KRISP Project Related Studies: PHN Workforce in Stark Relief

L. Michele Issel, PhD, RN ACHNE Annual Meeting, Pre Conference Workshop on Workforce Chicago, IL June 8, 2010 KRISP Project 0

KRISP : A Name and an Acronym

I K K R R I S S

eeping Ns to mprove trengthen

K

nowledge access

R

edesign job and work environment

I

nnovate to improve

S

cope and competency based practice

P P

opulation Health

P

opulation focused care Funded by HRSA’s Bureau of Health Professions, Division of Nursing KRISP Project 1

Introduction

KRISP Project ~ ◦ Require to report outcomes related to PHN practice ◦ Needed indicators for QI and for project evaluation ◦ HRSA required 4 indicators Population-patient ~ specific target or set of actual or potential recipients of PHN care, services or activities focused on or delivered to a population as the intended patient KRISP Project 2

Benefits to KRISP Participants

    To LHD as organization ◦ Recruitment, Retention of RN improved ◦ Increased readiness for PHAB accreditation To DONs ◦ Leadership and peer support ◦ Ability to focus on RNs only ◦ ◦ To PHNs ◦ Enhanced professionalism Skill at Quality Improvement Increased perceived appreciation for work done To County Population ◦ Appreciation of role of PHN ◦ Improved outcomes related to QI projects of PHNs

KRISP as PHN Workforce Intervention Research

2 years of experience ~  Low survey response rates from PHNs in LHDs  Expectations of PHNs are changing very rapidly making it difficult to anticipate appropriate measures of change  Turnover rates and program eliminations makes longitudinal studies of individual RNs questionable  Unions play a role in the PHN workforce

KRISP RELATED STUDIES: * PHN JOB DESCRIPTIONS * PHN-RN SALARIES * PHN COMPETENCIES

KRISP Project 5

Job Descriptions -Their Value

  Human Resources Department Uses: ◦ ◦ Recruit, place, and transfer of staff Share job expectations, standards, and competencies with applicant ◦ Establish scope of practice per position Job descriptions may be used to demonstrate compliance with standards to regulatory agencies Presented at 2010 APHA Annual Meeting in Denver, CO.

6

Methodology

 ◦ ◦ ◦ Obtained 33 PHN job descriptions ◦ 3 IL LHDs and 3 WA LHDs All 6 part of KRISP Project Provided by HR or Nursing Director All PHN job descriptions per LHD  PHN job descriptions (n=18) ◦ Deleted duplicates, outdated, clinical only (ie, NP)

Methodology

1.

2.

3.

4.

Ignored statements of job specification e.g., Licensure, driving, lifting, etc Cross-walk ANA PHN Scope and Standards Quad Council Competencies ~ Done to assure consistency in our coding of statements. Statements categorizing into the 20 ANA PHN

Scope and Standards (and sub-standards)

Coding Reliability Used iterative process for initial coding Used other researchers for reliability check

Description by LHD

(April 2010)

A B C D E F

% of ANA PHN Standards used in Job Description(s) 75% 90% 40% 100% 65% 100% PHN FTEs 31.0 29.1 19.6 23.4

6.3 24.3

PHN Positions 35 31 21 26 8 25 PHN Job Descriptions 1 1 1 5 1 9

Percent of Job Descriptions with the Standard 1: Assessment

94%

2: Population Diagnosis and Priorities

3: Outcomes Identification

4: Planning

5: Implementation

78%

22% 94% 100%

5a: Coordination of Services 5b: Health Education/Health Promotion 5c: Consultation 5d: Regulatory Activities 6: Evaluation 7: Quality of Practice 8: Education 9: Professional Practice Evaluation 10: Collegiality, Professional Relationships 11: Collaboration 12: Ethics 13: Research 14: Resource Utilization 15: Leadership 16: Advocacy

94% 94%

56%

44%

83% 83% 83% 89% 78%

94%

89%

50% 50%

89% 72%

Conclusions

  Population-focused PHN standards are used, but not universally included across Standards. Need attention to ANA Standards regarding:     Outcome identification Regulatory activities Research Resource utilization  Gaps in application of ANA PHN Standards to PHN job descriptions exist.

Job Description related references

 Fried BJ, Fottler MD.

Human Resources in Healthcare: Managing for Success.

3 rd ed. Chicago, IL: Health Administration Press; 2008.

 Fallon LF, Zgodzinski EJ.

Essentials of Public Health Management.

2 nd ed. Sudbury, MA: Jones & Bartlett Publishers; 2009.

 Kalb KB, Cherry NM, Kauzloric J, et al. A competency-based approach to public health nursing performance appraisal.

Public Health Nursing.

2006;23(1): 115-138.

KRISP Project 12

Salary Survey-Background

 General wisdom: Lower compensation paid by local health departments (LHDs) for public health nurses (PHNs) compared to hospital nurse contributes to the difficulty in recruiting registered nurses (RNs) in to PHN positions.  No studies appear to have substantiated this belief.  Anecdotally, LHDs benchmark PHN salaries against other LHDs, rather than the local market for RNs. Presented at 2010 APHA Annual Meeting in Denver, CO.

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Sample

10 Hospitals & 6 LHDs in 6 KRISP Counties (IL & WA)  One LHD per KRISP County  0-4 hospitals included per KRISP Co.

◦ One Co. had no comparable hospital data ◦ Overall hospital participation rate 58.8% (n=10)   Participation rate for IL = 40% Participation rate for WA = 85.7%

RN Hourly Wage by Location

RN Differentials by Location

Findings

  No differences found among benefits offered by LHDs & Hospitals.

Some differences exist among education packages ◦ 100% of LHDs provide CE reimbursement compared to 70% hospitals.

◦ LHDs provided on average 11% more ($2,924) tuition reimbursement compared to hospitals ($2,639)

Salary Study related References

American Nurses Credentialing Center [ANCC]. (2008). ANCC Magnet Recognition Program. Accessed October 12, 2008 from http://www.nursecredentialing.org/Magnet.aspx

Bacon, D. (2009). Results of the 2009 AORN Salary Survey. AORN Journal, 90(6), 829-844. Brewer, C., Kovner, C., Greene, W., & Cheng, Y. (2009). Predictors of RNs' intent to work and work decisions 1 year later in a U.S. national sample. International Journal of Nursing Studies, 46(7), 940-956. Ericksen, A. (2007). To your benefit. RN, 70(11), 42. NACCHO, (2005). Resolution to Support the Education and Recruitment of Public Health Nurses. Accessed September 28, 2008 from http://www.naccho.org/advocacy/positions/ Quad Council. (2006). The Public Health Nursing Shortage: A Threat to the Public’s Health. Accessed October 10, 2008 from http://www.astdn.org/downloadablefiles/Final%20Nursing%20Shortage%20Pa per.pdf

Serow, W., Cowart, M., Chen, Y., & Speake, D. (1993). Health care corporatization and the employment conditions of nurses. Nursing Economic$, 11(5), 279-291.

PHN Competency Assessment

Purpose

Assess current competencies of KRISP PHN workforce PUBLIC HEALTH NURSING SURVEY Advancing Public Health Nursing Education Grant Kathleen Baldwin, PhD, RN University of Illinois at Peoria College of Nursing 309/671-8467 [email protected]

and Michele Issel, PhD, RN University of Illinois at Chicago School of Public Health 312/355-1137 [email protected]

November 2, 2002 Funded by HRSA Division of Nursing Please Note: Answer both front and back of all pages.

Competency Scales for PHNs

Competency Domains (10 EPHS) Link people to services Mobilize community partnerships Assure competent public health workforce Enforce laws and regulations Diagnose health problems Inform, educate, and empower Monitor community health status Evaluate health services Policy and planning skills Research innovative solutions # items 4 13 8 4 5 4 13 8 6 6

Competency Scores per Domain

KRISP (n =81)

Mean (SD)

IL 2007 (n = 177)

Mean (SD)

Link people to services Mobilize community partnerships Assure competent PH workforce Enforce laws and regulations Diagnose health problems 3.3

(1.2) 2.4

(1.1) 2.1

(1.1) 2.1

2.0

(1.1) (1.2) 3.3

(0.9) 3.0

(0.8) 3.0

(0.9) 2.9

(1.0) 2.8

(1.0)

Competency Scores per Domain

KRISP (n =81)

Mean (SD)

Monitor community health status Inform, educate, empower Evaluate health services Research innovative solutions Policy & planning skills 2.0

(1.1) 2.2

1.9

(1.1) (1.0) 2.2

(1.1) 1.1

(1.0) 2007 (n = 177)

Mean (SD)

2.7

(0.9) 2.7

2.7

(1.0) (1.0) 2.6

(0.9) 2.5

(0. 9)

PHN competencies related references

   Quad Council of Public Health Nursing Organizations.(2004). Public health nursing competencies. Public Health Nursing, 21, 443 – 452.

Epstein, R. M., & Hundert, E. M. (2002). Defining and assessing professional competence. JAMA, 287,226 – 235.

Issel, L.M., Baldwin, K. A., Lyons, R., Madamala, K. (2006). Self-reported competency of public health nurses and faculty in Illinois. Public Health Nursing, 23: 168 – 177.

KRISP Project 23

What I’ve heard PHNs say…

       What is the social-ecological model?

How we supposed to add QI activities to our real work?

What is PHAB?

What is going to happen to my program with all the county cuts?

Evaluation is a managers job, not ours.

What’s a logic model?

I worry about my clients.

KRISP Project 24

On the other side, I’ve heard…



I like learning something new.



We do want to make improvements.



It’s beginning to make sense.

KRISP Project 25

WHAT DOES IT MEAN?

KRISP Project 26

My Soap Boxes ~

 Access to full-text online scientific journals for ALL LDH employees.

◦ What’s the reality where you live?

 Collaborate with unions to have PROFESSIONAL job descriptions  Nursing faculty attitudes need to reflect a value for PHNs KRISP Project 27

Advocating for PHN Practice

  PHN as advanced practice ◦ Requires population focus ◦ Requires analytic skills PHN wages ◦ ◦ Alignment with skill (not) Alignment with breadth of practice (not)

Job description as one route toward improvements for PHN as a job

Opportunities for Educ/Training

    Integrate quality improvement techniques into coursework Create more and more frequent opportunities for education of public health nursing along with other disciplines in public health Create coursework specific to the management of population-focused practice Etc…..

KRISP Project 29

Opportunities for Research

   PBRNs ◦ Collaboration as an opportunity RWJF’s PHSSR grants ◦ Workforce as a focus Topics (from the list of infinite needs) ◦ Databases needed for real-time QI ◦ Leadership KRISP Project 30

KRISP Related Publications

 Issel, L. M, Ashley, M., Kirk, H. & Bekemeir, B. (2011, in press). Public Health Nursing Job Descriptions: Are they Aligned with Professional Standards? Journal of Public Health

Management and Practice.

 Issel, L. M., Bekemeier, B., Baldwin, K. (2011). Three population patient indicators for public health nursing: Results of a consensus project. Public Health Nursing, 28: 24-

34.

 Issel, L. M., Bekemeier, B. (2010). Safe practice of population-focused nursing care: Development of a public health nursing concept. Nursing Outlook. 58, 226-232 .

KRISP Project 31

Thank You!

http://krispproject.wordpress.com/

Funded by HRSA Bureau of Health Profession, Division of Nursing, under the Nurse Education, Practice and Retention Program, grant number D11HP14605