Whatever became of RNs?

The crisis in nursing staffing has become one of the perennial issues in long-term care. Approximately 15% of all authorized RN positions in long-term care consistently have gone vacant. And the situation is getting worse.

These grim statistics appear in the April 2005 final report of the National Commission on Nursing Workforce for Long-Term Care. The American Health Care Association (AHCA) organized the National Commission in 2003 after Congress failed to act on legislation that would have established a federally funded commission on the topic. Staffed primarily by faculty of the Wertlieb Institute of Long-Term Care at The George Washington University, the commission was tasked "to develop recommendations for practical steps at the national, state and local levels to recruit and retain a skilled, dedicated, and experienced nursing workforce...."

The commission does a credible job of reporting the seriousness of the nurse staffing crisis. It points out that the work of the nursing staff is the primary determinant of nursing home quality of care, and that high labor costs, high turnover, and high recruitment costs for nurses are some of the most persistent barriers to achieving quality-of-care targets. The report cites one study that suggests SNFs should be providing an average of 0.75 hours of RN care per patient day rather than the more modest average of 0.4 RN hours achieved in 2004.

However, the commission's report fails to explain how and why the nursing shortage has occurred. It briefly mentions "[s]alaries that are lower than the salaries of alternative professions ..." as a contributing factor. AHCA's longtime warnings about the continuing "crisis" of Medicare reimbursement have been based on the assumption that increasing salaries for nurses will go a long way toward solving the staffing shortage. It's possible the theory has some validity: The "bonus" Medicare payments of the past three years have coincided with some increase in RN staffing.

Even so, increased Medicare payments to long-term care facilities won't cure the fundamental problems facing nursing as a profession in the United States. Very simply, although starting salaries in nursing are higher than starting salaries for other college graduates, fewer Americans are studying for nursing careers. According to the American Association of Colleges of Nursing (AACN), 96,438 graduates of U.S. nursing programs sat for the NCLEX-RN examination in 1995. By 2001, only 68,709 candidates sat for the same examination. Although the numbers have begun to climb slightly, the United States is still producing fewer graduates preparing for RN positions today than it did ten years ago. The largest drop has occurred among students preparing for the BS in nursing: from 31,000 in 1995 to under 25,000 in 2001. The reasons for this are complex--in some cases, motivational, with fewer young people finding nursing to be an attractive career option, and in some cases financial, about which more in a moment.

During the 1990s, the long-term care industry coped with the shortage of newly graduated American nurses by recruiting nurses from overseas. This option has lost some of its appeal, however, because American healthcare facilities are now competing for healthcare workers with newly wealthy healthcare facilities in the Middle East and East Asia. Graduates of nursing schools in the Philippines who once had the choice of working in the United States or in their home country are now recruited for positions in Kuwait, Singapore, and other locations with less stringent visa restrictions.

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Ultimately, the solution for the long-term shortage in nursing staff must rely on getting more Americans to enroll in nursing education programs. AACN has pointed out, however, two serious barriers to this solution. First, there is a desperate shortage of faculty for nursing programs. Many state universities and colleges have shut down nursing degree programs because of a lack of teaching staff, while others have had to greatly restrict the number of applicants admitted to programs. Second, rising tuition costs place four-year nursing programs beyond the reach of many qualified low-income high school graduates. Need-based college loans mean that students from middle-income families can expect less help from the government in paying for nursing education.

None of the "best practice" solutions offered by the National Commission on Nursing Workforce for Long-Term Care addresses the reasons--either financial or motivational--for the shortage of new graduates qualifying for RN positions. The commission suggests "partnerships with local community colleges ... to help develop a quality long-term care workforce," but the examples provided in the report focus on developing CNAs and LPNs, not RNs. Even a Medicare reimbursement "fix," whether temporary or permanent, is unlikely to help attract more American high school students to the possibility of a career as an RN.

So where does the solution lie? There are members of Congress who are aware of the origin and nature of the nursing shortage, and who are willing to enact legislation that would have a long-term impact on the number of Americans pursuing a BSN. In 2001, for example, Republican Sue Kelly of New York introduced the Nursing Employment and Education Development (NEED) Act, which would have provided scholarships for several hundred deserving low-income students to pursue a BSN degree, as well as additional incentives to recruit and retain nursing school faculty. Kelly's legislation had majority support in the U.S. Senate but was never granted a hearing in the Republican-controlled House of Representatives.

In every congressional session since 2001, bills similar to Kelly's legislation have been proposed. Some would provide scholarships for nursing school students, while others would grant student loan forgiveness for graduates of BSN programs who worked in appropriate healthcare facilities. One version of this legislation in the most recent session attracted 65 Republican and Democratic cosponsors. In every case, however, the bill was assigned to an apparently unmotivated House subcommittee.

The reforms and "best practices" described by AHCA's National Commission are worth a look because they address important questions of in-service training and retention. But the growing shortage of RNs won't be resolved through interagency collaboration and partnerships, and it cannot be fixed over the long term by recruiting nursing graduates of Third World colleges. Congressional leadership needs to make a modest investment in national preparedness for future healthcare needs by enabling more Americans to enter and complete four-year nursing school programs. It may not solve the motivational problem but could be highly effective against today's financial barriers.

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Long-term care is hardly a static field. New clinical guidelines and government regulations are being introduced constantly--often on a daily basis. To better provide readers with the latest happenings in long-term care, Nursing Homes/Long Term Care Management has decided to move all of its news coverage to its Web site, www.nursinghomesmagazine.com. There you will find--refreshed daily--the latest releases from trade associations and up-to-date news relevant to the field.

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