lichtenstein_nursing personnel 2005

8/7/2019 Lichtenstein_Nursing Personnel 2005

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Nursing and Nursing Personnel


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What is Nursing?

The diagnosis and treatment of human

responses to actual or potential healthproblems. Its aim is the care of the

patient


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What Qualities Does It Take to

Be a Good Nurse?


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Nursing deals with Biological,

Psychological, Social and

Environmental factors that shape

illness and human responses toillness.

It is HOLISTIC.


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General Focus of Nursing

To help people obtain, retain and

regaintheir health.


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Domains of Nursing and

Medicine Nursing

HealthMaintenance

Preventive

Caring

Medicine

CurativeDiagnostic

Prescriptive


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Nursings Relationship to

Medicine Legal Requirements

Nurse Practice Acts

Independent Actions Dependent Actions

Determining a Treatment PlanPhysicians Order

Nurse-Initiated Activities

Collaboration/Interdependence


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What Are the Functions Nurses

Perform?

How is what nurses do different

from what people in other

health occupations do?


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The Nursing Process

Assessment

Nursing Diagnosis

Planning

Implementation

Evaluation


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What is the Training of an RN?

Diploma

Associate Degree (AA) Bachelors Degree (BSN)

Masters Degree (MSN)

Doctoral Degree (Ph.D.) LPNs (LVNs)


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0

10

20

30

40

50

60

70

80

90

100

1952 1960 1970 1980 1990 1994 1996

Percentineachprogram

Diploma

Associate

Bachelors

Admissions to Nursing School by

Type of DegreeThere has been a major shift in the types of nurses being trained.


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Demographic and Employment

Characteristics of Nurses


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Age

Race

Place of Employment

Undergoing big changes

Salaries


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39.5

42.4

45.4 45.1

37.9

30

35

40

45

50

1980 1990 2000 2010 2020

AgeinYea

rs

Average Age

Actual and Projected Average Age of

RN Workforce, 1980 - 2020

Buerhaus, Staiger, and Auerbach, JAMA, 2000


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Nursing Graduates are Aging

National Sample Survey of Registered Nurses, BHPr, HRSA, 2000


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Distribution of RNs by Age

Average age of working RNs increased from 37.4 to41.9 years between 1983 and 1998, an increase of 4.5 years

(versus U.S. workforce as a whole: increased < 2 years)

During same time, number of working nurses under 30

decreased by 40%, from 30.3% of RN workforce to 12.1%

By 2010, average age forecast to increase to 45.4 years,

an increase of 3.5 years

By 2010, more than 40% of RN workforce will beolder than 50

By 2020, RN workforce will be 20% below projected

requirements, given current trends

Buerhaus, Staiger, and Auerbach, JAMA, 2000


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0

1

2

3

4

5

6

7

8

1984 1988 1992 1996 2000

Males

Percentage of Male RNs, US, Selected Years

Source: National Sample Survey of Registered Nurses, USDHHS, BHPr, 2000

Percen

ta

ge

Note: Approx.

94% of Nursesare female


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0

0.5

1

1.5

2

2.53

3.5

4

4.55

1984 1988 1992 1996 2000

BlackAsian

Hispanic

American Indian

Percent of RNs by Race/Ethnicity, Selected Years

Note: Approx. 87% of

Nurses are White

Source: National Sample Survey of Registered Nurses, USDHHS, BHPr, 2000


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Percent of RNs by Race/Ethnicity, Comparison

of Armed Services with National RN Population

0%

3%

6%

9%12%

15%

18%

Army Nurse C orpsNa vy N urse C orps Air F orce Nurse

Corps

National RN

Population

Black H ispanic Asian American India

Source: Schmieding, 2000


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Geographic Distribution of

Nurses


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Registered Nurses Per

100,000 Population by Area

782

1075

885788

815 831

654 596

0

200

400

600

800

1000

1200

US New

England

Mid-

Atlantic

South

Atlantic

East S

Cent

East N

Central

Mountain Pacific

Nurses

per100,000

Geographic Region


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The Supply of Nursing Personnel


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Total Number of Licensed

Nurses (RNs)

19922,239,816

19962,558,874

20002,696,540

20032,311,970

Source: Bureau of Labor Statistics


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N b f N i S h l


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Number of Nursing School

Graduates by Type of Degree

Offered, 2001-2002

0

20,000

40,000

60,000

80,000

100,000

200

1

200

2

Total BA AA Di loma

Source: Health, United States, 2004, Table 106.


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The supply of nurses has

fluctuated widely over time

Periods of dramatic shortages of

nurses have been followed by

periods of oversupply


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There was a majornursing

shortage in the late 1980s, butduring the 90s nursing units

were being re-engineered and

many nurses were hit by layoffs.

Now there is talk about an

imminent nursing shortage!


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Projection of RN Shortage


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The Nursing Shortage is Already

Affecting Many Urban Hospitals

In many cities, hospitals have to close their

emergency rooms (regularly) because they

cannot accommodate any new patients,especially critically ill patients. Some of

this is due to bed shortagesbut part is

also due to insufficient staffing


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Restructuring Nursing Practice

Team Nursing

Primary Nursing

Case ManagementCritical Pathways

Clinical Practice Guidelines

Patient Centered (Focused) Care


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Team Nursing

Characteristics

RN as team leader

Team consists of RN, LPNs and aides

RN assesses, plans, and evaluates care

and delegates tasks according to the skill

needed to perform them


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Team Nursing

Advantages

Functional Nursing

Disadvantages

Team changes daily

RN accountable for continuity one shiftonly

Minimal of care for patient or team


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Primary Nursing

Characteristics

Every patient has a primary nurse that isaccountable for planning care for all threeshifts

Associate nurses carry out plan of care

when the primary nurse is not on duty

Usually implemented as an all-RN model


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Primary Nursing

AdvantagesImproved patient outcomes and communication

between health care team

Improved nurse satisfaction because of the

increased continuity of care and accountability

Disadvantages

ExpensiveNot cost-effective to have RNs doing non-

nursing tasks

Burn-out


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Case Management

Characteristics

Blends team and primary care

RN is case manager (often is a MSN orNP)

Tends to utilize critical pathways as the

basis for the care plan


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Case Management

Characteristics (contd)

CM is accountable 24 hours a day and

from admission to discharge- sometimes

for an entire floor of patients

RNs on all three shifts make sure the plan

is carried out

Utilizes the team approach with nurse

extenders


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Case Management

Disadvantages

Requires a lot of coordination across all

disciplines

Requires the organizational structure to

increase nursings accountability


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Critical Pathways

Characteristics (contd)Tend to be developed by nursing-- review of

literature, approval by medicine

Developed on a hospital-by-hospital basis

Case managers are notified of patients that vary

from the expected course of treatment and then

determine why the variance is occurring and,

with MD, make plans for corrective actionA patient version of the pathway is developed

and used for teaching


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Critical Pathways

Advantages

Improves clinical processes over time

Increases collaboration between nursing and

medicine

Reduces redundancy

Decreases unnecessary variations in care-

grassroots standardization


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Critical Pathways

Disadvantages

Variations in care across the country will still

occur

Issues

Physicians are not uniformly in favor, it decreases

their autonomy and increases their accountability

for their decisions

Criticized for being cookbook medicine and

nursing


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Characteristics

Similar to pathways except usually focuses on a

condition or use of a technology not a DRGDifferent format -- narrative or algorithm

Developed by physician groups, HMOs and

government (AHRQ)


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Advantages Care is developed according to scientific evidence

May eliminate small area variations for certain

conditions Provides a means to identify outlier care

Disadvantages

Often crystallizes the status quo rather than appropriatecare as determined by empirical evidence

Almost none consider costs or cost-effectiveness


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The New Way of OrganizingCare in Hospitals

Patient-Centered Care

or

Patient-Focused Care


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Patient-Centered Care Prompted by:

Shift to capitation and managed care

Escalating labor costs (This was done toeliminate the shortage of the early 90s!)

and recruitment difficulties.

Fragmentation caused by traditional task-centered, departmental-based, hospital

organization Nursing dissatisfaction


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Three Components of Patient-

Centered Care

Restructured Care Delivery

Interdisciplinary Team Management

Shared Values of Excellence in Patient Care


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Patient-Centered Care

Restructuring of how care will be delivered

A movement away from task-centered,

centralized care to patient-centered,decentralized care. (Cross-training)

Attempt to eliminate single-function, dead-

end jobs, and replace them with multi-skilled, Unlicensed Assistive Personnel

(UAPs)


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C t l M d l f PCC


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Conceptual Model of PCC

Associate tasks

Obtain history

Take vital signs

Accuchecks

Phlebotomy

ABGs

Reinforce education

Simple treatments

Documentation

Telemetry application

Personal care

C t l M d l f PCC


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Conceptual Model of PCC Unit Assistant tasks

Room set-up

Orient to room

Transport patient

Change linens

Clean rooms

Maintain supplies

Tray passingAmbulate patient

Patient safety

Reposition patient


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Conceptual Model of PCC

Unit Secretary tasksLocate MDs

Transcribe

PhonesIntercom

Direct visitors

Call lights

Charts

Admissions

Computer

N i Vi f PCC/PFC


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Nursings View of PCC/PFC

PROFIT-FOCUSED CARE A DANGER TO PATIENTS

using Unlicensed Assistive Personnel (UAPs)

to provide technical care which they are not

trained to do

WILL CAUSE MASSIVE LAYOFFS OF

RNs

RNs not comfortable with delegating and

yet, still legally liable


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Nursings Concerns

Unlicensed workers are doing proceduresthat only physicians and nurses are

qualified to perform

Personnel trained in basic first aid areperforming ER procedures such as stapling

head wounds

Techs are assessing patients, doing sterileprocedures and complex wound care, and

inserting catheters


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What Strategies Should We

Pursue to Eliminate the

Impending Nursing Shortage?

Should states set minimum nurse

staffing ratios?

Magnet Hospitals (Aiken et al)


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Magnet Hospitals (Aiken,et al)Provide better nursing practice environments

and have better patient outcomes

Higher nurse/patient ratios

More autonomy (control over practice

setting and freedom to make patient-caredecisions)

Better RN support services (effective

supervisors and chief nurse executive)

Better nurse-physician collaboration

Not-for-profit, teaching hospitals

lichtenstein_nursing personnel 2005

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