Rethinking Nursing Workforce Models at Duke Health

Summary

Podcast Summary: Rethinking Nursing Workforce Models at Duke Health

Becker’s Healthcare Podcast – February 8, 2026
Guest: Terry McDonnell, Chief Nursing Executive & SVP, Duke University Health System
Host: Scott Becker

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Episode Overview

This episode features an in-depth conversation with Terry McDonnell, Chief Nursing Executive and Senior Vice President at Duke University Health System. The discussion focuses on the pressing challenges facing today’s nursing workforce, including workforce shortages, generational shifts in attitudes toward healthcare careers, and Duke Health’s innovative approaches to care delivery and staffing models. Terry also offers candid leadership advice and her vision for the future of the profession.

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Key Discussion Points and Insights

Terry McDonnell’s Background & Career Path

• [01:10] Terry shares her unique journey: nursing is a second career, with foundational years at Massachusetts General Hospital.
  • Worked clinically and administratively, eventually becoming Director of Clinical Operations for the MGH Cancer Center.
  • Was recruited to Seattle Cancer Care Alliance as CNO and SVP, leading growth, merger, and creation of Fred Hutchinson Cancer Center.
  • Oversaw construction of a new ambulatory innovation center and expanded the institution’s regional reach.
  • Appointed Chief Nurse Executive at Duke Health, serving for the last two and a half years, during a time of rapid change in healthcare.

“Nursing is a second career for me... I still also am a practicing nurse practitioner, so my clinical subspecialty is GI oncology and I've been caring for that patient population for the last 25 years.”
— Terry McDonnell [01:20]

The “Math Problem” in Healthcare — Workforce Shortage

• [03:31] Terry identifies a critical issue: increasing demand for healthcare and stagnant supply of workers.
  • Unlike past economic downturns, people are not flocking to healthcare jobs, creating a unique challenge.
  • The shift opens opportunities to rethink and redesign healthcare work with technology and new models.

“We have more demand than ever for our services and we have a stagnant workforce... Never before has my generation been faced with so much opportunity regarding transitioning what work looks like.”
— Terry McDonnell [03:33]

Generational Differences & Changing Expectations

• [05:29] The workforce spans five generations—each with distinct expectations and learning styles.
  • Younger generations may seek hybrid roles, shorter shifts, and a mix of hands-on and virtual care.
  • The changing definition of job satisfaction necessitates evolving the workplace structure.

“Work in healthcare, especially nursing, is challenging... people's expectations around what gratifies them and, and what really brings to them meaning in their lives has changed.”
— Terry McDonnell [05:44]

Leadership Philosophy & Advice

• [08:01] Terry champions inclusive and frontline-engaged leadership over top-down approaches.
• Empowers those closest to the work to drive change and co-develop solutions, which increases impact and staff engagement.
• Encourages leaders to avoid a “single phenotype”—embrace diversity and innovation.

“The most important thing we can do as leaders in 2026 is to listen and learn from the people who are closest to the work. Gone are the days where a top down leadership is effective... The more we empower the people who are at the front line and closest to the work... those bring about the most effective changes.”
— Terry McDonnell [08:06]

• [09:16] Stresses the importance of humor and levity to combat burnout.
  • Building psychological safety and a supportive team culture helps retain and motivate staff.

“Humor is very important... when you've got a healthy team that comes together and that feels safe and trusts each other, that's when you can be most effective. And that's when people really want to continue to come together and thrive.”
— Terry McDonnell [09:20]

New Nursing Workforce Models at Duke Health

• [10:40] Terry describes Duke’s launch of three new “innovation units” at the university hospital.
  • Rehabbed 30-bed units integrating new technology (e.g., computer vision) and novel staffing strategies.
  • Rotating nurses between in-person shifts and virtual care center roles.
  • Goal: Reduce physical and emotional burden on staff; improve outcomes for patients and staff.

“We've just opened three brand new innovation units at our university hospital... we're introducing computer vision. We're changing the model of staffing where a staff nurse will work two 12s on the unit and one 12 in the virtual care center as that virtual team member... I think that's really going to shift the physical burden, the emotional, psychological burden, and also bring about better outcomes both for our patients and also for our staff.”
— Terry McDonnell [10:44]

Rethinking Staff Ratios & Team-Based Care

• [11:46] Discussion on the national debate over nurse-to-patient ratios and evolving legislative pressures.
  • Terry argues the focus should shift from fixed ratios to resource- and team-based care.
  • Emphasizes the need to redefine safety standards based on total available resources, including technology and interdisciplinary teams.

“It's not necessarily about a nurse to a patient, but it's all the resources available... I think the definition of ratio will necessarily have to be revisited and evolve over time. I think it's going to be team to patient cadre.”
— Terry McDonnell [12:47, 14:30]

• Team-based models may offer better safety and outcomes than strict numeric ratios alone.
  • Example cited: 30 patients managed by a diverse team (nurses, virtual nurse, pharmacist, techs) may ensure safer, more effective care than a higher count of RNs without support services.

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Notable Quotes & Memorable Moments

• “I’m Duke all the way.” – Terry’s enthusiastic response to the Duke vs. UNC rivalry question, showing her pride in her institution. [07:23]
• “When you drill into burnout, it’s really about anxiety, fear and high intensity that doesn’t ease.” [09:23]
• “We're introducing computer vision... shifting the physical, emotional, psychological burden.” [10:44]

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Important Timestamps

• [01:10] – Terry introduces her background and path to Duke Health.
• [03:31] – Describes the “math problem” of workforce shortages.
• [05:29] – Explains workforce generational shifts and new job expectations.
• [08:01] – Terry offers leadership advice for emerging leaders.
• [09:16] – Discusses methods to prevent burnout and foster team well-being.
• [10:40] – Details Duke Health’s innovation units and evolving staffing models.
• [11:46] – Debate on staff ratios versus team-based care.
• [14:30] – Vision for evolving definitions of safety and staffing.

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Closing Thoughts

This episode delivers a candid, visionary overview of the pressures and opportunities facing nursing today. Terry McDonnell advocates for adaptable, technology-driven change and for empowering frontline staff, while emphasizing that humor and grace are vital for resilience. Duke’s experimental “innovation units” exemplify how major academic health systems can lead workforce transformation, offering a hopeful model for a strained profession.

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Transcript

[A]

This is where healthcare leadership comes together. Becker's 16th annual meeting brings more than 3,500 hospital and health system executives and nearly 800 speakers to Chicago, April 13th through the 16th. This year's event includes keynote conversations with Dallas Cowboys legend Troy Aikman and former President George W. Bush. For the agenda and event details, visit Beckershospitalreview.com and click on the Events tab in the upper right. We're looking forward to hosting you in Chicago.

[B]

This is Scott Becker with the Becker Healthcare Podcast. We're thrilled today to be joined by a brilliant leader. We're joined Today by Terry McDonnell, and Terry serves as the chief nursing executive and senior Vice president at the Duke University Health System. The Duke Health System, of course, is one of the great academic medical centers in the country. Terry has also worked at leading cancer operations at Mass General in that area, also at Fred Hutch Hospital. She's had a magnificent career. Terri, can you take a moment to introduce yourself and tell us what brought you to Duke?

[C]

So you're very kind and complimentary. Scott we take different twists and turns in our career, so nursing is a second career for me. As you said, I started, I cut my teeth at Massachusetts General Hospital. I still also am a practicing nurse practitioner, so my clinical subspecialty is GI oncology. I've been caring for that patient population for the last 25 years, and I proudly continue to do so on a modified basis from Mass General. I grew up clinically and administratively. I left there as the director of clinical operations for the MGH Cancer center, and I was recruited to what was then the Seattle Cancer Care alliance as the chief nursing officer and senior vice president for clinical operations. And over the course of my seven years there, we grew the organization, things evolved and changed, and we went through a merger and restructuring, and the baby that was birthed at the end was the Fred Hutchinson Cancer Center. I had the pleasure of overseeing the construction and design of a new, new ambulatory innovation center while I was out there. Again, we grew to care for more patients than we ever had historically over the WWAMI region, which for those of you who aren't from the Pacific Northwest, when you work in Seattle, you actually don't work for the state. You don't just serve the state of Washington. You serve patients from Wyoming, Montana, Alaska, and all the way to Hawaii. And after the merger and the restructuring, it was a nice point for me to make a move and I was recruited out here to be the chief nurse executive for the Duke University Health System, a role that I very proudly have held for the last two and a half years and boy, is healthcare changing right in front of us.

[B]

Well, and talk to us a little bit about that. So you've been in healthcare for some time, you've had this magnificent career. Talk about what changes or trends you're most focused on currently. What are you watching most closely? What excites you? What keeps you up at night? A little bit about the core things you're watching.

[C]

Well, I'll start with what keeps me up at night. And that is the math problem that we are currently facing in healthcare. What I mean by that is we have more demand than ever for our services and we have a stagnant workforce. Never before have I seen, in times of an economic downturn, have I seen where people actually don't run to healthcare as a next opportunity. This is the first time that I've seen where we're facing some economic headwinds as far as the workforce goes and jobs. And we're actually not seeing people running to careers in nursing and in healthcare, which is a unique dynamic. But with that keeping me up at night, that also presents us with some very unique opportunities also. Never before has my generation been faced with so much opportunity where with regard to transitioning, what work looks like. And what I mean by that is how do we integrate all of the incredible tools, new tools that are coming to us almost daily in AI, new technologies, robotics, and how do we integrate those things and really transform what healthcare delivery looks like?

[B]

Yeah, no, fascinating. And the math problem we talk about often, There's a million one physicians versus a population of 350 million people. There's about four, four to four and a half million nurses compared to 350 million people. The numbers are staggering. When you talk about people not running to healthcare careers. Talk about that for a moment. And why do you think that might be?

[C]

Well, I think part of it is really our philosophical generational approach to work. Right now we've got a, a workforce that spans five generations and each one of those generations, from the boomers all the way to Gen Z, learns differently, has different expectations and behaves differently in the workplace. And what we've seen is with that shift in dynamic, we also see a shift in what interests people and what people want to migrate towards for work. Work in healthcare, especially nursing, is challenging. You know, when you start out, a lot of it is very physical, A lot of it is at the bedside and, you know, people's expectations around what gratifies them and, and what really brings to them meaning. In their lives has changed. So we're having to shift our way of thinking, thinking more in terms of shorter shifts, gig hybrid, part at the bedside, part in a virtual care environment. All of these things are shifting what.

[B]

The work looks like 100%. And let me ask you this question, Terry. And, and you seem like a serious professional person, so bear with me because I'm somewhere in between that, so bear with me. You're now at Duke. Have you yet, do you cheer for Duke vs UNC North Carolina or have you yet gotten involved in the Duke UNC rivalry? Do you bleed Carolina blue or you Duke a Duke fan now?

[C]

Oh, I'm Duke all the way.

[B]

There you go. There you go. No, and it's, and it's a great, great school for. It's a great academic institution, plus a great, great basketball and so forth. So. Fair enough. I'll take you back to serious questions, I promise. Terry, talk a little bit about leadership. You've had this amazing leadership career. You talk about the different five generations in the workplace. You spent time at Mass General, you spent time really building a cancer program in Seattle, and now at Duke. Talk for a second about what advice would you give to emerging leaders who want to have interesting, impactful careers and be effective leaders.

[C]

The best piece of advice I can give to anyone in leadership is don't hang your hat on one particular phenotype. The most important thing we can do as leaders in 2026 is to listen and learn from the people who are closest to the work. Gone are the days where a top down leadership is effective and we can transform and we can have the most impact. The more we empower the people who are at the front line and closest to the work, engage them in change, engage them and involve them in co development of new solutions, new models of care. Those bring about the most effective changes. And those things engage your workforce.

[B]

In terms of encouraging your team members, the people that are growing into leadership with you, to thrive themselves, to avoid burnout, to keep trying to get better and to make improvements. What's the best way of doing that? To sort of grow and have a team that thrives.

[C]

Humor is very important. This is serious work and the team needs to be able to challenge each other in healthy ways, but also grant each other the grace and allow levity in the situation. You know, we are a serious profession, nurses, but we also, we can be fun at a party and when we allow ourselves that grace and the calm in the moment, that helps for a couple of things. It alleviates some of that intensity which drives burnout. I mean, when you drill into burnout, it's really about anxiety, fear and high intensity. That doesn't ease. And when you've got a healthy team that comes together and that feels safe and trust each other, that's when you can be most effective. And that's when people really want to continue to come together and thrive in that environment.

[B]

And I love that. And when we talked some about the math problem, when you think about you're the chief nursing executive at one of the best institutions in the world, what are you most focused on this year and most excited about this year? Where are you most focused and excited this year?

[C]

How we evolved from a nurse to patient ratio and think more about team care delivery. So we've just opened three brand new innovation units at our university hospital. And what I mean by innovation units is we rehabbed three 30 bed units and we've partnered with some technology firms. We're introducing computer vision. We're changing the model of staffing where a staff nurse will work two 12s on the on the unit and one 12 in the virtual care center as that virtual team member. And I think that's really going to shift the physical burden, the emotional psychological burden, and also bring about better outcomes both for our patients and also for our staff. I'm really excited about the potential and what we're going to learn from those three units and what we're going to be able to then develop and change.

[B]

Thank you. Talk about the movement away from nurse patient staff ratios and yet you have some states that are imposing new nurse staff ratios and there's different reasons for this, often political, but that seems so challenging given that everybody's trying to find different ways to deliver care that aren't so labor dependent on a labor force that's really hard to fill. Any thoughts on that as you move towards care delivery? And I don't want you to get involved in politics at all. I don't want to put you on the spot on it, but it does seem that those two things are in conflict with each other. Some states that are moving towards increased nurse patient ratios and really trying to move this to a care based delivery system based on need, not based on. We all like to be in a hospital where there's lots of nurses around. We just feel very safe and very comfortable. So we all understand the nurse patient staff ratio, but it's very hard for systems to make that work in the way that it used to be used to work.

[C]

It is hard and you're right, it is very Politically charged. But when you drill into the core of it, it's not necessarily about a nurse to a patient, but it's all the resources available. And I think we're, because we are very entrepreneurial. I think in the way we've grown up in American health care, there's not necessarily the same standards. And where the nurse to patient ratio work has really tried to make an impact is around standards and safety. But where we're going to have to have some difficult conversations, especially in states that have enacted legislation to your point is how do we think differently when there's not enough nurses to patients in order to continue to deliver the care and meet the demands, the basic demands.

[B]

Of a community 100%. That's where the issue is. Just not enough nurses in many places. And you have more and more nurses that like we had a fantastic nurse speak about job opportunities and so forth and really at this point in her career wanted to do anything but be an inpatient hospital nurse. And of course there is so much need in that area and there is so many people that prefer to work in different settings, in the ambulatory settings, other kinds of settings. Just there's a whole variety of opportunities for nurses. And so sometimes you're fighting this uphill battle of a nurse patient staff ratio when the workforce doesn't cooperate or doesn't want to be in that spot.

[C]

Right. So I think the definition of ratio will necessarily have to be revisited and evolve over time. I think it's going to be team to patient cadre. So if I've got, I'm making it up. If I've got a floor of 30 patients, but I've got a team of again making it up, four on site nurses and a virtual nurse and a pharmacist and three techs. Is that going to be a safer environment with better clinical outcomes than a 30 bed unit with five nurses on site and none of the other services available to help augment that on site nurse.

[B]

Could not agree more. Terry. What a magnificent career thus far and what a leader. Thank you for joining us on the Beckers Healthcare podcast. Just a pleasure and we'll cheer today. Raduke versus Uncle. But I don't have, I don't have a dog in that fight day to day. But thank you so much for joining us.

[C]

Thank you Scott. It's been a pleasure.