Workforce Issues M6920 October 30, 2001. Columbia University School of NursingM6920, Fall, 2001 Goalsfor discussion l Understand how professionals are.

Workforce Issues

M6920October 30, 2001

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


Evolution of work force

Healers exist in every culture

Healing associated with religious system

Enlightenment began Western separation


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?


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


Defining professionals

Special body of knowledge Control over education and

qualifications Limited entry into field Social recognition


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


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)


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


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


Interprofessional Issues

Socialization Actual and perceived power Economic competition


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


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


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


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


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)


Ethics of international movement

Beneficence• better care in underserved US areas

Non-malfeasance• Drain from neediest countries• Specialty interests not needed

Autonomy Social Justice


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?


Is nursing a profession?

Classics: clergy, law, medicine

Yes: • controls education• limited entry to field• social recognition • personal professional ethic


Maybe not. . .

social recognition limited only partial practice independence most are wage workers gender perception issues competition with more prestigious

fields


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


Types of nurses, 1996*

ADN/Dip

58%

BSN

32%

MS/PhD

10%

2,161,700 Nurses

*Health US, 1999


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


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


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


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%


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


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


Turnover issues

Stability associated with• older staff• higher income staff• longer tenure

Turnover associated with• tension• limited organizational commitment• supervisor’s behavior


Nursing Programs in NY

Graduate: 25

Baccalaureate: 45

AD: 57


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


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


Ethnicity of New York Nurses, 1996

White 76.5%

Black 11.5%

Asian 9.9%

Puerto Rican1.3%

Other Hispanic1%

Native American0.3%


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


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


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


Public health workforce

Multiple disciplines Multiple routes of entry Multiple settings Overlapping job duties Confusion among

• profession• setting• passion

Ratio of PH workers to population

*preliminary data

(by region)


Public Health Workers Region IV

Professionals

Paraprofessionals

Admin Support

Skilled Craft Workers

Service/Maintenance

Programs

Protective Service Workers

Officials/Administrators

Technicians


Workers Alabama and Mississippi

0

500

1000

1500

2000

2500

Alabama Mississippi

AdminProfessionalTechnicalClerical/Support


Consumer protection or control of competition?

Limit number licensed? Require certification? Extend credentialing process? Expand disciplinary actions?


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


Professional licensure

Provides validation in community Affects ability to earn Once gained, fiercely protected Very confusing in interdisciplinary

practice settings


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


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

Workforce Issues M6920 October 30, 2001. Columbia University School of NursingM6920, Fall, 2001 Goalsfor discussion l Understand how professionals are.

Documents

imgs slide

economic competition

social recognition slide

western separation slide

health professionals

health workforce

united hospital fund

population health us