Nursing Workforce Sustainability: An Evolutionary Concept Analysis

Abstract

Objective:

To clarify the concept of sustainability in the nursing workforce and identify its attributes, antecedents, and potential consequences.

Background:

While the term “nursing workforce sustainability” has been used to emphasize the critical implications of ensuring the efficiency of healthcare systems worldwide, a delineated understanding of the concept remains ambiguous in extant literature, causing uncertainty about its conceptual underpinnings.

Methods:

Rodger’s evolutionary approach was applied.

Results:

The authors identified “nursing workforce sustainability” as an evolving concept with four interrelated attributes: recruitment, retention, regulation, and recognition. The antecedents included demographic, occupational, and structural issues. Consequences include policy and systemic advancements, a diverse and inclusive workforce, enhanced workforce well-being, and improved patient safety and organizational effectiveness.

Conclusions:

A conceptual definition and framework of nursing workforce sustainability have been developed, offering groundwork for future research and policy development in workforce planning and management.

The World Health Organization (WHO) reported that nearly 50% of the world’s 65.1 million healthcare workers are nurses.¹ Research consistently shows that a cohesive nursing workforce, empowered by positive practice environments and transformative leadership, can improve both nursing and patient outcomes.^2–4 However, recent workforce trends reveal a large proportion of nurse turnover, with many leaving the profession entirely due to pre-existing workforce issues related to excessive workload and job demands, burnout, and workplace violence, including stigmatization and discrimination.^5–7 These issues significantly burden healthcare systems globally. For instance, nurse turnover yields unanticipated costs upward of $6 million for US hospitals annually.⁸ Similar outcomes have been reported in Asia, Africa, Europe, and Australia.^9,10 The cumulative effect of nurse turnover, amplified by the recent COVID-19 pandemic, poses substantial risks to the long-term sustainability of the nursing workforce.⁶ Sustaining an ample supply of nurses to meet the global demands for patient care is essential.

While prior studies have examined workforce factors, such as job satisfaction, recruitment and retention strategies, educational pathways, and practice environments,^1,4,11 the concept of “nursing workforce sustainability” and its underlying dimensions remain underexplored and have not been theoretically examined in existing literature. According to Keele,¹² sustainability is the ability to meet the current nursing care demands without compromising future workforce needs. Yet, the concept of sustainability may also evolve depending on contextual factors, such as external (eg, COVID-19 pandemic), internal (eg, practice policies), or cultural variations across countries. Much of the existing literature focuses predominantly on recruitment and retention strategies, but the distinction between these elements often lacks clarity in terms of underlying assumptions and definitions. As Rodgers¹³ notes, concepts can become ambiguous over time based on contextual conditions of a society, and their attributes and applications may become inadequately defined. The complexities linked with the concept of sustainability may potentially lead to confusion and uncertainty regarding a concept’s usage and relevance.¹⁴ A clearer conceptual understanding of nursing workforce sustainability is vital to inform workforce policy and guide future research.¹⁵ This concept analysis aimed to clarify the notion of nursing workforce sustainability by identifying its attributes, antecedents, and potential consequences.

Methods

This study was guided by Rodgers’ evolutionary framework for concept analysis, which consists of 6 iterative steps: (a) selecting a concept of interest and associated terms; (b) choosing the settings, sample, and sources; (c) collecting the data to identify the contextual basis of the concept; (d) analyzing the data; (e) determining an exemplar, if applicable; and (f) identifying implications for future concept development.^13,15

The search strategy was performed in December 2024, across 4 databases: MEDLINE, PubMed, Embase, and CINAHL, with an open time frame to capture the temporal scope and emergence of the concept. We also included English-written articles published in peer-reviewed journals, gray literature, and reviews. Nonretrievable full-text articles and those studies with mixed samples involving other healthcare professionals, such as nurse practitioners, were excluded. All articles were screened initially by the primary author, then reviewed by the second and third authors to verify eligibility for inclusion. Included articles were then appraised using the Johns Hopkins Nursing Evidence-based Practice (JHNEBP) Rating Scale to evaluate their methodological rigor and relevance to understanding the context of the concept’s characteristics. The selected articles underwent another round of review to confirm that all identified themes were adequately reflected in the concept’s operational definition. SDC#1, Supplemental Digital Content 1, http://links.lww.com/JONA/B406, presents the screening and selection process with the keywords employed in the search strategy by following PRISMA guidelines.¹⁶

For data extraction and thematic formation, multiple guiding questions were used and framed using the PICo (Population, Phenomena of Interest, Context) question format.¹⁷ These include (a) what themes are related to defining the characteristics of sustainability in the nursing workforce? (for attributes); (b) what events precede the occurrence of nursing workforce sustainability? (for antecedents); and (c) what happens after the application of this concept? (for consequences).

Results

Based on the systematic search of existing literature, 18 of the 124 articles met eligibility for inclusion in this concept analysis (SDC#1, Supplemental Digital Content 1, http://links.lww.com/JONA/B406). The outlined characteristics and relevant findings of sourced literature are shown in SDC#2, Supplemental Digital Content 2, http://links.lww.com/JONA/B407.

Conceptual and Operational Definition

These authors define “nursing workforce sustainability” as the ability to maintain an effective and efficient nurse workforce, proficiently providing high-quality patient care services that address the healthcare demands of a certain population over time. It is critical to ensure healthcare system resilience and support organizational success while considering multiple factors, including demographic, occupational, and structural workforce variables. These authors present our integrated model (Fig. 1), akin to blood flow in the heart, to emphasize that systemic inputs (antecedents) are transformed through functional processes (attributes) into vital outcomes (potential consequences).

Figure 1.

Integrated model of nursing workforce sustainability.

Attributes

In the context of nursing workforce sustainability, four central attributes emerged: recruitment, retention, regulation, and recognition, collectively referred to as “The 4Rs of Sustainability” (Table 1).

Table 1.

Summary of nursing workforce sustainability’s defining attributes based on the included articles

“4Rs of Sustainability”	Sources
Recruitment • Inclusive, nondiscriminatory hiring practices • Onboarding strategies including transition-to-practice, orientation, and preceptorship • Fair work benefits for both local and international employment	18–30
Retention • Positive organizational culture and work environment marked with adequate leadership, social, financial, and psychological support. • Providing continuous professional development and opportunities, including mentorship programs	18,20,21,23–28,31–35
Regulation • Nursing professionalization policies • Administrative frameworks and bodies for theory-practice alignment • Guidelines for workforce planning, workload management, and healthcare labor market • Ethical standards for local and international hire or enrollment	18–32,34,35
Recognition • Tangible (eg, financial incentives, schedule flexibility, additional time off) and nontangible (eg, culture of respect and inclusion, specialty acknowledgment) approaches • Authentic and meaningful leadership support	19–22,25,27,29,30,32–35

Sustainability Through Recruitment

“Recruitment” attribute refers to the successful attraction of new nurses into the profession and locally employing them to a specific healthcare setting. Thirteen articles referenced the characterization of recruitment in sustaining the workforce (Table 1). Recruitment involves hiring and onboarding qualified nurses or new hires into a profession through various strategies such as transition-to-practice, preceptorship, and nurse residency programs, which may enhance organizational engagement and commitment.^20,26 This attribute also emphasizes procedures that address systemic inequities, hiring bias, and employment barriers by ensuring inclusive hiring processes,^{21,22,25,27,28} supported by fair work benefits and equitable opportunities for both international and local employment processes.^{18,23,24,29,30,32}

Sustainability Through Retention

Fourteen articles isolated retention as essential to workforce sustainability (Table 1). “Retention” focuses on maintaining a stable, qualified nursing workforce by keeping them in the profession and within their primary roles for the long term. It is achieved by promoting work-life balance, offering leadership support, providing career opportunities and competitive pay, and fostering positive workplace conditions.^{31,18,21,26,32,33,35} Formal orientation and mentorship, particularly in rural settings, were found to reduce attrition among novice nurses²³. Promoting workforce well-being through interventions related to psychological rewards and financial stress management may also foster long-term retention, contributing to a more sustainable workforce.^{24,25,27,28,32,34}

Sustainability Through Regulation

Seventeen articles emphasized “Regulation” as an attribute of nursing workforce sustainability (Table 1). It entails the establishment of policies and frameworks that govern nursing education and ethical professional practice standards.^{18,25,28,29,34} Structured policies at both regional and international levels were shown to enhance nursing professionalization, as they shape theory-practice alignment, moral conduct, and healthcare labor market guidelines.^{21–23,26,27} In addition, regulations that promote fair treatment, equitable resource distribution, improve workplace culture, and workload management were linked to improved workforce conditions and reduced turnover intentions.^{19,20,24,30–32,35}

Sustainability Through Recognition

As identified in twelve articles, the “Recognition” attribute refers to the acknowledgment of nurses’ contribution and valuation of the nursing profession through tangible and nontangible approaches (Table 1). This may involve approaches that promote employee engagement, systemic collaboration, financial incentives, and a culture of respect within both the organization and society at large.^{19,20,25,30,33} Recognition also contributes to nurses’ moral and professional identity or self-concept, facilitating both professional and personal fulfillment.^22,29,34 A qualitative study from Australia highlighted nurses’ dissatisfaction during the pandemic when symbolic gestures, such as providing snacks, were not matched with adequate manpower support.²¹ Authentic leadership credit combined with psychosocial support and sufficient work resources enhances staff morale and contributes significantly to workforce sustainability.^27,32,35

Antecedents

For nursing workforce sustainability, several antecedents have been identified, including demographic issues, occupational issues, and structural issues.

Demographic Issues

Demographic issues pertain to the sociodemographic variations among nurses and the broader patient population. The combination of the retirement of experienced nurses and the aging global population creates an imbalance between the supply and demand for healthcare workers.^20,24 Succession planning and targeted training are essential to facilitate smooth and successful workforce transition. Generational, gender, ethnic, and educational differences also influence professional attitudes and career expectations, potentially impacting workforce stability.^22,26,28,35 Addressing diversity gaps due to bias, discrimination, and racism is vital for expanding the workforce.^19,30

Occupational Issues

Occupational antecedents encompass leadership factors, healthcare system models, workload and work-related demands (including physical and psychological strains), work environments, and professional motivators that influence workforce well-being and the culture of valuing nursing contributions and professional practice.^23–25,33 Montour et al.²⁶ reported that changing organizational structures related to leadership roles, scheduling, and staffing practices in both rural and small community hospitals in Canada have implications for nursing workforce sustainability. Team dynamics, organizational support, developmental opportunities, and a culture of safety and support were also considered key determinants of nursing workforce sustainability.^{20,28,32,34,35}

Structural Issues

Structural antecedents refer to societal and institutional structures and issues influencing nursing workforce dynamics. Challenges concerning policy gaps and regulatory variations related to nursing education programs, healthcare labor market conditions, and financial mechanisms all impact workforce sustainability.^22,30,32,34 For instance, the majority of policies focused more on workforce management, with less emphasis on workforce production, leaving gaps in addressing future workforce needs.¹⁸ The lack of awareness of nursing specialties like substance abuse and addiction nursing causes interprofessional stigma.²⁹ Addressing these issues through informed legislation and investment in workforce planning must be a priority for leaders and stakeholders, as it significantly frames nursing workforce sustainability.^21,23,27

Consequences

Manifestations of nursing workforce sustainability may yield to policy and systemic advancements, a diverse and inclusive workforce, enhanced workforce well-being, and improved patient safety and organizational effectiveness.

Policy and Systemic Advancements

When nursing workforce sustainability is prioritized, it can drive significant reforms in policies and systems within healthcare organizations. As the demand for nursing services grows, healthcare organizations must adapt their policies to address workforce needs. For instance, policy and systemic improvements that center on retention and recruitment strategies can foster supportive environments where nurses can thrive and advance their careers.^18,22,25,30 These may include standardized staffing ratios, fair compensation, and adequate leadership support for professional development and opportunities. Moreover, systemic policies that create a well-structured, supportive system can better respond to both routine and crisis events.^20,21,24,27 Such advancements ensure that nursing remains an attractive and viable profession over time.^22,28,33,34

A Diverse and Inclusive Workforce

Sustainability also promotes workforce diversity and inclusion, which brings a wide range of clinical perspectives and skillsets. This enhances the ability to meet complex healthcare demands by having a more comprehensive care delivery.^19,29 Furthermore, a sustainable workforce cultivates an environment where talent is nurtured and retained by ensuring equal opportunities for all nurses, regardless of their demographic background, which in turn reduces staff turnover and associated costs.^{18,22,24,26,30}

Enhance Workforce Well-Being

A sustainable workforce is one that allocates resources to promote mental, physical, and emotional well-being. Enhancing workforce well-being is fostered from a supportive psychosocial environment that promotes work-life balance and mitigates burnout, job dissatisfaction, and occupational strain.^18,21,32 Since well-being involves both personal and professional factors, workplace conditions may also become healthier and safer with fewer incidences of physical injury, increased resilience, strengthened professional self-concept or identity, and improved nurse workforce’s mental health.^20,24,33

Improved Patient Safety and Organizational Effectiveness

This is grounded in the principle that a sustainable and well-supported nursing workforce can provide safer patient care. When nurses are valued and recognized, they are more likely to follow best practices and maintain high standards of care, leading to a profound effect on patient safety and outcomes.^22,23,34 Healthcare organizations that prioritize the sustainability of their nursing workforce benefit from reduced healthcare costs due to lower staff turnover and higher job satisfaction.^26,31,33

Exemplar Case and Empirical Referents

Given the variable contextualization of sustainability across disciplines of human resource management and nursing, a direct exemplar case was not identified. Defining empirical referents for “Nursing Workforce Sustainability” entails identifying measurable indicators that concretely embody or may align with the concept’s defining attributes.^13,15 Currently, there is no standardized instrument that directly measures nursing workforce sustainability as a concept. There is a need to develop a specific tool that incorporates a multi-level index to holistically evaluate sustainability across individual, organizational, and system levels. Clearly delineating these empirical referents allows for a more objective and consistent evaluation of the concept, facilitating clearer insights into its implications.

Discussion

We define “nursing workforce sustainability” as the capacity to maintain an effective, stable nurse workforce that can meet current healthcare demands, while safeguarding future workforce needs. The “4Rs of Sustainability” (Table 1) reflect the multidimensional nature of the concept, with each attribute intersecting with one another. We found that nursing workforce sustainability involves dedicated recruitment across a broader equity context, addressing systemic barriers such as discrimination and hiring bias.^7,22,24 Further, the focus on retention attribute aligns with literature that underscores the importance of job satisfaction, supportive leadership, and healthy work environments, which have been linked to reduced turnover.^2,4,5,9 Despite ample evidence on the significance of recruitment and retention attributes, recognition emerged as essential to value nurses’ contributions and make them feel appreciated, boosting workforce stability.^11,21,34 Finally, regulation interacts with the other attributes, illuminating the role of policy and regulatory frameworks that shape the professional practice and healthcare systems to advocate for optimal workforce conditions.^10,22,25 Consistent with prior studies, we found that sociodemographic (eg, generational differences), occupational (eg, work-related demands), and structural issues (eg, workforce management) are antecedents to nursing workforce sustainability.^10,19,20 Moreover, the concept’s potential consequences were built on existing evidence, suggesting that a sustainable workforce contributes to the improvement of not just patient but also nurse and organizational outcomes.^7,8,31

Limitations

While this analysis offers valuable insights, several limitations must be acknowledged. First, the authors did not account for other members of the nursing workforce, such as nurse practitioners or nursing assistants. This restricts the applicability of results across the overall nursing workforce. Second, the search was limited to English-language publications, potentially omitting relevant evidence that could enrich the understanding of the concept. Third, the majority of included studies were performed in high-income countries. This limits the relevance of our analysis to less-resourced regions, particularly low- and middle-income countries. Although this analysis advances nursing workforce sustainability as a global concept as it draws from international sources, it still underscores the need for future research to refine the conceptual elements of sustainability and evaluate their appropriateness across diverse healthcare systems. Besides, the concept per se is highlighted as an area of further development to align with the philosophical underpinnings of Rodgers’ evolutionary approach.¹⁵

Implications for Nursing Leaders and Future Research

This study holds significant relevance for healthcare leaders, policymakers, and stakeholders, as it provides a theoretical framework necessary for cultivating a sustainable nursing workforce. Nurse scientists should prioritize the advancement of nursing workforce sustainability research, as it could have a profound impact on healthcare system resilience. Given the concept’s contextual complexity, empirical studies exploring holistic causal links between identified attributes and consequences remain limited. Future research and policy initiatives should be centered on the 4Rs of sustainability (Table 1), particularly examining how various regulatory and recognition practices influence nursing workforce recruitment and retention. Longitudinal studies are also needed to track the concept’s long-term impact and evolving application on healthcare outcomes. In addition, synthesizing a validated tool to measure the concept is warranted, as this could guide specific interventions tailored to foster a sustainable nursing workforce. Such tools should account for regional and global workforce variations, ensuring cultural and policy-specific relevance across health systems. A comprehensive tool that incorporates individual, organizational, and system-level indicators can enable a more holistic evaluation of the concept. Embedding the 4R’s framework into system-wide strategies may redefine sustainability as a proactive solution that strengthens the nurse workforce amid unprecedented healthcare challenges.

Conclusions

This study presented a novel conceptual definition of nursing workforce sustainability through Rodgers’ evolutionary model. Our analysis reaffirms nursing workforce sustainability as a dynamic concept needing ongoing dialogue that involves a multidimensional approach. Rather than viewing the concept as a static phenomenon, these authors argue that it should be viewed as an adaptive, cyclical process that integrates regulation and recognition with retention and recruitment as core dimensions rather than peripheral considerations. Exploring nursing workforce sustainability as a distinct evolving concept may lay the groundwork for potential theoretical exploration, instrument development, and future research that ensure the relevance and viability of the profession in meeting healthcare demands for future generations.

Ethics Statement

This concept analysis did not involve human participants, personal data, or any form of experimental procedures. The analysis was conducted using publicly available literature, ensuring that all sources were properly cited and acknowledged. As such, ethical approval was not required.

Acknowledgement

The authors acknowledge the Center for Health Policy at Columbia University School of Nursing for its invaluable support and the resources provided to facilitate this study.

Conflicts of Interest

The authors declare no conflict of interest.

Data Availability Statement

Data sharing is not applicable to this article, as no data sets were generated or analyzed during the current study.

Supplementary Material

nna-56-338-s001.docx ^{(38.1KB, docx)}

nna-56-338-s002.docx ^{(23.3KB, docx)}