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As nurses quit, states seek to train more

Under pressure from short-staffed hospitals and burned-out nurses, lawmakers in several states recently passed bills designed to expand nursing schools.

For more than two years, the COVID-19 pandemic has exposed both the importance of nurses and strain on the workforce. Hospitals, long-term care centers and even K-12 schools have been so short-staffed in recent months that they’ve had to cancel procedures, delay moving patients into inpatient beds or reduce other services. This legislative season, that sense of crisis has powered bipartisan efforts to increase nurse training and licensure.

The proposals have split somewhat along party lines, with Republican lawmakers in red states emphasizing reduced education regulations and Democrats in blue states emphasizing funding increases. Still, leaders in both parties agree on the need to get more nurses educated and helping patients.

Indiana, for example, needs to graduate 1,300 more nurses a year until 2030 to meet the state’s health care needs, said state Rep. Ethan Manning, a Republican. GOP Gov. Eric Holcomb last week signed a bill Manning sponsored that relaxes some nurse education requirements.

There was a nurse shortage in Indiana before COVID-19 hit, Manning pointed out. “The pandemic, of course, has only made it worse. So it was time to take some action.”

The new law drops limits on how fast two- and four-year nursing programs can grow, allows nursing schools to replace some required clinical hours with simulation hours—that’s training using mannequins, technology and role-playing—and allows two-year programs to hire more part-time faculty. 

A Kentucky bill, also Republican-sponsored, would lift limits on program growth and loosen the degree credentials required of nursing school faculty. Both the Kentucky and Indiana measures also would relax some nurse licensing rules.

Meanwhile, New Mexico Gov. Michelle Lujan Grisham, a Democrat, has approved a budget that sets aside $15 million in grants that nursing programs can use to expand enrollments and $30 million to endow nursing faculty positions.

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Washington state’s Democratic-controlled legislature has approved funds to expand public nursing programs by about 200 seats (about a 10% increase, according to the Washington State Hospital Association), improve simulation training and create a student loan assistance program for nursing school faculty. 

“This year in particular, I have never had more impassioned pleas for nursing workforce [policies] from nursing educators or from hospitals,” said Washington state Rep. Vandana Slatter, a Democrat who chairs the House College and Workforce Development Committee and sponsored the student loan assistance bill.

Slatter, a pharmacist, said she has heard from nurses who broke down into tears over the phone or called during the only 10-minute break they’d had for hours. “It broke my heart as a health care professional,” she said.

Indiana’s Manning this year also proposed a student loan relief fund for nurses and other types of providers who work in short-staffed areas of the state, among other criteria, but it went nowhere. Some of his colleagues were leery of creating a new government program, he said, and lawmakers and advocacy groups also disagreed over how to pay for it. 

Supply and demand

The COVID-19 pandemic has put the health care system under such unusual strain that it’s hard to say for sure how many new nurses the nation needs, academic experts say. 

Before the pandemic hit, Peter Buerhaus of the Center for Interdisciplinary Health Workforce Studies at Montana State University and his colleagues projected that the United States would gain a million new registered nurses between 2015 and 2030.

“I don’t think most people were worried that we were looking at a large shortage,” he said.

The pandemic scrambled forecasts by increasing demand for nurses in key roles, such as in intensive care units and emergency rooms, while simultaneously driving away nurses who were burned out, seeking higher pay, unable to find child care or unwilling to get vaccinated.

“We’re kind of in a volatile period right now,” Buerhaus said. It’s possible, he noted, that some nurses who quit during the pandemic will return, or that demand for services will settle back to pre-pandemic levels. 

Hospital associations and nursing groups in many states say local shortages are pressing, however. And they’ve been pushing lawmakers to respond.

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“Most studies are showing that in the next decade, Indiana is going to be a few thousand nurses short, given just the aging population and national trends of increased demand for nurses,” said Andy VanZee, vice president of the Indiana Hospital Association. 

“Layer on top of that the pandemic, and many organizations seeing 10-20% retirement and transitions of current nursing professions into other careers—it created this challenge,” he said.

One way to address the problem is simply to train more new nurses. Nationwide, nursing programs rejected more than 90,000 qualified applications last year because they didn’t have space for any more students, according to the American Association of Colleges of Nursing, a Washington, D.C.-based group that advocates for nursing programs.  

Colleges reject qualified applicants primarily because the schools don’t have enough faculty, clinical placements or funding to accept them, according to the association. 

Recruiting and retaining nursing faculty has long been a challenge. Nursing program accreditors typically require faculty to have at least a master’s degree, but such highly educated nurses can earn much more in clinical settings than they can teaching. 

“To be in academia is a passion,” said Deborah Walker, the executive director of the New Mexico Nurses Association. She said that in New Mexico, faculty members with graduate degrees can earn as little as $45,000 a year while practicing nurses with less education can earn $75,000.

About 8% of faculty jobs across 935 nursing programs were vacant in the 2021-2022 academic year, according to the American Association of Colleges of Nursing. 

Nursing programs also require hands-on training, including supervised placements in hospitals, clinics and other health care settings. 

“Expanding a nursing program is not an easy task,” said Donna Meyer, CEO of the Organization for Associate Degree Nursing, a San Diego-based group that advocates for community college nursing education. 

In her former job as dean of health sciences at Lewis and Clark Community College in Godfrey, Illinois, Meyer said, she expanded the nursing program from 93 to 300 students. But it required a big investment. “We built a brand-new building; we got resources to hire learning specialists, have a simulation lab, hire more faculty,” she recalled.

College enrollments overall also have dropped by 5% since the pandemic began—giving health care employers and all others who rely on highly educated workers reason to worry about future workforces.

Expanding nursing programs

Manning’s measure to relax nursing education rules was backed by the state hospital association and Ivy Tech Community College, Indiana’s statewide community college. However, it was only partially supported by the Indiana State Nurses Association, a professional group.

Ivy Tech turned away about 300 qualified students last year because of capacity issues, said Mary Jane Michalak, vice president of public affairs at the college. “We could not accept them because we did not have faculty to teach the classes, and we didn’t have clinicals available to place the students.”

The new law addresses both those bottlenecks, Michalak said, by letting the college hire more part-time faculty and swap some clinical training hours for simulation hours.

The law lifts limits on enrollment growth if 80% of a program’s graduates pass nurse licensing exams. The share of clinical hours that can be replaced also depends on exam pass rates.  

Some members of the Indiana State Nurses Association, however, worried that such changes would dilute the quality of nurse education in the state, said Blayne Miley, director of policy and advocacy at the association. 

“These regulations were put in place by the Indiana State Board of Nursing in an effort to ensure quality in nursing education, and the bill loosens those restrictions,” he said. 

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Four-year college administrators and faculty members successfully lobbied to ensure the bill didn’t empower four-year colleges to hire more part-time faculty.

The nature of legislative sessions this year shaped the bills that passed. In Indiana, lawmakers weren’t debating the state’s biennial budget this year.

But in New Mexico, lawmakers could consider only legislation relevant to the annual budget, Walker said. That’s why the New Mexico Nurses Association focused on increasing funding for nurse education.

“It’s a big deal,” Walker said of the millions of dollars lawmakers set aside for funding faculty positions. She noted that lawmakers also expanded college scholarships for all students, which will help aspiring nurses, and approved $1,000 tax credits for  nurses who worked full-time in a hospital this year. 

Ivy Tech likely will ask Indiana lawmakers for more funding next year, Michalak said. The college will need at least $8.7 million in recurring funding and $12.1 million in one-time funding for equipment, supplies and faculty to reach its goal of graduating 600 more nurses a year by 2025, she said. Some of that money will come from private-sector grants.

Some lawmakers also argue that states need to focus on improving nursing jobs as well as increasing the supply of nurses. 

“We don’t want to lose folks who have made a career of this, who are walking away because they have patient loads that are not manageable, and working conditions that are not fair,” said Washington state Rep. Marcus Riccelli, a Democrat.

Riccelli said he’s “fully supportive” of Washington’s new funding for nursing education, but disappointed that a worker safety bill he championed died in committee. The bill would have set minimum nurse-to-patient ratios and tightened the rules for their mandatory lunch and rest breaks.

His bill was opposed by the Washington State Hospital Association, which estimated that under the original bill, hospitals would have had to hire 15,000 additional nurses and certified nursing assistants to meet staffing minimums.

The bill wouldn’t fix existing shortages, said Chelene Whiteaker, senior vice president for government affairs at the hospital association. “If anything, I think it exacerbates them, and would result in rationing of health care services.”

Stateline is a nonpartisan, nonprofit news service of the Pew Charitable Trusts that provides daily reporting and analysis on trends in state policy.

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Jake Greenberg/U.S. Navy

Lawmakers in several states this year took steps to expand nursing education.