Addressing the Shortage of Nurses in Indian Health 2008 Annual Self Governance Conference Sandra Haldane, BSN, RN, MSN C

1. Addressing the Shortage of Nurses in Indian Health 2008 Annual Self Governance Conference Sandra Haldane, BSN, RN, MSN Chief Nurse, IHS

2. Average Length of Service for Selected Health Professions

3. IHS/Tribal/Urban RN Positions 2007 Alaska 436 Billings 181 Portland 53 Bemidji 207 Aberdeen 359 Phoenix 564 IHS Headquarters Rockville, MD California 53 Navajo 986 Oklahoma 544 Albuquerque 140 Tucson 51 Nashville 65 3588 RNs

4. Navajo 30% Tucson ?% California 17% Albuquerque 24% Phoenix 22% Alaska 19% Total Averaged VR: 20.75% Aberdeen 14% Billings 17% Bemidji 25% Oklahoma 14% Portland 19% Nashville 3% The IHS Nursing Vacancy Rates: CY 2007

5. IHS/Tribal/Urban APNs: CY 2007 • APNs (NPs, CNMs, CRNAs) • 400 positions; Averaged 26% VR • 275 NPs • 24% VR • 75 CNMs • 14% VR • 43 CRNAs • 58% VR

6. The U.S. Shortage • 116,000 RNs currently needed to fill vacant positions nationwide (8.1% Vacancy Rate). • American Hospital Association, July 2007: The 2007 State of America's Hospitals - Taking the Pulse • American Association of Colleges of Nursing (AACN), 2008, www.aacn.nche.edu

7. The Outlook for Tomorrow • The shortage of RNs in the U.S. could reach 500,000 by 2025 (Buerhaus, 2008). • Demand for RNs expected to grow by 2% to 3% each year. • The Future of the Nursing Workforce in the United States: Data, Trends and Implications • AACN, 2008

8. The Outlook for Tomorrow • More than 1 Million new and replacement nurses needed by 2016 to meet a 23.5% increase in the number of new nursing positions (587,000 new positions by 2017) • U.S. Bureau of Labor Statistics, Monthly Labor Review, 2007, www.bls.gov/opub/mlr/2007/11/art5full.pdf • AACN 2008

9. Adding to the Problem • U.S. nursing schools turned away 40,285 qualified applicants from BSN & MSN programs in 2006 due to • insufficient number of faculty (reported by 71% of schools surveyed), • clinical sites, classroom space, • clinical preceptors, • budget constraints. • 2007-2008 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing, AACN 2007

10. The Results of a Shortage • > 75% of RNs believe the nursing shortage presents a major problem for • the quality of their work life, • the quality of patient care, • amount of time nurses can spend with patients. • Almost all surveyed RNs see the shortage in the future will result in • increased stress on nurses (98%), • lowering patient care quality (93%) • causing nurses to leave the profession (93%). • Nursing Economic$, P. Buerhaus, April-March 2005

11. The Revolving Door • 13% of newly licensed RNs had changed principal jobs after one year, • 37% reported that they felt ready to change jobs. • “Newly Licensed RNs’ Characteristics, Work Attitudes, and Intentions to Work”  American Journal of Nursing , C. T. Kovner , September 2007 • AACN 2008

12. How Serious is the Problem? • "failure to retain nurses contributes to avoidable patient deaths." • Journal of the American Medical Association , L. Aiken, October 2002 • AACN 2008

13. How Serious is the Problem? • More nurses at the bedside could save lives. • University of Pennsylvania: patients who have common surgeries in hospitals with high nurse-to-patient ratios have an up to 31% increased chance of dying. • Every additional patient in an average hospital nurse's workload increased the risk of death in surgical patients by 7%. • Having too few nurses may actually cost more money given the high costs of replacing burnt-out nurses and caring for patients with poor outcomes. • Journal of the American Medical Association, October 23/30, 2002 • AACN 2008

14. The Aging of Workforce • March 2004: average age of the RN population 46.8 • RN population under the age of 30 dropped from 9.0% of the nursing population in 2000 to 8.0% in 2004. • 2004 National Sample Survey of Registered Nurses , HHS/HRSA/BHP/DNS, February 2007 • AACN, 2008

15. The Aged IHS (Federal) Nurse Workforce • 20-29: 75 • 30-39: 350 • 40-49: 675 • 50-59: 850 • 60-69: 250 • 70-79: 20 • 80-89: 1

16. Retirement Eligible • 55% of surveyed nurses reported their intention to retire between 2011 and 2020. • Nursing Management Aging Workforce Survey, B. Hodes Group, 2006 • AACN 2008

17. Is it all about Money? • GS 4 and 5 RN not competitive • GS 9 not competitive some specialties (ER, OR, ICU, OB) • GS 9 and 11 FNP and CNM not competitive • GS 9, 11, 12, 13 CRNA not competitive

18. Meeting the Need • 30,000 additional nurses should be graduated annually to meet the U.S. healthcare need, an expansion of 30% over the current number of annual nurse graduates. • The Council on Physician and Nurse Supply • AACN, 2008

19. Does Level of Education Matter? • U. Penn: clear link between higher levels of nursing education and better patient outcomes. • Surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level. • 10% increase in the proportion of nurses holding BSN degrees decreased the risk of patient death and failure to rescue by 5 percent. • Journal of the American Medical Association, L. Aiken, September 2003 • AACN 2008

20. IHS (Federal) Nursing Demographics -10/2005 • Ethnicity (n=2600) • AI/AN: 44% • Black: 1% • Hispanic: 3% • A/PI: .01% • White: 49% • Education • BSN: 44% • ADN: 33% • Diploma: 17% • MS: 6%

21. Growing Our Own Nurses • 437/Section 103 & 104 Scholarship Program • ADN, BSN • FNP, CNM, CRNA, WHNP, PedNP, PsyNP, Geriatric NP • Section 112 Grants to Schools of Nursing • ASU (BSN) • MSU (BSN) • OU (BSN) • SDSU (BSN) • UMN (MS) • UND (BSN, MS) • Section 118 • LPN-ADN or BSN • RN-BSN • BSN-MSN • Long Term Training • USUHS Nurse Anesthesia

22. IHS 437 Scholarship BSN, ADN, & Pre-Nursing Students Per Year

23. IHS 437 Nursing Scholarship Graduates

24. IHS 437 (103 & 104) Scholarship Students Per Year (Nursing)

25. 437 Nursing Scholarship Graduates 9/07-12/08 • Associate Degree • 21 • Bachelors Degree • 41 • Masters Degree • 3

26. LRP Awards to Nurses • 84 Awards • 73 New Awards • 11 Continuations • $3,200,000 total nursing LRP awards • $10,700-$51,600 range of awards • 40 awards to Tribal nurses • 9 awards to Commissioned Officers • 20 awards to Civil Service

27. LRP 2007 (Nurses) • Aberdeen 6 • Alaska 26 • Bemidji 4 • Billings 4 • Navajo 22 • Oklahoma 4 • Phoenix 9 • Tucson 1

28. Section 112 Program • Quentin N. Burdick American Indians Into Nursing Program • Arizona State Univ. • Montana State Univ. • University of Oklahoma • South Dakota State Univ. • University of Minnesota • University of North Dakota (non-competitive, legislated, earmarked)

29. Section 112 Data 8/01-Present

30. Section 118 (NECI) Students • 1964 to 2008 • 575 nurses funded • LPN to ADN or BSN • ADN to BSN • BSN to MSN • Payback obligation 3 times amount of time funded

31. Bonuses & Special Pays • 3 R’s Bonus (civil service) • Recruitment • Retention • Relocation • Nurse Accession Bonus (COs) • Special Pay • Title 38 (special pay GS 610 series) • Nurse Anesthetists (COs)

32. CS 3Rs Bonuses Awarded to Nurses FY 2000-2004 • FY2000-FY2004=$652,867 • Aberdeen 5 totaling $54K • Albuquerque 5 totaling $28K • Bemidji 1 totaling $9K • Billings 3 totaling $32K • Navajo 19 totaling $192K • Oklahoma 1 totaling $2500 • Phoenix 52 totaling $353K • Portland 1 totaling $6400

33. $15K CC Nurse Accession Bonus • $20K new CAD w/48 month obligation • $15K new CAD w/36 month obligation • Restrictions • Officer responsible for downloading and submitting contract w/in 60 days CAD • Cannot be obligated otherwise • 24 month break in service from DoD

34. CC ISP CRNAs • For obligated officers: • $15K/yr for 1 yr contract • For unobligated officers: • $20K/yr for 1yr contract • $25K/yr for 2 yr contract • $35K/yr for 3 yr contract • $40K/yr w/4 yr contract

35. IHS Nursing Student Mentorship Program Seeing the forest in the seed Developed by IHS Mentorship Program Development Team, November, 2005

36. Objectives of the Mentor Program • Develop a cadre of nurses sensitive to the needs of students and able to respond appropriately to those needs • Assist students’ adjustment to the role of student • Assist students to complete their nursing education • Assist students’ transition to professional nurse role • Assist graduate nurses move into professional roles • Develop resources that motivate students to excel • Develop a link between nursing students and professional nurses in Indian Health Service, Tribal, and Urban (I/T/U) facilities

37. Precepter Program Help new graduate nurses to: • Apply theory to practice • Set priorities • Organize patient care • Evaluate patient care • Function independently within the healthcare team © 2003 Vermont Organization of Nurse Leaders

38. Magnet Facilities • Study in early 1980s by American Academy of Nurses (AAN) identified factors associated with improved nurse recruitment and retention • “MAGNET” was coined to refer to hospitals with these characteristics. • Alaska Native Medical Center received initial magnet designation in 2003, currently attempting re-designation

39. Magnet Characteristics • Support for education • Nurses who are clinically competent • Positive nurse/physician relationships • Autonomous nursing practice • Culture that values concern for the patient • Control of and over nursing practice • Perceived adequacy of staffing • Nurse Manager support

40. IHS Division of Nursing • Sandra Haldane, Chief Nurse • Sandra.Haldane@ihs.gov • LCDR Cheryl Peterson, PHN Consultant • Cheryl.Peterson@ihs.gov • CAPT Carolyn Aoyama, Women’s Health/APN Consultant • Carolyn.Aoyama@ihs.gov • Cathy Stueckemann, CHR Director • Cathy.Stueckemann@ihs.gov Indian Health Service/OCPS/DNS 801 Thompson Ave. STE 300 Rockville, MD 20852 301-443-1840