By Victoria L. Tiase and William M. Sage
America’s nurses are a powerful force for good — four million strong, universally trusted, increasingly diverse, serving every community across the country, with an overall economic impact greater than the total output of the median American state. However, the pain of pandemic nursing is real and widespread. Urgent attention to nursing’s vulnerabilities is required for the profession to help the U.S. emerge from the confluence of the worst public health crisis in over a century and the most severe economic decline since the Great Depression.
How America deploys its nurses is flawed. The acute care focus of our lavishly funded “medical-industrial complex,” including the hospitals that employ nearly half the country’s nurses, is inadequate to preserve and improve our collective health. Because of longstanding imbalances in professional hierarchies, nurses’ work is relegated to the cost side of hospital ledgers, biasing care toward revenue-generating procedures performed by physician specialists. Nor does America invest enough in nurses on the true front lines delivering primary care, protecting against disease, and promoting wellness in the community. State laws, health insurance reimbursement practices, political and budgetary barriers to direct public employment of health professionals, and a thicket of self-regulatory organizations largely controlled by physicians help perpetuate this inequity.
Feelings of professional accomplishment among nurses from dedicated service to the sick and dying during the COVID-19 pandemic have been challenged, if not crowded out, by exhaustion, economic uncertainty, and concern for their own health and that of their families and neighbors. And for every nurse called a hero or feted with applause at something like New York City’s briefly famous 7 p.m. “clappy hours,” another nurse has been berated, harassed, or discriminated against because of public frustration and fear.
Moral injury is a major component of COVID-19’s harm to nurses’ well-being. When nurses cannot provide their best care, they breach strongly held personal ethical commitments. COVID-19 has required moral compromises that nurses never thought possible in our $4 trillion health care system: overloads of critically ill patients in makeshift beds, shortages of critical resources such as ventilators and infusion pumps, and a lack of basic protective equipment for staff. Crisis Standards of Care, where adopted, were small consolation, especially when nurses were asked to hide supplies or had to compete with one another to access them. These conditions have affected the entire country in waves for over a year, not just flaring briefly in one city or region after a discrete natural disaster.
A March 2021 report from the U.S. Department of Health and Human Services documents the enormous challenges facing U.S. health care delivery because of staff burnout and psychological harm. Post-traumatic stress from COVID-19 globally may approach that from World War II. Having witnessed by far the most pandemic deaths of any country, the U.S. health care workforce is particularly vulnerable. Many nurses cared for more dying patients in a week than during decades-long careers — and served as surrogate family members for most as infection control measures precluded visitors and mourners.
The U.S. health care system is unused to caring for caregivers, generally expecting those who experience trauma to show strength and return quickly to duty. This would almost certainly backfire post-pandemic, as those who seem to have recovered from COVID-related professional trauma experience small triggering events with severe emotional consequences. If attrition mounts in the next few years, worsening existing shortages and further burdening those who remain, patient care will suffer along with the nurses themselves. Tokens of caring — existing Employee Assistance Programs, yoga sessions, a little extra time off, small bonus payments — will not suffice. Much more is required.
Beyond Empathy to Opportunity
It is necessary to convert nursing pain to nursing progress. A first step is to confront burnout not only with mental health support, but also with professional opportunity. After COVID-19, some nurses will want — will need — to move away from the bedside. If policymakers and the public seize the moment, these nurses will find fulfilling, innovative, and well-paid jobs available in public and community health. Many nurses will seek additional education, which government should help support. As health care organizations digitally transform their operations, promising educational paths for nurses will include informatics, data science, and related technology. Advanced nursing expertise will be important to constructing data platforms and applications that move information into the hands of bedside nurses, other caregivers, patients, and the community.
COVID-19 is already leading to novel connections between nurses and patients, with consequent opportunities for both service and entrepreneurship. Virtual Nursing will be part of reimagining where and how nurses work, opening another career path for nurses seeking a post-pandemic change. Developing the field will require, for example, nurses learning to conduct telehealth visits from home or from virtual care centers without sacrificing the contextual, personal bond that is central to the profession.
Nurses cannot create and pursue these opportunities without more professional authority than they currently possess. Physicians must acknowledge and dismantle barriers to genuine professional partnership with other health professions, and they should share their power not only with advanced practice nurses but also with RNs. Nursing organizations should have parity with physician organizations in key self-regulatory entities such as the Joint Commission and the committees that advise Medicare on clinical coding and payment.
As the United States rethinks its health care priorities and investments, we must not forget the millions of nurses who have selflessly cared for our friends, our family members, and our country. We must reward them — and benefit ourselves — with both support and opportunity.
Victoria L. Tiase, RN, PhD is the Director of Research Science for New York-Presbyterian Hospital.
William M. Sage, MD, JD is the James R. Dougherty Chair for Faculty Excellence at the University of Texas at Austin School of Law; and Professor in the Department of Surgery and Perioperative Care at Dell Medical School.
This post is part of our digital symposium, In Their Own Words: COVID-19 and the Future of the Health Care Workforce.