Engaging the nursing pipeline

FigureAMONG THE MULTITUDE of challenges nurse leaders face, concerns about ensuring adequate staffing levels remain at the forefront. Nurse leaders have frequently partnered with Human Resources (HR) colleagues to enhance the recruitment of newly licensed nurses as the population of experienced nurses continues to dwindle. Current recruitment initiatives typically focus on nursing students participating in clinical rotations at hospitals or organized recruitment efforts. Other strategies aimed at securing the nursing workforce often emphasize staff retention, as hospitals contend with increasing competition among healthcare organizations and the appeal of travel nursing, which peaked during the COVID-19 pandemic but continues to persist postpandemic. As hospitals confront the stark reality of significant shortages of nursing personnel, a shift is emerging toward growing and investing in nursing pipelines by targeting a much earlier stage in the journey to become a nurse. Some trends even include beginning conversations as early as kindergarten with a much bigger focus on middle school.1 PROJECTED NURSING SHORTAGES According to the Health Resources and Services Administration (HRSA) Health Workforce Analysis, which focuses on projections through 2035, shortages of nurses will continue through 2030. However, by 2035, the supply is projected to outweigh the demand, assuming current trends continue without deviation from predictions. This report estimates a shortage of 78,610 full-time equivalent RNs by 2025; the projected number drops to 63,720 full-time equivalents by 2035. States with the highest projected shortages in 2035 include California, Georgia, Idaho, Louisiana, Michigan, New Jersey, North Carolina, Oregon, South Carolina, and Washington2 Nurse executives continue to worry about the numbers of early career RNs who are walking away from nursing and moving into less stressful careers with fewer safety concerns.3 As nurse leaders and organizations experience systemic nursing shortages, it's important to create innovative programs that drive relationships with community education providers, thus building a more robust pipeline of nursing staff, which ultimately impacts nursing staff retention and patient-care outcomes. A REVIEW OF THE LITERATURE Education and healthcare intersect Over the past 20 years, the benefits of vocational education in secondary schools have gained momentum with recognition of the value of careers that are in high demand and offer higher wages.4 Trends such as moving away from the term “vocational” and to the term “career and technical education” are helping to unlock opportunities formerly not available to high school students. Evidence indicates that enrollment in career and technical education boosts high school graduation rates and facilitates success in additional schooling.4 Another shift in education is having students identify their career paths at much earlier ages.5 Although it's common for secondary education students to discuss career choices, conversations are beginning as early as elementary school, and by late middle school, students are often asked to articulate a career or vocational preference. Class choices are frequently based on students' expressed interests, yet many students have minimal knowledge of what they may want to do in the future. Vocational and career choices are often based on parental influence, and students at times lack enough information to make decisions that greatly impact their futures. Parents' educational background has been identified as a central factor in helping students decide to pursue nursing as a career.6 Social factors appear to have more of an influence than financial benefits.6 There's an evolving trend of students expressing interest in STEM (science, technology, engineering, and math) careers early on but changing their minds at some point in high school. This concept is known as the leaky STEM pipeline.7 Nursing isn't widely recognized as a STEM field, and whether it should be classified as such is a source of debate. However, nursing is rooted in the sciences, and some government agencies, including the Department of Labor and the Department of Veterans Affairs, consider nursing to be a STEM profession.8 Nurse leaders possess an incredible opportunity to introduce students to careers in healthcare through a variety of ways and help spark, renew, or retain their interest in the profession. Partnerships with school districts, high schools, and associated technology schools provide an avenue for hospitals to capitalize upon students' openness to career choices. Focusing on programs designed to entice unlicensed assistive personnel, some of whom are in high school, into nursing is another strategy mentioned in the literature. Flexibility in onboarding, such as allowing high school students hired to work at an organization to complete orientation on Saturday or participate in some aspects virtually, is imperative as nurse leaders recognize the value of flexibility in recruiting high school students.9,10 Although recruiting unlicensed assistive personnel into nursing is a logical pathway, it's important to consider this group's vital role within the healthcare team and to look for additional recruiting options beyond promoting from within a group that's already in short supply. A variety of studies have explored the factors that motivate students' choices to pursue a career in healthcare.11-17 However, a careful analysis of the literature revealed a lack of studies that scientifically demonstrate the value of early career impacts and partnerships between hospitals and secondary schools. BACKGROUND A not-for-profit hospital with more than 400 beds in Anderson, South Carolina partnered with a local career and technology center that serves almost 2,000 high school students from four surrounding institutions to offer a summer healthcare immersion experience called the Med Ed Academy. The purpose of the Med Ed Academy was to provide an organized experience for selected high school students interested in healthcare to shadow nurses throughout the hospital for 2 weeks to gain experience in the healthcare environment. Objectives focused on exposing the high school student to nursing throughout the continuum of care while supporting the student's connection to the nursing profession through this experience. Program design began in the year prior to the program's launch with conversations between the CNO and the director of the career and technology center. As part of the design phase, approval and funding were secured from the hospital board, the chief executive officer, and HR. Obtaining approval for 16-year-old students to participate in the program was a barrier. The organization's policy prohibited individuals younger than 18 from shadowing employees, so the policy had to be updated. The CNO, along with the program leaders—who were nurse educators and administrative leaders—collaborated with HR to ensure all regulatory aspects were considered. These aspects included verifying adherence to the vaccination policy; obtaining parental consent; confirming that students received, reviewed, and acknowledged compliance and privacy documentation; and modifying the employment age policy. Another important consideration was ensuring that the students had transportation to observational experiences conducted off-site. Students who participated in the program were provided with a $200 stipend as well as uniforms and lunch when on site. As part of the program, students were introduced to a career path that could begin with the Med Ed Academy program and culminate with obtaining a Bachelor of Science in Nursing (BSN) degree. Like most organizations, local partnerships with nursing schools have enabled the organization to develop a path to increase the nursing pipeline by offering significant financial assistance to employees desiring to obtain an Associate Degree in Nursing or a BSN through formalized Nurse Scholar Program pathways. Hence, the student's initial encounter began with the summer immersion experience. Potential future encounters would be clinicals during the student's senior year of high school while enrolled in a Health Science course and employment as a nursing tech while enrolled in an associate or baccalaureate nursing program. METHODS A mixed-methods study design was used to measure four facets of program participation pre- and postimmersion experience. Because there's limited research on programs that provide hospital rotations or experiences for secondary education students, researchers couldn't identify a validated tool that has been used to assess the impact that participating in a summer high school immersion experience has on high school students. Thus, researchers developed a pre- and posttest tool for data collection with face validity confirmed by each of the study team's nurse leaders. Aspects rated on a 5-point Likert-type scale included: comfort level with being in the hospital; interest in a healthcare career; confidence in ability to talk with patients; and knowledge of the healthcare system. Institutional Review Board approval was obtained at the hospital prior to data collection. Researchers ensured confidentiality and participants' anonymity. Students already enrolled in the Health Science curriculum for a portion of their high school classes were eligible to apply to the Med Ed Academy. With assistance and encouragement from the Health Science lead instructor, more than 17 students submitted applications for 10 spots in the 2-week program during the spring of 2024. The application included demographic questions as well as a brief essay and recommendation letters. Applications were blinded, and leaders at the organization used a shared tool for evaluating candidates. The 2-week program was implemented in the summer of 2024. The 10 students selected were immersed in the clinical setting for 2 weeks. Participants were given the paper preassessment tool on their first day of the program and provided with time to complete the survey during the onboarding process. Students were told that participation in data collection was voluntary. Consent was obtained with the return of a survey. Program hours were 0800 to 1700 for a total of 10 days. Students were paired each day with an RN in a variety of nursing units. The first day included an orientation to the hospital and healthcare environment. Each day thereafter, students came dressed in scrubs and spent 7 hours in a clinical setting. Clinical sites included the ED, Cardiac Cath Lab, ICU, Neuro Med Unit, Behavioral Health, Kids Ambulatory Care, Medical Unit, Clinical Research Unit, Neuro Intensive Care Unit, and Cardiac Rehab with additional rotations in Wound Care and Vascular Access. At the end of each day, students came together for a formal debriefing with members of the Nursing Staff Development team. A recognition ceremony was held at the conclusion of the program with students' parents, school officials, and hospital and nursing leaders, including HR and preceptors. Med Ed Academy students completed a postassessment tool at the conclusion of the program. RESULTS The 10 students who participated in the program completed pre- and postsurveys. All participants were females entering their senior year of public high school and dually enrolled at a technical school. Further, 4 of the 10 students indicated in the survey that they had prior experience in healthcare. Current high school location was the only additional demographic information collected. All pre- and postsurvey responses were evaluated using a paired t test (P < .05). Three of the four questions demonstrated statistical significance. Findings indicated that students viewed this experience as beneficial in increasing their comfort level, confidence, and knowledge of the healthcare system (see Table 1). This study didn't find a statistically significant increase in interest in a healthcare career, but that result could potentially be attributed to the fact that these students already had some healthcare experience from the their current enrollment in the high school Health Science curriculum. TABLE 1: - Mean and paired t tests Question detail Pretest mean score Posttest mean score Paired t test Question 1 Comfort level being in the hospital 3.50 4.743 0.00105∗ Question 2 Interest in career in healthcare 4.60 5.00 0.34344 Question 3 Confidence to talk with patients 4.00 4.80 0.01071∗ Question 4 Knowledge of healthcare system 3.30 4.10 0.03679∗ ∗Statistically significant (P < .05) A nurse researcher performed a content analysis of the open-ended questions included in the posttest tool and identified themes of learning, confidence, affirming, experience, and rewarding (see Table 2). Results of this study indicated benefits to participating in early healthcare experiences to increase comfort level and knowledge of the healthcare system before entry into postsecondary education programs. TABLE 2: - Themes identified in participants' responses to posttest open-ended questions Themes Frequency Learning 11 Affirming 6 Experience 6 Confidence 5 Rewarding 4 DISCUSSION Two students expressed challenges with smells in the healthcare environment, and two students mentioned the sadness of observing suffering and death. Other participant comments alluded to the value of seeing healthcare firsthand, feeling a sense of purpose, witnessing the teamwork aspect of healthcare, and the influence that the program had in changing their perceived initial interest in a specialty area. Although not directly addressed in the survey tool, a common theme that the students verbally shared was the impact that the RN preceptors had on the students' learning experiences. Students conveyed in conversations that certain preceptors were more motivating and engaging and intentionally strived to ensure that the students had a good learning experience. Comments from participants included the following. “Before Med Ed Academy, I wasn't for sure about the medical field, but now I know I want to be a nurse.” “I highly recommend this program because you get to see what it is like working in the medical field and get to see where you see yourself working.” “It expands on how I feel about healthcare. I really wanted to be in peds but, after KidsCare, not so much. I feel as though wound care is the right fit for me, or ED. It made me think more of healthcare and not think it was all like TV shows.” “On my first day, I was in the ED and watched a woman pass away. Although I know people will die, it was sad to watch.” “There is no better way to truly be sure this career is right for you without experiencing it firsthand.” “Getting to talk with patients at such a vulnerable time in their lives and provide them comfort and empathy has given me such a feeling of purpose in just the past 2 weeks. I have loved being able to [provide] aid for people in their time of need; it is more rewarding than anything else I've experienced before.” Limitations Although this study supports the value of a summer immersion experience for high school students, the sample size was notably small, and therefore the ability to generalize findings is limited. The number of participants was limited to 10 because this was determined to be an adequate size for this pilot project. Another limitation to the sample was that all participants were female, and most were White. As nursing becomes more diverse racially and ethnically, it's important to ensure all demographics are represented in a program. Given that male RNs constitute about 12% of the American nursing workforce, recruiting males into the program is also important, as is ensuring diverse preceptors to reflect the diversity of the program participants. The team also encountered organizational challenges, including competing priorities for the nursing education department, and less preceptor availability due to increased numbers of newly licensed nurses and previously existing opportunities, such as the summer Volunteer program and the Nurse Extern program. Another project limitation is that there's currently no available evidence to substantiate the long-term success of this program. Researchers plan to follow up with the students upon high school graduation to learn more about their post high school educational or vocational decisions. IMPLICATIONS FOR NURSE LEADERS This study affirms the overall positive impact that a program can have on high school students and their future career choices. Traditional volunteer programs, although helpful, may not have the long-term impact that complete immersion in the healthcare setting has on students' perceptions of healthcare. It should be noted that the one-to-one pairing with an RN preceptor, although time intensive for the clinical area and the preceptor, is beneficial in providing the student with support and attention. Pairing each student with an RN preceptor also enables the student to accurately understand the RN's role and responsibilities and dismiss the often-preconceived notion that the nurse works under the physician. Rather, this program allows the high school student to observe firsthand the critical thinking and complexity of nursing as a profession. There was intentionality in ensuring that students were provided daily with a safe space to debrief with a supportive nurse leader about their experience that day. There's a risk that high school students not exposed to healthcare could witness situations that are shocking and disturbing, so planned opportunities to talk through situations were a vital component of the program. This debriefing also likely contributed to students' learning by hearing other students share their experiences. Consideration of exactly what the student is and isn't permitted to do is an important discussion point. The students were instructed that this role was observation only, and that they weren't allowed to have direct patient physical because they weren't this to preceptors was critical to Because this was the first time the program program leaders to some role Another part of the program included nurse leader support when the students in their clinical area. a and for the students was and students the opportunity to experience the supportive even provided for the students, which the students noted as being of this program is the that students may and talk with their about their and this may interest for students who weren't previously thinking about a career in healthcare. Other for healthcare leaders include the benefits of some organized education and and with the high school students during their senior offering support as they for and pursue education A brief on careers in healthcare could be beneficial to introduce students to in nursing not in the program, such as nurse nurse and nurse with the students could increase the that continue their education after high school. a direct care nurse or a nurse leader provide one-to-one of a high school student could also students the support and encouragement they to pursue a career in healthcare, students who lack a support system at should also consider such as and Although to support students and provide them with a of there's a in having who works in the healthcare a student to help them in and to them the options for a career path in nursing, such as through a program or an associate or in A for the hospital is that some students may to work as unlicensed assistive personnel after being introduced to the A Nurse leaders should consider the benefits of with career and technical education schools in their to provide opportunities for high school students to learn about a career in healthcare. 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