With more than 100 million Americans lacking access to primary care, employing more nurse practitioners (NPs) and allowing them to practice at the top of their license is critical to making healthcare more accessible in rural areas, NP leaders say.
NPs could ease "care deserts" created by physician shortages and rural hospital closings. Nearly 80% of rural U.S. counties are medical deserts, according to the NRHA. About 35% of all U.S. counties are "total maternity deserts"—no access to prenatal or delivery services—and another 54% are considered partial deserts, which equates to 7 million women without access to maternity care, according to the March of Dimes.
"It is definitely a need in rural health that we get providers out in every community," Kapu says.
Growing in number
The demand for NPs is growing and their role is expanding, thanks in part to an aging U.S. population, increasing infectious diseases, rising chronic diseases, and fewer physicians, the AANP says.
The percentage of rural physicians has declined—12.8% from 2008 to 2016. But the percentage of NPs increased 17.6% during that same time period, according to a 2020 study.
"We're growing at a rate of about 9% a year," Kapu says. "We are up to more than 355,000 nurse practitioners across the U.S. today, and we are estimated to grow by 46% by the year 2031."
Nearly 90% of NPs are certified in an area of primary care and 70.3% of all NPs deliver primary care, according to the AANP, with 83.2% of full-time NPs seeing Medicare patients and 82% seeing Medicaid patients. Additionally, nearly half of all rural primary care practices have at least one NP, according to the NRHA.
A well-rounded approach to healthcare
NPs' holistic, wellness-centered approach to primary healthcare—health promotion, prevention, and chronic disease management—is particularly beneficial to rural patients who must travel long distances when illness requires acute care.
"One really valuable thing they bring to rural health is the approach to healthcare, which differs a bit from the medical model," says Michele Reisinger, DNP, APRN, FNPC, a working NP and assistant professor of doctoral nursing at Washburn University in Topeka, Kansas. "Nurse practitioners are trained to look comprehensively at the individual."
NPs are well positioned for primary care roles because of their education and training, says Reisinger, who has helped obtain an advanced educational nursing workforce grant centered on educating nurse practitioners for rural practice.
"When we train them as nurse practitioners, we train them to manage chronic disease states; we train them to be experts in promoting health and wellness [as opposed] to an urban setting where they may work only in urgent care … or have a very targeted education in cardiology or neurology," Reisinger says.
Instead, rural nurses treat the spectrum of pregnant women, infants, children, adults, and geriatric patients, along with entire families, she says.
"Nurse practitioners in rural areas wear many hats," she says. "They may be seeing primary care patients; they may be tasked with extended care rounds in nursing home facilities, which requires extensive geriatric management; or they may be in a setting that requires knowledge of trauma. So, we try to prepare them in a way that is global in that manner."
Working closely with patients allows NPs to create collaborative prevention plans to help patients make lifestyle changes and health choices that can stave off chronic disease and keep them out of the emergency department, Kapu says.
"We know that timely access to care, particularly preventative care, is crucial to the early detection of health issues," Kapu says. "It has a huge impact on the mitigation of healthcare cost, and so important to health and well-being overall, and whenever that care is delayed, we know that individuals face a greater risk for complications for not following up on chronic diseases."
Such preventive care makes a difference to rural patients, Kapu says. "Many large-scale reliable studies have shown that we have a tremendous impact on the reduction of unnecessary emergency department visits," she says.
Breaking down barriers
Despite the advantages that NPs can bring to rural, underserved areas, barriers continue to limit them from working at the top of their license, Kapu says.
For example, even though more than half of U.S. states have granted NPs full practice authority (FPA)—which allows them to evaluate and diagnose patients, order and interpret diagnostic tests, and initiate and manage treatments under the exclusive licensure authority of the state board of nursing—nearly as many states make it illegal for NPs to practice their profession without a collaborative agreement with a physician.
The American Medical Association (AMA) and other physician groups accuse FPA of "scope creep" and charge that nonphysicians practicing medicine is a threat to patient safety. At its annual meeting in June, the AMA passed a policy amendment calling for advanced practice RNs (APRN) to be licensed and regulated jointly by the state medical and nursing boards. Nursing groups denounced the policy amendment.
States that have embraced FPA have increased their nursing workforce and helped ease care deserts, Kapu says. When Arizona enacted FPA in 2001, the NP workforce doubled across that state within five years and grew by 70% in rural areas, and North Dakota's adoption in 2011 saw its nursing workforce grow by 83% within six years, she says.
Some barriers are being reconsidered. The Improving Care and Access to Nurses Act (ICAN) was reintroduced in the U.S. Senate in April and would allow NPs, physician assistants, and other APRNs to provide particular services under Medicare and Medicaid. ICAN would, among other things, authorize NPs to order and supervise cardiac and pulmonary rehabilitation, certify when patients with diabetes need therapeutic shoes, and certify and recertify a patient's terminal illness for hospice eligibility.
"These are substantial barriers that, if they were removed," Kapu says, "we will be able to provide much-needed, timely care, and [for] our elderly and Medicare beneficiaries who live in these rural communities."
New initiative is expected to avert costly rehospitalizations while helping patients get and stay healthy.
Emory Saint Joseph's Hospital in Atlanta has launched a nursing-led program to help patients navigate post-discharge health needs with one-on-one lifestyle coaching to fend off future hospitalizations and the costs they incur.
More than $52.4 billion is spent annually to care for patients readmitted to the hospital within 30 days for a previously treated condition, according to a 2022 study.
At Emory St. Joseph’s, nurses not only will work with newly discharged patients for 12 weeks to ensure they properly take their medication and keep timely medical appointments, but they’ll also provide weekly lifestyle and health coaching to help them establish and maintain healthy behaviors that will keep them out of the hospital.
"In this program, our nurses will collaborate with patients to determine one lifestyle behavior that could be getting in the way of their overall health, such as smoking or blood glucose management, and then chart a course to make meaningful progress over those months," says Rebecca Heitkam, director of Emory Saint Joseph’s Congregational Health Ministries and Faith Community Nursing program.
The new initiative is part of Emory St. Joseph’s larger Faith Community Nursing program, which trains nurses on post-discharge transitional care management while connecting with the patients on a spiritual level, but it takes the original program one step further by connecting nurses with specific patients one-on-one for 12 weeks following a discharge and adds the lifestyle coaching component.
The nurses call patients once or twice a week either by phone or on Zoom for up to 90 minutes to help them determine small-step goals and actions for the next week, and help them stay motivated to accomplish the goal, she says of the program launched with the help of a two-year $60,000 grant.
"With the original program, the patients seemed to become almost co-dependent on their nurses to tell them what to do each step of the way, make calls for them to obtain resources they needed instead of doing it themselves, and be the go-between for the patient and physician provider, but few patients were really strengthening their skills on managing their own chronic conditions or better yet, making a change in the chronic condition through lifestyle behavior change, where appropriate," Heitkam tells HealthLeaders.
"I had recently taken a course and become board-certified in health and wellness coaching, and I was convinced that the nurses’ time might best be spent coaching willing patients into making lifestyle changes using SMART [Specific, Measurable, Achievable, Relevant, and Time-Bound] goals and positive coaching techniques rather than being so prescriptive for the patients’ outcomes," she says.
Some patients more readily accept post-discharge care management than others, she says.
"Once patients realize that they have a good bit of control over their health outcomes if they are willing to make some crucial behavior changes, they get very excited and are on board with being coached and supported to success," she says, "or they decide that the lifestyle changes are not worth it, and they keep doing the very same things that continue to get them readmitted to the hospital."
"We have learned to be a little more intentional with choosing patients to offer the program to, and we always leave space open for patients who didn’t appear to be receptive to change, but who surprised us and made incredible changes for their own benefit," she says.
The initiative is expected to do more good than saving rehospitalization costs, Heitkam notes.
"One of the unique aspects of this initiative is that rather than measure success only through a reduction in readmissions," she says, "we’re going to be taking into account overall outcomes for patients to demonstrate how focusing on attainable health goals can make a big difference in the lives of these patients."
Gov. Gretchen Whitmer vetoed a previous attempt in 2020.
Legislation to allow Michigan RNs and licensed practical nurses (LPNs) to hold multistate licenses through the Nurse Licensure Compact (NLC) has been reintroduced after a previous attempt nearly three years ago was vetoed by the governor.
The legislation calls for Michigan to enter into the compact allowing RNs and LPNs to practice in person or via telehealth, in both Michigan and the other 39 states and two U.S. territories—Guam, and the U.S. Virgin Islands—that have joined the compact.
Michigan Gov. Gretchen Whitmer vetoed a previous bill in 2020 because it violated the state constitution, she wrote at the time in a veto letter to the state legislature.
"While I value interstate cooperation, especially around issues that are peculiarly interstate in nature, these compacts require Michigan to cede its sovereign interest in regulating health professions to an outside body," Whitmer wrote.
State Rep. Phil Green, who introduced the new legislation, said he plans to work across the aisle during this go-round to ensure a different outcome, according to the Michigan Public Radio Network.
One of the most recent to join the compact is Pennsylvania, which allowed NLC RNs and LPNs to begin practicing in Pennsylvania September 5, 2023. Pennsylvania nurses must wait, however, to practice in NLC regions until certain preconditions are met, one of which is certifying to other compact states that Pennsylvania's State Board of Nursing has performed an FBI criminal background check on Pennsylvania applicants. That move is pending.
Rhode Island also recently enacted the compact when Gov. Daniel J. McKee signed the legislation. The state is awaiting implementation with no determined start date.
A multistate license eases cross-border practice for many types of nurses who routinely practice with patients in other states, including primary care nurses, case managers, transport nurses, school nurses, hospice nurses, and more. Military spouses who experience moves every few years also benefit from the multistate license.
The NLC also benefits facilities that might have an acute shortage in one of their units to recruit a nurse for that unit or shift around their resources if they're an interstate facility and moves nurses between different states, according to Nicole Livanos, director of state affairs at the National Council of State Boards of Nursing (NCSBN).
Each addition to the NLC helps to strengthen the nursing workforce, she said.
Front-line nurses are the clinicians most likely to encounter patients suffering from high anxiety.
Full-immersion virtual reality simulation decreased nursing students’ anxiety levels when communicating with anxious patients, says new research published in the September issue of Clinical Simulation in Nursing.
With anxiety as the most prevalent mental health disorder in the United States, nurses do not feel adequately prepared to care for anxious patients, according to the research by Tanae A. Traister, assistant dean of Nursing & Health Sciences at Pennsylvania College of Technology.
Traister researched the use of virtual reality simulation in nursing education to help lessen nursing students’ own anxiety in dealing with anxious patients.
Traister conducted the study by recruiting students in Penn College’s pre-licensure associate degree and bachelor’s degree RN majors to completed two full-immersion virtual reality simulations involving a patient suffering from anxiety.
Traister evaluated the students’ own anxiety levels before and after the first simulation and again after the second to identify and measure their anxiety knowing they would be caring for a patient experiencing acute anxiety.
"The goal for my research was to contribute to the currently small but growing body of knowledge surrounding the use of full-immersion virtual reality simulation in nursing education," Traister said.
Penn College’s nursing program, like other nursing schools, began incorporating virtual reality simulation into its nursing coursework during the COVID-19 pandemic, when nursing students were unable to do in-person clinicals in hospitals and had to rely on simulation to provide students with the education they needed. And although nursing students are returning to in-person clinical rotations, simulation labs remain an important part of their education.
As nurses spend the most time with patients, they are most likely to encounter those suffering from high anxiety, according to Traister.
"Unfortunately, many anxiety sufferers go undiagnosed or untreated because of a perceived negative societal stigma, personal embarrassment, or normalization of symptoms," Traister wrote. "Those who attempt to seek treatment for their anxiety symptoms may perceive their encounters with healthcare providers as unsupportive or dismissive; therefore, avoiding care."
However, nurses who are more comfortable treating anxiety-prone patients will have a more therapeutic nurse-patient relationship, the research notes.
4 nurse executives reveal how they are adapting to a challenging healthcare environment.
Until COVID-19 turned healthcare on its head, care models had not changed much since the early 20th century.
But now, nurse executives are finding new and more efficient care models to adapt to the current state of nursing shortages, workforce pipeline challenges, fewer physicians, increased patient acuity, and countless other challenges in today’s healthcare environment.
HealthLeaders talked with four nurse executives and asked each one, “What does practice redesign look like at your organization?”
Their replies have been lightly edited for brevity and clarity.
Associate vice president for advanced practice
Private Diagnostic Clinic at Duke University Health System
We started in 2010 in my practice of cardiology, and along with the cardiologists, we had a group of six NPs and PAs that had about 75 years of combined experience with high-quality training and yet, they were working far below scope, basically doing the work of a nurse.
We had an access issue because our next available appointment for a new patient was a month away, and that's not OK if somebody's calling because they're dizzy or because they have chest pain.
We received funding to hire nurse clinicians to form the hub of an interprofessional team consisting of four physicians, one APP, and the nurse clinician. The model that we chose for our patient population was that the APP would see return patients, acutely triaged patients, and hospital follow-up patients. This freed up the physicians to see complex patients new to our practice and establish a plan of care.
This met our aim of all members of the team working to the top of their scope of practice, while increasing access for our patients.
From there, it was so successful that it spread across our health system in all our ambulatory specialty practices. Each one looks a little bit different because each specialty practice is going to be different. For example, in dermatology, APPs might do general dermatology and the physicians might do the surgical subspecialty part of that.
As we move toward value-based care, we have to take care of lots of people, especially as Medicaid is expanded throughout our country. My mantra is everyone on the team will be working to the top of their scope and that means the top of their license, their board certification, and their training, and that aligns with how we attract and engage and retain the best talent. It’s worked. We have amazing people who come to work with our organization, and they stay.
Chief nursing officer and vice president for patient care
Brigham and Women’s Faulkner Hospital
We started with the fact that we have too many patients and they have to come up from the emergency department when we're overwhelmed and can't provide care. And we started weighing in: Can they go in many different arenas?
And we decided it would be hallway spaces, but what hallways? Can we use conference rooms? Can we use vacant office spaces? We had to look at what was there and what met potential code opportunities for necessary requirements: Can beds fit into them? Can we get suction and oxygen, etc., available to those patients?
Once we said, “No, it has to be in these hallways in these areas,” then we asked, “Will this fit for all of our units?” And the answer even at that was no. We needed to, again, be innovative and go back to redesign.
So, on one unit, we have larger rooms, so we knew we could double up rooms, and we did. We’ve also put potential hallways under certain criteria meeting certain trigger points, so we could bring up beds, put them in halls, and decide which patients are appropriate to be put there.
Executive vice president and chief nurse executive
Indiana University Health
As we are entering in this work, we want to be thoughtful about how this is going to be different. A lot of times we trial things, but then we don't always get good data for what works or what doesn't, or we try to wait for the perfect model before we would implement anything because, quite frankly, the stakes are high and there is that innate fear that you're going to make a mistake that's going to cause you not to give quality care.
So, we created a vision statement for care model redesign, and then associated guiding principles: we wanted to engage our frontline team members, we've encouraged autonomy, rapid testing, and frequent evaluation. We’re trying to get a little more agile and nimble with what works and what does not and spread that so we share the lessons learned across our system.
We have a lot of different pilots going on in the system and we have a research study that's going on with five innovation units across the state, so we're not waiting for perfection on this, but once we communicate the vision and the criteria, we developed some change management tools for our frontline leaders to help with how to go about this.
Part of the mindset shift for this has been to lead more through guiding principles that are not a one-size-fits-all. There were some who were probably waiting for me as the chief nurse executive to say, “This is the care model at IU Health; now everyone go out and implement this and everything will be fine.” I don't think that you can lead this way. I could have done that, but I think it would have failed miserably.
We’ve done some things not considered innovative now, but they were cutting edge at the beginning. We utilize LVNs [licensed vocational nurses], but not in an assistive supportive role; we use LVNs for part of our primary care model, to have them taking patient assignments, taking fuller extent of their capacity here in Texas to evaluate patients and take care of patients.
We’ve implemented and designed an LVN internship, residency, and fellowship program, recognizing that this entry to practice has not really been tapped here locally or in the region, as an opportunity to grow individuals in that space.
We put them on a path where we will pay them to get their RN through a transition program with a local community college partnership here, and that has been very successful. We had 15 individuals in our first cohort that we were able to upskill and get them onto the path to become an RN.
We are looking at our skill mix, as everyone in the country is looking at different skill mixes and how you can have unlicensed assistive personnel in the clinical environment. We redesigned some of our models where we're increasing our UAPs [unlicensed assistive personnel] and having them take on the care, feed, and activity roles where their sole focus is supplementing that aspect.
In addition, we are working further down the pipeline. We recognize that before COVID we were focusing on older adults—high school graduates, adults in the working world, or college kids trying to work toward the healthcare career. We've lowered our hiring limit to age 16. We are working with our local independent school district to create an Explorers program where not only do they get to come into the hospital and experience different areas of healthcare—different roles and disciplines—but also the ability to work as an unlicensed assistive personnel during their downtime that enables them for our employee benefits, such as tuition assistance.
We're getting these individuals plugged in earlier and getting them on a healthcare track so they're not waiting until they graduate to figure out what they want to do, and we as a hospital support them so that gives them a little bit of an edge when it comes to applying for whatever program they want to get into.
*Bredimus is a contributor to the HealthLeaders CNO Exchange Community,an executive community for sharing ideas, solutions, and insights. Please join the community at https://www.linkedin.com/company/healthleaders-exchange/. To inquire about attending a HealthLeaders Exchange, email us at exchange@healthleadersmedia.com
Pennsylvania nurses, however, must wait for criminal background check authorization before receiving a multistate license.
RNs and licensed practical/vocational nurses (LPN/LVNs) from 38 states and two U.S. territories who hold multistate licenses through the Nurse Licensure Compact (NLC) will be able to practice in Pennsylvania beginning September 5, 2023.
The compact allows RNs and LPN/LVNs to have one multistate license, with the ability to practice in person or via telehealth, in both their home territory/state and other NLC states.
The move is expected to help address Pennsylvania’s severe nursing shortage and increase healthcare access—both in person and via telehealth—for patients across the commonwealth.
Pennsylvania’s General Assembly authorized its NLC participation with Act 68 of 2021, signed into law by former Gov. Tom Wolf.
"This is a critical first step in the full implementation of the Nurse Licensure Compact," said Al Schmidt, secretary of the commonwealth. "The Department of State continues to work diligently with its state and federal partners to satisfy the preconditions necessary to fully implement the NLC."
Among those preconditions is certifying to other compact states that Pennsylvania's State Board of Nursing has performed an FBI criminal background check on Pennsylvania applicants, a process that requires FBI authorization. The Department of State has sought this authorization and is awaiting a response.
Indeed, licensure requirements are aligned in NLC states, so all nurses applying for a multistate license are required to meet those same standards, including submission to a federal and state fingerprint-based criminal background check.
Once that occurs, Pennsylvania's State Board of Nursing will issue NLC multistate licenses to Pennsylvania nurses, allowing them to practice in compact member states and territories, Schmidt said.
A multistate license eases cross-border practice for many types of nurses who routinely practice with patients in other states, including primary care nurses, case managers, transport nurses, school nurses, hospice nurses, and more. Military spouses who experience moves every few years also benefit from the multistate license.
The NLC also benefits facilities that might have an acute shortage in one of their units to recruit a nurse for that unit or shift around their resources if they're an interstate facility and moves nurses between different states.
"Anything we can do to attract nursing talent to the state is a win for patients and the commonwealth," said Debra Bogen, MD, acting secretary of health. "Participating in the nursing compact overcomes a barrier to attracting that talent and building our state's healthcare workforce."
Mercy Medical Center will provide clinical placements at its downtown Baltimore campus, in addition to other resources and support.
Loyola has formally requested and is awaiting a recommendation for implementation from the Maryland Higher Education Commission (MHEC).
The four-year undergraduate BSN program would be available for new incoming Loyola undergraduate students in the fall 2025.
"Loyola’s mission to prepare graduates for lives of meaningful professional service and leadership calls us to address the critical need for new nursing graduates in Maryland," said Terrence M. Sawyer, JD, president of Loyola University Maryland. "Through this step, Loyola would help address the critical shortage of registered nurses in Maryland and the nation."
A report commissioned by the Maryland Hospital Association projects a shortfall of 13,800 RNs by 2035 in Maryland alone. Additionally, the Bureau of Labor Statistics projects an average of 203,200 openings for RNs each year across the United States through 2031.
Loyola already enrolls about 600 pre-health students each year who take its natural and applied sciences courses, which include biology, chemistry, forensic studies, and pre-health sequences.
"Loyola is a proven leader, known for graduating young people who excel in the sciences. At our Jesuit, Catholic liberal arts university, our students also benefit from a rich, values-based core curriculum that helps them become the ethical, compassionate, analytical leaders needed in healthcare," said Cheryl Moore-Thomas, PhD, NCC, provost and vice president for academic affairs.
"This proposed major is a natural extension for Loyola, especially as our Jesuit mission calls us to graduate leaders who are capable of meeting the needs of our community," she said.
Loyola and Mercy have a shared history as faith-based, mission-driven institutions committed to the city of Baltimore.
"As a community teaching hospital, Mercy is excited to partner with Loyola University Maryland to begin building a leading nursing program amid the ongoing nursing shortage in Maryland," said David N. Maine, MD, president and CEO of Mercy Health Services.
"Our shared mission of service, core values, and Catholic identity form a strong foundation to build an exemplary academic program," he said. "This promising collaboration will generate a new pipeline of high-quality nurses."
Karmanos employs employment strategies typical of most hospitals—sign-on bonuses, competitive salaries, and additional education—but its mission of cancer care seems to resonate strongly in the nurses who work there, Carolin says.
Indeed, as a National Cancer Institute-designated comprehensive cancer center, Karmanos can offer exclusive treatments, as well as clinical trials, multidisciplinary teams of cancer specialists, and cancer prevention programs.
HealthLeaders spoke with Carolin about why nurses gravitate toward its mission of curing cancer and why, as Carolin has said, "Cancer nursing is nursing at its best."
This transcript has been lightly edited for brevity and clarity.
HealthLeaders: How do you apply your organization’s mission of curing cancer when recruiting nurses?
Kay Carolin: I have always felt lucky that we are so mission-driven because it helps when times are really tough. Our mission is to lead in transformative cancer care, research, and education through courage, commitment, and compassion. The vision is a world free of cancer. Our nursing vision is to provide therapeutic, cost-effective nursing care to persons, families, and communities across the continuum and to be a regional, national, and international leader in oncology nursing, patient care, and education, through courage, commitment, and compassion.
People don’t come into cancer nursing without [an impetus]. When I sit down with brand new grads who are coming in, or with nurses who have been here for a while, people come to cancer nursing for a reason, and I have found that it often has to do with someone that they loved a lot, or something that they saw that was very powerful, and it resonates with them. And they do nursing with that in mind.
We are a comprehensive cancer center and academic medical center, so some of the cool stuff is that you’re participating in research, you're seeing cutting-edge stuff, and you have an opportunity to be part of what's coming next. We're involved with nearly 70% of all new drugs approved in the United States for cancer treatment, and we typically offer those treatments to patients up to a year before they're commercially available, and that is really exciting. So, there's that whole thing of being part of something bigger than yourself.
Getting back to what I was saying earlier, when we talk about being with patients through the continuum, we really mean through the continuum. We do a lot with bone marrow transplants, so we see patients for periods of time as we’re getting them prepped. Then they come in for transplant and they may be here for up to six weeks and we’re with them all the time in these powerful, intimate periods, so you have these relationships, and that's often what keeps you going during tough days, because there's somebody there that you have a commitment to and that you've come to care for.
Kathleen "Kay" Carolin, chief nursing officer, Karamos Cancer Hospital / Photo courtesy of Karamos Cancer Hospital
HL:What is unique about being a nurse in a cancer hospital as compared to an acute-care facility?
Carolin: When we think about an intensive care unit in an acute-care hospital, the intensity of it can be diffused a little bit because you get varied patients with pneumonia, COPD, vascular surgery, or diabetic ketoacidosis. But the patients we see in our intensive care unit are always cancer patients. There will be cancer patients who are 19 or in their 20s or 30s, or cancer patients who have young kids at home.
That’s a real intensity of care and yet, it’s the opportunity to do the journey with your patients and their families through the continuum of care. To be the person who says, "OK, we've taught you how to take care of this, we taught you what you need to know, but if you get confused or if you get scared, you have my number and I'll talk you through it. I'm here. I'm going to keep you safe."
It’s a different kind of nursing care. I’m not saying it's the panacea and we have it covered on recruitment and retention, but it is easier to speak to it. It’s easier to talk about it, and I'm grateful for it.
HL:What kind of nurses gravitate toward working in a cancer hospital?
Carolin: Most of them have had cancer in their lives, so it means something to them to take care of these patients. It resonates. I can't tell you how often I've had people talk about their grandma that they loved so much.
I’ll tell you a couple of stories. I've got a wonderful nurse who is a childhood leukemia survivor and I remember saying, "How did you have the courage to have gone through this as an 11-year-old with all the fear of that experience and then come back full circle and work with patients needing bone marrow transplants?" That’s incredible courage. It’s facing your fears day in and day out.
I have this amazing nurse who was an attorney and his young wife died of cancer. He had an “Aha” moment and looked at the meaning of his work and his life and went back to school and became a nurse. To watch him provide care just blows you away.
These nurses take such great care of the patients, and they do the journey with them. It's pretty profound to watch them.
HL: You have said, "Cancer nursing is nursing at its best." What do you mean by that?
Carolin: I don’t think any nursing is easy, and I've done a lot of different kinds of nursing. There are a lot of easier ways to make a living than to be a nurse, so if you're a good nurse, you love what you do. But cancer nursing is nursing at its best. I think that is absolutely true.
HL: Can you provide some examples of extraordinary cancer nursing?
Carolin: It just goes on and on. I think of the patient who had been here who didn't have any family and it was her birthday. I saw her primary care nurse come in with her son on her day off with balloons and magazines. I said, "What are you doing here today?" and she said, "It’s my patient’s birthday and she doesn't have anybody, so we've come."
I think of the young man who we knew was going to die probably that day and didn't have any family. And I said to his nurse later, "What are you doing here? I thought your shift was long over," and she said, "Well, I’m just staying. I don’t want him to die alone."
During COVID in the ICU, we had a patient—she was a physician with lots of anxiety—and she was passing. That was when COVID was really bad, and we weren't letting people in, and I had two nurses who tag-teamed it and who never let her be by herself. One of them was always in there with her holding her hand, doing the journey with her.
Those are just some little stories, but they happen every single solitary day. And then there's all the joyful ones, too, all the miracles that you can't even believe. We do so much celebrating, too.
Nurse hiring and retention now entails upskilling, collaboration, and revolutionary solutions.
As hospitals and health systems continue to seek solutions to workforce staffing—particularly nursing—many are veering away from traditional methods and embracing new ways of attracting and retaining employees.
Though COVID-19 took an extreme toll on the healthcare workforce, nurse and other clinical leaders are creating and piloting efforts to maintain staff to provide quality care for patients, Robyn Begley, CEO of the American Organization of Nursing Leadership (AONL) and chief nursing officer and senior vice president of workforce of the American Hospital Association (AHA), told HealthLeaders.
“Especially the last six months, hospitals, health systems, and nursing leaders that I interact with every day, are working on solutions for the now, near, and far,” she says. “What I mean is, ‘now’ are actions and activities that are going to have impact right away. With the ‘near’ and ‘far,’ the actions will start right now but might not have impact for a longer time.”
Many of those actions involved upskilling, collaboration, and nontraditional support, as these examples provided by Begley and AONL show.
Upskilling
Geisinger, a Pennsylvania healthcare system, is filling critical nursing roles through its Nursing Scholars Program, which awards $40,000 in financial support to each employee pursuing a nursing career, providing that nurse commits to working five years as a Geisinger inpatient nurse. The program is open to any employee who is not already an RN, physician, or advance practice provider, and begins on day one of their employment.
UCHealth in Colorado plans to attract and keep employees through its $50 million investment in its Ascend leadership program, in which it will pay for several degrees, including bachelor and master’s programs in both clinical and behavioral health. The investment also fully funds several certifications, along with high school completion, college prep courses, and language classes for current and prospective employees.
Collaboration
Allegheny Health Network, based in Pittsburgh, launched Work Your Way, a mobile internal staffing model that provides flexibility for nurses to choose how and when they want to work. Mobile nurses work rotational, six-week shifts in emergency medicine, telemetry, critical care, and perioperative care at eight of AHN’s 14 hospitals. Those traveling more than 50 miles to work receive premium pay and mileage reimbursement; those traveling more than 75 miles also receive lodging reimbursement. Options to work weekends and night shifts are included.
A partnership between Mary Washington Healthcare in Virginia and Germanna Community College onboards two cohorts of as many as 60 nursing students each year through its Earn While You Learn program, in which those students work 12-20 hours a week using a clinical rotation model. The program includes an additional nursing school as well as mentor models for nursing assistants.
Nontraditional support
Bozeman Health in Montana, the city of Bozeman’s largest employer, has invested in 100 units in a future workforce housing complex to provide employees with affordable rentals. The first phase is reportedly expected to be completed by the end of 2023.
Northwell Health offers eligible employees as much as $5,000 in financial assistance to purchase a home on Long Island.
The Johns HopkinsLive Near Your Work program offers grants of up to $17,000 toward a down payment and closing costs associated with buying a house in designated city neighborhoods after completing eligibility requirements.
Pilot program is teaching U. of South Alabama Health University Hospital nurses to support peers in distress.
This story has been updated to clarify that the Pulse on the Nation’s Nurses Survey Series was conducted by the American Nurses Foundation, not the United Health Foundation.
A pilot program designed to identify, respond, and reduce stress reactions for nurses will help to “create a sense of community and provide nurses with emotional resources so they can feel empowered and supported,” says Sherry Fryman, RN, MSHA, chief nursing officer for University of South Alabama Health University Hospital, one of four pilot sites.
Stress First Aid, a peer support framework first developed by the U.S. military for battle-scarred soldiers, teaches individuals, either peer-to-peer or through leadership, how to identify stress in other individuals, in groups or teams, or even at the organizational level. It is being piloted at four U.S. healthcare sites, including University Hospital in Mobile, Alabama, funded by a grant from the American Nurses Foundation, the philanthropic arm of the American Nurses Association (ANA), and the United Health Foundation.
"Stress First aid is a set of knowledge and skills that we use every day to gain control of our experiences with stress," said Catherine Gaudet, MSN, RN, CNL, a clinical nurse leader at University Hospital and a co-champion of a new pilot program. "Stress can be necessary and helpful, but if stressors are not dealt with effectively, long-term mental and physical impacts can occur."
Nurses have suffered greatly from immense stress and burnout caused by the COVID-19 pandemic. The American Nurses Foundation's Pulse on the Nation’s Nurses Survey conducted in November 2022 found that 64% of respondents said they felt stressed, 60% said they were frustrated, and 57% reported feeling exhausted.
The pilot program’s purpose is to identify and reduce stress reactions before they develop into lasting issues. Upon identification, it suggests actions that can be taken to deal with that level of stress.
Helping nurses to speak about their stress/burnout using a common language normalizes talking about it so they can provide support to their peers.
How it works
Stress First Aid provides a scale consisting of colors—green, yellow, orange, and red—to describe stress levels.
Green means everything is proceeding smoothly, and the individual is in control, with optimal functioning. As stress builds, an individual may experience mild distress and feel irritable (yellow), severe and persistent distress (orange), and finally, stress causing life impairment (red).
"By giving stress a color, we allow nurses to express where they feel they are at on the ‘stress continuum’ without assigning any blame or shame for feeling stress," said Amy Campbell, DNP, RN, assistant professor in the USA School of Computing and a co-principal investigator on the project. "Similarly, this language also allows their peers to immediately identify steps they can take to better support a peer in distress.”"
At University Hospital, the program is still in its initial stages. Gaudet and another champion, Chris Clark, RN, a clinical nurse leader, are training nurses in their units how to respond to others in stress, including observing and listening, getting help, or simply covering someone’s duties while they take a break.
"This program gives you the ability to identify what stress level you’re in and, more importantly, what stress level your co-workers are in. It lets us take the temperature of the unit," Clark said. "It’s a learning language, so we can help each other."
This story has been updated to clarify that the Pulse on the Nation’s Nurses Survey Series was conducted by the American Nurses Foundation, not the United Health Foundation.
