In a place like Cedarcrest Center for Children with Disabilities in Keene, a stable long-term workforce is key.

Children who attend school here are taught by teachers who double as nurses. They operate computer programs that test their motor skills and card games that improve communication. Staff members have learned their personalities over years, developing an invaluable long-term rapport.

It’s an area of care that Cathy Gray, president and CEO of the private provider, says she is proud to serve. But it’s one she’s increasingly worried about. Recent tightening of Medicaid funding levels and high levels of staff turnover mean it’s harder to give children the continuity of care they once had. And the problem, she said, is worsening.

A shortage in nursing has plagued New Hampshire for years now. The ramifications are widespread, affecting bed counts in the state psychiatric hospital and wait times in emergency rooms. The issue took on prominence in the spring, when Gov. Maggie Hassan, D-Newfields, ordered a commission to study the problems afflicting the nursing industry across the state.

In the Monadnock Region, 229 nursing positions across 16 facilities have been left unfilled, according to Gray, who heads a local task force dedicated to addressing the issue.

But within the wider problem, a wrinkle has emerged: more and more students are shying away from shorter-term nursing programs like the eight-week Licensed Nursing Assistant (LNA) program or the year-long Licensed Practical Nurse (LPN). Instead, they are opting for the Registered Nurse (RN) degree, which can be completed in two years, or with a four-year bachelor’s degree.

LNAs and LPNs carry lower salaries, making them beneficial for nursing homes and schools for the disabled, like Cedarcrest, whose medical operations are less complex and whose budgets are tighter than those of hospitals. RNs are generally sought by hospitals and come with higher salaries — a prime draw for young nursing students today.

At Maplewood, the county nursing home in Westmoreland, the effects are being felt acutely.

Kathryn Kindopp, Maplewood administrator, said the absence of a stream of LNA and LPN nurses is holding back the facility’s ability to run at full capacity.

Understaffed, the 148-bed facility has filled an average of 134 beds this year, according to Cheshire County Finance Director Sheryl Trombly. The facility has stayed within its $15 million county-provided budget for 2016 in large part because it scaled its overall nursing staff down to meet the lowered enrollments, rather than increasing staff to try and fill beds, Trombly said.

For Kindopp, the shortage is a spiraling problem with few quick fixes.

Back in 2015, she says, the facility was down 25 percent of its LPNs and 25 percent of nursing assistants. That had an impact.

“You can’t function fully like that,” Kindopp said. “I’ve had to close a lot of beds.”

The situation has improved steadily; both categories of nurses are understaffed by about 13 percent. But Kindopp, who’s served as administrator for the home for 20 years, says long-term trends in nursing mean Maplewood’s problems aren’t going away soon.

To start, no local programs provide specific training for lower class qualifications. LPN training programs such as those offered at River Valley Community College in Keene, “used to pump out 80 LPNs a year,” Kindopp says.

But with LPN programs struggling to attract students, River Valley made a choice recently to focus solely on RN training — students in the program can take an exam for their LPN qualifications after one year, but they need to be in a two-year or four-year RN program to do it.

“We decided to put all our eggs in the RN basket,” Patricia Shinn, professor at River Valley’s nursing program, said. She explained that with such low demand, the college could no longer justify LPN programs financially.

Now, Kindopp said, there’s no program within 20 minutes of Keene for those looking for manageable nighttime LPN training.

Kindopp attributes those decisions to a shifting demand industry-wide: Hospitals are placing a premium on RN-trained nurses, preferably with four-year bachelor’s degree, and college nursing programs are responding. The entry-level expectation at many hospitals, she says, is for nurses to have an RN license.

It makes sense for clinics and hospitals, which value the clinical versatility that comes with an RN degree, she said. But it takes away a vital labor source for places like Cedarcrest and Maplewood.

“LPNs are absolutely perfect for nursing homes,” she said, citing their ability to provide many services that an RN would be overqualified for, and at a cost Maplewood can afford.

LPNs weren’t always in such short supply. In the years after the 2008 market crash, people surged to train as LNAs and LPNs, seeking quick entry into a reliable job market with living wages, Kindopp said.

Single parents with children could study for the nursing qualifications while juggling another job. Those aiming to continue qualifications could use an LNA or LPN job as a stepping stone to save money for courses and to get real-world experience, she said.

Through the surge, nursing homes benefited; Kindopp estimates that two-thirds of its staff was LPNs and a third RNs. “It used to be I couldn’t get enough RNs,” she said.

Now it’s more like 50-50. And Kindopp says that with a tighter budget, her nursing home doesn’t have the money fill those empty positions with RNs.

Meanwhile, many of her nursing staff members are nearing retirement. With uncertainty during the recession, many stayed in their positions at Maplewood for stability. But with a recently recovering economy, Kindopp said that many nurses are now set to leave.

Without a dedicated pipeline of younger nurses coming through the ranks, Kindopp says options are limited.

“These numbers are only going to get worse.” Kindopp said. “When I look at some of the staff that I have that are older, there’s no pipeline to even replace them. I can’t currently fill positions, let alone backfill retirees.

“That’s the same for Cedercrest, Home Healthcare (Hospice & Community Services) and the (Cheshire Medical Center/Dartmouth-Hitchcock Keene) hospital — we’re all struggling,” she said.

As the problem continues, those groups are coming together under one banner: the Monadnock Region Healthcare Workforce Group. The idea is to halt competition and work together, Kindopp says.

“We realize we’re just doing this — we’re stealing staff from one another,” Kindopp said. “We’re not creating new staff, we’re stealing staff.”

Gray, of Cedarcrest, is heading the effort.

“We soon realized it was a bigger issue,” Gray said, speaking of the need for collaboration.

But if the problems with nursing are glaring, the solutions are thin and scattered. Kindopp says the group is looking into finding a way for River Valley to restore a one-year qualification program for LPNs. But she says that it wouldn’t solve the issue of demand, and would likely hurt the college financially.

Perhaps there’s a way for a bigger provider, like Genesis HealthCare, a national provider based in Pennsylvania and operating in Keene, to help out, Kindopp said. It could provide funding for River Valley to allow extra nursing students to take the one-year program without the college losing money from other RN students, she added. But she said that solution wouldn’t be viable long-term.

Gray, on the other hand, said she hopes the solution can come from increased Medicaid funds. If payouts can be raised for services, she says, then places like Cedarcrest can provide higher salaries and entice more students to join as LPNs, even if only as a stepping stone.

In the end, though, Gray said it comes back to education.

“More LPN training programs will help,” Gray said. “(But) there’s gotta be some effort to make that happen.”

This story is part of a series of articles outlining the nursing shortage in the Monadnock Region.

Ethan DeWitt can be reached at 352-1234, extension 1439, or Follow him on Twitter at @EDeWittKS.