Challenges of American Nurses in the Age of Health Care Reform: Education, Policymaking, and

1. Challenges of American Nurses in the Age of Health Care Reform: Education, Policymaking, and the Nursing Care Delivery System Aichi Medical University College of Nursing: October 25, 2008 Elizabeth Madigan, PhD, RN, FAAN Associate Professor

2. Dean Wykle’s Message Dear Faculty and Students of Aichi Medical University College of Nursing: I am very excited about the new collaboration between our universities to establish Japan’s first flight nursing program. Due to a hip injury, please accept my humble apologies for being unable to visit your campus this year. I hope to have the opportunity in the future. You have my deepest respect and best wishes… May L. Wykle, PhD, RN, FAAN, FGSA Dean and Cellar Professor of Nursing

3. Contents • Introduction • Overview of American Nursing Education and Policy • The Role of Nurse Practitioners in the United States • Impacts of the U.S. Nursing Shortage on Nursing Care Delivery • Overview of the American Health Care System • Health Care Reform • Conclusions

4. American Nurses Education: • AD (2 year degree): 33.7% • Diploma (3 year degree): 17.5% • BSN: 34.2% • MSN or PhD: 13% Work settings: • Hospitals: 56% • Public health: 14.9% • Ambulatory care: 11.5% • Nursing homes: 6.3% • Nursing education: 2.6% • 5.4% are male; too few are from minority populations • Average salary of U.S. hospital RN: $56,800

5. Nursing Shortage: A Perfect Storm Three elements that explain the status of nursing in the U.S.: • Changing demographics • Rising costs of health care • Nursing education system’s inability to meet demand Source: The Nursing Shortage, By the Numbers: Robert Wood Johnson Foundation

6. 1. Changing Demographics • The aging of the baby boomer • Nurses are aging alongside the baby boomers • The pool of potential nurses has grown smaller • Fewer men and minorities choose nursing as a profession

7. 2. Rising Health Care Costs • U.S. health care costs are skyrocketing • Rising costs are forcing health care leaders to redistribute resources • The acuity of the patient has increased

8. 3. Educational Demands • Nursing education cannot effectively respond to increased demand • Due to combination of: • Lack of facilities • Shortage of new faculty • Lack of clinical placements • What is needed: • New appropriations and focus • New ways of addressing education

9. History of the Nursing Doctorate • Two DNP tracks created at Case: • Educational Leadership Track: prepares doctoral-level nursing educators for clinical and academic settings • Clinical Leadership Track: prepares doctoral-level clinicians or practitioners in research and health policy

10. Educational Leadership Track Clinical Leadership Track FPB’s DNP Core Curriculum Core Program Leadership Track DNP Project or Thesis Advanced Nursing Research Health Care Planning & Policy and Information Management Systems Nursing Theory Statistics for Health Sciences

11. DNP and PhD Differences

12. Nursing Education in the U.S.

13. Nursing Education Nursing schools turned away 5,000 qualified baccalaureate program applicants in 2001 because of faculty shortages.

14. Nursing Education “In 2001 the average age for nursing faculty was 50.9 years. Given that nursing faculty retire at approximately 62.5 years of age, this translates into a huge turnover by the year 2012.” (Bray, 2005) • The 78 million “Baby Boomers” in the U.S. are quickly approaching retirement • Texas and California rank 47th and 49th respectively in ratio of RNs per 100,000 residents, even though they are the two most populated states in the U.S.

15. Nursing Education Enrollment in RN education programs has declined by 50,000 (22%) since 1993. • Declining interest • Nursing program issues • Faculty shortages • Lack of training sites • Insufficient classroom space

16. Advanced Nurse Practitioner Education in the U.S.

17. History of NPs in the U.S. In the 1960s, there were two simultaneous developments that promoted the role of the NP: • A shortage of physicians in primary care (increase in the number of specialist physicians), particularly in rural and poor areas • Development of payment systems for the poor and elderly

18. Confusion Regarding Titles • The development of the NP role was not federally managed leading to many certification bodies (11 at one time) and confusion over titles and educational credentials • At first NPs were educated in certificate programs (post-basic RN training) • In 1993, the American College of Nurse Practitioners was created and became a single, more unifying voice for NPs

19. Evidence on NP Outcomes • Much resistance by physician groups regarding development of the role—concern over NPs being “safe” and “effective” • Also prestigious nurses thought the NP role lost the “nursing” element: mini-doctors • Several important research studies published in prestigious journals (Journal of the American Medical Association and New England Journal of Medicine) with interdisciplinary researchers showed the patient outcomes of patients cared for by NPs were as good and sometimes better than patients cared for by physicians

20. Effective Lobbying • Many groups, led by the ACNP, effectively lobbied at the state and federal levels for recognition of independent provider status • Took > 20 years (from 1965 to early 1990s) for NPs to gain independent provider status • Still some areas where NPs cannot prescribe (i.e. home health care)

21. Continuous Lobbying • Continuous lobbying and policy work is necessary as there is continued physician pressure to reduce the role of the NP • Requires policy savvy NPs on federal boards, oversight committees, working with political leaders and other areas to continue the fight for NP independence

22. NPs in the US • As of 2007, there were 120,000 practicing NPs (excludes NPs whose primary role is education) • The US prepares ~6,000 new NPs each year from the 325 university programs • Two primary settings: primary care and acute care

23. New Developments in NP Education • Increasing development of sub-specialty education for NPs where an NP obtains a more general specialization and then takes additional course work and clinical in a very specialized area • Example: Flight nursing NP—more general specialization is acute care nurse practitioner with additional education in flight nursing

24. Sub-Specialization • Example: Family nurse practitioners or adult nurse practitioners who take additional course work in dermatology • Practice is then care, prescribing and procedures in dermatology practice settings

25. Advantages of Sub-Specialization • Recognition of the specialized focus of much of US health care • Similar to physician sub-specialties • Increases job opportunities (joint practice with physician colleagues) • Increases NP recognition • Makes better use of physician expertise as NPs manage the routine cases

26. Forces Within the U.S. Health Care System Driving NP Demand • Increasing recognition that the biggest problems facing the US health care system are chronic diseases • Research demonstrates that the most effective chronic illness care is provided by teams of health care professionals • Policy is slowly changing to encourage this • Practice is also slowly changing

27. Example: Veteran’s Administration • “Group visits” for diabetics • Diabetic patients are scheduled for a 90 minute block of time and meet as a group • Group led by a psychologist or social worker and designed to provide support to patients adapting to diabetes, sharing experiences and feelings • Educational component to the group led by diabetic educator • Each patient is pulled out of the group to be seen by their NP, dietician or other specialist • Physicians see the patients who are the most difficult to manage medically

28. Research • Compared to traditional care, patients using a group visit approach have lower blood glucose (hemoglobin A1C), more satisfaction with care , more knowledge of diabetes and higher quality of life • The patient-to-patient sharing is critical: “I did not take care of myself and ended up on dialysis. Don’t let this happen to you”

29. Summary • NPs have demonstrated their worth to the US health care system • The forces within the US health care system are changing and there is no guarantee that things will remain the same • Constant political action is necessary to maintain and increase NP status

30. The Nursing Shortage in the U.S.

31. The U.S. Nursing Shortage “Nursing shortages are always cyclical, and each time we’ve had a shortage we’ve recruited nationwide and in foreign countries, options we don’t have now as the population ages and the shortage extends worldwide.” -- Paulette Standifer, Vice President, Dallas/Ft. Worth Hospital Council

32. The U.S. Nursing Shortage • Shortage causes delays in care delivery (delays in surgeries, overwork, ED closing). • Nurses have larger range of employment options than in the past, but still most are working in hospitals • RNs are the largest segment of the health care workforce. • Over 2.2 million people living in the U.S. are educated and licensed to practice, but only 1.8 million are employed.

33. Nursing Shortage By the year 2020, there will be an estimated shortage of 800,000 nurses. Source: Johnson & Johnson, DiscoverNursing.com

34. Nursing Shortage • Number of RNs will slowly increase through 2007, plateau, and then decline as greater numbers begin to retire each year. • Demand will accelerate through 2020 and create ever-widening gap Source: Robert Wood Johnson Foundation

35. Nursing Shortage Source: Robert Wood Johnson Foundation

36. Nursing Shortage • Financial issues have made it difficult for agencies to offer better working conditions, such as salaries and benefits to attract and retain personnel. • Some nurses are leaving hospitals for lower paying, less stressful workplaces.

37. Nursing Shortage: General Facts • There are 126,000 nursing positions currently unfilled in hospitals across the country. • Fifty-six percent of hospitals report they are using agency or traveling nurses - at great expense - to fill vacancies. • On average, nurses work an extra eight-and-a-half weeks of overtime per year. • It is estimated that by 2020, there will be at least 400,000 fewer nurses available to provide care than will be needed (JCAHO, 2002.)

38. Nursing Shortage • The average age of a working registered nurse, 43.3-years-old, is increasing at a rate of more than twice that of all other workforces in this country (JCAHO, 2002.) • The nursing workforce will shrink as the older nurses retire. • “By 2020, the nation’s baby boomers will hit their 60’s and 70’s and need more health care” • “The nursing workforce will fall to nearly 20 percent below the projected need.” (AACN, 2001)

39. Nursing Shortage According to the Census Bureau, racial and ethnic minorities only make up 28 percent of the population, and only 10 percent of the 2.5 million RN’s. • Nursing programs across the country have been setting up “shadow programs” for high school students to come and see what nursing is like. • Discover Nursing at the Frances Payne Bolton School of Nursing reaches out to minority students.

40. Nursing Shortage “This will not be a temporary shortage… Fundamental demographic changes are occurring in America, and the coming labor crisis will be with us for decades.” -- The Panel on the Future of the Health Care Labor Force in a Graying Society

41. Nursing Shortage Solutions • Transform workplace to provide better working environments • Bolster nursing education so new graduates are better prepared • Make new federal money available • Invest in nursing services • Invest in nursing scholarships and tuition support • Invest in preparing nursing faculty

42. Overview of the AmericanHealth Care System

43. How Hazardous Is Health Care?

44. 11% Alcohol dependence 23% Hip fracture 33% Peptic ulcer 45% Diabetes 69% Low back pain 73% Prenatal care 76% Breast cancer 79% Cataracts RAND Study: Quality of Health Care Often Not Optimal • Physicians provide appropriate health care only about half the time Percentage of time

45. Quality of U.S. Healthcare Americans spend 40% more per capita on health care and: • Rank 27th in infant mortality • Rank 27th in life expectancy • Are less satisfied with healthcare than the Canadians, English, and Germans Berwick, DM. (2003). JAMA, 289, 1969-75.

46. Under- and Uninsured • 47 million Americans are uninsured (15.8%) • Insurance in the U.S. is primarily tied to employment but not all employers offer health insurance • Having health insurance increases the likelihood of receiving routine and preventive care • Uninsured Americans have poorer health status

47. Health Care Reform

48. Presidential Results Will Be Key

49. Conclusions

50. Conclusions • U.S. health care system is very expensive and only moderately effective • Fixing it will take considerable political will • American nurses are many and can be powerful but are not united • Many more nurses will be needed but the source of these nurses is uncertain • International migration will persist