Appendix E

The Future of Nursing 2020–2030: Meeting America Where We Are Supplemental Statement of William M. Sage, M.D., J.D.

In 2019, the National Academies of Sciences, Engineering, and Medicine launched its second major consensus study (and third study in 15 years) of the future of the nursing profession in the United States, with an intended focus on community nursing and health equity. In 2020, the COVID-19 global pandemic changed how the United States understands its health and its health care system.

Such times cry out for policies with ambition and courage, especially from organizations such as the National Academies that serve as stewards and guardians of biomedical science and public health. I write separately today because, in my view, the conclusions and recommendations in this report are not sufficiently bold to fully meet the moment.

The committee’s charge was amended in mid-2020, and the project’s timetable extended, to consider COVID-19. Among other changes, the final report includes a COVID-focused chapter on “disaster preparedness.” Given the systematic issues of injustice and avoidable harm that the COVID-19 pandemic has revealed, it is my view that the least important lessons for the future of nursing may be about disaster preparedness. The U.S. pandemic experience has made plain that illness is unequally distributed across groups and communities, that the burdens of illness track long-standing racial and socioeconomic injustices, that public engagement and education are critical components of health improvement, and that nurses are essential to an effective public health system now and in the future.

As this report was being drafted, heartbreaking headlines proclaimed growing numbers of sick and dying across the country and throughout the world. Most severely—and unfairly—affected were individuals and communities of color, who suffer from the compound disadvantages of racism, poverty, workplace

hazards, compromised health care access, and preexisting health conditions resulting from the foregoing factors. Seniors in long-term care and other congregate settings were also profoundly endangered.

Nurses in COVID-19 hot spots went to work every day, often for extended shifts, caring for patients despite the hazard to themselves and their family members. Some nurses served on the front lines in hospital emergency departments and intensive care units, or in skilled nursing facilities. Many left loved ones to help strangers who were sick and dying, sometimes rendering care without adequate protective equipment. Other nurses have educated the public about COVID-related risks and protective measures, including overcoming vaccine hesitancy, while working to test communities and trace contacts of those infected. The rewards for such dedicated service are great, but so are the dangers of psychic trauma and moral injury to nurses and other health care workers. It seems likely that the scope and scale of post-pandemic stress on the health care workforce will be unprecedented in American history.

COVID-19 has also revealed profound problems with the financing and delivery of American health care, presenting both challenges and opportunities for nursing, and has reopened old wounds about lack of voice and subordination in professional hierarchies. Even as the pandemic raged, nurses with outstanding professional skills suffered economic hardship as reduced demand for nonemergency, specialized medical care and surgical procedures resulted in furloughs and layoffs. The value of nursing has often been obscured by hospital accounting practices that treat nurses as undifferentiated though dominant contributors to organizational “labor costs”—relegating them to the expense side of the ledger. This short-sightedness explains why nurses were among the first casualties of COVID-related financial pressures on many provider organizations.

Nurses cannot engage the social determinants of health as charity or in their spare time, but must be paid for the value they deliver, especially as hospitals and other major employers of nurses become accountable for population health. Considered as an engine of value creation, nursing is economically significant at the national level and in every community across the country. Nurses’ cumulative national earnings total approximately $250 billion annually, as much as the entire economies of Connecticut, Oregon, and South Carolina. Registered nurses earn more in the aggregate than any occupational classification in the United States except “manager” and “chief executive”—more even than physicians. Secure employment at fair wages contributes to economic stability for nurses and their families. Because the United States spends health care dollars in every region, nurses’ earnings also build health equity by helping to offset socioeconomic disadvantage, including in communities of color.

This supplemental statement focuses on missed opportunities—potential conclusions and recommendations within the project’s Statement of Task, illuminated by the COVID-19 experience, that were not included in the report. I regard these as critical omissions because I do not think the goal of a National

Academies report should be to publish a tome, or to compile a long list of approved areas for possible funding and future policy development. In my view, its goal should be to make a compelling case for action and advocacy through clear, unmistakable statements combining data, insight, and purpose.

A futurist project on the nursing profession at this moment in our country’s health care history demands the formulation of strong hypotheses for the post-COVID era, which ongoing research, some of it COVID-related, will continue to test. In my experience, moreover, major National Academies reports on health policy are most effective when they are self-critical. Some progress has been made since this report’s 2011 predecessor (FON-1), but other recommendations in FON-1 have languished or stalled. Whatever has been accomplished since 2011, the COVID-19 pandemic shows that it was not enough. Nursing has far more to do, and nursing must be inspired and empowered to do it.

As a physician, I might seem an unlikely messenger to suggest that a report on the future of nursing lacks sufficient ambition. But physicians still hold the greatest public authority in U.S. health care, and they still wield the most power. If radical change in our health care system is required to promote both health and justice, physicians must open their tent and welcome nurses and others inside, an urgent set of tasks that the National Academies can help move forward. I therefore feel a special responsibility for the reach and quality of this critically important work.

The recommendations in this report are well-intentioned and well-expressed, and I wholeheartedly endorse their goals and most of their details. But, in my view, they dwell excessively on generalities regarding health equity and the social determinants of health. Using the right vocabulary is not enough—COVID-19 proves that talking the talk without walking the walk does not shorten the journey, much less reach the destination.

I believe that substantial evidence, including ongoing research in connection with COVID-19, supports the following additional conclusions and associated recommendations to improve the future of nursing and promote health equity as called for in the Statement of Task:

1. Despite lavish expenditures, America’s “medical-industrial complex” is failing to preserve and improve the nation’s health. COVID-19 has shown that core public and community health functions are inadequately supported and poorly coordinated. At the same time, major segments of our massive yet often elective clinical enterprise—which employs the majority of nurses—now demand even greater taxpayer subsidy as they struggle to continue their accustomed activities. The report recommends workforce expansion, but would finance it indirectly through existing clinical revenue streams that would serve mainly to further medicalize social problems. Instead, it should call for substantially greater direct

1. public funding of community and public health nursing as part of an overall redirection of investment from medical care to health. Enhanced support for public employment should be accompanied by an expansion of scope of practice that empowers bachelor’s degree–trained RNs to serve their communities more effectively, amplifying the benefits of full practice authority for nurse practitioners and other advanced practice nurses.
2. The nursing profession is an economic force for health improvement and should be treated as such by hospital systems, other clinical settings, and payers. When a physician performs a clinical task, the presumption is that the physician will be paid for that task; when a nurse (leaving aside advanced practice) performs a clinical task, the presumption is that her or his work is subsumed in aggregate fees paid to the facility where she or he practices—even if both the physician and the nurse are employees of the same organization. Treating physician services as attracting revenue while nurse services impose costs disempowers nursing and favors procedural over community-oriented care. The report should devote greater attention to identifying, measuring, and rewarding the patient and public benefits of all nursing care, not just advanced practice—including facilitating revenue generation by nurses who improve quality, safety, and population health.
3. Nursing is too siloed and too rivalrous, both within itself and with respect to other professions. Significant gains in nurses’ authority and performance with respect to community health and health equity are more likely to result from partnering than from climbing ladders and pulling them up afterwards. Yet, the nursing profession remains dominated by the largely White, nearly exclusively female groups that have been most successful in hospital-based settings with physician-led hierarchies. The report should be more self-aware and self-critical of nursing’s professional blinders, including an acknowledgment and promise that the National Academies’ repeated, well-funded attention to the future of nursing is intended to be inclusive of rather than competitive with other health professions. The report should also be more attentive to recommendations affecting the basic RN nursing workforce, which was relatively neglected in FON-1 compared with advanced practice; to the various aspects of professional diversity that follow from generational change; and to the important roles played by nursing aides, community health workers, and others who may not be fully qualified nurses but who are key contributors to health equity and community health.
4. Fulfilling the promise of nursing means speaking truth to the medical establishment and making it acknowledge an ethical obligation to reform professional hierarchies. The laws and norms that constrain nurses’ ability to practice to the full extent of their skills and training were put

4. in place by physicians to protect their privileges, independence, and income. As the COVID-19 pandemic recedes, retrogressive lobbying campaigns by organized medicine have already resurfaced, aimed at rolling back improvements in nursing practice authority that were long overdue and that the report, admirably, speaks out to defend. Such outdated, unwarranted restrictions often apply not only to advanced practice nurses but also to other nurses and health professionals, and they include the payment policies that continue to fill health industry coffers primarily from orders, prescriptions, and referrals that originate with the physician’s pen. The report should be more demanding and explicit about examining these pathways and providing nursing with a meaningful voice and greater parity with physicians in performing professional self-regulatory functions, whether adding a nursing organization to corporate membership in The Joint Commission or revisiting the American Medical Association’s monopoly on clinical coding and its Medicare payment advisory structure (the “RUC”), which favors specialized physician services and retards progress on community health and health equity.
5. Racism and discrimination affecting health are ubiquitous, often not vestigial, and not always unintentional. The COVID-19 pandemic and the protests over racism in law enforcement synergized to raise public awareness of pervasive discrimination in today’s America. Inequities associated with race have been evident in the heightened vulnerability to disease within communities of color, in the comorbidities originating in social determinants that increased COVID-19 mortality among those infected, and in the tiering of hospitals by wealth and demographics with respect to accessing personal protective equipment and other critical resources. Although health disparities based on race are well documented in the report, the purposefulness of discrimination is often obscured by the detached tone in which scientific research is presented. In my view, the report also underplays racism in formulating its recommendations, especially concerning nursing practice.
6. Because disease tracks injustice, social advocacy is an essential element of nursing ethics. With few exceptions, ethical advocacy by the health professions has observed a line between the medical and the social, focusing mainly on issues of health insurance, treatment relationships, and biomedical technology. A major lesson of the social determinants literature, further validated by the COVID-19 experience, is that the most meaningful health laws are those that increase and equalize wealth and power and education and opportunity, not those limited to medical care. Nurses (and physicians) therefore must change lanes in their ethical causes and advocacy strategies, which they seldom have the knowledge, training, or independence to do effectively. The report is not sufficiently

6. explicit about nurses’ affirmative commitments to advocacy or about how to protect nurses who advocate from retaliation or discipline, nor does the report acknowledge that in a profession as large and diverse as nursing, a range of views and positions will be sincerely held and entitled to respect and discussion.
7. Hospitals have special obligations to accelerate improvement in health equity through nursing. America’s hospital sector remains the greatest beneficiary of health care spending and the largest employer of nurses. Although the report invokes health equity as the primary objective for nursing over the coming decade, hospitals are barely acknowledged and almost never directly advised. Hospitals possess the capital, organization, and position within communities to play a leadership role in advancing health equity. Whether hospitals embrace that responsibility, or instead sit on the sidelines or even oppose necessary change, is far from certain. Some hospitals consider themselves primarily community institutions, while others function more as giant revenue-generating businesses, research powerhouses, or workshops for private physicians. A fundamental shift is required in how hospital management perceives nurses, and in how those perceptions are translated into strategic planning, budgeting, and operations. The report should be much clearer about incorporating health equity into hospitals’ core clinical functions; about expanding leadership roles for nurses in forward-looking domains, such as informatics and community engagement; and about committing hospitals to respect and empower their nursing workforce while ensuring nurses’ well-being and building their resilience.

Although I value my participation on this committee and have learned much from my colleagues, I feel personally obliged to offer these frank observations and the priorities for action that they convey. The massive health-related and social and economic upheavals consequent to COVID-19, the trepidation associated with nascent and impending climate crises, and the rapidity of technologic and generational change make this a teachable moment for the nursing profession and for the nation. The top-line message of this report should be more than that the National Academies agrees on the importance of health equity to nursing policy; it should be that the National Academies calls for action. The late Supreme Court Justice Ruth Bader Ginsburg, whose former faculty office at Columbia Law School I once had the privilege to call my own, wrote that “real change, enduring change, happens one step at a time.” In my view, this report should do more to illuminate the path. It should see clearly, think deeply, lead, and inspire. It should help bend the arc of nursing, of health care, and of health toward justice.