When
you visit your father after a coronary bypass or your mother in an Alzheimer's
unit, you expect a competent nurse to be there. Twenty-four hours a day, seven
days a week, these professionals provide highly technical complex care and comfort
during the many critical moments from birth to death. The current nursing and
nurse educator shortages pose a major threat to the quality of healthcare all
Americans expect and deserve, but most importantly to our elderly, one of society's
most vulnerable populations. The care of our senior citizens is one of the most
important issues we face in our nation today. In Arkansas, where the percentage
of the older population is growing much faster than in 44 states, the care of
the elderly poses a major dilemma.
Arkansas
is a poor rural southern state with 57 of its 75 counties deemed totally medically
underserved areas (MUAs) and 13 partially underserved. Of the 2.5 million people
living in the state, 17.2 percent are minorities and 14.2 percent are 65 and older.
Elders in Arkansas tend to remain or settle in rural areas with 51 percent residing
in MUAs and 38 percent living in partially MUAs. In the past decade, the number
of older Arkansans has increased by 40 percent. By 2015, this number is expected
to grow by an additional 41 percent and by 2025 it is expected to almost double.
Like many states in the nation, the segment of the elderly population with the
fastest growth rate is the frail elderly, 85 years and older. In Arkansas, 75,000
older Arkansans over 65 live in poverty, and of those living in MUAs, 40 percent
have annual incomes below $10,000. The vast majority of these frail elderly require
a significant level of nursing care throughout the latter stage of life.
Healthcare
for Arkansas's Senior Citizens
Although
Arkansas spends 17 percent of its gross state product on health care, it continues
to be ranked 50th in the nation on health care indicators. Its citizens, particularly
the elderly, continue to carry a disproportionate burden of suffering and disease.
The primary health care services available to meet the needs of older Arkansans
include 102 hospitals with a total of 13,555 beds, 239 nursing homes with 25,404
beds, the Arkansas Department of Health, and a number of home health services.
Each of these components of the state's health care system is caught in the throes
of a nursing shortage that grows worse every day, limiting access and quality
of care.
In
the past three years, the numbers of registered nurse (RN) vacant positions has
greatly increased with some rural hospitals reporting vacancy rates of 30 percent.
A survey conducted by the Arkansas Hospital Association of its 102 members during
fall 2000, found 53 hospitals reporting 750 budgeted unfilled RN vacancies. When
asked how many RNs would be hired if available, those responding indicated 1,500
RNs were needed to cover turnover, vacant and new positions. At the present time
the RN vacancy rate in our University Hospital, the state's major safety net for
critically ill elders and the indigent, is 16 percent with 88 budgeted unfilled
positions. The vacancy rate would be even higher if a 19-bed unit and seven ICU
beds were not closed last year due to insufficient permanent RN staff. To cover
summer vacations for the overworked RN staff, our nursing director is trying to
contract now for traveling nurses at salaries of $40 to $50 an hour, twice that
of the average hourly wage of existing permanent staff. Among the staff, all of
whom are required to do mandatory overtime if needed, morale is low and frustration
is high. Although low salary is a major complaint, the most common frustration
stems from the inability to provide the comprehensive patient and family care
that originally held the attraction of nursing as a career.
Long-term
care facilities are also experiencing great difficulty recruiting and retaining
RNs. According to state and federal regulations, Arkansas's nursing homes must
have a minimum of one registered nurse on staff for every 105 beds. At the present
time, the state's 238 nursing homes are almost all minimally staffed and face
even greater difficulty than hospitals in recruiting and retaining RNs. The state
Office of Long Term Care experienced a 30 percent turnover rate among its 64 RN
positions last year and has four to ten vacancies at any point in time [C. Shockley
(personal communication, February 18, 2000)]. The state's home health care agencies
are similarly plagued with short RN staffing, further compromising access and
quality of care particularly for rural elders living in underserved areas.
Further,
the Arkansas Department of Health, the state's community-based safety net for
the elderly, has a wholly inadequate staff of appropriately educated RNs. Of the
approximately 1,000 employed public health nurses, only 15 percent hold a baccalaureate
degree with the remaining 85 percent having no formal course work in core public
health functions, leadership and management, or gerontology. In many rural areas
access to primary medical care is at a premium, and the nursing staff in the local
health unit may provide their only opportunity to see a health care provider.
Arkansas's
Nursing Workforce
The
cause for the critical nursing shortage in Arkansas reflects the national nursing
shortage. Enrollment and graduation rates have markedly declined; nursing faculty
shortages are escalating; educational resources are declining; clinical sites
for student placement have decreased; and fewer RNs are available to mentor students
and new graduates. At the same time the current nursing staff is aging along with
the rest of the baby boomer generation, retirements are increasing, and the demand
for highly educated RNs continues to exceed supply.
Nursing
Enrollments
Nationally,
over the past five years, entry-level enrollment in Bachelor of Science in Nursing
(BSN) programs has continued to fall by approximately 5 percent annually. In 1992,
enrollment in Arkansas RN programs peaked following the shortage of the late 80's
and early 90's. In the past eight years, however, enrollment has declined by 44.4
percent. Nationally during the past year the master's level enrollment also has
slightly declined. In our college's master's program, the largest among the four
in the state, enrollment declined 20 percent in 2000. Similar to most of the nation's
77 nursing doctoral programs, our nursing Ph.D. program is under-enrolled. Across
all schools of nursing and all degree programs nationwide, the number of students
from racially and ethically diverse backgrounds is below that in the general population.
In 2000, after intensive recruitment activities to increase the percentage of
minority students enrolled and to allow for attrition and bridging the gap in
the state, only 17 percent of students in the entering class were minorities.
There
is an increasing demand for baccalaureate-educated nurses prepared in critical
thinking, leadership, case management, and gerontology to care for elders in both
inpatient and outpatient settings. And nurses with master's and doctoral preparation
are needed to teach in our schools of nursing, conduct research, and fill key
clinical specialties such as gerontology, critical care, and the operating room.
The National Advisory Council on Nurse Education and Practice has recommended
that at least two-thirds of all registered nurses hold baccalaureate or higher
degrees by 2010. Nationally, only 32 percent are prepared at the baccalaureate
level and 10 percent at the master's level or above. In Arkansas 20.6 percent
of RNs are prepared at the baccalaureate level while only 4.2 percent are prepared
at the master's and doctoral levels. Arkansas ranks last in the nation in numbers
of baccalaureate nurses per capita. At the present time in the face of intensive
recruitment, applications to our baccalaureate program have plummeted with only
127 applications for 150 slots.
The
declining enrollment in nursing education can be attributed to a number of factors.
Over the past decade, the image of professional nursing has changed from a field
that offered many opportunities and high job security to one that holds great
uncertainty and difficult with sometimes dangerous working conditions. The bright
young women that dominated the nursing applicant pool 15 years ago are now applying
and are readily accepted into traditionally male dominated professions of law,
medicine, pharmacy, computer technology, and engineering. Today's college students
view nursing's beginning salaries as low compared to other professionals and when
choosing nursing as career salary compression remains a major problem. Students
at all levels cite financial support through grants, scholarships, and loans as
a key factor in choosing a field of study. With an average age of 26 for nursing
baccalaureate students in our College, many share the master's and doctoral student's
heavy family and financial obligations. Financial support for students is limited
at all levels but particularly at the doctoral level, with only 10 percent of
the federal graduate traineeship funds under Title VIII available for doctoral
student support.
Graduation
Rates
Nationally,
graduation rates for all basic nursing education programs continue to decline.
In Arkansas, the graduation rate for students in RN programs has declined over
one third after reaching a peak in 1996. A recent survey of the 25 schools of
nursing in the state indicated only 844 students are expected to graduate in May
2001. This number is less than those graduating in 1990, in the midst of the last
nursing shortage. The Bureau of Health Professions anticipated a growth of 22.7
percent in numbers of RNs for Arkansas between 1996-2006 as compared to 11.2 percent
nationally. However, Arkansas has experienced a decline of 35.6 percent in new
RNs in the first four years. Assuming all graduates pass the state licensing exam
and remain in the state to work, the number would fill the current budgeted vacancies
in only 53 of Arkansas 102 hospitals.
Recommendations
- Substantially
increase the FY 2002 appropriations request for the Nurse Education Act (NEA)
to provide additional funding for student recruitment and support.
- Increase
FY 2002 funding for the existing nursing education loan repayment program (Sec.
835 and 842 of the Public Health Service Act), and earmark for direct financial
support additional funds for Minority Nurse Initiatives (Sec. 821 of the Nursing
Education Act).
-
Under new legislative authority, consider the creation of a National Nurse Corps
to provide tuition and a stipend for baccalaureate students in their last two
years of study in exchange for working in underserved areas.
Nurse
Educator Shortage
Fewer
numbers of qualified nursing student applicants and a declining graduation rate
are certainly major factors in the nursing shortage. However, the critical shortage
of nursing faculty is also a key contributor. In many instances more qualified
nursing applicants are available than the numbers of faculty and educational resources
to support them. For example, in Arkansas in 1999, there were 153 qualified applicants
who were not admitted to the state's RN programs due to insufficient numbers of
qualified faculty, inadequate physical facilities and nursing learning labs, and
budgetary funding. In addition to these deficiencies in Arkansas' nursing education
programs, available clinical placements for student practical experience have
declined in hospitals and other health care facilities.
A
number of factors are converging that contribute to the nurse educator shortage.
Chief among these are the aging of faculty leading to increasing retirements,
low salaries, increased workload, and inadequate numbers of masters and doctoral
graduates to fill vacant and new faculty positions. The average age of nursing
faculty as reported by the American Association of Colleges of Nursing is 52 for
professors and 49 for associate professors. The average age of Arkansas nursing
faculty at all levels of basic RN education is 47 while the average age of doctoral
faculty is 53. In the year 2000, five of the state's 57 doctoral nursing faculty
members retired. With baby boomers comprising the bulk of nurse educators, the
number of retirements can be expected to reach alarming proportions by the end
of the decade yet the number of doctoral nursing graduates has remained relatively
flat for the past five years. Moreover, with the average age of new doctoral recipients
in nursing at 45 years of age compared to 34 in all fields, the small number of
young nurse scholars and researchers available to fill faculty ranks is totally
inadequate.
Recommendations
- Under
new legislative authority, create a program to fund full-time study for recent
BSN graduates and master's students to rapidly complete doctoral studies in order
to produce the numbers of doctoral graduates needed for the professorate.
- Create
a Nursing Faculty Loan Scholarship Repayment Program to provide substantial funding
for full-time doctoral study that would allow for payback by teaching full-time
for one year of funding.
Low
salaries are a major barrier to faculty recruitment and retention. As predominately
a woman's profession, salaries have historically lagged behind those in the male
dominated fields of business, law, engineering, and medicine. In Arkansas the
average nursing faculty salary remains approximately $39,000 compared to $62,000
in engineering and $59,000 in business. The only discipline with a lower average
salary is home economics with an average salary of $34,000. In the private sector,
similarly prepared master's and doctoral nurses earn $15,000 to $50,000 more annually
than in the faculty role. During 2000, of the 273 full-time and 63 part-time RN
nursing faculty, 28 resigned. Of these, 20 left nursing education as a career
citing low salary and increased work demands as primary reasons. Currently 13
faculty positions are vacant and 16.5 percent of the full-time and 54 percent
of the part-time faculty in the state's RN programs fail to meet the minimum standards
of a master's degree in nursing consistent with those required for national accreditation.
This along with only 47 doctoral faculty out of 336 full and part-time faculty
places the state's schools at risk for losing their national accreditation and
the nursing education infrastructure at risk for further deterioration.
Across
the nation, the physical facilities housing our nursing education programs are
severely lacking. As education programs have expanded over the past two decades,
appropriate space for nursing faculty offices, modern classrooms, and learning
labs have failed to expand to house them. Many universities have increased their
deferred maintenance, leaving faculty and students housed in less than adequate
physical plants. Learning laboratories are often lacking in technical equipment
and computers necessary to prepare the new graduate to enter the world of high-tech
nursing. Further, many schools lack the funding to purchase equipment and develop
the faculty for distance learning. During the last decade our college's faculty
has increased by 63 percent and our student body has doubled. We have established
a major research program and increased our faculty practice to include a nurse
managed primary care clinic that cares for 600 elderly residents in five federally
funded high rises. Our faculty is now housed in three distinct areas with one
department located in private rental office space two miles from the campus. Our
funding has failed to keep pace with growth and in the past three years we have
sustained a 9 percent budget cut. To aid in the support for additional faculty,
added salary support, and adequate modern learning facilitates, a bold federal
initiative is needed.
Recommendations
- Under
Title VIII increase support for basic nursing education and practice program support
to expand enrollments in baccalaureate programs.
- Reinstate
a capitation-type program for baccalaureate and higher degree programs to provide
monies to hire faculty, pay for overhead, benefits and salary, and to expand and
renovate nursing schools.
- Under
new authority enhance nursing education by funding the technical infrastructure
necessary to provide state of the art educational programming.
Clinical
Learning and Work Environments
With
the decline in RN staffing ratios, particularly in high acuity settings, clinical
placements for student practice are at a premium limiting the ability of the student
to gain the needed clinical competence for practice as a RN. In the Little Rock
hospitals, we are now restricted to placing only one or two students on a clinical
unit, while in the past we were able to place up to five. The RN staff on the
unit is so overworked, they are unable to assist the clinical instructor in students'
education, further contributing to faculty stress and work overload. At a time
when expectations of new graduates are rising, their learning environment cannot
provide the breadth of learning opportunities necessary to assure the clinical
competence needed to function in many specialized areas and particularly those
serving the elderly.
Recommendation
- Develop
a program through support of the Medicare Graduate Medical Education funding authorities
to authorize payment for clinical training costs and faculty salaries in the clinical
facility to support hospital based Post-BSN Residency Programs.
Summary
The
current nursing and nurse educator shortages pose a major threat to all American
citizens but most particularly the elderly. The well-educated nurse is at the
heart of elder health care and provides an indispensable level of competence for
which there is no substitute. As an educator for 35 years, who received federal
training funding for two degrees, I urge you to expand funding for nursing education
under Title VIII. Under new legislative authority consider creating new funding
programs that the nation and its elderly need to ensure a sufficient nursing workforce
and an educational system for preparing it. You have seen today the power of the
nurse to comfort and to heal. Please help us keep nursing in the picture of elder
care.
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