Future of Nursing in Texas

Future of Nursing in Texas

Like all other states in the U.S. Texas is on the brink of what many assume will be a disruptive nursing shortage (Texas Team, 2009). Nurses are the largest demographic portion of the health care delivery system, and they are in some way involved in the care of nearly every patient in need of care (Simmons, 2011). With a looming nursing shortage, with multiple causal factors including both the aging of the nurses themselves and the aging population, including the baby boomer population, that is likely to need advanced care more frequently in a system already stretched and with many disparities throughout many states including Texas are in need of improving these outcomes (Texas Team, 2009). The manner in which this is done has been strategized on for almost a decade but will need to include nursing educational reform that improves the numbers of successful RN licensure graduates as well as improving the education and capacity of existing nurses to improve the number of advanced practice nurses, needed to provide more primary care giving roles. Lastly, nurse recruitment for rural care is essential to reduce rural disparities in health care access and delivery (Texas Team, 2009). Texas is of course not alone in this looming problem but as the largest state in the nation it literally has a lot of ground to cover with regard to making every attempt to deliver the highest quality of nursing care to as many people in need as possible. This work will address the specific demographic and social issues associated with the future of nursing in Texas by analyzing it demographically and logically using the Institute of Medicine (IOM) report and additional sources.

The future of nursing in Texas is clearly one of turmoil and transition, reflective of the national projected growth in healthcare delivery needs, aging populations, mandates regarding health care coverage and access as well as an already challenging projected nursing shortage. There is a clear sense that Texas could be a stand out in just how much trouble they are in with regard to the future of nursing care delivery and medical provision shortages. Texas is the largest geographical state in the union and has a large population spread over the whole of the state, though condensed into several major metropolitan areas access to healthcare has been and will continue to be a growing problem. Nurses are in high demand everywhere, and especially in rural areas and yet Texas seems to be only limitedly addressing this need. Texas also has some of the most restrictive laws with regard to the IOM recommendations for the expansion of the scope of practice for advanced practice nurses, which are believed to be essential in the development of a medical care system in this nation that is both accessible and affordable for all. In other words responding to both a nursing shortage and a shortage of primary care physicians is a task that will hit Texas particularly hard but which really needs to be addressed aggressively from many angles, including; nursing education, local, state and federal legislation and regulation, heavy nurse recruitment to create a nursing migration to Texas as well as many other issues.

Population Demographics

Though there are several urban counties in Texas many rural counties and especially border counties are severely underserved with regard to nurses and particularly RNs. The population total for Texas in 2009 was 24,873,773 of those 87.4% live in metropolitan counties and 12.6% lived in non-metropolitan counties. The age range breakdown in 2009 looked like this:

Table 1 Age Demographics for total Texas Population 2009

(Texas Department of State Health Services, 2010, p. 11)

Age Groups

Total number

% of population

Under 20

7,255,037

29.2

20-39

7,568,893

30.4

40-49

3,546,192

14.3

50-64

4,055,031

16.3

65+

2,448,620

9.8

This age breakdown shows the significant issue of increased population need, as individuals age in the next few years, an issue already felt by many RNs and other nursing professionals as they report and increased workload associated with increases in patient numbers per shift as well as increases in the complexity of care as well as paperwork and other issues of workload stress (Texas Department of State Health Services, 2010, p. 16).

Demographic disparities between populations in rural and urban areas are also clear and demonstrate another area of concern but aging is likely to be the biggest concern going into the future as both the population and the nurses themselves are aging. The overall RN workforce in Texas continues to age.

In 2009 the median age of RNs was 47 years, compared to 44 years in 2000. The median age of non-metropolitan RNs was older on average (49 years) than metropolitan RNs (46 years). The median age of RNs in non-border counties were older (47 years) than nurses in border counties (43 years). In addition, the RN population age 55 and older jumped from 15.1% in 2000 to 26.4% in 2009 (Texas Department of State Health Services, 2010, p. 16).

Doing the math on nurses, most who work in hospitals but many who also work in other areas of health care delivery and education can be alarming, as overall total estimates incorporating new RNs and the strategies already in place to increase their numbers can be alarming.

"Texas Center for Nursing Workforce Studies (TCNWS) estimates that between 2005 and 2020 the demand for RNs in Texas will rise by 86%, while the supply will grow by only 53% with strategies already in place. Texas will be 71,000 FTEs (full-time equivalents) short of the nurses it will need," (Texas Department of State Health Services, 2010, p. 5). Though there is a limited amount of outward migration of nurses from Texas one of the most significant and successful strategies associated with recruitment is the inward migration of foreign born and trained nurses, but again this is in part limited to urban areas though incentive programs in place are helping to distribute these migrant nurses to the border counties (Brush, 2008, p. 21). The distribution of RNs by work title and job location is also telling:

Table 2. Distribution of actively employed RNs in Texas by position type, 2009.

Position Type Number %

Head Nurse, Staff Nurse, General Duty Nurse, or Assistant

108,389

64.0

Administrator / Supervisory / Assistant

16,905

10.0

School / Office Nurse

9,651

5.7

Nurse Practitioner

5,745

3.4

Faculty/Educator

3,956

2.3

Consultant

2,416

1.4

Nurse Anesthetist

2,183

1.3

Clinical Nurse Specialist

1,409

0.8

Researcher

1,194

0.7

In-service / Staff Development

0.6

Certified Nurse Midwife

0.2

Other

12,968

7.7

Unknown

3,372

2.0

The Future of APN nursing in Texas

Though it is not true in all cases, as the nursing population ages the desire of those nurses to continue into highly skilled advanced practice nursing programs may become limited, especially given the significant barriers to practice scope in APN professions, due to federal and state laws, regulations and standards. Yet, it is clear that APNs will fill a growing shortage of primary care provider services in family and general medicine as well as in some physician specialties like obstetrics and gynecology. IOM recommendation #1 for the future of nursing is: "Remove scope-of-practice barriers. Advanced practice registered nurses should be able to practice to the full extent of their education and training. To achieve this goal, the committee recommends the following actions" (2010, p. 1) Though Texas has made strides to change state and local laws to advance the cause of APN practice work is still clearly needed to address this issue as well as allowing regulations for practice to be expanded and most importantly encouraging new entrants currently in education programs (that need expansion) to continue their education and advance to APN degrees and practices (Texas Nursing Association, June 2011). Legislative action is a relatively slow process, even in the face of a national nursing crisis, and many states, including Texas rely heavily on national standards changes, as well as model legislative changes that advance nursing practice scope as well as changes in funding and billing structure of federal programs such as Medicare and Medicaid. Educational structure changes are in the works in Texas as well as elsewhere to attempt to respond to the projected need but again those changes are limited and slow in progress, as is reflected by the projected shortage statistics, note above which incorporate current efforts to expand nursing and redefine scope of practice (Texas Teams, 2009). There is also a clear sense that shortages in other health care professions including; general practice physicians (due in large part on emphasis to specialization) medical support staff (due in large part to pay scale issues) and other non-nursing non-medical support members. In short the whole medical industry, without decisive action will likely see an influx of need and a limited ability to address it, especially in the wake of the recent national health care coverage legislation. As late as February 2001 many advanced practice nurses and the organizations they belong to were calling for relaxation in the rules regarding scope of practice of APNs, according to the AARP (Krisburg, 2011).

Texas is one of the strictest states in the country for nurse practitioners who want to open their own clinics, requiring them to find a physician with the willingness and time to follow a complex set of rules. Those rules include requiring the physician to delegate prescriptive authority, review patient charts, make on-site visits or practice within a certain geographical distance of the nurse practitioner. It's a system many nurse practitioners say is unnecessary and burdensome, especially in light of the state's considerable health access problem and the success of nurse practitioners in other states who practice without such direct physician supervision (Krisburg, 2011, p. 1).