Diminishing Returns

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By Deloras Jones

The United States is currently experiencing a nursing shortage—one that is driven not by an insufficient number of nurses, but by an increased demand for nurses with the skills, competencies and experience needed to staff our health care facilities. Specialty units, such as intensive care units, operating rooms and emergency departments, are particularly impacted, as are those positions that require a baccalaureate degree in nursing, such as home health, care managers/coordinators and nurses in leadership roles. In the face of this changing demand, however, the opportunities to educate nurses with the necessary skills and competencies are diminishing. Enrollments in baccalaureate degree programs across the country are declining, while the current nursing work force is aging rapidly. Unless we take immediate, strategic steps to reverse the trend, we will soon have a work force that is neither appropriately sized, nor adequately trained to meet the health care needs of the population—a population that is increasingly diverse.

Today’s health care environment requires that nurses have more problem-solving, critical thinking and leadership skills than ever before. The highly technical environment requires a strong grounding in basic sciences.

The increasing acuity of hospitalized patients and a shift to providing care in out-of-hospital settings mean that nurses are being called upon to function in new and expanded roles. Changing practice settings require that the nurse is able to function autonomously with a high degree of accountability for decision making. Training at associate degree levels is no longer adequate to prepare nurses for these challenges.

Over time our primary educational preparation for nurses has shifted from hospital diploma programs to the associate degree from community colleges. This model has served us well for several decades, but it is no longer enough. Today’s health care delivery system demands nurses who are educated at a level that cannot be met by community colleges alone. There is still a place for the nurse prepared at the associate degree level, but this nurse is the “bedside nurse.” New and evolving roles require the additional training provided by the baccalaureate degree (B.S.N.).

What is particularly troubling then is the fact that school enrollments at the B.S.N. level are dropping, and access to baccalaureate education for associate degree nurses is limited. The American Association of Colleges of Nursing recently announced a 5% decrease in national enrollment for generic baccalaureate nursing programs, marking the fourth year in a row that enrollments have declined. The total drop from 1995 to 1998 was 20.9%. Additionally, B.S.N. programs in California project a 3% decrease in enrollment for 1999.

A study recently conducted by the American Organization of Nurse Executives, in collaboration with the U.S. Department of Health and Human Services’ Division of Nursing, the American Nurses Association and the American Society for Health Care Human Resource Administration, confirmed that there is a nationwide shortage of nurses with much needed experience and skills. It also indicated that shortages will become worse, and more widespread, as the current nursing work force ages.

One State’s Experience

In California, the shortage of specialty nurses is already being felt, as evidenced by hiring bonuses and other incentives offered to entice specialty-trained nurses to leave one hospital and join another. Hospitals are rebuilding the specialty training programs that were cut in the mid-1990s and refocusing on preparing nurses for specialty positions, instead of hiring those who are already trained. At the same time, the average age of both nurses and new graduates has crept up, so there are no longer as many younger nurses available to train for high-intensity positions.

The hospitals’ response to the shortage thus far, however, will not be sufficient to replace the current work force when a large percentage of it retires in the near future. For example, in California, the average age of nurses is nearly 47 (the national average is 44). A recent study conducted by the Board of Registered Nurses found that 30% of California’s nurses are over the age of 50, and half of those plan to retire by 2003. The educational pipeline is forecasted to replace only half of these. Additionally, California is a “debtor” state, i.e., it has never educated enough nurses to meet its own needs. Indeed, half of the nurses in California were educated elsewhere. However, since 1995 this number has dropped 27%, ranking California last among states in the per capita ratio of nurses to the population. Add to this shortage the fact that the population is expected to grow and age significantly, and it is clear that California will face a health care crisis if it does not take immediate steps to reinvest in the education of its future work force.

Kaiser Permanente is very concerned about the future of the nursing work force. The need to ensure competent nurses in sufficient numbers to provide care to our health plan members has been identified as an organizational priority. Several strategies are currently underway. We are engaged in an aggressive recruitment campaign that increased our R.N. work force by 16% in 1998 (paralleling an increase in demand led by membership growth). We instituted multi-educational programs, including training for most specialty areas and new graduates, and we expanded our in-house float pool. We are also working on long-term work force forecasting and are focusing on retention. Finally, we are engaged in several joint ventures with colleges, most notably Holy Names College in Oakland, Calif., to expand opportunities for nurses to pursue baccalaureate and master’s-level degrees. The joint venture with Holy Names College uses our National Teleconferencing Network to make a baccalaureate education accessible to nurses at 12 sites throughout the state. Last year 96 Kaiser Permanente nurses graduated from the first program. We began this year with over 190 enrolled. Other joint ventures include a master’s degree program with Sonoma State University, and CRNA programs with Samuel Merritt College and California State University, Long Beach.

Toward a Diverse Work Force

Moving ahead, the need to increase the number of underrepresented nurses in the work force will only continue to grow. Tapping into underrepresented populations could help offset the 21st century work force needs, especially as we know that the current nursing demographic falls sorely short of mirroring the population demographic. As we look at strategies to increase the prevalence of minority nurses, the need to ensure that incoming students have the basic competencies to be successful in college is often a concern. To this end, there is a highly successful program in Hawaii that could serve as a model for others.

The Farrington Health Academy began in the early 1990s as a joint venture between the Healthcare Association of Hawaii, the state government and private industry. The academy, open to students at Farrington High School, provides an additional curriculum geared toward careers in health care. Paramount to the academy’s success are programs that mentor students through the rigors of academic study and the challenges of distracting forces, while providing the students with a knowledge base necessary to be successful in college. Five classes of 50 students each have graduated from the academy to date. All of these high school graduates have gone on to careers in health care, and most have entered nursing. As Kaiser Permanente and other health care systems address the future of the nursing work force, we will need to engage in coalition and partnership planning with community groups, health care associations and the government. We will also need to identify and overcome barriers to nursing education, including the need for child care for students, financing school with supplementary incomes, and cultural attitudes toward a career in nursing. Only in this way will we have a work force that represents the size and diversity of the population.

Deloras Jones, R.N., M.S.N., is director of Divisional Nursing Services at Kaiser Permanente, California Division.