Learning why students and faculty drop out is key to progress.
Mississippi was one of many states experiencing a nursing shortage in 2000, and it was getting worse. Hospitals in the state reported an RN vacancy rate that year of 5.6%, which soared to 9.5% the following year, and remained about the same for the next two years.1 But efforts to educate more nurses have started to reverse the trend. In 2006, the RN vacancy rate in Mississippi hospitals was 9.6%; the next year it was 8.7%, and in 2008, the last year for which data are available, it was 6.3%.
Many activities contributed to the recent growth in Mississippi's nursing workforce. The Mississippi Office of Nursing Workforce, a group with many collaborative partners (including the Mississippi Nurses Association, Mississippi Hospital Association, Mississippi Board of Nursing, Mississippi State Department of Health, and the Mississippi Council of Deans and Directors of Schools of Nursing), conducted a series of surveys to determine why students failed to complete nursing school. Then steps were taken to address these barriers. Focusing attention on faculty development and retention helped the state build nursing education capacity. A history of strong collaborative relationships between education and practice has fostered the introduction of programs to prepare nurses to meet the challenges of working in today's health care institutions. Nursing leaders in Mississippi have looked beyond their borders and are learning from colleagues in other states, especially through their participation in the national collaborative effort cosponsored by the Center to Champion Nursing in America (CCNA) that's described in this series.
As a result of these combined efforts, Mississippi has doubled the number of nursing graduates since 2001. Graduation rates from the state's 16 associate's degree and seven bachelor's degree programs have been increasing steadily in recent years (Figure 1). With the hiring and retention of more faculty, fewer students are being turned away from nursing education programs.1
BARRIERS STUDIES
In 2002 and 2004, the Mississippi Office of Nursing Workforce conducted surveys to identify barriers to completing nursing education.2,3 All 21 nursing programs in the state participated in each survey, which used separate instruments to assess students and faculty.
In the initial survey, students indicated that the most important barriers to successful completion of their nursing education were "lack of financial support" and "family issues," inability to balance family and school, and inability to work and go to school simultaneously.2 Other data from the survey lent support to these concerns. Half of the nursing students were parents, and of these, 30% had two or more children. Most students said their school required nursing students to be enrolled full-time, yet 57% of students were also working, of which 67% logged more than 20 hours per week on the job. In addition, 66% "received some type of grant or scholarship."
In the fall of 2003, a barriers task force was established to develop strategies to address the problems identified in this survey. The task force comprised diverse stakeholders, including deans of nursing schools; hospital executives; and leaders from statewide nursing, health, and education organizations. One result of their work was the development of a Web site nursing students can access for help with issues that may prevent their continuing their education. The Mississippi Student Nursing Navigator (http://studentnavigator.org) directs students to information on financial, tax, utilities, fuel, and transportation assistance; health insurance; legal services; child care; stress management; and academic preparation. The task force also recommended ensuring a high level of participation by eligible students in Workforce Investment Act initiatives. The number of students receiving such funding rose from 87 in the 2002 survey2 to 106 in the 2004 survey.3
Addressing what nursing students identified several years ago as major barriers to completing their education is paying off. In surveys of Mississippi nursing programs for the 2006-2007, 2007-2008, and 2008-2009 academic years, academic challenges had replaced family responsibilities and financial problems as the top reason for attrition.1, 4, 5
FACULTY
In both the 2002 and 2004 surveys, about half the faculty respondents indicated that their school was experiencing a shortage of nursing faculty.2, 3 When asked to identify barriers that prevented their school from filling faculty positions, educators named "salaries not competitive" as the most important one.
In addition to difficulty recruiting faculty, retirement and resignation also contributed to faculty shortages in nursing schools. At the time of the initial barriers survey, 45% of faculty members were 40 to 49 years of age, and 40% were 50 years of age or older.2 Six to 10 nurse educators retired in each academic year from 2004-2005 through 2008-2009.1, 4-7 And retirements are expected to rise substantially in the next few years.1, 5, 7 In addition, 28 nurse educators resigned in the 2004-2005 academic year and 25 more resigned in 2005-2006.4, 6
To stem the tide of resignations, a group of stakeholders-the Mississippi Board of Nursing, Mississippi Nurses Association, Mississippi Office of Nursing Workforce, Mississippi Council of Deans and Directors of Schools of Nursing, and the Mississippi Hospital Association-worked to get the legislature to approve raises for nurse educators in state nursing schools (only two of the colleges and universities with nursing programs are private). In 2006 the legislature voted for a significant increase in faculty salaries, and the move was repeated the following year. As a result of the total annual increase in faculty pay over the two years, teachers are remaining longer. For the 2006-2007 academic year, 418 full-time and 86 part-time nurse educators worked in the state.7 The next year, 456 full-time and 102 part-time nurse educators were employed. The number of budgeted but unfilled faculty positions fell from 49 in 2006 to 15 in 2008 (Figure 2). Only 16 nurse educators resigned in the 2007-2008 academic year.1 For the first time in a number of years, career advancement and not salary was the most common reason for nurse educator resignation.1
CHANGING HOW STUDENTS LEARN
Mississippi is one of the 18 lead states in the nationwide collaborative effort cosponsored by CCNA to address nursing education capacity. After attending a summit of teams from these 18 states in June 2008, the Mississippi team decided to explore the use of simulation and dedicated education units. Both of these approaches to nursing education can increase student capacity and improve clinical competency. Through these and other innovations, Mississippi is changing how nursing students learn and is addressing an ongoing problem identified in annual surveys-the limited number of sites for clinical placement. These strategies also strengthen the bond between education and practice.
Simulation. In 2008, the nursing community and strategic partners persuaded the Mississippi legislature to appropriate $75,000 for a statewide feasibility study on the use of simulation in nursing education.8 In the spirit of sharing strategies among states, which is the hallmark of the CCNA collaborative effort, representatives from Mississippi visited simulation laboratories in Denver, Colorado, and Portland, Oregon. The feasibility study also included surveys conducted in Mississippi nursing schools. The data collected convinced the legislature to award $500,000 in 2009 for the creation of a statewide simulation collaborative. Much of the funding is being spent on faculty development, using a "train-the-trainer" model. Some funds are enabling the development of simulation scenarios and Web-based resources.
Clinical placement. To improve opportunities for clinical placement, Mississippi turned to Oregon for guidance. The Oregon Center for Nursing developed StudentMAX, a Web-based, centralized clinical placement program that matches nursing students to available clinical sites.9 Mississippi tested this program in two areas (Jackson and Vicksburg) and found that it resulted in substantial increases in student placement opportunities between 2005 and 2008. Now StudentMAX is available throughout Mississippi.
Dedicated education units. In 2008, nurses from Mississippi visited a dedicated education unit in Portland and listened to an audio seminar created by the unit's experts. Then the Mississippi Office of Nursing Workforce collaborated with Hinds Community College (the largest community college in the state, with several campuses) to receive a Partners Investing in Nursing's Future grant through the Hinds Community College Development Foundation. This grant money became available last fall to establish dedicated education units focused on the aging population. The funding supports five partnerships between schools of nursing and hospitals throughout the state.
The dedicated education units began functioning this spring. In these units, selected nursing staff work one-to-one with senior nursing students. Faculty members serve as a resource for the staff nurses. The initial dedicated education units are in hospital areas with large geriatric populations because these areas have the most difficulty recruiting staff. If the program is successful in hospitals, it will be expanded to long-term care facilities.
Education redesign. To create a nursing workforce better able to deliver the complex care required today and in the future, Mississippi hopes to develop a program that encourages higher levels of nursing education. Leaders in the state are studying the model of the Oregon Consortium for Nursing Education.9 Last fall, a team from Mississippi attended a program arranged by CCNA in Oregon and participated in a related Webinar.
The goal is to unite community colleges and universities so that students in associate's degree programs can more easily continue their education for a bachelor's degree. Hinds Community College and the University of Mississippi Medical Center are already collaborating to facilitate advanced education; this program takes students from an associate's degree to a master's degree.
Residencies. In a field such as nursing, education doesn't end upon graduation; nurses continue to learn on the job. Some realities of nursing practice can't be taught in the classroom.
A program funded by a grant from the Health Resources and Services Administration is helping to ease the transition from education to practice. This six-month hospital residency for new graduates from associate's degree or bachelor's degree programs has greatly increased retention of hospital nurses in the first year of practice. A residency for newly licensed practical nurses is also being developed for long-term care facilities.
Challenges
Although more qualified students are being admitted to both associate's degree and bachelor's degree programs in Mississippi, the state still has work to do. In the 2007-2008 academic year, 1,729 qualified students were turned away from associate's degree programs, and 173 were denied admission to bachelor's degree programs.1 Reasons these applicants were denied enrollment included
* a lack of classroom and laboratory space.
* limited sites for clinical experiences.
* insufficient funds to hire faculty.
* the inability to fill faculty vacancies.
Despite efforts to address these problems, more must be done.
Mississippi's annual nursing survey asks about faculty members' plans to retire during the next three academic years. The number of anticipated retirements has been decreasing. For example, the anticipated numbers of retirements in the 2008-2009 school year were 37 faculty on the 2006 survey, 32 on the 2007 survey, and 22 on the 2008 survey.1, 4, 7 Some delayed retirements are doubtless attributable to the increased faculty pay. Others presumably are related to the economic downturn. When the economy improves, some nurse educators who put their retirement plans on hold will probably choose to leave. New nurses must be ready to step in to teach the next generation.
The history of cooperation among nurse educators, employers, professional associations, funders, and others who have successfully addressed Mississippi's nursing workforce problems bodes well for meeting the challenges of the future. As the state continues to collect data that support improved retention of nursing students and faculty, the nursing shortage should decline further, and stakeholders should be emboldened to move on to new challenges such as education redesign.
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