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Transition and Crisis in New Jersey's Nursing Profession

As older nurses edge closer to retirement, can the state's nursing programs turn out enough graduates to take their place?

This is the first article in a two-part series on nursing in New Jersey.

Pat Barnett's grandmother as a student nurse. Barnett is the CEO of the NJ State Nurses Association & Institute for Nursing.

For Julie Williams, RN, it was a typical shift as critical care coordinator in the surgical ICU and telemetry units at HackensackUMC Mountainside Hospital in Montclair: clock in at 6 a.m., care for ICU transfers, ready patients for surgery, summon a team to resuscitate a critically ill patient, and clock out more than 12 hours later.

It's a challenging, constantly changing environment, observed Bonnie Michaels, vice president and chief nursing officer at the hospital -- as well as a member of the board of directors of the Organization of Nurse Executives New Jersey.

Her comments are equally apt when it comes to the field of nursing itself. Today's nurses do far more than take temperatures and jot notes on clipboards. In hospitals and doctor's offices across the state they help patients manage their diabetes, prescribe medicine for high blood pressure, scan ID bracelets to confirm medication, and use mobile phones to update doctors on patient status.

And in some cases, advanced practice nurses (APNs) are taking on many of the jobs once the province of primary care physicians.

Yet even as nurses assume greater responsibilities, the nursing profession is in a double bind. Many older nurses are looking to retire; according to a recent survey they'll do just that when the economy rebounds. Meanwhile, their replacements will likely be in short supply. But the key obstacle to filling the demand is not lack of nursing applicants or potentially qualified candidates -- it is a lack of available training.

By 2020 the supply of registered nurses in the state will be nearly 50 percent below demand, resulting in a shortfall of more than 42,000 registered nurse (RN) positions, according to projections by the Health Resources and Services Administration of the U.S. Department of Health.

Surveying Older Nurses

The average registered nurse licensed in New Jersey is age 56 and works more than 10 hours a day, according to a new survey of 1,000 older nurses who responded recently to questions posed by the Collaborating Center for Nursing based at Rutgers University.

Pat Barnett's mother in England during WWII.

“They work on their feet typically eight- to 12-hour shifts, three to five days a week, in a job that requires high energy and critical thinking skills,” said Michaels.

“When you’re in a fast-paced unit, you’re lucky if you get a break to go to the bathroom,” added Jeannie Cimiotti, the Collaborating Center’s executive director.

Cimiotti, a former pediatric nurse for critically ill children who switched midcareer to academia, heads the center’s research on the nursing workforce and its impact on patient care. The most recent research on older nurses, the Nurses' Retirement Planning Survey, surveyed a random sample of 2,000 nurses between the ages of 50 and 70. It is currently under review and the center plans to present its results to Gov. Chris Christie this fall. Among its findings: 58 percent said the current economic climate has delayed their retirement plans.

The expected exodus is leaving many in the field of nursing wondering who will take their place.

“It’s going to be scary,” said Mary Krug, one of the masters-prepared APNs practicing in the state. “We tease each other,” she said referring to her colleagues, other nurses also in their midfifties. “We better stay healthy. Who’s going to take care of us?”

A Family Tradition

At HackensackUMC Mountainside (the Montclair hospital recently changed its name after its purchase by Hackensack University Med¬ical Center and LHP Hospital Group) the registered nurses were entering data into computers on wheels -- or COWS – at the patient’s bedside.

“Basically, healthcare is increasingly more difficult and complicated,” said Patricia A. Barnett, chief executive officer of the New Jersey State Nurses Association & Institute for Nursing. “Nurses must be better prepared to deal with a world where we have gene therapy, new ways to identify diseases, and new treatments that require a much broader background.”

Barnett reflected on this changing role, sharing vintage family photos and stories.

“When my grandmother graduated from South Chicago Hospital as an RN in 1916, nurses could not take a blood pressure because that was considered a sophisticated piece of equipment [and the purview of doctors],” she recalled.

“When my mother graduated in 1942 from Michael Reese Hospital School of Nursing, nurses could not insert a nasogastric tube [for feeding] because it was a difficult procedure [and should be left to doctors]. When I graduated from Michael Reese in 1971, nurses couldn't do a femoral stick [to draw blood] because it was considered a difficult procedure,” Barnett said.

With each generation, nurses are acquiring new skills and competency through advanced education, training, and on-the-job experience, she said.

But there’s a worry that nurses working at New Jersey hospitals will leave a void when they retire. Hiring and training new nurses takes time and today’s nurses possess a level of experience that experts predict will be missed when the economy improves.

The Graduating Class

Experts also point to the need to improve the nursing education system, especially as patient needs have become more complicated, Barnett said. Meanwhile, they’re being called upon to fill expanding roles and to master technological tools and information management systems, while collaborating and coordinating care across teams of health professionals. Achieving higher levels of education and training is key.

But among the obstacles is a shortage of faculty to teach entry-level and graduate students. “We also need more nurses to get their degree completion,” Barnett said.

For the past 10 years, the Robert Wood Johnson Foundation has been working to increase by 80 percent the number of nursing students earning bachelor degrees, according to Susan Hassmiller, senior adviser for nursing at the foundation.

Despite the shortfall, however, there are signs of an uptick in the number of students choosing nursing careers, many attracted by labor figures that predict the registered nursing workforce will top occupations in terms of job growth through 2020.

Michaels, who also runs a hospital-based nursing school, is seeing many applicants with bachelor’s degrees from other disciplines and others leaving careers in areas like teaching or accounting. And while women still dominate the field, 25 percent of the new applicants at the Montclair hospital’s nursing school are men, she said.

Yet applicants are being turned away from college nursing programs every year. In New Jersey in 2011, only 1,000 of the 12,000 students who applied were able to enroll, according to data from the Collaborating Center for Nursing.

Addressing the Shortage

Efforts to address the shortage are under way, said Hassmiller, including making it easier for students to transfer credits from community colleges to universities, a single statewide curriculum, shared faculty, tuition help, and paid differentials when students receive their degrees.

Still, nursing schools across the country turned away 75,587 qualified applicants from baccalaureate and graduate nursing programs in 2011, due to an insufficient number of faculty, clinical sites, and classroom space, as well as budget constraints, according to the American Association of Colleges of Nursing.

Almost two-thirds of the nursing schools responding to ACN's 31st Annual Survey of Institutions with Baccalaureate and Higher Degree Nursing Programs released last March blamed faculty shortages as a reason for not accepting all qualified applicants into their programs.

That’s been the case in New Jersey, where schools are struggling to expand their nursing faculty. “The lack of educators is creating a serious backlog,” Barnett said.

The Robert Wood Johnson New Jersey Nursing Initiative is the main program to educate nurses. To help encourage others to consider nurse faculty careers, NJNI

The Robert Wood Johnson NJ Nursing Initiative is the leading program in the state to encourage nurses to switch to teaching. It recently launched WeTeachNursingNJ.com, a website that features resources and information about what a career as nurse faculty involves and the pathway to that career.

The initiative has provided about 40 scholarships and is collaborating with Rutgers and Seton Hall universities to establish additional doctorate scholarships. Other state institutions are providing aid for master’s programs. Online learning and simulation options are also under consideration to help schools expand their nursing programs.

The Nursing Initiative’s flagship program, the Faculty Prep Program, comprises 61 nurse scholars (nurses and doctoral-prepared nurses) who have committed to being nurse faculty in New Jersey. Hassmiller said this will go a long way to addressing the more than 10 percent nurse faculty vacancy rate in NJ’s nursing programs.

Marilyn Joyce Lehren is a contributor to New Jersey Spotlight. She has worked as a journalist throughout the state and edited a hyperlocal news website.

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