Nursing student loan repayment

Causes of the current nursing crisis are interconnected and ongoing. Economic pressures, an aging nursing workforce, and scientific advances extending life span all point to an evolving crisis. According to a July 2002 report by the Health Resources and Services Administration, 30 states were estimated to have shortages of registered nurses in the year 2000. The shortage is projected to intensify with 44 states plus the District of Columbia expected to have RN shortages by the year 2020.

The solution lies in redefining recruitment and retention. Hospitals should develop techniques that can be sustained--building interest and image, developing scholarship programs, and cultivating a positive workplace culture and sense of community These efforts are only successful with bridge building among all stakeholders, including CEOs, CFOs, nurse executives, nursing schools, and physicians. To encourage this collaboration, HFMA brought together five experts to offer their perspectives on both problem and possible solutions.

Nursing is the healthcare staffing area mast affected by the current workforce shortage. Is the shortage temporary or indicative of emerging trends?

Tyler: I think it is temporary--the nursing schools will be filled again in the next few years. The word is getting out that in nursing you'll always have a job. The economy is cooling down, but that's not necessarily a negative for nurses, because the opportunities will continue to increase. So hospitals should tap into this trend with retention and recruiting efforts.

Hecht: The economy of the past decade is partly to blame for the shortage. There were so many more options out there, particularly in the technology sector. And people were moving to those career paths without realizing that technology might not continue its rapid growth. Health care, on the other hand, has been around for many decades. Today's situation will change, but it won't be immediate. It's going to take some time to tell the story about health care as a profession and the security of employment found in the healthcare profession.

Landstrom: I agree that things are slowly changing. There has been a movement regionally--at least in western Michigan, where there has been a number of layoffs in industry--in which we have seen a rise in nursing school enrollment. But we can't say that it's necessarily a trend yet.

Ratcliffe: The cause of the shortage is a factor to consider. The nursing shortage was brought about by an aging workforce, with the average age of a nurse falling between 40 and 49 years of age nationally, and by unresolved or unaddressed workplace issues. Grassroots efforts to encourage school-age students to choose nursing as a career have not been a priority, but that is changing, too. A big problem is that nursing has always been a predominately female occupation, and given a wide array of opportunities, women are choosing other careers. Nurses are leaving the bedside and hospital setting to work in other areas, such as pharmaceutical sales, outpatient settings, and physician offices--and some are leaving health care altogether. Until something is done to make nursing more attractive to both men and women, we will continue to see a problem.

Nisbet: Hospitals are facing an uphill battle to reclaim the heart of nursing and maintain levels of care for their patients. Nurses say that hospitals must improve the environment of care. Doing so will no doubt require that models of care are redesigned to focus nurses on direct patient care and use other support staff to fulfill the duties that take nurses from the bedside. Today's shortage appears to be the tip of a very large iceberg. With the aging of the population and higher utilization, the need for nurses will not abate; in fact, it will increase. The baby boomers are no doubt wondering who will provide the care they will need in the not-too-distant future.

How can a staffing shortage affect the financial outlook of a healthcare organization?

Tyler: It can cause the organization to look to traveling nurses as a solution to the shortage issue, and that can cost the organization up to three times more for that staffing resource. This type of problem-solving is not necessarily proactive, and it has a direct negative impact on a hospital's bottom line.

Ratcliffe: If an organization chooses to use contract or travel nurses to temporarily fill vacancies, its labor costs are driven up dramatically. And it's true that these expenses can rapidly diminish an organization's bottom line. Staffing shortages also can reduce the number of beds that are available, resulting in emergency-department overcrowding due to the unavailability of beds. Also, hospitals may choose to close beds to avoid the substantial financial impact of using contract staff. But if you do that, you have to ensure that closing beds does not hurt your most profitable service lines. Staffing shortages can also be associated with low staff satisfaction, turnover, and low patient satisfaction, thus affecting whether patients return to your organization.

Nisbet: Hospitals are learning that retention is as important--perhaps more important--than recruitment. The cost of turnover is tremendous in financial terms, and then there is the issue of the morale of remaining staff.

How should hospitals address these problems?

Ratcliffe: It's imperative that they hire the right person for the right job and ensure that the individual is a fit for the organization. Hospitals need to take time to review their mission and core values with the applicant during the interview process. The applicant needs to know what is important to the organization's success.

Hospitals also should make every attempt to avoid implementing compensation programs that are too costly over time to continue. Wages and benefits should be market competitive. And hospitals should maintain strong relationships with local schools of nursing.

Advocacy is also important. Hospital leaders should make sure that state legislators in their area are educated about how the community is being affected by workforce shortages and how the legislators can help. Hospitals should develop comprehensive student and preceptor programs that provide hands-on experience. Providing onsite education is very important for recruitment, as well as retention.

Also, hospitals should involve staff in decisions that affect their work environment, helping ensure the organization is meeting their needs.

Hecht: The old way of attracting and retaining nurses has not worked, and it is very important that we redesign that process. Building facilities and opening services were sufficient in the past to attract new graduates from the nursing programs. Today, nurses need the greater challenges of a career that provides personal satisfaction for the long term. Therefore, recruitment and retention go hand in hand.

What new strategies for retention and recruitment are hospitals using?

Nisbet: Hospitals and health systems are focusing their efforts on retention and employee satisfaction because they are recognizing that internal scorecards reflecting employee satisfaction are as important as measures of financial viability Involving nurses in professional development and patient care issues is extremely important. Hospitals have developed shared governance models to bring nursing staff to the table in making decisions that will affect their daily lives, such as developing staffing models, redesigning patient care models, recruiting and interviewing nurse candidates, and defining equipment needs.

Hecht: Our nursing team is breaking new ground with their best practice, which involves on-line access to applications, a retention study, and a return-to-work program (see sidebar, p. 58). I support the nursing department's efforts to improve recruitment and retention.

Ratcliffe: Nursing managers have been challenged with thinking out of the box, to provide alternatives to traditional 8-, 10-, and 12-hour scheduling. Providing for associates to work full-time at higher pay in lieu of benefits and integrating flexible scheduling are important ways to meet changing needs and expectations of associates. There has recently been, and will continue to be, a more proactive focus on nursing. Prioritization will be based on each region's need.

Many organizations are working with their local elementary and high schools to promote nursing and health care as a profession. Johnson and Johnson recently launched an excellent campaign to promote nursing. Also, President Bush has signed the Nurse Reinvestment Act, which will provide for scholarships, a loan repayment program, public-service announcements to promote nursing as a career, and many other programs to support nursing.