Since the 20th century ushered in the new millennium, a nursing shortage has been looming over America like a storm cloud, warning the country’s health care industry of impending change. 

In the year 2000, senior nurses, about half of the workforce, were on track to retire. New recruits were needed to fill the massive hole they would leave behind. Institutions set up programs, widening the pipeline so more students could become registered nurses faster. 

But the forecasts changed when the Great Recession hit. Those aging nurses clung to their jobs, and the projected gap never materialized.
“Ah, the elusive nursing shortage. That was a huge thing,” recalls Carrie Guerra, a recent Sierra College nursing graduate. “Supposedly, all the nurses were going to be retiring, but then everybody got scared and Social Security was in question. The shortage of nurses that was supposed to be never was.”

But the downturn only delayed the inevitable. Now, with the economy back on track — and the average age of nurses hovering around 50 — cries of a nursing shortage have come back with force: Obamacare is going to overload the health care system! The baby boomers are coming! We need more nurses, stat! By 2020, the country will be short about 193,000 nursing professionals with 1.6 million job openings in the field, according to a recent Georgetown University study. This news is especially distressing for California, one of the worst states for its ratio of registered nurses to population.

If there’s a silver lining, it’s that the recession might have softened the blow. Senior nurses put retirement on hold, but the delay gave the health care and education industries more time to prepare for the turbulence ahead by training novice graduates, advocating for advanced degrees and expanding the roles of nurses to better fit the future. The question now is whether the newbies will be ready in time.

Not Easy Being Green

When the nursing shortage didn’t happen, new registered nurses felt the pain. There they were, fresh out of school and ready to care for those in need, but the jobs they wanted didn’t want them. It was a matter of experience, and compared to senior nurses, new graduates didn’t measure up.

“You can’t staff a hospital with all brand new graduates,” says Robyn Nelson, dean of the College of Nursing for West Coast University in Irvine, Calif.

“Ah, the elusive nursing shortage. That was a huge thing. Supposedly, all the nurses were going to be retiring, but then everybody got scared and Social Security was in question. The shortage of nurses that was supposed to be never was.” Carrie Guerra, Sierra College nursing graduate

It’s not uncommon for recent graduates to wait six months or more to land a job in a local hospital. Many are still unemployed in the field. Others have left for other states or areas with less competition. Guerra, who has been looking for an acute care position for more than a year, acknowledged the catch-22.

“The acute care hospitals want you to have two years of experience,” she says. “But you can’t go anywhere to get experience because no one will hire you without experience.”

Guerra did land a job in an emergency room in Oroville. It was two hours away from her home, so she was driving four hours every day to work a 12-hour shift. But it turned out the hospital hired too many people, and she was let go. Guerra says a few graduates in her class left California for nursing jobs in Tennessee, Oklahoma and North Dakota. She’d be willing to move, too, if there was a position available. Currently, she works the graveyard shift at a local psychiatric hospital.

Unfortunately, Nelson says, adaptability is not typical for this generation. She says many graduates want to avoid rural settings and work in big urban hospitals near their home and friends.

“If they were willing to move, they could probably get a job sooner and come back when they’re not a new graduate,” Nelson says. “They don’t want to move to Central California or go to Idaho or the plains of Texas. They don’t want to work weekends or nights. Unless they’re more flexible, it will take them longer to find a job.”

Related: The New Age of Nursing 

On the education side, a key strategy to fix the skills gap is connecting students to industry resources sooner. New programs have emerged in recent years to train potential nurses through simulations and externships at the region’s major health care organizations. For example, the Los Rios Community College District partnered with Sutter Health to develop an accelerated nursing program. Sutter put down $17 million to launch the program, which allows nursing students at Sacramento City College and American River College to get hands-on experience at the Sutter Center for Health Professions.

“They’re not expensive programs compared to going to a for-profit school and spending $50,000,” says Jamey Nye, associate vice chancellor of instruction at Los Rios Community College District. “But the extended campus allows us to offer additional degrees.”

For one year, students in the program earn income and receive training across two departments. When they finish, they can slide into a regular, fully benefited position as a new hire, says Anette Smith-Dohring, Sutter’s director of workforce development.

Heather Young, the founding dean of UC Davis’ Betty Irene Moore School of Nursing, established in 2009, supports this model of pre-graduate training. “If students can be embedded when they’re in school, there’s less of a learning curve. They’ll have a leg up when they get out there.”

Degrees of Separation 

Education plays as vital a role as experience. To become a registered nurse, a student can choose one of three different pathways: bachelor’s of science in nursing (BSN), associate’s degree in nursing (ADN) or a diploma in nursing. In 2011, the Institute of Medicine recommended that 80 percent of the nursing workforce have a bachelor’s degree by 2020. 
The IOM report noted that, “Although a BSN education is not a panacea for all that is expected of nurses in the future, it does, relative to other educational pathways, introduce students to a wider range of competencies in such arenas as health policy and health care financing, community and public health, leadership, quality improvement and systems thinking.”

This recommendation has set off a chain reaction: More hospitals started taking degrees into account when hiring new nurses, and colleges have responded by collaborating with universities to help students earn bachelor’s degrees. Sierra College and Sacramento State, for example, merged their nursing programs into one academic track. By taking additional classes at Sacramento State, nursing students at Sierra College can graduate with an associate’s degree and receive a bachelor’s degree six months later from Sac State.

“Some hospitals are only hiring bachelor’s-prepared nurses,” says Nancy Schwab, associate dean of Nursing and Allied Health at Sierra College. “That’s why we answered that recommendation with this call. You will go further in your career with a bachelor’s degree. Actually, we say in nursing that a master’s is what you should be shooting for.”
In 2010, UC Davis launched its post-graduate nursing program, which now hosts 150 students. Next summer, the school will initiate a master’s program in nursing for registered nurses and people who have a bachelor’s degree in any other field. This move supports the call by IOM for more graduate students to assume roles in advanced practice, leadership, teaching and research. It also speaks to the evolution of the nursing field at large.’

Thinking Outside the ER

There’s a saying in the nursing field that goes something like: “Unless you do acute care in a hospital, you’re not a real nurse.” According to Young, this lore is not only outdated, but also untrue. Five years ago, more than 80 percent of new nurses went to work at hospitals. Now, that number is below 60 percent, she says. As the health care arena shifts toward more community-based care and nontraditional settings, nurses have become more critical than ever in taking on emerging roles.

To help usher health care organizations away from a model of “providing care” to one of “managing health,” the California Institute for Nursing and Health Care identified five new nursing roles that would help meet the demand of the state’s health care services: care coordinator, faculty team leader, informatics specialist, nurse/family cooperative facilitator and primary care partner.

Rayne Soriano, a nurse and doctoral student at UC Davis, specializes in informatics. He led a team that introduced a hospital-wide electronic health records system at Kaiser Permanente. The system allows health professionals to keep track of patient data and observe trends to improve quality of care. Soriano admits most new graduates are still focused on the past century’s images of nursing, and that, at this point, informatics isn’t yet “the cool thing.”

Instead, students will say, “‘I want to work in a trauma center, put in lines and tubes and do what they do on TV,’” Soriano says. The irony is that this generation of graduates is well suited for technology-based niches. Specializing in tech-based care and services can give new graduates an advantage over senior nurses who aren’t as interested or proficient.
“Technology has evened the playing field,” Soriano says. “Before, you had to be an experienced person to come into the field, but with the infusion of technology and informatics, now there are younger and newer nurses with more leverage because they’re so skilled.”

These new positions might not be what students have in mind when they think about nursing, but the need to evolve is urgent, according to the CINHC report: “As the largest provider group in California, nurses represent one of the greatest opportunities to rapidly expand capacity within the health care delivery system. However, to be fully effective in this context, nurses will need to assume new roles.”