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Outsourcing Nursing Education

With nursing schools in California falling several thousand graduates short of meeting demand each year, state labor officials are seeking help in an unlikely place.

If all goes as planned, as many as 40 bilingual Californians now stuck on nursing school waiting lists will begin classes in January at a college in Guadalajara, Mexico – apparently the first attempt by any state to outsource nursing education to another country.

Program supporters say it’s a reasonable way to train more Californians, especially those who can work in communities that need more Spanish-speaking health care workers.

“The concept is meant to be a niche solution,” said Stephanie Leach of the California Labor and Workforce Development Agency, which is developing the program.

Some critics, however, worry that nurses trained in Mexico won’t learn the same skills – especially those involving technology – as their U.S.-educated counterparts.

“Wouldn’t it be better to take those bilingual (students) and help them get into nursing school here?” said Lorie Shoemaker, chief nurse executive for Palomar Pomerado Health District, the operator of two North County hospitals. “I think the money could be better served keeping it here at home.”

The Mexico program is the latest of numerous attempts – some unorthodox – by the state and the health care industry to address what has become a chronic shortage in nursing school graduates.

California’s 117 nursing programs graduated 7,528 students in the 2005-06 school year, according to the state Board of Registered Nursing. That number fell short of meeting the state’s annual demand for new nurses by 3,382.

The need for nursing graduates is expected to increase as more baby boomer nurses reach retirement age and their aging cohorts require more hospital services. California will need an average of 10,910 new registered nurses each year through 2014, according to the state Employment Development Department.

Serena Steinke, a third-semester nursing student at San Diego State University, wanted to be a teacher when she was younger but decided she could make more money and have more job opportunities as a nurse.

“It’s a very stable occupation,” she said.

In San Diego County, there is a need for 847 new nurses each year, but San Diego and Imperial counties together only graduated 739 nurses last year. Nursing employment in San Diego County is expected to grow to 22,460 by 2014.

That demand and an average salary of $67,524 for registered nurses in San Diego have made nursing the “hottest” profession in the county, according to the EDD, the agency that tracks employment trends in the state.

Like Steinke, many Californians see the opportunity and are flooding the state’s nursing programs with applications. The number of qualified people applying to nursing school in California has nearly tripled in the past six years to 28,410 last year, according to the Board of Registered Nursing, the agency that tests and licenses nurses.

But last year 61 percent of qualified applicants were rejected, largely because the state’s schools didn’t have room for more students. In San Diego and Imperial counties, schools turned down 65 percent of the 2,862 qualified applicants.

Many of the 12 nursing schools in San Diego County lack the funding to expand nursing classroom space, and those that have the money often can’t find enough instructors to add more classes, say nursing school officials. Academic wages haven’t kept pace with rising salaries in the clinical world, said Catherine Todero, director of SDSU’s School of Nursing, the largest training program of its kind in the county with 670 students.

“It’s not just a matter of putting 10 more chairs in a classroom,” Todero said. “You have to find people who are experienced in order to teach. And experienced faculty wages really haven’t kept pace with the wages” in the clinical health care world.

Salaries at SDSU range from $60,000 for an instructor with a master’s degree to $65,000 for one with a doctorate, Todero said.

An experienced registered nurse working in a senior role in a San Diego hospital can earn as much as $94,000 a year, said Jennifer Jacoby, chief nursing officer at Sharp Memorial Hospital in San Diego.

Lacking a large enough pool of newly graduated nurses, hospitals make up the difference by hiring foreign nurses or traveling nurses on temporary assignment. Those options are expensive and sometimes impractical. The cost for employing a temporary nurse can be triple the cost of an experienced staff nurse. A foreign nurse can be equally expensive and spend as long as two years waiting for immigration approval and taking makeup courses to become eligible for U.S. licensing.

As a result, state officials have made boosting enrollment at nursing schools a top priority. Two years ago, Gov. Arnold Schwarzenegger launched Nurse Education Initiative, a broad effort to funnel more public and private money to universities offering bachelor and master’s degrees in nursing and to community colleges offering two-year associate degree nursing programs.

The initiative has produced $129.8 million in additional spending on training new nurses, said Paul Feist, a spokesman for the Labor and Workforce Development Agency.

Hospitals also are chipping in. In San Diego County, hospitals have contributed more than $4.7 million to fund additional classroom faculty, clinical instructors, classroom space, high-tech patient simulator laboratories and student financial assistance.

The biggest single donation came from Palomar Pomerado Health, which donated $2.6 million to California State University San Marcos for the creation of a four-year nursing program.

It opened in the fall of last year with 44 students in 15,000 square feet of converted classroom space in a medical office building owned by PPH near campus. Sixty more students entered the program this school year, said PPH spokesman Andy Hoang.

The district is hoping to benefit directly from the investment, said Shoemaker, the district’s chief nurse executive. PPH will need at least 200 more nurses by 2011 as it builds a new hospital in Escondido and expands Pomerado Hospital in Poway, she said.

Nursing students who attend classes close to the PPH hospitals and do some clinical work at the facilities are more likely to seek jobs at the hospitals when they graduate, Shoemaker said. Funding the startup of the new program at San Marcos “was clearly in our best interest.”

Scripps Health, which operates five acute hospitals in the county, has contributed more than $1 million since 2005 to local nursing schools, said Scripps spokesman Stephen Carpowich. The money created space for 145 more students and supported 50 foreign nurses who took extra courses through Grossmont College’s Welcome Back program to qualify for a U.S. nurse’s license.

Other hospitals are turning to the Internet.

Sharp HealthCare has teamed up with the University of Oklahoma to offer an accelerated nursing program to people who have bachelor’s degrees in other fields. The classroom part of the 14-month program will be taught online, and clinical work will be done at Sharp’s seven hospitals in San Diego County.

Students who complete the program will graduate with a bachelor of science degree in nursing from OU’s College of Nursing in Oklahoma City.

Sharp is hoping the program will tap into the large supply of people with science and technology degrees who work in the region’s sizeable bio-technology industry and might want to change careers, said Jacoby, the chief nursing officer at Sharp Memorial. “We thought these people would make ideal candidates to take care of patients in our organization,” she said.

The program was launched last month with 24 students, Jacoby said. OU already has filled about half the 72 slots for the semester that starts in January, Jacoby said, and the program has generated more than 2,000 requests for information over the Internet.

In terms of innovation, however, the California Labor and Workforce Development Agency’s plan to ship nursing students to Mexico stands out.

Some overseas nursing schools have begun recruiting American students individually, but the California program appears to be unique, said Robert Rosseter, spokesman for the American Association of Colleges of Nursing in Washington. “I’ve not heard of anything that comes close to that,” he said.

The program, which could begin as soon as January, will be open to students who speak English and Spanish and are waiting to be admitted into a California nursing school program, said Leach, the workforce development agency’s assistant secretary for policy and program development.

The students will spend their first year attending classes and doing clinical work in Guadalajara, which is Mexico’s second-largest city with a population of 3.6 million. They will return to California for clinical training before heading back to Guadalajara for their final year of studies.

Once they graduate, the students could be required to work for a period of time – possibly two years – in a bilingual community in California where their language and health care skills are most needed.

The students will attend classes as a group, and they will be accompanied by American faculty mentors.

The cost for educating and housing each student in Mexico will be about $20,000, or about half the cost of providing the same education in California, Leach said.

Some important details remain unresolved.

The agency hasn’t worked out how to pay for the program, though Leach said funding sources likely will include the state, private contributors (such as hospitals) and the students whose fees will be “nominal.”

The agency is considering two colleges in Guadalajara to host the program, said Leach, declining to name them.

It’s also unclear how the students will be treated by California’s nurse licensing board once they graduate.

Many foreign-trained nurses must do extra course work in California before being permitted to take the nursing license test because their overseas transcripts don’t comply with state academic standards, said Heidi Goodman, assistant executive officer of the Board of Registered Nursing.

Leach said developers of the Guadalajara program are hoping their graduates will automatically qualify to sit for the license test, but that still has to be worked out with the Board of Registered Nursing.

The nursing board is scheduled to discuss the Mexico program Thursday during its regular meeting in Los Angeles.

As part of the process of judging the quality of the program, the work force development agency sent a team of five evaluators to Guadalajara in April, Leach said. The team spent five days reviewing the curriculum, shadowing instructors, meeting school administrators, and exploring housing and transportation options.

Not everyone sees the program as an answer to the state’s shortage of nursing graduates.

“Why there and not here?” asked Sally Brosz Hardin, dean of the University of San Diego’s Hahn School of Nursing and Health Science. “Why not provide the resources to provide the faculty we need and pay them what they deserve, so that we can educate the students here?”

Leach said the program’s funding requirements will be minimal and will do nothing to slow efforts to boost nursing programs in California.

“It represents the out-of-box thinking that is going on to address this problem,” said Feist, the work force development agency spokesman.

The program is an indictment of the state’s commitment to maintaining an adequate work force of nurses, said Donna Fox, a regulatory policy specialist for the California Nurses Association.

“This illustrates very dramatically how underfunded California’s nursing education system is,” she said. “We think it’s a real shame that prospective RN’s can’t get educated in their own communities.”

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