Creating a 21st Century Nurse Workforce: What will it take?The Soule Lecture, University of Washington

Susan Hassmiller, R.N., Ph.D., F.A.A.N.

Health Reform

Reform must:

expand access

improve quality

reduce costs

add value

Nursing workforce goals must be the same

My Objectives:

1. Discuss health care system’s needs

2. Explain how nurses can help

3. Share 8 goals for creating a 21st century workforce

Health System’s Needs:

Aging, sicker population:

85 and older fastest growing segment*

20% of Medicare beneficiaries have 5 or more chronic conditions**

75 cents out of every health care $ treats chronic conditions**

5% of beneficiaries who die each year take up 30% of Medicare budget***

*The Aging Population in the Twenty-First Century: Statistics for Health Policy (1988) Commission on Behavioral and Social Science Education.**Medicare Standard Analytic File, 1999.***Lubitz J.D., Riley G.F. Trends in Medicare payments in the last year of life. N Engl J Med 1993;328:1092-1096.

Health System’s Needs

We’re plagued by:

health care disparities

high infant mortality rate (ranked 37th)*

lagging life expectancy (ranked 31st)*

primary care shortage

unacceptable medical errors

*World Health Statistics 2009. World Health Organization, 2009.Available at: http://www.who.int/whosis/whostat/EN_WHS09_Full.pdf

Creating a 21st Century Health System:

Our health system will need:

chronic care management

care coordination

end-of-life care

preventionPerfect role for nurses

Why Nurses?

Largest component of health care workforce

Spend most time with patients

Most likely to catch medical errors*

Work in many care settings

*Preventing Medication Errors. Washington, D.C.: Institute of Medicine, 2006.

Goal #1: Develop Nurse-Led Innovations

New models of care:

expand access

improve quality

reduce costs

enhance value

Example: 11th Street Family Health Center

Nurse-managed clinic at Drexel University:

addresses health care disparities

coordinates care

provides health promotion and disease prevention services

serves as clinical training site

11th Street Family Health Center

Example: 11th Street Family Health Center*

7,837 primary care visits in ’06, up 19%

20% reduction in hemoglobin A1C

68% of clients have controlled hypertension

14% increase in adult immunization rates

Fewer low-birth weight babies

Decreased depression rates in vulnerable adults with chronic illness

Increased rate of breast cancer screening

*http://www.aannet.org/files/public/11thStreetFamilyHelthSvcs_template.pdf

Example: Community and Retail Clinics

Over 1,200 retail clinics use NPs for common acute problems.

ERs and urgent care clinics freed up for more severe aliments

Patients enjoy convenience

NP-staffed clinics are more affordable

Retail clinic*

*Photo by Jim Amon, The Denver Post, September 30, 2009.

Example: Community and Retail Clinics

Compared to physician practices, NP practices show equivalent or better:

health status, patient adherence and symptom relief*

care management*

patient satisfaction*

NP practices also decrease health utilization and costs**

* Horrocks, S., et al. (2002). Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ; 324:819-23.* *American Academy of Nurse Practitioners. Nurse Practitioner Cost-Effectiveness, 2007.

Example: TCAB

RWJF and IHI program. AONE on board.

Goal:Goal: to empower nurses and others to redesign work processes on med/surg floors to achieve better clinical outcomes

Goal:Goal: to improve patient quality

Goal:Goal: to ensure a high-quality work environment and retain nurses

Example: TCAB

Example: TCAB

Promising findings:

Falls with harm declined by 45% from 2005-2007*

“Code blue” calls declined 30% from 2005-2007*

30-day re-admissions declined 25% between 2006-2007*

Nurses’ time at the bedside increased from 47% to 49%**, (with some hospitals up to 70%)

*Needleman, Jack and Susan Hassmiller. “The Role of Nurses in Improved Hospital Quality and Efficiency: Real-World Results” Health Affairs 28 no. 4, 2009 (published online 12 June 2009). **Needleman, Jack, et al. “Overall Effect of TCAB on Initial Participating Hospitals” American Journal of Nursing, 109(11) November 2009.

Example TCAB

Improvements Cost Savings

Reduction in nurse turnover $5.6 million

Reduction in patient falls $7.9 million

Reduction in pressure ulcers $59.3 million

TCAB Savings at Cedars-Sinai Medical Center 2007-2008*

Bolton, Linda Burnes, et. al. “The Business Case for TCAB” American Journal of Nursing109(11) November, 2009.

Transitional Care Model

Goals:

avoid repeat hospitalizations

attain longer-term positive health outcomes

TCM Improves Quality of Care*

*Source: Transitional Care Model Web site:

http://transitionalcare.info/ToolQual-1801.html.

Transitional Care Model Savings*

*Source: Transitional Care Model Web site:http://transitionalcare.info/ToolQual-1801.html.

Nearly $5,000 in savings at one year.

Nurse-Led Innovations

AAN has designated these examples:

Go to: http://www.aannet.org

Goal #2: Engage in Research

Build evidence base:

collect data and evaluate outcomes

publish

translate research to action

show link between nursing and high-quality patient outcomes

invest in faculty who will conduct the research needed for new solutions

Goal #3: Redesign Education

Make curriculum relevant and current

Teach students to think, make critical judgments, create solutions

“Today’s nurses are undereducated for demands of practice”

-- Carnegie Foundation report*

*Benner, Patricia, et al. Educating Nurses: A Call for Radical Transformation. San Francisco: Jossey-Bass, 2009.

Goal #3: Redesign Education

Curriculum must teach students to:

prevent disease

coordinate and manage chronic illness

offer solutions for and use new technologies

provide palliative and end-of-life care

work in every setting where society needs us

lead and advocate

Goal #3: Redesign Education

Residency program for nurses:

on-the-job learning and clinical preparation

safer patient care

Lifelong learning:

remain competent in practice area

keep pace with new technology

Goal #4: Embrace Medical Technology

Medical devices

E-records

Virtual patient visits

Simulation labs

Online classes

Social mediaNursing simulation lab

Goal #5: Foster Inter-professional Collaboration

Example: INQRI

Interprofessional teams conduct research showing how nurses can improve quality

Ex) Nurse and engineer team reducing pressure ulcers

Goal #6: Pursue Academic Service Partnerships

Engage:

1. hospitals

2. clinics

3. public health offices

4. area health education centers

Provide right clinical training to meet community’s needs

We must know what’s going on in the real world!

Goal #7: Develop Leadership at Every Level

Speak up to improve patient care

Serve on a board

Run for public office

Know your area of expertise

Develop your skill set

Goal #7: Develop Leadership at Every Level

Nurses hold about 2% of all board positions

Goal #7: Develop Leadership at Every Level

RWJF/Gallup survey of 1,500 health opinion leaders:

insurance

corporate

health services

government

university faculty

thought leaders

See significant barriers that prevent nurses from fully participating as health reform leaders

Who Will Influence Health Reform in the United States in the Next 5-10 Years

Question Wording: Thinking about the next five to ten years, how much influence do you think each of the following professions or groups of people will have in health reform in the United States?

Nurses Should Have More Influence in Planning, Developing Policy, and Management

Question Wording: Would you like nurses to have more influence, about the same influence, or less influence than they do now in planning, developing policy, and management of the following health systems and services?

Medical Errors

Quality Care

Access to Care

Goal #8: Be at the Table

Join boards

Enter policy debates

Communicate clearly

Show supporting data

Volunteer

Explain how nurses improve patient care

8 Goals to Create a 21st Century Nursing Workforce:

1. Develop nurse-led innovations

2. Generate evidence

3. Redesign education

4. Embrace medical technology

5. Foster inter-professional education

6. Pursue academic service partnerships

7. Develop leadership at every level

8. Be at the table

Creating a 21st Century Workforce

Nurses must take a leadership role in influencing:

policy

health planning

management

Creating a 21st Century Workforce

“Be the change you want to see.”

--- Gandhi

Thank You