Ilana Borkenstein

Why the Nursing Shortage Is Really a Retention Crisis

Nurses aren't leaving because they don't want to work. They're leaving because we've made staying too hard. M7 Health CEO and RN Ilana Borkenstein on what it will actually take to fix it.

We've Been Calling It a Shortage. It's Actually Something Else.

We keep hearing about the projected nursing shortage. According to the 2026 NSI National Health Care Retention Report, the average RN turnover rate sits at 17.6%, it costs an average of $60,090 to replace a single bedside RN, and it takes more than 78 days to fill a vacancy. Becker's Hospital Review has outlined the burden across ten distinct cost categories: recruiting fees, onboarding, lost productivity, team disruption, and patient safety risk, among others.

Those numbers are real. But they're still not the full story.

From where I sit, as someone who has worked at the bedside and now works with hospital leaders across the country, the bigger issue isn't just supply. It's sustainability. Nurses aren't leaving because they don't want to work. They're leaving because the systems we've built make it incredibly hard to stay.

Our shortage is a retention crisis.

Stability is what we're really losing.

When I was a new nurse at MSK, I had incredible teammates. But even at a well-resourced hospital, there were nights where we had unexpected callouts or the unit was flooded with admissions overnight. I would have more patients than I was used to, my charge nurse would be taking patients too, and everyone was stretched.

I remember being scared on those nights. Because I wanted to deliver the best care for my patients, and I worried that I wasn't going to be able to. I couldn't always get a second opinion. Those nights were hard. In the hospitals I visit today, these situations are happening more and more.

And when that becomes the norm, people burn out. They leave. The people who stay get stretched even thinner. Then they leave too. The hospital starts relying on overtime or agency. That disrupts the unit even more, and the cycle continues.

Retention isn't separate from safety, finances, or culture. It's at the center of all three.

The retention strategy everyone recommends doesn't work.

Raises alone temporarily help, but they don’t solve the problem. Sign-on bonuses are a band-aid. Free parking and an employee assistance program aren't the sole solution.

It’s not that these things don't matter. They are just typically not the determining factors in why nurses stay or leave.

Nurses leave when the work environment is unsustainable. When schedules are unpredictable. When they feel like their needs don't factor into the equation. When they're constantly absorbing the fallout from a system that wasn't designed with them in mind.

I've watched nurses with 15 years of experience walk away from competitive health systems because the day-to-day had become unmanageable. And I've watched nurses take pay cuts to go somewhere that offered real schedule flexibility that enabled them to balance their personal needs and professional aspirations.

The way we respond to "unreasonable" requests really matters.

There's a pattern I see again and again. A nurse asks for something: maybe they never want to work Saturdays, maybe they need more predictability around childcare. And the first reaction is, "That's not practical."

But if we write those requests off without understanding where they're coming from, we're missing the point.

If someone says, "I can't work Saturdays," that might sound inflexible. But then you find out they're coaching their kid's basketball team. And if you say, "Okay, we can try to make that work, but it means you'll be the first to float to the ED when we're short," or “do you have more flexibility on Sundays or Friday nights” most people say yes. Because they're not trying to do less. They're trying to make this job work for their life.

When those conversations happen openly and transparently, people stay. When the system makes them impossible to have, people leave. It really is that simple.

Turnover is ten costs, not one.

The Becker's breakdown is useful because it forces hospitals to look at the full picture. When a nurse leaves, the hospital absorbs costs across recruiting, background checks, agency or overtime coverage during the gap, orientation, preceptor time, productivity loss during ramp-up, reduced quality and patient satisfaction scores, impact on team morale, and the risk of additional turnover from the nurses who stay and absorb the burden.

By the time you add it all up, the NSI 2026 data puts the average cost of replacing a bedside RN at $60,090. Some specialties, like the ED, ICU, and OR, run significantly higher. And for every 1 percent improvement in RN retention, the average hospital saves around $295,000 annually.

That number changes the conversation. This isn't about being "nice." It's about creating sustainability — both for staff and for health systems.

Flexibility and cost savings are not opposites.

One of the biggest myths I hear is that staffing strategy can either help nurses or help the bottom line, but not both. That's just not true.

If we keep losing staff, we're going to keep spending more: on agency, on recruiting, on onboarding, on burnout-related turnover. If we meet people where they are, we keep them longer. And we spend less in the long run.

It’s not about saying yes to everything. It’s about leveraging data on staff preference to identify more balanced ways to meet in the middle and ensure patients are well cared for.

How do we start making progress?

A lot of people are excited about what AI can do for staffing. I am too. Forecasting volume, predicting acuity, optimizing schedules — that's all extremely exciting and important. But none of it matters if the people using the tool don't trust it, or if staff don't see how it helps them.

Technology is only as good as the people who are willing to use it. What we've built at M7 is grounded in real front-line workflows. Fewer clicks. Clearer views. Data-backed decisions. When someone logs in and immediately says, "Oh, this was obviously built by a nurse," that's when you know you're on the right track.

But the tools are only part of the answer. When turnover becomes the norm, it's time to call a code on your workforce. You need a shock to the system. Something that says, "We hear you. We're making a change. And we're not just asking you to hang on. We're fixing this now."

That means building schedules that reflect real-life needs. It means giving teams the visibility to make fair, sustainable staffing decisions. It means making flexibility part of the core strategy, not a last resort.

Until we address the conditions that are driving nurses out, we're going to keep calling it a shortage. What it really is, is a signal that we've made staying too hard.

Let's make it easier.