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The evolving picture of nursing in the United States

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Title: The evolving picture of nursing in the United States


1
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

2
Appreciation
  • Amazing that Nursing Summit celebrating 10th
    year
  • Very pleased to be back
  • Part of leadership journey
  • RWJF Executive Nurse
  • Fellow (2000-2003)

3
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

4
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

5
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

6
5 growth between 2004 and 2008
7
Employed in nursing nationally 84.8, Maine
84.6
8
  • 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

9
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)
10
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
11
RNs salaries rose almost 15.9 since 2004,
slightly outpaced inflation
12
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

13
2009 employed RNs, NPs, and PAs per 100,000
population
14
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

15
  • 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

16
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

17
54,000 qualified applications professional
nursing programs turned away in 2009, including
9,500 applications to masters and doctoral
degree programs
18
  • loss of RN jobs as hospitals face losses in
    investment income, increases in numbers of
    uninsured patients, and decreases in elective
    procedures

19
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
20
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

21
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

22
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
23
IOM Key Message
RECOMMENDATION NO. 4
24
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

25
  • 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

26
  • 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

27
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28
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29
20.8 additional degrees, BSN 12.1
21.6 advanced degrees
30
Maine (NSSRN) RNs employed in nursing by
highest nursing or nursing-related education
(2008)
31
IOM Key Message
RECOMMENDATION NO. 1
32
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

33
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

34
  • 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

35
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36
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37
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

38
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

39
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40
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41
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)

42
IOM Key Message
RECOMMENDATION NO. 5
43
  • 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

44
Enrollments increasing in both DNP and PhD
programs (1997-2009)
AACN 2009 over 9,500 applicants turned away
masters and doctoral programs
45
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

46
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)

47
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)

48
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

49
Diffusion of Knowledge (Hughes, 2008)
Source EA Balas SA Boren, Managing Clinical
Knowledge for Health Care Improvement. Yearbook
of Medical informatics 2002
50
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

51
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)

52
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

53
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

54
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
55
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

56
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)

57
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

58
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

59
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

60
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

61
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)

62
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

63
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
64
Values/ Ethics
Roles/ Responsibilities
Work in Interprofessional Teams? 4 Core
Competencies

Teamwork
Communication
Teamwork competencies, adapted to IPEC Expert
Panel Work
65
Values/EthicsOverall Competency
  • Work with individuals of other professions
  • to maintain a climate of mutual respect
  • and shared values

66
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

67
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

68
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

69
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

70
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

71
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

72
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

73
Obj. 4 - identify preferred strategies for how
nurses will achieve and maintain desired
competencies over their careers
74
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

75
IOM Key Message
RECOMMENDATION NO. 6
76
  • 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

77
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

78
Commission on Collegiate Nursing Education and
National League for Nursing Accrediting Commission
  • Require all nursing students demonstrate
    comprehensive set of clinical performance
    competencies

79
Academic administrators
  • Require all faculty
  • participate continuing professional development
  • Perform cutting-edge competence in practice,
    teaching, and research

80
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

81
IOM Key Message
RECOMMENDATION NO. 3
New graduates and nurses in transition
82
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

83
Questions and comments
  • again, appreciate this opportunity and your
    thoughtful attention

84
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 
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