Who Will Care? Meeting Vermont's Nursing Needs, Now and For the Future

By Mary Elizabeth Fratini

Her routine is constant whether she is reporting to work at 7 a.m. or leaving at that time.

After two years, thousands of commuter miles and many more thousands of dollars in loans for educational and living expenses, Susan Paris is now a post-partum registered nurse (RN) at Fletcher Allen Health Care (FAHC) in Burlington.

She listens to the tape-recorded report from the previous shift, followed by a verbal update from the nurse assigned to her patients. Then it's time to meet the three couplets on this shift for an assessment of mothers and babies - blood pressure, temperature, pulse, respiration, check incisions from cesarean sections, check for a properly contracting uterus, and examine breasts for engorgement and milk production and blisters.

"There's a lot of breasts, especially in the staff room when we are talking about nursing babies and demonstrating our stories," she said.

"I'm fortunate to work in a wellness unit. Some moms who come in are sick and it is good that Vermont has a high-needs acuity ward for their care, but most of my patients just had babies. It is one of the only times people are in the hospital for a joyful moment and my job is really to support the fact that these women just had a child. Even moms with three kids at home have questions, so I do a lot of education. I like that there is a lot of dialogue between nurses and patients," Paris said.

Nursing is the nation's largest health care profession, with more than 2.9 million RNs nationwide, according to a 2004 survey conducted by the federal Health Resources and Services Administration (HRSA). The number of hospital-based RNs has decreased steadily since 1980, however. By 2004 just over half of all RNs nationwide remained at hospitals as health care was increasingly provided at external sites such as private practices, home health care, outpatient surgical centers, mental health agencies, hospice and the military, according to the American Association of Colleges of Nursing (AACN).

Paris' journey, however, has not been easy. After completing Vermont Technical College's (VTC) program for licensed practicing nurses (LPN) with honors in 2006, Paris was waitlisted for the RN program at the Randolph site last fall, which takes just ten students per year. While she was already working at two health care sites as an LPN and could have reapplied for the following year, Paris was reluctant to delay her plan to pursue a Master's of Science in Nursing (MSN) with a certificate in midwifery. She opted to enroll in the RN program at VTC's Bennington site, which has space for 18 students, instead, continuing her classroom studies from Randolph, via Vermont Interactive Television (VIT) and traveling to Bennington or Albany, New York from her home in Montpelier one to two days per week for her clinical.

"Albany and the Southwestern Vermont Medical Center were both good experiences - Southwestern is a magnet hospital, which is an elite status, and Albany treated more acute patients than some Vermont hospitals, including transplants," Paris noted. Part of her clinical time was spent in Albany's new Labor/Delivery/Recovery/Post-Partum floor, which combines departments generally located in separate areas of the hospital. "Everything was in one place - the C-section room was on the unit, 20 feet away - so once a mom came in she never had to leave her room," Paris noted with obvious excitement.

The logistics of clinical overnights two-and-a-half hours from home were challenging for this single parent of a seven-year-old son, but not insurmountable. "I was successful because his father was very supportive. He understood that this was my last year and was flexible about trading days, or taking my son on the nights I had clinical," she said. The help of a local classmate living in Bennington also proved essential. "She opened her food, her bath, her whole life and said, come and sleep here two nights every week for a year."

Paris' experience is not unusual for VTC students, according to the college's Nursing Admissions Counselor, Susan Fredette. VTC's RN programs in Williston and Brattleboro are stand-alone sites, but RN students in Randolph, Bennington and White River Junction conduct all classroom time via VIT. "For students who are accepted into a program where the clinical is far away, we allow them to sit at the closest VIT site so they don't have to travel every day. It allows us to maximize a single instructor for 30 or 40 students spread out across the state, which is an advantage when it is difficult to find classroom instructors," Fredette noted.

The Changing Path to Scrubs

As nursing education has moved into colleges and universities, the traditional path of hospital-based instruction in a diploma-granting program now represents less than 10 percent of all basic RN programs. VTC is one of five colleges in Vermont offering nursing degrees, and they have seen consistently increasing interest: applications for the incoming class rose five percent for the LPN certificate and 24 percent for the Associate's Degree program (RN).

The National Council on Nurse Education and Practice has recommended that by 2010, 60 percent of RNs nationwide should have Bachelor's degrees to meet the complex demands of modern nursing. In Vermont, only one-third of RNs have completed a BSN program. The continuing majority of Vermont nurses with Associate's degrees is troubling because surveys by the HRSA have indicated that less than five percent of Associate-degree graduates complete a graduate program, potentially exacerbating the existing shortage of nursing faculty.

Paris, who already held a B.S. in Environmental Science from Johnson State College, is in the minority of nurses with an Associate's degree intending to pursue graduate study in the field. While she is grateful that VTC's two-year program allowed her to change careers, Paris has contradictory feelings about the prevalence of the programs. "I recognize that if there wasn't such a program I might not have been able to become a nurse, I do feel that nursing should be a four-year degree. Patients are very sick, there's a lot of critical thought and care involved and I don't know if you can get it all in two years," she said. "VTC is an exemplary program because of their huge clinical component. In that sense, I felt very prepared to be on the floor. But in the classroom I was definitely rushed through topics to fit everything into a certain amount of time."

Nationally, enrollment for entry-level Bachelor of Science in Nursing (BSN) programs has increased for six consecutive years, following an equivalent time of declining enrollments. But a continuing shortage of nurse educators and clinical sites forced schools to turn away more than 32,000 qualified applicants last year due to a shortage of nurse educators, according to the AACN.

Research by the Office of Nursing Workforce at the University of Vermont found similar challenges, noting in a report last year that, "The five schools of nursing in the state are hard pressed to be able to accommodate the renewed interest in careers in nursing. This is directly related to resources available for additional faculty positions, not to mention the problems finding appropriately educated faculty to fill existing positions. Student clinical placement sites are also limited."

"I don't know what the solution is," Paris said. "We need nurses, and many interested people are, like myself, looking at a second career - do you make them go back for another four years, especially if they already have a bachelor's degree in a different field? It's a double-edged sword because you need more nurses, but for more nurses you need more instructors, and for more instructors you need more hospitals, and we are in a small state."

Nationally, the average age of RNs is approaching 50 years old with the percentage of RNs under 30 also decreasing. In Vermont, practicing nurses range in age from 21 to 85 years old, but more than three-quarters are over 40. A survey last year found that 55 percent of nurses intended to retire by 2020, the majority of whom were nurse managers.

While researchers agree that the country has an existing shortage of nurses that will only worsen as the baby boomers - patients and providers - age, the severity and nature of that shortage is murky at best. One federal report last year estimated a projected need of one million new RNs by 2020. A report in the January/February 2007 issue of Health Affairs, however, reported that the nursing gap had shrunk from an earlier figure of 800,000 RNs needed by 2020 to just 340,000. Even that smaller figure represents a three-fold increase over the current shortage, however.

The shortage comes even as research increasingly indicates a correlation between quality nursing and improved patient care, as well as between higher levels of nursing education and better patient outcomes. A 2007 study of almost 50,000 patients by researchers at the University of Toronto found that a 10 percent increase in the proportion of BSN nurses was associated with nine fewer deaths per 1,000 discharged patients.

A survey of 329 nursing schools by the AACN in 2006 found an average of two faculty vacancies per school and more than half required a doctoral degree. In addition to existing vacancies, the schools identified a need for an additional 55 new positions to accommodate student demand. Salary is a primary deterrent in recruiting additional faculty. A nurse practitioner with a Master's degree averages $72,480 a year in salary, whereas the average salary for an associate professor with a Master's degree is just $58,249, according to a recent survey by The Nurse Practitioner.

Home-Grown Solutions

The state of Vermont has created several financial incentives for nurses to pursue graduate studies, including loan repayment programs for those who agree to serve as nurse educators and faculty in the state, and schools and nursing leaders are finding creative ways to address the practical realities of modern nursing without sacrificing quality. UVM, for example, created a new four-year Masters in Nursing program for students already holding a bachelor's degree in an unrelated field. The efforts are bearing fruit: enrollment in MSN programs jumped 28.6 percent in Vermont last year, compared with just a 5.2 percent increase nationwide, according to the AACN.

When reports demonstrated an exceptionally high turnover rate for new graduates - in 2001 as high as 35-60 percent within the first year of employment - the Vermont Organization of Nurse Leaders created a unique training model known as the Vermont Nurse Internship Program (VNIP). From 2003 to 2007, VNIP's turnover rate remained lower than 10 percent for new graduates completing the internship. The Northeastern Vermont Regional Hospital in St. Johnsbury joined the program after consistently seeing 20 percent and higher vacancy rates for nurses on the medical-surgical unit. For the last three years, they had a 0 percent vacancy rate for all nursing positions.

The internship includes 40 hours of instruction over 10 weeks on topics including quality improvement, policy and procedure, medication administration, cultural competence, managed care and pain management. During this time, interns are paired with a primary preceptor with whom they share a patient assignment.

According to VNIP Director Susan Boyer, the program reduces turnover and improves recruitment by changing the culture of the workplace to one of support and nurture. All graduates hired into acute care at Vermont hospitals, and many coming into other services areas, participate in the program, which currently includes 500 interns, both RNs and LPNs.

"There is a great deal of foundation knowledge that can only be learned via experiential learning," Boyer wrote. "The intensity, technology and knowledge-base requirements have grown so dramatically in recent decades, that nurses truly need to have internships and residencies as a concrete, organized component of their educational preparation."

The 10-week training program was one reason Paris chose to work at FAHC. "As a brand new nurse with only two years of school, I thought it was important. One of my nurses has been on the floor for over 20 years, and it is really good to have that consistent support behind you. Even after training, she'll be a resource for me," Paris said.

While she appreciates the opportunity to move straight from school into the unit of her choice, Paris also noted that there is some experience lost with that immediate mobility. "I had no desire to be a medical-surgical nurse, my field of interest is women and children. But you also lose the opportunity to see a wide range of medical conditions and there's always the possibility that I'll miss something in a mom just because I never saw it."

Paris' long term plans are to work as an RN for a year and then apply to the Frontier Midwifery School in Kentucky for a low-residency MSN program with a certificate in Midwifery. "I can't predict life, but I would rather do it right away and get it over with, like I did with this program," she said, the better to start in on her even longer-term goal of opening a free-standing birthing center in Vermont. "Vermont's birthing centers, because they are connected to a hospital, require a certain amount of intervention as protocol - you are hooked up to an electronic monitoring system, IVs are started - but not every mom needs that. A free-standing birthing center would expand women's choices for giving birth beyond simple home-versus-hospital."

Assistant Editor Mary Fratini lives in Barre.