EAB’s Lilia Shea and Lauren Edmonds examine factors limiting the growth of undergraduate and graduate-level nursing programs despite strong demand. The two urge leaders to build partnerships with regional healthcare providers as a way to supplement faculty ranks and help secure clinical placements for students.
They also discuss the value of recruiting future instructors from among the student body and suggest creative ways to recruit, reward, and retain preceptors.
0:00:12.1 S1: Hello, and welcome to Office Hours with EAB. Today, we explore why higher ed can't seem to expand nursing programs fast enough to meet surging demand among prospective students who are eager to get into the field. While there is no silver bullet solution, our experts offer tips on ways to address two of the biggest bottlenecks; filling vacant faculty positions and helping your nursing students land those coveted clinical placements. Give these folks a listen, and enjoy.
0:00:49.6 Lauren Edmonds: Hello, and welcome to Office Hours with EAB. My name is Lauren Edmonds, and I'm a director here, overseeing our work on market responsive program development. I'm excited to be joined today with my colleague, Lilia Shea. Lilia, do you wanna introduce yourself and tell our listeners about the topic of today's discussion?
0:01:06.6 Lilia Shea: Sure, and thank you, Lauren. I'm Lilia, I'm an analyst here at EAB, and for the last few months, I've been digging deep into research on nursing programs, and the challenges preventing them from growing. And before I was on this research, I was a research associate on a market insights team, where I wrote a lot of customer reports for our partners, and a topic that often came up for those reports, were nursing programs, and that's really due to the fact that there is this great job market for nurses, it's at unprecedented levels. It's actually, as many of you might know, there is a nursing shortage going on, and this really represents a high opportunity for universities to launch and grow programs in this area, and that's what we're going to be delving into a little deeper today.
0:01:58.1 LE: And before we get deep into today's research, and first off, can you just talk about why this matters so much for our listeners who might be less familiar with nursing and nursing education?
0:02:06.5 LS: Definitely, so something that really surprised me when I was doing this research, was that the nursing shortage is not by any means recent, it actually stretches back decades, we read reports addressing it as far back as the 80s and 90s, but it's really come to the forefront of public attention in the last couple of years, especially with COVID-19, and an aging US population, really putting an extra strain on the healthcare system. So to give you an idea of the scale of the shortage, there's a Health Resources and Services Administration report from 2017, that sets the projected shortage at 1 million nurses by the year 2030, and I think it's important to note that this report was published in 2017, so this was pre-COVID, this was pre-record high levels of nurses retiring early, changing profession, because of the danger, the long hours, the high levels of burnout associated with the position. I'm gonna place an educated guess here and say that that number has only gone up.
0:03:17.4 LE: And I can say, I see this play out in the real world, and in my own life, as you know, my mother's a recently retired nurse, left the profession after about 35 years or more, in nursing, and it is a difficult job. It has long hours, it is not enough recognition for the good work that they do, and the last few years have been incredibly difficult. And so it's, I think, not at all surprising, as you share some of those statistics to think about the many nurses who are in the profession and realizing it's time for their retirement or that it's time for them to move on to another field, that it's asking too much of them after what the pandemic has put them through. I do know that creates complications obviously for our communities, our healthcare systems, and really think about the schools that you and I work with and the programs they're trying to launch to then bring new nurses into the profession, there are challenges to all of that. Can you start talking through a bit about that problem that we've found?
0:04:17.0 LS: Of course, so something, another surprise in this research for me, was, I think, I had imagined that because so many nurses were leaving the profession, that there just wasn't going to be the student interest in becoming nurses, but we actually found the opposite, student levels of interest in nursing programs are at an all-time high. I think overall, it's a field with great job security, it's interesting, it's challenging, and you're helping people, at the end of the day, and as much as COVID-19 increased levels of burnout and strain on current nurses, it also increased in interest in nursing overall. So, I know Emory University reported unprecedented growth in their nursing school applications in 2020, nationwide, nursing programs actually had to turn down over 80,000 qualified applicants in the year 2020 alone, and that's really due to two major constraints. So if I'm a nursing program or running a nursing program I should say, that program needs to meet specific accreditation requirements. And one of the things those accreditation requirements entail is a specific faculty-to-student ratio, and that ratio gets more difficult to meet the higher the program is in term of level, so a graduate level nursing program requires more faculty per student than a lower level nursing program, and we're about gonna dig more into that topic in a minute.
0:05:54.1 LS: And then the second part of this problem, is that, in order to graduate as an accredited or a licensed nurse, nursing students need to participate in clinical hours conducted at local hospitals or other healthcare settings. And finding those placements for students is also getting more and more challenging.
0:06:15.9 LE: And I wanna pick up first on that instructor shortage point, because as you said, the nursing shortage has been going on for decades, this is a perennial and familiar problem for our nursing schools, but now that staffing shortage are affecting virtually every industry, this is only increased the pressure on bringing in talented staff. So I wanna ask a question that I know is consuming many of our partners today, how in the world can a university compete with hospitals and clinics and other healthcare settings, to lure in that top nursing talent, to fill their instructor positions.
0:06:48.0 LS: So I think in order to answer that, I'm first gonna have to address why there is this faculty shortage, why there is such a problem in recruiting and sourcing faculty. The first reason is simply that faculty tend to be on the older side and they're retiring, and there aren't enough incoming faculty to take their place. Now, the reason there aren't enough incoming the faculty to take their place really comes down to a pay gap. If I'm a nurse with a PhD, and I'm working in a hospital or another acute care setting, I can actually make almost twice as much as a faculty member teaching nursing with that same PhD. So at the end of the day, it's really a matter of incentives and it's hard to say no to that.
0:07:34.4 LE: And when you think about that typical nurse who has a family, is working incredibly hard, that nearly half salary cut is going to be entirely unsustainable. Can you talk a little bit about some of the ways that our partners have found to mitigate that challenge, when simply doubling the salary of faculty is typically not going to be an option for most institutions?
0:07:57.7 LS: Yeah, definitely, and it's pretty hard, almost impossible to actually compete with the hospitals or other healthcare providers when the salary question is in play. So we talked to several of our partners, heads of nursing programs, and something that came up repeatedly was this idea of not competing with healthcare providers and hospitals on nursing faculty, but actually partnering with them to share these professionals. So that can take two forms, a full-time, or a part-time partnership. In the full-time partnership, a nursing program will enter into a partnership with a local healthcare provider to borrow their working nurses to act as adjunct faculty, and that's done on a full-time basis. And in these partnerships, the faculty member borrowed from the hospital is paid by that hospital or other provider at their clinical wages. So that takes the whole wage gap issue out of contention completely. Now that can be more difficult to arrange, and given that there is already a nursing shortage, it's gonna be a lot harder to work out a full-time faculty arrangement with a local provider. So something else that our partners have been doing is doing more of a part-time partnership.
0:09:20.6 LS: And in these partnerships, the provider lends out the nurse to act as a faculty member on a part-time basis, and that faculty member is paid at academic rates, which are, again, lower, a lot lower than their clinical wages, but because they're not working full-time at those lowered wages, that pay discrepancy is a little easier to swallow.
0:09:47.3 LE: And Lilia, I can see where this greatly benefits the schools and colleges that we work with. What's the incentive for a hospital or a healthcare provider to loan out their nurses, when, as you said, they're facing such a shortage?
0:10:00.7 LS: Definitely, so it is luckily actually a win-win for both parties here. There's the obvious benefit for colleges and universities with nursing programs, but there's also a benefit for the hospital or other healthcare provider involved, which is they now have direct access to a pipeline of recently graduated nurses, which is especially helpful as they themselves are dealing with these big nursing shortages. And I think another part of this equation, that's a bonus for hospitals, or the other providers, is that they have a direct insight into the skills being taught in these nursing programs, and it offers a better flow of communication between the programs preparing the nurses for working in the healthcare setting, and the healthcare setting, saying, "Here's what we'd really like from your recent graduates to work with us."
0:10:55.8 LE: And that makes great lens of ways we can benefit both the healthcare providers and schools, totally get more students through these programs. I'll ask, are there any other strategies you saw in your research for how schools could be increasing the faculty pipeline?
0:11:10.8 LS: Yeah, so another big strategy we came across is much more of a long-term investment, but also really tackles the faculty shortage at its route, and that's by making a concerted effort to cultivate faculty from your existing student body. In fact, in our interviews with different nursing administrators and leaders, we found that this was often how they had actually become faculty members, and so it's really a three-step process. The first is making sure your existing faculty can identify, target, and support students who are showing an interest in teaching or an interest in research. And then obviously going on to further education is going to be expensive, so it's important to make sure that those students are gonna receive funding, and that can be through institutional or program scholarships, but there's also a nurse faculty loan grant from the federal government that allows those students to fund their education. And this grant's widely available, but we often saw that our partners are not necessarily advertising this opportunity in the way that they should. So really important to make sure that that is readily available to interested students. And then finally, it's important just to make sure you're gonna hire those home-grown faculty, we know that on campus, there's often concerns about making sure there's a diversity of thought, making sure you're hiring faculty from all over.
0:12:42.7 LS: But in this situation, it is important to make sure that you're willing to commit to hire those new faculty members back into your programs. And that's, obviously, a lot about the faculty, but I know there's another big part of this equation, which is finding those clinical placement for students, so, again, just a little background, nursing students of all degree levels have to complete these placements to earn an accredited degree. Lauren, do you mind walking us through the bottleneck here?
0:13:17.5 LE: And we talk about a clinical placement shortage, really the biggest missing piece here is the preceptors, and I mean and preceptors who are going to supervise nursing students during those clinical experiences. Someone who's not familiar with the concept. The role of a preceptor is really to help nursing students translate their theoretical learning from the classroom or online into clinical practice, and so that preceptor needs to be an experienced in licensed practitioner, they're gonna be supervising the students, they need to have specialization in whatever specialty or practice area the student is meant to be experiencing during that time period. Requirements can vary by the program they're working with, but in many cases, they're going to need to be on at least advanced practice, registered nurses, or nurse practitioners, this means our physicians, are going to have to have that specialization, and so we're describing, again, a very well-educated and prepared nurse who already had a busy day, already is working a long shift, and now is being asked to supervise students ranging from bachelor's level, a master's, post-graduate, even at the doctoral level, in some cases. And so, these preceptors do a critical role for our nursing programs, but it is something that can be a difficult position to fill.
0:14:35.2 LS: Yeah, and I know that something that surprised me in my research was that, most of these preceptors receive no financial compensation for their work. Can you talk a little bit about why that is?
0:14:50.9 LE: And that is really the underlying challenge here, that very few schools are paying their preceptors, so we have to rely on those people who are qualified, but are also willing to volunteer, that precious time to do so. The first thing I do wanna talk about the question of paying preceptors, because from outside of nursing, it can seem like a very simple answer. Many fields do you pay their preceptors, and that includes for medical students or PA students, they're able to pay their preceptors, which in some cases are the same people who could have been precepting a nursing student. And so it's a clear decision then which student you might take on based on what type of incentives are there for the preceptor to step up. When we look though to nursing itself, and what those programs are offering to students, there's been this hesitancy to start paying preceptors because it's ultimately going to increase the cost of those programs, that once many start doing it, all will need to do it. And then we have this added cost that's going to truly lead to programs, but ultimately probably get passed on to students, and now, we're, again, narrowing the number and the type of students who can come into a nursing program. So what was one of the helpful things in talking to nursing program leadership was to think about, the actual cost and consequences of paying preceptors. And so instead that led us to all the different ways that schools can instead.
0:16:12.3 LE: One, offer what benefits and incentives they can, outside of just compensation. And, two, work to reduce that burden of precepting we've been talking about. As we talk through those two different sides of this, and so first as we talk about benefits and incentives, a lot of that per school is just looking at what they can already offer, to these nursing professionals, in many cases that is for free or with very low cost education credits for nurses to either complete the required continuing education to maintain their licensure, or even topics or certificates that can be building their professional skillset into things that they might not have learned in their own program. Telehealth would be a great example today of something that's suddenly more important than it was in the past. Aside from those education credits, some programs are also using something even as simple as awards and recognition, preceptors can use to varnish their resume, get the attention they deserve for the extra work they're doing for these nursing students. As we talk about reducing the burden on the second half of this, it often is creating the support systems to make their jobs easier. And so we're trying to think of ways to either help keep them better informed of what's happening in the classroom, or some nursing schools are making sure to share syllabi and course materials with preceptors.
0:17:29.7 LE: And others are giving them support groups, whether it's physical, networking, an opportunity to meet the other preceptors in their area. Or more often, something as easy as a Facebook group can help connect those preceptors and help them sort out some of the challenge that they might be facing and just feel more of that community. So finding ways to incentive stepping up as a preceptor and make that role easier or ways that we can make that more attractive for people to that role on for nurses.
0:17:57.3 LS: And what does that support look like on the student side of this? So is there anything these programs can be doing to help their students go out and secure these placements, find these preceptors?
0:18:10.3 LE: It is something that we've seen schools emphasize much more is helping students find their own placements, especially if you're an online program and students will need to find that placement in their community, and won't be able to just come to campus for relationships you might have. And so schools are supporting students, in similar ways to their preceptors, and in some ways it is creating those support groups, maybe those Facebook groups, connecting incoming students with practitioners in their area, with your alumni, around the region, it can be simple guides to help them through that process of how do you find and then approach a preceptor, what are you going to need to do to set up that relationship? The far end that we've seen for schools that are willing and able to make the investment is even hiring staff to support this process, so having a clinical placement liaison who can identify and where students are going to need their preceptor-ship, build those relations with hospitals, ideally even form long-term relationships, getting memoranda of understanding to last multiple years that you can continue to send students to the same location over time.
0:19:12.8 LE: It is costly to have that staff member dedicated, but especially for programs that are at that stage of being able to grow to a very large scale, and, again, especially if they are online and their students are going to be needing placements outside of their immediate area, that staff role can be really essential.
0:19:30.5 LS: Definitely, I know from speaking to several leaders of nursing programs that having that clinical liaison made a huge difference for them in terms of securing those clinical sites, when it's left to students who are faced with this overwhelming task, sending cold emails, we've heard of them sending preceptors or potential preceptors gift baskets, that sort of thing. It really becomes daunting when you're a student who's already trying to balance financial aid, working, and studying at the same time, it really becomes an overwhelming task, so having that support makes a huge difference.
0:20:08.4 LE: Again, it can vary by the program, what their resources are, but just making sure that students do have some level of support is going to be essential to opening up the number of students you can have and the preceptorships they'll be able to access. At this point, I know we've only scratched the surface of this issue, but, and we are tight on time. So I do wanna sort of recap a bit, Lilia, when you're working with nursing school leaders and helping identify ways they can grow their programs, what are the top, let's say, three pieces of advice that you're typically giving them to make some changes and bring more nurses into their programs, and ultimately their workforce?
0:20:48.2 LS: So obviously, this is not a silver bullet kind of question, and there's a lot of forces outside of Higher Eds or anyone in higher ed's actual control. But, yeah, there's really three things I think we can take away from this research on how to deal with some of these obstacles to program growth, and the first really comes down to those partnerships with healthcare providers, and that's gonna help your program both source faculty members, but also source clinical placements, and the longer-term the partnership, the easier it will be to really nurture these relationships, and help ensure you have faculty and placements for students for years to come. And then the second part of this also relates to preceptors finding those clinical sites, and that's providing extra support and whatever incentives you can to those clinical preceptors. And then, finally, it's making sure to support the student side of the equation, whether that's helping them in their search for clinical placements, or whether that's supporting them in their movement up to the faculty ranks, and really hitting that shortage at its root.
0:21:56.0 LE: Thanks so much Lilia. And the last I'm gonna ask about is, I know this wasn't the entirety of your nursing research. Are there just other topics in nursing that you would invite nursing programs to come to us for help with?
0:22:08.6 LS: Yeah, definitely. So something else we really looked into was more of the job market in depth, we looked at top skills emerging amongst job postings, different trends in terms of what's emerging as a top priority in healthcare positions, even the top trends in what nursing students are looking for, especially as they look beyond the typical acute care role. We also looked into some of the actual issues around attracting students, so while we know there's tons of interest in nursing students out there. We know that not every one of our partners is having the same problems in terms of turning students away. So we did also look into ways of really attracting or optimizing your nursing program to appeal to more students. And we'd encourage schools to reach out if they're looking for any additional help on these issues.
0:23:03.1 LE: And I'm sure listeners will have a ton of follow-up questions on these additional topics or even just wanting more information on the nursing faculty shortage and clinical placement shortage. I'd encourage anyone who's listening to both, you can check out Lilia's blog post, we're going to include a link to that in our program notes, or you can be reaching out to me, Lauren Edmonds, if you wanna talk about the challenges you're facing with your nursing programs. Our bios are also linked in the program description, and it'll have our email addresses in those bios, so we should be easy to find if folks have other questions. Lilia, thank you so much for joining me today and sharing your research on Office Hours with EAB.
0:23:39.7 LS: Thank you so much as well, Lauren, I had a great time.
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