What’s Next for The Future of Nursing?

At the Core of Care

Published: June 14, 2021

SARAH: This is At the Core of Care, a podcast where people share their stories about nurses and their creative efforts to better meet the health and healthcare needs of patients, families, and communities. 

I'm Sarah Hexem, Hubbard, Executive Director of the Pennsylvania Action Coalition, and the National Nurse-Led Care Consortium. 

We're launching a new access to care special series. And joining us here to kick it off are Regina Cunningham and Marcus Henderson. Both served on the committee for the recently released future of nursing 2020 to 2030 report from the National Academy of Medicine. They'll be sharing with us some of the key findings and recommendations to come out of the seminal study that's dedicated to charting a path to achieve health equity. Regina Cunningham is the Chief Executive Officer at the hospital of the University of Pennsylvania, as well as an adjunct professor and assistant dean at Penn School of Nursing. Marcus Henderson is a psychiatric mental health nurse and serves as the charge nurse of adolescent services for the Fairmount behavioral health system. He's also a lecturer at Penn School of Nursing. Regina and Marcus. Welcome to At the Core of Care.  

Regina and Marcus, welcome to At the Core of Care.  

REGINA: Thanks, Sarah.  

MARCUS: Thank you, Sarah.  

SARAH: So, to start our conversation about health equity in the United States, let's first get a sense of how our country compares to other developed nations? When it comes to rates of poverty, income inequality, mass incarceration, we do seem to be up there. 

REGINA: Yes, absolutely. I think we all know that the U.S. spends an incredible amount of money on health care more than any other developed nation, but we don't get a tremendous amount for that money. And as you mentioned, we do have extremely high poverty rates. We have income inequality that's really substantial in this country. And we have some of the poorest health outcomes of any of the developed nations. So, when you look at us compared to other OECD nations, our outcomes look pretty bad. I think one of the factors in the U.S. and something we go into in a lot of depth in the report is really what other than medical care really influences people's health outcomes? Right? And so, there's a tremendous discussion about this, from our research that's published in the report. And we know that beside for medical care, there are lots of other factors, you know, that influence health outcomes, including where people live, what kind of jobs they have, and what kind of income they have. So, sort of their socioeconomic status, their level of education, certainly is an important influencer and access to things like you know, can they get healthy foods? Can they maintain a healthy diet? Do they have access to that in the neighborhoods where they live? Do they have ways to get back and forth to healthcare, reliable transportation, you know, reasonable safe housing? Those are some of the factors that we really go into in a lot of depth of what we call the social determinants of health as well as social factors that we know really influence what happens to people in terms of health, and their access to healthcare services.  

MARCUS: And it's also inclusive of the way that structural racism impacts the lived experiences of American citizens. I think for me, it's absurd to think that in the United States, because of where you live, how much money you make, what level of education you have, what type of job you have, what racial and ethnic background you're from determines how long you’ll live, and how healthy you'll be. And piggybacking off of Regina, the social determinants of health, we think of it more of a population level. So this is how we as a society, a community, a government distribute resources across various sectors, education, housing, transportation, and how we also distribute those across different population groups. And at the individual level, it's about whether or not I have the ability to keep a roof over my head, for me and my family, put food on the table, get to and from a health care provider, have access to a quality education, not experience racism and discrimination when I walk out my front door, into my school, into the workplace, or anywhere in my community, and have a job that pays me enough to have all of these things. So the biggest difference is in how much an individual versus another has to worry about these issues because of where they live and where they work.  

SARAH: So can you give us an example of how someone from a high and low socioeconomic status might address social determinants of health in their lives? 

MARCUS: I would add an extension beyond the traditional social determinants that we talk about also thinking about social support, do I have the family with the resources and ability to support me in my efforts to work to raise my children, to be a productive member of my community? If we think in the context of COVID-19 communities of color, parents who are essential workers having to leave their children at home to experience schooling by themselves, losing grandparents, or not having the ability to have those social support systems around in their community in their school to kind of also support their everyday living. So when we think about the differences between high-income families and low-income families, it's also thinking more beyond the nuclear family that we often think about. 

REGINA: Yeah, I think that's a really important point, Marcus, and, you know, just going back to living conditions, and you don't have to look any further than COVID-19. Right? So we saw in very, very sharp focus, the inequities really laid bare around some of the social factors, you know, that Marcus's talking about so that really illustrated many of the issues that we talk about in the report. 

I want to go back to the structural racism, piece of things, which, you know, Marcus talked about very eloquently before,  

We did spend a lot of time as a committee focused on this. You know, the research really shows that that is one of the most important variables in determining health outcomes. So we talked a lot about structural racism, cultural racism, and discrimination, which Marcus mentioned before. But really the most important determinant of those three was thought to be based out of the research findings was really around the structural racism issues that really come into play in shaping outcomes of health. 

REGINA: I think one of the things that we identified in our research on the report was that structural racism has contributed to this very high incarceration rate in the United States, which really exceeds the rates that we see in other countries. And what the research shows is that people who are incarcerated have greater chances of developing chronic health conditions, you know, and some of that's related to the factors of being incarcerated. So like the conditions, the impact on long-term physical and mental health, and things of that nature. 

SARAH: But you know, I recall that in the first Future of Nursing report, the 2010 report, it wasn't really until 2015, that diversity was pulled out as we really need to have a recommendation here. And there have been conversations about, you know, why wasn't it more prominent in that first report? Why wasn't it its own recommendation? And some discussion about was there not enough research? You know, because that's something that the National Academy of Medicine really looks to write that that body of research? Can you speak a little bit to the research that you found, is it that in the last 10 years, this body of research has developed? Were we not paying enough attention to it before? I would love to hear your perspective on that. 

MARCUS: I think it's the latter. It's that we haven't paid enough attention to it. I mean, Dr. David Williams, co-chair of the committee has dedicated his life's work to documenting the impacts of racism on health. So it's that we weren't in a place as a profession, and as a nation, to call out racism as a determinant of health. And that's one thing that this report does. And when we talk about diversity, it goes beyond that. It's about equity and inclusion because I can hire a person from a diverse background. But that doesn't mean I treat them equitably. And that doesn't mean I make them feel included. So when we use the word diversity, we need to ensure that we're also talking about equity and inclusion. And that's what this 2030 Future of Nursing report really talks about. It doesn't call out only racism as a determinant of health. But it also talks about racism in nursing and how nursing has been complicit. And that's what's really important here that we, as a profession of nursing, are saying that we need to address this because if we don't address racism as a root cause to health inequity, we're never going to be able to achieve health equity and the vision that we set out for in this report. 

REGINA: I would underscore exactly what Marcus said. We did identify research evidence in the area of racism in nursing, a number of, you know, important papers that were written about this. But I do think those have been more recent. I think it's exactly what Marcus said, I don't think that we were in a place or at a time when we wanted to pull it out as explicitly as we do in this report. And I think the events in the nation over the past year, really set the stage and created an important platform for us to be very, very deliberate in the way that we approach that as a committee and I think that is a really, really important component of this report, for sure. 

SARAH: And thank you for providing that broader overview and the future of nursing report, it's the why of why nurses are doing what they're doing. And Marcus, I know that you started to talk about nurses being complicit in these structures and our healthcare systems, I think being complicit. As we look at health equity, right, so turning toward the positive, creating that that culture of health equity of healthcare equity, how do nurses fit in?

REGINA: I think that nurses are very well positioned to play a really, really important role here. And that's what we're calling out in the report, that's part of our vision to really empower nurses, to begin to use their skills and knowledge to make a difference in this arena, which is huge. It's not really a new thing for nursing, to be honest with you, if you went back in time, you’d see plenty of really profound examples of nurses addressing social determinants of health. So, you know, we do address some of these, although not all of them, certainly in the report, but nurses have a very holistic way of looking at the people they're caring for the communities they're serving. So they look at the whole person, not just really the sort of immediate needs that are in front of them related specifically to their health. But they look at things like what is their home environment like? What do they have? Do they have access to the right foods that can help them to maintain a diabetic diet, or whatever it is that's required. So nurses have a very, very long, and I think, very rich and meaningful history of working in this space. There's definitely more that we need to do in order to bolster nurses to be able to continue to do that and to expand their work in this space, to really drive health equity and we have to improve access to health services for all people. 

MARCUS: And for me, the question really is not where do nurses fit in? But it's really where do nurses not fit in? Because the answer is shorter, because nurses fit in everywhere. And that's what this report lays out, that you don't have to only be a nurse in a traditional medical setting to address health equity. You can be a school nurse, a public health nurse, a homecare nurse, a nurse that works for the housing authority and nurse that works for the transportation department, fill in the blank, nurses are needed everywhere, because of that perspective, that holistic perspective that we provide, grounded in the individual's experience to improve their life and quality of life in their community and where they live. And we discuss that in the report, we talk about all the different ways through leadership, through the workforce through education, you know, pick a chapter, and we discuss where nurses fit in and why nurses are poised to do this. But to the point you mentioned earlier about this being a report for nursing and being more than that. And that was something we as a committee talked about often. Yes, this is a report on the future of nursing, but it's a report on the future of health, the future of communities and population.  

SARAH: And so what are some of the big goals in this area? Can you provide any examples of some of the goals that this report sets forth? 

REGINA: One of the key issues and recommendations that we talk about is lifting scope practice barriers, right? First of all, scope of practice barriers, or practice barriers can influence Nursing at a variety of different levels. We tend to think about it more at the Advanced Practice level. And that's, that's the example that I will use. But it's not exclusively restricted to advanced practice providers. But you know, one of the issues is that we have called for scope of practice barriers to be relaxed. And we have good evidence from the states where that has happened, as well as the District of Columbia, right? We know that from those states, first of all, there are more advanced practice registered nurses working in those states, because they have more flexibility in what they are able to do, they're able to do the things they're actually educationally prepared and trained to do. And so that becomes an important attractor for those resources to be in that state. But we also know that access to care is improved in those states, we know that the quality of care is improved in those states, in the 27, states, that do not still have a practice authority, we know that there are a lot of barriers to quality of care and barriers to access to care. And, you know, one of the really interesting things that happened during the pandemic, that is worth paying a lot of attention to, as we move forward was that many of the states that have restrictive practices relaxed those, either they, you know, completely removed scope of practice barriers under sort of emergency operating procedures for states had waivers around certain things. For example, the Commonwealth of Pennsylvania had, like over 100 waivers, a number of those before those were related to the advanced practice scope. And so it's a natural experiment in many respects, right, because we can look at the outcomes of the states where those waivers or relaxation of the practice, you know, restrictions were put in place and see what the outcomes were, there was an early study that's already come out. But we didn't include this in the report, because it's new. But it's come out already at of a Midwestern state, where the mortality rate was lower when they relaxed the barrier, and I think we need to play we need to pay really close attention to the outcomes that we see related to, you know, the COVID-19 changes in legislation that we saw some of the states that relaxed their barriers have already made that permanent, but others have not. And so we'll have to be watching that closely and see what happens. Our recommendation is that they should leave them in place. But we, of course, don't know yet whether they will or not. 

MARCUS: I think another big goal that the report establishes is talking about payment, and how are we paying for health equity. And we really call for establishing sustainable and flexible payment models that support nurses to do exactly this work. And we call out specific attention to school nurses and public health nurses. These are two specialties that have been undervalued and under-recognized by our system, but contribute leaps and bounds to promoting health and health equity in our communities. So this report really calls attention to we need to think differently about how we pay for nursing services, and how we value nursing care. Because nursing needs to be off of the expense side of the ledger, where we've spent too much time. And this report is calling for a shift in that language in the way that we view how nursing care is provided and where it's provided and how we pay for it. 

REGINA: Yeah, absolutely. We have a chapter dedicated to that looking at, potential for innovative models. I just underscore exactly what Marcus said regarding the public health school nursing situation. There's an incredible lack of school nursing, and many times, that's the only resource that children might have that's health-related. So finding ways to value those roles to a greater extent and fund the work that's going on in that context is a critical recommendation of the report. 

SARAH: And I think it speaks to, Marcus earlier talked about the cross-sector nature of this work and unfortunately school nursing is sort of the victim of cross-section of silos, right? So we have, you know, education and public health and health care. And despite being critical resources in all three of those areas end up sort of as a, you know, not a priority. So it was such a great call out in the report to recognize that school nurses have to be a priority, they should really be a priority across all three areas.

MARCUS: When we take nurses out of schools, we're not helping children, stay in school, manage their social, emotional behavioral needs. And it's not only about supporting the child, it's about supporting the family, sometimes that school nurse is the only connection for a family to get food, to find shelter, to get access to a primary care provider, or whatever it might be. So school nurses plays such a critical role. And I've learned so much more about the importance of school nursing because I take students into public schools in Philadelphia. And I get to see firsthand the impact that a school nurse has on a child and on a population. My second point, as a goal of this report, is we're calling on nursing to do a lot. We're calling on nurses on top of everything else that we do, you're also now responsible for addressing social determinants of health and social needs. So we talk a lot in the in one of our chapters about well-being and how do we support the well-being of nurses and making sure that nurses are supported to do their job? Because if we don't get the support that we need, how can you expect us to go out in our communities and do that work. And that's a really important goal that this report sets up. And the National Academies has had previous reports about well-being. But it's all been words with no action. And I think that this report, in combination with other work the National Academies is doing is keeping that at the forefront, especially in the context of COVID-19. 

REGINA: I wanted to just add something about the school nursing as well. You know, one of the things that our committee, obviously reviewed all the research evidence on and you know, the topics that we cover in the report. But we also did, you know, field research, I mean, we also went out and talked to people and visited different programs that were, nurse-led kind of interventions or programs that were really making a difference in terms of the social determinants of health. And we saw a couple of different models of school nursing, in place that were just absolutely inspiring and amazing in terms of what these nurses were doing. But I would say that one of the things that I didn't appreciate before we did this research was the incredible complexity of the populations, the children they're dealing with. I mean, I would say that some of these children have very, very complex healthcare needs both physical and behavioral health, as Marcus pointed out. It's a very, very complex role in many respects. And I think that in and of itself is somewhat underappreciated. So just wanted to add that to the discussion. 

SARAH: I really appreciated both of you calling specific attention to the mental health needs of students and how that really does often fall on school nurses. It's something that we heard from school nurses early in the pandemic, we had done a few episodes, sort of right when the pandemic started, and we had reached out to school nurses. And that was something that they really called out right at the beginning. And we recently followed up to say, what does it look like now? What are we hearing, so stay tuned for that, that actually is going to be addressed in our access to care series as well.  

So I definitely want to move us to talking about how we sort of like cultivate these skills.  

I’m wondering if you could speak a little bit about other ways of increasing nursing capacity. And what's coming to mind looking at nursing compacts, looking at telehealth, national nurse identifier systems, I know that has a relationship to the to the funding piece as well. What are you seeing as promising practices in that space and looking at removing some of the barriers in health care more broadly? 

REGINA: Well, we can talk a bit about the nursing licensure compact, which is an opportunity. There are I think 35 states now that have participated in the nursing licensure compact, which essentially allows nurses who meet the criteria. And it could be registered nurses, or I believe licensed practical nurses as well, but not advanced practice registered nurses, not yet, although that's in the sort of talking development stages. But what it does is allow multi-state licensure, which is important. You know, in terms of things like telehealth, which you mentioned, right, because it provides access to services particularly in areas that might be geographically remote, or in other states across state lines, which is important in places like New Jersey, Pennsylvania, which are so close or other states that are configured, geographically in proximity. It allows that flexibility for nurses to be able to practice across state lines. And so that is I think, something that has been done to help address the barriers as well. 

MARCUS: Thinking about how are we transforming nursing education to also increase that capacity? So what do we really need to focus on? And what do we not need to focus on? Or where do we shift and put that onus on the employer to ensure nurses are being trained with those skills on that end and so we can focus on some of those more core competencies of sdoh, equity, population health addressing racism, and so many other topics within that foundational period when they're learning. To then enter practice is what I was thinking about how we increase capacity, because that's what we're lacking in right now. Nurses are saying I wish I had better training in social determinants of health, population health, mental health, complex care working with underserved populations. I wish I had better training in these areas, so I could do my job better. So one way that we increase capacity is ensuring that we're producing graduates who feel prepared and feel competent to perform their job no matter where they work. 

REGINA: I think you know, one of the things to building on Marcus's comment, it is a lot of information, nurses need the knowledge and the skill to be able to do it. So when we think about the nursing education piece, you know, we didn't find a lot of evidence about this being in the curriculum sort of across the board, right. So this does need to be in the curriculum so that nurses received the appropriate content. But it's not just the didactic content, which I'll talk about in a minute. But you can't keep to Marcus's point before just jamming in more and more and more into the curriculum. Right. So you have to figure out okay, what are other things that can come out? Are there things that are less relevant? How do you prioritize the curricular content? I'm not an expert in this at all. But how do you prioritize this so that you're preparing the future workforce in a way that they will feel confident and have the ability to do this effectively. The other piece about this, which we talked about in the report, and we thought was a critical component of this is that, you know, historically, our sort of historical approach to the educational process has been very much focused on traditional clinical settings, like the hospital, even ambulatory care is a stretch, most of the clinical experiences that people get are in the hospital setting, or maybe they have one sort of community health rotation. And what we're talking about is, in order for people to really understand how to work in this space, and how to drive the vision that we have outlined, they really need to have their clinical experiences in very different locations. So within the community, in housing projects, in prisons, in environments where they'll really get a sense, a very meaningful sense of how to what the impact of these, you know, social determinants are, and what are some of the things that nurses can be doing about them. So it's really calling for a major shift or major reframe of the way that we are doing both the didactic and the clinical education of the future workforce. 

MARCUS: And I think an important part there is that we have to stop viewing these topics as an add on the way we prioritize it is integrating it throughout the curriculum in a comprehensive way to ensure these topics are covered in every single course. That's how we produce graduates with the capacity to address SDOH and social needs. When we as an educational community, recognize that this lives throughout and not just in its one course, or one elective course that often we see in nursing schools. And quickly back to the capacity question, I was looking at the word telehealth, and I was thinking about something, you know, we're in this digital age, the use of technology is not going away. It's only going to increase, which has a lot of concerns with it when we think from an equity perspective about access, but also thinking the competencies and skills that nurses need to also keep up with that digital age. So what are the technical competencies necessary for nurses to keep performing their job when we're relying more on technology, AI, applications, patient monitoring devices, and all of those things? So also thinking about what we're using in practice? And how are we ensuring that nurses have the skills and ability to use those technologies and things that we keep calling for, for nurses and so many other health care providers to use? 

REGINA: Yeah, I think that world keeps on evolving, and it's evolving so rapidly, technology changes, just thinking about things in practice, that people are doing wearables, all kinds of things that, you know, keep on changing and transforming, you know, the way that things are happening in healthcare. So there does need to be space for that for sure. 

SARAH: Marcus, you talked earlier about we're asking a lot of nurses and I you know you correctly also saying that that we need to prioritize right that this isn't the add on that's how we do it. The report asks a lot of nurse educators to write so these are these. That's where the pipeline comes from. But concretely, what can nursing schools do in the next year in the next six months even to start to make those changes, what would that look like? 

MARCUS: So I think, for me, and, and I spoke to this earlier, first and foremost, the report calls out racism, not only how racism impacts health, but how nursing has been complicit. So if schools of nursing do not call out and acknowledge, and I'm going to quote, Dr. Kenya Beard here, acknowledging To what extent racism is operating within these spaces and institutions, then how are we going to intentionally meaningfully develop strategies to address these issues within schools of nursing. So for me that those actions are examining the curriculum, institutional policies, and practices, teaching strategies, how we allocate resources, how we distribute power, and how all of that in the context of racism, bias, and discrimination are impacting the learning environment, not only for students but also for faculty. Because we know that students of color and faculty of color, experience racism, discrimination, and bias in our educational settings. So we need to do in-depth examinations of how we perpetuate these systems, in order to move toward a more equitable and inclusive learning environment where students and faculty feel safe, feel welcome, have a sense of belonging, feel supported, have the mentorship, have the resources that support them socially, economically, professionally, academically. And against holistic admissions, holistic admissions is not something that's new. And we also talk about it in the report, the American Association of Colleges of Nursing has done a lot of work around holistic admissions. But again, it's not just about holistic admissions. It's about who serves on those admissions committees, who are the gatekeepers that are determining what students get in and what students don't. So you can move towards holistic admissions, but again, examining who is looking at the student profiles, and who is making those decisions, because the pipeline in nursing is before, is when students are in elementary school in high school. So what are the barriers and the structural barriers that we as schools of nursing place on communities, because of who we admit where we recruit, and what we do. And again, it has to focus on equity and inclusion, how we treat each how we treat individuals and how we make them feel valued in educational settings? 

REGINA: Absolutely, I think that was a perfect response, Marcus, and it covers so much. I do think, you know, we talked before about the curricular elements, the didactic and the clinical experiences, but I also think the faculty are so critical here, right. So we do talk about the need to diversify the faculty, we need faculty, who understand the, you know, the way social determinants of health operate, and how to how to contextualize all of that, and how to translate it all into, you know, a meaningful practice. And so that's those are skills and competencies that, you know, are very high level. And so we need to take a look at that in terms of our faculty as we think about the student body, but the faculty as well as Marcus mentioned. 

MARCUS: And another thing, we have to stop feeling this intense amount of ownership of who teaches nurses. So there are also regulatory barriers in place by state boards of nursing that determine who can teach nurses. So we're talking about health equity, racism, social determinants public health, we know that nursing faculty don't feel comfortable, nor have the companies cease to teach in these areas. But we're limited by regulatory barriers on who we can hire to also teach nurses. I mean, it's crazy that a nurse with a Master's in Public Health, but because they don't have an MSN is not able to teach public health nursing and a school of nursing. I mean, that's crazy. They're the expert. But because of these barriers, we're limiting not only in public health, but we're talking about health policy, finance all of these other bigger population-level topics on how we move the needle and advancing health equity. We need to kind of begin examining those barriers and how we can ensure that we have the faculty, not just nursing faculty, but interdisciplinary faculty from all backgrounds and disciplines who can support our efforts in this space. And the report also talks about some practical strategies that nurse educators can use now. In the education chapter, we have a section on discussing difficult topics where we provide strategies and recommendations, and references to say this is how you can begin talking about race and racism in your classroom. And it's okay to be uncomfortable. I think that's the biggest piece. And something that I've learned as an educator is that you have to be comfortable with yourself to being vulnerable and making that space, and allowing your students to teach you because we don't know everything.  

The experiential learning piece is so, so important, and, and to comment on the experiential learning piece, because I know that Regina had mentioned that about where we train nurses. And I've always taught in the community.

MARCUS: We have data that suggests that when we only talk about these issues in the classroom, that students were actually unintentionally reinforcing the biases and stereotypes for when these students enter clinical practice about vulnerable populations. So experiential learning is key to ensure that we're using the community as the teacher, that we're teaching students about health and health care beyond the walls of a hospital. And that's by taking students into libraries, public schools, prisons. As an educator, I teach Community Health Nursing, and I take students into those sites every day. 

SARAH: We're talking about bringing nurses out of out of the classroom, you know, even in the foundation of their education. How about when they enter the field? How do we how do we support nurses? How do we create an environment where they can be advocates for their clients, for their patients, for their community? What does it look like in the workplace? How do we foster that environment? 

REGINA: So I mean, we're calling on employers to really support nurses, no matter who those employers are, so they could be traditional or they could be in a community setting, schools, etc. Making sure that nurses are supported to do this work is an absolutely essential. Part of what we need to do moving forward. So I mean, there's lots of different ways that that could happen. Right? I mean, like, when I think about my own setting, I work in a traditional setting, there are nurses who are engaged in, you know, looking at assessing patients for social determinants of health, making sure that those things are happening. I think, to the comments that Marcus made before about the schools, I think healthcare environments also need to look at those issues, they need to look at racism within their structures, they need to look at policies, procedures, practices, that might be perpetuating, or endorsing some of the, you know, structural factors that have led to some of the challenges that we talked about in the report. So that's another thing that I think employers need to be accountable to do. So we call them out, in and make recommendations about them, addressing those issues and supporting nurses, we also call out the importance of employers of nurses to pay attention to the issues about wellness, right, and nurse well being. These are critical factors they're not new, I mean, COVID, 19, certainly brought them into sharper focus, but they in no way shape or form to COVID-19, create these problems. These problems have been in place now for decades, but they have not been addressed in a meaningful way by most employers of nursing. And so we do also call out employers to begin to take seriously addressing many of the issues that influence both the mental and physical health and well being of nurses. 

SARAH: I would love to hear more about recommendations included in the report about how employers can support physical and mental well-being of staff. And as you had mentioned, this is something that's been in other reports from the National Academy of Medicine. Are there specific call-outs in this report or specific things to nursing potentially? What are some of those concrete recommendations that you that show promise?  

REGINA: One of the things that we need to do is make sure that employers actually acknowledge and take these things seriously. Right. So they have to be aware of them and they have to put resources in place to support nurses. You know, one of the things that again, during the pandemic nurses were so taxed, incredibly taxed in terms of their response, we saw nurses step up all over. And you know, worldwide, really, in terms of their response to the needs that patients had related to COVID-19. I think, that also created a lot of a lot of additional stress for nurses, tremendous stress. I mean, you know, one of the things that we talked about in the report is the need for psychological PPE. In addition to personal protective equipment, thinking about that as a physical barrier. We also talked about it as, you know, as a psychological need. There was a huge need for psychosocial and psychological support for nurses and organizations need to allocate resources, in order to do that they need to recognize that need as something that has an important impact on outcomes, because we know that when nurse wellbeing is low, we know that medical errors increase, we know that many other outcomes are negatively influenced by that. And so I think employers need to recognize the impact of that, and to make investments and to use their voices, particularly nurse leaders within organizations, like my own role. I'm a nurse, but I'm functioning as the CEO of an organization to use your voice in order to, help other people understand the importance of doing things to improve the health and well-being of nurses, and to allocate resources in order to put programs in place. I mean, one of the things that we did, in the institution where I practice, Penn Medicine was to implement a program to help nurses as well as other clinicians with mental health issues that we're coming up for them during the pandemic, and there were a lot of them, and many, many nurses accessed that resource. And we also heard from nurses that just knowing that that resource was available, made a big difference for them in terms of their in terms of the way that they felt So things like that, I think are important for employers to be able to do. 

MARCUS: And I would add that nursing education as well, and we talked about this in the report within our well-being recommendation about integrating content about well-being and self-care early on. So when nurses graduate, they have an idea, or an ability to care for themselves, and then can adapt based on the resources that their employer would provide. So it's about ensuring from day one, when you enter nursing school, that we're prioritizing your health and well-being as we educate you, and as you transition to practice. So it's again, investing in those evidence-based programs providing the resources and support both in schools of nursing and in hospitals. But it's also about ensuring a culture of safety, and a culture of psychological safety. So in the quality improvement space, you hear a lot about a culture of safety, and a culture of blame. And we talk in the report about how there needs to be protections for nurses when they speak up, again, about poor working conditions about bias about experiencing discrimination or injustice or experiencing racism. So we also need to ensure that the mechanisms are in place to protect nurses that are doing their jobs, advocating for themselves, their colleagues, and their patients. which is which is extremely important. And I would also add much like the recommendations and strategies I discussed about education, it's taking it a depth examination of a hospital's culture, values, systems, and practices, and how and looking at how racism might be operating in that space. 

REGINA: I think another thing that we call out and Marcus your point about, including this early in people's education and preparation for the profession, we call out the need for nurses to recognize their own role in assuring their own mental health. So that's also part of the equation, helping nurses to understand how important it is and what their own role is in ensuring their mental health.  

MARCUS: And not penalizing nurses or students when they reach out for support and help. Because we often do that as well. And we make a recommendation in the report about creating mechanisms to ensure that when a nurse or a student reaches out for support, that it's provided, and they're not treated differently, because we know that nurses and people, in general, are hesitant to reach out for mental health support because of fear of stigma, fear of being treated differently. And in some states to my understanding, a nurse could lose their job because they reach out for mental health support because they might be suicidal, for example. So why don't we have this same type of peer assistance programs that we do for nurses who have experienced substance use disorder for all of these other issues, social issues that they might be experiencing. 

SARAH: So if we change the equation about nurses being an expense, versus nurses being a value add, a resource that we want to invest in, the nurses, they're the greatest resource, it's not, it's not what they're doing. It's who they are, and what they're bringing to these scenarios, to patient care, to safety, to quality improvement to all of the things that we've been talking about social determinants of health. And I think they it's, yeah, it's just sort of shifting that orientation to that person, the whole person is the resource that is the most valuable.  

MARCUS: You raise an important point, because from a business perspective if I invest in nursing, I'm ensuring their well-being, I’m reducing the potential for error, which would then reduce costs. So from the business perspective, it makes sense. And from the population perspective, we're ensuring nurses are supported and valued to do their job to improve population health. So it's a win-win on both sides of the coin, when we make that investment, into nursing.  

SARAH: So if you could change something about nursing education based on what you've learned and experienced, what would it be? 

MARCUS: We as nursing educators must stop promoting the notion that you must have one to two years of med surge experience to validate yourself as a nurse. It's absurd. It's unnecessary. I have never practiced in a med surge environment. I'm a community health and psychiatric mental health nurse. That is my skill set. That is my expertise. And there is nothing to say that I'm not a better nurse because I didn't have med surg experience. So we need to stop shifting and promoting students to go towards certain specialties because we believe that's what's important. We believe that's important because that's what society leads us to believe. Because again, back to Regina’s comment, nursing started in the community, public health are the roots of our profession, hospitals came to be because of a whole variety of reasons. And we transition to that emphasis on medical care and being treated in hospital and the system that we have today. So we have to move away from this frame of thinking that you need to do med-surg in order to validate who you are as a nurse. Because I personally had an identity crisis, because that's what I was being told for so long. So I said to myself, well, am I a nurse? I'm working in a shelter, does that make me a nurse? And I came to the realization that yes, I am a nurse, I'm the nurse of the community. I'm looking at things differently. I'm looking at social determinants of health. I'm looking at populations. And as I I'm still emerging in my career, but I've come to seek get validation. When people come to me and say, Marcus, you're a psych mental health nurse, I need your expertise. That's my skill set. That's what I bring to the table. So we need to ensure that we empower nurses to understand what their skills are, what their voices and what they bring to the table into these conversations. And that starts with educators giving up this notion about med-surg.  

REGINA: I think that frameshift is absolutely essential, letting go these anachronistic notions about things is really, important to us advancing the health equity agenda. That is a very, very important component of our thinking, changing our thinking around this. 

MARCUS: The way that we talk about race, and how we conduct research and how we write textbooks, and how we educate in the classroom promotes this false narrative that because of your race and ethnicity, that you're less than white people. So when when people in power, who reflect the majority population are developing programs and policies that impact education, that impact housing, they lack empathy, because they don't understand the experience that many individuals in this country live with every day. So when the way that we write in textbooks that because you are a certain race, you're at more risk for something, or because you're a certain race, you have the potential to have a lower IQ, or because you're a certain race, you're more at risk for entering the criminal justice system that promotes this false narrative that supports what Regina talked about in terms of cultural racism, these ideals that people hold to be true, that are not, and how they live, how they practice and how they interact with people. So that's how downstream racism impacts health because we're promoting this false narrative that allows people to think because you're a different color, because you look differently than I do, that I am less than, and that I'm not worthy. And that's how we have the issues that we have with mass incarceration, with the issue of the school to prison pipeline, and so many other things that we see in our nation. 

SARAH: Thank you so much for joining us and for all of the work that you've done in this area and on this report.

REGINA: Thanks, Sarah. It's been a great conversation. I appreciate you inviting us. 

MARCUS: Yes, thank you so much, Sarah, for having us to discuss the Future of Nursing Report. 


SARAH: Funding for special access to care series comes from the Center to Champion Nursing in America, which is a joint initiative of the Robert Wood Johnson Foundation, AARP, and AARP Foundation. 

For more about us and our programs, log on to paactioncoalition.org and nurseledcare.org.

You can also stay up to date with us on social media @PaAction and@NurseLedCare. At the Core of Care is produced by Stephanie Marudas and Emily Previti of Kouvenda Media and mixed by Brad Linder.

I'm Sarah Hexem Hubbard of the Pennsylvania Action Coalition. Thanks for joining us.