Innovative regional partnerships take on the nursing shortage and lack of workplace diversity in the most populous state.
Although California has more RNs than any other state in the country—240,470 in 2008, or almost 10% of all U.S. RNs1—there are hardly enough to serve the needs of the state's nearly 37 million people.2 In fact, in 2004 California had the lowest number of working RNs per capita among all 50 states, with 589 employed RNs per 100,000 residents, compared with a national average of 825.3 The federal government projected a shortfall of 116,600 full-time equivalent nurses by 2020.4 A 2004 mandate that California hospitals have a 1:5 nurse–patient staffing ratio could only worsen the nursing shortage.
In response to the shortage and mandated staffing ratio, in 2005 Governor Arnold Schwarzenegger established the California Nurse Education Initiative, a public–private partnership involving educators and nurse employers. An initial $90 million in funding provided a five-year investment in nursing education at California community colleges partnering with regional health care providers. The University of California and the California State University systems received funding for baccalaureate and master's programs in nursing. The initiative included a loan forgiveness program as well as a program to interest high school students in the health professions. In 2009 Governor Schwarzenegger announced $60 million in additional funding over five years.
California's investment in nursing education has resulted in measurable successes. Since 2004, 28 new prelicensure nursing education programs have begun in the state. Men and women who want to become RNs now have a choice of 132 programs. Enrollment in California's nursing programs has increased 68% between 2004 and 2008, and the number of nurse graduates has also grown each year (Figure 1 5).6 The new graduates helped increase the number of RNs per 100,000 residents to 654, raising California's national ranking from 50th to 46th.7 If current patterns continue, California could reach the 25th percentile by 2016 and the national average by 2029.8
As one of 18 lead states in a collaborative effortjointly sponsored by the Center to Champion Nursing in America at AARP, the Robert Wood Johnson Foundation, the U.S. Department of Labor, and the U.S. Department of Health and Human Services, California had teams at the 2008 and 2009 national summits and shared experiences with other state teams. California has brought together multiple stakeholders in partnerships devoted to increasing nursing education capacity.
This article describes the general approaches to building nursing education capacity and presents a few specific examples of the many initiatives that have begun in the state of California.
Of the 132 nursing education programs in California, 84 grant an associate's degree in nursing.6 Sixty-nine percent of the state's new nurses are graduates of these 84 programs. One goal is to produce not just a larger nursing workforce but one that's educated at a higher level.
White paper. The California Institute for Nursing and Health Care, a statewide nonprofit group that brings together diverse stakeholders (including education institutions, hospitals and health systems, health care companies, foundations, and policy leaders) developed a white paper to address nursing education redesign.9 It outlined seven strategic priorities:
- to forge strong partnerships between academic institutions and nurse employers
- to clarify clinical and professional competencies
- to create a collaborative education model that enables seamless advancement to higher nursing degrees
- to recruit, develop, and retain a well-prepared and diverse faculty
- to integrate high-fidelity simulation, technology, and informatics into nursing education
- to ensure a safe and effective transition from the educational setting to entry-level practice
- to create a centralized nursing education resource center and data repository
Encouraging higher degrees. The state is encouraging collaborative models of nursing education between community colleges and branches of the California State University system. At present, 35 schools of nursing are participating in collaborative model partnerships. These models are similar to that developed by the Oregon Consortium for Nursing Education (see "Oregon Takes the Lead in Addressing the Nursing Shortage," March). The goal is seamless progression from one level of nursing education to the next. Features of the collaborative models include dual admission, shared faculty, and integrated curricula. In only one more year of full-time education, a nurse with an associate's degree can obtain a bachelor of science in nursing (BSN).
Community partnerships are also making higher education more accessible to nurses with associate's degrees. For example, the Sacramento Employment and Training Agency provided funds that allowed 10 students at Sacramento City College to enter the RN-to-BSN program at California State University, Sacramento. And California State University, Long Beach, partnered with Long Beach Memorial Medical Center to produce 288 nurses with baccalaureates by 2008.
University of California campuses are also preparing more nurses with baccalaureates and with advanced degrees. In 2006, the University of California, Los Angeles, reopened its undergraduate nursing program, and the Irvine campus began a new baccalaureate nursing program. Master's degree programs at University of California campuses in Los Angeles and San Francisco have seen increased enrollment.5
After the introduction of these and other initiatives, 16% of associate's degree nurses had baccalaureates by 2008 and 8% had earned higher degrees (a master's or a doctorate).10 The percentage of nurses working in California with baccalaureates and higher degrees also increased between 2004 and 2008, from 38.1% to 41.6% and from 8.5% to 12.2%, respectively.
The dramatic increase in enrollment has created an increased demand for nursing faculty. Between 2004 and 2008, California nursing programs added 1,240 faculty members in their prelicensure programs, an increase of 57%.6
Several programs encourage nurses to become teachers. With a grant from a local philanthropic group, the Gordon and Betty Moore Foundation, programs in the San Francisco Bay Area gained 60 clinical faculty members. These nurses completed a program that combined classroom learning, Web-based instruction, and student teaching under experienced faculty. The program is now being replicated in Los Angeles.
Almost 40% of California's nurses work in settings other than acute care hospitals.10 To give student nurses experience with care in nonhospital environments, their clinical placements are now in more diverse settings, such as long-term care facilities, hospice programs, primary care clinics, and public health programs. According to Stephanie Leach, assistant secretary for policy and program development at the California Labor and Workforce Development Agency, adjunct faculty also receive training in these clinical settings so they can teach and mentor students in these nontraditional placements.
Loan forgiveness programs encourage nurses to go back to school to earn advanced degrees that will qualify them to teach. The California Student Aid Commission administers a loan assumption program for nursing students committed to becoming nursing instructors.11
California is the third largest state in the union in terms of land mass. It includes large metropolitan areas—San Francisco in the north, Los Angeles in the south—other good-sized cities throughout, and huge rural spaces. This mix makes regional programs both necessary and practical. A program that proves successful in one region can serve as a demonstration project before statewide expansion or be modified to meet the needs of other regions.
Educational institutions, health care organizations, and other stakeholders have formed regional collaboratives with specific objectives, such as developing simulation experiences for nursing students or supporting nurses who want to teach. Funding from both government and private foundation sources often helps the collaboratives achieve their goals.
The San Francisco Bay Area has become a leader in introducing programs that can subsequently be expanded to other regions of the state. The Gordon and Betty Moore Foundation has been a major strategic partner, funding several initiatives, including the faculty development program described above. In addition, this foundation made possible the centralized clinical placement system in the San Francisco area, which has now expanded to the Los Angeles area. It has also backed development of simulation in the Bay Area.
Simulation is an excellent example of the targeted focus of initiatives that spread from regional to broader state areas. The Bay Area Simulation Collaborative comprises representatives of nursing schools and hospitals in 10 San Francisco Bay Area counties. Faculty learn how to use simulation to teach nurses and then share the information with their local colleagues using a "train the trainer" approach. Another important aspect of the collaborative's work is the development of simulation scenarios. This collaborative is sharing its training approach and scenarios with other facilities statewide through the California Simulation Alliance.
In addition, the state has funded three regional clinical simulation laboratories in rural areas: in Northern California, in the Sierra area, and in Sonora County. Each is a joint project involving at least one medical center and one college.5
About 77% of nursing programs in the state use high-fidelity simulation.6 In a current demonstration project, about half the clinical time in pediatrics training is with simulation. Assessment of its effectiveness will be important, given the shortage of clinical placements in pediatrics.
California is not only the most populous state, it's also one of the most diverse. In the last official census (2000), 26% of the population had been born outside the United States, and English was the only language spoken at home in just 61% of households.12 One-third of the population was Hispanic; Mexicans accounted for 77% of this group. Eleven percent of Californians were Asian, and about 7% were African American.
The ethnic background of the state's nurses doesn't match the state's demographics as a whole (Figure 2). Hispanics and African Americans are underrepresented among California's working RNs, accounting for only about 8% and 4%, respectively.10 On the other hand, one-fourth of nurses are Asian. Filipinos—only about 3% of the state's population—account for 18% of the state's nurses.10 In specific areas, the disparities are even more marked. In Los Angeles County, where nearly half the population is Hispanic,13 only 9.6% of nurses were Hispanic as recently as 2008.10
A major goal is to develop a nursing workforce that reflects the diversity of the state and its inhabitants. The California Institute for Nursing and Health Care has developed a master plan with specific objectives and targets in five-year intervals to reflect projected demographic shifts. For example, California's population is expected to become increasingly nonwhite (Figure 2).9 , 13 One stated goal is to increase the number of Hispanic graduates by 15%, or by 85 new nurses, per year.14
Minority students often have relatively weak academic preparation, English language skills, and financial resources—factors that could influence their success. Therefore, some programs are specifically targeting these nursing students. To improve retention, Los Angeles County College of Nursing and Allied Health received $200,000 in Song-Brown grants to support at-risk minority students with services such as tutoring. Regional Health Occupations Resource Centers offer programs for students whose first language is not English, as well as a program to recruit another underrepresented group in nursing—men.5
HELPING NEW GRADUATES
Recent graduates of nursing programs have reported difficulty in finding jobs. In March 2009, the California Institute for Nursing and Health Care surveyed employers and found that only 65% of hospitals were hiring new graduates1 5—a phenomenon widely considered to be a temporary result of the economic downturn. In these uncertain times, experienced nurses are postponing their plans to retire, working more hours, and returning to the workforce. As a result, their employers don't feel an urgent need to hire new graduates. The situation should reverse as the economy improves.
When the institute convened concerned parties—including nursing schools, nurse employers, state agencies, and workforce investment boards—the group came up with the idea of community-based transition-to-practice programs or internships housed in nursing schools. Depending on local needs, the programs would provide specialty training in hospital work (such as in labor and delivery or critical care) or experience in nonhospital settings (such as hospice, long-term care, or public health). The Gordon and Betty Moore Foundation has contributed $500,000 to establish such transition programs in the San Francisco Bay Area.
This approach to addressing recent graduates' difficulty in finding jobs is typical of how California addresses nursing workforce challenges. A diverse group of stakeholders come together to discuss the problem and arrive at a potential solution. With the aid of a financial backer, the idea is then tested in one locality and, if successful, it can then be introduced elsewhere in the state.