Juan Ochoa:  

Welcome to the Michigan Minds podcast, where we explore the wealth of knowledge from faculty experts at the University of Michigan. I am Juan Ochoa, international public relations representative for the Michigan News Office. With me is Christopher Friese, vice provost of academic and faculty affairs and a professor of nursing and of health management and policy at the School of Public Health.

Juan Ochoa:  

Professor Friese is a national authority on the quality of care delivery and nursing work environments. His research focuses on health policy, nursing, student debt and the staffing crisis currently impacting the U.S. health care system. Welcome to the podcast, Professor Friese.

Christopher Friese:  

It’s great to be with you.

Juan Ochoa:  

We know that nursing is one of the most trusted professions, and that the U.S. health care system heavily relies on nurses. And yet, the gap between the number of nurses available and the number needed continues to rise. What are some of the issues at play here, and how could that affect the care we all receive?

Christopher Friese:  

So one of the things that’s really great about our health care system is we’ve identified that registered nurses are the glue that keep our U.S. health care system going. And we’ve heavily invested in the registered nursing workforce. And in fact, I often say to folks it’s not really a shortage of nurses. It’s really a shortage of workplaces that support them, that keep them in their setting.

Christopher Friese:  

We actually have plenty of individuals in the U.S. who hold an RN license. What we don’t have is sufficient numbers who are actively working in practice. And when we ask nurses — our studies and others — what we often hear is that the workplaces are not supportive. We often hear more recently that they don’t feel safe in their workplace, that they’re facing violent situations that are not being addressed.

Christopher Friese:  

And then we also hear that they don’t have the support of their leadership and their management. So those are often the things that are leading nurses to say, either, “I don’t want to work in this setting any longer,” or they reduce their hours or they leave nursing entirely. Now, the good news is all of those things can be addressed and fixed.

Juan Ochoa:  

But if there are a lot of nurses leaving, then why can’t we call it a shortage?

Christopher Friese:  

What we have is, when we look at national data of country to country, we have a sufficient number of individuals in the U.S. who hold an RN license for our population. Other countries are not in that same spot. We are preparing plenty of nurses. What we’re not doing is keeping them in the workplace. What our recent study showed is that the group that is most likely to leave are the newest entrants.

Christopher Friese:  

So some of us have called this sort of a leaky bucket problem. You keep bringing people into the workforce and they’re the fastest to leave. So what we really need to do is, instead of just pouring more people into the bucket, we need to plug the hole. So if we can focus on improving the working conditions, we have an ability to kind of stem this tide.

Christopher Friese:  

Now, you’re right that we certainly — I and others have argued — that we do need more nurses. We need some slack in the system, because we have to handle these unanticipated issues like COVID or other things. But we really do have a sufficient number in the country. It’s the question of, are we committed to keeping them in the workplace?

Christopher Friese:  

In our study and the work of others would suggest that’s where the investment really needs to happen.

Juan Ochoa:  

It seems like with the recent Department of Education changing the rules, it might even be a little bit more difficult. The rules go into effect this summer and set new caps on how much graduate students can borrow from the government to finance their education. These limits, which the department says are meant to curb the cost of programs and resulting debts for students, apply to doctors, nurses, social workers, dentists, occupational therapists and others.

Juan Ochoa:  

What makes caps on borrowing for graduate nursing degrees different?

Christopher Friese:  

So we’re worried about caps on loans for graduate nurses for a couple of reasons. Number one, our study — the Michigan Nurses Study — identified that a substantial number of existing nurses, not even nurses who are in grad school yet, but registered nurses who have yet to go to grad school, just about a third of them have pretty substantial levels of debt to begin with.

Christopher Friese:  

So if you already are carrying a lot of debt, imagine trying to advance your career in nursing. That usually means you have to go back for a graduate degree, and then you’re facing yet an even higher bill while you have debt. So what we know is that, when nurses go back for graduate school, it does pay off eventually.

Christopher Friese:  

It doesn’t pay off as quickly as some of these other higher-paying professions like law, medicine, dentistry, etc. So we want to make sure that nurses don’t see the affordability of graduate school as the barrier for them to enter. What we’re worried about is that these new proposed caps will deter people from even thinking about graduate school. They won’t even think about applying.

Christopher Friese:  

They won’t have a conversation with the university about financial aid or loan payment or loan programs, or some kind of novel program for health systems to support them. They’ll just decide, “I’m not going to pursue graduate school.” And that’s bad for the country, because it’s really clear that advanced practice nurses — nurses with a graduate degree — do a tremendous amount for our health care system.

Christopher Friese:  

These are folks like nurse practitioners, nurse midwives, nurse anesthetists and the future faculty that train nursing students. So if we cut off this supply route for graduate nurses, we’re really worried about health care outcomes. We’re worried about the future of nursing education. And we think that these proposed caps are likely going to reduce interest overall in graduate education for nurses.

Christopher Friese:  

And that’s a shame.

Juan Ochoa:  

You know, I think back when I was applying for schools, the first thing I would do is look at costs. Can’t the universities just reduce the cost of tuition and hopefully get more students to apply that way?

Christopher Friese:  

I think that nursing schools are looking for opportunities to try to make graduate nursing education more affordable. But this is highly specialized training, right? This is not education that can be substituted with other experts. We have pretty strict rules as to who can teach graduate nurses, the proportion of faculty members to students, because of the intensity of the work they do.

Christopher Friese:  

So unfortunately, graduate nursing education is not a space where we have a ton of opportunity for cost containment, which would lower tuition. In fact, we continue to want advanced practice nurses to do more and more. So there are some opportunities there. But I think what we really need are more flexible models and partnerships that help reduce what I would call the out-of-pocket cost for a graduate student in nursing.

Christopher Friese:  

So that might mean — and we have some federal programs for loan repayment — we have some health systems that are stepping up and saying, “If you agree to work with us as an RN while you get your graduate degree and you stay with us, we’ll offset your tuition.” I think those are promising models, and we need more of those.

Christopher Friese:  

We can look for ways to bring down the cost of graduate nursing education, but this proposal puts applicants — potential applicants — in a bind. And I think that’s what we’re worried about in the moment. So I think there will be some innovation here. I just don’t know how much we can squeeze to really bring costs down in a demonstrable way that students will feel.

Juan Ochoa:  

Right, right. What are the Department of Education’s proposed changes to nursing graduate loans?

Christopher Friese:  

So the proposal from the Department of Education, issued in late winter and then went through rulemaking in early 2026, would take graduate nurses out of the pool for the highest level of available loan amounts. And instead, they would be capped at $20,000 — $20,500 — for one year, and a total lifetime amount of $100,000. So that would put constraints on how much nurses could borrow toward graduate education.

Juan Ochoa:  

The Department of Education rule proposal inspired your recent research on what impact that had on nurses’ career decision-making in Michigan. What are your key findings in that?

Christopher Friese:  

Well, first, I’m really proud of this team. So we came up with this need to reanalyze our study data right before Thanksgiving. And our results were published at the end of January — 57 days from the original research question to publication. And in my career over 27 years, I’ve never had that experience. So I’m first of all grateful to our team and our publisher, and all that goes into that to make that happen.

Christopher Friese:  

So we really wanted to put the numbers out there. We were hearing individuals who were talking about this proposal — that putting these caps on graduate nursing education wouldn’t affect a large number of nurses — and we didn’t believe that at face value. And so we wanted to go back into our data from the Michigan Nurses Study.

Christopher Friese:  

We had fortunately asked this question in 2022: What are the levels of student debt that you’re holding? — of individuals who are both registered nurses and individuals who had completed graduate school in nursing. And again, about a third of our entire sample had substantial debt, and just about a third of the advanced practice nurses — these are folks who have already gone through graduate school — about a third of that group that had debt had debt levels that exceeded that $50,000 cap that’s being proposed.

Christopher Friese:  

So in 2022, we were already seeing these high levels of debt. The next thing we did is we wanted to ask about their career plans: Did they plan to stay in their job? Were they looking for another job?

Christopher Friese:  

And what we found is far higher numbers of nurses who had debt had either recently left their job or were more likely to look for a new job because of pay and benefits. So the point is, our assumption here is that high levels of debt are actually associated with nurses making different job decisions, contributing to that leaky bucket.

Christopher Friese:  

Right. We’ve already prepared this nurse. They’re working in our setting, but they’re going to leave us. And part of that reasoning is they feel like they can make more money elsewhere or improve their finances. And a lot of those nurses were holding debt. So that was a big part of it. The other thing is that the burden of this debt was high.

Christopher Friese:  

And so among our individuals who had debt, they were far more likely to tell us that their household finances were a top concern for their family. So we often hear — we think that nurses are well-paid, and I guess relative to the entire U.S. that’s true — but it’s hard work. They hold a lot of debt, and they’re feeling this directly in their family.

Christopher Friese:  

So they were far more likely to be worried about their family finances when they held debt. So to me, that speaks to this is not the time to put caps on what nurses can borrow if they want to pursue graduate education, if they want to advance in their profession. In fact, the opposite is true. We want to open opportunities.

Christopher Friese:  

We don’t want to cut people off. And that’s what our study showed.

Juan Ochoa:  

I want to touch back on the point that you made that nurses are leaving the profession. Where are they going?

Christopher Friese:  

It’s a good question. Most often we see nurses leaving to take another job in nursing, so they’re leaving their current employer, moving to another employer. And particularly in the recent study that we did that was published in 2026, we show that that group is far more likely, because they have debt, to move.

Christopher Friese:  

So they’re looking for a better economic opportunity, etc. Then there’s a group that leaves nursing entirely and they never come back. And then there’s a group that is not well-studied, but we see this in nursing year after year: They leave nursing oftentimes to raise a family, to attend to caregiving responsibilities, and then they reenter.

Christopher Friese:  

They come back after their caregiving. Maybe their children have gotten older, entered school, their caregiving responsibilities have eased, and they come back into nursing. It’s actually one of our secret weapons — the flexibility that we have in the nursing profession to work in one area, step out for a bit, come back and retrain, and come back either in the same area or another.

Christopher Friese:  

That’s the good news. The bad news is that puts employers, health systems and others in a pinch because they’ve invested all this money to train these folks and support them, and they’re likely to leave. So it’s a bit of a conundrum for the economists in the room, because we want employees to move as they wish.

Christopher Friese:  

But the substantial investments that hospitals and health systems put into preparing and training these folks on the job, once they’re in the role, is money that they don’t get back. And it’s quite expensive to replace an experienced nurse.

Juan Ochoa:  

Interesting. The problem most people aren’t aware of is the lack of nursing educators and state laws that limit how many students each educator can supervise for clinicals. Can you share some thoughts on that?

Christopher Friese:  

As a profession, we’ve identified what we believe are best practices. The complexity of what we’re trying to teach our students requires expert nurses, in many cases — not all, but in many of our classroom activities, or particularly in the clinical setting. Our profession has identified we need expert nurses to do that work. That usually means holding a master’s degree or higher.

Christopher Friese:  

And we have shown that when we have higher and more investment in education and nurses, outcomes are better for patients, educational outcomes are better for students. It’s a win-win. That comes at a cost that is more difficult to do. We have been chronically short on nursing faculty — people who are capable and credentialed to teach students — for quite some time.

Christopher Friese:  

We’ve been really strapping this together. Most nursing schools are actively looking for faculty almost every year. And what that does is creates a problem, because most of the individuals who can teach in nursing can also be advanced practice nurses like nurse practitioners and nurse midwives, which is usually reimbursed at a higher rate. They can get a better salary when they’re an advanced practice nurse out practicing, as opposed to teaching.

Christopher Friese:  

So we don’t have the incentives lined up for experienced nurses to come into our settings and teach. So that’s one of the proposals that we put out to say, can we incent these advanced practice nurses to at least spend part of their time teaching? Maybe not all of it, but some of it at a minimum.

Juan Ochoa:  

I have a family member who has taught clinicals in the past, and they’ve been unemployed for about two months now, and they’ve looked for positions and they’ve been having a hard time. What do you say to those who want to teach but are having a hard time?

Christopher Friese:  

I think this speaks to the current mismatch and the current instability in our system right now. I think schools of nursing — higher education in general — is a challenging place to be right now. And I think that a lot of schools are trying to assess where they’re going. And because of that, they’re probably working with the folks that they have in place, as opposed to lots of hiring in this very moment, as we speak together in 2026.

Christopher Friese:  

What I would say is, what I’ve always loved about nursing is the flexibility and the ability to think differently about how I do my roles. So I’m a professor at the University of Michigan School of Nursing for 18 years. I’ve also had a clinical practice almost the entire time. Until very recently, I’ve been able to be flexible with my knowledge and skills. And so I know it’s a difficult time out there in higher education.

Christopher Friese:  

There’s a lot of uncertainty, and when there’s a lot of uncertainty, people become cautious and they have fewer posted positions and they want to see if things get better. What I will say is, it’s really clear to me that nursing in the long run is a good bet. It’s a good investment, and we will find a way to use your skills.

Christopher Friese:  

One quick anecdote: I graduated with my Bachelor of Science in Nursing in 1997 — the entry degree for nursing here — and I didn’t get a job for six months as a staff nurse.

Juan Ochoa:  

Wow, that’s a long time.

Christopher Friese:  

And that uncertainty was really difficult. And I tell that story now to my students because everybody hears “health care is booming,” “there’s no problem.” We do see these pockets of uncertainty right now. In the long run, like a cat, we will land on our feet. There’s a lot of instability right in this moment, as we speak.

Juan Ochoa:  

If the cost of education prevents nurses from becoming educators, what does that mean for our ability to train the next generation and make sure that there are enough nurses when needed most?

Christopher Friese:  

I think that’s what concerns me the most with this proposal, as well as the broader sort of underinvestment in professional nursing in the moment. So the cap on graduate loans is one example of a structural policy decision to make it really hard for us to continue to advance in nursing. I think that our students really require — and benefit from — expertise in their programs.

Christopher Friese:  

I worry that these forces that we’ve talked about together are colliding forces of increased demand for health care services. We need to hire nurses quickly. We’re starting to see a movement to shorten degree programs, get people through nursing programs faster. Maybe we’re making some cuts that we wouldn’t otherwise make. I think we have to be really careful about that, because the nursing education programs we have in this country are a model for other countries.

Christopher Friese:  

We don’t want to make decisions quickly that have a long-term impact on the quality of nursing education. I worry that with some of these competing demands, the thinking will be to, “Let’s just get people out faster.” Again, we’re pouring more folks in the bucket. We haven’t stopped the leak, right? We’ve got to make sure that not only are we supporting nurses in their workforce, but the people that we’re bringing in are competent, qualified and prepared to work in those settings.

Christopher Friese:  

And that doesn’t come with shortcuts.

Juan Ochoa:  

Many support changing the DOE rules before they take effect. Nurses have protested outside the White House, and a bipartisan group of 100 federal lawmakers sent a signed letter to the Department of Education requesting that nurses be included in the department’s definition of a professional degree. For those who want to register their dislike of these new rules, what do you suggest they do?

Christopher Friese:  

So we’re in an interesting time because the public comment period has closed. So the things that I offer are to make sure that lawmakers hear from their constituents that nursing issues matter. Thank the legislators — if you’re supportive, thank the legislators who have signed on to that letter. Sometimes we forget to thank the folks who are supporting the policies that we advocate for.

Christopher Friese:  

So we often work on trying to get more people to join in — that’s great — but also thanking people to say, “We saw that you supported this.” So we thank you for that. I think we’ll have to see where the Department of Education weighs in here. One thing I think we can just say in this moment is we’ve seen a lot of policy proposals issued, and then retracted or changed, after this kind of period that we’re in right now.

Christopher Friese:  

So I think letting legislators know that these matters are of concern to you. The other thing we’re starting to see are states are picking up strategies: Can they reduce the debt burden with their own loan repayment programs? We’re starting to see hospitals do the same thing. There’s just a piece in The Philadelphia Inquirer a few weeks ago that a donor donated to a hospital to pay off student loan debt for their nurses.

Christopher Friese:  

So it’s an interesting time, and I think we’ll have to see how these things play out.

Juan Ochoa:  

Dr. Friese, we’ve reached the end of our podcast. Any last thoughts?

Christopher Friese:  

So we talked about some tough issues today. What I would say is despite these tough issues, I’m optimistic for nursing in the long run. I think it’s a great profession. I think these issues will get resolved, and I always count on nurses to do the right thing and be in the right position for patients.

Juan Ochoa:  

Yes, I hope things change, too, because I feel like I trust nurses more than I do doctors at times. So thank you for being here.

Christopher Friese:  

It’s a pleasure. Thank you.

Juan Ochoa:  

Thank you for listening to this episode of Michigan Minds, produced by Michigan News, a division of the university’s Office of the Vice President for Communications.