Transcript The evolving picture of nursing in the United States

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Amazing that Nursing Summit
celebrating 10th year
Very pleased to be back
Part of leadership journey
RWJF Executive Nurse
Fellow (2000-2003)
Describe how nursing shortage in U.S. has
evolved over past decade toward what is
on the horizon
 Discuss how roles of RNs and APRNs will
evolve over next decade
 Identify competencies that RNs will need in
order to meet health care needs in America
by 2020
 Identify preferred strategies for how nurses
will achieve and maintain desired
competencies over their careers

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High alert, to concern, to chronic shortage

Findings from the 2008 National Sample
Survey of Registered Nurses (September 2010)
› US Department of Health and Human
Services Health Resources and Services
Administration
› Maine sample 517 RNs
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5% growth between 2004 and 2008
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Employed in nursing – nationally 84.8%, Maine 84.6%
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
Median age of RNs, 46 years old, remained the
same between 2004 and 2008

number of RNs under age 30 increased first time
three decades
› ¼ RNs are nurses in 50s
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55-59 years 65%
full-time and 60-64
years 47.6%
Not employed in
nursing 12.5%
(50-54 years),
14.9% (55-59),
29.1% (60-64),
50.4% (65-69)
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Since 1980
the largest
percentage
of RNs
working in
hospitals
was 68.2%
(1984) and
the low
was 57.4%
(2004), in
2008 62.5%
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RNs’ salaries rose almost 15.9 % since 2004, slightly outpaced inflation
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
Shortfall of RNs developing around 2018
and growing to about 260,000 by 2025,
twice as large as any shortage since mid1960s (Buerhaus, et al., 2009)
› 2006 HRSA projection, one million short by
2020

Bureau of Labor Statistics analysts project
more than 581,000 new RN positions will
be created through 2018 (22% increase in the
workforce)
› Impact of healthcare reform
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RNs
NPs
Ratio
NPs : RNs
PAs
Ratio
NPs : PAs
842
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1: 16.5
24
1 : .47
Maine
1,093
74
1 : 14.8
43
1 : .58
Massachusetts
1,260
91
1 : 13.8
27
1 : .30
New Hampshire
1,006
108
1 : 9.3
34
1 : .31
914
78
1 : 11.7
40
1 : .51
United States
Vermont
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“real RN wages unlikely to increase, as
employers (particularly hospitals) will not
need to offer pay hikes to induce
employment
 vacant RN positions will be filled, and
many hospitals will predict end to the nurse
shortage
 some new nursing graduates will
experience difficulty finding jobs”

› ADN graduates and time between graduating
and being hired has lengthened
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“nursing education programs could
experience an increase in demand, as
some people are attracted to the relative
job security and earnings offered in nursing
seek to become RNs
 capacity of some education programs
could be affected negatively by state
budget cuts”

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
2009-2010 American Association of
Colleges of Nursing (AACN)
› Enrollments entry-level BSN programs
increased 5.7%, down from 6.1% 2009
› Enrollments RN to BSN programs increased
21.6%
› 73,570 BSN graduates – 51,039 entry-level
and 22,531 RN to BSN
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54,000+ qualified applications professional nursing
programs turned away in 2009, including 9,500+ applications
to master’s and doctoral degree programs
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 “loss
of RN jobs as hospitals face
losses in investment income, increases
in numbers of uninsured patients, and
decreases in elective procedures”
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“easing or end to the current
shortage brought about by the
recession gives employers and
nurses a chance to ‘catch their
breath’ and focus their efforts
on addressing the implications
of the changing composition of
the RN workforce” (Buerhaus et
al., 2009)
2010
Tri-Council
of Nursing
raised
serious
concerns
about
slowing
production
of RNs
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2011 IOM report – The Future
of Nursing Leading Change,
Advancing Health
National Consensus Model
APRN

18 member committee
 Donna E. Shalala (Chair), President, University of
Miami
 Linda Burnes Bolton (Vice Chair), Vice President
and Chief Nursing Officer, Cedars-Sinai Health

Evidence based

IOM part of National Academy of Sciences
›
private, nonprofit, self-perpetuating society of distinguished scholars
engaged in scientific and engineering research, dedicated to the
furtherance of science and technology and to their use for the general
welfare
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patientcentered
care
seamless and
coordinated
Foster Interprofessional
Collaboration
All
health care
professionals
practice to full
extent
education,
training, and
competencies
more primary
care (vs.
specialty care)
more care in
community (vs.
acute care)
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IOM Key Message
Nurses should
achieve higher
levels of
education &
training through
an improved
education
system that
promotes
seamless
academic
progression
RECOMMENDATION NO. 4:
•Increase the
proportion of
nurses with a
baccalaureate
degree to 80%
by 2020
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“Several studies support significant
association between educational level of
RN and outcomes for patients in acute care
settings, including mortality”
 “Other studies argue that clinical
experience, qualifications between
entering a nursing program (e.g., SAT
scores), and the number of BSN-prepared
RNs that received an earlier degree
confound the value added through the 4year educational program”

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
“This debate aside, an all-BSN workforce
at the entry-level would provide a more
uniform foundation for the
reconceptualized roles for nurses and
new models of care”
› “vision for a transformed health care
system…(p. 22)
 makes quality care accessible to the diverse
population of the United States,
 intentionally promotes wellness and disease
prevention,
 provides compassionate care across the
lifespan”
› prevention and primary care central drivers
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patientcentered
care
seamless and
coordinated
more primary
care (vs.
specialty care)
more care in
community (vs.
acute care)
NURSING ROLES – coordinating
care traditional strength
• Care coordinators
• Health coaches, help people stay
healthy
• Systems innovators, do their
own work and look for ways to
improve individual and system
performance
NURSING ROLES – RNs and
APRNs provide primary care
across variety of settings, need
to fully actualize
• health promotion
• education
• assessment
NURSING ROLES – need strong
public health infrastructure to care
for people where they live, work,
play, and study
• “nurses will need to form new
partnerships with community
leaders and have strong
community care competencies,
such as ability to develop,
implement, and access culturally
sensitive interventions” (p. 59)
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20.8% additional degrees,
BSN 12.1%
21.6% advanced
degrees
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US
Maine
Est. #
% Diploma
2,596,599
12.1%
16,279
13.5%
% ADN
% BSN
% MSN/
Doctorate
37.6%
37.3%
13.0%
38.5%
31.6%
16.3%
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IOM Key Message
RECOMMENDATION NO. 1:
Nurses
•Remove
should
scope-ofpractice to
practice
the full
barriers
extent of
their
education
& training
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Survey published JAMA September 2008,
only 2% fourth-year medical students plan
to work in primary care after graduation,
despite need for 40% increase in number of
primary care physicians in the U.S. by 2020
 Association of American Medical Colleges
predicts shortage of 46,000 primary care
physicians by 2025
 Expanded opportunities for APRNs
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
Josiah Macy Jr. Foundation January 2010 –
“Who will provide primary care and how will
they be trained?”
› “…physicians, nurse practitioners, and
physician assistants in primary care, state and
national legal, regulatory, and reimbursement
policies should be changed to remove barriers
that make it difficult for nurse practitioners and
physician assistants to serve as primary care
providers and leaders of patient-centered
medical homes or other models of primary care
delivery”
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
AARP March 2010
http://www.aarp.org/makeadifference/advocacy/Governm
entWatch/Nursing/articles/providing_nurses_we_need.html
› “Remove the numerous federal legislative
and regulatory barriers that prevent
advanced practice registered nurses from
fully using their skills to provide services
within Federal health programs.”
› Tipping point with consumers weighing in
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
Consensus Model for APRN Regulation:
Licensure, Accreditation, Certification &
Education (July 7, 2008)
› Available at
http://www.aacn.nche.edu/education/pdf/
APRNReport.pdf
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Lack common definitions related to
APRN roles
 Lack of standardization in programs
leading to APRN preparation
 Proliferation of specialties and
subspecialties

› Examples: Palliative Care NP, Cardiovascular
CNS, Homeland Security NP

Lack of common legal recognition
across jurisdictions
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2004,
AACN’s members endorsed Position
Statement on the Practice Doctorate in
Nursing; 4 years of dialogue with array of
stakeholders and opportunities for comment
Target goal for transitioning APRN programs
from the master’s to DNP by 2015
Position identified the DNP as the
appropriate degree for advanced nursing
practice or specialty preparation, including
four APRN roles (NP, CNS, CRNA, CNM)
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IOM Key Message
Nurses should
achieve higher
levels of
education &
training through
an improved
education system
that promotes
seamless
academic
progression
RECOMMENDATION NO. 5
•Double the
number of
nurses with
a doctorate
by 2020
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 Additional 106 DNP programs in planning stages, enrollment grew
35.3% last year, 7,034 students
 Enrollment in PhD nursing programs increased 10.4% (434
students), 73 research focused BSN to doctoral programs, 13 under
development
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6000
Research
Focused
5000
4000
3000
DNP
2000
1000
0
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
AACN 2009: over 9,500 applicants turned away master’s and
doctoral programs
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AACN Essentials for Baccalaureate Education
Core Competencies for Interprofessional
Collaborative Practice
Observations
General
education reform,
involve nursing
faculty
Don’t confuse
generational
differences with
concerns that
new graduates
do not have right
values

Recognize solid base in
liberal education (sciences
& arts) provides cornerstone
for practice and education
of nurses
› “Strong emphases on
development of personal
values system that includes
capacity to make and act
upon ethical judgments hallmark of liberal education”
(Essentials, p. 11)
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Observations
Patient safety
considerable
strengthening
(QSEN www.qsen.org)
Shift from
evaluation
research to
quality
improvement

Basic organization and
systems leadership for
quality care and patient
safety
› Understand and use quality
improvement concepts,
processes, and outcomes
measures
› Safety… minimization “risk
of harm to patients and
providers through both
system effectiveness and
individual performance”
(Essentials, p. 13)
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Observations
Rethink “research”
course and
placement in
curriculum
Focus on emerging
“evidence”

Scholarship for
evidence-based
practice
› Basic understanding
how evidence is
developed, including
research process,
clinical judgment,
interprofessional
perspectives, and
patient preference as
applied to practice
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Landmark study*
National Healthcare Quality
Report 2005
Flu vaccine
1968
63%
Pneumococcal
vaccine
1977
56%
Diabetic eye
exam
1981
68%
Mammography
1982
70%
Cholesterol
screening
1984
73%
Clinical procedure
Source: EA Balas & SA Boren, Managing Clinical Knowledge for Health
Care Improvement. Yearbook of Medical informatics 2002
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
Evidence-based guidelines
› Reduce inappropriate variations in practice
› Promote high-quality care
› Accountability

Evidence-based practice culture
› Better decision-making, grounded in scientific
knowledge
› Decision-making process includes:




Research evidence
Patient preferences
Available resources
Clinical expertise
› Central to the ability to deliver safe, effective,
and patient-centered care
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Observations
Leveraging the
generations,
“digital natives”
Access for
learning

Information
management and
application of patient
care technology
› “Computer and information
literacy are crucial…
improvement of cost
effectiveness and safety
depend on evidence-based
practice, outcomes
research, interprofessional
care coordination, and
electronic medical record”
(Essentials, p. 17)
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
Observation
Fiscal
accountability clinical
microsystems
Healthcare policy,
finance, and regulatory
environments
› Solid understanding
 Broader context of
health care, how patient
care services are
organized and financed
and how reimbursement
is structured
 Scope and role of
regulatory agencies
 Development healthcare
policy and how to
change
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HC largest
sector, 5.5%
education
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15
% GPD 10
5
0
1993 2002 2003 2004 2005* 2006* 2010* 2015*
Year

Congressional Budget Office about half of all growth health care
spending in past several decades associated with changes in
medical care made possible by advances in technology
 Other: higher income levels, changes in insurance coverage, rising prices
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Observation
Requires
interprofessional
education
> Fundamental
effective
interprofessional
collaboration

Interprofessional
communication and
collaboration for
improving patient health
outcomes
 Definition shared goals
 Clear role expectations of
members
 Flexible decision-making process
 Establish open communication
patterns and leadership
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Observations
Reinvest in public
health
infrastructure
Assure everyone
has access to
“prevention”

Clinical prevention and
population health
› Individually focused
interventions such as
immunizations, screenings,
and counseling aimed at
prevention
› Aggregate, community, or
population health promotion
and disease prevention
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Observation
Patients
increasingly
diverse – cultural
humility (lifelong
commitment selfevaluation and
critique, to redress
power imbalances
patient-clinician
dynamic, and
develop mutually
beneficial and
advocacy
partnerships with
communities on
behalf individuals
and populations)

Professionalism and
professional values
› Inherent in accountability
is responsibility for
individual actions and
behaviors, including
civility (fundamental set
accepted behaviors for
society/culture upon
which professional
behaviors are based)
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
Roles
 Provider of care
 Designer/
manager/
coordinator of
care
 Member of a
profession
Baccalaureate
generalist nursing
practice
› Practice focused
outcomes that
integrate knowledge,
skills, and attitudes
delineated in Essentials
1-8 into nursing care of
individuals, families,
groups, communities,
and populations in
variety of settings
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





American Association of Colleges of
Nursing
American Association of Colleges of
Osteopathic Medicine
American Association of Colleges of
Pharmacy
American Dental Education Association
Association of American Medical Colleges
Association of Schools of Public Health
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
Recommend a common core set of
competencies relevant across the
professions to address the essential
preparation of clinicians for
interprofessional collaborative practice

Recommend learning experiences and
educational strategies for achieving the
competencies and related objectives
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

IPE “When students from two or more
professions learn about, from and with each
other to enable effective collaboration and
improve health outcomes” (WHO, 2010)
ICP “When multiple health workers from
different professional backgrounds work
together with patients, families, carers, and
communities to deliver the highest quality of
care” (WHO, 2010)
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








Patient and population-centered
Relationship-centered
Process-oriented
Stated in “common” language
Applicable across practice settings
Applicable across professions
Relevant to the learning continuum
Outcome driven [performance]
Relevant to all of IOM’s goals for
improvement-patient-centered [above],
efficiency, effectiveness, safety, timeliness,
and equity
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Provide PatientCentered
Care
Utilize
Informatics
“Work in
Interprofessional
Teams”
Core
Competencies
Employ EvidenceBased
Practice
Apply Quality
Improvement
IOM 5 core competencies, adapted to IPEC Expert Panel Work
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Values/
Ethics
Roles/
Responsibilities
“Work in
Interprofessional
Teams”
4 Core
Competencies
Communication
Teamwork
Teamwork competencies, adapted to IPEC Expert Panel Work
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Work with individuals of other professions
to maintain a climate of mutual respect
and shared values
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Place the interests of patients and
populations at the center of
interprofessional health care delivery
 Recognize and respect the unique cultures,
values, roles/responsibilities and expertise
of other health professions

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Use the knowledge of one’s own role
and those of other professions
to appropriately assess and address
the health care needs of the patients
and populations served
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Recognize one’s limitations in skills,
knowledge and abilities and engage others
when appropriate
 Engage diverse health care professionals
who complement one’s own professional
expertise, as well as associated resources,
to develop strategies to meet specific
patient care needs

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Communicate with patients, families,
communities and other health
professionals in a responsive and
responsible manner that supports a
team approach to the maintenance of
health and treatment of disease
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Organize and communicate information
with patients, families and health care team
members in a form and format that is
understandable, avoiding disciplinespecific terminology when possible
 Give timely, sensitive, instructive feedback
to others about their performance on the
team, and respond respectfully as a team
member to feedback from others

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Apply relationship-building values
and the principles of team dynamics
to perform effectively in different team
roles to plan and deliver
patient/population-centered care that is
safe, timely,
efficient, effective, and equitable
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Integrate the knowledge and experience of
other professions-appropriate to the
specific care situation-to inform care
decisions, while respecting patient and
community values and
priorities/preferences for care
 Use process improvement strategies to
increase the effectiveness of
interprofessional teamwork and teambased care

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“major flaws in the way [continuing
education] is conducted, financed,
regulated, and evaluated”
 evidence base underlying current continuing
education is “fragmented and
underdeveloped”
 Called for new vision of professional
development that enables learning both
individually and from collaborative, team
perspective

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IOM Key Message
Nurses should
achieve higher
levels of
education &
training through
an improved
education system
that promotes
seamless
academic
progression
RECOMMENDATION NO. 6:
•Ensure that
nurses
engage in
lifelong
learning
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
Accrediting bodies, schools of nursing,
health care organizations, and
continuing competency educators from
multiple health professions should
collaborate to ensure that nurses and
nursing students and faculty continue
their education and engage in lifelong
learning to gain the competencies
needed to provide care for diverse
populations across the lifespan
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
Develop and prioritize competencies so
curricula updated regularly across all
programs
› go beyond task-based proficiencies to
higher-level competencies
 demonstrate mastery over care management
knowledge domains
 provide foundation decision-making skills
under variety clinical situations across care
settings
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
Require all nursing students demonstrate
comprehensive set of clinical
performance competencies
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
Require all faculty
› participate continuing professional
development
› Perform cutting-edge competence in
practice, teaching, and research
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Foster culture of lifelong learning
 Provide resources for interprofessional
continuing competency programs
 If offer continuing competency
programs, regularly evaluate for
adaptability, flexibility, accessibility, and
impact on clinical outcomes

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IOM Key Message
Nurses should
achieve higher
levels of
education &
training through
an improved
education system
that promotes
seamless
academic
progression
RECOMMENDATION NO. 3:
•Implement
nurse
residency
programs
New
graduates
and nurses in
transition
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



Don’t lose sight of evolving nursing
shortage
Commit to take action on
recommendations from IOM report, this is
about patient-centered care and health
care reform, essential that nurses mobilize
Actively pursue meaningful partnerships
between education and practice
Commit to continuing competence and
interprofessional care
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…again, appreciate this
opportunity and your
thoughtful attention


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
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AHRQ – Rhonda G. Hughes, PhD, MHS, RN, Senior Health Scientist
Administrator, “Evidence-based patient safety & quality improvement: The
nursing imperative”, American Association of Colleges of Nursing, Doctoral
Conference, January 2008
American Association of Colleges of Nursing. (2008). The essentials of
baccalaureate education for professional nursing practice. Washington, DC:
AACN. http://www.aacn.nche.edu/education/pdf/BaccEssentials08.pdf
Buerhaus, P.I., Auerbach, D.I., & Staiger, D.O. (2009). The recent surge in nurse
employment: Causes and implications. Health Affairs, 28(4), W657-68
Institute of Medicine. (2009). Redesigning continung education in the health
professions. Washington, DC: That National Academies Press
Institute of Medicine. (2011). The Future of Nursing Leading Change,
Advancing Health. Washington, DC: The National Academies Press
U.S. Department of Health and Human Services Health Resources and
Services Administration. (September 2010) The Registered Nurse Population
Findings from the 2008 National Sample Survey of Registered Nursing.
http://bhpr.hrsa.gov/healthworkforce/rnsurvey/2008/nssrn2008.pdf
World Health Organization (WHO). Framework for Action on Interprofessional
Education & Collaborative Practice Winter 2010
http://www.who.int/hrh/resources/framework_action/en/index.html
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