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Nurses Needed: Will anyone be available when a patient signals for help?

While state policymakers throughout the nation wrestle with the rising cost of health care, they're becoming increasingly worried about a shortfall in the number of caregivers. 

Studies suggest that Illinois and most other states will face a nursing shortage in the near future if they don't already. Yet quantifying this problem, and finding a way to solve it, is proving difficult.   

Here's the best guess based on the most recent data. Nationwide, the health care system will be short some 800,000 registered nurses by 2020, according to 2002 projections made by the federal Health Resources and Services Administration. Illinois reflects this trend, with the latest hospital and nursing association data suggesting the state will be short some 20,000 nurses each year until 2010. 

Furthermore, social changes over the next few decades are expected to put even greater pressure on health care services. An aging population of baby boomers, coupled with the impending retirements of longtime nurses, has been fueling concerns.

Illinois officials agree there's a looming problem, though data isn't yet available to measure the extent of it. In any event, solutions for a future nursing shortfall are likely to be costly. And, in previous attempts, officials faced empty coffers.

Still, Gov. Rod Blagojevich has committed $5 million to train new nurses in the fiscal year 2006 budget, a sum he says will add 1,500 to the ranks. As of February, the state Department of Financial and Professional Regulation reported 145,401 registered nurses, 28,208 licensed practical nurses and 5,017 advanced practice nurses licensed in Illinois. Blagojevich also wants to boost those numbers by easing Illinois licensing constraints on foreign and out-of-state nurses. Lawmakers will have to agree on the licensing changes, as well as the training dollars.

The governor's plan offers an immediate course of action that might add to the nursing profession's headcount. But some lawmakers complain the funding boost would have happened earlier if the Blagojevich Administration hadn't used the nurses' licensing fees to prop up its first two budgets. And they worry he won't easily relinquish that fiscal strategy.

In fact, only a fraction of nurses' fees would cover the new training costs. The bulk of the cost — $4.7 million — would come from a state economic development fund earmarked for worker training. However, the Nursing Dedicated and Professional Fund, which is replenished by the licensing fees, does award $750,000 each year for nursing scholarships, and in the past the state has tapped it to cover its fiscal shortfalls. Last spring, lawmakers voted to increase scholarship awards from the fund to $1.2 million. The governor vetoed the increase. Legislators overrode him in November, but the program has yet to award new money because applicant criteria are still being developed. 

With that history in mind, some lawmakers worry the governor might negate his own efforts to expand access to nurse training programs by siphoning more of the dollars generated by the licensing fees. "They have tried over the past two years to move it into the general revenue fund," says Rep. Elizabeth Coulson, the Glenview Republican who sponsored the scholarship legislation.

Blagojevich's second initiative has the advantage of avoiding any battle over the budget. He has called for easing nurse licensing constraints. Generally speaking, students who have earned nursing degrees must take the National Council Licensure Examination for Registered Nurses before they can practice in the United States. In Illinois, however, foreign-born nurses must first complete the Commission on Graduates of Foreign Nursing Schools exam, which is an indicator of how well they might perform on the actual licensing test. The governor wants to eliminate the pretest.

Dropping this requirement would not lower standards for foreign nurses seeking to practice in Illinois, says Susan Hofer, spokeswoman for the state Department of Financial and Professional Regulation, which oversees the licensing of nurses. The state, she says, would simply make it easier for qualified foreign nurses to begin practicing in Illinois. "[The pretest] is only offered three times per year, which makes for a very large logjam of people who, in the interim, will probably find jobs in other states who don't require applicants to take two tests," Hofer says.

Nationally, foreign-born nurses comprise 17 percent of nurses and psychiatric and home health aides, according to a 2004 Immigration Policy Center study. And at least one group, the Chicago-Bilingual Nurse Consortium, has already identified the potential to boost the nursing workforce by recruiting foreign-trained nurses. The consortium's program provides educational support and training to foreign-educated nurses who are U.S. citizens or legal residents and want to practice in Illinois.

Jean Lytle, the group's executive director, says participants are often stuck in low-paying jobs that do not utilize their nursing skills.

Applicants to the program typically enroll in classes to improve their English skills as they prepare for the state's licensing requirements. Students also undertake clinical studies, as Lytle estimates the average applicant has not practiced nursing in a decade.

Since the consortium was established almost three years ago, it has enrolled 55 individuals representing 14 countries. And Lytle says she thinks the program model could be duplicated in other parts of the state.

Another possible solution would be to make it easier for out-of-state nurses to begin practicing in Illinois. Sen. Susan Garrett, a Lake Forest Democrat, wants Illinois to join a licensure compact under which nurses could move to a participating state without having to reapply for a license. Eighteen states have joined the compact since its creation in 2000, including Wisconsin and Iowa. Garrett says joining the compact would shred some red tape for nurses seeking to practice in Illinois.

These proposals might ease the path for new nurses, but experts suggest such initiatives fail to address more fundamental problems. 

Job burnout is one. According to a 2003 survey conducted by Nursing Spectrum magazine, nurses cited inadequate pay, lack of mobility, lack of respect and long hours among the top reasons for leaving the field. 

Patients could be harmed as well. National studies cite an increase in the number of medical errors made by nurses who work longer shifts or more than 40 hours per week. And in Illinois, it's not uncommon for a nurse to work 12-to-16-hour shifts, according to Pam Robbins, second vice president of the Illinois Nurses Association.

California lawmakers moved to limit case workloads for nurses by approving legislation that defined nurse-to-patient ratios. And that state, along with Maine, New Jersey and Oregon, has banned mandatory overtime shifts for nurses, a trend Illinois could soon follow if a bill sponsored by state Sen. Donne Trotter becomes law.

The Chicago Democrat says nurses should not be required to work more than 12 consecutive hours in a 24-hour period unless there's an emergency. Trotter, a former hospital administrator, says the proposal focuses on good patient care but could also help keep nurses in the workforce.

"You keep nurses by not burning them out," he says. "Many people have left the nursing field because they are just tired."

Others argue the nurse shortage is the result, in part, of training programs that are stretched to capacity. "It's not an easy answer just to say, 'Take more students,'" says Pamela Brown, president of the Blessing-Rieman College of Nursing in Quincy and chairwoman of the Illinois Association of Colleges of Nursing.

National enrollment in entry-level nursing programs increased by 14 percent from 2003 to 2004, but some 32,000 qualified applicants had to be turned away due, in part, to faculty shortages. This study, released last month by the American Association of Colleges of Nursing, surveyed nearly 86 percent of U.S. nursing schools.

In Illinois, candidates must have a master's degree to teach nursing and schools struggle to offer salaries that would entice qualified candidates. "Salaries in education certainly don't compete with salaries that nurse practitioners can make," says Ellen Davel, who coordinates the associate degree nursing program at the College of DuPage in Glen Ellyn. 

Davel says increasing scholarship opportunities for nursing students might address some concerns about a nursing shortage but the state should also consider incentives that would address the shortage of instructors.

Shrinking university budgets make attracting faculty a steep challenge, says Joan Shaver, the dean of the University of Illinois at Chicago College of Nursing. The result is often fewer instructors at higher prices. "We feel like we have to enter into more intensive recruitment to attract faculty," she says. "There are just fewer people who might be attracted into education instead of practice."

College of DuPage developed an arrangement with area hospitals to use as teachers practicing nurses who have master's degrees. Nurses who hold a master's are usually licensed either as registered nurses or advanced practice nurses, while licensed practical nurses typically earn a bachelor's degree from one-year certification programs. More schooling opens the door to better pay, often in more specialized areas of practice. 

Educators also are challenged to find a sufficient number of ways in which students can receive clinical training. Competition for room in hospitals has education administrators searching for alternative training locations. 

At Southern Illinois University at Edwardsville, for instance, the nursing school utilizes high-tech simulated labs where students interact with electronic patients to develop their skills. Marcia Maurer, the program's dean and a nursing professor, compares the process to flight simulator training for pilots.

"I think the students know going in that it's going to be a testing situation," Maurer says. "It's very real."

As nursing schools work to address a range of problems, it is clear that scholarship dollars alone won't cure the state's nursing shortage. But more disconcerting is the lack of comprehensive, Illinois-specific information that could determine the extent of the problem on a state level.

In 1999, the Illinois Hospital Association established a task force to undertake this effort, and, a year later, the Illinois Coalition for Nursing Resources was established. But the not-for-profit agency has been unable to secure state funding to carry out its mission. Last year, Rep. Renee Kosel, a New Lenox Republican, sponsored legislation that would have earmarked $1 million in nurse licensing fees to help the coalition create a system for projecting workforce supply and demand and develop strategies for addressing the statewide problem. 

Despite some legislative support, the proposal never made it to the governor. Kosel blames her measure's fate on the governor's move to shift nurse licensing fees into the state's general operating fund. "I really think that the biggest problem with this was that nobody had one million dollars," she says.

Blagojevich did sign another measure to create a statewide nursing workforce database, but the state budget did not include any cash to pay for the initiative. So the coalition is forging ahead with private funds, says Executive Director Nancy Krier. "We frankly got tired of waiting." 

The group's main objective this year is to create a nursing information center that would provide data on the state of nursing in Illinois. Funded by grant money, the project will develop an online database of information on nursing, including scholarship opportunities and schools. 

"What we found when we started working on this is that information on nursing in Illinois is scattered, and it's often slanted," Krier says. "We want this to be a one-stop objective."

The group is also looking at ways to expand the capacities of nursing schools, and it's compiling hospital data to identify practices successful in retaining nurses and improving their work environment.

Krier says the group relies on volunteers to gather nursing data, which they previously received from Department of Financial and Professional Regulation surveys. However, the state's most recent nursing survey dates to 2001. The department was supposed to conduct an updated survey of registered nurses last year. But, Hofer, the department spokeswoman, says there was no nursing coordinator on staff to oversee such a project. That position is now filled and the department is assembling a new survey. It won't necessarily put a number on the shortage, but would provide insight into the workload carried by Illinois nurses.  

Nursing groups support immediate ways to move forward, including the governor's plan to boost scholarships for future nurses. But a more fundamental step, they believe, is documenting the status of nursing in Illinois and assessing all of the hurdles to attracting, training and keeping good nurses in this state.  

"We really think it's essential," Krier says. "Policymakers need that if they're going to make any informed decisions at all about the nursing shortage." 

Illinois Issues, April 2005

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