Registered nurses (RN), licensed practical nurses (LPN), and certified nursing assistants (CNA) continuously rank among the most in-demand careers in Washington with exceptionally long vacancies. From 2019 to 2021 the average length of time it took to fill an RN vacancy in Washington hospitals increased by 54 percent—from 74 to 114 days. In 2021 hospitals alone needed 6,100 licensed RNs to fill their open positions. From 2014 to 2020, an average of 3,200 qualified nursing program applicants were turned away annually due to insufficient capacity in RN programs.
The Nursing Care Quality Assurance Commission (NCQAC) regulates the nursing profession in Washington by establishing, monitoring, and enforcing licensing, consistent standards of practice, continuing competency mechanisms, and discipline.
The NCQAC is currently making the following efforts to address the nursing workforce demands:
Skill centers are regional career and technical education (CTE) instructional venues established and operated by a host school district to provide access to comprehensive, industry-defined CTE programs that prepare high school students for careers, employment, apprenticeships, and postsecondary education. There are 17 skill centers in Washington. About 7,000 students attend Washington skill centers from high schools in approximately 85 school districts annually.
Expanding Nursing Credential Opportunities.
State Board for Community and Technical Colleges. Subject to appropriations, the community and technical colleges must develop a plan to train more nurses over the next four years with an emphasis on shortage areas such as rural communities. In developing the plan, the State Board for Community and Technical Colleges (College Board) must consult with health care employers, local workforce development councils, and exclusive bargaining representatives of nursing professions. The plan must prioritize expanding existing programs or creating new ones that: (1) create new capacity for training; (2) expand training opportunities for rural and underserved students; (3) demonstrate long-term sustainability; and (4) expand partnerships between employers and exclusive bargaining representatives. A report detailing the plan is due to the Legislature by December 1, 2024.
Subject to appropriations, the College Board must select two community or technical colleges, one on either side of the Cascade Mountains, to develop and implement an online LPN program. The curriculum may include use of a mobile skills lab or other innovative approaches to serve rural students.
The College Board must contract with a firm that has expertise in human resources consulting and health care to conduct a salary survey on nurse educator compensation. Results of the survey are due to the Legislature by December 1, 2025.
Workforce Training and Education Coordinating Board. Subject to appropriations, the Workforce Training and Education Coordinating Board (Workforce Board) must contract with a firm that has expertise in public relations and marketing to develop and execute a marketing plan about available training opportunities and jobs for CNAs, personal care aides, LPNs, licensed vocational nurses, and related nursing professions. The marketing plan must include targeted outreach to serve workforce needs in rural and underserved communities, as well as long-term care facilities.
The Home Care Aide to Licensed Practical Nurse Apprenticeship Pathway Pilot Program (Pilot Program) is created. The Pilot Program must be located in three geographically disparate sites during the 2023-25 fiscal biennium. The Workforce Board and the NCQAC jointly administer the Pilot Program in consultation with the Department of Labor and Industries. A report detailing the status of the Pilot Program, options to expand, and barriers faced by current and prospective participants is due to the Legislature by August 1, 2025.
Eliminating Bottlenecks in Nurse Training.
Nursing Care Quality Assurance Commission. The NCQAC is permitted to grant approval to bachelor degrees in nursing programs where the nurse administrator holds a graduate degree with a major in nursing and sufficient experience as an RN but does not hold a doctoral degree.
The NCQAC must count one hour of simulated lab learning as two hours of clinical placement learning up to 50 percent of the required clinical hours for nurse licensure.
Subject to appropriations, the NCQAC must expand the Student Nurse Preceptor Grant Program to provide incentive pay to nursing candidate clinic supervisors with a focus on shortage areas such as rural and underserved communities and long-term care facilities. Increased clinic opportunities must be achieved, in part, by reducing the required number of qualifying hours of precepting clinical instruction from 100 to 80. A report on the outcomes of the grant program is due to the Office of Financial Management and the Legislature by September 30, 2025.
Growing Kindergarten through Grade 12 Pathways into Healthcare Credentials.
Career and Technical Education Grant Program. Subject to appropriations, a competitive grant program to support high school Career and Technical Education programs in starting or expanding offerings in health science programs is created. The grant program is established and administered by the Office of the Superintendent of Public Instruction, which must consult with the Workforce Board and the Washington State Apprenticeship and Training Council in developing award criteria. Priority for grants is given to applications that include partnerships between employers and exclusive bargaining representatives as sponsors or cosponsors. Grant funds may be used to purchase or improve curriculum, add additional staff, upgrade technology and equipment to meet industry standards, and for other purposes intended to initiate a new health science program or improve the rigor and quality of an existing health science program.
High School Certified Nursing Assistant Pilot Projects. Subject to appropriations, at least two High School Certified Nursing Assistant Pilot Projects (Pilot Projects) are established at rural hospitals on either side of the Cascade Mountains to address the workforce shortages and promote nursing careers in rural hospitals. The Pilot Projects utilize high school students who are training to become nursing assistant-certified or high school students who are nursing assistant-certified by, in part, providing information about related careers and educational and training opportunities including certified medical assistants, LPNs, and RNs. The Pilot Projects are established by the NCQAC in collaboration with rural hospitals, relevant employer and exclusive bargaining unit partnerships, nursing assistant-certified training programs, the Department of Health, and the Department of Labor and Industries. A report on the status of the Pilot Projects is due to the Legislature by December 1, 2024.
(In support) According to the Employment Security Department, nursing is the most in-demand job in Washington and per the American Association for Colleges of Nursing, we need 200,000 more Registered Nurses (RN) 10 years from now. Yet, we saw an unprecedented loss of 100,000 nurses from 2020-2021. More than half of the state's counties have listed nursing as the most solicited job. The Washington Center for Nursing states that an average of 2,600 people graduated from registered RN programs in the state from 2014-2019, but close to the same number are expected to retire through 2029. Thus, we are simply replacing the nurses in the workforce, not growing the workforce. And while the Legislature added 220 nursing education slots last year, it is still not enough to meet current needs. There is no single solution: we must retain the existing workforce, attract new nurses to the state, and graduate new nurses. This bill addresses the underlying problems impacting the nursing workforce shortage and expands capacity at two- and four-year institutions.
This bill addresses two of the most commonly referenced barriers to expanding nursing programs. The first is allowing nursing directors with a graduate degree but not a doctorate to run Bachelor of Science Nursing programs. Colleges have difficulties recruiting administrators statewide, but this issue is especially prevalent on rural campuses. The second is the 1-to-2 clinical hour simulation ratio. Securing clinical placement is a challenge especially when our healthcare providers are so overextended. This is particularly challenging in rural areas, where many hospitals have been forced to close entire units due to lack of staffing. Allowing for one hour of high-quality simulation to count as two hours of clinical site placement relieves some stress and allows for growth in programs without compromising education for students. Simulation learning fills a vital gap and focuses learning in a very concentrated way. Unlike in-person learning where students learn at a slower pace, best practice in simulation demands labor-intensive small groups of four to five students. For example, a student can go through five cardiac arrest simulations in one hour, where in a hospital it could take up to six months to have that experience. On the other hand, while simulation is great in terms of increasing the workforce, a lot of nurses that earned their degree in part online due to COVID-19 had a long delay in being able to work independently.
Two chief executive officers at local hospitals state that they are losing $1 million per day because they have to bring in traveling nurses, which also impacts their ability to house students and provide clinicals at their hospitals. For nurses who have extensive experience and are qualified to teach, it is financially infeasible to do so because they earn a better wage working as a nurse than they would teaching.
The bill requires a comparison of faculty salaries of the community and technical colleges but not the universities or clinical salaries. There is about a $50,000 difference between faculty salaries and clinical salaries. Many nurses are leaving faculty positions and transitioning to clinical positions. The bill also states that the preceptor grant money would be awarded to clinical supervisors, but this should say clinical preceptors. Clinical preceptors are the ones helping the students; clinical supervisors are employers.
(Other) This bill falls largely outside of the Governor's budget. Proposed components of this bill are currently already in process as part of the 2022 budget: the Home Care Aide Nursing Assistant Certified to LPN Registered Apprenticeship Program Development and a broader long-term care workforce initiative, which are both working toward policy recommendations that will ultimately improve patient quality of care. This bill is a great opportunity to promote healthcare careers in long-term care, especially for rural and underserved communities.
(In support) This bill will increase the pipeline of nurses into the profession. In addition to the investment made in the budget, there will be an increase of 200 full-time equivalent nursing enrollments that will help colleges step up to address nursing shortages.