Building a Nursing Workforce for the 21St Century

Building a Nursing Workforce for the 21st Century

Brenda L. Cleary, PhD, RN, FAAN

Today, as health-care reform begins expanding health-care coverage and access and as our population ages, we face a significant nursing shortage. To address the challenge of educating enough nurses with the skill sets required for the 21st century, the Center to Champion Nursing in America (CCNA), the Robert Wood Johnson Foundation, the U.S. Employment and Training Administration, and the U.S. Health Resources and Services Administration cosponsored two national Nursing Education Capacity Summits. This article provides the national view of the initiatives resulting from the summits and further explores the challenges in nursing education and nursing practice to ensure enough well-prepared nurses for the future.

n 2008 and 2009, the Center to Champion Nursing in clearly perceive the value of nurses. In all, 87% agree that nurses America (CCNA), the Robert Wood Johnson Foundation, can play an important role in reducing health care costs in the ar- Ithe U.S. Employment and Training Administration, and eas of patient safety, medical-error prevention, care coordination, the U.S. Health Resources and Services Administration (HRSA) and primary and preventive care (Center to Champion Nursing held two national Nursing Education Capacity Summits. These in America [CCNA], 2009b). summits addressed critical issues regarding educating sufficient numbers of nurses with the skill sets required in the 21st century (Cleary et al., 2010). Challenges in Nursing Education To ensure a 21st-century nursing workforce with the skills A shortage of nursing faculty is forcing nursing schools across and knowledge America needs, the CCNA is leading efforts to: the country to turn away thousands of qualified applications each c remove barriers that limit nurses’ ability to provide the health year. In the academic year 2007–2008 alone, more than 93,000 care consumers need were turned away from pre-licensure registered nursing programs c retain older nurses beyond the traditional retirement age (National League for Nursing [NLN], 2008). The most common c develop the competencies of newly graduated RNs, using resi- reasons for not accepting more students are inadequate num- dencies. bers of qualified faculty and insufficient clinical training sites (American Association of Colleges of Nursing [AACN], 2009c). The average age of a nurse educator in the United States is Nursing Shortage by the Numbers 53.5 (AACN, 2009c), and the pipeline for new nursing faculty is Registered nurses (RNs) are well positioned across the health- woefully inadequate. About 60% of nurses begin their careers care system to increase access to care and provide high quality, with an associate degree. A small percentage pursues additional cost-effective health care (Kane, Shamliyan, Mueller, Duval, & education, and very few achieve the master’s or doctoral degrees Wilt, 2007). Unfortunately, just as our nation tries to expand required to become educators (Bevill, Cleary, Lacey, & Nooney, health-care coverage and access and as our population ages, we 2007; Joynt and Kimball, 2008). face a nursing shortage estimated at 260,000 over the next 15 Nurses who do acquire high levels of education are lured years (Buerhaus, Auerbach, & Staiger, 2009), and that number from lower-paying academic settings to more lucrative jobs in does not tell the whole story. We need the right number of nurses clinical settings. A study published by the American Associa- with the right skill sets. tion of Colleges of Nursing in 2009 found the average salary According to a recent Omnibus Survey, 87% of Americans of a master’s-prepared nurse practitioner was $84,250, and the agree that health reform laws must address the current short- average for a master’s-prepared faculty member was $69,489 age of nurses and nursing faculty, and 88% agree that ensuring (AACN, 2009b). Also, a 2008 statewide survey by the North enough nurses to monitor patient conditions, coordinate care, Carolina Center for Nursing revealed that faculty salaries are and educate patients should be part of the effort to improve the lower and often workloads are disproportionately high (North quality of health care. Agreement is strong regardless of region, Carolina Center for Nursing, 2008). sex, age, party affiliation, voter type, income, or race. Americans 26 Journal of Nursing Regulation Enrollment in nursing schools is also constrained by an RN-to-MSN Programs inadequate number of sites where clinical training can take place. Designed for experienced diploma or associate-degree nurses, In a 2008 survey, baccalaureate-nursing programs identified “in- these programs provide direct enrollment into master’s-degree sufficient clinical sites” as the second most limiting factor to programs that encompass completion of upper-level baccalaureate accepting a greater number of applications, right behind the course work as well. Graduates of these programs often receive faculty shortage (AACN, 2009b). their BSN and MSN simultaneously. According to AACN, there were 160 RN-to-MSN programs in the U.S. in 2009 (AACN, 2009a). Solutions in Nursing Education Accelerated BSN and MSN Education After the two national collaborative summits, CCNA provided These programs are designed for applicants who hold a baccalau- ongoing technical assistance to 30 state teams on developing reate (or higher) degree in another field. Most students are able to state-level strategies for expanding nursing education capacity. complete the BSN within 18 months or the MSN in 3 years. In Teams are comprised of representatives from nursing education, 2008, there were 218 accelerated BSN and 57 accelerated MSN health-care delivery systems, state government, state workforce programs across 43 states, and demand for these programs has entities, consumer groups, local business, philanthropies, and increased steadily, as have enrollments (AACN, 2009d). other stakeholders. Technical support is geared toward helping Collaboration between Community Colleges and Universities states expand capacity by fostering collaborative learning expe- These partnerships are designed to prepare more nurses with riences that allow sharing of best practices and lessons learned baccalaureate degrees and to ensure competencies needed in the along the way (Ronald et al., 2010). 21st century by creating common admission standards and core curricula and sharing resources, such as faculty, simulation labs, More Federal Funding and clinical placement systems. Led by groundbreaking work by To increase educational capacity, policymakers and other stake- the Oregon Consortium for Nursing Education (Tanner, Gubrud- holders are finding new ways to boost funding for faculty devel- Howe, & Shores, 2008), a total of 11 of the 30 states receiving opment and diversity. In many states, funding increases are out technical assistance on expanding nursing education capacity of reach because of severe budget constraints. However, federal from CCNA are working to implement collaborative models of funding for nursing education has reached historically high levels. nursing education. The American Economic Recovery and Reinvestment Act Dedicated Education Units (ARRA) included $500 million to address critical health-care Dedicated education units within health-care delivery systems workforce shortages. About $200 million of this funding was provide clinical education for upper-level nursing students, while dedicated to tackling the growing nursing (and other primary- delivering care that results in high patient satisfaction. In these care provider) shortages by providing a much needed funding units, qualified staff nurses are paired with one or two student increase for the Title VII and VIII nursing and other health-care nurses who shadow them, often for an entire semester. Facul- workforce development programs administered by the HRSA. ty members provide guidance for multiple clinical instructors, Another $250 million was allocated to the Department of Labor expanding the numbers of students they can educate (CCNA, for competitive grants for job training and placement in high- 2009a). growth sectors, with priority given to health-care jobs. Online State or Regional Clinical Placement Systems Also in 2009, Title VIII nursing education programs re- Nursing programs and health systems in many states and re- ceived $171 million, an increase of almost $15 million over fiscal gions have increased efficiencies in clinical placements of students year 2008. This increase is on top of the $500 million provided through centralized, real-time systems for scheduling clinical to address health workforce shortages through ARRA. In 2010, placements. The process is relatively simple: Health-care agen- Title VIII funding was increased to $244 million, including an cies enter information online concerning available opportunities increase from $12 million to $25 million for the nurse-faculty and times for clinical rotations that nursing schools can request loan repayment program and an increase from $27 to $94 mil- (Joynt and Kimball, 2008). lion for the nurse loan and repayment program. Simulated Clinical Learning Experiences Greater access to clinical simulation allows students to learn Expanding Learning Opportunities in a safe environment, increases student-to-faculty ratios, and New strategies for increasing the faculty pipeline and innovations guarantees exposure to critical clinical scenarios. Advances in the for expanding clinical learning opportunities have been devel- development of simulation technology, partnerships, and sharing oped. These initiatives are critical to expanding nursing educa- of simulation scenarios make simulation training for all types of tion capacity (Cleary, McBride, McClure, & Reinhard, 2009). health-care providers more accessible and realistic (Jeffries, 2009).

Volume 1/Issue 2 www.journalofnursingregulation.com 27 Regulatory Implications reflect a search for a safe place to land and mentoring that is so Related to Education important on the journey to developing expertise. Because boards of nursing (BONs) approve nursing education Nurses are also leading the way in providing a health-care programs in most states, regulation plays a valuable role in ex- safety net in community health centers. Public health nurses are panding capacity. Reasonable flexibility that provides the op- essential to promoting population health and creating the infra- portunity to evaluate innovations in nursing education is critical. structure for disaster preparedness. However, severe budget cuts Building an evidence base for the most effective mix of simulated in local and state health departments have led to the reduction and patient-care experiences would provide further guidance, or elimination of the contributions of public health nurses. His- strategic planning, and implementation of clinical learning ex- torically, every state health department had an executive public periences in nursing education programs throughout the country. health nurse position that provided leadership and coordinated Support of new partnerships and collaborative efforts will be public health nurse activities. Today, only 23 states support such critical in providing incentives for such partnerships. Approval a leadership position (Association of State and Territorial Direc- of arrangements that allow students to earn dual degrees in the tors of Nursing, 2008). This change has profoundly affected the same program, such as in RN-MSN programs, is important. voice of public health nursing and its capacity to advocate issues Regulatory boards can also be a vehicle for disseminating best in the policy arena. practices and for collecting nurse supply data to determine how we are doing in expanding the nursing workforce, both in terms of numbers and competencies. Solutions in Nursing Practice RNs bring a lot to the table in terms of health promotion in primary care as well as in chronic disease management. Stud- Challenges in Nursing Practice ies demonstrate that for more than 40 years, APRNs have been Over the next few decades, the aging boomer generation will delivering safe and effective health care to all populations, across stretch America’s health-care resources, including our nursing settings, and in many specialties. Research shows no difference workforce, and alter the array of competencies needed. The good in outcomes of primary care delivered by nurse practitioners and news is that many boomers are “aging well” at a greater rate physicians, including such outcomes as patient health status, than their ancestors (Potkanowicz, Hartman-Stein, & Biermann, number of prescriptions written, return visits requested, and re- 2009). However, age is still a major risk factor for many chronic ferrals to other providers (Lenz, Mundinger, Kane, & Hopkins, illnesses. More than 70 million Americans age 50 and older have 2004). A recent review of the quality and effectiveness of care at least one chronic illness, and 11 million live with five or more provided by APRNs from 1990 to 2008 further demonstrates chronic conditions (AARP Public Policy Institute, 2009). This evidence of high quality (Stanik-Hutt, Newhouse, White, & Jo- scenario results in growing need for primary care, chronic care hantgen, unpublished data). management and care coordination, and transitional care and Research continues to show that hospital care and transi- thus an increased demand for advanced practice RNs (APRNs). tional care by APRNs can reduce the number of hospital days for With the enactment of health-care reform, APRNs will also play patients (Lenz et al., 2004; Naylor, 2006), good news for payers, a large role in ensuring access to care. patients, and their families. Nurse-led clinics are especially ef- The economic downturn late in the first decade of the 21st fective in secondary prevention or the care provided to patients century has resulted in older workers staying in the workforce who are striving to stay as healthy as possible while learning to longer. However, it is projected that RNs in their 50s will exceed live with one or more chronic diseases, such as diabetes or heart all other age cohorts by 2012 (Auerbach, Buerhaus, & Staiger, disease (Raftery, Yao, Murchie, Campbell, & Ritchie, 2005). 2007). What happens when this age cohort exits the workforce Nurses in these clinics provide care coordination services as well while, driven by the health-care needs of an aging population, as direct care. the demand for nursing care will remain at an all-time high? Recently, the board of AARP (formerly known as the Not only will there be an inadequate supply of nurses in terms American Association of Retired Persons) approved adding new of the numbers needed to deliver quality care, but there will be language to the AARP Policy Book, which guides AARP pol- a loss of wisdom and knowledge When nurses at the expert level icy initiatives at both the state and federal level. The language of practice leave organizations, experience-based knowledge is proposes that current nurse practice acts and accompanying lost (Bleich et al., 2009). rules should be interpreted or amended where necessary to al- New RNs joining the workforce face a good deal of vari- low APRNs to practice as fully and independently as defined by ance in how they transition from school to work. According to their education and certification. Kovner and Brewer (2009), the turnover rate among RNs in the With a rapidly aging population, nurses will have greater first 2 years of their careers is 26%. Turnover is costly and may opportunities to provide leadership for support of family care- givers. Nurses can also serve as leaders in promoting and imple-

28 Journal of Nursing Regulation menting end-of-life care that is markedly different from the 20th Table 1 century. However, after the economic recovery, retaining older Health Care Reform Law: Nursing nurses in the workforce will be critical to having the highly Workforce Provisions skilled nurses Americans need. The CCNA is seeking to serve The Health Care Reform Law enacted in 2010 resulted in addi- as a catalyst for such retention. tional provisions for building the 21st century nursing work- For example, the CCNA has created a national advisory force: group to help disseminate a successful innovation developed by c The Graduate Nurse Education Demonstration Program Massachusetts General Hospital. This nurse residency program aims to increase the number of highly skilled advanced prac- pairs older, experienced nurses and younger nurses with 2 to 5 tice nurses by providing $200 million to bolster their train- years of experience. The residency program promotes retention ing. This program lays the foundation to transform the way and meets the growing demand for geropalliative care competen- Medicare pays for nursing education, targeting dollars to- cies (Lee, Coakley, Dahlin, & Ford-Carleton, 2009). ward educating nurses with the specific skills needed to meet the needs of Medicare recipients. Advanced practice Nurse residencies are emerging not only as important nurses can provide the primary and preventive care, chronic- transitions for new graduates that result in a more competent care management, and care coordination needed to reduce nurse workforce, but also as a powerful tool in reducing turnover waste and bring down costs while increasing access and among new nursing graduates. In 2009, Goode and colleagues quality. reported a dramatic reduction in turnover to 5.7% among BSN- c The National Health Service Corps provides $150 million in additional support for nurse practitioners who agree to serve prepared nurses who participated in a year-long residency pro- at least 2 years in underserved communities across the gram immediately after graduation and licensure (Goode, Lynn, country. Kresk, & Bednash, 2009). c Programs for nurses who agree to teach in accredited nursing schools provide expanding loan forgiveness. c lifting an arbitrary cap on spending for doctoral nursing pro- Regulatory Implications grams to 10% of total grant funding awarded for expanding nursing education programs bolsters training for future Related to Practice nursing professors. APRNs and other RNs should be members of interdisciplinary c Reauthorization of Title VIII funding of the Public Health Ser- teams in care coordination efforts. In regulation and certifica- vice Act creates resources for nursing education and work- tion of medical homes, APRNs should qualify as primary-care force development at historically high levels. providers and lead these efforts, as is stated in the 2010 Health c A demonstration program for the Family Nurse Practitioner Training Program provides a 1-year residency program for Care Reform Law (see Table 1). Top among the recommendations nurse practitioners in federally qualified health centers and of a panel convened in January 2010 by the Josiah Macy Foun- in nurse-managed health clinics. dation is this: State and national reimbursement policies should Source: http://www.aarp.org/makeadifference/advocacy/GovernmentWatch/ remove barriers (such as not being included on provider panels) Nursing/ that make it hard for APRNs as well as physician assistants to serve as primary-care providers (Josiah Macy Foundation, 2010). Nurse practice acts should indicate that APRNs can practice in- beyond the traditional retirement age, and develop the compe- dependently and with full prescriptive authority. Laws and rules tencies of newly graduated nurses. Through collaborative initia- should be updated, so the BON is the sole regulatory authority tives with consumer and national nursing organizations, we have of all RNs—including APRNs. already begun to develop innovative solutions to the challenges BONs can also play a monumental role in assuring ad- we face. But we still have much to do if we are to deliver the equate time and mentoring for skill acquisition and confidence- nursing workforce of tomorrow. building among new nursing graduates. Regulatory solutions include standardized residencies and graduated licensure. BONs can also recognize residencies for the purpose of retooling nurses References in specialty areas later in their careers as part of continuing com- AARP Public Policy Institute. (2009). Chronic care: A call to action for petency requirements. health reform. Washington, DC: Author. American Association of Colleges of Nursing. (2009a). Accelerated baccalaureate and master’s degrees in nursing fact sheet. Retrieved from http://www.aacn.nche.edu/Media/pdf/AccelProgs.pdf Conclusion American Association of Colleges of Nursing. (2009b). Degree comple- Building a workforce with the size and skills needed for the tion for registered nurses: RN to master’s degree and baccalaureate 21st century poses challenges to nursing practice and education. programs fact sheet. Retrieved from http://www.aacn.nche.edu/ To meet them, we must remove barriers that keep nurses from Media/pdf/DegreeComp.pdf providing the health-care consumers need, retain older nurses

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