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The Growing Shortage in New Jersey Nursing

Healthcare reform will demand more and more nurses -- rather than pricey doctors -- but where will they come from?

Major changes in healthcare delivery are on the horizon, and the ways in which they will ultimately affect patient care in New Jersey are still murky. But there are some things the experts do agree on: the current nursing workforce will be unable to meet the demands of healthcare reform, and we are likely looking at an enormous nursing shortage in the years ahead.

As tens of thousands of state residents are enrolled in managed care through federal reforms slated to occur in 2014, more and more nurses will be needed to handle everything from blood-pressure screenings to respiratory treatments. What’s more, if healthcare reform is to be effective, it requires nurses to take on a greater role in patient care.

For example, state health officials are discussing changes that would move scores of patients from nursing homes and other long-term facilities to community and homecare settings. This reform -- which requires federal approval -- would also rely heavily on nurses to provide much of the daily personal care, rehabilitation and other specialized services.

Factor in an aging Baby Boomer population and the need for nurses becomes even more critical. Indeed, many experts say an existing nursing shortage is currently being masked by the fact that the recession brought nurses out of retirement to help pay the family bills.

The crisis is not just one of high demand but also of short supply. There is a significant lack of potential nurses in the educational pipeline. More than a thousand faculty vacancies exist at nursing schools across the country, and roughly three dozen exist in New Jersey. Experts say the system for training these specialized nurses -- and the professors needed to teach them -- is not going to be able to meet the needs of the nursing.

As it is, more than 67,000 potential caregivers were turned away last year from nursing programs across the country, an increase of nearly 20 percent over 2009, according to the American Association of Colleges of Nursing. In New Jersey, some 1,500 qualified applicants are now rejected annually.

Given the problems finding faculty -- along with facilities needs and financial concerns in general -- nursing schools will continue to have a limited capacity, Federal estimates suggest that there will be a shortage of more than 40,000 nurses in the Garden State at the end of this decade alone.

“It is growing to be far worse than in the 1960s,” said Patricia Barnett, CEO of the New Jersey State Nurses Association, recalling another time when widespread changes in the healthcare system combined with a population boom that resulted in a lack of caregivers. “If we don’t pick up the pace, this is going to be a real problem.”

Dwindling Resources

When the economy soured in 2008, the nursing workforce actually expanded as caregivers came out of retirement or took on extra shifts to bolster their family’s income. But as the job market starts to improve and wage-earners in other professions return to work, some of these nurses will retire or cut back their hours, leaving nursing homes and health clinics struggling to find nursing staff once again. Advocates fear this economic cycle will coincide with changes in healthcare policy, exacerbating the problem.

The primary policy change is the federal Patient Protection and Affordable Care Act, which seeks to enroll tens of thousands of additional Garden State residents in Medicaid, the state and federally funded health insurance program for poor and disabled residents. Thousands more will receive tax breaks to help them purchase health insurance in the private market, further adding to the pool of patients requiring care.

On the state level, Gov. Chris Christie has called for an overhaul of the way Medicaid is administered, with changes that include de-institutionalizing patients in a process dubbed “rebalancing.” State officials are still crafting the details of this reform, which must be approved by the federal government, but they say it can save hundreds of millions of dollars. Acting Health Commissioner Mary O’Dowd told a Senate committee last week that to prepare for this transition her department has focused on expanding medical daycare and has included nearly $48 million in extra funding in the upcoming budget to help seniors transfer from nursing homes to community or homecare.

One factor these reforms have in common is a heavy reliance on nurses. “Healthcare is moving out of the hospital,” said Aline Holmes, a nurse and senior vice-president at the New Jersey Hospital Association. “And we just don’t have enough nurses in the queue to fill these spots.”

To address this issue, legislators have offered several proposals to provide more state aid for nursing schools and student aid, but they have received little attention. Another proposed measure would raise the educational bar and require all nurses to complete four-year programs, instead of the more popular two-year courses; the bill would also give those already certified ten years to meet the new requirements. Advocates say this change would help nurses master new treatments and technology, improve the overall quality of patient care and also increase the pool of candidates for faculty positions at nursing schools – which in turn would help stem the loss of qualified candidates and grow the nursing workforce.

“In order to push up the profession of nursing, we have to expect them to have a [four-year] baccalaureate at least,” said Assemblywoman Nancy Munoz (R-Union), a sponsor of the bill and a nurse with a master’s degree. “The role of the nurse is changing,” she said, “and we need to get more people with baccalaureate degrees into the pipeline.”

But Munoz noted that this issue has been debated within the nursing community for several decades -- predating her own baccalaureate degree, which she received in 1976 -- and it still prompts quiet criticism among some members of the profession, particularly older nurses (like her mother.) Despite bipartisan support in the Senate and Assembly, the legislation is not advancing; the latest version of this bill was introduced last year in both houses and has yet to have a committee hearing.

Nursing Programs

In New Jersey, more than three dozen schools or hospitals offer nursing programs that include two-year diploma or associates degree courses or four-year baccalaureate degree course. Another dozen or so colleges have advanced study courses for masters or doctoral students.

All together, these programs churn out more than 2,600 graduates each year; roughly 1,600 receive two-year degrees, according to recent figures compiled by the state Nursing Association. Roughly 760 students obtain baccalaureate certification, some 225 get a master’s degree and there are only a handful of nursing Ph.D.’s each year.

“It’s kind of a chicken and an egg situation,” said the association’s Barnett. “You’ll never have enough masters if you don’t have more” baccalaureate students.

This problem was highlighted in a report on "The Future of Nursing" issued in October, which grew out of a two-year Institute of Medicine study funded by the Robert Wood Johnson Foundation.

The report noted that, with 3 million caregivers, nurses are the largest segment of the nation’s healthcare workforce, and that they must be prepared to help implement the federal reform plan and respond to the “rapidly changing healthcare settings and an evolving healthcare system.” One key to their success is more education, according to the authors.

“Patient needs have become more complicated, and nurses need to attain requisite competencies to deliver high-quality care,” the report says. In addition to learning the technical skills required, nurses today must understand healthcare policy, evidence-based research and information technology.

To meet these demands, the report recommends several educational targets for the nursing workforce. The Institute calls for an increase from 50 percent to 80 percent by 2020 in the number of nurses with a four-year, or baccalaureate degree; the group also advocates for a doubling of the number of nurses with doctorate degrees by the same year.

New Jersey's Nursing Initiative

In New Jersey, some help is on the way. In the coming weeks, the first of 49 advanced nursing students will graduate from programs across the state as part of a five-year $13.5 million scholarship and stipend program created in 2009 as part of the New Jersey Nursing Initiative. Twenty master’s degree candidates are slated to get their degrees this year, followed next year by another 18 master’s candidates and a record 11 doctoral students, a spokesperson said.

Funded by the Robert Wood Johnson Foundation and the New Jersey Chamber of Commerce, the Nursing Initiative also studies recruiting and retraining issues and nursing curricula and seeks private sector support for the nursing workforce. This work is continuing, but there are no plans at this point to fund another round of nursing scholarships.

Holmes, of the Hospital Association, hailed this scholarship program, noting that it alone will allow the state to reach the Institute of Medicine’s goals of doubling the number of Ph.D. graduates. “But the problem is, there’s no one behind them,” she added, explaining that it will take more than a dozen Ph.D. graduates to fix the system. (In fact, the doctoral students graduating from the Nursing Initiative’s program will only be able to fill a third of the current faculty vacancies in New Jersey.)

While in the past, nurses have complained about the time and cost involved with taking advanced classes, Holmes said those excuses seem thin today given the wealth of online courses that allow them to study at home on their own schedules. Advanced study work is primarily book study, not clinical work, so the online option makes sense, she adds. In addition, many employers will reimburse nurses for their tuition costs.

“It’s just so easy today” to continue your education, Holmes said.

But getting more nurses to go back to school is only part of the solution, experts say. Something needs to be done to keep enough graduates on campus, as faculty, in order to continue to train the new generations of nurses needed for healthcare’s future. Nursing programs are expensive to run, require a large number of faculty per student and don’t pay as well as clinical work: a recent report from the American Association of Colleges of Nursing found faculty nurses earn $15,000 less a year on average than those working in hospitals, nursing homes or other healthcare facilities.

There is some state and federal funding assistance for nursing education programs, designed to ease the burden on students, but advocates say more needs to be done -- especially to help students in advanced programs that can graduate more nursing faculty. Christie’s proposed budget for 2012 includes nearly $2 billion for higher education, almost $118 million less than the previous year. But the state does not dictate the details of how most of this is spent, with the bulk -- $1.5 billion – going directly to the public universities and community colleges, who can determine which programs get what.

Advocates also noted that the $30 million in additional graduate medical education funding provided by the governor this year will pay to train doctors, not nurses. State officials were unable to isolate any other funding specifically for nursing education.

Even programs dedicated to nursing education appear difficult to fund. A measure signed into law in December 2008 by then-Gov. Jon S. Corzine to provide loan forgiveness for advanced nursing students has never been funded, advocates said. Designed to take effect in July 2009, the program is slated to receive an $800,000 boost in federal funds, thanks to the Affordable Care Act, but there is no state money budgeted for the program in 2012.

“De-funding programs aimed at addressing the critical shortage of primary care providers may very well be the most irresponsible of the proposals before you today,” insisted Sen. Joseph Vitale (D-Middlesex), a longtime advocate for New Jersey nurses when he testified on March 9 before a Congressional subcommittee that was discussing a proposal to suspend funding for the federal reform plan.

Vitale sponsored the loan forgiveness program and other funding efforts and he is also a Senate sponsor of the baccalaureate bill. “The primary care workforce shortage is not solely a New Jersey problem; it is a problem in every single state that will reach a critical level as access to healthcare coverage is expanded to currently uninsured populations,” he said.

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