PURPOSE OF THE DOCUMENT

The members of the MNA Nurse Shortage Task Force have prepared this document to fulfill the charge of the MNA Board of Directors to propose an MNA Agenda of Initiatives in Response to the Nurse Shortage. The Task Force believes that this summary represents a WORKING DRAFT for use by the Board of Directors and their designees engaged in strategic planning for the Association.

The brief report summarizes the

• Purpose of the Document
• History of the MNA Nurse Shortage Task Force
• Assumptions
• A Draft of Agenda Initiatives

HISTORY OF THE MNA NURSE SHORTAGE TASK FORCE

In the summer of 1999, members of the Safe Care Steering Committee requested that the MNA Board of Directors form a task force to propose proactive initiatives that the Association might undertake in response to the nurse shortage. In October 1999, the MNA Board of Directors authorized the MNA Nurse Shortage Task Force. An Action Item was drafted in the Labor Relations Meeting at the MNA/RISNA Convention in October 1999 which was, in turn, overwhelmingly approved by the membership at the MNA Business Meeting later that day. The item requested broad membership support of the work of the Task Force. In January 2000 the Task Force was convened. The membership is comprised of representatives from various MNA structural units (attachment forthcoming).

The Task Force agreed upon a task:

To originate and guide a process designed to support the production of a white paper outlining a proposed agenda of initiatives for the Association to respond to the nurse shortage.

• MNA Board of Directors
• Congresses (Practice, Health Policy & Legislation, and Health & Safety)
• Center for Ethics
• Safe Care Committee/Community Health
• Diversity Committee
• Staff Development Committee
• Psychiatric/Mental Health Role Group
• Retired Nurses Networking Group

An invitation was posted in the MASSNURSE and on the web site inviting any member to submit feedback. Summaries were mailed to all Districts. District 5 hosted a brainstorming session with its Board of Directors and requested feedback at its March "Transition Into Practice" event for graduating seniors from schools of nursing. A member from District 5, Lisa Bergendahl, also hosted a brainstorming session with colleagues in the Bargaining Unit at her workplace. All feedback was tallied as described below.

The external groups which participated in the brainstorming process included:

• Massachusetts Council of Nursing Organizations (MCNO)
• Organizational Affiliates (OA)
• Massachusetts Association of Colleges of Nursing (MACN)
• Associate Degree/Diploma Council
• Coalition of Nurse Practitioners
• Massachusetts Student Nurses Association (MaSNA)

The President of MaSNA, Kristin Clark, hosted a session with classmates at her school of nursing. The Coalition of Nurse Practitioners invited participation in the process from its members in its spring newsletter.

The Brainstorming Process utilized was as follows:

• A Task Force member visited each group to overview the work of the group and the brainstorming process.
• A Task Force member returned a second time to work with the group for approximately 30-45 minutes.
• Each group member was asked to list a single "issue" or "solution" on a sheet of paper.
• Group members could list as many "issues" or "solutions" as they chose.
• All idea sheets were posted with the "issues" in one cluster and the "solutions" in another.
• The group as a whole reviewed each suggestion, clarified any as necessary, and eliminated duplicates or generated other ideas that were suggested by those that had been advanced.
• Each group was invited to identify their most important "issue" or "solution." Many groups did not choose to label a particular concern or solution. A few did. For example:

Congress on Health & Safety

ISSUE: Lack of control of practice environment (time, workload)

SOLUTIONS: Nursing education that prepares nurses with strategies to address a work environment that can be restrictive and hazardous; Increased accountability by management for the oppressive work environment in health care settings.

Congress on Health Policy & Legislation

ISSUES: Lack of respect/decreased professional image; Recruitment-related issues (lack of funding for entry level and aging of nurse workforce); Retention

SOLUTIONS: Higher pay & respect of other comparable professions

Center for Ethics

ISSUE: We don't respect ourselves: This has internal and external consequences.

SOLUTION: Project respect!

Diversity Committee

ISSUE: Majority of nurses representative of white-anglo background—others entering differing professions

SOLUTION: Provide incentives for nurses to become bi-lingual with bi-cultural sensitivity.

Psychiatric/Mental Health Role Group

ISSUES: Poor salaries, Lack of control/autonomy; Nurses not encouraging young people to go into nursing; Low status

SOLUTION: Stipends & financial support to encourage entry into nursing

• The results were tallied.
• In a May 2000 meeting, each Task Force member identified the top five (5) "categories" or concerns drawing from the tally sheets of the brainstorming sessions. The group then identified the top five categories from this subset of items. These were:
  1. Support the creation of safe, respectful workplaces in which registered nurses practice.
  2. Enhance the image of nurses and nursing.
  3. Encourage educational reform to assure the continuing preparation of registered nurses for practice.
  4. Support the legislative initiatives of the MNA Blue Ribbon Commission and those of the task force that address nurse shortage.
  5. Engage in collaborations with nursing organizations, government agents/agencies and employers to respond to the nurse shortage.
  6. NB: The numbering does NOT imply ranking. Summaries of individual brainstorming sessions are available upon request. To request a copy, call the MNA at 781.821.4625.
• The Task Force then evolved a proposed agenda of initiates to address each category of concern.
• The proposed agenda was developed through exchange of working drafts in preparation for submission to the MNA Board of Directors and Cabinet for Labor Relations, as well as the Steering Committee for the Statewide Campaign for Safe Care.

WORKING ASSUMPTIONS ABOUT THE NURSE SHORTAGE

The following represents a distillation of the working assumptions members of the Task Force shared with regard to the nature of the nurse shortage and a brief discussion of each.

Pivotal assumptions include:

• An insufficient nurse workforce represents a significant public health crisis.
• Issues and solutions related to nurse shortage can be clustered into two (2) categories:
  1. Those concerned with "competence drain".
  2. Those concerned with "critical shortage".

The first category, "competence drain," refers to those issues and solutions that are an outgrowth of the belief that nursing practice is experience-based. Competence requires practice- specific experience. [Benner, P. (1984), Benner, P. & Tanner, C. (1987)] It is not possible to expect competent/expert-level practice from a nurse in a setting different from that with which she/he is experienced. Neither can one expect competence/expert-level practice in settings over which the nurse has no or limited control.

Currently, this cluster of issues/solutions represents those that we see predominantly. One reads about the supply not meeting the demand in terms of preparation or desired level of skill rather than as a lack in actual numbers of nurses. It is the Task Force's belief that this cluster of issues/solutions is a consequence of the radical re-structuring of health care/nursing delivery systems and the subsequent "speed-up" that impacts nurses in their practice environments. Characteristics of this "corporatized" mentality that is centered on controlling costs include: Rapid discharge, the creation of a "just-in-time workforce," increasing "productivity" demands with a more acutely ill patient population. As more experienced nurses leave positions in these work settings due to job loss, career transition, injury, burn-out, early retirement, or reduction in hours, there are few supports remaining to assist other nurses in re-tooling to fill them. Transition programs, preceptorships, etc. designed to support nurses to gain competence in areas of practice new to them are very rare. Consequently, the "experienced" nurse becomes a "desirable commodity" in the hiring race and the nurse who is less experienced/setting-competent is recruited and supported only as a distant second choice. [Hay Group (1998)]

Solutions related to this category include initiatives directed toward assurance of safe, respectful workplaces. One essential component of this goal is the institutionalization (including the design, funding, and start-up) of staff development/professional education programs to assist nurses in gaining competence in practice settings of their choice.

The second cluster of issues/solutions, "critical shortage," represents those issues and solutions associated with a decreasing supply of nurses relative to demand. The Task Force believes that this will be the case if we do not aggressively act to recruit nurses. [National Sample Survey of Registered Nurses (1996); AACN (1998, 1999)] The National Sample Survey as summarized by ANA indicates that "nursing, the largest of the health professions, is also the fastest aging occupation of all occupations in the United States. For example, as of 1996, only 10% of nurses were under the age of 30" (ANA, Nursing shortage talking points, 1999). At the same time there appears to be a decreasing supply of nurses (Buerhaus, P. Nursing outlook. April/May 1998).

Nursing schools report lagging admissions to schools of nursing (AACN Survey, 1998). The Massachusetts Board of Registration in Nursing reported a drop of approximately 38% in admission rates in the schools of nursing across the Commonwealth between 1994 and 1998.

At the same time demand appears to be escalating. Identified factors contributing to the greater demand for nursing care include: The significant aging of the U.S. population, extended life expectancy, the accompanying rise of chronic illness, the emerging "minority majority" in the U.S. as a consequence of minority populations becoming the majority of Americans, and the touted greater focus on primary care and health promotion.

Solutions related to this cluster involve recruitment-related initiatives. Educational re-design and continuing collaborative efforts among nursing organizations, government agencies and employers are essential to ensuring that the authority for control of workplaces is SHARED by nurses and other healthcare professionals.

PROPOSED AGENDA INITIATIVES

Based on the feedback for the extensive brainstorming effort summarized above and discussions about assumptions related to the nature of the nurse shortage, the MNA Task Force on Nurse Shortage proposes the following agenda of proactive initiatives. This document designed to guide this Association's address of the nurse shortage rests on the central understanding that the MNA must continue to organize nurses for collective bargaining to give them a protected voice in decisions concerning their practice.

1. Create safe, respectful workplaces in which registered nurses practice.

• Define common elements of safe, respectful workplaces for registered nurses. Consider issues related to diversity, strategies to address violence, and roles for continuing care/aging nurses among other concerns/factors.
• Design initiatives to create safe, respectful workplaces.
  • Promote institutional standardization of supportive programs and practices designed to enable nurses to provide safe and satisfying care. (e.g., Develop standards for role functions & contract language related to safe staffing levels).
  • Advocate for educational support initiatives in the workplace (e.g., Identify models for mentoring, preceptor and orientation programs; Secure funding for a model project(s); Develop model contract language to assure Staff Education support on individual units as well as throughout the institution.)
  • Design model, role-specific, competency-based, clinical development programs (including for nurses in management level/supervisory roles).
  • Develop model compensation plans (money and scheduling privileges) to include consideration of salary ranges that are respectful of increased experience, advancing educational achievement, leadership activities, mechanisms to permit portability of benefits, early retirement options).
  • Create a bargaining unit position for a nurse who would be responsible for identifying risks in the work environment of nurses and effectively institute corrective measures to eliminate those risks.

2. Enhance the image of nurses and nursing.

• Develop strategies/activities that support nurses' pride in nursing. The intent of this strategy is to support nurses in representing nursing positively to others.
• Design and implement several local models for outreach to elementary, middle and high school students building upon the work of the National Student Nurses Association, Inc. (NSNA), the American Association of Colleges of Nursing (AACN), the American Nurses Association, Sigma Theta Tau and other national nursing groups. Many of these national organizations have developed materials for effective outreach campaigns to strengthen the recruitment of nurses and students interested in preparing for entry to practice.
• Educate membership to the importance of identifying ones self as a registered nurse when one writes a letter to the paper, a column for a publication, speaks to an issue at Town Meeting etc. Invite articles for the MassNurse, Advocate and provide training sessions similar to David Schildmeier's media training workshops as two ways to educate nurses about this way to enhance the image of nursing. Inventory and evaluate articulation with/between programs designed to support competence in public outreach currently in place in the Commonwealth.
• Establish a Resource File of members who could speak to issues in the media.
• Develop an ad campaign with the national/local ad council showcasing nurses in a variety of roles and settings.
• Promote the idea of instituting a role for a "nurse reporter" (like Dr. Timothy Johnson, various consumer specialist or science experts) who would report routinely on local television channels. (A member of the ReTIREd Nurses Networking Group produces a show each month featuring community health issues for her local cable station.)
• Promote the use of nursing research findings in the media.
• Seek additional consultation regarding image strengthening if required.
• Create a dotcom company: "Got questions? Need answers? Ask a nurse.com." Advertise with a billboard.

3. Encourage educational reform to assure the continuing preparation of registered nurses for practice.

• Authorize a Task Force to:
  1. Identify important aspects of nursing education such as:
     • Clinical experiences that occur early in the curriculum.
     • Leadership development.
     • The balanced role of in-patient and community practice.
     • Internships prior to graduation and/or post-graduation internships that are a collaborative effort between educational institutions and practice settings.
  2. Communicate the Association's ideas concerning these elements to local/national organizations/associations promoting curriculum re-design.
• Seek increased financial support (federal, state and institutional) for nursing education—both formal and continuing education.
• Recognize the connection between a positive role image and the ability to maintain high standards for admission to schools of nursing. (Assumption: We must attract the best and brightest.) Educate Guidance Counselors to the reality of nursing practice—e.g., Host a "Shadow Day." Organize "Return to Meet With Your Guidance Counselor" sessions by recently licensed nurses.
• Continue to support the work of national and local associations in their work to recruit/retain faculty.
• Continue to support articulation efforts between a variety of educational programs—AD/BSN/MSN).

4. Support legislative/ regulatory actions.

• Work toward the adoption of a Safe Staffing Bill that would provide a legal framework/guidelines for safe staffing in particular clinical areas. These guidelines should reflect consideration of varying nurse competence as an important variable in the equation to determine safe nurse to patient levels (e.g. entry level nurse vs. experienced nurse).
• Link to and support efforts to increase Federal/State funding for nursing education.
  • Target funds to activity that increases diversity in the nurse workforce.
  • Identify sources of funding awarded to nursing departments within health care facilities. Tie awards to those nursing departments that provide clinical placements for students of nursing.
  • Apply revenue generated from the sale of "RN vanity" plates to the support of nursing education.
  • Institute a loan forgiveness program tied to years of work as a Registered Nurse.
  • Institute no or lowinterest loans for nursing education.
  • Encourage a linkage between advancing education and increases in pay (e.g., the Quinn Bill).
  • Increase funding to programs of nursing housed in community colleges.
  • Increase funding to RN to BSN programs.
  • Decrease paperwork requirements for nurses.
  • As an implicit outcome of Single Payer Health Reform, the Association should continue to support this reform.
  • Influence change in JACHO standards to encourage an increase in the required time dedicated to direct care provided by a registered nurse and decrease time required for documentation.
  • Influence HCFA to require (1) staffing ratios in acute care to qualify for Medicare/Medicaid reimbursement and (2) less nursing time dedicated to documentation related to Medicare/Medicaid reimbursement.
• Propose a minimum level of institutional revenue that will be apportioned to the provision of nursing care and a maximum level that will be applied to executive salaries, administrative costs, profit margins and capital improvements.
• Explore opportunities to collaborate with the Department of Labor in an effort to define the safe duration nurses might work within a 24 hour period.
• Request an assessment by the Department of Industrial Accidents of illnesses/injuries of nurses acquired/occurring in various practice settings. This information is essential to promote guidelines/initiatives designed to reduce preventable occupational hazards.
• Work toward the appointment of a Registered Nurse to the Board of the Department of Industrial Accidents.
• File legislation to establish an RN position on the Public Health Council.
• Testify before the Legislative Nursing Commission concerning issues of concern related to nurse shortage. Propose a legislative agenda to address this issue.
• Propose the allocation of National Institute of Nursing Research funding for research related to staff nurse health and safety.

• Continue support of the Association's Single Payer Agenda.
• Design and implement teaching/learning activities to educate nurses about the significant relationships between health care economics/funding mechanisms and their ability to implement effective nursing care delivery systems.
• Host a Summit with Nursing Organizations, Government Agencies and Employers to frame this nurse shortage as a public health crisis and share the Association's agenda to respond to it.
• Continue to support work of Colleagues in Caring through the Worcester State College Center for Health Professions related to the design and implementation of a sustainable process to collect nurses workforce supply and demand data.