"Nursing Is in Crisis: Staff Shortages Put Patients at Risk" was the title of an August 21, 2021 article in the New York Times.1 Citing rising hospital admissions, reporter Andrew Jacobs probed the impact of the COVID-19 Delta variant surge on nurse staffing in hospitals. An interesting and informative article, yet something about it has been gnawing on me.

While the piece opened with a quote from a nurse likening the hospital's emergency department to a war zone, the focus was on problems related to adequately staffing hospitals with nurses. In addition to the opening comment, nine additional persons were cited in the article but none were identified as nurses though four of them are or most likely are nurses including a professor with expertise in nursing workforce economics, a chief nursing officer, a person who "oversees nursing," and a director at the American Nurses Association. Five additional persons cited were identified as hospital chief executive, a medical center's top executive, a chief operating officer, a president of a nurse recruitment agency, and a professor and director of a healthcare workforce research center.

A couple of thoughts about why this is gnawing on me. The only person identified as a nurse is the nurse working in the emergency department. Her engagement in clinical practice is clear; she does things for patients in the hospital and therefore fits the stereotype of nurses as doers. Nurses in non-clinical roles like professors, administrators, or leaders are somehow different and estranged from real nursing, which presumably consists only of nurses who are doers of clinical things. As currently designed, hospitals function because nurses staff them and COVID is making this abundantly clear. Because hospitals are staffed by nurses but not controlled by nurses, others in authority must be consulted as experts on nurse staffing. Nurses are a commodity to be managed by others. Nurses are expected to do things at the direction of others; nurses are not viewed as holding authority and autonomy over designing systems, identifying the priorities, managing outcomes, or controlling costs.

During this pandemic, clinical nurse specialists and other advanced practice nurses stepped up and led at clinical and systems levels. At the 2021 National Association of Clinical Nurse Specialist annual conference, offered virtually, about 25% of the presentations dealt with clinical nurse specialist leadership in the design, implementation, and management of care models and system initiatives for accommodating demands created by patients with COVID. At the 2021 International Council of Nurses' Advanced Practice Nursing Network Conference, offered virtually, the Canadian Centre for Advanced Practice Nursing Research presented preliminary findings from their work exploring the global impact of advanced practice nurses on health/health systems in response to the COVID pandemic. The researchers interviewed clinical nurse specialists and nurse practitioners from 36 countries representing North America, Latin America, Caribbean, Europe, Middle East, Africa, Asia, and Australia. The study findings reflected content similar to the clinical nurse specialists' presentations. Globally, in this time of crisis, advanced practice nurses are leading in the design, implementation, and management of models of care to accommodate the demands for health and nursing care in hospitals and community settings.

The Canadian Centre went one step further, gathering data about barriers to continuing nursing practice with expanded autonomy and authority after the pandemic. No nurse will be surprised by the findings. Within healthcare there is a deeply engrained imbalance of power and nurses lack opportunities to influence healthcare policy and decision making, which is grounded in insufficient and inequitable funding and reimbursement models. Nurses are viewed as a commodity to be managed by others.

Shortly after graduating from my initial nursing preparation in a hospital-based diploma program I realized that nurses were expected to be doers, not thinkers. My diploma program did not emphasize thinking; the faculty emphasized doing things correctly, which meant doing as told, usually by physicians. As a student, my practice was expected to be in compliance with the hospital's procedure book where, notably, each individual procedure was approved and signed by the chief medical officer. Having been trained by the hospital, administrators expected graduates to become the workforce for the hospital. Thankfully nursing education has moved away from hospital-based apprentice education and into university-based academic preparation. Yet still, nurses are largely seen as a commodity, the doers of deeds to be managed by others. The pandemic has highlighted the consequences of designing health and hospital systems dependent on a marginalized workforce. The doers are leaving. It is long past time to recognize nurses as thinkers, as judgment workers, as leaders, theorists, scientists, administrators, educators, innovators, entrepreneurs, colleagues, and expert clinicians whose interventions reduce health risk, prevent disease, enhance function, manage symptoms, and provide care and comfort. Nurses can and should design and manage the systems in which nursing care is delivered. Yes, nurses have many different roles, we do a lot of things, and we can contribute so much more - in addition to staffing.

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