An advocate for public education and first-generation college students, Heather Tubbs Cooley brings significant experience building research teams and leading clinically-integrated health services research studies. Her research examines effects of nurse workload and direct care resourcing on quality of care and outcomes in pediatric and perinatal care settings.

Below is a Q&A interview between the School of Nursing's director of communications, Joe Schilling, and Heather Tubbs Cooley.

What brought you to VCU, and what drew you to the Richmond research environment?

So many things. First, VCU’s strategic institutional and school-level focus on increasing research appealed to me. I came from an organization that similarly underwent a significant research expansion with much success. Being part of the growth is exciting and coming to VCU as a senior researcher is an opportunity to support the momentum. Next, VCU’s mission resonates deeply with me. I attended a public access university in Michigan as a first generation student and Pell Grant recipient—an opportunity that made my dreams come true. Since then, I’ve studied and worked in an Ivy and a public flagship university. But, what I love about schools like VCU is an emphasis on educating all students regardless of economic background or educational pedigree. Public education supports social mobility and the American Dream, and even in this cynical time I still believe it’s true. Third, the first day I interviewed at the School of Nursing I knew I’d like it here because the people are excellent at what they do, and on top of that they are exceptionally kind and welcoming. Finally, the ability to do interdisciplinary research with pediatrics colleagues at the Children’s Hospital of Richmond and the Child Health Research Institute was a major attractor. 

As a senior researcher, what are your immediate goals for expanding the research agenda here over the next few years?

My first priority is maintaining momentum in my research program while building new collaborations locally. I’m writing new grant applications and diversifying my research portfolio. Each grant brings money to sustain research operations staff and support trainees, and in the current environment of declining numbers of nurse scientists and federal research funding cuts, I’m feeling a lot of urgency to support scientific training opportunities for nurses starting at the pre-licensure level.

Additionally, as assistant dean for research, I’m working alongside Amy Salisbury and Dean Kinser to support their research vision and help drive the school’s goals forward.

Your work explores how subjective workload—like stress and fatigue—impacts care just as much as nurse-to-patient ratios. What drove that research, and what surprised you most?

I’ve always been interested in the specific mechanisms of how the work that nurses do, and the context in which we do it, affects the healing trajectory of patients. Nurses intuitively know that with more assigned patients we have more care to deliver than time available, which forces us to triage care. Some core things are missed; it’s a rational response to time pressure but can have negative consequences for patients. That said, the number of assigned patients—the ratio—doesn’t capture everything that drives a nurses’ workload. A nurse can have what on paper seems to be a reasonable ratio but still be triaging care because the patient’s family needs a lot of teaching or emotional support. That’s actually very common in pediatrics because we take care of both the child and the family.

I started collaborating with human factors researchers to measure workload that is experienced by workers in real time using a tool called the NASA Task Load Index (TLX). It's a brief measure originally developed by NASA (yes, the space agency) to gauge six types of demands on humans during active work, such as cognitive demand and time pressure. We found that a neonatal intensive care unit (NICU) nurse's experience of workload is actually more predictive of missed care for assigned infants than nurse-to-patient ratio alone. It's the most real-time, proximal manifestation of how the environment and the work is affecting the nurse’s ability to deliver in the moment. We also know that while staffing does impact nurses’ ratings of subjective workload, so do teamwork dynamics. These are tangible things we can work on.

Given the retention and burnout crises in healthcare, how can leaders use your research to redesign systems and support frontline workers?

By the numbers, we don't actually have an overall nursing shortage—we have a workplace retention problem. When researchers ask nurses what would bring them back to direct patient care roles, nurses put safe staffing and workplace safety at the top of the list. Hospitals need to ensure nurses have the time and resources to adequately care for patients and mechanisms to prevent violence and harassment against a predominantly female workforce. 

One trend we see is hospitals keeping nurses but eliminating other unit roles such as unit clerks, supply stockers and environmental services roles. The implication is that ratios are stable but the nurse will now answer phones, clean rooms and stock supplies on top of delivering all necessary care. Again, high workload under this model won’t be visible in ratio estimates but it will definitely show up in nurses’ experiential workload ratings and in what gets missed for patients. Thinking carefully about how to organize and finance nursing in ways that preserve the integrity of direct patient care is a constant challenge for leaders, and I stand ready to work with them to test different approaches.

Looking back at your journey from bedside nurse to senior researcher, what was a pivotal moment that shaped your passion for research?

It actually happened before I became a nurse, when I was an undergraduate student. I was a first-generation college student and had never known anyone with a Ph.D., but I got the opportunity to work as a research assistant on a federally funded project. That experience was transformative. I got to see science in action and fell in love with the scientific method. I also realized that while I loved one-on-one clinical care, research would enable me to make a broader, population-level impact. I think my experience highlights how important undergraduate research opportunities can be both for nursing students who often don’t know about research as a viable career pathway in the field and for students who haven’t had much exposure to science overall.

Outside of work and research, what do you enjoy doing?

I have three active teenagers who play sports so I spend a lot of my free time near an athletic field. I volunteer in my community organizing food donation pickups for my local food pantry. And, to my family's mixed delight, I like trying out new recipes I find on Instagram.