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Silver Linings: Where are all the nurses?

New Hampshire Union Leader

December 17. 2016 9:35PM
Nursing students Erin Murphy of Deerfield and Ken Williams of Manchester work in a simulation lab at Manchester Community College on Friday. New Hampshire is experiencing a nursing shortage, particularly in the area of senior care. (DAVID LANE/UNION LEADER)

There are beds available at the New Hampshire Veterans Home in Tilton, but there aren't enough nurses for the facility to take in new patients.

Of the 225 budgeted beds, only 203 were filled last month because the facility was down 33 full- and part-time nurses and nursing aides.

"I won't admit someone if they can't get that level of care they deserve," said Commandant Peggy Le­Brecque.

In-Home Care of Concord provides at-home care to frail, elderly and poorer patients who would otherwise be in nursing homes. And it's turning away clients every week because they don't have the nursing staff.

"The state tracks the number of people served, but they don't track the numbers that are turned away," said Amy Moore, director of In-Home Care. "There are a good number of people who are not getting services. Who knows what happens to those people? I'm sure there are hundreds of them."

New Hampshire, like the rest of the country, is facing a shortage of nurses. And the area of elder care, particularly New Hampshire's nursing homes and at-home care providers, is feeling the brunt. Brendan Williams, president and CEO of the New Hampshire Health Care Association, calls the shortage a "crisis."

"It will diminish the quality of care in facilities. It will diminish the kind of applicants who go into the profession," Williams said. "It's going to injure vulnerable people. We can't keep doing more with less."

Williams' group recently did a survey of New Hampshire nursing homes and assisted living centers, which heavily rely on licensed practical nurses (LPNs) and licensed nursing assistants (LNAs) to provide care. Of the 50 respondents, 84 percent said they had LPN positions they were unable to fill with 93 percent reporting they couldn’t even find candidates. With LNAs, 74 percent found candidates had trouble obtaining state licenses.

Providers across the state say the shortage is exacerbated by too few LPN-only programs, long delays in licensing by the state, and Medicaid reimbursement rates that leave little left to pay nurses and aides the wages they can get elsewhere — like at McDonald’s.

“I can’t offer the money that they pay down the street at Hobby Town,” said Barbara Laganiere, program director of skilled nursing at The Homemakers Health Services in Rochester. “I have 30 to 45 people on a wait list and it breaks my heart. I want to provide these people quality care, but we can’t without the staff.”

Rapidly aging

New Hampshire’s population is aging rapidly and among the top three in the country for highest median age. An exodus of younger families coupled with a generation of baby boomers means more people are reaching senior status in the Granite State.

Nurses are getting older too. The state’s Board of Licensing and Regulatory Services found that half of all nurses in New Hampshire are between the ages of 50 and 69 and more than two-thirds are over age 40. At New Hampshire Technical Institute in Concord, the average age of the nursing students is 31.

Another issue, Williams said, is the Medicaid reimbursement rate for nursing home care. It has gone up 4.5 percent since 2009, while the Consumer Price Index has gone up 13 percent.

Licensed Nursing Assistants

A licensed nursing assistant has the least amount of class time and the most amount of physical labor. To become an LNA, one must take a course that is usually about 10 weeks and costs on average $1,200. They can provide basic levels of care, such as taking vital signs, bathing the patient, emptying bed pans and cleaning catheterizations.

Rockingham County Nursing Home currently has an LNA opening for a 7 a.m. to 3 p.m. shift with pay starting at $11.66 an hour. At nearby Market Basket, a person bagging groceries earns $10 an hour. Williams said a recent survey in the Monadnock region showed there are currently some 70 LNA vacancies in that area alone, with many potential employees “flipping burgers” instead.

“It’s a huge competition for us,” Williams said. “The service industry is so robust right now with such low unemployment around the state.”

Licensed Practical Nurses

New Hampshire has about 26,000 licensed nurses, including 3,000 LPNs. An LPN is a nurse who has completed about 100 hours of education and their scope of responsibilities include more than an LNA, but must work under a registered nurse when providing more complex care. They are usually found in places where the patient is more stable — like a nursing home as opposed to an emergency room.

There are several community college-level programs where a person can become an LPN on their way to becoming an RN, but there are just two LPN-only programs in the state — The Salter School of Allied Health and Nursing in Manchester and Harmony Health Care Institute in Merrimack.

That means there are no LPN-only programs up north where the state’s oldest population lives.

At last week’s annual meeting of the Home Care Association of New Hampshire, the question was asked of 40 providers how many still use LPNs. About 30 raised their hands.

In elder health care, the need is for more LPNs. According to the Eldercare Workforce Alliance, nursing assistants, home health aides and personal care aides provide 70 to 80 percent of paid care to older adults in nursing homes, assisted living, and in their homes. The number of positions in this field is expected to climb by 48 percent from 2010 to 2020, while the numbers of LPNs and LNAs are expected to decline.

Fewer teaching

The shortage is also affecting nursing schools. With fewer nurses in the state, there are also fewer to teach nursing.

At NHTI, they had to cut enrollment from 96 to 72 this year for the simple reason it could not find faculty to teach the courses, said Mary Jean Byer, the nursing department head at Concord’s community college. The Monadnock Regional Healthcare Workforce Group recently reported that area is short four nursing faculty members out of a complement of 18, making for an 18 percent vacancy rate.

Other solutions

John Getts of Home Health & Hospice Care of Merrimack has another possible solution to the shortage. He suggests some leeway in the scope of duties different nurses can perform. He knows it’s a topic some don’t want to broach.

“Every profession feels they have to have higher standards to provide the best outcomes for patients,” he said. “Any talk about relaxing those standards might be considered heresy by some.”

Getts said New Hampshire’s demographics are what should be driving a change to allow less educated nurses to do more. He said it’s already being done in homes across the state. With a shortage of nurses, more family members are being trained in such tasks as wound care and IV management. “There are these unskilled family members who haven’t had six years of college but are being trained and are doing it,” he said.

Getts also suggests apprenticeship programs at high school levels, much like those seen with electricians, plumbers, and others. He said it gives students more experience and opportunities to jump into nursing.

“It shouldn’t be a barrier to a student, going from high school to a six-year program,” Getts said. “We’ve got to be encouraging our youth.”

Silver Linings is a continuing Union Leader/Sunday News report focusing on the issues of New Hampshire’s aging population and seeking out solutions. Union Leader reporter Gretchen Grosky would like to hear from readers about issues related to aging. She can be reached at or 206-7739.

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