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Rethinking Nursing Workforce Models at Duke Health · Becker’s Healthcare Podcast

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This is where health care leadership comes together.
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Becker's sixteenth annual meeting brings more than 3,500
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hospital and health system executives and nearly 800
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speakers to Chicago April.
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This series event includes keynote conversations with Dallas
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Cowboys legend Troy Aikman and former president George
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w Bush. For the agenda and event details,
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visit beckershospitalreview.com
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and click on the events tab in the
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upper right. We're looking forward to hosting you
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in Chicago.
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This is Scott Becker with the Beckers Healthcare
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Podcast,
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but we're thrilled today to be joined by
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a brilliant leader.
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We're joined today by Terry McDonnell,
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and Terry serves as the chief nursing executive
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and senior vice president at the Duke University
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Health System.
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The Duke Health System course is one of
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the great academic medical centers in the country.
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Terry has also worked at, leading
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cancer operations at Mass General in that area,
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also at Fred Hutch Hospital. She's had a
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magnificent career.
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Terry, can you take a moment to introduce
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yourself and tell us what brought you to
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Duke?
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So, you you you've you're very kind and
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complimentary, Scott.
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You know, we take different twists and turns
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in our career, so I nursing is a
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second career for me, as you said. I
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I started, I cut my teeth at Massachusetts
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General Hospital.
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I still also am a practicing nurse practitioner,
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so my clinical subspecialty
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caring for that patient population
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for the last twenty five years, and I
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I proudly continue to do so
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on a modified basis.
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You know, from Mass General, I I grew
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up clinically and administratively. I left there,
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as the director of clinical operations for the
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MGH Cancer Center,
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and I was recruited to what was then
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the Seattle Cancer Care Alliance,
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as the chief nursing officer and senior vice
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president for clinical
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operations. And over the course of my seven
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years there, we grew the organization,
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things evolved and changed, and we went through
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a merger and restructuring.
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And, the baby that was birthed at the
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end was the Fred Hutchinson Cancer Center.
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I had the pleasure of,
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overseeing,
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the construction
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and design of a new ambulatory innovation center
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while I was out there. Again, we we
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grew to care for more patients than we
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ever had historically
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over the the WWAMI region, which for those
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of you who aren't from the Pacific Northwest,
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when you work in Seattle, you actually don't
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work for the state of you don't just
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serve the state of Washington. You serve patients,
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from Wyoming, Montana,
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Alaska, and all the way to Hawaii.
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And,
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after the the merger and the restructuring,
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it was a nice point for me to,
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make a move, and I was recruited out
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here to be the chief nurse executive for
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the Duke University Health System,
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a role that I very proudly have held
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for the last two and a half years.
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And, boy, is health care changing right in
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front of us. Well and and talk to
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us a little bit about that. So you've
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been in health care for some time. You've
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had this magnificent career.
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Talk about what changes or trends you're most
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focused on currently. What are you watching most
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closely?
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What excites you? What keeps you up at
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night?
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A little bit about the core things you're
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watching.
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Well, I'll start with what keeps me up
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at night,
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and that is,
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the math problem that we are currently facing
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in health care.
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And what I mean by that is we
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have more demand than ever for our services,
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and we have a stagnant
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workforce.
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And never before
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have I seen in times of an economic
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downturn
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have I seen where people actually don't
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run to health care
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as a next opportunity.
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This is the first time that I've seen
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where we're facing some economic,
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headwinds
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as far as,
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the workforce goes and jobs,
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and we're actually not seeing people running to
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careers in nursing
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and in health care, which is a unique
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dynamic.
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But
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with that keeping me up at night,
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that also presents us with some very unique
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opportunities.
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Also, never before
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has my generation
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been faced with so much opportunity
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with regard to transitioning what work looks like.
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And what I mean by that is how
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do we integrate
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all of the incredible tools, new tools that
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are coming to us almost daily
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in AI, new technologies,
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robotics,
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and how do we integrate those things and
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really transform what health care delivery looks like?
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Yeah. No. Fascinating. And and the math problem
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we talk about often, there's a million one
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physicians versus a population of 350,000,000
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people.
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There's about four to four and a half
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million nurses,
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compared to 350,000,000
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people.
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The the numbers are staggering.
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When you talk about people not running to
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health care careers,
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talk about that for a moment, and and
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why do you think that might be?
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Well, I I think part of it is,
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you know, really our philosophical
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generational approach to work.
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You know, right now, we've got a workforce
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that spans five generations.
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And each one of those generations from the
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boomers all the way to gen z
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learns differently, has different expectations,
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and, you know, behaves differently in the in
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the workplace.
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And, you know, what we've seen is is
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with
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with that shift in dynamic, we also see
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a shift in
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what interests people and what people wanna migrate
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towards for work.
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Work in health care, especially nursing,
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is challenging.
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You know, when you start out, a lot
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of it is very physical,
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a lot of it is at the bedside,
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and, you know,
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people's expectations
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around what gratifies them
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and what really me brings to them meaning
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in their lives has changed.
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So we're having to shift our way of
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thinking,
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thinking more in terms of of shorter shifts,
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gig,
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hybrid,
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part at the bedside, part in a virtual
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care environment.
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You know, all of these things are shifting
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what the work looks like.
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100%.
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And and and let me ask you this
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question, Terry. And and you seem like a
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serious professional person,
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so bear with me because I'm somewhere in
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between that. So bear with me.
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You're now at Duke.
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Have you yet?
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Do do you cheer for Duke versus UNC
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North Carolina, or have you yet gotten involved
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in the Duke UNC rivalry?
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Do you bleed Carolina blue, or are you
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a Duke a Duke fan now?
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Oh, I'm Duke all the way.
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There you go. There you go. No. And
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it's and it's a great, great,
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school for it's a great academic institution, plus
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a great great basketball and so forth. So
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fair enough. I'll take you back to serious
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questions. I promise,
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Terry. Talk a little bit about leadership. You've
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had this amazing leadership career. You talk about
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the different five generations in the workplace.
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You've spent time at Mass General. You've spent
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time really building a cancer program in Seattle,
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and now at Duke.
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Talk for a second about what advice would
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you give to emerging leaders who who want
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to have interesting impactful careers and be effective
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leaders?
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The best piece of advice I can give
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to anyone in leadership
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is don't hang your hat on one particular
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phenotype.
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The most important thing we can do as
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leaders in 2026
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is to listen and learn from the people
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who are closest to the work.
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Gone are the days where a top down
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leadership is effective,
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And, you know,
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we can transform
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and we can have the most impact
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the more we empower the people who are
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at the front line and closest to the
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work.
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Engage them and change.
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Engage them and involve them
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in co development of new solutions,
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new models of care.
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Those bring about the most effective changes,
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and those things engage your workforce.
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In terms of encouraging
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your team members, the people that are growing
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in the leadership with you
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to thrive themselves,
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to avoid burnout,
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to keep trying to get better and to
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make improvements,
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What's the best way of doing that to
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sort
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of grow and have a team that thrives?
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Humor is very important.
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This is this is serious work,
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and the team needs to be able to
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challenge each other in healthy ways, but also
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grant each other the grace
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and allow levity in the situation.
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You know, we're we are we are a
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serious profession nurses, but we also,
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we we can be fun at a party.
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And, you know,
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when we allow ourselves,
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that grace and the calm in the moment,
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that helps for a couple of things. It
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alleviates some of that intensity, which drives burnout.
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I mean, when you drill into burnout, it's
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really about anxiety, fear, and high intensity
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that doesn't ease.
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And when you've got a healthy team that
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comes together
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and that, you know, feels safe
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and trusts each other,
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that's when you can be most effective, and
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that's when people
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really wanna continue to come together and thrive
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in that environment.
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You know, and and and and I love
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that. And when you we've talked some about
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the math problem.
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But when you think about
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you're the chief nursing executive at one of
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the best institutions in the world.
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What are you most focused on this year
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and most excited about this year?
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Where are you most focused and excited this
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year?
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How we evolved from a a nurse to
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patient ratio
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and think more about team care delivery.
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So we've just opened three brand new innovation
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units at our university hospital. And what I
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mean by any innovation units is we rehabbed
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three,
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30 bed units
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and we've partnered with some technology firms. We're
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introducing computer vision.
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We're changing the the
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model of staffing where a staff nurse will
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work two twelves on the on the unit
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and one twelve in the virtual care center
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as that virtual team member.
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And I think that's really going to shift,
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the physical burden,
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the emotional,
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psychological burden,
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and also
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bring about better outcomes,
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both for our patients and also for our
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staff. I'm really excited about the potential and
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what we're gonna learn
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from those three units and what we're gonna
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be able to,
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then develop and change.
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Thank you. You talk about the movement away
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from nurse patient staff ratios.
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And yet, you have some states
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that are imposing new nurse staff ratios,
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and and there's different reasons for this, often
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political.
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But that seems so challenging given that everybody's
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trying to find different ways to deliver care
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that aren't so labor dependent on a labor
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force that's really hard to fill.
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Any thoughts on that as you move towards
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care delivery? And I don't want you to
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get involved in politics at all. I don't
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wanna put you on the spot on it.
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But but it does seem that those two
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things are in conflict with each other. Some
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states
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that are moving towards
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increased nurse CF
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patient ratios
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and really trying to move this to a
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care based delivery system based on need, not
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based on when we we all like to
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be in a hospital where there's lots of
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nurses around, we just feel very safe and
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very comfortable.
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So we all understand the nurse patient staff
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ratio, but it's very hard for systems to
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make that work in the way that it
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used to be used to work.
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It it is hard, and you're right. It
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is it is very politically charged. But when
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you drill into the core of it,
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it it's it's not necessarily
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about
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a nurse to a patient, but it's all
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the resources available.
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And I think we're
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because we are,
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very entrepreneurial,
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I think, in the way we've grown up
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in American health care,
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there's not necessarily,
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the same standards.
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And where the nurse to patient ratio
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work has really tried to make an impact
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is around standards and safety.
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But where we're gonna have to have some
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difficult conversations,
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especially in states that that have enacted legislation,
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to your point is,
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how do we think differently when there's not
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enough nurses
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to patients
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in order to continue to deliver the care
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and meet the demands, the basic demands
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of a community.
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Yeah. 100%. And that that's what it is.
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There's just not enough nurses in many places.
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And you have more and more nurses that
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like, we had a fantastic nurse
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speak about job opportunities and so forth.
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And, really, at this point in her career,
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wanted to do anything but be an inpatient
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hospital nurse.
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And, of course, there is so much need
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in that area.
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And there is so many people that prefer
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to work in different settings, in the ambulatory
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settings, other kinds of settings. Just there's a
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whole variety of opportunities for nurses.
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And sometimes you're you're you're fighting this uphill
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battle of a nurse patient staff ratio
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when the workforce doesn't cooperate or doesn't wanna
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be in that spot.
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Right. So I think the definition of ratio,
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will necessarily have to be revisited and evolve
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over time. I think it's going to be
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team
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to patient
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cadre.
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So if I've got I'm making it up.
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If I've got a floor of 30 patients,
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but I've got a team
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of,
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again, making it up, four
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on-site nurses
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and
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a virtual nurse
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and a pharmacist
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and three techs,
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is that going to be a safer
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environment
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with better clinical outcomes
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than a 30 bed unit
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with five nurses on-site
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and none of the other,
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services available to help augment that on-site nurse.
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Could not agree more.
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Terry,
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what a magnificent career thus far, and what
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a leader.
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Thank you for joining us on the Becker's
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Healthcare podcast. Just just a pleasure,
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and we'll chair today with Duke versus UNC,
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but I don't have a I don't have
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a a dog in that fight day to
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day. But thank you so much for joining
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us. Thank you, Scott. It's been a pleasure.