Questions Nurse Leaders Now Ask

By Rose O. Sherman, EdD, RN, NEA-BC, FAAN

Nurse leaders are worried as they enter the last quarter of 2025. Most have already begun strategic planning for 2026, but this time is different. Discussions about doomsday scenarios and nuclear options in executive suites have become much common. The headwinds of change are much stronger and don’t seem favorable to health systems. Here are five questions that nurse leaders are asking right now:

1. What will be the financial hit to our health system from the One Big Beautiful Bill Act? Much of today’s economic challenges stems from uncertainty about how the OBBBA will impact individual health systems and hospitals. The Congressional Budget Office has projected close to a half trillion dollars in cuts to Medicare and a $911 billion reduction to Medicaid. Additionally, more than 10 million people may become uninsured due to cuts to healthcare exchanges. Academic medical centers are already experiencing cuts as a result of reduced NIH funding. As unemployment increases, fewer people may have employer insurance. But the severity of these headwinds is also contingent on state policy and other changes in payment models. The truth is, at this point, everyone expects severe budget cuts, but no one really knows for sure how catastrophic things could become. Most systems are planning for different scenarios. Many have already cut most discretionary spending, including travel, and have frozen all non-essential hiring. Increasingly, everything, including Magnet Redesignation, is on the table for discussion.
2. When I am asked to cut my staffing budget with our current volumes, how should I respond? All the cuts to healthcare are coming at a very challenging time. Volumes are soaring, and the population is aging. Nurses already feel exhausted, stressed, and burned out. Many CNOs have recently shared with me their own moral distress and concerns for staff. They realize that nurses can only be asked to do so much and wonder what lines they need to be sure not to cross. Investment in things like professional development matters for the future but may end up being a casualty if doomsday scenarios are implemented.
3. How can we meet patient expectations when we begin serious budget cuts? Reimbursement is still impacted by the patient experience. Many leaders tell me that they see patient expectations if anything increasing and more time is spent in service recovery. The public isn’t prepared for huge cuts to healthcare services and politicians have not been transparent about the impact of legislation they have passed.
4. How can we promote higher retention in acute care especially among our Generation Z nurses? Many health systems have made great strides in retaining staff but there are no guarantees of continued success moving into the future. Younger staff view their careers differently and many come into organizations explicitly telling their leaders that they don’t intend to stay in acute care. The current cost of replacing an RN in acute care averages $61,000 and can take up to 83 days to replace an experienced nurse but is far higher in specialty areas. For the average hospital in the US today, the annual cost of RN turnover already averages between 5 and 9 million dollars. In their recent Nurse Experience Report, Press Ganey noted that nurses with negative perceptions of resources and teamwork are 1.53x more likely to leave than those with positive views. Significant resource reductions may become the norm in the new world of healthcare making retention even more challenging. Turnover is already the highest among Generation Z nurses (24%) who leave positions when dissatisfied. Even organizations with strong workplace culture now worry about sustainability of these cultures in the face of huge budget challenges.
5. What strategies should we be using to get violence under control in health settings? One thing is clear about the legislation that was passed. It will impact significant numbers of the American Public in very unfavorable ways. Access to care is likely to become more challenging and financial bankruptcies will be more common. Anger such as that directed toward the United Healthcare Executive late last year could become more commonplace. We could see much more violence in healthcare settings. Nurse leaders worry about this because they feel the current situation is out of control and that changes with OBBBA could escalate it. Individual hospitals are expected to develop security plans which cost money as budgets are shrinking.

Not surprisingly, nurse leaders are unsure about how to prepare staff for the possible changes ahead. Many of the biggest changes won’t happen until after the mid-term election but without legislative revision, they are on track to begin. For those of us who lived through the introduction of DRGs in the early 1980s, we witnessed how massive changes in reimbursement totally upended healthcare and nursing. These changes definitely bear watching as they could substantively change what we are able to do in nursing.

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