Introduction

The current nursing shortage comes as no surprise to nursing leaders in California. Nursing work force forecasts completed by the California Strategic Planning Committee for Nursing (CSPCN) predicted the current and continuing shortages (Sechrist & Lewis, 1996; Sechrist, Lewis, & Rutledge, 1999). The identification of the problem resulted in public policy action by CSPCN members to obtain additional funding for nursing education. Other initiatives address nursing program articulation and competency-based role differentiation.

The purpose of this article is to summarize nursing shortage issues in California and describe the role of CSPCN in addressing the issues from a public policy perspective. Reasons for the development of CSPCN as well as goals, objectives, and phases of work are presented. Selected findings from CSPCN's 1999 synthesis of data on the demand for and supply of nurses as well as resulting recommendations are summarized. The role of CSPCN in public policy initiatives is described. This information can be useful to others who intend to address public policy issues involving nursing supply and demand regionally, nationally and internationally.

Shortages of Nursing Personnel

Reports of impending and actual shortages of registered nurses (RNs) as well as other nursing personnel appear frequently in the California and national press (Gray, 1997, 1998; Griffith, 1998; Kagan, 1999; Kucher, 2000a; "Nurse Shortage: More Nurses Needed," 2000; Rose, 1999; Ruh-Means & Hacker, 2000; Stewart, 1998; Valcke, 1999). Factors contributing to California's nursing shortage include changes in the healthcare environment that resulted in downsizing of the nursing work force as a result of managed care, the aging nursing work force, and public policy regarding nursing education. As a result, California ranks 50^th in the nation in number of RNs per 100,000 population (Moses, 1997). The current shortage is termed a "public health crisis" owing to a projected shortfall of 25,000 nurses within the next five years (California Strategic Planning Committee for Nursing [CSPCN], 2000; Educating California's Future Nursing Work Force Report, 2000). Finding 25,000 additional nurses over the next five years only maintains the status quo (Sechrist, Lewis, & Rutledge, 1999). Others also project the need for additional RNs in California (Coffman & Spetz, 1999). However, one report, based on an analysis of previous shortages, indicates that the problem is one of distribution rather than supply (Seago, Ash, Grumbacher, Coffman, & Spetz, 1999).

California cannot easily obtain additional RNs by increasing out-of-state recruitment. Half of the RNs working in California already are educated in other states or countries (State of California, Department of Consumer Affairs, Board of Registered Nursing, 1999). The shortage is occurring in other states and the educational pipeline, especially at the baccalaureate level, is decreasing nationally (AACN, 2000a). Recruitment efforts aimed at increasing enrollments in California programs are problematic. Until recently, all RN pre-licensure nursing education programs were fully subscribed, many with waiting lists of up to four years. Additionally, the number of RN pre-licensure nursing education enrollment opportunities have decreased slightly over the last 10 years rather than increasing to keep pace with increases in population (CSPCN, 2000; Sechrist, Lewis, & Rutledge, 1999).

Need for Baccalaureate Preparation

While nursing shortages are not new, the current situation differs from past shortages. Not only is the shortage in number of nurses, the educational preparation of nurses is inadequate to meet the demands of today's health care system. Employers demand more baccalaureate prepared nurses for hospitals and specialty nurses for intensive care units, operating rooms, emergency rooms, and other specialized areas of acute care (Nelson, 1997; Sechrist & Lewis, 1996; Stewart, 1998; Sechrist, Lewis, Rutledge, 1999).

Only 60% of California's nurses practice in hospitals. The remainder are practicing in community settings such as out-patient clinics, home care, public health, and non-traditional case management settings (State of Callifornia, Department of consumer Affairs, Board of Registered Nursing [BRN], 1990, 1993, 1997). These practice settings need nurses prepared with at least the baccalaureate for the knowledge and skills necessary for service in the community. Yet, approximately 70% of nurses in California received their initial education at the associate degree level and of these, only 16% return to school for the bachelor's degree in nursing (BRN, 1997; Sechrist, Lewis, & Rutledge, 1999). Advanced practice nurses such as nurse practitioners, nurse anesthetists, nurse midwives, case managers, and clinical specialists are also in demand. These nurses have at least a master's preparation and practice in a variety of settings.

Faculty Shortage

In addition to the nursing work force shortage, there is a dangerous shortfall of nursing faculty nationally. Most baccalaureate and higher degree nursing programs across the country are experiencing a lack of well-prepared nurse educators. The faculty is aging and educational programs are in fierce competition with industry for nurses who hold advanced degrees (American Association of Colleges of Nursing [AACN], 2000b). The same scenarios are present in California (Sechrist, Lewis, & Rutledge, 1999). At least a master's degree is required for clinical instructors and a doctorate is required for teachers in baccalaureate and higher degree programs. This situation is ominous, as it is the faculty who prepares the nurses for the future; and even if additional students are recruited for the profession, schools of nursing will be hard pressed to provide educational programs.

Development of CSPCN

As a result of the nursing shortage in the late 1980's, the California State Legislature appointed the RN Special Advisory Committee charged with developing recommendations to increase the supply and utilization of RNs. One of the recommendations called for establishment of statewide "master plans for nursing manpower and education" (RN Special Advisory Committee, 1990). At the same time the report was released, California experienced an economic recession with a downsizing of nursing staff in hospitals. The profession and the public perceived that a shortage no longer existed. Therefore, there was little interest or effort in pursuing the recommendations of the RN Special Advisory Committee to prevent future nursing work force shortages.

A group of California nurse leaders, however, recognized the need to address the master planning recommendations. They met and founded the California Strategic Planning Committee for Nursing (CSPCN) in 1992 to specifically address nursing data and master planning issues. Today, there are over 35 organizations continuing to contribute to the initiative.

Goal and Objectives

CSPCN has as its goal the development of reliable data for public policy and resource allocation decisions to meet California's need for nurses.

Objectives to meet this goal are:

• Develop and maintain a dynamic forecasting model to predict the nursing work force California's people will need for their health care
• Develop a strategic plan to ensure the supply of nurses meets the demand
• Implement the strategic plan.

Organization and Financial Support

CSPCN is a virtual organization. It has no by-laws or formal officers. The organization was founded with seed money from the Association of California Nurse Leaders (ACNL) and a matching grant from Foundation Healthplan (FHP). Sponsoring organizations send representatives to meetings at their own cost. The organizations and agencies also provide released time and significant in-kind support for CSPCN activities. The University of California, Irvine provides project space, computer access and web hosting (see www.ucihs.uci.edu/cspcn). ACNL provides fiduciary management. Funding for the CSPCN Principal Investigator and other costs come from significant donations from the involved organizations and agencies.

CSPCN also received funding from The Robert Wood Johnson Foundation as one of twenty collaboratives funded under the initiative, Colleagues in Caring: Regional Collaboratives for Nursing Work Force Development (see www.aacn.nche.edu/CaringProject/index.htm). A special project related to revising California's plan for educational mobility was funded by The Helene Fuld Health Trust (Fox & Welch, 1999).

Phases of Work

To accomplish the goal and objectives of CSPCN, the work was divided into three phases. During all three phases, activities in support of public policy initiatives have occurred.

Phase I. The first phase focused on development of a dynamic work force forecasting model to measure the need for nurses. The model is multivariate and includes actual numbers of nurses in practice and in the educational pipeline, employers' intentions to hire nurses, and educators' intentions to enroll and graduate nurses (Figure 1). Although the original goal was to forecast work force demand five years hence, industry respondents indicated that they were only able to provide data for the current year and intended data for one to two years. Owing to the rapidly changing health care system and managed care, it was impossible for employers to project intended employment of nursing personnel five years into the future. The findings from the 1996 and 1999 surveys demonstrate accuracy for these time spans (Sechrist & Lewis, 1996; Sechrist, Lewis & Rutledge, 1999). The first Nursing Summit under the sponsorship of CSPCN and the California Board of Registered Nursing (BRN) was held in 1996 when approximately 600 nurses from California assembled to hear and discuss the findings from the 1996 report. At that time, a group of nurse leaders developed a position paper to represent the beliefs that nurses hold regarding health care (California Strategic Planning Committee for Nursing, 1996). Its major points are presented in Figure 2.

Phase II. The second phase of the CSPCN initiative focused on a master plan for nursing education and practice based on the findings of the work force survey. Both the 1996 and 1999 reports demonstrated the need for additional nurses and more baccalaureate and higher degree prepared nurses. A group of CSPCN members formed the Education Industry Interface Work Group whose charge was to develop a collaborative model for preparing nurses to meet health care needs. This group reviewed the literature and contributed their perspectives on nursing practice and education. A competency-based role differentiation model was developed for the licensed vocational nurse (LVN), the registered nurse (RN) and the advanced practice nurse (APN). The major roles of the nurse are provider, advocate, teacher, care coordinator, and supervisor. Within these roles, competencies are listed for varying performance levels including novice, competent, proficient, and expert.

A draft of California's Framework for Competency-Based Role Differentiation (Framework) Fox, Walker, & Bream, 1999) was presented at a second Summit of California nurses held in 1997. Nearly 800 nurses attended and presented their ideas and reactions to the framework. At the third Nursing Summit held in 1999, findings from the second nursing work force forecasting survey and the final version of the Framework were presented.

Phase III. The third phase of CSPCN's work includes: 1) evaluation of the utility of the competencies for education and practice; 2) synthesis of the next set of data; and 3) creating an ongoing mechanism to continue collecting and analyzing data regarding the nursing work force within a state agency. The competencies are scheduled for study at three alpha demonstration sites in Spring 2001 located in northern, central and southern California. The demonstration sites are tri-partnerships comprised of representatives from an associate degree program, a baccalaureate nursing program, and a health care agency.

Synthesis of Nursing Demand and Supply Data

CSPCN is a reliable source of data about the nursing work force in California. All of the activities of CSPCN are data-driven in that they are an outgrowth of findings from the data processes. The Strategic Planning Model (Figure 1) indicates the data sources and types of data required for the strategic planning process.

Data on the intention to employ RNs with varying educational backgrounds, LVNs and unlicensed assistive personnel (UAP) and data on the intention to enroll students in educational programs were obtained twice by CSPCN (Sechrist & Lewis, 1996; Sechrist, Lewis & Rutledge, 1999). These data were synthesized with the other data sources available in the state and nationally.

A summary of selected findings related to the demand data for RNs and LVNs and supply data for RNs from the 1999 report are presented in Table 1. The summary of findings related to the demand for RNs and LVNs includes state and federal projections for nursing demand, vacancies and intended increases from employers of nurses, as well as specific demand for RNs with baccalaureate and higher degrees. RN supply data provides indicators of the relationship of Californi

a RN supply to federal supply and the educational pipeline to provide for additional RNs. Recommendations resulting from the data synthesis are presented in Table 2.

CSPCN Policy Initiatives

The CSPCN leadership continues to work toward reaching the goal "to develop a master plan for nursing education and practice in California that will assure an adequate nursing work force to meet the health care needs of its people." Policy initiatives have been undertaken with mixed success. Efforts have been directed toward providing for ongoing data processes and support for additional nursing education opportunities.

In 1998, a bill sponsored by State Senator Richard Polanco was introduced into the California Legislature. Its purpose was to assure continuation of the forecasting model and to meet work force demands through an adequate education system. Representatives from CSPCN, the Board of Registered Nursing, the Board of Licensed Vocational Nurses and Psychiatric Technicians, professional nursing organizations, state educational systems, and industry testified on behalf of the bill. The bill was passed through both houses of the Legislature. However, then Governor Pete Wilson, vetoed the bill.

Targeted Funding for Nursing Education

In 1999, another attempt was made to secure funding. The Scott Bill, AB655, was introduced requiring the chancellors and presidents of the California Community College, California State University, the University of California, (CSU) and the Association of Independent Colleges and Universities to issue a joint report with a recommended plan and budget for increasing the number of nurses graduating from nursing programs in California and providing specialty training for RNs. The bill passed and Governor Gray Davis signed it in October, 1999.

Through the leadership of the Board of Registered Nursing, a "Scott Commission" was formed and met several times in the winter of 2000. There were representatives from CSPCN, the four education systems, industry, the boards of nursing, and professional organizations. The report of the Commission was submitted to the Governor and the Legislature with recommendations for financial support to state-supported institutions and increased financial aid for nursing students enrolled in private schools. Included were recommendations for recruitment into nursing and a master plan for state supported schools. It was also recommended that the work force forecasting model be institutionalized and housed in the Board of Registered Nursing (Educating California's Future Work Force Report, 2000; CSPCN, 2000). The recommendations with funding were included in the final budget but were vetoed by line item by Governor Gray Davis. In comments regarding the deletions, the Governor's aides for education indicated that the Governor continues to support current practices of regional decision-making for allocation of education monies rather than directed funding allocations.

Scholarship Funds

Funding efforts will continue in order to provide critically needed additional nursing education opportunities in California through all the systems. The Legislature and the Governor approved increases in scholarship aid to all eligible high school graduates in the coming year's budget. These scholarships are known as CalGrants. This action is an incentive for potential nursing students planning to attend private, independent colleges as well as state supported schools. However, additional educational opportunities are needed.

Unwilling to wait for legislative action, nurse leaders in San Diego created a $1.3 million dollar partnership between industry and education to double enrollments at San Diego State University. Six hospitals or health systems will contribute $70,000 each over three years to support the addition of six instructors and enrollment of 120 additional students (Beresford, 2000; Kucher, 2000b).

Recruitment

There are several additional initiatives underway in the state that require future political action on the part of the interested parties. The Coalition for Nursing Careers in California (CCNC) is an apolitical organization of nurses and other interested parties that focuses on recruitment into nursing (see www.cncc.org/faq.html). It is active in publicizing the nursing shortage and its related public health crisis and has a liaison with CSPCN. CNCC also collaborates with national initiatives and campaigns to recruit people into nursing.

Articulation Agreements

Plans are underway to improve articulation agreements among licensed vocational nursing (LVN), associate degree (ADN), and baccalaureate programs to foster continuing education for LVNs and ADNs (Fox & Welch, 1999). The CSU and the community college systems are developing one master plan of articulation among their programs to enhance direct transfer of ADNs into baccalaureate programs. It should be noted that most independent colleges with RN programs have programs for nurses to easily transfer credits or receive credit for previous education and experience. To assure success with these initiatives, it becomes imperative that CSPCN enlists the aid of consumers to increase the chances of realizing its ultimate goal for a master plan to meet the health care needs of the people of California.

Conclusion

During the last decade of the 20^th century, CSPCN developed a dynamic strategic planning model to evaluate the future need for nurses. The multivariate model is a successful forecasting model; it has been adopted or adapted by approximately half of the other Colleagues in Caring nursing work force initiatives in other states. Data resulting from the survey and synthesis processes inherent in the model resulted in legislative initiatives to obtain funding for nursing education and served as the basis for other CSPCN initiatives.

Based on the findings from two surveys for an increased demand for baccalaureate and higher degree prepared nurses, CSPCN developed a competency-based role differentiation model. Its purpose is to delineate differences between experience and educational levels in the nursing roles of care provider, care coordinator, manager of care, health care teacher, and advocate. Currently, CSPCN plans three alpha demonstration sites across California to test the utility of the Framework in the clinical practice and education settings. The demonstration sites are comprised of a tri-partnership of associate degree programs, baccalaureate programs, and health care agencies. Students, staff nurses, and faculty will be involved in the partnerships (see www.ucihs.uci.edu/cspcn).

CSPCN and its colleagues must continue the political action necessary to recruit nurses into the profession, increase the diversity of the workforce, continue support for state schools, increase scholarships for students enrolled in private schools, and develop smooth articulation plans for LVNs and ADNs to continue their education. It is important for it to include consumers into the initiatives to insure that the people of California receive the best of nursing care from an adequate and well-prepared nursing work force.

It will probably take another decade to realize the goal. Although it took many years, CSPCN's political action through building coalitions among education, industry, regulating agencies, and professional organizations is a model for other collaborative efforts. The demonstration sites to evaluate the utility of California's Framework for Competency-Based Role Differentiation in Nursing (Fox, Walker & Bream, 1999) illustrate the ability of two nursing education systems and industry to work in partnerships. These are major achievements for an organization that has no formal structure and relies on donations and grants for financial support. Its mission will be realized when the strategic planning model and process is institutionalized within a state supported agency and a master plan for nursing education is in place.

Figure 1

Figure 2

. Statement of Beliefs that California Nurses Hold Regarding Health Care

Table 1. Selected Findings Related to California's Demand for Registered Nurses (RNs) and Licensed Vocational Nurses (LVNs) and Supply of RNs, 1997-1999.

Table 2. Recommendations Resulting from the Synthesis of California's Nursing Demand and Supply Data, 1999

¹Some of the recommendations are based on results not presented in Table 1.

Authors

Sarah B. Keating, RN, EdD, FAAN
E-mail: sbkeating@earthlink.net

Dr. Sarah Keating has a Bachelor of Science in Nursing from the University of Maryland, a Master of Public Health from the University of North Carolina, Chapel Hill, and a Doctorate of Education from the State University of New York at Albany. She has a Certificate in Primary Care from the University of Rochester and is a Certified Pediatric Nurse Practitioner. Dr. Keating's contributions to nursing regionally, nationally, and internationally consistently focus on nursing work force issues, public policy in community health and primary care and their relevance to education, research, and practice. Currently, Dr. Keating serves as Chair of the California Strategic Planning Committee for Nursing, a position she has held since 1992. She is former Dean and Professor Emerita of the School of Nursing at Samuel Merritt and Saint Mary's Colleges.

Karen R. Sechrist, RN, PhD, FAAN
E-mail: krsech@pacbell.net

Dr. Karen Sechrist received the Associate in Arts in Nursing from Pasadena City College, Bachelor of Science in Nursing from Wheaton College, Master of Science in Medical-Surgical Nursing from DePaul University and Doctor of Philosophy in Higher Education from the University of Pittsburgh. Over a twenty-year period, she held graduate teaching and research positions in nursing at the University of Pittsburgh, University of Arizona, University of Ibadan, Nigeria, and Northern Illinois University. Following her academic career, Dr. Sechrist became the Director of Research for the American Association of Critical-Care Nurses (AACN). Dr. Sechrist currently is the Project Investigator for the California Strategic Planning Committee for Nursing. She also is a Principal and Research Specialist with Berlin Sechrist Associates.