Helping Nurses Find Their Voice - Rebecca Love, IntelyCare

Michael Carrese: Hi, everybody, I'm Michael Carrese. Today, we welcome one of those guests with so many accomplishments and involvements, it's hard to know where to start. Suffice it to say that Rebecca Love is a force in nursing, leading efforts to empower nurses to be innovators and entrepreneurs in improving the healthcare system and advocating for the profession in a wide variety of other ways. 

She's an entrepreneur herself, founding HireNurses.com in 2013, where she served as the managing director of U.S. markets until its acquisition several years ago. In early 2019, Rebecca -- joined by a group of leading nurses across the globe -- founded and led the Society of Nurse Scientists, Innovators, Entrepreneurs, and Leaders, a nonprofit that quickly attained recognition by the United Nations as an affiliate member. 

On the education front, Rebecca holds a master's degree and bachelor's degree, in addition to

being an RN. She was the first director of nurse innovation and entrepreneurship at Northeastern School of Nursing, which was the first program of its kind in the United States. 

Other groundbreaking roles include being the first nurse featured on TED.com and appearing on the first nurse panel at SXSW. Currently, she serves as the Chief Clinical Officer of IntelyCare,

which offers workforce management solutions for healthcare facilities. We're very pleased to have you with us today. Thanks for coming.

Rebecca Love: Mike, thank you so much for having me.

Michael: So, I'm just scratching the surface there with that introduction. What would you like to add to that? And what do you think is your most significant accomplishment so far?

Rebecca: Mike, I appreciate you saying that. I think that the one thing that I feel that I've always stayed very true on is the fight for the nursing profession and staying as close to the issues that matter to the frontline as possible. I think it's very easy as we grow in our careers to forget where we came from and for me, it's always been about nursing. 

I think some of the things that are the most important thing for me and that I still value is recognizing where I started and how important those roles are at the bedside. It's so weird when you hear people read back things that you've done in your life, because in the moment you still suffer from imposter syndrome and feeling like you're not making any difference and sometimes people read things back to you and you feel rather surprised of the things that you accomplish when you put them in a format like that. So, thank you for the introduction. 

But, I still really pride myself on saying that we're going to represent nursing to the fullest and try to help them find a voice on a larger scale so that the profession is recognized for the value that they bring to healthcare.

Michael: So, where did your nursing career start, and what drew you to it in the first place?

Rebecca:  Actually, I had no interest in being a nurse. My first degree was in international relations and a minor in Spanish at Boston University. My path to nursing actually began with a conversation with my mom. I had been accepted into law school and I was working on a presidential campaign. At the time, healthcare was a major issue and what I realized is everybody would go to these conferences and these meetings to talk about healthcare and all the people in the room were, like, attorneys and lobbyists and there were no healthcare people in the room. I found that very strange working on this presidential campaign. 

I thought I was going to law school and joining the campaign down in D.C. as I had been asked to go, and there was a conversation in which my mom said to me, “You know, Rebecca, we're not going to support you going into law school. We believe that you should be a nurse.” And why that happened was she had gone back to nursing school later in life. She was forty-nine when she was accepted into nursing school. She said, “There's plenty of strong lawyers in the world, but there's not enough strong nurses.” 

She felt the most prestigious career that you could have was being a nurse. She felt that there was no greater profession than being a nurse and what she experienced after becoming a nurse was a place of deep disempowerment. I remember I agreed to apply to one nursing school at that time and I sent in my application. They called me, and they said, “Come in for an interview, but just know it's a two-year waiting list to get into an advanced nursing program.” Because I had a bachelor's, I was going into one of those accelerated RN, BSN to MSN programs. I have the interview and said, “OK, well, I guess I'm off to law school.” Two weeks later, they sent me a letter saying I had been accepted and could start in the fall. If you're like me, all of a sudden I'm thinking to myself, “OK, that's a sign I'm supposed to do that.” So, I went to nursing school and it was a very hard process for me.

I don't think nursing school is easy. It's been said that nursing school is actually the most difficult degree to achieve of any degree out there because of the high degree of technicality in wide areas. But if you're looking at it, almost one in three individuals who start nursing school today actually fail out or leave the actual program due to the amount of rigor and also inflexibility and that's sort of what I experienced in nursing school. But, I made it through, and the rest is sort of history. 

Michael: So, you talk about coming into this with your mother's sense of nurses being disempowered. I imagine that was on your mind from the beginning, so how soon was it that you started identifying opportunities to maybe do something about that? And were you always thinking, “OK, I'm going to be a leader, I'm going to help change this culture?”

Rebecca: Gosh, no, that is funny. I mean, that statement would have immediately made you think that I would have thought that I had to be a leader in it. In nursing school -- in my program at least -- there wasn't a lot of talk about leadership as nurses, even though I was a nurse practitioner. The idea was always very clinically focused. You know, you're going to graduate, you're going to be by the bedside, then you're going to come back to us and finish graduate school. You're going to go out and be a nurse practitioner at the bedside. 

At the time, I was in Massachusetts, where we did not have full practice authority so even the idea of being a nurse practitioner with full practice to have your own clinic was never an idea. 

So, I always knew that I would probably always be in a role that would be in the hierarchy of healthcare which I know you're very familiar with. Nurses are under the roles of physicians and administrators and so when I when I graduated as a nurse practitioner, I realized quickly that you would operate largely like a resident for the rest of your life as a nurse practitioner, right? You would operate as a resident does who's in medical school because of the degree of the complexity of the job and the need for it, but also the lack of autonomy within the state of Massachusetts. 

I think my first experience of leadership really came when I started teaching at Bunker Hill Community College in Boston, an inner-city college. I realized the vast majority of my students in front of me had chosen nursing because they were told that nursing would always give them access to a financial means to live a life that would allow them to pay bills and to have opportunities that most of these individuals had never experienced. They were told that if they became nurses, they could live the American dream.

Most of my students were from other countries. Many of them had grown up in foster care. I had a significant number of single mothers and very high percentage of minority women in my classes and nursing for them became the American dream. I started to realize I stood between them and financial security and their dreams and aspirations for what it meant for their lives. That is probably where my belief in nursing changed...what it meant to me and what it meant to our society, but also what it meant as a driver for security for some of the most compassionate, intelligent people that I ever met, but the odds of life had largely been stacked against them. 

So, that's where my first opportunity for leadership came and I threw myself into it. I loved every minute of teaching at a community college associate degree nursing program because the odds were definitely stacked against them. The degree, the rigor, is no less in an associate degree nursing program. You just don't have all the theory that a bachelor's program does, but all of the clinical rigor in an associate degree nursing program is equal to that of the best universities that offer nursing in the country. But with a population who had come from such a difficult background...their basic understanding and knowledge of traditional education was at best weak, if not broken in critical areas. 

Michael: Yeah. What a responsibility to have, too, with all of that in mind. So, your former students now are out there in this nursing workforce. It's kind of messy out there in the nursing workforce world and everybody seems to be wringing their hands about what to do about

it. What's your take on what's happening with nurse staffing -- where it went sideways, let's say -- and where does IntelyCare fit into that? 

Rebecca: Mike, I think nursing is in the most critical place I've ever seen it in as a profession. I'm sure you've researched the recent studies, but there was a McKinsey report that came out in 2021 and was updated in 2023. Everybody thought it couldn't have gotten worse from the 2021 report, which said that one in three bedside nurses in the United States are unhappy. It's a really interesting study that's been played out, but the most recent study came out showing that nurses are equally as unhappy, if not more unhappy, than two years ago. The interesting thing is, Mike, there's actually more nurses today in the United States than ever before in history -- nearly a million more than there was a decade ago. We have over five million nurses in the United States. The average age of a nurse is fifty-four, so 50% of the population is over the age of 54. 70% is over forty.

But I think the concerning thing is that we graduate 250,000 nursing students a year in the United States -- that is the largest number of any profession that we graduate from any degree program in the United States -- and an increase of 15% per year over the course of the last five years based on research out of University of Pennsylvania led by Linda Aiken. This means that we are graduating more nurses than ever before in history, but the reality is they're

not staying. Even before the pandemic, 57% of new grads left the bedside within two years of practice and we believe that in the last two years, the largest demographic of nurses leaving the bedside are nurses with less than one year of experience. This is something no one is talking about. 

What I say often, which is not popular, is that we don't have a shortage of nurses in this country. We have a shortage of nurses willing to practice in the healthcare environments as they are today. Actually, the average length of experience on a twelve-hour shift has dropped from six years of experience prior to the pandemic down to 2.8 years of experience, which is the lowest ever in the history of the United States.

So, what's going on in the nursing profession right now is that healthcare has consistently staffed nursing to the lowest cost denominator within healthcare systems and why that happens is because nursing is a cost to healthcare system. They are the only profession that is a cost to healthcare systems, and I think it has become increasingly difficult for nurses to be able to operate. 

So taking a step back from all of it, like, who is IntelyCare? Why am I here? What is this about? Why did I join? IntelyCare is one of the few platforms in the country that took a paper process, put it into a technology for nurses, sped it up, and actually drove greater efficiency and better usability and satisfaction among the nursing population. We are basically a workforce management solution or staffing company for nurses across long-term care. I oversee a 35,000-nurse workforce across thirty-eight states who pick up shifts when and where they want, because we took a scheduling system and largely made it Uber-like for nurses to pick up shifts. 

What we saw through our experience, Mike, was that when you gave nurses the ability to pick up shifts when and where they wanted to work on a schedule that was not as difficult as it's been traditionally for per diem models, on average they were picking up five shifts a month with us when we expected them to pick up only one shift. So, what you see in this process is that technology certainly can scale a workforce who otherwise would not be scaling themselves in traditional models. 

I joined IntelyCare because I believed as long as nurses remained a cost to healthcare systems, healthcare was never going to invest in anything to make the lives of nurses better and it was going to take private industry to do so. I strongly believed by joining IntelyCare that we could change the future of work for nurses when we gave them technology that was designed with them at the heart of it to enable them to scale when they could work so that we could take care of more patients in more settings by using technology to allow us to do so.

Michael: So, really it sounds to me the flexibility is key to this.

Rebecca: Absolutely. I think we have been so rigged into directional scheduling models in nursing for decades that when the simple thing of flexibility optimized through technology was brought about, suddenly nurses love you just for the simplicity of allowing there to be flexibility. I know it sounds almost too simplistic to believe that that could be a silver bullet, but honestly, that's basically all we offer, Mike. 

I wish to say that there was tremendously more...you know, whiz gas and bells and a hundred times more pay for nurses -- because I would pay nurses as much as the market would ever allow -- but none of that is true. We simply created a platform that allows nurses more of a credentialing passport to pick up and work at any facility. It allows them to meet those credentialing standards so they can work anywhere that they want, when and how, and allow them that flexibility to make it happen, and guess what? Nurses work more, not less, when they have that opportunity. 

Michael: Well, and it just meets them where they're at. I think people learned this a lot during the pandemic...people are juggling a lot in their lives. Most nurses are women, and most women are responsible primarily for the children and their parents and everything else. How could you, in a way, keep a full-time job and do all of that? So, you can totally see how this would make it easier to fit into their lives with all their other responsibilities. 

Rebecca: It certainly does and actually -- you would be really surprised, Mike -- the vast majority of people who work with us still have full-time jobs, they just use us as their secondary source. I don't know if you know this, but the vast majority of nurses in this country work more than one job. It's always been a profession that’s always worked more than one job because even though we think that nurses are very well paid, compared to any other degree program in the country they are the only hourly employee in all of healthcare that is at a degree level. We do not have salaries, so nurses are constantly working more shifts, more overtime and other jobs because their financial security is not as secure as you would expect for being a nurse. You really can't afford to make ends meet when you have a family of four living on a nursing salary in this country. That is still a misnomer. 

I think that if you look at average hourly wages, you're looking at nurses across the spectrum with twenty years of experience to one year of experience, so things are skewed. As I said, 50% of that population is over fifty-four. So, your Bureau of Labor Statistics data is skewed to higher amounts of hourly pay for nurses when actually, if you looked across the country, those numbers are dramatically lower. 

Michael: So, flexibility is part of the solution here, but you've also pointed out that a lot of the burnout is because they don't want to work in the healthcare environments that exist. What are your thoughts about changing that? That's a much bigger problem to address, obviously.

Rebecca: It is a much larger problem. And Mike, I'm going to talk about something that I think is really important to talk about, and I mentioned it earlier -- nurses are cost to healthcare systems. Every other profession has a reimbursement code. Nursing becomes the largest cost center to healthcare systems on their operating budget and you know this from running a business: nobody invests in costs in businesses. They cut costs, and nurses have remained cost in the healthcare system since the earliest development of insurance in this country back in the 1930s. 

So, if you don't mind, I'd actually like to step back about hundred years in history, because I think it's really important to tell the story. 

Michael: We lovetime travel. 

Rebecca: (laughs)Time travel, that's exactly it. So, we'll take us backwards to the early 1900s when women in this country were fighting for the right to vote. The American Nurses Association actually remained external to that fight until 1919, when they helped organize the largest march in the history of the United States for the women's suffrage movement. In 1920, women get the right to vote in this country. In the 1920s, nursing becomes the largest economic vehicle for women's financial independence in the history of the United States. 

Now, at this time, hospitals existed, but they were places of the most deplorable condition. Only the most destitute would seek care there. But as surgery started to develop, families started to bring private duty nurses into the hospitals to deliver care. At that time, nurses all ran their own independent practices, they billed independently for their services. Hospitals started to see that this care started to get better so they started to bring nurses into hospital systems and employ them. If you look at bills in the 1920s, every bill from a hospital will specifically have a line for nursing services.

Nursing started to become more powerful because of that. At that time, hospitals were run by men, physicians were men, and they started to feel threatened by the increasing economic capacity that nurses started to have and as the expert and historian Donna Deere said, they wanted to develop a model to keep nurses as far away from the money as possible, because they started to see nurses as economic competition to the hospitals. 

In the 1930s, national insurance starts to get developed. Hospital administrators and physicians start to look for a model to pay for nursing, but not to recognize them on the bills any longer. They turned to hotels, realized that maids are rolled into room rates, and then they roll nurses into room rates, forever hiding their value. One hundred years later, nursing is still the only healthcare professional that does not have a billable service and remains the largest cost center to hospital systems. 

In full disclosure, we have launched a commission to take on nursing reimbursement to pull them out of the room rate, because the only way we are going to truly solve this misalignment -- more nurses equal more costs without associated revenue lines -- is to make sure that we get them out of being a cost structure. We need reform on our payment models to pull nursing out of the healthcare system’s room rates and make sure that they are a billable service, and we can invest in them accordingly. 

Everything else is going to be lipstick on pigs, as they say, or band-aids on gorges. As President Biden says, if you want to understand what people value, look at where their budgets are. We’ve known for far too long there has been no value because nursing is hidden from any budget line, from investable resources within healthcare. 

Michael: But...you talk about upsetting the apple cart! I mean, you've got to have a lot of people at the table to agree to a lot of change. So, what's the strategy to get that to happen? 

Rebecca: The good news is, actually, there's quite a bit of strategy behind it and luckily for me, it's not me leading on that because I'm not the economist. We have John Welton, who is one of the most brilliant historians in this space. We have Olga Yakusheva, who is one of two economists in the United States who are studying this too, to develop this model alongside Rob Longyear, who's a data scientist in the nursing space, studying the impacts of these things and coming up with models. 

Now, the reality is actually in the 1980s, when DRG (Diagnostic-Related Group) codes were actually established in this country, there were a whole bunch of DRG codes that were written to actually address nursing services but they were lobbied against from going into the system. For the last fifty years, nurses have repeatedly tried for models to get nursing recognized but have always been sort of beaten down. So, we're looking at models that are pretty much conventional occupational therapy and physical therapy models and coming to the table with a whole bunch of options that we have seen work for all the other professions that have gotten reimbursement codes. 

I mean, in all honesty, respiratory therapy, MRI techs, occupational therapists...all of these are relatively new DRG codes in the course of the last ten or twenty years. OT/PT is a little bit older. It has happened for every other profession. It's only nursing that has stayed in the room rates. I don't know if you had followed, Mike, the work of the State Treasurer's Office in North Carolina. Have you been following any of the stories that have come out of North Carolina? 

Michael: No. 

Rebecca: Let me just give you a little bit of why we think this can happen and why it's important to happen. Treasurer Dale Folwell ended up pulling the Medicaid license for Novant's healthcare system after Novant started to see emergency room wait times going up to over twenty hours and they had eliminated nursing positions across the entire system, claiming they could not afford more nursing pay or more nurses at the bedside. So, patients started dying in the hallway emergency rooms at Novant's healthcare system and Treasurer Folwell looked into this and said this is crazy because we've given you millions of dollars in the last few years. Why are you not staffing your hospital system? He said, you're violating the social contract that you have for Medicaid reimbursement, pulled their Medicaid license and Novant suddenly found millions of dollars to hire nurses. 

So, the Treasurer wondered, where did they find this money and where did all the money go? He launched an investigation that he published about six months ago that showed in the course of the last ten years, the state of North Carolina had given $1.75 billion to nonprofit healthcare systems that had specifically only gone to executive pay in that time. They found that CEO pay had doubled within five years, but nursing salaries had only increased 14% over ten years at the rate of 1.4% per year. What he also found was that during 2020, when most of the healthcare systems were furloughing nurses on the front lines of the pandemic, none of these executives took a pay cut during that time. What he also found based on his report was that executive pay had no correlation to the mission of the hospital nor patient outcomes. 

So, the report basically showed billions of dollars had been going into nonprofit healthcare systems to support executive pay, but at the same time, crying that they could not afford to support nursing. What we're trying to argue is we know there's plenty of money going in, it's just not going to support the nursing services and the only way we're going to find out those models and measures better is to start tracking that and paying nurses accordingly so those dollars cannot be misdirected to other directions within healthcare.

Michael: So, financially, you're seeing this as zero sum as opposed to a new stream of funding or additional funding that's needed?

Rebecca: That's correct. Some people have asked me, why won't value based care solve this? And the issue is that nursing is the only profession that does not have an NPI number -- which is the National Provider Identifier. Every other profession has one. So, even if we rolled out value-based care, the truth is there would only be tracking the outcomes back to the room, and it would be amazing if beds got patients better. 

But I think we all know, or we should know, that the only thing that really drives outcomes in hospitals and nursing homes -- the only reason patients are there -- is because they need nursing care. Everything else could be done outpatient, like OT, PT, respiratory therapy, surgery...all of that could be done outpatient. What we know for certain is the reason that patients are in hospitals and nursing homes today is because their life is so at risk that without 24-7 attention by a nurse, they could die, and somehow we have lost that focus in healthcare...that the most critical workforce in all of healthcare to keeping our hospitals open is nurses. 

We always knew this was coming, but so many people seem caught off guard that today healthcare is at a teetering point. Literally, hospitals are closing their doors. They are not staffing beds because they don’t have nurses. I ask people this a lot, where would we be in the world without nursing in our society, but more importantly, within our hospitals? I think we're starting to see that play out. 

Michael: Well, this is going to be super interesting to keep our eye on, and it's going to be really interesting to see what kind of adjustments you can get the system to make. But in the interest of time, I want to wrap up by giving you a shot to address our pretty young audience -- a lot of learners, nursing students, medical students, and also early career professionals -- about how to approach their career in a very challenging time, particularly with what you said about nursing and burnout and all of that. So, what is your go-to advice for people starting out?

Rebecca: I think I'll speak directly to your nursing workforce and those who are going to work with nurses. Nursing is a profession that has been part of our social fabric as one of the greatest vehicles for society to focus on people who cross a threshold when nobody else will care for those individuals and care for them at the expense to themselves and to their families on a consistent basis. So, what we need is we need a generation to come in and to see this profession differently and demand what they deserve to stay at the profession. Because I think my generation and before us accepted things that were unacceptable and I think that the next generation coming in recognizes very simply the things that they need to stay by the bedside, which is safe work environments, ratios that make it safe to practice, and pay that is commensurate with the experience that they have. 

If you are looking to help lead, I still believe that nursing is the greatest profession you can go into in healthcare to make a difference -- not only in individual patients' lives when you're by the bedside -- but the ability to drive significant changes at a societal level that actually makes society better. I'm not sure there's a lot of those professions out there. 

So, what I would just say is if you're up for the challenge -- because life in itself is a

challenge -- and you want to make a difference, we want you in nursing, because we need the best and the brightest to stay there. If you're not choosing nursing, we need you to be a champion of the profession because without nurses, there simply is no healthcare.

Michael: Well, on that very inspirational and thoughtful note, we're going to have to wrap it up. I want to thank you very much for being with us today. It's been fascinating.

Rebecca: Mike, thank you so much for having me.

Michael: Thank you to our audience as well for checking out today's show. I'm Michael Carrese and as always, remember to do your part to raise the line and strengthen the healthcare system. We're all in this together.