The rise of advanced-practice nursing has been accompanied by another welcome change: a closer partnership between physicians and nurses.  What have been your observations?

The partnership between nursing and medicine is long standing, though it has changed dramatically in the US and elsewhere as well.  In many resource poor countries, the partnership is very strong based on significant need. The model of primary healthcare, which is practiced in many countries as a cost-effective strategy for enhancing the health of all people, depends on a close collaborative relationship between medicine and nursing.  While the rise of advanced practice nursing has been a part of what has changed the partnership, it is also a reflection of the recognition of physicians and others of the important role that nurses can and do play.  The growing interest in quality and safety of care is another force that reinforces this partnership -- nurses and physicians care deeply about these issues and, when they work together, have an enormous impact.

What do you see as the most critical problem facing nursing today?

The biggest challenge for nursing worldwide is that of a global shortage of nurses in the face of greater than ever care needs.  Nurses are a fundamental, though all too frequently invisible, component of the health of people and societies around the world.

Why did you decide to become a nurse?  

I decided to major in nursing in my final year of high school.  I had worked as a nursing assistant from the time I was 13 in my rural community and my mother was a nurses - I saw nurses as powerful forces for good.  However, I really became a nurse when I worked in an inner city emergency department and saw the profound impact that nurses in that community and in the hospital had on the lives of people.  It touched me deeply to understand the privilege that was mine by virtue of my being a nurse --and the enormous trust that people placed in me to be a part of their lives at their most vulnerable moments.  My love of nursing has really been a life long "affair" -- one whose rewards are unending and ever unfolding.

You travel all over the world to work on health care issues.  What is the most significant change you've seen?

"One long awaited change that I am seeing is that there is finally recognition that human health is essential to healthy societies -- and that without health, the social and economic foundations erode and collapse."

When most people think of nurses, the Director of the Division of Nursing at the U.S. Department of Health and Human Services does not come to mind.  As a nurse, why did you decide to pursue a more policy-focused and activist role?  

Nursing is my way of making a difference in the world.  When I was offered the opportunity to play a role in building our national nursing capacity, I saw it as a way for me to both be a nurse and to enable all of nursing to make the difference that it can.   When I think about the work that I have done in the policy arena or as an activist, I really see these roles as a part of my professional responsibility to use the tools that I have available to make the difference that I can.  Policy is an extremely powerful determinant of health -- whether we are talking about seatbelt laws or access to healthcare coverage.  Nurses have important perspectives about the needs of patients, families and communities -- and a responsibility to advocate on their behalves. My role with HHS is really just one example of many.

In the United States, who is becoming a nurse these days?

Nursing is attracting a very different group of people than previously.  There are more people of color, men and younger people who are entering the profession.  And, there are increasing numbers of people with degrees in other fields who are seeing the career as an opportunity to use their intelligence, creativity and knowledge in service to humankind.  In short, nursing is more representative of the peoples of this country than ever before.  However, having said that, the challenge we face now is our capacity to educate all of those who are interested in nursing -- and to retain them once they become nurses.  We have enormous need; however, our shortage of nursing faculty and lack of educational resources are a barrier to opening the doors to the profession to these qualified and interested individuals.  There is a certain irony to our increasing importation of nurses from around the world at the same time that we are denying access people in our own country access to the profession.  (A sort of reverse exportation of jobs abroad.)

What can we do about the growing shortage of nurses both in the U.S. and around the world?

The "we" in this question is the single most important word.  While nurses are struggling with addressing the care needs of people around the world, the solutions to this problem mostly lie outside of their hands.  WE need to address the root causes of the shortages, which include the need for workplaces that support the work of nurses and provide safe and rewarding conditions so that they will not leave the profession or their home countries.  WE in the US also need to take more responsibility for our impact on the rest of the world.  Because WE have not yet addressed our own issues relating to the nursing workforce, we continue to have a huge impact on the rest of the world, particularly in resource poor countries.  This is not to say that migration, per se, is wrong -- it is more to say that we as a country need to develop a sustainable core workforce to decrease reliance.  And, even more importantly, we need to adequately compensate countries who are educating the nurses that we are employing.  Developing appropriate international agreements, appropriate guidance for ethical recruitment and country-to-country relationships are all ways to improve that situation.  Lastly, for all nurses everywhere, employers, the public, governments and international agencies need to view nursing as a crucial resource and investment that should be thoughtfully supported.  All of the global investment in medication and technology will be for naught without a sufficient workforce to enable their reaching the people in need of help.

Another key dimension of what WE need to do relates to the basic question of numbers.  Frankly, there are simply not enough nurses to provide care in the ways that care is currently structured -- nor will there be.  Nurses spend inordinate amounts of time (estimates range from about 25-50%) on work that does not require their expertise -- the "hunting and gathering" tasks, documentation and so forth.  WE need to recapture that time -- which will not only accomplish getting more nurses time but will also retain nurses in the workforce because their work becomes more meaningful.  HOWEVER, WE also need to bring together the forces of engineering, technology, architecture, management, design, psychology, etc and create care environments, resources and new ways of caring that support greater independence and self/family care and the best use of nurses' time and expertise.  A better future will be one in which nurses can work closely with patients, families and communities -- to provide the best possible health for all.

Where do you see nursing a profession in the future?  

Nursing is at the turning point -- but more importantly, CARING is on the threshold of great change.  The preferred future that I see is one in which societies around the world understand nursing's' enormous capacity to contribute to the health of people and society.  Nursing is an enormously interesting, challenging and exciting profession -- it has the most opportunities, I think, for people to do work that matters in the widest variety of settings; using an enormous breadth and depth of skills.  Nurses work in so many different sectors and settings -- their roles range from discovery and research --finding new and better ways to care to the bedside, launch pad (yes, there is a specialty of space nursing), community, government, remote frontier, inner city, universities, executive offices, religious organizations,  law firms, pharmaceutical companies, etc, etc, etc,.  What other profession has this much to offer?  My own career is but one example of what I mean -- I have been in national and global policy settings, universities, public health, hospital and international health settings.  Never boring and even better times, I believe, ahead.

What is the essence of nursing?

For me, it is the convergence of that most wonderful of all attributes of humankind -- caring for others with the sciences and disciplines that come together in the knowledge, skills and art of the profession.  Nursing bridges the gaps between people and the healthcare experience.  We are invited into people's lives at their most vulnerable and most remarkable moments -- and entrusted with their hopes, wellbeing and deepest emotions.  Nursing is a privilege, responsibility, challenge and joy.  

Why this book -- why now?  

Simple:  My hope is that all people will understand that nursing is an all-too-often invisible ingredient of their wellbeing and the future of humankind.  And, that nursing and caring is endangered -- and that this is something that needs the action of people everywhere.  I also hope that those reading this book will experience in some way the great joys and enormous challenges that are part of the lives of nurses everywhere -- and celebrate this wonderful profession.

Question: Can you share a story about a time when you saw the impact of a nurse in the inner city emergency room?

The patient, like so many others, is on a gurney in the hallway - not enough staff, not enough rooms.  This is the safest place to make sure he is okay - he's been having seizures again and needs to be observed.  Like the community around the ED, this patient has the struggles of his life etched in his face and body. His poverty, poor diet, hard living and lack of care have resulted in myriad health problems, including the diabetes to which his feet and legs have been sacrificed.  He is emaciated - fragile really - and old beyond his years.  He is like so many others who come in every day - endless streams of suffering.

 Now, in the quiet of his post-seizure state, he is at rest - seemingly far away from the bright lights and noisy corridor where he is lying.  The nurse walking down the corridor approaches him and does what ER nurses do all the time - uses every sense to observe and assess the status of the patient.  As hoped, his breathing is regular, color as good as can be - but, he is also caught up in crumpled sheets, lying in a fetal position having slipped down off his pillow.  The nurse acts - she speaks to him despite believing that her words won't reach him.  Talks to him by name, touches his arm: "Mr. ____, I'm here with you and just want to get you as comfortable as possible.  You are all caught up in your sheets and look like you can't move. Let's try to do something about that."  The nurse then gently repositions the patient, tightening his sheets, placing his head on a plumped pillow, placing pillows at the end of his stumps so that he won't slip down so much in his bed.  As she covers him carefully with the crisp sheet - she pauses - one last assessment before she moves.  Suddenly, he opens his eyes and grabs her hands.  He manages one sentence before he slips off back into his semi conscious state.  His words shock and touch her deeply.  His gift to her...a simple phrase "There's nothing like seeing a professional at work".

The nurse will never know where that phrase came from - nor does she know what has become of that patient.  But as a nurse, this was her defining moment - the point where she understood that being a professional was all about reaching someone in the most intimate, expert and caring ways.  As with so many patients, this one ended up giving so much more than he received."

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