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.
As part of our special COVID-19 pandemic coverage, we're continuing with a series of podcast episodes that can be helpful to nurses at this time and the communities they serve.
On this episode, Dr. Paula Milone-Nuzzo is joining us from Boston to discuss the current workforce crisis in health care and the continued need to reframe training and education for the health professions. We’ll also explore potential solutions that could help cultivate more support, resilience and retention.
Paula has led an extensive career in academia as both a professor and an executive administrator. Her research interests include workforce development and health care careers as well as care for the elderly. She’s currently a professor and the president of MGH Institute of Health Professions, a graduate school started by Massachusetts General Hospital.
Before her role at MGH, Paula served as Dean of the Penn State College of Nursing from 2008 to 2017. She was also a founding member of the Pennsylvania Action Coalition, and in 2015, became the chair of our Advisory Board, before relocating.
Our producer Stephanie Marudas spoke with Paula.
STEPHANIE: So to start off, one of the questions we always love asking on the podcast is how you decided to go into nursing? And could you share your story with us?
PAULA: When I was a young woman and graduated from high school, I really didn't want to go into nursing. I didn't even think of nursing as a career. I wanted to be a bank teller. And I am the youngest of four children. And, and my parents said all your other brothers and sisters went to college, you will go to college, too. And I said, well, I don't really have anything I want to study in. And my mother said, I think you would be a great nurse. It was really her encouragement that really shaped my destiny in healthcare. It took me about two weeks in nursing school, and I was hooked. It was the best experience of my life. I loved taking care of patients. I loved being with families. I loved the notion of being part of the healthcare delivery system. I loved everything about it.
And that next step really took me to all the rest of the steps that I had in my career. So early on, right after I finished that associate degree, I had the opportunity to do some patient teaching. And what I realized is I love to teach. And I love being part of that educational experience, went back and got my bachelor's degree. And when I finished that bachelor's degree, I had the opportunity to teach in an LPN program. And these LPN programs were embedded in the hospitals. And so I was able to maintain my clinical practice and grow my clinical practice. But I was able to really hone the skills of a good teacher at that time. And what I realized is if I really wanted a career in academia, I needed more education. So I went back and got a master's degree. After all those years in the hospital, I got a master's degree in Community Health Nursing, because I believed the future of healthcare was in the community. Now, this was in 1978. And so that was a lot of years ago. And we are now seeing the future of healthcare be in the community. So, it's taken many, many years to get to this point. But I do believe that that community-based care, and the delivery of even acute care in the community is what we'll see as we go forward.
STEPHANIE: Well, you were ahead of the curve.
PAULA: Absolutely. And then got the opportunity to teach in a baccalaureate program. I taught Community Health Nursing for 10 years in that Baccalaureate program. I really focused on home care. And it was the home care work that really drove my interest in workforce. But those experiences that were really unplanned, unanticipated, but great opportunities that I realized I had to take advantage of, those drove my career to where it is today. I worked for 10 years teaching community health, had this great opportunity to go to Yale to start the first homecare program for advanced practice nurses in the country. Did that for about 14 years and worked as an academic administrator along the way. So I married both the passion for nursing and my passion for academic administration. And then I had this wonderful opportunity to be the president of a small college graduate program only that prepares all the health professions. And this brings all the pieces together, because I do believe and I always have believed in interprofessional practice as a vehicle for better patient care, greater patient satisfaction and greater provider satisfaction, greater job satisfaction for providers. So this is a wonderful opportunity to bring all the pieces together to advance healthcare delivery. The one thing I have to say is, when people ask me what I do, I always say I'm a nurse. I mean, that's the first thing I say. And then I always kind of add additional information. But my identity as a nurse, my passion for nursing hasn't waned over the years. It's only gotten stronger. I believe what we do is so critically important, so valuable, so integral to the healthcare delivery system, that I always lead with that. And the other lesson that I think is important, is that we also have a path forward. We all should be thinking about what our plans are. But our plans should always evolve, just as we evolve once new opportunities come. New ideas come your way and we grow as professionals. So that's, those are the two take home messages that I would say.
STEPHANIE: It sounds like it's the best of all worlds, for you, coming together now. And what we're going to talk about mainly through this episode is the workforce development piece and how that's played out during the pandemic. But before we get there, just a little bit about your interest in workforce development. You said that it really was spurred by your work in home care?
PAULA: I went into homecare in 1980. And in 1980, homecare was really not a very popular place for people to work. Pay was low, the paperwork burden was high. We didn't have a lot of infrastructure to support the professional development of nurses. And so the people who went into homecare were people who were at the end of their career. And so there wasn't that vibrant community of professionals that were spurring each other on towards professional development. Remember, too, homecare is a very isolated practice. We would go into the agencies in the morning. We spent about an hour there reviewing our list of patients, picking up our equipment, supplies, whatever we needed. We were out in the community for about six hours. And then we came back at the end of the day. Most of us did. Some people didn't. And that was it. Those were the only times we saw our colleagues, unlike hospital nursing, where you work with your colleagues all day. You have physicians there. You work with them, you have other providers, PTs, OTs, physician's assistants. All of those other providers. So home care really was not a very exciting, dynamic place. People didn't realize how intensely complicated homecare practice was if you did it right. They really saw it as kind of you go in, you do a dressing and you leave. But that's not really what homecare was about.
I started looking at how we brought nurses into homecare and what we did to excite them about practice. The late 80s, I wrote a book with a colleague of mine, Carolyn Humphrey, that talked about how we orient homecare nurses to prepare them for the complexities of homecare nursing practice. And I realized that that was a way to not only bring people in, but retain them into practice. So starting to look at workforce issues. But later in the 1990s homecare did become popular, that was when hospitals were reducing their length of stay. Many hospitals were buying homecare agencies so that they could get a bigger share of the Medicare reimbursement. So around the 1990s, homecare got very popular and we saw a migration out of the hospital into the homecare agencies.
And so that precipitated myself and my colleague Carolyn Humphrey writing a second book, and that was transitioning hospital nurses to home care. And so those years where we really tried to improve the quality of the homecare workforce, which really led me to my interest in workforce generally. When I went to the Penn State University in 2003, soon thereafter, I was asked to be part of the Pennsylvania leadership of the Pennsylvania Center for Health Careers and be on the Leadership Council for that. And that's when I really started looking at workforce writ large. The therapy workforce, nurses, home health aides, nurses aides, the paraprofessionals that are in the work workplace as well as nurses and nurse practitioners. So all of that fueled that interest in making sure that we had a robust and very responsive workforce to the changing needs that we see in healthcare. And so that was really what continued my interest, as well as beginning to have a leadership role in a state institution that prepared nurses. I currently am on a very similar committee in Massachusetts called the Massachusetts Health Care Coalition.
STEPHANIE: Bearing all that in mind, and the work that you were doing in the early 2000s, and watching that play out over the past two decades to this point preceding the pandemic, we already knew that we were going to be facing some shortages as more baby boomer registered nurses are retiring. There's just a nursing shortage in general. You know we were in a crisis mode before the pandemic. But as you've pointed out, it's really amplified now. There's various studies out there that say, just even across the board with health professions, you know, maybe it's upwards of 30% of health professionals are thinking about leaving their careers entirely. So from the vantage point of 2022, where are we in terms of helping our healthcare workforce stay satisfied with their jobs and how to retain when the trends are looking somewhat non-favorable?
PAULA: The whole notion that the healthcare workforce is changing is apparent. And the workforce in general is changing and healthcare is a segment of that and it's not immune from that change. And, and you're right, we all know that people are saying that they're ready to leave, they're burned out. They're frustrated, they're not able to meet the needs of their families, their friends. It's a hard time for health care workers. And we all read about every day in the healthcare workforce literature and in the lay literature. People are tired. They're, I describe it as weary. They come in every day. They face the same challenges. They take care of complex patients in ways that didn't allow them to practice the way they wanted to and knew they should. Not being able to have visitors at the beginning of the pandemic, limiting visitors even now. It's a very, very challenging time in the acute care settings. And I think part of the difficulty that we're seeing is the uncertainty. You know, we kind of left last summer thinking that we were past the hard part. And this blow with Omicron has really put a level of uncertainty in everyone's perspective. And I think that makes it even harder to practice effectively.
I think we need to look at this from a couple of different perspectives. We need to really think about these issues from a policy perspective. So even before the pandemic, we had issues of pay equity for nurses. When you think about the role of nurses, and nursing, they're not nearly paid what they should be paid for doing that role. And now this pandemic has amplified that crisis. And it's not only for nurses, it's for all healthcare providers. We think of physical therapists who invest many 1000s of dollars, many 10s of 1000s of dollars getting a Doctor of Physical Therapy, for example, and come out and don't have the pay equity that they should be having. I think we also are challenged with continual practice barriers for both our advanced practice nurses, our physical therapists, our occupational therapists, our physician assistants, they all have practice barriers. And we've been fighting with the Action Coalition, the good fight, to remove those practice barriers for nurse practitioners. And it's worked in a lot of places, it's not universal. And we just need to make that happen.
STEPHANIE: That’s a whole effort in and of itself, right? And a dedicated team to do that kind of advocacy work and try to change policy, on top of just the support and training and everything else that goes into the profession.
PAULA: We need to build resilience in our academic programs. So we need to help our students learn how to take care of themselves, learn how to recognize when they need help, learn where to get help, because our professions are hard. And they've only gotten harder over the last two years. And I think you know we're in for some really challenging times, even ahead. So I do think there are opportunities for us to be a little more reflective in our academic programs, and help people learn some skills that will allow them to be more resilient.
And we need to increase the number of providers. We need to continue to hold onto our excellence, but increase the number of people that we prepare. We are still turning away 80,000 qualified nursing applicants every year. And so doesn't that say to us that we have something broken in the system that prevents us from preparing the number of people that we need. If we had more people in the hospital right now, we wouldn't be having nurses have to work double shift, nurses have to work mandatory overtime. People on the floors that shouldn't necessarily be on the floors who don't have the experience that they need.
STEPHANIE: From your perspective, Paula, you're really in the conversation. What kind of short-term solutions are out there that you've been thinking about, that people are not talking about? And that maybe should be considered, especially when we're in this crisis mode?
PAULA: I think that there are a lot of short-term solutions, there are a lot of long-term solutions. Let's think about this for a minute. We have our academic programs, we have our clinical entities, our hospitals, homecare agencies, whatever. Why can't we admit more students into nursing schools or other health professional schools? Well, there's three things that prevent us from doing that.
One is the lack of qualified faculty. Now, we've dealt with that a little bit with the development of the DNP program and the vast number of graduates that we have prepared at the DNP level. The number of graduates of DNP programs increased seven to nine percent over the last year. So we really do have a pipeline of potential faculty that could teach in programs.
The second variable that prevents it is the number of clinical placements. This is a problem that we should be able to overcome. There are hundreds of 1000s of beds, hospital beds, and nursing home beds, and homecare opportunities. They're not beds. But there are lots of opportunities for our nurses and our health care students to work at the hospitals, but they keep us at arm's length. They keep us away. And I know why they do. Students take time. Students take effort. So what could we do to change that? What can we do so that they would welcome more students to alleviate their workforce challenges?
I think there are a couple of things that we haven't tried. One is we tend to bring our students to hospitals, to do basic care, to do things that require them to have a lot of oversight, a lot of attention, a lot of staff time. Maybe what we need to do is prepare them better before they go into the clinical setting. So they're not seen as a burden, they're seen as a benefit. And this I think, would really help us if we change the way we thought about education, and help us to be the kind of resource that the hospitals would be excited about.
Another solution for this crisis is to think about other individuals, other kinds of providers in different settings within the hospital. For example, maybe we could begin to use EMTs or medics in the emergency room. The emergency room right now is the bottleneck. It's the highest stress environment in the hospital. We're seeing challenges in terms of aggressive behavior from patients in these emergency rooms because people are frightened, people are anxious. The healthcare workers are stressed, they're overly busy. So that whole mixture of emotions is not a good scenario. We need to bring additional resources. We may need to think of different kinds of people than we have in the past besides the nurses, or the Pas or the physicians. So let's think of unique providers that we hadn't thought of before. Years ago, we eliminated in many hospitals, the LPN. We went to a fully RN workforce model, maybe it's time right now to think about bringing LPNs back into the acute care setting, to help with this crisis situation, to help us be able to delegate some of the work that the RN does and help that environment take the strain off, and allow people to practice under less stress. So there are things that we can do in the short run, that will allow us to reduce the stressors that everyone is feeling in healthcare today.
From an educational perspective, I do think we have to build more academic service partnerships that will allow us to do some of the things, to build those relationships that we talked about, that will allow the service side to see us as a valuable partner. Not someone who they push away, or push an arm's length. I mean, we saw that during the pandemic when things got really difficult at the hospital. They asked most of the academic experiences to stop. And so it really becomes challenging, because then we're not producing the numbers that they need. And then it’s a cycle that we can't get out of.
STEPHANIE: Speaking of the next generation, during this past year, at MGH Institute of Health Professions, have you seen more enrollees? Or is there an interest because of what's happening in the pandemic?
PAULA: So quite frankly, I am so proud of the people that come through our door, because they're showing courage. They're showing bravery. They're moving towards a crisis, when so many people have backed away from that crisis. They're coming into health care, when we really are going through such a transition in how we provide care. So I tell them all the time, I'm just in awe of their bravery. I'm in awe of their courage, I think they're incredible. And we have as, as most schools of nursing, and many health professional schools, over the course of the last two years seen an increase in enrollments, seeing an increase in the interest in health professions education. Because people are seeing how critically important we are, and how critically impactful our work has been over the course of the pandemic. And so we're seeing our enrollments stay very strong. And, again, we struggle with the same challenges that almost everybody else struggles with. We need to find them clinical placements, so that they can get out into the workforce. All the all the accrediting bodies require certain experiences. Some do it by the number of hours, some do it by the number of experiences. And so without those experiences or hours, students can’t graduate. And so you backup the pipeline. And that’s not a good thing.
The other thing that I don't think a lot of people recognize that at the very beginning of the pandemic, nurses lost their jobs. So nurses in doctors’ offices, nurses in clinics, nurses in outpatient departments, a lot of them lost their jobs. And so what we're trying to do now is on reskilling them for areas where we know we need a lot of nurses, and that is in mental health and psychiatric nursing. So we are facing a tremendous crisis in terms of the mental health of our population, children, teens, adolescents, adults, geriatric, we are seeing an increase in the challenges faced in that space by almost every population.
We see it in colleges and universities. We see it in schools, K through 12. We see it in the workforce. So we need to have a much larger psychiatric, mental health workforce than we have now. And what we could do, what we are trying to do is help nurses who have been displaced during the pandemic reskill in the area of mental health.
We need to recognize that they have an opportunity to also provide service to this population, and we need these kinds of higher-level providers. We don't have enough psychiatrists; we don't have enough psychologists.
STEPHANIE: It could leave listeners feeling grim. But I think I'm hearing that there's solutions here.
PAULA: Absolutely, I do think there are solutions. And I think, you know, there, there are things that we as leaders in healthcare need to pay attention to. We need to acknowledge the fact that our nurses are struggling. We need to let them know that we understand what they're going through. And we appreciate every day that they come in, and they struggle with these challenges. And if the healthcare leaders aren't doing that, we absolutely should be doing it. And at every level, and you know, it's the nurse manager. It's the nurse director. It's the CNO. It's the CEO of the hospital. Every single one of them has to tell the nurses that report to them or the providers that report to them, we get it. We understand, we appreciate you, we value you. And that has to be a message that happens regularly in the environment.
We need to help our students be leaders when they graduate, every single one of them, because they need to change the healthcare delivery system that we work in. They need to know how to change policy. They need to know how to advocate for not only the profession, but for the patients that they serve. They need to know that nursing is not just about a shift, it's about a way of life, it's about a commitment to a community. And we need to redouble our commitment to mentoring the next generation of nurses.
I'm sure if we look at this, and I'm just speaking anecdotally, not from data, but I bet the mentoring relationships have declined over the last couple of years, because people are so busy thinking about the kinds of things that they have to think about every day in clinical practice. But we know how important mentors are. And we know how important they are to the development of young professionals. And we need to get back to some of that, and be thinking about how we integrate that in the practices that we all have.
STEPHANIE: As you talk about what is going to be required to train the next generation of health professionals, certainly the Future of Nursing Report, which we've covered on this podcast and continue to come back to, you know one of the major goals is to increase diversity among providers as well as create more competencies when it comes to treating patients from a wide range of backgrounds. And from your perspective, and from being at MGH, can you share, what kind of curriculum shifts are happening at this moment? When it comes to sort of taking an anti-oppression, anti- racist approach to nursing curriculum and across the health professions?
PAULA: I do think that we all underwent a racial reckoning in 2020. And we started to really think about who we are, as an academic program. Many academic programs did this. What we needed to do to prepare the next generation of individuals, whether they're healthcare providers or people in business. Or educators, whoever it is. We happened to look at health care providers. And we started to look internally at what aspects of our organization are inconsistent with an anti-racism and anti-oppression framework. We looked at admissions. We looked at workload. We looked at support structures. We looked at models of inclusion. We looked at all those dimensions of what we do in academia. But probably the most important dimension that we looked at was the curriculum.
So we know that healthcare has a history of discrimination of those from under underrepresented backgrounds and underrepresented minority backgrounds. You just need to scratch the surface to know that black women have a higher maternal mortality rate than white, regardless of socioeconomic status. Black men have a lower surgical intervention for cardiac disease than white men, regardless of socioeconomic status. So why is that? What's inherent, what's systemic, in our healthcare delivery system that makes these outcomes different? So we started, we started to look at that. And we started to look at how we teach, and whether that that whether we recognize the racism that's in healthcare delivery, and the oppression that's in healthcare delivery, as a way to understand how to better prepare our students to take care of patients. And so we started looking at things like our case studies that we had, and our case studies were largely white patients. And if we had a black or brown patient, they were portrayed in a negative light. We looked at how we did assessments. And, and sometimes we only did assessments related to white skinned individuals, as opposed to black or brown individuals. So we knew we needed to have work to do work on our curriculum to address some of these issues around racism that students need to understand. Because they need to know that our marginalized communities are coming to the hospital, knowing that and feeling that and having those historical experiences that makes them different than perhaps what we expect. So this is I think, where we're changing the paradigm. We're changing the approach of education of our students. And, we hope that this will make our students and all students who go through these kinds of educational programs, more thoughtful and more compassionate caregivers.
STEPHANIE: Any final thoughts that you would like to leave listeners with, just as we come to the end of the podcast?
PAULA: I just think that we need to be as creative as we can, and open to the possibility of any new idea to solve some of these issues that we're facing. I don't think we should dismiss any idea out of hand, I think we should think about it, we should address it, we should, we should ponder it. And if it makes sense, if it helps, if it helps the organization, if it helps the profession, if it helps the individual, we should take advantage of those ideas.
We need to support our providers, and in so many ways that we talked about today. And we need to reframe education. And that's going to require sometimes changes in legislation, sometimes changes in statute, sometimes changes in accreditation standards. All of that is possible, because we are in a new area of health care.
STEPHANIE: Paula, thank you so much for being here with us. We really appreciate all your insights here. And bringing some new ideas and solutions to this podcast.
PAULA: Thanks so much
CREDITS:
SARAH: Support for our special COVID-19 pandemic coverage comes from the Centers for Disease Control and Prevention.
You can find our most current and past episodes of At the Core of Care wherever you get your podcasts or at paactioncoalition.org.
For more information about related upcoming webinars and where to find COVID-19 resources, log on to nurseledcare.org. And you can stay up to date with us on social media @NurseLedCare.
At the Core of Care is produced by Stephanie Marudas of Kouvenda Media and mixed by Brad Linder.
I'm Sarah Hexem Hubbard of the Pennsylvania Action Coalition. Thanks for joining us.
