What Are Some Solutions to Address the Shortage of Nurses?
The traditional approaches to increasing the number of registered nurses are failing. Public sector nursing programs while understanding the need for more nurses merely is in most cases not able to come up with creative solutions to address the problem. Federal and state government funding, for the most part, has remained relatively flat for several years. Boards of Nursing continues to base many of their regulatory requirements on unproven beliefs on what is, for example, appropriate curriculums and clinical hours. There is no consistent policy regarding either of these issues. For example, some state reported in NCSBN Educational Program for Entry into Practice require clinical experience in a pediatric and maternity setting to meet the mandatory hours of clinical. The rule continues despite ample evidence that few students will ever practice in these setting given the limited opportunity. Nor is there a consideration that the NCLEX® has few questions regarding these competencies in their assessment. There is ample evidence the clinical competency can be met via simulation is provided by the NLN Center for Innovation in Simulation and Technology. The Boards of Nursing continue to operate in many states without updates to reflect today’s nursing competencies.
Impact of Boards of Nursing
An excellent example of the lack of congruency is how Boards allow the use of simulation to substitute for clinical hours. Some states do not allow any simulations (or minimum hours) while others such as the Texas Board of Nursing- Simulation in Pre-licensure Nursing Education regulations allows up to 50% of clinical to be used for simulation. These practice of not using standardized national guidelines for the use of simulation continues despite significant evidence to support the use of simulation. The resistant to changes continues regarding what should be an adequate number of clock hours. The regulations regarding the number of clinical hours are usually left up to Boards of Nursing’s subjective opinions. The amount varies from high of 900 hours in American Samoa found in the NCSBN Educational Program for Entry into Practice report to some states being nonspecified. There is no validity to either of these parameters. The regulations are based on what Board members think is appropriate. In the meantime, the shortage continues in many locations and patients suffer because of the lack of professional nurses to provide care.
First Time NCLEX® Pass Rate Impacts Viability of Schools of Nursing
Another factor impacting schools is the arbitrary rules set by the Board of Nursing regarding first time NCLEX® pass rates. Schools are rigorously regulated by their first-time pass rates. If a school (in many states) fails to achieve the national first-time pass rate typically over a period of time can be placed on probation and even closed. There is little or no evidence that students who pass the NCLEX® on the second attempt are less competent than those who pass the first time around. 2018 Number of Candidate Taking NCLEX Examination and Percent of Passing report reveals that the first-time pass rate for first and second quarter 2018 was 89.54% for a total of 95,904 new nurses and another 17,155 passed on the second attempt. This means 18% more nurses passed NCLEX© on their second attempt. New Jersey has a 70% passing rule while Texas has an 80% first time passing rule before the Board will begin to monitor program’s performance. If your program is located in Texas and your passing rate does not meet the first time pass rule of 80% over a three year period the school is closed.
The first-time pass rate rule is discriminatory against private sector schools who typically admit all students who have the potential to be nurses. Given the highly competitive nature of admission to public schools, few of their students should fail the NCLEX® on the first attempt. Board still follow these rules regarding first-time pass rates and this means some schools are forced to close during a time of significant shortages.
There needs to be a comprehensive, evidence-based review of Board of Nursing regulations that is national in scope. The result should be regulations that are designed to educate competent nurses and protect the public. What exists now is a mixed bag of “beliefs” not based on substantial scientific evidence. This process needs to be driven by the consumers, employers, policymakers as most Board, if left to act alone, are often not able to be innovative. Boards do not seem to understand their apparent lack of innovations and creativity are contributing to the loss of lives of their family members, neighbors, and friends who do not have access to competent professional nurses.
Push for BSN Entry into Practice
Another factor has been the Institute of Medicine which changed its names to National Academy of Medicine (NAM) in 2015, who advocates having at least 80% of the nurses prepared at the Bachelor of Science in nursing (BSN) level. While there is some research that shows hospitals with a higher percentage of BSN have in some cases better patient outcomes, there is no evidence what specifically in a BSN curriculum contributes to these higher outcomes. American Association of Colleges of Nursing which represents BSN and graduate nursing programs have assembled a summary of several studies supporting in part this statement. Associate Degree (AD) and BSN nurses all take the same NCLEX® examination. One would then assume the competencies of both graduates at least on entry into practice should be the same. The push for BSN graduates has created significant bottlenecks in the educational system because BSN programs are unable to meet the demand for registered nurses. Most of these BSN students take five years or more before they can graduate primarily because waiting for a slot to open. For public sector AD programs while the student should theoretically graduate in two years because of waiting lists and required pre-requisites the length to graduation can be up to four years.
A Place for Private For-Profit Schools
In contrast most, private for-profit schools admit four times per year and students in most cases can graduate within two years. These students take all the required course within their prescribed curriculum and are not delayed waiting to take pre-requisites courses. There is no “cherry picking” of only selecting the best students as typically all who meet the admission criteria are admitted. Some will argue that the education in the private for-profit sector is “less than” even though the final passing rate on the NCLEX® is similar to the public sector when first and second-time pass rates are calculated many schools will meet the benchmark requirement for graduate success on the NCLEX®. Yes, in many cases the first time passing rate is higher in the public sector as they should be given they only admit the very best applicants. Their pass rates should always be 90% and higher. There is little evidence that supports a second-time candidate for the NCLEX® is less competent than those who pass on the first attempt. Forcing schools to close because their overall pass rated based on first and second attempts at the NCLEX® is very short cited. These actions mean fewer nurses in times of urgent needs.
A Call for Action
There needs to be a call to action for Boards of Nursing as well as educators to join forces with consumers and employers to create new curriculum models using the latest evidence-based approaches and innovation in curriculum and instruction to address factors contributing to limiting the number of graduates. While not a part of my discussion equal attention needs to be placed on new nurse orientation and mentoring programs and overall working conditions. There needs to be an openness to encouraging students to seek AD programs so they can enter the workforce sooner. The requirement for seeking the BSN within a pre-determined time frame is reasonable assuming the RN to BSN curriculum is adding competencies. At this point, this statement has yet to be proven. My suggestion would be for those AD nurses who want to remain at the bedside be promoted and compensated for a demonstration of excellence thought national certifications and performance reviews linked in part to patient outcomes. At this point, with a reported bedside nurse turnover rate is 18.2%, 2.0% greater than 2016, should there not be some new approaches considered? Data regarding the percentage of BSN degree nurses turnover is not reported in the National Health Care Retention & RN Staffing Plan. There is speculation that BSN nurses tend to leave bedside nursing to seek positions which require a BSN and/or to pursue graduate education. Most of these non-bedside positions lack a requirement for shift rotations and no weekend and holiday hours. They are 40-hour week positions with little or no mandatory overtime nor require 12-hour shifts including weekends. No wonder it is thought that BSN nurses are fleeing bedside positions.
The time to act is now and I “get” a number of my nursing colleagues may not agree with my statements. I encourage dialogue and with open minds based on substantial evidence lets together work on resolving the nursing shortage.
Dr. Bob
