Why more money won’t fix the nursing crisis; and what will


May 9, 2023

In 2021, the number of registered nurses dropped by more than 100,000—the most it has ever dropped in 40 years. As if that wasn’t concerning enough, in a survey of nurses conducted in January 2022, 52% responded that they intend to leave or are considering leaving their positions. Their top reasons for leaving were insufficient staffing, work negatively affecting their health and wellbeing, and the inability to deliver quality care consistently. Eighty-nine percent of nurses in that same survey responded that their organization is experiencing staff shortages. Additionally, 60% of acute care nurses reported feeling burned out, and 75% reported feeling stressed, frustrated, and exhausted.

It’s never been an easy time to be a nurse. But given the circumstances, the last few years may encompass the most difficult time to be a nurse. While some readers may be skeptical that a solution of additional dollars toward nursing salaries or bonuses aren’t sufficient to tackle this challenge, lifting the hood on what fundamentally drives people to make life choices (e.g., regarding their careers) can provide a clear understanding for a more sustainable, effective solution. 

Why financial incentives are not enough

To try and address this crisis, employers have turned to financial incentives to attract and keep nurses. A survey of hospital executives showed two in every three respondents were offering hiring bonuses, and more than half of the respondents surveyed were improving pay packages. 

For example, the Colorado Department of Human Services is offering nurses hiring bonuses from $7,000 to $14,000. Similarly, the West Virginia University Health System is offering bonuses from $5,000 to $15,000. The highest noted so far is Monument Health, offering a sign-on bonus that is available up to $40,000.

However, money may be able to attract staff, which would fix the insufficient staffing issue and, in turn, the nurse-to-patient ratios enabling nurses to deliver quality care to their patients—but that’s only part of the issue. How are employers addressing the negative effect that work has on nurses’ health and wellbeing? And if they aren’t, how long will they be able to retain staff? It’s like the psychological saying goes: “You can’t pour from an empty cup.” Likewise, nurses can’t provide quality care for the wellbeing of their patients when their own wellbeing is suffering. Furthermore, according to a report by Deloitte Insights, “[m]ultiple studies have tied employee health and well-being with organizational productivity, engagement, and profitability. Low attention to the employees’ [drivers of health] prove to be a blind spot for organizational growth.”

Even before covid, nurses were fighting burnout due to the same issues they are facing now, perhaps at a different extent, but these issues are not new. Because of this burnout, nurses are experiencing prolonged trauma, lasting PTSD symptoms, and increased rates of suicide. 

Why better working conditions could be a better solution

If more money isn’t a long-term, sustainable solution, then what is? To find a more effective solution, employers can apply a theoretical framework that aims to uncover behavior.

Developed by the late Professor Clayton Christensen and his longtime collaborator Bob Moesta, the Theory of Jobs to Be Done (or Jobs Theory) is a useful framework that helps understand customer behavior. It highlights the fact that people don’t simply buy products or services (or in this case, work at a job or in a particular profession); they hire them to make progress in specific circumstances (what we call their Job to Be Done, or “job” for short). Understanding the “job” or progress for which customers hire a product or service helps innovators more accurately develop products that align with what customers are already trying to accomplish. 

One example of this theory in action can be seen in a Harvard Business Review piece highlighting Bob’s work in bolstering sales of new condominiums for a Detroit-area building company. The company had targeted downsizers—retirees looking to move out of the family home. Its units were priced to appeal to that segment with high-end touches to give a sense of luxury. A generous marketing campaign splashed ads across the relevant Sunday real estate sections. The units got lots of traffic, but few visits ended up converting to sales. Bob applied Jobs Theory to learn from the people who had bought units what job they were hiring the condominiums to do. “I asked people to draw a timeline of how they got here,” he recalls. But the conversations revealed an unusual clue: the dining room table. People kept saying, “As soon as I figured out what to do with my dining room table, then I was free to move.” The table represented family. In short, what was stopping buyers from making the decision to move wasn’t the right high-end feature configuration, but rather, the idea that by giving up a large dining room table, they’d be giving up the idea of family. “I went in thinking we were in the business of new-home construction,” Bob recalls. “But I realized we were in the business of moving lives.” The insight into the job the customers needed done changed everything. By 2007, when industry sales were off by 49% and the market was plummeting, the developers had grown business by 25%.

Applying this framework to hospitals, for example, an executive could interview a group of nurses using the Jobs theory. Suppose they receive a critical insight that one of the main “jobs” of their nurses is that they are motivated by the goal of feeling like their work ultimately improves people’s lives. However, because they’re having difficulty managing their mental health due to the stresses of work, they’re not confident that their attitude or attention to detail is accomplishing this goal, which, ultimately, demotivates them. In other words, the circumstances of their working environment aren’t aligned to their personal motivations, making their time at the hospital short-lived. With this insight, the executive could put into place different programs or activities directed at mental health such as meditation classes, a wellness room, additional breaks during the day, or group or individual therapy. These better working conditions could help retain positions long-term, and even attract other nurses from competitors. This example serves as merely a hypothetical; executives would want to do their own research by interviewing their nurses and analyzing the information they receive from the interviews.

Why being heard matters

In harnessing Jobs Theory, executives should ask nurses questions pointed at unpacking the circumstances of the situation, what is pulling them to want to leave, and if there are any circumstances that are keeping them from doing so. Analyzing and listening to their answers with a reflective mindset will enable executives to identify long-term, sustainable solutions. 

The New York Times quoted a nurse stating: “To continue to attract and retain nurses, ‘hospitals need to look at how they’re going to radically improve their work environment.’” Another news outlet, The Washington Post, quoted a Minnesota nurse stating: “The violence against nurses has increased as well. But the security has not gotten better. So we need to make working in the hospital appealing again to the nurses.” 

Across the nation, thousands of nurses are speaking out and protesting. They are telling us that things need to change. Will executives listen to them and learn how to improve work conditions? 

I hope so.

Emmanuelle is a health care research fellow at the Clayton Christensen Institute for Disruptive Innovation. She focuses on business model innovation in the child welfare system. Her current research addresses how child and family well-being organizations are moving towards a focus on prevention and what enables success in this domain. She is tackling these questions through the lens of Jobs to Be Done and business models.