Nursing as a Profession Brain Dump

STORYTIME

I remember the last time I was a charge nurse as an RN. I was just weeks away from finishing grad school and a month or two away from my boards. I was working on a 16-bed cardiac ICU unit. I had taken every Saturday-Monday shift during the last year of my master's. This was a win for the nurse manager - I was one of the more seniored nurses on the unit, even having been on the unit longer than her when she accepted the management position. She was also missing a "team leader", job titles given to divide the workload of what would have been considered an assistant nurse manager position without having to increase someone's salary. I was in a position for her to utilize me to fill that role, keep her under budget, and have a charge nurse every weekend without her having to risk having to come in on an off day.

One weekend, I come in to my usual staffing: 1 nurse short of full to save an FTE, about 1/2 to 1/4 of my beds full of patients on ventilators, and the rest being what we called the "walker-talkers". I would have 2 nurses with a team of 3 (patients) and the rest would be limited to two beds, often with two ventilators. Oh, and I'll have a whole team as charge nurse.

Morning meeting would consist of reporting our available beds to be told what we were taking from the ED - not asking if we had the staffing or the equipment available. Often times we would be receiving overflow from another ICU specialty and our nurses would most likely have zero experience with that treatment plan. Additionally, we were a regional hospital and this meant having to move people out of the ICU, ready or not, to make room for the cardiac alerts en route via helicopter from some rural part of Alabama.

This particular weekend, I had two nurses with the training to manage a balloon pump and I was one of them. The other nurse already had two very sick patients on ventilators and attached other life-sustaining equipment. The rest of my nurses had nothing but ventilators. I think I had 3 walker-talkers that weekend.

A cardiac alert rings in: patient with witnessed arrest, levophed, dopamine, dobutamine, and a balloon pump. Policy and procedure for this until mandated this patient would be 1:1. I had no more nurses. No one was on call. No one was available to come in and help anyway. There was no experienced staff that could be a charge nurse. The house supervisor had nobody with balloon pump experience. There was only one team member and a nurse manager to call and until they answered, I had to take this patient.

I immediately am calling this nurse manager: this is a critical nursing situation, this cardiac alert is super sick, 1:1, I'm the only person here who can charge and take a balloon pump and I can't do both, I need you to come in and help.

Her response was only, "Let me see if I can find someone to come in".

She never came in to help.

Her one and only Team Leader came in and took over as charge nurse - and refused to take my other team. Leaving me with 3 patients on a ventilator, one balloon pump, and my license on the line. This was so far from policy and procedure and my refusal to take care of these patients by myself was being completely ignored. At that point, I made the choice to risk my license and take care of the patients - it felt like I was the only one who cared about them.

I was never asked to charge again after that - as if I was the problem in that situation. I even got written up because I didn't titrate oxygen on a patient while waiting for a doctor to just give me orders for the vent in the computer. Just side note, titrating oxygen on a ventilator without an MD order is outside of my scope of practice. It's been the only time I've ever been written up and it was for working inside my scope; I'm proud to have been written up for doing the right thing.

THIS IS THE NURSE. THE NURSE IS WORKING. THE NURSE IS OVER IT. SEE THE NURSE QUIT.

The picture perfect idea of a nurse is a woman with a cap and apron, sitting bedside with a sick person and keeping surfaces clean and patients comfortable. It's quiet and calm, the nurses are silent and composed. The nurse is watching and waiting for her orders, no matter the status of the patient. The doctor is miraculously available at every emergency, leaving the nurse free from any emergent intervention or critical thinking.

"Nurses, more with less and to make sure it's perfect!"

The truth of nursing is much grittier and far from calm.

Nurses everywhere and everyday are experiencing similar situations and attitudes. Everyday, nurses report to work and forego bathroom breaks, water, and lunch breaks to meet the daily expectations of being at the bedside. Nurses must be vigilant for not just what their patient needs but doctor's rounding, lab draws, medication schedules, off unit testing (which in ICU, they are often expected to transport their patient to the test and stay for its entirety), turning patients, escorting patients to the bathroom - the task list is endless.

And stop me if you've heard this before - did you know there was a critical nursing shortage and it's been ongoing since 1998.

Policy and procedure is considered quality patient care, often prioritized over the patient's needs. Additionally, staffing shortages are critical, leaving nurses with nurse to patient ratios that have far surpassed unsafe. When expectations are not met or there is a poor outcome, the nursing care is scrutinized and somewhere along the journey, a nurse will likely be written up for not meeting the unrealistic expectations put upon them.

Do you remember the outcry when we were asked why we were using a "doctor's stethoscope" or accused of playing cards? Having our professional status removed validates feeling unappreciated, invisible, and abused.

Just imagine, if you will, being a full-time parent to a child with special needs. You have to work full-time to pay for medical bills, you still have to grocery shop, make appointments, therapy, school, social events, maintain your house, cook, etc - all while helping your child with bathroom needs, changing clothes, managing tantrums, constantly stop them from getting hurt from something, take their medicine, keep them clean, feed them, etc. On top of all of this, you are responsible for all of the side dishes for a holiday event and you have missed one ingredient or bake time. The host knew the current burden you carried when you were given this task, assured you it wouldn't be "too bad" and that you could "handle it". And now they look at you with disdain and betrayal and demand to know how you could have missed this one detail while you are standing there ragged, overstimulated, and barely able to hear you own thoughts. It's a John Travolta gif moment where you look around at all of the fires burning around you.

This scenario likely wouldn't happen in the real world so why are we putting nurses in similar situations with lives at stake? Better still, why are we requiring education and licensing to protect and save lives for a field of work that is not professional? I mean by definition, a profession requires qualifications, skill, and competency. Nursing is a calling; people do not subject themselves for this level of abuse for just a paycheck.

Nursing exit surveys have identified several reasons nurses are leaving. Boomers, our largest generation, are retiring; there are older and sicker patients, increasing demands; fewer people are enrolling in nursing school leaving these vacancies unfilled; and nurses are just burned out. Even before COVID, we were leaving the bedside because we just didn't have anything left in us to give.

Nursing has the highest turnover rate in healthcare. If you still wonder why, I'm assuming you are part of the percentage of people who still treats emergency rooms as a doc-in-a-box and thinks a hospital stay should be on par with a visit to a Holiday Inn.

PAYING FOR ABUSE

Recruiting students to enroll in nursing programs is challenging with stories and videos documenting the abuse of nursing staff. If I had known then what I would have experiences over the last 12 years, I would have said there were better ways to spend my money.

When I was working on my BSN, tuition increased every semester by 7.5%. My first year alone, I spent $20,000 on tuition, books, fees, food, and housing - and that was with a scholarship. By the end of my 4-year degree, I had accrued $75,000 in student loans in order to finish school. The first two years, I worked part time to help offset costs. The last two years were spent in my upper division, spending all of my time studying, writing papers, preparing for clinicals, or in clinicals. In order to meet academic expectations, I was sleeping 4-5 hours a night and was budgeting to eat on $2 a day. A DAY.

The debt stacked even higher when I went back for my master's, with fewer scholarships and daycare on my payroll. I was told I needed to quit my full time RN job to focus on the dual certification program. This was financially not an option pure resiliency took over to carry me through the next 24 months.

Nursing school is incredibly demanding. Currently, the general estimated workload of a typical BSN program is 4 exams per class per semester (typically 4-5 classes each semester), approximately 800 clinical hours at the bedside, 50-60 writing assignments (truly felt like more), remediations for each failure, and studying 40+ hours a week. Most universities recommend students treat their programs as full time jobs and forego trying to work at the same time due to the rigorous demands and time commitment. Participating in an athletic programs or extracurricular activities simultaneously in incredibly rare. I've never met a BSN with a minor degree.

Given current working conditions, academic expectations, the resulting mediocre income, and cost of the degree, what incentive is there for a student to pursue this path?

VACANCIES, SHORTAGES, AND NO CALVARY

When I was researching statistics for nursing, I was initially taken aback by how little was available comparing vacancy trends and tuition increases. I mean, why hasn't anyone really taken a hard look at why there is a worsening gap in new grads and vacancies? Roughly trying to trend what information I could find, the number of nurses leaving the nursing field is increasing at the same rate that tuition is climbing. And even though the number of nurses entering the field is increasing, it remains consistently lower than the students entering a nursing program.

Nurses - exhausted, underpaid and now not a profession

The nursing turnover is estimated to be almost 150,000 nurses a year, and that was in 2022.

Consistently increasing cost of tuition, current cost of living, and the exorbitant cost of student loans makes one wonder how enrollment trends have not already plateaued. The national average for a BSN program today is more than $30,000/year. My alma mater is charging a bargain deal of $27,000 for in-state students and nearly $50,000/year for out-of-state admissions.

Then there is the next hurdle: the master's program or the DNP. To make a career out of nursing, majority will have to obtain some level of an advanced degree.  An MSN can take your total to $130,000 on educational costs, the DNP comes in at over $170,000. Unfortunately, pay increases are stunted with "performance failures" and "average" reviews (I am told every year that the perfect scores (that make you eligible for a pay raise) are not possible. Nursing is incredibly underpaid and "side hustles" should be included in the job description. After mortgages, food, childcare, student loans, utilities, insurance, transportation, and miscellaneous expenditures, paying out of pocket for an advanced degree is truly for those who don't have to work to live.

We have identified a nearly 30-year-long problem of missing nurses while simultaneously inhibiting the calvary. Increasing tuition rates and a loan cap of $20,500 a year still leaves potential students with a $10,000 balance. When enrolled in a program with such exhaustive hours, there will be no hours available to work a job to pay what's owed. Nursing education is once again left open to those who are already financially fortunate and hopefully not afraid to get their hands dirty.

When the physical and emotional toll of nursing has made the average survival rate of a new nurse 6-9 months at the bedside, healthcare cannot afford to have nursing school affordable only for higher classes. Beggars simply cannot be choosers.

DROPPING THE GLASS CEILING

Statistics are informative. The following is factual, hard data on who is enrolling in BSN programs taken from the American Association of Colleges of Nursing (AACN) and the National League for Nursing:

• 43% White/Caucasian

• 21% Hispanic

• 17% Black/African American

• 12% Asian

Out of these demographics, the AACN reports 48% of these students were from populations that have been historically marginalized or face systemic barriers.

So what about sex and gender?

Of enrolled nursing school applicants:

• 82% female

• 17% male

In 2024, males accounted for less than 12% of enrollment and a whopping 9.1% of the total RN workforce.

In 2023, the US census reported the following household (3.15 people) incomes:

• Asian $112,800

• White/Caucasian $83,274

• Hispanic $65,540

• Black/African American $56,490

In 2025, the Bureau of Labor Statistics reported weekly earnings by sex:

• Men ages 16-24 (college age) - $797 ($41,444/year)

• Women ages 16-24 (college age) - $712 ($37,024/year)

What does this data tell us? Underrepresented populations and women want to go to school and can't while White/Caucasian males can better afford nursing school and are rarely submitting an application. Removing the professional title for nursing to cap student loans is not just a hurdle to jump; for women and people of color, this is the Berlin Wall.

ERASING RESILIENT PROFESSIONALS

There are many failures to talk about with the political crimes against nursing professionals. Ultimately, the patients will suffer the most. This "One Big Beautiful Bill" hurts hospitals with cuts to Medicaid and Medicare. Funding will not be available to adequately pay a nurse or higher more nurses. Additionally, the financial expense of high nursing turnovers on hospitals is not sustainable. People are not going to enroll into a program that results in burnout, abuse, and thankless pay.

The nursing talent will disappear.

There will be no nurses in research, leadership, or quality improvement measures.

There will be no one to advocate for you.

There will be no voice for you, the patient.

So what do we do?

For starters, it's time to change the culture and eliminate this perception that nurses are inferior to physicians. This is hierarchy was born of educational difference and gender roles stereotyped over 100 years ago. Nurses have repeated proven their indispensable role and qualifications. Nurses are not "the helpers"; they are the eyes, ears, mouth, and hands of your healthcare. Behind every good doctor is an even stronger nurse. There is a mutual respect and partnership.

Second, we must not overlook the educational standards of BSN, APRNs, PAs, and MDs. MDs may have 11-15 years of total education while the PA and APRN average around 6-10 years. MDs and APRNs are closest in academic path with a bachelor's degree and either 4 years of medical school or 4 years a doctoral nursing program. Additionally, the APRN enters with graduate school with bedside experience in addition to his or her bachelor's education. Cumulatively, a seasoned nurse can easily have as many if not more hours of bedside training than the MD. The educational routes for both the APRN and the PA lead to high-quality and cost-effective patient care. MDs may have a larger scope, however, they are more expensive and typically focused on the specific intervention or treatment. It's not uncommon to see an MD as business oriented while the APRN and PA are typically more holistic and broad, focusing on conventional medicine and other patient needs to for improved health and wellness.

Please note, this is typical and but not the standard. Doctors who treat the whole patient do exist! APRNs and PAs with a "treat 'em and street 'em" mentality are also in the workforce. The interchangeable roles and stereotypes are all the more reason to recognize these roles as professional equals.

During COVID, our nurses were celebrated as heroes. Simultaneously, these nurses were reporting increased workloads, emotional overload, fatigue, burnout, and generally being overwhelmed. In the pandemic, the US had 1.2 million COVID-related deaths - 115,000 of these deaths were nurses who gave up their lives to take of the whole of us during the world's darkest hours.

While this political move may be a venture to curb student loan debt, it is a giant middle finger to the millions of nurses who hold the hands of our mothers, fathers, sisters, brothers, and children when fear and uncertainty rule. They have missed birthdays, Christmases, and risked their lives. They are paid just enough to survive, work with limited resources, and are now unable to obtain an educational loan that helps them better their lives. One can't help but wonder why doctors are deserving of this and nurses and PA's are not.

Regarding the current rhetoric that nurses shouldn't be going back to school if they can't afford it or to obtain a personal loan, that's cute. If the goal is to reduce the educational debt of our workforce, this ideology moves us in the wrong direction. The healthcare system does not pay well enough for the hardest working of them all to afford out of pocket and if going into debt is the only option, then higher interest is not the solution.

Without educational funding, the nursing profession is doomed to disappear.

IT'S EXPENSIVE TO WORK IN MEDICINE

If you want quality health professionals, then you need to pay for quality health professionals. Removing nursing from the list of professionals and limiting funding makes future nurses sacrificial lambs for a political agenda. Students won't be able to afford current tuition, nurses will not continue to submit themselves to the current abuse in the system, and eventually, schools will sacrifice quality education to increase enrollment.

What once was considered a prestigious and highly respected degree will soon be available on the clearance rack at Wal-Mart.

Nurses pay, hospitals pay, healthcare pays, patients will pay.

And at the end of the day, all of us are a patient.