Nursing is entering an era of great transformation that is driven by three major changes: an aging baby boomer population; the ongoing impact of the Affordable Care Act (ACA); and rising educational goals for the profession, including greater emphasis on the bachelor’s of science in nursing (BSN) and advanced practice nursing (APN) degrees.
For minority nurses, these changes bring a variety of benefits, as well as some possible drawbacks.
The aging of the baby boomers is expected to produce a plethora of new nursing jobs, which could lead to higher wages, greater job security, and greater variety in types of work. By the same token, this deluge of new patients could put new strains on the nursing workforce, possibly leading to higher patient-to-nurse ratios.
The health care law is changing the way nurses deliver care—emphasizing more outreach into the community and closer collaboration with patients. These changes could boost the need for nurses from the same cultural background as patients, at a time when African Americans and Hispanics are underrepresented in nursing. But the changes also mean less work for nurses in the traditional hospital setting.
Finally, nurses will have greater opportunities to advance their careers by going back to school for more training; APNs, and especially nurse practitioners (NPs), are already in great demand to cope with a growing physician shortage. However, having to spend more time in school may be challenging for nurses with limited finances.
Nursing is embracing these fundamental changes to keep pace with a rapidly evolving health care system, says Jo Ann Webb, RN, MHA, senior director of federal relations and policy at the American Organization of Nurse Executives. “Health care is changing, and nursing has to change with it.”
Baby Boom Changes Postponed, But Not Cancelled
For several years now, the profession has been bracing for a massive shortage of nurses, but it’s been slow to materialize.
The massive baby boomer generation, making up almost one-third of the population, began to turn age 65 in 2011. As they continue to get older, both supply and demand of nurses will be affected in a big way. On the supply side, retiring baby boomer nurses will empty the ranks of the profession. On the demand side, aging baby boomer patients will need more nursing to manage their declining health.
Yet, these massive changes were postponed by the 2008-2009 recession and the weak economy that followed, argues Marcia Faller, RN, PhD, chief clinical officer for AMN Healthcare, a health care staffing company based in San Diego.
Aging nurses, short on household funds, held off retiring and even came out of retirement to work again. Meanwhile, the aging patients have put off care, flattening the demand for health services. “Everybody is trying to figure how these changes will play out,” says Faller, who led a major AMN Healthcare survey on registered nurses in 2013.
But as a result of this delay, new nurses who had expected a strong jobs market have struggled to find openings. For example, a Denver TV station reported in 2013 that, of 752 openings for RNs in Colorado at that time, only four were for new graduates.
Lack of jobs has been especially hard on minority nurses, many of whom lack savings to fall back on. With their careers sidetracked, they’ve had to take non-RN jobs in health care or in completely unrelated fields.
In a new graduate hiring survey, the California Institute for Nursing & Health Care reported that in 2012–2013, the latest year available, a little over 40% of new RN graduates in the state hadn’t found an RN job—only a slight improvement over the previous three years. Of those who didn’t find RN jobs, 20% were working in non-RN roles in health care and 23% took jobs outside health care. The rest went back to school or volunteered in health care at no pay.
Many new graduates are angry and mistrustful. In a 2013 survey by two nursing professors at Molloy College, which was published by the National Student Nurses’ Association, many new RN grads thought the nursing shortage was just a “myth,” created by nursing schools to attract more students.
The impending nurse shortage, however, is not going away, says Mary H. Hill, PhD, RN, nursing professor and assistant provost of Howard University in Washington, DC. Aging patients can’t continue to delay treatment and aging nurses can’t continue to put off retirement. Indeed, states like Texas and many rural areas are already encountering shortages. “Nursing has experienced some challenges, but even greater challenges lie ahead as the baby boomers retire and leave the nursing workforce,” says Hill.
The need for more nurses will be overwhelming, according to the US Bureau of Labor Statistics (BLS). In a recent occupational outlook report, the BLS said there will need to be about 500,000 more nursing positions by 2022. In addition, about 500,000 baby boomer nurses are expected to retire over that same time period, meaning that over 1 million new nurses will be needed over the next decade, according to the BLS.
That means that the hospitals and other employers who are now rejecting young applicants will end up begging for them to apply, which could push up nurses’ wages. Hospitals could also simply pile more work onto existing nurses, but doing so would be unworkable in the long run.
Nursing schools have been pushing hard to expand class size so there will be enough nurses for this tsunami of demand. But they’ve had to turn applicants away, due to a lack of nurse educators. Nursing schools in New York, for example, rejected 2,900 qualified applicants in 2012, more than in any year since 2005, according to the Healthcare Association of New York State (HANYS). Many of these spurned applicants have probably moved on to other careers, which is a great loss for nursing.
Repercussions of the Affordable Care Act
Like the baby boom, the health care law represents another great sea change for nursing and is also still in its early stages. The full impact of the ACA “hasn’t shaken out yet,” according to Webb.
Beginning in January 2014, millions of Americans gained coverage under Medicaid and in subsidized policies sold on the new health insurance exchanges. But it’s still unclear how much these people will boost demand for health care and thus nurse hiring. Exchange policies tend to have very high deductibles, discouraging people from getting care. Additionally, millions of Americans still haven’t signed up, despite a federal requirement to do so. The penalties in the first year were fairly minor but will rise in succeeding years, which may boost coverage.
The elephant in the room, of course, is Republican opposition to the law. Republicans continue to promise repeal, and it could happen since they’ve gained control of the Senate and the House. In the meantime, however, this sweeping law is fundamentally changing the face of health care in this country—not just in terms of sheer numbers of patients, but also in the way it is delivered. And in another few years, it would be very hard to turn these changes back.
“I’m not saying it’s a perfect law,” says Webb, “but it has, in my view, put nursing on the map. Nurses have a bigger role now.” Accountable care organizations and patient-centered medical homes are new models of care that are encouraged by the ACA. Both models reward hospitals and other providers that coordinate care and provide more patient education—two areas where nurses excel.
“The ACA emphasizes primary and secondary prevention and education of patients,” says Shawona Daniel, MSN, CRNP, assistant professor of nursing at Tuskegee University, a historically black institution in Alabama. “Education is one of the most important nursing roles. I’d say 90% of what nurses do involves teaching patients and working on preventive issues, which helps keep patients out of the hospital.”
Webb added that working in medical homes requires computer skills in order to deal with electronic health records and telehealth services, such as e-mailing and Skyping patients, as well as using remote monitoring devices. “These patients need monitoring, and this is where nursing is really critical,” she argues.
The Shift Away From Hospitals
Daniel reported that virtually all of her students still expect to work in a hospital—at least initially. But the ACA favors new models of care outside the hospital. For example, Medicare is reducing hospital reimbursements, and hospitals are being penalized for readmissions within 30 days.
“There is an ongoing shift from inpatient to more community-based outpatient care,” says Hill.
Faller agreed with this assessment. “Only the sickest of the sick will be in the hospital, and care will flow out into the community,” she explains. As health care moves out of the hospital, home health is already a growing field, and it has become a magnet for telehealth and other high-tech services, she adds.
In addition, Hill says nurses will be able to find ample jobs at dialysis centers, community health centers, physicians’ offices, outpatient surgery centers, and pain management clinics, to name a few settings. “There are just so many opportunities,” she argues.
As part of the de-emphasis on hospital care, many patients are being discharged earlier and placed in long-term acute care (LTAC) facilities, where they spend many weeks often still on ventilators and IVs. Care in the LTACs is “complex and challenging,” says Joseph Morris, CNS, GNP, PhD, director of nursing and allied health at Victor Valley College in Victorville, California. “Nurses who work in these facilities require advanced skills, such as advanced cardiac life support and telemetry training.”
Morris, who is trained in gerontology, welcomes the influx of aging baby boomers. Many nurses seem to feel that a geriatrics career—which can mean working in a nursing home—means “lowering your sights,” he says, but he disagrees. “It’s clinically challenging because you’re more likely to see multiple health problems.”
Dealing with older patients is also personally rewarding. Morris, who is African American, has fond memories of taking care of elderly black men in Detroit. In contrast to the stereotype of geriatric patients sitting in their wheelchairs muttering to themselves, “most geriatric patients are still active,” he says.
Nurses Get More Training
The job market is beginning to favor nurses who have a BSN degree, and advanced practice nurses such as NPs are in great demand.
Both trends earned key endorsements from the Institute of Medicine (IOM) in its 2010 report, The Future of Nursing. The report set a goal that 80% of nurses should have a BSN degree by 2020 and urged states to drop barriers against NPs working “to the full extent of their education and training.”
Hospitals are quickly shifting to BSNs. In New York, 70% of hospitals in 2013 preferred hiring BSNs, compared with 46% in 2011, according to HANYS. Many younger nurses are heeding the call. Faller pointed to the 2013 AMN Healthcare survey showing that almost one-quarter of nurses ages 19–39 said they would pursue a BSN, and more than one-third said they would pursue a master’s degree in nursing.
Hill says it’s fairly easy for someone with an associate degree in nursing to transition to a BSN degree. They can enroll in a “RN-to-BSN” transition program, which lasts 12–18 months and is available in many locations across the country.
Meanwhile, NPs have been proliferating. According to a 2013 report by the Health Resources and Services Administration (HRSA), the number of NP graduates grew by 69% from 2001 to 2011, fueled by the growing shortage of physicians in primary care and easing of state restrictions on NP practice.
“Nursing students are more ambitious than they used to be,” argues Daniel. “A lot of them want to go back to graduate school and become nurse practitioners.” She says she hopes some of them will choose a career in academia so that more nurses can be trained. This was another goal of the IOM report.
Morris says the new doctor of nursing practice credential, which will be required for all NP students starting in 2015, expands the amount of study, making NPs even more desirable as primary care providers as well as specialty caregivers.
Of course, the extra time and money needed for a BSN, and especially an NP, can be a barrier for minority students. Rather than pile up loans, Morris urged students to thoroughly research available scholarships. “Nursing students have not always been proactive in seeking out the opportunities.”
Push for Diversity
The new models of care fostered by the ACA require closer relationships between providers and patients, which means hiring nurses from the same ethnic background as their patients. Hospitals and other employers “want their nurses to be compatible with the culture or their patients,” says Faller. “But this will be a challenge, particularly for the Hispanic population.”
While Hispanics make up 17.1% of the population, they account for only 4.8% of RNs, according to the HRSA. There is also a gap for African Americans, who account for 13.2% of the population but just 9.9% of RNs.
As a black male nurse, Morris says it’s easier for him than for white caregivers to connect with black patients. He says many of them are still painfully aware of the infamous Tuskegee experiment. In a project that lasted until 1972, white doctors didn’t inform black male patients that they had syphilis, so that they could follow the natural progression of the disease. As a result, older black patients in particular are still wary of “being used as guinea pigs,” he says.
Morris has worked hard to boost African American representation in nursing, visiting schools to spread the word about a nursing career. He is also interested in boosting the number of black men in nursing. While men make up almost 10% of all nurses, very few black males enter the field, he says.
Nurses Have a Central Role to Play
There are many opportunities for minority nurses in this era of great change in the health care system. According to the IOM report, nurses will take center stage in this process.
“We believe nurses have key roles to play as team members and leaders for a reformed and better-integrated, patient-centered health care system,” the report maintained. “How well nurses are trained and do their jobs is inextricably tied to every health care quality measure that has been targeted for improvement over the past few years.”
Leigh Page is a Chicago-based freelance writer specializing in health care topics.