Jason Altmire (00:04)
According to federal workforce data, there's almost 200,000 registered nursing job openings every single year. And on average, one of every 10 RN positions in the US is unfilled. And we're going to drill down on that very issue on this episode of Career Education Report. I'm Jason Altmire, and today for our guests, have Susan Mayer. She is the chief learning officer.

for achieving the dream, which is a very important organization in higher education. She's doing incredible work on the nursing shortage. And Susan, thank you for being with us.

Susan Mayer (00:44)
Thank you for asking me to join you today to talk about this important topic.

Jason Altmire (00:49)
Maybe we can start by talking about Achieving the Dream. It's an organization that works with community colleges. I see you and others quoted in the news very often about different issues. Maybe tell the audience a little bit about what the organization does.

Susan Mayer (01:04)
Achieving the Dream is a nonprofit organization that supports approximately 300 community colleges across the country, rural, urban, large, small. We've been in existence for slightly over 20 years, and we support senior leadership teams at the college to transform the way they do business. So initially that was to make sure that students had opportunities to engage in post-secondary education.

Over time, our focus shifted to making sure that students earned a credential. And most recently, our focus has been on earning a credential that has labor market value. And so we work with the colleges to help them build capacity to do transformational work at large scale and sustainably. So one of our competitive differentiators is that we coach college teams to be able to do this work for the long haul and at very large scale.

really building vibrant communities in which they serve.

Jason Altmire (02:05)
How would a community college become involved in the work that you're doing at achieving the dream? Because there's an organization, of course, the National Association for Community Colleges is the American Association of Community Colleges. What's the difference between the work that they're doing and then the work that you're doing, which is my understanding is more selective of the type of community colleges that you work?

Susan Mayer (02:30)
Well, at a base level, they're a membership organization, and we're not. We're a network of colleges. And colleges choose to participate in the Achieving the Dream Network because they get this coaching and other types of support. So there are peer learning opportunities for colleges. And the primary difference is that American Association of Community Colleges does not currently and has not for a while provided coaching support.

to help colleges build the capacity to do the work that I was talking about. But I think it's also fair to say that there are a number of us, the Community College Research Center, Complete College America, the Aspen Institute, along with AACC, that all work as partners in the Student Success Reform Movement and have for 20-some years.

Jason Altmire (03:15)
And I mentioned the nursing shortage, you in particular as an individual at Achieving the Dream has worked extensively on the nursing shortage. And we've all seen the statistics. I quoted a couple of them at the beginning of the show. But in addition to that, just the demographics, both of the country and of nurses themselves are not on our side. Because America's population is aging very rapidly.

I've seen that by the end of this decade, the entire baby boomer population, 73 million Americans are going to be age 65 or older. So that's going to increase demand for healthcare services, especially the more complicated and expensive healthcare needs. And then at the same time, nurses today, the average nurses in her early fifties and about 40 % of nurses I saw in a survey are thinking of leaving the profession.

within the next five years. So when you add that on top of that 200,000 vacancy that already exists, maybe we need to start thinking about that as a country and taking action to prevent that from happening rather than reacting years from now when it creates a problem. talk a little bit about if you would, what the consequences are of the nursing shortage and what we can do to get out of it.

Susan Mayer (04:39)
So I think there's a couple of factors there. also had, in addition to the statistics you're citing, we had a real exodus of nurses in the COVID post-COVID period of time when I think we lost something like 100,000 nurses in a year, 18 month period of time. And most of them were 35 or younger, which doesn't help the nursing population point that you made. I think there is an estimate that there are 65 to 70,000 open positions right now. And part of the

problem has been, regardless of which level of nursing you're talking about, that there have been capacity constraints on the number of people who can enroll in nursing programs. So when I first started this work, I was surprised to learn how small nursing programs at many institutions are. Even among the community colleges that are very large and very place-based and play an important role in the local communities generally have small nursing programs. So there have been some mindset issues historically about how many people are

prepared to become nurses, what it takes to become a nurse. And that's exacerbated by the fact that there are clinical rotations as part of a nursing program and there's been a dearth of faculty trained to do those clinicals. So some of the ways to solve the problem are adding seats into programs and that can be done through innovations like Pierce College in Washington state that added a part-time nursing program. ⁓ It can be accomplished by using technology. So during COVID,

colleges increase the amount of technology they use for simulation. So mimicking what went on in a hospital clinical, for example. And what we've learned over time is that the clinicals not only expand capacity, but they also are really good adaptive learning technology and help people learn better and retain what they're learning. So really changing the situation requires a number of different factors. It's a mindset shift about how large nursing programs can be and who's

who's suited for those nursing programs or who we should be recruiting to those programs. It's changing the way we teach. It's streamlining programs to remove prerequisite requirements or courses that aren't necessary that enable more people to complete more quickly, thereby opening up more spots at the front end. Using technology to help people complete at higher rates. And then supporting students, particularly adult students coming back to colleges.

with the supports they need to be successful, which include things like credit for prior learning where people who have been, for example, licensed an LPN nurse or a CNA nurse can get credit for some of that work so they can streamline their and accelerate their journey through an R in program, for example.

Jason Altmire (07:24)
That is one of the issues that has been in the news quite a bit related to the nursing shortage is that you mentioned CNAs and LPNs. I would put medical assistants in the same category. People who have worked in healthcare have been in that setting in some cases for decades. People who've been at it for a really long time, but they're unable to make that next jump. They would like to be a nurse. They would like to pursue nursing school.

achieve the education that's required and then become a nurse, but they can't. And there are systemic barriers that are preventing them from doing so, logistical barriers, financial barriers. Can you talk more about how we can get around that issue and move some more of those very highly qualified people onto a nursing track?

Susan Mayer (08:12)
A large percentage of students who you're describing are what we call adult learners. So they are 25 years or older, and they very often have a number of different responsibilities that they're balancing. They're parenting students, they have other family responsibilities, they're working in their field already. And so New America pointed out that the root cause of the inability of a of these trained professionals to move forward is the lack of flexibility in historical nursing programs.

And so thinking, this goes back to the mindset issue I was talking about before, thinking about what do we need to do to meet the needs of the students as opposed to how do we get the students to meet the needs of our institution? So this is a big issue for community colleges overall, not just for nursing students, as our population changes and significantly more adults are coming back to engage or to complete their post-secondary education.

Institutions historically have been designed for students coming directly out of high school. And those structures and the policies and the practices, even the way we teach, are ideal for a lot of adult learners. And so we have to interrogate the whole way we provide higher education for nursing programs if we want to change that dynamic that you're referring to.

Jason Altmire (09:25)
It's a misconception among some that the shortage is driven by a lack of interest in nursing among students. And I know you're aware that is certainly not the case. And when you look at the number of qualified applicants that are turned away every year by schools across the country because they lack the capacity to accept those students, that is a big issue. And you mentioned clinical training slots and

the problem with filling those slots because they are so competitive. So you have students that get into a very, very highly selective program and then they have to get in for their clinical training slot, which is also very highly selective. What can we do to increase the number of clinical training slots and why is there such a dearth of them in the country?

Susan Mayer (10:17)
Well, historically, clinicals have required what's called a clinical preceptor, someone who can supervise the students while they're doing their clinicals. And those people typically are required to have a master's or higher credential in their field. And they historically, at least, have typically been in hospitals. So there was a limited supply of them. But as the health care environment overall changes, and we're seeing a move out of hospital-centralized settings to more community-based health care, we're seeing

technology that allows advanced procedures to occur outside of the hospital. We're opening up new opportunities so clinicals can take place in various settings in the community as well as the hospital. We're seeing a move towards thinking about clinicals on a 24 by 7 basis. So historically they've been occurring during the business day. And so we've seen several of our colleges expanding night and weekend clinical rotations. And then there's the use of technology and the

The beauty of simulations as a way to solve the capacity limitations for clinicals is that they allow students to have access to situations that they may not see in the hospitals. So for example, technology will enable multiple organ systems to fail at the same time or require comorbid things to happen at the same time, which you may not see in a hospital clinical rotation. They also enable

Students have access to clinical experiences that are no longer open in hospitals because of some health care regulations. So not all states allow nursing students into OB-GYN, for example, but you can do that in technology. So the combination of a more diverse set of clinical places expanded clinical opportunities within the historical hospital setting and then the use of technology.

should have over time a significant impact on opening up the number of students who can enroll in nursing programs.

Jason Altmire (12:16)
When you talk about the use of technology, when you think about hybrid and online programs, they've taken hold all across higher education and nursing should be no different. What is the benefit to the students' learning experience of those online and hybrid experiences and how do they relate to the students' educational opportunity before they move into a clinical setting?

Susan Mayer (12:41)
I mentioned earlier that a lot of our ⁓ nursing students, particularly those that are on a pathway where they're moving from an entry-level credential to a higher level, higher mobility, higher wage credential, many of them have multiple responsibilities, some of which could include parenting, for example. And so a hybrid environment gives a student an opportunity to make up a class that they may not be able to attend in person. It enables students who are working

during the day when some classes are only offered to be able to take those classes in the evening. It's a complicated or complex set of factors, however, because the data shows that certain courses or certain sequences of courses in the nursing pathway or in any educational pathway work well or work better in an in-person situation. So we know, for example, that entry-level math and English.

students are more successful when they take those gateway courses in a in-person environment. And then as they build up additional skills and confidence, they do find in many cases in online environments. And so what we're seeing is after COVID, we went all to online and we did an excellent job of pivoting. We've learned a lot over that period of time. And so now we're being much more discerning about which courses or which parts of courses

are best delivered to which groups of students in an online environment versus an in-person environment and providing students with the advising support they need to make informed choices about that.

Jason Altmire (14:15)
At Achieving the Dream, you work with high performing community colleges, those who wish to be transformational, take a futuristic look and operate with a sense of urgency on a lot of these issues. How would you describe the difference between a higher quality school to serve as a model, a school that's doing it the right way? And what advice would you give to other types of schools to look for?

when they're thinking about nursing education and how to make sure they're maximizing the efficiency of their program.

Susan Mayer (14:50)
Well, I would say that colleges that stand out as exemplars of high impact practice are doing a number of things. They use data and they disaggregate the data and they look at the data to make sense of why they're seeing different levels of performance or different types of performance for different student groups. And they use that evidence to inform the strategies and the interventions and the changes that they make to their structures and policies and practices. They also build capacity in several areas, leadership.

teaching and learning. ⁓ They're organizationally agile. They are really disciplined at execution. They're well connected in their communities. And they approach this from a whole college or a whole community perspective as opposed to student success as a project or an initiative. It really becomes part of the way they do that work. They're also innovative. So they're willing to take some risks to think about.

designing curriculum a little bit differently or providing supports to students. So in the, you referenced earlier some of the nursing work that I've been involved with over the last couple of years, some of those colleges realized that students would benefit from thinking about financial incentives differently. So instead of just providing stipends for books or for transportation, tying it to some changes in behavior. So making sure that students were getting the academic and non-academic supports they needed to be successful.

and tying the incentives to it. So thinking a little bit outside the box about what mentoring, what supports are needed for students to be successful and how students who are taking college courses in high school could be really different from adult learners who are 25 or 35 and coming back and what that means for curriculum and supports.

Jason Altmire (16:35)
Speaking of the high school demographic, what is the benefit of early exposure to a nursing career? Because folks in high school were thinking about what they want to do when they grow up, what type of college they want to go to, or education that's interesting to them. How do you entice people, get them interested in nursing as a career when they're in high school?

Susan Mayer (16:58)
Some of the potential lack of interest is driven by lack of information. So sometimes you don't know what a job entails if you don't know someone who does it. So part of ⁓ the beauty of outreach to students, not just in high school, but in middle school, is exposing them to different career pathways, ⁓ nursing, other fields within nursing, because the problem we talked about earlier, which is ⁓ limit on number of seats available.

is not gonna go away overnight. So there are lots of other medical fields or allied health fields that also have strong mobility pathways and could be of interest. But if students, potential students don't know about them, they're not gonna think about an opportunity to do phlebotomy or to do EMT or something else. So part of the advantage of working with students in high school is to give them the information about what you can do in a healthcare profession.

But it also is getting them onto a pathway while they are in high school. So roughly 30 % of the students enrolled ATD network colleges are students who are still in high school, who are taking college level courses through dual enrollment or early college high school programs. And so if they have an early exposure to nursing education or nursing career pathways, they can take some of the courses in high school.

that prepare them for or that satisfy the prerequisite requirements for nursing programs. So when they graduate from high school, they're ready to immediately go into the selective admission part of the nursing program. Some of our colleges that we've been working with have very clear pathways where students can earn LPNs or CNAs in high school at the same time they graduate and then immediately go into at the community college and RN program. So it really is an effective on-ramp. It reduces the overall cost.

of nursing education, which is a factor in enrollment as well. And it enables students to have a greater sense of belonging. They see themselves in a nursing career because they've gotten some of this work under their belt already.

Jason Altmire (19:02)
I think to close, let's talk about one of the questions that I get most often when I'm out there speaking about these issues is folks don't necessarily understand the difference between a CNA, LPN, an RN, associate's degree, a bachelor's degree. What are the different levels of nursing and how do they in the workforce, what are the differences of the jobs that they're doing?

Susan Mayer (19:29)
So, CNAs and LPNs do not require a degree. They have a credential, but they have a certificate type of a credential. They have documentation that they've completed, structured sequence of courses that provide them with a certain set of skills. RNs have either an associate degree or a bachelor's degree or an associate and a bachelor's degree. So, the credentialing levels, the licensure exams that they're required to be able to work in their field are different.

So CNAs, you see CNAs and LPNs in nursing homes, in non-hospital settings. You see them very often. Hospital settings in, they're doing the entry-level nursing work, whereas the RNs are doing the heavier duty, the dosing, the medication administration. So it's a spectrum. There's historically been the thought that LPNs need to work for several years before they become RNs.

And that's another one of sort of the old wives tales in the nursing field. And what we're seeing very successfully in a number of areas with nursing shortages is a pathways directly from LPN to an RN. And the difference in salaries is about 25, $30,000. So it's a significant mobility improvement.

Jason Altmire (20:44)
And then when you get above that baccalaureate level, that's where you get into the instructors for clinical slots, the faculty at schools, right? That's what would be expected as a degree requirement to hold those roles.

Susan Mayer (21:00)
Right, and also nurse practitioners have master's degrees. you if you start, think that's the top of the spectrum for nurses. And several nurse practitioners not only have master's degrees, but some of them have PhDs as well. Faculty at nursing institutions, especially directors of programs, have master's and are PhDs.

Jason Altmire (21:21)
I said the previous question was the last question, but this really is. If you were testifying before Congress or you were giving a speech on how to solve the nursing shortage, the actions that would be most influential and important in addressing this crisis, what would be your recommendations?

Susan Mayer (21:40)
I would say open up more slots at the front end of the funnel, number one. Number two, streamline the programs, not sacrificing any of the skills development that is required, but really taking a hard look at whether the historical curriculum meets the needs of the evolving health care market. There are additional skills. For example, nursing is becoming an increasingly collaborative position where nurses have to work with a number of other health care professionals in solving

complex medical histories, so making sure that there's room in the curriculum for that. And then really understanding the needs of students to be successful. So when we started the work, we heard very often from the colleges and the nursing faculty in the colleges that the biggest challenge was the mindset change, that we needed to move from, let them fail to we need to help them succeed. So in addition to opening up more slots, really thinking about curriculum and the support services that wrap around the instructional.

work in a way that builds confidence, builds belonging, and enables students not only to enroll, but to accelerate and complete their credentials.

Jason Altmire (22:49)
If somebody wanted to get in touch with you or learn more about achieving the dream, how would they do it?

Susan Mayer (22:55)
So I can be reached by email. It's S. Mayer, M-A-Y-E-R, at achievingthedream.org. And love to have a conversation with anyone to follow up or understand some of the innovative work that they're doing.

Jason Altmire (23:09)
Our guest today has been Susan Mayer. She is the Chief Learning Officer at Achieving the Dream. Susan, thank you for being with us.

Thanks for joining me for this episode of the Career Education Report. Subscribe and rate us on Apple Podcasts, Google Play, Spotify, or wherever you listen to podcasts. For more information, visit our website at career.org and follow us on Twitter @CECUED. That's at C-E-C-U-E-D. Thank you for listening.