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Increasing Capacity for Preparing Nurses in Nebraska: A Call for Action

February 1, 2004

This paper addresses the need to expand the capacity of schools of nursing for preparing registered nurses (RNs), licensed practical nurses (LPNs), advanced practice registered nurses (APRNs), and other masters and doctorally prepared nurses in Nebraska.  Particular emphasis will be on faculty to teach nursing.  It may be used to support health policy and legislation.

Need for Increased Numbers of Nurses
Increased Demand
In 2000, the Bureau of Health Professions, USDHHS, estimated that there was a shortage of 110,000 or 6% in the demand for full-time equivalent (FTE) registered nurses, and projected shortages of 20% by 2015, and 29% by 2020.  Factors driving the growth rate include an 18% increase in population, a larger proportion of elderly compared to those of workforce age, and medical advances (National Center for Workforce Analysis, 2002). 

RNs Save Lives and Prevent Complications
While in the past, cost cutting and nursing shortage have been used as reasons for short staffing, double shifts, and increasing utilization of lesser prepared or unlicensed assistive personnel, recent research has been demonstrating the impact of shortages of RNs and of employment of RNs with higher levels of educational preparation.  At the University of Pennsylvania, researchers found that hospitals with high ratios of patients to nurses had a higher risk-adjusted 30-day mortality rate in patients and higher rates of failure-to-rescue when complications developed  (Aiken, Clarke, Sloane, et. al., 2002).  The Joint Commission on Accreditation of Health Care Organizations (JCAHO) examined 1,609 hospital reports of patient deaths and injuries since 1996 and concluded that low nursing staff levels were a contributing factor in 24 percent of the cases (JCAHO, 2002).  A study of 799 hospitals in 11 states found that when a higher proportion of surgical patients’ (1,104,659 discharges) care was provided by RNs and they provided greater number of hours of care per patient, there were lower rates of urinary tract infections (UTIs) and failure-to-rescue.  Medical patients also had lower rates of UTIs and upper gastrointestinal bleeding (Needleman, Bauerhaus, Mattke,et. al., 2002).  Finally, in regard to educational preparation, a cross-sectional analyses of outcomes data for 232,242 general, orthopedic, and vascular surgery patients discharged from 168 non-federal adult general Pennsylvania hospitals between April 1, 1998 and November 30, 1999, indicated that in hospitals with higher proportions of nurses educated at the baccalaureate level or higher, surgical patients experienced lower mortality and failure-to-rescue rates (Aiken, Clarke, Cheung, Sloane, and Silber, 2003).  Despite the fact that nurse practice environments and systems design often do not allow nurses to utilize the full extent of their knowledge and expertise, there is an ongoing call for a better educated nursing workforce.

Capacity Issues
Increased recruitment efforts and a tight job market have resulted in increased applicants to schools of nursing.  The preliminary report of American Association of Colleges of Nursing’s (AACN) 2003 survey of baccalaureate and higher degree programs in nursing found that more than 11,000 qualified applicants were not accepted, despite the fact that enrollments in entry-level baccalaureate programs in nursing increased by 16.6 % in fall 2003 over fall 2002, and enrollment of RNs with diplomas or associate degrees into RN-to-Baccalaureate programs increased 8.1%.  Associate Degree programs in nursing offer a shorter and quicker route to RN licensure, and they, too, have waiting lists of qualified students turned away because of capacity.  However, the fastest route to licensure as a registered nurse is the accelerated baccalaureate programs offered to transition into nursing adults with baccalaureate and graduate degrees in other fields.  There are now 129 of these accelerated programs, with 24 of those launched in 2003 (Berlin, Stennett, & Bednash, 2003).  Despite the many routes to RN licensure, there are still waiting lists that are not only frustrating to applicants, but lead some applicants to pursue education in another field.  Factors which influence the capacity of schools to accept qualified students include:  limited numbers of faculty (In the 2002 survey, this was cited by 41.7% of schools as the reason for their inability to accept more students), a shortage of capacity in science and humanities courses which are required by nursing programs, a shortage of clinical facilities in which to place students for learning experiences, and in some cases, shortages of classroom and laboratory space in schools of nursing.

Nursing Faculty Shortages and Projected Shortages
Not only will it require additional faculty for schools to be able admit more of the qualified applicants needed to meet the projected demands for RNs in the future, but there are existing vacancy rates of 6.4% in Nebraska and 8.6% nationally.  Most of the vacancies at the national level were for faculty positions requiring a doctoral degree.  Even more ominous than the current vacancies is what AACN has called an emerging crisis in faculty numbers caused by an aging faculty, budget constraints, and increasing non-teaching opportunities for nurses with masters and doctoral preparation (AACN, 2003a).
Aging faculty:  The average age of nursing faculty at retirement is 62.5 years and the average age currently of doctorally-prepared faculty is 53.5 years (Berlin and Sechrist, 2002).  In Nebraska, the average age of nurses with a doctorate is 53, almost the same as nationally, and the average age of nurses with a masters as their highest degree is 47 (Nebraska Center for Nursing, 2003).  Particularly troubling is the fact that between 1993 and 2002, there was an 18.1% decrease in the number of doctorally prepared faculty between the ages of 36 and 45.  Data on the 365 recipients of nursing doctoral degrees in 1999 showed a median age of 46.2 years.  Very few nurses engage in full-time study for masters and doctorates.  In fact the median time between entering a master’s program to completing a doctorate in nursing was 15.9 years, compared to 8.5 years in other fields.  So, the time that can be devoted to a career, once doctorally prepared and before retirement, is short for nurses compared to other professions (AACN, 2003b).
Competition from other settings:  More and more nurses with masters and doctoral degrees are opting to be employed in settings other than schools of nursing at salaries considerably higher than those of faculty.  Berlin, Stennett, and Bednash (2003) found that 28.6% of the 457 doctoral graduates in the 2001-2002 school year had commitments to settings other than schools of nursing.  Median salaries in clinical settings are generally higher than in educational settings: $74,556 for a doctorally prepared associate professor compared to $113,100 for a VP for Nursing or $93,344 for a Nursing Director; or $60,556 for a masters prepared associate professor compared to $69,407 for a Nurse Practitioner in specialty care or $69,416 for a nurse manager.  In fact, it is difficult for nurses to take on the economic burden and foregone income required by graduate study when many are earning salaries in non-academic master’s level positions that are almost as high as doctorally prepared faculty (AACN, 2003b).
Workload and role issues:  Not only are clinical salaries attracting nurses with graduate degrees, but changing faculty workload and role expectations are creating dissatisfaction that contributes to nurses leaving faculty positions or taking early retirement.  Nursing faculty engaged with masters and doctoral programs are expected to be involved in research and publication.  More and more nursing faculty are being expected to develop proficiency in teaching with distance learning technology.  In addition, nursing faculty are expected to maintain clinical expertise, engage in faculty practice, and instruct students in clinical agencies where they may be responsible for increasing numbers of very ill patients.  Add to these role stresses the fact that almost 73 percent of undergraduate nursing students are “nontraditional” in terms of having independent financial status and competing responsibilities such as jobs and families (AACN, 2003b).

Other Contributing Factors
Budgetary constraints were earlier mentioned as factors contributing to the inability to increase capacity.  Most states are experiencing budget difficulties, and have cut or barely maintained the amounts allotted to public higher education.  The University of Nebraska has had to absorb two rounds of budget cuts and further state budget cuts may be necessary.  The drop in the stock market from 2000 to 2002 has resulted in decreased earnings and decreased value of endowment funds held by foundations of institutions of higher education and has made contributions more difficult to solicit.  These budgetary restraints have made it difficult to expand classroom and laboratory space or buy new computers and other teaching equipment.

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Some Strategies for Increasing Capacity
Possible Actions by Schools
More sections of prerequisite courses should be offered.  In Omaha, Metropolitan Community College has been offering several sections of science and humanities prerequisites and at unusual times, like a Friday evening and blocks of time on Sunday to schedule around most school or work schedules.  Schools of nursing should critically examine their existing curriculums/programs for repetitive or unnecessary material, considering consolidating core curriculum requirements across nursing majors, working with other disciplines to make such courses as physical assessment, pharmacology, informatics, gerontology, and ethics multidisciplinary, or collaborating with other schools of nursing or consortia to offer joint courses if proximity and classroom size permits or through distance technology.  Better use might be made of about to retire faculty by offering phased retirement and of retired faculty by offering them opportunities to teach part time, tutor students, supervise skills labs, assist with research projects or serve on thesis and dissertation committees.  Schools might partner with their clinical agencies to use qualified, non-faculty clinical preceptors, concentrated clinical experiences late in the program, internships, and residencies.  Some other practice disciplines like engineering, architecture and design, use a quarter system with a quarter of classes followed by a quarter of employment in appropriate setting, although these may require five years to complete.  College faculty could encourage outstanding students to consider enrolling in graduate school to prepare for teaching.  Teaching assistantships could be offered to graduate students.  AACN expands on several of these suggestions, offers many others, and cites examples of schools using particular strategies in their two white papers on faculty shortages and building capacity (AACN, 2003b & 2003c).

Strategies Requiring External Action or Policy
More money must be available to increase faculty salaries to make them more competitive; to fund additional positions; to provide scholarships and traineeships to allow for full-time study for nurses preparing for faculty positions; and where needed, to build additional classroom or laboratory space or equipment.  Some schools have received scholarship and faculty salary money from their partnering agencies, but universities and colleges need to allocate more to nursing budgets.  Foundations should encourage private gifts to nursing schools.  The State Legislature should line-item money for nursing faculty positions.  In 2003, the New Mexico Legislature provided two million to the Commission on Higher Education for special projects to establish equitable nursing faculty salaries and fund additional grants to state nursing programs.  Congress and federal agencies should appropriate funds, grants, scholarships, and traineeships.  Many of the existing schools of nursing were made possible by federal grants, and 40-45 years ago the National Institute of Mental Health provided not just scholarships but traineeships to prepare teachers and clinical specialists in psychiatric nursing. 

 

References

Aiken, L.H., Clarke, S. P., Sloane, D.M, Sochalski,J. & Silber, J.H. (2002, October 23).
Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction, JAMA,
288, 1987 - 1993.

 

Aiken, L.H., Clarke, S.P., Cheung, R.B., Sloane, D.M., & Silber, J.H. (2003, September 24). Educational levels of hospital nurses and surgical patient mortality. JAMA, 290, 1617-1623.

American Association of Colleges of Nursing. (2003a)  AACN’s Nursing Faculty Shortage Fact Sheet. . Washington: The Association.  Available from: URL: http://www.aacn.nche.edu/Media/Backgrounders/facultyshortage.htm.

American Association of Colleges of Nursing. (May, 2003b) Faculty shortages in baccalaureate and graduate nursing programs: Scope of the problem and strategies for expanding the supply. Washington: The Association.  Available from: URL:http://www.aacn.nche.edu/Publications

American Association of Colleges of Nursing. (2003c) Building Capacity through University Hospital and University School of Nursing Partnerships. Washington: The Association.  Available from: URL:http://www.aacn.nche.edu/Publications

Berlin, L.E. & Sechrist, K.R. (2002). The shortage of doctorally prepared nursing faculty: A dire situation. Nurs Outlook, 50, 50-56.

Berlin L.E., Stennett, J., & Bednash, G.D. (2003). 2002-2003 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing. Washington, DC: American Association of Colleges of Nursing.  Available from: URL:http://www.aacn.nche.edu/Publications

Joint Commission on Accreditation of Healthcare Organizations (2002). Health Care at the Crossroads: Strategies for Addressing the Evolving Nursing Crisis. Washington, D.C.

National Center for Workforce Analysis, HRSA Bureau of Health Professions.(2002). Projected Supply, Demand and Shortages of Registered Nurses : 200-2002 Rockville, MD.

Nebraska Center for Nursing (2003). Lincoln, NE: Nebraska Department of Health and Human Services, Regulation and Licensure.

Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., Zelevinsky, K. (2002). Nurse staffing levels and the quality of care in hospitals. 346: 1715-1722.

 

 

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Retaining Older Nurses
The nursing workforce is aging.  We are faced with losing many veteran nurses to retirement at a time when healthcare demands are rising. These nurses are needed for their skills and experience.  There are not enough younger nurses yet to replace them.

Strategies that can enhance the older nurse’s work experience include:

  1. Time off for renewal—both vacation time and on-the-job breaks.
  2. Services that enhance time off (laundry service, elder care).
  3. Principle-centered policies and procedures rather than rigid ones.
  4. Provide newly structured positions or new service area roles.
  5. Respect, including shared decision making and sharing credit.
  6. Managers and physicians show compassion, competence, honest, and ethics.
  7. Give and receive feedback.
  8. Honor personal values.
  9. Promote staff development.
  10. Promote new technologies to ease the work burden.

 

Contributions of senior nurses include:

  1. Promoting an atmosphere of calm, especially during emergencies.
  2. Accomplishment, dedication, experience.
  3. Commitment to the profession.
  4. Hard-working, knowledgeable and committed.
  5. “Been there, done that” experience.
  6. Accomplished decision-making skills.
  7. Intuitive
  8. Good role models and mentors.

 

Best Practices:

  1. Flexible schedules, preferred holiday schedules, varied shift lengths.
  2. Focus on ergonomics.
  3. Restructured pension plans.
  4. Smaller patient workloads.
  5. Lighter physical requirements.
  6. Role as mentor, preceptor, educator.
  7. Job sharing.
  8. Health promotion to improve strength and stamina.
  9. Care giving and grief resources.
  10. Phased retirement.

 

We must develop and promote strategies that support the continued employment of the older nurse by supporting them in modifying their work role land environment.
We can’t afford to lose experienced nurses who want to continue to contribute to their profession.

For a full report on this topic, visit the Robert Wood Johnson Foundation at www.rwjf.org  “Wisdom at Work:  The Importance of the Older and Experienced Nurse in the Workplace” June 2006

 

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