Episode 7: The Nursing Pay Gap

Cara Lunsford, RN (00:00.169)
unscripted. I am an unscripted person. I already know too much about you. Most of...

Rebecca Love (00:07.736)
We know a lot about each other. how long have you been in your role now? Has it been five years now too?

Cara Lunsford, RN (00:12.923)
It hasn't been five, it has been three. It has been three years, yes. So three years as of March 23rd, 2025.

Rebecca Love (00:20.302)
Congratulations.

Rebecca Love (00:25.838)
Well, this is a huge success. Congratulations on moving from like the world of entrepreneurship into the corporate culture and congratulations.

Cara Lunsford, RN (00:29.481)
Thank you.

Cara Lunsford, RN (00:35.281)
Yeah, it's a thing. It's a thing. It's its own thing. It's its own thing. So, well, I love that you're back. I don't even remember what season I had you in before. But Rebecca Love, again, you're like one of my favorite people. And I mention you.

Rebecca Love (00:43.34)
Yes, it is. is. yeah. Anyway.

Rebecca Love (01:03.724)
Well, Kara, I mean, we've been in this a long time together, right? Lots of conversations trying to move nursing forward. So I am thrilled to be back with you guys because the evolution of nursing just keeps happening and we need to keep having bold conversations, right?

Cara Lunsford, RN (01:16.553)
It keeps happening. And yes, we have been a part of it. We've been talking about it. We talked about the Commission for Nurse Reimbursement the last time. So for those of you who don't know, this is Rebecca Love. She's amazing. I'm gonna let you just quickly introduce yourself and then we'll kind of dive into a little bit of a recap of what

where you are now with the Commission for Nurse Reimbursement and some updates there. And then I wanna jump in and ask you some other questions that have to do with salary and pay and this kind of stuff.

Rebecca Love (02:00.545)
I love it, Kara. And so, you know, thank you for having me on and to everybody that's listening. I'm a nurse. I've been a nurse now for, my gosh, nearly 20 years. But my career sort of spans the entire movement of how do we empower, elevate and amplify and support nursing. Today, I have two current roles. I serve as a chief clinical officer for an AI company called Quadrivia AI, as well as I am a visiting professor entrepreneur in residence for Florida State University, building out their first MSN in AI track in the country.

And honestly, guys, I'm new to that six months into AI, but the world is changing fast. And so those are my titles for my day shifts. But in all honesty, where I've spent my career is largely around nurse led innovation. Started the first nurse innovation movement at Northeastern, spun that out into a now international nonprofit called Sansiel. We've moved on to our third president. I serve as president emeritus, but also founded the Commission for Nurse Reimbursement, which Kara had me on as a previous segment, which is, think, my next marathon in life.

on unbundling nurses from the room rate and making them a payable and billable service, which we are not. And I won't dive into the history of it because you can listen to Kara's further and former episode with us that we talk about it. But here today, we also founded the Nursing a STEM Coalition, trying to fight to get nursing identified as a science, technology, engineering, and mathematics profession because it would open up billions of dollars in access to grants and research and funding in a way we don't have.

My day jobs, I have very serious day jobs. And after I joke that I have no other life outside of nursing and just spend my time building nonprofits to try to move nursing forward. So that's a little bit about me, And I'm just glad to be here with you because, goodness gracious, you built your own company, sold it, and it moved into a whole new world yourself of leading now one of the best podcasts that we have in nursing, in addition to a number of other communities that you're building around nursing. So thank you, Kara.

Cara Lunsford, RN (03:52.614)
Well, thank you.

Cara Lunsford, RN (03:58.553)
my gosh, well thank you, was very kind of you to throw in that little head nod to me, thank you. I don't know how you have enough time in a day, honestly. I think you may have made some deals with the devil.

sure where you get it all from. I don't know where you get the energy, I don't know where you get the time, the stuff I've seen you do. I am in a constant state of awe. I'm like if anyone is going to move this profession forward, it's gonna be you.

Rebecca Love (04:42.637)
It takes all of us, Kara, but I appreciate it. And honestly, just to everybody who's listening, Kara, appreciate the kind of adequate. Every day, I feel as though I am failing every single day. So I just want you to know, you can't do everything well. And you know, I'm a mom of three. We try to manage everything we do in life to the best of our ability. And I fail on the front every single day. It's work or family or something that I don't get done. But you know what? As long as you just keep going forward.

And the truth is, when you're passionate about something, sometimes that doesn't feel like work. And I think that's the message that I give to people, is people are like, how do you do so much? I'm like, it doesn't feel like I'm doing that much when it's something that I feel passionately about. So if people are stuck in doldrums and can't figure out why they're exhausted all the time or that there's never enough time to get everything done, all I would say is you're probably spending time on things that don't speak to your soul. And as soon as you get into doing that stuff again, suddenly you find that

time moves forward.

Cara Lunsford, RN (05:38.505)
Amen, sister. Amen to that. That's such a good point. And I want the listeners just to take that in for a second because it's so true. If you feel drained, it's not to say like, maybe nursing isn't for you anymore, but maybe.

where you're nursing, like where you're working, where, you know, that, maybe that is what you need to move on from. Maybe you need to find that next specialty, that next place of work. It's always important to check in with yourself because the times when I've been doing stuff that feeds my soul and makes me feel like I'm doing the work I came here to do.

You're right, it doesn't feel like work. And I totally agree with you, every day I feel like I'm failing, but that's okay also because sometimes we're failing fast and we're failing forward. And...

That was something that was said to me when my company was acquired. The person at Relias who sat down with me and was making the offer to me said, you know what we love? We love that you know how to fail fast and fail forward. And so that's, it's okay. It's not just okay to fail, it's important. It's important to know how to fail.

Rebecca Love (07:19.277)
I mean, if you never fail, you're never going to grow and you're never going to risk anything and big risk lead to big rewards. And what I would just say to people is you can be in environments that suck your energy or you can be in environments that build your energy. And that's why I think this conversation today is important, Kara, right? I think nurses are feeling burned out at levels as high as reported up to 90 % of them are feeling some level of burnout. And the truth is they're in environments that just keep pulling from them, but not building them back up. And I think that when you get into your, your groove, it's not,

that it's going to be easy. But the fight in front of you doesn't feel as though it's pulling your soul or your mind or everything away into a place of grimness. It's pulling you forward to say that you're going make a bigger impact. And I think the risk though is that it feels scary and you are taking a risk when you start doing the unknown as opposed to the same thing. And you know that, right? Like there's certain things to be said about repeatability and structure and a path that's and a role that's defined.

and then it's a whole other thing going out there when that hasn't been done and trying to figure out do you bet on yourself to make it happen.

Cara Lunsford, RN (08:28.156)
Yep, absolutely.

You know, and we will, we're gonna jump into the meat of this podcast, but I think there's just so many important little gems of wisdom that you have and I love that you share. And for people out there that are thinking, you know, I'm not comfortable, I don't want to do things that make me uncomfortable, I don't want to make some big career move, I don't want to move from MedSurg to ICU, I don't want to move from this hospital to that hospital.

you can start out with things that are uncomfortable and they can be small things. I told somebody once when they were trying to start a business and they had this whole idea around wanting to give B12 shots and they had this idea of doing a pop-up and being able to just have people come up and get a B12 shot and stuff like that.

They were paralyzed, they were just absolutely paralyzed. And I said, well then go out and sell lemonade. Go do a lemonade stand. And they were like, I'm like 40 years old, what do mean I'm gonna do a lemonade stand? I said, it's gonna be really uncomfortable. And that's why you should do it. Is go stand out there, not with your kid, with a sign that says lemonade for a dollar.

and make it yourself and put yourself out there because it's being vulnerable, right? Like you're being vulnerable and that's scary. So you can find other ways of doing things that make you uncomfortable that don't mean, raising $2 million of capital and trying to like start a business. that's, don't need to like bite off all that much right at first, but like there's definitely ways of being uncomfortable. So I, you know, I had to learn how to grow my hair out. That was uncomfortable.

Rebecca Love (10:08.941)
Yes.

Rebecca Love (10:32.365)
It's fabulous, Kara. And for each of us, those things are different, right? And to your point, that's exactly what we have to learn to get uncomfortable with. I love it.

Cara Lunsford, RN (10:38.908)
Right, there's little things. So, I am uncomfortable talking about salary. I'm uncomfortable, many of us are uncomfortable talking about pay or sharing our pay or so leading into this conversation. you...

you started working on the commission for nurse reimbursement and I'm going to like, I promise you, this is going to make sense in a second. So if the hospital or wherever you work makes money because you're there, not, you know, you're not a cost, but they're actually making money because you're there, that would stand to reason, then it would stand to reason that

maybe nurses would make more money.

Rebecca Love (11:36.846)
Well, think absolutely. think, you know, anytime that you are in a business, your cost is something we cut costs, we don't invest in cost. And hence why salaries for physicians are on average 10 times the amount of the average salary of a nurse in this country. Why? Because nurse physicians can bill for their services. What that means on every activity that they can do. Insurance companies will reimburse the hospital for the delivery of that nurses. And this speaks back to our former podcast in the 1930s were bundled into room rates to take after a model similar to maids in hotel rooms.

where we could capture their services but not break them out on a P &L, a profit and loss statement, to show the amount of revenue that nurses actually could bill in their services. In the 1920s, every single hospital bill actually listed out nursing services, but those in charge started to feel threatened that the women and the nurses of their systems had too much knowledge of the amount of money they were generating for hospital systems, which in turn led them to be able to negotiate higher wages. In the 1930s, they look for a model that would capture that but not break it out so nurses would have that line.

of knowledge rolled us into the room rates and in the 1930s we saw the first starting of the nursing shortage when nurses started to protest the loss of their economic model and freedom. That model still exists today 100 years later. It has led us into a situation where nurses enter a capitated payment system which means that every year that you are a nurse you will on average increase your salary by only 1.4 percent per year which is less than half the cost of living adjustments and cap out at your 20th year of

It's all been predetermined. It doesn't matter how much you work, the knowledge you have, the experience you have, your earning capacity is capped predetermined by the healthcare systems you work for based on the model that exists today.

Cara Lunsford, RN (13:23.152)
Uggh. Uggh. That's my response. So, a while back, and I say a while back, but every, I think it's every other year, we do, look at me frozen.

Look at my frozen face. Did you see my frozen face? look like that was ridiculous. That was a terrible frozen face. Anyway, okay. So every other year, we do a salary report for nurse.com salary report. And a couple of years ago, there was, we saw that there was a gender pay gap, even between.

female nurses, male nurses, that there was this gender pay gap.

Rebecca Love (14:18.943)
What percentage care? Out of curiosity, what was the average gender pay gap? I've been reported that male nurses on average make about 30 % more than female nurses, but I'd be curious what your data showed.

Cara Lunsford, RN (14:30.726)
I'd have to look it up. didn't bring, I didn't come, I didn't come prepared. I didn't come prepared with my number. Okay, but, yes, so, but this, what was interesting about this is that we...

Rebecca Love (14:32.449)
Okay, yeah. Yeah, that's okay. We will look into it. In some of those situations, we know that this has been similar. Keep going.

Cara Lunsford, RN (14:48.168)
We posted this on our social media. We shared this information. But it was something to the tune of like 30%. It was around there. I just don't want to be completely wrong, but it is something to that effect. And it was crazy how many people were angry. First of all, angry that this was a fact or that this was true. Okay?

Then there was people who were saying, that's ridiculous, it's absolutely not true. People who say, I know for a fact I don't make more money than my fellow colleague. And then there was other people who were saying, this is just another way to create divisiveness within nursing. And we already have enough divisiveness within nursing, so basically don't talk about it.

So there was all these different responses and I was really surprised. I guess I shouldn't have been surprised because we can tend to be a little divisive, I think, even within our own.

Rebecca Love (16:02.898)
As nurses we're terrible. We do such a good job at tearing each other down in our own profession down. That's why we've never been able to

and effectively motivate and mobilize together to effectively stand and fight back on the policies that absolutely keep the profession down. So in any kind of disempowered profession, you find that they create their own internal hierarchies of way things should be talked about or how things can do it so that somebody feels like they have power within this organization. And for far too long, because nurses have been so disempowered in the healthcare landscape, we've created these internal conversations that have left us less effective both within

negotiating amongst ourselves to being absolutely 100 % ineffective of negotiating outside our profession. And to your point that the knowledge is power, data is power, and I think that the work that you guys are doing to talk about salaries, regardless of what the discrepancies are being shown, are critical for us to examine why they happen and why they exist. Because if we don't address them, we're never going to change them. And the reality is in the data. And if data is being predetermined that they are not factual, then this

the problem of the premise of a breakdown of our ability to actually operate as a profession. So I think to your point that there's always going to be critics of any kind of research or data that's put out there. But the bigger conversation that probably should have resulted in this is how is this happening? We know that on the overall greater scheme of things, women in the United States make 21 percent less than men in the United States. It's been that way since the 1990s. We saw the largest rectification of women's salary against men's salaries between the 70s and 90s, where they become largely flat.

So it makes sense that women nurses are going to make less than male nurses, but if it's an additional 10 % gap, then we're not even meeting the United States minimum gap between men and women anyway. Inherently though, why do we not discuss salaries? Because salaries is about power. Power is a distinguishing factor that's held by those at the top of the chain as opposed to those often at the bottom of the chain. And the way that power is often determined comes down to how much money you make. Irregardless if we like it or not, our society

Rebecca Love (18:08.569)
values money as a differentiator to your overall value. If you make a lot of money, you have greater value. If you make less money, unfortunately the world sees you as less valuable. Hence why nursing has been commoditized for so long and why they tell us as nurses, don't worry about the money. Do more with less. Thank you for everything we know you're doing. You are so wonderful. We don't know what we would do without you. How many of us have heard that time and time again? And the truth is, is when you come in

you ask, can I have more nurses because that would really help me? Or hey, you know what, I actually am doing the job of two as opposed to one nurse, can you pay me more? The answer more often than not is simply no. There is no money, but we thank you for all you do.

Cara Lunsford, RN (18:52.68)
And one of the things that actually came up in that salary report was that men are more likely to advocate for themselves and to ask for because inherently they maybe believe that they deserve it and that has been what they have seen in society.

Rebecca Love (19:07.893)
in person.

Cara Lunsford, RN (19:22.02)
And so therefore, if you grow up as a young boy and then a young man and that you inherently believe that you deserve this, so you ask for it. And then because you ask for it, oftentimes you see results from asking for it. Whereas if you are a woman and you have been

Rebecca Love (19:36.861)
Absolutely.

Cara Lunsford, RN (19:51.047)
trained and taught that this is a calling. This is what this is. You should do this because you love it. Don't do it because of the pay. Do it because it's something you care about.

Rebecca Love (20:05.761)
to your point.

We hear this all the time. You don't do nursing because you want to make money, right? Like that has been the established premises of it. And to your point, Kara, I think that, you you made a very good point. It's those who ask for it and those who don't is really the differentiating factor. And, you know, the reality is between men and women, I hope there's more men that come into nursing. I hope there's more women that come into nursing. What I'm worried about is that the next generation isn't going to come into nursing at all. Why would you choose nursing today? When you're told, don't expect to make a lot of money, do more with less, deal with the most

difficult environments that you could known to man. Go ahead and be tolerated being beat up at work. Go ahead and be tolerated that you're going to have a capitated payment model. Go ahead and be tolerated that you're going to work a day night holiday weekend rotation for the rest of your life and be expected to be thankful for missing constant birthdays and holidays with your families because you come second to the needs of this hospital before all else. Honestly, those are the conversations we should be having Kara. And I think to your point, asking is the first step because many of us will just sort of say,

we've been taught to ask for permission, but we've never been taught to advocate for ourselves. And I think when this salary discussion comes up, there is a reason, an inherent reason that we don't talk about it because all of our training, all of our nursing education, nobody ever talked to us about what that should expect. When we were getting ready to graduate, they helped us make our resume and they talked about like average salary that we could expect moving in, but nobody talked to us about, hey, how should you be thinking about that long-term? What is the impact

of staying in a job that will start you at a dollar higher than your friends with a business degree, but in two years time you'll be making a 3 % raise. They'll have had equivalent to a little minimum of an 8 to 10 % raise on their things. And bonus structure, what does that mean to your long-term earning capacity and the ROI on your nursing education over a 20-year career? And I don't think we're having that conversation enough.

Cara Lunsford, RN (22:00.86)
Yes, and that's exactly why so many nurses, you hear about them going into these other models. Like I've joked for a long time that Rodan and Fields is gonna be the reason why there's no nurses ever left in the hospitals because they're all gonna leave and do this MLM, multi-level marketing because there's more room for growth in multi-level marketing in that thing.

Rebecca Love (22:23.201)
Take care.

Cara Lunsford, RN (22:30.824)
a lot.

Rebecca Love (22:30.925)
Totally. How hard you work returns on your things. It doesn't matter how hard you do work in nursing. You're not going to make more money at the end of the year. You're not going be bonus more at the end of the year. If you're lucky, you'll get a Daisy Award at the end of the year, which is a great recognition. But how does that impact your future growth from a financial security perspective is limited. And I think that's also why you find 57 % of new nursing graduates leaving the bedside within two years of practice and finding that those who do stay at the bedside, nearly 80 % of all nurses

flipped to per diem after having their first child. Very few nurses are staying nurses as a full-time profession at the bedside for any living capacity. And to your point Kara, I don't think you and I know a nurse who works just one job. The reality is though, if I look at my husband in finance, he only works one job, right? His salary covers more than enough to make me feel that I still need a second job as a nurse to compensate for the differences in our salary to make sure that we're gonna have the quality of life we want.

have for our family, right? And I think that is the disconnect, right? Most other professions, most of our friends that are working in other fields are not feeling that they have to work more than one job to make ends meet. No side hustles. And I'm talking specifically about degree professions, right? I'm talking about those who went to school for four years, got a bachelor's, most of us who've gone on and got masters. Those people work one job, not two. But that's the difference in nursing. The vast majority of nurses work more than one job to make

ends meet to match the salaries of the levels that are being engaged by our colleagues.

Cara Lunsford, RN (24:07.24)
So that's a really good point. I have a couple of questions. So one of my colleagues asked me the other day, and she said, we don't have time to get into it now, but at some point, I'd really like you to explain to me how this whole culture of travel nursing came about. And.

Why is it that suddenly now all these places want to cut their travel nursing, obviously, because it's very expensive. But how did it, she's like, how did it come about to begin with? Like, where did this come from?

Rebecca Love (24:49.325)
Yep.

Well, it actually it's a great question. And to your points, mean, travel nurse salaries are going down to pre-pandemic levels at lower levels than we've ever seen actually, like in the last decade. But so it really started, honestly, and you should have her on your podcast. PK Shirley was the founder of really the first major nurse travel company founded by a nurse called Gifted Healthcare and what she witnessed. Gifted Healthcare, yep, all those signs and what she witnessed. And I should not speak on her, you'll have to have her on to talk more about the origins of this. But from her hearing her talk and

Cara Lunsford, RN (25:11.036)
Gifted, yeah.

Rebecca Love (25:21.261)
and sharing with me her personal story. You know, she witnessed that most of the hospitals in the area that she worked couldn't staff with the specialty nurses that they could find, right? The HR departments centralized all, you know, hiring and firing, and they really weren't focused on nursing, right? Like they weren't incentivized to find nurses, right? Again, nurses don't add revenue. They got bigger bonuses to bring on physicians because physicians, PTs, OTs, respiratory therapists, filling those positions was a revenue generator for hospitals.

right? So although nurses were needed, they weren't prioritized in human resources systems to hire because they were cost and they would be much more pressured to fill the position of a physician position that was open or a physical therapist than they ever were given resources to fill nursing. So she went to the nurse manager and she said, what if I found you a group of nurses from other hospitals that would come here and work for you on an occasional basis to fill in? And that's how the model started. And what it started to realize is there became a niche market because general HR departments in

were not incentivized to focus on nursing. That there became a niche market to identify nurses ones that sold to chief nursing officers and hospitals to meet their needs. And that became the rise of this one. But these hospitals didn't want to just bring in a nurse for one day a week because you know we have different systems, different policies, want to do those things. And it eventually turned into the minimum three month rotation of what we know is travel nursing today. Now because these travel nurses were not entitled to the benefits of a full time employee,

worked like a full-time employee. For hospital systems on average they would usually cost 30 % less than a full-time employee which allowed that daily hourly rate to increase. And based on laws that were established largely through the Department of Labor, when an individual travels external to more than 50 miles there has to be increased compensation to count for pay, not pay, but for housing and external benefits because that is not a local job and hence became the rise

of this movement of travel nursing. Now, as you know, Kara, during the pandemic, the first time ever, the United States started to play by fair market demand and value of economics during the pandemic, in which the demand for nurses reached such a high that for the first time ever, the federal government actually issued dollars specifically to support funding nursing within hospitals. This was called the CARES Act. And during the pandemic, this is why you saw the rise of travel nursing rates

Rebecca Love (27:50.79)
the level is because for the first time ever hospitals who brought in travel nurses or external labor were able to bill the federal government for those services to pay for nurses. First time ever in history and when the CARES dollars went away those dollars all disappeared. it is the only time, fascinating right, and it is the only time in the course of the last 20 years that based on the Bureau of Labor Statistics

Cara Lunsford, RN (28:10.79)
Fascinating

Rebecca Love (28:20.623)
that nursing salaries actually increased more than 1.4 % was in the year 2020 when the average nursing salary increased to 3.29 % increase over that year where everybody else's salaries on average increased by 5.2 % that year based on cost of living adjustments. Still less, but it was the only meaningful increase in nursing salaries reported in decades was because of that external model. And this was the first time ever we saw that money was

was being given and reimbursed for nursing services, which drove the mass expansion and adoption of travel nurses and staffing companies that we saw that first arrived the tech staffing companies for people who don't know. I served as the chief clinical and chief nursing officer of two of the largest nurse staffing companies in the United States during the pandemic and right after. And there was a way to pay for nurses that were finally actually investing in and paying nurses the salaries that the market demanded. All of that is coming to an

Cara Lunsford, RN (29:17.958)
And this was like a dot com boom. It was like the dot com boom, but like for nurses, yeah, for staffing.

Rebecca Love (29:20.361)
It was like.

Rebecca Love (29:26.185)
It was by far, was nurses were the profession of the greatest needs, but everybody else sat home behind computers, stayed at home. It was the nurses who kept going into the hospitals to make sure and nursing homes to make sure they operated and kept honestly the United States and the global economy operating because if they had not done what they had done, millions of more lives would have died. Now, what happened during the pandemic though, is that suddenly a spotlight was placed on travel nursing in a way that it had never done before, where before less than

3 % of all hospitals spend itchers of nursing would go to support travel nurses son you know a nurse went out on maternity leave or you know a patient had a leave of absence for a period of time that they would bring in staffing this had become a problem during the pandemic though up to 20 to 25 and in some places 30 percent of all nursing staffing came from travel nursing that and they started and the CFO and the CEO everybody started to look at that and hence that is why during the pandemic you

that the American Hospital Association advocated to cap nursing salaries during the pandemic. Not cap any other profession. No CEO cap, no doctor cap, no anything, but nursing cap because they felt like too much money was going to nursing. Long story short, after the pandemic

Wearing down on travel nurses was hard. So the focus because nurses are a cost to health care systems They wanted to get rid of those costs so all attention and eyes and fixing that problem has become a singular focus for the health care industry from nursing homes all the way to hospital systems the best way to cut cost is to get rid of travel budgets and you know what they've learned how to do it they don't ever want to be in this situation again, and I hate to say it but the future of nurse staffing

is not only going to revert back to less than 3 % of overall nursing workforce in this country, but unfortunately due to the amount of attention of trying to bring it down, my guess is that the future nursing workforce and future of travel nursing is actually going to fall to less than 1 % based on the metrics and the new services that hospitals are bringing in to control and dominate the staffing of nursing not only in their community, but also the pipeline of travel nurses coming in to work for them.

Cara Lunsford, RN (31:43.784)
So we feel like that potentially it's gonna drop to 1 % of travel nursing. or what? Oh, 1 % will be travel.

Rebecca Love (31:51.726)
1 % of overall staffing in hospitals will be supplied by travel agencies. Prior to the pandemic, it used to be 3%. So you'll see a two thirds reduction.

Cara Lunsford, RN (31:59.688)
and then it went up to like 20 to 30%.

Rebecca Love (32:01.805)
And it went up to 20 to 30 % in nursing homes. It went as high as 50 to 80 % in some nursing homes, right? Nursing homes, a different one, but hospitals, that's what you saw. Height of 30 % in some rural ones. Tripple had been three to 5 % depending on the needs of a hospital facility will go to one to 2 % based on these new things that are happening. And honestly, the new technology softwares that are out there largely being developed by nurses to deal with staffing scheduling, which they would never have invested in new scheduling software in hospitals.

are all now being focused on because they start to recognize that if they can build their own per diem workflow, if they can offer more flexibility for nurses to swap, they're going to be able to communicate and control that local nursing workforce much better.

Cara Lunsford, RN (32:46.3)
You know what's really fascinating about what you're saying is that the very first technology that I built for Holly Blue, which was not a social networking app, it was a workforce management app. It was a workforce management because my model back then was why make sure you use who you have in the most efficient way and that

And, okay, I even gave examples of this. Okay, so I gave examples of this, like when I would do this, when I would pitch this to investors and to organizations, I'd say, okay, look, if I kept all the clothes in my closet on the floor and I didn't put them on hangers,

Rebecca Love (33:19.725)
head away for free. Yep.

Cara Lunsford, RN (33:37.222)
I would end up going out and buying more clothes than I need because I don't know who I have. I don't know what I have. And I'm not using it efficiently. It's not hanging up in my closet where I can see that I already have five white t-shirts. Instead, I keep going out and I keep getting more. And at some point, I'm not using what I have efficiently. And so...

Rebecca Love (34:05.303)
Yes.

Cara Lunsford, RN (34:07.226)
And you know, at the time, was like blinders. People just had blinders on. And I was trying to sell this model, sell this model. finally, everyone was just like, we just want more nurses. We just want more nurses. And I'm like, this isn't making sense to me. And sometimes you create something and you're too early for the industry. You're too early. that's...

Rebecca Love (34:32.077)
It's always, and also nobody wanted to pay for it back then, right? They didn't see this as.

They saw this as an expenditure that was well controlled. They didn't understand why you would ever actually ever have to court nurses, why they weren't there going to be plenty of them, why you would ever have to spend money to invest in them. And to your point, that was it. I mean, you saw the same thing happen with NurseGrid, right? And their acquisition by HealthStream, one of the most viral takeoffs of nursing spilt technology ever that 500,000 nurses like downloaded and used in six months and they couldn't accident. They couldn't get hospitals to pay for it because they did not want actually nurses.

to have this much control over the workforce and the way that they worked, right? Like I wish to say, I know we're talking about this, schedules are almost equally as powerful as salary, right? Controlling schedules, controlling things like this.

These are the things that drive our ability to feel worth and value of who we are as individuals and making sure that we can have work-life balance and managing what we want to do with what we love. so I think, Kara, to your point, travel nursing became a central place of evil seen by the system that is going to go and take this down. So I think if we're talking about future predictives and if you have a lot of travel nurses listening, my best advice to you is to

Try to make sure that you move into the specialty. The more specialized you are, the more needs that there's going to be. I actually also think that med-surge is such a field that nobody wants to work in, that travel nursing will come back into med-surge. However, there's lot more re- abilities by hospitals to float nurses down to med-surge floors because of their ability to just do those systems. But I unfortunately think that we saw the era of the power of what rose when you gave nurses a chance to have

Rebecca Love (36:21.537)
third-party employers where you can control how much you wanted to make and when you wanted to work. And because that gave so much power back to the nursing workforce, there is direct movements to regain that control and re-emphasize it. And the systems will never ever, ever allow the rise of what we saw again. That was probably the golden era of it. And unless nurses everywhere

or choose to leave their employers and start third party systems. And this is the argument doctors are making to each other, like stop working for hospital systems. You're giving away our autonomy, our ability, right? This is a conversation that hospitals and physicians are saying to the next generation of physicians who don't want to join independent practices and license their services to hospital systems. This is how you go from your own independence to being an employee of a system. And I think

That's when you lose that negotiation power and where you're seeing what's happening today.

Cara Lunsford, RN (37:19.752)
Yes, yeah.

What I find so fascinating, and I love sociology, I the study of people, I love looking back and seeing how things came to be, what happened and how did we get here and what do we anticipate is going to happen? especially around these pay gaps, speaking to...

just to go back to travel nursing, I think that that was very hard for the culture of nursing too because there was bedside nurses who felt like they were doing the same job and that someone was coming in and they were making exponentially more than that. And that's bad for the culture, that's bad for the teamwork, because we are a team profession and we rely on each other as a team.

when there is such a huge gap between a staff nurse and someone who's coming in for three months, granted, we all understand that a...

they're not getting the benefits, right? And maybe they're away from home or they're having, and that there's some amount, right, of difference between what they're, you know, what a staff nurse is making and what a travel nurse is making. And there's like an acceptable difference. But then I think there became an unacceptable difference, at least in the eyes of staff nurses.

Rebecca Love (38:48.173)
Yes.

Rebecca Love (39:01.911)
Yes.

I it's very hard. mean, it's an unfortunate situation. I mean, it's an example again of where we pitted nursing against nursing, where what we really should have been looking at is CEO compensation during the time of the pandemic and those who had it. I mean, a study that broke out in North Carolina, right, was a very interesting study that showed that during the pandemic, most executives did not take any kind of cut to their salary, even though they received billions in dollars from the CARES Act, while they furloughed nursing workforce, right? And it showed also based on that study, that also that CEO compensation of the course

of the last decade had doubled in its salary time and that where nursing salaries had only increased a total of 10 or 11 percent over the course of that decade. Right. So the reality is, is that we became angry at each other. What we really should have been looking up at is what is the system of health care doing and funding and where is those dollars and why we should do things. So when you are in a place again, and this comes down to sort of the situation we find ourselves in nursing, a feeling disempowered as a profession where we fight amongst each other as a

opposed to looking at the system which has created this as a sort of inherent imbalance, that's where we should be focusing. And what I would say to nurses everywhere is that when we are jealous of each other, we hurt our profession. And the best thing we can do is the more nurses who have success, the more success our profession will have. I'm a big believer, rising tide raises all boats. The more nurses who make more money is better for all of us. We should be helping and amplifying and making more nurses make more money in every instance environment that you

Possibly can do and I think the reality is is that? You know it's a natural thing not to sometimes feel jealous or threatened by others and what I would sort of stop and I think What what some of this was best is when those nurses step back and they finally think good for them like thank God Thank you for being out there and doing these things and redefining what our earning capacity is and we should be championing a sword and instead of being angry at those nurses they should be going and they should have been negotiating with their health care systems to say increase my pay to know several health care systems have

Rebecca Love (41:04.535)
Right? Like there is direct evidence of hospitals who looked at that budget that they were paying to travel nurses and they brought those dollars in and actually started to reimburse and pay their nurses more by substantial amounts of money, which led to significantly higher staff retention and staff satisfaction. It's been proved more money equals to greater retention and better staff satisfaction. Why? Because that nurse is not trying to host a second job. They recognize that there is a value in what they're servicing and they're able to

live on the wages that you're providing them and not feeling threatened by anybody who comes in as being a threat to their financial well-being, but more of supporting them in those institutions. So Kara, I think that's a natural reaction, but if I could just reframe it for nurses everywhere, again, the more nurses who make more money, the better it is for all of us because finally we're pushing through that glass ceiling of what our earning capacity was as a nurse. And what we want to do is we want to shatter that glass ceiling. want to make it nurses capacity

for earning as great as every other profession in healthcare. To me there is no reason why nurses are making 10 times, one-tenth that of a physician. That is not something that I feel is a system that is designed to work and we really need to re-figure out what is going on and redefining where it is happening so that we can support the nursing workforce. And I know somebody would say back to me like, well Rebecca that's impossible because you know nurses are the largest workers

workforce and healthcare. They take about 50 % of the profitability of any healthcare systems because of their cost. And I would argue that again comes down to the design of the economic model without nurses being reimbursed. And if we did reimburse for nurses, basically unbundle us from the room rate and start actually billing for the services that we provide, which are actually billed on behalf of every other profession but ourselves, physicians, PTOTs who take credit for the work nurses do, we can actually create a more just, fair system.

that actually will support the nursing workforce and make this much more achievable from a financial perspective.

Cara Lunsford, RN (43:12.494)
Amen, sister. Amen to that. Well, it's true because we can sit there and we can point to all these things, right? And we can say the what ifs we can say, what about that? And we can counter and we can, and honestly, I'm a pretty optimistic person and...

Rebecca Love (43:15.053)
See what we can do.

Cara Lunsford, RN (43:38.982)
I tend to live in that world a little bit like we're gonna get this figured out. We're gonna do this someday. And then there's this part of me that sees things happen where I'm like, are they just gonna start bringing people in from developing countries and paying them less money because there's more profit? Yeah, because there's more profit.

Rebecca Love (44:00.302)
I mean, that's what they did in the 1980s. Right. I mean, it's a repeatable.

And yes, of course they're going to. It's just the way that it's going to be, right? Like, I mean, we live in a, in a, in a, you know, an economic model and system that normally is demand and supply, right? So they're incentivized to do all of those things. I think that the argument or the thoughts that I would be talking to, you know, Kara is when nurses are thinking about salaries, I would start talking about them. I think we don't. And actually in every speech I give, I tell every single nurse I speak to, it's time you start talking about money, how much you earn, what's your grades of things and how you do those things. The only

you're gonna have any effective negotiating ability is to find out what others are making and negotiate accordingly, right? You also are only ever gonna make your most money if you determine to leave and jump. Your only negotiation really power happens at the moments when you're looking to go to a new place and negotiating that because you're never gonna have a huge amount of money when you're at one place. But then you also have this ability to renegotiate when you leave, right? If somebody wants to retain you and I think that you need to have

a conversation with nurses to say we shouldn't be fearful.

And I know we're told that we shouldn't, but you know what? We know every single health system around the country talks about what are they paying their new grad nurses, right? That starts the bar and they know how much an increase should happen every single day from that point in time. So if I can say to you, along those lines, the reality is, is I feel terribly for what's happening to travel nurses and per diem nurses because for the first time they actually helped nurses increase their earning capacity for the first time meaning

Rebecca Love (45:39.264)
in generations.

And what we should not lose is the power by which we showed when nurses stand together and the market needs us, we can move the needle. And so for all those travel nurses and staffing companies out there right now who are seeing a race to the bottom, the dollars are going down, they're running margins very slim, and the nurses are entering into environments for less dollars than they actually could if they were working their full time. I don't know what comes next for you. But I know that if we don't talk about the financial models, if we don't start talking about sales,

with each other, then we're not going be able to move those needles effectively going forward. And the data and the research that you guys do as a company is absolutely critical because if we can't have access to data, we're not going to be able to effectively navigate and negotiate what needs to change to keep nurses at the bedside.

Cara Lunsford, RN (46:32.264)
And that's why it's so important to have things like...

you know, having a salary report, for example, and coming to your manager and saying, look, here's this salary report and here's how I stack up against my peers. Here's where my salary is landing and I have X number of years of experience and I haven't seen a raise and, you know, I can't afford to pay my rent. I'm looking for a second job. If I have to work

second job, I'm not going to be able to stay in this profession, you're going to lose me. And then you are going to be responsible for replacing me and we know that it's costly to replace a nurse. Having that information...

Rebecca Love (47:18.955)
It might be costly to replace a nurse. I'll be honest, Kara. Yes, it's costly to replace a nurse, but I actually think hospital systems and healthcare systems are incentivized to actually run you lower, right? Because nurses are cost. So if they can handle the same number of patients with four nurses as opposed to five, they save money. So they might say, this is very costly. But actually when you're running lower nurses and you're managing 30 patients, you're making more money than if you're managing five nurses on 30 patients. So I know that there's this big thing and we start

call me all the time, but it costs so much money to replace the nurse. And I'm like, you know, in all honesty though, when you look at the bottom line, the less nurses working actually makes more money for hospital systems. So you may want to use that metric to pitch investors and unsophisticated investors are going to tell you, absolutely, this makes so much sense. But when you actually talk to a CFO, they're going to tell you, you know, actually we were fine as long, you know, by the time our HEDIS metrics catch up, these are the things that we're not going to worry about. So Kara, I do hear you.

Cara Lunsford, RN (48:16.936)
You're so right, no, but you're absolutely right about that because here's the thing, I mean, I've used the number of, well, it's gonna be $88,000, it's gonna cost, and that's not even for a specialty nurse. But the thing is, that's assuming that they are replacing. And a lot of times, they're not. You leave and they're like, ch-ching.

Rebecca Love (48:24.877)
$88,000 cost to replace a nurse.

Cara Lunsford, RN (48:43.784)
We'll just make them do more with less. And maybe they'll keep those positions up on their job board to make it look like they're trying to hire.

You know? And so that everyone feels good about the fact that their institution is trying to hire and they have all these positions that are available. I can't tell you how many times I've heard from nurses who are like, I know there's a position available on my floor. I told a friend about it. They applied for the position and they haven't heard from anybody. And so...

Rebecca Love (49:20.749)
That's right. It's like a black hole. mean, you you started your first company that way. I studied my first company, hire nurses for that exact reason, right? I said, I put my job applications, my students are putting job applications everywhere across Boston. Nobody's calling them back. So I started a job board for nurses for that reason, because I was like, I am tired of this black hole and Carrie, you got it too. And, and I think the reality that you know, right, is to your point. I have nurses who reached out to me with 10, 20 years of experience who are desperate to become nurses again. They cannot get hired.

Unfortunately, I thought the conversation you and I had today, or having today, was just nurses who were disgruntled, that were older than me. I didn't believe it. I was like, no, there really is a nursing crisis. Like, there is a shortage of nurses. The reality is there is not a shortage of nurses in the United States. We have more than five million nurses, more than anybody else in healthcare. In fact, more than any other profession in the entire United States, there's more nurses. In fact, we graduate 185,000 nursing students a year, the largest graduating class of any degree in the United States,

of over 20 % of graduates in last two decades, but they cannot get jobs. And why? It's because we're a cost. And this is why we're having this conversation. you don't know if we hit on, I think if I, you know, I know we sort of went off course a little bit, Kara, but if I was a nurse.

What I would tell you in life, what I've learned, is when things get really hard, it's the way that the universe is telling me that I'm supposed to jump or do something else. And if I ignore that, I end up in a space that I feel awful.

And so I moved jobs relatively quickly. People like Rebecca, how did you go from being like, I mean, it's not even been a decade now that I've gone from being like a community college professor with a failing startup to leading some really big companies as an executive, as a nurse, right? And it had been welcome into places that is highly unusual. And what I would tell nurses out there is because I stopped letting the profession of nursing and career paths define where I could go and just started jumping.

Rebecca Love (51:23.765)
same thing, Kara, right? Like, and it's scary, but the way to do it is you guys, and every time I've jumped, even in moments where I was certain I was going to crash and burn, it's always taken me to the next level. And I just want to give you guys

Cara Lunsford, RN (51:37.865)
I wouldn't you agree that it's less scary each time you do it? Like the more you've done it, the more, like the more you, the more you try something new. It's not that it's not, it's not that you're not scared or that it's not nerve wracking or that you don't have some level of imposter syndrome or, but your coping mechanisms develop over time. And, and I think you,

Rebecca Love (51:49.985)
That's true.

Rebecca Love (52:05.441)
Yes, and you start to know who you are, right? You know who you are a little bit more and what you're capable of. And I think all of us at some point in time, Kara too, are gonna be taken down, right? We're gonna have the hot air taken out of our balloons, right? And you're gonna have to pull yourself up by the bootstraps and keep going.

Cara Lunsford, RN (52:08.391)
Yeah.

Rebecca Love (52:26.613)
And we all go through it. Every, the most successful people in the world I know. And I mean, I'm lucky I'm sitting in places where billionaires call me to ask me to come work for them now, right? Like that's a great place to be. It's a weird place to be, but that's where I've gotten with my career, right? Along those lines. Now those aren't the salaries you make and those kinds of things, but that's your calls. And what I can tell you is every single one of those that really, really made it, and I'm never going to have the guts to be a billionaire, but every single one of them has

Cara Lunsford, RN (52:27.112)
Yep.

Rebecca Love (52:56.687)
their company, they've lost something major, and they got through it. For nurses, for people like you and me that built a small startup, raised some funds, exited it, right? Like those, that was enough for us, right? Like I will never start a company again without significant other friends and family of like, you know, people that have done it before. But I keep risking small things. Like I, you know, stand between my job of going and working for a big corporation or going back to another startup. And that was hard again, Kara, to be like, gosh darn it, am I ready to go and do

this again with a small team and trying to figure out how to make this work and I said I had one more rodeo but all of us run our course at some point in time and so this is what I'm gonna tell you if you're listening to this today. Time is finite.

You only have so many times up to bat. So get up there and swing for the end. Like swing for the outfield, swing for the home run because life is at some point, either you or your age or your timing is going to stop you from being able to do those things. So make it count today. And you know what?

If you fail, in all honesty, you will always find a job as a nurse. You will always. It might not be a back in the hospital, but you can find a job in a nursing home and get your way back. Like the reality is, take the risk. Go and do it. And if you are looking for somebody to give you permission, I am giving you that permission. Go do it. Bet on yourself and make it happen.

Cara Lunsford, RN (54:21.17)
Yep.

Absolutely. That was like the best. Hey sister, that was like the mic drop of the century. And I mean really I'm just, I'm so grateful. I'm grateful to have you in my life. I'm grateful to know you. I'm grateful that this nursing industry has you and has people like you and that you build

teams and organizations and foundations and non-profits that keep this message.

the forefront, you know? It's instead of it being, you know, this quiet, this quiet voice, it's like you, you keep it out there, you keep it at the front. And it's hard and tiring, I'm sure at times, I'm sure, to, to scream into a void, which sometimes it feels like that. Sometimes it feels like we're yelling into a void. But...

I think that we keep doing it and then there's going to be people that come along and they take that torch and they run with it. You know, when you and I are too old and too tired and feeble and we're going to play backgammon in some, you know, old nursing home together, then we're going to pass the torch to some young person who has that...

Cara Lunsford, RN (56:02.128)
that vinegar running through their veins and energy and that's it is that you just gotta keep it going until you can hand it off.

Rebecca Love (56:09.869)
that you just gotta keep it going until you can hand it off. That's right. And hopefully inspire enough to come into this profession. And I hope that those who are out there listening, the young nurses, because I don't feel young anymore, right? And I think I just need to say to them, what keeps me going is, and we didn't talk about this, but the reality is, back in the day,

Florence Nightingale, who I know if you guys were like me in nursing school would think, oh my god, could there not be somebody else that you could relate to? But she had this thing that people told me to look up and in her journals in 1870s she began to write, it's gonna take 150 years for the world to see what I have envisioned for nursing. And 1870 plus 150 is this decade. So somehow she knew it was gonna take 150 years.

for us to fight to get our profession to where we needed to be. But it's on us now to make it happen, Kara. I take that really seriously. I don't know how it cannot be less foretold, right? And so what are we gonna do? Like, gosh darn it, I will start every nursing association, new company I can, if it's not gonna be done, to keep advocating these issues that need to be done.

Cara Lunsford, RN (57:13.34)
Yeah, we can't. Yep.

Rebecca Love (57:28.961)
But yeah, let me tell you guys, it's gonna be exhausting and that's why we need you with us because it can't just be a couple of us. And I hope all of you leave here today and you get out on social, you make a profile on LinkedIn and you start letting the world know who you are, what we do and the power of nursing because we need your voices. And the best way you're gonna change your future is by letting people know who you are and what you're about. So that's what I would say, get out there own who it is and where you wanna go

you're gonna be the one at the end of the day who makes it happen. So Kara, I'm so glad we've spent this time together and I know you've been longer than we've together. I love you too. Well, it's always a great and pleasure and I hope we see each other. Thank you Kara.

Cara Lunsford, RN (58:03.336)
I love you. I love you. I just love you.

Thank you.

We get to see each other again soon. And I'm gonna make that happen. I don't know how, I'm gonna win. But I'm gonna make it happen.

Rebecca Love (58:21.751)
I'm looking forward to it.

Cara Lunsford, RN (58:22.95)
giving you a big hug from here. I love you, friend.

to stop us and then I'm going to let us upload.