KRISP Project Related Studies: PHN Workforce in Stark Relief

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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

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KRISP A Name and an Acronym
K Keeping Knowledge access
R RNs to Redesign job and work environment
I Improve Innovate to improve
S Strengthen Scope and competency based practice
P Population Health Population focused care
Funded by HRSAs Bureau of Health Professions,
Division of Nursing
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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

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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

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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

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KRIsp related studies PHN job descriptions
PHN-rn Salaries Phn competencies
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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.
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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 (n18)
• Deleted duplicates, outdated, clinical only (ie,
  NP)  

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Methodology

• 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

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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
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Percent of Job Descriptions with the Standard
1 Assessment 94
2 Population Diagnosis and Priorities 78
3 Outcomes Identification 22
4 Planning 94
5 Implementation 100
5a Coordination of Services 94
5b Health Education/Health Promotion 94
5c Consultation 56
5d Regulatory Activities 44
6 Evaluation 83
7 Quality of Practice 83
8 Education 83
9 Professional Practice Evaluation 89
10 Collegiality, Professional Relationships 78
11 Collaboration 94
12 Ethics 89
13 Research 50
14 Resource Utilization 50
15 Leadership 89
16 Advocacy 72
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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.

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Job Description related references

• Fried BJ, Fottler MD. Human Resources in
  Healthcare Managing for Success. 3rd ed.
  Chicago, IL Health Administration Press 2008.
• Fallon LF, Zgodzinski EJ. Essentials of Public
  Health Management. 2nd 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. 200623(1) 115-138.

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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 (n10)
• Participation rate for IL 40
• Participation rate for WA 85.7

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RN Hourly Wage by Location
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RN Differentials by Location
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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)

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Salary Study related References

• American Nurses Credentialing Center ANCC.
  (2008). ANCC Magnet Recognition Program. Accessed
  October 12, 2008 from http//www.nursecredentialin
  g.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 Publics Health.
  Accessed October 10, 2008 from http//www.astdn.or
  g/downloadablefiles/Final20Nursing20Shortage20P
  aper.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.

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PHN Competency Assessment
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 kbaldwin_at_uic.edu  and
Michele Issel, PhD, RN University of Illinois at
Chicago School of Public Health 312/355-1137 issel
_at_uic.edu    November 2, 2002  Funded by HRSA
Division of Nursing  Please Note Answer both
front and back of all pages.

• Purpose
• Assess current competencies of KRISP PHN workforce

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Competency Scales for PHNs
Competency Domains (10 EPHS) items
Link people to services 4
Mobilize community partnerships 13
Assure competent public health workforce 8
Enforce laws and regulations 4
Diagnose health problems 5
Inform, educate, and empower 4
Monitor community health status 13
Evaluate health services 8
Policy and planning skills 6
Research innovative solutions 6
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Competency Scores per Domain
KRISP (n 81) KRISP (n 81) IL 2007 (n 177) IL 2007 (n 177)
Mean (SD)   Mean (SD)
Link people to services 3.3 (1.2)   3.3 (0.9)
Mobilize community partnerships 2.4 (1.1)   3.0 (0.8)
Assure competent PH workforce 2.1 (1.1)   3.0 (0.9)
Enforce laws and regulations 2.1 (1.1)   2.9 (1.0)
Diagnose health problems 2.0 (1.2)   2.8 (1.0)
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Competency Scores per Domain
   KRISP (n 81) KRISP (n 81) 2007 (n 177) 2007 (n 177)
Mean (SD)   Mean (SD)
Monitor community health status 2.0 (1.1)   2.7 (0.9)
Inform, educate, empower 2.2 (1.1)   2.7 (1.0)
Evaluate health services 1.9 (1.0)   2.7 (1.0)
Research innovative solutions 2.2 (1.1)   2.6 (0.9)
Policy planning skills 1.1 (1.0)   2.5 (0. 9)
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PHN competencies related references

• Quad Council of Public Health Nursing
  Organizations.(2004). Public health nursing
  competencies. Public Health Nursing, 21, 443452.
• Epstein, R. M., Hundert, E. M. (2002). Defining
  and assessing professional competence. JAMA,
  287,226235.
• 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 168177.

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What Ive 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.
• Whats a logic model?
• I worry about my clients.

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On the other side, Ive heard

• I like learning something new.
• We do want to make improvements.
• Its beginning to make sense.

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What does it mean?
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My Soap Boxes

• Access to full-text online scientific journals
  for ALL LDH employees.
• Whats the reality where you live?
• Collaborate with unions to have PROFESSIONAL job
  descriptions
• Nursing faculty attitudes need to reflect a value
  for PHNs

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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

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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..

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Opportunities for Research

• PBRNs
• Collaboration as an opportunity
• RWJFs PHSSR grants
• Workforce as a focus
• Topics (from the list of infinite needs)
• Databases needed for real-time QI
• Leadership

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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.

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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