How to heal WA's acute nursing shortage

A recent Seattle Times article recounts the challenges faced by Washington state hospital systems as they grapple with an entrenched shortage of nurses [“WA is stuck with a travel nurse dilemma, pitting care against costs,” Sept. 24, Local]. This shortage should matter to everyone because it impacts health care quantitatively and qualitatively. When there are not enough nurses, hospitals close units. And when nurses are exhausted, the quality of care provided will inevitably decline.

While The Times’ article outlined the dilemma hospitals face, and the stresses experienced by caregivers and patients alike, it did not capture three key challenges contributing to the shortage of Registered Nurses and Nurse Practitioners:

• Burdensome regulation of nursing education that prevents nursing programs, like those we operate at Seattle University, from rapidly responding to a historically tight labor market.
• Clinical placement barriers born of expectations that hospitals and clinics will precept the next generation of nurses and nurse practitioners for free.
• Nursing faculty shortages.

While shortage of nurses in Washington predated COVID-19, there is no question the pandemic exacerbated its impacts. The need to respond quickly to unprecedented demands have led hospital systems to rely extensively on out-of-state “traveling nurses,” who earn multiples of the salaries paid to nurses employed in Washington. Reliance on traveling nurses has stressed the finances of Washington hospital systems and sapped the morale of local nurses, who are already suffering the stress and fatigue of a medical system stretched thin by COVID and staffing shortages.

In a functional labor market, students interested in careers in health care would gravitate toward the favorable job prospects, meaningful work, significant salary, and opportunities for progression that a career in nursing offers. Indeed, we have seen increases in nursing applications at Seattle University in recent years. Unfortunately, each year we turn away hundreds of qualified applicants to our nursing programs because we cannot increase the number of students in our incoming undergraduate and graduate classes.

A key factor limiting the number of students we can accept are state regulations that restrict nursing education in Washington. The most significant constraint on our ability to graduate more nurses is the arbitrary number of clinical placement hours required by the Washington Administrative Code for Registered Nurses to obtain their licenses. The hours required in Washington exceed most other states and is not grounded in any research that demonstrates an association between the number of pre-licensure clinical hours and post-graduation outcomes.

Alternatively, there is a growing body of research that affirms one hour of simulated clinical education meeting rigorous pedagogical standards is more impactful than two hours of hospital-based clinical practice. Simulation enables reliable presentation of highly complex, demanding situations that require rapid clinical judgment that students are unlikely to encounter in an actual clinical placement. (This is the same reason that simulator training is such an essential part of training for airline pilots.) Thankfully, the Washington state Legislature recently made a significant investment in simulation laboratory equipment. It is now essential nursing programs be supported by the Washington Nursing Care Quality Assurance Commission to reduce reliance on clinical placements and approve Registered Nurse education programs to offer one hour simulated learning in lieu of two hours of clinical training.

A second challenge is the lack of uniform funding of clinical nursing education. Unlike medical training where clinical placements are subsidized by the federal government, nurses and other providers are expected to provide clinical supervision free of charge, and to do so in active clinical settings already experiencing profound labor shortages. Although the state Legislature recently appropriated funding for supervision, the amount was about 1/10 of what would be necessary to bring nursing up to par with other fields. When clinical placement opportunities are in short supply, responsible nursing programs will not admit students without first ensuring that they can obtain adequate clinical placements. Most disturbing is the recent trend of Nurse Practitioner students paying out-of-pocket to obtain clinical placements, or worse yet to third party vendors who broker those placements.

The third significant constraint is the shortage of qualified nursing faculty. Since nursing professors are themselves licensed practitioners, they can typically earn far more money in practice than universities can afford to pay them to teach. Washington recently tried to address this situation by increasing compensation for nursing instructors in the community college system, that had the effect of attracting instructors away from four-year colleges. Thus, nursing programs are in a vice: not enough faculty to sustain current enrollments, let alone increase enrollments, which would enable universities to pay higher nursing faculty salaries.

If Washington is serious about relieving the shortage of nurses and allowing hospitals to dial back their reliance on out-of-state nurses, it needs to examine the structural causes of the nursing shortage. The single most important step the state could take to increase our capacity to graduate more nurses would be to open the clinical placement bottleneck by reconsidering the required number of clinical hours and enabling one hour of simulated learning to be counted as equivalent to two hours of clinical placement learning.

Other states already allow far more extensive use of simulation in lieu of clinical hours without undermining the quality of the nurses they license. (In fact, many of the traveling nurses working in Washington today come from states where they received a superb nursing education from nationally accredited schools that are far less burdened with duplicative state regulations than those suppressing innovation in Washington state nursing programs.) The state should also provide adequate funding to compensate hospitals, care providers, and other clinical employers for the time they contribute to clinical education of nurses and nurse practitioners.

Third, the state should expand the salary support it has extended to our community college colleagues to all accredited nursing programs in the state. More than half of the nurses who graduate from nursing programs each year in Washington state are educated in private (not for profit) and four-year public institutions. Increasing salaries at the community colleges alone (or even at all public institutions) will not sufficiently increase the supply of nursing instructors so much as shift nurse educators from one setting to another. Only a solution that includes all of Washington’s existing public and private not-for-profit programs can match the scale of the challenge.

The protracted nursing shortage our state has been facing for the past several years is untenable. It has stretched hospital budgets to the breaking point and had a negative impact on patients seeking care. Fortunately, Washington is blessed with a robust group of nursing programs made up of community colleges as well as four-year public and private not-for-profit programs. We must lift unnecessary regulatory burdens and address financial obstacles that stand in the way of higher education’s ability to increase admissions and solve this important public health challenge.