workforce issues m6920 october 30, 2001. columbia university school of nursingm6920, fall, 2001...
TRANSCRIPT
Columbia University School of Nursing M6920, Fall, 2001
Goals for discussion
Understand how professionals are thought about generally
Understand some major issues about health professionals
Increase sensitivity to licensure issues
Columbia University School of Nursing M6920, Fall, 2001
Evolution of work force
Healers exist in every culture
Healing associated with religious system
Enlightenment began Western separation
Columbia University School of Nursing M6920, Fall, 2001
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?
Columbia University School of Nursing M6920, Fall, 2001
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
Columbia University School of Nursing M6920, Fall, 2001
Defining professionals
Special body of knowledge Control over education and
qualifications Limited entry into field Social recognition
Columbia University School of Nursing M6920, Fall, 2001
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
Columbia University School of Nursing 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)
Dumpe et al 1992 Forecasting the Nursing Workforce Nursing Economic$ 16:4 (170-9)
Columbia University School of Nursing M6920, Fall, 2001
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
Columbia University School of Nursing M6920, Fall, 2001
Health Profession/ Population Ratio*
0
200
400
600
800
1000
1980 1996
Dentists
RegisteredNurses
BSN Nurses
MS/PhD Nurses
Pharmacists
Physic ians
*per 100,000 populationHealth US, 1999
Columbia University School of Nursing M6920, Fall, 2001
Interprofessional Issues
Socialization Actual and perceived power Economic competition
Columbia University School of Nursing M6920, Fall, 2001
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
Columbia University School of Nursing M6920, Fall, 2001
Physician/population ratio*
0
5
10
15
20
25
30
35
1975
1997
NE MidAtlantic
E NCentral
W NCentral
SouthAtlantic
E SCentral
W SCentralMountain
Pacific
*Health US, 1999
Columbia University School of Nursing M6920, Fall, 2001
Physician Supply in NYC
Neighborhood Total FTE # MD'sneeded
Shortage
Total 1224 921.6 -302.4
Central/WestHarlem
140.3 83.9 -56.4
South Bronx 410.2 294.7 -115.5
North CentralBrooklyn
673.5 543.0 -130.5
Denise Soffel, United Hospital Fund
Columbia University School of Nursing M6920, Fall, 2001
Diversity in Medical Students
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
White Black Hispanic Asian
1990
1994
1990: 65,1631994: 66,629
Columbia University School of Nursing M6920, Fall, 2001
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)
Columbia University School of Nursing M6920, Fall, 2001
Ethics of international movement
Beneficence• better care in underserved US areas
Non-malfeasance• Drain from neediest countries• Specialty interests not needed
Autonomy Social Justice
Columbia University School of Nursing M6920, Fall, 2001
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?
Columbia University School of Nursing M6920, Fall, 2001
Is nursing a profession?
Classics: clergy, law, medicine
Yes: • controls education• limited entry to field• social recognition • personal professional ethic
Columbia University School of Nursing M6920, Fall, 2001
Maybe not. . .
social recognition limited only partial practice independence most are wage workers gender perception issues competition with more prestigious
fields
Columbia University School of Nursing M6920, Fall, 2001
Distribution of Nurses*
0
100
200
300
400
500
600
700
800
USA NE Midwest South West
RN's
ADN/Dip
BSN
MS/PhD
*Per 100,000 populationHealth US, 1999
1,272,900 nurses1980
Columbia University School of Nursing M6920, Fall, 2001
Types of nurses, 1996*
ADN/Dip
58%
BSN
32%
MS/PhD
10%
2,161,700 Nurses
*Health US, 1999
Columbia University School of Nursing M6920, Fall, 2001
Aging out of nurses
0
5
10
15
20
25
30
35
40
45
1983 1998
Average RN age
US worker age
% below 30
Buerhaus, Steiger, Auerhach JAMA 283:22
Columbia University School of Nursing M6920, Fall, 2001
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
Columbia University School of Nursing M6920, Fall, 2001
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
Columbia University School of Nursing M6920, Fall, 2001
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%
Columbia University School of Nursing M6920, Fall, 2001
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
Columbia University School of Nursing M6920, Fall, 2001
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
Columbia University School of Nursing M6920, Fall, 2001
Turnover issues
Stability associated with• older staff• higher income staff• longer tenure
Turnover associated with• tension• limited organizational commitment• supervisor’s behavior
Columbia University School of Nursing M6920, Fall, 2001
Nursing Programs in NY
Graduate: 25
Baccalaureate: 45
AD: 57
Columbia University School of Nursing M6920, Fall, 2001
Diversity in Nursing Students
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
White Black Hispanic Asian
1990
1994
1990: 221,1701994: 270,228
Columbia University School of Nursing M6920, Fall, 2001
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
Columbia University School of Nursing M6920, Fall, 2001
Ethnicity of New York Nurses, 1996
White 76.5%
Black 11.5%
Asian 9.9%
Puerto Rican1.3%
Other Hispanic1%
Native American0.3%
Columbia University School of Nursing M6920, Fall, 2001
Employment settings, NY State RN’s
58%
10%
2%
13%
6%1%
7% 3%Hospital
Nursing Home
Nursing Education
Public Health
Student Health
Occupational Hlth
Ambulatory Care
Other
Columbia University School of Nursing 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
Columbia University School of Nursing M6920, Fall, 2001
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
Columbia University School of Nursing M6920, Fall, 2001
Public health workforce
Multiple disciplines Multiple routes of entry Multiple settings Overlapping job duties Confusion among
• profession• setting• passion
Columbia University School of Nursing M6920, Fall, 2001
Public Health Workers Region IV
Professionals
Paraprofessionals
Admin Support
Skilled Craft Workers
Service/Maintenance
Programs
Protective Service Workers
Officials/Administrators
Technicians
Columbia University School of Nursing M6920, Fall, 2001
Workers Alabama and Mississippi
0
500
1000
1500
2000
2500
Alabama Mississippi
AdminProfessionalTechnicalClerical/Support
Columbia University School of Nursing M6920, Fall, 2001
Consumer protection or control of competition?
Limit number licensed? Require certification? Extend credentialing process? Expand disciplinary actions?
Columbia University School of Nursing M6920, Fall, 2001
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
Columbia University School of Nursing M6920, Fall, 2001
Professional licensure
Provides validation in community Affects ability to earn Once gained, fiercely protected Very confusing in interdisciplinary
practice settings
Columbia University School of Nursing 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
Columbia University School of Nursing M6920, Fall, 2001
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