Facing a growing, aging population, reports from state agencies show that Central Texas is expected to face nursing shortages across multiple vocations and in several categories of health care. An October 2016 nursing supply and demand report co-authored by the Texas Center for Nursing Workforce Studies and the Texas Department of State Health Services, or DSHS, projects that nursing supply will not keep up with demand over the next decade. Another report issued by the Texas Center for Nursing Workforce Studies in 2015 shows that Williamson County in 2015 ranked 63rd in the state for its supply of registered nurses with a ratio of 565.2 nurses per 100,000 residents. Travis County ranked 23rd overall in that same report, with a ratio of 943.1 registered nurses per 100,000 residents. Central Texas combined is expected to experience a shortage of 7,459 registered nurse full-time equivalents by the year 2030, an employment trend exacerbated not only by baby boomers entering in-home care, but experienced nurses leaving the workforce altogether. “We’re getting a ‘double whammy.’ We’re getting an increased demand … at the same time a good portion of the nursing population is retiring,” said Dr. Cindy Zolnierek, executive director of the Texas Nurses Association, a statewide professional association of licensed nurses.

Nursing numbers down the road

According to the DSHS 2016 report,  “Nurse Supply and Demand Projections, 2015-2030,” Central Texas will face nursing shortages for positions across the board, including registered nurses, or RNs, licensed vocational nurses, or LVNs, nurse practitioners, or NPs, certified registered nurse anesthetists, or CRNAs, and certified nurse midwives, or CNMs, by the year 2030. The demand for RNs across all forms of care is rapidly rising in Texas. The 2016 supply and demand report predicts that statewide, demand for inpatient care, or care for patients that requires admission to a hospital, is expected to grow by 57 percent, by far the most amount of health care attention required from RNs. When the nurse-to-patient ratio dips too low, Zolnierek stated patients experience longer rates of stay and a slew of adverse outcomes, such as pressure ulcers or falls. Chronic diseases, such as diabetes, require attentive, daily care to offset potential health care risks. “What nurses do is knowledge-based work, looking at that individual person and understanding what that risk is. The nurse understands what those risk factors are and is vigilant. That’s what slips between the cracks when you don’t have enough nurses,” Zolnierek said. RNs account for the largest share of nursing jobs in the Austin area, according to data from the U.S. Department of Labor. Nearly 13,000 RNs were employed in the Austin metropolitan statistical area as of May 2017. The next closest category of nurses—licensed practical and licensed vocational nurses—employed 9,000 fewer nurses. Despite those numbers, Central Texas is currently experiencing a nursing shortage in all but one category, according to DSHS’ 2016 supply and demand report.

Growing supply, booming demand

The largest contributing factor to the projected nursing shortage is the sharp uptick of demand, according to the state reports. The area not only has a ballooning population, but also a growing number of senior residents. According to the most recent demographics data from the U.S. Census Bureau, from 2010-16 the number of residents age 65 years or older in Round Rock grew by approximately 4,000 and now represents 7.4 percent of the population. Similar aging population trends occurred in Pflugerville and Hutto in that same period of time. Those climbs may seem insignificant, but as the average lifespan extends, so, too, does the amount of time required for geriatric health care. “As we get older we may have many different diseases that need to be coordinated. Nurses … are very prepared for that role,” Zolnierek said. Chronic disease and acute health care needs may go untreated as general nursing becomes harder to access for geriatrics, per Zolnierek.

THE EXPERIENCE GAP

“We’ve been watching [the nursing shortage] from leadership for quite some time,” said Sheila Fata, chief nursing executive for St. David’s Central and West Texas Division. Fata stated that the St. David’s hospital system has not experienced a great overall shortage of nurse supply, but that one particular kind of worker is leaving with few replacements. “We’re finding a shortage of supply in the high-experience domain,” Fata said. Fata claims the hospital network is increasingly watching experienced nurses retire, a sentiment echoed by Janice Walker, senior vice president and nurse executive for the Central Texas Division of Baylor Scott & White. According to the two, there is currently an experience gap—that is, there are fewer nurses with extensive work experience poised to step into those roles. “There are pockets of talent related to seasoned nurses, which is another reason why you need to stay ahead of recruitment,” Walker said. Dr. Alexa Stuifbergen, dean of the School of Nursing at the University of Texas at Austin, expressed concern over the departure of aging nurses, particularly nurse educators. Nurse educators practice in health care settings in addition to teaching nursing students at higher education institutions. “Nurse faculty in Texas are an aging group,” Stuifbergen said. “If we don’t pay attention to [the number of] nurse educators and nurse scientists we’re producing, we won’t be able to make more RNs in the long run.” Despite the apparent growing demand for nurses, local Bachelor of Science in Nursing programs—the common course for nursing students to attain clinical work and study for RN licenses–have not expanded in recent years. Records from the DSHS show St. David’s School of Nursing at Texas State University in Round Rock offered admission to 126 students in 2017—only one more than it offered admission to in 2012. From 2012-17, UT did not increase or decrease the number of admission offers—125 students—to its BSN program. In 2017, Round Rock-based South University offered admission to 25 students, five less seats than the school offered in its BSN program’s inaugural 2014-15 school year. Dr. Marla Erbin-Roesemann, professor and director at St. David’s School of Nursing at Texas State University, states the schools are constrained by the number of clinical space for its students. “Finding the amount of nursing faculty it takes to educate that many students, plus finding clinical sites for them, has been a challenge,” Erbin-Roesemann said. As a result the school has also created more focused programs, including a family nurse practitioner program in 2013 and a leadership and administration program in 2017. Stuifbergen reports that the School of Nursing at UT is also seeing a climbing demand in its graduate enrollment, particularly in nurse practitioner programs. In the 2016-17 school year, Texas State University graduated 86 BSN program students. UT graduated 132 BSN and 51 MSN students, while Austin Community College graduated 234 with associate degrees. Source: Texas Department of State Health Services/Community Impact Newspaper *University of Texas at Austin numbers includes Bachelor of Science in Nursing and Masters of Science in Nursing graduation numbers.

NURSING WAGES IN THE AUSTIN AREA

A low comparative pay rate may also contribute to the projected nursing shortage. Statistics from the U.S. Department of Labor reveal that RNs in the Austin MSA on average make $10,000 a year less than their peers in Houston and $5,000 a year less than nurses in Dallas. Sources: U.S. Department of Labor Occupational Employment Statistics, American Nurses Association/Community Impact Newspaper Officials from St. David’s and Baylor Scott & White provided statements that said their respective companies rely on data reporting to construct “competitive” nursing wages and benefits packages. There does not seem to be an industry consensus on why the wage gap exists. Zolnierek contends that it may be because the Austin-area is still considered “non-urban,” and both she and Erbin-Roesemann have been told that the pay is less because the Austin area is considered a desirable place to live. Essentially, nurses will move to the area despite a lower salary. Wages could be driving young nurses away, however. In an internal survey of UT nursing students after the 2017 spring semester, only 32.2 percent of students stated the area as their geographic preference. In the three semesters prior, that number hovered around 50 percent. “Economically, you can attract more people by paying more, but if Houston and Dallas are paying more, that would drive [students] to those areas,” Erbin-Roesemann said.

FINDING SOLUTIONS

To continue attracting nursing candidates both from within the region and abroad, hospital officials say the area’s medical centers are working on enhancing the working environment within the hospital itself. Fata and Walker both stated their respective hospital systems are working on developing leadership from within through initiatives such as unit councils. These “councils” are meetings where unit-specific nurses are invited to review materials relevant to their practice. “They have a council that takes on practice issues, staffing issues—any kind of barrier,” Walker said. Area hospitals and local universities continue to strengthen their partnerships, said both Erbin-Roesemann and Stuifbergen. According to Erbin-Roesemann, the schools and hospitals meet quarterly as part of a coalition to open dialogue. Student nurses from every program do their clinicals in St. David’s, Seton or Baylor Scott & White medical centers, as well as clinics throughout the area. “Not only do they evaluate our students, but our students get to evaluate them,” Erbin-Roesemann said. Innovation may also play a pivotal role in addressing the region’s nursing woes. Language in the 2016 nursing supply and demand report stipulates that advancing health care technology may help to increase access to nursing care. Local universities are increasingly using simulation labs to offset the lack of available clinic space, according to Erbin-Roesemann and Stuifbergen. These simulation labs utilize high-tech mannequins and immersive exercises to train nurses in real-life situations. Zolnierek stated she has seen technology such as telehealth—health care that employs telecommunication technology like video calls or cell phone apps—help underserved rural and elderly populations. According to the TNA director, these advancing technologies are becoming more and more common. “There are some innovative models that try to expand the reach of a nurse,” Zolnierek said.