State Legislatures Magazine: October/November 2002

Editor's Note: This article appeared in the October/November 2002 issue of NCSL's magazine, State Legislatures. To order copies or to subscribe, contact the marketing department at (303) 364-7700.

States Tackle the Nursing Shortage

Getting at the Problem
Improving Work Conditions
California Hard Hit
Expanding the Pipeline
States Not Alone

Snapshot of the Nursing Profession

Using Nurses to the Best Advantage

States Tackle the Nursing Shortage

The lack of qualified nurses is reaching epidemic proportions. States, universities and hospitals
all are trying to do something about it.

By Kristine Goodwin
It's an impending disaster that may, ultimately, touch the lives of everyone. The growing shortage of qualified nurses has already hit some states and threatens just about everyone in the coming years.

Today, America's hospitals have 126,000 unfilled nursing positions, and that number is expected to rise to 400,000 by 2020, according to an August report from the Joint Commission on Accreditation of Healthcare Organizations. "It's critical, not only in our state, but in the whole country," says Maryland Delegate Marilyn Goldwater, a registered nurse.

The shortages have been blamed on demographics, hospital restructuring in the 1990s and a waning interest in nursing as a career.

Going up against demographics is no easy battle as public and private players try to find ways to entice more bright minds to join the nursing ranks and change the culture that some say has driven them away.

And bright young people are needed. The average age of nurses is 45.2, and there aren't enough new nursing school graduates to replace those who will soon retire. Add to this the fact that the U.S. population is getting older (the 65 and older numbers are expected to double in the next 30 years), which means greater need for medical care and nursing.

To make matters worse, many states are struggling with budget shortfalls-situations that further challenge legislators to favor low or no-cost solutions. The bleak budget picture "has hampered us," Goldwater says. "There are lots of things we'd like to do, but can't because of a lack of resources."

At the heart of the problem, say many, are concerns over difficult working conditions and a general lack of respect. In addition to taking care of more and sicker patients, nurses point to such issues as mandatory overtime, disrespect from patients and doctors, an ill-defined promotion ladder, and other practices as evidence of a culture that doesn't value them.

GETTING AT THE PROBLEM
There are myriad ideas for correcting the problem. Although "this is no simple problem," Pam Thompson, CEO of the American Organization of Nurse Executives, says it is best addressed as a system. We need to focus on all the system's parts, says Thompson, like improving the work environment, bringing enough young people into the profession-and making sure that there are enough faculty to teach them-and changing the way providers deliver care, among others.

For their part, states have enacted a broad range of legislative plans to address the problem. In their arsenal: forgiving loans in exchange for working in a shortage area, boosting the capacity of state schools to admit and train nurses, and collecting data to aid in state and regional workforce planning, to name a few.

IMPROVING WORK CONDITIONS
Recent studies suggest that nurses are not satisfied in their jobs. About 30 percent of nurses say they are dissatisfied in their current position, according to the 2000 National Sample Survey of Registered Nurses. This is higher than levels seen in other kinds of jobs. Nurses working in hospitals and nursing homes have an even lower job satisfaction than all nurses.

A 2001 American Nurses Association survey of nurses found that 75 percent of those surveyed believed that the quality of nursing where they work had declined in the past two years, and 56 percent said that the time they have for patients has decreased.

Senator Bob Hagedorn in Colorado sees working conditions, and specifically, forced overtime as "the single most important issue here." Six states have enacted legislation to prohibit or limit mandatory overtime. Policies like mandatory overtime, argues Hagedorn, turn young people who are considering having a family away from the nursing profession. Mandatory overtime "does not work if a parent wants to be home with small kids. Something has to be done," Hagedorn says.

The Maryland legislature in April prohibited hospitals from requiring nurses to work overtime. Maryland has also joined 12 other states in passing so-called whistleblower protection legislation. Whistleblower laws prevent hospitals from retaliating against nurses who report illegal, unethical or incompetent practices.

CALIFORNIA HARD HIT
Ranking second to last among states in the number of nurses per 100,000 population-California has 566 RNs per 100,000 population compared with a national average of 798-the nursing shortage is front and center in the Golden State. In "Nursing in California: A Workforce Crisis," released in 2001, the University of California at San Francisco's Center for Health Professions reports that the state is likely to need another 60,000 RNs "to meet the projected demand for nursing services in 2020."

To fill some of the gaps, California Governor Gray Davis announced in January a three-year, $60 million project called the Nurse Workforce Initiative. It would, among other things, commit $24 million to train 2,400 additional nurses at community colleges and the state university system. Also on his agenda: standardizing prerequisites and curricula for the state's community colleges and the California State University system, and a career ladder program for certified nurse assistants. The initiative will get most of its funding from the federal Workforce Investment Act.

Addressing complaints about working conditions and concerns over quality of care, California took the lead on setting minimum nurse-to-patient ratios in 1999. The legislation established minimum staffing levels for registered nurses and licensed vocational nurses working in hospitals and also limited the tasks performed by unlicensed personnel.

There is evidence suggesting that nurse staffing levels-referring to the number of hours of care by RNs and the proportion of hours of nursing care provided by RNs-are "associated with better care for hospitalized patients," according to a May 2002 Department of Health and Human Services study published in the New England Jour-nal of Medicine. Specifically, the report said that higher nurse staffing correlated with up to a 12 percent reduction in patient problems, such as urinary tract infections, pneumonia, upper gastrointestinal bleeding and shock.

Moreover, "when there are too few nurses, patient safety is threatened and health care quality is diminished," according to the August 2002 report published by the Joint Commission on Accreditation of Healthcare Organizations.

Mandating minimum nurse-to-patient ratios, as legislated in California, is one option. Another alternative: requiring hospitals and other facilities to develop a staffing plan that would ensure safe patient care. The joint commission, for example, developed staffing standards that do not mandate specific staffing levels or ratios, but instead require organizations to determine their own ratios based on factors such as nurse competency and level of patient needs. Oregon enacted legislation in 2001 that requires hospitals to develop nurse staffing plans.

Although the regulations for enforcing ratios have not been finalized, their impact may be significant on hospitals and other facilities that are already struggling to find enough nurses. "There are not enough licensed nurses now," says Jan Emerson, California Healthcare Association vice president for external affairs. "You can tell us that there need to be more nurses on the units, but they don't exist." As a result, Emerson fears that "hospitals may be forced into some very tough choices. People haven't really grasped how severely the ratio law will affect an already severe shortage."

The American Organization of Nurse Executives' Thompson warns against "legislating what patient care is"-as is the case with mandating ratios. "If you take the clinical judgment away by legislating it, that affects quality of care."

EXPANDING THE PIPELINE
From scholarships and loan programs to signing bonuses and increased salaries, financial incentives are a significant tool for government and businesses alike. In exchange for financial rewards, many states require nurses to work in medically underserved areas for a certain amount of time. California scholarship recipients, for example, must work in a county-operated health facility for at least a year, while recipients in Louisiana, Indiana and Colorado must work in medically underserved areas.

Several states enacted legislation that established financial incentives in 2001, according to NCSL's Health Policy Tracking Service. South Dakota set up a tuition reimbursement program for 60 nurses each year. In exchange for working in eligible health facilities, recipients receive $5,000 in tuition reimbursement. Nebraska created a scholarship and loan repayment program for students enrolled in approved nursing programs.

Getting more students through the educational system faster is another approach. "We've got waiting lists of three years of students wanting to get into nursing school, but we don't have enough teachers or class space," says Emerson.

Assisting entry level staff who are already in the nursing setting and interested in moving up the ladder is another approach taking hold. "A career ladder program would be wonderful. Nurse techs are bright, but don't have the educational advantages" to move up the career ladder, says Indiana Representative Peggy Welch.

Massachusetts has such a program in place: the Extended Care Career Ladder Initiative. This $5 million program funded by the legislature helps certified nurse assistants become licensed practical and registered nurses by providing training at community colleges. It also pays for English literacy and math instruction, and child care and transportation. The initiative also attempts to change the culture of institutions so that burnout and frustration don't continue to drive people away from the profession and into less demanding fields.

There are "huge staffing shortages across the board," says Senator Hagedorn, "and certainly long term care will be a growth industry for the next 30 years." In order to get more people into the nursing workforce, Hagedorn sponsored legislation that passed in May that gave a "gentle nudge" to Colorado's work force investment board "to place more TANF (temporary assistance to needy families) recipients into one-year education programs for practical nursing." At $16 per hour for a starting wage, Hagedorn said, "we're literally getting to a living wage ... with job security for a lifetime." Moreover, he sees an opportunity for LPNs to "continue with their education, at their own expense, to become RNs." Though Hagedorn believes his bill provides "huge opportunities," he admits that the budget situation limited the options on the table.

Although scholarships, loan forgiveness and the like may be effective, Indiana's Representative Welch says "all that stuff costs money." In tough economic times, her state legislature could consider only no-cost options like the Interstate Nurse Licensure Compact that provides reciprocity to nurses who are licensed in other states. The legislation that passed in March would help because, Welch says, "People are bypassing Indiana because it takes too long to get licensed." Furthermore, foreign nurses are "going to states with reciprocity."

STATES NOT ALONE
"Some of the best work in the country is happening at the state level with collaboration and partnerships," said Thompson. But states are not alone in trying to address the problem. Case in point: State policymakers have joined forces with health care providers, business and other stakeholders in the Colleagues in Caring Project, funded by the Robert Woods Johnson Foundation. These regional projects-now in over 20 states-bring people together to implement permanent systems of nursing workforce planning. "There are a lot of people out there with really good ideas," says Thompson, and these collaborative efforts are on the right track of solving what is a "very local issue."

To fill gaps, hospitals have looked to temporary nurses and un-licensed personnel to cover their immediate needs. Hospitals are offering financial incentives like signing bonuses, tuition reimbursement, child care benefits and higher salaries in addition to other things geared to improving working conditions. Recognition programs, flexible schedules, mentoring programs and advertising are all ways to improve the image of nursing.

There are numerous examples of exemplary hospitals that have weathered the storm better than others. The American Nurses Credentialing Center has certified 50 such hospitals so far that have succeeded in ensuring adequate staffing, competitive pay and a collaborative culture. These hospitals do a better job keeping nurses and also do a better job with patient care, according to the joint commission report.

A number of initiatives also exist at the federal level. Congress approved the Nurse Reinvestment Act in July. Though it does not appropriate any money, it authorizes scholarships and a repayment program for nursing loans. The American Organization of Nurse Executives CEO Pam Thompson calls it an important "first step" in recruiting new nurses into the profession. Also in the legislation: grants for career ladder programs, public service announcements and a National Nurse Service Corps.

Recognizing the need to diversify the nursing workforce-nurses are overwhelmingly female and white-Health and Human Services launched a "Kids Into Health Careers" initiative that promotes health careers to children, especially minorities.

HHS Secretary Tommy G. Thompson announced in June a series of grants to the tune of $30 million aimed at increasing the number of nurses across the country. Colleges and universities will receive the bulk-about $22 million-to train nurses working to become nurse anesthetists, nurse practitioners and geriatric nurses, among other things. About $8 million will repay educational loans of nurses who agree to work for two to three years in a public or nonprofit health facility facing a nursing shortage.

Kristine Goodwin specializes in primary care issues for NCSL.

Snapshot of the Nursing Profession

There are three basic categories of nurses that require different levels of education.

Registered nurses receive their training from a two-year associate degree in nursing program, a three-year hospital-based diploma program or a four-year baccalaureate program. RNs assess symptoms, give medications and educate patients. Full-time registered nurses earned an average of $46,782 in 2000, about 11 percent higher than in March 1996, according to the 2000 National Sample Survey of Registered Nurses. However, after adjusting for inflation, real earnings during that same period remained relatively stagnant.
Advanced practice registered nurses, a subcategory of RNs, number about 200,000 nationwide. In addition to a baccalaureate degree, APRNs have several additional years of education allowing them to become clinical nurse specialists, nurse midwives, nurse anesthetists and the like. Salaries vary from 20 percent to 120 percent higher than registered nurses.
Licensed practical nurses have one year of vocational school or community college training. LPNs are required to pass a licensing exam and earn, on average, $27,000 per year. They provide basic bedside care-checking for vital signs, applying dressings and giving injections.
Nurse aides and home health aides receive 75 or more hours of basic instruction in high school or community college. There is no official licensure, though some states may require it. With an average income of $16,000, nurse aides are able to serve meals and help patients with eating and bathing, for example.

Some 82 percent of those trained as RNs (or about 2.2 million people) were employed in nursing in 2000. The majority of them-about 60 percent-work in hospitals, and about 18 percent work in public or community health facilities, like community health centers or state or local health departments.

Using Nurses to the Best Advantage

States are exploring two ways hospitals can best use nurses to avoid fatigue and burnout, and protect the well-being of patients.

Nurse staffing plans: Five states (California, Kentucky, Oregon, Texas and Virginia) have adopted legislation or regulations requiring hospitals to use "valid and reliable" nurse staffing plans that reflect various factors-how sick the patient is, the experience of the nursing staff, technology and support services available to nurses.
Nurse ratios: California is the only state to enact legislation requiring specific nurse-to-patient ratios to be used by all nursing units in the state's hospitals.

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