Nursing Workforce: If it was just about adding another Nurse Justine L. Medina, RN, MS Director,

1. Nursing Workforce: If it was just about adding another Nurse Justine L. Medina, RN, MS Director, Professional Practice and Education Programs American Association of Critical Care Nurses March 26, 2008

2. “Individuals and organizations learn and evolve through conscious, deliberate action. Deliberate action is ethical. When the time to act has come, it is unethical not to do something.” - David Thomas, ethicist

3. The Three “R”s of Nursing Workforce

4. Reality Recruitment Retention

5. He who thinketh he leadeth and hath no one following him is only taking a walk. Author Unknown

6. Reality • Current shortage began in 1998 • Is the longest stretch in 50 YEARS • Driven by the aging workforce and the low domestic production of nurses

7. Reality Trends, Stakeholders and Forecast • Dire Predictions: In 2007 it was estimated that 8.5% of nursing positions were unfilled • This is expected to triple by 2020 as 80 million baby boomers retire and expand the ranks of those needing care • Average vacancy is higher in urban and isolated rural areas • The Department of Health and Human Services (HHS) predicts a shortfall of over 800,000 RNs by 2020

8. Reality Trends, Stakeholders and Forecast • Department of Labor in 2005 estimated the creation of 703,000 new jobs between 2004 and 2014 • New jobs plus retirement of nurses led to predictions of 1.1 million additional nurses needed between 2002 and 2012. • This would require graduations of around 110,000 RNs as year between 2002 and 2012. We continue to fall short of this target. • The American Association of Colleges of Nursing reports that 32,000 qualified applicants were turned away from baccalaureate and graduate nursing programs in 2005-06 and 43,000 for the academic year 2006-07

9. Reality Immediate Solution Areas • Faculty Shortage: in 2006, the shortage translates to at least 2 faculty vacancies per school of nursing across the nation. • 54% of these positions required a doctorate • Average age of faculty 54-55 years • Average retirement age is 62.5 years • Average salary of a masters prepared faculty is $58,000, (a NP average is $72,000) • Average 56 hour workweeks

10. Reality Implications • Research shows that inadequate staffing in hospitals show • Increased risk of adverse patient outcomes • Increased mortality • A reduction in hospital capacity • Delays in timeliness of patient care • Longer patient lengths of stay, and • Interruptions in care delivery processes • Impact on patient safety, and • The inability to achieve national quality goals.

11. Reality AACN data indicate inadequate staffing is a major source of stress and dissatisfaction of among acute and critical care nurses

12. Sometimes you just have to create what you want to be a part of. Geri Weitzman

13. Recruitment Is your organization a place where nurses want to work? What is your recruitment strategy?

14. Recruitment • A nurse is a nurse is a nurse… right? • Is foreign nurse migration your answer? • What makes your organization a “magnet” or a “beacon” to attract the best of the best?

15. Recruitment Reasons employees may leave within 2 years after being recruited: • Inability to do the job • Role Ambiguity • Lack of Training • Lack of Confidence to “do” the job • System Problems • Attitudes of Resistance or Refusal • Poor Communication related to Change

16. Recruitment What can you do • Using education strategies to address your recruitment needs • Partner with schools of nursing • Subsidizing nursing faculty salaries • Reimburse nurses for advancing their education in exchange for work commitment • Flexible schedule for nursing to attend classes

17. Principles for People Development Value people: This is an issue of my attitude Commitment to people: This is an issue of my time Integrity with people: This is an issue of my vision Influence over people: This is an issue of my leadership John D. Maxwell

18. Retention Nurse turnover rates in hospitals is high and more nurses are opting to work in jobs outside of hospitals and non-clinical roles • Retention has strong links to poor work environments with nurse job dissatisfaction, burnout, turnover and increased costs • Recommendations for a solution is modification in nurses’ practice environments to retain nurses at the bedside and facilitate their productivity • The long term solution to the future shortage must include a redesign of nurses’ work, particularly in the area of productivity

19. Retention • The long term solution to the future shortage must include a redesign of nurses’ work, particularly in the area of productivity • Research shows that nurses spend only 20% of their time per shift per patient (in a 12 hour shift) • Increasing efforts to address the physical and scheduling needs of older nurses to delay retirement

20. Lower your standards and nothing will ever disappoint you. Author Unknown

21. Healthy Work Environments Background: • AACN launched the AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence as a solution to the deepest and often most overlooked problems in healthcare • This is the highest priority for AACN’s advocacy concern because work environments are the foundation that must be strengthened if significant positive progress is to be made in improving patient safety and nurse retention.

22. Healthy Work Environments • Published in January 2005, the So-called “soft skills” are elevated as vital • These systems and behaviors are not optional if we are to ensure patient safety

23. Healthy Work Environments The 6 Standards necessary to achieve a HWE: • Skilled communication • True collaboration • Effective decision making • Appropriate staffing (criteria mirror SP#5) • Meaningful recognition • Authentic leadership

24. Healthy Work Environments • Driving forces for implementation of the Standards include • the natural resonance they have with our constituents; • the Silence Kills research data; • Joint Commission sentinel event root cause data identifying communication as the leading root cause for sentinel events including medication errors and • Standards’ potential to complement existing change initiatives in hospitals.

25. Healthy Work Environments Implications • Like achieving World Peace or ending poverty, this initiative will be a constant work in progress. • It may be many years before we see evidence of the ultimate change – nurses rate their work environments high on a consistent basis, leading to improved patient outcomes and higher retention of nurses. • A positive note, the patient safety/quality movement and call for greater transparency may facilitate implementation of the standards and inclusion of work environment data in key hospital indicators. • The connection between Beacon and Magnet status and the health of the work environment as perceived by nurses is another factor to be leveraged.

26. References • American Association of Colleges of Nursing website – www.aacn.nche.edu • Student Enrollment Rises in U.S. Nursing Colleges and Universities for the 6th Consecutive Year. Press Release. 2006 Survey. • New Partnerships and Grant-Funded Initiatives in Nursing Education. June 2002-August 2007. • Nursing Shortage Fact Sheet. Updated March 2007. • Nursing Shortage Resource. Updated March 2007. • Nursing Faculty Shortage Fact Sheet. Updated March 2007. • National League for Nursing. Key findings of Nationwide NLN-Carnegie Foundation Study of Nurse Educators. Nurse Educators. Press Release. www.nln.org. • National Foundation for American Policy. U.S. Nursing Shortage Contributing to Death and Illness for U.S. Patients: Increasing Nursing School Faculty and Immigration Quotas are Best Options. September 2007. www.nfap.com. • D. Auerbeck, P. Buerhaus, D. Staiger. Narrowing Gap in Nursing Shortage Due to Influx of Older First-Time Nurses. Health Affairs. January/February 2007.

27. References • P. Buerhaus. Nursing Shortage Impacts Communications. Health Affairs. May/June 2007. • L. Aiken. U.S. Nurse Labor Market Dynamics are Key to Global Nurse Sufficiency. Health Research and Education Trust. 42:3, Part II, 1299-1320. June 2007. • IT Studies Say Nurses Spend Little Time with Patients. HITS E-newsletter. September 28, 2007 • Health Systems Top AARP List of Best Employers for Workers Over 50. AHA News Now, September 25, 2007. • AACN. AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence, • AACN. Aliso Viejo, January 2005. • Safety Leaders: Quality Choir, video, accessed from www.safetyleaders.org, 9/25/07. • National Quality Forum, Safe Practices for Better Healthcare, Update 2006. Accessed from www.nqf.org and www.safetyleaders.org, 9/25/07. • Comcare: Emergency Response Alliance, newsletter: www.comcare.org.

28. References • HIMSS, Nicholas E. Davies Awards of Excellence Program,www.himss.org/davies. • Carla Smith, Executive VP. Why is Universal HER Adoption Taking So Long? HIMSS, June 7, 06. • Excess Length of Stay, Charges, and Mortality Attributable to Medical Injuries during Hospitalization. JAMA, Oct 2003; 290:1868-1874. • “eIatrogenesis,”The most critical unintended consequence of CPOE and other HIT, JAMIA, March 2007. • The Extent and Importance of Unintended Consequences Related to Computerized Provider Order Entry, JAMIA, April 2007: 12:315-423. • David Swankin, et al. Implementing Continuing Competency Requirements for Health Care Practitioners, Citizen Advocacy Center, 2006, AARP 601 E Street, N.W., Washington, DC 20049. http://www.aarp.org/ppi. • Committee on Quality of Health Care in America, Crossing the Quality Chasm, Washington, DC: Institute of Medicine, 2001.