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The evolving picture of nursing in the United States


* Place the interests of patients and populations at the center of interprofessional health care delivery Recognize and respect the unique cultures, values, roles ... – PowerPoint PPT presentation

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Title: The evolving picture of nursing in the United States

The evolving picture of nursing in the United
  • Jane Kirschling, DNS, RN, FAAN
  • Dean and Professor
  •, 859-323-4857
  • 2011 Maine Nursing Summit
  • April 5

  • Amazing that Nursing Summit celebrating 10th
  • 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

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

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

5 growth between 2004 and 2008
Employed in nursing nationally 84.8, Maine
  • 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

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)
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
RNs salaries rose almost 15.9 since 2004,
slightly outpaced inflation
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

2009 employed RNs, NPs, and PAs per 100,000
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

  • 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

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

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

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
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

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

changing landscape of health care system and
changing profile of population require that the
system undergo a fundamental shift (IOM, 2011, p.
All health care professionals practice to full
extent education, training, and competencies
Quality, Access, Value
Foster Interprofessional Collaboration
IOM Key Message
Rationale (p. 169-170)
  • Several studies support significant association
    between educational level of RN and outcomes for
    patients in acute care settings, including
  • 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

  • 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.
  • makes quality care accessible to the diverse
    population of the United States,
  • intentionally promotes wellness and disease
  • provides compassionate care across the lifespan
  • prevention and primary care central drivers

  • NURSING ROLES RNs and APRNs provide primary
    care across variety of settings, need to fully
  • 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
  • Care coordinators
  • Health coaches, help people stay healthy
  • Systems innovators, do their own work and look
    for ways to improve individual and system

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20.8 additional degrees, BSN 12.1
21.6 advanced degrees
Maine (NSSRN) RNs employed in nursing by
highest nursing or nursing-related education
IOM Key Message
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
  • Expanded opportunities for APRNs

Removing barriers
  • Josiah Macy Jr. Foundation January 2010 Who
    will provide primary care and how will they be
  • 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

  • AARP March 2010 http//
  • 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
  • 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//

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

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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)

IOM Key Message
  • 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

Enrollments increasing in both DNP and PhD
programs (1997-2009)
AACN 2009 over 9,500 applicants turned away
masters and doctoral programs
Obj. 3 - identify competencies that RNs will need
in order to meet health care needs in America by
  • AACN Essentials for Baccalaureate Education
  • Core Competencies for Interprofessional
    Collaborative Practice

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)

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)

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

Diffusion of Knowledge (Hughes, 2008)
Source EA Balas SA Boren, Managing Clinical
Knowledge for Health Care Improvement. Yearbook
of Medical informatics 2002
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
  • Decision-making process includes
  • Research evidence
  • Patient preferences
  • Available resources
  • Clinical expertise
  • Central to the ability to deliver safe,
    effective, and patient-centered care

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)

Essential 5
  • Healthcare policy, finance, and regulatory
  • 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

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

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

gt Fundamental effective interprofessional
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

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)

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

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

IPEC Interprofessional Education Collaborative
  • American Association of Colleges of Nursing
  • American Association of Colleges of Osteopathic
  • American Association of Colleges of Pharmacy
  • American Dental Education Association
  • Association of American Medical Colleges
  • Association of Schools of Public Health

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

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)

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

Provide Patient- Centered Care
Utilize Informatics
Work in Interprofessional Teams? Core
Employ Evidence- Based Practice
Apply Quality Improvement
IOM 5 core competencies, adapted to IPEC Expert
Panel Work
Values/ Ethics
Roles/ Responsibilities
Work in Interprofessional Teams? 4 Core

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

Values/Ethics Example competencies
  • Place the interests of patients and populations
    at the center of interprofessional health care
  • Recognize and respect the unique cultures,
    values, roles/responsibilities and expertise of
    other health professions

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

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

Interprofessional Communication Overall
  • 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

Interprofessional Communication Example
  • 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
  • Give timely, sensitive, instructive feedback to
    others about their performance on the team, and
    respond respectfully as a team member to feedback
    from others

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

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

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

IOM Key Message
  • 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

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

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

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

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

IOM Key Message
New graduates and nurses in transition
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
  • Actively pursue meaningful partnerships between
    education and practice
  • Commit to continuing competence and
    interprofessional care

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

  • 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//
  • Buerhaus, P.I., Auerbach, D.I., Staiger, D.O.
    (2009). The recent surge in nurse employment
    Causes and implications. Health Affairs, 28(4),
  • 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//
  • World Health Organization (WHO). Framework for
    Action on Interprofessional Education
    Collaborative Practice Winter 2010
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