Wisconsin’s Statewide Clinical Placement Summit: Meeting the Challenge of Expanding Clinical Nursing Opportunities

1. Wisconsin’s Statewide Clinical Placement Summit: Meeting the Challenge of Expanding Clinical Nursing Opportunities Roberta Gassman, Secretary Department of Workforce Development

2. Wisconsin’s Economy

3. Wisconsin’s Economy • Fiscal house in order and economy on track • Jobs up, unemployment down-Gained 187,400 jobs & 9,000 employers since Jan ’03 • Nat’l Honor Roll twice -1 of 6 states Corp for Enterprise Dev. • Exports up 60% since 2003

4. Governor’s Opportunity Budget for Working Families • Fiscally Responsible • Invests in Shared Priorities • Creates Opportunities • Tax Relief for Middle Class Families-Health Insurance, Child Care, Tuition, Social Security • Create Jobs • Save Taxpayers $1.7B in 4 yrs • Helps Communities and Businesses

5. Governor’s Opportunity Budget for Working Families Education • Tripling School Breakfast • Quality Child Care • Funding 2/3 of K-12 • Special Ed increase by $54M • 4 yr old K & SAGE • 3rd year Math & Science • Wisconsin Covenant • Tech College/Worker Training increased x 4 • Doubling Youth Apprenticeship

6. Governor’s Opportunity Budget for Youth Apprenticeship 30% in Health Care Careers • Youth ApprenticeshipFunding Doubled

7. Governor’s Opportunity Budget for Higher Education To increase nurse capacity • $225 M to UW System • Covenant Office • Financial aid increased by $44M • Limited tuition increase to 4% • $21M UW Growth Initiative • Funding for emerging and essential occupations: nurses, teachers, scientists, engineers

8. Governor’s Opportunity Budget for Working Families Affordable Health Care • Expand BadgerCare Plus -all children -low wage adults, pregnant women • Catastrophic coverage • Anti-smoking

9. DWD Efforts 2nd Annual WI Health Care Workforce Report • This document represents our yearly checkup • Defines challenges • Provides updates • Copies available on-line at: dwd.wisconsin.gov/healthcare

10. Health Care Occupationsin High Demand • Nationally - 30.3% growth and 4.7 million new jobs by 2014, 3 of every 10 jobs will be in health care • Wisconsin – Specifically for nursing, we will need RNs to fill 1,600 new jobs and 1,010 replacements every year to 2014

11. The Top Jobs by 2014 • Top jobs in new job growth • Health Diagnosing and Treating Practitioners, Registered Nurses, Health Technologists and Technicians, Nursing/Psychiatric/Home Health Aides, Home Health Aides, Other Healthcare Support Occupations • Top jobs in % growth • Physician Assistants, Registered Nurses, Respiratory Therapists, Dental Hygienists, Diagnostic Medical Sonographers, Surgical Technologists, Medical Records and Health Information Technicians, Home Health Aides, Dental Assistants, Medical Assistants • Top job growth in overall #s • Health Diagnosing and Treating Practitioners, Registered Nurses, Health Technologists and Technicians, Nursing/Psychiatric/Home Health Aides, Home Health Aides, Other Healthcare Support Occupations

12. Collaboration • Health Care stakeholders must work together to avoid potential shortages of nurses and other health care workers • Working together, we can make the health care sector more attractive by building career ladders and bridges to family supporting jobs

13. Summit Resolution • Let us reaffirm our commitment to finding solutions to the challenges facing the health care sector • Please join with me in the signing of this Resolution

14. DWD Efforts Select Committee on Health Care Workforce Development formed in 2003-key stakeholders:  Health Care Organizations & Advocacy Groups- home health, nursing homes, & long-term care  Labor  Education  Other government agencies

15. DWD Efforts • Workplace Issues - Developing best practices to improve retention rates. • Stronger Data for Planning – To improve projections of health care occupations in demand. • Clinical Site Capacity and potentially developing an on-line product to assist with placement and reservation.

16. DWD Efforts • Governor Doyle’s Safe Lifting Initiative • $325,000 WIA funds-18 projects around the state • 7,500 nurses & other health care workers rec’d training in proper lifting • Bureau of Labor statistics-6 of top 10 occupations at highest risk for back injuries are in health care • Employees from Gunderson Lutheran Hospital, La Crosse, demonstrate a safe lifting device to Secretary Gassman

17. Working together keeps our Health Care Workforce #1

18. Senator Herb Kohl’s Health Care Agenda JoAnne Anton State Director Senator Kohl’s Office

19. Overview of Clinical Placement Issue Nancy Sugden, Director Wisconsin Area Health Education Centers

20. Health Workforce Concerns Changing healthcare needs of the population Current and projected shortages in the healthcare workforce Chronic maldistribution of the workforce - number of rural and urban underserved areas (HPSAs) Limited access of students from minority and rural backgrounds to health professions careers

21. Initial Statewide Efforts April 2000 - Formation of Health Care Workforce Coalition joint project of WHA, AHEC and many other partners April 2002 - WTCS organized conference: Taking Action! Creating Healthcare Workforce Solutions Spring 2003 - Formation of Governor’s Select Committee for HealthCare Workforce Development

22. Initial Statewide Efforts Health Care Workforce Coalition • early conversations about actions needed to address anticipated shortages • initial focus on health careers recruitment/pipeline, career ladders, apprenticeship programs and longterm care needs • quickly found major roadblock - limited capacity of training programs to expand, in part due to need for clinical placements WTCS activities • standardization of health professions curricula and pre-requisites across campuses, transferability of courses, development of on-line options, expansion of facilities and use of sophisticated patient simulators

23. Academic Program Initiatives • support for health careers activities and pipeline programs in underserved areas and populations • several grant-funded projects focused on increasing the number of masters-prepared nurses available to teach in the health professions programs, especially nursing • NET • SWIFT • LEAP • Other grant-funded initiatives to develop capacity of community-based sites and providers - to provide learning opportunities for health professions students

24. Regional Efforts Development of regional collaborations under leadership of several different groups • Regional AHECs and academic partners: • health careers • continued effort to develop new community-based training sites • Local Workforce Boards giving increasing attention to health workforce issues • Fox Valley Health Care Alliance • La Crosse Health Science Consortium

25. Current Status Diminishing federal grant resources available to academic programs to address healthcare workforce issues (Title VII Health Professions funding) Increasing appreciation of • the challenge posed by current and impending health workforce shortages • the need for a collaborative, regionally-focused approach with broad external statewide support to get the job done Must expand capacity for clinical placement

26. Clinical Placement What are “clinical placements”? Coursework involving hands-on, direct care or service experience and evaluation of the student’s skills, variously referred to as: • Clinical • Clinical rotation • Clerkship • Fieldwork experience • Community placement • Practicum • Internship

27. Clinical Placement Why are clinical placements so important? • Couldn’t we fill the need through expanded use of manikins, clinical simulators and standardized patients? Students need experiences outside the formal classroom, in community and patient care settings under the supervision of skilled practitioners, to develop their critical thinking and clinical judgment skills and learn to use those skills in a dynamic work environment.

28. Clinical Placement What kind of students? • Technical college associate degree and technical training programs • Undergraduate health professions degree programs • Advanced degree programs What fields?

29. Clinical Placement What kind of facilities? • direct patient care (inpatient or ambulatory) • technical and support services such as: pharmacy radiology dietetics social work • long-term care facilities • mental health facilities • hospice • home health • other community agencies • schools and public health agencies

30. Clinical Placement How scheduled? • Time blocks of 2 hours to a full day • A few days a week, integrated into a general education curriculum and a regular campus course schedule or • A full-time block of several weeks when students may be engaged in the field experience full time

31. Clinical Placement Who teaches and supervises the students? • faculty from the academic program who accompany students to the site or • staff at the clinical site in consultation with a faculty clerkship director who makes occasional site visits On-site staff are often called preceptors, mentors or community faculty and may have volunteer appointments with the academic program.

32. Clinical Placement What are the expectations of the student? • The student may be merely observing, or may be participating directly in patient care or service delivery. • The independence expected of the student in carrying out assigned tasks evolves as the student’s training progresses. • Sites and preceptors must be prepared to evaluate the student’s progress and permit increasing responsibility appropriate to the student’s level of development.

33. Focus on Nursing Summer of 2006 survey of health professions programs indicated a need for more clinical placements in many disciplines. Why initial focus on nursing? • nursing shortage affects so many different care settings and agencies • training site requirements so varied within just one discipline • expectation that lessons learned and regional collaborations developed will speed efforts for other disciplines.

34. Nursing Curriculum Diverse curricula, but in general: • ADN and BSN students need 4-5 clinical placements - at least one every semester (except BSN sophomore entry programs). • “One clinical placement” may involve scheduling experience for the student on more than one service within a facility. • Students spend from 12-24 hours per week at the clinical site, in 2-6 hour blocks of time. • PN, first year ADN and junior year BSN students are taught in groups of 8, usually by a faculty member who travels with the students to the site. • Second year ADN and most senior year BSN programs use preceptors on site for one of the clinicals. The “transition” or “practicum” experiences provide a 1:1 relationship of student to preceptor, and an opportunity for the student to exercise more independence.

35. Nursing Clinical Placements Needed Core clinical skills • Hospitals • Long term care facilities Community health and service learning • Public health • Community agencies Other • School health clinics • Mental health facilities

36. Challenges for Nursing Programs in Arranging Clinical Placements • Will the patient or client mix at the site meet the needs of the specific component of the training program for which a training site is needed? • Is the site able to provide space for students to meet as a group? Will students be able to access computers and on-line information resources at the site if needed? • Are there staff at the site qualified to teach/precept/supervise students? Can they get release-time for preceptor development activities? • Is housing available on-site if students will be there full time and must travel a distance to the site? • Does the site understand the role of the student as learner, not as an extension of the workforce? • Does the site understand its obligation to provide emergency care for students who become ill or are injured? • What are the requirements of the partnership agencies regarding documenting students, affiliation agreements, and risk management, liability and malpractice issues?

37. Challenges for Healthcare Organizations and Providers • Meeting the needs of different occupations, educational programs and levels of student. • Assuring that the patient to student ratio is acceptable and that patients are agreeable to student-delivered/observed care. • Establishing and verifying both school and facility expectations regarding staff role with students. • Coping with the lack of standardization in record keeping processes and expectations among the educational programs. • Providing clinical time around academic program schedules. • Clarifying risk management/liability and all other variables relating to the relationship. • Educating managers and staff regarding their own responsibilities, school expectations and student abilities. • Small or specialty units and facilities far removed from the school location may have additional special issues to address.

38. Barriers • lack of trained community preceptors with time to teach • barriers of time and distance for students and faculty • limited scheduling flexibility • lack of classroom space and equipment for students at smaller facilities • administrative burden on smaller facilities without an education coordinator • some academic programs are proprietary about sites • unwillingness to change from “the way we have always done things”

39. Opportunity to explore these challenges in our regional discussions over lunch

40. Update on Nursing Shortage: 2007 Ann Cook, RN, PhD Board Member, Wisconsin Center for Nursing Professor, Columbia College of Nursing

42. Nursing Workforce: National Picture Overall Trends • Shortage easing somewhat? • Latest projection is 340,000 (vs. 1 million) shortfall by 2020 • Health Affairs, Jan/Feb 2007: Auerbach, Buerhaus, Staiger • Age of entry into profession has increased • Vacancy rate 8.5% (Down from 13%) • Demand continues to increase • Salary increases have slowed • Aging workforce • Looming PMD shortage = ↑ Demand for NPs

43. Current RN WorkforceNational Sample Survey of RNs: 2004 • 2.9 million registered nurses • Increase of 7.9% from 2000 • 2.4 million (83.2%) employed in nursing • Increase of 10% from 2000 • 58% employed full-time • 25% employed part-time • 16.8% not employed in nursing • 56% employed in hospitals • Decrease of 3% from 2000 • 11.5% employed in ambulatory care • Increase of 2% from 2000

44. Aging Workforce: National Picture • Average age of RNs is 46.8 years • 26.6% under age of 40 • 16.6% under age of 35 • 2000: 31.7% under age of 40 • 1980: 40.5% under age of 35 • 25.5% over age of 54 • 2000: 24.3% over age 54 • 1980: 17.2% over age 54 • Largest age cohort in 2004 is 45-49 Source: 2004 RN NSSS

45. Age Distribution of RNs in U.S. Source: National Sample Survey of Registered Nurses: 2004

46. Nursing Workforce: Wisconsin • 73,073 licensed RNs (As of Sept. 2006: Dept of Regulation and Licensing) • Estimate 60,000 in workforce (based on National Sample Survey figure of 83%) • 41% of RNs work part-time (2004 RN National Sample Survey) • 54% of RNs work in hospitals (2001 WI RN survey) • Average age of RNs is 47.6 years • 27% of RNs are under 40 years of age • 44% of RNs are 50 years or older • Average age of nurse educators is 50.3 years

47. Source: WI DWD, Bureau of Workforce Information: 2006

48. Will there be enough RNs in 2015 and 2020 to care for you and your family? • Aging Population and Aging RN Workforce • Increased demand in outpatient, home health, long term care, hospice settings • Impact of technology • Could make nurses more efficient and able to manage more patients • Could also increase demand

49. Employment ProjectionsOffice of Economic Advisors, WI DWD, July 2006 • RN is one of top 5 occupations with most openings • RN is one of top 30 fastest growing occupations • RNs are the top occupation with most new jobs • From 2004-2014: 26,100 jobs (2,610/year) • 16,000 new jobs • 10,000 replacements • Many new jobs are in Ambulatory Health Care Services

50. Current State Demand: RN Jobs • Based on quick web site search – 3/26/07 • Approximately 1000 RN openings • Many openings required advanced education or specialty area experience: • Nurse Practitioner • Clinical Nurse Specialist • Critical Care or ER • Hospice and home care • Surgery services • Behavioral health • Floating or PRN pool • Management • Long term care