Human resources in nursing education: A worldwide crisis
Article Outline
- Summary
- Forces affecting the faculty shortage
- Does our current clinical education model exacerbate the faculty shortage?
- Potential solutions for the faculty shortage
- Summary
- References
- Copyright
Summary
The global shortage of nurses is escalating. A key contributing factor to the production of new nurses is the growing shortage of qualified faculty. This paper explores the forces influencing the global faculty shortage, including those that increase demand and those that limit the supply of nursing faculty. The authors discuss potential solutions to the shortage, placing particular emphasis on leveraging the strengths of the profession to accelerate the progression of nurses to graduate school, the enhancement of funding for graduate education, changing the paradigm of clinical education, and the expansion of the science base for practice.
Keywords: Nursing shortage, Faculty shortage, Clinical education model, Graduate education funding
The current and impending escalation of a global nurse shortage is well known. Fifty-seven countries claim critical workforce shortages of nurses severe enough to thwart essential health interventions (WHO, 2006). In the U.S., the shortage of nurses will grow to over 1 million by the year 2020 (HRSA, 2004). One major barrier to the production of nurses worldwide is the unavailability of infrastructure, most critically, faculty (Hinshaw, 2001, Hinshaw and Leino-Kilpi, 2005).
The World Health Organization (2006) reported a critical shortage of both nurses and nursing faculty in the majority of its member states. In the U.S., nearly 74% of the schools of nursing are turning away qualified nursing student applicants due to a shortage of faculty (Fang, Wilsey-Wisniewski, & Bednash, 2006), a total of 38, 415 in 2006 alone (AACN, 2008a, AACN, 2008b). Nearly 300 nursing faculty in the U.S. are expected to retire in 2008 with a peak in nursing faculty retirements projected in 2010 (Yordy, 2006). Yet, only approximately 400 nurses are awarded a doctorate in the U.S. each year, many of whom do not enter academe (Potempa, Redman, & Anderson, 2008).
Table 1 represents the distribution of registered nurses prepared at all levels of education in the U.S. While the specific numbers are different among countries, the basic picture of the distribution is quite similar, with the top of the pyramid or those nurses prepared with graduate degrees being far fewer than those prepared at the baccalaureate or lesser degree level. The scarcity at this top level, particularly the doctoral level, significantly reduces the capacity of nursing to not only educate the next generation of nurses, but perhaps most importantly, reduces the capacity of nursing to generate the science base to improve health care and the leadership to advance health delivery systems. This latter point is one that is not receiving the attention that it must have if we are to have the impact we need on the health of nations.
Table 1. Distribution of registered nurses at all levels of education in the United States.
| Highest level of preparation in nursing or related field | Estimated number | Estimated percentage |
|---|---|---|
| Doctorate | 26,100 | 0.9 |
| Master's | 350,801 | 12.0 |
| Baccalaureate | 994,276 | 34.2 |
| Associate | 981,238 | 33.7 |
| Diploma | 510,209 | 17.5 |
The purpose of this paper is to explore the forces influencing the global faculty shortage and to discuss potential solutions to the shortage. A particular emphasis will be on leveraging the strengths of the profession to accelerate the progression of nurses to graduate school, the enhancement of funding for graduate education, and the expansion of the science base for practice.
Forces affecting the faculty shortage
What are the forces that contribute to this situation of faculty shortage? One might think of these forces as either ‘positive’ or ‘negative’. Positive forces are those that occur because nurses are in increased demand, driving the need for greater production and thus increasing the need for more faculties. Negative forces are those that limit the number of nurses seeking preparation for faculty roles or cause nurses with faculty-level preparation to seek positions outside of the academy. An outline of the positive and negative forces is displayed in Table 2.
Table 2. Positive and negative forces contributing to a shortage of nursing faculty.
| Positive forces | Negative forces |
|---|---|
| Awareness of nurses’ impact on care management | Stagnation of funding |
| Aging population | Predominance of females |
| Maturing of nursing science | Expansion of opportunities for women |
| Unattractive salaries in comparison to clinical roles | |
| Demands of academic roles |
Positive forces affecting the faculty shortage
Many anecdotes as well as descriptive data illustrate the growing awareness of the importance and influence of nurses on primary health care as well as episodic and chronic care management (Frampton & Wall, 1994; Needleman, Buerhaus, Mattke, Steward, & Zelevinsky, 2002; Aiken, Clarke, Sloane, Lake, & Sheney, 2008; Aiken, Clarke, Cheung, Sloane, & Silber, 2003). The aging population in many areas of the world has also expanded the importance of nursing in chronic care management (Burl, 1994). As well, the mature nursing science and scholarship is growing in influence on the healthcare system. For example, the data demonstrating the relationship of baccalaureate or greater education of nurses and higher quality and safety of nursing care (Aiken et al., 2003) is compelling many health systems to augment its workforce. All of these factors are increasing the demand for nurses and a parallel demand for nurse educators to allow the expansion of enrollments in our schools of nursing (AACN, 2008a, AACN, 2008b).
Negative forces affecting the faculty shortage
Yet, while the demand for more nurses and faculty has never been higher, there is stagnation or decline in funding sources for graduate education in the United States as well as other countries (HRSA, 2003). While more men are entering nursing and obtaining graduate degrees, nursing is still largely a female profession. The opening up of many other fields for women that may be more attractive in terms of financial reward or prestige has influenced the number of individuals entering the nursing field in the last 30 years or more (GAO, 2001). While the U.S. is now showing an increase in enrollment in schools of nursing (AACN, 2007), this has not yet translated into a substantial increase in the workforce, either of staff nurses or faculty. Moreover, as the general shortage of nurses has risen, so have salaries in clinical roles providing an attractive alternative to faculty positions that generally have lesser pay scales. The relative attractiveness of the clinical roles such as nurse practitioner or clinical nurse leader may also make nurses less inclined to complete the doctoral degree or prepare for a faculty role.
Does our current clinical education model exacerbate the faculty shortage?
Current emphasis of many if not most nursing faculties is clinical education, especially pre-licensure clinical education. The enactment of the faculty role in many areas of the world includes intensive oversight of undergraduate or pre-licensure students while in the clinical area for practicum. For example in the U.S., many states regulate the ratio of faculty to students when in the clinical area. Is this model of direct and intense clinical oversight of students necessary to their learning and development? As an alternative, allowing students to fully immerse in the practice environment working as junior partners with staff nurses as their primary mentors can provide an excellent learning atmosphere. As well, many of the technical and professional aspects of care do not have to be learned only through formal or ‘for academic credit’ practicum. Many practice based disciplines such as engineering, social work and public health, utilize ‘not for credit’ externships to help students develop skill and the professional role. The ‘for academic credit’ practicum may be best utilized for the higher order development of judgment and leadership under the oversight of faculty. This latter circumstance assumes that the faculty is actively engaged in the clinical environment in more than an educational oversight capacity. The faculty role can expand beyond the observation and oversight of specific students to the inclusion of other aspects of the faculty role, for example, engagement in research, staff development and oversight of evidence based practice implementation. A central thesis of this proposition is that the best clinical education occurs in a milieu of faculty driven research and faculty driven practice.
It bears noting that staff nurses sometimes cite legal concerns about supervising the care of students in the clinical setting. This is often a result of staff nurses having inaccurate information and understanding of the law. Under the various state laws in the United States, the staff nurse holds responsibility for the management of patient care. The individual nurse should understand the level of competency of the student nurse they are mentoring before delegating various aspects of care commensurate with that knowledge. If the student is immersed in the clinical setting, rather than a guest as they often are currently, the staff nurse is more likely to have an accurate understanding of the competency level of the student. Ultimately, it is the student themselves that hold the responsibility for their own actions. With appropriate delegation and oversight of patient care, the staff nurse's concern about liability for the student's actions is unsupported. It is always advisable to seek a legal opinion for clarification of these matters.
The current culture and predominant structure within nursing education encourages the BSN graduate to exit the academic setting and gain clinical experience before pursuing advanced degrees. This creates a barrier to further academic education as reentering the academic track, with its costs and limitations on time and clinical income, is a challenging lifestyle adjustment. Likewise, nursing educational structures include a separate Master's level, not found in many other academic disciplines. This creates one more exit point, further limiting potential advancement to the doctoral level of education. These structures and predominant culture slow the progression of the student to doctoral education, limits the productive faculty and clinical research time, and risks the student remaining in the service sector and not returning to academe at all.
In a recent publication, Potempa et al. (2008) described the differences in scholarly productivity among schools of nursing, schools of medicine and schools of public health in the U.S. Clearly, schools of medicine and public health are far surpassing the faculty of schools of nursing in their productivity even with far fewer schools and in the case of public health, far fewer faculty members. Perhaps this is because the time of faculty in schools of nursing is too concentrated in direct clinical observation of students, not allowing the same level of engagement in the scholarly mission as other health disciplines. If we are to adequately compete with other disciplines in developing the science and evidence base for our practice, then the faculty need to have the time to fully engage in the missions of education, practice and research.
Potential solutions for the faculty shortage
Table 3 provides an outline of potential solutions for the worldwide faculty shortage.
Table 3. Potential solutions for the worldwide nursing faculty shortage.
| Leverage public recognition of the importance of nurses to quality of patient care |
| Make a compelling case for the need to expand funding for higher nursing education |
| Modify the current paradigm of nursing clinical education |
| Augment nursing faculty with faculty of complimentary disciplines |
| Deploy faculty with greater emphasis on scholarship and research |
Leveraging our strengths
One of the first principles of change is to leverage strengths in creating forward momentum. The current recognition of the importance of nurses to the quality of care provided is compelling in most nations of the world. We need to emphasize this important contribution in media and policy arenas. The public needs to be consistently apprised of the societal health benefits of nurses, nursing research and nursing faculty development. Buresh and Gordon (2000) stressed that the public will more readily understand the relevance of nursing to health and illness when nursing becomes more visible. Individual nurses can give greater visibility to nursing by accessing the various media outlets. However, it is most powerful when nursing can make public statements that are representative of coalitions across many organizations of individual nurses and nursing. It is even better when organizations other than nursing also make public statements in support of the work that we do. It is incumbent on the leaders of nursing organizations and institutions to find ways to coalesce around these key messages and to seek support from others in their delivery and translation to the public.
Enhancing funding from multiple sources
The public exposure of nursing and its ultimate benefit to society is a critical foundation to seeking multi level and multi faceted funding support for education especially higher education of the professoriate. With economic pressures around the world, it is not likely that a single source of financial support will continue, such as at local or regional levels of government. While government supports will continue to be necessary and indeed must be augmented, we need additional sources of contribution if we are to achieve our goal of ameliorating the faculty shortage. Expanding the support of individuals through philanthropy, foundations and international aid agencies will be necessary to achieve this goal. It is important to note that nothing draws resources more than enhancing perception of ‘value’ and ‘quality’. Sometimes in our field of nursing we emphasize our shortages and our need that, while true, may be perceived negatively by donors. We need to elevate the message of why supporting nursing is a high quality proposition.
Changing the paradigm of clinical education
What can we learn from other models of clinical education? It should be noted that the disciplines of medicine and public health also have extensive clinical training for their students. Yet these schools employ other models of clinical education that have proven to be effective in preparing students for practice. Medicine, for example, uses a hierarchical model of clinical training with medical students being immersed in teams of physicians including interns, residents and fellows in the supervision of medical students in the clinical arena. Attending physicians direct the training but are not involved in every aspect of clinical training oversight. The field of public health employs field practicum that allows more independent practice of students under the oversight of clinicians and public health officials in the agencies.
Schools of nursing can partner more effectively with practice environments to drive scholarship, care and clinical education. As well, practice environments could support schools of nursing as generously as they now support schools of medicine if nursing schools were significant partners in care. Finally, nursing education may not require the type of faculty oversight it now utilizes as basic skills can be achieved in ‘not for credit’ externships and other field experiences with lesser direct faculty oversight.
While a particular model is not being advocated for nursing, it is time for us to experiment, innovate and perhaps go ‘back to the future’ in ways nursing students have been immersed in the clinical world in the past to not only enhance their education but also to allow faculty the time to engage in other missions that will enhance the clinical environment and the profession.
Adding faculty of complimentary disciplines
The quality of our scientific efforts does now and can continue to attract those with training in complimentary fields to work with nursing faculty in interdisciplinary projects and programs. Welcoming those with advanced education in these complimentary fields onto our faculty will expand our capacity to educate and to expand our interdisciplinary research as well. Balance of faculty will always be an important consideration so that nurses are leading the advancement of the science as well as the educational programs. However individuals from complimentary fields such as psychology, sociology and public health can be enormously beneficial to enhance our curriculum and research programs. This should not be viewed as a ‘stop gap’ method in the face of a faculty shortage but rather a method of incorporating an interdisciplinary perspective to our colleges and schools that will enhance our development for the future.
Focus on scholarship and research as the basis for growth
Our value to society is based on the growing maturation of our profession in its utilization of cutting edge knowledge and evidence in practice. By allowing faculty the time to engage in the full roles of the professoriate, most notably enhancing scientific and scholarly productivity, we are creating the environment for more rapid development of nursing. What influences the perceptions of a field if not the quantity of scientific output that enters the public domain? More importantly, what provides the basis for the betterment of health care than the advancement in understanding of the methods to improve care? The public is now barraged with the scientific discoveries of the disciplines of medicine and public health and to a far lesser extent, nursing (Potempa et al., 2008). What if nursing could significantly accelerate and leverage its faculty's capacity to generate scientific discoveries? What possibility would that have on the impact of the field in health care and in health policy?
Summary
Positive momentum and growing public image can serve as an accelerant, attracting students to the field of nursing and to graduate school. In other words, if we make clear the value of education and research in nursing to our public and to our students, this should provide motivation for them to want to emulate and progress to a faculty role. This momentum can also accelerate the interest of the public in funding nursing education as a value proposition for society and the health of nations.
References
- . Education levels of hospital nurses and surgical patient mortality. Journal of American Medical Association. 2003;290:1617–1623
- . Effects of hospital care environment on patient mortality and nurse outcomes. Journal of Nursing Administration. 2008;38:223–229
- American Association of Colleges of Nursing. (2008). Nursing faculty shortage – fact sheet. Retrieved November 15, 2008 from http://www.aacn.nche.edu/Media/FactSheets/FacultyShortage.htm.
- American Association of Colleges of Nursing. (2008). American enrollment growth in U.S. nursing colleges and universities hits a 8-year low according to new data released by AACN. Press Release. Retrieved December 5, 2008 from http://www.aacn.nche.edu/Media/NewsReleases/2008/EnrlGrowth.html.
- American Association of Colleges of Nursing. (2007). Enrollment growth slows at U.S. nursing colleges and universities in 2007 despite calls for more registered nurses. Press release. Retrieved November 15, 2008 from http://www.aacn.nche.edu/Media/NewsReleases/2007/enrl.htm.
- . From silence to voice. Ottawa: Canadian Nurses Association; 2000;
- . Demonstration of the cost-effectiveness of a nurse practitioner/physician team in long-term care facilities. HMO Practice. 1994;8:157–161
- . 2005–2006 Enrollment and graduations in baccalaureate and graduate programs in nursing. Washington, DC: American Association of Colleges of Nursing; 2006;
- . Exploring the use of NPs and PAs in primary care. HMO Practice. 1994;8:165–170
- Government Accountability Office. (2001). Nursing workforce: Emerging nursing shortage due to multiple factors (GAO-01-944). Retrieved November 15, 2008 from http://www.gao.gov/.
- Health Resources and Services Administration. (2004). What is behind HRSA's projected supply, demand, and shortages of registered nurses? Retrieved November 15, 2008 from http://bhpr.hrsa.gov/healthworkforce/reports/nursing/rnbehindprojections/index.htm.
- Health Resources and Services Administration. (2003). National Advisory Council on Nurse Education and Practice: Third Report to the Secretary of Health and Human Services and the Congress. Retrieved December 8, 2008 from ftp://ftp.hrsa.gov/bhpr/nursing/nacreport.pdf.
- . The nursing shortage: A continuing challenge: The shortage of educationally prepared nursing faculty. Online Journal of Issues in Nursing. 2001;6:3
- . Future directions in knowledge development and doctoral education in nursing. In: Ketefian S, McKenna H editor. Doctoral education in nursing: International perspectives.. London: Routledge Publishers; 2005;
- . Nurse staffing levels and the quality of care in hospitals. New England Journal of Medicine. 2002;346:1715–1722
- . Capacity for the advancement of nursing science: Issues and challenges. Journal of Professional Nursing. 2008;24:329–336
- World Health Organization. (2006). The world health report 2006: Working together for health. Retrieved November 15, 2008 from http://www.who.int/whr/2006/en/.
- Yordy, K. D. (2006). The nursing faculty shortage: A crisis for health care. Association of Academic Healthcenters. Retrieved November 19, 2008 from http://www.ahcnet.org/pdf/factors_affecting_the_health_workforce_2005.pdf.
PII: S1322-7696(08)00072-3
doi:10.1016/j.colegn.2008.12.003
© 2009 Royal College of Nursing, Australia. Published by Elsevier Inc. All rights reserved.
