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@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. Today’s 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 master’s 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. Riskemployers 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. All health care professionals practice to full extent education, training, and competencies changing landscape of health care system and changing profile of population require that the system undergo a fundamental shift (IOM, 2011, p. 86-87) 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

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/makeadifference/advocacy/GovernmentWatch/Nursing/articles/providing_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

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

41. AACN members endorse DNP • 2004, AACN’s 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 master’s 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 master’s 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. 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 1

47. 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 2

48. 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 Essential 3

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