Demand for nurses in Montana remains high

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BILLINGS, Mont. (AP) — Rising patient numbers combined with a booming need for more care has created growing demand for more nurses in Montana that's putting extra strain on health care facilities across the state as they race to fill the need.

"I know that our members are having huge issues with staffing their nursing staff," said Casey Blumenthal, vice president of the Montana Hospital Association. "There's not a continual pool of people (to fill the jobs), especially in the small towns."

But, at least in Montana, some help may be on the way in the form of new programs designed to seek out, educate, train and retain qualified health care workers.

It's not that there are fewer nurses than before in Montana. There are actually far more licensed today than just seven years ago.

According to the Montana Board of Nursing, a division of the state Department of Labor and Industry, the number of licensed nurses has increased by more than 1,500 since 2008, from 18,263 to 19,897 as of mid-August.

But with more patients seeking health care due to an aging population and more people using insurance through the federal Affordable Care Act, a steady bump in retirements as baby boomers leave the workforce and not enough students graduating nursing programs, among other things, it's been tough for many facilities to meet the need for more nurses.

"We're entering into an incredibly challenging time," said Lu Byrd, vice president and chief nursing officer at Billings Clinic. "... I wouldn't call it one just yet, but we are at a point where we're approaching a perfect storm. It's all those factors coming together."

A DLI study published in 2013 projects Montana's health care industry to grow by about 1,300 jobs each year until 2022, with registered nursing expected to see 349 openings annually.

Montana's growing demand is in line with national trends. Last year, the U.S. Bureau of Labor Statistics projected there will be more than a million openings for RNs and advanced practice registered nurses in the coming years, with about 555,000 due to retirements and 575,000 in the form of new jobs. It also predicts a 19 percent job-growth rate from 2012 to 2022.

As Baby Boomers age and the number of people over the age of 65 grows dramatically, as many as 3 million new patients are expected to sign up for Medicare each year nationwide. The need for people to care for them will grow as well, according to the American Nurses Association.

In addition to those patients, more than 11 million people have signed up for health insurance under the federal Affordable Care Act, including 54,266 Montanans for 2015, bringing many people in seeking health care who might not have in the past without insurance coverage.

Compounding the problem is an aging workforce — the average age of a registered nurse in the U.S. is 47 years old, according to the American Association of Colleges of Nursing — and the expected retirement of hundreds of thousands of nurses, including baby boomers, who'd put it off or returned to work during the recession that struck in the late 2000s.

At the same time, educational institutions aren't producing enough new nurses to fill those spots, largely because they don't have the capacity, resources or faculty to educate as many nurses as are needed.

"We've seen a big demand for more nurses, especially in critical access facilities like ours," Kristi Gatrell, CEO of Big Horn County Memorial Hospital in Hardin, told The Billings Gazette ( "I think that programs aren't turning out enough nurses and there's a lack of professors qualified to teach them."

In Montana, schools within the Montana University System graduated 230 registered nurses for the 2013-2014 academic year, while they produced 155 practical nursing and 260 bachelors of science in nursing graduates, according to MUS statistics.

Since the 2009-2010 school year, they've produced 1,080 BSN, 684 PN and 983 RN graduates.

A report from the American Association of Colleges of Nursing detailing the nursing shortage said that for the 2012-13 academic year, American schools turned away nearly 80,000 qualified applicants to nursing programs due to limitations on classroom space, finances, faculty and clinical resources.

Those schools are expected to produce about 140,000 graduates annually through 2022, which isn't enough to fill the 1.1 million openings expected to come up in that time.

John Cech, MUS Deputy Commissioner for Academic and Student Affairs, said that Montana hasn't been immune to turning qualified students away from nursing programs due to a lack of space or resources.

"We've seen students waiting for seats," he said. "In both the two-year colleges and the four-year level, we continuously have more students applying than we have space for."

One of the key players in filling all of those roles and helping to meet demand is Montana's ability to produce well-trained and qualified nurses, a task that falls on the state's higher learning institutions.

In 2014, the state secured a $15 million grant from the federal government, targeted at addressing the growing demand for health care workers.

With Missoula College at the University of Montana acting as the lead, the four-year grant goes to help 15 two-year, community and tribal colleges work "to really get their arms around focusing on health care training opportunities around the state," Cech said.

"We're looking at ways to do a better job of creating access to these opportunities across the state and positioning our partners to really help us," he said. "Part of that is helping us to reach out into the rural areas and also reaching out to the adult learner."

The MUS has partnered with more than 40 health care organizations around the state in the project.

The grant helps colleges redesign curricula in order to speed up access to the field, from certified nursing assistants to registered nurses who've earned bachelor's degrees, and focus on transferability.

Another program in the works, which hasn't yet been approved by the MUS Board or Regents or the state nursing board but will be discussed soon, allows students who've earned a two-year associate's degree in registered nursing, which takes five semesters, to earn a bachelor's in another three semesters.

"This will create a tremendous opportunity for these associate RN grads to continue on and complete their BSN in three semesters, and many may choose to work while they're doing this," Cech said.

Hospital officials are all for training and educating more nurses, but that can only fill so much of the need. In that vein, keeping the already employed nurses on staff and fulfilled is just as important.

"The key success factor, I believe, going forward is looking at and understanding how you can retain your senior staff," Byrd said.

She went on to say that retention could involve finding ways to keep nurses at the patient's bedside more, getting creative with and evaluating alternative shifts and supporting growth and advancement among nurses.

They're also important in passing on their knowledge to new hires.

"The success there will be, 'I am able to work, but not work 12-hour days,'" Byrd said. "We need them for quality and care of patients and to teach our new staff."

Bridging the gap with that new staff and ensuring they're set up for success is also a key retention tactic that can help keep nurses at a facility.

At St. Vincent, all nurses hired out of school go through a 13-month transition program in an effort to set them up for success in their careers and ensure they remain in the industry.

"Our future, as far as employment goes, is those new graduates coming out of nursing schools," said BJ Gilmore, chief nursing officer and vice president of patient care services at St. Vincent Healthcare. "We have to ask, 'What are the ongoing resources that are here to make people solid in their careers during their first two years here?'"

Byrd agreed, saying that bridging the gap between working after graduating from nursing school and helping staff on board already is vital to retention.

"We want to support people coming into the health care industry and encourage their professional goals," she said. "There has to be a professional practice model where the voice of the nurse is heard."

Big Horn County Memorial Hospital, a 25-bed critical access hospital that sees as many as 400 emergency room visits each month and employs 204 people, touts its modern technology, signing bonuses and benefits packages to prospective nurses and as a way to keep those it does hire.

"We stay very up-to-date with good equipment and technology," said Gatrell. "That's a real struggle for hospitals and we've been very fortunate here."

Gatrell said she'd also like to see looser restrictions on Health Resources and Services Administration grants that offer loan forgiveness for working in underserved areas, which could apply to places like her hospital, which currently doesn't qualify for the money.

Continued educational opportunities for nurses and reaching out into the community to find people who might be interested in nursing careers also play into efforts to keep employed nurses at, and recruiting them to, health care facilities.

Billings Clinic has recently set up an educational fund to help cover tuition costs for its nurses who decide to go back to college and hopes to establish a residency-type program for nurses.

At St. Vincent, the hospital is working to build pipelines to bring people into the profession, including through a CNA program in collaboration with the Adult Education Center and a nurse extender program that brings in students over the summer to work with its nurses.

"We're trying to provide opportunities to build a pipeline of people coming in," Gilmore said.

Statewide efforts by hospitals and educational groups to dip into Montana's high schools in order to spur early interest in potential students are also under way.

Hospital administrators across Montana have been aware of the complex issue for years, and while there's no easy answer, they have been exploring and implementing solutions, along with state officials.

Finding those solutions is important because they're already feeling the strain of the growing need.

For starters, higher patient loads and fewer nurses to deal with them can lead to a worn-down staff. Blumenthal ticked off a list of the ways it affects them, including higher stress levels.

"Nurses work a lot of overtime," she said. "The people who are perhaps the directors of nursing in the small facilities may not have a lot of time to do their managerial work because they're filling in on the floor. Nurses get burned out and they need more vacation or sick time. It's not good and it's not something we can sustain."

Billings' two major hospitals — St. Vincent Healthcare and Billings Clinic — have between 40 and 50 open nursing positions on any given day.

At St. Vincent, that's about a 25 percent increase over years past, while Billings Clinic officials said that they've stayed within an eight to 11 percent vacancy rate.

Gilmore said the demand can challenge organizations to re-evaluate and sometimes restructure how nursing duties are assigned, including through shift hours.

"Are there ways to be more effective," she said. "Sometimes we're looking at the care model, how to streamline work to meet needs and demands of patients."

The demand can also force a shuffling of shifts and duties to cover areas that need extra attention and nurses.

However, it's tough to tell exactly what the demand for nurses is statewide because there's not a mandatory data collection method to determine how many of the state's licensed nurses are actually employed and where they work.

Blumenthal said that a voluntary survey has been issued in the past, but results have been inconsistent, with about 30 percent responding one year followed by 10 percent the next.

"You don't have to complete it to get your license renewed," she said. "We're not even sure where the nurses are. There might be a ton of nurses that are not working. We need a statutory fix to allow the board of nursing to collect that information. That's the best way to get it. We just want to know where you work and how much you work."

The efforts won't fill the rising demand right away, but health care and education officials across the state hope that a rounded approach combined with more educational support will turn things around.

"I think we're also going to really work on retaining them once they're produced and try to keep more and more of them in-state," Blumenthal said. "I think we're working harder on retention and recruitment from different areas and helping people get through school. Growing your own works well, especially in our small communities. That's a better longer term solution for a lot of places."


Information from: The Billings Gazette,

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