Illinois Issues: Is Nursing Headed For Crisis Or Crossroads?

Oct 1, 2015

Many Illinois nurses are nearing retirement. Baby Boomers in the state are also aging and may need more care. Will there be enough nurses to meet the demand?

Lindsay Lundvall graduated with a Bachelor's degree in Nursing from Rockford University in May. After graduation, she moved to Madison, Wisconsin to complete a nursing residency. She plans to get a master’s degree there, too.

Lundvall does not know where she will end up after that. But she says she would like to come back to Illinois to work some day. “I would actually love to go back to Rockford Memorial after I’m done and work there as a manager or something like that on a unit,” she says. 

If a recent survey conducted by the Illinois Department of Financial and Professional Regulation is an indictor, Illinois might need her.

The survey, released in May, polled nearly 53,000 registered nurses as part of their license renewal process and found that many were planning to retire soon. The news release that went out to reporters with the survey warned that the state could face a shortage of nurses. 

Data from the Illinois Department of Financial and Professional Regulation's survey of registered nurses
Credit IDFPR

That warning was echoed in several headlines the day after the survey was released. But as is the case with many statistics, there is more to the story. Demand for nurses is difficult to estimate, and at least one other projection found that the state could instead have more nurses than it needs.

Whether Illinois finds itself with a surplus or a shortage, it is facing a mass retirement of nurses at the same time that the state’s senior population will be spiking, likely leading to a demand for more complex care.

Those two realities — as well as expanding roles for nurses and changes in the health care industry, both of which have been accelerated by Affordable Care Act — put the profession at a crossroads.

So, which is it? Will Illinois have too many nurses or not enough?

Of the registered nurses polled by the IDFPR’s Illinois Center for Nursing, 40 percent are 55 years old or older. Of that group, one third plans to retire in the next five years. According to the department, Illinois “may soon face a shortage of registered nurses, across all specialties, as an aging workforce readies to retire.” 

On the other hand, a 2014 report from the U.S. Department of Health and Human Services (HHS) estimates that by 2025 the state will have a surplus of 9,700 registered nurses. The department projects a national surplus of 340,000 by 2025.

Back in 2004, HHS had predicted a nationwide shortage. But the more recent report says the number of new nurses entering the workforce has more than doubled since the early 2000s.  HHS does estimate that 16 states could be in danger of shortages. Most of them are in the southern or western parts of the country. The report predicts that the Midwest as a whole will have more nurses than it needs by 2025.

So, which is it? Will Illinois have too many nurses or not enough?

Peter McMenamin, a health economist and senior policy fellow at the American Nurses Association, says that this conundrum is not uncommon. He knows of a handful of other attempts at predicting the future of the nursing workforce that have come up with what appear to be contradictory outcomes.

But he says the conclusions are actually not that far apart. In its projection model, one report might estimate demand as being slightly higher than another. When that difference is applied across a large group, like the number of nurses in a state or a country, that small variation in the models results in a large difference in the numbers they produce.

“Given the variability, I’m not surprised that some people project shortages, and some people project surpluses. They’re usually in the same ballpark, but because there are so many registered nurses, if you have a one or two [percentage point] difference in your estimates, that can put you on either side of the line. Is it a surplus? Is it a shortage?” he says. “Because of the history of shortages and the shortage-surplus dichotomy, it looks like there’s a lot of different opinions, when in fact the opinions are close. It’s just that they’re right at that particular threshold.”

He says it can be even harder for individual states to make workforce projections because it is difficult to predict in-migrations and out-migrations. “The state estimates are even more squirrelly because people come in from one or two states over.” The HHS projections do not even take such moves into account and instead assume that nurses will practice in the same state they were trained.

Nancy Valentine, associate dean for practice, policy and partnerships at the University of Illinois Chicago College of Nursing, thinks that predictions of nursing shortages spark attention from the media and the public because most people have received care from nurses in a time of need. “I think why people really pay a lot of attention to the nursing shortage is that the kind of care delivered by nurses is so critical,” she says. “People can really sort of feel the pain of not having nurses at the bedside, or nurses in community settings, or nurse faculty teaching students.”

Lundvall, who is president of the Student Nurses Association of Illinois until later this month,  says she and other student nurses are also concerned about the future workforce. “I worry about the safety for the patients. That’s not something you think about when you get hospitalized, that your nurses have four other patients or five other patients. But that ratio is kind of scary.”

Data from the Illinois Department of Financial and Professional Regulation's survey of registered nurses
Credit IDFPR

Even if Illinois does not find itself with an overall shortage, there will be shortages in some parts of the state. “Illinois is a big state, and you’ve got a lot of very rural areas, and you’ve got some major metropolitan areas,” says JoAnne Spetz, a labor economist and professor of Health Policy Studies at the University of California San Francisco. “What we usually see is that in the metro areas there are plenty of nurses, and sometimes some of the rural areas or smaller towns and cities might have shortages simultaneously.”

She says these areas have two options. They can offer nursing education programs locally, or encourage local access to online programs, so they can create a workforce that is more likely to stay close to home. Or they can try to recruit aggressively from urban areas.

Spetz says the need for more nurses in rural areas is not exclusive to Illinois or the United States. It’s an international problem. “It really doesn’t matter where in the world you go. You hear a similar thing whether you are talking about Ethiopia, or Thailand, or Canada or the United States: that nurses tend to end up in urban areas because that’s where the education is. That’s where their spouses can easily get jobs. And then the rural areas tend to have shortages.” There may also be shortages in certain specialty areas, such as psychiatric or home health care. 

Despite the dire warning from the IDFPR’s news release, those who work closely with the department say it isn’t time to panic, yet. “We’re not looking at a crisis situation at this point in time,” says Linda Roberts, manager of the Illinois Center for Nursing. But she says the retirement numbers are definitely a cause for concern.

Dueling projections aside, that cause for concern is something that all the sources interviewed for this story agreed upon. “We’ve known for more than a decade that the Baby Boomers are going to retire, and it’s going to be very tough for the nursing profession to have that many experienced nurses leave at once,” Spetz says. 

A sign in Springfield seeking nurses
Credit Jamey Dunn

One particular area of nursing has experts especially worried. Most of the respondents to the IDFPR study who work in education fell into the 55-years-old or older age category, meaning that they may be nearing retirement.  Illinois needs educators to teach the new nurses who would replace the soon-to-retire ones in the Baby Boomer generation. 

There are few financial incentives to go into nursing education. Generally, nurses working in clinical settings make more than faculty. “There needs to be more funding for nursing education and specifically better pay for nursing faculty,” says Alice Johnson, executive director of the Illinois Nurses Association. 

Valentine agrees.  “There is a large discrepancy in pay. … Workloads for faculty are high … and yet the pay is definitely lower than those that go into service. So your nursing graduate is looking at things like that. They are factors that they are certainly considering when they start to map their career.”

The IDFPR survey did find that fewer nurses ages 25 to 35 are entering doctoral programs. Lundvall, the Rockford University graduate, says she does not want to rule out the possibility of teaching. “I don’t want to say no,” says Lundvall, whose mother is a nurse educator. But, she says, “I really like working with patients.” Many young nurses have difficulty picturing work outside of a clinical setting and giving up the satisfaction that comes with providing direct care to patients.

Lundvall agrees that more educators are needed. “Education is a huge issue — trying to find people that want to teach.” But she says few if any of her peers are interested in the job. “Being in school, nobody wants to go and say ‘I’m going to teach it, too.’ … Maybe once we get experience, maybe people will have a second opinion on it.”

Young nurses like Lundvall are preparing for careers that could look very different than those of the Baby Boomer nurses who will be retiring in the coming years. A great number of people—often sicker and older—will need care.

More patients are entering the health care system as hundreds of thousands of Illinoisans now have insurance or Medicaid coverage under the Affordable Care Act, otherwise known as Obamacare.

According to the Centers for Disease Control and Prevention, half of all American adults have a chronic health condition as of 2012. One in four have two or more chronic conditions.

College of DuPage nursing students participate in a training simulation in 2013.
Credit College of DuPage

  The U.S. Census Bureau estimates that by 2030, 2.4 million people in the state will be 65 or older.  Spetz calls these patients a “wild card” when it comes to trying to predict future needs. “If I am going to use a general stereotype, as a generation they’ve been pretty proactive about their health,” she says of Baby Boomers. It’s the generation where women first had access to college sports. It’s the generation where there’s been a lot of attention to health and wellness.” She says that despite chronic conditions, Baby Boomers could have a better chance at living into their 80s and 90s, when health care needs “really ramp up.”

“We know the demographic trend. I think the piece that everyone is trying to figure out is how to take care of that aging population more effectively,” Spetz says.

The role of nurses is also changing. They are moving to settings outside of hospitals, such as in-home care and clinics in the community. Some of these positions require new skills and higher levels of education.

Valentine says that what some may view as an uncertain future, she sees as a positive for nursing. “In any industry when there are major changes going on, it really forces those people that are in that industry to come up with novel and new innovations in order to change and to adapt.” For instance, health care systems are seeking more care coordination to satisfy new regulatory demands and hopefully improve quality. Valentine says nurses are a natural fit for leadership roles in that transition because working in teams and coordinating care is such a big part of what they do now.

Advance practice nurses could also fill gaps in health care, such as providing mental health services to underserved areas, and offering primary care in areas that don’t have enough primary care doctors. “We’re hearing more and more in the news every day about the lack of mental health services for populations at risk. … It just seems to me it’s a glaring opportunity and case for having more of these nurses out there on the front lines, where they want to be.”

As all these shifts occur, a wealth of institutional knowledge will be exiting when older nurses retire. McMenamin says hospitals and other providers should be making plans to capture as much of that knowledge as they can before those experienced nurses go. “These people with 30 or more years of experience will walk out the door, and they won’t come back,” he says. “We can see the retirement wave coming. It’s not like it’s going to arrive in 2022, and all of a sudden, 500,000 nurses don’t show up for work.”

Spetz says hospitals are preoccupied with regulatory changes, including a move away from a set fee-for-service payment model. Instead, they face financial penalties for negative results, like infections picked up in hospitals, and incentives for better patient satisfaction and outcomes. “They’re trying to figure out what they’re going to do. And so in that environment, the idea of strategically thinking five years ahead about what your workforce needs are going to be seems to be the last thing that they’re considering.”

Both Spetz and McMenamin say that they have seen providers pass on hiring less experienced nurses in recent years, especially after the recession made the job market more competitive.  

“I don’t know if employers think that the experience fairy comes from the sky and just magically gives nurses experience, but there seems to be a reluctance to hire new graduates and recognize that there needs to be an investment in hiring newly graduated nurses,” Spetz says.

McMenamin suggests that hospitals reduce clinical workloads for nurses nearing retirement, making time for them to mentor new hires. He says hospitals should also hire a few more new nurses than they think they need. “If you treat these new nurses properly, you’ll be growing your own experienced work force. And because you treat them properly, they’re more likely to stay with you.”

McMenamin says projections of nursing surpluses can give health care administrators and policymakers a false sense of security. The HHS estimates, for example, assume that the current graduation rates will continue. But McMenamin says that increases in graduation rates have had a direct correlation to spikes in federal nursing education funding. So if funding was cut, the graduation rates would probably slip. Johnson, director of the Illinois Nurses Association, says potential cuts to higher education in Illinois could have such an affect on the state’s nursing schools.

“I liken this to a guy in a kayak in a whitewater rafting contest and [he’s] at the top of the course,” McMenamin says. “You can do it, but you can’t do it with your eyes closed. You can’t assume that the current in one section of the course is going to be the same as the other.”

Valentine has a more optimistic take on the future. “I see it as an absolute crossroads of opportunity … for people to come into the field of nursing. The shortage opens the door. It highlights the need. But I think that we’re getting some of very best-and-brightest people coming into this field across the country, and they are going to change the field just by being in it.”