Cover Story
Who Will Teach the Nurses We Need?
By Laurie Larson
The good news is, nursing is once more considered an attractive profession. For the fifth straight year, nursing school enrollment is up, according to the American Association of Colleges of Nursing (AACN), growing from a 3.7 percent increase in 2001 to a 13 percent increase last year. That’s also good news since the American Nurses Association has predicted a 21 percent increase in the need for nurses nationwide between 1998 and 2008, and the U.S. Bureau of Labor Statistics has projected nursing to have the largest projected job growth of any field between 2002 to 2012.
However, the bad news comes in two parts: More nurses are retiring from the field than entering it, and there aren’t enough faculty to teach them.
The U.S. Department of Health & Human Services (HHS) estimates that by 2020, the United States will need 2.8 million nurses—1 million short of the projected supply, representing a 36 percent vacancy rate. Today’s nurse vacancy rate stands at 10 percent, HHS reports. The National League for Nursing (NLN) reports that, in 2005, more than 147,000 qualified applicants were rejected from the nation’s nursing schools because there were not enough qualified faculty to teach them—an increase of 18 percent over the year before.
“That’s the showstopper—there are not enough nurses becoming faculty as there are faculty approaching retirement,” says AACN’s president Jeanette Lancaster, R.N., Ph.D., professor and dean at the University of Virginia School of Nursing.
The NLN estimates the total current number of budgeted, unfilled, full-time nursing faculty positions in the country at 1,390. This represents a 7.9 percent vacancy rate to teach in baccalaureate and higher degree programs, a 32 percent increase since 2000; and a 5.6 percent vacancy rate to teach in associate degree programs, an increase of 10 percent from four years ago. A recent report from the NLN cites three specific trends contributing to the nursing faculty shortage: a 72 percent growth in faculty seeking to teach only part-time over the past four years; the aging of the faculty population; and the fact that more than 56 percent of full-time nurse faculty are not prepared at the doctoral level.
Pamela Thompson, executive director of the American Organization of Nurse Executives (AONE), says her organization has been studying the nursing shortage since 2000 and lists six “domains” that contribute to the problem: education, work environment, technology, the health care delivery system itself, regulatory restrictions and financing.
“We have to look at this as a whole system; you can’t look at any part in isolation,” Thompson says. “All domains are interdependent and interconnected.”
In addition to the aging of the nurse faculty population, Tim Porter-O’Grady, R.N., Ed.D., senior partner of Tim Porter O’Grady Associates Inc., a health care consulting firm in Atlanta, cites the need for more sophisticated technological skills that older faculty may not be trained to incorporate, and the major disincentive that nurses will always make more money out in the field than as teachers.
“We need to have comparability between salaries for nurses and those who teach nursing,” Porter-O’Grady says. “It’s hard to draw someone out of the service sector who is making $70,000 to $80,000 a year to a faculty position that might pay $60,000 max.” Nurses with top training may make as much as $100,000 a year in a clinical setting, some nursing school directors say.
A New National Council
To look at the overall nursing shortage, as well as the physician shortage, a group of national health care leaders has created the Council on Physician and Nurse Supply, based at the University of Pennsylvania in Philadelphia. The council, which has its first official meeting planned for this month, plans to act as an advocate for change, finding practical methods to solve the physician and nurse staffing shortage, advising legislators on what they can do to solve the problem and working to shape policy.
Last year, council co-chair Linda Aiken, R.N., Ph.D., who is professor and director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania, attended an international conference on the global nursing shortage that stimulated the idea of creating the council. Participants there concluded that “the global nursing shortage cannot be solved unless the United States, the United Kingdom and Canada become more self-sufficient in providing and training their own workforce.” All three nations have been recruiting nurses worldwide—and the United States already has one-fifth of all the world’s nurses, Aiken says.
“The government has to ante up for nurses as well as [for] doctors,” she says. “It needs to increase the number of teaching slots [at universities]—we want to place this issue higher on the political radar.”
The council has discussed capitation as a way to expand enrollment in the nation’s nursing and medical schools, wherein the government would pay schools on a per capita basis for each nursing student enrolled, thereby providing more funds for nursing faculty. Spurred by the 1965 passage of the Medicare bill, the federal government did the same thing in 1971 (called the “Nurse Training Act”) with great success, Aiken says—the number of nursing graduates grew by 50 percent at the time.
The AACN is working with other nursing groups to mobilize support for more federal funding for nursing education, including more money for the Nurse Faculty Loan Repayment Program, which would keep existing nursing faculty working longer to repay their loans, Lancaster says. Two new bills are also in the works to provide more money to prepare nurse faculty: the Nurse Faculty Education Act, in the Senate, and the Nurse Education, Expansion and Development Act, in the House of Representatives. Additionally, Lancaster says that the AACN has worked to expand the Graduate Assistance in Areas of National Need program, succeeding in getting the U.S. Department of Education to now recognize nursing as an area of national need, creating more doctoral program funding.
Hospitals don’t need to be convinced of the importance of this funding and are taking action on their own. “Across the country, we are seeing a strong hospital commitment to their affiliated nursing schools,” Lancaster says. In addition to donating money directly to schools to add faculty, “hospitals are offering tuition reimbursement to their nurses, giving them flexible schedules to go to school and aligning scholarship support with future work commitments” of typically at least a year to two years. She also is seeing more hospitals paying their full-time, advanced-practice nurses to take one of their weekly shifts to teach nursing student rotations in the units.
Some experts in the field believe that using soon-to-retire nurses as clinical teachers may solve everyone’s problems. “Baby boomer” nurses might prefer a lighter schedule with more teaching and fewer patients, while students would benefit from following a nurse with a lifetime of experience, they say. However, that experience is likely no longer enough.
Porter-O’Grady says the nursing field is in a “paradigmatic moment,” moving from a “residency- to a mobility-based world,” where inpatient care has gone from an average length of stay of at least a few days to sometimes only a few hours. He contends, however, that the majority of nurses have been trained to work under the longer length-of-stay model.
As the pace of care has accelerated, so has its complexity, Thompson says. Nurses today need to know more about how to access information rather than expecting to possess a finite body of knowledge, she says. “Disease management is complex, and now we see only the acutely ill … patients are sicker throughout the hospital.” She adds, “You can’t ‘know’ everything anymore, there is too much to learn. Nurses have to be able to synthesize information for patients and function in relationship with other providers to do that. The ultimate goal is managing the journey for the patient.”
A New Kind of Nurse
“Today’s nurse has to make faster decisions—priority-setting is very sophisticated,” Lancaster affirms. For this reason, she says many health care systems have “identified the need for a new type of nurse.” The AACN has been at the forefront of introducing this new role, the Clinical Nurse Leader (CNL). Lancaster describes the CNL as a master’s-level “advanced generalist” who oversees care for a small group of patients, providing direct care in complex situations and working as part of an interdisciplinary team with an emphasis on strong communication skills and planning further ahead, she says.
Today, 92 schools of nursing are partnering with 190 practice sites to begin training CNLs. At least two nursing schools—Vanderbilt University in Nashville, Tenn., and Oklahoma University Health Science Center in Oklahoma City—have already graduated their first CNL students.
Partnering with Schools
Lancaster says that there is a clear connection between where students study nursing and where they decide to work. “You can build institutional loyalty early,” she advises.
One organization that understands this well is Bronson Healthcare Group in Kalamazoo, Mich. The health care system provides funding, clinical training sites and mentorship for nursing students at Western Michigan University in Kalamazoo, which renamed its bachelors’ nursing program after Bronson a few years ago. Bronson also provides clinical training rotations for Kalamazoo Valley Community College, which offers an associate nursing degree.
To these schools and several others in the area, Bronson offers what it calls a “nurse extern” program that hires both associate and bachelor’s degree nursing students to shadow nurses at either Bronson Methodist Hospital or Bronson Vicksburg Hospital during their last year of school and during winter and summer breaks. Externs are Bronson employees and have many duties, all under the supervision of staff nurses. Although not required to do so, many externs stay on after graduation.
“It’s a tremendous recruiting tool for us,” says Bronson’s Human Resources Director, Marilyn Potgiesser, R.N. “We think all these programs help attract and retain nurses to work with us.” Bronson also hosts a “welcome back” brunch at Bronson Methodist Hospital each fall for faculty from Western Michigan University and three area community colleges whose students are externing or doing clinical rotations with the health care system. “It’s all about a partnership,” Potgiesser says. “We are customers of each other.”
Relationships with schools are vital—but so is getting nurses out of school and on the hospital unit. With that in mind, the AONE supports accelerated nursing programs, sometimes called direct-entry programs. These degree programs, which typically last 12 to 18 months, are designed for those who already have a bachelor’s degree in another field who want to become nurses.
Thompson believes these “second-degree students” bring skill sets and work experiences from other fields that can augment their nursing work. Accelerated programs are offered in 43 states, the District of Columbia and Guam, the AACN states.
What Trustees Can Do
The possible solutions are encouraging, but the shortage problems remain daunting. Rather than getting lost in either, Thompson recommends that trustees stay focused on providing the best quality of care to their community.
“What do patients need? That’s the driver,” she says. “Warm bodies are not the answer [for filling nurse vacancies]. What do you want patients to say about the hospital? What level of care can you guarantee?” Trustees should know their hospital’s quality and safety priorities, receive reports on nursing, including recruitment, retention and turnover numbers, and they should have a long-range workforce plan.
“It’s really aligning what you say [about the nursing workforce] with what you look at and measure and value as a board,” Thompson says. She also recommends that trustees lobby for more federal funding to expand workforce faculty, pushing for both two-year and four-year nursing education support, since funding for all public universities comes through state governments. To support those lobbying efforts, the AACN offers some valuable research.
“We are compiling [data] on what all the states are doing to create more nursing faculty … and what faculty are being paid,” Lancaster explains. “Most states understand that to have more nurses, they need faculty, so they need to provide more funding to public universities … lots of states are moving forward on this … and we are working to build that awareness.”
Aiken also thinks that trustees should advocate for nurses to begin practice at the BSN level, since hospitals currently spend “two to three billion dollars a year,” by her estimation, on tuition assistance to pay for their associate level nurses to become BSNs. “Is that the right way to invest that money? Could you do it better?” Aiken asks. She points out that the number of nurses working in the hospital is not increased with tuition assistance; only their qualifications are improved.
“Trustees could help set a requirement that their hospitals will hire only BSN-level nurses,” Aiken says. “It’s in hospitals’ interest to force that as a public-policy issue.” She adds that associate degrees often take three years now anyway, so the time difference in training is not as significant as it once was. She also thinks hospitals could contribute directly to nurses receiving their BSNs by: investing money at local colleges in IT, computer literacy and distance learning; paying their advanced practice nurses their current salary to teach at universities; and providing clinical nursing rotations.
“There needs to be stronger collaboration between the service and academic environments,” Porter-O’Grady says. “Hospitals and health care systems need to build partnerships to be sustainable, and the more diverse the partnerships we can create, the more sustainable the situation will be.”
Laurie Larson is Trustee’s senior editor.
This article 1st appeared in the December 2099 issue of Trustee Magazine.
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