What’s the state of nursing in 2013? If anyone knows, it is Buffalo’s Carol Brewer.
She is a professor of nursing at the University at Buffalo School of Nursing and the associate dean for academic affairs. She is a member of the New York State Regional Action Committee for the Future of Nursing, an initiative that arose out of a key report by the Institute of Medicine, an organization that advises the government.
Brewer also is co-leader of the RN Work Project, a national study of new nurses, focusing on career changes and work attitudes. In addition, she is the director of nursing for the New York State Area Health Education Center System Statewide Office, developing nursing policy and nursing and health care workforce development programs.
Q: There is increasing demand for nurses to pursue higher education levels. What is behind the call for nurses with bachelor’s and master’s degrees?
A: A solid body of evidence, reviewed in the 2010 Institute of Medicine Report on the future of nursing, exists on the positive effect of BSN- [Bachelor of Science in Nursing] prepared nurses on various patient outcomes, and on the outcomes of nurse practitioners being equivalent to physicians – equally good, and a lower cost. Bachelor of Science nurse graduates are younger and so are in the workforce longer, and go on to graduate school at a higher rate.
Nurses in graduate school are important because there has been a bottleneck at the level of faculty that prevented sufficient increases in enrollment to solve the nursing shortage.
The shortage finally resolved when the recession hit, so as job availability tightened and nurses stayed put, hospitals in particular have chosen to selectively hire BS graduates (because of the better outcomes and quality).
Q: A large portion of nurses leave their jobs within two years, usually for another nursing job. Why is there such a high turnover rate, and what might be done to improve their retention?
A: There are several factors at work here. Culturally, nurses have always started training in hospitals. Even though the health care system is changing rapidly to out-of-hospital care, the integration of skills and expertise development that occurs there is still considered valuable in most settings.
The last 2008 national sample survey showed 60 percent of nurses work in hospitals, so we know there is a migration out of the hospital settings compared to the high percentage that start in hospitals (about 85 percent are still in hospitals within 18 months of their first job).
However, nurses may be dissatisfied for many reasons with their first job and choose to change to another hospital setting. We know that about 26 percent have left their first jobs within three years or so, and over 50 percent within six years, but the majority have chosen another job in a hospital.
Typically they are likely to be looking for a better fit with their clinical interests, a healthier work environment, or work-life balance issues – commuting time, shift, or other things we don’t measure very well. For example, we did a recent analysis that showed a steady move to settings with stable hours (likely to be daytime). These settings may have been in hospitals or not.
The research is pretty clear on what retains nurses. Magnet hospitals have consistently demonstrated high retention and they become magnet hospitals by focusing on nurse satisfaction, practice autonomy, career opportunities, and other factors that impact satisfaction and organizational commitment which ultimately impact turnover.
We also know that educational innovations used in Western New York, like “dedicated education units” help attract new graduates to hospital units they were students on and helps to retain them there as well. Consistent leadership that values nursing care and contributions to the system makes a difference.
Q: With health reform insuring more Americans at a time of a primary care physician shortage, are there opportunities for registered nurses to expand their duties, and what are they?
A: Nurses don’t need to expand their roles to take their place in the evolving health care system. Nurses understand communities and health, and how to navigate and transition patients throughout the health care system to effect better outcomes, but the role has not been rewarded by the health care financial system.
Ambulatory care physicians, for example, have steadily moved to unlicensed personnel or, at best, LPNs in office care, because RNs are costly and are not reimbursed for what they do.
Nurse practitioners, likewise, are already prepared to provide safe and effective primary care in a variety of settings. In New York state, a collaborating physician is required, which does not improve quality and inhibits the practice of nurse practitioners.
There are many opportunities for RNs to function up to the full scope of their practice.
Q: States are considering measures to ease restrictions on nurse practitioners and other advance-practice nurses, but physician groups voice concern over advance-practice nurses treating patients on their own or calling themselves “doctor.” What’s the nursing perspective on this?
A: “Doctor” is a role title, not a credential. Nurse practitioners are entitled to call themselves “doctor” just as is a pharmacist, physical therapist or dentist when the title fits their educational credential. Nurses who practice independently and have their “own” patients – as already is true in many states – have the same patient outcomes as nurses who practice under the rules of collaboration, as required in New York state.
Laws designed to protect turf that do not improve quality are not useful. The real issue is money – loss of income for physicians who can bill for collaborating with nurse practitioners.
Q: The economic downturn eliminated the nation’s nursing shortage. Older nurses delayed retirement; part-time nurses became full-time; and nurses who had left the workforce returned. As a result, new RNs had trouble finding jobs. Is that expected to last? Aren’t experts predicting another serious shortage?
A: The two unknowns are whether an economic recovery will ever occur and what nurses approaching retirement age will do. I have been doing this work for over 20 years and personally lived through at least three acute shortages of varying lengths (the last one lasted almost 10 years). Typically, it is increased demand following years of slowly declining graduations (and flat or declining real wage growth) that precipitates a shortage.
The demographic bulge of aging nurses virtually guarantees that at some point in the relatively near future we will have large number of nurses leaving the workforce. If that coincides with an increase in demand – yes, we will see a dramatic shortage. It is just how and when these two forces tip the balance that we don’t know.
A continuing sluggish economy or severe cutbacks in health care funding may moderate the problem. Also, there is no evidence I know of that indicates new graduates aren’t getting any employment – just that they are not getting the first-choice jobs they always had under shortage conditions.
Interest in nursing seems high, but the nursing education system has lacked the capacity to handle demand, and many applicants to schools are denied admission. Why? Is it a shortage of nurses with teaching credentials?
It takes three to seven years to produce a doctoral-prepared nurse, and the numbers are small. Salaries are low. Also, because of mandated faculty to student clinical ratios of 1 to 8, undergraduate education is expensive for universities. SUNY is certainly not providing more salary money for schools of nursing.