LAC 48:I.11907. Registered Nurses

A. Introduction. In the mid 1970s both the federal Department of Health, Education and Welfare and the Louisiana Board of Regents reported that the state and the nation were well on their way to solving previously noted shortages in the area of nursing manpower. In light of this perception, federal funds were curtailed for nursing education and other initiatives were aborted. However, enrollment in nursing programs began to level off and as more job opportunities opened for women in other fields, many nurses left the profession for jobs that were either less strenuous or more rewarding, financially and otherwise. Due in great part to these trends, there is no longer an abundant supply of nurses and most areas and health care facilities in the state have difficulty filling all their nursing staff needs. This is true for both Registered Nurses (R.N.'s) and Licensed Practical Nurses (L.P.N.'s); however, the data reported in this analysis relates only to R.N.'s. The number of L.P.N.'s in the workforce is unknown at present since a nurse registry is maintained only for R.N.'s. B. Supply 1. Louisiana lags behind the national average in the ratio of nurses to general population. The most recent data published by the U.S. House of Representatives and its Subcommittee on Health and the Environment indicate a national average of 520 nurses per 100,000 population. Similar figures for Louisiana indicate a rate of 367 nurses per 100,000. Relative to other states in the region, Louisiana's nursing supply is also below several comparable averages, as is reflected in the following table. Active Registered Nurses Geographic Area | per 100,000 general population United States | 520.8 Louisiana | 367.6 Alabama | 350.2 Kentucky | 402.6 Mississippi | 394.8 Tennessee | 363.0 Arkansas | 325.7 Oklahoma | 390.7 Texas | 374.3 2. It can be seen that Louisiana is not unique in the southern region in having fewer nurses than is the average nationally. The Louisiana Board of Regents has reported that this disparity decreased greatly in Louisiana with the aid of federal funds for nursing education. In the years before funds were available (1958-1966), nursing enrollments in Louisiana grew not at all: 306 graduates in 1955 and 306 in 1965. After the enactment and implementation of the nurse training act of 1964, the number of graduates had risen to 435 in 1970. This number nearly tripled by 1978, as 1148 new graduates entered the nursing profession in Louisiana. Since then, there has been a significant decline. In 1981, there were 21,317 licensed R.N.'s in Louisiana. C. Distribution 1. Because much of nursing work is done in health care institutions, geographical distribution is for the most part an inappropriate measure of judging the shortage or surplus of supply. The Louisiana State Board of Nursing has reported that more than 58.2 percent of the registered nurses within the state are employed in hospitals. Others are employed in nursing homes, by public and private health care agencies, and by physicians. A practitioner to population ratio analysis by small geographic area is limited in terms of its ability to identify areas of need. A more reliable indicator of supply need is whether primary employers of nurses are able to fill available positions. D. Utilization 1. The following table depicts the relative distribution of nurses among various types of employment. Registered Nurses in Louisiana by Field of Employment Number | Percent Hospital | 9665 | 58.2% Nursing Home | 2161 | 13.2% Nursing Education | 580 | 3.4% Private Duty | 382 | 3.5% Public Health | 772 | 2.3% School Nurse | 333 | 4.6% Occupational Health | 242 | 1.4% Office Nurse | 1364 | 8.2% Other | 872 | 5.2% 2. Since nurses are an essential component of hospital care and hospitals such a large employer of nurses, the availability of nurses to meet the needs of hospital employment must be addressed. SHPDA staff spoke with a number of hospital administrators who state that due to high turnover rates and chronic shortages of nursing personnel, they are almost always forced to operate at less than full capacity. One administrator reported that at the time they had only 60 percent of the needed nursing staff complement. Other administrators noted that because of the shortages, they were forced to close down certain units of their hospitals. 3. Essentially it is the nature of the work which makes nurse retention in a hospital setting difficult. Shift work and holiday work make the field unattractive, especially to women who may have primary child care responsibilities at home. Another factor contributing to retention difficulties is the conditions of employment in hospital settings. In a survey conducted by the Mid-Louisiana Health Systems Agency, many nurses interviewed suggested that they were often perceived as "handmaidens" or "hired help" for physicians. They felt that these were the perceptions of the doctors and hospital administrators. Furthermore, they felt that these perceptions were not only destructive to their professional status but also to their ability to perform their jobs. In this same survey, salaries were not mentioned as a problem by many of the nurses. It seems clear that there is a combined problem of too few students being attracted to nursing and too few hospital positions which offer satisfying work conditions to nurses. 4. Within other areas of nurse employment there are also problems with supply, though not as critical. Within nursing homes, the supply of R. N. personnel is not as inadequate. Part of the reason for this can be seen in the fact that nurses enjoy a greater degree of autonomy in decision-making and a higher professional status in nursing homes. The lack of a severe "shortage" in fields of employment outside hospitals lends credence to the thought that hospital employment conditions play a significant part in the nursing shortage. 5. State Health Planning Agency conducted a survey of major health care employers in March, 1982 requesting data on budgeted positions and vacancies among various allied health professions. Nurses were not included in the survey because of the availability of documentation concerning the number of R.N.'s in the Louisiana job market and the shortage of nursing personnel. Many responses from nursing home administrators contained comments added on the survey questionnaire concerning a shortage of licensed practical nurses (LPN's). Nursing home administrators in all areas of the state reported chronic shortage of LPN's. E. Resource Renewal 1. Currently there are eighteen institutions within the state which provide nursing training. Six of these schools offer an associate's degree and graduated 319 nurses (or 32.8%) of the 1980 nursing class. Eight of these schools offer a baccalaureate degree and graduated 459 (or 47.2%) of the 1980 class. Four of the schools offer a diploma in nursing and graduated 194 (or 19.9%) of the 1980 class. (See Chapter XII for inventory of programs). Both enrollment and numbers of nursing graduates have been declining since the late 1970's, as is depicted in the following table. Number of Graduating Nurses | 1975 | 1976 | 1977 | 1978 | 1979 | 1980 | 1981 Associate Programs | 279 | 366 | 371 | 339 | 350 | 319 | 308 Baccalaureate Programs | 396 | 462 | 501 | 577 | 451 | 459 | 426 Diploma Programs | 230 | 182 | 191 | 232 | 237 | 194 | 175 566 | 1010 | 1063 | 1148 | 1038 | 972 | 909 Number of Nursing School Enrollments | 1975 | 1976 | 1977 | 1978 | 1979 | 1980 | 1981 Associate Programs | 961 | 1056 | 1082 | 979 | 936 | 959 | 1000 Baccalureate Programs | 3069 | 3197 | 3064 | 3003 | 2693 | 2728 | 2818 Diploma Programs | 761 | 770 | 794 | 750 | 713 | 706 | 715 4791 | 5023 | 4940 | 4732 | 4342 | 4393 | 4533 F. Summary and Conclusions 1. Given the declining number of nursing graduates compared to increasing population and increasing numbers of hospital and nursing home beds, the nurse shortage that the state is now experiencing can be expected to persist and worsen. Several solutions have been suggested to deal with this urgent problem of health care manpower. 2. Hospital administrators have suggested that either more schools for nursing or more funds for nursing education are needed. In light of declining numbers of enrollments and unfilled nursing classes, this solution may be an expensive and inefficient approach to the problem unless emphasis is on programs in geographic areas where nurse education has been relatively inaccessible. A spokesperson for the Louisiana State Nurses Association notes that the focus should shift to appropriate utilization and retention of nurses rather than to increased supply. The Board of Nursing does not find new schools of nursing to be an effective solution. 3. As a result of the Mid-Louisiana Health Systems Agency survey, four recommendations were developed which it was thought could improve hospital retention of nurses: a. Improved communication between nurses, physicians and hospital administrators—It is felt that this would give nurses a needed voice in problem-solving and decision-making and help to enhance their professional status and professional self image. b. Career Counseling—Potential nursing students and nurses considering returning to the field need a place to turn to for practical advice. Nurse burnout and job stress should be dealt with. c. Continuing Education—Professional as well as personal growth should be a priority. Classes should be offered during work hours with in-service opportunities to work in specialty areas. d. Incentives—It was felt by the respondents of this survey that more pay for more experience and shift differentials for night and weekend work would be of value in improving retention. Flexible work shifts and innovative scheduling were also mentioned, especially for working mothers. It was also recommended that day care facilities should be made available at the hospitals for pre-school children of employees. G. Resource Goals 1. Nursing schools operating with full complement of students, that is at least 5,000 students enrolled annually. 2. At least 1,200 nursing graduates annually.