Nursing, which has experienced staffing difficulties over the last decade, has seen higher rates of turnover and staffing shortages during the past year. The Missouri Hospital Association’s 2021 workforce report shows that the statewide turnover rate for health care professions was 21.5% in 2020, an all-time high for the state.
Staffing shortages and high turnover rates have afflicted nursing for many years, but the COVID-19 pandemic exacerbated the issue.
“There was really fierce competition out there, not only for nurses but for respiratory therapists and other occupations,” said Jill Williams, vice president of workforce initiatives at the Missouri Hospital Association and author of the report. “COVID-19 kind of created a national bidding war. Many of our nurses were leaving hospitals to work for travel (nurse) agencies that were offering sky-high wages.”
According to the Missouri Hospital Association’s COVID-19 workforce report, there were about 36,000 job postings at the end of 2020 seeking registered nurses (RNs), an increase of almost 1,000 openings, or nearly 3%, since 2019.
However, some hospitals in areas with a higher population saw lower vacancy rates than hospitals in rural areas. University of Missouri Health Care in Columbia reported a 9.8% vacancy rate for RNs. Meanwhile, Bothwell Regional Hospital in Sedalia reported a 17.4% vacancy rate for nursing positions, of which most were for RNs.
Bothwell also reported a 20% turnover rate in 2020 and a 25% turnover rate so far in 2021, which is higher than average for the hospital according to Lisa Irwin, Bothwell’s human resources director.
‘A snake eating its own tail’
The Missouri State Board of Nursing’s 2020 workforce report shows that a majority of nurses are employed in metropolitan areas, including 68.1% of Licensed Practical Nurses (LPNs) and 86.2% of RNs.
LPNs typically complete their training in roughly two years and work in hands-on positions with patients. RNs take up to four years to finish their training and, while they also do hands-on work, they also take on more administrative roles.
The concentration of nurses in the state’s metro areas means that there is a much lower ratio of nurses to patients needing care in rural areas. In Missouri’s rural counties, there are 77 nurses per 10,000 residents, compared to 118 in micropolitan counties and 156 in metropolitan counties.
This increased level of responsibility can lead many nurses feeling overwhelmed and can contribute to burnout in the field. Short staffing also leads to nurses being asked to take on additional shifts, sometimes outside of their normal working hours.
“If you’ve got a burnt-out nurse who is unable or doesn’t feel like they want to be in the nursing profession anymore, they leave, which then contributes to the shortage of nurses,” said Heidi Lucas, director of the Missouri Nurses Association. “It’s almost like a snake eating its own tail.”
The State Board of Nursing evaluated where students are placed following receipt of their nursing license, revealing that LPNs are more likely than RNs to work in rural or micropolitan areas. Most LPNs accept employment outside of the hospital setting in nursing homes and assisted living facilities, most of which were located in smaller communities.
Many hospitals are facing an additional issue as a large portion of their nursing staff nears retirement age. About 21% of the statewide workforce is between the ages of 55 and 64. In the rural counties of Dekalb, Reynolds and Worth, more than half of the nursing workforce is over 54.
The Bureau of Labor Statistics estimates that the nursing field will grow faster than most occupations within the next several years, with 9% growth for LPNs and 7% growth for RNs, compared to a 4% average increase for all occupations.
As the field continues to grow, so will demand. As aging nurses retire, baby boomers will grow older and begin to need additional care. The combination of these two factors could further stress an already strained health care system.
“There’s a whole big group of nurses who will be retiring soon, and we don’t have enough folks to fill that need,” Lucas said. “Within the next 10 years, we are expecting to lose nurses in the profession, even as more come in. We’re potentially facing a massive crisis in the future.”
A shortage of instructors
While staffing shortages continue to grow, nursing schools educate future nurses, though not at a rate that can fill all of the empty positions. There are a myriad of factors that contribute to this, though the chief concern is a lack of qualified nursing instructors.
According to the same workforce planning report, nursing schools in the state in 2019 were seeking at least 50 full-time faculty members and 17 adjunct or part-time employees. Due to these staffing shortages, seats in nursing programs are also limited, which means that many qualified applicants are turned away. If nursing schools were able to accept all of the qualified candidates who applied in 2019, it would have taken an additional 118 full-time faculty members to instruct them.
“When we take students into the hospital to learn nursing, the ratio is either 10 students to one faculty member or eight students to one faculty member,” said Robin Harris, associate dean for academic affairs and professor at the University of Missouri nursing school. “So while we could be in a lecture hall with 100 students, I can’t put them all in one clinical unit.”
The MU nursing school offers a bachelor’s of science in nursing degree that is designed to prepare students to take the National Council Licensure Examination and receive an RN license, as well as a master’s and doctoral programs in nursing.
According to the MHA’s workforce planning report, there were almost 2,500 people who graduated from one of Missouri’s American Association of Colleges of Nursing member schools with a bachelor of science in nursing degree in 2019. This degree qualifies the graduate to take the National Council Licensure Examination exam to receive a state RN license.
Most LPNs are trained at community colleges, which also face difficulty recruiting instructors. While LPNs account for about one in six nurses in the state, the turnover rate is much higher for LPNs than for other nurses. They have the highest vacancy rate of all health professions in the state at 17%.
Fewer people are choosing to become LPNs, opting instead to continue their education and become RNs.
“Many students know they eventually want to be an RN, but aren’t ready for that long of a commitment when they begin their education,” said Michelle Crum, director of the Practical Nursing Program at Ozarks Technical Community College in Springfield. “Becoming an LPN first gives them the flexibility to work as a nurse, at a higher salary, after approximately one semester of pre-reqs followed by an 11-month program.”
The pandemic also had an impact on the way that nursing programs were conducted. Many schools were forced to find creative workarounds for hands-on clinical training, while many others had to reduce class sizes.”
“Obtaining clinical placements during the pandemic was very difficult and is still not fully restored to pre-pandemic levels,” Crum said. “As a result, we reduced enrollment slightly to make sure we had adequate clinical placements to ensure that all clinical objectives could be met.”
Other programs have experienced issues filling all of their seats during the pandemic. At State Fair Community College in Sedalia, some nursing students were forced to withdraw for a variety of reasons relating to the pandemic.
In an effort to combat the shortage of nursing instructors, the Missouri Hospital Association has launched the Clinical Faculty Academy, which trains registered nurses to serve as adjunct faculty in nursing schools across the state.
While this could increase the amount of nursing faculty, it could also reduce the number of nurses available to fill current staffing shortages.
“While there’s a nursing shortage, there’s also a faculty shortage,” Harris said. “So it’s competing with your own discipline to try to help it grow.”