Nursing Crisis Looms over Iowa

A shortage of nurses has caused concern among elected officials and health care analysts for decades. At least two Iowa governors have convened task forces to investigate the problem and offer recommendations.

With all the added scrutiny and few practical solutions to show for it, most signs point to a nursing crisis that continues to get worse, and Iowa is likely to bear the brunt of it.

The American Health Care Association estimated in July that 116,000 nursing positions in hospitals and more than 19,000 positions in long-term care facilities were vacant. The problem is projected to skyrocket by 2010 to an estimated shortage of 275,000 nurses. By 2020, the U.S. Department of Health and Human Services anticipates a shortage of 1 million nurses.

A significant cause of the problem is a lack of qualified educators to train new nurses. Nearly 2,000 otherwise qualified applicants to Iowa nursing programs were not able to attend in 2008 due to educator shortages.

“It is the single largest contributor to the shortage,” explained Dr. Rita A. Frantz, professor and dean of the University of Iowa College of Nursing. “We have a national shortage of nurse faculty as well as a shortage of practicing nurses. The two are intricately intertwined. That is, without the appropriate number of nurse faculty, we can’t admit all the qualified applicants to our nursing programs.”

And new nurses are not only needed to fill existing vacancies but to replace a rapidly aging nursing workforce.

In December 2007, the Iowa Board of Nursing stated that 41 percent of the state’s active licensed practical nurses (LPNs) were age 47 and up. In addition, 51 percent of the active registered nurses (RNs) in the state were age 47 and above.

“Here at the University of Iowa, the average age of a faculty member is 56,” Frantz said. “If you look at them by rank, with the most senior rank being a full professor, the average age is 59. Those are your more senior, experienced researchers and teachers. We’re going to have large numbers of them leaving the academic environment to retire in a fairly short period of time.”

Demographic shifts, worsening economy exacerbate Iowa’s nursing crisis

The Iowa Nursing Task Force, which presented a written report in March 2008, predicted that by 2020, the state would experience a shortfall of about 9,000 RNs, or one-fourth of the current workforce.

This is dire news for the Hawkeye State, whose aging population places increasing demands on health care services, especially on long-term facilities. An older population, combined with trends of younger families vacating rural counties, could result in a magnified problem in Iowa’s rural areas and smaller hospitals.

“Because rural hospitals have a primary population of older patients, their primary revenue stream is from Medicare,” Frantz said. “Those reimbursement rates for acute care hospitalization are in many cases not sufficient to cover the costs of delivering care to that patient population. … Hospitals in larger areas draw from a larger cross-section of the general population and have more sources for their revenue stream.”

As more of the population is impacted by the economic downturn, more people will likely turn to public health care coverage like Medicare/Medicaid as their primary coverage. This forces even mid-sized, urban hospitals in Iowa to tighten their belts, implementing hiring freezes to control costs. That can have the effect of masking the underlying nursing shortage.

“Hiring freezes are the case in some pockets of the country,” said Frantz. “I worry that might be misinterpreted by the public to mean that the nursing shortage is over. That is not the case. It is a blip on the economic radar screen.”

Frantz believes that once the economy improves and unemployed or underemployed people return to work, many will once again begin full use of health care benefits.

“There is a projection that once the economy turns around again, we will have a huge upswing in the demand for health care services,” she said. “Along with that will come a major upswing for nursing services. At that same time, we have these factors that we know are contributing to the shortage. Those will be more evident and place further stress on health care facilities at the same time."

More Educators Could Stem Crisis

Though reforming the U.S. health care system will likely produce controversial answers to a long list of complicated questions, one proposed solution to the nation’s worsening nurse shortage is alluringly simple.

Each year, nursing schools turn away thousands of qualified applicants for lack of the instructors and resources to accommodate them. If only schools could admit more students, the looming nursing crisis might be reversed.

“If I can put it in anatomical terms, there’s not enough red blood cells flowing through the blood stream. We need to make more red blood cells,” said Dr. Rita A. Frantz, professor and dean at the University of Iowa’s College of Nursing. “It’s not that we don’t have the students. We definitely have the applicant pool — way more than we can accommodate. And this isn’t a problem unique to our school. It’s happening throughout the country.”

U.S. Rep. Tom Latham (R-Ames), who has been an active participant in policy discussions related to nursing for years, thinks the federal government can help give schools like Frantz’s the resources they need to attract more nurse educators. Together with U.S. Rep. Tammy Baldwin, a Wisconsin Democrat, Latham introduced a bill that would establish a federal student loan repayment program for nurses who agree to teach full-time at an accredited school of nursing.

Programs already exist to help nursing school graduates pay student loans, but none specifically target prospective instructors. In 2004, Iowa began a new Nursing Education Loan Repayment Program that took aim at alleviating the shortage of nurse educators and registered nurses (RNs), especially those who work in long-term care facilities or in rural communities. The program, administered by the Iowa College Student Aid Commission, does not eliminate required payments to student loans, but supplements the payments. Depending on the nurse’s chosen place of employment, the supplements can range from $5,000 to $20,000, spread over a four-year commitment.

The bill proposed by Baldwin and Latham would specifically target individuals who are interested in pursuing advanced degrees to become nurse educators.

Frantz is all for it. “It gives individuals an option of working off their loan by being a faculty member,” she explained. “If the legislation passes as it is currently written, these educators could work off as much as 80 percent of their total loan debt — which is just amazing.”

Among other benefits, the bill might do a better job keeping nursing school graduates in Iowa than efforts targeted at other types of nurses. Students who hope to become nursing instructors “have family and other ties to the state that will keep them here, which is not necessarily the case with our undergraduate students,” Frantz said.

A few interest groups have already come out in support of the Latham-Baldwin bill. Dr. Polly Bednash, executive director of the American Association of Colleges of Nursing, applauded it.

“A significant barrier to addressing the nurse faculty shortage is enticing nurses with advanced degrees to pursue careers in academia when salaries in the practice setting are much higher,” Bednash said. “One way to compensate for these lower salaries and attract younger nurses into teaching roles is to relieve their educational debt.”

The Service Employees International Union, which counts 80,000 nurses among its 2 million members nationwide, has also endorsed the measure.

When free market incentives go wrong, government help may be needed

Recognizing that its own nursing instructors were growing older and that few replacements were coming in to fill the void, the University of Iowa launched a multi-faceted program in 2007 that shifted more emphasis toward the preparation of new nursing instructors.

The program has achieved some success. Forty-five students are expected to graduate at the end of this summer with an advanced degree that will have prepared them to teach in Iowa’s community college system. An additional 70 students were admitted to that program this spring and are scheduled to graduate next summer.

Despite the university’s efforts to train more nurse educators, once students graduate with advanced degrees, it is often in their financial interests to work in clinical practice instead. The average annual salary for nurse educators is about 20 percent less than nurses with higher degrees can earn in clinical practice. (This despite the fact that nurse salaries are low industry-wide.)

Latham and Baldwin hope their bill will correct the disparity, making it less of a sacrifice to teach.

“I believe this would go a long way toward addressing the nursing shortage,” Latham said. “There are plenty of qualified applicants who want to become nurses that are shut out each year.”

Latham says he is not opposed to the bill being grouped into a larger health care reform package. He understands that either way it would require a new appropriation, but he says the cost is necessary to avert a health care disaster.

“Nurses really are the face of health care,” he said. “If left unaddressed, this shortage is going to undermine access and quality of care in Iowa and throughout the nation.”