Doctoring up the Nursing Profession

Several factors are contributing to the national nursing shortage, but initiatives, perceptions and college programs can nurture industry's growth

By Crystal L. Keels

For all the baby boomers who've embraced and adopted healthier lifestyles, including proper diet and exercise, there may be an even more compelling reason. If you get sick or become hospitalized, you may not have the critically needed services of a well-trained nurse.        
It's been widely reported that there is a nursing shortage in the United States, and it is expected to grow worse as the population increases and ages and new medical procedures are developed. Hospitals, nursing homes, adult-care facilities and home-care services will suffer increasingly, industry experts say, as the current trend seems likely to continue.
The U.S. Department of Health and Human Services (DHHS) projects a 29 percent shortage in registered nurses by 2020, compared to 2002, when the shortage was measured at 6 percent. The American Association of Colleges of Nursing (AACN) predicts that by 2020, 44 states and the District of Columbia will be affected by the dearth of registered nurses. And Trendwatch, a publication of the American Hospital Association, reported in 2001 that nursing career opportunities comprised 75 percent of national hospital vacancies. 
But does the nationwide nursing shortage reflect what's going on in colleges of nursing across the country? And how is the higher education community responding to this challenge?

Recruitment and Retention
According to reports issued by organizations including the U.S. Department of Health and Human Services, the American Association of Colleges of Nursing and the Health Resources and Services Administration, there are a number of factors such as lack of adequate funding, long hours and unfavorable working conditions contributing to the nursing shortage that arguably threatens the quality of national health care.
There are several other well-documented reasons for the growing scarcity. In spite of recent increases in the number of nursing students matriculating at the undergraduate level, enrollments fall short of both the current and the projected gap in the number of available caregivers. Additionally, many practicing nurses are now reaching retirement age.
"(A previous) decline in enrollment has resulted in a decline in the educational pipeline," says Lisa Fuller, program coordinator/advisor at the Wayne State University College of Nursing in Detroit.
To complicate matters even further, there are fewer people to educate would-be nurses, especially as nurse educators also move closer to retirement. In addition, nurses with Ph.D.s, who are qualified to teach, are difficult to find. As a result, qualified nursing school applicants are often turned away, and for those who make it through a bachelor of science in nursing (BSN) program, teaching in the academy may not necessarily be the goal.
"A lot of nurses are not interested in teaching," says Dr. Rosie Calvin, professor of nursing, principal investigator and director of the Jackson Heart TRAIN (Training for Research Awareness in Nursing) program in the School of Nursing at the University of Mississippi Medical Center in Jackson. "They can make more money doing things other than teaching. Not many are interested, or feel they can do it."
"It," in this case, is the pursuit of the doctoral degree that is required for nurse educators at the postsecondary level.
"You have to be in the market before you are in the market," says Dr. Clinton Bristow Jr., president of Alcorn State University in Mississippi, about recruiting doctorally prepared nurses. "You can't start looking in November for January. You've got to start a year or so in advance and do national searches," he explains.
 Nursing schools are now taking deliberate steps to address the complexities of the nursing shortage with an array of initiatives designed to attract more students at both the undergraduate and graduate levels, particularly those from underrepresented groups.
Historically, African Americans, as part of the underrepresented population, were not flocking in great numbers to become nurses, says Dr. Cornelia P. Porter, dean and professor in the School of Nursing at Florida A&M University. Porter says looking at the issue from a social psychological framework, nursing was not a field that African Americans were encouraged to pursue because of the perception that the profession perpetuated the type of servitude into which Blacks — particularly Black women — had historically been forced. Even now, Porter points out, the percentage of African American nurses in the United States is small, accounting for 4.8 percent of all registered nurses, according to the March 2002 National Sample Survey of Registered Nurses. (Data from 2004 are currently under analysis.) Alcorn's Bristow offers similar sentiments about the history of African Americans in the nursing profession, but adds that contemporary notions of the nursing profession have shifted to the point that many African Americans — male and female — now perceive the profession as a means for upward mobility.
And many educational programs see this and other underrepresented segments of the population as important resources for the future of the nursing profession.
At Wayne State University, for example, the Future Nurse Professionals (FNP) program was established with a grant from the King-Chavez-Parks Initiative from the state of Michigan five years ago.
"The university realized the critical need for retention for underrepresented minority students," explains Fuller, who created and developed the FNP program. "There is a great emphasis on the economically and academically disadvantaged to bring them into nursing at the entry level."
FNP participants are students with Pell grants whose SAT and ACT scores prohibit their entrance into the general nursing school population. Twelve to 14 applicants enter the FNP program as pre-nursing students and must complete a rigorous fall and winter program that includes chemistry and microbiology courses. Students have the benefit of tutors and learning specialists as they work toward admission into the first-year nursing program.
Fuller says the goal of the FNP program is to make sure pre-nursing students who might be at risk are successful by providing academic support and additional educational services including instruction in time management skills, test taking, money management, health assessment seminars, interactions with physicians and other activities designed to enhance their academic preparedness, as well as their confidence. "When their confidence levels are high, they don't drop out," Fuller says.
Part of the FNP program confidence-building strategy includes a mentorship component that has been successful, she adds, and is the only part of the FNP program that is open to all nursing students. A mentorship advisory board at Wayne State, including nursing faculty and nurses from the surrounding Detroit area, oversees this part of the program. Mentors are College of Nursing faculty, senior student nurses and nurses actively recruited from area hospitals who volunteer their services. Although mentoring is voluntary, participating nurses can use this activity as part of their professional development. Certificates are issued twice a year during a reception for mentors and their protégés.
"We have about 34 mentors, many who work with two or three students because they love mentoring, to see (the students) progress over time," Fuller says. "Students become more purposeful as well."
Producing culturally competent nurses able to work with diverse populations who can become nurse leaders is the ultimate aim of the FNP program. In May 2004, five female FNP program participants, four African American students and one Middle Eastern student, graduated from Wayne State, and next year another FNP cohort will do the same.  Fuller is now working on funding to make the FNP program institutional and at that point hopes to open FNP to all Wayne State nursing students, many of whom are now asking to participate. "We need to offer this to all of our students," Fuller says.
At the University of Mississippi, Calvin gives her perspective on the current nursing shortage.
"This is not the first time," says Calvin, who has been a nurse since 1976. "There have been three periods that we had shortages. This is the longest, though, and the worst."
Calvin explains that this shortage is complicated by the numerous options that have recently emerged for nurses.
Schools of nursing develop programs for the consumer, she says. "Forensic nursing has become popular because of "CSI" (the popular television series). Several schools are not focused on the more traditional bedside programs," Calvin says.
At the University of Mississippi Medical Center, faculty and administrators are employing a number of tactics in an attempt to alleviate the shortage. One method is a collaborative Early-Entry program with historically Black Tougaloo College, Jackson State University, and The University of Mississippi, among others, through which students are admitted to the University of Mississippi Medical Center after completing prerequisites.
"Students can be admitted now, will be followed and monitored and then come to the University of Mississippi for their junior and senior years," Calvin says. Once at the Universitiy of Mississippi, students also receive support like mentorship and tutors, as well as support from the Office of Multicultural Affairs, to help them adjust and succeed at a majority institution, and are also encouraged to pursue graduate school. "We are trying to develop similar programs with more colleges in the area," Calvin adds.
The Jackson Heart Study, a long-term, multi-institutional study of the factors contributing to cardiovascular disease in African Americans, the first of its kind in the nation, is another collaboration between University of Mississippi, Jackson State and Tougaloo, funded by the National Institutes of Health's Heart, Lung, and Blood Institute and the National Center for Minority Health and Health Disparities, that also serves as a means to recruit students into the health professions.
The Jackson Heart Study Undergraduate Training Center at Tougaloo College provides minority high school students and college students hands-on experience with investigative research and preparation for advanced studies in health professions and public health. In addition, The Jackson Heart TRAIN (Training for Research Awareness in Nursing) initiative is a summer program during which HBCU students spend nine weeks at the University of Mississippi Medical Center to participate in workshops to strategize degree completion and learn about pursuing more advanced degrees.
Calvin also reports that grass-roots, word-of-mouth recruiting strategies can work as well. University of Mississippi Medical Center faculty members, 10 of whom are African Americans with advanced degrees, have been taking the initiative to reach out to young people who are contemplating a nursing career.
"Every one of us started packing a box in the car," she says. "We give information to people if they mention an interest in nursing."
Calvin says she recently provided information to a young African American girl she encountered at the dry cleaners. "‘I want to be a nurse,' she said, so I went to the car, whipped out a brochure, a card and a catalogue," recalls Calvin, who is the 2004 recipient of the Association of Black Nursing Faculty in Higher Education Inc.'s Researcher Award. "I told her to try to make the best grades she can to be competitive." Calvin says that faculty members take every opportunity they can to promote the nursing program. "I've got to have a replacement at some point," Calvin says.
 
A Diversifying Profession
Dr. Joan Tilghman, associate dean for master's education in nursing at Coppin State University, in Maryland, says that nursing has traditionally been a female-oriented profession, like teaching, but "now young women are opting to explore other occupations." She adds that for those who are interested in pursuing a nursing career, the image of the nurse is shifting away from "bedpans and blood" to include community consultants, nurse practitioners who can work independently of physicians, and even textbook writers and journal editors. This type of diversification is beneficial, but certainly contributes to the shortage of bedside nurses and nurse educators who, Tilghman says, are primarily 40- to 55-year-olds.
"There is a shortage in general but hospitals may feel it more acutely," she adds. Many hospitals are actually recruiting foreign nurses from countries like Nigeria, India and Mexico to address staff shortages, which has also served as a source of controversy in the United States. A 2002 article in Nurse Week, revealed that some critics object to the importation of foreign workers when the capital and resources used to recruit those nurses could be used to improve opportunities in the United States, while others morally condemn the practice of luring nurses away from countries where they are sorely needed.
Tilghman points out, though, that some relief may be in sight as more men are considering and entering the nursing profession. In addition, people are pursuing nursing as a second degree.
However, a lack of faculty remains a significant contributing factor to the national nursing shortage. Coppin State Nursing School currently has vacancies for three full-time faculty positions. And although two nursing faculty members recently retired, Tilghman says even if they hadn't, more faculty would be needed to accommodate the school's increased enrollment to over 250 nursing students. Tilghman says that many nursing programs across the country actually have waiting lists because they cannot accommodate interested students. "Faculty salaries don't always mirror those of nurses who are not in the academy," she says.
Coppin State is undertaking an eclectic mix of measures to address these and other problems facing the nursing profession, Tilghman  says. Historically a teacher-training institution, part of the current mission of Coppin State is to reach the underserved urban community. In the case of the nursing school, that mission is manifested in a nurse-run community care facility, the Helene Fuld School of Nursing Community Health Center, established to provide health care services to surrounding urban communities. Nurses at the center offer holistic family health care for routine medical conditions. The center accepts many insurance plans and also offers income-based self-payment plans.
Tilghman says the center is doing well, especially as patients are less hesitant to seek medical care in their own communities where, she says, "People who look like you takes away the fear and distrust" that may keep some patients from seeking health care. "The center is very successful," she says and points out that there are few similar care facilities in the country. "We are able to do client-need research and are working to reach women incarcerated and released to meet health care and societal needs," she adds.
The Coppin State Nursing School has also established partnerships with more than 10 junior high and high schools in the Baltimore community in an attempt to create a pipeline of students interested in pursuing nursing as a career. And Tilghman also points out that the Nursing School has an on-staff recruiter to actively generate interest among potential students.

The Future of Nursing
Increased funding is obviously essential to address the problems that plague the nursing profession. The Nurse Reinvestment Act, signed into law by President Bush in 2002 and funded through 2007, is a federal response to the nursing shortage and includes grants, scholarships, loan cancellation programs and other funding mechanisms to entice people into the profession and increase educational initiatives. In July 2004, the U.S. Department of Health and Human services also announced grants in the amount of nearly $15.5 million for the Nurse Education, Practice and Retention Program, a Department of Health and Human Resources program intended to increase national enrollment in baccalaureate nursing programs and for the Nursing Workforce Diversity Program, a Health, Resources and Administration initiative designed to enhance diversity in the health care professions, as well as to provide access to those for whom health care has been lacking. At the state level, funding initiatives have been put in place in Michigan, Texas, and many other states to cover costs of tuition and fees for aspiring nursing students. Major corporations like Johnson & Johnson have also dedicated resources to help alleviate the current and impending shortages in nursing professions. Johnson & Johnson's Campaign for Nursing's Future entails a recruitment advertising campaign kicked off during the 2002 Winter Olympics, a Web site, scholarships and various outreach programs, all funded at $20 million over a two-year period.
Online courses are also being developed at institutions like Delta State University in Cleveland, Miss., says Dr. Lizabeth Carlson, dean of the school of nursing, making the pursuit of degrees in nursing more accessible and attractive for prospective nurse educators. The Delta State School of Nursing is part of a SREB online pilot program that began earlier this year for nurse educators, and the program now includes several students from Texas. Carlson adds that Delta State is the first in the nation to offer online nursing educator courses every semester.
Carlson also says that recruiting strategies for nurses must become more creative, and innovative partnerships must continue between hospitals, universities, corporations and communities. She adds that people with ties to their communities who are more likely to serve in areas where they live, especially minority groups and people of color, must be tapped.   
Community colleges are also a significant resource and source for addressing the future of the nursing profession. Miami Dade College, for example, reportedly produces more nursing graduates than any other institution in the nation. Furthermore, a report in Community College Week reveals that "community colleges graduate nearly six out of every 10 new registered nurses each year." But community colleges, like other institutions, also face difficulties from the impending increased shortage of faculty.
For the future, Wayne State's Fuller says to mitigate both the nursing educator and nursing shortages it is key to promote the pursuit of doctoral degrees in nursing — which was not necessarily a possibility a few decades ago. Previously nurses pursued doctorates in fields like higher education. Fuller says a Wayne State initiative, BSN to the Ph.D., will get more students to consider a doctorate in nursing. "If we are going to graduate more nurses," Fuller says, "we need to have more doctorally prepared nurses so they can teach. Nurses get the M.A. but don't often think about (pursuing) the Ph.D."
In her assessment of the nursing profession's future, University of Mississippi's Calvin says that it's uncertain whether the profession will ever return to its traditional bedside practices. To re-establish a significant bedside nursing presence in hospitals, Calvin says better working conditions, more manageable shifts and salaries competitive with those in emerging fields of nursing are essential.
She adds that it is important to increase the numbers of African American educators, nurses and faculty at historically Black schools as well as at majority institutions. "Students need to see others that look like them" as role models she says.
And although public perceptions of nursing have changed to a certain extent, Coppin State's Tilghman says further transformation is vital.
"It's a wonderful time to be a nurse," she says. "Many associate nursing tasks with being a nurse. An injection may be part of the function, (but) this (occupation) is science-based. Nurses are deeply schooled, deeply rooted in science and research, but people generally don't have that perception."