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Workforce Issues. M6920 October 30, 2001. Goalsfor discussion. Understand how professionals are thought about generally Understand some major issues about health professionals Increase sensitivity to licensure issues. Evolution of work force. Healers exist in every culture

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Workforce issues

Workforce Issues

M6920

October 30, 2001


Goals for discussion

Goalsfor discussion

  • Understand how professionals are thought about generally

  • Understand some major issues about health professionals

  • Increase sensitivity to licensure issues

M6920, Fall, 2001


Evolution of work force

Evolution of work force

  • Healers exist in every culture

  • Healing associated with religious system

  • Enlightenment began Western separation

M6920, Fall, 2001


Policy questions about the health workforce

Policy questions about the health workforce

  • What is the role of a professional?

  • Who is a "provider”?

  • How do we know they are “safe”?

  • How many should we have?

?????????

M6920, Fall, 2001


Professionals or providers

Professionals or providers?

  • Workforce is labor market term

  • Provider is a term of art from payment systems

    • Independent billing has generally recognized MD, DO, DDS

  • Others generally seen as either

    • institutional staffing

    • secondary practitioners

M6920, Fall, 2001


Defining professionals

Defining professionals

  • Special body of knowledge

  • Control over education and qualifications

  • Limited entry into field

  • Social recognition

M6920, Fall, 2001


For all health professionals

For all health professionals

  • Content and volume of education has grown

  • Cycles of excess and shortage occur

    • related to employment shifts

    • related to age groups

    • related to educational policy

  • Public expectations have changed

M6920, Fall, 2001


Predicting supply and demand

Supply factors

delivery system (wages, benefits)

education system (capacity)

economic system (unemployment)

demographics of profession (age, gender, etc)

Demand factors

delivery system (technology, acuity)

economic system (reimbursement)

education system (faculty)

population demographics (age, epidemiology)

Predicting supply and demand

Dumpe et al 1992 Forecasting the Nursing Workforce

Nursing Economic$ 16:4 (170-9)

M6920, Fall, 2001


Geographic distribution

Geographic distribution

  • The range of practitioner to population is extremely variable

  • US: 22.4/10,000 in 1997

  • Regional range:

    • New England 30.4

    • West South Central 18.3

M6920, Fall, 2001


Health profession population ratio

Health Profession/ Population Ratio*

*per 100,000 population

Health US, 1999

M6920, Fall, 2001


Interprofessional issues

Interprofessional Issues

  • Socialization

  • Actual and perceived power

  • Economic competition

M6920, Fall, 2001


Physician questions have dominated

Physician questions have dominated

  • Because of the cost of preparation

  • Because of their primacy in the cost and access equation

  • Mechanisms have included

    • Residency support (Medicare)

    • Enrollment support (HRSA)

    • Policy on IMG’s

M6920, Fall, 2001


Physician population ratio

Physician/population ratio*

*Health US, 1999

NE

Mid

Atlantic

South

Atlantic

E N

Central

W N

Central

E S

Central

Pacific

W S

Central

Mountain

M6920, Fall, 2001


Physician supply in nyc

Physician Supply in NYC

Denise Soffel, United Hospital Fund

M6920, Fall, 2001


Diversity in medical students

Diversity in Medical Students

1990: 65,163

1994: 66,629

M6920, Fall, 2001


International medical graduates

International medical graduates

  • 18,000 US graduates for 24,000 residency positions

  • IMG’s are ~25% of licensed physicians. . .

  • but 50% of HHC residents and

  • 75% of 392 residents at Lincoln Hospital (Bronx)

M6920, Fall, 2001


Ethics of international movement

Ethics of international movement

  • Beneficence

    • better care in underserved US areas

  • Non-malfeasance

    • Drain from neediest countries

    • Specialty interests not needed

  • Autonomy

  • Social Justice

M6920, Fall, 2001


Some current questions

Some current questions:

  • What is the role of the specialist?

  • What proportion of practitioners should be specialists?

  • How do we support the academic research machine?

?????????

M6920, Fall, 2001


Is nursing a profession

Is nursing a profession?

  • Classics: clergy, law, medicine

  • Yes:

    • controls education

    • limited entry to field

    • social recognition

    • personal professional ethic

M6920, Fall, 2001


Maybe not

Maybe not. . .

  • social recognition limited

  • only partial practice independence

  • most are wage workers

  • gender perception issues

  • competition with more prestigious fields

M6920, Fall, 2001


Distribution of nurses

Distribution of Nurses*

*Per 100,000 population

Health US, 1999

1,272,900 nurses

1980

M6920, Fall, 2001


Types of nurses 1996

Types of nurses, 1996*

*Health US, 1999

2,161,700 Nurses

M6920, Fall, 2001


Aging out of nurses

Aging out of nurses

Buerhaus, Steiger, Auerhach JAMA 283:22

M6920, Fall, 2001


Nurse questions

Nurse questions

  • Shortage focus: hospital staff

  • Population ratio has grown: 366/100K (1970) to 697/100K (1991)

  • Responses have included

    • Changes in length/type of education

    • International recruitment

    • Enrollment support (school & student)

    • Salary changes

M6920, Fall, 2001


Intensity of nursing

Intensity of nursing

  • Prior to 1975, number of beds and nurses roughly parallel, with a few less nurses than beds

  • Since then, number of nurses has risen dramatically while beds decrease

M6920, Fall, 2001


Impact of hospital closure shorter stays

Impact of hospital closure & shorter stays

  • up to 300,000 displaced nurses

  • 1.2 out of 1.9 million nurses work in hospitals

  • Home health has doubled

  • Out patient settings have grown 15%

M6920, Fall, 2001


International graduates

International graduates

  • Nursing Relief for Disadvantaged Areas Act of 1999

  • 500 nurses may enter for up to 3 years

    • at least 190 beds

    • in Health Professions Shortage Area

    • 35% days Medicare; 28% Medicaid

  • originally only 14 facilities nationwide qualified

  • M6920, Fall, 2001


    Some current nursing workforce issues

    Some current nursing workforce issues

    • use of assistive personnel

    • use of contract personnel

    • differentiated practice

    • compression of advanced practice nurses

    • relationship to vulnerable populations

    • anticipated shrinkage

    M6920, Fall, 2001


    Turnover issues

    Turnover issues

    • Stability associated with

      • older staff

      • higher income staff

      • longer tenure

    • Turnover associated with

      • tension

      • limited organizational commitment

      • supervisor’s behavior

    M6920, Fall, 2001


    Nursing programs in ny

    Nursing Programs in NY

    • Graduate: 25

    • Baccalaureate: 45

    • AD: 57

    M6920, Fall, 2001


    Diversity in nursing students

    Diversity in Nursing Students

    1990: 221,170

    1994: 270,228

    M6920, Fall, 2001


    Nurses in new york state 1996

    Nurses in New York State, 1996

    • 96% FEMALE

    • Average age 47

      • in 1983 it was 40

      • 36% over 50

    • Average age by type of education

      • BSN 42

      • DIPLOMA 52

      • AD 44

    M6920, Fall, 2001


    Ethnicity of new york nurses 1996

    Ethnicity of New York Nurses, 1996

    M6920, Fall, 2001


    Employment settings ny state rn s

    Employment settings, NY State RN’s

    M6920, Fall, 2001


    New york state mean salaries late 1990 s

    CRNA 67,200

    CEO 60,000

    Midwife 56,700

    Dean 54,600

    DIR/DP 54,100

    Head Nrs 44,500

    NP 43,400

    CNS 42,100

    STAFF 34,900

    Faculty 33,800

    New York State Mean Salaries (late 1990’s)

    $$$$$

    M6920, Fall, 2001


    Salaries cont

    Salaries, cont.

    • Asian 46,700Black 45,900Puerto Rican 43,800Other Hispanic 43,400Native American 34,400White 33,300

    • By region of state

      • Range 48,900 TO 25,200

    M6920, Fall, 2001


    Public health workforce

    Public health workforce

    • Multiple disciplines

    • Multiple routes of entry

    • Multiple settings

    • Overlapping job duties

    • Confusion among

      • profession

      • setting

      • passion

    M6920, Fall, 2001


    Ratio of ph workers to population

    Ratio of PH workers to population

    (by region)

    *preliminary data


    Public health workers region iv

    Public Health Workers Region IV

    M6920, Fall, 2001


    Workers alabama and mississippi

    Workers Alabama and Mississippi

    M6920, Fall, 2001


    Consumer protection or control of competition

    Consumer protection or control of competition?

    • Limit number licensed?

    • Require certification?

    • Extend credentialing process?

    • Expand disciplinary actions?

    M6920, Fall, 2001


    Licensing certification and credentialing

    Licensing, certification and credentialing

    • License is a state issued assurance of minimal competence

    • Certification is a verification of specialty competence

    • Credentialing is verification by employing or reimbursing institution

    M6920, Fall, 2001


    Professional licensure

    Professional licensure

    • Provides validation in community

    • Affects ability to earn

    • Once gained, fiercely protected

    • Very confusing in interdisciplinary practice settings

    M6920, Fall, 2001


    Licensing board discipline

    Denial

    Applicant never granted a license

    Revoke

    Licensee loses practice privilege

    Voluntary surrender

    Licensee agrees to quit practice

    Suspend

    License put on hold (time certain or open-ended)

    Probation

    Can practice with special conditions

    Licensing board discipline

    M6920, Fall, 2001


    Institutional licensure

    Institutional licensure

    • Enormous increase in number of licensed or registered groups may rekindle this debate

    • The employer would be held responsible for hiring people with the right skills for each job

    • Current credentialing approaches may stimulate

    M6920, Fall, 2001


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