...nursing faculty shortages are a crisis at both the state and national levels.The Executive Board of the World Health Organization (WHO) has designated 2020 as the Year of the Nurse and Midwife (WHO, 2019), and in the state of Washington, nurses are at the table. For example, nursing faculty shortages are a crisis at both the state and national levels. “It takes an RN to make anRN. We need to get those in charge of higher education funding and compensationto recognize how desperate our state’s situation has become,” stated Bill Strader, CEO and Chief Financial Officer of Panorama, a retirement community located in Lacey, Washington (Strader, personal communication, 2019). The need to prevent nursing shortages and address them when they occur was originally identified by the Washington State Legislature when it passed RCW 18.79.202 in 2005 (Central Nursing Resource Center, 2005). This statute established a central nursing resource center for the state of Washington, currently known as the Washington Center for Nursing (WCN).

In celebration of the Year of the Nurse, we would like to share the success of Action Now!, an initiative that involved the work of many nurses, groups, individuals supportive of nursing in the state of Washington. This coalition achieved the top priority of obtaining a meaningful wage increase for nursing faculty who teach at state community and technical colleges. We share this in hopes that other states will act to secure a sufficient and diverse nursing educator workforce.

Action Now! began as a coalition of nursing leaders that expanded to include nursing employers, policy makers, and others. They, as separate organizations, noted the shortage in nurse educators. Without a solution, the consequence would be the inability of nurse educators to meet the demand for nurses in the workforce.

Action Now! began as a coalition of nursing leaders that expanded to include nursing employers, policy makers, and others.The Action Now! initiative was spearheaded by WCN, the statewide central nursing resource center; the Washington State Nursing Care Quality Assurance Commission (NCQAC), the state regulatory board for nurses (Washington State Department of Health, n.d.); and the Council on Nursing Education in Washington State (CNEWS), the statewide organization of deans and directors of Washington nursing programs. The Washington State Nurses Association; the Service Employees International Union (SEIU) Healthcare 1199NW; and United Food & Commercial Workers (UFCW) 141 Nursing Union provided analysis and strategic expertise to help secure the additional funding for nursing faculty salaries from the state legislature. This was key because the nursing unions had the ability to lobby the legislature and had existing relationships at the state capitol. As not-for-profit organizations, neither the WCN nor CNEWS are permitted to lobby, due to funding and capacity constraints. The NCQAC also had limitations on lobbying. Ultimately, support from these unions led to a new appropriation of $40 million to increase nursing educator salaries by the state legislature. The article describes vision and implementation for Action Now!, our successes and lessons learned, and the effort to move forward with ongoing challenges to identify and address barriers in nursing education.

Background: An Environment of Opportunity

...asserting that faculty shortages at nursing schools across the country are limiting student capacity at a time when the need for professional registered nurses continues to growThe American Association of Colleges of Nursing (AACN) recognizes a nursing education shortage, asserting that faculty shortages at nursing schools across the country are limiting student capacity at a time when the need for professional registered nurses continues to grow (AACN, 2019). According to national data, Washington State nursing programs turn away an estimated 34% of qualified applicants (NLN, 2017).

The Washington Health Sentinel Network, a quarterly workforce survey of employers of all health professions recognized by the National Bureau of Labor Statistics has reported prolonged vacancies for Certified Nursing Assistants, Licensed Practical Nurses (LPNs), Registered Nurses (RNs), and Advanced Practice Registered Nurses (APRNs) in a variety of practice settings statewide (Gattman, 2018). Since its establishment in 2016, employers report exceptional vacancies for these healthcare providers across a variety of facilities (Gattman, 2018). When completing the WA Health Sentinel Network survey, employers are asked the question “…recently (in the past few months) have you had exceptionally long vacancies…” (Skillman, 2016). Exceptional vacancies are defined as vacancies that are longer than expected (S. Skillman, personal communication, December 12, 2019) and are considered an indicator of shortage. 

Exceptional vacancies are defined as vacancies that are longer than expectedThe Sentinel Network noted that nurse educators have higher than usual demands, including increased program array and numbers of students enrolled, and an ongoing increase in service requirements. In addition, new specialties, such as psychiatric/mental health nursing, are growing in demand. Educators are also increasingly required to acquire expertise in simulation and the need for simulation coordinators and faculty lead has grown. Existing nurse educators also spend significant time mentoring new faculty (Aragon & Skillman 2018).

Other efforts at the federal and state levels highlighted the need for a stronger healthcare workforce. Funded by the Centers for Medicaid and Medicare Innovation, the Healthier Washington Initiative is the state plan to redesign the healthcare system to achieve better population health, reward high-quality care, and curb healthcare costs. WCN was invited to participate in the Healthier Washington Initiative efforts to strengthen the overall health workforce of the state and increase access to equitable care.

Other efforts at the federal and state levels highlighted the need for a stronger healthcare workforce.In sum, the nursing workforce is clearly a key workforce to transform Washington State’s health system to meet the needs of our aging and demographically shifting communities. However, it was obvious that while we had an environment of opportunity, there were challenges to improving outcomes. To move forward, we needed more information.

The Crisis in Nursing Education: Further Analysis

First, we worked to clearly define the crisis.For years, the WCN provided staff and collaborated regularly with the CNEWS to advance nursing education. However, it was clear that the complexity of this crisis required a change in structure from narrowly focused groups addressing the problem on an individual basis, to convening a broad group of stakeholders. First, we worked to clearly define the crisis.

In 2008, the WCN published “A Master Plan for Nursing Education in Washington State” ([MPNE]; WCN, 2008). This plan included a set of state-specific recommendations to address the nursing shortage. The plan outlined steps to ensure the supply of a more highly educated nursing workforce and to provide quality care to an increasingly diverse, growing, and aging population. A status update on Washington’s MPNE (WCN, 2014) found the following areas of continued focus since the original 2008 plan:

• Assuring the continued competency of nursing professionals
• Assuring an adequate supply of nursing professionals
• Enhancing educational access throughout Washington State
• Promoting a more diverse nursing workforce

The most frequent reason for nurse educators to consider leaving was for higher pay, followed by lack of a manageable workload In response to growing concerns by CNEWS about the rapid turnover among deans and directors of nursing, the WCN saw an opportunity to study and quantify their concerns. In December 2017, leaders at the WCN surveyed nurse educators in the state of Washington and published their results (Aragon & Ellis, 2017). The most frequent reason for nurse educators to consider leaving was for higher pay, followed by lack of a manageable workload (Aragon & Ellis, 2017). Alarmingly, the survey reported that 70% of Washington nursing education administrators identified at least one faculty vacancy in their nursing program. The survey went on to report:

• Approximately 40% of Washington nursing faculty report being dissatisfied or very dissatisfied with their income.
• Reflective of workload, faculty work an average of 50 hours per week when school is in session, and 20 hours per week when school is not in session.
• Thirty eight percent of community and technical college faculty and 40% of four-year college and university nursing faculty expect to be retired by 2027.

While updating the administrative rules for nursing education prior to 2016, the NCQAC also heard several challenges faced by the nursing education community, specifically:

• Clinical practice experiences
• Faculty qualifications, preparation, and salary issues
• Program resource issues
• Academic progression for all levels of nursing education

These challenges became the basis of our Action Now! strategy. Figure 1 illustrates additional challenges identified by nurse faculty employed in Washington State.

Figure 1. Washington State Nursing Faculty Challenges 2017. (used with permission)

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Meanwhile, some nursing education programs reported to the NCQAC that they would not be able to admit as many students as planned, due to a shortage of faculty (M. Schaffner, personal communication, October 3, 2018). Washington State nursing schools already lack space for qualified candidates as an estimated 34% of qualified applicants to nursing schools are turned away (NLN, 2017).

...some nursing education programs reported... that they would not be able to admit as many students as planned, due to a shortage of faculty In addition, 29% of RNnursing programs hired new nurse administrators. (M. Schaffner, personal communication, October 3, 2018). High turnover created concerns of instability in administration of nursing programs and can hinder program function. NCQAC was also increasing the number of granted faculty exceptions, commonly known as waivers. Such waivers permit nursing schools to hire faculty who hold a Bachelor of Science Degree in Nursing (BSN) but lack a graduate degree, asrequired by the nursing education rules set forth by Washington Administration Code 246-840-529 (Wash.Admin.Code, 2016).

The NCQAC then requested that the WCN work with them to convene a “Solution Summit.” The goal of the summit was to obtain greater public input to address the four key problems facing nursing education as identified by the NCQAC: faculty concerns; academic progression; clinical experiences; program resources (as listed above in detail).

This was a time when the Institute of Medicine (IOM), “The Future of Nursing: Leading Change, Advancing Health,” (2011) report proclaimed a national call to advance nursing education so that nurses have access to and are enabled to succeed at the baccalaureate and graduate levels. A press release announced a new initiative called Action Now! to tackle these challenges and transform the state’s nursing education system (WCN, 2018).

The Action Now! Vision and Implementation

The overarching Action Now! vision was to improve challenges in nursing education to secure the future of a healthier Washington. Action Now! leaders set out to work with key stakeholders to develop priorities, strategies and initiatives to:

• Ensure quality practice experience for all nursing students.
• Create a stronger and more diverse faculty and nursing leadership pool.
• Establish sustainable financing for nursing programs.
• Provide opportunities for nurses to advance their education.

This section will describe the Action Now! steering committee development and priorities in greater detail.

A One Project Approach
Our consultant assisted the three organizations to identify and craft a framework to capture their mutual goals.The WCN first contracted with a consulting firm. Our consultant assisted the three organizations to identify and craft a framework to capture their mutual goals. The coalition identified a common thread between the MPNE and the proposed Solutions Summit as both projects were seeking solutions to complex problems in nursing education. As the central nursing resource center, the WCN, along with CNEWS and NCQAC, are the leading authorities on nursing issues. Together, leaders from these factions decided to form a new time-limited, concentrated, initiative called Action Now! to streamline and avoid duplication of efforts to address the mutual goal of strengthening nursing education.

A steering committee was formed with co-leads from the three founding organizations: the Executive Director of the WCN (first author); the then President of CNEWS; and the NCQAC Associate Director for Nursing Education, Licensing, & Research (fourth author). The third author of this article assumed a co-lead role in the group when she replaced the retiring President of CNEWS.

The WCN secured grant funding to hire additional staff for the growing body of its work, including Action Now!. WCN also provided additional staff for financial management of the project, event planning for the Summit, convening space, remote conferencing, fundraising support, and other services as needed and as resources allowed.

Strategies for Implementation
The coalition steering committee concentrated on four complex issues, or “big rocks” facing nursing.The coalition steering committee concentrated on four complex issues, or “big rocks” facing nursing. Members had previously identified that these four priority core issues were obstacles to produce a nursing workforce in Washington State to serve our growing and changing communities. We ultimately formally defined these issues as a lack of quality practice experiences for all students; a nursing faculty shortage due to inability to recruit and retain nurse faculty and/or administrators that emphasize diversity; nursing education funding that fails to keep pace to sustain programs; and a lack of opportunity for nurses to advance their education. After agreeing upon the Action Now! initiative as the strategy, we developed these as stated priorities; identified strategic imperatives; and created action plans. Figure 2 illustrates the strategy map we used as a framework to implement the project vision. This section will briefly discuss each of these individual strategies.

Figure 2. Action Now! Steering Map (used with permission)

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More residency and preceptorship programs are needed for nursing studentsPriority #1: Quality Practice Experiences for all Nursing Students. Nurses need the ability to provide care in a variety of settings. Currently, there is an alarming shortage of clinical placement experiences and clinical faculty to teach the practice of nursing. (WCN, 2008). More residency and preceptorship programs are needed for nursing students (Aragon, Bear, & Schaffner, 2018). The NCQAC recently revised the nursing education rules to allow up to 50% simulation in clinical placement (Wash. Admin. Code, 2016). However, no school in Washington has yet to achieve that level of use of simulation technology.

To frame the nurse faculty priority, we worked to learn lessons from salary increases in state government. Priority #2: Faculty Recruitment and Retention. Prior to Action Now!, all nurses working in state agencies and institutions received a 26.5% salary increase in July of 2017. At that time, no increase was provided for nurses who teach in public higher education (Kohel, 2018). To frame the nurse faculty priority, we worked to learn lessons from salary increases in state government. Action Now! invited state employees involved in the planning and implementing of the pay increase to present to the steering committee. In particular, this strategy provided the Action Now! steering committee with information about how to build the case for increasing nurse educator pay with the use of data.

Priority #3: Sustainable Financing for Nursing Programs. Financing for nursing programs encompasses more than nurse faculty pay. However, after convening through two years, Action Now! leaders determined that nurse faculty pay was the top priority on an individual and systemic level. Nurse faculty pay in educational institutions lags compared to other forms of nursing practice (WCN, 2008). This is a barrier to attracting the best-qualified faculty. A healthy pool of the best qualified faculty is necessary to meet demand so that programs can admit more students, who then graduate to practice nursing in different settings and roles. These graduates become nurse educators, nurse practitioners, researchers, and organizational leaders. As an example of one strategy to research potential funding sources, a subcommittee of Action Now! studied the approaches of other states.

Nurse faculty pay in educational institutions lags compared to other forms of nursing practice Priority #4: Academic Progression for All Nurses. Health needs are changing. Nurses must be prepared to deliver increasingly complex care and have skills to lead healthcare into the future. The IOM report (2011) recommended an increase in the percentage of nurses with a BSN or higher degree to 80% by 2020, as well as increasing the number of graduate-level prepared nurses. In addition, a bachelor’s degree is required to pursue advanced degrees in nursing and for key nursing leadership roles.

Washington State has made significant progress, propelled by strong partnerships formed over the past few years among community colleges, four-year colleges, and universities. The WCN has received grants to boost academic progression in nursing from the Robert Wood Johnson Foundation from 2012-2016. At a national level, the WCN is a founding partner in the National Education Progression in Nursing Initiative to promote academic progression for nursing at all levels nationwide (NEPIN, 2019) and to promote academic progression for nursing at all levels nationwide help ensure our nation’s population has access to high-quality, patient-centered care.

Action Now! Successes and Lessons Learned

Our Successes
The work of Action Now! leaders to address the nursing faculty shortage in Washington State has resulted in a new appropriation of $40 million to increase nursing educator salaries by the state legislature. This investment reflects an approximate 26.5% increase in salary, is aligned with salary needs estimated by the Action Now! steering committee, and directly resulted from advocacy by a coalition of nursing unions.

Securing sustainable financing for nursing programs was among the top goals set by the Action Now! coalition...Securing sustainable financing for nursing programs was among the top goals set by the Action Now! coalition when it was formed in 2016. The goal of increasing salaries is to address nurse educator recruitment and retention issues, and to ensure that Washington State can fully enroll the currently open nursing student opportunities that are unfilled due to lack of nurse faculty. With an aging population and a strong demand for more nurses, ensuring we can graduate the maximum number of nursing students is critical to our state’s healthcare system.

The Workforce Education Investment Act, Washington State House Bill 2158 (2019), directly addresses what nurse educators have consistently found as the most challenging issue associated with faculty recruitment and retention: pay that is dramatically lower than what first year nurses earn in a hospital setting and in direct care settings. Beyond nurse faculty raises, two-year and technical schools are using funds from House Bill 2158 (2019) to reinforce nursing programs by adding needed nursing faculty and expanding LPN, ADN, and simulation programs.

Lessons Learned
Shared governance among nursing organizations with different missions, roles, and culture in the nursing community is not easy to create, but is necessary to success. Maximizing or building on the strength of each organization is key.

Maximizing or building on the strength of each organization is key. As the state nursing workforce center, the WCN worked with CNEWS to survey the Washington State nurse faculty population. The survey was adapted from the Oregon Center for Nursing nurse faculty survey (Allgeyer & Bitton, 2017). It is important to disseminate the findings from such surveys to support the efforts for improvement. Thus, the results were published in December of 2017 (Aragon & Ellis, 2017).

Yearly, NCQAC collects and reports data from approved nursing education programs across the state. Reports included important data that reflected the number of full and part time nurse faculty; retirement rates of nursing faculty; demographics; and other characteristics of nurse educators and nursing schools.

CNEWS is an organization of deans and directors of schools of nursing in community and technical colleges and four-year colleges and universities. For many years they met regularly to share challenges and offer support to each other. A troubling trend the group observed was the high rate of turnover in their organization. To address this concern, one of the co-leads specifically studied dean and director turnover. The results indicated a potentially negative impact to student NCLEX scores. (S. Bear, personal communication, December 1, 2016).

...one of the co-leads specifically studied dean and director turnover.The union faction of WSNA, SEIU Healthcare 1199NW, and UFCW 21 were collectively known as the nursing coalition at the state legislature. There, they coordinated legislative advocacy around numerous health workforce issues, including nurse faculty salaries. Using information provided from the Action Now! Steering Committee, they crafted a brief document stating the needed legislative appropriation and justification for the dollars. They also crafted a question and answer sheet in anticipation of questions from lawmakers. This coalition was important to achieving funding to significantly increase faculty salaries, as discussed above.

Moving Forward with Ongoing Challenges

Policy Challenges
While House Bill 2158, the Workforce Investment Act (2019), was a tremendous victory that provided $40 million in funding to increase salaries by 26.5% for community college faculty. It is now important to address compensation for nurse educators in four-year colleges and universities so as to not create inequities between these two systems. The unintended consequence of salary inequity is increased recruitment and retention of students for nursing programs in community and technical colleges, but not for programs in four-year colleges and universities.

The success of Action Now! has created support for two additional initiatives... The success of Action Now! has created support for two additional initiatives; academic progression for LPNs to a BSN and recruitment and retention of diverse nurse faculty. The WCN received a planning grant to support a workgroup of nurse educators, higher education policy makers, and interested stakeholders to create a blueprint for a direct transfer agreement for LPNs to pursue a BSN degree. The WCN also received a two-year implementation grant to expand workshops for nurses seeking to become professors. These workshops, designed for practicing nurses and promising nursing students of underrepresented groups, increase awareness of and encourage nurses to consider a career in nursing education. The workshops provide an overview of the requirements and the work life of nurse educators in community colleges, four-year public colleges and universities, and private four-year colleges and universities. While nurse faculty representing diverse backgrounds also agree that compensation is the greatest barrier to recruitment and retention, an intentional focus on the unique issues facing diverse nurses is needed.

The priority related to quality practice experiences will remain on the list... In revising the two remaining priorities, the steering committee decided that the most imminent focus is equitable compensation for the four-year colleges and universities. The priority related to quality practice experiences will remain on the list, allowing the coalition to identify opportunities to pursue this goal.

Continued Stakeholder Engagement
Action Now! steering committee and workgroup members committed tremendous time and energy throughout the two years of their gathering. Inevitability, work demand and turnover necessarily changes the composition of the coalition. Action Now! leaders sent an e-mail to workgroup members acknowledging accomplishments and the end of the first chapter of this work, thanking them for their partnership. In addition, stakeholders were asked to respond with details about their area of focus in the initiative and the most important priorities from their perspective. We have received some feedback, such as how the vision for Action Now! will continue related to further promoting completion of the BSN degree.

Communication within the Action Now! coalition will include ongoing efforts to address the four “big rocks,” or significant barriers. The WCN and NCQAC will continue to take the lead to assure continued data collection about the nursing workforce. While data are collected by the NCQAC, the WCN provides the analysis and reports to describe specific characteristics of the nursing workforce. In addition, the WCN and the University of Washington Center for Health Workforce Studies collaborate to monitor trends in nursing workforce demand noted by employers. CNEWS is a key forum for nurse educators to take leadership to improve and strengthen nursing education with nursing partners and key stakeholders to prepare future generations of nurses.

Conclusion

A handful of survey respondents were in their 70s, demonstrating that this is a career with potential for longevity. A positive finding of the WCN 2017 Washington State nurse educator survey (Aragon & Ellis, 2017) is that these educators enjoy professional satisfaction, especially when it comes to relationships with students, colleagues, management, and professional autonomy. A handful of survey respondents were in their 70s, demonstrating that this is a career with potential for longevity. As more and more faculty approach retirement, it is crucial for leaders in nursing education to be able to increase recruitment and retention of the next generation of faculty. Nursing education is an attractive career choice which is ideally pursued for workplace satisfaction, and should not be deterred by inadequate compensation and unmanageable workload. The efforts of the Action Now! coalition have made important strides to address their identified barriers in nursing education and hope that the discussion of our initiative will prove useful to others with similar goals.

Authors

Sofia A. Aragon, JD, BSN, RN
Email: sofiaa@wcnursing.org

Sofia Aragon is the Executive Director for the Washington Center for Nursing. The WCN is the state nursing workforce and resource center advancing nursing leadership, diversity, and workforce development for LPNs, RNs, and ARNPs. She is also the Immediate Past President of the National Forum of Nursing Workforce Centers. Her previous roles include Senior Governmental Affairs Advisor for the Washington State Nurses Association, representing the legislative interests of registered nurses, the School Nurse Organization of Washington and Advanced Registered Nurse Practitioners United of Washington State. She also serves on the board of directors of the WA Low Income Housing Alliance to address homelessness and affordable housing in WA State and on the board of Asian Pacific Americans for Civic Empowerment, which works to elevate the civic engagement of API residents. She earned a Bachelor of Arts degree in Economics from the University of Washington, a Bachelor of Science in Nursing degree from Seattle University and a Juris Doctor from Loyola University-Chicago School of Law.

NOTE: The acronym ARNP is used in Washington State (Central Nursing Resource Center, 2005, § 4 ).

Gerianne M. Babbo, EdD, MN, RN
Email: Gerianne.babbodoh@doh.wa.gov

Dr. Babbo has been a nurse educator for the past 28 years, serving as a tenured professor and Associate Dean of Nursing at Olympic College. Dr. Babbo led the team for the first RN-BSN program in the community college setting in Washington State, and the third in the nation. She is currently the Director of Nursing Education for the Nursing Care Quality Assurance Commission of Washington State.

Sarah J. Bear, EdD, MSN, RN, CNE
Email: Sarah.bear@doh.wa.gov

Dr. Sarah Bear is a Nursing Education Consultant for the Washington State Department of Health Nursing Care Quality Assurance Commission. She has a broad range of nursing education experience in the community college, private university, and public university settings. Her area of research includes exploration of factors contributing to retention of academic nursing program dean and directors. Dr. Bear’s clinical practice included hospice, medical surgical, and emergency department nursing.

Mindy L. Schaffner, PhD, MSN, RN, CNS
Email: maschaffner@ensignservices.net

Dr. Schaffner has served in public policy administration and administration for over thirty-years. She has held positions in nursing education and at the time of this writing was the Associate Director of Nursing Education for the Washington State Nursing Commission. She continues her work in healthcare by now serving as a Clinical Consultant in long-term care services.

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