Seeking The Right Prescription

Shortage of nurses may stunt growth of retail health clinics

Last updated Friday, October 3, 2008 9:07 PM CDT in Business

By Pamela Hill
THE MORNING NEWS

The rub is that while nurse practitioners can help fill the gap in the doctor shortage, they too are in relatively short supply.

St. Romain said the nursing shortage is directly related to the limited faculty needed to teach more classes.

Nationally, the average working nurse is 46, but older in Arkansas.

Lepaine Sharp-McHenry, president of the Arkansas State Board of Nursing, said the working nurse's average age in Arkansas is between 50 and 59. The average nursing faculty is 55 years old, a fact that doesn't bode well for the industry as teachers reach retirement age in the next decade.

Nan Smith-Blair, interim director of the Eleanor Mann School of Nursing at the University of Arkansas, said retention of faculty is also a problem when advanced practice nurses working in the field typically earn more than nursing teachers. She said the salary gap makes it hard to draw them back into the classroom.

The University of Arkansas has 12 full-time faculty and 15 to 18 part-time faculty at a given time. Starting salary for clinical instructors at the UA is $50,000, Smith-Blair said -- more for tenured professors.

The lack of teachers means fewer opportunities to bring more nurse practitioners on board. While classrooms for nursing students are full, on average more than two-thirds of qualified candidates are turned down and can't even get into the programs, experts said.

For example, NorthWest Arkansas Community College had 230 applicants this fall for its traditional and accelerated registered nursing tracks for associate degrees. They accepted only 75. Percentages were similar at the University of Arkansas for its bachelor's and master's degree nursing programs.

Undergraduate degrees are a vital step on the path to becoming an advanced practice nurse, which requires at least a master of science degree in nursing plus certification by a national body. The shortage of teaching faculty, registered nurse graduates and, ultimately, advanced practice nurses could stunt the growth of the burgeoning convenient care industry, experts say.

NWACC offers degree programs to become an LPN, taught onsite at Northwest Technical Institute in Springdale, and three different tracks to become a registered nurse at its Rogers campus. All nursing graduates must pass the National Council Licensure Examination-RN to be licensed.

Elaine Holloway, director of nursing education at NWACC, said more and more of her students with associate degrees are choosing to get bachelor's and master's degrees. "They want that NP certification," she said.

Smith-Blair said she gets frequent calls from people in the health care industry who are looking for qualified, available graduates. She helps when she can but she wishes there were more people to refer.

She said the UA admits 48 students per semester into the baccalaureate program -- but that's only one-third of the qualified applicants who apply.

"We have very competitive admission. We're not unusual to most of the programs in Arkansas and the nation," Smith-Blair said. Admission into the graduate-level program is even tougher. The UA master's program graduated seven students this year. There are approximately 15 students currently enrolled in the graduate program.

The biggest concern right now is at the undergraduate level -- having enough registered nurses at the bedside, she said.

The interest in the profession is high, but so is the need, according to Smith-Blair, who said there are more areas in which to be a nurse today such as schools, industries and free-standing clinics.

Sharp-McHenry said insufficient staffing in hospitals and long-term care facilities cause some nurses to leave their positions, or at least Arkansas, due to long hours and stress. She also said Arkansas doesn't pay well enough to retain higher-trained nurses, especially those who have doctoral degrees.

"We need to do a better job of financially rewarding people for the work they do -- and seek more strategies to retain them in the state," Sharp-McHenry said. "It is still a field that is predominantly women and there is gender-inequity in the salaries."

Sharp has worked in clinics, hospitals and rural health clinics in Arkansas. She said she's seen the importance of advanced practice nurses, especially in rural areas that have no doctors and are miles away from a town that does have a doctor or hospital.

"Nurse practitioners really fill that gap, fill that shortage," she said.

New Popularity

Nurse practitioners have been around for more than four decades, but just recently have been recognized for their skills, knowledge and cost-effectiveness, according to the 2008 Pearson Report, published in the February issue of The American Journal for Nurse Practitioners.

"In the past two years, consumer desire has aligned with industry's profit motive, producing walk-in retail clinics that feature, not apologize for, NPs," noted Linda J. Pearson, an advanced practice nurse and author of the annual report. She said industry projections are that 5,000 to 10,000 APN-staffed clinics will open in the next few years but that patient demand could warrant more than 10,000.

The acceptance of advanced practice nurses is what has allowed clinics like RediClinic, staffed entirely by APNs, to be successful. RediClinic LLC has two Arkansas locations -- one in the Walmart Supercenter on Mall Avenue in Fayetteville and the other in the Walmart Supercenter in Lowell. The Houston-based corporation has 35 clinics in five states and plans to open 200 more in the next few years, according to a company spokesman.

At least 42 other businesses have jumped on the bandwagon, based on membership in the Philadelphia-based-Convenient Care Association, which boasts membership of 90 percent of the convenient care industry.

There are about 125,000 nurse practitioners in the United States, said Mary Jo Goolsby, director of research and education for the American Academy of Nurse Practitioners.

NPs practice in all areas: ambulatory primary care, hospital-owned clinics, emergency/urgent care, in-patient settings, long-term care, community health, and other areas, Goolsby said.

MANA Medical Associates has 15 clinics in Northwest Arkansas and is owned by the clinics' physicians. Paula Maxwell, MANA's chief operations officer, said nurse practitioners work as a "care team" with MANA's 75 doctors. Six nurse practitioners and three physician assistants currently work at MANA clinics. (Physician assistants work under the supervision of licensed doctors and are nationally certified. Like APNs, they, too, can write prescriptions.) Maxwell said MANA has used nurse practitioners for 10 years in its primary care and specialty clinics.

"We have found that using mid-level providers allows our practice to get patients in sooner," Maxwell said. Doctors often also use NPs to educate patients or counsel with them on health care issues, and the patients seem to approve, she said.

Wage Gap Equals Cost Benefit

While APNs don't garner a six-figure income equal to those of doctors, their advanced degree gives them more earning potential than other nurses. The lower salary is one reason why APNs are more cost-effective for patients, clinics and medical facilities.

A 2008 national salary survey conducted by the American Academy of Nurse Practitioners showed a mean base salary of $84,250 -- a jump from 2004, when the average was $73,830. The survey showed salary variances based on clinical specialty, setting, experience and region.

Nurse practitioners in the southeast region, which includes Arkansas, had a mean base salary of $81,560 but a mean total income of $88,930. Nurse practitioners can get a portion of patient per-visit fees in addition to their salary. The southeast region's earnings fell close to the middle, with NPs in three regions reporting lower earnings and four regions reporting higher earnings.

Various studies show nurse practitioners are money-savers for health clinics, hospitals and long-term care facilities. According to information from the American Academy of Nurse Practitioners, different studies done between 1985 and 2005 indicated: Adding a nurse practitioner could double the number of patients seen in a physician clinic as well as a 42 percent drop in long-term costs when APNs assisted Physicians opposed to physician-only teams. Another study revealed nurse practitioners in a physician clinic had the potential to decrease the cost per patient visit by one-third and hospital patients had shorter stays with fewer complications.

FAST FACTS

Advanced Practice Nursing -- The Details

• The Advanced Practice Nurse (APN) has at least a master's degree in nursing, additional education and certification from a national body recognized by the State Board of Nursing.

• Advance practice nursing encompasses four specialties: advanced nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist and certified nurse-midwife.

Specialty Certifications approved for APNs in Arkansas:

• Acute Care Nurse Practitioner

• Adult Nurse Practitioner

• Family Nurse Practitioner

• Gerontological Nurse Practitioner

• Neonatal Nurse Practitioner

• Pediatric Nurse Practitioner

• School Nurse Practitioner

• Women's Healthcare Nurse Practitioner

Levels of nursing education

• A licensed practical nurse (LPN), or vocational (LVN) nurse, is trained in basic nursing techniques and direct patient care. The LPN practices under the supervision of a registered nurse (RN) in a hospital or other healthcare setting. The LPN receives one year of education and training. Practical nurse graduates receive a diploma and take the state board examination for licensure.

• The registered nurse associate degree program is a two-year program offered at a community college. General education and nursing courses will transfer to other institutions of higher education. Associate Degree Nursing graduates take the state board examination for RN licensure.

• The registered nurse baccalaureate degree program involves four years of study at the university level. The program focuses on sciences, arts, nursing theory and clinical practice. Graduates receive a Bachelor of Science degree in Nursing (BSN). They also take the state board examination for RN licensure.

• The master's and doctorate in nursing degree programs are at the graduate level of higher education. These RNs can choose to focus in specialized practice, administration, education and/or research. Professional advanced practice nursing, i.e., the anesthetist, clinician, midwife, or specialist, requires education at or beyond the master's level.

Different levels of licensed nursing positions

• A LPN works in direct patient care under the supervision of an RN. Their scope of practice is limited in the area of medication administration, management, care planning, etc.

• A RN with an associate degree or a diploma works in direct patient care, often in a charge nurse or supervisory role.

• A BSN RN fills managerial positions in hospitals, clinics, and

community agencies.

• An MSN RN and a Ph.D. RN are in administrative, teaching, research

or advanced practice roles.

Area nursing programs

Certified Nurses Assistant (CNA):

• Petra Allied Health, Springdale, 756-6038

• Health Careers Training Center, Lowell, 659-5304

• Patient Care Assistant Plus (PCA+) Northwest Arkansas Community College, 619-4164

Licensed Practical Nurse (LPN):

• Northwest Technical Institute, Springdale, 751-8824, www.nti.tec.ar.us

Associate Degree Nursing (ADN):

• NorthWest Arkansas Community College, 619-4151, www.nwacc.edu/nursing

Baccalaureate Nursing (BSN); Master's of Science in Nursing (MSN):

• University of Arkansas, 575-3904, www.uark.edu

• University of Arkansas for Medical Sciences/AHEC-NW, Fayetteville, 521-8269

Information on other nursing schools in Arkansas and nationwide can be found at www.discovernursing.com.

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