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How the U.S. Could Fix Its Nursing Crisis

Illustration of health care settings without nurses due to workforce shortage

Illustration by Rose Wong

Illustration by Rose Wong

  • Shanoor Seervai
    Shanoor Seervai

    Researcher, Writer, and Lead Podcast Producer, The Commonwealth Fund

  • Shanoor Seervai
    Shanoor Seervai

    Researcher, Writer, and Lead Podcast Producer, The Commonwealth Fund

Toplines
  • The nursing profession in the U.S. is in crisis, with nurses facing burnout and hospitals dealing with staffing shortages at unprecedented rates. Listen to the latest episode of #TheDosePodcast to learn more about how to fix it.

  • On the latest episode of #TheDosePodcast, nurse @RNRebeccaLove shares her ideas about how to fix the nursing crisis, from new reimbursement models to new ways of training and empowering nurses to provide the best care possible.

Nurses in the United States are experiencing burnout at unprecedented rates. More than two years into the COVID-19 pandemic, they are still processing the trauma of what they witnessed in the early days. Staffing shortages, meanwhile, are creating unmanageable workloads.

On the latest episode of The Dose podcast, host Shanoor Seervai interviews Rebecca Love, a nurse and president of SONSIEL, the Society of Nurse Scientists, Innovators, Entrepreneurs, and Leaders, a nonprofit dedicated to creating new opportunities for nurses in health care innovation.

Love talks about what it would take to fix the nursing crisis, from changes in nursing reimbursement to new ways of training and empowering nurses to provide the best possible patient care.

For more on the future of nursing in the U.S., read this issue of Transforming Care, on empowering nurses, and this interview, about reimagining nursing.

Transcript

SHANOOR SEERVAI: Nurses make up the largest share of the health care workforce. This means that most of the care received by patients in the U.S. is delivered by nurses, and the dominance of nurses is projected to grow significantly in the next five years. That is, if the challenges to the profession from burnout to nurse training can be met and overcome.

I’m Shanoor Seervai, host of The Dose, and we’re going to talk about this today with my guest, Rebecca Love. Rebecca is a nurse and president of SONSIEL, the Society of Nurse Scientists, Innovators, Entrepreneurs, and Leaders, a nonprofit dedicated to creating new opportunities for nurses in health care innovation.

Rebecca, thanks so much for being here today.

REBECCA LOVE: Shanoor, thanks so much for having me.

SHANOOR SEERVAI: We’re here to talk mostly about the future of nursing, but it would be impossible to have this conversation without talking first about the pandemic. So let’s start with some context. The nursing profession was facing major challenges even before COVID-19. Could you briefly catch us up to what the key issues for nurses and nursing were before?

REBECCA LOVE: When COVID hit, literally what happened in our hospital systems was a substantial portion of other providers ran for the doors while the nurses ran in, and you will see this across imagery, across COVID, where the nurses are standing inside the patient’s room, writing instructions and following instructions from physicians or colleagues standing outside of the room, directing care. And nurses were so responsible for this level of care that was going on, that there was no time for a break.

And what we also saw though, was this incredible amount of trauma being experienced because as nurses, although we’re prepared to meet death, they were not prepared to meet the level of death in which was occurring during the time of the COVID pandemic. And you have to imagine, these nurses were crossing a threshold at a time where every exposure, there was no treatment, there was no vaccine. And they were risking their lives as well, the lives of their loved ones, when most other individuals were able to stay home and work from home.

SHANOOR SEERVAI: And did this tragedy change the focus on what to fix when it comes to nursing?

REBECCA LOVE: I think the pandemic at least illuminated the value of nurses in this country, which has largely been hidden from the public view. I think the public and I think even most providers have little understanding of the scope of what nurses do, which is nurses deal with multiple complex systems. If you’re looking at IV pumps to medication administration systems, to blood transfusions, to wound care management, to catheter insertions, IV therapy.

And what we started to see during the pandemic, although there’s an illumination of the value, when hospital systems and health care systems started to see less turnout of their kitchen staff, of their IV teams, of their transport staff, all of those additional responsibilities fell on the shoulders of the nurse. And I think that what we saw because of the pandemic is nurses that were close to the retirement age decided to retire for risk to themselves and also to their loved ones.

And also, the young nurses who had come into the profession were so traumatized by what they witnessed, which actually, this last year was the largest demographic of nurses leaving the profession were actually nurses with less than one year of experience. That’s never happened in the history of our profession before. It was just a double whammy that hit everything, has left us in a really terrible spot, as I predict for the future of the nursing workforce for the next five years.

SHANOOR SEERVAI: You can hardly blame people. I want to ask you now, the National Academy of Medicine has devoted significant resources to their future of nursing papers and campaigns. They identify key issues like improving health equity, diversity, interprofessional collaboration, nurse education. Do you think that these are the critical issues in nursing right now?

REBECCA LOVE: The most critical issue that’s facing to the sustainability of the nursing workforce is based on nurse reimbursement models into hospital, which is based on an antiquated model that was established back when Medicare was first established that rolled nurses into room rates, which what that meant is that nurses have been placed squarely on the cost side of health care systems, which means more nurses equal more costs without associated revenues. And we know from a business perspective, which it is the business of health care, you deinvest in costs.

And even though Medicare has gone through multiple changes of which reimbursement models exist, they’ve never taken nurses out of the cost structure of health care systems within organizations, and that is vastly different than any other provider that currently provides health care in this country. Doctors, OTs, PTs — all of those lead to associated revenue lines tied to their organizations. And hence why you see investment into those professions where you don’t see the investment into the nursing profession.

SHANOOR SEERVAI: So basically, what you’re saying is that the services that nurses provide are getting squeezed when hospitals are trying to cut costs.

REBECCA LOVE: Absolutely. So to give you an example, the hospital would be reimbursed a rate if they have a ratio of one to four patients per nurse as the same if they have a ratio of one to eight patients per nurse. So hospitals, when they’re being squeezed are going to do less patients per nurse or less support services of nurses because the reimbursement model does not change.

And that doesn’t factor in any things of the level of acuity, the level of critical patients, the absolute complexity of the workload, or of the patients which are in the hospital. It just simply comes down to a simple metric of, “Hey, this is how much we’re getting reimbursed by. If we need to cut costs, we need to save money, it means we’re going to deinvest in our nursing workforce and the support services around them.”

SHANOOR SEERVAI: So there are many different types of nurses with limits on what they can and can’t do. Could you just quickly tell us about the differences between registered nurses, advanced practice registered nurses, licensed practical nurses, and licensed vocational nurses?

REBECCA LOVE: Yeah. So LPNs and LVNs are nurses who have one years of nursing experience, who sort of what you’ll see where historically they’ve spent most of their time in the last 20 years is operating within long-term care. They were sort of the ones who do it and what we would consider really activities around daily living, medication administration, monitoring of patients, and care in subacute settings. And an RN can be two types of degree classifications: one is an associate degree nurse, which can be accomplished through a community college, and a bachelor’s prepared nurse, which is a four-year degree.

Both of those sit for what’s called an RN exam. A registered nurse is those who operate to the top of the nursing sphere of license before you actually step into nurse practitioner, which is a master’s prepared nurse who sits for a licensing board, who has full practice authority in 21 states across the country for diagnosing and prescriptive purposes, which means they don’t have to have physician oversight.

SHANOOR SEERVAI: Okay. And this is helpful as we start to talk more about the shortage, because as you mentioned, there’s been this accelerated exodus of older nurses. But if we want to look ahead at training new nurses, what are the enrollment numbers in these different programs?

REBECCA LOVE: We roll about 200,000 nurses a year that go into nursing school for what we would consider their LPN associate degree or bachelor’s programs. We graduate about 175,000 nurses a year in this country, which is by far the global leader by tens of thousands of nurses. We’ve seen an uptick in applications for bachelor’s programs into nursing this past year.

The issue that we have in this country though, is not about producing enough nurses. The issue that we have in the United States is that those nurses who graduate in the course of the last five years, less than 50 percent of new nursing graduates are staying by the bedside longer than two years. That is the largest exodus from any profession that no one is talking about. The reality is that the largest demographic of nurses leaving the bedside this last year is nurses with less than one year of experience.

I know that we say that we have a shortage of nurses in this country, but I think what the real problem is, is that we just have a shortage of nurses willing to work in health care environments today. Because if you look historically, there are actually more nurses today in the United States than any time in history ever. But they are not working in health care because the systems are not designed to make it sustainable.

SHANOOR SEERVAI: So it’s really an issue of making their worklife bearable and enjoyable.

REBECCA LOVE: I think we need to study this. The truth is any other industry, my guess is we would do an internal audit of what is going on that kind of turnover exists in your newest population, because it would tell you that something is likely wrong with the system, not that there’s something wrong necessarily with the nurse. And I think that we keep just looking at solutions saying, “Hey, we’re going to make more nurses,” but 50 percent of the workforce is over [age] 50. We’ve lost so much knowledge that everything across health care, all of those infections and outcomes, everything is worsening in hospitals and nursing homes today. Patient care is getting incredibly worse based on what’s going on, and we must start looking at the systems to sustain the nursing workforce because ultimately, the people that are going to be hurt the worst are going to be the patients.

SHANOOR SEERVAI: And so, if you were designing ways to train new nurses who are coming into the workforce, setting aside, of course, the fact that we should also build in ways to retain them, how would you recommend training new nurses?

REBECCA LOVE: If you were to look at the medical model of residency, medical models of residency mean that you are going to be trained with a resident, by a doctor who has decades of experience to train you. What we have seen is that there is no residency program. They’re giving nurses three-month trainings in ICUs and saying, “Good luck. You’re brand new out of nursing school. Go ahead and operate in the ICU.”

The reality is that these nurses coming out of nursing school, especially over the course of the pandemic, have lost years of clinical experience, but more importantly, they’re being trained by nurses with 18 months of experience. And the reality is if we want to create sustainable models for new grads, we need to bring in a medical residency model, similar to that of nursing, for at least experienced nurses with 10, 20, 30 years of experience, who would create that kind of opportunity to engage with them.

I think that is one of the most fundamental gaps that we currently have in our nursing workforce and why that churn exists, but also why we’re seeing so many mistakes happening because we have so many nurses with such little knowledge leading the vast majority of care across wide swaths of this country.

SHANOOR SEERVAI: And why don’t we have a residency model for training nurses?

REBECCA LOVE: Again, it comes down to how nurses are reimbursed. It’s a cost, it’s a cost that’s not reimbursable. It’s a cost when you add services onto trained nurses larger, it’s a sunk cost without associated revenues. So where physicians actually have reimbursable models — they’re paid by Medicare, Medicaid, and private things to actually do residency programs — there is no such funding to exist in nursing today. And as long as a nurse is a nurse is a nurse, and a cost and a cost and a cost, you’re never going to see associations actually investing to create sustainable residency models for nursing because it’s what they consider a lost cost and not an investable resource. And that is the problem then, the entire thing. Nurses are seen as a cost, not as a resource, not as a value to health care systems in our current model.

SHANOOR SEERVAI: I also have a question on technology. How much innovative technology is used in nurse training like VR, AR, even MR or mixed reality, which is being used at some medical schools?

REBECCA LOVE: Very little is being used across nursing schools for training. Simulation is about as innovative as the models have gotten. Largely, this is due to the organizational structure, boards of nursing approval of what qualifies for training or clinical experience within our health care systems. And there is definitely a lag of adoption or accessibility or acceptance of these new models of training and education across boards of nursing, and that is a limiting factor.

You’re going to see that I think what’s going to happen is medicine will lead with these models and nursing will be five to 10 years behind that adoption for new forms of training, because to your point, if you could actually give them some of this VR and as RN opportunities of this kind of magnitude, nurses could witness in clinical experiences to gain vast amounts of knowledge in a much more seemingly meaningful period of time than probably in much of their clinical time of what currently is dictated as face-to-face time for necessary clinical requirements.

SHANOOR SEERVAI: You said nursing will follow five or 10 years later. We’re seeing a lot of pressure right now to grow the nursing workforce. So do you think that professional organizations and licensing boards will embrace tech more rapidly?

REBECCA LOVE: I would strongly hope so. I think that there’s enough studies coming out of medical school to show that competencies can be made by watching and using this kind of technology. But I think there is a deep-held belief still largely within our structures of nursing that we don’t move quickly because everything that we need to have is based on evidence-based practice, and evidence-based practice, amazing as it is, unfortunately limits and inhibits our ability to rapidly access new trainings or new ways of thinking about nurse training in a meaningful way.

SHANOOR SEERVAI: Now let’s talk a little bit about nurse practitioners. Restrictions on what advanced practice registered nurses could do were lifted during the COVID-19 public health emergency, but we may see them being reimposed in the future. So first, why? What’s the evidence for rolling back?

REBECCA LOVE: I don’t believe there’s any good evidence to roll back this, except the American Medical Association specifically strongly opposes full practice authority for nurse practitioners, which actually seems crazy. Because if our goal as providers is to increase access to patients who don’t have access to care, nurse practitioners often practice in primary care, which is the number one growing need in this country for access. Most physicians are specializing in areas of practice models and do that because obviously, there is more money to be made in other verticals in health care outside of primary care. Primary care historically has the lowest reimbursed rates across the country.

Nurse practitioners though love primary care and they love to manage patients and spend time with them, but largely it comes down to one thing, which is money. As long as nurse practitioners practice underneath the physician scope of practice, that physician will make more money, and also so will the access to practice, and also patients. There are increases when you have nurse practitioners who practice, that creates a competitive nature within the health care landscape, but more importantly, nurse practitioners in most rural communities is the only access point to care for thousands of American citizens.

And that is where I think the biggest disconnect is happening here, is that nurse practitioners can finally get Americans that did not have access to care, access to really good quality care that nobody else wanted to provide.

SHANOOR SEERVAI: You basically answered my next question, which was what is going to happen in the poor rural places where nurses have been providing care during the pandemic, and the people who have been depending on this care?

REBECCA LOVE: It’s shocking to me that we’re going backwards. COVID gave us an opportunity to do things differently. We saw why health care didn’t work across multiple factions. Everything that we thought we knew worked about health care largely failed in the face of COVID, right? It allowed for telehealth to step up. It allowed us to do new things. It allowed greater access to care. It allowed us to actually treat and get ourselves through a pandemic because we increased this access to care. And suddenly, we’re going to go backwards?

SHANOOR SEERVAI: And of course, there was another change that we made during the pandemic, which was that traveling nurses worked in COVID hotspots often for higher pay. Now, this was to meet staffing shortages, but it also created tension in many communities because local nurses typically found themselves earning a lot less. So let’s start first with how nurses’ salaries stack up. Generally speaking, would you say that compensation is fair?

REBECCA LOVE: Perhaps starting salaries are fair. I don’t know if you know this, but nurses are based on a capitated payment model.

SHANOOR SEERVAI: Okay.

REBECCA LOVE: It means because we’re rolled into cost structures, every year, the average nursing salary over a span of 20 years across every system, only on average is increases of 1.5 percent. That means it’s half the cost-of-living structure. So do I think that’s fair? Absolutely not. It’s a capitated model.

Most nurses didn’t know that hey, you’re going to graduate nursing school, and the most by the bedside you’re going to make every year is going to be $60,000, the next year, $62,000, the year after that, $64,000. And after you’ve worked for a health care system for 19 years, you will never have a raise again because you’ve reached the total capitated model that, that health care system will pay a nurse because of their room rate reimbursement model.

So functionality right there, that’s the breaking system. So to me, absolutely, it’s archaic, it’s wrong, and no, I don’t agree with that. That being said, travel nurses came in and they were able to go after a different bucket of money, which was considered emergency funding from hospitals that actually would pay the value of a nurse.

SHANOOR SEERVAI: Right.

REBECCA LOVE: Treating nurses simply as a commodity, there was never a way to actually value nursing until COVID really happened because then it started to become apparent that the only way to save patients’ lives was by having nurses there, right?

So I think it comes down to a basic level of capitalism and democracy, which is regardless if nurses were paid more as travel nurses, were they finally being paid fair market value for the services they’ve delivered? At which this capitated, antiquated payment model that we’ve had in place for the last 100 years showed that this too has to be broken and restructured to fairly value the market of nurses, and also create a sustainable profession forward because right now, the average hospital has a shortage of 25 to 30 percent nurse vacancy in this country. They cannot fill that. And this is going to be a crisis going forward.

SHANOOR SEERVAI: Do you think that traveling nurses are at least a short-term solution to the workforce crisis?

REBECCA LOVE: I think traveling nursing is going to be the only solution to our nursing shortage crisis for the next three to five years. And the reason being is that we’re going to have to look at areas where there are hotspots and needs and those nurses with that level of experience, because traveling nurses largely have more experience now than what’s staying at the bedside, fortunately or unfortunately. But it’s going to be the only way hospitals are going to access nurses who have the training and the skill sets to actually sustain their most critical patients in their ICUs and their operating rooms.

What our systems have done are archaic scheduling and shift-scheduling softwares that they have burned through nurses who have 10, 20, 30 years of experience. They’ve treated them like their lives and their work–life balance does not matter, that they’re simply a commodity and a 24/7 schedule.

And I don’t know if you’re aware of this, but nurses, let’s say that you go in and they find that their census is low, they’ll send that nurse home, but they’ll make that nurse take their paid time off because they don’t want to cancel their hours, regardless because they’re being sent home. Then when that nurse asks for paid time off, they say, “I’m really sorry. You don’t have any, and we’re denying you paid time off.” There’s these antiquated ways that we’ve been treating this incredible valuable resource as though they are simply indentured servants to a system whose only value to them is making sure that they have them 24 hours a day, seven days a week.

SHANOOR SEERVAI: What about the idea of increasing the number of nurse visas and bringing in more nurses from other countries. Do you think that could help?

REBECCA LOVE: We did this in the 1970s in the last nursing shortage, and we opened up to the Philippines and moved over a vast number of nurses into this country. At that time, nursing was a very different state than it is today. I think that we can open up those visas, but as you know, there are some questions and restrictions, even the Philippines has capped how many nurses they can export a year. So I think there’s an opportunity. I’m just not sure it’s a short-term fix in the way that we’re hoping.

SHANOOR SEERVAI: Right. And of course, we wouldn’t want to create a crisis or a nursing shortage like the one we’re facing in other countries.

And so, Rebecca, we’ve talked about a couple of short-term fixes, but what are the longer-term plans for making sure that nursing is viable both for health care institutions and for the individuals who are doing this really important work?

REBECCA LOVE: Well, the first one is changing the reimbursement models to remove nurses out of the cost structure of health care systems and have them tied into what would be referred to as national provider numbers that nursing could actually track, and that more nurses don’t just equal more costs without associated revenue. The second thing that we have to do is largely create these new kind of residency models, similar to what’s in medical school. Which is that they are trained by very experienced nurses. Take those nurses who have years of experience, bring them back, educate and train them. And lastly, I think that the big thing that we have to do is as much as we want to look towards, let’s just produce more nurses, the reality is we need to fix the systems. And right now, everything always falls on the nurse, without necessarily trimming off that extra work that they’re already doing.

There is just so much work. It always falls on the nurse, and we can’t keep doing that. The reality is also we used to use technology in our systems to drive better nursing staffing and scheduling models that don’t keep burning them out in this archaic message. And then more importantly, and the last one is, every health care company today that sells products that are used by nurses needs to invest in the nurse and their executive suite to make sure that the products they’re designing actually make less work for the nurse, as opposed to more work for the nurse and keeps the nursing profession safe.

Because the way these devices are functioning today, currently create many obstacles to safety for nurses. And it is time that we as nurses say, “If you do not have a nurse on your team to drive through safety policy protocol within your organization as a health care institution, we no longer are going to use your products,” because that’s how we’re going to start feeling safer about how we practice and knowing that the devices that we’re using actually work better for us as we work to save patients’ lives.

SHANOOR SEERVAI: Rebecca Love, thank you so much for joining me on The Dose today.

REBECCA LOVE: Shanoor, thank you so much.

SHANOOR SEERVAI: This episode of The Dose was produced by Jody Becker, Mickey Capper, Naomi Leibowitz, and Joshua Tallman. Special thanks to Barry Scholl for editing, Jen Wilson and Rose Wong for our art and design, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions. Our website is thedose.show. There you’ll find show notes and other resources. That’s it for The Dose. I’m Shanoor Seervai. Thank you for listening.

Show Notes

Rebecca Love, M.S.N., R.N.

Publication Details

Date

Contact

Shanoor Seervai, Researcher, Writer, and Lead Podcast Producer, The Commonwealth Fund

[email protected]

Citation

Shanoor Seervai, “How the U.S. Could Fix Its Nursing Crisis,” May 6, 2022, in The Dose, produced by Jody Becker, Mickey Capper, Naomi Leibowitz, and Joshua Tallman, podcast, MP3 audio, 23:34. https://doi.org/10.26099/2vwk-8a73