Emory & Henry College nursing students work in a clinical simulation lab that features seven patient rooms, two high-fidelity patient simulation rooms, a control room, a student debriefing room, a patient lounge and a student waiting room. Some nursing leaders believe that increased use of simulations could help ease the competition for clinical placements. Courtesy of Emory & Henry.

Correction Feb. 18, 2022: Nursing students do not graduate as registered nurses; they must first pass the National Council Licensure Examination and be licensed by the State Board of Nursing. An earlier version of this story was incorrect on this point.

Additionally, Lauren Hayward, director of nursing at Virginia Western Community College, clarified after publication her statement that a majority of the program’s full-time faculty would be retiring within five years. She expects four of eight faculty members to retire, she said Friday. Her statement has been updated.

First came the baby boomers, then came COVID.

For years, the nation’s nursing corps had been stressed by an influx of millions of patients from the aging boomer generation, and by a wave of retirements by the boomers in its own ranks.

And then in early 2020, a new challenge: overflowing hospitals, critically ill patients, shift after shift after shift in head-to-toe PPEs. Some nurses contracted COVID-19. Others took early retirement or just quit, burned out and frustrated. And patients kept coming.

By September 2021, the nursing field was in the midst of an “unsustainable” staffing shortage, the American Nurses Association wrote in a letter to the secretary of Health and Human Services.

Calls came to improve nurses’ working conditions, to provide recruitment and retention incentives – and to train more nurses.

“The pressures are there for nursing programs to expand, no doubt,” said Johnnie Sue Wijewardane, dean of Radford University’s School of Nursing. “The pressures are there from the universities and institutions, the pressures are there from the clinical agencies who need nurses so desperately.”

The problem has less to do with attracting enough students, nursing leaders say, and more with the challenges expanding programs to accommodate them all.

The number of students admitted into Virginia’s 81 registered nursing programs – and the number of graduates from those programs – both reached all-time highs in the 2019-20 academic year, the state Department of Health Professions reported. Admissions rose 5%, while graduates increased 7%.

But that same year, 26% of qualified applicants weren’t offered a spot in Virginia nursing programs.

Look beyond Virginia’s borders, and the picture is the same: Enrollment in baccalaureate nursing programs increased by 5.6% in 2020, according to the American Association of Colleges of Nursing, but more than 67,000 qualified applicants were turned away for lack of space.

Nursing leaders point to two pressure points: attracting and retaining more faculty, when salaries are higher elsewhere, and securing enough clinical placements for more students in hospitals and clinics that may already be struggling to fill the existing need.

Both of these challenges have been around for years. But, much like the shortage of nurses, both have been exacerbated by the pandemic – and thrust into a national spotlight.

Lawmakers and nursing leaders are looking for solutions. The Virginia General Assembly is being asked to fund a study to determine the overall needs at the state’s nursing programs, and to earmark money for an expansion of community college nursing programs, and to fully fund existing scholarship opportunities for nursing students.

The heads of nursing programs in Virginia have been meeting with each other, and with their counterparts at health systems and the state Board of Nursing, to brainstorm solutions.

“We are going to have to deal with this on a policy level, in a much more aggressive way,” said Laurie Anne Ferguson, founding dean of the School of Nursing at Emory & Henry College, which recently enrolled its first cohort of nursing students. “The curtain’s been pulled back, and the need is there.”

***

Nursing students at Virginia Western Community College in Roanoke helped with an on-campus COVID-19 vaccination clinic last spring. The school has about 115 associate-degree nursing students. Courtesy of Virginia Western Community College.

In the early 2000s, alarms were sounding about the state of the nursing workforce, as older nurses were preparing to retire in droves.

The same demographic trend was threatening the very institutions that were tasked with turning out the next generation of nurses.

By 2015, nearly a third of full-time nursing faculty were 60 and older, compared with 18% less than a decade earlier, according to a study reported in the journal Nursing Outlook. The authors projected that roughly a third of nursing educators who were teaching in 2015 would retire within 10 years.

A 2019 survey by the American Association of Colleges of Nursing found 1,637 faculty vacancies across 892 nursing schools, a rate of 7.2%. In addition to the vacancies, the schools said they needed to create another 134 faculty positions to accommodate student demand.

The pandemic only intensified the shortage, nursing leaders said, as educators who might have been thinking about retiring were pushed to that decision by the increased stress.

Lauren Hayward, director of nursing at Virginia Western Community College in Roanoke, said she expects that four of her eight full-time faculty members will retire within five years.

On a national scale, she said, “our talent and our knowledge base is walking out the door, between retirement and other opportunities.”

Luring enough students into teaching tracks to replace those retiring educators has proven to be difficult, nursing leaders said. It’s a problem that often comes down to money.

The typical registered nurse in Virginia earns between $70,000 and $80,000 annually, according to a 2021 survey by the Virginia Department of Health Professions. Half of registered nurses in the state hold a bachelor’s degree as their highest professional degree, the survey found, while another 26% capped their education with an associate degree.

A nurse with a master’s degree – the minimum required to teach nursing – might start off making $70,000 to $80,000 in an academic setting, said Shanna Akers, dean of Liberty University’s School of Nursing. In a clinical setting, that same nurse could expect to pull down $100,000 or $110,000, she said.

“If you can make more as a staff nurse with a bachelor’s degree, why would you get a master’s or a doctoral degree” to teach? asked Ferguson, at Emory & Henry.

Nursing educators – who are primarily women – have never had the same prestige, or pay scale, as engineering or business faculty, Wijewardane said. 

“It’s hard to attract people into teaching nursing because the pay is for the most part pretty abysmal across the board,” she said. “You have to really want to do it.”

The pay disparity is in part a factor of the risks and tasks involved, said Lisa Smithgall, chief nursing officer at Ballad Health, which serves Southwest Virginia and northeast Tennessee. A nurse working in a hospital is exposed to bodily fluids, caring for critically ill patients, working nights and weekends, she said – and that’s different from teaching.

But not all nurse educators work 9-to-5 shifts in a classroom, Donna Meyer, CEO of the Organization for Associate Degree Nursing, pointed out. Faculty who supervise students on clinical rotations are right there in the hospital with them, whether during the day or in the middle of the night. And while the faculty don’t have primary responsibility for the patients – staff nurses also oversee the students – they do take on some of the care as they advise their students.

While the pay disparity between bedside nurses and nurse educators isn’t new, the pandemic has added another twist: the increasing reliance on highly paid travel nurses to fill critical vacancies in hospitals. Travelers, who might spend months at a time away from home, can make in 13 weeks what it would take six months for them to earn in a regular hospital job, said Kim Brown, founding chair of the Division of Nursing at Ferrum College, which recently accepted its first baccalaureate nursing students.

For hospitals, it’s been a vicious cycle. As more registered nurses have left stable jobs to join the travel ranks during the pandemic, hospitals have had to rely more and more on travelers to fill those voids.

“A lot of our graduates are coming back and saying they can make quadruple what they’re making at the bedside with our local health care facilities, so they’re doing traveling,” said Nancy Haugen, who leads the nursing program at the University of Virginia’s College at Wise. “And many times they come back to the same facility.”

Ballad had about 3,500 staff nurses before the pandemic, Smithgall said, with 150 or so vacancies at any given time. Today, the health system has brought on about 400 contract nurses and still has vacancies to fill. Staff nurses are picking up extra shifts, as are managers: Smithgall has been working Tuesday nights in the emergency department at Johnson City Medical Center.

And good luck luring travel nurses away from their lucrative – and flexible – gigs to tie themselves down to a teaching job, noted Hayward, who said the increasing reliance on travelers has affected her part-time pool of faculty.

“Unless you can offer two and three times the wages that they used to make, you’re not competitive with what’s happening in the travel world,” she said. 

Nurse educators need to sell students on the idea of teaching as a career – to show “the joy” that comes with the work, said Beverly Malone, CEO of the National League for Nursing, which represents nurse educators. 

“Thank goodness it’s not always about money,” she said.

Some people fall in love with teaching, she said, and want to support future generations of nurses. Others, who maybe are caring for small children or elderly parents, like the more standard hours usually offered by teaching jobs.

Virginia Western, which has about 115 nursing students, has made a point of partnering with its graduates on opportunities to earn master’s degrees in nursing education, Hayward said. 

“We spend a lot of time selling the role,” she said. “When your students graduate, they don’t see themselves as educators. They are trying their hardest to put the nursing RN badge on and go out there and take care of patients. That’s what they trained for. But there are people that are uniquely suited to education, and once they get their feet wet in the nursing role, they start to grow into that.”

Liberty started offering a master’s degree in nursing education in 2004, and it is now the nursing school’s largest graduate program, with about 350 students, Akers said.

Many of the students are bedside nurses who want to get into education, she said. Others are nurse managers who need to earn a master’s degree if they want to continue to advance in their jobs. Some are – or want to be – nurse educators who work for hospital systems.

And then there are the nurses who want to reclaim a work-life balance.

“Lifestyle balance is a huge attractor for nurse educators,” Akers said. 

Jordan-Lee Slowik, who earned a master’s degree in nursing education at Liberty and is working toward her doctorate there while teaching at the University of Central Florida, echoed that.

“When I was a bedside nurse, I worked every Christmas, every Christmas Eve,” said Slowik, who started her nursing career in pediatrics. Her mother, who’s a flight nurse, still works all holidays. 

Academia is different, she said: There are no weekends or holidays, summer vacations are possible, sabbaticals become an option at a certain point in your career.

“It’s a lot more freedom and flexibility to have a family, and I think that’s what a lot of nurses do crave at some point,” she said. It’s been helpful to her, she said: She has a 1-year-old and a 3-year-old, with another baby coming in June.

The profession has to find a way to encourage more nurses to take a path toward teaching, she said. 

“I have met so many nurses in my career, so many students, and I have not met a single person, personally, that is remotely interested in being an educator,” Slowik said. “I’m not sure how we go about letting people know about our role and what we do for our society, but we definitely need to get what we do out there.”

***

The University of Virginia’s College at Wise has about 20 prelicensure undergraduate nursing students this year. Another five students are on the school’s RN-to-BSN track, which accepts registered nurses who hold associate degrees and want to earn a bachelor’s degree. Courtesy of UVA-Wise

Nursing students in Virginia must complete 500 hours of clinical training to graduate. They work with patients – side by side with nurses – in hospitals and clinics, on rotations that range from acute care to obstetrics to psychology. 

Large health systems work with hundreds of nursing students at a time; the benefits accrue to both, said Karri Proctor of Carilion Clinic.

“We need them just as much as they need us,” said Proctor, student services supervisor for visiting student affairs at the Roanoke-based health system, which this semester is working with about 700 nursing students from schools including Virginia Western, Radford, Ferrum, Liberty and New River Community College.

But the desire to take on more students bumps up against the realities of how many beds a hospital has, and how many nurses are available to work with students. So competition for clinical slots can be fierce in some regions, especially in high-demand specialties like pediatrics and psychology.

And then, of course, the pandemic introduced a slew of new challenges.

Many hospitals converted regular wards into COVID wards, removing them from the usual clinical rotations. Other hospitals took beds out of service because they didn’t have enough nurses to handle them, again reducing the availability of clinical slots for students – sometimes overnight.

Dr. Daniel Harrington, vice president of academic affairs at Carilion, still recalls the “red letter day” in March 2020 when word came down that all of the students doing rotations at Carilion hospitals and clinics needed to leave. 

“You can imagine the impact that that had on people needing experiences to be able to graduate,” he said.

Even when students were allowed to continue their rotations, rules and regulations about PPE, quarantining and testing were fluid, often changing quickly. And the nurses who normally would be supervising students were quickly becoming overwhelmed with their bedside duties.

Not every nursing program in the region is feeling the clinical crunch; Hayward and Wijewardane, for instance, both said that they’ve been fortunate to have enough availability for their students.

For Ferguson, the challenge of clinicals is intertwined with the challenge of hiring: Ballad has assured her of clinical opportunities for Emory & Henry students, but those openings might be late at night or on weekends. And while those can be great times for students to learn, it can be hard to hire faculty when they know they’ll have to supervise off-hours clinical rotations.

A rural location can make clinicals more challenging as well. Emory & Henry had to get an exemption to a state rule that clinical sites must be within 25 miles of campus, Ferguson said. UVa-Wise had to get an exemption, too, to a state rule that says 80% of a school’s clinical program must be within Virginia. Right now, about 60% of UVa-Wise’s clinical opportunities are outside the state, Haugen said.

Ferrum’s nursing program, which currently has 14 pre-licensure baccalaureate students and has the capacity for up to 20 at a time, will be able to expand after three years, the state has said – as long as there are sufficient clinical placements for more students, Brown said.

Expanding nursing programs will have to mean expanding clinical opportunities – or changing the way everyone involved thinks about clinicals, nursing leaders said.

Nursing programs have for some time been looking beyond hospitals for clinical rotations. 

Nursing students have set up in malls, offering blood pressure checks and engaging mall walkers in conversations about their health and safety, said Meyer, whose organization works with community colleges. They staff vaccine clinics and pull rotations at long-term care facilities and Head Start centers.

It’s a way to supplement hospital and clinic rotations, Wijewardane said – but it also has another benefit: showing nursing students that acute-care work isn’t their only option.

“We have to expose these nurses to different areas where the possibilities are for them to work,” she said. “We have tunnel vision because that’s the way we’ve always done it, which is such a dangerous place to think in.”

Another idea that Malone likes: Allow students to fulfill more of their clinical hours through simulations. 

Simulations can range from the very low-tech – working with role-playing “patients” who present various symptoms – to the very cutting-edge, like using virtual-reality devices to simulate pelvic exams or intubations. 

Simulations are useful not only to alleviate shortages of clinicals opportunities, Malone said, but to give students valuable practice in performing procedures and communicating with patients and families in a low-risk setting.

She remembers being a young nursing student and apologizing to patients when she was performing a new procedure. “Think about being able to practice until you really were able to perform the skill,” she said.

In Virginia, up to 25% of a student’s clinical hours can be achieved through simulations. Malone thinks that up to 50% should be considered.

Simulations should be part of the conversation, said Melody Eaton, who has been part of statewide talks about the future of nursing as president of the Virginia Association of Colleges of Nursing and a member of the governmental affairs group at the Virginia Nurses Association. 

But there’s a caveat, said Eaton, who also heads James Madison University’s nursing program: Simulation labs are very expensive to set up and run, and require faculty to supervise them. Any increase in the use of simulations would need to ensure that everyone – small schools and large ones alike – has equal access to the technology, she said.

***

With clinical opportunities sometimes in short supply, nursing programs have been turning to alternate ways for their students to get real-world experience. At Virginia Western Community College, nursing students have helped with on- and off-campus COVID-19 vaccination clinics. Courtesy of Virginia Western Community College.

The creation of new nursing programs like the ones at Emory & Henry and Ferrum increases opportunities for students. But it also increases competition for the already limited faculty and clinical resources.

“In a lot of ways, I want to say it’s a really great thing,” said Akers, of Liberty. “More nursing schools equal more students. However, until we solve the problem of clinical sites, it creates a competition for the clinical sites. Until we solve the problem of a lack of faculty, it creates a competition for the faculty.”

Wijewardane said she has had a couple of faculty leave Radford for better pay at other programs. It’s a perpetual problem when public schools have to compete with private institutions that often can pay more, she said.

“The resources are not infinite,” she said. “When one program goes up, regardless of whether it’s public, private, associate degree or community college or university, it certainly impacts the availability of resources, be it clinical or faculty.”

Brown said she has thought about the effect that Ferrum’s new program could have on the state’s existing nursing programs.

“I don’t miss the fact that we have lots of competition,” Brown said. “We’ve got Radford, we’ve got Virginia Western, we’ve got Liberty an hour down the road. What made Ferrum think that a small private liberal arts school could bring up a nursing program?”

But she believes that students are looking for varying types of experiences, and that some might want to be part of a smaller cohort. The same goes for faculty who might be looking for a new opportunity but want to stay in the area, she said.

“We’re not in an environment anymore where people work at the same organization their whole life,” said Brown, who also has worked at Liberty, Radford and JMU. “Sometimes change is good.”

With so many stakeholders – public schools, private schools, four-year programs, community colleges, state regulators, practice partners – holding so many points of view, it would be easy for competition to overtake collaboration in the race to improve nursing in Virginia.

That would be a mistake, Wijewardane said

“We need all hands on deck,” she said.

“It’s time that we pulled the competition back out of it and said, What’s the best for all of us? Because we all need help with this,” she said. “These are pressure points and pain points that we’re all having. How can we look at what’s best for our state and region and not just what’s best for one school?”

Eaton agreed. “We need to collaborate,” she said, “because it’s a system problem.”

Eaton’s organization, the Virginia Association of Colleges of Nursing, has asked the General Assembly to fund a study to evaluate the needs of the state’s nursing programs, bringing together stakeholders from across the spectrum: nursing schools, practice partners and regulatory agencies.

It’s one of several nursing-related budget amendments that the General Assembly will deal with in the coming days. Another asks legislators to support existing nursing scholarship opportunities that have been on the books but not funded for several years.

The Virginia Community College System has asked for $26 million per year over the next two years to expand its nursing programs; several budget amendments that are on the table would provide varying degrees of funding – up to $90.5 million over the biennium – to hire faculty, increase salaries, recruit students and upgrade labs.

Twenty-two of the state’s 23 community colleges offer nursing programs, said VCCS spokesman Jeffrey Kraus; the only one that doesn’t, Paul D. Camp in Franklin, would like to add one, he said.

During the last academic year, Kraus said, 4,077 students were enrolled in associate degree nursing programs across the state community college system. More than 1,700 completed an associate degree or registered nurse bridge degree or certificate, he said.

Eakin said the community college system has been at the table during discussions about how best to address the challenges with nursing education in the state, and she sees associate-degree programs as a critical piece of the puzzle. But she expressed concern that funding one area without addressing others could lead to further problems – for instance, will there be enough clinical spots for those added students?

“Our stance has always been, we wish we would wait and do it together,” she said. “Funding one sector over the other for large amounts of money isn’t really going to solve the whole problem. It might shift directions but not really look at the whole infrastructure.”

Kraus said the community college system sees no reason to wait to begin to address the problem.

“Our community colleges produce nearly half of Virginia’s new nurses every year and the need for more of them is urgent,” he said by email. “The partners with which we work assure us there are more clinical hours to be had. While we look forward to working with nursing leaders across Virginia to address this issue more broadly, we see no benefit to delaying our response to the immediate needs of the communities we serve.”

Radford’s Wijewardane said cash isn’t always the answer – but it’s certainly part of it.

“You hate to just say, throw more money at it,” she said. But state funding is needed to help boost faculty pay and increase hiring, she said. 

Nursing leaders also said they’d like to see more opportunities for scholarships and loan forgiveness.

One existing initiative, the federal Nurse Corps Loan Repayment program, will cover up to 85% of nursing education debt in exchange for the graduate working for at least two years in a critical shortage facility or eligible nursing school. For faculty, the program will repay up to $40,000 in student loan debt for those who will serve at an eligible school,

***

With clinical opportunities sometimes in short supply, nursing programs have been turning to alternate ways for their students to get real-world experience. At Virginia Western Community College, nursing students have helped with on- and off-campus COVID-19 vaccination clinics. Courtesy of Virginia Western Community College

Even as state efforts to address the nursing shortage continue, innovation has been happening in targeted ways across Virginia.

Ballad collaborated with several nursing programs to provide space and staffing for clinicals if the schools admitted a certain number of additional students each year, Smithgall said.

It worked well, she said – they increased the number of nursing students graduating in the region by 110 annually, and nurses who were interested in teaching were able to take on some educational duties without seeing a drop in pay.

Meyer set up a similar program when she headed up a nursing program and needed additional adjunct faculty to teach clinicals. 

“That worked beautifully,” she said. “A lot of those nurses wanted to work for us, but it was like, Oh, I’m already working at the hospital, and then to do another shift … it’s just too much. But allowing them to kind of make it part of their routine was really a blessing.”

She and Smithgall both said an arrangement like that could be more challenging today, as bedside nurses are busier than ever.

“Practice and education have to come together to help work on this situation,” Meyer said. “But I know right now, we’re both overwhelmed.”

Ballad also has committed $10 million to create the recently announced Appalachian Highlands Center for Nursing Advancement, which will bring together four-year schools and community colleges in Virginia and Tennessee, including Emory & Henry and UVa-Wise.

The center will look for ways to bolster the supply of nurses, and to keep nurses who are already in the workforce fulfilled and healthy. 

The Virginia Association of Colleges of Nursing is looking at creating a program that would help nurses move from the bedside to the classroom. Many faculty come in as practitioners, Eaton said, and even if they have a doctorate they’ve never taught. A targeted academy that would provide training on that side of the job could encourage more practitioners to teach, she said.

“Nursing education is so hard because you have to maintain an expertise on the clinical side, you have to maintain an expertise in teaching and learning,” said Hayward, at Virginia Western. “And those are two separate worlds. So it’s hard to grow somebody – you can’t just pull them off the bedside and say, ‘Here, here’s a class.’ That’s not adequate preparation for the role.” 

Liberty started an accelerated program that allows some students who have already completed their general education requirements to graduate with a bachelor’s degree in nursing in a year, instead of two.

In 2019, the school also launched a doctoral program focused on nursing education. It already has 160 students, Akers said.

“I was talking to a friend of mine, and I told her, if we don’t find the solution, other people who are not nurses will try to find the solution,” Akers said. “We really need to own this.

“Can we come together and solve our own professional concerns? I think we can. I think it’s just having the right impetus to do so.”

Megan Schnabel

Megan Schnabel is a reporter for Cardinal News. Reach her at megan@cardinalnews.org.