President’s Video: Addressing Nursing Challenges – AACN and ANA Presidents’ Chat

Amanda Bettencourt, AACN President (AB): Hello, I'm Amanda Bettencourt, president of the American Association of Critical-Care Nurses. We are the world's largest specialty nursing organization with over 130,000 members from high acuity and critical care nursing. I'm a pediatric clinical nurse specialist and an assistant professor in Penn Nursing's Department of Family and Community Health. I'm joined by the new president of the American Nurses Association, Dr. Jennifer Mensik Kennedy. Nursing and healthcare are undergoing a period of rapid transformation and I feel the urgency for nurses to work together to find solutions to both longstanding issues and new challenges. Today we've come together to address some of the big challenges facing nurses in 2023, including staffing, workplace violence and healthcare disparities, and to recognize the amazing day-to-day contributions of nurses everywhere. Jennifer, welcome. Please introduce yourself to our viewers.

Jennifer Mensik Kennedy, ANA (JMK): Thank you. So glad to be here and thank you for inviting me. I'm the president of the American Nurses Association and think the world of AACN. AACN has been very valuable, important partner affiliate to the American Nurses Association and the work that we've done together and many avenues will continue, so looking forward to really working on nursing issues together.

AB: Thanks. Yeah, we value our partnership with the ANA as well. Thinking about the topics that were on the docket for today, let's just get the biggest one out of the way, which I don't know what you're thinking these days, but I'm thinking staffing and the downstream effects of our staffing challenges are the most pressing, probably, on most nurses’ minds. I'm sure like me, you get a lot of opportunity to hear from nurses and to speak about this issue. What's top of your mind around staffing and the downstream effects of not having enough staff in most places today?

JMK: It's so important to recognize that this has been going on for decades. We have these cyclical challenges with staffing and we put some patches on it, we think we fixed it, and then a few years go by and it's bad again. And we try some of the same things over and over again thinking that they're going to be the solution this time. And this is decades, 50, 60, 70 years of us do doing some different things, but the same things. And we really just need to stop and really say, "Okay, how are we going to fix it this time?" Because trying the same things in a different manner aren't working, so what should we do and how are we going to do it differently and to move this forward? And we need everyone at the table, but most importantly, we need staff nurses, the nurses who are doing and taking care of patients directly. We need their voices and their input to make these changes occur.

AB: Yeah, I totally agree with you because I feel like whenever I think about it at AACN, as we think about the staffing challenges, like you said, they're not new. We've been dealing with staffing challenges in nursing for decades, and there are solutions out there that have been proposed. And sometimes I wonder, are we in a new era of healthcare where we need new solutions? Or are we finally in the era where the solutions we've been asking for for decades also are now lining up with the problems that we have in our healthcare system? I think about the fact that yes, the supply of nurses, the education of nurses to fill the pipeline has always been a challenge. It's more of an exposed challenge now because we need those nurses to fill positions that have been vacated by nurses who've decided, "I can no longer take this environment. I can no longer take this job. I'm out." That's a longstanding problem. But now that we're feeling it really acutely, maybe now it's just the time for people to actually act on the solutions that are already out there.

JMK: Oh, absolutely. And I think you bring up a really good point. We've toyed around with some ideas for a very long time, and I think the challenge becomes how do we work in the same system and innovate and do new things while maintaining everyone's budgets and the way everything healthcare is financed? And it's like trying to live in two worlds, but we really are at a point where we know staffing committees work. We know that direct care nurses need to be involved in determining what is safe for their unit and their organization based on patient population and acuity. The American Nurses Association recognizes there's a lot of different ways we can attack this, but the same things. Whether it's standardization of ratios or numbers at a state level, public disclosure of staffing levels in an organization... I think the public needs to be aware of how much nurse time you're going to get or your loved one's going to get if you go to a certain department or a hospital.

And then staffing committees at a local level need to be majority staff nurse. We've been toying with those for a very long time. Some states have put some of these in and a variety of them, but we know these can and do in fact work. How do we really move forward with that? And at the same time, looking at the value and contribution of the whole team, how do we bring in more nurse practitioners into this acute care setting? And I'll speak of acute care, but really staffing is every setting. I'll note staffing and home health, hospice, nursing homes, but how do we bring in nurse practitioners and other advanced practice nurses (CNSs) to supplement what the units and departments need? There's a lot of ways to know what we take, what we have and put it into practice, but also look at truly a new model of providing care.

AB: But what you mentioned is a really good point, which is that nursing is not just patient with nurse at bedside and how many hours that nurse is with them, it's so much more than that. It's the support services that nurses have that are maybe not nurses but that help us do our best work. It's the layer of support for educators and clinical nurse specialists and advanced practice nurse practitioners, et cetera, that can augment our care and can support our care so that maybe the number of nurses, is not just about numbers of nurses to patients, but it's so much more than that. And I find that that argument is one that we've been making as nurses for a long time, but maybe one that's been laid bare a little bit more over the pandemic years because when we, in critical care, started taking care of critically ill patients outside of traditional critical care environments, we did some of those innovative staffing models where we had a CNS mentor and guide nurses who maybe hadn't taken care of that patient population before to meet the needs of the patients at the time.

And people could see with their own eyes how those things can really be value added. We've known that for a long time, how much all of us contribute similarly when we don't have environmental services and nurses are having to do trash removal and room cleaning and all of that. Our best contributions are not felt by patients. And so, what you said earlier about patients understanding how much nursing they're getting, I think it's a really important point because I think we don't talk enough about that with the public. And if they knew what their nurse was being asked to do in certain environments, they could be our biggest advocates. Because they definitely want, when they hit the call bell, us to show up and tend to their needs and sometimes we just can't do that. I think it's a really interesting world we're living in and I think that it's maybe the right time for those kinds of things to come to light and for us to try old solutions to old problems in a new era of healthcare with a new lens on it these days.

JMK: Absolutely. And I was getting my hair done last week and my beautician was saying how her father-in-law had passed away and that she was in the hospital and she was telling me all the things that she was doing, and she's like, "I know the nurses were short-staffed." And what she was describing to me was the care coordination that she was doing as a family member at the end of life. And she was trying to bridge the gaps amongst everyone and her family. And I said, "That's what nurses do." And she was seeing the direct result of just being short-staffed on her unit trying to do this, which is the work of nursing. And I think oftentimes people think of the tangible tasks, the passing meds and moving things around, but it's really about that care coordination piece that sometimes just gets lost. And that's where we need people to realize that we can make such a big difference just in length of stay and the way families interact. I really do think that actually has an impact in improving communication so families don't feel so lost in the system.

AB: I think so much of what we do as nurses — and I'm going to ask you about the most trusted profession poll in a second, because I have some thoughts on that these days — but so much of our work we just do and we don't talk about, but then when it's missing, that void is felt. Even the comfort, if you look at the data on missed nursing care, the stuff that we don't do when we don't have enough time to do everything, the stuff that we triage, if you will, in our minds, we often triage comforting and talking to patients and we triage teaching about their illness or discharge planning. And I think those are harder to see the effects of, but if you're a patient, you feel it. Because you absolutely in that moment, when your child enters the world, you want the nurse to be able to care and be there and comfort you and talk to you.

And that moment where you are getting discharged with a new illness and a complicated medication regimen or whatever it may be, you want that nurse practitioner to explain it to you and you want that nurse to be able to teach you… in my world, I'm a burn nurse, so how to do the dressing change and all of that. And I think that's work that becomes, is less visible until it's gone. And then suddenly the patients and everybody is feeling that. And I think that's been the a-ha moment for a lot of people during this time, like, "Oh, I can feel it. I don't know what's going on, but my work is a whole lot harder and patients aren't getting what they need." And oh, by the way, maybe nurses have been doing that all this time and now we just don't have time to do it.

JMK: Exactly. And I think that contributes to that moral distress because as a nurse, you go home after your shift, you don't think about everything you got done. You think about everything you did not get done. And that's so important because you're wondering if that's going to negatively impact the patient. And so, we have to pause and make sure we have the resources so nurses don't have to go home feeling guilty for what they may have forgotten. We all wake up in the middle of our sleep thinking, "Oh my God, I forgot to pass X, Y, and Z med." We've all had that experience, and that's not okay.

AB: Yeah, you're right. I mean, I've woken up in the middle of the night and through dreaming remembered that I didn't do something and then called, "I forgot to change the tubing on that one," and they're like, "Go back to sleep. It's not a big deal," but you're right. I mean, because it affects us personally when those things happen. And a lot of focus in healthcare has been on burnout and resiliency and those types of things. But yes, I think healthcare workers need some tools and skills to keep ourselves healthy for this work that will inevitably be stressful. There's no way around it, nursing is emotionally difficult at times and stressful and our environments are certainly something to be reckoned with.

But a lot of times I think that whole resiliency conversation shifts towards, "Well, you just need to deal with it yourself. Your moral distress is your problem. Here's a meditation room. Go in there and see if you can get your mind right about having to basically not meet every patient's needs in the way that you want to,” … that moral distress piece. And so, a lot of times when I'm asked by the media or other people about resiliency and burnout, I say, "Yes, of course that's a reality of our profession, but it's also the responsibility of the places we work to set the system up, the environment up, so that we are not experiencing moral distress every single day." There's absolutely things that can be done that are not in our control that would help us be less burned out and more resilient. And they usually come down to the work environment.

JMK: Absolutely. And our work as nurses inherently is traumatic. We are there around some of the worst times in people's lives. And so, we know that as nurses that this is what we experience, but what we've seen and what I hope we collect are some of the real good stories that say during the pandemic, here's what really worked or here's what we needed because it would be good, even in a non-pandemic time to put some of these in practice. I remember an ICU nurse saying, "I needed a break from being an ICU nurse, so either I leave my job altogether or can you rotate me off onto a med-surg unit for a few weeks? I just need a break and then I'll be back.” But when the option is, "I need a break, so please help me go to another unit," versus, "I need to leave the organization," I think organizations fell short on coming up with some really creative opportunities for nurses to decompress and to contribute, but in a less stressful manner sometimes.

AB: I think it comes back to flexibility and this idea that we shouldn't do what we've always done in an era where what we've always done is clearly not working. And I think even things as simple as requiring people to do day/night rotations or work weekends or some of these things. Flexibility is a huge satisfier for nurses. Whether you're talking about how long a shift is, how many days you work… I think some of the attraction to travel nursing was the fact that it's a short-term gig and you have some flexibility in whether you want to stay there or not. And I think sometimes the solutions are just simple, but we have to look past our way-we've-always-done-things mentality and just be like, hey, if the option is losing that nurse forever or to never working in nursing or never working in that place again, versus letting them rotate to med-surg for a while or to, I don't know, mother/baby... I don't know where, another part where they'd like to work in the hospital, that's so much better.

But we're just so sometimes stuck in our box about things that we just don't see those solutions when they're right in front of our face. Absolutely.

JMK: And I think the work that we've done between American Nurses Association, AACN and with our other partners on the staffing think tank, coming up with the document that says, "Here's short-term 12-18-month ideas," I think we need to continue to widely distribute that. For people to see what types of things they could go ahead and put into place that were really great ideas, but I think sometimes just they don't always get into the right hands of people.

AB: Yeah. They don't always get into the right hands or sometimes they're just really hard to implement. I mean, they're not easy changes. As for our partnerships together on this work, we've had a think tank and then a task force that are driving the changes we need to see… to address the staffing crisis in the country right now. And the recommendations didn't surprise me. Things like appropriate staffing, flexibility, equity, diversity and inclusion work. These are things that we all know need to happen, but also none of them are things that are easy to change or implement.

JMK: Yeah, absolutely.

AB: I think that's the place where we distribute our stuff and then we hope for the best. And I think as organizations too, it's a little bit on us to help people actually do it. Because it's not just enough to say, "Hey, these are the things nurses need so you can retain us in a hospital somewhere. And by the way, here's how you do it. Here's the first thing that you need to do, to, let's say, work on staffing.” For example, as you mentioned, a staffing committee that nurses’ voices are involved and that there's accountability in public reporting. Things like that. If you wanted to implement it's hard to just do that on your own if you're one hospital in one place.

JMK: And giving them the tools to be able to do that is so important. We have a tendency to push a lot of stuff out and hope it catches, and so we're going to need to help people catch it.

AB: What are you all doing to help people? Because when I hear this and everybody in AACN world anyway, we've been talking about Healthy Work Environment standards for oh, at least a decade. I mean, more than that, 15 years, something like that. And it's always, "Okay, I understand. I believe you, that these things matter and we need to do them." And then the how part is harder. We've been doing things like having a blog where people share their solutions to some of these things. We have forums at our conference where people share solutions. What other ways have you guys found to reach people when those good ideas are out there? And it's not a research paper, it's just like somebody's sharing what they did. How can you get people to learn from each other?

JMK: Well, that's a great question. And some of the things that we have done is outside of our partnerships is really working with our state constituent member associations. Every state basically has a member site for the ANA, and there's a lot of local work that gets done. Every state might have a slightly different view or opinion about how they want to do things. And so, we help provide resources, and we actually come together several times a year. The states, the state leadership come together in December and in June, and we have really great conversations about what's going on in their state, what legislation is occurring and then sharing, and then there's a listserv for everyone. They share best practices. And so, that connection at the state level to the nurses in that state is really, really important to help us get those messages out and trickle that information down to a more local level.

AB: I was at the ANA member for last June as a AACN representative, and there was a lively open mic-ish discussion on staffing where it was just that just as you mentioned, different state affiliates were discussing what has worked for them. Of course, those from California have some feelings about ratios. It was very lively, by my recollection. But I think those things are so important to learn from each other because I think right now people aren't giving us the solutions we need, so we have to crowdsource them ourselves. We have to grow them ourselves because I think we're the closest to it and we know what's going to work best for us. And I find those forums to be lively, but also helpful for us to learn.

JMK: Very helpful. And that's exactly the issue is sometimes the nursing... You just want to take care of our patients and take care of people, but if we're not part of the solution, someone's going to come up with the solutions for us and they're not going to be what we want, and that's where we're at, so we really need to be the ones that drive our solutions. And I think that might contribute to why maybe we haven't got some stuff moving forward is because we've left it up to others and we need to really push this forward.

AB: And the tough thing is we're all tired and we're all swimming in the same sea of all the things that are affecting nursing. And then, oh, by the way, and we have to find solutions. But you're right, our voice is so important. One of our AACN Healthy Work Environment standards is effective decision-making, which is basically that it's the idea that nurses have a voice in what's happening in their organization. And when we did our latest survey in October of 2021 on the work environment, that was one of the standards that's declined the most over pandemic time from between 2018 and 2021. And for me, that was just so concerning because I think exactly as you mentioned, if we're not involved in the decisions for our patients, for the policies in our hospitals or for the profession of nursing's future, we're just going to have to be victims of what others decide for us. It's interesting, there's a sad movement away from us being involved in those decisions because we're tired and resources are shoestring, but it's so important.

JMK: Exactly. And this is the time for us to step forward and really get involved. And I've heard organizations who, they have a lot of travelers or they're short-staffed and they're afraid to pull nurses away from the bedside, but that's not the time to not pull people away. We need everyone at the table. Even if you're, you are short, how can you still get nurses’ voices there?

AB: Yeah, it goes back to that idea that our value is not just in our direct task with a patient in that moment, but what we think and what we know and how we perceive the systems around us is another really important value of us to an organization. And if they're not tapping into that, we're missing a whole lot of what we could offer to an organization or to our patients. And I think it's just a new way of thinking about nursing.

JMK: And it contributes to... The ANF did a study this last summer and 42% of nurses still feel unsupported in their work. And we have to do something. That's a large amount of nurses who still don't feel... And so, we need to figure out solutions for them.

AB: I mentioned earlier we nurses are the most trusted profession yet again, for many years running, I've lost track of how many.

JMK: Twenty.

AB: And I always see that result year after year. And I usually am filled with gratitude and I'm very appreciative of how I feel that the public sees us and what we contribute. But I have to admit that this year when I heard it, I felt a little less full of gratitude. And I had a couple moments where I thought, "I wonder if this could be used against us in some way," almost like we're martyrs or we're expected to give more than we can or should to organizations because patients need us. It comes, there's a bit of this new feeling in me and I hear from others that we shouldn't be sacrificing ourselves or we shouldn't be always expected to go above and beyond what our jobs are. And I'm wondering it is, it's not that I don't appreciate that the public trusts us. They should, and I think we deserve the ranking.

But also I'm wondering if things like that play into this idea that we just have to keep on giving more and more and more and expecting nothing in return from the places that we work for our well-being and to support us in our work.

JMK: Absolutely. And I think that you bring up a really good point. It's how we then own that. How do we own being the most trusted? How do we keep it? Because at the same time, I've thought about, well, what happens if one year we're not the most trusted? What did we do to not have that happen? But at the flip side, how do we get people to trust us not based on being a martyr or the expectation, but they trust us because they know and public know that we will be there to stand up for them and to advocate for them, and that we do the care coordination, we're ensuring that they're safe, that we communicate with them appropriately? What are all of those soft and measurable things that we contribute that really, I think, also go towards being the most trusted?

Because we're there 24/7 with the person. Someone doesn't necessarily go into the hospital for anything else but nursing care, you're there for mainly nursing care. And so, how do we balance that? And I think too, it's really important because at the same time, how is that connected with workplace violence, and people thinking then that they can yell at nurses and be violent to nurses? In our recent survey found that nurses, 53% of nurses say that they feel that there's more verbal abuse occurring now. Yes, we're the most trusted, but there's a whole avenue of things that are going on that don't make sense together. If you trust us, why is there so much verbal and workplace violence right now?

AB: Yeah. No, that's a question that's been swirling in my mind too. It's like this weird dichotomy where you see how we are advocating for you in a place that can be really dangerous and unsafe and how we give our best to our patients all the time, yet in our survey, we saw a similar 50% of nurses say that they don't feel that where they work has their back, that if that kind of thing, if violence happens, that they're left on an island to deal with it instead of the hospital having their back. And they're reporting, like you said, more instances of physical and verbal abuse from patients. And I think some around verbal from each other too, which is also very, very concerning.

I'm sure you do too, get to be in forums with other types of professionals to talk about these issues. I was recently in one where we were talking about workplace violence with a bunch of physicians, and I was with an ER physician, and they mentioned that they recently had an a-ha moment in the trauma bay because they were talking to one of the nurses who said, "Basically every day I expect to be kicked, bitten, spit on … all these things happening to me from patients." And it's just an expectation of their job is what they were sharing with this physician. And they said, "Hey, it's interesting. I never go to work expecting to be assaulted by a patient. That's not a thing that I have to think about." And then they said, "So how can I help advocate for the safety of the nursing staff?"

They were absolutely just not aware that this was happening to us, and at the same time didn't really have tools to say, "Hey, administrators or whoever, how can I stand up for the nurses who are having to experience this rate of violence that's just unbelievably unfair for them and their contribution?" And I was like, "Oh, I bet if more people understood it, they would be against such a thing." And it happens all the time. And sometimes we just accept it like, "Oh yeah, it's going to happen today. I work in the ER so I know that I'm going to be physically assaulted today." I mean, that's again, not tenable for a long-term career for a nurse.

JMK: Well, and I think to your point, how do we share these stories with larger groups? Because you should never feel like you're going to be assaulted. In our survey the American Nurses Foundation just completed, 43% of nurses either don't know or don't have a way to report these types of issues within their facility. Even if they did, 43% of people aren't reporting because they don't even know how to report these issues, let alone get this into the hands of people that are important. And again, this must be before COVID, too. My husband was an ICU nurse, and he was choked with IV tubing. What stopped him from being a bedside nurse was when a patient basically pushed him into a monitor and then he couldn't feel his right hand anymore. He had long-term sustained injuries from violence, and that was well before COVID. And again, nothing has... We've known about this stuff. This has been going on, it's getting worse.

And so, one thing we have, there's a workplace violence bill at the federal level, and it's HR 1195 and Senate bill 4182. And it requires OSHA to develop and implement standards for citations and penalties against employers who don't start to create processes locally to prevent this from happening. And so, we have got to get into legislation. ANA believes we have to get into legislation, something that's going to make employers accountable for collecting and looking at this information and then doing something about it. This shouldn't be upon... Not everything is the nurse’s to solve. Yes, nurses should be involved with their voices, but sometimes the organization is responsible as the employer to be able to keep people safe.

AB: Thinking about workplace violence, we started off talking about the staffing challenges that we have. And I think these things are all related. It's like, how can we expect nurses to work in unhealthy environments where they are the victims of violence and incivility? I mean, there's so many reasons why we have moral distress and why so many nurses have said, "You know what? I would love to do this work. I wanted to do this work my whole life, but I just can't do it anymore." And I think it's on nursing organizations to use our voice the best way we can to advocate for things that make it easier for nurses to stay.

JMK: Absolutely. And like you said, there's staffing and it's all the issues around it that we've known about. It is the work environment, it's well-being, it's violence, and it just compounds staffing issues and who wants to go and work into that environment? And we see people not necessarily leaving the profession, but just leaving to other settings where they can get a break. And I think if we really want to make a difference, we have to go back. And if people want nurses and people are scrambling for nurses in hospitals and other large settings, we're going to have to focus in and tackle all of those issues so that nurses want to come.

And there are organizations that do it right, so this isn't doing it wrong, but there are plenty of organizations that do function, that do have shared leadership who are working through the work environment and doing the steps that they need to. And the nurses go there and the nurses know that, and that's where the nurses are at. And so, for the organizations that struggle, sometimes I have to question what all is going on in the organization that they're not doing to support their nurses?

AB: I think that feeling that where you're giving your all to patients, that organization has your back. I mean, that was one of the most startling statistics from our work environment survey is that just more than half of nurses don't feel like where they work has their back. And that feeling is about giving us the resources we need to do our job. It's about if a patient is violent towards us, that that patient is asked to leave that hospital or is told that that's not tolerated here. Those types of things, they really do matter. And you're right, we've voted with our feet, a lot of us, and said, "Hey, I'm working in this place and maybe it's convenient, maybe it even pays more than another place, but this other place I could work, I'm going to feel safe and valued and I'm going to make my best contribution to patients. I'm sorry, but I'm going to go over there. I'm not going to stay here." And I think that's the biggest megatrend I've seen as more nurses feel empowered to do that and to say, "I don't want this anymore for myself. I want something better."

JMK: Absolutely. And you know what? That is good for them to empower themselves and we shouldn't, again, goes back to that most trusted. People shouldn't have to be martyrs. And if they decided to make a decision that was best for them and their well-being, then I'm very supportive of that.

AB: And sometimes that's travel nursing, and that's a heated topic in my world these days because many critical care nurses have left to travel. But that's what I say about that too. If that helps you find your meaningful contribution as a nurse to patients, then travel nurse. I did it for many years and I loved it. Yeah, it's about being flexible and supporting nurses in their professional journey.

JMK: I was a travel nurse and that's how I got myself to Phoenix from Washington State. Now I'm back in the Northwest. But it was a really good experience.

AB: It taught me a lot about what's the same and what's different everywhere you go as a traveler. Let's talk a little bit about one of the other things that the nurse staffing task force slash think tank talked about, which was equity, diversity and inclusion in nursing. And certainly on the AACN side, we've been working towards lots of different internal and external goals related to equity, diversity, inclusion since, again, I think 2018, a while before the pandemic, before the summer of George Floyd, et cetera. It's something we've recognized for a long time. And we recently did a survey of our members and asked them, "How important is this initiative to you and your practice?" And we heard overwhelmingly from nurses that, yes, this is something that we do need to address in nursing and that is something that professional organizations should work on, promote, educate, advocate for. From the ANA side, what are you guys focusing on in the equity, diversity and inclusion space these days? And has anything changed in your thinking around that lately?

JMK: Well, we've been doing a lot and we have a lot of work to do. We had our reckoning statement this last year, which was supported by all of our state and constituent associations and then our work on the Commission for Racism and Nursing, which we're continuing that work very closely. And I personally, as the president of the American Nurses Association, will own this and continue to move it forward because nurses shouldn't experience racism in our own profession. Our patients deserve nurses that represent their cultures and backgrounds because we know it makes for better care. And so, we're really working through that now that we've made these statements and really put these groups together, what do we need to do now to operationalize and to change? For decades, unfortunately, Black nurses weren't allowed to be members of the ANA, and we've apologized for that behavior and we're making amends internally.

This is really important work for us. And again, providing and working through operationalizing and toolkits of how do we all then do this? How do you and your organization have a nursing workforce that looks and represents the workforce of the population of your community? Nursing schools. How do we ensure we have diverse candidates and students in the nursing programs and advanced practice and our doctoral program? This is just in every avenue that we've talked about it for decades. I remember we all remember probably taking our cultural competency course, which was taught by mostly a white, old woman who is teaching us about some nuances. And to me, unfortunately, those were some of those cultural pieces. "This culture does this, culture does that." But that was just almost inappropriate now to think about, in some instances. And really, we need to move this needle and stop just thinking that a cultural competency class is going to fix things and we need to have everyone at the table from now on.

AB: Yeah. No, what you say about cultural competency resonates with me because I was in one of those courses as well, and I think at the time I thought that knowing those things about... Which sometimes now I cringe at them a little, but basically knowing those things about groups was supposed to help me honor their differences. But one of the things I hear a lot from nurses who are maybe earlier on the journey to understanding how racism affects patient outcomes or health equity or how it persists in our profession over all this time. The thing I hear the most is, "As nurses, we treat all the patients the same. No matter what they are, we treat them the same." And that's a thing that has come out of my mouth before, before I learned some things. I definitely said that. And it took me taking a step back and saying, actually, the better thing to do is to see how the things about this person are affecting their health, are affecting the way society may treat them and treat them with care for them with those things in mind.

This colorblindness narrative means that I'm disregarding all of those things that make certain groups absolutely experience health disparities and inequitable care and unequal treatment. And so, I think that's the most powerful narrative to overcome in nursing, because many nurses grew up with that cultural competence and the colorblindness. And it's hard because I think all of us have the same intention in mind. We don't want to be disparately treating different individuals, but we have to recognize what about those individuals is making them need healthcare differently, need care from us differently? Instead of just saying, "Everybody's the same, everything's fine," because it's just not true.

JMK: Absolutely. And I think about in my last leadership role, I had my BIPOC staff come to me and say, we would really like to start a BIPOC committee because we have issues and things that are unique and different as employees. And then I said, "Well, figure it out." To me, it was shared leadership for this group of individuals. And one of the things they pointed out that I just didn't get, because this is one of the very important things in nursing, is that on job descriptions for hospitals for instance, was to require nursing experience in the hospital. “We would prefer hospital experience.” And what I was told by some of my BIPOC employees was this actually in the BIPOC community stops people from actually getting hired. And they actually maybe go into positions out of school that are easier to get because they're looking for the income and then need the job.

And so, they get really valuable experience with their diverse cultures and populations and community settings, which is actually what we need in the hospital to take care of patients. But because we have these structural barriers in our job descriptions and hiring practices, our workforce isn't diverse. And because we're not saying, "You know what? In order to take care of our patients, we need this experience," which might actually be more important than hospital experience. And that was just a real eye-opening thought for me because I thought I was doing good when I didn't realize the impact it had on some.

AB: It goes back to the same thing we said about staffing, expecting different results and doing the same old thing all the time in this space is also really important. Another thing that our members said in our equity, diversity and inclusion survey that's still sticking with me, I'm still thinking about it, is the lateral racism. That Black nurses were more than two times as likely than white nurses in our survey to say they experience racist things from their colleagues or nurse colleagues. And it's just so heartbreaking to think about, and at the same time, it makes me have a fire fueled inside me to try to change it. And so, we've talked a lot about, well, what do nurses need when they witness those things or when they're in a workplace where a person is experiencing those behaviors? How do we speak up? How do we advocate for them?

It made me think about many years ago and AACN, we did a lot of crucial conversation training and it was about patient safety. We would say, "this is making me uncomfortable." And to try to get physicians to listen to us when things were happening with patients. I feel like we almost need something like that for nursing where when we witness things either towards patients, from patients, or towards each other that are racism in action or that are unequal treatment, how do we have those? We need some tools to have those conversations because it's such a touchy emotional subject, but it's happening. The reality is it's happening every day and it's not okay.

JMK: And when we let it happen and we don't stop it, those employees who are experiencing it distrust the system to do anything about it. And oftentimes they may elevate it or escalate it only to have nothing done or to be labeled a troublemaker. And so, we need everyone in alignment. We need structures that are safe for people to report this without fear of being ousted or in trouble because that's how we start to move the needle. I remember reading a comment from someone who had taken implicit bias training and they said that the course was spreading white racism by teaching implicit bias. To see these comments and to see people do these acts is unfathomable as a nurse, who is supposed to be the most trusted profession, and that we, even between ourselves, and colleagues have this type of behavior occurring. I think creating structures and being allies, we need to be the allies and stand up for others when we see it happen.

AB: That allyship idea is so powerful. One of my colleagues recently told me a story, and she's a nurse of color, about how there were a lot of years where she didn't feel like she was a good nurse. And since you're a nurse, I'm a nurse. We know that being a good nurse is a thing we all want to do. We also want our colleagues to think that we are good nurses and that we work together and do the best thing for patients. And she described how hard it was for her to be validated by her colleagues as a good nurse and much harder than it would've been for somebody who is not a nurse of color. And her telling that story to me, it made it personal for me. Maybe I haven't experienced that, but I am now her ally so that nobody has to feel like they're not a good nurse because of some identity that they have.

And so, it goes back to this really powerful tactic we have as nurses of storytelling. If you share with me what happened with you, and I share with you honestly how I feel like we can move the needle on not just this, but other problems we have. Even telling our stories to the public has been really powerful. I think a lot of it is listening and learning and then once you know, having something you can do about it, if you want to be an ally or if you want to change this piece of our profession or the way patients are being cared for. Got to have to start maybe with stories so we understand each other a little better.

JMK: Absolutely. And I think that's listening, because I think oftentimes people might be afraid that if they say the wrong thing, they'll be thought of as racist. "If I say this or say this, I don't know what to say that's correct." And so, asking your colleagues and talking with them and asking how you can be an ally. You don't have to have the right words and you can listen and learn, and it's a journey for all of us. It's a journey for us so that future generations will not have to deal with some of this. I remember someone said, I think at membership assembly, they said, "If we really wanted to, we could stop racism tomorrow and stop being racist." And I love that belief, but I think there's a lot of people who don't even maybe recognize that implicit bias that they have and that they need to educate themselves, but then also partner and be that ally.

AB: Yeah. I mean, our organization, AACN, it provides education for all kinds of things in acute and critical care nursing. And another thing that we've found in our survey for EDI is that nurses want us to give them some resources to learn on this topic. We didn't wonder if this was our place or not. Definitely on the board, we're all nurses. We all feel this issue. But it was really nice to see the membership say, "Yeah, actually, please give us some education. Please help us understand." Whether you feel a certain way about this topic, education is the way to open up doors and to learn and to listen. I think it's not something we can change overnight, but it starts with that listening and then that teaching, that opening up awareness about a topic that maybe people don't think about on their day-to-day basis if it's not affecting them personally.

JMK: And with our associations too, is really working on getting the diversity and inclusion on our boards so that people see that it's not... What typically happens in nursing is a bunch of white women on our boards, and that we really do need to get males on boards, we need to get people of color on boards, and that our organizations start to look like the profession that we want it to look like.

AB: Yeah, absolutely. That's something we're also working on at AACN too. Sometimes when we think about leadership of professional organizations, we tap the people that we know. And what we learned through our EDI training is that limits you to only the people that, and so getting that circle bigger so that we can absolutely have our organization represent our membership and nursing in general is top priority for us.

JMK: Absolutely.

AB: Thinking about... I feel like everything we've talked about really is about how valuable nurses contributions can be if they are given in the right place, to the right people, with the resources we need to do our jobs. And I think about the value of nursing and recognizing our value as the meta-agenda for nursing these days. "Listen to us, we have the answers, but also we need some things to give our best to patients."

And the era of pizza parties and ice cream socials, that's gone, please don't give me a slice of pizza. Help me, give me professional development. Support me so I have enough staff to do the work I need to do. Those are the things that we need as nurses to feel valued. But how are you thinking about recognizing the value and the contributions of nurses and getting more people to see that we're not just cogs in a machine that do labor and also that pizza parties and ice cream socials, while nice, are not enough to recognize our contributions?

JMK: Absolutely. It's a great point. And what I think we need to do is take that veil off, the veil off the mystery of what nurses are doing. And where we start one way is through every nurse in the American Nurses Association, I would like every nurse to start getting their NPI number. And I know some will say, "Well, I'm not billing or I'm not doing this." But as soon as you get your license, you also apply for an NPI, we can start to utilize these numbers then to attribute what nurses are doing in all these reports. And we have physicians and surgeons and everyone else taking credit for all this work that nurses are doing because they're tying information to NPI numbers.

And so, I think one of the places to start... And it's not that hard. I'm not billing or I have no reason to bill, but I went out and got my own NPI number. Because I thought, "Well, how does this work?" And it took me 15 minutes and got my NPI number as a registered nurse, and then we start to move the dial on the conversation. How do we work with EHRs to start connecting that nurse’s NPI number to the work that they're doing to the outcome, how many times that they've contributed to doing all the work that they do, and start to get a very quantitative view of what's occurring?

And so, I think value could be a lot of things, but I think value also is taking credit for what people are taking credit for already. Every time a nurse is educating someone in a clinic or doing a nurse only visit, that usually trickles up underneath the provider's NPI. And so, our value is not seen to the public and we need to move out from underneath that structure. Often nursing didn't want to be involved with the money piece. We just want to take care of patients, but here's where we're going to need to say, "Our value does have a monetary dollar amount." We're in the room and board, but how do we take credit for the work that we're doing? And I think that's a first step.

AB: I'm embarrassed because I don't have an NPI number.

JMK: I just did it. I just did it a couple months ago.

AB: No, that's great. And I hear about the NPI number and I think, "Oh my gosh, the administration have actually..." Quantifying nursing work sounds like really hard thing to do. But in principle, I love the idea of everybody else or all our professional colleagues have a way to make their work visible in the EMR or in the whatever, and we really have it.

And so, I do like the idea that something needs to make our work more visible so that we can ask for the things we need: more staff, and healthier environments, and tools to reduce our burnout, and moral distress, and zero-tolerance policies for violence against us. I mean, we're asking for a lot, but also we bring a lot to the table. And as we've said, some of that becomes invisible wrapped up in the bed charge nurses. Yeah, we've been thinking about that a little bit too, and how to make our contribution visible and valued, I think. And so, yeah, maybe an NPI number is a good start. I just think about the millions of nurses and the keeping track of all that. And I feel overwhelmed, I guess, by the people who would have to do it. But maybe I'll get mine after this. I just thought, "Well, nobody's making me do that," so I'm not going to do it. But I do see how it could be a step into making our work a little bit more visible.

JMK: Absolutely. And so, it's like your social security almost. You keep track of your number and you give it on unemployment, and we have all the ICD nine, 10 codes, or 11 codes. We have all these codes and all these CPT and procedural numbers, and we know how to connect them to all the other providers. I think we can take that next step and then connect it to the nurse.

AB: Yeah, because when you think about the business side of healthcare, which I do think if nurses understood the business side of healthcare more, if it was more part of our training, we would understand how some of these things relate to each other. But the only financial incentives for nursing are usually disincentives. "We're going to take money from you if you have a pressure ulcer, we're going to take money from your hospital if you get an infection. We're going to take money." There's no way to actually get more money if you're doing excellent things in nursing care. It's totally fascinating. And it's flipping the narrative, right? It's not like we haven't had incentives related to nursing care in the past, but they've all been negative. They've always been like, "Oh, if you mess up, we're going to take money for this and take money for that."

And so, we get the pressure to reduce those things or we'll lose money. But investing in nurses is a whole other story for excellent patient care. And I think that's the narrative shift. Patients are sicker in our hospitals now. They're requiring more of nursing. And if we don't get a handle on quantifying that, and we just stay in the same old bed charge that we've always been in, maybe it's not even accounting for the way our work has evolved over time, because it really hasn't changed in decades, the way that nursing is paid for. I think it’s really fascinating. I think that's, at least on my personal AACN agenda, is understanding some of that stuff a little bit more so that we can advocate for what nurses need.

JMK: And we've seen all the work that's been good, great for the advanced practice nurses. And so, they've been able to do all of this work, and they contribute to the profession greatly as well from a value perspective. Taking care of patients in underserved areas and being sometimes the only provider in underserved areas. We've been able to track and quantify through their numbers what they've been providing. I think we can learn a lot from what the advanced practice providers have been doing.

AB: Okay. Well, I think it's been amazing chatting with you. I've enjoyed this conversation so much. I think I'm encouraged by the fact that we agree that now might be a really interesting opportunity for nurses to change healthcare. AACN's vision is that we're dedicated to creating a healthcare system driven by the needs of patients and families where nurses make our optimal contribution. And so, I think we're aligned on that. I think this idea that we've been talking about is patients and families really need us, and we need some things to make our optimal contribution, and I think now's the time for revolutionary change.

JMK: Absolutely. And thank you for having me. And I so enjoyed the conversation and the partnership and the work that we're going to continue to do because even though we've talked about so many problems and so many issues, we really are in a good spot because we have this recognition and that people trust us, and we have momentum on our side to really make the changes happen. And if anything good was to come from COVID, it was really unifying our profession and to propel us forward to get these changes done.

AB: Yeah, absolutely. Our AACN theme this year is Starting Now. And I like to say often that starting now with a renewed hope for a better future and a cooperative spirit like you and I have about this, we're going to move closer to meaningful and sustainable solutions. Thanks so much, Jennifer. It's been amazing chatting with you today. Our time is now up. If you are watching this and you have questions or comments about today's discussion, please write to me at startingnow@aacn.org. And for myself and Dr. Jennifer Mensik Kennedy, thanks so much for watching. And thanks, Jennifer.

JMK: Thank you.

If you have comments or questions about this Presidents’ Video Chat, please email Amanda at startingnow@aacn.org.