Nurse Brenda Moss contends with the side of a tent on a windy morning in Greensboro on March 20. Photo credit: Noah Long

By Rose Hoban, RN
North Carolina Health News
For close to two decades, nurses have been ranked as the most honest and trustworthy profession in the U.S. but with the coronavirus epidemic sweeping the country, there’s a new gravity to how people are thinking about the nation’s 2.8 million nurses. 

“Nurses are really at the forefront of caring for these COVID patients,” said Cathy Madigan, chief nurse executive at UNC Health. 

During a media briefing Wednesday morning, Madigan noted that even before the onset of the coronavirus epidemic, the World Health Organization designated 2020 as the Year of the Nurse and Midwife in honor of the 200th birthday of Florence Nightingale. 

“It really couldn’t come at a better time to be the year of the nurse,” Madigan said. 

When I was still a practicing nurse prior to 2005, the most I ever received for National Nurses Day was an insulated mug with my agency’s logo on it and a tag that said, “Thank you!” For years, nurses have endured boom and bust cycles where salaries went up during shortages, and then were summarily let go when times got tough for hospitals. 

The ‘90s were a particularly turbulent time for nurses. I was laid off my first nursing job at Children’s National Medical Center in Washington, D.C., along with everyone else in my unit, two weeks before Christmas 1992–the same week executives at the hospital gave themselves bonuses. 

This year’s celebration of nurses comes at a perilous, yet promising time for nurses. Many fear for their health as they walk into work situations where they may not have enough protective equipment.

At the same time, the recognition of the nurses’ work during the pandemic could be an inspiration for a new generation to follow in their white shoes.  

Challenges in long-term care
There are many kinds of settings for nurses to work. Madigan leads nurses at a large academic medical institution that is relatively well-organized, funded and staffed. 

But just under half of the North Carolinians dying of COVID-19 infections have done so in long-term care facilities, a large number of those deaths have occurred in facilities that were chronically understaffed. 

“We are not paying enough attention to the staffing issues in long-term care facilities,” said Erin Fraher, who studies health care workforce issues at the Sheps Center for Health Policy Research at UNC Chapel Hill. “This is where we see the rising COVID rates, we may see them particularly in rural communities.”

Fraher noted that these long-term care facilities, while often staffed by people who are passionate about serving seniors in their community, are often less attractive places to work than a well-appointed hospital, which tends to attract younger nurses. 


A – Hospital
B – Ambulatory Care Setting
C – Public Health
D – Occupational Health
E – Insurance Claims/Benefits
F – Nursing Home/Extended Care/Ass’t Living Facility
G – Home Health/Hospice
H – Academic Setting

Registered Nurse Ages by Setting – data courtesy Erin Fraher, Sheps Center, UNC Chapel Hill 

“We know it’s not as well paid,” Fraher said. “It’s like anything, you have to do it because you love it. But I do worry about those nurses in long-term care and home health and those people who are caring for our elderly in this state, and how do we recruit nurses into that.”

And it’s not just nurses who make up the staffing at these long-term care facilities, much of the hands-on work is done by certified nursing assistants who Bureau of Labor Statistics data show make, on average, $14.25 an hour, about $29,000 a year.

“My fear is that if you already have a shortage or a situation where nurses and all the staff are not attracted to that sort of setting,” Fraher said. “What happens in a situation where that setting becomes even more dangerous, and less attractive?”

There’s a certain poignancy that National Nurses Day was the day the Department of Health and Human Services put out a call noting “an urgent need for Registered Nurses and Certified Nursing

Assistants, among other roles to supplement current workers and in some cases fill in for workers affected by COVID-19,” particularly at long-term care centers.

The department is working with East Carolina University to match these facilities in need of staff with people willing to pick up shifts to care for these most vulnerable, who are at highest risk of dying from COVID-19 infections. 

This is on top of a volunteer effort being coordinated by DHHS, placing health care professionals into places where there are gaping holes in staffing. 

According to data from the NC Board of Nursing, nurses have answered the call. 

“DHHS asked us could they utilize our data to put a call out for help so they could place nurses, and 2,500 responded affirmatively,” said David Kalbacker, a vice president at the Board. 

“My feeling is that when there’s a house on fire, nurses will not run away, they will run toward a disaster,” he said.

Staffing matters
In the short term, these long-term care facilities will scramble to fill in their staffing needs, but in the long term, there needs to be policy to address the funding and business models at these centers. 

“The biggest crunch we face is the direct care workforce,” said Jeff Horton, head of the North Carolina Senior Living Association. “A provider that takes Medicaid sometimes finds it difficult to offer competitive wages.” 

Recently DHHS bumped up the personal care services rate to $16.40 an hour to address COVID-19 needs, but Horton said that other states pay more in normal times.

“It’s in the neighborhood of $18.50 an hour,” he said. “Getting up to a wage like that to attract folks to our industry is a goal we’ve had for a long time.” 

There is now decades of research showing that better staffing by nurses – not physicians – produces better outcomes for patients. University of Pennsylvania researcher Linda Aiken has shown this in hundreds of articles, including one published last year in the Journal of the American Geriatric Society that showed poor staffing in skilled nursing facilities showed higher levels of burnout in facilities where they were unable to complete their tasks. These nurses also had higher levels of burnout. 

“Extensive evidence from hospitals has shown that when RNs work with insufficient staff and resources in poor safety climates, they are more likely to leave necessary patient care undone,” Aiken and her co-authors wrote. “This phenomenon, also known as ‘missed care’

nursing care,’ has been found to be a predictor of worse care quality, increased adverse events, and decreased patient satisfaction.” 

In North Carolina, about half of the state’s 140,000 nurses work in hospitals and another 10 percent of RNs work in practice-based settings such as physicians’ offices. “The rest are working in those areas like long-term care and rehab and public health, schools, jails, community health, hospice,” said Dennis Taylor, president of the North Carolina Nurses Association. 

“You’re looking at an area where they have had a difficult time being able to recruit nurses and a lot of that has to do, unfortunately, with what the pay scales are in those areas,” he said from his home where he’s currently furloughed. 

“There’s a shortage across all areas, but especially in that one because there aren’t many people that really want to go and take care of that population of patients,” he said. 

Not for the money, or the working conditions they face. 

Long overdue recognition
Perhaps coronavirus can help turn the tide when it comes to giving nurses their due. This year, the North Carolina Nurses Association solicited messages of support and thanks that will be posted on their social media channels throughout this year’s National Nurses Week.  

Beyond Gov. Roy Cooper, DHHS Secretary Mandy Cohen and Sen. Thom Tillis, the Nurses Association has heard from athletes, musicians, actors and other North Carolina notables. On Wednesday, the organization posted social media messages from Devonte’ Graham from the Charlotte Hornets, Christina Koch, the NASA astronaut, and Brady Skjei, a defenseman from the Carolina Hurricanes. 

“We appreciate them taking the time to talk about nurses, it’s been cool to see the seriousness with which they took these messages,” said Chris Cowperthwaite, director of communications and outreach for the North Carolina Nurses Association. “A lot of them did more than just ‘Hey, happy nurses week,’ they approached it with the respect we’d want to hear in their voices, and it was cool to see.”

Taylor said the recognition is nice, but there needs to be opportunities for nurses to make it into a more attractive profession. 

“We know that being able to place folks in educational programs and then make it easy for them to bridge their education to higher levels and make it convenient for them is going to be the real key to keeping people in place,” he said.

This article first appeared in North Carolina Health News and is republished here under a Creative Commons license.

North Carolina Health News is an independent, non-partisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina. 



Rose Hoban is the founder and editor of NC Health News, as well as being the state government reporter.

Hoban has been a registered nurse since 1992, but transitioned to journalism after earning degrees in public health policy and journalism. She’s reported on science, health, policy and research in N.C. since 2005.

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