Indiana doesn’t have enough nurses to meet growing demands, with thousands of openings across the health care industry. By the end of the decade an estimated one-in-four Hoosiers will be retirement age or older, a population that has more health needs and more complicated care.
Estimates predict that Indiana would need an additional 5,000 nurses by 2031, equal to graduating an additional 1,300 nurses each year until that time, according to the Indiana Hospital Association.
A nationwide nursing shortage has spurred states to take action, with some investing $125 million to lure students to the profession and other states providing a living allowance alongside child care benefits.
In Indiana, those types of add-ons are still in the hands of employers and legislator attention remains fixed on widening the pipeline of students and adding licensing flexibilities.
Building upon the passage of a 2022 nursing bill, House Bill 1259 seeks to continue expanding the nursing workforce by addressing foreign-educated nursing licensure requirements and on-the-ground training.
“We changed policy a couple of years ago … and then we found that these bottlenecks still existed,” said Rep. Brad Barrett, (R-Richmond) the author. “I think it’s great, legislatively, to put something in place, watch it in action, identify a couple of bottlenecks and then address those. (House Bill 1259) was just following up on this real intent to increase the nursing workforce.”
House Bill 1259 details
While most of the bill received glowing support in testimony, one issue was a bit of a sticking point for nurses working in clinical settings: language striking minimums for preceptors, or licensed nurses supervising students during rotation. Previously, preceptors needed 18 months of experience before they could be drafted to teach and mentor the next generation.
The new law has no minimum requirement.
Rep. Cindy Ledbetter, (R-Newburgh) a nurse practitioner with a doctorate, cautioned against the move, saying unprepared nurses would be given to students to address a shortage.
“My concern is you have a brand new nurse and the hospital requires them to precept and they’re not ready to translate what they’ve learned in the classroom themselves into a real-world scenario,” said Ledbetter, R-Newburgh. “(I’m concerned) that we’re going to … lose more nurses on the other end.”
Barrett said that it was in hospitals’ and other employers’ best interest to identify and assign good preceptors, not just anyone with 18 months of experience.
“Does period of time served automatically qualify you to be a good preceptor? I think quite the contrary; I think preceptors should be chosen by merit and not by time,” said Barrett. “I think it opens up the field … you could be in any profession for five years and not be a good preceptor. You can be in the game for six months and be a wonderful preceptor.”
“This is a may provision that gives the hospitals the ability to pick the right person for the right situation,” he continued.
On the other hand, foreign-born nurses help ease the shortages for some health care providers but recruitment can be lengthy and expensive, especially under a federal visa regression that delays processing and limits applications.
State barriers include requiring an English proficiency exam — even when an interview and clinical examination determine fluency — and using CGFNS International, Inc. as the sole entity to review visas when other states rely on multiple credentialing organizations.
The language on foreign-educated nurses has already been approved by the Senate in a separate omnibus health care bill.
Matilde S. Upano, a registered nurse and president of the Philippine Nurses Association of Indiana, said CGFNS reported that 60.8% of their nearly 27,000 visa screenings are Filipino. She testified in support of both the Senate and House bills addressing foreign-educated nurses.
“We really need to streamline the licensure requirements for foreign-educated nurses. Right now, we have a critical shortage,” Upano said in the Senate. “We have to compete with 50 other states to recruit nurses to Indiana. If we have them come in sooner, then we would be in a better position to ease the shortage and have qualified nurses who will deliver safe (care) to our Hoosiers.”
Challenges for nursing homes
Nick Goodwin, the director of government affairs for the Indiana Health Care Association/Indiana Center for Assisted Living, said the domestic supply of nurses isn’t meeting the needs of long-term care. Because of that, providers might spend thousands of dollars recruiting foreign-educated nurses.
“We look to international nurses to make a multi-year investment in bringing them over here,” Goodwin said. “You also get a commitment for the length of their visa that they’re going to work for you. Now, does everyone fulfill that? No … but the retention and the stability there is greater than just the market variables.”
Working in long-term care comes with its own drawbacks. While nurses employed in the field can create lasting relationships with residents and their families — unlike temporary stays in hospitals or clinics — the reality is that patients age and die or can even decline mentally and become abusive.
COVID-19 also pushed an unprecedented number of nurses to seek other careers. Nearly every other industry — from hospitals to outpatient centers — have recovered from their pandemic losses when comparing their current labor force to February 2020. Nursing facilities, however, are still 7.4% lower (equal to roughly 3,500 employees) than their staffing levels from February of 2020, according to the Bureau of Labor Statistics.
Goodwin noted that while entry-level nursing jobs in nursing homes aren’t minimum wage and have increased wages in recent years, the $20-25 hourly wage is still competing with other industries like hospitality and warehousing jobs that offer similar pay.
As an added layer of difficulty for nursing homes in particular, the federal government is in the process of instituting staffing mandates for long-term care facilities. Goodwin observed that several roles were excluded from such counts despite their experience, including nursing directors.
“We’re not opposed to the idea but the implementation is not where it needs to be,” Goodwin said. “It’s an unfunded mandate, in short, and it does nothing to actually support us in our workforce needs. It just adds more regulation.”
Continuing education for nurses
At first blush, Senate Bill 45 appears to be a simple move to incorporate trauma-informed training into nursing education. Author Sen. Mike Crider (R-Greenfield) passionately described how trauma-informed training had transformed his investigative approach during his law enforcement career and how he wanted other professions to have the same knowledge.
But unlike the majority of states, Indiana doesn’t have any continuing education requirements for nurses. Under Crider’s original bill, nurses would have to recertify every two years but the state’s Professional Licensing Agency (PLA) doesn’t track continuing education for nurses like it does for doctors or other health care professions — nurse employers do that work.
Following pushback, senators amended the bill to say every nurse must certify within five years and there shall be a study about incorporating it into secondary education institution curricula.
Katie Feley, the chief executive director of the Indiana State Nurses Association, said most of Indiana’s school already had trauma-informed training in their curriculum. Her organization opposed the legislation, saying that PLA already struggles to meet its current workload.
“Employers do require, most of the time, annual training if not bi-annual training. Several of our members have shared that they do receive this training from their employer,” Feley told the committee. “If the nurse is practicing and employed, he or she should be receiving it through their employer.”
Committee members still seemed incredulous that nurses didn’t have continuing education requirements in Indiana, meaning “a nurse that graduated 25 years ago is practicing what she was taught 25 years ago” in the words of Chair Sen. Ed Charbonneau.
“We’ve done a lot of talking about why we haven’t. But every patient that comes in is hoping that the person that’s seeing them has had it. And we’re not doing enough to make sure that happens,” Charbonneau, R-Valparaiso, said about trauma-informed care.
Indiana does have continuing education requirements for one nursing profession: advanced practice nurses with prescriptive authority must get 30 hours between license renewals, eight of which must be in pharmacology. There is also a continuing education requirement for nurses with a controlled substance registration.