Spring 2004 TN Nurse Feature Article

Can the Nursing Pipeline Meet Tennessee’s Demand for Nurses?

 By Nancy B. Moody, DSN, RN, and
Ann P. Duncan, MPH, RN

The nation is experiencing an unprecedented shortage of registered nurses (RNs). Several recent studies have linked nurse staffing with patient inju d other adverse outcomes. Medical errors are the 7th leading cause of  death in the United States. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO, 2002) examined 1,609 hospital reports of patient deaths and injuries since 1996 and found that low nurse staff levels were a contributing factor in 24% of the cases. Additionally, a study published in the Journal of the American Medical Association reported that each additional patient over four in an RN’s workload increased the risk of death for surgical patients by 7% (Aiken, Clarke, Sloane, Sochalski, and Silber, 2002). What, if anything, can be done to address the impending shortage of RNs in Tennessee? That is the question posed by the Tennessee Independent Colleges and Universities (TICUA) Board of Directors.

TICUA appointed a Commission on Nursing composed of Deans of Nursing from private and public colleges and universities, the Executive Director of the Tennessee Center for Nursing, Inc. (TCN), and a university president, who chaired the Commission. Acknowledging the work of the Tennessee Hospital Association (THA) to address the retention of registered nurses, the Commission decided to examine actions to increase the number of qualified nurses in the workforce – getting more people interested in nursing as a career and increasing the capacity of programs preparing nurses for initial  RN licensure. The Commission’s report, Securing Tennessee’s Future: Increasing Educational Capacity in Nursing, funded by TICUA, THA, and TCN, was released in January 2004.

The TICUA Board of Directors is to be commended for recognizing both the emerging nursing workforce shortage crisis and the more immediate nursing educational capacity crisis in Tennessee; for commissioning this private-public higher education partnership; and for taking the lead in communicating the report’s policy recommendations to the higher education community, the legislature, and the public. It is also important that data be brought to the attention of Tennessee‘s nurses.

Tennessee data and assumptions predict a significant shortage of 9,495 RNs by the year 2020 (TCN, TDH, & THA, 2001). The current nursing shortage is due to a combination of factors that are different from previous nursing shortages.

There is a declining number of nursing school graduates. In 2000, the Nation graduated 26% fewer registered nurses than in 1995. Although enrollment in initial RN licensure programs in Tennessee increased slightly from 2000 to 2002, Tennessee enrolled 1,196 fewer nurses in 2002 than in 1996 (TBN: 1995-2003).

Schools are experiencing limited nursing program capacity. In 2002, nursing schools turned away more than 3,600 qualified applicants due to nursing faculty shortages and other limited resources (AACN, 2003). The Southern Regional Education Board (SREB) (2002) identified Tennessee as one of six states expected to have a critical shortage of nursing faculty within the next five years. Some Tennessee schools of nursing report having faculty vacancies for more than one year, and several report that 50% of their faculty will retire in the next five years. Faculty and other essential resources limit Tennessee schools in their ability to increase enrollment.

The RN workforce is aging resulting in a larger percentage RNs who are approaching retirement.

There is increased demand for nursing services. Population growth; aging of the population resulting in increased per capita demand for health care; and trends in health care financing (an average of 85% of the population are covered by some form of health insurance) are major factors driving the increased demand for RNs.

There have been steady declines in relative RN earnings since 1991. After adjusting for inflation, RN salaries have been relatively flat and have resulted in no increase in purchasing power. The average salary for elementary school teachers has constantly been greater than that for RNs and is growing at a faster rate.

The Commission assessed the nursing pipeline in Tennessee to arrive at conclusions and recommendations. Tennessee currently has 32 nursing programs that prepare prelicensure nursing students to take the National Council Licensure Examination for Registered Nurses (NCLEX-RN). The programs meet the Tennessee Board of Nursing, Southern Association of Colleges and Schools, and specialized accreditation standards for nursing education programs. The addition of new nursing programs will be costly to the state and will further compromise existing programs by diluting the available pool of qualified faculty and scarce clinical resources, Because the 2000 census for population figures reflects that over 95% of Tennesseans live within 35 miles of a nursing program, the Commission recommended that resources for existing professional nursing programs be augmented to increase program capacity,

The Commission made the following recommendations:
Preparation for the nursing career –
Tennessee ranks 49th in the nation for the amount of money spent on education relative to the economy; only 19.6% of Tennesseans 25 years of age or older hold a bachelor’s degree compared to 25.2% nationally; parents’ educational attainment is closely related to student educational outcomes (TICUA, 2003); and; 25% of high school students score below the basic level for reading; 40% score below the basic level in math; and 60% score below the basic level in science (Bottoms & Feagin, 2002). Alarming numbers of students are not continuing their education beyond high school and many are not adequately prepared for college, therefore:

1.  The Commission recommends that the Tennessee Department of Education adopt a long-term educational awareness campaign to promote the value of higher education and create a culture that assumes students will seek education beyond high school.

2.  The Commission recommends that the Tennessee Department of Education expand initiatives to stimulate elementary and secondary students’ interest in health sciences, provide academic advising for students to take high school courses that realistically prepare them for the academic rigor of nursing programs, and that accurately inform students and parents of the roles of nurses.

Support for nursing students –
Factors influencing the recruitment, enrollment, and persistence to graduation of nursing students include affordability and support systems. Many students need to work while attending college and, for students who are single parents, must be employed in order to have medical insurance for themselves and their dependent children. Working 20 or more hours per week is one of the three most consistently identified characteristics of students at risk for not passing the NCLEX-RN on the first attempt. The other two factors are students for whom English is a second language and students with family responsibilities at home (California Board of Nursing, 2002). Following enrollment, the academic rigor of nursing education is difficult. Therefore:

3.  The Commission recommends that the Tennessee legislature appropriate funding to professional schools of nursing for stipends and scholarships, and to provide for enrollment in TennCare for nursing students who do not have medical insurance.

4.  The Commission recommends that the Tennessee legislature appropriate funding for schools of nursing to support initiatives that promote the success of RN students. Suggested strategies include funding to strengthen nursing student support systems, such as tutor/mentoring, career counseling, stress reduction, and test-taking skills.

Program capacity –
While the numbers of applicants who are denied admission to Tennessee schools of nursing is not available, applications exceed available seats in most programs. The chief reason for not admitting more students into nursing programs is the lack of qualified faculty. Educational requirements for holding a faculty position require a minimum of a master’s degree in nursing. Accreditation standards require that 25% of student credit hours in baccalaureate nursing programs be taught by faculty with a doctorate. In Tennessee, enrollment in graduate nursing programs declined from 2000 through 2002, further limiting the pool of potential faculty. Many nurses who are master’s-prepared choose nursing practice over teaching due to a lack of competitive salaries in academic institutions. Therefore:

5. The Commission recommends seeking ways to increase the capacity of existing professional nursing programs by increasing appropriations to the Tennessee Board of Regents, the University of Tennessee System and the Tennessee Higher Education Commission’s Contract Education Program for nursing education. The appropriations should be used to add faculty positions, develop accelerated graduate programs in nursing, develop a competitive salary structure, and provide scholarships or traineeships to faculty pursuing graduate degrees in nursing who commit to teaching in a Tennessee school of nursing.

Clinical facilities –
As enrollments increase, clinical facilities’ ability to accommodate the required number of students becomes strained. Barriers to accessing essential clinical resources include: a shortage of new clinical sites; existing sites not accepting enough students due to a shortage of nurses; competition for access to clinical facilities with other schools of nursing and other health professional schools; shortened hospital stays; more acutely ill patients requiring more highly skilled nursing care; issues related to the Health Information Portability and Accountability Act (HIPAA); and emphasis on cost containment. Therefore:

6. The Commission recommends that professional schools of nursing and health care providers work collaboratively to increase nursing program capacity by developing creative clinical schedules to include evenings, nights, and week-ends; expanding non-traditional clinical placements; and building new clinical education partnerships.

Diversity –
Only 7.1% of RNs are black and only 2.4% are from other minority groups (TBN, 2000). In contrast, blacks comprise 16.3% of the state’s population and other minority groups comprise 3.3% (TDH, 2001). Increasing the diversity of the nursing workforce depends on successful recruitment, admission, retention, and graduation of students from underrepresented groups. The lack of appropriate career guidance and inadequate pre-nursing academic preparation has been identified as factors that inhibit successful enrollment of a diverse student body in nursing programs. Once enrolled, the lack of an infrastructure for systematic mentoring is a major shortcoming in minority retention. Therefore:

7.  The Commission recommends increasing support for scholarships and stipends for students from diverse backgrounds to pursue professional nursing education; funding to provide tutorial and other support services aimed at promoting their academic success; and funding to support RNs from diverse backgrounds to pursue graduate nursing education in preparation for faculty roles where they might serve as mentors.

Access, funding, program capacity, sufficient numbers of appropriately credentialed faculty, adequate clinical facilities, and a lack of racial and ethnic diversity are some of the major issues facing Tennessee’s ability to build a nursing workforce to care for the health care needs of our growing population. Even immediate action may not be enough to avert a health care crisis.

The complete report is available for viewing at http://www.sitemason.com/page/esvtRe. For more information on the nursing workforce, visit www.centerfornursing.org.

Acknowledgements: The authors would like to recognize the members of the Commission on Nursing: Dr. Nancy B. Moody, President, Lincoln Memorial University, Chair; Dr. Joan

Creasia, Professor and Dean, College of Nursing, University of Tennessee; Ann P. Duncan, Executive Director, Tennessee Center for Nursing; Dr. Ruth Elliott, Professor and Chair, Department of Nursing, Tennessee Wesleyan College; Dr. Mary Ella Graham, Dean and Professor, School of Nursing, Tennessee State University; Dr. Patty Kraft, Dean and Professor, Division of Nursing, Carson-Newman College; Dr. Carla D. Sanderson, Provost and Professor of Nursing, Union University; and Dr. Debra Wollaber, Dean and Professor, College of Health Sciences and School of Nursing, Belmont University. The Commission of Nursing would like to express appreciation to TICUA staff that provided support: Dr. Claude Pressnell, President; Susanna L. Baxter, Vice President for Member Services and Grants; and Alan Duesterhaus, Vice President for Research and Policy Development.  

References

Aiken, L., Clarke, S., Sloane, D., Sochalski, J., & Silber J. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job satisfaction. JAMA,288(16), 1987.

AACN. (2003). Enrollments and graduations in baccalaureate and graduate programs in nursing. Washington, DC: AACN.

Bottoms, G., & Feagin, C. (2002). Improving achievement is about focus and completing the right courses. Atlanta: SREB.

California Board of Registered Nursing. (2000). NCLEX-RN Task Force Report: The problem and the plan. Sacramento: CA.

JCAHO. (2002). Health care at the crossroads: Strategies for addressing the evolving nursing crisis. Oakbrook Terrace, IL: JCAHO.

SREB. (2002). SREB study indicates serious shortage of nursing faculty. Atlanta: SREB.

TBN. (1995-2003). Tennessee Professional Schools of Nursing: Report to deans and directors of nursing programs. Nashville, TN: TBN.

TBN. (2000). Tennessee Board of Nursing licensure database. Nashville: TBN.

TCN, TDH, and THA. (2001). Projection of the supply of anddemandfor nurses in Tennessee, 2000 through 2020. Nashville: TCN.

TDH (2001). Population estimates from the Tennessee Department of Health. Nashville: TDH

TICUA. (2003). Securing Tennessee’s Future: Strategies for increasing higher education attainment. Nashville: TICUA.  

Nancy B. Moody, DSN, RN, President of Lincoln Memorial University in Harrogate, Tenn., serves as a member of the Board of Directors for the Tennessee Center for Nursing (TCN). Moody served as Executive Director of TCN from 2000-2001. Her professional experience includes several years as a faculty member in various schools of nursing, she also worked as a staff nurse in Kentucky and Florida from 1972-1975.

Ann P. Duncan, MPH, RN, Executive Director of the Tennessee Center for Nursing (TCN) since 2002, has a rich work history in public health starting in 1965 and most recently serving as the Deputy Commissioner for the Tennessee Department of Health. Duncan also served as the Director of Public Health Nursing for the Metro Davidson County Health Department for eight years. Some of Duncan’s professional activities include serving as a clinical instructor and associate faculty member at various universities in Tennessee including Vanderbilt’s School of Nursing.