How to End the Nursing Shortage

With the graying of America has come a shortage of health-care professionals, especially nurses. One major contributor to this problem is a lack of capacity at nursing schools. From 2009 to 2011, 85 percent of Associate Degree in Nursing (ADN) programs turned away qualified applicants; in 2011, 51 percent of qualified ADN applicants were turned away due to lack of capacity. The leading cause of this crunch is a dearth of faculty and clinical sites.

That's the bad news. (Well, most of it.) Now for the good: There are national programs available to increase our capacity for nursing education. Even better, these programs come at no cost to the state and do not compete with in-state schools for new-to-nursing students. Instead, they enroll students who already work in the health-care field, provide them the means to gain additional knowledge and skills, and then require students to pass rigorous competency exams before graduation.

Back to the bad news: The federal government -- along with many states, including California, our nation's largest -- is not helping, but in fact is hampering, these needed programs, thereby stifling the creation of new pathways into the nursing profession as well as depriving patients of needed care. How? By refusing to treat these programs as equal to other types of training. These programs' students are ineligible for federal Title IV funding for the competency-based components of the curriculum, and many states either refuse to license the programs' graduates or make them clear hurdles that graduates of traditional nursing schools do not face.

The harm done by governments' failure to recognize the effectiveness of the competency-based approach becomes clearer when we examine its effects on one of the leading institutions providing competency-based ADN programs, the Excelsior College School of Nursing. This school admits into its associate degree in nursing program only students already possessing significant health-care experience -- licensed practical/vocational nurses, paramedics, and select classifications of military corpsmen. Before graduating, students must demonstrate, through rigorous assessment, the knowledge and competencies required of newly minted RNs. This program, established through support from the Kellogg Foundation in 1973, has graduated over 40,000 nurses since 1975.

As an added benefit, this competency-based model has proven quite effective at increasing access for groups underserved by traditional campus-based nursing programs -- men, as well as Hispanics and other minorities. In fact, the American Assembly for Men in Nursing has four times named Excelsior as the Best School for Men in Nursing.

You'd think that graduates of Excelsior's program -- accredited by the National League for Nursing Accrediting Commission for over 35 years and designated three consecutive times as a Center of Excellence by the National League for Nursing -- would be welcome additions to the nursing work force. Unfortunately, this is not always the case.

Thirty-six U.S. jurisdictions allow Excelsior's graduates to sit for the RN examination. Happily, my home state of Texas is one of these forward-thinking jurisdictions. Unhappily, California does not license graduates of the program, and a number of other states impose additional requirements on these graduates, such as mandating that they work as an RN in a federal facility before receiving a license.

Why these added hurdles?

Regulators have failed to weigh the evidence that there is more than one way to educate nursing students. They are ignoring the nearly 40 years of experience and over 40,000 graduates who substantiate the competency-based model and approach to learning.

There is still more that governments neglect. Excelsior, as a private non-profit school, offers nursing education at no cost to the state, and 97 percent of Excelsior's AD in nursing graduates are still working as RNs three years after graduation -- a substantially higher percentage than the national average. A 2007 study estimates that the cost to taxpayers of recruiting, hiring, and orienting a medical-surgical nurse is $20,000 to $92,000, so the savings from higher retention are substantial. In failing to recognize the value of competency-based programs, government holds taxpayers for ransom.

All this may be changing. Across the spectrum of higher education, competency-based programs are gaining ground -- and, in the process, lowering education costs and increasing education access. In March the Department of Education (DOE) released a memo detailing how it might go about approving competency-based programs for Title IV funding.

Time will tell whether and how DOE implements this memo. We should hope it doesn't take much time to find out, because the nursing profession -- and, more importantly, patients -- deserve better.