NURSING EDUCATION AND THE HEALTHCARE SHORTAGE
Strategies for Improvement
As the baby-boomer generation came into full bloom and wandered into the era of retirement, several factors came into focus regarding our nation’s ability to provide adequate and effective healthcare. Although the baby boomers created a large work force, many of them with college educations, the percentage of that group that sought careers in healthcare was not unusually high. Because there were so many new and exciting technological fields to explore, many in the subsequent generations chose more technical or lucrative careers to explore, leaving a gap in the service industry of healthcare. As the generation of baby boomers reached retirement, it created a large supply of individuals needing healthcare without a sufficient supply of healthcare providers, be it nurses, physicians, dentists or physical therapists to supply those services. Therefore national attention has been focused on this problem as well as solutions to further problems in the future.
In the 1970s and 1980s, medical schools had a difficult time recruiting individuals into their Family Practice programs because other subspecialties were more interesting and more lucrative for the individual practitioner. As a result, incentive programs were created to stimulate interest and ranged from repayment of tuition and training expenses, to reimbursement of costs by healthcare entities for establishing and maintaining a practice until it could sustain itself. Alternative sources for recruiting physicians were explored and programs which would facilitate additional training and licensure of foreign physicians were also implemented. These programs would foster immigration to the United States on training visas, provide on-sight supervision and sufficient training so the physicians could prepare to sit for board certification and eventually open practices to care for the increasing patient population. In addition, programs were established to lure physicians to remote areas without medical coverage, often by increasing their reimbursement for services offered in rural or indigent practices. As a result, many medical students entered this general practice arena and more patients received the care they needed.
For over a decade, there has been much conversation regarding the nursing shortage and what methods could be implemented to alleviate this problem before the current generation heads out to greener pastures. Many individuals felt that a nursing career was not as exciting as those other technological careers offered to the younger generations and others felt it was not adequately reimbursed for services rendered. Much like with medicine and physicians, nursing had to take a serious look at its destiny and shape a new course. Advertising campaigns were implemented to entice individuals into nursing programs and nursing specialties with certifications were developed. Advanced practice programs were created to help bridge the gap in the healthcare market. Healthcare facilities reviewed the salaries offered for nursing positions and increased reimbursement significantly. As a result record numbers of individuals began applying to nursing programs across the country. The number of associate degree and baccalaureate programs grew as did the numbers of master and doctoral level programs in nursing. Bridge programs were developed to facilitate transition from associate degree programs to those with more theory and clinical exposure in hopes of retaining nurses in the workforce who are better prepared for the future needs of nursing. Yet in spite of this growth, many nursing school applicants have been wait listed or turned away because there were no spots available in the programs. The time and effort spent in developing interest in nursing as a career seems to have been wasted.
Now as a solution to the nursing shortage, especially here in Texas, legislators have introduced bills that would decrease the amount of education a nurse must have in order to be prepared for patient care in order to expedite their entry into the workforce. Legislation is being considered that would once again open diploma based programs to train nurses as healthcare providers. This paper will address opposition to that concept and discuss more relevant factors in the nursing shortage we face today.
When one looks at the history of the physician shortage, at no time was abbreviating the educational process viewed as a solution to the problem. In fact, many physician specialty programs continue to have such extensive residency and fellowship criteria that there remain significant gaps in specialty care delivery across much of the country. Current conversations addressing this shortage still look to marketing and educational funding as answers to the problem. Why then, should one expect an abbreviated nursing education would either alleviate the nursing shortage, or adequately prepare nurses for the increasing burden of healthcare responsibility that currently rests on their shoulders? Similar moves have been suggested in the past and have tired implementation without sufficient impact on the current crisis. Suggestions for “hospital based training” and bedside technicians do little to adequately prepare patients or nurses for the problems that could be encountered daily.
Funding for nursing education in the true sense of education must be increased if our country is to see a true solution to the nursing shortage. Studies over the years have more than adequately demonstrated that a baccalaureate level education is the most appropriate level for independently functioning nurses in the clinical setting. Mandates have come and gone, especially within the state of Texas, requiring that programs which do not meet BSN criteria would be phased out in the pastmillennium. Yet LVN programs and ADRN programs, and some diploma programs still exist in order to keep nursing bodies in the clinical setting.
The result of this course is that individuals are inadequately prepared and subsequently require additional supervision by other nurses who could be providing patient care or meeting other clinical needs. In addition, inadequately prepared providers burn out faster and leave the job market sooner, either because they are too overwhelmed by their role, or because there is little opportunity for advancement in monetary reimbursement. Furthermore, inadequately prepared nurses lack the critical thinking skills necessary to fully address the complex issues of patient care in light of the shortage of other providers in the market. Nurses have long been viewed as the “fill-ins” for whoever else may be missing, whether it is a dietician, a physical therapist, a psychologist, or a pharmacist. Nurses without a college prepared program will not be taught how to handle the complex healthcare issues that face nurses today with these additional responsibilities.
Funding for nursing education must also address the education of our educators. Although there are more post graduate nursing programs available than in the past, many of these programs address clinical gaps for advanced practice, anesthesia, and midwifery. Most nurses will agree that in order to be a good instructor, one must have excellent clinical skills and intuition as well as educational interest and expertise. Because many good clinical nurses do not have sufficient educational training to assume a faculty role, there is a gap in the numbers of individuals within this country who are qualified to be faculty. Unlike in medicine where physicians earn a “doctorate” and can teach or practice clinically, nurses do not possess this terminal degree in sufficient numbers.
Many of those nurses with advanced degrees use these degrees for clinical practice because reimbursement for faculty time is poor. While a registered nurse can contract with a facility to work for $40-75/hour, most faculty earn less than $40,000 per year. For this they are asked to develop lesson plans for several clinical tracts, develop and administer tests, work additional hours in the clinical setting to oversee these students or students of other faculty and act as counselor for the multitude of issues that arise in the course of providing patient care in a less than optimal environment where nursing students are more often than not figured into the daily census of those providing care. Nursing faculty are often expected to market and recruit for their programs as well. Until sufficient funding is provided to secure appropriate salaries for nursing faculty, there will no solution to the nursing shortage.
Funding for nursing education must also address reimbursement for healthcare facilities that offer clinical sites for nursing students. In a time when many healthcare facilities are closing because of revenue shortfall, there are fewer and fewer clinical sites to train nurses adequately. Although many activities may be simulated in a “learning lab,”there is no alternative for hands on learning in a patient care setting. Nursing cannot simply be taught by the book, or the computer, or the simulator. Nursing must be taught with hands on experience in order to fully prepare individuals for the frailty of human life and the complex issues that threaten it on a daily basis. Nurses must continue to be offered experiences in the clinical setting with sufficient supervision to properly train them.
Therefore when one looks at the impact that current legislation would have on Nursing education and the Nursing shortage, one must address the impact of the proposed new programs on the current educational process. If the legislative process were to dedicate specific funding for new facility based diploma programs, it is funding that would be taken dedication to improving current nursing programs. Is the question that there are not sufficient programs, or sufficient funding for faculty and facilities to utilize the current programs to their full potential? If facility based diploma programs are introduced the following questions must be addressed.
How will these programs be staffed with faculty when there is currently insufficient faculty for existing nursing education programs?
How will healthcare facilities that currently do not have sufficient nurses to provide patient care, have nursing positions to be involved in these new programs.?
What qualifications will the faculty have and/or will there be modifications in existing faculty requirements in order to get individuals in place to staff these programs?
What impact will these new programs have on the current limits in clinical settings for existing nursing programs?
What criteria will be in place for regulation of these new programs in order to maintain uniformity in the educational process? Will the BNE need additional staff in order to regulate these programs and if so, who would provide funding for these positions?
How will the transition from these diploma programs to collegiate based programs be handled in order to ensure that there are nurses adequately prepared to take leadership roles and be prepared for faculty positions in the future?
How will the implementation of these programs effectively impact the overall future of Nursing as a profession and a component of the healthcare arena?
Since the beginning of Nursing as an art, a science, a profession, nurses have made compromises in order to meet the needs of patients in situations they could not handle alone. Since the beginning of formalized training programs for nurses, the educational process has been manipulated to meet the current healthcare problem. If we do not ask our physicians to compromise in their level of educational preparation in order to provide adequate patient care, why is it appropriate to expect nurses to be better prepared with less education? If Nursing continues to allow physicians and legislators to shape our future without asserting our rights and responsibilities for appropriate education, the nursing shortage will not be resolved.
In a time when there are too few providers in all arenas of healthcare to meet patient needs, the future of nursing should be directed at amplifying the role that nurses play in patient care, not minimizing their abilities to function at the current level. TNP believes that the future of Nursing is dependent on the educational preparation of critically thinking individuals who can create consistent and creative roles for Nursing in the future.