3. POLICY OPTIONS AND STRATEGIES

“Real solutions for the long-term will be expensive, painstaking and slow.  Targeted investment, constant evaluation, and willingness to tackle difficult issues are the necessary components of sustained success.”

Georgia’s Workforce Policy Advisory Committee

“What’s Ailing Georgia’s Health Care Workforce?” Report, 2002

Although State experience demonstrates that no single solution exists to the problems facing the States, there are promising approaches in these five States and others that are reversing the downward enrollment and graduation trends.  This chapter describes some promising strategies aimed at expanding the nursing supply through expanded educational capacity, faculty and student recruitment and retention efforts, and other initiatives.

State Strategies Share Common Themes

Despite the large number of policy options available to States, some common themes are shared by all States that are working toward a long-term solution to the nursing shortage problem.  Among them: the importance of partnerships, targeting public funds into successful programs, and leveraging public funds with investments from other sources.

Partnerships.  A common thread in the strategies outlined here is partnerships and collaboration.  Health care employers, already feeling the pinch of the nursing shortage, are providing significant financial and human resources to help schools enroll a growing number of students.  Schools, in turn, are making changes to improve access to nursing programs and to maximize current resources to reach as many students as possible.  States are facilitating—and, in many cases, requiring—these partnerships, especially when State funds are being used.  In times of tight State budgets, some States are finding that targeting existing funds into these collaborations may be among their most effective contributions.

A key theme that emerged from the 2003 National Conference of State Legislatures nurse shortage summit in San Diego was the importance of meaningful collaboration between State legislatures, academia, the health care industry and the nursing profession.  Put simply, the problem is too complex for one group to solve.  State legislatures, although they play a key role in funding and regulating nursing education, need strong partnerships with industry and academic programs to implement changes.  Collaborations and partnerships are a means to an end—not an end in themselves—and the synergy created when groups pool their expertise and resources is making a difference.

Targeting Public Funds into Programs that Work.  The second theme is the importance of targeting existing funds into successful programs and relationships.  With limited new dollars for nursing education, States and their partners are demanding tangible outcomes: specifically, more nurses and more instructors. 

Leveraging Public and Private Funds.  Finally, leveraging State funds with Federal, private and university funds and resources is important to the success of the strategies discussed below.  Ensuring that public and private funds are used for maximum benefit is a critical element in solving this complex problem. 

Numerous Stakeholders, Varied Roles and Responsibilities

The nursing shortage affects many organizations and groups; solving the problem also requires that various stakeholders be involved.  A 2002 Robert Wood Johnson Foundation report summarized some of the key stakeholders and their role in the overall effort to deter a nursing crisis.  Table 8 also underscores how important it is that organizations invest in those areas where they can be most effective; it summarizes various stakeholders and their strategies and roles. 

Table 8. Nursing Shortage Stakeholders and Strategies

Source: Bobbi Kimball and Edward O’Neill, Health Care’s Human Crisis: The American Nursing Shortage, (Princeton, New Jersey: Robert Wood Johnson Foundation, 2002).

Because such a variety of players, roles and responsibilities exists, this report does not provide in-depth information about each of the above solution areas.  Rather, this chapter focuses on strategies that States have implemented to directly and indirectly affect the nursing pipeline, such as funding schools of nursing and supporting partnerships between programs and industry.

Policy Goals

Although there is no quick or simple remedy, States and their partners are finding ways to approach the problems.  State activities designed to improve the supply of nurses include the following major goals:

• Implement proven recruitment efforts to expand the available labor pool, including reaching out to nontraditional nursing students such as males and individuals from diverse racial and ethnic backgrounds;
• Expand the State’s institutional capacity to enroll and graduate an increasing number of individuals.  Expanding the nursing pipeline is a critical challenge in each of the five States, and the strategies range from faculty recruitment and retention to increased—or targeted—funding for nursing education programs to expand the number of slots available to nursing students; 
• Develop a sustainable nursing workforce.  Understanding the specific and dynamic issues relating to nursing supply and demand is critical for policymakers and others as they engage in workforce planning and resource allocation.  In addition to establishing processes for monitoring the workforce, States also are fostering public-private partnerships to promote a long-term solution; and
• Improve work conditions to aid in retention efforts.  States across the country passed numerous laws in an attempt to improve the nursing workplace, including whistleblower protections, minimum staffing requirements and mandatory overtime prohibitions.  Although these efforts do not directly affect the nursing pipeline, some argue that improving the job is a critical step in ensuring the success of recruitment and capacity-building efforts. 

States are involved in other ways, such as examining the regulatory requirements in place and their effect on the nursing workforce.  Given the States’ regulatory responsibilities, some are undertaking an assessment of certain laws and regulations (e.g., scope of practice and nurse practice acts) and are considering how these relate to the nursing pipeline, patient care and job satisfaction.

In addition, States are involved in promoting partnerships among educators, employers, State governments and regulatory bodies.  These partnerships are used in State after State for various purposes—to pool resources to expand the nursing pipeline, gather data and monitor the workforce, and seek long-term solutions to the nurse shortage problem.  In other words, promoting partnerships is a means to one of the ends listed above, not typically a free-standing goal.  The existence of partnerships will be seen in each of the strategies that follow.

I.  Expand the Available Labor Pool

States and their partners in industry and academia are implementing various measures to expand the potential labor pool of future nurses.  These activities include informing youth about nursing career options and promoting interest and understanding of the profession among a broad labor pool.  Some States also are targeting Federal and State resources to improve diversity by reaching out to minorities, disadvantaged students, immigrants, males, and dislocated and older workers.  Some specific concerns relating to expanding the labor pool include the following.

• Expand the overall supply of potential nursing students.  Under the broad goal of expanding the quantity of prospective nurses, States are engaging in recruitment efforts with middle school and high school students, displaced workers, retired workers and others who may seek a second career in nursing.
• Increase diversity in the profession so it more closely reflects the State’s demographics.  Although increasing the quantity of nurses is critical, many States also are attempting to influence the mix of the labor pool by reaching out to individuals from diverse racial and ethnic backgrounds.
• Train individuals from varied geographic areas, particularly underserved locations in rural and urban areas of the State.  Students—especially non-traditional students—tend to work where they live.  Therefore, training students who live in underserved areas promotes the State’s goals of an effective workforce distribution.

In short, expanding the nursing workforce involves a number of approaches—some aimed at simply increasing the quantity, and others that seek to influence certain characteristics within the labor pool, such as geographic distribution and gender, racial and ethnic diversity of the workforce. 

Objective: Expand access to nursing education by providing financial resources and support services for traditional and nontraditional students. 

The cost of receiving a nursing education is a barrier for many would-be nursing students.  This is especially true among non-traditional students, who tend to be older and more likely to have family and work responsibilities that make it difficult to pay for the high cost of a nursing education.  The average baccalaureate graduate has an educational debt of $14,600 from a public school or $16,100 from a private school. ^[1]   To alleviate this dilemma, the Federal government, States and the private and academic sectors are offering financial incentives—such as loan repayment programs, scholarships, tax credits, and even health insurance—to help ease the financial burden for potential nursing students.  Many of these incentives come with certain requirements to ensure that, to receive full benefits, recipients practice for a certain number of years or practice in certain shortage areas.  Specific examples follow.

Strategy I-A: Promote nursing careers to traditional and non-traditional students. 

In addition to promoting health careers to young people in elementary, middle and high schools, States and others in academic and private settings are launching outreach efforts aimed at youth in middle and high school and at nontraditional students, such as displaced workers, retired workers and others who may seek a second career in nursing.  In 2002, half of all States reported having initiatives in place to market health careers. ^[2]   Area Health Education Centers (AHECs) administered marketing programs in approximately 40 percent of States with marketing initiatives. The goal: to promote the nursing profession and educate prospective students about the various career paths available, including clinical practice in hospitals, schools and long-term care facilities, and about teaching, policy and research opportunities.

According to a report by the DOL Employment and Training Administration, among the workforce strategies with the “clearest impact” were youth programs that are developed and administered by partnerships of schools, employers, and nursing and public workforce entities. ^[3]

• Florida’s Nursing Shortage Solution Act set aside funds for grants to promote the nursing profession in middle and high schools.
• In Massachusetts, the Nursing Career Ladder Initiative, beginning in 2002, is charged with examining the nursing development infrastructure and bringing 1,000 individuals into the nursing pipeline.
• Currently, men represent only about 5 percent of the workforce.  To increase the ranks of male nurses, the Oregon Center for Nursing launched a poster campaign, “Are You Man Enough to be a Nurse?”  Other States are considering actions that would attract students of color, including certain financial and educational incentives such as transportation, child care assistance and tutoring.
• A Tennessee Independent Colleges and Universities Association (TICUA) commission recommended that the State appropriate funding to schools of nursing for scholarships and enable nursing students to enroll in TennCare for medical insurance.

Strategy I-B: Expand access to nursing education by providing financial assistance in the form of scholarships, stipends or loan forgiveness to potential students. 

States are redirecting existing funds—and, in some cases, finding new money—to invest in nursing education.  According to the American Nurses Association (ANA), more than 140 bills addressing nursing education were introduced in 2004, many of which would fund loan forgiveness and scholarships for nurses who pursue teaching or practice in underserved areas. 

In 2002, 38 States reported scholarship and loan repayment programs for health professionals; of those, 24 had programs specifically targeted to RNs, according to the Center for Health Workforce Studies at SUNY’s University of Albany.  Some examples are described below.

• The Florida Nursing Shortage Solution Act encourages nurses to obtain advanced training and provides $1 million in matching grants to hospitals that offer funds for nurse retention and recruitment efforts.
• Georgia almost tripled the amount of funds it makes available for service cancelable loans for certain health professions—from $1.1 million in 2000 to more than $3.1 million in 2003.  The number of students who participated in the program more than doubled from 2000 to 2002; 1,200 students participated in 2002, and another 250 were on the waiting list.  This program, run by the Georgia Student Finance Commission, not only helped to increase enrollment (enrollment was up in 2001 for the first time in eight years) but also encourages nurses to practice in Georgia to repay their loan. ^[4]
• Also in Georgia, the amount allocated to the Nursing Education Loan Repayment Program increased from $2.3 million in 1999 to $15 million in 2003. ^[5]
• Illinois legislation authorized scholarships for nursing students who pursue graduate degrees and agree to practice in underserved areas.
• In New York, the Regents Professional Opportunity Scholarship Program awards up to $5,000 per year for four years to racially diverse and/or economically disadvantaged State residents who are pursuing an RN degree.  Recipients must work for one year in the State for each annual reward received. ^[6]  
• Legislation in Pennsylvania created a one-time $3 million appropriation to establish a nursing loan forgiveness program administered by the Pennsylvania Higher Education Assistance Agency.
• A 1993 State law in Texas created a "health careers fund" to encourage high school students from underserved areas to consider careers in medicine, osteopathy, nursing and allied health. Students who participate receive education loans that are forgiven when they return to practice in their home communities on completion of training.

Examples of Federal and Other Funding

Each of the five study States received Federal funds for nursing workforce development.  The Nurse Reinvestment Act of 2002 (which amended the Nursing Education and Practice Improvement Act of 1998) distributed more than $140 million nationally in 2004 to help States recruit and retain faculty and students, promote diversity, and train more nurses in specialty areas. 

According to HRSA’s Divison of Nursing, preference is given to projects that benefit rural or underserved individuals and help meet public health nursing needs in State or local health departments.  The Nursing Education Loan Repayment Program helps RNs repay educational loans in exchange for work in critical shortage facilities.  The Federal funds ranged from $45,831 in Utah to $1.4 million in California.  Some examples of HRSA-funded projects include the following.

• With the help of two Federal HRSA grants, Clayton College and the State University in Georgia now have programs to combat rising failure rates among BSN students on NCLEX exams, language barriers, and declining preparation levels in math and science.  The university provides cultural competency training to faculty, offers mentoring experts to students, and arranges a 10-week summer opportunities program for high school students. ^[7]   In addition, the school opened admissions to full-time students in both the fall and the spring and allowed part-time students to enroll in the summer, which increased the diversity of applicants.
• Federal Workforce Diversity Grants provide scholarships or stipends to enable students to complete nursing education programs.  In 2004, workforce diversity grants totaled $16.4 million, and 20 grants were awarded.
• The Nursing Education Loan Repayment Program provides loan repayment to nurses with educational debt and ultimately forgives those loans in return for a commitment to work in facilities with a critical shortage of nurses.

Strategy I-C: Change the Way Nursing Education Is Delivered to Accommodate a More Diverse Population. 

Schools of nursing are making many program changes to ensure they are responsive to student’s needs and situations.  One obstacle to entering the nursing profession—particularly among individuals with family and work responsibilities—is the lack of convenient opportunities to attain a nursing education, particularly in rural and remote areas. 

Although schools of nursing are taking the lead to implement the projects, State and Federal resources are, in some cases, helping to support these innovations.  One concrete example is offering a nursing degree in a format that allows students to remain in their community and continue to meet work and family obligations.  Distance education, as well as more flexible tracks—including fast tracks and slow tracks—allow individuals in various situations to obtain a nursing degree.  Some specific examples follow.

• To address a severe nursing shortage in the central San Joaquin Valley, the Bakersfield College Nursing Program is collaborating with Porterville College and West Hills College to provide nurse training where it previously was not available—in the rural communities in southwestern San Joaquin Valley.  The Bakersfield Distance Education Program allows students to remain in their home towns to complete most of the course work.  The $883,800 initiative is funded through grants, collaborative partnerships with local health care agencies, and general funds from the colleges.  Student enrollment is limited to 10 students per year at each remote site for a total of 30 students in the program. ^[8]   Among program benefits are the new availability of the RN degree and the fact that many participants will choose to practice in their home community. ^[9]
• In Georgia, as described in Chapter Two, the Georgia Perimeter College’s Hybrid Fellowship Program combines face-to-face classroom instruction with on-line instruction, reducing classroom space requirements by 50 percent. ^[10]
• Chapter two described several efforts that are under way in the five States to streamline course requirements and facilitate transfers among schools and between educational levels.  In Texas, for example, a standard set of courses, known as the Field of Study Curriculum, helps students transfer without having to duplicate coursework. ^[11]

II. Expand Institutional Capacity

Each of the five States—along with others nationwide—struggle with insufficient institutional capacity.  As a result, they turn away significant numbers of qualified applicants who may not enroll elsewhere.  States may have increased interest in nursing, but if the pipeline is too small to accommodate the demand, those efforts may be wasted.  Expanding the size of the pipeline is a daunting task, given the numerous obstacles—including a worsening faculty shortage and limited financial resources—that make it a challenge to open new programs and expand existing ones. 

This section describes strategies States are undertaking to expand institutional capacity.  These strategies are divided into two main categories: those aimed at expanding the faculty workforce and those aimed at building the capacity of nursing education institutions.  The strategies include ways States can change funding practices to more directly benefit nursing education programs.  In addition to State aid, the Federal government is a significant funder of pipeline initiatives, providing grants and scholarships for faculty and student recruitment and retention.

The worsening faculty shortage prevents programs from expanding their class sizes.  Nursing programs have high instructor-to-student ratios and, therefore, a lack of instructors limits the number of students.  Moreover, according to the American AACN, nursing programs cited lack of faculty as a top reason for turning away qualified applicants.  Addressing this problem is likely the most critical need facing States.  Increasing faculty is a long process, given the length of time needed to complete a degree, and will require long-term investment by States, the health care industry and educators.

Numerous barriers exist to solving the faculty shortage.  Table 9 identifies some challenges and opportunities related to the faculty shortage. 

Table 9.  Addressing the Faculty Shortage: Challenges and Opportunities

Although the challenges are daunting, States across the country are channeling the above opportunities into strategies to expand the faculty workforce.  Some strategies used by States and the private and academic stakeholders are summarized below.

Objective: Expand the faculty workforce through recruitment and retention efforts. 

Strategy II-A: Fund scholarship and loan forgiveness programs for students who agree to pursue teaching.

To bolster the faculty supply, some States are targeting funds to recruit nursing students who intend to pursue teaching.  Some specific examples follow.

• Legislation was introduced in 2005 in Arizona that requested $20 million from the State over five years to expand nursing faculty.  This allocation would combine with a $20 million Federal investment for a five-year demonstration program to pay for new and existing nurse faculty at the State’s universities and community colleges.
• To increase faculty, Connecticut legislation requires the Department of Education to provide financial aid to certain community colleges that partner with hospitals that also have received private funding.
• As described in Chapter 2, with funding from the State Department of Labor and the Woodruff Foundation, Georgia provides funding for students to enroll in graduate level programs at public or private universities in Georgia.  For every year they teach in the State, they are eligible to cancel up to $2,500 in loans.  The result: over 5 years, this program has produced an additional 25 faculty who are geographically dispersed throughout the State.

In addition to State assistance through loan forgiveness and scholarship programs, employers and nursing programs are implementing numerous strategies to alleviate the faculty shortage.  Table 10 illustrates some strategies that employers and educators are implementing to alleviate faculty shortages.

Table 10.  Strategies Used By Employers and Academic Institutions

In addition to funding faculty recruitment and retention efforts, States also play a role in funding program expansion at schools of nursing.  Some approaches States and others are adopting are summarized below.

Objective: Maximize the existing infrastructure to see how it can be stretched to educate greater numbers of students.  In light of budget constraints, doing more with less is often a requirement.

Strategy II-B: Examine approaches that maximize the State’s collective educational resources. 

Many States are examining how they can more effectively and efficiently use all the State’s educational resources, including funding private schools of nursing, to enroll additional students and absorb some of the excess capacity.

• Legislation was introduced in Arizona in 2005 (HB 2385) that would allow community colleges to offer four-year baccalaureate degrees so long as they meet certain provisions.
• The California State Policy Committee for Nursing recommended that the State provide scholarship support for RN prelicensure nursing students who are enrolled in both private and public programs. ^[13]
• In Georgia, the Helping Outstanding Pupils Educationally (HOPE) Scholarship Program awards scholarships to students who are enrolled in private colleges or universities in the State.
• The Contract Education Program in Tennessee allows the State Higher Education Commission to contract with private institutions to address education needs that may be met more efficiently through the contract program.  Among the grants provided under the program are two $10,000 nursing slots at Vanderbilt University.  The program requires recipients to practice in-State for every year they receive the grant. 

Objective: Expand State nursing education programs as needed to meet the State’s current and expected demand. 

Nursing education funding methods include general revenue support for higher education institutions and formula funding arrangements that allocate funds based on factors such as student count, credit hours and degree type.  Other ways States fund nursing education include appropriating funds to nursing programs, targeting Federal and State funds to nursing education, and offering financial incentives for students to pursue nursing education (for a clinical or academic career). 

State funding can be used to expand existing programs or create new ones.  According to a report by Georgia’s Healthcare Workforce Policy Advisory Committee, “It is generally less expensive to increase enrollment capacity in existing programs than it is to make equivalent increases by beginning new programs.”  All States may not reach the same conclusion or may have reasons to build new programs, particularly those States where entry-level RN programs are not readily available throughout the State.  Nonetheless, this provides examples of how States are evaluating the best use of their limited resources.

Strategy II-C: Examine process for appropriating State funds to nursing education.

As described in Chapter 2, States use various methods to fund higher education.  Some States provide a block grant to the institutions of higher education and leave funding allocation to local institutions.  Others determine State funding based upon a formula that could include factors to help offset the higher cost of nursing programs.  In addition to these methods, some States are considering instituting a process to reward institutions that fulfill certain needs or public policy goals.  Some specific examples follow.

• The California Strategic Planning Committee for Nursing recommended that the State  “… directly support a State-determined RN pre-licensure class size and provide funds directly to programs rather than leaving decisions to fund nursing education to individual campuses.” ^[14]
• In 2002, the New Mexico Commission on Higher Education named a Blue Ribbon Task Force to evaluate the current funding method and recommend changes to reward successful institutions that are meeting the State’s economic needs.  The task force developed a Base-Plus-Incentives Funding Model comprised of several base or formula factors, including current appropriations, compensation and inflation.  In addition to the base funding, the formula would provide incentives to address the nursing and teacher shortage and would allocate funds to institutions through a competitive proposal process. 
• Virginia developed a similar funding formula that offers incentive funding for performance on outcome measures such as graduation and retention rates, exam passing rates, post-graduate placement and faculty productivity.

Strategy II-D: Invest additional State funding in programs that meet the State’s policy goals. 

Fund programs to help schools of nursing increase faculty, develop accelerated programs, provide scholarships to potential faculty, and develop competitive salaries.

• In California, where currently about 70 percent of nurses have an associate degree in nursing, the CSPCN recommended that the State take measures to change the mix of RN prelicensure students so that 40 percent of enrollments are in BSN and master’s-level entry programs and 60 percent are in associate degree in nursing programs. ^[15]
• In North Carolina, an AHEC-administered grant program provides funds to schools of nursing to develop new sites for clinical experiences, with a focus on shortage areas such as long-term care and rural and underserved locations in the State.  As a result of these funds, more than 160 new clinical sites have been developed. ^[16]
• As described in Chapter 2, Texas lawmakers in 2001 identified an existing $11.3 million in FY 2002 funds earmarked as Dramatic Growth Funds for normal enrollment increases. First claim on those funds was given to RN training programs that demonstrated from FY 2000 to FY 2001 increased contact hours above 5 percent for community colleges, increased weighted semester credit hours for universities above 3 percent, and increased student full-time equivalents for health science centers. An additional $11.3 million enrollment growth fund for FY 2003 was subject to the same first-claim priority for nursing programs that could demonstrate continued growth at twice the growth rates required the prior year, but calculated from FY 2000 to FY 2002. Consequently, up to $22.6 million could be spent on enrollment growth for professional nursing programs during the biennium, of which $1.5 million was specifically dedicated for this purpose.

Strategy II-E: Redirect existing State and Federal funds to nursing education programs. 

In times of tight State budgets, States are considering how they can target existing funds—from Federal and State sources—into nursing education. 

Redirect State Funds to Nursing Education.  Some States are directing portions of existing funding streams—a State lottery or State tobacco settlement proceeds—into nursing education initiatives.  Some examples are described below.

• The Georgia lottery funds the Helping Outstanding Pupils Educationally (HOPE) Scholarship Program, which was established in 1993.  Eligible Georgia residents who enroll in a State college, university or technical college may receive financial assistance for tuition and certain mandatory fees plus a book allowance; those enrolled in an eligible private college or university in the State may receive up to $3,000 annually.
• Nevada used some of its tobacco settlement funds to establish the Trust Fund for Public Health. In 2001, the Legislature appropriated funds from the trust fund to support a loan program for nursing students. The lesser of either 25 percent of the trust fund proceeds or $250,000 is appropriated annually for this loan program. In July 2001, the appropriation was $96,000.
• In Virginia, $1 million in tobacco settlement funds were recently appropriated by the legislature for undergraduate college education in the south and southwest parts of the State. Although some of these funds were likely to support nursing students, none of the funds were earmarked specifically for nursing education.

Redirect Federal Funds to Nursing Education.  According to a 2002 survey by The Center for Health Workforce Studies at the University of Albany, 7 States reported that they have health workforce training and education initiatives funded by Federal programs such as H-1B Visa Grants, Workforce Investment Act funding, Medicaid funding to support hospital-based clinical nursing education, and Temporary Assistance to Needy Families funding. ^[17]  

• In Arizona, the State uses WIA funds, tuition, State resources and private sector contributions to expand graduations by nearly 200 over two years and implement an accelerated BSN degree programs at 3 State universities. 
• In New York, the State departments of Health and Labor administer the TANF Health Worker Training Initiative, which provided up to $20 million for job training, recruitment and support services for TANF-eligible recipients.
• Also in New York, the departments of Health and Labor administered the Health Workforce Retraining Initiative, which made available up to $90 million to train or retrain health care workers in shortage fields such as nursing. ^[18]

Another source of Federal funding is the President’s High Growth Job Training Initiative.  This DOL initiative has invested Federal funds into collaborative projects in 12 shortage fields, including health care.  The goal is to promote collaboration among employers, employees, educators, community and technical colleges and the public workforce system.  The initiative has invested more than $24 million in health care projects to expand the pipeline, identify alternative labor pools such as immigrants and older workers, and enhance the capacity of educational institutions. ^[19]   For example, the Department of Labor’s Employment and Training Administration provided a grant of $1.5 million to the Maryland Governor’s Workforce Investment Board to provide 40 faculty scholarships to nurses who pursue teaching. 

Strategy II-F.  Encourage or direct institutions of higher education and State schools of nursing to achieve certain outcomes.

Given States’ often significant investment in higher education, many direct institutions to ensure that adequate resources reach nursing; some are prescribing that institutions divert funds to high-priority areas (such as entry-level master’s degree programs in California).  Some specific examples follow.

• In 2002, Arizona legislators passed a law that directed the State Board of Regents and community colleges to develop a plan to double the number of graduates from the State’s nursing schools by 2007. 
• In California, as described in Chapter 2, lawmakers passed legislation in 1999 that required the chancellors and presidents of the four higher education systems in California to develop a joint strategic plan to expand enrollment in basic RN education programs.  The California Strategic Planning Committee for Nursing submitted its report in 2000. 
• Also in California, the Legislature directed the chancellor of California State University to provide supplemental funds to universities to establish an entry-level master’s program in nursing.  The governor signed into law the Entry Level Master’s Nursing Programs Act in 2004.
• In 2001, Florida passed the Nursing Shortage Solution Act, which allows nursing programs to increase enrollment without approval from the board of nursing if the program has the necessary resources.

Other Strategies

Because of State budget constraints, public resources do not always meet current needs.  As a result, private and other funding sources are supporting program expansion in a number of ways (table 11).

Table 11. Strategies Used by Employers and Nursing Programs

III. Develop a Sustainable Workforce

Ensuring an adequate nursing workforce requires much more than simply increasing the number of RNs in the population.  Policymakers need consistent data to identify the most pressing needs, plan programs and evaluate the programs’ success.  This requires comprehensive State planning and data collection; leveraging funding and other resources; and developing adaptive workforce partnerships at National, State, and local levels.

Objective: Develop a process for gathering data and trends on the nursing workforce and using data to inform policy and workforce planning. 

According to the Center for Health Workforce Studies at the University of Albany, in 2002, 44 of 50 States reported that they convened task forces or commissions to study the health workforce shortage. ^[20]    Although most of these entities are temporary—formed to answer specific needs and inform State policy on those issues—some evolved into more permanent structures.  These coordinated planning approaches are needed to identify needs; set priorities; and build coalitions among public, private and academic groups. 

Strategy III-A: Develop a structure to obtain current information, inform policy, and have a sustained focus on nurse workforce issues. 

Some States have created such a structure through legislation, while others were led by State health care and hospital associations.  These entities are charged with answering various questions, such as the following:

• How is the State’s current nursing pipeline and workforce meeting the State’s and employers’ needs?  Does the State have enough BSN-trained nurses and, if not, how might the State increase baccalaureate graduations? 
• Where are the shortages most acute? If the State is short nurses in rural areas, what type of approaches will direct RNs to those high-demand areas?
• What are the gaps and overlaps in the current educational infrastructure?  What programs are needed?  What programs are succeeding in certain measures, such as retaining students and faculty?  What programs need sustained investments to meet the State’s and employers’ needs?

States can choose to develop a temporary commission, committee or advisory council to answer a specific set of questions or fulfill a need, such as conducting a needs assessment or survey.  In addition, some States have set up permanent structures within State government to monitor workforce trends, gather data and inform policymaking.  Some specific examples follow:

• In 2004, Connecticut legislation established a health care workforce policy board to make recommendations. 
• In Florida, the Center for Nursing was created by the Legislature in 2001 to address the nursing shortage and develop a strategic plan. 
• Illinois legislation requires the Department of Public Health to establish a nursing workforce database. 
• In Massachusetts, recommendations from the faculty shortage report included establishing a Center for Partnerships in Nursing Education, Research and Practice, which would support not only collaborations between employers and educational institutions, but also doctoral fellowships. 
• New Jersey appropriated $1.2 million to establish the New Jersey Collaborative Center for Nursing at Rutgers University.  The center works to improve nursing education, recruitment and retention. ^[21]
• In 2001, the New York State Board of Regents appointed a Blue Ribbon Task Force on the Future of Nursing to assess the nursing shortage and develop solutions and recommendations. ^[22]
• North Carolina’s State-supported agency, the North Carolina Center for Nursing, has provided continuous monitoring of health workforce supply and demand since it was created in 1991.  “As a result of the continuing work of these groups, North Carolina has been able to anticipate changing health care needs and address them in a timely fashion through various policy initiatives.  Consequently, the shortages … are less pronounced in North Carolina.” ^[23]
• Also in North Carolina, the Cecil G. Sheps Center for Health Services Research at the University of North Carolina collects health care workforce data and produces issue briefs, fact sheets, longitudinal studies and policy recommendations.
• Washington’s Workforce Training and Education Coordinating Board in 2002 convened, at the request of the Legislature, a Health Care Personnel Shortage Task Force to address the Statewide shortage of health care personnel. The task force was charged with identifying ways to increase education and training program capacity for health care personnel, improving student recruitment into health careers, and recommending modifications to State regulations and statutes to help alleviate the shortage.  With special attention to the nursing workforce, the December 2002 task force report to the Legislature calls on the State to provide additional funds to health care training programs to expand capacity, increase compensation to faculty, and expand clinical training opportunities.
• West Virginia’s Center for Nursing was created through legislation to establish a Statewide strategic plan.

In addition to creating structures such as a commission to assemble information and guide policy, 27 States and Puerto Rico report having some type of workforce data collection activities under way.  For example, the Indiana State Department of Health and Indiana Health Professions Bureau collaborated to implement the 2001 Indiana Registered Nurse Survey.  The survey provides information about the RN supply and about RN distribution within the State.  In addition to State agencies—departments of health or education and boards of nursing—other organizations such as State health workforce research centers and area health education centers (AHECs) gather data through provider surveys and other means. 

Strategy III-B: Develop partnerships to monitor the workforce and gather data.  In addition to analyzing health workforce data, these partnerships also convene meetings to discuss challenges and best practices.

A number of States received assistance from the Robert Wood Johnson Foundation Colleagues in Caring Project, which provided grants to States and regions to help them bring together stakeholders from State government, nursing schools, employers and professional associations, among others, to build “ … systems of work force development with the capacity to adapt to the rapid and continual changes in the nation’s health care system.”  The program was funded between 1995 and 2003.  Other examples of State approaches are the following:

• In North Dakota, a broad partnership (involving the Board of Nursing, nurse and health care associations, the State Department of Health and the State Center for Rural Health) worked to analyze health workforce data and trends.
• Also in North Dakota, the Board of Nursing contracted with the University of North Dakota Center for Rural Health to develop a nursing needs assessment to focus on certification, recruitment and retention. ^[24]
• The AHEC at Oregon’s Health Sciences University is conducting research on workforce data, with the support of the Northwest Health Foundation. ^[25]  

IV. Improve the Work Environment

About 30 percent of nurses said they were dissatisfied in their current job, according to a 2000 National Sample Survey of Registered Nurses (NSSRN).  Nurses who work in hospitals and nursing homes have an even lower job satisfaction level than all nurses.  Moreover, a 2001 American Nurses Association survey found that 75 percent of respondents believed that the quality of nursing where they work had declined during the past two years, and 56 percent said that the time they have for patients had decreased.

Policymakers and employers are taking steps to ensure a safe and positive work environment for nurses who already are in the workforce.  A number of States have made legislative changes, such as mandatory nurse-to-patient ratios, limits on mandatory overtime and guaranteed whistleblower protections. 

• According to the ANA, Connecticut and West Virginia enacted legislation in 2004 to prohibit a hospital from requiring a nurse to accept overtime (except under certain circumstances, as was the case in Connecticut).  In 2004, mandatory overtime legislation was introduced in Florida, Georgia, Hawaii, Iowa, Illinois, Massachusetts, Michigan, Missouri, New York, Ohio, Pennsylvania, Rhode Island, Tennessee, Vermont and Washington.
• In 2004, Florida, Hawaii, Illinois, Massachusetts, Rhode Island and Washington introduced legislation that would require certain health care facilities to develop nurse staffing plans.  In 2003, Nevada enacted legislation that requires a legislative committee to conduct an interim study on nurse staffing issues.  In 2002, five States—California, Kentucky, Oregon, Texas and Virginia—adopted legislation or regulations to require hospitals to use “valid and reliable” nurse staffing plans that reflect various factors—how sick the patient is, the experience of the nursing staff, and technology and support services available to nurses.
• A number of States—including Colorado, Hawaii, Iowa, Illinois, New Jersey, New York, Pennsylvania, Rhode Island and Tennessee introduced whistleblower legislation in 2004 (it was enacted in Vermont).  Whistleblower legislation, although it varies, typically protects workers who speak out against practices that threaten the quality of care patients receive.

In addition, some States are supporting career ladder initiatives, which are designed to help current health care workers upgrade their skills and education to move up the nursing ladder. According to the Center for Health Workforce Studies at the University of Albany (SUNY), in 2002, 14 States were developing or had developed health career ladder programs, and many provided career ladders for certified nurse aides. ^[26]   For example, the North Dakota Health Related Technical Skills Project provides career ladder training in nursing to entry-level workers in health-related jobs.

In addition to State-led strategies, employers and schools of nursing are taking steps to improve the quality of nursing (table 12).

Table 12.  Employer and School of Nursing Strategies to Improve Working Conditions

Conclusion

As Chapters 2 and 3 demonstrate, a wide spectrum of policy tools are available to States and their counterparts in business and education.  Although some involve significant financial investments, other strategies—such as developing a commission to study workforce trends—do not.  To determine the best mix of solutions, States must address the following questions.

• What are the State’s immediate needs and priorities and how should funds be distributed to reflect those priorities?  For example, if the State’s most critical problem is a faculty shortage, limited resources should be directed to expanding master’s and doctoral level enrollment and to offering scholarships and other incentives to future nursing faculty.  On the other hand, if the State’s top priority is expanding the number of BSN-trained nurses, solutions will more likely focus on funding new programs or helping existing ones expand or use technology to reach individuals in rural areas.
• How can existing State funds be targeted to more effectively meet the State’s long-term workforce needs?  The five States and others are finding ways to direct State and Federal funds into nursing education to achieve certain goals. 
  • Pooling Resources.  States are not only fostering collaboration among the various stakeholders, but they also are leveraging State resources with investments from their partners—a model in many States, including Georgia, where the Intellectual Capital Partnership Program brings together employers, schools of nursing and State funding and resources.  In addition to State funds, many States are finding ways to direct existing Federal workforce funding to nurse training.
  • Achieving Desired Outcomes.  States also are directing institutions of higher education and schools of nursing to achieve certain results with the State funds they receive.  Some States have required their universities and community colleges to work together to develop a plan for increasing enrollments and graduations.
• How can States create a sustainable nursing workforce?  States across the country realize that the problem requires more than funding to expand the pipeline.  Rather, the dynamic nature of the nursing shortage—and the various factors that affect supply and demand—often dictate a systematic approach to monitor the workforce.  States are creating entities such as commissions and advisory councils not only to gather and analyze data, but also to inform policymaking and workforce development efforts.

Through targeted efforts aimed at expanding the pipeline of incoming students, states are beginning to see increases in applicants, enrollees and graduates, as well as a more diversified student body.  However, despite these successes, states continue to struggle with finding ways to expand the capacity of their nursing schools to train and graduate more nurses.  At the heart of this problem is an increasingly serious faculty shortage that, left unchecked, is putting the brakes on state efforts to expand their nursing ranks.  States and their partners in the private and academic sector will continue to rely on each other to meet the many challenges facing them now and in the future.  These partnerships will be critical as states look for ways to expand and sustain a stable and qualified nursing profession.

[1].  Deborah Greene, Janet Allen and Tim Henderson, The Role of States in Financing Nursing Education (Washington D.C.: NCSL, October 2003), 5.

[2].  The Center for Health Workforce Studies, School of Public Health, University of Albany, State Responses to Health Worker Shortages: Results of 2002 Survey of States (Albany: SUNY, November 2002).

[3].  Alexander, Wegner & Associates, Health Care Industry: Identifying and Addressing Workforce Challenges (Washington D.C.: U.S. Department of Labor, Employment and Training Administration, February 2004).

[4].  Georgia Department of Community Health, Healthcare Workforce Policy Advisory Committee, What’s Ailing Georgia’s Health Care Workforce?  Serious Symptoms. Complex Cures (Atlanta: GDCH, August 2002).

[5].  Ibid.

[6].  The Center for Health Workforce Studies, School of Public Health, University of Albany, State Responses to Health Worker Shortages: Results of 2002 Survey of States (Albany: SUNY, November 2002).

[7].  Lydia McAllister, Clayton College and State University, (informal remarks at the National Conference of State Legislatures State Nursing Education Summit, San Diego, Calif., September 2003).

[8].  Bakersfield College, “BC Creates Partnership to Train Rural Nurses” (Bakersfield, Calif.: Bakersfield College, October 2003, news release), http://www.bc.cc.ca.us/marketing/news_releases/2003/October%202003/nurse.asp.

[9].  Joanne Spetz, University of California San Francisco, Center for Health Professions, phone interview by author, February 2005.

[10].  The University System of Georgia, “Regents Recognize ‘Best Practices’ Within University System,” (Atlanta: USG, November 17, 2004, press release), http://www.usg.edu/news/2004/111704.phtml.

[11].  Texas Legislature, Senate Subcommittee on Higher Education, “Request for Information From March 29, 2004 Hearing” (Austin: Texas Legislature, 2004), http://www.thecb.State.tx.us/HealthRelated/NursingShortageHearing032904.pdf.

[12].  Brenda Nevidjon and Jeanette Ives Ericson, “The Nursing Shortage: Solutions for the Short and Long Term,” Online Journal of Issues in Nursing 6 (January 31, 2001): 1. 

[13].  Karen Sechrist, Ellen Lewis and Dana Rutledge, Planning for California’s Nursing Work Force: Phase III Final Report (Sacramento, Calif.: Association of California Nurse Leaders, 2002).

[14].  Ibid.

[15].  Ibid.

[16].  The Center for Health Workforce Studies, School of Public Health, University of Albany, State Responses to Health Worker Shortages: Results of 2002 Survey of States (Albany: SUNY, November 2002).

[17].  Ibid.

[18].  Ibid.

[19].  U.S. Department of Labor, Employment and Training Administration, “Local Solutions with National Applications to Address Health Care Industry Labor Shortages,” department Web page, http://www.doleta.gov/BRG/Indprof/Health.cfm.

[20].  The Center for Health Workforce Studies, School of Public Health, University of Albany, “State Responses to Health Worker Shortages: Results of 2002 Survey of States” (Albany: SUNY, November 2002).

[21].  Ibid.

[22].  Ibid.

[23].  Georgia Department of Community Health, Healthcare Workforce Policy Advisory Committee, What’s Ailing Georgia’s Health Care Workforce?  Serious Symptoms. Complex Cures (Atlanta: GDCH, August, 2002). 

[24].  Ibid.

[25].  Oregon Center for Nursing, Oregon’s Nursing Shortage: A Public Health Crisis in the Making (Portland: Northwest Health Foundation, April 2001), http://www.oregoncenterfornursing.org/about/shortage.pdf.

[26].  The Center for Health Workforce Studies, School of Public Health, University of Albany, “State Responses to Health Worker Shortages: Results of 2002 Survey of States” (Albany: SUNY, November 2002).