The State of Nursing in the U.S.

Nursing is in a state of crisis. Overwhelmed by the critical need for more nurses, nursing is at a crossroads, and according to the president of the largest school of nursing in the U.S., it’s time to adopt a new professional model.

Daily Nurse chatted with Chamberlain University President Karen Cox, Ph.D., RN, FACHE, FAAN, about the state of nursing in our country and what we must do to help fill critical nursing shortages.

What is the state of nursing today?

I would have to describe it as that we’re in a crisis. And it’s a crisis of nurses being willing and physically able to work in acute care. We have four million nurses. And of those, if you needed to work in acute care in hospitals, direct care, and other home care roles, we would be okay, but the current environment is not satisfying to them for several reasons. And so, we’re at a crossroads where we need to consider a new professional model.

What do you envision a new nursing model will include?

First, let’s talk about how we got here. The pandemic certainly was an accelerant to having a crisis develop. But it wasn’t. It was predictable. It just got moved up and made more real by COVID.

Nursing is the only profession that doesn’t quantify its financial contribution. Nurses are seen as part of the bed charge, so their value is different than a physician who bills for visits. Physicians bill either by minutes or by the procedure. So the reality is nurses must be better and more capable of demonstrating their value to positive patient care outcomes. Because we are valuable, and there’s evidence of this when we’re engaged in the right numbers and skill sets. The outcomes are better when we have the things we need. So that’s one big piece.

The other piece is because nurses are hourly, that sets us up to be commoditized. When I need you, I need you. When I don’t, I don’t. If I need you really bad, I’ll pay you a lot more. And then we wonder why nurses go after these travel contracts that are so lucrative. But if you treat somebody like a commodity, that’s how they’re usually going to act. Some CEOs understand this and are trying to get past anything we can do to change that mindset on both sides of health leadership and nursing.

Has the bubble burst for travel nurses?

I’ve had a lot of discussions about the bubble being burst with travel nurses. During COVID, they were responding and getting paid a lot of money. Now the value they showed and their dedication it’s not needed anymore.

So, would you say that’s adding to the problem in nursing?

I absolutely agree. It’s supply and demand, as opposed to treating somebody as a valued professional. Why don’t healthcare leaders around the country understand that the pay scale isn’t high enough? Why wouldn’t nurses take those jobs when the pay was so high? The answer is somewhere in the middle. Nurses have yet to have an increase, taking into account inflation in many years. And then the role is so much harder than it has ever been. When I was doing direct care, it just changed. The expectations are demanding. It’s a hard job.

I always tell people this: if you’re not in healthcare, you don’t think about it. We’re asking people to work 12 hours a day, for the most part, and to be physically present, and they’re expected to lift patients. The other thing that no one wants to say out loud is  60% of the population is overweight or obese. Twenty years ago, lifting somebody with a knee replacement and helping them get to the bathroom wasn’t a problem. It’s different now if they weigh 100 pounds more! Then it’s the mental and emotional part of dealing with people who are vulnerable. And on top of this, nurses must use critical thinking and make critical decisions. Making clinical judgments and doing all the left-brain things make a difference in how people experience their illness in their care, which impacts outcomes.

What are ways that you recommend nurses demonstrate their value?

The pandemic has accelerated the move to value-based care and getting paid for the outcomes, not procedures. Nurses make a difference in hospitalized patients’ outcomes. If patients don’t get an infection, if they don’t experience anything imposed by poor care, any of the outcomes getting patients out within so many days, no readmissions within 30 days, that’s nursing and nursing care. Others participate in it, but it’s heavily influenced by nurses who are there 24/7. And so it is changing the discussion. And it’s not just about employee or patient satisfaction. It’s about real-world outcomes.

And that’s how the health systems will get paid in the future — they will get paid more when they do well, as opposed to more when they do more. And that’s a different relationship. So there’s an opportunity to change the relationship and the governance. We need to change the mindset of leadership and nursing. COVID, if anything, has shown nurses that if they stay in acute care, they want to be at the table for more decisions that impact them and their patients.

Is the biggest challenge facing nursing today the loss of nurses?

That’s a piece of it. And then the second part is, how are we trying to resolve it? One of the things that’s important for people to know is unless we get people back to the acute care setting who have left or haven’t been there for a while, we aren’t going to have enough nurses for at least five-10 years to deliver care the way we have for the last 20 years. And we need to be able to do it the way research supports us. But the answer is not to throw in more patients and nurses having more to delegate to. We need fundamental shifts in the role and supplement with new roles. And the one role that is the future is the virtual nurse.

What is the role of the virtual nurse?

This role does a lot of different things. For example, if you have an inpatient unit and a nurse with seven or eight patients, they usually have less than two years of experience. People would be surprised to know the need for more experience in acute care settings. So you would have a virtual nurse who can be down the hall in a room or even at home, and they’re there with the knowledge and experience to answer patient/family questions.

Some nurses are physically challenged, and it is too much to do the 12-hour shifts. The virtual nurse can do many things that nurses want to do and need to do but don’t have time or experience. It’s about more than tasks. It’s about the social determinants of health. For nurses to impact and improve health disparities, we must be less transactional and more relational with patients and families.

I can do many things if I’m a virtual nurse sitting in a room. I can notice if somebody is in trouble. I can answer their questions. But more importantly, I can start working on how they go home and not end up in a diabetic coma in a month, talking to their family, talking to their caregivers, understanding what got them in the hospital in the first place, and what they need. Those are, again, things that nurses want to do. But they need the wherewithal, and they need the experience. That’s why you make that role how we get both out of this staffing crisis and working on health disparities, which is what the National Academy of Medicine The Future of Nursing 2020-2030 report recommends.

What other things should we be doing to attract more people into nursing?

It goes back to what are we? Are we valued professionals? A commodity? Somewhere in between? How nurses choose to be and how they’re valued does make a difference. And it goes back to how involved nurses are in decisions, much like physicians. Physicians control their practice within limits and have a governance structure that some argue could be more robust in some places.

Nonetheless, it exists. And it puts nurses in place to advocate and influence patient care. They can do it in other settings, not only at the bedside. And that’s an opportunity.

The other thing we have to do is increase diversity. If you follow Chamberlain University, you know we’re diverse, much more than anybody else’s student nursing population. But it means that we have to do it. Students who’ve been in low-resource high schools or have not attended another nursing program will not get into the big traditional schools because their GPA isn’t 3.8 or 3.9. But at 3.0, they’re also incredible nurses, and it’s about their life experiences. So that’s on the education side. We must use a holistic process to admit students to the nursing program.

Talk about the growth of online nursing programs and their impact on nursing. What kind of infrastructure is needed to make online nursing programs more appealing?

We’re doing a high flex or a hybrid model at Chamberlain University. When the pandemic began, I can’t tell you how many students were adamant about returning to campus full-time. And now, they learned to adjust their classes to their family life and are enjoying this model. So, there’s a lot to be said for having that flexibility.

We’re finding that with faculty too. At first, they thought online classes were horrible. I’ve never done this before, that sort of thing. And now they’re thinking, maybe these online classes are okay, and they’re identifying some courses that academic leaders say should be in person, and here’s why. But a lot of it doesn’t have to be. And what we’re trying to develop at Chamberlain is a way for students to do it the way that makes sense for them. That’s one of the reasons we have an evening & weekend program. I didn’t think people would flock to that. And I was wrong.

You can sit there and try to be traditional all day long, the way we were before, but nothing will be the way it was before. It’s not just education. It’s everything. That’s all changed.

Chamberlain has a BSN Online Option. It’s not entirely online, but it’s close. It’s our same curriculum, but we administer it differently. And that’s going to be the wave of the future. We will need to offer different options for people. If we’re to solve the nursing crisis in terms of the numbers and the diversity, and trying to get people who are mid-career that have 20 good years plus, they can’t necessarily just quit work altogether.

The online BSN program just started, and we’re up to 350 students, which sounds small because we’re Chamberlain. But that’s the size of some schools of nursing. We’re working out the kinks in the system, learning from that, and doubling down on this across the country. Every state board will be different about what they view as okay. So everything has to be geared toward that in terms of our priorities.

(This story originally appeared Daily Nurse.)