The evolving picture of nursing in the United States

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The evolving picture of nursing in the United
States

• Jane Kirschling, DNS, RN, FAAN
• Dean and Professor
• janek_at_email.uky.edu, 859-323-4857
• 2011 Maine Nursing Summit
• April 5

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Appreciation

• Amazing that Nursing Summit celebrating 10th
  year
• Very pleased to be back
• Part of leadership journey
• RWJF Executive Nurse
• Fellow (2000-2003)

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Objectives

• 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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Obj. 1 describe how nursing shortage in U.S.
has evolved over past decade toward what is on
the horizon

• High alert, to concern, to chronic shortage

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RN Population

• 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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Todays projection nationally

• Shortfall of RNs developing around 2018 and
  growing to about 260,000 by 2025, twice as large
  as any shortage since mid-1960s (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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2009 employed RNs, NPs, and PAs per 100,000
population
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As recession continues mix of outcomes
(Buerhaus, et al., 2009)

• 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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BSN enrollments

• 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 masters 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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Risk employers and policymakers see nursing
problem as over
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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Obj. 2 discuss how roles of RNs and APRNs will
evolve over next decade

• 2011 IOM report The Future of Nursing Leading
  Change, Advancing Health
• National Consensus Model APRN

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Nursing has an unprecedented opportunity to have
one voice on behalf of patient care

• 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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changing landscape of health care system and
changing profile of population require that the
system undergo a fundamental shift (IOM, 2011, p.
86-87)
All health care professionals practice to full
extent education, training, and competencies
Quality, Access, Value
Foster Interprofessional Collaboration
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IOM Key Message
RECOMMENDATION NO. 4
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Rationale (p. 169-170)

• 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 4-year
  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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• 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)

• 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

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20.8 additional degrees, BSN 12.1
21.6 advanced degrees
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Maine (NSSRN) RNs employed in nursing by
highest nursing or nursing-related education
(2008)
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IOM Key Message
RECOMMENDATION NO. 1
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Health care reform

• 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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Removing barriers

• 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/makeadifferenc
  e/advocacy/GovernmentWatch/Nursing/articles/provid
  ing_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

• Consensus Model for APRN Regulation Licensure,
  Accreditation, Certification Education (July
  7, 2008)
• Available at http//www.aacn.nche.edu/education/pd
  f/APRNReport.pdf

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Reasons for a Future APRN Model

• 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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AACN members endorse DNP

• 2004, AACNs 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 masters 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
RECOMMENDATION NO. 5
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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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Enrollments increasing in both DNP and PhD
programs (1997-2009)
AACN 2009 over 9,500 applicants turned away
masters and doctoral programs
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Obj. 3 - identify competencies that RNs will need
in order to meet health care needs in America by
2020

• AACN Essentials for Baccalaureate Education
• Core Competencies for Interprofessional
  Collaborative Practice

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Essential 1

• 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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Essential 2

• 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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Essential 3

• 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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Diffusion of Knowledge (Hughes, 2008)
Source EA Balas SA Boren, Managing Clinical
Knowledge for Health Care Improvement. Yearbook
of Medical informatics 2002
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Why evidence? (Hughes, 2008)

• 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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Essential 4

• 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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Essential 5

• 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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Health Care Spending US Gross Domestic Product
HC largest sector, 5.5 education
Consumers pay half, government pays rest

• 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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Essential 6

• 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

gt Fundamental effective interprofessional
collaboration
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Essential 7

• 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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Essential 8

• 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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Essential 9

• 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

• Roles
• Provider of care
• Designer/ manager/ coordinator of care
• Member of a profession

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Interprofessional Team-Based Competencies

• IPEC Expert Panel Presentation
• February 16, 2011 Invitation Conference HRSA,
  Macy Foundation, Robert Wood Johnson Foundation,
  and ABIM Foundation
• Amy Blue, PhD
• Jane Kirschling, DNS, RN, FAAN
• Madeline Schmitt, PhD, RN, FAAN-Chair
• Thomas Viggiano, MD, MEd

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IPEC Interprofessional Education Collaborative

• 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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IPEC Charge to Expert Panel

• 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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Definitions Interprofessional Education and
Interprofessional Collaborative Practice

• 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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IP Competencies General Criteria

• 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 IOMs goals for
  improvement-patient-centered above, efficiency,
  effectiveness, safety, timeliness, and equity

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Provide Patient- Centered Care
Utilize Informatics
Work in Interprofessional Teams? Core
Competencies
Employ Evidence- Based 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

Teamwork
Communication
Teamwork competencies, adapted to IPEC Expert
Panel Work
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Values/EthicsOverall Competency

• Work with individuals of other professions
• to maintain a climate of mutual respect
• and shared values

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Values/Ethics Example competencies

• 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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Roles ResponsibilitiesOverall Competency

• Use the knowledge of ones 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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Roles ResponsibilitiesExample Competencies

• Recognize ones limitations in skills, knowledge
  and abilities and engage others when appropriate
• Engage diverse health care professionals who
  complement ones own professional expertise, as
  well as associated resources, to develop
  strategies to meet specific patient care needs

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Interprofessional Communication Overall
Competency

• 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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Interprofessional Communication Example
Competencies

• Organize and communicate information with
  patients, families and health care team members
  in a form and format that is understandable,
  avoiding discipline-specific 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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Interprofessional Teamwork Team-based Care
Overall Competency

• 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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Interprofessional Teamwork Team-based Care
Example Competencies

• 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 team-based care

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Obj. 4 - identify preferred strategies for how
nurses will achieve and maintain desired
competencies over their careers
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2009 IOM study Redesigning Continuing Education
in the Health Professions

• 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
RECOMMENDATION NO. 6
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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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Faculty partner with health care organizations

• 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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Commission on Collegiate Nursing Education and
National League for Nursing Accrediting Commission

• Require all nursing students demonstrate
  comprehensive set of clinical performance
  competencies

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Academic administrators

• Require all faculty
• participate continuing professional development
• Perform cutting-edge competence in practice,
  teaching, and research

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Health care organizations and schools of nursing

• 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
RECOMMENDATION NO. 3
New graduates and nurses in transition
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in conclusion

• Dont 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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Questions and comments

• again, appreciate this opportunity and your
  thoughtful attention

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References

• 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/edu
  cation/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/healthwor
  kforce/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