##### California Institute for Nursing & Health Care

*Optimizing the Health of Californians through Nursing Excellence*

######### Master Plan for the California Nursing Workforce

**GOAL I: Building Educational Capacity in**

**California Schools of Nursing**

######## Submitted by

###### The California Institute for Nursing & Health Care {#the-california-institute-for-nursing-health-care .unnumbered}

**March 31, 2005**

**Prepared By**

######## Deloras Jones, MSN, RN

**California Institute for Nursing & Health Care**

**Executive Director**

**&**

**Linda Searle Leach, PhD, RN, CNAA**

**Childrens Hospital Los Angeles**

**Versant RN Residency**

**Vice President, Research and Innovation**

# BUILDING EDUCATIONAL CAPACITY IN CALIFORNIA 

# SCHOOLS OF NURSING

### **Introduction**

Increasing educational capacity in California schools of nursing is the
state's most pressing nursing workforce need. It is also one of the
essential elements of a master plan to address the registered nurse (RN)
workforce crisis. Therefore, *Building Education Capacity in California
Schools of Nursing* is Goal I for California's Nursing Workforce Master
Plan.

Goal I identifies the priority recommendations and actions steps that
are needed to overcome three primary areas that present barriers to
expanding capacity. A fourth area, although not directly related to
increased capacity, is directly related to increasing the number of
successfully graduating student nurses. These areas are:

> 1.) Funding to support student enrollments,
>
> 2.) Availability of qualified faculty,
>
> 3.) Infrastructure to include:

-   Clinical training capacity,

-   Facilities for classrooms and laboratories, and

-   Availability of prerequisite courses,

> 4.) Increase completion rates and successful passing of the RN
> licensing examination.

Goal I plan addresses underlying assumptions, summarizes the background
and the issues involved in nursing education in California, and includes
the objectives, strategies, and actions necessary to achieve the desired
results of Goal I.

Goal I plan was the outcome of an intense workshop held November 22 -
23, 2004 that addressed actions needed to overcome barriers to expanding
capacity in the state's schools of nursing. Invited to this workshop
were representatives of all the educational programs (community
colleges, state universities, University of California, and the private
colleges), major nursing organizations, the hospital association, the
Board of Registered Nursing, and representatives from both the
Governor's office and the legislation. A complete list of invitees is
attached.

## Assumptions

Three assumptions provide the framework for the plan. The first
assumption is that significant "second order" change is necessary to
address the complexities of supply, demand, and population growth and
changing demographics that underlie the nursing workforce crisis. Second
order change focuses on outcomes and is based on examination of a system
of causes involving a shift in thinking. In contrast, first order change
occurs within a system that remains unchanged. It is based on the
application of a problem-solving process, is circular and incremental,
maintains the status quo, and frequently represents quick fixes. Quick
fixes will not provide sustainable solutions. First order change will
not adequately address the health care needs of California's growing and
aging population. Whereas second order change produces action choices
focused on desired results.

The second assumption is that an adequate supply of educated nurses is
necessary to preserve and promote the health of the people of
California. Embedded in this goal is the need to understand that nursing
is not a technical vocation nor is it a job that requires some
post-secondary training. It is a complex set of behaviors based on
scientific knowledge and skill that requires the use of critical
thinking, diagnostic clinical reasoning, and ethical actions in the
delivery of health care, and the management of individual, group, and
population health care needs. Nurses need more education to be
adequately prepared for the complexities of the delivery of health care.
An adequately prepared nurse is the necessary outcome and the real
challenge of increasing the supply.

The third assumption is that in order to forestall and hopefully prevent
a health crisis, addressing educational capacity, and the development of
a nursing workforce prepared for the complexities of contemporary health
care, is indeed an investment in California's future. The shortage of
nurses in California is a threat to the state's ability to compete as a
desirable place to work and to live. Businesses are attracted to
communities that can offer a high quality of living. Access to health
care and qualified health care providers is an essential outcome that
affects regional quality of living. Without a substantial and
strategically coordinated plan, access to care via emergency services,
surgery, and hospitalization will be severely curtailed. Delay in
treatment can escalate costs and more importantly, impair recovery
unalterably, and contribute to deaths that could have been prevented.
Furthermore, an insufficient number of registered nurses will lead to
adverse outcomes, including increased complications and sentinel events,
and longer lengths of stay.[^1] As the shortage escalates, it will be
more severely felt in out-of-hospital settings such as skilled nursing
facilities and long term care, home health and ambulatory care,
significantly impacting vulnerable populations such as the elderly and
the underserved.

### **Nurse Shortage**

The population in California is expected to increase by 11.3 million
persons by 2020, which will approximate ¼ of the total population growth
in the United States.[^2] The California Employment Development
Department (EDD) forecasted that the state would need 109,600 more
registered nurses (RNs) between 2000 and 2010 - to replace those
retiring and to meet an increased demand for nursing care. In 2000, the
state schools had the capacity to graduate only about 50% of the numbers
of RNs needed.[^3] The latest figures from Health Resources and Services
Administration's National Center for Health Workforce Analysis indicate
that by 2010 California will only be able to meet 76% of the state's
demand for RNs and will have a shortfall of 47,600.[^4] The agency
predicts that the shortage will increase to 116,600 RNs by 2020, meeting
only 55% of the state's demand for nurses.

The forecasted demand for nurses can be met through a variety of means.
Most significantly, the demand will be met by increasing the numbers of
nurses educated; however, in order to set realistic targets for
expanding capacity, consideration must also be given to the contribution
toward meeting demand that migration of nurses from other states and
counties will have on the supply of nurses, as well as, to a smaller
extent, increasing retention of nurses in the workforce and lowering
attrition rates from nursing programs.

##### Enrollment is Limited by Capacity in Schools

In 2003 California schools had slots for 7,521 first year nursing
students, 98% of these slots were filled, and nearly all schools had
more qualified applicants then could be admitted, with a reported 31%
increase in the applicant pool between school year 2002 and 2003.[^5]
The number of applicants attempting to enter nursing schools has
continued to grow -- public interest in nursing as a career is strong
and not an issue at this point. In 2003, the SF Bay Area schools
reported that only 44% of those applying could be admitted, and in the
LA Area, 42% of those applying could be admitted.[^6] **Clearly,
opportunities to dramatically increase enrollment exist.**

Barriers to expanding capacity are varied, but are generally related to
the number of slots available for nursing students (driven by funding
available to the nursing program), faculty shortages, and space for
clinical placements, skills labs, and classrooms. Additional barriers to
increasing the number of graduates include high attrition rates in
community colleges and the length of time to graduate from a program,
frequently driven by insufficient access to prerequisite courses,
cumbersome transfer agreements between colleges, and student personal
circumstances (a high percentage of students are second career and need
to work to support a family). Private colleges report having the ability
to expand more quickly as they are unencumbered by state funding
mechanisms; however, the high cost of tuition in private colleges is a
major barrier to these schools expanding capacity.

Solutions for overcoming barriers range from innovative approaches for
expanding capacity under the control of the school to policy decisions
at the highest level in the state government to increased funding for
nursing education. But money alone is not the answer. When solutions
lack strategic and coordinated innovation, money is not well spent.
Redesign of the system of education for nurses is needed. Without
redesign from a systems perspective, we continue to "tinker" around the
edges, doing more of the same and perpetuating traditional approaches.
Without redesign it is unlikely that solutions, which will make a
difference for the long term, will be obtained.

Educational redesign is currently taking place in multiple sites across
the state. Many of the redesign efforts are a result of partnerships
between colleges or between colleges and hospitals. These innovative
approaches to nursing education are serving as demonstration models of
what is possible. Identifying and replicating successful innovative
models for expanding capacity, supporting new innovations, and linking
them together will help create a desirable statewide system with
long-term solutions. (A compendium of *Successful Innovations for
Expanding Nursing School Capacity* that are currently in place in
California is available through CINHC.)

Building education capacity must also be addressed within the context
of:

-   increasing the diversity of the workforce, thus increasing the
    number of ethnic and racially diverse applicants to schools of
    nursing;

-   the recruitment of students into nursing and the promotion of the
    desirability of nursing as a career for the younger generation of
    students, and for men;

-   the healthcare delivery system which drives demand for nurses and
    curriculum requirements to ensure that nurses are educated to meet
    the evolving needs of care delivery; and

-   the work environment, to retain nurses in a professionally rewarding
    environment.

Thus, a comprehensive strategic plan includes the focus areas of
diversity, recruitment, nursing practice, and work environment,

Gaps in the current education system that must be closed to build
capacity and meet regional demands for nurses need to be identified.
This includes ensuring that the data is available for defining the
shortage, forecasting the demand, and establishing targets for
increasing capacity. Identifying gaps and establishing targets is needed
to be able to direct resources to have the greatest impact on building
needed capacity. Designing and implementing strategies to close these
gaps will be fundamental to the success of the Master Plan.

##### Current state of California Nursing Programs

In 2003 the Board of Registered Nursing reported there were 101 schools
of nursing leading to a licensure as a registered nurse.[^7] In 2005,
four more schools have received approval for pre-licensure programs;
three of these are Entry Level Masters programs.

Of the 101 schools of nursing:

-   48 of these programs are in Northern California

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-   53 of these programs are in Southern California

-   73 are ADN programs (31 in No. CA, 42 in So. CA)

-   23 are BSN program (12 in No. CA, 11 in So. CA)

-   5 are Entry Level Masters (4 in No. CA, 1 in So. CA)

In 2003 these schools graduated 5611 students. Although this number
represents an increase in enrollment per year of almost 28% over four
years, it is only 6% more than the number of nurses that graduated
(5292) in 1994/95. **The state's current ability to educate nurses is
not much greater than it was ten years ago. Furthermore, most of the
increase in capacity that has occurred is the result of public/private
partnerships and contributions made to schools by hospitals, health
systems, and foundations.**

Nearly all schools of nursing report that they are at capacity with long
waiting lists of students attempting to enter the nursing programs.
During 2003, although many schools were increasing capacity in SF and LA
(45% and 59%), some were decreasing capacity because of budget cuts (35%
and 15%). Additionally, with the closure of the USC nursing program in
2004, California has lost about 80 BSN graduates per year. At the nurse
shortage worsens, California schools do not have the capacity to educate
the number of qualified students that desire to become registered
nurses. **Increasing California's capacity to educate registered nurses,
including those at the baccalaureate and graduate levels, is the most
urgent step to be taken to address the nurse shortage.**

Additionally, loss of nursing students is high. Attrition rates in
community colleges are reported at between 20% and 26% with higher
attrition rates reported in underrepresented minority student
populations. [^8] This represents a loss between 1300 and 1400 students
a year. A 25% decrease in attrition will add 1800 nurses to the
workforce over 6 years; a 50% decrease will add 3600. That attrition
rate needs to be stemmed, as the state cannot afford to lose students
that are admitted into an already insufficient number of slots in
nursing programs.

Adequate faculty resources are fundamental to expanding capacity in
California schools. In 2003 schools of nursing reported 129 vacancy
faculty positions. Current vacancies in faculty positions; expected
increase in faculty retirements, because of the aging faculty pool; and
the need to increase the number of faculty available for program
expansion, all contribute to a critical need to increase the number of
nursing faculty. High faculty vacancy rates are in part explained by the
fact that faculty salaries cannot compete with industry. In addition,
healthcare systems are increasing their use of masters and doctorally
prepared nurses, thus decreasing the available pool for educational
institution employment.

####### Conclusion

California is on the verge of a health crisis, as the nurse shortage
worsens. The shortage of registered nurses must be addressed to mitigate
the effects of this looming crisis. Increasing educational capacity in
the state's schools of nursing is California's most pressing nursing
workforce need. Barriers to expanding capacity must be overcome, and
investments in nursing education strategically made to leverage the
impact in developing long-term sustainable solutions. Following is Goal
I of the Master Plan for the California Nursing Workforce. This plan
describes the actions steps that the government, education, healthcare
providers, and the profession must take to ensure that California will
have the nurses needed to care for its people as we reach the end of
this decade and beyond.

[^1]: Needleman, J. et al. Nurse Staffing Levels and the Quality of Care
    in Hospitals. *New England Journal of Medicine.* 346:1715-22. May
    30, 2002; *Health Care at the Crossroads: Strategies for Addressing
    the Evolving Nursing Crisis*. Joint Commission on Accreditation of
    Healthcare Organizations. 2002. p. 6; Aiken, L., et al. Hospital
    Nurse Staffing and Patient Mortality, Nurse Burnout, and Job
    Dissatisfaction. *Journal of American Medical Association.* 288
    (16):1987-1993. October 23, 2002.

[^2]: California Futures Network 2003

[^3]: Scott's Commission Report as a response to AB 655, prepared for
    the Governor and the Legislation by the Chancellors of the
    California Community Colleges and California State University, and
    the Presidents of the University of California and the Association
    of Independent Colleges. *Educating California's Future Nursing
    Workforce.* June 2000.

[^4]: Health Resources and Services Administration, *What is Behind
    HRSA's Projected Supply, Demand, and Shortage of Registered Nurses?*
    September 2004
    www.ncsbn.org/pdfs/Projected_Supply_Demand_Shortage_RNs.pdf.

[^5]: California Board of Registered Nursing *2002-2003 Annual School
    Report*, September 2004.

[^6]: Jones, D. C. Bradley, CINHC and HASC Education Service Partnership
    Initiatives. Final report. October 2004. Personal communication.

[^7]: BRN Annual School Report 2002-2003

[^8]: Seago, JA., J. Spetz, *Admission Policies and Attrition Rates in
    California Community College Nursing Programs*. San Francisco: UCSF
    Center for California Health Workforce Studies, Center for the
    Health Professions, March 2003.