Participants: Janis P. Bellack, PhD, RN, FAAN, Associate Editor, Journal of Nursing Education
Lisa Skemp Kelley, PhD, RN, John A. Hartford Postdoctoral Scholar, Assistant Editor, Journal of Gerontological Nursing
Pamela V. Moore, EdD, MPH, RN, FAAOHN, Editor, AAOHN Journal
Shirley A. Smoyak, RN, PhD, FAAN, Editor, Journal of Psychosocial Nursing and Mental Health Services
Patricia S. Yoder-Wise, RN, BC, EdD, CNAA, FAAN, Editor, The Journal of Continuing Education in Nursing: Continuing Competence for the Future
On September 18, 2003, SLACK Incorporated sponsored a roundtable discussion during the National League for Nursing Education Summit in San Antonio, Texas. The Editors of our nursing publications gathered to talk about the nursing shortage and how it was affecting their various areas of the profession. Read on to learn about the innovative ways they think current and future nurses can advocate for change and improvement.
Dr. Tanner: When I was approached about moderating a roundtable discussion on the nursing shortage, my first response was it's old news because many of us are experiencing it, hearing about it, and living with it. But the more I thought about it, I realized there are a lot of areas that would be good to explore in terms of different parts of the country, as well as different specialties and how they may or may not be affected by the nursing shortage.
I would also like us to think about how we might use our journals as a vehicle to affect policy around the shortage. In many ways, it's a really dark time in our profession's history, and probably the worst shortage we've had. It is predicted to be pretty horrible unless we do something about it, and that something can't be the traditional solutions. But every prediction says as high as one out of every two positions will be unfilled within the next 20 years. That's pretty terrifying.
Christine A. Tanner
Christine A. Tanner, Janis R Bellack, Shirley A. Smoyak, and Lisa Skemp Kelley (left to right) discuss how the nursing shortage affects nursing education, psychiatric nursing, and gerontological nursing.
However, we just got additional money added to the Nurse Reinvestment Act. [And] We've just had the first round of grants come out. That's very positive that we're getting that kind of response.
What's your sense about where we are with the shortage, in your own area or specialty?
Effects on Specialty Areas
Dr. Smoyak: You asked is it any worse than it was in the past. It's so significantly different that I don't think you can make comparisons. In the 1970s, we had the National Joint Practice Commission, half funded by the American Nurses Assocation and half by the American Medical Association, to look at the roles of nurses and physicians for realignment. What is it that nurse practitioners will be doing that only docs did in the past? That kind ofthing. Nobody is talking about that today. And today you have a whole range of technological innovations that were not there in the '70s, and you have new players in the scene, and nobody's talking about them. In the '70s, we talked mostly about nurses and physicians, but now you have all levels of other players in the field who are neither nurses nor physicians.
Shirley A. Smoyak
Dr. Tanner: Is there any kind of national standard around that, or do you think it's around these other fields, or do you think that's going to be geographically isolated?
Dr. Smoyak: In the area of psychiatry, the psychosocial rehabilitation folks are very active. Many were formerly consumers. One of our editorial board members invented a word for them: "prosumers." They're providers, but they were consumers. Now they're master's prepared psychosocial rehab folks, and they work alongside nurses. They defer to the psychiatric nurse clinical specialist or nurse practitioner for medications and interventions, but when it comes to herbs they tell the clinical specialist what works for them or what doesn't - the natural path approach. So that's another area where the two can work together.
The difference between us and nurses in Europe is their men in nursing are doing very well. At the top level, they're all men. All my colleagues in the U.K. and in Europe are men, and they hold prestigious positions, and they recruit men, and we don't do that.
Dr. Tanner: What percentage?
Dr. Smoyak: In psychiatry, if you're at the administrator level, more than half are men. Even in Australia and New Zealand they're men.
Dr. Tanner: Is that because historically they have been? Because the U.S. used to have diploma schools in mental health that were predominantly targeted to getting men into nursing. Did they never change that model over the years as we did in the U.S.?
Dr. Smoyak: No, except that in the U.K. now they're switching, and there are lots of arguments about that. In a nutshell, they think that everybody needs to be generic. They don't think that there should be a mental health nurse who doesn't have other skills. Who knows what's going to happen to them in 10 years.
Dr. Tanner: What about in gerontology?
Dr. Kelley: The shortage in gerontology has been chronic; we've never had an adequate number of nurses in gerontology. Certainly, there's been more of an emphasis on it because consumers are aware of this aging cohort, and that they're going to be frail and have complex needs. We expect they will require complex system intervention.
Lisa Skemp Kelley
However, it will also be a different cohort. It's going to be individuals who have probably had a different degree of education and different expectations in terms of interactions with the health care system in terms of alternative kind of mechanisms.
In terms of the shortage, it's severe. A 2003 survey showed the greatest shortage of nurses is in longterm care. Some of the push is for us to get more numbers, predominantly at the community college level. Consumers are asking for that, and the role of community college is to meet local needs.
At the University of Iowa we've had some discussion about the clinical nurse leader, really trying to reconceptualize that, looking at the numbers and looking at where nursing as a profession wants to impact.
The Hartford Institute has recognized this need, and the Five Centers of Geriatric Excellence are trying not only to meet increased numbers but also [to meet] expertise in gerontology in terms of scholars. They are trying to promote their undergraduate students through the Young Scientists Program, so they can think about being a geropractitioner. So there are a number of initiatives that are underway.
Dr. Tanner: It's interesting that the emphasis is on educating more scientists. In past shortages, I think there's been an emphasis on the lowest common denominator of our nursing education; just grinding out as many new people as we could. I appreciate this effort to keep education for clinical leaders and scientists. For educators, this is absolutely essential.
Dr. Kelley: Part of that is we're looking at a new practice model. If we look at quality (e.g., the 2001 IOM report "Crossing the Quality Chasm"), we really need to have nurse scientists and educators who can look at what the current paradigm is, explore what's happening, and try to do something for the next century and reconceptualize health care so that nursing has a voice.
Response to Institute of Medicine Reports
Dr. Yoder-Wise: I would like to play off that last point, because I think that [the] subsequent IOM report about interdisciplinary approaches leads us back to something that Shirley was talking about, that is, looking at all of the dimensions. The other piece is the whole idea of health care reform. The New England Journal of Medicine recently published an article about the 8,000 physicians who had signed on to, "You have got to reform the health care system."
Patricia S. Yoder-Wise
It's very hard to sell almost any discipline within health care right now because everybody is dissatisfied. There are two things we really need to look at. One is the way we change the role within nursing so there is a way to reward and recognize clinical nurse leaders. The other piece is how we can work effectively on an interdisciplinary level to really effect change in the health care system. Until that happens, we are all going to have trouble selling our respective disciplines because it's the system that is failing, and it's going to get worse now that we have cutbacks in Medicare and in almost all of the states with the Medicaid budget.
Dr. Tanner: The [IOM] quality chasm report and the issues around major problems in the health care system certainly account for a lot of the bleeding out of the system, of nurses leaving the profession because they no longer can practice the way they were taught, or learned, or what they valued about the discipline.
Dr. Yoder-Wise: But I think it also discouraged others from seeking the discipline, because they read about these reports and then they think, "Why would I want to do that?"
Dr. Tanner: But applications are up nationally. So there's been some tide turn there.
Dr. Yoder-Wise: Isn't it interesting that enrollments are up, and now state funding is down, and the majority of our education occurs in state institutions, and now some hospitals are starting to cut back?
Dr. Tanner: I wake up with nightmares that we now have turned around, and that we're going to produce too many nurses.
Dr. Moore: In terms of occupational health nurses, and the impact on our practice right now, we also see an increasing age in our own population. And they're more advanced in terms of the skills mix that occupational nurses have to have, higherlevel management skill, and higherlevel consultation skills. On top of that, we're getting more diversity in the workplace, including the chronically ill worker. So there's more of a demand for specialized services. We have a special focus on workplace health and trying to improve the environment for health care workers, because we believe that we don't have a safe and healthy enough work environment. That contributes to nurses leaving.
Pamela V. Moore
In the AAOHN Journal, we're publishing more articles on workplace health for health care workers, everything from research related to lifting to bloodborne pathogens, workplace violence, and ergonomics. Some of that's been deliberate, and some of it has just happened with our contributions.
Dr. Tanner: One of the things you're saying that I think is true across many specialty areas is increased diversity and complexity of care. Technological advances are requiring a different skill set, or at least an expanded skill set, than nurses have needed historically. What about nursing education? How does this shortage affect nursing education?
Dr. Bellack: I think we've seen the same kind of response that we've seen with previous shortages, and that's a scramble to increase enrollments because of pressure we received from our public policy makers and communities. We are seeing the greatest enrollments in the 2-year colleges, despite longterm proposals for changing the mix of the entry-level work force to two thirds baccalaureate-prepared nurses, and we're nowhere near that. In fact, I think we've just exacerbated the status quo.
Janis P. Bellack
Dr. Moore: I think one thing that has really impacted nursing education, at least at Eastern Kentucky University, is our enrollments are up but our resources are down, which is always challenging. We started an accelerated option program last year, and we have over 100 on the waiting list for next fall. So we're getting an increasing number of students who have a bachelor's degree in something else, and in 16 months, we educate them as a BSN.
Dr. Tanner: We were talking earlier in our board meeting for the Journal of Nursing Education how we've seen some demographic shifts in our students. We looked at baccalaureate and associate degree programs where we're getting more second-career people [and] many people with previous bachelor's degrees, and many of us have developed programs to try to respond to and get those people into nursing and out very quickly as one means to create more nurses.
Dr. Smoyak: The larger economic picture affects nursing education very dramatically, because a bright, energetic, career-oriented nurse finishing a master's degree, who might have been persuaded to be a clinical instructor, now becomes a clinical specialist or a nurse practitioner making $60,000 or $80,000 at graduation, at least in the New York area. Why would she come to an academic place and get $30,000?
The other piece that the academics like better is to sign them on to a new clinical position, encourage them to get the doctorate, and then they work the two 12-hour days in the clinical setting. The nursing faculty are increasingly aged and less likely to be comfortable in a clinical area.
Dr Tanner: The average age of nurse educators in Oregon, at least a couple of years ago, was 55. I think it's gone down because a lot of people have retired, [laughter]
Revisioning and Reforming Health Care
Dr. Yoder-Wise: I'm wondering what each of us has done in terms of our role as editors related to Nursing's Agenda for the Future. Sixty of our professional organizations got together and agreed on the top issues that we need to address. What are we doing about it?
Dr. Bellack: So much of that agenda was based on a total revisioning of the way the U.S. provides health care. If anything, we've regressed from that model because of the technology, because of budget cuts, because of public demand for specific procedures. It's the high-tech, exciting glitz that captures people, and our policy makers. Low-tech, long-term interventions that really make a difference to the health of the public don't capture the attention of funders. I don't think they'd capture the attention of many of us in education. We still do community health, but it's almost become home health not public health. We're trying to respond to the demands and prepare our students for that, but I think we've really lost sight of the long view. I think there's a disconnect between our words and actions. What we say we believe in and are committed to [doesn't] translate into our daily work, whether it's education or practice, [general agreement]
Janis R Bellack notes that, "It's the high-tech, exciting glitz that captures people, and our policy makers. Low-tech, long-term interventions that really make a difference to the health of the public don't capture the attention of funders."
Dr. Tanner: But it also seems this is a time not just to be responding to what looks like a public health crisis but an opportunity to really bring about major reform. We got together a group called the Oregon Nursing Leadership Council [Oregon's version of the Tri-Council]. It includes representatives from the state boards, the nurse executives, nurses associations, and the baccalaureate and associate degree programs. We got a facilitator to work through a lot of the old issues between baccalaureate and associate degree educators, and decided that we needed to make a commitment to have education that would be responsive to health care needs, not to some degree level or a particular philosophy of education. We all agreed that none of us are doing a good job in education. We talk about health promotion, but how many of us teach health promotion? We talk about teaching family caregivers the importance of helping other caregivers learn how to give care, but where is that in our curricula?
We are developing a state-wide baccalaureate program to be offered through community colleges via distance technology and joint appointments, and we're creating a shared curriculum and shared competencies. We'll be admitting our first class of students in the fall. We saw it as an opportunity to make changes that have really been needed for a long time. With the public concern and interest and attention toward nurses, and the recognition of how nurses are the glue of the health care system in almost every regard, how is it that we can assure they're prepared to serve that role now, given all the changes? If they're not, well see the rise of a bunch of other disciplines where we have failed.
Dr. Moore: I think one of the keys to that is accessability. We spend a big part of our time with distance learning with our RN-to-BSN programs, as well as our graduate programs. And it's reaching out to people and giving them the ability to do the kinds of things that you're talking about.
Dr. Yoder-Wise: Chris, back to your comment on the Oregon program, I do think that's been one of the exciting things that has happened as a result of the shortage. It has been made very clear that the real key of the whole health care organization is nursing, because that's who is delivering the majority of the care. Achieving Magnet status has changed perceptions about some facilities. And secondly, in the process, they discover where they are within the whole context of what could be. Even if they come away clearly knowing there's no way they're ever going to get Magnet, at least they've figured out they have work to do and have a plan for it. When Magnet started it really was in the qualitative research mode. Now we've really evolved to a science. This core work benefits all of us, but I don't think we're taking it to its full potential; for example, changing administrative programs so the focus is really on those kinds of criteria and expectations and outcomes.
Dr. Tanner: I think another example is the things that support autonomy in practice and having competent coworkers. What's the first thing to go in budget cuts? It's our clinical specialists and our education departments. Those are the budgets that get cut initially, yet those are the very things that sustain and nurture the nurses that we want to keep. So it's really trying to look overall at our priorities in the work environment.
Dr. Smoyak: There was a recent article in The Journal of Continuing Education in Nursing [September/ October 2003] about the Genome Project. Yes, nurses need to be able to explain to a lay person what DNA sequencing is. But what's not addressed in that piece is, who does what? If the nurses' role is to help people decide whether or not to do something with a fetus that comes out with an abnormality, or to engage in treatment for something that now you know you're going to get 30 years from now, that's not in the nursing curriculum anywhere. How do you parcel that out in a policy way? That's a perfect example of a new thing that never existed before, and the professions haven't sorted out who has the obligation to do what.
Dr. Tanner: There are two issues embedded in that. One is leadership. We are lacking in leadership within the profession to really bring out some of these things to coalesce groups. The second is in interdisciplinary work. We've been mouthing the words "interdisciplinary education" for how long now, and how many of us are really able to pull it off? Those are exactly the kinds of things that we need to be doing.
Dr. Yoder-Wise: The issue of continuing competence is so critical it is now the subhead of our journal.
Strategies to Address Additive Curricula
Dr. Bellack: I think the flip side of Shirley's comment about putting what's new in the curriculum is, we're not taking anything out.
Dr. Yoder-Wise: So now we cover it more superficially.
Dr. Bellack: Right. We need to look critically at what we have in our curricula that our students don't need to know or don't need to know until they need to know it.
Dr. Yoder-Wise: The other piece ofthat in the real world of practice is that so many facilities don't have the resources because they've laid off the clinical specialists, shut down the education departments, and don't have some kind of technological access to policies and procedures.
Dr. Smoyak: In the '70s, with the National Joint Practice Commission, the nurses and physicians in academia would lay out their syllabi, lay out what the curriculum is for both nursing and medicine, and say, "What's the stuff that they could learn together?"
Dr. Bellack: But it's never been one that's worked in any practical sense because of the discrepancy in our levels of nursing and medical education. And even within the same academic environment, there are the scheduling differences. Trying to get nurse practitioner students who typically are in clinic 2 days a week to practice with the medical students, who are there 40 hours a week in their clerkship rotations, is an impossibility. There's no continuity in the way we frame our educational experiences.
Dr. Kelley: Some of what we've tried to do is open up our curriculum, some of our nursing courses, to nonnursing majors. Because some of the courses we offer are applicable across disciplines. When you start talking interdisciplinary, you bring much more to the table, and this promotes the dialogue.
Dr. Bellack: Then you have to make sure that the pedagogy does indeed do that, that it's just not parallel learning, that there's opportunity around case scenarios or critical thinking/problem solving where they bring in those perspectives.
Dr. Smoyak: I've seen recent models that do work. There was a family health track in the master's program in public health at Rutgers University. I was the nurse side, and a family practice physician was the physician side, and in the class were the 5-year medical students who elect to get both the MD and the MPH by going an extra year.
Dr. Bellack: That does work, but if you look at the bulk of the work force, it's basic nurses. It's not master's level nurses in family health or public health. It's the 4-year and the 2-year graduates in terms of daily interaction, whether it's in a unit or in a clinic. Yes, few and far between you do get those, and they can be very positive.
Dr. Tanner: There are some other driving forces that are helping us now, for example, the new ACGME competencies that emphasize interdisciplinary communication. The other move is toward simulation as an educational tool. We just opened a simulation center that's interdisciplinary. We are hoping to have some full-scale simulations that medical and nursing students will go through together where they each play out their respective roles.
Dr. Kelley: We've been working on evidence-based practice models (Titler and Buckwalter in Iowa). Thirty-one of them have been completed so far. They aren't just for nurses, and we're developing a piece involving consumers. In that we recognize the movement to try to institute some of these evidence-based practice models in the clinical setting. The Journal of Gerontological Nursing has been publishing these quarterly. In the past 4 years, Iowa has had about 2,000 inquiries for those protocols. Anything that we can do to help one another work together at a multitude of levels [is beneficial]. We have to look at how practice is differentiated within nursing and health care to figure out how to include nurses, other health professionals, and consumers in a collaborative, forward-thinking way.
Dr. Tanner: That sounds like something that would really encourage interdisciplinary work. Historically, gerontology and mental health are two specialties that have enjoyed higher levels of interdisciplinary collaboration than other areas.
Dr. Kelley: It's because those disciplines can't do the work without involving a broad array [of disciplines], including public health. We have tried some different models to really focus on aggregate, to pull us back to what public health is all about.
Dr. Smoyak: Public health and mental health were together at the turn of the century, fell apart, and now they're putting them back together again.
Dr. Tanner: One of the predictions of the old agenda for health care reform that has really come through is the knowledgeable consumer of health care. They demand a level of service and know a lot more and often know more than the providers. And pharmaceutical companies are pitching to the consumer.
Dr. Kelley: I think that speaks to an important role for nurses as well, because who do consumers usually come to? To nurses. So again, it's that role, like the clinical nurse leader role, which is based on outcomes, which is based on aggregate, which is based on knowing the science, to help consumers be wise consumers of health. And so in curricula, we really have to look at differentiating some of these roles and responsibilities. And there definitely is a need out there for care managers or consumer advocates. It's a critical place for nursing research and some of what we need to respond to as to how the system is changing. Take, for example, the communitydwelling elders. That health care system is extremely fragmented and complex. Although the formal elder care system may create health care products we believe consumers need, want, and will use, it is critical to ensure these products do indeed meet consumers' needs. Ideally, [this would be done] before costly spending.
But then there's the balance with policy. We have to deal conceptually with what's happening in policy, and understand how to get a voice, or at least use one, to help get evidencebased practice into the policy making.
Nurses' Role in Easing the Shortage
Dr. Tanner: We have a lot to do. This notion of thinking about how we can get nurses in policy groups and learning how policy is made, I'm not sure how it's really being taught and implemented.
Dr. Moore: One thing that's a really important part of all of this we're talking about is mentoring, bringing people up to speed, role modeling for them, helping them move to a different level of practice, and I think that's one thing that all nursing journals should take part in.
Dr. Tanner: How can we do that?
Dr. Moore: One of the things that we do with the AAOHN Journal is that we spend a fair amount of time mentoring authors. We work a lot with graduate programs in occupational health, as well as practicing nurses, to get their work out there in print and help them develop the skill of writing so they can continue to do that, and we've seen some success.
Dr. Kelley: The evidence-based practice protocols are very helpful, and the Try This tools for assessment have been positive in the Journal of Gerontological Nursing. They are user friendly. Also, highlighting the positive and the innovative, especially in terms of what nurses have to offer and how they went about offering it as a model.
Dr. Bellack: There's some really great work being done by Kathy Davis [in New Mexico] with the whole notion of appreciative inquiry and getting staff nurses at the grassroots level engaged in appreciative inquiry groups where they focus on developing their narratives and their stories about the most defining moments for them in their practice, and the positive things, the contributions they've made, and thinking collectively about how great we are, as opposed to [talking and thinking about] the shortage and so-and-so calling in sick all the time. She's got strong evidence of the complete turnaround it did in that system, and it reduced their nurse turnover and increased nurse satisfaction.
Dr. Kelley: Two other suggestions include recognizing excellence in practice and policy, and publishing debate articles that explore the health paradigm shift already under- way. Debate articles may foster dia- logue, discussion, and innovation.
Dr. Bellack: I think the other issue we really haven't addressed, except indirectly, is we have been completely unsuccessful in selling nursing as a career to men.
Dr. Moore: The only place I see that differently is with accelerated students, second-degree students.
Dr. Tanner: The same could be true [about] our success rate with ethnic minorities. We had one initia- tive after another to try to recruit minorities into nursing, and largely it's been unsuccessful, especially with some populations.
Dr. Kelley: The other piece is how we're recruiting nurses international- ly. It's a brain drain on many of these small countries.
Dr. Tanner: We are bringing them from countries that are desper- ate and don't have nurses and have high populations of HTV.
Dr. Bellack: The sad thing is if and when the shortage goes away, then those jobs may go away.
Dr. Tanner: I think many of the things we're experiencing now are also symptoms of a system that is poorly put together. The reform of 1992 and 1993 never took, and what's replaced what we had then seems to be much less responsive.
Dr. Bellack: Or, responsive only to special interests.
Dr. Tanner: There is a growing movement toward a single-payor sys- tem. It would be interesting to be having some debates in each of our journals about that and how it might impact care.