Back in October, Maggie touched on America’s shortage of nurses, as well as the different factors behind the crisis—namely, hectic working conditions, insufficient academic resources for nurse training, and a hospital building boom that has outstripped the nursing workforce. Thanks to the convergence of these forces, the government predicts that the nursing shortfall will grow to more than 1 million nurses over the next 12 years.
What can be done to nip this problem in the bud? According to a new white paper, our priorities should lie with expanding the capacity of nursing schools and doing more to make sure that existing nurses work under better conditions.
First, the nursing schools: “there is widespread agreement that the primary bottleneck at this point in time is the faculty shortage,” say Jennifer Joynt and Bobbi Kimball, authors of “Blowing Open the Bottleneck,” published jointly by the AARP, the U.S. Department of Labor, and the Robert Woods Johnston Foundation. According to the authors, “a 2007 survey of baccalaureate nursing schools found that 71.4 percent of schools indicated faculty shortages as a reason for not accepting all qualified applicants.” Turning away potential nurses is a bigger problem than you might think: according to a companion write-up in JAMA, more than 42,000 qualified applicants were turned away from nursing programs in the U.S.
Unfortunately, this inability of schools to embrace applicants comes at
a time when demand for nurses is actually growing, thanks to the aging
of both the U.S. population (which means more people need medical care)
and the aging of nurses (which means more nurses are going to retire
soon). In fact, Joynt and Kimball report that “surveys report that over
half of today’s employed nurses plan to retire within the next 15 to 20
years” and that “analysts at the US Bureau of Labor Statistics project
that more than 587,000 new nursing positions will be created through
2016 and that more than one million new and replacement nurses will be
needed by 2016.” Bottom line: “the supply of new nurses is not keeping
pace with rising demand.”
JAMA reports that the solution for this problem lies in “creating
strategic partnerships between corporations and other stakeholders and
leveraging the assets of such partners, as well as expanding the
capacity and diversity of nursing school faculty, redesigning nurse
education, and involving government and accrediting bodies in program
development.”
This may sound like a lot of managerial mumbo-jumbo, but JAMA does a
good job at showcasing how these strands have come together in the
example of the Oregon Consortium on Nursing Education:
“As part of an agreement formalized in 2006, the Oregon Health and
Science University (OHSU) School of Nursing and 8 Oregon community
colleges have created a common 4-year nursing curriculum that will
result in a baccalaureate degree in nursing, with much of the course
work available online. Some students will be accepted directly into
OHSU; others, who will be accepted jointly by OHSU and 1 of the
community colleges, will complete their initial course work at the
community college and complete their final year at OHSU.
“Various outside organizations have signed on to provide funding or
technical assistance for the Oregon Consortium on Nursing Education,
including the Northwest Health Foundation, Meyer Memorial Trust, James
and Marion Miller Foundation, Kaiser Permanente Northwest, the Ford
Family Foundation, the Robert Wood Johnson Foundation, and the Health
Resources and Service Administration. The shared curriculum will expand
faculty capacity by allowing faculty to teach at various institutions
and facilitate the creation of an online database of course materials
that can be shared among faculty. Early clinical experiences will take
place in a variety of settings, including nursing homes and homeless
shelters. More advanced clinical work will be supervised by practicing
nurses trained through a 2-day workshop created as part of the program.
The consortium worked closely with the Oregon State Board of Nursing to
gain the board’s approval for the common curriculum.”
The Oregon Consortium is the sort of collaborative, flexible program
that pulls in many different stakeholders to create broader
opportunities for nursing education. There are, of course, simpler
solutions that also deserve consideration.
For example, someone should be looking at how much nursing school
faculty are paid. Joynt and Kimball note that, “the nursing shortage
has led to significant increases in salaries for nurses in clinical
practice, while nurse faculty salary growth has remained flat.” As one
nurse put
it on the online form allnurses.com, “why would a master’s-educated
nurse accept a job as a professor at a local college or regional
university for $60,000 yearly when (s)he can potentially earn $80,000
to $100,000+ per year as a…[clinical practice nurse in] a large
healthcare network?” As with the geriatrician shortage, which I
discussed here, there is a need for greater academic funding in order to make nursing academia a more attractive option.
Yet even as there is a need to lure more nurses into academia, it’s
also important to make sure that clinical nurses are happy in the
workplace. And while clinical nurses make more than their academic
counterparts, they’re by no means thrilled with their compensation.
“No, we are not paid what we are worth,” railed
another commenter on allnurses.com. “For the stress we have to deal
with, the pace we must keep, the missed breaks and lunches, and the
fact we have peoples lives in our hands… we are definitely not being
compensated adequately.” A nurse practitioner with a mater’s earned, on
average, $81,517 in 2007, far less than the average earnings of any
physician. How much should nurses be paid? It’s hard to say,
though “more” seems like a good bet. At the very least, we need to put
serious thought to improving job satisfaction or else we won’t get the
necessary long-term boost in nurses. It’s about retaining nurses, not
just recruiting them.
Some of the changes that can make nursing a more enticing prospect are
very basic. The JAMA article notes that “better lighting, reduced
running around, or ‘no-lift’ policies [which require patients to be
lifted with the aid of a mechanical lifting device, thus reducing the
burden]” would help to make day-to-day nursing less burdensome for
older nurses.
Other potential changes that could improve prospects aren’t necessarily
specific to nursing, but are the sorts of changes that can make any job
more pleasant. In Yakima, Washington, one hospital offers
a leadership training and professional development program, flexible
shifts, and “benefits that include a matching 401k, onsite child care
and tuition reimbursement.” Thanks to this generous package, the
hospital “has no problem attracting a steady steam of job candidates.”
JAMA discusses another strategy to empower nurses: increasing their
presence on the boards of health care organizations. Susan Reinhard, VP
of the AARP Public Policy Institute, tells JAMA that “too many health
care–related boards lack a nurse” and “that the board for Healthy
People 2020, a national health promotion and disease prevention
initiative, does not include a nurse, despite the important role that
nurses play in preventive care.” Giving nurses a greater role on boards
can help them feel valued and invested in health care organizations.
Indeed, the issue of respect is an important one. As one nurse lamented
on allnurses.com, “nurses deserve respect …so much more than they get.
People just have no idea what being a nurse is all about. I hate the
perception that all nurses do is change bedpans, bring patients
something to drink, and follow doctor’s orders.” Making sure that
nurses are heard at the highest levels of health care organizations—as
well as improving the offers with which their presented—would go a long
way in showing that institutions understand their important
contributions to health care.
I am grateful to you for spotlighting professional nursing, but it’s interesting and concerning that you cite JAMA for models to alleviate the shortage. The Association of the American Colleges of Nursing website is a rich repository of FAQs about the shortage, the faculty shortage, models that effectively address the shortages, nursing education and profession white papers, and career and professional development. The National Institute of Nursing Research fields a formidable research agenda, yet its experts receive rare, if any, attention form traditional media. Nurses are almost never used as experts, nor is professional nursing covered in health reportage.
Indeed, you didn’t use any nurse experts or commentaters (I blog pretty extensively about nurses and nursing), and it’s important that this be addressed throughout health policy and reporting so that the public is informed.
I blieve that the practice mdoel for nurses is borken, and that nurses have been divided and so work against themselves and their professional interests. Fix that – by way of self governed nursing organizations, direct contracting with traditional nurse employers, and with much fuller practice autonomy where nursing leaders work for nurses and not for the employers, and I predict that the shortage will begin to self-correct.
The current trends of attempting to legislate what should be professional judgment (nurse/patient ratios and practice case loads) externalize control and contribute to the ongoing occupation/profession dichotomy. Having umpteen routes of educational preparation into nursing also confuses and doesn’t address the need to have the baccalaureate degree as the minimum entry credential (research shows significantly better patient outcomes when cared for by nurses with the BSN or higher).
Annie–
We’d be interested in hearing moreabout the National Institute’s Research–in particuarly nurses workng for nurses, and nurses in management.
You can email us at Karvounis@tcf.org and Mahar@tcf.org
The biggest reason why there are no faculty at nursing schools is because the nursing schools have decided that only PhD-educated nurses are qualified to teach.
That wasnt always the case. As late as the 1980s, there were very few PHD-nurse educators in nursing schools.
Once that de facto requirement came into play, the number of nursing school grads plummeted.
I see no evidence to indicate that a PHD level person is required to teach all courses at a nursing school.
Get rid of that needless bottleneck.
Our local community college has indeed suffered from a shortage of clinical instructors. One former instructor shared with me that not only wasn’t the pay great, but the school offered no health insurance and that is why it was difficult for her to stay on, even though she found the work very rewarding. I found this article very interesting.
I would like to offer several thoughts on this.
First, during a presentation I attended last May at the University of Pennsylvania sponsored by its School of Nursing, one of the experts on the panel, who grew up in Denmark, commented that NP’s in the U.S. have as much medical education as PCP’s in Denmark. She also claimed that NP’s, in her opinion, can competently handle up to 85% of all primary care, not just the simplest cases.
Second, regarding nursing faculty, I think it is important to note that many nursing educators are likely to find the work environment much more pleasant and less stressful than working in a busy, and often chaotic, hospital. Moreover, the opportunity to enjoy the summer off as well as long breaks during Christmas and, probably, around Easter are perks that make a lower salary than they could earn as a nurse acceptable. In short, it’s a lifestyle choice. Finally, if it’s not necessary to have a PHD degree to competently educate the next generation of nurses, it should not be a requirement of nursing faculty.
Third, on a personal note, in the last six months or so, I have twice called my insurer’s nurse hotline (which is staffed around the clock seven days a week) for medical help. On one of these occasions, I was over 2,000 miles from home on vacation. Both times, using computerized decision support tools to help diagnose my problem and what I should do about it, my anxiety was eased, I got very good guidance about what to do, and was saved the time and expense of going to an ER. In the future, as video communication gets cheaper, the nurse and the patient will be able to see each other as well as hear each other which should make such services even more valuable.
great analysis, but what’s the prescription?
if we paid them more, they might simply cut back on hours and see fewer patients while holding income stable.
is there any evidence suggesting that more docs would provide primary if they were better compensated? some say work in specialities is more interesting and cutting edge. If that’s so, changing compensation wouldn’t make much difference.
maybe the answer lies in accepting that they’re a limited resource and training patients to use other options — big-box store clinics and paraprofessionals generally as well as better educating patients about situation where a physicians care isn’t required.
Another segment of nurses whose career needs are being neglected are re-entry nurses who live in states where their licenses are inactive due to taking some time off to raise children.
The re-entry/refresher courses are few & far between, expensive, do not offer rolling admission and do not offer any compensation—as a matter of fact they’re pretty expensive.
It amazes me that hospitals are not reacting quickly to recruit, train, pay, and hire experienced, inactive RN’s.
Barry: I teach nursing. I don’t get summer’s off.
My position is a 9 month position: Sept thru April, plus half of May and half of August. I’m not paid for the “time off” if I teach, and I have to pay my insurance premium to keep my insurance during that time. I usually DO teach, because our ADN program is 5 semesters, and my chair gets a contract extension to keep me teaching through the summer because we don’t have enough 12 month faculty positions to cover all the classes.
I get paid for 30 hours a week. But between grading student work, counseling students, and other “duties as required” it is not uncommon for me to put in 50 hours of uncompensated work.
I love teaching, absolutely love it. But it is nerve wracking to take a student in to the hospital, knowing they practice on my license, and not knowing what mistake they will make while I am helping one of their peers with someone else.
For example, just this week one of my students called a doctor and got orders for insulin coverage on a diabetic–without telling me or even having another RN listen in. She then didn’t know how to write the order correctly, and also confused the Novalog the doctor actually wanted given with the Novalog 70/30 the patient received BID along with the Novolog sliding scale. In short, the student nearly wrote the coverage in the wrong insulin. Fortunately, I found out as she was trying to figure out how to enter the order into the chart, and called the doc to clarify. The patient got the right insulin.
The student knew she shouldn’t be calling a doctor without me, btw.
Worse, sometimes the staff RNs, who like the students and truly want to help them learn, will allow them to perform procedures such as sterile dressing changes, inserting Foley’s or NG’s, or administering medications “with the RN watching,” even though both the students and the staff know this is a violation of college and hospital policy.
The state allows 10 students per clinical instructor on the floor. But things are so busy, I hate to have more than six. Too many students, and I can’t supervise them adequately, nor can I help them with all the learning opportunities that come our way.
On the flip side of the coin, our program would LOVE to admit more students. We have 3 qualified applicants for every seat with each new cohort. But the state limits the number of students we can take based on the number of faculty we have (whose numbers are limited by the budget), availability of clinical units, and the lab and classroom resources we have on campus.
I would love to get paid more–I took a huge pay cut to teach. I don’t regret it, but low pay does limit my options, so I have to work part time to make up for the loss. There are perks to being a professor: I don’t have to work holidays any more, though I do have to teach evenings and weekends at times.
Annie: re legislating professional judgement. As long as nurses are in a dependent role, rather than independent, legislation will be necessary. Nurses don’t have the power to set their own nurse to patient ratios, so the legislature has to do it, because hospital administration won’t. Studies have shown the fewer patients per nurse, the better the outcomes. Until hospitals regard nurses as income generators rather than overhead, nothing will change.