Nevada shortage of hospital staff nurses.

STATEMENT OF PROBLEM/ISSUE #1

Nevada has an inadequate supply of registered nurses (RNs) to meet in-hospital demand.

Recommendations

1. Establish a Nevada Center for Nursing to study and make recommendations to address the hospital nursing workforce shortage. This would allow the legislature to take steps to increase the supply of hospital nurses based on the Center's findings.

2. The NHA could work with its member organizations to improve the workplace environment for hospital based nurses, including encouraging them to obtain American Nurses Credentialing Center Magnet designation, increase wages to meet housing and cost of living challenges, and address nurse-patient ratios to meet safe staffing recommendations.

Facts/Background

1. The US Health Resources and Services Administration's (HRSA's) Bureau of Health Professions identifies the following Nevada counties as having a nursing shortage, based on data from the American Hospital Association (http://bhpr.hrsa.gov/ nursing/shortage.htm): Humboldt, Lander, Lincoln, Lyon, Nye, Pershing, White Pine. Note that this list does not include either Clark or Washoe counties.

2. According to a University of Nevada Reno report for the Nevada Hospital Association (NHA), between 2000 and 2004, the Nevada population grew from approximately 2 million people to 2.5 million. Licensed medical surgical beds grew from 1.85 to 1.93 per 1000 population during that time period, while occupancy rates stayed constant at 64%. http:// www.nvha.net/papers/hospitalcontributions.pdf

3. A 2005 survey of Nevada RNs by the Medical Education Council of Nevada (University of Nevada Medical School) found that there were 20,494 persons licensed as RNs in the state in 2004 (http://www. nvha.net/papers/nursesurvey.pdf). Of these, about 15,000 were residents of the state. Approximately 66% resided in the urban south. Although the number of RNs grew between 1999 and 2004, the number per capita has declined due to rapid population growth. Rural areas have the worst per capita statistics. Only 25% of respondents to the survey reported getting their original license in Nevada; most came from other states. Slightly more than half (58%) of the RNs were employed in inpatient care; this parallels national statistics. Approximately 9% held a master's or higher degree. Less than a third of hospital-based nurses (29.8%) reported being "very satisfied" with their jobs compared to nearly half (47.7%) of RNs not employed in hospitals. An estimated 16% of southern Nevada nurses reported dissatisfaction with their jobs versus 8.6% in northern Nevada and 9% in rural/ frontier areas.

4. The etiology of nursing shortages is complex. Some reasons for the national bedside nursing shortage include:

* Sweeping layoffs of RNs by hospitals in the 1990s as cost-cutting moves; those RNs found alternate employment and have not returned to the bedside.

* More prestigious, better paid professions opening up to women in the 1980s

* Failure of state and federal legislatures to fund expansion of nursing education programs

* Wages that have not kept pace with inflation and the cost of living

* Rapidly increasing elderly population increasing the demand for hospital care

* Poor working conditions and risk of injury in hospital environments discourages RN employment in those settings.

5. In addition to the above, some Nevada-specific reasons for the bedside nursing shortage include:

* Rapid increase in housing costs making this state unattractive for RNs to stay after graduation or to relocate here. For example, according to the National Association of Home Builders in 2006, Las Vegas ranked 168th out of the 199 regions in housing affordability, which means those earning a median income of $58,200 can afford to buy only 16% of the single family homes sold in the first quarter of 2006. http://www.reviewjournal. com/lvrj_home/2006/Sep-03-Sun-2006/ opinion/9364632.html

* RN wages have not increased to reflect the cost of living in Nevada. According to a 2004 study of average RN salaries adjusted for cost of living, Nevada ranks 21st in purchasing power. (Texas is ranked #1, Washington State #3, Utah #5, Oregon #11, Colorado #14, Arizona #16, and California #44.) http://www.ga.unc.edu/NCCN/research/ quickfacts/Salary%20adjustment%20table.pdf

* Job dissatisfaction with hospital work, particularly in southern Nevada, where a unionized RN labor action just occurred, reportedly over nurse-patient ratios.

* Lack of any American Nurses Credential Center Magnet-designated hospital in Nevada. Magnet designation indicates a facility is an employer of choice for RNs. (There are only 5 other states that lack a Magnet hospital: Arkansas, Delaware, Mississippi, New Mexico, and Wyoming.)

* Lack of any legislature-designated Center for Nursing, similar to ones set up in many other states (see below) to address nursing workforce issues.

* Legislative inattention to providing adequate resources to expand state-funded nursing schools

* Rapid increase in the state's population, particularly the elderly who need more medical care, increasing the demand for hospital services

* Perception of unsafe nurse-patient ratios. A recent survey of new Nevada RN graduates found that 57% of respondents had left their first position in nursing by 2 years. "Patient care issues, such as unsafe nurse-patient ratios, were perceived as the most negative aspects and the most frequent reason for leaving." Bowles, C., & Candela, L. (2005). Journal of Nursing Administration, 35(3), 130-7.

6. Centers for Nursing. Many state legislatures concerned about the impact of bedside nursing shortages on the health of their residents have established and funded centers to conduct research and make recommendations on nursing workforce issues; e.g.,

Mississippi Office of Nursing Workforce: http://www.monw.org

North Carolina Center for Nursing: http://www.nursenc.org/about/mission.htm

Florida Center for Nursing: http://www.flcenterfornursing.org/

Oregon Center for Nursing: http://www.oregoncenterfornursing.org/

Washington Center for Nursing: http://www.wacenterfornursing.org/

Michigan Center for Nursing: http://www.michigancenterfornursing.org/about.cfm

STATEMENT OF PROBLEM/ISSUE #2

State Senator Joe Heck has stated he will file a Bill Draft Request that would either require or allow schools of nursing in the state to employ BSN-prepared RNs as clinical faculty without going through the current Nevada State Board of Nursing's (NSBN's) waiver process.

Recommendations

Nurses would view the Nevada legislature as supportive if it avoided passing statutes that over-rule or weaken the standards set by the NSBN.

A new Nevada Center for Nursing (see above) could make recommendations that would support and encourage more master's and PhD-educated faculty in the state.

Facts/Background

1. Allowing BSN nurses who are currently at the bedside to leave to become teaching faculty will only worsen the hospital nurse shortage by robbing Peter to pay Paul.

2. The National Council of State Boards of Nursing's Model Nurse Practice Act stipulates that all professional nursing faculty members have graduate degrees. Nevada would be out of compliance with this national standard if by legislative fiat, its Nurse Practice Act and rules are changed.

3. Such a legislative action will further worsen the climate for RNs in Nevada, as it takes away the right of nursing to regulate and set standards for itself.

4. Lowering the education requirement for nursing faculty may put accreditation of the state's nursing schools in jeopardy. For example, the National League for Nurses (NLN), an accrediting body, asserts that the nurse educator role requires specialized preparation beyond a baccalaureate degree, which is considered an entry level degree. The NLN states: "There is specialized knowledge and preparation that is essential for practice as a nurse educator." http://www.nln.org/aboutnln/PositionStatements/ prepofnursed02.htm To be a Certified Nurse Educator, applicants must hold a graduate degree in nursing.

5. The legislature's role is to enact laws that are progressive, not ones that lower standards in a state that already compares poorly to other states for health outcomes.

INTERIM EDITOR'S COMMENT:

In recent months, several stakeholders in the state's registered nurse (RN) workforce have identified specific issues affecting the sufficiency of the supply of RNs to meet the needs of hospitalized Nevada residents. The Nevada Nurses Association presents below its comments on those issues, as well as recommendations it supports. NNA believes nursing can be a formidable force to ensure this growing state continues to have an adequate supply of the most trusted professionals-nurses. Betty Razor RN, BSN, CWOCN