Higher Education's Role in Easing the US Nursing Shortage

During my career as a nurse and nurse educator, nursing shortages have long been an issue and one I'm personally very committed to finding solutions for. I was interested to read this report from the Center for American Progress (CAP), How to Ease the Nursing Shortage in America, which highlights the numerous challenges to generating new nursing professionals and makes recommendations for long-term solutions. Nursing shortages are causing immense strain on healthcare systems and putting the health of our communities at risk today, which is why I advocate for a comprehensive mix of short- and long-term solutions to adequately ease current shortages and work towards a more robust and healthy nursing workforce for the future.

The CAP report states, "Evidence points to three main constraints that prevent higher education institutions from graduating more nurses: a shortage of nurse educators, a lack of clinical placements for student nurses, and inadequate campus facilities and equipment."  While I agree with these three major categories, emphasis must be placed on addressing a few other challenges that constrain higher education's ability to train new professional nurses, specifically BSN-prepared RNs.

Prioritize the Increase of New BSN Registered Nurses

There is an overabundance of programs that bridge the gap between an Associate Degree in Nursing (ADN) and a Bachelor of Science in Nursing (BSN) degree (commonly referred to as RN to BSN programs). There is a critical, identified need for RN-BSN programs ­– we know that BSN-prepared nurses improve patient outcomes. Hospitals prefer BSN-prepared nurses, and many employers are already helping individuals bridge from ADN to BSN. Some states, like New York, even mandate that nurses bridge from an ADN to BSN within a specific time period. However, RN-BSN programs do not increase the number of new registered nurses.

Most State Boards of Nursing Do Not Regulate "Post-licensure" BSN Programs

With employer and state licensure requirements generating demand for RN-BSN programs, the ease of offering these programs creates a surplus. Universities are able to deliver RN-BSN programs without constraint from the state boards of nursing. While program-level accreditation is an industry standard and does require resources and effort to obtain, RN-BSN programs are significantly easier for universities to offer because they do not include the laboratory, simulation, and clinicals required in a pre-licensure BSN program.

These programs have a significant online presence (reducing the burden of commuting), minimal clinical requirements (usually community or public health) and are generally inexpensive - more than 100 programs have tuition of $15,000 or less (Online Degree Database, 2022, https://onlinedegreedata.com).

Pre-licensure BSN Programs Face Considerable Roadblocks

In addition to bridging the educational gap from RN to BSN, professional regulating bodies, state boards of nursing, and higher education institutions should focus on preventing the gap by increasing enrollment in pre-licensure BSN programs. The BSN has long been recommended as the degree for entry into nursing practice by organizations such as the ANA, AACN, and Institute of Medicine (now the National Academy of Medicine). Creating more opportunities for the recommended entry-level degree in nursing helps build a highly-qualified workforce and increases the number of new nurses entering the field.

However, pre-licensure BSN programs are highly regulated by each state's board of nursing, creating 50 different sets of rules. Some of these rules actually impede educational innovation that could increase the capacity of universities to offer BSN programs to aspiring nurses. Additionally, thousands of applicants are turned away each year from existing BSN programs for various reasons, including lack of faculty, lack of clinical placements, and even program enrollment caps set by the state board of nursing.

Expanding Distance Education Opportunities Benefits Students, Universities, and the Workforce

The landscape of higher education was changing even before the COVID-19 pandemic, and the past two years have accelerated that change as more individuals see the benefit of online educational programs. Online or hybrid options allow students to maintain some semblance of balance between school and other life responsibilities, such as family, work, and social obligations, which significantly impact an individual's physical and mental well-being. Not to mention that distance education relieves the burden of relocating to a different city or state, an economic impossibility that many potential students cannot shoulder today.

Distance Accelerated BSN programs geared to second-degree students leverage online didactic coursework, in-person skills residencies, and in-person clinicals near the students' home community. This format is designed specifically for adult learners who already have a degree but want to pursue a second career in nursing. Second-degree BSN programs prepare nurses in 12-16 months on average because students have met all the general education requirements via their first bachelor's degree and completed nursing prerequisites before entry. This innovative model relieves many challenges to expanding nursing programs and gets new nurses into the workforce relatively quickly.

Distance Education Increases Clinical Placement Capacity

The distance model for accelerated second-degree BSN programs offers shorter-term solutions to increasing the number of BSN-prepared nurses because it reduces clinical placement bottlenecks. Enrolling students from across - or even outside of - their state distributes the placement locations. Placing a handful of students in a geographical area is usually significantly easier than placing multiple cohorts of students in one local region. Students are directed and evaluated by faculty from afar while utilizing qualified registered nurse preceptors to accomplish clinical placements in their home community.

Distance Education Helps Maximize the Use of Campus Infrastructure

Universities can also leverage existing physical infrastructure more effectively with distance programs. Students come to campus for skills residencies for concentrated periods, which universities can schedule when the simulation lab is utilized less or when campus-based students are on break, maximizing the use of existing resources. The increased enrollment capacity can then empower universities to build additional simulation resources over time, resulting in continued opportunities for growth.

Distance accelerated second-degree BSN education programs have already been proven to successfully prepare BSN graduates. University of Wisconsin Oshkosh (UWO) has implemented this model for over 20 years and consistently has above-average NCLEX pass rates for first-time test-takers, as demonstrated by a 94.05% in 2021. Additionally, their website boasts a retention rate of 99%.

However, states like Oklahoma, New Jersey, and Louisiana either have specific rules that prevent aspects of this innovative model or rules that are "silent" on distance education. This absence of rules on distance education or innovative models is handled differently by each of the 50 boards of nursing—with some allowing it and others indicating that because no rules exist, it cannot be done. Nursing boards can directly impact their state's ability to train BSN-prepared nurses via accelerated second-degree programs by allowing innovative educational models and increasing enrollment caps. Many states can do this immediately because no rules prevent distance education or preceptors. For many boards, the only barrier is their interpretation of the absence of rules.

Addressing Faculty Shortages with Increased Funding

The Center for American Progress report cites BLS salary data for nursing faculty, with a median faculty salary of $77,400 per year- almost identical to the median registered nurse salary of $77,600. However, when examining salary data for 13,028 registered nurse job postings requiring 5+ years of work experience, the median salary is $84,700. Looking further into salary data for the 3,926 postings listing MSN or Ph.D. with required 5+ years of experience, the median salary increases to $94,500 (Emsi Burning Glass – economicmodeling.com, June 2021 to May 2022, 20 June 2022). This data demonstrates that it is not just advanced practice registered nurses (APRNs) making more money, and faculty salaries need to account for this. Academic positions may have perks related to work-life balance that can justify a salary differential; however, many nursing programs run 12 months per year, and many faculty are not getting "summers off." Higher education institutions must be willing to offer competitive pay if they want to recruit and retain qualified faculty.

The CAP report also calls for legislative action to increase funding to prepare future faculty, better analysis of the healthcare workforce via commissions at federal and state levels, and funding to incentivize clinical placement opportunities within health systems. While I agree that these initiatives will likely address the nursing shortage, they will take time. It is also important to note that the referenced Graduate Nurse Education (GNE) program that demonstrated monetary incentives to increase clinical placements was for graduate-level advanced practice nursing student placements, not pre-licensure placements. While I anticipate financial incentives for health systems and/or preceptors would increase their capacity for BSN placements, funding is years away.

The shortage of nurses is real and growing. Yes, increasing funding to generate doctorally prepared nursing faculty will help with one aspect of the enrollment limitations; however, doctoral education takes multiple years, and the recent impacts of the COVID-19 pandemic will only deepen the shortage. It's essential to address these longer-term solutions now to impact the future, but we also need to lean into solutions with more immediate impacts.

I believe the ideal shorter-term solution is for boards of nursing and health systems to embrace innovation and permit new pre-licensure BSN distance education models that will provide a pipeline of potential new BSN-prepared RN hires. State boards of nursing have a role to play in the inception of new nursing programs in their state to protect students and ensure infrastructure is in place for a BSN program to be successful. However, once a pre-licensure program has achieved CCNE or ACEN accreditation, state boards should rely on the expertise of professional accrediting bodies that set standards for nursing education programs rather than creating and implementing their own set of rules and regulations related to program changes and instruction. Other health disciplines such as speech-language, clinical mental health counseling, and physical therapy have long relied on professional accrediting bodies to monitor degree programs. Embracing an innovative model for pre-licensure BSN education offers a shorter-term solution that overcomes many of the constraints to easing the nursing shortage, alleviating some of the need while the implementation of long-term solutions begins.

Keypath currently supports second-degree distance Accelerated BSN programs with seven university partners, helping overcome the challenges that limit program capacity, creating opportunities for aspiring second-career nurses, and making an impact on nursing shortages. To learn more, get in touch with us here.