Nurses and the Allied Workforce: Who are they, and are there enough?

Joanne Spetz

University of California, San Francisco

August 2011

2

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

3

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

4

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

5

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

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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

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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

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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

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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)

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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

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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 non-physician

12

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)

13

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)

14

Do non-physicians provide high-quality 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 nurse-led care.”

– Many studies find that NPs spend more time on consultation, some find better quality consultation from NPs (Horrocks et al 2002)

15

Do non-physicians provide high-quality 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)

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Barriers to use of non-physicians

• Education program availability and quality

• Guilds and protective interests of physicians

• Bureaucracy, licensure

• Payment

• Acceptance by the public

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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?

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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

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What do nurses do?

• Nursing process

– Assess and diagnose needs of patients

– Plan and implement interventions

– Evaluate the outcomes of care

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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

21

Measures of shortage

• Reports of shortage

• Vacancy rates

• Time to recruit for new positions

• Econometric demand models

• These measures are highly correlated!

22

Reasons for shortages…

• Limited number of employers

• Delays in wage increases

• Delays in producing new nurses

• Licensing regulations

• Minimum staffing requirements

• Minimum wages

23

Forecasting the nursing workforce…

24

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

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LABOUR MARKET DYNAMICS Health Care Education Labour Force Health Care Labour Take-up Rate Participation Force Participation

Rate Rate

High

School

Pool of

Qualified HW

Other

Training

Training

in Health

Non-Health Care

Sector

Health Care

Sector

Unem-ployed

Employed

USA, UK

1. Geographic distribution

2. Private/Public sector allocation

3. Absenteeism 4. Skill mix 5. Productivity 6. Quality

MIGRATION

Policies on enrolment

Policies on selecting students

Policies to address inflows

and outflows

Policies to mobilize

unemployed health workers

Policies to draw health workers back into the

health 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

What information is needed to diagnose problems/identify priorities? What information is needed to guide policy reform?

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Forecasting supply is simple (mostly)

• Stock-and-flow models

Nurses with Active Licenses

Living in CaliforniaOutflow of nursesInflow of nurses

Full-time equivalent supply of RNs

Share of nurses who work, and how much they work

27

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

28

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

29

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

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Age distribution of California RNs, 2006 & 2008

0%

5%

10%

15%

20%

25%

20062008

Source: California Board of Registered Nursing Surveys

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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

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Inflows of RNs

• Graduations from California nursing programs

• Immigration from other countries

• Migration from other states

• Transition from inactive license

• Transition from lapsed license

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Outflows of nurses

• Migration to other states

• Transition to inactive or lapsed license

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Percent of RNs Working in Nursing, by Age

0%10%20%30%40%50%60%70%80%90%

100%

20062008

Source: California Board of Registered Nursing Surveys

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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

36

Supply forecast ranges were offered

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

2021

2022

2023

2024

2025

2026

2027

2028

2029

2030

Best Supply Forecast

Low Supply Forecast

High Supply Forecast

2007 Forecast

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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

38

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

39

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?

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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

41

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

42

Forecast strategies gave different results

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

2021

2022

2023

2024

2025

2026

2027

2028

2029

2030

National 25th percentile FTE RNs/populationNational average FTE RNs/populationCalifornia Employment Development Dept. forecastMaintain 2009 FTE RNs/PopulationOSHPD hours per patient day-based forecast

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0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030

Best Supply Forecast

National 25th percentile FTE RNs/population

National average FTE RNs/population

Put supply and demand together…

44

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

45

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?

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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

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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

48

Policy levers for demand

• Funding for employers

• Regulations and staffing mandates

• Financial incentives to hire

• Ease hiring

– Streamline bureaucratic requirements

• Population health and wealth