Sunday, February 27, 2011

Nurses Are Needed. Where Will They Come From?

We have encountered a number of discussions of changes needed to provide better and less expensive healthcare. Inevitably the role of nurses comes up. There are compelling arguments for giving nurses more input and more responsibility in all aspects of healthcare.

The Institute of Medicine (IOM) recently released a study titled: The Future of Nursing: Leading Change, Advancing Health. The report summary included this statement.
“With more than 3 million members, the nursing profession is the largest segment of the nation’s health care workforce. Working on the front lines of patient care, nurses can play a vital role in helping realize the objectives set forth in the 2010 Affordable Care Act, legislation that represents the broadest health care overhaul since the 1965 creation of the Medicare and Medicaid programs. A number of barriers prevent nurses from being able to respond effectively to rapidly changing health care settings and an evolving health care system. These barriers need to be overcome to ensure that nurses are well- positioned to lead change and advance health.”
The report indicated the following as its four key messages.
“Nurses should practice to the full extent of their education and training.”

“Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.”

“Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.”

“Effective workforce planning and policy making require better data collection and information infrastructure.”
Better health outcomes can be produced by moving away from a doctor-dominated office-visit mode where patients are left to their own devices between 5 minute visits with a physician, to one in which patients are actually monitored to ensure that they are following the recommended treatments and lifestyle changes. This type of approach has been proven to provide better results at lower costs. It involves incorporating larger numbers healthcare workers who do not command the revenue demanded by doctors. Nurses will play a dominant role. This is the type of approach that is talked about in the context of the Accountable Care Organizations the recent healthcare law has encouraged.

These topics were discussed in the previous posts: Doctors Versus Nurses: Let’s Root for the Nurses, and Medical “Hot Spots” and the Future of Healthcare.

Having arrived at a significant level of enthusiasm for these anticipated changes in the way healthcare is delivered, it was disconcerting, to say the least, to discover that we may not have the capability to produce nurses in the number required. A note found on Health leaders Media announced:
“Enrollment in entry level baccalaureate nursing programs increased 3.5% in 2009, but nearly 40,000 qualified applicants were turned away, according to preliminary data released today by the American Association of Colleges of Nursing AACN).”
The best source of information on nursing as a career can be found at the Bureau of Labor Statistics (BLS). There are about 3.1 million registered nurses in the nation, of which 2.6 million are currently employed as nurses. BLS projected the need for the number of employed nurses to increase from 2.6 million to 3.2 million in the ten years between 2008 and 2018. That means that about 60,000 new nurses have to be added each year just to account for job growth. Also consider that there will be attrition. If one assumes a uniform age distribution and a 40 year career for nurses, the average yearly attrition rate will be about 65,000 per year. The combined effect is a need to produce, on the average, 125,000 nurses per year—and this is in the 2008 concept of healthcare.

How many nurses are we producing each year? That is a number that is difficult to find. Most nurses are produced in the college and university systems, either with a four year BSN degree or a roughly three year ADN certificate provided mostly by community colleges. Both graduates are required to take the same test to be certified as a registered nurse (RN). The best numbers I have been able to find indicate about 22,000 graduates are coming out of the BSN path and an estimate of about 30,000 from the ADN path—about 52,000 total. There is a quote on the AACN website recognizing a need to increase this.
“....officials state that to meet the projected growth in demand for RN services, the U.S. must graduate approximately 90 percent more nurses from US nursing programs.”
This would indicate a need for about 100,000 graduates per year, and this would be consistent with my rough estimate. According to AACN:
“U.S. nursing schools turned away....qualified 2009 due to insufficient number of faculty, clinical sites, classroom space, clinical preceptors, and budget constraints.”
Those all sound like things that could be solved by a long-term increase in funding.

The point is clear: we need to produce twice as many nurses as we are now. We have the needed additional candidates and we are throwing them away. Who knows how many applicants would apply if it was known that slots were available. And luring them away from other countries where they are also needed is not an acceptable solution.

One hears many people worrying about how we are going to find enough doctors to treat the millions of people who will soon have healthcare coverage. I don’t recall any national outcry about a shortage of nurses. I am not worried about doctors. They are as much a part of the problem as they are a part of the solution. It’s time to start worrying more about nurses and nursing schools.

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