A WORKFORCE IN CRISIS:
A TIME FOR INNOVATION IN NURSING
Contents
Background
Supply
Demand
Recommendations
The purpose of this paper is to disseminate the emerging recommendations for consideration by the public, legislators, and the nursing community that we might form a common understanding of a platform for innovation in the development of the future nursing workforce. The background offers a brief review of context and trends in healthcare nationally and regionally of this crisis in the nursing workforce. It is followed by supply, demand, and safe care factors in Colorado and recommendations for action.
This is in alignment with the vision and mission of the Colorado Alliance for Nursing Workforce Development Opportunities (CANDO), to proactively meet the future nursing care needs of the growing Colorado public through service and education partnerships. The shared vision is an improved Health Care System in the state with:
- Nursing students readily employable;
- Training for current nurses;
- Education that teaches and allocates resources based on workforce needs;
- Employers that foster service-learning and career advancement.
The infra-structure of the CANDO statewide activities is established to provide local input through regional task forces, housed in each of the five Area Health Education Centers. The purpose of each task force is, in collaboration with all groups with common goals, to identify, implement, and disseminate nursing recruitment/retention strategies for education and service.
The four goals are to:
- Increase health care career interest
- Increase public knowledge and value of the nursing role
- Identify new nurse role potentials and paths
- Implement 21st Century setting specific competencies in service/education
This is a brief overview of national and state trends.
Background
Since 1990, the U.S. Health Care System has undergone unprecedented change and upheaval in its organization, financing, and delivery. This system transformation is having a massive ripple effect on supply/demand, roles, responsibilities, and employment patterns of the health professions workforce.
Nursing is the largest of the health professions and RN's the largest segment with 2.6 million licensed to practice in the United States in 1996. The Bureau of Labor Statistics reports the jobs for RN's will grow 23% by 2006. That is faster than the average for all other occupations. The American Association of Colleges of Nursing reports that enrollments in schools of nursing are down. Entry-level BSN enrollment has fallen 6.6% from a year ago, dropping for the fifth year in a row.
Health care issues and trends impacting Colorado are changing the nursing workforce climate and contributing to the current instability in the market.
Influencing variables include:
- A growing market penetration by managed care organizations.
- Diversity, complexity and changing reimbursement methods.
- Inpatient to outpatient shift.
- Expansion of community based service.
- The increasing use of nurse extender's.
- The aging of the population and the providers of care.
- Unprecedented population growth rates.
- Record low unemployment rates nationally and in Colorado.
- Recently legislated prescriptive authority for advanced practice nurses.
Although existing sources of baseline and projected nursing workforce data are difficult and complex; the consensus is that Colorado is experiencing a greater demand than supply for nurses. This paper will next examine some of the variables of supply and demand and recommendations for action. (Refer also to Supply/Demand Model inside cover)
Table 1 Aging Colorado RN workforce reduces available participants. (1997)
For the past five years the nursing workforce in Colorado has been growing progressively older and we can expect that a substantial proportion of the nursing workforce will retire within the next 15-20 years. The mean age nationally and in Colorado of both RN and LPN workforce members is 43-44 years. (Table 1). Adding to this concern is the fact that Colorado is now the third fastest growing state in the nation, according to estimates released recently by the U.S. Census Bureau. The predication is that growth will continue for the next 25 years with a gain of 1.5 million people by 2020. Finally, the ethnic background of RN's in Colorado does not parallel the 30-45% ethnic background of the projected Colorado citizens.(Table 2) Will there be an adequate supply of nurses, with cultural competency and match, to fill this void when there has been a decreasing enrollment in nursing programs in the state in the past several years?
Table 2 Ethnic make-up of Colorado RN workforce (1997)
Since 1988, the education and health systems in Colorado have worked together to address the nursing shortage in the state. As a result of this collaboration a benchmark statewide Nursing Articulation Model was developed, as was The Colorado Differentiated Practice Model for Nursing. The articulation model went into effect in 1991, and the Colorado Council on Nursing Education continues to promote ongoing communication and evaluation of the model. As evidence to the articulation model's success in rural regions, during the past ten years, rural nurses continued with their nursing education pathway in greater numbers (more than 1 in 5) than did the urban (1-6).
The Colorado Alliance for Nursing workforce Development Opportunity members identified the top 5 issues for action to impact the nursing workforce development in Colorado and provided an opportunity for new partnerships to develop. Increased student clinical time and experience is one of the areas being examined through several new collaborative's between service and education. Clarity about most desired entry competency areas in multiple settings has contributed to sharing common expectations of employers and education.
Despite this collaboration and innovation, Colorado is faced with a crisis in the nursing workforce.
- 9% of the Colorado RN's self-report that they will not be in nursing in five years (1997)
- Despite a 37% increase in the RN population in Colorado over the last 8 years, today there are over 1600 job openings in urban Colorado.
- Two of five RN's and three of four LPN's were educated in Colorado.
- Consumers are asking "Who is delivering my care and is it safe?"
In consideration of the over all purpose to develop and implement strategies to promote the recruitment and retention of nurses, the following Recommendations are made:
- Increase enrollments in all nursing programs.
- Increase access to nursing education programs via long distance multi-media.
- Increase number and accessibility of LPN to BSN programs.
Supply
Projected nursing shortage in Colorado for 2000 became a reality in spite of a 37% workforce expansion in last eight (8) years. Recruitment efforts include the traditional and non-traditional and the challenge remains in attracting competent culturally diverse candidates for all nursing positions, experience and specialty training are at a premium. High utilization of outside agency personnel-temporary workers in all settings, due to a lengthening time to hire into vacant positions exceeds the projections made in 1997 and 1998 employer survey. This is both a rural and urban phenomenon.
Another important factor on the supply side of the model is the category of career mobility with six data points of consideration. The following three data points pertain to licenses: 1) the number of RN/LPN renewal licenses or Nurse Aide certifications; 2) the number of Colorado nurse license endorsements; and 3) a migration pattern (the ins and outs). The three final points pertain to career mobility: 4) access to education and technology, 5) the Colorado Nursing Articulation Model; and 6) availability to cross train nurses, relevant to changes in practice and settings, within organizations and across organizations.
Cross training for role change within an organization or crossing boundaries of an integrated system of health care is an important supply factor. It may be the transition from the acute inpatient care to the outpatient setting, home health, school or industry nurse role, etc. Wherever the role change occurs, having the appropriate competency and skills set to safely meet the needs of the clients clearly is a factor in the establishing and maintaining of a appropriately competent supply of nurses.
Recommendations:
- Implement strategies that address the image of nursing and the recruitment of diversified students into nursing as a career.
- Implement strategies to promote retention of nurses in education and service.
- Continue to facilitate an effective and progressive statewide articulation model that reflects the competencies/roles needed for the 21st century marketplace.
- Increase career interest by implementing math, science, and health curricula through elementary and secondary school links.
Demand
Personnel positions are fluctuating, as the change in demand for services has gone into a steep increase that has not demonstrated a sign of reducing in the last year. Colorado has seen significant growth in population, third fastest in the nation at 2.2%, surely more than expected when a nursing shortage in Colorado was projected for 2000 in 1992 HHS report to President.
The demand for the number and types of nursing personnel is partly a function of the money available to pay the salary and benefits. The money generated in the acute impatient, the long term care and home health settings are significantly impacted by the third party reimbursement system. In Colorado, we have advanced rapidly, only behind California and Minnesota in the managed care penetration and capitation. Nationally, salary has been flat per Beurhaus since 1992 and especially suppressed in highly managed care markets. Managed care penetration is greater in urban than rural Colorado.
Health care employers of nurses state that three to six months ago they were able to offer competitive salaries and benefit packages and today they are once again having a salary survey completed and re-analysis of their budget and staffing patterns. Interim or middle of the year salary changes have been reported in many health care settings both in urban and rural locations in 1999. This has not been the case until the last year for such rapid salary analysis, budget and staffing pattern adjustments to meet the minimum salary requirements to maintain a current nursing workforce.
Reports of salary range hikes for the unlicensed assistive personnel and certified nurse assistants parallels the changes in salary and benefit incentives for the RN's. As recent as 1998 employers reported a 30-40% margin between LPN and RN salary and as small as 10-20% gap between Certified Nurse Assistants and LPN's. Notable is the difference in preparation of 2 weeks for a CNA and 12-18 months for LPN.
LPN's are being hired into some settings, like acute inpatient care, where there has been a long history of reduction and actual absence of their role in that skill mix. This is at the same time when the LPN's primary setting of nursing homes is suffering from a loss of RN's and the continued revolving door of sometimes 100% turnover of certified nurse assistants.
| Primary practice Location | Registered Nurses (1997) | Licensed Practical Nurses (1998) |
|---|---|---|
| Hospital | 55% | 20% |
| Private. Group Practice | 10% | 18% |
| Home Health | 9% | 8% |
| Long Term Care | 7% | 39% |
| Community Health | 4% | 2% |
The use of temporary staff is another indicator of a change in the demand in the workforce. The 1997 employer survey response to the percent of staff that is replaced by temporary staff showed a clear majority of no or 0% use across the rural settings, with use of 5-25% only in inpatient and ambulatory settings for RN's and LPN's. Then, the urban picture showed a wide variation in use from zero to over 25% utilization of temporary staffing in all categories and settings. They projected less or status quo use of temporary personnel for 2000 and even less for 2003. Today there are very few, if any, organizations in urban sites who are not using temporary agency support staff, and the rural locations are reporting increased use also.
Recommendations:
- Investigate feasibility of developing a Cooperative Career Development Center.
- Promote work environment innovations that meet or exceed Magnet facility certification criteria.
- Distinct salary for distinct role & competency – aligned with expected Quality Outcomes.
Safe care is basic expectation / right of every Colorado citizen
Regulation, Education and practice arenas are all affected and need to be involved in the innovations to reach solutions to avert the questionable safety situations reported in all types of health care settings across the country and in Colorado such as:
- Many emergency rooms are spending more time on "divert", than not.
- Staffing ratios are being called into review and even legislated. (California)
- Lack of staff has forced reduction in available services, actual unit closings.
- Health care insurers are concerned about the increasing patient incidents
Consumers also have a strong opinion about what kind of job health care groups are doing to serve health care consumers – and at the top of the list is nurses doing a good job (83%) with Doctors next (69%), hospitals (61%), Pharmaceuticals third (62%), HMO’s (36%) and Managed Care companies at 34% in this Kaiser/Harvard National Survey of Americans' Views on Managed care, 1997.
July 1999 Harris Poll reveals that an overwhelming majority of the public – 92% said they trust information about health care provided by registered nurses, ranking nurses just one percentage point below physicians (commissioned by Nurse Week Publishing, Inc. and Sigma Theta Tau International included 1000 people nationwide).
Recommendations:
- Identify and develop continuing competency validation methodologies.
- Partnership of consumers, regulation, education and service to research relationship of nurse staffing models' with patient outcomes.
- Competency based education program to ensure that nurses understand appropriate delegation.
- Investigate needed changes in LPN scope of practice to meet changing population health care needs.
- Central housing for a systematic method to integrate the multiple resources of information and data for more efficient method to communicate the trends identified for policy, practice and public health care and safety impact.
The dynamic and ongoing changes in healthcare demand bold actions by new collaborative's and coalitions of public, legislators, and the nursing community.
The next step is the consideration of these recommendations with the following questions in mind:
- What needs to be changed?
- Why does it need to be changed?
- What benefits are derived by each stakeholder?
- Who may benefit as a result of the change?
- Who can make the change?