Episode 29: America needs more nurses—Sean Burke of Ascend Learning says the answer is in the pipeline

Justin Steinman:
Definitively Speaking is a Definitive Healthcare podcast series recorded and produced in Framingham, Massachusetts. To learn more about healthcare commercial intelligence, please visit us at definitivehc.com.
Hello and welcome to another episode of Definitively Speaking, the podcast where we have data-driven conversations on the current state of healthcare. I'm Justin Steinman, Chief Marketing Officer at Definitive Healthcare in your host for this podcast. Regular listeners of this podcast know that we love nurses. We talk about them frequently on this show, and we give them shoutouts for their compassion and the mission-critical role that they play in healthcare delivery. Yet we also know that there is a massive shortage of nurses in the United States. According to the American Colleges of Nursing, there will be more than 203,000 vacant nursing positions each year between now and 2031, even as the total number of registered nurses grows from 3.1 million in 2021 to 3.3 million in 2031. Clearly, we cannot create nurses fast enough to meet the demand of an aging population, but this just isn't a problem we can ignore. We have to do something about it.
And to help us think through this challenge today, I've invited Sean Burke, president of healthcare at Ascend Learning to join me on Definitively Speaking. Ascend Learning is an education technology company that includes at I nursing education, which partners with over 60% of undergraduate nursing programs in the US and is a major provider and administrator of the leading nursing school entrance exam. Ascend also includes National Health Careers Association, which offers training and certification for several allied health professions. You might say that Ascend is in the business of solving the supply side of our nursing and healthcare workforce crisis. Sean has been hollering on healthcare for a long time, including more than 20 years at GE Healthcare where he made the career limiting move of hiring me onto his team. And yet, Sean seems to have overcome that mistake and moved on to great things, including his stent running GE Healthcare Asia-Pacific, where he lived in Japan for several years and served as a Chief Commercial officer for GE Healthcare in the US and Canada before taking his current role at Ascend Learning.
Sean, great to see you. Welcome to Definitively Speaking.

Sean Burke:
It's great to be here. Justin. Good to see you again.

Justin Steinman:
Good to see you. Sean, let's start with the foundational issue here. Why is there a nursing shortage in the United States?

Sean Burke:
Yeah, it's really a number of factors. Some of them have existed for a while and we're predictable, like demographics. An aging population. Clearly our population often is getting sicker, so that's also putting a demand factor there. But also with those demographics, we have a bolus of nurses who are clearly retiring. I think we also have attrition in the workforce, the work environment and other factors which are certainly clearly documented. And then, of course, where our focus as a company is really looking at the pipeline, and so we've got to make sure that the pipeline of future workers is robust and that's an area that the pipeline is growing, but we always have to keep our eye on what our constraints as we look further upstream.

Justin Steinman:
Has this problem been getting worse over time? Did the pandemic make things worse? People just bail?

Sean Burke:
Yeah. If you look, Justin, back at some of the articles and papers that are written by a number of the nursing related organizations, it really was a known problem. This is something that the industry, the educators, the healthcare providers have known, there's probably not enough workers that are out there. It certainly accelerated during COVID. We moved quickly from people banging pots and lauding the healthcare heroes to as the pandemic continued, it became weary, and lots of weary headlines about some of the real challenges that are out there, the workload, the work conditions. And so, I think we've seen an increase in attrition in the nursing workforce, which clearly also can have carry-on impact into the perceptions of those that are considering healthcare-related careers as well. Known demographic issue, certainly an acceleration during COVID.

Justin Steinman:
Yeah. I mean, it really seems like the perfect storm. You've got an aging population of nurses, you've got an aging population getting sicker. Then you got the unbelievable stress that happened on these nurses. They were really on the front lines during COVID, and some are just like, "It just ain't worth it."

Sean Burke:
Nursing always is and was a tough job. It's tough emotionally. It's a physical job that people perhaps don't always fully comprehend, and there's a lot of demands for them, and so many of those factors have increased. When we look at, and I just spent this week with hundreds of nurse educators talking about some of these issues, when you compound some of the mental health factors that are plaguing our nation at this time. And then let's also talk about the instances of workplace violence. The nurses are also having to deal with that. And I think as one of the nursing school leaders I spoke to this week said, many of these nurses will go into a work situation where there's as much security walking around hospitals now as there is healthcare professionals. And so, I think the overall work environment is certainly a factor here for the part of the issues that we're talking about.

Justin Steinman:
How do we fix that environment? What can we do?

Sean Burke:
It really is a nationwide problem. I think if you look at the American College of Healthcare Executives as a group that I've looked to for a long time, I've always tracked their annual CEO survey of what are the big issues facing healthcare executives, for I think 16 years in a row. Those issues, number one, were financial performance or financial factors. Last year and this year the number one issue is healthcare workforce issues. This is something that I think all stakeholders play a role in. It's clearly multifaceted. I think the most immediate action is stopping leaks that are in the bucket now. How do we retain the workers that are there? How do we create a positive, rewarding opportunity for those that are in these roles and create career paths in nursing, whether that's through specialization or continuing education? I think retaining the workers and making them feel rewarded is clearly the next step and most important.
But at the same time, and a quote I use a lot, "If you want shade now, the best time to plant the tree was 20 years ago. If not, the next best time is now." And I think our focus with many of our efforts has been calling attention to some of the upstream issues. And so, I think there's an opportunity. There are many that are working in health systems or the health careers now that in the roles they are, if they're not yet a nurse, there's a way they can progress or go up the career ladder to become a nurse. And I think one of the things we're focused on is how do you create career pathways for allied health workers, or patient transport, or environmental health and safety? Other workers that are in the health system, can we create a career progression for them to get into nursing? And then beyond that, I think we need to look out to what is the future pipeline.
Naturally, we also always think about high school grads and people that could enter right out of school as they go in, but I think nursing is also a good profession for career switchers. Going in later in life as a second profession is really an opportunity and the profession needs to be welcoming to them as well.

Justin Steinman:
Yeah, I actually think of my brother-in-law who was an engineer at a chip company and he got tired. He couldn't find meaning in his work, and so he went back and got an NP degree at 31 years old, and he's now been a practicing nurse practitioner for almost 15 years. Perfect example there.

Sean Burke:
That's great. There's a large number. They are equally great nurses, and I think in other cases they've got great work experience that they bring to the table. I think regardless of background, age, experience, I think this is a profession we can and should be welcoming of all people.

Justin Steinman:
Is this a problem nationally? Is it worse in certain regions than the other urban, suburban, rural?

Sean Burke:
Yeah. As I mentioned, American College of Healthcare Executives says it's the number one issue for health systems nationwide. It very clearly is a national issue. Our company is very much focused on the US so I spend less time overseas, but I know having lived and worked in Japan, workforce was an issue there. I think in many ways this is a global issue, Justin. As it relates to the US, we clearly have been tracking it. The hotspots seem to move, as different employers change policies. I do know, and I think we need to keep our eye on rural healthcare, making sure there's enough workers, not only nurses, but all healthcare workers of all types. I think rural healthcare is an area we must constantly keep our eye on and make sure there's enough support there.

Justin Steinman:
Got it. Got it. Let's talk a little bit about travel nurses. What role do you think they play in this nursing shortage? One article I read called travel nurses, a double edge sword, or that phrase. they're necessary, but in the long run, they can be detrimental to the financial stability of a company's finances. I mean, you were just talking about, and according to the American Hospital Associations, hospitals spent almost 40% of their total nurse labor expenses on travel nurses in January of 2022, a significant increase from the just 5% that they spent in January 2019. That seems like a really expensive short-term fix that could have long-term ramifications.

Sean Burke:
Yeah. No, absolutely. Travel nurse clearly is a big topic. It's a topic that we just had our user group meeting this week and I clearly came up. You're right, it is a double-edged sword. That is less of the space that I spend my time in, but we know it's clearly a factor in the industry. We have to remember, how did this originate? It really originated how do we help health systems solve short-term needs., That is where travel nursing came in and was well suited for that purpose given the situation that we're in, travel nursing has persisted and many institutions are using it out of dire need. I think we know they probably cannot afford to do that in the long term, which is part of that challenge.
One thing we know is, and you're a marketer, so you probably spend a lot of time trying to understand what benefits are people seeking. We do look and say, what does that tell us that nurses were seeking? They were seeking flexibility in their schedule. They were seeking empowerment to choose where they want to be and how do they do it. And of course, they were seeking more compensation as a chance to do that. I do think you see some health systems now that are creating almost internal travel pools, et cetera. I think there's going to be lessons that are learned there, but long-term, I think the answer is how do we help and come up with long-term solutions to what is clearly a long-term problem?
As an interesting example, I told you as with lots of nursing school deans this week, and they were sharing an anecdote that they're having a discussion with a bunch of nursing students and talking about specializations in nursing. And they asked one of the students, "Well, what kind of nurse do you want to be?" And her answer was a travel nurse. I think we've got to make sure we differentiate what type of nurse from how they practice. But I think there's learnings there, but it just points to a longer term problem that we're excited to be working on.

Justin Steinman:
Yeah, I think you're right. I think that that's a real how versus what type of thing. And some of those key problems, flexibility, empowerment, compensation, are all there, but it doesn't seem like it's the right long term solution. Because you also wind up pulling nurses from regions of the country, particularly rural regions that may need them, chasing the almighty dollar to a big city where a big New York hospital system can afford just to pay more than a small rural test system in Texas, for example.

Sean Burke:
Yeah. No, there's many people that are expert on this one. It's a controversial topic and one that we specifically don't have an or in other than our focus are trying to help the nation provide more nurses. However, it does point to that this is a significant challenge and people are pulling all sorts of levers to say, "How do we solve it?"

Justin Steinman:
Let's get back to the supply problem. How do we begin to fix the supply problem here?

Sean Burke:
Yeah. No, look, I think there's clearly, there's the sentiment of nursing, and that has been a big topic as we talk about it. It has always been and always will be a noble profession that calls people with the heart to care for patients and give back to folks. There's no question that the last several years have just seen persistent headlines about how challenging these roles are, and that, I think, has a real risk of diminishing interest in this profession. I do think from a communication perspective, the sentiment by which we speak about those roles, I think that's a big opportunity. I know in one of your podcasts as a listener, one of your former speakers talked about how different health systems have taken different approaches to talking about the role that a nurse can have in team-based care, et cetera. But I think the industry finding the voice to promote the positive aspects of this profession versus just the negative sentiment, I think is an important piece.
The other piece is clearly diversifying the pipeline. How do we make sure we're reaching to all people, regardless of background, and making sure we're making them aware of the opportunity to succeed in this profession? Healthcare professions are one that is also a great story of social and economic mobility. Often people of different means have entered this profession and it's one that can propel people into the middle class and support for their families. I think it's another reason for us to think about this. Lastly, a big piece of this is academic readiness and support. You've probably seen in the headlines everywhere ACT scores are down, math scores are down. We did a recent survey of nursing school faculty with a large sample size. The number one disruptive factor that they told us this year is academic readiness of students. In some schools, we can hear we are accepting people that we might not otherwise have accepted, but they know that means a lot more support for them as they go through the process here.
The other pieces we surveyed, we are lucky to offer tests that we call TEAs the test of essential academic readiness. It's more of an assessment than a entrance exam. We surveyed thousands of students that took the exam but did not apply to nursing school, and that's actually a significant number. And we asked them, "Why is that?" And they did not feel academically prepared to go into the career. We know they have the passion, the interest, but they don't feel that they're ready. One thing we have to think about is academic support to help school students either before they're to that stage or once they're in the school, how are they successful there? There's another whole supply side here, which is there is real capacity constraints in nursing schools, which we can speak about as well.

Justin Steinman:
Yeah, so we'll get to that in a second, but I want to come back to something you talked about a couple times here. How do we help these students get more academically prepared for a nursing career? I mean, that seems to be a real root problem you called out.

Sean Burke:
Yeah. We are a very data-driven organization, but as I know yours is. We believe that really assessing where are their strengths and weaknesses allows for focus remediation. We firmly, we are working on offerings on this regard. It's what we do in our core business while students are in nursing school. But we think assessing what their challenges are, what types of resources are needed is a key part. And so, having the right resources that are needed there. And we also think there's a real role for coaches. How do we coach students? Right now, we spend a lot of time coaching students between graduation and them taking the national exam. We know helps boost their pass rates, which is a step to becoming a practice ready safe nurse. We think there's a real need for coaching and support earlier in the academic journey to make sure that they're ready for the path that they're on.

Justin Steinman:
Do you see a whole world? My daughter just got through applying to college. We had a college counselor help her with their essays and I spent a lot of money for an AST prep class that didn't really move her score, but we can talk about that later. I want my money back. Do you see a world where either your company or another company steps in and helps kids get ready to apply to nursing, the way that we got my daughter ready to apply to college?

Sean Burke:
We do have offerings in that regard, Justin. Really early in their first semester, even after they're accepted, before they start, there are offerings and solutions we have to help in this regard for schools that want to offer that for their students. When I went to business school, there was math camp for students that did not have a quantitative background. This is kind of like that. There are students that are going to need certain support and coaching to get them ready for the rigors of the profession, and we're eager to help nurture the pipeline to help there where we can.

Justin Steinman:
I have to know the answer. How many years of training are required to become a nurse?

Sean Burke:
On average it's two to four. There's different degree types, but BSN is a typical four-year program. Some students can go through faster, but I would on average, it's two to four, knowing that there are some accelerated programs that are out there.

Justin Steinman:
And do some people consider BSN as an alternative to getting a traditional college BA? Think [inaudible 00:18:45] in high school.

Sean Burke:
Many students will go into the bachelor science of nursing.

Justin Steinman:
Got it. Do you think the time is an inhibitor for people? That they're looking to go four year program, "Oh my god, I don't want to do it," or not an issue?

Sean Burke:
Again, it's not always a four-year program. There are shorter programs, Justin. Depending on the student's experience or background, we think there's also other solutions. We are proud to be in the allied health field, so we spend a lot of time thinking about what our career ladders or in other ways as some of our team says, "How can you earn while you learn?" Perhaps we are through our National Health Careers Association, we offer the certificate to be a phlebotomist. One could get the phlebotomist certificate, become a certified medical assistant, which we offer on their way to becoming a nurse. We do think there's multiple paths. Justin don't always think of this as being a traditional higher education pathway.

Justin Steinman:
Interesting. I didn't know that. Let's talk a little bit about nursing education. How has it changed over the past 20 years and how do you think it's going to change over the next 20? I'll put you on the spot with a big question here.

Sean Burke:
That is a big question. One thing that's very clear, Justin, is we're asking nurses to do more and more, and that has certainly progressed as we were with a bunch of nursing school deans this week. Patients are also sicker. How do we prepare nurses for that environment? I think when you think about what's different, as I mentioned, and this is what some of the faculty we were with this week spoke about, they also have other things, increasing prevalence of mental health issues, their own safety. Violence in the workplace is one thing. I was at a dinner this week talking to people about. Number one is there's a lot more context around what needs to be educated on. The other piece is actually it's timely we're having this question and podcast now. The National Council of State Boards of Nursing, NCSBN, just had perhaps the biggest change they've had in decades around the national licensing exam.
They're calling it the next Generation NCLEX exam. They have put much more emphasis on clinical judgment, so traditional memorizing the things and knowing different bodies of knowledge. There's whole new question types and different questions to say, how do we make sure the student's thought process to have solid clinical judgment to ensure that we have safe practice ready nurses? The new exam has just changed this month, which is really driving changes all the way back into the education system, how we get students ready, I think is great news. Again, how do we really focus on what we want is solid clinical judgment that will be with the students for their whole career.

Justin Steinman:
It's not just, though, like a nursing shortage. I think I also heard you say it's a shortage of nursing educators.

Sean Burke:
That's right.

Justin Steinman:
How big is that shortage?

Sean Burke:
It is a big problem. It's one that we speak about all the time. The huge proportion of our nation's nursing schools have faculty shortages, Justin. One thing that is clearly important, and you mentioned travel nursing, et cetera, is some nursing school faculty have retired early amongst all the changes. Others have gone back to the bedside given a wage differential there. Making sure that we think through how do we attract, retain and reward nurse educators is incredibly important. That's not only classroom instructors, that is clinical instructors, preceptors, all of the clinical rotations that need to take place, that is also part of the challenge that we face. That is a big piece of our supply constraint. Another part of the supply constraint is access to clinical rotations, is you can imagine when hospitals and nursing homes and everything shut down during COVID, accessibility to clinical rotations for students was part of that challenge.
We think that also is limiting, and we've heard that as a frustration with some of the nursing faculty. We offer, and we think simulation is one way to alleviate some of that challenge. The good news is simulation is available 24/7. It never has a bad mood, and you're going to see the types of cases or be exposed to the types of cases you need to, where sometimes you could do a rotation and not see certain types of cases just as a function of the patient mix. We don't think simulation can replace all hours, nor should it, but we do think there's a way for educational technology to step in and deal with some of these capacity constraints.

Justin Steinman:
Interesting. To put some status on this, as I was prepping for it did some research and they came across a report from the American Association of the College of Nursing that said, nearly one in 10 nurse faculty positions are vacant. And then according to that same report, nursing schools turned away more than 90,000 qualified applications last year, the highest number in decades because there wasn't enough teaching capacity. It feels like it's a very chicken or egg problem here. Again, I like to ask the big questions here, Sean. What's more important? Do we fix the nursing gap or the faculty gap?

Sean Burke:
Yeah, I'm a big believer in a line I've been using a lot, Justin is to me, this is an and problem, not an or problem, right? I've had some say, "Hey, we only have to focus on nursing attrition to solve the problem." And I say, "Well, and we have to work on the pipeline." Talking about nursing or nursing faculty is a bit chicken or egg. There's no way to produce more nurses without more nursing faculty. I do think we've got to really, and with policy makers, we have to focus on both, always making sure we don't sacrifice on patient quality, safety or access.
And so, we don't think an answer is lowering standards, but in this shortage, things that we look at as a company are how do we make these instructors more effective and more efficient? How do we give them tools that can help them? If they're new faculty, how do they get proficient faster and learn from their peers? We have lots of examples at our user conferences. It's not unheard of to see a brand new faculty member sent to our conference who says, "I was in clinicals last week. This is my first week and they sent me to this conference." How we help onboard, prepare both new nurse educators, but also nursing education leaders, we think is a big opportunity that can help here.

Justin Steinman:
You mentioned it a little bit, the government. What role does the government play in all? I mean, healthcare is a public needed and individual right. The government pays for healthcare through Medicare, Medicaid, they give financial aid to kids going to college. Should we look to the government to help address the nursing shortage?

Sean Burke:
We do believe that the government can play a role. And this is both federal and local. We have seen some states in recent months take some important actions to think through how do we create some of the capacity and put resources there? How do we support and foster academic practice partnerships to create clinical rotations, et cetera? I think the state boards of nursing can also look at wide variation in the rules between states in terms of nursing school capacity and other expectations. There are levers and policy levers that government clearly can take, and we think there are examples of locations that are doing that well, but we think that's an opportunity, an area that we're advocating.
What we find, and this is often the case, you typically, in a crisis like this, see short-term thinking. How do we focus on the here and now? We're big believers that we as a society need to be looking at the pipeline and think about this problem. Without interventions, it's not going to get better. We are encouraging policymakers to look at things like education, technology, looking at access and making sure there's equal access to all populations to access educational resources like this. We think there's a number of levers policymakers can pull and we hope they'll do so.

Justin Steinman:
What about the private sector? What world does a hospital at an IDN have in solving this problem? I look at other industries like Biopharma companies sponsor a lab at MIT or Caltech, right? Consultants or investment bankers, partner with the business school. What responsibilities do the hospital healthcare systems have here?

Sean Burke:
First of all, I'd say it's all healthcare providers think of, we need school nurses. We need nurses in nursing homes. We need nursing and assistant care facilities. If you think about the many hats or locations of nurse can work, it's everywhere. It's not only hospitals and IDNs. That said, hospitals and IDNs are where nursing students can get the most access to clinicals and the types of clinicals they need to become a good licensed nurse. And so, industry, we think, plays a key role. It's one of the pillars we think on the path forward. There are a number of healthcare systems and providers that are taking all sorts of steps through great academic practice partnerships. It could be simply access to clinical rotations. It could be allowing staff time to be clinical instructors. We are also seeing major health systems own and operate their own nursing schools.
In many cases, you're starting to see examples of health systems really say, "We've got to help provide for our own pipeline," not in a way that replaces a local education system, but they know, "Hey, there's a gap of X capacity. How might we go after that?" Some of the industry veterans who've been in the industry much longer than I say, this is a little bit of what's old is new. When there's been real shortages, you've seen the employers step in a big way and we are keen to that. We are having some of these discussions to try to foster some of those partnerships.
The secondary piece, not only operating their own schools, but we do believe career pathways and career laddering is a great way to boost the nursing workforce. Whether it's current allied health workers, how do we give them a path into nursing careers or how do we give other workers a path into allied health and then a path into nursing? We think it can also help in the retention of existing workers by giving them a career pathway and solve the broader problem. We don't see a path forward to a solution without great collaboration and creativity on the part of employers.

Justin Steinman:
That's fair. That makes a lot of sense. One thing we haven't talked about yet is the impact on patient care. With such a big nursery shortage, do you see the patient suffering? It seemed like they have to be suffering.

Sean Burke:
Yeah. If you've spent time in a waiting room anywhere lately, you know that's a part of a problem. I think all of my training of my years in healthcare, I think it always comes down to the variables of cost, quality or access. And you can see in any of those cases, a lack of any healthcare workforce can play with those variables. As you try to manage to staffing or how many elective surgeries can you do, et cetera. We do think all of the issues that we're talking about link to patient care. What we don't want to do is lower the educational requirements or lower the training requirements. We think maintaining safe, practice ready nurses is the ultimate goal, and we have to do that.
We also think we need to prepare the future healthcare workers for the onboarding phase of this job. What we do know is in the first two years of some of these healthcare careers, there's a high turnover rate, because perhaps they weren't prepared or didn't have the coaching or support they needed when they had their first near miss safety event, or they had a incredibly tough clinical case. We do think robust support through the onboarding phase is incredibly important, as well as preparing them for what they're going to experience when they get in the workforce.

Justin Steinman:
Sean, this has been fascinating. I've learned so much today. You got one last set of questions before I let you go, and so it's 2023. We have to talk about ChatGPT in every conversation, right? Whether doesn't matter, every industry, every field. Turn on your TV, turning your computer, it's ChatGPT all the time. What role do you see generative AI playing in med medical education?

Sean Burke:
Look, there's a lot. We just came off of a fantastic conference called ASU, GSV, which is one of the preeminent EdTech conferences. This was the buzz, and I think the ways in which it can be used are many in all part. Whether it's early, as people consider their career types, how do we train them through school with coaches, or how do we help with onboarding? So it can help on the employer side as well. There are a lot of ways and exciting pilots we have underway to figure out how this is going to play out. But we think it's exciting both in our offerings, but how do we enable our staff to be more creative and productive as well?

Justin Steinman:
Yeah. I just swear I don't want ChatGPT to take over this podcast. I really have a good time doing it.

Sean Burke:
Might do be better than me and my seat, but you're doing a great job.

Justin Steinman:
We'll see. Well, [inaudible 00:32:41] to another day. Sean, thanks for joining me today. This has been a lot of fun. Great to catch up, and certainly thanks for teaching me all about nursing education today.

Sean Burke:
Awesome. Thanks, Justin.

Justin Steinman:
And to all the listeners out there, thank you for listening to Definitively Speaking, a Definitive Healthcare podcast. Please join me next time for a conversation with Dr. Ben Hassin around navigating disparities in trans healthcare. Dr. Hassin is an openly trans South Asian graduating physician, author, and transgender health advocate of Bangladeshi descent who just graduated from the Morehouse School of Medicine and will be starting as a medical resident at Duke University in June. Ben is committed to health disparities, research, publishing, and presenting on transgender care, health equity, and health literacy. Since the start of his academic career, Ben has written extensively detailing his experience as being a transgender Muslim, growing up in marginalized neighborhoods in Atlanta, Georgia.
Lastly, he's spearheaded multiple trans and queer education resource programs. Please join Ben and me for what should be a very interesting and educational discussion. If you like what you've heard today, please remember to rate, review, and subscribe to the show on Apple Podcast, Google Podcasts, Spotify, wherever you get your podcasts. To learn more about healthcare, commercial intelligence can support your business. Please follow us on Twitter @definitiveHC or visit us at definitivehc.com. Until next time, take care. Please stay healthy and don't forget to thank your favorite nurse.