Andrea Mazzoccoli is retiring from her role as Bon Secours chief nurse and quality officer in June after nearly 15 years in the position. The 13-hospital system with locations in Kentucky, Virginia and South Carolina, like others, has dealt with staffing shortages and labor challenges throughout the pandemic.

Reflecting on her time in the role, here’s what she wants future leaders to consider and trends she’ll keep an eye on as pandemic recovery continues and a new generation of nurses and nursing leaders begin entering the workforce.

Editor’s note: This interview has been lightly edited for clarity.

HEALTHCARE DIVE: What advice do you have for your successor, and others in similar positions?

ANDREA MAZZOCCOLI: My sense in terms of what’s happening now and the advice that I have for the next generation of nursing leaders is to be excited about what is happening today and what it brings for us for the future.

There’s no question that there are challenges today in terms of our systems being able to respond to what I believe are just new demands and needs of the next generation of professional nurses, both those nurses who will choose to deliver care directly, deliver care in an advanced practice way or help us to lead the profession.

I think our biggest challenge that we have, is challenging ourselves to respond differently in the structures and processes and the ways that we've always done them. Like scheduling, staffing, considering retention and turnover. And how we respond as a health system to begin to do things differently.

That means flexibility, mobility, ability to connect with purpose and meaning, ability to have their own choice about growth and how quickly they’re able to accelerate in their growth.

Those are things that we can do and we should be doing. I think many other industries have responded and done that. And my excitement about the challenges that we have is I think it will force us to do some of these things.

How do you think hospitals are handling current nursing shortages and workforce challenges, what more needs to be done?

Some of the shortages are handled by bringing help in and trying to provide the resources that we need. I think every hospital is thinking about the model of care.

In our own system a study that we did of over 500 nurses working in medical surgical units suggested that 30% of the time that a nurse spends is on non-professional activity that they themselves believe could be delegated.

So I think every hospital is trying to respond to the shortage by providing a model of care in which nurses do the work that professional nurses could and should be doing, and trying to figure out how to build a model of care around them that supports the work that they don't need to do.

How long do you think it will take for hospitals to fully minimize their use of temporary nurse staff?

I think hospitals who are wise and can see the future will learn how to build that flexibility in their own systems. I think it's our job to figure out how to use them effectively, and allow them to be integrated into places where we need them, that doesn't have an impact on our outcomes.

They are paid a premium for the choices that they make about their flexibility, their willingness to travel, but we have lots of opportunities internally to do that ourselves.

At Bon Secours Mercy Health for instance, we’ve started our own traveling nursing program so we can respond, allowing a traveler-like program around our states and offering our own premium dollar inside our system with nurses who we believe are connected to our mission and our vision and our values.

I think we’ll see a lot more of that. I think we'll see a lot more people developing their own response to what is the need for travelers? I don't think travelers will ever go away though.

Some nurses don’t necessarily want to travel all the time, but they want the experience to do it. The value that we saw is we have nurses who will be like, “Yeah, I’d like to go there for six months, and then I want to come home.” Our value is that we allow people to maintain benefits and their tenure within our ministry and be able to know the systems that they have.

I think we’ll see how systems come together around this, and also unusual partners.

For instance, we have a unique opportunity like other health systems in the country and we are now beginning an international program. So we have a health system in Ireland, we offer a very unique opportunity for nurses to be able to travel and work internationally by exchanging the nurses from Ireland to the U.S. and the U.S. to Ireland.

Are there any other specific trends playing out in the nursing workforce you’ll keep an eye on?

Probably more in the short term, but the implications of how new-to-practice nurses were educated and trained is real. We have a whole generation of nurses who didn’t get trained the way the generations before them did. They weren’t in hospitals, most of their training was through simulation. We are receiving nurses today who graduate, have passed an exam and have yet to take care of patients.

So that's a real implication, particularly for hospitals, about what it’s going to mean to bring the next generation of nurses inside the walls of the hospital, and assume a burden of training and building competence that we never had to do before.

As the pandemic has eased and our understanding of the where and how we use student nurses during these kinds of situations grew, I think we’ve learned a lot.  But at least the next two years are going to be very challenging. We already knew that our first year turnover of new-to-practice nurses is one of the single biggest workforce challenges that we have, and so this is just an additional burden.

Dive Brief:

• The gender pay gap among physicians narrowed last year for the first time in five years, although women physicians still earned 19% less than their male counterparts, according to Medscape’s annual physician compensation report out Friday.
• The racial pay gap, however, remained unchanged and Black physicians were found to earn 13% less than White physicians.
• Across the board, physician salaries rose about 4% last year compared to 2021. The highest paid specialties included plastic surgery, orthopedics and cardiology while the lowest were infectious disease, family medicine and pediatrics, according to Medscape.

Dive Insight:

The rise in salaries can partly be attributed to the national physician shortage, which was made worse by persistent burnout that spurred clinicians to leave the profession, according to the report.

A Doximity report from earlier this year reported that 36% of physicians were considering early retirement due to overwork. By 2034, the U.S. could experience a shortage of up to 124,000 physicians, according to the Association of American Medical Colleges.

The COVID-19 pandemic exacerbated burnout as providers faced a growing potential for patient violence, increased workloads and emotional exhaustion. 

But the vast majority of healthcare leaders don’t have any formal plan for reducing physician burnout and improving retention.

“At a time of growing physician shortages, it’s important for institutions and organizations to continue to examine industry norms and practices that can hinder physician satisfaction with their career choices,” Leslie Kane, senior director of Medscape Business of Medicine, said in a statement.

Still, 73% of physicians said they would choose to enter medicine again. And, this year saw a record number of residency matches, which have risen nearly 15% over the past five years.

The Medscape study, which surveyed 10,011 physicians across 29 specialties, found that over half of physicians said they were satisfied with their pay, but some cited insurance reimbursement, particularly from Medicare and Medicaid, as a source of frustration. The percentage of physicians who said they would continue to see patients in those programs dropped from 71% in 2021 to 65% last year.

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Turnover, vacancies, and the constrained access to talent have been challenges for healthcare organizations for the past three years. Today, in efforts to control costs, and help ensure greater control and access to flexible staffing solutions, some health systems are establishing internal agencies, a dedicated internal contingency staff layer that serves your organization, under your requirements, policies, and employment.

This resource will walk through the key components of establishing an internal agency, including the use of analytics to analyze the size and mix of staff needed, strategies to acquire staff, and deployment methodologies to deliver staff to areas of need.

Analyzing Your Situation

Having the right mix of core and contingent flexible resources allows for the cost-effective management of the workforce based on patient volume and ensures quality by optimizing staff levels and empowering individuals to work at the top of their training and licensing.

The first phase of establishing an internal agency, or any staffing strategy, is to analyze your current staffing levels (supply), volumes (patient demand), and workload indicators to begin to identify needs and the possible reallocation of resources.

A workforce analysis will look at historical resource utilization data by specialty for core, flexible/float staff, and agency, as well as the inputs listed above to identify the proper number of core staff and the optimal size and layering of internal flexible resources, i.e., float pools, needed to meet typical patient demand department by department.

An internal agency, one of the layers of your flexible resources, is a custom solution, and variability of demand, as well as the proper staff sizing targets from a workforce analysis, will help determine the size support the varying levels of predicted demand.

Acquiring Your Agency Staff

Once the workforce analytics have illuminated the size and mix of staff required for the internal agency to support the organization, sourcing talent begins.

Looking Inward

Engage with and attract RNs who had left the organization for travel nurse roles and provide an internal agency option to current RNs who have expressed interest in leaving the organization for travel nursing careers.

It is important for healthcare organizations to provide opportunities for clinicians who may want more flexibility in when and where they work.

Direct Sourcing

Many healthcare organizations already enjoy strong brand recognition. Utilizing that brand to attract clinicians interested in travel to their internal agencies can provide a good foundation. With the right infrastructure in place, many organizations can leverage their strong brand and help reduce the costs of acquiring those resources and do so faster.

Managing and Deploying Your Workforce

Whether an organization utilizes a vendor management system (VMS) or an internal scheduling tool, there is a need for technology to manage both the internal, core and float resources, as well as an external agency.

A VMS allows organizations to manage internal and external resources through one platform. Healthcare systems can leverage the technology to store the credentials for all healthcare professionals and monitor for expiration dates, reducing the heavy administrative burden and the risk of clinicians working without the proper credentials.

Deployment Strategy

Once the schedules are created, the success of the day-to-day utilization of the internal agency hinges on the effectiveness of the deployment strategies an organization adopts.

Here is one example of a deployment strategy:

1. Core staff members: These healthcare professionals are assigned to a home unit and will expect to work shifts on their home unit.
2. Internal Agency Pool: With the use of a predictive scheduling tool, members of the internal agency can be confirmed to the areas of greatest need up to two weeks in advance of the shift.
3. Internal and FTE float resources that can be placed by the central staffing office two hours before the shift.

Each organization's deployment methodology will vary depending on the numbers and types of staffing sources of the organization, typically dictated by the variability of demand.

Learn how you can leverage our experience, technology, and dedication to help create a more flexible, cost-effective workforce at AMNHealthcare.com.

Dive Brief:

• A federal nurse staffing law to set minimum nurse to patient ratios for all hospital units will be considered by lawmakers after the COVID-19 pandemic highlighted concerns around healthcare staff workloads and labor shortages.
• On Thursday, Sen. Sherrod Brown, D-Ohio, and Rep. Jan Schakowsky, D-Ill., said they are reintroducing the Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act, which would also protect nurses who speak out against unsafe staffing standards.
• The bill mirrors California’s nurse staffing law, which outlines exactly how many patients a nurse in specific hospital units can care for at once. It was previously introduced in the Senate in 2021.

Dive Insight:

The COVID-19 pandemic highlighted the struggles of front-line healthcare workers including long-standing issues like staffing shortages and burnout.

Some workers have taken action through union organizing, picketing and strikes to secure new contracts with terms to quell challenges — especially regarding staffing levels.

National Nurses United is among the unions lobbying for federal staffing standards, arguing that safer conditions are needed to keep nurses from “leaving the healthcare field in droves” and making the crisis worse for workers who remain, NNU President Deborah Burger said at a Thursday press conference.

An NNU survey of 2,800 union members conducted in September and November, showed about 57% said staffing has gotten slightly or much worse at their hospitals.

Nearly half said their facility is using excessive overtime to keep units adequately staffed, and more than half said they are considering leaving nursing, according to that survey.

About one million registered nurses with active licenses are not practicing today, Burger said.

“It's not because they don't love nursing — they don't love the stress, they don't love putting their patients at risk, and they don't love going home every day fearing that they had harmed someone,” Burger said.

Some states have passed their own nurse staffing laws during the pandemic.

New York passed a staffing law that stipulates hospitals from clinical staffing committees that include front-line nurses and other direct care staff when setting annual staffing standards for units.

Colorado also passed a staffing law that similarly required hospitals to form their own nurse staffing committees tasked with setting staffing plans.

Hospitals and their lobbies have previously opposed legislation mandating nurse staffing ratios, saying a one-size-fits all approach would harm flexibility and facilities’ operations.

Dive Brief:

• Steady job growth in the healthcare industry seen last year is expected to continue this year as pandemic-driven staffing shortages ease, according to a report released last week from nonprofit Altarum.
• Employment in ambulatory services is now well above pre-pandemic levels, while hospital employment is just slightly above pre-pandemic levels, according to the report.
• However, wage growth has been declining in the sector compared to others, with healthcare wages growing 4.2% year over year in January, while total private sector wages grew by 4.4%.

Dive Insight:

The healthcare industry suffered massive job losses at the start of the pandemic and has grappled with ongoing staffing shortages since.

But certain parts of the industry have recouped all lost jobs —  and even added some —  in areas like ambulatory care, which has seen the most job growth as patients, providers and payers shift their preferences toward non-hospital based care.

Ambulatory services now employ 440,000 more people than they did three years ago, reflecting 5.6% job growth, according to Altarum’s report.

Hospitals now employ 42,000 more people than three years ago, notching 0.8% growth.

Nursing and residential care facilities suffered the worst job losses when the public health crisis began, as those facilities with older, higher-risk residents became hot spots for COVID-19 infections.

The nursing and residential care sector still hasn’t recouped about 270,000 jobs since around the time the pandemic started, according to the report.

Nursing homes jobs have seen gains in recent months though, and added 14,000 jobs in February, according to data from the Bureau of Labor and Statistics.

Job growth across the industry has slowly picked up since the pandemic began.

In 2021, the sector added about 9,000 jobs on average each month, according to data from the BLS. In 2022, the sector added about 49,000 jobs each month.

Over the past six months, the sector has added 54,000 jobs on average, according to the BLS.

Dive Brief:

• Two out of three physicians are considering an employment change, according to a survey and report out Thursday from Doximity.
• About 36% of respondents said they were considering early retirement due to overwork, with women physicians more likely than men to report that they were overworked and considering an employment change.
• Compensation was stagnant or down across many specialties in 2022, after rising across all specialties the prior year.

Dive Insight:

Physicians are reporting high levels of burnout and sentiments about leaving their jobs since the pandemic began, according to Doximity’s report.

Many physicians are now open to accepting lower pay in exchange for more autonomy and work life balance, Doximity found, with some 71% of physicians in another 3,000-respondent survey saying they have accepted jobs with lower pay or would be willing to.

The Doximity report also looks at annual changes in physician pay, and includes survey responses collected last year from over 30,000 physicians in the U.S.

The pay gap between male and female physicians fell slightly from 2021 to 2022, from 28% to 26%.

However, women physicians still earned about $110,000 less on average than their male counterparts in 2022, even when accounting for specialty, location and years of experience.

And women physicians earn about $2 million less than male physicians over the course of a career, a 2021 report from the nonprofit Rand Corporation published in Health Affairs found.

Pay gaps vary widely by specialty, though just two specialties had pay gaps of less than 10% — pediatric cardiology and nuclear medicine.

The specialty with the largest gender pay gap is oral and maxillofacial surgery, where women physicians earn $395,687 on average annually, while men earn $568,789.

While compensation was stagnant or down across most specialties last year, one area saw higher pay and growing demand.

Emergency medicine saw the largest annual increase in compensation in 2022, rising 6.2% to an average of $385,554.

It comes as interest in emergency medicine wanes, exacerbated by a growing number of residency positions left unfilled in the specialty, including in this year's match.

Primary care specialties were the most recruited and highest in-demand, falling in line with reports projecting a shortage of primary care physicians in the next decade.

Psychiatry was the second most recruited and child and adolescent psychiatry was the fifth. The coronavirus pandemic has led to an uptick in rates of anxiety and depression, especially among children.

Dive Brief:

• A record number of soon-to-be-doctors-in-training matched into residencies for 2023, according to a release from the National Resident Matching Program.
• Some 40,375 residents matched into programs, an increase of 1,170 over last year, according to the release. Over the past five years, residency matches have risen almost 15%.
• Specialties like orthopedic surgery, plastic surgery, radiology, diagnostic and thoracic surgery filled all available positions. Resident interest in emergency medicine has waned, however, with 554 positions unfilled in the 2023 match.

Dive Insight:

The COVID-19 pandemic has led physicians to report widespread burnout and is also driving an uptick in resident organizing for union representation. But that hasn’t kept aspiring doctors away from training for those careers, with a record number matching into residencies in 2023.

Ultimately, 42,952 medical school graduates applied for 40,375 available positions during the 2023 match.

The number of primary care residencies offered also hit a record, and has risen 17% over the past five years, NRMP said. Interest in the specialty remained steady with a 94.2% fill rate, on par with last year.

Fewer residents are interested in emergency medicine, though, with 335 more open positions than last year.

Emergency clinicians in particular were hit hard by the pandemic and have reported increased violence from patients and family members, adding greater stress for those in the roles.

Applications overall increased for 2023, driven mainly by international medical graduates, with 481 additional applicants compared to last year, according to the release.

Dive Brief:

• Two major hospital groups are pushing back against the CMS’ plans this year to issue federal staffing minimums for nursing homes, according to a Monday letter sent to CMS Administrator Chiquita Brooks-LaSure from the American Hospital Association and American Health Care Association.
• In the letter, the groups argue that federal staffing mandates are a “one-size-fits-all” approach to the labor crisis and that issuing mandates would further reduce capacity by forcing some nursing homes to shut their doors.
• The Biden Administration has focused on nursing home staffing, with the White House announcing last year that it was directing the CMS to create a set of reforms for nursing homes in wake of the pandemic, including minimum staffing standards.

Dive Insight:

Nursing homes suffered the worst job losses in the healthcare industry at the start of the pandemic and are still struggling to retain staff.

While hospitals and ambulatory care services have fully recouped all the jobs lost at the start of the pandemic, nursing homes and residential care facilities still haven't recouped about 27,000 jobs, according to a recent report from nonprofit Altarum.

Tight nursing home capacity has led to longer patient stays and delayed discharges for hospital patients throughout the pandemic.

“This has a detrimental impact on patients who must wait days, weeks, or even months in hospital beds awaiting discharge to post-acute care; the capacity of care providers to serve our communities; and the costs to the entire health care system,” the groups wrote in the letter.

Under Biden’s order, the CMS announced it would conduct research to find appropriate levels of staffing needed and would issue proposed rules within a year.

The Biden Administration has also been cracking down on nursing home ownership, particularly private equity ownership, with the CMS issuing a proposed rule in February that requires nursing homes to disclose ownership and management information to the agency.

Nursing homes participating in Medicare and Medicaid currently must provide 24-hour licensed nursing services sufficient in meeting residents’ needs, and must use a registered professional nurse’s services at least eight consecutive hours a day, every day, according to the CMS.

But understaffing is still a concern, with ratios informed by older care models that don’t consider modern capabilities with technology and new team care models, the groups wrote in the letter.

“In short, specific staffing levels should be a clinical decision customized to the resident population and facility characteristics rather than a policy decision made with lack of regard to real-life situations,” they wrote.

The groups suggest other tools to ease current healthcare staffing challenges, like Congressional action to create a temporary visa program for foreign-trained registered nurses. Other recommendations include policies to expand loan repayment and other incentive programs to attract and retain talent, they wrote.

The letter comes as federal nurse staffing ratio legislation was reintroduced in the House on Thursday, and as labor unions renewed their push for Congress to pass a bill related to nurse staffing levels in wake of the pandemic.

The Nurse Staffing Standards for Hospital Patient Safety and Quality Care Act, introduced by Sen. Sherrod Brown, D-Ohio, and Rep. Jan Schakowsky, D-Ill., would set minimum nurse to patient ratios for all hospital units.

It mirrors California’s nurse staffing law, which outlines exactly how many patients a nurse in a specific unit can care for at once. It would also protect nurses who speak out against unsafe staffing levels.

Schakowsky also led House efforts urging the CMS to include nursing home staffing standards in the proposed fiscal year 2024 Medicare payment rule.