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Can we calm the sea? A reflection on steadying the nursing workforce

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      Kenneth R. White, PhD, AGACNP, ACHPN, FACHE, FAAN
      The breaking of a wave cannot explain the whole sea.” ― Vladimir Nabokov
      Once again, we face two key questions: (1) how many nurses are enough? And (2) how can we make sure we have enough nurses? The most common—and most accurate—answer to the first question is, “It depends.” Neither numbers nor ratios alone can account for the many factors, such as what nurses do, how their work intersects with the responsibilities of other healthcare professionals in various settings, and how the availability of nurses affects healthcare outcomes that influence what is considered “enough.” Answering the second question requires a complex analysis that not only embraces but also transcends the first. To make sure we have enough nurses, we have to know how many nurses are needed—and we also have to know what motivates people to choose nursing careers, how the pipelines that supply nurses function, and how the work and working conditions of nurses today (and tomorrow) do (and will) influence their decisions about staying in the profession.
      Nursing shortages are like a chronic societal illness, punctuated by acute exacerbations.
      • War has usually increased demand for nurses; World War II led to the Cadet Nurse Corps, and the current, continuing war in Ukraine and other places have created pressing needs for nurses to care for both military and civilian casualties.
      • Changes in health care delivery systems have either increased or decreased demand for nurses; in the 1990s, managed care and related cost-containment strategies undermined the nursing workforce and led to lower enrollments in nursing schools (see

        Buerhaus, P. (1998). Is another RN shortage looming? Nursing Outlook., Retrived from: https://www.nursingoutlook.org/article/S0029-6554(98)90034-3/pdf

        ). Those trends continued into the early 2000s and were worsened by the Great Recession in 2007-2009; including efforts to combat the shortage included Johnson & Johnson's Campaign for Nursing's Future, which began in 2002.
      • Fewer nurses, and even fewer nursing faculty, experienced more difficulty recruiting deans—the problems of the 2000s grew more challenging through the 2010s.
      • And then, COVID—but not just COVID— the pandemic plus social disruption, challenges to democracy, climate change, and long overdue redress for inequity increased the demand for nurses. Whether anticipated or not (and whether any of them should have been anticipated or not), these events created a multidimensional crisis from which society—and nursing—have not yet emerged. Nurses, rightly celebrated as the pandemic strained healthcare resources and killed hundreds of thousands of Americans (including many frontline nurses), struggled to keep going as the politics of the pandemic turned uglier and uglier.
      Attempts to answer the two key questions noted above fell completely apart as the pandemic, especially, showed the stark limitations of traditional projections. Differences in assumptions and methods had earlier produced disputes among health economists and government agencies about the number of nurses needed in the future; the complex circumstances of the pandemic and its social and cultural accompaniments emphasized the importance of better; and more inclusive, data analysis and more contextually sound forecasting. Addressing the nursing shortage is, and has always been, exceedingly complicated; as Nabokov wrote, the breaking of a wave cannot explain the whole sea. What we face now feels more intense, more overwhelming, and more daunting than any of the supply and demand challenges of the last 25 years. The complexities of these challenges require an all-hands-on-deck approach to finding solutions. Workforce shortages will not be resolved by recruitment and retention efforts focused solely on numbers alone. A “units-in = units-out” mentality is shortsighted and dehumanizes nursing professionals. Instead, we need a comprehensive, holistic, and multifaceted approach to solving nursing workforce challenges.
      • We must focus first on the mental health and wellbeing of nurses, find ways to help them be and stay healthy, and establish an empathic, responsive culture that destigmatizes and embraces those who seek help. The pandemic has added layers upon layers of trials that have caused or exacerbated anxiety, depression, and moral distress among many of our colleagues. The

        American Nurses Association (2022, March). Pulse on the Nation's Nurses Survey Series: COVID-19 Two-Year Impact Assessment Survey Younger Nurses Disproportionally Impacted by Pandemic Compared to Older Nurses; Intent to Leave and Staff Shortages Reach Critical Levels. Retrieved from https://www.nursingworld.org/∼4a2260/contentassets/872ebb13c63f44f6b11a1bd0c74907c9/covid-19-two-year-impact-assessment-written-report-final.pdf

        COVID-19 Impact Assessment Survey - The Second Year (March, 2022) found that, of the acute care nurses surveyed, 75% reported stress, frustration, and exhaustion; 60% noted feeling burned out. As many as 66% of nurses under age 35 noted feeling anxious, and 43% felt depressed; fewer of their colleagues over age 55 reported feeling anxious (35%) or depressed (21%). Staffing levels, workplace conditions, high levels of very demanding critical care, and inferior employment policies are certainly among the reasons for these findings.
      • Second, it is imperative that registered nurses and advanced practice registered nurses are enabled—and allowed– to practice to the fullest extent of their education and training so that we can be fully activated as a profession. Restrictive laws and regulations impede access to high quality healthcare (see
        • Costa D.C.
        • Friese C.R.
        Policy Strategies for Addressing Current Threats to the U.S. Nursing Workforce.
        ); advocating change with policymakers is a high priority for our profession and the Academy. Increasing the number of nurses in the workforce alone will not “fix” the shortfalls we are witnessing across geographic regions and within certain populations and communities; nursing shortages are not equitably distributed.
      • We must do more to advance equity, diversity, and inclusion in our profession. In July, the Academy's Diversity and Inclusivity Committee hosted a “Creating a Culture of Belonging in the Nursing Profession” webinar to discuss three primary questions: 1) Why does a culture of belonging matter? 2) What challenges does the profession face in creating this culture? and 3) What actionable steps can nursing leaders take to promote inclusion and belonging in their professional environments? Four distinguished speakers–Teresa Brockie, PhD, MSN, RN, FAAN, Magdalena Correa, MSN, APRN, FNP-BC, Emerson Ea, PhD, DNP, APRN, FAAN, Jorge A. Valdes, DNP, CRNA, APRN, and moderator Kimberly Adams Tufts, ND, WHNP-BC, FAAN–shared their own perspectives and highlighted both the conversations we ought to have and the actions we need to take to achieve a culture in which all can thrive.
      • The Academy's Building Health Care Systems Excellence Expert Panel hosted policy dialogues in 2021 (Healthcare Systems Post-COVID) and 2022 (Optimizing the Nursing Workforce: Exploring Innovative Reforms and Policy Implications) to explore ways in which policy reform can advance the goal of strengthening and sustaining the nursing workforce.
      Honoring our profession as one rooted in science, we will depend on data and evidence to guide our decision-making and define our strategies. Peter Buerhaus, PhD, RN, FAAN, FAANP(h) and Linda Aiken, PhD, RN, FAAN engaged Academy members and attendees in a fireside keynote launching this year's Academy Health Policy Conference; they discuss the trends they are seeing and debate the policies the Academy should consider in order to ensure our profession can provide equitable access to high-quality care. In 2023, Nursing Outlook will welcome a new Editor in Chief, Sean Clarke, PhD, RN, FAAN; his most notable research concerns nurse staffing and working conditions. Dr. Clarke's expertise will be a strong asset to our collective thinking about the current nursing workforce challenges that face us.
      Last month, the Academy welcomed 250 new Fellows, our largest class to date. With their talent and experience, we will be better equipped to navigate this critical time in our profession's history. So to return to the question in the title of this essay, can we calm the sea? Yes. The strategies we advance and the policies we advocate with the help of trusted stakeholders will lessen the stress on our workforce. More important, though, we have learned the importance of readiness, and of anticipating the unexpected. Of course, another storm will come. We will respond, as we have done many times before—and we will rise, as nurses, to strengthen, sustain, and make more equitable the health of our profession, this nation, and our planet.

      References

      1. Buerhaus, P. (1998). Is another RN shortage looming? Nursing Outlook., Retrived from: https://www.nursingoutlook.org/article/S0029-6554(98)90034-3/pdf

      2. American Nurses Association (2022, March). Pulse on the Nation's Nurses Survey Series: COVID-19 Two-Year Impact Assessment Survey Younger Nurses Disproportionally Impacted by Pandemic Compared to Older Nurses; Intent to Leave and Staff Shortages Reach Critical Levels. Retrieved from https://www.nursingworld.org/∼4a2260/contentassets/872ebb13c63f44f6b11a1bd0c74907c9/covid-19-two-year-impact-assessment-written-report-final.pdf

        • Costa D.C.
        • Friese C.R.
        Policy Strategies for Addressing Current Threats to the U.S. Nursing Workforce.
        The New England Journal of Medicine. 2022; https://doi.org/10.1056/NEJMp2202662