent times, where we have a lot of clinical demand and a very turbulent workforce.

People find purpose in nursing

Lucia Rahilly: My niece is in high school, and she recently surprised me by raising the possibility of getting an RN degree.

It occurred to me when she was talking about this that we hear so much now about the importance of purpose, particularly vis-à-vis Gen Z. Do you think the pandemic has in any way created pull into the nursing field because it has surfaced as so vital and so high stakes?

Gretchen Berlin: Yeah. It’s a really interesting point.

In some ways, I think the pandemic has shone a light on the purpose, as you said. But also, we have seen in our own research that some nurses are more likely to stay in the profession now than they were before.

We haven’t surveyed to see if that translates into more folks interested, but we do see an increase in applications to schools going up. And I think some of that is because of the importance of purpose, and some of it is because the profession is changing, and nursing can be much more flexible than your traditional office job.

In a lot of ways, the criticality of the role has been elevated for people. A lot of people want nothing more than to support society and individuals on the biggest challenge of the day, which right now is COVID-19 and meeting the pent-up demand that it has caused.

An optimistic view of the future

Lucia Rahilly: Acknowledging that access to quality nursing care is, in part because of COVID-19, such a high-stakes and collectively vital issue, are you optimistic about the potential for positive change, both for the sake of nurses and for all of us?

Gretchen Berlin: I am quite optimistic. I think there are a lot of really bright minds trying to solve this. There are a lot of committed health systems, employers, and societies trying to invest and fix it. I think more than anything, there’s a really committed workforce who’s excited to innovate, who has shown tremendous flexibility and resilience already and will continue to do that going forward.

Lucia Rahilly: Any suggestions for keeping this issue on the front burner, assuming COVID-19 starts to recede?

Gretchen Berlin: I think that there are ways we can continue to recognize as a society. I think that’s part of the power of conversations like these. We have National Nurses Week in May. There are obviously national companies that run nurses campaigns. There are ways that each of us as individuals, or our small businesses, or our large businesses, can draw attention to our first responders and our clinicians in general but our nurses especially through celebrations, promotions, and accolades.

Lucia Rahilly: Let’s close there. Gretchen, that was a fascinating discussion. Thanks so much.

Gretchen Berlin: Thank you. I hope we all have a better 2022.

Lucia Rahilly: Roberta, so many of us have had the experience of relying elementally on nursing care. My daughter, who is now a happy, coltish, and—knock on wood—healthy six-and-a-half-year-old girl, had respiratory surgery at birth and spent almost two weeks in the surgical NICU [neonatal intensive-care unit]. And those NICU nurses were just invaluable.

During that experience, our family will never, never forget them. They were vital not just to her survival but also to our own emotional stability and well-being. At that time, it was incredible.

Roberta Fusaro: I feel the same way, Lucia, and I’ve had the complete opposite life cycle experience of dealing with in-home nurses for my mother when she refused to move out of the house that she had been in for, you know, some 70 years.

The fact that we felt comfortable enough to have people come into our house to take care of my mother made the final months of her life that much more comfortable, which gave us a lot of comfort too.

It’s horrible to see such flux within the nursing workforce. And there’s another cohort of people that are at risk of quitting, in part because they don’t feel valued at work. It’s our transgender colleagues. We’re about to hear from David Baboolall about our recent article: “Being transgender at work.”

Segment two: Being transgender at work

Lucia Rahilly: David, thanks for joining us today.

David Baboolall: Lucia, thank you so much for having me. I’m very excited that we’re having this conversation.

Lucia Rahilly: Acknowledging the range and the variety of experience within the trans demographic, what has our research taught us about what it’s like to be trans in today’s workplace?

David Baboolall: I’d like to start off with just a few facts around unemployment, if that works with you. Unfortunately, I’ll start quite stark.

Only 73 percent of transgender adults are actually in the workforce compared with 82 percent of cisgender adults. Our survey, which we ran across a number of trends over this past year, shows that trans individuals are two times more likely to be unemployed than cisgender people, which is kind of crazy.

And in the US alone, almost two times as many trans people report being recently out of work. The scarcity and precarity of transgender employment can lead to loneliness, instability, and alienation from the rest of the workplace. When we look at wages, candidly, the situation is equally as stark. Transgender people make far less money than cisgender people do.

The average household income of a transgender adult is about $17,000 less than that of a cisgender one. And our survey showed that transgender individuals are almost 2.5 times more likely to work in places such as retail or food, which, as we know, in large proportion are entry-level-paying jobs, paying the minimum wage in the US.

Then, when we take it one step further to intersectionality, when we look at folks who are marginalized in addition to being trans—for example, people of color—the figures are worse. Seventy-five percent of Native American trans people and 43 percent of Hispanic trans people make less than $25,000, with that figure only equating to 17 percent for White cisgender people.

Lucia Rahilly: That’s a dire picture, and it sounds like an urgent need to take action. The stakes are high. What are some examples of the specific challenges—the trends employees confront daily in the workplace?

David Baboolall: In the corporate push for more diverse workplaces, especially since the racial reckoning last year, the transgender population candidacy is unsupported. And this is more than just a matter of career progression, promotion, or climbing to the top of the ladder.

Whereas other populations strive to feel included in the workplace, transgender workers want to feel safe. For members of the trans and gender-nonconforming community, safety is top of mind—safety from physical harm, mental harm, or emotional harm. And what we’re seeing in our data is that less than half of transgender adults are comfortable being fully open about their gender identity at work.

And when we take that a step further, two-thirds are uncomfortable being out with their customers and their clients. And being in a client-facing role myself, Lucia, the inability to be out with folks that I’m talking to not only on a monthly but also a weekly—if not hourly—basis is a lot to grapple with, especially if you’re in client service.

Lucia Rahilly: Safety is obviously fundamental. I mean, that’s Maslov’s hierarchy of needs, right? That’s basic. Besides ensuring that employees feel safe and are able to bring their full selves to work, what can leaders do to help at the enterprise level?

David Baboolall: I think step one is education and awareness. That’s my biggest goal with this report and this research. I’m hoping corporate leaders and leaders of different sectors will take this report and say, “I have a reference to learn.”

I have a glossary that we put together to discern different words that are used in the trans community. And then I think you can go across the employee life cycle and be intentional in recruiting. How can you connect with potential trans new hires or participate in specific recruiting events? Signal to those that are coming to your firm that you are excited to be a workplace where trans individuals thrive.

I think the second step is to think about offering trans-affirming benefits. And this doesn’t just mean medical benefits, gender-affirming surgery or hormone therapy. It also involves thinking about whether you have mental-healthcare support for a community that is disproportionately affected by mental-health issues.

The third step is about other policies and programs, such as reviewing company dress codes, eliminating gender-specific language, offering diversity trainings that are nuanced to gender identity. And I think the last step is adopting an overall inclusive culture—are the forms and documents that you ask your employees to fill out on a weekly, annual, or half-annual basis asking for personal pronouns? Are they asking for preferred names? Does your office have gender-neutral bathrooms?

Lucia Rahilly: You mentioned language and a glossary in the report, which seems vital, particularly because fear and confusion over language can hold colleagues back from talking about some of these issues. What are some small steps that all of us in the workforce might take to signal support for our transgender colleagues and potentially improve their daily experience directly?

David Baboolall: My teams actually practice it at McKinsey. When we kick off a new project at McKinsey, we do team introductions. And within those sort of simple five to ten introductory questions—What’s your name? Where are you from? Where did you grow up? How did you join McKinsey?—there’s the question of what are your personal pronouns? What is your preferred name? Those two simple questions signal to any person in the trans community, “Hey, this person seems like an ally.”

Lucia Rahilly: Are there any examples from your own career of allyship?

David Baboolall: I think personally there have been a number of instances over the last year where folks have noticed my pronoun change—clients have come to me, I’ve had senior individuals at McKinsey come to me, I’ve had people in my building when I would wear work name tags back home. They see my pronouns, and they’re inquisitive, asking, “Hey, is everything OK? How can I be supportive? Is there anything that you’d like to talk through? How can I become educated?” And that’s been great. I think that that has been an opportunity for folks to engage because I’m very open about my personal pronouns, and I use those for every introduction that I actually have.

Lucia Rahilly: Any thoughts for leaders on the best way to know that they’re making progress?

David Baboolall: I think the more it comes up in conversation, the more you’re likely doing things right. We tend to avoid conversations when it comes to topics of diversity that we’re not used to, that make us uncomfortable, that we’re nervous about getting wrong.

So the more that these topics are being brought up, the more ideas that are being brought to senior leaders—such as “Hey, maybe we should do this for our trans colleagues? Maybe we should do this in terms of gender identity? Have we thought about offering this healthcare benefit? Have we thought about changing this policy? Have we really thought through placing a gender-neutral bathroom at our factory site?”—the better it is. As those ideas are flourishing, as folks are being more vocal about it, you’re doing something right. And they’re open to having the conversation to advance change.

Lucia Rahilly: David, fascinating. Thanks so much for being with us today.

David Baboolall: Thank you so much for having me.