That there is a shortage of nurses in the United States today should surprise no one. The scope of the current shortage of nurses at the bedside is well documented. In a recent article in Health Affairs, Auerbach, Buerhaus and Staiger (2007) estimated that by the year 2020 the shortage of nurses in the United States may well reach 340,000. The American Association of Colleges of Nursing (AACN) cited a 2007 report from the American Hospital Association describing a national registered nurse vacancy rate of 8.1% amounting to 116,000 unfilled positions (American Association of Colleges of Nursing, 2008a). Failure to solve the shortage may have dire consequences for the people who entrust themselves to us for healthcare. Articles in the Journal of Advanced Nursing, New England Journal of Medicine and the Journal of the American Medical Association consistently cite the need for a staffing mix with a sufficient proportion of registered nurses to ensure better patient outcomes (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002; Tourangeau et al., 2007).
Although as nurses we are likely to agree that resources must be found to increase our overall numbers in the workforce, we certainly do not agree on the most appropriate educational preparation of the entry-level nurse. Recent studies have indicated that a higher proportion of baccalaureate-prepared nurses in the staffing mix lowers mortality rates for hospitalized patients (Aiken, Clarke, Cheung, Sloane, & Silber, 2003; Tourangeau et al.; Friese, Lake, Aiken, Silber, & Sochalski, 2008). Yet the percentage of nurses with a baccalaureate degree remains well below that of graduates of associate degree programs.
Exacerbating the nursing shortage is the concurrent shortage of faculty at our nursing schools. Over 42,000 qualified applicants were denied entry into baccalaureate and graduate nursing programs in 2006 because of insufficient numbers of faculty (AACN, 2008b). Obviously we cannot address the nursing shortage without also addressing the shortage of faculty in our schools. Hinshaw (2001) described the circuitous course of the shortage in a 2001 article in the Online Journal of Issues in Nursing noting, “The shortage of nurses requires the educational programs of the profession to supply more graduates. But the shortage of nursing faculty will limit student enrollments and likely decrease the number of graduates” (p.1). Over seventy percent of nursing schools responding to a 2007 AACN survey reported turning away qualified applicants from baccalaureate programs. These same schools reported a faculty vacancy rate of 8.8% equal to 2.2 vacancies per school. The vast majority of these vacancies were positions preferring a doctoral degree (AACN, 2008b). Contributing to the faculty shortage is the continuing failure to graduate sufficient numbers of nurses from master’s and doctoral programs. Livsey, Campbell, and Green (2007) cite AACN data indicating that despite an increase in the number of nurses enrolling in graduate programs, the graduation rate of doctoral nursing students has remained flat, averaging only 406 students each year from 1995 through 2005.
The federal government has long recognized the crucial position nurses hold in the healthcare system by supporting the funding of nursing education in the United States (US). For example, the federal government created the U. S. Cadet Corps in 1943 to provide support for nursing education (Willever-Farr & Parascandola, 1994). In 1963 the Surgeon General’s Consultant Group on Nursing identified an impending shortage of nurses and prompted Congress to pass the Nurse Training Act which added Title VIII to the Public Service Act. The Nurse Training Act provided funding in the form of construction grants for nursing schools, student loan programs, education grants, and traineeships for advanced practice nurses. The Health Professions Education Partnerships Act of 1998 created the National Advisory Council on Nurse Education and Practice (NACNEP) to advise the federal government on policy within Title VIII. In 2002 the NACNEP cited the need to ensure the availability of an adequate number of qualified nursing faculty to teach prospective students (Reyes-Akinbilege & Coleman, 2005). The Nurse Reinvestment Act of 2002 amended Title VIII to incorporate key recommendations of NACNEP including career ladders to recruit and retain nurses; nurse education, practice, and retention grants; internships and residencies; comprehensive geriatric education; nurse faculty loans; and the Nurse Scholarship Program. More recently, in 2005, nursing was added as an area of need under the Graduate Assistance in Areas of National Need (GAANN) program via the Higher Education Act allowing schools of nursing to fund research-focused doctoral students. Livsey, et al. (2007) cited a 2006 U. S. Department of Education report noting $2.4 million was awarded to 14 programs to support 57 nurses in doctoral programs.
Most currently, in fiscal year 2007, the Bureau of Health Professions in the Health Research and Services Administration (HRSA) awarded $37 million through a total of 134 education, practice, and retention grants to basic nursing education programs. Nine percent of the money was granted to associate degree programs, 25% to diploma programs, and 66% to baccalaureate programs. HRSA funds graduate nursing programs via the Advanced Education Nursing Program (AENP) and the Nursing Faculty Loan Program (NFLP). The AENP provided $57 million to 134 programs. However, only 25% of funding went to doctoral programs. The NFLP provided $4.5 million in loan repayment relief to 73 programs with 33% awarded to MSN programs, 62% to programs with an MSN and doctoral track, and only 5% to doctoral programs. The proposed budget for the current fiscal year will decrease funding to nursing education programs by 30% overall (Suzanne Begeny, personal communication, September 12, 2008).
Despite years of government funding of nursing schools we continue to suffer shortages within the profession. By our defining the current shortage of nurses in the US as solely a nursing or nursing faculty problem is to ignore its magnitude. It is indeed a much broader problem. The depth of the current nursing shortage and its impending expansion must be recognized as a public health emergency with implications for all Americans.
It is essential that we develop a clear plan to strategically inject funding into the education of nurses so as to increase the output of our nursing schools and strengthen the nursing workforce. Federal and state nursing education policy must reflect current evidence suggesting that it is time to focus especially on expanding baccalaureate and graduate degree programs. We authors contend, based on literature cited above suggesting a higher percentage of the baccalaureate-prepared nurses in the staffing mix lowers mortality rates for hospitalized patients, that federal funding should be directed to nursing programs culminating in the baccalaureate or higher degree. This would ensure both an adequate supply of qualified nurses at the bedside and a cadre of nurses prepared to continue their education in master’s degree programs that prepare them as advanced practice nurses, and especially in doctoral programs that prepare them to serve as future nursing faculty. Acknowledging that the majority of nurses enter practice through diploma and associate degree programs, and accepting that there is a need for these programs to continue bringing nurses into practice, we suggest that funding for diploma or associate degree programs be targeted to nursing programs that develop strong articulation agreements and career ladders that will serve as pipelines to facilitate their graduates’ progression into baccalaureate, master’s, and doctoral degree programs.
It is the responsibility of all nurses to ensure that funding for nursing education continues to be strengthened in the federal budget. As we struggle to alleviate the shortage of nurses, we must also struggle to reform nursing education policy by recognizing the added value of nurses prepared at baccalaureate and higher levels. If it is not possible for nurses to enter nursing practice at the baccalaureate level, a plan such as the requirement to obtain a Bachelor of Science in Nursing (BSN) degree within ten years of graduation, as put forth by New York Board of Nursing, would be appropriate. Nursing must come together to provide a unified front before federal policy makers. As Hinshaw noted in 2001, competing interests for the federal dollar may decrease the current relatively high priority level of nursing education on the national agenda. To adequately address the two-tiered shortage of both nurses and nursing faculty and to prevent a public health emergency, it will be necessary for nurses to inform Congress and the public with one united voice.
Greer Glazer, RN, CNP, PhD, FAAN
Charles Alexandre, RN, MS
Article published November 14, 2008