Ashley Hulet works at the main desk of the intensive care unit floor on June 5 at University Hospital. Hulet said the nurse shortage issue provided her with good job prospects after graduating from the nursing program at the Sinclair School of Nursing at MU.
COLUMBIA — Ashley Hulet applied for just one job after graduating in May from the Sinclair School of Nursing. Because the job outlook was so promising, one application was all she needed.
A student position in the intensive care unit at University Hospital turned into a job for Hulet as a nurse technician after graduation. Beginning today, she will become a full-time nurse in the same unit.
“I knew there was a pretty good job outlook because, obviously, nationwide there’s a shortage of nurses," Hulet said.
The shortage of nurses in Missouri hospitals is at an all-time high, according to a 2017 report by the Missouri Hospital Association. Almost 16 percent, or about 6,000, of staff nursing positions in Missouri hospitals are vacant.
In mid-Missouri, the number doubled from 8.1 percent to 16.2 percent between January 2016 and December 2016. About 600 positions in mid-Missouri hospitals are open.
A representative for Boone Hospital Center said its vacancy rate was on par with the rest of the state. The MU Health Care system, including all of its clinics, has a staff of around 1,000 nurses and an 8.5 percent vacancy rate — about 90 positions across the system.
“It’s tough when you’re short-staffed all the time, and it’s not administration’s fault,” Jill Kliethermes, chief executive officer of the Missouri Nurses Association, said.
“Sometimes it’s just the way it is. You can only get what you can get, even with agency nurses or trying to bring outside people to fill the void.”
A leading reason for the high vacancy rate is the number of nurses reaching retirement age in Missouri. When the economy began to improve after the 2008 recession, nurses started choosing retirement instead of job security, Kliethermes said.
According to the Missouri Hospital Association, 34 percent of nurses in the state are older than 55 and reaching retirement age.
“Now that the economy has recovered and people feel like they can retire, we’re going to see more of that retirement or cutting back," Kliethermes said.
Some may adjust their schedules to work one day a week, say, instead of three, she said.
“Nursing work is hard, and being on the floor for 12 hours — you’re never on the floor just 12 hours — those are very long days, and it’s hard on the body,” she said.
Another factor contributing to the shortage is the number of advanced registered nurse practitioners leaving the state to work where there are no restrictions on their ability to practice.
Missouri has a geographical proximity rule formulated by the Board of Nursing and the Board of Registration for the Healing Arts that means advanced registered nurse practitioners must practice within 30 miles of a doctor, 50 miles in rural areas.
These nurse practitioners are especially needed in rural communities where medical access is limited, Kliethermes said. A radius of 50 miles is not wide enough for many parts of the state where the closest medical care may be much farther away.
In Theodosia, a southern Missouri town with a population smaller than 300, residents will often drive nearly an hour to Mountain Home, Arkansas, the closest town with medical access, state Rep. Lyle Rowland, R-Cedarcreek, said. The closest Missouri city is Springfield, and it's more than 90 minutes away.
A nurse practitioner wanted to settle in Theodosia, but the closest doctor willing to enter an agreement with her was at 52 miles away. Rowland tried to get a waiver, but the Board of Healing Arts rejected it. That was five years ago.
"The people of Theodosia, they're just out of luck," Rowland said.
Every year, the Missouri Nurses Association pushes for legislation to widen the radius or do away with it completely. Rowland also repeatedly sponsors bills to increase the radius or eliminate it.
While a bill often makes it through the House of Representatives, Rowland said state Sen. Rob Schaaf, R-St. Joseph, a physician himself, stalls it in the Senate.
The Board of Healing Arts has said the rule to keep doctors and nurse practitioners closer together is intended to ensure that patient care is not impeded. Rowland and Kliethermes claim the issues are money and competition.
If nurse practitioners can work without geographic limits, clinics run by physicians will be forced to compete for patients, they say.
Missouri is bordered by less-restrictive states like Illinois, Kansas and Arkansas, while Iowa, along with at least 20 other states, allows full practice authority for nurse practitioners. This incentivizes some nurses to leave Missouri.
Nurse practitioners in less-restricted states still may have to enter collaborative practice agreements with doctors, but they have more authority. In a full-practice state, they do not need to form an agreement with a physician, and they can practice to the full extent of their education.
David LaFevers, director of the master's degree of science in nursing program at the University of Missouri-Kansas City, has found it difficult to continue his nursing practice in Missouri for other reasons.
In order to retain his certification to practice, LaFevers must complete a certain number of clinical hours.
He cannot work full time as a nurse practitioner in Missouri, often a requirement, because of his teaching load. So, he is starting a clinic with a colleague in New Hampshire, a full-practice state.
"Because of the rules and regulations here in Missouri, it makes it very challenging," he said.
Supply and demand
According to the Bureau of Labor Statistics, nursing jobs are projected to increase 16 percent between 2014 and 2024. While nurses won’t have trouble finding jobs, it's unlikely hospitals and clinics will find enough to fill all of the open positions.
The issue is a classic economic one, Dave Dillon, vice president of public and media relations for the Missouri Hospital Association, said. There’s a growing demand for nurses and an insufficient supply.
Because nursing schools have limits on the number of students they can take, not enough nurses graduate in Missouri each year to fill the vacancies.
Missouri has 28 four-year degree nursing programs, 43 practical nursing programs and 36 schools that offer associate degrees. Columbia College, with bachelor's and associate degrees, graduated 26 students this spring from both the on-campus location and at the Lake of the Ozarks location.
At MU, enrollment numbers at the Sinclair School of Nursing have increased 2 percent since fall 2016.
A total of 79 undergraduates and 54 graduate students graduated from the MU nursing school in May. Twenty-three percent of recent MU graduates will work in the MU Health Care System, and 72 percent will work somewhere else in the state, according to the school.
To keep nurses in Missouri, hospitals have started incentive programs, such as tuition forgiveness and career ladders. The ladders help health care workers climb their way up from, say, nurse technician to registered nurse and nurse practitioner.
"I think nursing as a whole is one of the most gratifying professions that I can think of," LaFevers said. "It truly is. But if you have professionals that are not supported and nurtured to the role, it can be very daunting."
He believes the health care industry is beginning to recognize this strategy and apply it.
"We need to be able to grow these new graduates and help them be safe, happy, healthy and successful."
To handle burnout and turnover, some hospitals provide extra support for new graduates to help them transition to the work force.
MU Health has a one-year residency program for its nurses, for example, with continued skills training and a week of real-world scenarios with patient simulations.
Some schools recruit early for their nursing programs. This year, Columbia College held a weeklong summer camp to give high school juniors and seniors hands-on training by nursing faculty and students
The camp was created directly in response to the nursing shortage, Joyce Gentry, program director for the Columbia College nursing program said.
Supervising editor is Jeanne Abbot.