The Ventura Nursing Legacy Project: Working Together to Solve Our County s Nursing Crisis
Imagine you are in the hospital with your child. She has just had surgery. She is in pain and perhaps needs her medication adjusted, but the nursing station is empty and no one is responding to the call button. Imagine your father has been admitted to the hospital for evaluation. Doctors suspect a broken hip, but tests have not been scheduled. He is uncomfortable and needs to be moved, but he is too heavy for you to lift and no one is available to help. You stay with him and try to reassure him, but in truth you feel completely helpless. Unfortunately, scenes like these are not rare. Anyone who has been a patient or had a loved one in the hospital may already have experienced these situations, or ones much like them. And if they haven t, they probably will soon. The problem is not our nurses it is a lack of nurses. We have a severe nursing shortage and nurses in many healthcare facilities are so overburdened they cannot respond quickly to the needs of all their patients. Patients and their families are frustrated and, in some cases, patient health has been jeopardized. Research shows that low nursing levels lead to: Increased medical errors Longer hospital stays More hospital-acquired infections Higher rates of patient mortality Increased healthcare costs Decreased patient satisfaction People are beginning to experience firsthand the implications of the serious nursing shortage that is facing this country, our state, and in particular, Ventura County. This is not just a systemic or policy problem, it is a crisis that has the potential to impact each of us as individuals. It is a problem that affects the entire Ventura County community and, as such, will require community-wide resources and collaboration to solve. A shortage of nurses endangers quality of care and places patients at risk for increased illness and death. A long-term shortage could undermine the American healthcare system... Robert Wood Johnson Foundation Recognizing the need for immediate action, the Ventura County Nursing Legacy Project was established to bring members of the community together to come to grips with this public health crisis, and identify the best ways forward. We have brought together leaders in the Ventura County nursing community and other key stakeholders across our region to examine the situation in detail and identify the priority issues that must be addressed. We have examined many facets of the crisis and have held a series of collaborative summits and symposia in which we asked tough questions, and challenged community leaders to think about both questions and answers: what should we do and how should we do it? The result is consensus around a set of strategies that address the fundamental issues that have contributed to the nursing shortage in Ventura County. We believe that by implementing these strategies we can begin to make progress in solving what may soon become one of the county s most serious public health crises. Our nurses spend their lives helping us and our families. They have played a leadership role in trying to address and surmount the challenges facing their profession. Now it is time for the community to step forward and join them. Funders, policymakers, educators, business leaders, healthcare providers and private citizens all of us can and must work together if we are to succeed in meeting this challenge. The Ventura Nursing Legacy Project has created a roadmap to help us move forward. It is time for the community to join us. The Ventura Nursing Legacy Project is a collaboration of the Ventura County Community Foundation and California State University Channel Islands, funded through Partners Investing in Nursing s Future, a joint initiative of the Robert Wood Johnson Foundation and the Northwest Health Foundation. The Ventura Nursing Legacy Project 1
The Challenge According to the American Hospital Association, there are currently more than 100,000 nursing vacancies in healthcare facilities throughout the United States. Experts say the situation will get much worse as Baby Boomers begin to retire in large numbers and experience the health problems that usually accompany old age. The federal government s Bureau of Labor Statistics projects that by the year 2016, the country will need more than one million new and replacement nurses. In California, and especially Ventura County, that shortage is already here. California graduates fewer than 6,000 nurses annually, but according to the Governor s office, studies show that at least 9,500 new nurses are needed each year to keep pace with demand a 30% gap. The state s hospitals have a shortage of nearly 15,000 nurses and yet more than 40 percent of applicants to the state s nursing education programs are turned away each year because the schools cannot accommodate them. The state s aging population promises to exacerbate the shortage severely in the years ahead. The number of Californians over age 65 is expected to nearly double from 3.7 million in 2000 to 6.3 million in 2020. At the same time, according to the Bureau of Registered Nurses, three quarters of California s registered nurses are age 40 and older and almost half are age 50 and older. As a result, experienced nurses who are leaders in the profession will begin retiring in large numbers precisely at the time when their skills and expertise are needed most. There is also a serious mismatch between the demographics of California s population and the nursing workforce. Although Latinos are quickly becoming the majority population in California, they currently make up only 4% of the state s registered The Problem in Ventura County Only 430 nurses for every 100,000 residents in Ventura County, less than two thirds of the state average An F grade from the California Institute for Nursing and Health Care Local colleges graduate only 175 nursing students per year, more than 600 qualified students on waiting lists Rapid population growth and changing demographics require more nurses with specialty skills High cost of living forces many skilled nurses to leave the county nurses. Bringing more Latinos into the profession is essential for more effective care. In Ventura County, the shortage is more acute than in the state overall. There are 372 nurses for every 100,000 residents in Ventura, half the state average of 622 nurses per 100,000 residents (the national average is 787 nurses per 100,000 residents). In addition to overall population growth, Ventura County is projecting an increasingly diverse and aging population. The number of nurses the County needs will increase dramatically as the demographics of the population shift, so we must develop a cohesive, proactive strategy to reverse the trends and bring more nurses into the Ventura County healthcare system, and we must do it now. 2 The Ventura Nursing Legacy Project
Finding Solutions While there may be agreement that the nursing shortage has reached critical levels, until now there has been little agreement on what to do about it. As with most issues related to the healthcare system, the factors behind the shortage are complex, and vary from one community to another. The nursing shortage is a national one, but it cannot be solved at a national level. The list of stakeholders who must be engaged to affect any solution is long and incredibly diverse. Consequently, if solutions to the problem are to be effective, they must take into account the circumstances on the ground, at a local level, and they must include all stakeholders who can play a role in addressing the problems. Educators, policymakers, health care providers, employers, business leaders, community activists, labor unions, philanthropic organizations, physician and nurses groups, insurance companies, researchers, the media, local citizens all can, and must, work together to address this serious healthcare crisis. Northwest Health Foundation and the Robert Wood Johnson Foundation, whose specific goal is to help local and regional philanthropies develop solutions to the nursing workforce shortage. The Ventura County Community Foundation (VCCF) was one of only ten foundations nationwide selected to participate The Robert Wood Johnson Foundation, the nation s largest philanthropy focused on healthcare issues, is playing a leadership role in addressing the nursing shortage. By shining a light on the seriousness of the situation, the Foundation has rallied some of the nation s top healthcare experts to begin to work together to look for solutions. But, like Clara Barton, America s most famous nurse, the Foundation believes in doing things differently. They know they cannot go it alone and that it is critical for local communities to engage their own experts, community leaders and funders to address the nursing shortage. Thus a key component of Robert Wood Johnson s national strategy is the Partners Investing in Nursing s Future program (PIN), developed to encourage local foundations to invest in nursing workforce solutions. PIN is a partnership of the I have an almost complete disregard of precedent, and a faith in the possibility of something better. It irritates me to be told how things have always been done. I defy the tyranny of precedent. I go for anything new that might improve the past. in the inaugural phase of the PIN program. VCCF has partnered with California State University Channel Islands (CSUCI) to implement the Ventura Nursing Legacy Project (VNLP). The goals of the VNLP are to work with a diverse group of stakeholders to: Identify the priority nursing issues for Ventura County Develop consensus around a common set of strategies to deal with the County s present and future nursing shortage Educate funders, policy makers, educators and other stakeholders regarding the crisis and how they can be a part of the solution Clara Barton The Ventura Nursing Legacy Project 3
Identifying the Issues Upon receiving the PIN grant in 2006, the VNLP immediately began an analysis of nursing issues in our community and then, through a county-wide Summit and two working symposia, moved to identify and prioritize potential solutions that would lead to concrete progress. A key element of the process was the establishment of the Partners Investing in Nursing Committee (PINC) a group of 24 nurse leaders recruited from all six area hospitals, three community colleges, the University of California, California State University, the Hospital Association of Southern California, county agencies, workforce agencies and public and home health agencies. Through a series of meetings the PINC determined the priority nursing issues for the Ventura County region. The PINC identified 14 priority issues that fall into three broad categories: Barriers to Supply and Diversity, including insufficient capacity in the education system, high attrition rates, lack of early academic preparation in math and science, a shortage of qualified faculty, limited numbers of clinical placements and preceptors, inadequate diversity representation of nurses and lack of cross-cultural communication skills The Working Environment, including workplace safety and violence issues, difficulties moving from academic environment into the workplace, difficulties juggling demands of the job with family and financial challenges (including childcare and transportation), and a lack of management training and mentorship for new nurse managers Workforce Practice and Skill Issues, including lack of comprehensive orientations for new nurses, disconnect between expectations for novice nurses and support provided to ensure they can meet the challenges of the profession, lack of programs to support mid-career transitions and re-entry, and changes in mandated nurse ratios adding more administrative burdens to practicing nurses Last year we had 37 slots in the nursing program at Cal State Channel Islands, but I had more than 150 qualified applicants. That scenario is being repeated throughout the entire Cal State system. We have good, motivated candidates, but we have to turn too many of them away. Information on all 14 priority issues was released in 2007 in the Consensus Report on Ventura County Nursing Issues. Through the Ventura County Nursing Summit and two working symposia, stakeholders developed and prioritized potential strategies to address these issues. From these symposia, it was clear that there were six major priorities around which PIN committee members and key stakeholders believed there to be appropriate and effective strategies that could be implemented locally which would help solve the crisis. Karen Jensen, RN, PhD Director, CSUCI Nursing Key Issues Facing Nursing in Ventura County After one year of research and dialogue with stakeholders throughout Ventura County, the Ventura County Nursing Legacy Project identified the following issues as those that most need to be addressed if the County is to solve its nursing shortage: Insufficient capacity in the current education system to meet the demand. Nursing schools across the United States reject one third of QUALIFIED applicants because of a lack of capacity. In 2006 alone, more than 40,000 qualified students were turned away from baccalaureate and graduate nursing programs. In Ventura County, that percentage is higher, because the ratio of slots to applicants is considerably lower. The principal barrier to increasing capacity is funding funding for expansion of infrastructure, for financial aid, and for increasing the number of faculty to handle expanded student populations. Shortage of qualified faculty due to difficulties in recruitment and retention. The shortage of slots in baccalaureate and graduate nursing programs has a direct impact on the number of nurses available to teach, as it is nurses with advanced degrees who become the source for academic leadership. In addition, schools must compete for top talent with the nursing practice sector itself, which offers considerably higher salaries. Restrictions on the teaching loads of part-time faculty make it difficult to tap practicing nurses as adjunct faculty members, and many dedicated faculty at our local colleges and universities are rapidly approaching retirement age. Without increasing the number of faculty members, it will be 4 The Ventura Nursing Legacy Project
Identifying the Issues impossible to increase enrollment and increase the supply of new nurses. Difficult burdens placed on nursing students. Students who choose to attend full-time nursing school face a number of challenges. Academic demands are high, and many students are inadequately prepared, especially in math and science. They may also have unrealistic expectations of the demands of the curriculum and the time commitments required to succeed, leading to high attrition rates California loses more than 1,000 nursing students every year because they drop out. Many struggle financially nearly 90% of nursing students are eligible for and apply for financial aid and lack key support systems, particularly in the areas of childcare and transportation. Unrealistic demands placed on new nurses. Novice nurses are often surprised by the demands that are placed on them when they enter the workplace. The pace of the job and the shortage of staff make on-thejob training difficult, if not impossible. As a result, it is extremely difficult for many new nurses to make an effective transition from the classroom to the workplace. Senior nurses do not have the time to train their new colleagues, and professional development overall is not a day-to-day priority. The result is dissatisfaction in the workplace and delays in the development of competent and confident practitioners. are not given the training they feel they need to be successful managers. Job dissatisfaction often results, leading to high attrition rates among the experienced nurses the workforce desperately needs. Lack of diversity, cultural competency and crosscommunication skills. In Ventura County, more than 50% of county residents will be Latino by the year 2020. Yet only 4% of registered nurses in California are Latino. Latino students may not feel completely at home in nursing school or welcomed in the workplace; we need additional Latino nursing faculty, support for Latino nursing students, and Latino nurses who can serve as role models and mentors. We also need language and cultural competency training for all nurses to help them serve an increasingly diverse community. The U.S. Department of Minority Health defines cultural competence as a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations. In essence, it refers to an ability to interact effectively with people of different cultures. In the nursing profession, that means interacting not only with patients of different cultures, but also with one another. Lack of consistent mentoring and training programs for new nurse managers. Nurse managers are critical to the successful development and retention of the nurses with whom they work. They serve as mentors, leaders and teachers for their colleagues. But too often the managers themselves The Ventura Nursing Legacy Project 5
Strategies for Success Identifying the critical issues that need to be addressed is the crucial first step in solving any serious problem. The next step, reaching consensus around possible solutions, is clearly more difficult. Over the course of the three county-wide meetings, stakeholders in the local community assisted the Nursing Legacy Project in prioritizing long-term sustainable solutions to these major issues. Here are the priority goals and ways in which we believe the community can work together to solve the nursing crisis. Goal #1: Increase Educational Capacity Our education system cannot admit all the students qualified to attend nursing programs, and too many who are admitted leave before they complete their program. The math is simple: enroll and graduate more nursing students and we will see more nurses in the workforce. Strategies: Expand system capacity through public/private partnerships. Ventura County s associate degree nursing programs have a waiting list of almost 700 students, while the bachelors program at CSUCI has room for less than 40 students in each class. The private sector can help by providing dedicated dollars to local nursing programs to match the dollars provided by the state. It costs approximately $10,000 per student per year to fund nursing programs at area schools a small investment for a large societal return. Enhance academic preparation in math, science and language skills at the middle and high school levels. Students who are not adequately prepared in math and science will not be qualified to attend or succeed in nursing school, decreasing the pipeline of potential students. Innovative curriculum programs that will teach both math and science effectively, and inform students about possible careers in the healthcare field, should be a priority. Increase the dollars available for scholarships and forgivable loans. Too many qualified students do not attend nursing school because they cannot afford the tuition or sustain family obligations while in school. More dedicated scholarships, and better information about existing scholarships, will encourage more students to consider the profession. Goal #2: Increase Recruitment and Retention of Qualified Faculty We need good nurses in the classroom as well as in our hospitals. Without teachers, we will not have the new generation of nurses we need. Low pay and few incentives to join the academic environment make teaching an unattractive option. Addressing the barriers to faculty recruitment and retention must be a priority. Strategies: Create doctoral pathways and increase funding for tuition support for prospective faculty in undergraduate and masters programs. For many nursing students, the prospect of spending the additional years in school that are necessary to teach at the college level is financially unrealistic. Examining the curriculum and adapting its timetable to accommodate nurses who are working in the service sector, and providing them with financial support, can lead to more nurses completing advanced degrees. Increase starting salaries for faculty members. Nurses who work in the service sector make considerably more money than those who teach. It is unrealistic to believe nurses who sacrificed financially to attend nursing school will turn around and take a pay cut to teach. Salaries for faculty members must approach the market rate for nurses or our current generation of nursing faculty will not be replaced. Establish joint faculty appointments with service institutions. There are many nurses who may be interested in serving as both a part-time instructor and a part-time service provider. Healthcare providers and academic institutions can achieve everyone s goals by working together to establish joint faculty/ service appointments, allowing nurses to both teach and practice. 6 The Ventura Nursing Legacy Project
Strategies for Success Goal #3: Help Nursing Students Succeed and Graduate The academic, financial and personal demands of full-time nursing school are difficult to navigate. As a result, California loses more than 1,000 nursing students every year because they do not complete their program. Helping students understand what is expected of them and providing the tools to succeed will ensure more students graduate and enter the profession. Strategies: Increase the amount of financial support available to nursing students by providing more scholarships and forgivable loans. Since many of the pressures on nursing students are financial, additional funding will help more students stay in school. Develop school to career mentorship programs to help students succeed and graduate. Nursing school is hard. Students do not always know what to expect, and may have trouble balancing their workload, particularly if they are also working or taking care of a family. Having the benefit of the wisdom of mentors who have succeeded in meeting the challenge will encourage more students to stay in school and graduate. Nurses serve their patients in the most important capacities. We know that they serve as our first lines of communication when something goes wrong or when we are concerned about health. Representative Lois Capps RN, U.S. Congress Goal #4: Keep Novice Nurses in the Workforce According to the California Institute of Nursing and Healthcare, the retention rate of nurses after two years on the job is less than 65%. Students find it difficult to make the transition from classroom to workplace. They start their jobs without a real understanding of what is expected of them, and do not believe they get the support they need from colleagues or employers. Disillusionment and frustration quickly set in, and talented nurses leave the profession. Strategies: Create collaborative rotation programs to increase options for training in clinical settings. In the fast-paced world of nursing, it is impossible to teach students what to truly expect when they leave the classroom and enter the workplace. Only firsthand experience will enable them to understand the demands of their profession. By increasing clinical opportunities and hospital rotations for students we can help them succeed in the long-term. More collaboration between teaching programs and employers will benefit everyone. Academic institutions will enhance their curricula, and hospitals and clinics will gain dedicated human resources and an opportunity to evaluate potential employees. Most important, students will get an invaluable orientation to the world of nursing. Replace signing bonuses with a paid first-year orientation. Employers compete aggressively to recruit graduates from California s nursing programs. Many offer signing bonuses, but little in the way of orientation or training to meet the challenges of the workplace overall, or the particulars of their own institution. Using those dollars to provide new nurses with a paid, first-year orientation will minimize staff turnover and help deliver better patient care in the long run. Programs like VERSANT, a oneyear institutional training program for new grads, or hospital initiated efforts that help nurses transition from novice to proficient practitioner, can have a dramatic impact on staff retention. The Ventura Nursing Legacy Project 7
Strategies for Success Goal #5: Provide Training and Support for Nurse Managers Leadership is critical to ensuring success at every level in nursing. Employers rely on nurse managers to provide that leadership, but too often they do not help nurses cultivate the skills they need to enhance their own career development or their staff s. Providing nurse managers with mentorship and training will ensure the success of their teams, and maximize staff retention. Strategies: Build time into the schedule of senior managers to mentor new nurse managers. Management training must be an institutional priority. Nurse managers should be rewarded for the time they devote to mentoring, and must not be expected to do it on their own time. Develop leadership training programs that incorporate practical management skills. Too often leadership training programs neglect to focus on the actual issues that nurse managers deal with in the workplace. By incorporating practical skills like conflict resolution and motivational techniques, training programs can contribute to a healthier and more balanced workplace for all. Reform governance structures to ensure nurses have a voice in institutional management. Teamwork is critical to quality healthcare. Nurses, doctors, administrators, support staff must all work together to ensure successful patient outcomes. The same approach should be applied to running the organization. As crucial members of the medical team, nurses should be included in all decision making. Knowing their voices will be heard is vital to nurse job satisfaction and retention. Nursing is an art: and if it is to be made an art, it requires an exclusive devotion as hard a preparation, as any painter s or sculptor s work; for what is the having to do with dead canvas or dead marble, compared with having to do with the living body It is one of the Fine Arts. I had almost said, the finest of Fine Arts. Florence Nightingale Goal #6: Remove Barriers to Diversity During our research phase, the Ventura Nursing Legacy Project took a careful look at the demographics of Ventura County and how the county s population was reflected in the nursing workforce. There is a lack of cultural competency and inadequate diversity relative to the regional population being served. A large pool of potential nursing students is not being tapped because of ineffective outreach to Latinos and other minority communities. Strategies: Recruit and graduate more students who are bilingual and bicultural. Develop programs to outreach to Latino middle and high school students to educate them about the nursing profession, including the importance of the job, relative salaries, educational preparation needs, and financial supports available for school. Once they are in a nursing program, support them with financial and academic support if needed, and encourage them to become actively engaged in the school s student activities. Recruit Latino nursing faculty and experienced nurses to serve as role models and mentors to Latino nursing students. Develop and institute language training and cultural competency programs at the workplace. Giving nurses access to language and cultural competency training will improve communication among team members and between nurses and patients. Employers should consider instituting language training for all nurses (Spanish for native English speakers and English for nurses for whom English is a second language). Such training will enhance their ability to communicate with each other and with a diverse patient population. Build linkages to translators in the community and educate staff on the role of translators in the effective treatment of patients. Many patients in Ventura County do not speak English well enough to communicate with nurses or doctors. In order to avoid medical errors and ensure patient compliance, they need translators to be a part of every conversation. By working effectively with translators, nurses can reinforce a culturally sensitive and welcoming workplace. 8 The Ventura Nursing Legacy Project
How You Can Help The Ventura Nursing Legacy Project was built on a foundation of collaboration. Working together, engaging in sustained, cooperative dialogue, sometimes across traditional boundaries, brought us to where we are today with a strong understanding of the issues Ventura County needs to address and consensus on a set of strategies that we believe can make a difference. So where do we go from here? We are not going, we are coming. Coming to you. Funders, policymakers, educators, employers, students, doctors and nurses. Everyone can and must play a role in addressing one of the most serious public health crises facing our community. What can you do? There are as many ways to help as there are citizens and civic-minded organizations. Some options to consider If you are philanthropic institution, consider increasing your support of local nursing programs and for early academic preparation in math & science. It costs approximately $10,000 per student per year to educate a nurse. It will take sustained and significant support to make a difference, and the kind of financial resources that the state alone no longer provides to our educational institutions. If you are a corporation or a civic organization, you can institute scholarship funds targeted directly to nursing students, or fund faculty chairs in nursing. If you are a healthcare provider, you can collaborate with local universities to create joint programs that will provide much-needed faculty members to local nursing schools. Shared faculty appointments, incentives for nurses who return to school and take time to teach, are among the many ways that you can be involved. If you are a policymaker, you can use your public platform to raise awareness about the nursing shortage, seek policy solutions particularly regarding community colleges and public institutions, and work to dedicate more state funding to local solutions. If you are a healthcare employer, you can play a critical role in creating a positive workplace for nurses. You can provide more and better training for both novice nurses and nurse managers. You can give new nurses a more comprehensive orientation to your workplace. You can provide language and cultural competency training at your work site. And you can ensure your management structure includes a strong and central role for nurse managers. If you are an educator, you can work with local schools to improve math and science education at every level, and provide mentoring support to students who are interested in nursing. If you are a nurse or a doctor, you can mentor young nurses, and teach them what they need to know to be an effective member of your team. You can spend time with nursing students, teaching them about what to expect on the job. We are looking for partners to help us implement these and other strategies we believe will be effective in addressing the nursing shortage in Ventura County. We need individuals and organizations to help with funding, with program development, with policy development, with workplace reforms, with new education programs. Come join us and extend the legacy that will sustain excellent healthcare in our community for years to come. Dialogue is the first step. We want to hear from you to discuss what you or your organization can do. Please contact us at nursing@vccf.org or (805) 988-0196. The future of our healthcare is in all of our hands. The Ventura Nursing Legacy Project 9
This publication is sponsored by Partners Investing in Nursing s Future (PIN) through the Robert Wood Johnson Foundation and Northwest Health Foundation. For additional information on the Ventura Nursing Legacy Project and how you can become involved, please contact: Ventura County Community Foundation 1317 Del Norte Road, Suite 150 Camarillo, CA 93010 (805) 988-0196 nursing@vccf.org www.vccf.org