Nursing Education

¶ … Cross-Sectional Study to Determine Factors in the Educational Advancement of the Licensed Practical Nurse to the Registered Nurse in the State of North Carolina

According to the Harvard Nursing Research Institute, United States nursing school enrollments dropped by 20.9% from 1995 to 1998 (Healthcare Review, 2000). Behind headlines such as this one are the overwhelming issues which threaten the nursing workforce: 1) staffing cuts, 2) mandatory overtime, and 3) the use of unauthorized personnel to perform care, all at the cost of the patient's safety. The state of nursing in this country is very disturbing. There are hospitals grossly understaffed by registered nurses and with practical nurses who are being told to perform tasks beyond their skill and training levels (Mee & Robinson, 2003).

The pervasive nature of the problems which are present within the nursing profession are being acknowledged by the nurse-researchers, themselves, "Every article, speech, and interview about the nursing shortage notes that it is a different shortage from those of the past." (Nevidjon & Erickson, 2001). Health care experts are worried that a national nursing shortage could become widespread later in the decade - just as the aging U.S. population requires more care. The "baby boomers" are getting older and will create a demand for more hospital beds, more competent staff, and better programs aimed at keeping the most desirable people in the profession. A recent study at Vanderbilt University's School of Nursing in Nashville, Tennessee, found that the numbers of full-time registered nurses was projected to peak in 2007 and then decline steadily as more nurses retire along with the "Baby Boomers" ("Some worry nursing shortage could put patients at risk. Http://www.CNN.com.heath.Retrieved: 03/18/2003).

The Scope of the Problem

There have been two major nursing shortages within the past century, but there are distinct differences between them and the one we are presently in. According to Unique Staffing, the labor and population trends are causing massive disruptions in the supply of nurses, while at the same time the need for nursing care has begun to skyrocket (Mee, C. & Robinson, E., 2003). The current workforce shortage is different and more critical than the previous deficits because it is projected to be of unprecedented severity and to endure long into the future, it demands significant attention and innovation (Sorensen, E., 2001).

What caused this problem? Secretary of the Department of Health and Mental Hygiene in his testimony before the U.S. Congress, Dr. Georges C. Benjamin, M.D stated, "...nurses are not entering the profession, they are not staying in the profession, and they are not happy when they are there." (Romig, 2001). Carolyn F. Scanlon, president and CEO of The Hospital and Healthsystem Association of Pennsylvania, stated at the organization's April, 2002 meeting, "The nursing shortage is a result of many factors, including declining enrollments in -- and graduations from- nursing schools, and existing workforce that aging, and an older and sicker patient population." As evidence of that statement, below are the numbers of people who took the NCLEX-RN Examination for the first time for the years 1995-2002:

Number of Candidates Taking the NCLEX-RN® Exam

First-Time, U.S. Educated Candidates Only

Program 1995 1996 1997 1998 1999 2000 2001 2002 Diploma 7,335 6,346 5,240 3,978 3,161 2,679 2,310 2,223 Baccalaureate 31,195 32,278 31,828 30,142 28,107 26,048 24,832 24,421 Associates 57,908 55,554 52,396 49,045 45,255 42,665 41,567 39,642 Total 96,438 94,178 89,464 83,165 76,523 71,392 68,759 66,286 The American Association of Registered Nurses, Media Backgrounder outage. http://www.aacn.nche.edu.-The Nursing Shortage

Cheryl Johnson, president of the United American Nurses, stated on the highly esteemed National Public Radio program, "Talk of the Nation," "I think there is a variety of reasons, but I think probably the single biggest thing is just the amount of work that nurses are incurring right now. In an attempt to save money in hospitals and get around the shorter reimbursements or lesser reimbursements that they are getting, hospitals are asking nurses to do more with less. That means that you have less nurses and you have less resources around you to assist you in getting the work done." (Conan, N. "Shortage of registered nurses in the U.S.").

In the same radio broadcast, Dr. Peter Buerhaus, senior associate dean of research at Vanderbilt University School of Nursing, made this statement: "It is a myth that there is a shortage of trained nurses in this country, there isn't. They are just not willing to work in a hospital setting where the caseloads are huge, the support staff is smaller that it should be, and where 'corporate cuts' keep them from having the relationships with their patients as they once had. They have too many patients to care for and too little time to complete the large number of tasks they are expected to carry out. (Conan, N. "Shortage of registered nurses in the U.S.," National Public Radio).

In The Journal of Perinatal and Neonatal Nursing, Elaine Sorenson writes:

It finally happened. The forces we warned about - increasing system complexity, high costs, greater technology, decreased nurse staffing, increasing age and battle fatigue among nurses decreasing public esteem, and general disarray of health care institutions - all came together and drew nurses into the crisis.

Nurses had enjoyed public trust as patient advocates and had remained largely invisible in the conflict for power in the health care system...until that quiet September morning when copies of The Chicago Tribune landed on 500,000 doorsteps with the headline screaming, "Nursing Mistakes, Kill, Injure thousands."

Sorensen goes on to say that now the nurses, probably the only health care professionals whom the patients still trusted, had been moved into the enemy camp by the headline. The fact is, nursing mistakes have risen, people have died from them, and good nurses have lost their jobs because, in the name of good business management, one nurse might have two to three times the number of patients to care for than is safe. Nurses are human, humans make mistakes, especially if they are exhausted, have too many non-nursing tasks to attend to, and are not treated as professionals by the "suits" in the large, glass-enclosed offices whose main concern is the bottom line, not the lines on the monitors in their patients' rooms. Thus, the result is good people suffering from nurses' mistakes and good nurses leaving the hospital setting because they can no longer take the hours, the stress, and the general feeling that they don't matter much to anyone.

The Causes of the Nursing Shortage

In a problem as complex as the nursing shortage is there is no "right" side and "wrong" one. Many factors over several years have finally come together to create what many fear will be a juggernaut aimed to destroy the quality of healthcare in our country. When a search is begun to investigate the major conditions and attitudes which have caused this healthcare disaster, it should begin in the business offices of healthcare facilities as well as in the legislative chambers of all fifty states. According to a CBS news special entitled, "Nursing Shortage is in the Critical Stage" hosted by Leslie Stahl and broadcast on January 17, 2003, "There is a major reason for the shortage. Ever since the mid-'80's, young people have been choosing more lucrative careers. At the same time, the nurses we (Ms. Leclaire, one of the nurses interviewed) do have are getting older; the average age is now 45. Just as the baby boomers are starting to need more nursing care, the pipeline is running dry, and it's going to get much, much worse."

What Are Some Solutions?

There are many "plans" being made to correct this healthcare crisis involving collaboration, research, and cooperation among healthcare specialties which are worthwhile undertakings, but will not come to fruition for several more years. One college, The Ohio Valley General Hospital School of Nursing, has even gone so far as to promise a tuition-free education with the assurance of a job at the time of graduation for anyone who completes their nursing program (AORN Journal, April, 2001). The solutions which must be sought are those which will send competent, educated healthcare professionals back to the hospitals where they are so desperately needed. These solutions must not take many years to affect change, because the healthcare system as we know it doesn't have many years to wait around. Too many good nurses are leaving the only career they ever wanted, and too many mistakes are being made by their under-paid, over-worked colleagues who have remained in the hospitals for now.

One solution which is being tried by several hospitals in this country is to look overseas for nurses to fill widening gap. According to Carolyn Banks, vice president of labor and workforce development at the Massachusetts Extended Care Foundation, which represents nursing homes, "Our members are choosing the overseas route just out of frustration, of not being able to find nurses here" (Rowland, 2002). Many hospital officials go as far as to travel to South Africa, a country where the most experienced nurse makes about $7,000 per year, and try to recruit the most experienced nurses to move to the United States. South Africa is being chosen because the scarcity of physicians in some parts of the country means that nurses receive extensive medical training because there may be times when they are the only medically trained person within hundreds of miles. Hasina Subedar, head of the South African Nursing Council, states, "The pitch is 'pack your bag', we'll do the rest. As long as the nurse agrees to work in an American hospital for two years, everything else from green cards for the entire family to airline tickets to apartments are taken care of" (CBS News, January 17, 2003).

One option which has been overlooked by many during this period of "healthcare hysteria" is the cadre of skilled, intelligent and available licensed practical nurses. These nurses have one year of educational training and, usually, a great deal of "hands-on" experience. At first glance, it would appear that they are an untapped resource in North Carolina. With closer examination, it becomes evident that not many of them go back to school either through an R.N. program or a B.S.N. program. There are several incentives, both monetary and esteem-building, which are meant as encouragement for them, but the numbers taking advantage of these incentives is still very low. This reluctance is puzzling since there is such a need for them in healthcare facilities. For these reasons, this study will examine practical nurses in North Carolina participation or non-participation in higher educational programs. Of course, the desired outcome will be an increased rate of practical nurses returning to school, however, whether that will happen or not is unforeseeable at this time.

What This Research Will Answer

The nursing crisis in the United States as a whole, and in North Carolina, particularly, is severe and only expected to get worse in the near future. Various plans and educational programs have been suggested which will affect the situation in several years, but the need for trained, educated health service practitioners is urgent. One of the main reasons for this shortage in North Carolina and the rest of the United States is demographics. The general population of the country is aging and, as it ages it requires an increasing degree of health care. The nursing population is getting older, also, with more nurses retiring each year. The number of nursing educators is dwindling, because of the number of retiring faculty members as well as the lack of students to teach. The general population of nurses has declined throughout the last decade resulting in a disproportionate number of lower level degrees. The nation and North Carolina in particular, need more upper level nursing practitioners.

Practical nurses are no longer employed in the majority of acute care settings in North Carolina. Many of the institutions that do hire PN's have begun to make the intention of pursuing of a higher level degree a condition of employment.

Theory and Hypotheses

The theory: Barriers exist in the educational system in North Carolina that are preventing PNs from pursuing the RN degree. It is expected that PNs will be motivated to pursue higher education if the barriers to achievement are removed and if they feel they will gain significant benefits from it.

Hypothesis # 1: The barriers preventing PNs in the state of North Caroling from pursuing RN education are identifiable and are expected to fall into the following categories: 1) subject's time for further education, 2) economic ability and perceived benefit of further education, 3) perceived value of further education, 4) perceived convenience of further education, 5) perceived institutional barriers to further education, and 6) motivation to pursue further education.

Hypothesis # 2: Identification and removal of the barriers preventing PNs in the state of North Carolina from pursuing RN education will motivate these PNs to strive for a higher level of education.

Hypothesis # 3: A distance learning approach will eliminate many of the barriers to PN to RN education in the state of North Carolina and provide a greater motivation and opportunity for this group of individuals to pursue RN education.

Summary of Chapter One state of upheaval and unrest exists in the healthcare profession today, most especially in the areas of nursing and supportive services. Nurses have become disenfranchised due to negative public opinion, extreme job stress, added job responsibilities and heavier caseloads with no additional help. As the population as a whole ages, the number of young people choosing to become a nurse is declining. Nurses and nurse educators are retiring with no one stepping up to fill their places. This is a very frightening statement when it is presented as fact. In an article entitled, "A Call to Action: Addressing Vermont's Nursing shortage," the author stated, "The stability of a healthcare system pivots on a sufficient supply of an appropriately education and skilled nurse workforce today." (Healthcare Review, 2001).

An untapped resource is a significant number of Licensed Practical Nurses who would have to get more educational training before they saw significant gain in salary and other job options. This study will investigate the seeming reluctance of PNs to return to school in order to become a Registered Nurse instead of a Practical Nurse. The following chapter will investigate the reason(s) PNs are not taking advantage of monetary incentive and sign-on bonuses to become Registered Nurses.

The History of Nursing in the United States - A Proud Legacy Until Now?

Chronology

1800's

The need for skilled nurses during wartime sparks the profession's birth.

Florence Nightingale improves conditions in Crimean War field hospital hospitals, reducing mortality rates.

Thousands of women on both sides of the American Civil War leave their homes to tend to the wounded.

The nation's first school for nurses opens in Boston.

1900-1960's

The nursing profession flourishes after nurses' training programs are established. Periodic shortages occur due largely to wars.

Army Nurses Corps is established.

North Carolina enacts the first nursing-licensure law.

The University of Minnesota establishes the first university-based

Nursing education program.

World War I triggers a nursing shortage; nurses' groups try to get

Nursing education programs moved from hospitals to colleges.

All states have adopted nursing licensure laws. Only nurses who meet the educational standard prescribed by the laws can call themselves, "Registered Nurses," or RNs.

The nation's entry into World War II sparks another nurse shortage.

Congress passes Nurses Training Act, which provides scholarships to students who agree to work in essential nursing services during the war.

A government panel predicts more shortages and recommends the government provide more financial aid to nursing education.

Congress passes Nurses' Training Act of 1964 providing $240 million over five years for nursing scholarships and education programs.

1970's - 1980's

Interest in nursing wanes as the women's rights movement creates new job opportunities for career-minded women. Questions arise about whether a true nursing shortage exists.

President Gerald Ford vetoes the Nurses' Training Act, claiming that the nursing shortage is over, skeptical Congress overrides his veto.

President Jimmy Carter tries unsuccessfully to slash funding for the Nurses' Training Act, claiming the U.S. has enough nurses. But nurses groups predict "the biggest nursing shortage ever."

1990's - 2000's

The managed-care revolution prompts cost cutting hospitals to lay off thousands of nurses, creating extra work for those who stay. Job dissatisfaction and retirement spark widespread nursing shortages.

California passes law setting minimum nurse to patient ratios for hospitals; law is expected to go into effect in 2003.

Chicago Tribune investigation finds that thousands of hospital patients have accidentally died or been injured due staff shortages caused by hospitals' cost cutting.

Following the September 11th terrorist attacks, Congress questions whether the nursing shortage might imperil the nation's ability to respond to additional assaults.

A government report estimates the nation lacks 110,000 RNs.

The American Hospital Association estimates that 13-22% of all hospital RN jobs are vacant.

The New England Journal of Medicine reports the nursing shortage is endangering patient care.

President Bush signs the Nurses' Reinvestment Act, establishing the National Nurse Service Corps and providing federal aid for nursing students and grants to improve nursing education, practice and retention. It also establishes a program to help nursing schools train people in geriatric.

CQ Researcher, 2002).

Cross-Sectional Study to Determine Factors in the Educational Advancement of the Licensed Practical Nurse to the Registered Nurse in the State of North Carolina

Chapter Two

Review of the Relevant Literature

As has been discussed, a serious nursing shortage exists in this nation as well in nations throughout the world. The purpose of this descriptive research study is to examine the related scholarly literature especially, the studies and articles which address the educational opportunities which exist for the licensed practical nurse to gain further education.

The following questions framed this descriptive research study: A) Is there a nurse shortage in the United States and more particularly, does a shortage exist among the health care agencies in North Carolina? B) What is the status of enrollments in the schools of nursing throughout the country? C) What can institutions which provide nursing education do to positively impact the nursing shortage in the most timely manner? D) Why are the Licensed Practical Nurses in North Carolina not continuing their education to become registered nurses? E) Are there financial incentives in the U.S. And more specifically, in North Carolina which would enable PNs to return to nursing school? and, F) Do barriers exist in nursing education within the state of North Carolina that are preventing PNs from pursuing an RN education, and if so, what are they? and, E) would a distance education approach help eliminate the barriers which are preventing the PNs from pursuing the RN education?

The areas of this review of literature include: A) the state of nursing in the United States and particularly, in North Carolina? B) what are some of the reasons there is a nursing shortage in the United States, particularly in North Carolina? C) what is the state of nursing education institutions in the United States, especially, in North Carolina? and, D) is distance education a medium which may be considered as an appropriate model of teaching and learning for nursing educations?

Theory and Hypotheses

The theory or assumption of this study is that barriers exist in the educational system in North Carolina which are preventing or discouraging PNs from pursuing RN education. It is expected that PNs will be motivated to pursue higher education if the barriers which prevent it are identified and removed. It is also assumed that the PNs will wish to take part in an educational program to obtain the RN degree.

Hypothesis # 1: The barriers preventing PNs in the state of North Carolina from pursuing the RN degree are identifiable and are expected to fit into the following categories: A) time away from work and family for further education, B) economic concerns about the need to continue working full-time while working toward another degree - will the effort be worth it? The hypothesis is: if all the variables and barriers which are perceived as hindering PNs from returning to school are addressed, the PN population will begin to return to school for more training.

Hypotheses # 2: Identifying and removing all of the barriers preventing PNs in the state of North Carolina from seeking an RN education, the PNs will strive for a higher level of education.

Hypothesis # 3: A distance learning approach will eliminate many of the barriers which PNs face when they decide to obtain an RN education in the state of North Carolina. In conjunction with this statement, a greater motivation and opportunity will exist within this group who do decide to get the RN level of certification.

The State of the nursing profession in the United States, especially in North Carolina

The state of the nursing profession in the United States cannot be described easily. Some of the answers will depend upon who is asked. However, one question that receives a unanimous answer is, "Does a nursing shortage exist in the United States, and more particularly, in North Carolina?" The overwhelming answer is "yes."

There are 1.8 million nurses working in the United States, primarily in hospitals, which is also where the shortage is being felt the most, or is being anticipated with the greatest concern. There are few "quick fixes" to the problem, but this shortage is structural in nature and requires both sort-term and long-terms strategies to mitigate the problem (Nevidjon).

Reasons for the shortages

The causes of the current nursing problems are interconnected and on-going. Economic pressures, an aging workforce, and scientific advances extending the life span of all point to an evolving crisis. According to a July, 2002 report by the Health Services Administration, 30 states were estimated to have shortages of registered nurses in the year 2000. This shortage is projected tot intensify with 44% of the states plus the District of Columbia to have a shortage of RNs by the year 2020 (Cox, 2003).

Changing demographics signal a need for more nurses to care for our aging populations. According to a July, 2001 report by the Government Accounting Office, Nursing Workforce" Emerging Nursing Shortages Due to Multiple Factors, " A serious shortage of nurses is expected in the future as demographic pressures influence both supply and demand. The future demand for nurses is expected to increase dramatically as the baby boomers reach their 60's, 70's, and beyond" (Nursing Workforce" Emerging Nursing Shortages Due to Multiple Factors, July, 2001).

Another social scientist states, "this shortage has been attributed overwhelmingly to nurses. It is their feelings of being overworked, underpaid, and undervalued that lend credence to these statements. Nurses cite the lack of support that is essential to provide cost effective, high quality health care (Weyrauch, 2002). Job burnout and job dissatisfaction are driving nurses to leave the profession. A study released in the Journal of the American Medical Association in October of 2002, says that nurses reported greater job dissatisfaction and emotional exhaustion when they were responsible for more patients than they could safely care for. Lead researcher, Dr. Linda Aiken, concluded that, "failure to retain nurses contributes to avoidable patient deaths" (Journal of the American Medical Association, October, 2002).

In another study published by Dr. Aiken in the May/June 2001 issue of Health Affairs, more than 40% of nurses working in hospitals reported being dissatisfied with their jobs. The study concluded that one out of every three hospital nurses under the age of 30 was planning to leave their current job within the next year (Aiken, 2001).

The American Associates of Colleges of Nurses collected data about the current state of the nursing shortage and any actions different agencies or organizations are taking to address it (Medical Ethics Advisor, 2000):

126,000 nurses are currently needed to fill vacancies at out nation's hospitals (Trendwatch, 2002).

According to the National Council of State Boards of Nursing, the number of those taking the national licensure exam decreased 28% from 1995-2001. A total of 27,679 fewer students in this category of test takers sat for the exam in 2001 as compared with 1995.

Projections from the U.S. Bureau of Labor Statistics published in 2001, more that one million new nurses will be needed by 2010 (The U.S. Department of Labor).

American hospitals have 128,000 unfilled nursing positions at this moment and that number will rise to 400,000 by 2020 (Goodwin 2002).

The worsening shortages of nurses in the U.S. poses a direct threat to the quality of health care and the safety of patients, according to the urgent call to action by the Joint Commission on the Accreditation of Health Care Organization (Hospital Peer Review, 2002).

Peter Buerhaus, associate dean of the Vanderbilt University School of Nursing, says the shortage could lead to "a disaster scenario in terms of the quality of care." In fact, the shortage has already compromised patient health and even caused hundreds of unnecessary deaths and injuries according to several recent surveys (Needleman, et al., 2002).

The nursing shortage has already resulted in:

Higher costs of delivery of care (69%)

Emergency departments overcrowded (51%)

Diversions for more than four hours per week 51%)

Closing beds (25%)

Increased wait time for surgery (11.1%) and Reduction or elimination of services (6%).

Unfortunately, these figures of just the tip of the "iceberg" of costs if the nursing shortage continues.

Many blame the problem on the managed-care revolution of the early 1990's, which sought to lower health-care costs by cutting staffs and limiting customers' access to expensive medical procedures (Bettelheim, 1999; bettleheim, 1999b). Many of the nurses survey in a recent ANA survey said that they feel compelled to skip meals and work overtime to complete their duties. Neary 55% said that they would not recommend nursing as a career for their children or their friends (CQ Researcher, 2002).

Some experts say that state laws mandating hospital staffing levels would help solve the nursing shortage. Mandated staffing ratios are also seen as a way to address the problem of poor working condition - one of the biggest causes of the shortage. Nurses say that they are being called upon to care for an increasingly large number of patients. For example, 76% of the registered nurses polled in the recent ANA poll said that their patient loads had grown larger in the last two years due to understaffing. And, more that two-thirds had been required to work mandatory or unplanned overtime in the previous two years due to understaffing (Cooper, 1998).

The Federation of Nurses and Health Professionals (FNHP) reports similar trends. This labor union found in a recent survey that 50% of the RNs questioned had considered leaving the field altogether. Poor working conditions were cited as on of the major reasons for this decision. Forty-three of the respondents said that the best thing employers could do to improve nursing conditions would be to hire more nursing staff (CQ Researcher, 2002).

Further results of the shortage in North Carolina

Causes of the current nursing claims are; interconnected and on-going economic pressures, an aging nursing workforce, and scientific advances extending the life span. According to a July, 2002 report by the Health and Sciences Administration, 30 states were estimated to have shortages of registered nurses in the year 2000. This shortage is projected to intensify with 44 states plus the District of Columbia expecting to have a shortage of RNs by the year 2020 (Cox, 2003).

According to experts" a severe nursing shortage is being predicted by this end of this decade. This shortage has been attributed to nurses overwhelmingly feeling over-worked, underpaid, and undervalued. Nurses feel strongly that there is a lack of support which they consider essential to provide cost effective, high quality care (Weyrauch. 2002).

The American Associates of Colleges of Nursing collected data about the current state of the nursing shortage and actions of the different organizations are taking to address it: (Ethics Medical Advisor, December, 2000):

126,000 nurses are currently needed to fill vacancies at our nation's hospital (Trendwatch, 2001).

According to the Council of State Boards of Nursing, the number of those taking the national licensure exam decreased 28% from 1995-2001. A total of 27,679 fewer students in this category of test takers sat for the exam in 2001 as compared with 1995 (Hospital Peer Review, 2002).

Projections from the United States bureau of Labor published in 2001, more than one million new nurses will be needed by 2010 (Goodwin, 2002).

The United States Department of Nursing projects a 21% increase in the need for nurses nationwide from 1998 to 2004, compared with a 14% increase for all other occupations (Medical Ethics Advisor, 2002).

American hospitals have 128,000 unfilled nursing positions and that number is expected to rise to 400,000 by 2020 (Goodwin, 2002).

The worsening shortages of nurses in the United States poses a direct threat to the quality of health care and the safety of patients, according to an urgent call to action by the Joint Commission on the Accreditation of Healthcare Organization (Joint Commission on the Accreditation of Health Organizations, 2002).

In an extensive survey effort conducted jointly by the Kaiser Family Trust and the Harvard School of Public Health in 2002, 42% of the public and more than 33% of the U.S. doctors said that they or their family members have experienced medical errors in the course of receiving medical care, with significant percentages reporting serious consequences. Three physicians in 10 said that in their role as a physician they had seen a medical error that resulted in serious harm to the patient within the last year, and a majority of those who had seen an error said it is "very likely" (15%) or "somewhat likely" (45%) that they would see a similar one at the same institution within the next year. The physicians said that the leading causes of errors are a shortage of nurses (53%) and overwork, stress, or fatigue of health professionals (50%) (Harvard School of Public Health and the Kaiser Family Foundation, 2002).

In another study conducted at the University of Pennsylvania in 2002, researchers determined that patients who have common surgeries in hospitals with the worst nurse staffing levels have an up to 31% increased chance of dying. More nurses at the bedside could save thousands of lives each year (The Journal of the American Medical Association, October 22, 2002).

The Penn researchers found that every additional patient in an average hospital's workload increased the risk of death in surgical patients by 7%. Patients with life-threatening complications were also less likely to be rescued in hospitals where nurses' patient loads were heavier. The findings impact the national legislative. More that 20 states have enacted or are considering nurse-staffing legislation.

Table 2.1 For every 100 surgical patients who die in hospitals with a 4:1

Patient ratio, the number that would die in hospitals with ratios larger than a patient - nurse ratio of 4:1

Patient to Nurse Ratio

Surgical Patient Deaths to 1

Penn Research Finds More Patients Die in Hospitals with Lower Nurse Staffing, October 22, 2002)

Specifically, the Penn researchers found that:

If all hospitals in the nation staffed at eight patients per nurse rather than four, the risk of hospital deaths would increase by 31%, roughly translating to as many as 20,000 avoidable deaths in the U.S. annually.

Having too few nurses may actually cost more because of the high costs of replacing burnt-out nurses and higher costs of caring for patients with poor outcomes.

Adding two patients to a nurse already caring for four, increases the risk of death by 14%, adding four increases the risk by 32% (Penn Research Finds

More Patients Die in Hospitals with Lower Nurse

Staffing, October 22, 2002).

The nursing shortage results are already being felt as evidenced by:

Higher costs of delivery of care (69%).

Emergency department overcrowding (51%)

Diversions for more than fours hours per week (51%)

Closing beds (25%) increased wait time for surgery (11.9%) and reduction or termination of services (6%).

According to American Hospital Association Senior Vice President Rick Wade, "Nurses are the backbone of what hospitals do." He went on to say that the shortage is affecting the delivery of hospital care "in some ways." He also acknowledged that the nations' hospitals are facing "tremendous pressure" to cut costs (CQ Researcher, 2002).

Conclusion

The prevention of serious errors in medical care has long been of concern to health professionals, as well as courts and legislatures. However, the recent report done by the Institute of Medicine (IOM), To Err Is Human, focused attention on the problem, particularly its conclusion that, each year, more Americans die as a result of medical errors made in hospitals than as a result of injuries from automobile accidents (Institute of Medicine, 2002).

The nursing shortage in North Carolina

The worsening shortage of nurses in the United States poses a deadly threat to the quality of health care and the safety of patients, according to an urgent call to action by the Joint Commission on the Accreditation of Hospitals (Institute of Medicine, 2002).This indictment targeted hospitals in North Carolina as well as those in other states.

The extent of the nursing shortage in North Carolina was recently investigated by The North Carolina Center for Nursing (Sherrod, Lacey, & Myers, 2002). In the summer of 2000, the North Carolina Center for Nursing surveyed 372 North Carolina long-term health care facilities about their current and future needs for nursing proposal. They especially highlighted the recruitment and retention of nursing staff. The table below details the ways most agencies recruited both RNs and PNs:

Hospital retention strategies

Table 2.1

Legend for Chart:

Strategies

# times mentioned

% of total responses

Competitive wages, strong pay scale

Flexible scheduling, control over shifts

Opportunity for decision-making, participation, and input

Comprehensive, flexible benefits

Continuing education, professional practice development opportunities

Positive collegial environment

Recognition programs

Bonus programs

Adequate staffing

Opportunity to work in varied settings

Preceptorships, mentoring

Night-shift human resources availability

Total Responses

Note: The percentages in this table are based on the total number of strategies reported by hospitals, rather than the total number of hospitals that responded to this question; a total of 87 hospitals responded to the question.

North Carolina Center for Nursing). March, 2002)

Effective strategies listed most often included competitive wages, flexible scheduling, opportunities for decision making, assuring a positive collegial environment, offering continuing education opportunities and a bonus program.

Although community nursing standards state that the baccalaureate degree (B.S.N.) is the entry level recommended for practice, the reality is that over 60% of the workforce has less than a bachelor's degree (Havens & Stephens, 1998). Filling the gap between qualified nurses and the positions to be filled is not an easy task. Bright, young people are needed. The average age of nurses in North Carolina is 45.2 years old and there certainly aren't enough qualified newly-trained nurses to take their places (Goodwin, 2002).

In a recent survey conducted by "RN Magazine" (April, 2002), the mean vacancy rate for each section of the nation was stated. In the south, the mean vacancy rate was 13% for RNs and 12% for PNs. The western area has the highest and the largest shortage with 14.8% shortage for RNs and 16.4% for PNs.

Another survey commissioned by the American Nurses' Association News found that North Carolina's RNs have been with their current employer for 7.8 years and PNs have been with theirs for 8.6 years. Of the nurses surveyed, 25% of the RN staff and 20% of the PNs say that they plan to leave their present employer within the next three years. The survey also found that one half of the North Carolina nurses surveyed had considered extending their education within the past two years, although only 25% of the staff RNs and 29% of the PNs indicated that their employers provide education incentives.

The recruiting situation of nurses in North Carolina is:

staff nurses in general medical/surgical areas are the most difficult to recruit.

A hospitals report a below average vacancy rate of 8.4% for RNs.

A fewer than 35% of RNs hold bachelor's degrees or higher: only 11% are racial or ethnic minorities.

The PN population has a 76% minority

Minority representation.

The Carolina Center for Nursing brought together 250 stakeholders in October, 1998 to develop a statewide plan for recruiting and keeping the nurses who are now working in North Carolina. The goals the arrived at are:

Goal # 1 - Create a dynamic statewide system for projecting nurse workforce demand.

Goal # 2 - Insure an adequate nursing workforce for North Carolina, in terms of numbers, ethnic diversity, educational mix and geographic.

Goal # 3 - Promote collaboration between nursing education and practice to determine necessary competencies and design professional practice.

These goals are certainly noteworthy and achieving them will be an accomplishment which will benefit the state and its nurses (Tar Heel Nurse, 1999). Another publication, Nursing Shortage, NCHA Surveys North Carolina Nursing Shortage (Tar Heel Nurse, June 1, 2000), states that a 2000 registered nurses and half that many certified nurse aides are being sought by 143 hospitals and health care systems throughout the state.

The North Carolina Center for Nursing revealed this plan for retaining the RNs and PNs who are now employed in North Carolina:

Table 2.2 RN and PN Retention Strategies

Strategies

Percent Reported

Competitive wages, strong pay scale

Flexible scheduling, control over shifts

Opportunity for decision making, participation, and input

Positive collegial environment

Continuing education, professional practice development opportunities

Bonus programs

Adequate staffing, nurse-to-patient ratio

Recognition programs

Comprehensive, flexible benefits

Orientation

Total Responses

Do Barriers Exist Which Keep PNs from Pursuing the RN Degree?

The next step in this puzzle called "nursing shortage in North Carolina" is to find and recognize the barriers which presently exist and keep PNs from going back to school for the RN degree.

A mere list of some of the "barriers" might appear at first to trivialize the problem, but that is certainly not the intent of this researcher. There probably are as many reasons for not going back to school as there are PNs, however, an attempt will be made to identify and categorize these reasons.

O'Connor (1982) studied 1700 nurses and found six factors that were identified as meaningful in their professional development. These factors were: A) improved social relations, B) professional knowledge, C) compliance with regulatory authority, D) relief from the normal routine and, E) professional advancement potential. Since none of these factors is monetary or material, it may be surmised that professional development is not pursued for financial reasons alone. Other motivators have been identified as; peer learning and interaction, personal benefits, job security, and self-interest (Peutz and Peters, 1981; Abruzzee, R. 1998; and Urbano, M. et al. 1988). Just as all the topics mentioned above are positive reasons to further educational development, the barriers spoken of by so many PNs are; current work pressures, unit transfers, overtime, fatigue, administration and hospital ownership changes, money, time, work conflict, family commitments, illness, transportation, child care, location, weather, death, and attending a program alone (St. Clair, 1986; Parochka, 1985).

Brown (2001) found that many "barriers" to further education may involve previous educational experiences. Until recently, women were discouraged very strongly against entering into highly technical fields. Years of discouragement and feelings of low self-esteem may also cause PNs, particularly minorities or those who grew up in a lower socio-economic situation, from striving to attain advancement through education.

Is Distance Education the Answer?

Nursing professionals are challenged to continuously develop and sharpen skills to provide effective care. Many nurses have found that changes in practice (i.e. fiscal and case management responsibilities, new leadership expectations of staff nurses, and advances in science and technology) have left them functioning without a strong theory base for decision making (Kozlowski, 2002). Distance education may well be the means of attaining new knowledge and skills without having to leave your home or lose time at work. Distance education is a method of teaching where the faculty and the students are not in the same geographical location when learning activities are scheduled. Furthermore, in distance education, the teacher and student may not be working simultaneously on the same projects for learning to occur (Kozlowski, 2002).

There are basically two kinds of distance educations methods of teaching and learning. Snychronous learning environments are also called "real time" learning. This means that although the teacher and the students and the teacher may be in different geographical locations, they are working on the same tasks at the same time, and are able to talk to the teacher and other class members. Class sessions are generally mimicking those found in the regular classrooms. The instructor lectures and leads the discussion group, Course and classroom assignments are similar to traditional courses. Students submit course assignments as e-mail attachments or via the mail.

The advantage of synchronous programs is decreased travel time and greater diversity as the student communicates and interacts with individual members of the class. Synchronous learning may be the type of distance learning in which some adults do well (Kozlowski, 2002).

The other main type of online education is asynchronous learning. Asynchronous learning permits instruction from different geographic locations as well as allowing for variability for when the teaching and learning may occur. The learning activity does not have to be scheduled or completed at the same predetermined time.

This learning environment is made possible with current access to computer technology and a high-speed internet connection. Communication switches from a predominant "face-to-face" mode to a computer environment in which e-mail, chat sessions, listservs, and bulletin board posting are the predominant communications styles.

Most asynchronous learning programs provide the student with course modules, student handbooks, faculty advisors, and other resources to aid in the completion of the course. The modules are designed so that the adult learner will be able to complete a course with minimal direction from another individual. These modules are typically accessed via a course Web site and facilitated by an instructor. The instructor's role is not to lecture but to facilitate learning.

Computers and the internet are constant presences in the lives of nursing professionals, particularly at the higher levels of licensure. Insecurity about using the computer may very well be one of the biggest reasons some PNs are not returning to school for advanced training. Myles (2000) suggests that staff development training in computer usage and the internet may well be needed to help encourage all nurses to complete continuing education and career advancement activities. The Alliance for Nursing Accreditation has disseminated the following policy statement concerning distance education:

All nursing education programs delivered solely or in part through distance learning technologies must meet the same academic program and learning support standards and accreditation criteria as programs provided in face-to-face formats, including the following:

Student outcomes are consistent with the stated mission, goals, and objectives of the program; and The institution assumes the responsibility for establishing a means to assess student outcomes. This assessment includes overall program outcomes, in addition to specific course outcomes, and a process for using the results for continuous program improvement.

Mechanisms for ongoing faculty development and involvement in the area of distance education and the use of technology in teaching-learning processes are established. Appropriate technical support for faculty and students is provided.

When utilizing distance learning methods, a program provides learning opportunities that facilitate development of students' clinical competence and professional role socialization and establishes mechanisms to measure these student outcomes.

Each accreditation and program review entity incorporates the review of distance-education programs as a component of site visitor/evaluator training (Alliance for Nursing Accreditation, March, 2002).

This statement on Distance Education Policies has been endorsed by the following organizations:

American Academy of Nurse Practitioners Certification Program

American Association of Colleges of Nursing

American Association of Critical-Care Nurses

American Association of Critical Care Nurses Certification Corporation

American College of Nurse-Midwives Division of Accreditation

American Nurses Credentialing Center

Association of Faculties of Pediatric Nurse Practitioners

Commission on Collegiate Nursing Education

Council on Accreditation of Nurse Anesthesia Educational Programs

National Certification Corporation

National Council of State Boards of Nursing

National Organization of Nurse Practitioner Faculties

National Association of Nurse Practitioners in Women's Health, Council on Accreditation

National Certification Board of Pediatric Nurse Practitioners & Nurses

There are several issues to consider when making a decision about using distance learning to further job aspirations or to obtain a college degree. The most important to professionals such as nurses, teachers, and attorneys is whether or not the educational institution is correctly licensed and accredited. For most of the people in the fields listed above, this licensure or accreditation is of paramount importance. If the credentials of the learning institutions are not correct in these areas, one could lose an entire degree program or even a career.

For nurses, a distance education program must have the approval of the National Council of State Boards of Nursing (Myles, 2000). There are many programs already established and producing knowledgeable and well-taught graduates, and there are many more on the horizon. Two of the most promising are programs proposed by the University of North Carolina. After receiving approval, a bachelor's and master's degree program will be administered through Gaston College and Rowan-Cabarrus Community College. These programs will be directed toward practicing registered nurses with a diploma of an associate's degree. Developed for full-time employed RNs, all the courses will be scheduled on a one-day-a-week format, with an occasional Saturday morning lab class at UNCC (University of North Carolina - Charlotte expanding, 2000).

The University of North Carolina is also enlarging and improving the continuing education center at the Chapel Hill School of Nursing. "Operating since 1964, the UNC-CH School of Nursing will offer continuing education credits to nurses at all levels of licensure"

Wilcher, 2002).

To help combat the shortage of nurse educators and control the downward plunging enrollments - according to the Harvard Nursing Research Institute, U.S. nursing school enrollment dropped by 20.9% from 1995 to 1998 (River's College's Nursing Education Program, 1999), The River's Edge College of Nursing is offering a master's degree in nursing education - the only one of its kind in New Hampshire. This action will surely help the individuals in the upper strata of nursing, but the need for a means of advancement for PNs still exists.

One of the reasons some PNs may be reluctant to return to school is what is being called "The Third Shift" (Chronicle of Higher Education, 2000). A recent report by the American Association of University Women reports, "distance education is harder on women than on men... U.S. women taking distance education classes must a squeeze study and online time into their day in addition to first and second shifts at their fulltime jobs, homemaking, and childcare" (Chronicle of Higher Education, 2000).

What are some of the distance programs available?

There are many institutions of higher learning which do offer distance learning nursing degree programs. One that is mentioned consistently in the literature as having an excellent RN-to-BSN degree program is Jacksonville (Florida) University (www.RNtoBSN.com/hr).The nursing shortage motivated Jacksonville to implement this program and the forecast of there being at least another 450,000 vacancies by 2008 is the force which sustains it. By the end of this decade 1.7 million nurses will be needed, while less that 650,000 will be available (Valley, 2001).

Another program receiving a great deal of publicity is the nursing program at the University of Phoenix. According to their promotional data, "earn your degree via the internet for more career opportunities and higher income potential with the University of Phoenix online...With over 57,000 online students, the University of Phoenix online has one of the most successful online degree programs in the country (University of Phoenix Online, 2003).

Many of the universities which offer nursing degrees online also give the student the option of taking tests (CLEP) to ascertain prior knowledge and then give college credit if merited. This situation is perfect for the PN who wants to upgrade to an RN. As has been mentioned previously, most PNs have the clinical experience hours required for an RN degree, but they need the coursework and more are turning to distance education for their answers.

The final program to be covered in this discussion is considered one of the best by many nurse educators. The University of North Carolina and the North Carolina Research and Education Network (NCREN) have implemented a program of distance learning in which they broadcast high quality over the internet. John Killebrew, director of NCREN stated, "With this accomplishment, NCREN has leapfrogged to the forefront of innovative technology solutions for today's universities and businesses by delivering top quality video and audio with one-eighth the bandwidth previously required" (PR Newswire, 2000). This quality of service means that the University of North Carolina can continue to offer the best courses in nurse education to students all over the world.

Monetary Assistance

There are several provisions for financing further medical education which have grown from this nursing shortage. All of the programs discussed are, of course, in addition to any of the university's or school of nursling's scholarship or grant monies and any of the federal or state loans or grants available to all those who seek higher education.

The Nurse Reinvestment Act was signed by the President on August 1, 2002, and has been sent back to Congress for Appropriations. Provisions of the new law include scholarship money to attract new students into nursing, a Faculty Loan Cancellation Program to re move financial barriers to faculty careers, funding to promoted best practices in nursing care, and public service announcements to champion nursing careers. All stakeholders are encouraged to contact their federal legislators and indicate support for funding this legislation (American Association of Colleges of Nursing, 2003).

Two national media campaigns have been launched to help polish the image of nursing. Nurses for a Healthier Tomorrow is a coalition of 40 nursing and health care organizations working together to raise interest in nursing careers among middle and high school students. The coalition has conducted nationwide focus groups with students ages 6-15 years; secured over $600,000 in sponsorships, launched a website' created a televised public service announcement, and designed print ads that can be downloaded for free from the web. In February 2002, Johnson & Johnson launched the Campaign for Nursing's Future, a multimedia initiative to promote careers in nursing that includes paid television commercials, a recruitment video, a website, and brochures mailed to schools across the country (American Association of Colleges of Nursing, 2003).

Summary of Chapter Two

This chapter has been devoted to an intensive review of the literature related to nursing, the present and future shortage of qualified nurses, the conundrum of why PNs aren't taking advantage of these vacant RN positions when education is much more easily attainable through distance learning than ever before. Several exemplary programs were described. The next step in this investigative process is to attempt to find out from the PNs themselves what barriers or circumstances are keeping them from seeking further education. This research will be described in the following chapter.

Advancement of the Licensed Practical Nurse to the Registered Nurse in the State of North Carolina

Chapter Three

Methodology

This study was designed to investigate the reluctance of some Licensed Practical Nurses to pursue higher degrees and thereby advance their careers. To make sure that the data collection instruments were covering all the issues which had been identified in the literature as pertinent to continuing education, especially on the internet or in some other unconventional manner, a pilot study was implemented.

Pilot Study pilot study consisting of 10 completed surveys were solicited from practicing PNs in the Winston-Salem, NC area. The purpose of the pilot study was to discover any obvious flaws in the methodology and to make adjustments, if necessary, prior to beginning the actual research. The data obtained from the pilot study was not included in the data obtained from the primary research. Subjects participating in the pilot study were ineligible for participation in the primary research.

Data Collection

This research was conducted by using a cross-sectional survey of the 14,820 PNs who are currently licensed in the state of North Carolina. It involved sending a survey to 500 randomly selected PNs throughout the state. The survey focused on the research questions: A) is there a nurse shortage in the United States and more particularly, does a shortage exist among the health care agencies in North Carolina? B) What is the status of enrollments in the schools of nursing throughout the country? C) What can institutions which provide nursing education do to positively impact the nursing shortage in the most timely manner? D) Why are the Licensed Practical Nurses in North Carolina not continuing their education to become registered nurses? E) Are there financial incentives in the U.S. And more specifically, in North Carolina which would enable PNs to return to nursing school? and, F) Do barriers exist in nursing education within the state of North Carolina that are preventing PNs from pursuing an RN education, and if so, what are they? and, E) would a distance education approach help eliminate the barriers which are preventing the PNs from pursuing the RN education?

The survey was conducted through the United States Postal Service and each copy of the survey sent contained a self-addressed, stamped envelope to encourage timely return of the completed instrument. Each survey was coded from 1 to 500 for tracking purposes. A follow-up mailing was sent to all subjects who had not responded within two weeks of the initial mailing. Data were recorded on a continual basis as each survey was returned. The data collection phase concluded four weeks after the first mailing. An incentive of a $100 cash drawing was offered in an attempt to encourage the return of the survey. Each person returning the survey prior to the two-week deadline was entered into the drawing.