Addressing the nursing shortage

More episodes in the The Vantage Point Podcast

The Institute of Medicine has called for raising the percentage of registered nurses in the workforce who have at least a bachelor's degree in nursing to 80 percent from the current number of 56 percent. The Texas A&M College of Nursing is working to help increase that number and address the nursing shortage in the state and nation.

Episode Transcript

Lindsey Hendrix:  Hi everyone. Welcome to The Vantage Point. I’m Lindsey Hendrix. We’re sitting here today with the College of Nursing dean, Dr. Nancy Fahrenwald, who’s going to talk to us about the nursing shortage in America and some of the solutions that we have coming out of Texas A&M to address it. Welcome.

Nancy Fahrenwald: Thank you so much for inviting me, Lindsey.

Lindsey Hendrix: Well, we’re really happy to have you here. So, as I said, we’re going to talk about the nursing shortage, so I think we should start with defining what is the nursing shortage that we’re experiencing in the United States and in Texas specifically?

Nancy Fahrenwald: When we talk about nursing workforce, the word shortage often comes up. The shortage of nurses is due to several reasons. First off, you mentioned the state of Texas. Texas is known to be one of, if not the fastest growing states in the country. Not only is it growing very fast, the aging population of Texas is growing very quickly. At the same time, the birth rate in Texas is higher than the national average, which means there are more people being born here, but there are certainly more aging people here and there are more people relocating here.

Anywhere there are growing numbers of people, especially older adults, there are workforce demands in health care. Nursing workforce demands are especially high because they are the direct care providers. But not only are they the direct care providers, they are the people who are managing the care, transitions of care to other teams of providers, or from acute care to the home, or long term care from home. So with more people and more aging people, the demand for the role of the registered nurse, in particular, continues to climb in the state of Texas and across the country.

Lindsey Hendrix: And with that aging population comes an aging nursing workforce. So I’m sure we’ve got lots of nurses who have all of that experience who are ready to retire. So is that contributing to the problem as well?

Nancy Fahrenwald: The Baby Boomers are aging. That group of people who were educated in the post-war years or that group of cadet nurses or World War II nurses who were educated by our government for the purposes of serving our country, as they retire and move on, it leaves a gap. And that gap means that the workforce demands are very great and the experienced nurses are in particular declining. So we see some very innovative programs coming across the country, tapping the expertise of older nurses or utilizing older nurses in roles to extend the life of their career. Certainly I have learned from many mentors that a registered nurse serves their entire life. To walk away from a calling that you are highly experienced in or have a specialty gift for certainly means that you can continue to contribute in some meaningful way well into your older adult years.

Lindsey Hendrix: Yeah, we hear about that a lot with military veterans. If you’ve got this very niche expertise that not a lot of people have, that’s so valuable. And so I think it’s really important to pass that knowledge on. And so what are some of the things that the College of Nursing is doing, specifically, to address the gap?

Nancy Fahrenwald: The College of Nursing has a mission that’s focused on preparing nurses of today and leaders of tomorrow to provide excellent care and research and advanced practice to serve the people of the state of Texas. In particular, those who are historically underrepresented in Texas health care provider roles. So our minority populations, our rural populations, our remote isolated populations such as, even offshore oil. The College of Nursing is strategically focused on actualizing our land grant mission as a university to reach those who need care.

Lindsey Hendrix: And so you talk about the different populations. Are we talking about educating nurses that represent those target populations so that there’s better communication and cultural alignment there?

Nancy Fahrenwald: That’s a really good question. It really comes both ways. So, preparing health care providers who represent the diverse population of the state, whether that be age, race, ethnicity, language of origin, gender, all of those things that define, people with disabilities, and serving the people of the state in rural areas, educating rural nurses. It goes both ways. So we are strategically focused on both areas.

And one area that I’d like to mention that I think most of us at Texas A&M take for granted, or at least we think everyone knows, is our military history as a university and our Corps of Cadets. Certainly with our Corps of Cadets who are interested in nursing as a career, we are keenly supportive of them and very interested in supporting them to achieve their nursing education and provide a pathway for them to enter our program as they are completing their core education requirements here at Texas A&M.

Lindsey Hendrix: And so what are some of the benefits that we’ll see with educating the Corps of Cadets?

Nancy Fahrenwald: Well, certainly we’ll see the benefits of more people who go on to be commissioned as an officer and then go in a nursing role and are commissioned in a nursing role and serve our country, but also have opportunities to advance their education and advance their rank in their years of service and really represent the profession, but also our university.

Lindsey Hendrix: Right. That’s fantastic. And so are there any particular populations that are experiencing the shortage more so than others?

Nancy Fahrenwald: When we talk about health care access in our country, we know very well that it’s our rural dwellers who lack access to care, but it’s also our populations who are socioeconomically or disadvantaged in other ways, but certainly some social determinants of health that might differentiate people as having less access to health care, either through education, geography, economics, and in Texas, rural, all things rural.

So, strategically focusing on recruiting rural dwellers into our programs, not only our registered nurse program, but our second degree programs. So people who have a degree in another area who want to come in and complete a nursing education can earn a bachelor’s degree in nursing. There’s another pathway to earn a bachelor’s degree in nursing, and that’s for currently licensed registered nurses in the state and beyond the state who have an associate degree in nursing to finish that bachelor’s degree. We also prepare graduate prepared nurses, and the role that’s really in demand right now is the family nurse practitioner role. Our family nurse practitioners, we prepare strategically to provide primary care services in rural and underserved areas, which means for us that if we say those things, our students have to have experiences in those areas. And, we seek funding opportunities or support for rural initiatives so we can augment the education of our students.

Lindsey Hendrix: So for people who might not understand the difference between a licensed vocational nurse, an LVN, a registered nurse, an RN, and a nurse practitioner, NP, what are the differences between those three?

Nancy Fahrenwald: There are many pathways to advance a nursing career. Since you mentioned the advanced nursing degrees, I’ll start at the highest level of degree and work my way downward. So from degree perspective, the PhD, so the Doctor of Philosophy in nursing, is the highest academic degree from a research perspective. It’s the terminal research degree in nursing. Why do we need those and do we need more? Absolutely. The science of nursing is younger than the basic sciences, but we know that there are many things that nurses do that can improve quality and outcomes and reduce costs. But testing those and showing the impact of those differential types of care means more research. So the PhD in nursing. In order to pursue a PhD in nursing, you have to have at minimum a Bachelor of Science degree in nursing or a Master of Science degree, depending on the program and their criteria.

There’s another doctoral degree in nursing, the Doctor of Nursing Practice, and that is the terminal practice degree in nursing, much like people are familiar with the MD or the Medical Doctor, or the Doctor of Pharmacy, the Doctor of Physical Therapy. So the Doctor of Nursing Practice is prepared in one of many advanced specialty areas to provide care to populations of people, or serve as a leader in advancing health care, translating that research evidence into clinical practice.

The Master of Science degree is another degree and people who pursue a Master of Science degree, which we offer three specializations here at Texas A&M, are prepared in an advanced nursing specialty or role to provide population and specialty specific care. In order to enter a master’s program, nurses have to have a Bachelor of Science degree in nursing. We offer the family nurse practitioner. We also offer the nurse educator role and we offer the forensic nursing specialty.

At the Bachelor of Science level, I already mentioned, we have the traditional for people who don’t have a current a degree, and we have the second degree in the RN to BSN. So there are associate degree programs in Texas and across the country for registered nurses. And then there are certificate programs, like the LPN, or LVN, as we call them in Texas, licensed vocational nurse. That’s not an academic degree. It’s a vocational certificate program where they can sit for a licensure exam as a licensed vocational nurse.

Lindsey Hendrix: So I would imagine at these different levels of nursing, there are different levels for career advancement and different salary tiers and things like that. So is that why you would encourage people to advance their degrees?

Nancy Fahrenwald: There are a lot of reasons to advance your degree. I think nursing, because of the demand for our workforce, we have been very innovative for decades in providing pathways for our students to advance their education because we know that the more highly educated the nursing workforce, the better the patient outcomes. There’s been a very long program of research done by a nurse scientist named Linda Aiken, and her work has shown that the higher the ratio of Bachelor of Science prepared nurses in acute care settings, the less complications, or even deaths occur among those patients. And that work has been replicated in many settings and across the globe.

Lindsey Hendrix: That’s fantastic. And so what are some of the implications that we might see if the nursing shortage is not addressed? How will that impact patient care?

Nancy Fahrenwald: What we see if there are not enough nurses is that care quality is diminished and there’s burnout because people are overtaxed in their roles, but certainly our eyes are always focused on the populations of the people that we serve. So the ethics of providing a highly educated, accessible workforce for the people of the state is an ethic of our profession—the state, region, the country, in the world, in fact. So if there are workforce shortages, that’s a serious issue. In Texas, you asked me about where in Texas there are shortages, and I mentioned rural, but I’d also liked to call out south Texas, in particular, in the Rio Grande Valley. Certainly the large population and growing population is experiencing extreme growth but also demands for health care, and yet the nursing education needs of that part of our state are not being met. We’re seeing a lot of nurses coming into south Texas from other countries, such as the Philippines, to practice just to meet workforce demands.

That’s happening all over the country where foreign educated nurses are coming to fill roles and that’s OK. They are quality licensed providers like those who are educated here. But certainly we know that we want to do better for our state. So one of our strategic areas of growth is to expand our pre-licensure education. So that’s for people who don’t already hold a nursing degree into the Rio Grande Valley.

Lindsey Hendrix: And so how are you all addressing that?

Nancy Fahrenwald: Well, certainly a commitment to put it into our strategic plan, and then we’re raising funds to launch the program. In order to launch the program, we require funding for the startup for faculty and the clinical experiences, the simulation experiences and the right space for our students. But we are seeing that with the Higher Education Center that Texas A&M opened in the Rio Grande Valley in the fall of 2018 has had some excellent outcomes already. Much higher enrollment than anticipated. So I anticipate over time that there’ll be an investment to have nursing education in the Rio Grande Valley.

Lindsey Hendrix: So clearly there’s an interest by the youth, the adolescents, there to pursue that career. There just needs to be a facility there that can provide it.

Nancy Fahrenwald: Certainly. There are all kinds of hurdles to overcome as there are with any new program. But I do want to say there is a highly educated student population there coming out of the high schools that, they are ready to start our program. There are so many innovative educational initiatives going on in the Valley that we are proud to partner with our secondary education schools and with the community colleges to advance nursing education.

Lindsey Hendrix: That’s great. That’s great. And so we talked earlier about the different levels of nursing. Are there any particular points that have a higher demand, or is everybody in demand across the board? They just need all nurses at all levels.

Nancy Fahrenwald: Yes, all nurses at all levels. But I do want to speak to, when you need all nurses at all levels, who are the people who prepare those nurses? And they are the nurse educators. The minimum education of a nurse educator is a Master of Science degree in nursing. Access to graduate nursing education and advanced education beyond the master’s level is something very important in nursing. Thus, we have a Master of Science degree program with three specialties, but we are planning to launch a Doctor of Nursing Practice program. That paperwork is underway. And then after that, our Doctor of Philosophy program here at Texas A&M, where we’re a tier one research university, recruiting faculty to a program where we can offer a PhD in nursing is going to be critical. But these are future nurse educators and nurse scientists who will prepare them.

Lindsey Hendrix: So with nurse educators, are the nurse educators typically career long academic pursuit, or do you also have nurses who have practiced clinical application?

Nancy Fahrenwald: Certainly, many of the people who pursue a Master of Science degree with a focus in nursing education or even a Doctor of Nursing Practice with a focus in nursing education serve either in the academic setting, but they come with a cadre of clinical skills based on their experience. Many of them certified in their specialty, whether that be pediatrics or long-term care, care of older adults, care of neonates, public health. So they come with those clinical expertise skills. But being able to educate the nurses in that specialty is what they are specialized in their graduate education.

They also serve in clinical settings. Not only hospitals, but clinics, in insurance companies, businesses providing education on chronic disease management, educating nurses who are practicing on best practices, new policies and procedures.

Lindsey Hendrix: So when it comes to nursing research specifically, what are the types of things that are being studied at the college?

Nancy Fahrenwald: A lot of nursing research focuses on how to keep people healthy, but we recognize that prevention is key. Yet much of the work that we do is also helping people to manage or respond to any kind of health care issue that they have because it’s really that human response to a health care issue that nurses are specialized in. And then there is that aspect of nursing that is supporting people who are at the end of their life. The work that’s being done in the College of Nursing in the area of research is focused in really three areas. First off, care of women and children. So maternal, child health. Understanding why there are different pregnancy outcomes for certain populations of women or why, when we expect not as good outcomes, how come some people have great outcomes? Yet the data would tell us that they’re better than we would expect. So looking at those variables that might positively influence maternal and birth outcomes, like spirituality.

We’re also looking at some of the factors that just determine from a cultural perspective influences on birth outcomes. Then there is some work being done in the area of trauma and trauma care. So trauma informed care is an aspect of forensic nursing research, but we know that trauma pervades many nursing specialties, many health issues. So trauma can be from post-traumatic stress from some adverse childhood experience. It can certainly be the experience of interpersonal violence or even witnessing violence, serving in a war situation or a traumatic area. But our nurse scientists are working to understand the neurobiology of the brain and what happens when someone is exposed to trauma so that we can intervene earlier to help to limit the long-term consequences on the brain, the influences on the brain. And help people to live quality lives without the post-trauma stresses and challenges that many people experience.

Lindsey Hendrix: That’s very interesting. And so how has this research then translated into practice?

Nancy Fahrenwald: Certainly. Well, let me give you an example of research translated into practice in that area of forensic nursing that I just spoke about. Our faculty in the Forensic Nursing Program are currently funded by the federal government to provide education for sexual assault nurse examiners to serve in rural and underserved areas of the state of Texas. In order to prepare those sexual assault nurse examiners, they provide classroom education and practical education in our clinical simulation laboratory on the experience of interpersonal violence, how to communicate with people who experienced violence, how to document the evidence, how to do the assessment. And all of that is based on research findings and what the research tells us provides the best health outcomes.

So translating research into that area of practice is so critically important.

Lindsey Hendrix: You mentioned the sexual assault nurse examiners going into the rural and underserved areas. It’s interesting that there’s a nursing shortage and there’s a nursing need, but there’s also a need for that sub specialty of nurses specifically in those areas. And with the nursing shortage, though, we also have hospital closures. The infrastructure to support health care teams in these rural communities is starting to deteriorate. And so, how does educating a workforce to go out into these communities and provide nursing services work if they don’t have the facility to work in?

Nancy Fahrenwald: When we think about rural care, the only way we’re going to solve the challenges of access to care is by working as a team. Interprofessional teams might involve health care professionals, but they also might, these teams could also involve experts in technology or transportation, experts in education. Certainly innovation opportunities are out there for us right now to address these issues, but telehealth care is one area. Another area is making sure that people who are in the communities can practice to the full scope of their license. Whether that be advanced practice registered nurses, especially family nurse practitioners who are so in demand, but also assuring that we are educating people who are committed to serve in the rural areas, whether it be as a registered nurse or a family nurse practitioner or in the very near future as a psychiatric mental health nurse practitioner.

One of the unique challenges of rural nursing, which I have so much respect for having grown up a rural dweller, having practiced in a rural area in some of my years of clinical practice, you’re an expert generalist. You have to know a lot about everything. Many rural nurses have multiple specialization certificates. They might be specialized in trauma, they might be specialized in pediatric life support, adult life support. They might be specialized in wound care. There are a lot of things that they have to be specialized in because they never quite know what’s going to happen and they might be the only provider available if there is a hospital, in the hospital at the time. And if there isn’t, when you’re a rural dweller and people know that you are a registered nurse or a physician or a physician’s assistant or nurse practitioner, they will seek you out for advice and consultation. But we know that supporting our rural professionals is critical. For example, the sexual assault nurse examiners who we are preparing, we’re not only preparing them to serve in rural areas, those nurses who already work and dwell in those areas, but we’re creating a collaboration network of support over the distance so that these nurses who might encounter something they never experienced before and not be able to talk about it with other people who’ve experienced it will have a network of support with their peers across the state so that they don’t burn out. Because the turnover for sexual assault nurse examiners is quite high, it’s very stressful work. So building that infrastructure in will assure that our workforce that we’re preparing has that support needed.

Lindsey Hendrix: And what other continuing education opportunities are available for the nurses that you’ve educated or who have gotten their education elsewhere?

Nancy Fahrenwald: Well, advanced nursing education is ripe with opportunities. I’m going to speak to one thing that I think is really great about Texas A&M. We have a partnership with the Board of Nursing for the KSTAR nursing program. Now KSTAR is a program whereby nurses who have some type of practice violation or infraction are assessed and remediated and re-educated for safe competent care. We know that no one wants to create an error in the practice of health care. We know that it happens, but the KSTAR program in particular is something offered here at Texas A&M. It’s offered for both nurses and physicians to allow those nurses to develop the skills and competencies they need for safe care and to re-enter the workforce so that we don’t lose that practitioner in the workforce, but we retool and re-equip so that the Board of Nursing then can consider reinstatement of the license.

Lindsey Hendrix: It’s interesting to see that Texas A&M is not only preparing nurses from the very beginning, but they’re providing that support network throughout their career.

Nancy Fahrenwald: It’s critical for us, and I mentioned the land grant mission before. Of course, Texas A&M is a land, air and sea grant institution, so everything that we do has to cast that vision of beyond our borders or beyond our wildest imaginations. So the innovation about how we deliver care, how we offer educational programs, online through distance accessibility, and also meet the needs of a global citizenry I think is where we are right now in the College of Nursing, and we look to grow in the next 10 years from our current 440 students to about doubling that.

Lindsey Hendrix: You mentioned community college partnerships. What does that look like?

Nancy Fahrenwald: Community college partnerships are essential to many professional programs or degree programs, but we know that our community colleges in the state of Texas provide high-quality education to the people who are served by that community college, that geographic area. Not all education can be provided by four year degree granting institutions across the state. And assuring that the students who are consumers of education at community colleges have a very clear pathway forward to earn the Bachelor of Science degree or the Bachelor of Arts in another discipline is critical. It’s the ethic of higher education, but it’s also critical to assure that those students who their only option might be to start at the community college to work or to have it be more affordable, to live at home, to advance their education at the graduate or at the bachelor’s level means having those partnerships to assure that they’re not duplicating courses, that their courses will be reviewed and accepted as transfer credits by the university. And those kinds of partnerships in nursing are critical.

Lindsey Hendrix: So Texas A&M has partnerships with community colleges where?

Nancy Fahrenwald: Right now our partnership in Lufkin is with Angelina College. We actually have a professional student affairs staff person, an advisor who supports the students at Angelina College to not only complete their Associate of Science degree in nursing successfully, but to begin their preparation to earn a Bachelor of Science degree once they earn their associate degree and complete their education at Texas A&M while they are a working professional and accessing our education online.

We also have an advising site in the Rio Grande Valley right next to South Texas College. And those associate degree students at South Texas College have access to Texas A&M College of Nursing, not only by geographic proximity, but by the presence of a highly qualified student affairs staff person who helps them navigate a pathway forward to advance their education to the Bachelor of Science level. But even at the Master of Science level for both of these areas.

Lindsey Hendrix: And it’s so important to help anybody who wants to pursue this profession get there because we know there can be so many barriers to pursuing a degree. So it’s fantastic to hear that you’re helping to address some of those barriers in communities across Texas.

Nancy Fahrenwald: We know that we have more applicants than we can admit and we have many qualified applicants. Our admissions, especially here in Bryan-College Station, and in Round Rock, are limited for several reasons. First off, it’s clinical education capacities, so the placements that we can get in our health care systems so that our students have quality experiences. We’re growing those, but we have to share with other goals and colleges of nursing, but also get our graduates out there in the workforce so that more and more of our health systems understand the value of a Texas A&M education. And I hear it everywhere I go, that the Texas A&M nursing graduates are different. Those Aggie core values, but also their level of qualification. But as long as I mentioned competitive applications, I do want to say that there’s a pathway forward in nursing for everyone who wants to pursue a career in nursing. And if they apply for a program and aren’t accepted, they should continue to pursue their education perhaps in another setting, but to not lose hope because we know it’s competitive. But certainly continue to pursue your dream because we need more nurses, we need more registered nurses.

But the career of a nurse is the most rewarding and meaningful work that I really believe one can do. It is the best decision I’ve ever made to become a registered nurse with a Bachelor of Science degree. It opened doors for me to serve in rural America, to serve people who lived with cancer, to serve people in schools, school health nursing, to live and work in a remote area of our country, to serve in the Peace Corps doing AIDS prevention and control. And look at me now. I’m here at Texas A&M serving as a dean of the College of Nursing. That foundational degree paid off in a big way.

Lindsey Hendrix: What a great message to end this show on. You hear that everybody? Pursue your dreams. Don’t let anything get in your way. Thank you so much, Dean Fahrenwald, for joining us today.

Nancy Fahrenwald: Thank you.