An ag­ing nurs­ing work­force con­fronts rapid change

Modern Healthcare - - NEWS -

Nurses have al­ways played a cen­tral role in de­liv­er­ing health­care.

Hospi­tal pa­tients typ­i­cally spend far more time with sev­eral nurses over the course of their stay than with the physi­cians who are in charge of their care. Nurses are an in­dis­pens­able part of the ser­vices de­liv­ered in ev­ery physi­cian’s of­fice.

But, to­day, nurses are be­ing asked to take on new jobs. As the health­care pay­ers de­mand greater value for their health­care dol­lars, de­liv­ery sys­tems must learn how to care for their pa­tients more safely, with higher qual­ity and in a less costly man­ner. That’s led health sys­tem lead­ers to ask the na­tion’s 3.1 mil­lion nurses to play a greater role in co­or­di­nat­ing care.

Are they up to the task? The na­tion’s nurs­ing work­force is grow­ing older, with the av­er­age age ap­proach­ing 50. About a quar­ter of cur­rent nurses are slated to re­tire in the next decade. Given the ag­ing of the pop­u­la­tion — 10,000 baby boomers are re­tir­ing ev­ery day — the gov­ern­ment projects the na­tion will need to train and em­ploy a mil­lion new and re­place­ment nurses be­tween now and the mid­dle of the next decade.

Through­out 2017 Mod­ern Health­care will con­duct a se­ries of roundtable dis­cus­sions with C-suite lead­ers drawn from many of the na­tion’s lead­ing hospi­tal sys­tems, large physi­cian prac­tices and the or­ga­ni­za­tions rep­re­sent­ing groups that make up the health­care land­scape. We de­cided to launch the se­ries with a chief nurs­ing of­fi­cers roundtable, mod­er­ated by Mod­ern Health­care re­porter Maria Castel­lucci, be­cause of the in­creas­ingly im­por­tant role that nurses must play as the na­tion drives to­ward bet­ter co­or­di­nated, value-based care.

Par­tic­i­pat­ing in a con­ver­sa­tion that took place early this month were Kim Hen­rich­sen, vice pres­i­dent of clin­i­cal op­er­a­tions and chief nurs­ing of­fi­cer at In­ter­moun­tain Health­care, based in Salt Lake City; Linda Burnes Bolton, vice pres­i­dent for nurs­ing and chief nurs­ing of­fi­cer at CedarsSi­nai in Los Angeles; Jan­ice Walker, se­nior vice pres­i­dent and chief nurse ex­ec­u­tive for the cen­tral divi­sion of Bay­lor Scott & White, based in Texas; and Pamela Cipri­ano, pres­i­dent of the Amer­i­can Nurses As­so­ci­a­tion. The fol­low­ing tran­script has been edited for brevity and clar­ity.

Mod­ern Health­care: How is the role of the nurse chang­ing? How are they be­com­ing a more im­por­tant part of the care team?

Pamela Cipri­ano:

The role of the nurse has been chang­ing dra­mat­i­cally as nurses have not only be­come more ed­u­cated, but have as­sumed roles as part­ners in trans­form­ing health­care. If we think about some of the im­por­tant changes that came about with the Af­ford­able Care Act, nurses have jumped in and em­braced val­ue­based re­im­burse­ment. Sim­i­larly, they have been in­stru­men­tal in af­fect­ing pos­i­tive and suc­cess­ful tran­si­tions of care across nu­mer­ous lo­ca­tions and have key roles in the co­or­di­na­tion of care. Kim Hen­rich­sen:

It’s very energizing to watch this tran­si­tion and the on­go­ing evo­lu­tion of the role of the nurse in health­care. Our nurses who work in all dif­fer­ent walks of health­care have a lot of re­spect, and are tak­ing on lead­er­ship roles in places that we haven’t had the op­por­tu­nity to take on be­fore.

It’s also been fun to watch and to par­tic­i­pate in not only the ex­pan­sion of the op­por­tu­ni­ties for nurses but the skill sets that they are de­vel­op­ing. There are so many op­por­tu­ni­ties for nurses to work in hos­pi­tals, am­bu­la­tory set­tings, ed­u­ca­tion, IT and the home. Tele­health ser­vices are (also) grow­ing and ex­pand­ing, and nurses are play­ing a key role in de­liv­er­ing care through elec­tronic means.

MH: What are your con­cerns about the nurs­ing short­age, and how can it be ad­dressed?

Cipri­ano: We’re grad­u­at­ing about 150,000 nurses per year, and we ex­pect those num­bers to go up. (But) we also know the de­mand is go­ing to go up. Our big­gest con­cern right now is that in pock­ets across the coun­try many nurses are telling us that they are very un­der­staffed, and we know that that cre­ates a se­ri­ous risk for pa­tients.

Our goal is to make sure that re­gard­less of set­ting and ge­og­ra­phy we’re able to have nurses in po­si­tions that keep pa­tients safe and pro­vide the right care they need.

Also, we have clin­i­cal nurses who are be­gin­ning to age out of the work­force, so we know we have a lot to do as a pro­fes­sion to make sure that our sup­ply stays in place over the next decade as more baby boomers live longer.

Linda Burnes Bolton: This nurs­ing short­age is dif­fer­ent than the other nurs­ing short­ages that have pre­ceded it. In­di­vid­u­als who grad­u­ated from nurs­ing schools in the late ’60s, ’70s and early ’80s are re­duc­ing the hours that they want to work, so we have to cre­ate en­vi­ron­ments that re­tain nurses and pro­vide them with op­por­tu­ni­ties to de­liver mean­ing­ful work.

One of the things that keeps me up at night is how am I go­ing to as­sist in pre­par­ing nurses to work out­side the walls of hos­pi­tals? So, pop­u­la­tion health man­age­ment is some­thing that we are chas­ing.

Our nurses who work in all dif­fer­ent walks of health­care have a lot of re­spect, and are tak­ing on lead­er­ship roles in places that we haven’t had the op­por­tu­nity to take on be­fore. Kim Hen­rich­sen

“Nurses are re­tir­ing faster than they are en­ter­ing, and we have to have a good solid foun­da­tional plan around that. Jan­ice Walker

“One of the things about the mil­len­ni­als is you have to keep it in­ter­est­ing for them. The days of a nurse work­ing in ob­stet­rics for 25 or 30 years are gone. Linda Burnes Bolton

Jan­ice Walker: Part of any strong sys­tem’s strate­gic nurs­ing plan is to con­tinue to fun­nel nurses into their or­ga­ni­za­tion. Many stu­dents make the de­ci­sion to en­ter health­care in their sopho­more or ju­nior year, so at Bay­lor Scott & White we have part­nered with schools of nurs­ing to do sum­mer camps. And one thing that we have found to be very in­trigu­ing is when we reach out to the chil­dren of our em­ploy­ees. They have a call­ing and a need to en­ter health­care. We have found a tal­ent pool there. But we can­not ever lose fo­cus on build­ing our in­fra­struc­ture and our work­force plan­ning as part of our strate­gic plan. (Nurses) are re­tir­ing faster than they are en­ter­ing, and we have to have a good solid foun­da­tional plan around that.

MH: A big part of this re­ten­tion and re­cruit­ment of nurses will in­volve mil­len­nial nurses. What are your sys­tems do­ing to en­cour­age or pre­pare for nurses that will in­creas­ingly in­clude mil­len­ni­als?

Walker: As mil­len­ni­als en­ter our work­force they are re­ally look­ing for that work-life bal­ance, so we’ve had to get cre­ative with our sched­ules. We’ve also had to get cre­ative with our in­no­va­tion around IT and in­fra­struc­ture.

I think ev­ery­one would agree that when we went to nurs­ing school we were not trained with the tech­nol­ogy that they are trained at. When our stu­dents come out, and en­ter the work­force, they are look­ing for that tech­nol­ogy. Hos­pi­tals strug­gle to stay up with that, so we are look­ing at any way that we can de­ploy tech­nol­ogy to take the bur­den off of the nurse at the bed­side.

Bolton: One of the things about the mil­len­ni­als is you have to keep it in­ter­est­ing for them. The days of a nurse work­ing in ob­stet­rics for 25 or 30 years are gone. You have to have mul­ti­ple pro­grams that al­low nurses to tran­si­tion into dif­fer­ent roles. I men­tioned ear­lier the need to help nurses tran­si­tion from acute-care set­tings to pop­u­la­tion-health set­tings. The use of nurse prac­ti­tion­ers in nurs­ing homes, which has dra­mat­i­cally de­creased the ad­mis­sions from those fa­cil­i­ties to the hospi­tal, is an ex­am­ple of cre­at­ing that value propo­si­tion (and) sup­port­ing nurses to ad­vance their knowl­edge and ex­per­tise, and then de­ploy­ing them in set­tings where they can be able to act at the top of their li­cense.

Cipri­ano: One of the unique as­pects that we’re see­ing with the younger gen­er­a­tion — and I wouldn’t want to just pi­geon­hole mil­len­ni­als be­cause I think we have a lot of se­cond-ca­reer en­trants in nurs­ing as well — is that we’ve done a good job of ed­u­cat­ing nurses to say ev­ery­one can be a leader. But I’m not sure we’ve ac­tu­ally cre­ated those op­por­tu­ni­ties.

One of the tra­di­tional prob­lems with nurs­ing is that we’ve not al­ways sup­ported young peo­ple mov­ing ahead rapidly, and that’s some­thing this gen­er­a­tion wants. They want to know that they’re not go­ing to be held back. I see this as a cul­tural shift that is be­gin­ning to hap­pen, but will have to hap­pen more rapidly.

If we think back to our con­ver­sa­tion on short­age, we have to make sure that we are re­tain­ing nurses. Their skills and knowl­edge are so es­sen­tial, so we can’t af­ford to lose any ed­u­cated nurse to a sys­tem that doesn’t sup­port their pro­fes­sional growth and de­vel­op­ment.

MH: There were a num­ber of nurs­ing strikes in 2016. What do you think is driv­ing nurses to take or­ga­nized la­bor ac­tions?

Cipri­ano: In to­day’s world, what we see is that nurses re­ally care about tak­ing care of their pa­tients, and in or­der to do that, staffing is one of the most im­por­tant is­sues to them. So, as we hear re­ports across the coun­try, that is one of the key pro­vi­sions.

It’s a wake-up call to be mind­ful of the fact that nurses re­ally have to have a good work­ing re­la­tion­ship with the lead­ers in their or­ga­ni­za­tion in or­der to be sure that they have pro­vided the right re­sources and struc­ture to care for pa­tients.

MH: How can health­care or­ga­ni­za­tions im­prove oc­cu­pa­tional safety and health for nurses?

Cipri­ano: One of the key ar­eas where staff can be very help­ful is mak­ing sure that they’re fol­low­ing the most cur­rent guide­lines for safe pa­tient han­dling and mo­bil­ity. Nurses orig­i­nally were ed­u­cated to think that body me­chan­ics were the an­swer. We now know that’s re­ally not true at all. Par­tic­u­larly as pa­tients are get­ting heav­ier, we know that nurses re­ally are at risk. They’re the fourth high­est oc­cu­pa­tional cat­e­gory that misses days from work be­cause of mus­cu­loskele­tal in­juries, so this is a key area.

Hen­rich­sen: To get bet­ter vis­i­bil­ity into what nurses are deal­ing with ev­ery day, we’ve started hud­dles on our units at In­ter­moun­tain Health­care that ad­dress nurse safety. (It’s) a place where we talk about qual­ity met­rics (and) pa­tient-safety top­ics. We also ask if there have been any in­juries or any­thing that ap­pears to be un­safe for our staff, whether it’s staffing is­sues or whether some­body had a nee­dle stick. We’re watch­ing those in­juries al­ways.

MH: Why have nurses faced dif­fi­culty in rais­ing the ed­u­ca­tional bar for con­tin­ued prac­tice?

Bolton: I’m go­ing to put on the hat of both the sys­tem chief nurs­ing ex­ec­u­tive here at Cedars-Si­nai but also the hat as one of the di­rec­tors at the Robert Wood John­son Foun­da­tion, which has funded aca­demic pro­gres­sion that has been go­ing on for the last sev­eral years. The good news is that through that work, many states, in­clud­ing Texas and Cal­i­for­nia, and some ru­ral states, have seen an in­crease in the num­ber of grad­u­ates hold­ing bach­e­lor’s and mas­ter’s de­grees. The pro­grams in the ru­ral states that have been very suc­cess­ful in­clude the ju­nior col­leges grant­ing bach­e­lor’s de­grees.

Hen­rich­sen: We are see­ing the same thing here in Utah. We talked with the schools of nurs­ing across the state of Utah and we have been work­ing to­gether to cre­ate op­por­tu­ni­ties for nurses to move seam­lessly through an as­so­ciate’s pro­gram into a bach­e­lor’s pro­gram. We are be­gin­ning now to see the fruits of those labors. When we started the work, at least 75% of our new nurs­ing grad­u­ates were grad­u­at­ing from as­so­ciate de­gree pro­grams. It’s been a pretty big hur­dle.

MH: Are there any ef­forts your sys­tems are mak­ing to en­cour­age a more di­verse work­force of nurses?

Hen­rich­sen: We don’t have a very di­verse work­force at In­ter­moun­tain Health­care at this point, and it is some­thing that is very im­por­tant to us. We’ve got such a great part­ner­ship with our schools of nurs­ing, and we’ve been sup­port­ing some schol­ar­ships for nurses who come from di­verse back­grounds.

Our goal is re­ally to in­crease the num­ber of nurses that come from a di­verse back­ground and move more of them into the nurs­ing work­force, whether it’s within our own or­ga­ni­za­tion or just some­where within the state be­cause we do have a grow­ing di­verse pop­u­la­tion. It’s im­por­tant for us to be able to meet the needs of our pa­tients.

Bolton: This is life­long work for me. Un­der fund­ing from the Robert Wood John­son Foun­da­tion and its Cen­ter to Cham­pion Nurs­ing in Amer­ica we have been suc­cess­ful in cre­at­ing a task force to ex­pand the di­ver­sity of the nurs­ing work­force across all ar­eas. It’s not just staff nurses, but the nurses in ex­ec­u­tive po­si­tions, fac­ulty po­si­tions and nurses who sit on boards. We want it to be a more in­clu­sive work­force.

We have worked with the Na­tional Coali­tion of Eth­nic Mi­nor­ity Nurse As­so­ci­a­tions as well as the Amer­i­can Assem­bly for Men in Nurs­ing to sup­port their pro­grams that they have had. We’ve seen a dra­matic in­crease in the num­ber of men in nurs­ing, African-Amer­i­can nurses and His­panic nurses. The one area that we have not been as suc­cess­ful in terms of a na­tional ef­fort is Na­tive Amer­i­can nurses. But North Dakota, South Dakota and Idaho have a coali­tion un­der­way to try to work with their pop­u­la­tions to try to in­crease it, and we’re sup­port­ing some of that work.

It’s a wake-up call to be mind­ful of the fact that nurses re­ally have to have a good work­ing re­la­tion­ship with the lead­ers in their or­ga­ni­za­tion in or­der to be sure that they have pro­vided the right re­sources and struc­ture to care for pa­tients. Pamela Cipri­ano

Linda Burnes Bolton VP for nurs­ing, chief nurs­ing of­fi­cer Cedars-Si­nai Med­i­cal Cen­ter

Jan­ice Walker Se­nior VP and chief nurse ex­ec­u­tive Bay­lor Scott & White cen­tral divi­sion

Kim Hen­rich­sen VP of clin­i­cal op­er­a­tions, chief nurs­ing of­fi­cer In­ter­moun­tain Health­care

Pamela Cipri­ano Pres­i­dent Amer­i­can Nurses As­so­ci­a­tion

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