Download Nurses

Nurses and the Allied
Workforce:
Who are they, and are
there enough?
Joanne Spetz
University of California, San Francisco
August 2011
Goals of this session
• Understand unique features of workforce for
licensed/registered & unlicensed professionals
• Consider domains in which substitution of
personnel is feasible or appropriate vs. not
• Learn specific issues regarding nursing
shortages
• Understand how surveys can be conducted to
expand understanding of the workforce and
shortages
2
Who are non-physician health
professionals?
• Nurses
– Registered nurses (RNs)
– Licensed practical nurses, enrolled nurses, etc.
– Unlicensed aides
• Advanced Practice Nurses
– Nurse Practitioners
– Nurse Midwives
– Nurse Anesthetists
• Physician Assistants
3
Who are non-physician health
professionals?
• Community health workers
– Promotoras
– Non-nurse midwives
– Health officers, clinical officers
• Allied health professionals
– Dietiticians
– Educators
– Coordinators
• Oral health
– Dentists
– Dental Hygienists
4
Roles of these professionals vary by
setting
• Hospitals
– Nurses deliver most daily care
• RNs do complex care
• Other licensed nurses and aides do basic care
– Allied health professionals provide specific services
• Radiology tech, respiratory therapy, physical therapy
– Coordinators and others support the process
• Dietiticians
• Patient care coordinators, discharge planners
5
Roles vary by setting
• Clinic / ambulatory care
– Physicians
• Examination, ordering tests, diagnosis, treatment plan,
prescription of medications, hospital admission
– Physician assistants
• Examination, ordering tests, collaboration on diagnosis
& treatment plan & prescriptions
– Nurse practitioners
• Examination, ordering tests, diagnosis, treatment plan,
prescription of medications for primary care only
6
What determines overlap?
• Scope of practice regulations
– Vary country-by-country, state-by-state
– Main areas of difference:
• Ordering tests
• Prescriptive authority
• Collaboration vs. supervision vs. independent practice
• Payment policies
– Vary by type of payment
• Government
• Private insurance
7
Overlap can be surprising
• RN – MD overlap in US scope of practice
– Physical exam
• Assessing vital signs
• Auscultating lung, heart, and abdominal sounds
• Assessing eyes and ears using ophthalmoscope and
otoscope
• Performing breast exam
• Testing range of motion and muscle strength of upper
and lower extremities
• Assessing pain
8
Overlap can be surprising
• RN – MD overlap in US scope of practice
– Implementing treatments
• Administering medications
• Collecting blood, urine, stool samples
• Obtaining sputum and wound cultures
• Providing health and mental health counseling
• Coordinating care
• Providing wound care
• Inserting foley catheter and nasogastric tube
• Inserting peripheral intravenous catheter
• Obtaining 12-lead electrocardiogram (ECG)
9
Overlap can be surprising
• RN – MD overlap in US scope of practice
– No overlap:
• Diagnosis
• Prescribing treatments
– Medications
– Diagnostic tests
• Advanced practice nurses and physician
assistants can do these last two things
10
How much do non-physicians
provide care?
• United States
– ~152,000 licenses for advanced practice nurses
(2007), even more prepared in advanced practice
– ~123,000 nurse practitioners employed in US
• Only 81,000 had job title of NP (57%) in 2004
– ~85,000 Physician Assistants (2008)
• ~37% of work in primary care medicine
– 36.1% of US patients saw a non-physician clinician in
1997 (Druss, 2003)
• 30.9% of all patients saw both physician and nonphysician
11
How much do non-physicians
provide care?
• Africa
– Long history – traditional medicine, apothecaries,
dressers, dispensers
– Some programs developed due to loss of physicians
to developed countries
– Research indicates non-physician providers active in
25 of 47 African countries (Mullan 2007)
• Less often in French-speaking nations
• Clinical officers can provide primary care, provide
surgeries and anesthesia
• In some countries there are more non-physicians than
physicians (Malawi, Mozambique, Uganda)
12
Advantages of non-physician
providers
• Lower time and cost for training
– Nurse practitioner – Master’s degree
– Clinical officer – high school or RN
– Other providers – varies, can be non-Western care
• India has more non-physician clinicians than
physicians, many in Ayurveda and homeopathy
(Phadke 2008)
• Can have a broad skill set
– Nursing focus on care and daily support
– Mental health and whole-body philosophy
• Managed care organization research finds that
higher use of NPs saves money at no loss of
quality (Roblin et al 2004)
13
Do non-physicians provide highquality care?
• US and Europe
– Cochrane review found “no appreciable differences…
between doctors and nurses in health outcomes for
patients, process of care, resource utilisation or cost.”
• “Patient health outcomes were similar for nurses and
doctors but patient satisfaction was higher with nurseled care.”
– Many studies find that NPs spend more time on
consultation, some find better quality consultation
from NPs (Horrocks et al 2002)
14
Do non-physicians provide highquality care?
• Anesthesia
– Training program in Haiti has produced 24 nurse
anesthetists, 19 still in Haiti, with good outcomes (Rosseel
2009)
• HIV/AIDS care
– RNs demonstrated equivalent knowledge to physicians of
when to start antiretroviral therapy for HIV patients (Vasan
2009)
• Childbirth and gynecology
– Study of emergency obstetric surgeries in Mozambique
found equal outcomes between medical officers and
clinical officers in district hospitals
– Insertion of IUDs in Turkey, Mexico, and Nigeria safely
done by non-physicians (Farr 1998)
• Cardiovascular risk assessment and management
– Similar quality from WHO program to train non-physicians
(Abegunde 2007)
15
Barriers to use of non-physicians
• Education program availability and quality
• Guilds and protective interests of physicians
• Bureaucracy, licensure
• Payment
• Acceptance by the public
16
Questions
• Can non-physician health professionals help meet
the needs of your patients and population?
– What needs do you have?
– What gaps do you have?
• What types of non-physician providers are available
to you?
– Do you need to train your own?
• What regulations must be addressed?
– What legal barriers will you face?
– What payment barriers will you face?
• How will monitor quality to ensure the change was
good?
– Can you get data to compare quality and cost?
17
Focus: Registered Nurses
• RNs help “people and communities attain,
maintain, and recover optimal health”
• Science and art
• Care, not cure
• Modern nursing developed as a profession in
the 1800s
– Military and religious roots
– Florence Nightingale and the Crimean War
• >13 million nurses worldwide
18
What do nurses do?
• Nursing process
– Assess and diagnose needs of patients
– Plan and implement interventions
– Evaluate the outcomes of care
19
US experience:
Cycles of shortage and surplus
• Since WW2, there have been near-constant
nursing shortages
• Cycles of surplus and shortage have been
studied by policymakers and economists
• Most recent “surplus” was mid-1990s
• We have had a “shortage” since the late 1990s,
although this might be changing
20
Measures of shortage
• Reports of shortage
• Vacancy rates
• Time to recruit for new positions
• Econometric demand models
• These measures are highly correlated!
21
Reasons for shortages…
• Limited number of employers
• Delays in wage increases
• Delays in producing new nurses
• Licensing regulations
• Minimum staffing requirements
• Minimum wages
22
Forecasting the nursing
workforce…
23
Why do we forecast the health
workforce?
• To predict future needs and future supply
• To understand whether perceived shortages are
real
• To learn whether a shortage is likely to persist
• To guide policy to educate and retain health
workers
24
LABOUR MARKET DYNAMICS
 What
information
Health
Care Education
 Take-up
What Rate
information
is needed to diagnose
priorities?
Labour Forceproblems/identify
Health Care Labour
Participation
Force Participation
is needed to guide
policy reform?
Rate
Rate
Policies on
enrolment
Policies on
selecting students
High
School
Training
in
Health
Policies to draw
health workers
back into the
health care sector
Pool of
Qualified
HW
Employed
Unemployed
Other
Training
MIGRATION
Policies to
mobilize
unemployed
health workers
Policies to
address inflows
and outflows
USA, UK
Health
Care
Sector
1. Geographic
distribution
2. Private/Public
sector
allocation
3. Absenteeism
4. Skill mix
5. Productivity
6. Quality
NonHealth
Care
Sector
Policies to retain
health workers in
remote areas
Policies to govern
dual practice
Policies to
improve
productivity,
quality of care
Policies on skill
mix
25
Forecasting supply is simple
(mostly)
• Stock-and-flow models
Inflow of nurses
Nurses with Active
Licenses
Living in California
Outflow of nurses
Share of nurses who work,
and how much they work
Full-time equivalent supply of RNs
26
A more complex supply approach
• Multivariate regression
– Supplyt+1 = f(Supplyt, demographics, graduations,
wages? Federal immigration policy? Stock market
performance?)
– There are many endogenous factors
• Wages is the most important
• New graduations (also affected by wages)
• Most forecasts do not use this strategy
27
California wanted forecasts in 2005
• Statewide surveys of RNs since 1990
– 1990, 1993, 1997, 2004, 2008, 2010 in field
• National forecasts were out-of-date (from 2000)
• National forecasts did not seem to predict
California’s situation well
28
California had extensive supply data
from their surveys
• Data on:
– Age, gender, marital status, children, etc.
– Education, year of graduation
– Employment status, hours per week
– Out of state nurses who work in California
• Estimate supply of traveling nurses
29
Age distribution of California RNs,
2006 & 2008
25%
20%
15%
10%
5%
2006
2008
Un
de
r
30
30
-3
35 4
-3
40 9
-4
45 4
-4
50 9
-5
55 4
-5
60 9
Ov -64
er
64
0%
Source: California Board of Registered Nursing Surveys
30
Nurses with active licenses
• Number of nurses with active licenses and
California addresses in 2009 provided by BRN
• 5-year age groups provided by BRN
31
Inflows of RNs
• Graduations from California nursing programs
• Immigration from other countries
• Migration from other states
• Transition from inactive license
• Transition from lapsed license
32
Outflows of nurses
• Migration to other states
• Transition to inactive or lapsed license
33
Percent of RNs Working in Nursing,
by Age
2006
2008
Un
de
r
30
30
-3
35 4
-3
40 9
-4
45 4
-4
50 9
-5
55 4
-5
60 9
Ov -64
er
64
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Source: California Board of Registered Nursing Surveys
34
How does the supply forecast work?
• The supply of actively licensed RNs next year
for an age group will equal….
– 4/5 of the nurses in the age group (1/5 will “age
up” to the next group)
– 1/5 of the nurses from the younger age group
– Inflow of nurses in the age group
– Outflow of nurses in the age group
• Multiply the number of actively licensed RNs
by the labor-force participation data to get
Full-Time Equivalent Supply
35
Supply forecast ranges were offered
700,000
600,000
500,000
400,000
300,000
200,000
100,000
Best Supply Forecast
Low Supply Forecast
High Supply Forecast
2007 Forecast
20
0
20 9
1
20 0
1
20 1
1
20 2
1
20 3
1
20 4
1
20 5
1
20 6
1
20 7
1
20 8
1
20 9
2
20 0
2
20 1
2
20 2
2
20 3
2
20 4
2
20 5
2
20 6
2
20 7
2
20 8
2
20 9
30
0
36
Demand forecast method 1:
Worker-to-population ratios
• Example: Our state should match the national
average of 825 RNs per 100,000
• Benefits
– Easy to calculate
– Simple to explain to the public
• Drawbacks
– Does not control for differences across states/regions
– Does not change with population aging
– Does not assess whether the benchmark is adequate
– Money might not be available to fund the positions
37
Demand forecast methods 2 & 3:
Historical staffing method
• Example: California forecasts (2005) used hospital
data to compute RN hours worked per patient day in
2004
– Patient days per 1000 population were computed for each
age group using discharge data
• Alternate: budgeted positions per 1000 population
– Future patient days were forecasted based on age group
population changes
– Demand for nurses was forecasted by multiplying
forecasted patient days by RN hours per patient day
– Adjust to full nursing demand by assuming hospital
employment will continue to be 60% of all RN demand
38
Demand forecast methods 2 & 3:
Historical staffing method
• Benefits
– Relatively easy to compute
– Adjusts for aging of the population
– Reflects true utilization of nurses, not just wishful thinking
• Drawbacks
– Harder to explain
– Is historical staffing adequate?
– Does not include settings for which you don’t have data –
need to fudge for this
– Is money available?
39
Demand forecast method 4:
Multivariate method
• Example: US Bureau of Health Professions RN models
– Estimate demand for health services in 12 sectors
– Estimate demand for RNs based on demand for services
• Benefits
– Considers factors that affect demand, such as population
demographics, health policy
– Can develop simulations based on changes in factors
• Drawbacks
– Try explaining this to a politician or policymaker!
– Difficult to follow the methodology and replicate
– Overly complex: couldn’t we do a reduced-form model?
– Demand is not the same thing as need
40
Demand forecast method 5:
True need for services method
• No U.S. example: Estimate what the true need for
health services will be, and then derive health worker
demand
• Benefits
– Encourages vision of ideal health services system
– Allows for creative strategies for meeting population needs
• Drawbacks
– Full of value judgments
– Challenges historical precedent, power positions
– Extremely hard to do in a convincing way
– Money might not be available to achieve it
41
Forecast strategies gave different
results
400,000
350,000
300,000
250,000
200,000
150,000
100,000
National 25th percentile FTE RNs/population
National average FTE RNs/population
California Employment Development Dept. forecast
Maintain 2009 FTE RNs/Population
OSHPD hours per patient day-based forecast
50,000
20
09
20
10
20
11
20
12
20
13
20
14
20
15
20
16
20
17
20
18
20
19
20
20
20
21
20
22
20
23
20
24
20
25
20
26
20
27
20
28
20
29
20
30
0
42
Put supply and demand together…
450,000
400,000
350,000
300,000
250,000
200,000
150,000
Best Supply Forecast
National 25th percentile FTE RNs/population
100,000
National average FTE RNs/population
50,000
0
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030
43
Typical forecasts assume:
• Wages do not change
• Changes in numbers of graduates follow a time
trend
• Demand does not fundamentally change
– RN demand is based on health care demand
44
Forecasting methods are weak
• None of the demand methods are very
satisfactory
– “Per capita” approach is too crude
– Market demand approaches aren’t normative
– Health needs approaches are too difficult and
subjective
• At least we can do supply pretty well
– But supply changes with wages – how do we “close
the loop” of the model?
45
What next?
• Transparency in forecasting methods has high
value
• Government forecasts are extremely influential
– But the US government 2002 model didn’t perform
well for some states
• Analyses should not focus on one workforce
group in isolation
46
Policy levers for supply
• Short-term supply
– Increase work hours of those now working
– Recruit nurses who are licensed but not working
• Long-term supply
– Attract more people to the profession
• Improve working conditions, salaries
• Marketing – men, underrepresented minorities
– Expand nursing education pipeline
– Increase efficiency of nursing programs
47
Policy levers for demand
• Funding for employers
• Regulations and staffing mandates
• Financial incentives to hire
• Ease hiring
– Streamline bureaucratic requirements
• Population health and wealth
48