A Sense of Urgency in 2023: A New Iceberg Awaits Us

From my vantage point as a senior academic leader and manager in a college of nursing in an academic health science center, I recently read Our Iceberg Is Melting (Kotter & Rathgeber, 2006) as part of preparing for an administrative retreat. At first, I was a bit dismayed to find that the book was published in 2006 and had not been written in contemporary, pandemic-affected times. I was worried that it was an old reference and too simplistic for understanding current issues in health care and nursing education. Upon reading and reflecting on the book, published 17 years ago, I became engaged in the fable, which seems to have some essential truths that may be prescient for not only academic nursing but also for health care and, specifically, contemporary and future nursing practice. The fable depicts a penguin colony in Antarctica who are living happily until one young penguin discovers ice loss and a huge pool of water underneath their home iceberg. He brings the issue to the leadership council, and an open-minded leader listens to the young penguin and goes with him to view the melted underlayer of ice. They bring the issue back to the leadership council, who reluctantly consider this perspective and these data. Although skeptical, they reach a conclusion: The young penguin is correct, and they must find a new iceberg after having lived on their particular iceberg for many generations. The leadership council accepts the potentially devastating truth: They must move from their home and seek a new home or face catastrophe.

How does this fable provide a lens through which to view today’s healthcare systems? The fable incorporates eight stages of change management. The first step, a sense of urgency, seems to be missing in healthcare discussions right now. In our current pandemic-associated times, healthcare systems have multiple strains that contribute to instability, yet there is a lack of solutions to address the scale and context of the problems. The focus appears to be on waiting for normalization and a change back to prepandemic conditions. However, one major aspect of the instability of the system is getting worse. The nursing shortage appears to be intensifying. By 2025, it is estimated that the United States may have a gap of between 200,000 and 450,000 nurses available for direct patient care, equating to a 10%–20% gap (Berlin et al., 2022). This demand cannot be met; more than double the number of new graduates entering and staying in the nursing workforce would be needed every year for the next three years. Converging evidence supports that this time, there may be other differences in the attrition in the nursing profession. New data support that there is a sustained reduction in the number of younger-age RNs, leading to a generational pipeline shortage (Auerbach et al., 2022).

The second step in the fable, pulling together the guiding team, is a place for potential leadership by nurses in healthcare systems and a critical step toward the changes that will provide optimal patient care while also addressing work–life issues of nursing staff. However, in many organizations, although nurses constitute the largest category of employees, they have little input into long-term planning. Budgeting is centralized, and nursing staff are considered to be a cost center. Because of the shortage of nurses who are qualified and willing to work in current inpatient systems, much of the conversation has turned to short-term solutions, including traveling nurses and other contingent workers. This has led to accusations of price gouging by traveling nurses and contributed to the blaming of individuals or categories of employees who have become free agents in the current market. Decades of research provide data that lead to two major, modifiable dynamics that have contributed to fragmentation and lack of institutional commitment by nurses: poor workplace conditions and inadequate and inflexible staffing models. Changes to address these issues have profound economic implications for healthcare systems that can be facilitated by funding models that promote the enactment of nurse–patient ratios that consider not only the acuity of patients but also the contribution to a work environment that helps to promote the short- and long-term career.

This is a call for oncology nurses, including advanced practice nurses, researchers, and administrators, to not only consider our specialty but also to think about the collective future of nursing and take the opportunity to lead in the local, state, and national arenas. If we do not collectively contribute to the creation of new models, it is likely that solutions will be enacted that narrow the purview of nursing and further marginalize the actual and potential workforce of the future. In designing our professional future, we must look for ways to harness the passion, expertise, and commitment that lead and keep nurses in the healthcare delivery system as trusted patient advocates and skilled practitioners. Crisis can lead to innovation. Transformed models of care delivery combined with career-span working conditions for nurses could energize not only current nurses but also lead to a new “iceberg” that facilitates a healthcare future that will be optimized for patients, families, and the healthcare workforce for generations to come.

About the Author

Debra Lyon, RN, PhD, FNP-BC, FAAN, is the executive associate dean and Kirbo Endowed Chair in the College of Nursing at the University of Florida in Gainesville. Lyon can be reached at ONFEditor@ ons.org.