The Future of Care
- Joan Bundley, advocate and lobbyist with the Illinois Nurses Association from the mid-1970’s until 2001."Nursing is healthcare's best-kept secret.”
Increasingly, healthcare experts and advocates are emphasizing the importance of social determinants of health (SDOH) in deciding people's health. As the NASEM report argues, nurses are uniquely positioned to address SDOH because they have a long history of caring for the whole person in their community, in schools, clinics, community centers, and homes.2 In the coming years, Black nurses who are trusted in and knowledgeable about marginalized communities will play an important role working on SDOH. Tackling SDOH will require that nurses coordinate care with social workers, community organizations, and government agencies to address issues like food insecurity, housing instability, and transportation, which all affect a person’s health. Read more about SDOH here.
Additionally, experts are pushing for the U.S. healthcare system to move to a focus on prevention and disease management over acute care. This requires healthcare staff who can take the time to build relationships with patients and educate them about how to live healthier lives and manage their health conditions. Black nurses have been filling this role in hospitals, clinics, community organizations, and schools for generations.
These efforts are all part of a broader push to address health inequalities with person-centered approaches that focus on the whole person, including their “physical, mental, and social needs,” as well as on the beliefs and values of their community.3 For most of U.S. history, Black people have faced rampant discrimination from white-led healthcare institutions. Real improvements in health in the Black community will require changes at many levels – in primary care offices and clinics, in public health efforts, and in legislation. Nurses with deep ties in communities hold valuable knowledge about how to address these interconnected issues.
Yet experts point to a growing nursing shortage, with older nurses retiring and record numbers of young nurses leaving the profession since the COVID-19 pandemic.4 Additionally, over eighty percent of U.S. nurses are white and just under seven percent are Black.5 As the U.S. faces growing healthcare challenges, Black nurses will provide critical labor and perspectives. To be able to do so, they will need support from nurse training programs, healthcare institutions, nursing organizations, and lawmakers.
Nursing Education: Barriers and Supports
Policymakers must invest in more programs that provide accessible pathways into nursing for young people from historically marginalized communities.
Between 1993-2012, Sandra Webb Booker coordinated the Chicago Public Schools (CPS) Practical Nursing program, in which students took two years of courses and then the nursing board exams. They graduated high school eligible to work as licensed practical nurses. Webb Booker notes that many graduates of the program went on to earn associate or bachelor’s degrees and become registered nurses. The program made nursing education freely accessible to diverse students across the city for decades. For low-income Black students, who often have to care for family members or cannot afford to go away for college, the program provided an affordable way to get a nursing license. It also created a pipeline of licensed nurses working in Chicago who had knowledge of local communities, a key skill for providing quality healthcare. Unfortunately, CPS closed the program in 2013.
Black nurses we interviewed provided different perspectives on the balance between making nurse training accessible and maintaining quality. Deborah Bump began her nursing education in community college, which she believes is a valuable path for many students. “It really is a good foundation,” she says, “it kind of gives you an opportunity to see if you can do [nursing],” before taking on the expenses of an undergraduate nursing program. Margaret Okodua notes her concern about the growth of online nursing programs, where oversight of student work is more limited. She feels that it’s important that most nurses have at least a bachelor’s degree because nurses’ skills can have life-or-death consequences.
For Black students who do make it to nursing school, they often face many challenges. Many of the Black nurse educators who participated in our oral histories spoke about their concerns and their efforts to support Black students.
Fred Brown, a Director of Generalist Education at the RUSH University College of Nursing, notes that the costs of nursing education have skyrocketed since he completed his training in the 1970’s. He makes a special effort to provide mentorship and connections for students. “If there's somebody on the other side of the door pulling,” he says, “it just makes it that much easier for the next person.” Similarly, Angelique Richard, the Chief Nursing Officer of the RUSH University medical system, takes very seriously her responsibility to support nursing students of color at RUSH. She says: “I want to create an environment where they see people that look like themselves.”
Tamara Bland, Dean of the Borra College of Health Sciences at Dominican University, is concerned about the lack of support for students of color in nursing programs. Many nursing students of color begin as Certified Nursing Assistants (CNA), because CNA programs are affordable and fast. Those students need encouragement to continue their education. Bland has sensed how these students struggle and, "I am trying to understand why there are so many barriers in place that minority students are unable to or feel as though it's not worth it to complete their bachelor's of science in nursing.”
What barriers do these students face? Bland has taught at various schools and heard white colleagues make racist remarks. There have also been few other faculty of color at each institution, meaning that students have few mentors that share their racial identities. Students of color have also told Bland explicitly that they feel uncomfortable on campus. Pamela Pearson, the Director of the Nurse Midwifery program at UIC, has seen white faculty criticize Black students more than other students. Margaret Okodua described being pushed out of a nurse practitioner program by a professor who doubted her abilities and tried to pressure her to transfer to a different program (Okodua eventually completed her nurse practitioner training elsewhere and has since even served as a clinical preceptor6 for nursing students from her original program).
Pearson explains that sometimes Black students struggle not because of blatant discrimination but because faculty lack cultural understanding about students’ realities, such as being single parents or needing to care for family members while in school. As one of the few Black faculty members in her department, Pearson feels that she is doing important work advocating for those students. Bland argues that it is not enough to accept more students of color into nursing schools. “How do we support students?” she asks, “ What are the wraparound support services that we need to put into place outside of the classroom?”
While it is important to increase the numbers of Black faculty in nursing education who can support students of color, they cannot fix these many issues without broader institutional changes in policy and culture.
Nurses At the Bedside: Burnout and Shortages
Some of our oral history participants spoke about the shortage of nurses “at the bedside,” meaning nurses engaged in direct patient care in hospitals. Fred Brown noted that there were not enough bedside nurses before the COVID-19 pandemic, and the pandemic has made conditions worse. “People are coming into nursing, seeing how difficult it is,” he says, and “they rush back to school to become a nurse practitioner.”
Bedside nursing has many unavoidable challenges: it requires a lot of physically difficult work and being exposed to disease and death on a daily basis.
There may also be generational shifts about what nurses are willing to accept. Askale Facey-Philips, who graduated from nursing school in 2021, has learned to set boundaries around work. If she has taken vacation, “don’t try to guilt trip me into taking [another shift],” she says about supervisors. Her first priorities are herself and her family. One can see this as part of a greater culture shift, in which Americans, especially from younger generations, are prioritizing their own well-being over work.7
Yet work conditions have also become increasingly difficult for bedside nurses. Titilola Turton notes that since she joined the nursing profession, technology has come to play a much bigger role than it once did. Technology can be helpful, but it also takes away time that nurses could spend with patients. The authors of the NASEM report similarly write that federal policymakers and insurance companies need to lift “the burden of technology” and technological requirements from nurses.8 Nurses are also facing higher workloads, staff shortages, extended shifts, and increasing documentation requirements, all of which create high levels of stress and burnout.9 “People are being driven away,” by these conditions, Turton says. These realities do not just affect nurses, they also mean worse care for patients.
Joan Bundley argues that the problems start with the fact that healthcare administrators do not include nurses in their decision-making:
“We have to hire staff based on a budget that we had no part in creating. [Administrators] tell us what we're going to do…I have to staff for 24 hours. You go home, you come in at 9:00 and go home at 5:00, and you're going to tell me how to run the joint.”
Much news coverage since the COVID pandemic has also highlighted how many hospitals focus on profits over patients and staff, leading nurses to quit their jobs and patients to have worse health outcomes.10 Many Black nurses have used unions as a way of fighting these trends, both historically and in recent years.
Bundley, who worked at the Illinois Nurses Association (INA) for decades, believes that nurses must work their way into leadership positions. She decided to pursue a master’s in public health so that she could demand a voice in hospital decision-making processes.
Black Nurses in Leadership Positions
Nurses’ voices are crucial to improving a healthcare system that often fails both healthcare staff and patients. Black nurses have a long history, particularly in Chicago, of advocating for change on these issues (include link to unions).
Many Black nurses with whom we spoke emphasized how nurses, especially Black nurses, must seize opportunities to impact healthcare outside of day-to-day patient care. Mary Maryland works as a nurse practitioner with senior citizens, while also serving on the board of the American Nurses Association (ANA). Maryland previously served as president of the INA. She noted that many organizations, like the ANA, excluded nurses of color from leadership for much of their history. Now, she argues, young Black nurses need to seek leadership in such organizations: “if you're not at the table, you can't participate, you can't impact change.”
Of course, when Black nurses do move into leadership positions, they must contend with various forms of racism in institutional policies and culture. Tamara Bland notes that, as one of the few people of color on her faculty, she has the burden of being expected to serve on every single committee, so that there will be diverse racial representation. Joan Bundley similarly expresses a frustration that she has often been asked to speak for all Black people. But, she said, “We’re not monolithic, okay? Ask me what I think. I’m not speaking for the rest of the race.”
Black nurse leaders cannot be expected to represent all Black staff or patients. Fred Brown notes that he sometimes feels that he is “not Black enough.” He grew up lower middle class, but he earned an education, including a doctorate, with minimal student debt. He sees many African Americans struggling to access healthcare or employment and does not share those life experiences, which makes it harder for him to connect with them. Yet Brown prides himself on his ability to exist “in the middle,” to be the administrator in the suit and tie who goes down to the basement to speak with hospital dining staff and support their careers. Brown’s perspective is an important reminder that institutions must support more Black nurses moving into leadership precisely because each Black nurse has diverse experiences.
Black Nurses in Healthcare Policy
When Black nurses move into leadership positions, they can impact not just a certain organization, but broader systemic issues. Janice Phillips ,Assistant Director of the Illinois Department of Public Health, expresses hope that Black nurses are becoming more organized and trained on advocacy and policy. As Phillips said: “If you’re the CEO of a hospital, you get to advocate with the hospital association [to politicians]…we definitely need to be in leadership roles so that we can exert some more influence.”
Black nurses have already helped to shift how laws and insurance companies value nursing services, which the NASEM report argues will be crucial for improving healthcare in the coming decade. Joan Bundley helped to lead the effort in the 1990’s to pass advanced practice legislation in Illinois. These laws recognized nurses with training in certain specialties – like anesthesia, midwifery, or primary care – and licensed them to provide certain services without doctor oversight. The NASEM report laid out other laws that could expand nurses’ impact. The government made temporary changes to various regulations in response to the COVID-19 pandemic, which allowed nurses to “practice to the full extent of their education and training…increasing access to equality health care.”11 The report’s authors argue that these changes should be made permanent. Legislators need to also push to increase Medicare, Medicaid, and private health insurance coverage for nursing services. Multiple oral history participants noted how the current insurance system prevents equal access to quality healthcare.
Joan Bundley believes nurses need to act not just as lobbyist and advocates: “I'm glad about what little contribution I made,” she says, “But…what we need are more nurses in the legislature.” Bundley points to Lauren Underwood, a Black nurse who won a Congressional seat in Illinois in 2019. Underwood has since sponsored laws focused on making healthcare more affordable and accessible, as well as on increasing funding for nurse training.12
One of the biggest areas where Black nurses, whether as advocates or politicians, can exert pressure is on more evenly distributing resources – both in healthcare and in underserved communities more broadly. As Deborah Bump said, “I just don’t think there are enough resources, not only in the hospital setting but in school settings…I mean, they, just have abundant resources, and you can barely get the ceiling fixed in some of these schools... sometimes when you look at the disparity, it's just so, so glaring.” People of color’s health suffers from structural racism that extends beyond healthcare to most aspects of life.
Titilola Turton,who co-founded the Nigerian Illinois Nurses Organization, explained that her advocacy for her community has taught her that “nurses need to be at the legislative level.” Many of the challenges that nurses face in ensuring the health of their communities start on the policy level. Turton said, “Nurses, we try to shy away from politics. [But] everything in this world is political…If you are not at the table, you'll be the next meal.”
These nurses are part of a long history of Black nurses advocating for policy changes, stretching back to the National Association for Colored Graduate Nurses, founded in 1905.
As we look towards the future of healthcare in the U.S., we must learn from our history. Since the Jim Crow era, Black nurses have been first-hand witnesses to how structural racism and inequality have impacted the health of communities of color. As the individuals doing much of the day-to-day healthcare work in hospitals, schools, churches, and homes, Black nurses understand the complexities of educating and empowering communities about their health. Their perspectives are invaluable in helping to decide how schools, hospitals, healthcare organizations, community groups, and government agencies should direct their energy and resources as they seek to improve the health of all Americans.
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This page references:
- NASEM Report, 316
- NASEM, 303-306
- NYT On Hospital Profits & Patients
- NASEM Report, 116
- NASEM Report, 31-32
- Lauren Underwood Congressional Page
- NASEM Report, 363
- NASEM report, 112
- AACN Nursing Shortage Fact Sheet
- AACN Diversity in the Workforce
- Preceptor definition
- Fast Company - Changing Work-Life Balance