The United States is in a nursing crisis.

According to the American Nurses Association, the nation’s nurse workforce experienced shortages prior to and were exacerbated during the height of the Covid-19 pandemic. Retirements, racism, unsafe work conditions, and a lack of policies that support quality care are among the many reasons nurses are leaving their jobs.

About 100,000 nurses left the workforce during the height of the pandemic and within four years, 900,000 registered nurses are predicted to leave the workforce, according to the National Council of State Boards of Nursing. The U.S. Bureau of Labor Statistics predicts over 193,000 average annual openings for registered nurses between 2020 to 2030. The median salary for a registered nurse in the U.S. is $81,220, but heavily depends on the person’s location, experience, and educational attainment. Even though there is great demand for nurses nationwide, some say there are too many barriers to entering the industry that also work against a diverse and inclusive nursing workforce.

Dr. Martha Dawson, the immediate past president of the National Black Nurses Association, is a nurse educator and supporter of health equity. She became interested in the techniques of medicine and the satisfaction of saving someone’s life.

Dawson remembers her father getting second-degree burns and helping him wrap bandages around his wounds when she was a little girl. She remembers her brother falling from a horse and breaking a bone, then watching it heal over time. When her mother bought her a doll, that remains in Dawson’s house today, she wrapped it in bandages and cared for the doll like it was a patient in the hospital.

“I keep (the doll) to remind me of my mother’s sacrifice, but also her belief in my dream and my journey into nursing,” Dawson told Direct Relief in July.

But throughout her adolescence, adults told Dawson that she would make a great teacher. Dawson said she thought to herself, ‘Why can’t I be both?’

There are few nurses who identify as Black, Indigenous, and People of Color, or BIPOC, in the U.S. They make up less than 20% of the profession, according to the National Council of State Boards for Nursing. Far fewer hold a doctorate degree, and it takes longer for BIPOC nurses with advanced degrees to obtain managerial and executive positions.

Like many BIPOC nurses, Dawson began her educational journey at community college before advancing to a four-year institution and eventually earning her doctorate.

Nursing programs can also be costly.

Dara Koppelman, the Executive Vice President of Health Services and Programs at Mary’s Center in Washington, said her one-year, accelerated nursing program cost nearly $100,000 after completing her bachelor’s degree.

“The program I did was very expensive, and I had to take out loans to complete it,” she told Direct Relief. “And that’s not always accessible to everyone.”

Koppelman comes from a long line of nurses. Her mother was a nurse, her grandmother was a nurse, and several other women in her family are nurses. She now has a master’s degree in health services administration.

The executive VP began her career at a hospital within labor and delivery and was influenced by midwives who encouraged her to try different avenues of nursing. Koppelman said she listened to their advice and worked for the health department before finding her place at Mary’s Center, a not-for-profit health center. However, she may not have found a workplace that she truly loved without their help. Koppelman said that much of what is taught in nursing school prepares students to work in hospitals, not community health.

Mary’s Center, which Koppelman said employed nearly 800 people in July, is a community health center that operates under a social change model. The executive VP said their health care model goes against what has “historically or traditionally” been thought of as health care because they focus on the social determinants of health. They lost a few nurses during the pandemic, and Koppelman says she saw nurses leaving for better paying jobs given the high demand of the industry.

The health center’s social change model includes support for staff. Mary’s Center offers a scholarship program of up to $10,000 per year for staff who wish to further their education. Koppelman said that completing advanced degrees and certifications can be challenging, especially for those who must work or support families while in school.

The health center also works with a public charter school in the area to increase access to the medical field. Students can attend a medical assistant training program for free, which typically costs $20,000.

Even after some nurses have completed their education, finding a job or advancing in their career can be difficult.

In a recent survey conducted by the National Commission to Address Racism in Nursing, 63% said they have witnessed or experienced an act of racism in the workplace.

“It takes us longer from the product to practice, meaning being in the hospital, being in an ambulatory setting, being in clinics for us to move from bedside nurse to a nurse manager, a nursing director, the chief of nursing officer and then a chief nurse executive,” Dawson said.

She also said that job postings aren’t always accessible, and some institutions place higher value on candidates based on the schools they attended, whether they have family within the industry, and how willing they are to assimilate into the traditional forms of medicine.

Dawson has been influential in training the next generation of nurses. Her NBNA colleagues founded a Mini Nurses Academy to introduce students to nursing wellness, health promotion and disease prevention.

Dawson’s successor, Dr. Sheldon Fields, is known as a unicorn in the industry. Less than 10% of nurses are male, and he’s one of the less than 20% BIPOC nurses. Fields said he fell in love with the nursing profession and was encouraged to pursue nursing by his aunt, who was also a nurse.

Fields received scholarships to pay for his bachelor’s, master’s and doctoral degrees, and says he witnessed institutional and structural racism at every step. He said there is a lot of ‘gatekeeping’ within the industry, that portrays to potential nurses, “you’re not worthy,” he told Direct Relief just before becoming President of NBNA.

“Nursing has never been upfront about it, you know, because a lot of people think ‘well, nurses are angelic and kind and altruistic’,” he said. “Well, nurses are also straight-up racist and rude and can be unkind.”

Fields said it’s “irritating” to see who is deemed capable of becoming a nurse through institutional barriers when nurses are needed nationwide. The NBNA President, who is also a college professor and policy expert, said that the industry has to change for nurses to be successful moving forward.

“Covid revealed the very fragile state of our public health infrastructure,” he said.

Carli Zeggers became a nurse in 2013. She had previously worked at a food pantry and enjoyed work that allowed her to help others. Zeggers completed an accelerated nursing program to become a nurse practitioner and began working in a hospital emergency room and in hospice care management.

It was strenuous work, and she made time to continue her education. Zeggers, a first-generation college graduate, also earned her graduate degree in business administration and her doctorate of philosophy and family practice in nursing. She began a new teaching position at Florida State University this fall and continues to work in an emergency room setting. Zeggers told Direct Relief earlier this year that working in a clinical setting has helped her become a better teacher for other nurses.

“There is a huge divide between bedside nursing in the hospital, community nursing, and any sort of leadership in academia, but they’re so disconnected,” she said. “That’s a huge issue I see.”

Zeggers said that the nursing profession is reactionary rather than proactive, which was exacerbated during the height of the pandemic. Too often, she saw nurses working extended hours, put in risky health situations, and neglected during salary negotiations.

“I was getting very frustrated and actually left a couple of hospitals because there was turmoil, and I was definitely overextended and unsafe so many times,” she said.

Pati Knight, director of corporate compliance at Southeast Mississippi Rural Health Initiative, said several of the nurses who worked at the health center retired during the height of Covid-19.

Also a nurse, Knight said that nurses who worked throughout the pandemic were emotionally and physically exhausted. There was also extreme worry among staff who questioned whether they made family members more susceptible to the virus. It was easier to retire than to continue working.

“So you ask other people to take on additional roles and pitch in,” she said. “And we just got it done with the dedicated staff…they took on additional hours.”

Knight says the health center has not replaced all nurses who left during the pandemic, but they are finding new ways to incentivize those who remain at work. Knight says the health center now offers more paid holidays, higher wages and bonuses.

Registered nurses at public hospitals have the highest turnover rate, but those who work within all levels of nursing at not-for-profit health centers, private institutions, and academia say they, too, have endured the brunt of the industry. Academics and association leaders are pressing for policy changes, and community leaders say they are advocating for staff members and colleagues in every way possible.

During the height of the pandemic, Angie Settle participated in clinical hours for West Virginia Health Right. As CEO of the free clinic, that’s not in her job description.

“I wanted to make sure that if I was establishing practices and expectations, I had to have hands-on experience doing it,” Settle, who has a doctorate in nursing practice, told Direct Relief.

Settle said that Covid-19 was the “worst-case scenario come true,” as the global pandemic strained all facets of the health industry. She’s worked at the health center for almost 30 years and had to hire additional nurses during the pandemic to support the new workload while trying to maintain her full-time staff. West Virginia Health Right hasn’t lost any full-time nurses since the beginning of the pandemic, but Settle told Direct Relief in July that the health center’s budget was strained, and employees were put in emotionally taxing situations.

The free clinic partnered with the county health department and set up a drive-thru system for rapid Covid testing. It became wildly popular, especially with first responders. However, it required long hours and a six-day work week for Settle’s employees, whose interactions with others put them at risk for Covid.

“We were out there putting ourselves on the line, and it was just day in and day out,” Settle said.

A mother of eight, Settle said she has learned to treat her employees like family. She praises them at work and in the community, while advocating for access to health care for all at the state legislature.

Direct Relief provided Mary’s Center, Southeast Mississippi Rural Health Initiative, and West Virginia Health Right with funding during Covid-19 to support health staff and operations during the pandemic. Direct Relief has also provided the National Black Nurses Association with funding to strengthen the pipeline of nurses entering the field through the Mini Nurses Academy, which introduces young people to the healthcare field.