Fixing the Nursing Shortage

Staff writer Lori Ponoroff addresses the worldwide nursing shortage by highlighting strategies being used by associations, universities and governments to combat the problem in the first in a series of nursing articles.

Lori Ponoroff discusses one strategy being used to eliminate the worldwide nursing shortage.

They’ll need a million in Europe, a million in the United States, two million in India, five million in China... and the list goes on. Throwing numbers like these around almost sounds like playing with Monopoly money... but these are real numbers for the critical nursing shortage the world is facing now, in the next several years – and likely, way beyond.

The nursing shortage isn’t breaking news; the world has been dealing with an ever-increasing shortage of nurses for close to 20 years. The problem is that nursing shortage forecasts seem to get exponentially bigger with each new prediction.

In July 2002, the US Department of Health and Human Services released a report saying the nursing shortage it previously projected would start in 2007, was already evident by 2000 when the national supply of full-time employed (FTE) registered nurses (RN) was about 1.89 million, while demand was estimated at two million – a shortage of 111,000 or six percent. It also predicted the shortage would grow relatively slowly until 2010, by which time it would have reached a workforce of 2.3 million, or a shortage of 12 percent.

In reality, RN employment in the US in 2009 was already more than 2.5 million, according to the US Department of Labor Bureau of Labor Statistics (BLS). By 2012, RN employment grew to 2.74 million, according to the BLS’ Employment Projections 2010-2020 report released in February 2012. That same report projected from 2012 to 2022, the number of new RN jobs would grow 19 percent, with 526,800 new jobs; add to that the projected need for 525,000 replacement nurses in the workforce, and the total number of job openings for nurses by 2022 will be 1.05 million – out of a total of almost 3.4 million jobs. Many believe there won’t be nearly enough nurses available to fill those jobs, like the “United States Registered Nurse Workforce Report Card and Shortage Forecast”, also published in 2012, which predicts a shortage of 300,000 to one million nurses in 2020.

So why the need for so many nurses? There are almost as many reasons as there are countries trying to hire them. Besides the current issues of an aging population and job dissatisfaction among nurses, China plans to build 20,000 new hospitals in the next 10 years and is going to need millions of nurses to staff them. In some countries – like India, the Philippines, Jamaica, Nigeria, Russia and Canada – the hunt for higher pay, more sophisticated facilities and better chances for advancement lead nurses to migrate to other countries.

The US is one of those countries importing nurses to fill many more vacancies than there are natives available to fill them. This country shares some of the same issues others are facing, like a steep population growth resulting in a growing need for health care services, but it faces some unique ones, too, like an aging nursing workforce getting ready to retire, not enough students in the pipeline, and a shortage of professors curbing the already stretched capacity of nursing schools and their ability to crank out new nurses. The new Affordable Healthcare Act calls for nurses to have more roles as team members and leaders, the US baby boom generation is requiring more healthcare services and with improved technology and managed-care issues, only the sickest patients require hospital stays and intense treatment – requiring more skilled and specialized nurses in hospitals and home-health organizations. Finally, even though they are available and anxious to work, many new nursing graduates are unable to find jobs because so many hospitals require up to two years experience.

It’s clear we need strategies to deal with the nursing shortage that will address all these issues, and many ideas have been presented by the World Health Organization; individual governments; universities; and medical, surgical and nursing organizations – like the National League for Nursing (NLN). The NLN sees its job as making sure it is bringing new nurses into the faculty arena, according to its CEO, Dr. Beverly Malone, who says that too many qualified applicants are turned away from nursing schools each year because they don’t have the clinical space or the teachers to teach them.

So the NLN is “encouraging nurses to continue their education”, she says, and “helping to sustain them once they get into teaching, so that we have enough faculty members. We help faculty learn how to use the newest equipment and the newest technology – we help keep them at the top of their game, because they are the ones who are teaching the students to become nurses – and getting them ready for the new world of healthcare.”

It’s that new world that makes the shortage much more than just a nursing issue, so many of the strategies call for a collaborative effort among nursing leaders, practitioners, health care executives, governments and the media. For our part, MEdSim will begin by focusing on strategies developed by nursing organizations such as the American Association of Colleges of Nursing (AACN), the NLN, and the Tri-Council members for Nursing (made up of the AANC, the American Nurses Association (ANA) and the American Organization of Nurse Executives (AONE). We’ll give an overview and feature individual strategies in upcoming issues.

State Legislative Initiatives

Resolving the US nursing shortage will require the collective effort of stakeholders at the national, state and local levels. Federal legislators are demonstrating a commitment by funding Nursing Workforce Development programs like Title VIII of the Public Health Service Act, and many states have initiatives underway to increase the number of new nurses entering the workforce and pursuing faculty careers. These efforts generally center on the creation of new legislation to remove financial barriers to pursuing a nursing degree, mostly at the graduate level, and often result from a collaborative push by representatives from both the education and practice communities.

The number of statewide legislative initiatives are multiplying – some enact legislation to address the shortage of Registered Nurses (RNs) and nurse educators; others focus efforts on the shortage of nurse educators, the primary obstacle facing nursing schools looking to expand student capacity; and still others are working to launch programs involving strong collaborations between education, practice and community stakeholders.

Other states pursue different strategies; awarding colleges grants, offering loan repayment or forgiveness programs for nurse educators and loans to students that can be paid back through service to the state.

Partnerships and Grant-funded Initiatives

Corporate foundations, non-profit agencies and government programs offer a host of grants to students, teachers and universities to help fund tuition, research, scholar programs, fellowships, interprofessional education and more.

The Association for Prevention Teaching and Research (APTR) 2014 Paul Ambrose Scholars Program (PASP) is an example of a grant that exposes health professions students to influential public health professionals and prepares them to be leaders in addressing population health challenges at the national and community level. It provides mini-grant funds for students to implement a Healthy People 2020 Leading Health Indicators-focused project within a student's community or at his or her academic institution. A different example is Cape Fear Community College using a $60,000 grant received from the Cape Fear Memorial Foundation (a private, non-operating foundation) to help fund the salary of a Simulation Hospital/Lab Coordinator, a position that serves both the Associate Degree Nursing (ADN) and Practical Nursing (PN) programs. CFCC’s ADN and PN programs currently rotate 205 students through simulation experiences, using its newly expanded nursing lab. The addition of a dedicated simulation coordinator means the nursing programs now have the ability to maintain open lab hours and structured clinical practice environments.

“The ability to use our simulated hospital as a clinical site will assist in graduating a greater number of nurses to serve the community and enhance the comfort level and expertise of these nurses,” said Brenda Holland, ADN program director. “Without a qualified faculty member to run the simulation equipment and simulated hospital unit, this additional clinical space could not be used to its full potential.

Strategic Partnerships

Nursing colleges and universities are searching for creative solutions to increase the number of registered nurses to help offset barriers to expanding student capacity and meeting the projected demand for nursing care such as budgetary constraints, a limited pool of nursing faculty, insufficient clinical sites and a lack of scholarship monies.

One solution is for nursing institutions to collaborate with clinical partners and other stakeholders to build student capacity and satisfy mutual needs. These partnerships take many forms and serve various functions – some schools use expert practitioners to augment the nursing faculty supply, some create collaborative arrangements to increase student enrollments, while others form partnerships to provide tuition forgiveness to students in exchange for work commitments. Some service partners share physical resources and infrastructure with schools to help overcome limitations in clinical, classroom and research space.

Accelerated Programs

Nursing schools are looking for ways to increase student capacity and reach new student populations without sacrificing the integrity and quality of the nursing education. One approach is the accelerated degree program for non-nursing graduates that builds on previous learning experiences and transitions individuals with undergraduate degrees in other disciplines into nursing – in 12-18 months.

The typical second-degree nursing student is motivated, older and has higher academic expectations than high school-entry baccalaureate students. Accelerated students typically excel in class, are eager to gain clinical experiences – and faculty find them to be excellent learners who aren’t afraid to challenge their instructors.

Increasing Diversity

Another strategy is to attract more men and minority students. Although nursing schools enroll more diverse students than medical or dental colleges, the majority of students in today's baccalaureate nursing programs are female from non-minority backgrounds.

Studies point to many reasons why men and minority groups do not pursue nursing: role stereotypes, economic barriers, few mentors, gender biases, lack of direction from early authority figures, misunderstanding about the practice of nursing and increased opportunities in other fields. Compounding the lack of student diversity and further impacting minority recruitment efforts is the fact that nursing school deans and faculty also comprise a gender-skewed, racially homogenous group.

Schools are using a combination of traditional marketing methods, targeted outreach campaigns, and strategic planning to recruit more men and minority students into their degree programs. Central to any outreach campaign is a marketing message with visual cues that speak to a target audience, so schools are using updated brochures, promotional messages and images of diverse groups of nurses to appeal to underrepresented groups. They are also working to reach middle- and high-school students to develop a pool of future nursing students from diverse backgrounds.

Some schools are helping prospective students better understand what is involved in a nursing degree to help lower attrition rates, while others are making direct one-on-contact and providing more support during the application process.

Boosting Enrollment and Capacity

Recognizing the critical need for a larger pool of nursing professionals, nursing schools are focusing on ways to boost enrollment and capacity.

Before schools can think about adding more students to their programs, they first have to deal with faculty shortages, state-mandated enrollment caps on baccalaureate programs, a limited supply of clinical training sites, or other resource constraints. Luckily, state governments are helping with these issues with new legislation, creative partnerships and financial aid programs.

Proactive efforts include recruiting from within by encouraging nursing graduates to continue their education – from associate degrees to bachelor degrees to master’s programs and offering tuition assistance if they go straight from one program to another. They’re finding creative ways to improve financial aid and enhance distance learning; they’re using television, radio and newspaper ads and service announcements; and they’re targeting young people early to stimulate interest now, that nursing is a rewarding career choice, which hopefully will pay off later. Some offer college-credit courses on their campuses to high-school students in areas such as medical terminology and introduction to health careers and others offer summer nursing camps for interested high-school students.

National Image Campaign

Nurses for a Healthier Tomorrow (NHT) is a coalition of 43 nursing and health care organizations working with a communications campaign to attract people to the nursing profession and to heighten awareness of the shortage and the excellent opportunities available to those who choose a nursing career. NHT’s website offers nurses and those interested in becoming nurses a variety of resources on careers – with descriptions of the many kinds of nursing positions and specialties available, job profiles and recruitment campaigns; education – including different types of nursing programs, nursing schools and financial aid; links to other points of interest such as corporate programs, choosing a career in nursing, and higher education possibilities; and communications notices from the Nurses for a Healthier Tomorrow coalition.

Focus on the Workplace

Working off the premise that constant change in the health system challenges the notion that one nurse can be all things to all people, Tri-Council members for Nursing say nurses with varied education and practice competencies bring different skills to patient care, and they must be able to practice to the fullest potential their capabilities. To compete as attractive professional destinations, practice environments should consider recognizing and rewarding these differences by defining nurses' roles, using and compensating nurses according to their educational preparation and competencies, providing more manageable workloads and creating happier and healthier work environments.