Workforce
Call for Papers
Evidence for Planning the Future Health Care Workforce
Chair: Lori Melichar, Ph.D.
Sunday, June 6 • 11:30 a.m.-1:00 p.m.
• Factors Influencing Registered Nurses’ Decisions to
Work
Carol Brewer, Ph.D., R.N., Christine Kovner, R.N., Ph.D.,
F.A.A.N., Yow-Wu Wu, Ph.D., William Greene, Ph.D., Yu Liu,
M.S., Ph.D. Candidate
Presented by: Carol Brewer, Ph.D., R.N., Associate Professor,
School of Nursing, University at Buffalo, 918 Kimball Tower,
Buffalo, NY 14214; Tel: 716.829.3241; Fax: 617.829.2021; E-mail:
csbrewer@buffalo.edu
Research Objective: To analyze demographic, work-related
and market level factors that are related to RN decisions to
work or not work (WK/NW); and, if the RN works, whether to
work full or part-time (FT/PT).
Study Design: We used bivariate probit regression with
selection bias correction to examine RNs’ decisions to work or
not (WK/NW), and, if they chose to work, whether they
worked full-time or part-time (FT/PT). We included
demographic variables, work-related variables, satisfaction,
and Metropolitan Statistical Area (MSA) variables
representing physician-related demand, managed care and
poverty.
Population Studied: The sample was a randomized stratified
sample of U.S. RNs. The analytic sample was 27,057 female
RNs from MSAs. Of these, 4,634 were unemployed and 22,423
were employed. Variables from the 2000 National Sample
Survey of Registered Nurses County Public Use File, the
InterStudy Competitive Edge Part III Regional Market Analysis
(2002) and the Area Resource File (ARF: 2002) were merged
into one file.
Principal Findings: The Rho p values for the bivariate probit
regressions were 0.02 for single female RNs and .0004 for
married RNs, indicating that the WK/NW and FT/PT work
decisions were related. Different variables were important for
each decision, and for married versus single nurses. All of the
market level variables for the PT/FT decisions were significant
except “Percent of HMO hospital services paid through fee
schedules.” “Index of Competition” was the only market level
variable that was significant for the WK/NW decision. The
influence of age, children, minority status, and student status
had strong effects on the probability of working FT but were
much less influential on the WK/NW decision. Total family
income increased the probability of working, although the
effects were larger on higher income categories for married
RNs. Age was influential on both decisions and the marginal
effects were larger for married RNs over 55. Married RNs who
were more dissatisfied in 1999 were less likely to be in FT jobs
in 2000. Previous health care work experience had a positive
effect on whether married RNs worked. Settings and positions
also affected the FT/PT decision differently for married and
single RNs.
Conclusions: One of the very intriguing findings of this study
is the very different effects of the MSA level market variables
on the two types of work decisions as well as differences
between married and single RNs. The typical WK/NW
decision of an RN is influenced by demographic factors, but
very little by the economic environment. Models of turnover
consistently cite satisfaction as an important factor in a RN’s
intention to leave the job. However, satisfaction was not a
major factor influencing FT/PT compared to other factors.
Married RNs may have the economic security to act on their
satisfaction level.
Implications for Policy, Delivery or Practice: Different
factors influence the WK/NW and FT/PT decisions. Married
and single RNs are influenced by different factors, indicating
that different policy and employer options are relevant. Other
variables such as education and position have implications for
workforce development and productivity. Findings from this
study will be useful to employers and policy makers as they
make decisions on how to manage the cyclical imbalances in
the nursing workforce.
Primary Funding Source: AHRQ,
• Genetics Workforce Concern: A Limited Supply of
Medical Geneticists
Judith Cooksey, M.D., M.P.H., Miriam Blitzer, Ph.D., Gaetano
Forte, B.A., Judith Benkendorf, M.S., Ed Salsberg, M.P.A.
Presented by: Judith Cooksey, M.D., M.P.H., Epidemiology
and Preventive Medicine, University of Maryland School of
Medicine, 660 West Redwood Street, Baltimore, MD 21201,
US; Tel: 410.706.1277; Fax: 410.706.5751; Email:
jcookseyumuic@aol.com
Research Objective: Translation of human-genome related
discoveries into clinical practice will require sufficient numbers
of genetics-trained professionals. Yet the supply of physicians
with specialty training in genetics is small (about 1,000), and
new entrants declined from an average of 100/yr in 1996 to
about 60/yr in 2002. This study examined the distribution,
characteristics, practice parameters, and perspectives of
medical geneticists to better understand the profession and to
inform overall genetics workforce planning.
Study Design: Confidential written survey of all board certified
medical geneticists conducted in February 2003. The 67
survey questions covered demographics, education,
professional practice, and perspectives; two survey sections
were addressed to geneticists providing either direct patient
care or clinical laboratory services. All analyses were
conducted using SPSS. The study had IRB approval by UMB
and SUNY-Albany.
Population Studied: All diplomates of the American Board of
Medical Genetics, ABMG, which includes MDs and PhDs,
certified prior to 2002. Surveys sent to 1,594 individuals; 861
responded, 70 declined to participate, for a 56% RR; 96 were
excluded from analysis due to retirement not practicing in
USA, etc. Results are reported for 478 analyzable physician
respondents, with MD or MD/PhD degrees.
Principal Findings: ABMG certified clinical geneticists have
required prior GME training; most were trained in pediatrics
71%, internal medicine 11%, obstetrics/gynecology 10%, or
pathology 6%. Primary work settings were academic health
centers 66%, medical practices 12%, and hospitals 8%. Work
effort averaged 54 hours/week, with 42% reporting more than
60 hrs/wk. By individual respondent, 86% reported providing
patient care and 30% clinical laboratory services. Only 51% of
aggregate time effort was spent in clinical service, with 42% in
patient care and 9% in lab services; the remaining time is
spent in research 20%, education 10%, administration 9%,
and other activities 10%.
In aggregate, the largest numbers of patients were
infants/children 71%, followed by adults 18%, and women
receiving reproductive genetic services 11%. Genetic patient
visits per year averaged 240 for new patients and 190 for
returns; these required in-depth consultation time, averaging
75 minutes for new patients. Geneticists reported additional
patient care capacity; average waiting time for non-urgent new
patients was under four weeks for 52% of respondents.
Respondents frequently worked in teams with genetic
counselors, nurses, and others.
Only 45% would recommend medical genetics as a profession
to young physicians. However, 67% were somewhat or very
satisfied with their current position. Many respondents were
dissatisfied with reimbursement levels for their services.
Conclusions: The current medical geneticists’ practice is
largely focused on pediatric genetics. Patient care
productivity, as measured in patient visits per year, is very low
compared to other medical specialists. Yet productivity gains
may be difficult to achieve, in part due to multiple professional
responsibilities and already long work schedules. Further
analysis of the questions on professional perspectives may
provide insights on the low rate for recommending the
profession as a career choice for young physicians.
Implications for Policy, Delivery, or Practice: Leaders in
genetics are concerned with the limited supply of highly
trained genetic specialists, including medical geneticists,
laboratory geneticists, genetic counselors, and nurses in
genetics. The increasing complexity and breadth of new
genetic testing, counseling, and diagnostic services will
require a sufficient supply and distribution of specialists.
Further study of the factors related to the declining numbers
of new entrants into the specialty of medical genetics is
warranted. Policy makers should be made aware of the limited
patient care capacity of the current workforce and asked to
consider options to recruit and train new entrants into these
professions.
Primary Funding Source: HRSA
• Crisis in the Mental Health Workforce: The State of the
Advanced Practice Nurse Workforce
Nancy Hanrahan, Ph.D., R.N.
Presented by: Nancy Hanrahan, Ph.D., R.N., Post Doctoral
Research Fellow, Center for Health Outcomes and Policy
Research, University of Pennsylvania, 420 Guardian Drive,
NEB #337, Philadelphia, PA 19104; Tel: 215.573.6759; E-mail:
nancyp@nursing.upenn.edu
Research Objective: 1. Describe the 2003 advanced practice
nurse (APN) mental health workforce characteristics including
demographics, education, experience, employment, patient
encounters, and geographic distribution.
2. Explore APN workforce trends including education,
experience, employment and geographic distribution from
1980-2000.
Study Design: Over the past twenty five years, assessment
and treatment of mental illness has changed due to the
significant growth in knowledge of neurobiology and behavior.
One result is the rapid development of effective
psychopharmacologic interventions which has, in turn,
required different skills from the mental health workforce.
Recent evaluations of the mental health workforce have
pronounced the current workforce lacking in the training and
skills to deliver evidence based assessment and interventions.
However, while the physicians, social workers, and
psychologists are included in these workforce analyses,
advanced practice psychiatric nurses (APNs) are often not
referenced. This lack of workforce detail exists despite the fact
the APN workforce has the necessary training and skills to
provide psychopharmacologic interventions. These skills are
acknowledged by 37 states that allow APNs to prescribe and
manage medication. The purpose of this study is to describe
and explore trends of APNs providing mental health services
so that strategic planning to solve the mental health workforce
crisis can include APNs along with other mental health
providers.
This was an exploratory, descriptive study using data from the
following sources: 1) 2003 American Nursing Credentialing
Center (ANCC) data on certified advanced practice psychiatric
mental health nurses and, 2) National Nurse Sample Survey
(NNSS) data 1980-2000. The ANCC data described the
demographics, education, experience, employment, patient
encounters, and geographic distribution of the population of
advanced practice psychiatric nurses working in the mental
health workforce. The NNSS data provided trends in the
psychiatric mental health workforce from 1980-2000 in
education, experience, employment, and geographic
distribution.
Population Studied: 8751 board certified advanced practice
nurses practicing in the psychiatric mental health specialty.
This is the entire 2003 population of advanced practice nurses
certified.
Principal Findings: The APN workforce is mostly white,
female with an average age of 51 years. Nearly three quarters
of the APNs provide services in urban areas. APNs have a
masters degree or higher and 5% have a doctorate. Places of
employment include solo practice, hospital, home health and
group practice. 60% of APNs work 40 hours or more a week.
Nearly two thirds of APNs have 25 years or more experience as
a registered nurse and 20 or more years in the specialty of
psychiatry. The APN workforce is fading with fewer
enrollments and graduations since 1980.
Conclusions: Nursing is a core discipline that has been
virtually invisible in the debate about how to solve the mental
health workforce crisis. There is a short supply of both nurses
and doctors trained in the specialty of psychiatry. These
providers need to take care of the sickest people with serious
mental illness in order to obtain the best possible treatment
results. In the mental health workforce, the contribution and
expertise of advanced practice psychiatric nurses to treating
people with mental illness are slipping away.
Implications for Policy, Delivery or Practice: Data suggests
that patients with mental health issues may not be receiving
treatment from specialized clinicians such as APNs.
Encouraging growth in this specialty is a cost effective strategy
for addressing the shortage of qualified mental health
professionals.
Primary Funding Source: National Institute of Nursing
Research
• Impact of Patient Turnover on Nurse Staffing
Lynn Unruh, Ph.D., R.N., LHRM, Myron Fottler, Ph.D.
Presented by: Lynn Unruh, Ph.D., R.N., LHRM, Assistant
Professor, Health Professions, University of Central Florida,
P.O. Box 162205, Orlando, FL 32816-2205; Tel: 407.823.4237;
Fax: 407.823.6138; E-mail: lunruh@mail.ucf.edu
Research Objective: Measures of nurse staffing calculate the
volume of nurses or nurse hours given the volume of patients
or patient days. Frequently, intensity of patient care is also
considered by adjusting patient volume for patient acuity.
However, intensity of patient care is also affected by many
other factors, an important one being patient turnover. As
patient turnover increases, nurses must do more in each
patient day of care. The objectives of the study are to examine
the trend in patient turnover and its impact on nurse staffing.
Study Design: After multiplying patient volume by turnover
(the inverse of length of stay) we examine the difference in
nurse staffing measures from 1991-2000 with and without the
turnover weight. The measures assessed are the numbers of
RNs, LPNs and nursing assistants given adjusted patient days
of care.
Population Studied: Secondary data from all Pennsylvania
acute-care general hospitals from 1991 through 2000.
Principal Findings: We find a significant difference between
standard and adjusted nurse staffing measures. The
differences are also significant when applied to the changes in
nurse staffing from 1991-2000. When staffing is additionally
weighted for patient acuity we find a sharp decline in RN
staffing over the 1990s in Pennsylvania hospitals.
Conclusions: When nurse staffing measures are weighted for
patient turnover they provide a more accurate indicator of
actual staffing patterns.
Implications for Policy, Delivery or Practice: Since greater
patient turnover has been identified as causing greater
intensity of nursing care, we suggest that nurse staffing
measures use a turnover weight.
Primary Funding Source: AHRQ
• What’s Up Docs? Population-Based Supply and Use of
Family Doctors, 1991-2001
Diane Watson, Ph.D.. M.B.A., BSOT, Noralou Roos, Ph.D.,
Robert Reid, Ph.D., Alan Katz, M.D., Bogdan Bogdanovic, B.S.,
Petra Heppner, M.H.A.
Presented by: Diane Watson, Ph.D., M.B.A., BSOT, Faculty,
Centre for Health Services and Policy Research, University of
British Columbia, #209 2150 Western Parkway, UBC,
Vancouver, British Columbia V6T 1V6; Tel: 604.222.6870; Fax:
604.224.8635; E-mail: dwatson@chspr.ubc.ca
Research Objective: The focus of this paper presentation is
to share findings regarding our assessment regarding how FP
supply, workloads and access to care have changed over the
past decade. This population-based study was undertaken
using data from Winnipeg, Manitoba – a city, like others in
Canada, where FPs report unhappiness with workloads,
citizens express frustration regarding access to FPs, and
journalists document widely held views that many FPs
practices ‘restrict’ access to new patients. The implications of
findings on current perceptions of supply and accessibility of
FP services and on future requirements for physicians will be
discussed.
Study Design: For this population-based study, we calculated
the following measures of supply and workload: FP-topopulation ratios, FP full-time equivalent (FTE) -to-population
ratios, FP activity ratios (FTE/FP), visits per FP per annum,
and visits per FP per full time day of work. Trends in FP
remuneration were assessed and analyses stratified by FP age
and gender. On the use side, we measured standardized visit
rates and stratified the analysis by populations deemed at risk
of needing FP services.
Population Studied: We used an anonymized, populationbased physician and population registry, as well as
administrative health service data for 1991/92 to 2000/01.
Principal Findings: In 2000/01 FPs between 30 and 49 years
(64% of the workforce) provided 20% fewer visits per annum
than their same age peers did 10 years previously. Conversely,
FPs aged 60 to 69 years (11% of the workforce) provided 33%
more visits per annum. Similar workload shifts were evident
using activity ratios, total billings from patient visits, and
price-adjusted billings. FPs per capita declined 5% to 92 per
100,000 population in 2000/01 from 1991/92 paralleling
national estimates of FP supply. Per capita visit rates among
Winnipeggers and workloads among FPs were stable, on
average, over the decade. Per capita visit rates declined 3% to
3.49 visits in 2000/01, and no substantial shifts in visit rates
were documented among at risk populations. The activity ratio
workload measure increased 1%. Visits per FP per annum
were virtually unchanged between 1991/92 and 2000/01 (i.e.,
4,198 versus 4,193 visits), as were visits per FP per full time
day of work (i.e., 27.9 versus 27.8 visits).
Conclusions: Beneath stable measures of aggregate FP
supply and population estimates of FP utilization, there have
been substantial shifts in the workforce in ‘who’ is providing
‘how many’ services. Younger FPs are providing many fewer
visits (i.e., those who have been called the ‘get a life’
generation) and older FPs are providing many more visits
than their same age predecessors did 10-years ago.
Implications for Policy, Delivery or Practice: Policy makers
and providers should focus on setting standards for access,
volume and types of services they expect from primary care
providers and move beyond simply increasing numbers of FPs
services.
Primary Funding Source: Ministry of Health, Manitoba,
Canada
Call for Papers
Impact of Practice Organization & Demographics
on the Workforce
Chair: Sean Clarke, Ph.D.
Sunday, June 6 • 3:00 p.m.-4:30 p.m.
• RN Characteristics and Staffing Patterns: A Comparison
of VHA and Non-VHA Hospital RNs in the United States
Gwendolyn Greiner, M.P.H., M.S.W, Anne Sales, Ph.D., R.N.,
Nancy Sharp, Ph.D., Yu-Fang Li, Ph.D., R.N.
Presented by: Gwendolyn Greiner, M.P.H., M.S.W, Research
Health Sciences Specialist, Health Services Research and
Development, VA Puget Sound Health Care System, 1660 S.
Columbian Way (HSRD 152), Seattle, WA 98108; Tel:
206.277.4583; Fax: 206.764.2935; E-mail:
gwendolyn.greiner@med.va.gov
Research Objective: Identifying optimal nurse staffing is a
crucial task for hospital management in an era of acute
nursing shortages, and recent national and international
studies have examined the relationship between key patient
outcomes and nurse staffing levels. In this paper, we report on
a study of nurse staffing patterns, job satisfaction, and
burnout in Veterans Health Administration (VHA) hospitals,
and compare the VHA RN sample with a sample of RNs from
Pennsylvania hospitals.
Study Design: This analysis is part of an observational, crosssectional study of nurse staffing, nursing care processes and
patient outcomes in VHA. In the first phase of this project, we
administered a survey to nursing staff at VHA facilities with
inpatient services between February and June 2003. The
survey, adapted from an instrument developed by the
International Hospital Outcomes Consortium (IHOC),
obtained data on staffing levels and workload, nursing work
environment, and job satisfaction from RNs, LPNs, nurse
aides and health technicians providing clinical nursing care in
all hospital units. To compare the results of the VHA survey
with a Pennsylvania nursing sample reported by IHOC, we
identified RNs working regularly on inpatient medical/surgical,
ICU, OR/PACU or other (including psychiatric, rehab and SCI)
units. We examined job satisfaction, burnout, nurse to patient
staffing (calculated as the mean patient load across all RNs in
a VA medical center who reported being responsible for at
least 1 but less than 20 patients on their last shift worked) and
several hospital and nurse characteristics. Frequencies and
distribution of staffing, hospital and nurse characteristics, job
satisfaction and burnout were compared between VHA and
Non-VHA RNs.
Population Studied: We obtained survey responses from
4,684 RNs providing clinical nursing care at VHA Medical
Centers with acute inpatient services.
Principal Findings: Most hospital and demographic
characteristics were similar for both samples. VHA RNs report
more years working as a nurse (19.9 yrs vs. 13.8 yrs), a greater
percentage with a baccalaureate or higher educational degree
and are more likely to work in tertiary, teaching hospitals than
non-VHA RNs. 59% of VHA RNs report responsibility for 4 or
fewer patients on their last shift compared with 17% of nonVHA RNs; non-VHA RNs reported higher nurse to patient
ratios overall than VHA RNs. VHA RNs also report greater job
satisfaction (68.3 vs. 58.5%) and less burnout (62.6 vs. 56.8%)
than non-VHA RNs.
Conclusions: RN staffing ratios in VHA hospitals compare
favorably to the non-VHA sample. VHA RNs report greater job
satisfaction, less burnout and lower patient to nurse staffing
ratios than non-VHA RNs.
Implications for Policy, Delivery or Practice: VHA may
demonstrate better practices in RN staffing with regard to job
satisfaction and burnout, key variables in nurse recruiting and
retention than many non-VHA inpatient care settings. A better
understanding of this relationship, and the associations
between nurse staffing structures and nursing care processes,
is essential.
Primary Funding Source: VA
• Educational Preparation and Registered Nurse Turnover
Cheryl Jones, Ph.D., Michael Gates, B.S.N.
Presented by: Cheryl Jones, Ph.D., Associate Professor,
School of Nursing, UNC Chapel Hill, CB # 7460, Carrington
Hall, Chapel Hill, NC 27599-7460; Tel: 919.966.5648; Fax:
919.966.7298; E-mail: cheryl_jones@unc.edu
Research Objective: A recent report asserts that in hospitals
with higher proportions of registered nurses (RNs) educated
at the baccalaureate level or higher, patients experience lower
mortality and failure-to-rescue rates (Aiken et al., 2003). This
finding has renewed interest in the role that education plays in
defining patient outcomes, as well as organizational
outcomes, such as turnover. RN turnover is a recurring
problem for hospitals, especially during workforce shortages.
In fact, a recent national hospital RN turnover rate was
estimated at approximately 21% (AONE, 2002). Past research
has indicated that higher RN educational preparation is
associated with increased RN turnover (Hinshaw, Smeltzer, &
Atwood, 1987; Roberts, Minnick, Ginzberg, Curran, 1989), yet
turnover in these studies was operationalized as a
dichotomous variable – i.e., nurses either turned over or they
did not. In reality, however, RNs are faced with three turnover
options: to remain in their job and with their employer (i.e.,
no turnover), to change jobs within the organization (internal
turnover), or to leave the employing organization altogether
(external turnover). Each option holds different financial and
professional implications for nurses, and different financial
and policy implications for hospitals. The objective of our
study is to examine the impact of RN education on these
turnover behaviors, with the intent that our results may inform
the development of more effective recruitment and retention
strategies to ensure a highly qualified nursing workforce.
Study Design: A secondary analysis of cross-sectional data
from the 2000 National Sample Survey of Registered Nurses
was conducted to examine the turnover behaviors of hospital
RNs. Nursing turnover behaviors were conceptualized to
reflect nurses’ perceptions of opportunities within and outside
of their current hospital setting relative to their human capital,
and other factors (Ehrenberg & Smith, 1991). Using
multinomial logistic regression, we explored RN turnover by
testing hypotheses of turnover behaviors relative to nurses’
education and other socio-demographic, professional,
employment, and economic factors.
Population Studied: RNs employed in U.S. hospitals.
Principal Findings: The results of our analyses indicate that
higher levels of RN education are associated with a greater
likelihood of internal RN turnover behavior, but not external
turnover behavior. Moreover, other socio-demographic,
professional, employment, and economic variables play an
important role in determining the likelihood of hospital
nurses’ internal and external turnover behaviors.
Conclusions: We found that educational preparation does not
increase the likelihood of nurses turning over externally; only
when internal turnover is considered does education influence
RN turnover.
This suggests that previous conceptualizations of RN turnover
as a dichotomous variable may have overlooked an important
aspect of turnover, and subsequently led to incomplete
conclusions about nurses’ turnover behaviors and inadequate
actions to address turnover.
Implications for Policy, Delivery or Practice: It is important
to view nurses’ turnover behavior not simply as a
dichotomous variable, but instead as a behavior that reflects
another choice. Furthermore, given that nurses with more
education may not be more likely to turnover externally,
retaining such nurses by creating a rewarding work
environment and internal job opportunities may add value to
– and improve care in – organizations that invest in an
educated RN workforce.
Primary Funding Source: HRSA
• Women in Radiology
Rebecca Lewis, M.P.H., Mythreyi Bhargavan, Ph.D.
Presented by: Rebecca Lewis, M.P.H., Research Statistician,
American College of Radiology, 1891 Preston White Drive,
Reston, VA 20191; Tel: 703.295.6771; Fax: 703.264.2443; E-mail:
rebeccal@acr.org
Research Objective: Radiologists, like most other physicians,
have been overwhelmingly male over the years. Although the
total proportion of female medical residents has increased by
approximately ten percentage points from 1989-2000, the
percentage of diagnostic radiology residents who are female
has decreased by 0.4%. This paper describes professional
and practice characteristics of women radiologists in the
United States, with emphasis on their changing roles and on
implications that this may have for provision of care. We plan
to compare our findings to statistics reported in earlier
studies, and examine if there have been changes in
characteristics for all women radiologists, and for younger
women entering the field in the recent years.
Study Design: We use simple descriptive statistics and
multivariate analysis to test for statistically significant
differences between male and female radiologists. We control
for age to examine if younger women radiologists make
choices that are significantly different from choices made by
older women radiologists. Survey responses will be weighted
to make them representative of all radiologists in the United
States.
Population Studied: Data were taken from a national
stratified random sample survey of diagnostic radiologists.
The response rate was approximately 60%, with a total of 1923
respondents including 1597 men and 326 women. For this
paper, we focus on post-training active (non-retired)
radiologists
Principal Findings: Female respondents tended to be
younger (47) than their male counterparts (51) and worked
fewer mean hours per week (44%) than males (52%).
Fewer female respondents (64 %) than male respondents (86
%) report working full-time. There was no significant
difference in the percentages of female and male respondents
who report being board-certified, but fewer female
respondents (20%) than male respondents (32%) report
having a Certificate of Added Qualification (CAQ) or other
special competence. Significantly a larger proportion of
female than male respondents report working in academic
practices (23% and 15% respectively) and a smaller proportion
of female than male respondents in private practice (26% and
46% respectively). Also a smaller proportion of female
respondents (38%) than male respondents (64%) are practice
owners. All of the above results were borne out when
running logistic regressions while controlling for age.
A greater percentage of females (49%) than males (20%)
report that 25% or more of their clinical time is spent on
breast imaging/mammography, while there was no significant
difference in numbers of females versus males who
subspecialize in breast imaging/mammography.
Conclusions: As a whole, women represent a fairly low
percentage of professionally active post-training radiologists,
though greater numbers of women are entering the radiology
profession than for previous time periods. Controlling for the
fact that female radiologists tend to be younger than male
radiologists, we still find differences in professional choices
made by the two groups with respect to hours of work,
practice ownership and academic departments.
Implications for Policy, Delivery or Practice: Women in
radiology still seem to choose different aspects of the
profession. It appears that women in radiology frequently end
up in salaried positions such as academic and non-ownership
practices. Given the funding spent on residency training and
mentorship programs to promote more women in radiology,
it might be a useful aspect to consider.
• Evaluation of Strategies to Recruit Oral Health Care
Providers to Underserved Areas in California
Elizabeth Mertz, M.P.A., Gena Anderson, M.P.H., Kevin
Grumbach, M.D., Edward O'Neil, Ph.D., M.P.A.
Presented by: Elizabeth Mertz, M.P.A., Project Director,
Center for the Health Professions, University of California, San
Francisco, 3333 California Street, Suite 410, San Francisco, CA
94118; Tel: 415.502.7934; Fax: 415.476.4113; E-mail:
bethm@itsa.ucsf.edu
Research Objective: Evaluate the impact that oral health care
providers participating in programs focused on recruiting
providers to underserved areas have on access to care for
underserved populations.
Study Design: A literature review informed the development
of the theoretical framework for the study and the
identification of underserved populations. Expert interviews
and Internet searches identified recruitment programs and
policies in California. Program administrators were contacted
by phone and asked a standard set of questions regarding
program goals, structure, participants, and outcomes. Data
collected were analyzed to estimate the individual and
combined impact of all programs on access to care for
underserved populations.
Population Studied: The focus of our study was any program
or policy with the direct or indirect goal of recruiting oral
health care providers to work in underserved areas or with
underserved populations. Programs were classified according
to whether their recruitment efforts employed a practice
environment, dental education, or applicant pool strategy.
Principal Findings: At minimum, 3 million California
residents have a problem with access to dental care. Strategies
to recruit providers to care for these underserved populations
include; loan and scholarship programs, independent dental
hygiene practice (and related scope of practice legislation),
foreign trained dentists (4 pathways), pipeline programs at the
five California dental schools, dental residencies, postbaccalaureate, outreach and mentoring programs. Two types
of programs showed immediate impact on service to
underserved patients. Annually, the 51 current participants of
loan repayment and scholarship programs provide 130,000
patient visits, and those participants retained in underserved
areas from each graduating cohort provide an additional
15,000 patient visits annually. Dental residents provided
59,000 patient visits to underserved patients annually.
Examining projected impact of proposed program expansions
found; a mandatory PGY-1 residency could provide 280,000
visits annually, expansion of loan repayment and scholarship
programs could provide 153,000 visits annually, Mexican
dentists participating in a pilot project could provide 76,000
visits annually, and independent hygiene practices will add
34,000 visits annually. Dental education strategies show
promise; however, evaluation of results will not be available
for years.
Conclusions: Data on many of the current programmatic
efforts was inadequate to evaluate the impact on access to
care. Many of these programs have similar goals, but efforts
across the different strategies were not coordinated.
Measurable program are meeting only 2-6% of the estimated
need. However, the programs evaluated clearly have a strong
impact in the specific underserved communities where they
place providers. Yet the overall impact of current
programmatic efforts, compared to the oral health care needs
and lack of access to care in California remains in stark
contrast.
Implications for Policy, Delivery or Practice: Current
programs and policies are effective, but not comprehensive
enough to address the magnitude of the problem. The current
budget environment in California as well as professional
reluctance to try new models limits potential new programs.
Expansion of current programs may be more feasible than
entirely new programmatic endeavors, however new models
are needed to truly begin to address the lack of access to care
for underserved populations.
Primary Funding Source: , California Program on Access to
Care
• Turnover of Critical Care Registered Nurses
Patricia Stone, Ph.D., Jeannie Cimiotti, DNS (candidate),
Andrew Dick, Ph.D., Elaine Larson, Ph.D., Cathy Mooney,
M.P.H., Jack Zwanziger, Ph.D.
Presented by: Patricia Stone, Ph.D., Assistant Professor of
Nursing, School of Nursing, Columbia University, 617 West
168th Street, New York, NY 10032; Tel: 212.305.1738; Fax:
212.305.6937; E-mail: ps2024@columbia.edu
Research Objective: The purpose of this research was to
identify factors related to turnover of critical care registered
nurses (RNs) including: 1) demographics (i.e., age, work
experience and tenure), 2) hospital characteristics (i.e.,
hospital size and region), and 3) perceptions of organizational
climate.
Study Design: A cross-sectional design was used. RNs
employed in intensive care units (ICUs) were surveyed.
Hospital characteristics were identified using American
Hospital Association (AHA) data. The measure of
organizational climate included seven independent subscales:
Collaboration, Participatory Governance, Staffing/Resources,
Scheduling, Supervision, Professional Practice, and Training.
Turnover was indicated by one item behavioral intention to
leave (ITL) in the coming year. Narrative qualitative
descriptions of reasons for those indicating positive ITL were
obtained and coded. Descriptive statistics, analysis of
variance, and logistic regression were conducted.
Population Studied: A voluntary sample of 2,330 RNs
(response rate 41%) employed across the nation was obtained
(East 38%, Midwest 31%, West 22%, and unknown 9%). A
majority of respondents worked in large hospitals (400 beds
or more 49%, 300-399 beds 23%, less than 300 beds 19% and
unknown 9%). The average RN was 39.5 years old (SD =9.40),
had 15.6 years (SD=9.20) experience in health care, and had
worked in their current position for 8.0 years (SD= 7.50).
Principal Findings: Overall, 17% (n=391) of the nurses
indicated positive ITL. Reasons for ITL were coded as negative
working conditions (72%), positive career move (25%), and
retirement (3%). Those reporting ITL due to negative working
conditions had significantly lower mean scores (p<.05) for all
scales than non leavers or those leaving for other reasons.
Three factors had independent effects on ITL: Participatory
Governance (odds ratio [OR] = .54, 95% confidence interval
[CI] .40, .72), Supervision (OR= .74, CI .55, .98), and Training
(OR= .63, CI .46, .85). There were no significant differences in
ITL related to nursing demographics or hospital
characteristics.
Conclusions: Turnover of RNs working in ICUs across the
nation is great and negative perceptions of organizational
climate significantly impact this phenomenon. Lack of
participation in governance, poor leadership of supervisors
and lack support for RN training are important factors in
nursing turnover.
Implications for Policy, Delivery or Practice: Organizational
factors resulting in poor nurse working conditions is a
problem in health services and has been related to patient
safety outcomes. Turnover is expensive with the cost to
replace one RN estimated to range from $30,000 to $50,000,
with higher costs associated with high skilled critical care
nurses. Interventions and policies aimed at improving RN
participation in governance, supervisors’ leadership
capabilities, and ensuring adequate training of RNs may
decrease turnover, improve patient safety and reduce health
care costs.
Primary Funding Source: AHRQ
Related Posters
Poster Session B
Tuesday, June 8 • 7:30 a.m.-8:45 a.m.
• Assessing the Effectiveness of Alternative Options to
Address the Nursing Shortage
Marilyn Biviano, Ph.D., Timothy Dall, M.S., Stephen Tise,
Marshall Fritz, M.S., William Spencer
Presented by: Marilyn Biviano, Ph.D., Director, National
Center for Health Workforce Analysis, Health & Human
Services, Bureau of Health Professions, HRSA, 2616
Bainbridge Lane, Silver Spring, MD 20906; Tel: 301.443.9792;
Fax: 301.443.8003; E-mail: mbiviano@hrsa.gov
Research Objective: (1)Identify, at the state and national
level, the extent and distribution of the registered nurse (RN)
shortage and (2) Demonstrate the value of these models by
estimating and analyzing the impact on the projected national
shortage resulting from an increase in RN graduates or RN
wages and the impact resulting from a delay in RN
retirements.
Study Design: The National Center (for Health Workforce
Analysis) maintains the Nursing Supply Model (NSM) and
Nursing Demand Model(NDM)to project national and state
level supply, demand and shortages as well as the
effectiveness of alternative strategies to address shortages.
The NSM projects nurse supply based upon projections of
new graduates from nursing programs, immigration,
interstate migration, changes in educational attainment, labor
force participation rates, and attrition from the workforce. The
NDM estimates demand for RNs based on projections of
future demand for health care services and future nurse
staffing patterns.
Population Studied: The National Sample Survey of
Registered Nurses (NSSRN), administered by the National
Center, is the Nation's most extensive and comprehensive
source of data on RNs. Year 2000 survey data includes
response from over 35,000 RNs sampled from all states lists
of licensed nurses, providing information on the
demographics, educational background, specialty area,
employment status and setting, and geographic location. The
NSSRN provides essential information for both supply and
demand projections.
Principal Findings: A national shortage of 36% (over 1 million
nurses) is projected, based on current trends, for 2020. To
meet the projected growth in demand, the impact of
alternative nurse graduates, salary increases and delaying
retirement were estimated using the models. It is estimated
that the U.S. needs to graduate about 90% more nurses (from
nurse training programs). Substantial real wage increases of
3% per annum may help to eleviate the shortage. Delaying
retirement by 4 years increases RN supply by an estimated 9%
in 2020.
Conclusions: The RN workforce is aging and faced with
declining entrants at a time when the growth and aging of the
population is likely to increase demand for nurses. The
situation is complicated by the fact that alternative careers,
with higher salaries and less stressful working conditions,
continue to attract current and potential nurses.
The National Center nursing workforce models allow the
assessment of the impact of alternative strategies to increase
supply and decrease demand for nurses. It appears that,
because the projected shortage is severe, several strategies
may be needed to address the projected long-term shortage.
Implications for Policy, Delivery or Practice: Strategies
must be employed to expand the nursing workforce by
increasing entrants and the capacity to train them. Employers
must also address working conductions and create an
atomosphere which increases retention of RNs currently
employed in nursing.
Primary Funding Source: HRSA
• Projected Supply and Demand for Physicians
Marilyn Biviano, Ph.D., Timothy Dall, M.S., Stephen Tise, Atul
Grover, M.D., Ph.D.
Presented by: Marilyn Biviano, Ph.D., Director, National
Center for Health Workforce Analysis, Health & Human
Services, Bureau of Health Professions, HRSA, 2616
Bainbridge Lane, Silver Spring, MD 20906; Tel: 301.443.9792;
Fax: 301.443.8003; E-mail: mbiviano@hrsa.gov
Research Objective: (1) Incorporate new research and update
data used in National Center (for Health Workforce Analysis)
physician supply (PSM) and demand models (PDM) and
assess the adequacy of projected supply. (2)Conduct
sensitivity analysis in projected supply and demand
projections for key variables such as hours worked, increased
health care utilization, specialty composition, increased
productivity, and changing practice patterns.
Study Design: The PSM is an inventory model that tracks
physicians by 36 medical specialties, age, gender, MD or DO,
and whether a U.S. medical graduate or an international
medical graduate. Model assumptions regarding the number
of U.S. and international medical graduates entering U.S.
residency programs, choice of medical specialty, and
retirement patterns are based on current trends. The PDM
projects the future demand for physicians in 18 medical
specialties based on changing demographics, historical
patterns of the use of physician services, and assumptions
regarding future changes in insurance coverage and the use of
non-physician clinicians.
Population Studied: Doctors of Medicine (MDs) and Doctors
of Osteopathy (DOs) in the U.S., and the population that uses
physician services.
Principal Findings: The supply of physicians is projected to
increase by approximately 25% between 2000 and 2020,
which is a 7% increase in the physician-to-population ratio.
During this same period, if current trends in per capita
healthcare utilization of physician services continue, then
demand for physicians will increase by approximately 24%.
This growth in demand is attributed mainly to the growth and
aging of the population. Female physicians compose an
increasing proportion of the physician workforce. Because
female physicians tend to work fewer hours per week in
patient care activities and tend to retire earlier than male
physicians the “effective” supply of physicians will grow by
slightly less than 25%. Inadequacies in physician supply will
exist in some specialties.
Conclusions: The baseline projections suggest that the U.S.
will have an adequate supply of physicians overall at the
national level through 2020. Pockets of physician shortages
will likely remain in some specialties and in some geographic
areas. Although there is usually a consensus regarding
projections of the future physician supply, there is often
disagreement regarding the accuracy of demand projections
that are heavily dependent on the forecaster’s assumptions.
There exists a paucity of research on the relationship between
demand for physicians and factors such as economic growth,
the use of non-physician clinicians, and the increasing use of
copays and deductibles to make consumers more conscious
of the costs of medical services.
Implications for Policy, Delivery or Practice: Projections of
an adequate supply of physicians overall suggests there is no
need for major changes in the training pipeline or changes in
policies regarding the number of residency slots or number of
foreign doctors allowed to practice in the U.S. However, there
may need to be some reallocation in the number of residency
slots for selected medical specialties. It should be noted that
the analysis is based on market trends, and, thus does not
address the impact of projected supply, demand, or
composition of the physician workforce on the quality or cost
of health care, nor does it estimate or address physician
supply or distribution needed to assure health care access.
•Changing Demographics and the Implications for
Physicians, Nurses, and Other Health Workers
Marilyn Biviano, Ph.D., Timothy Dall, M.S., Stephen Tise,
James Cultice
Presented by: Marilyn Biviano, Ph.D., Director, National
Center for Health Workforce Analysis, Health & Human
Services, Bureau of Health Professions, HRSA, 2616
Bainbridge Lane, Silver Spring, MD 20906; Tel: 301.443.9792;
Fax: 301.443.8003; E-mail: mbiviano@hrsa.gov
Research Objective: An aging population will increase
demand for health care services at the same time that many of
the nation’s health workers are nearing retirement. In
addition, the growth in racial and ethnic diversity in the U.S. is
not matched by an increase the racial and ethnic makeup of
many healthcare professions—most notably physicians. This
study synthesizes the literature on changing demographics
and presents the findings of empirical research to better
understand the health workforce implications of changing
demographics in the U.S.
Study Design: This study combined a comprehensive review
of the literature with analysis of national healthcare databases
and model building.
Population Studied: Physicians, nurses and other health
workers in the U.S, as well as the population that uses
healthcare services.
Principal Findings: If health care consumption patterns and
physician productivity remained constant over time, the aging
population would increase the demand for physicians per
thousand population from 2.8 in 2000 to 3.1 in 2020. Demand
for full-time-equivalent (FTE) registered nurses per thousand
population would increase from 7 to 7.5 during this same
period. At the same time that the population is aging, the
supply of health workers is also aging. The aging population
will likely raise average patient acuity levels, which could in
turn require higher nurse and physician staffing levels. One
countervailing trend is that tomorrow’s elderly might have
lower disability rates than today’s elderly, controlling for age,
because of improvements in economic resources, education
levels, lifestyle, public health, and medical technology.
Minorities are underrepresented in the physician and nurse
workforce relative to their proportion of the total population,
yet minority health workers are more likely than non-Hispanic
whites to provide services in underserved areas.
Conclusions: The aging of the health workforce raises
concerns that many health workers will retire about the same
time that demand for their services is increasing.
Implications for Policy, Delivery or Practice: : The rise in
health care expenditures associated with the rapid increase in
the elderly population will likely place additional pressures on
the Medicaid and Medicare programs, as well as private
insurers, to control health care costs. Efforts to control costs
will likely have a negative impact on both the supply of and
demand for health workers. Many government and private
organizations have the stated policy to improve minority
representation in the health workforce, but minorities continue
to be underrepresented in many medical professions.
Primary Funding Source: HRSA
• Organizational Structure and Adverse Events in Home
Health Care
John Bridges, Ph.D., Penny Feldman, Ph.D., Timothy Peng,
Ph.D., Margaret McDonald, M.S.W., Christopher Murtaugh,
Ph.D., Robert Rosati, Ph.D.
Presented by: John Bridges, Ph.D., Assistant Professor,
School of Medicine, Department of Epidemiology and Biology,
Case Western Reserve University, 10900 Euclid Avenue,
Cleveland, OH 44106-4945; Tel: 216.368.6962;
Fax: 216.368.3970; E-mail: healtheconomics@hotmail.com
Research Objective: This paper examines the effect of
organizational structure on the rate of (risk-adjusted) adverse
events in home health care using an econometric approach to
risk adjustment and a two-stage regression approach. The
study aims to provide home health agencies with evidence on
which to base management decisions related to how their
organizational structure may affect patient outcomes.
Study Design: Data were collected over a six month time
frame, resulting in 56,346 episodes of care. The dependent
variable was the occurrence of any of the 13 adverse events
defined by Center for Medicare and Medicaid Services in its
Outcome Based Quality Monitoring Reports. First stage
regression models included risk-adjustment for episode-level
case mix, and used a fixed effects approach to calculate quality
scores across 87 teams. Second stage multivariate
regressions modeled the effect on team-attributable adverse
events of organizational factors including: volume of episodes,
team size, and concentration of effort across staff within each
team using a Herfindahl-Hirschman Index for visits.
Population Studied: Data come from a large urban home
health care agency. Service is delivered across 87 different
teams with natural variation in structure. The patient
population served averages 71 years of age, with 66% female.
The population is highly diverse; 40% white, 26% black, 24%
Hispanic, 4% Asian and 6% other ethnicity. Clinical
diagnoses cover a wide spectrum of conditions, with the most
common conditions being diabetes (13%), hypertension (8%)
and congestive heart failure (5%).
Principal Findings: Regressions examining a variety of
measures of organizational structure are presented.
Organizational factors consistently unrelated to risk-adjusted
patient adverse events include: number of different skilled
nursing staff providing visits for an episode, home health aide
utilization, and direct admission managed by an agency
representative within a hospital. In all regressions, volume
has a protective effect for risk adjusted adverse events, but
fails to reach any major level of significance (p < 0.15). Team
size and concentration are highly correlated (r = -0.78), and in
regressions appear significant (p < 0.05 for both variables)
when the other is not included, but not when they are both
entered. However, using a restricted least squares approach,
team size and concentration have a joint significance of p <
0.05 (F = 3.30, 2/83 d.f.), indicating that both should remain in
the model. Thus we can conclude that team size increases
the likelihood of an adverse event and that higher levels of
team concentration decrease the likelihood of an adverse
event.
Conclusions: The finding that increased team size is
positively related to the incidence of risk-adjusted adverse
events, after controlling for volume and distribution of work
across the team, may be due to the greater complexity
involved in managing a larger team. Reduction in adverse
events as concentration of work volume across staff becomes
increasingly asymmetrical may be due to several factors. First,
higher concentration of work among fewer staff reduces the
number of clinicians that team managers must juggle for a
given set of patients. Second, there may be a protective effect
of volume on the individual clinician level.
Implications for Policy, Delivery or Practice: Risk-adjusted
adverse events are significantly influenced by a small number
of organizational variables. Home care agencies should
consider the potential of increased adverse events among
patients if the number of staff under a given manager
increases.
Primary Funding Source: AHRQ
• Monitoring the Nursing Workforce in Pennsylvania:
Survey Results and Policy Implications
Helen Burns, R.N. Ph.D., Margaret Potter, JD, M.S., Jacqueline
Dunbar-Jacob, R.N., Ph.D., Joseph May, M.S.
Presented by: Helen Burns, R.N. Ph.D., Associate Dean,
School of Nursing, University of Pittsburgh, 350 Victoria
Building, Pittsburgh, PA 15261; Tel: 412.624.6616; Fax:
412.624.2401; E-mail: burnsh@pitt.edu
Research Objective: Establish a system for monitoring the
supply and distribution of the nursing workforce at the state
level.
Study Design: Registered nurses received a survey and were
asked (but not required) to submit it as part of their licenserenewal process in early 2002. The survey asked about
educational background, career choices, present work status,
job satisfaction, and geographical distribution. Focus groups
were held with key stakeholders including nurses, other health
care professionals, professional organizations, private health
sector managers, public sector policy makers, and
academicians. Data analysis was conducted by staff of the
state health department.
Population Studied: To initiate this workforce monitoring
program, a plan was developed to survey all registered nurses
in the Commonwealth of Pennsylvania via a survey at the time
of their biannual license-renewal. The first cohort included
55,000 RNs and the second cohort consisted of 40,000 RNs,
representing 50% of licensed RNs in the state. Subsequently,
each remaining 25%-cohort of registered nurses received the
survey as its license-renewals came due at six-month intervals.
Analyses for this study include data from two cohorts – those
renewing their licenses in April 2002 (n = 40,667) and
October 2002 (n = 42,391), resulting in a total of 83,058
participants. Excluded from this analysis are data from the
remaining two cohorts with license renewals due in 2003.
Principal Findings: The response rate for the two cohorts,
April 2002 and October 2002, are 94% and 82% respectively.
Among those responding from both cohorts, 77% indicated
that they both lived and were employed in health care within
the state; and fewer than 40% both lived and worked full-time
here. The average age of participants was 44.8 years, of which
approximately one-third were between the ages of 50 and 64
compared to one-fourth nationally in this age group. AfricanAmericans were under-represented at 2.9% of respondents,
compared to 8.9% of this ethnicity (age 20 and older) in the
state’s population as a whole. Reported job satisfaction was
84% (“very” or “somewhat” satisfied) and was positively
correlated with educational level. Responding to whether they
planned to leave nursing in the future, 29% of those under
age 35 said they would do so within ten years. Focus group
interviews indicated that perceptions of a nursing “shortage”
varied with work setting and geographical location within the
state. The Health Department reviewed findings with a
stakeholders’ Advisory Committee and subsequently
published a report in both hard copy and on its web site.
Conclusions: The voluntary survey coupled with statewide
stakeholder focus groups yielded reliable information for
public policy-makers, professional associations, and educators
interested in the supply and distribution of registered nurses
in the state. The survey procedure became routinely
integrated with license-renewals for registered nurses.
Implications for Policy, Delivery or Practice: Routine,
licensure-related monitoring the nursing workforce avoids
some limitations inherent in nursing workforce studies that
are episodic or employer-sponsored. This approach
systematically includes both employed and unemployed
respondents, includes all work sites, and minimizes the
potential for response bias toward those dissatisfied with job
or career. However, one limitation of this approach is that
response rates may decline over time if license-renewal
applicants become less willing or interested in survey
participation.
Primary Funding Source: The survey development, data
gathering, data analysis, stakeholder meetings and focus
groups, and report production were all funded entirely by the
Pennsylvania Department of Health. Additional data were
provided by the Pennsylvania Department of State.
• Predicting Radiation Therapists' Workplace Satisfaction
Richard Harris, Ph.D., Jason Chapman, B.S., Salvatore
Martino, Ed.D.
Presented by: Jason Chapman, B.S., Research Specialist,
Research, American Society of Radiologic Technologists,
15000 Central Avenue, S.E., Albuquerque, NM 87123-3917; Tel:
505.816.1888; Fax: 505.298.5063; E-mail: jchapman@asrt.org
Research Objective: Determine predictors of satisfaction with
various aspects of the workplace environment among
radiation therapists (RTTs) and RTT managers, to aid in
retention of RTTs in the workforce.
Study Design: Separate questionnaires were sent to 1,970
RTT managers (cf. “Population Studied”) and to 7,566 staff
RTTs. 594 (30%) of the managers and 2,111 (28%) of the staff
therapists responded.
Each questionnaire asked about the respondent’s
professional profile (first certificate obtained, years in radiation
therapy, hours worked per week, etc.), workplace profile (type
and size of facility, satisfaction with ten broad aspects of the
facility, rating of 27 specific facility characteristics, etc.), and
demographic characteristics, as well as opinions on
professional issues.
Population Studied: American Registry of Radiologic
Technologists (ARRT) registered, radiation-therapy-certified
technologists choosing "staff or senior staff technologist" as
the most apt job description (aka “staff RTTs”) + ARRTregistered technologists designating "radiation therapy" as
their primary discipline/sphere of employment and listing a
supervisory/managerial/administrative job title (aka “RTT
managers”).
Principal Findings: For RTT managers, 1.Two-thirds of the
variance in ratings of satisfaction with ten general aspects of
the workplace was accounted for by two principal components
closely approximated by the following two linear
combinations:
OvSatisf = the mean of all 10 ratings and
PeerVAdm = the mean of ratings of respondent’s radiation
oncologist(s), physicist(s), and coworkers, and of quality of
patient care, minus the mean rating of direct supervisor(s),
radiation therapy administration, and “overall administration
of the larger facility within which your department is located.”
2. The multiple correlation between OvSatisf and 27 specific
characteristics of the respondent’s primary workplace was .514
(as compared to the .458 correlation with the simple average
of all 27 specific-characteristic ratings). The only predictor
whose regression weight was individually significant at the .01
level was “Communications within the department.”
3. The multiple correlation between PeerVAdm and 27
workplace characteristics was .488. The only individually
significant regression weight was the negative weight for
“adequacy of internal, on-site training.”
For staff therapists,
1. The first principal component of the ten general
satisfaction ratings had the only eigenvalue greater than 1.0,
and accounted for 54% of the individual-difference variance. It
was essentially the simple average of the ten ratings.
2. The multiple correlation between OvSatisf and facility
characteristics was .596 (vs. the correlation of .549 with the
simple average of the characteristics). The facility’s
reputation, the extent to which therapists’ input is valued, a
department layout that facilitates the RTT’s job, the respect
RTTs receive from radiation oncologists, communication
within the department, and coworkers who act professionally
each contributed positively and significantly to overall
satisfaction.
Pending analyses:
Examination of the relationship between RTT managers’
and staff therapists’ workplace satisfaction and the
demographic and professional characteristics of the
respondents.
Conclusions: Radiation therapists’ satisfaction with their
workplaces is moderately related to 27 core attributes of their
facilities, to demographic variables, and to their professional
profiles.
Implications for Policy, Delivery or Practice: The
relationships delineated in this paper can be used by radiation
therapists to guide their choices of settings and by RTT
administrators to aid in recruitment and retention of radiation
therapists.
Primary Funding Source: ASRT and ASRT Education &
Research Foundation
• The Educational Preparation of the Nursing Workforce:
Implications for Policy
Robyn Cheung, R.N., Ph.D., Jennifer Seamon, R.N., MHSA
Presented by: Robyn Cheung, R.N., Ph.D., Research Fellow,
Center for Health Outcomes and Policy Research, University
of Pennsylvania School of Nursing, 420 Guardian Drive, NEB
336R, Philadelphia, PA 19104; Tel: 215.746.0205; Fax:
215.573.2062; E-mail: cheungr@nursing.upenn.edu
Research Objective: The educational preparation of
registered nurses has been shown to be associated with
patient outcomes in hospitals. Hospitals that employ larger
proportions of nurses prepared at the baccalaureate and
higher level have lower rates of mortality and failure to rescue.
In 2000, 61% of registered nurses were graduates of associate
degree programs, while only 38% were graduates of
baccalaureate programs. Associate degree programs enroll
and graduate more nurses than baccalaureate programs,
further widening the gap in the educational composition of
the nursing workforce. Given the empirical evidence that
educational preparation of nurses makes a difference in
patient outcomes, the purpose of this study was to examine
and describe past and current trends in the educational
preparation and composition of registered nurses employed in
hospitals.
Study Design: Secondary analysis of the National Sample
Survey of Registered Nurses (NSSRN), 1980-2000.
Population Studied: The NSSRN is a national random
sample of registered nurses that is conducted every four years,
beginning in 1980. It is the nation’s most extensive and
comprehensive source of data on all registered nurses with
current licenses to practice in the United States, whether or
not they are employed in nursing. The NSSRN provides
information on the number of registered nurses, educational
background and specialty areas, employment, and personal
characteristics.
Principal Findings: Forty three percent of hospital nurses had
a baccalaureate or higher degree as their highest level of
education. About 22% of these nurses received their initial
nursing education in a diploma or associate degree program.
The proportion of hospital nurses pursuing further education
has declined from 14% in 1980 to 9% in 2000 and the percent
of nurses enrolled in an academic program and receiving
employer tuition assistance has been steadily declining since
1996.
Conclusions: While 59% of the nation’s registered nurses
were employed in hospital settings in 2000, less than half
were educationally prepared at the baccalaureate level or
higher. Fewer registered nurses reported they were pursuing
post diploma or post associate degree education. Of those
enrolled in an academic nursing program, the percent
reporting they were receiving tuition assistance has steadily
declined since 1992. Whether there is a cause and effect
relationship between the declining numbers of nurses
pursuing advanced education and the decline in those
reporting receipt of tuition assistance is unknown and
warrants further examination.
Implications for Policy, Delivery or Practice: The finding
that only 43% of hospital nurses are prepared at the
baccalaureate level and higher falls far short of the 70%
preferred by surveyed nurse executives. Registered nurses
pursuing post-diploma or post-associate degree education are
an important resource for entrants into baccalaureate nursing
programs. That fewer hospital nurses are furthering their
education is an alarming trend given the evidence that
hospitals employing higher proportions of baccalaureateprepared nurses have better patient outcomes. The Nurse
Education Act, a major source of funding for all levels of
nurses’ education, may need to be targeted toward nurses
seeking post-diploma or post-associate degree education and
students entering baccalaureate programs. Employer support,
financial and otherwise, will provide incentives to pursue
continued academic education for currently employed nurses
and diminish barriers that nurses face in their quest for
education. National workforce planning should focus on
aligning the educational composition of the nursing workforce
with the health needs of the population.
Primary Funding Source: National Institute of Nursing
Research
• International Nurses: Transition to U.S. Practice
Catherine Davis, Ph.D., R.N., Barbara Nichols, DHL, M.S.,
R.N., FAAN
Presented by: Catherine Davis, Ph.D., R.N., Director of
Research and Evaluation, Research and Evaluation,
Commission on Graduates of Foreign Nursing Schools, 3600
Market Street, Suite 400, Philadelphia, PA 19104; Tel:
215.387.6950; Fax: 215.387.7497; E-mail: crdavis@cgfns.org
Research Objective: To identify the transitional needs of
international nurses entering U.S. practice.
Study Design: Surveys were developed by CGFNS and
distributed to international nurses and to U.S. nurse
executives in the United States. Data were analyzed using
quantitative and qualitative methods.
Population Studied: 1. Internationally educated nurses
entering U.S.
practice between 1997 and 2003.
2. Nurse executive members of the American
Organization of Nurse Executives (AONE) who
employed international nurses in 2002-2003.
Principal Findings: International nurses worked
predominantly in adult health and critical settings within
hospitals. Both the international nurses and the nurse
executives identified language skills (including use of nursing
idioms, slang and abbreviations), in-depth orientation,
knowledge of U.S. medications and technology, and clinical
nursing, including psychosocial, skills as critical to successful
adaptation to U.S. practice. However, while employers rated
English skills as the most critical, international nurses cited
knowledge of the U.S. healthcare system as the most essential
element in the transition process.
Measures that facilitated the transition were increased
orientation tailored to the needs of the international nurse,
mentor/preceptorship, English language assistance and
classes in cultural awareness.
Most nurses executives indicated that international nurses
were safe practitioners within six months of beginning U.S.
practice.
Conclusions: Overall, the experiences of employing
international nurses are viewed as positive by both the nurses
and the nurse executives. International nurses become a
valued and integral health team member in the United States.
However, to achieve integration, there is a committment
required by employers hiring international nurses directly from
their countries of origin - the committment to provide for
cultural and social adjustment, language fluency and clinical
assessment and support.
Implications for Policy, Delivery or Practice: Recruiting and
employing international nurses will continue to increase in the
United States to meet the current need for nurses and to
address anticipated nursing shortages. The responsibility of
employing international nurses, however, does not end with
recruitment and the bringing of nurses to the United States.
Policies need to be in place to address their adaptation to U.S.
nursing practice, their ability to care for and interact with
patients, and their continued clinical and language
competence.
• Nurses’ Use of Discretion in Managing Situations of
Intermediate Patient Risk
Linda Hughes, Ph.D., R.N., Barbara Mark, Ph.D., R.N., FAAN
Presented by: Linda Hughes, Ph.D., R.N., Research Associate
Professor, School of Nursing, University of North Carolina at
Chapel Hill, Carrington Hall, CB # 7460, Chapel Hill, NC
27599; Tel: 919.960.5167; Fax: 919.843.3168; E-mail:
lchughes@email.unc.edu
Research Objective: Hospitals operate in an environment
that is technologically complex, ambiguous with respect to the
actions that are possible, and highly uncertain in terms of
outcomes. According to organizational theorists, front-line
workers in such environments must exercise considerable
discretion in the performance of their job, where discretion is
defined as the latitude to act or the range of behavioral
options through which employees can complete their work.
The purpose of this study was to describe behavioral options
available to experienced critical care nurses when managing
situations of intermediate patient risk, defined as any situation
in which an intervention is warranted in response to changes
in the status of a patient.
Study Design: This exploratory study was conducted using
the descriptive mode of qualitative inquiry. Individual
interviews were conducted with experienced critical care
nurses who were asked to describe intermediate patient risk
situations in which they exercised discretion.
Population Studied: The sample included 13 critical care
nurses with at least one year of experience as a registered
nurse, employed at least 20 hours each week in direct patient
care, and assigned to their current unit a minimum of six
months.
Principal Findings: Two actions are endorsed by the
organizatio
Principal Findings: Two actions are endorsed by the
organization when nurses encounter a situation in which
intervention is warranted: contact the physician for an order
or, when the physician is unavailable, activate the chain of
command. Without exception, participants identified
situations in which limiting themselves to these actions could
result in unnecessary delays in treatment or be detrimental to
patients. In such cases, these nurses exercised discretion by
considering actions including but not limited to those
authorized by the organization. Both direct and indirect
actions were identified as constituting the range of behavioral
options available to nurses when managing situations of
intermediate patient risk. Direct actions were defined as a
proactive response in which a nurse acts on his/her own
initiative to provide initial management of the situation.
Indirect actions focused on notifying someone about the
situation and waiting for that person to provide an initial
response to the situation. The decision to exercise discretion
was based on physician availability, familiarity and immediacy
of the clinical situation, and perceived physician support.
Factors influencing the use of discretion included experience
as a nurse, strong relationships with physicians, and a unit
culture in which discretionary behaviors are supported.
Conclusions: Findings suggest that discretion may function
as a mediating variable in the relationships documented
between nursing experience, nurse staffing, and prevention of
avoidable adverse patient events.
Implications for Policy, Delivery or Practice: Studies of
“high reliability” organizations suggest that no organization
can be effective if it fails to capitalize on the ability of front line
workers who often have the expertise to respond to
unanticipated problems. These findings suggest the need to
reconsider the policies and regulations that restrict nurses
from responding in a timely fashion to adverse patient events.
Primary Funding Source: , National Institute for Nursing
Research
• Changes in Nurse Satisfaction after Conducting
Educational Interventions to Improve Nurse-Physician
Collaboration
Erin Jakubek, B.S., Jane Grady, Ph.D., Diane Homan, M.D.,
Sanford Stein, M.S., Shawn Tyrrell, R.N., M.S.N.
Presented by: Erin Jakubek, B.S., Administrative Project
Analyst & Student, Health Systems Management, Rush
University, 1700 West Van Buren Street, Suite 126B, Chicago,
IL 60612; Tel: 630.336.6030; E-mail: erin_jakubek@rush.edu
Research Objective: The relationship between a physician
and nurse represents a classic in society. Once identified as a
"game," this relationship has evolved considerably from its
historical background. Today, results from an employee
satisfaction survey conducted at a 150-bed suburban
community medical center indicate the need for higher quality
nurse-physician collaboration. The current nursing shortage
warrants closely examining the influence physician-nurse
collaboration has on nurse satisfaction. The purpose of this
research project is to determine the effect of various
educational interventions designed to improve nursephysician collaboration on nurse satisfaction. This study
examines changes in nurse satisfaction survey scores before
and after educational interventions. In addition, this study
assesses whether nurse demographics including shift,
unit/specialty, years in practice, and years at the organization
are important predictors of nurse satisfaction.
Study Design: This study is a quasi-experimental design
aimed at evaluating changes in nurse satisfaction scores at a
community medical center after implementing educational
interventions focused on nurse-physician relations.
Population Studied: The population includes approximately
300 registered nurses employed at a suburban community
medical center. There are three main phases of this study.
First, a pretest survey was conducted in April 2003. Next, a
variety of educational interventions occurred from October to
December 2003. The educational interventions included new
policies, revision of existing policies, staff meetings,
educational posters, self study packets, and lunchtime
learning sessions with the goal of improving this professional
relationship. The final step of the project was a posttest survey
conducted in January 2004.
Principal Findings: Preliminary survey results suggest that
educational interventions significantly effect nurses'
satisfaction regarding the overall quality of nurse-physician
relationships, physicians' respect for nurse input and
collaboration, views on disruptive behavior, impact of
relationships on retention, contribution of collaboration to
better patient outcomes, and the formal support system
established by an organization. Nurse demographics were not
found to be significant predictors of nurse satisfaction based
on pretest survey results.
Conclusions: This multifaceted, educational approach offered
support for the importance of nurse-physician collaboration
toward nurse job satisfaction. Positive physician-nurse
collaboration can impact quality of care, decrease hospital
costs, increase patient and employee satisfaction, and
improve healthcare outcomes.
Implications for Policy, Delivery or Practice: Determining
the effectiveness of educational interventions on nurse
satisfaction is vital for an organization especially during the
nursing shortage and economic hardships. The results of this
project identify the most influential aspects of the nursephysician relationship as perceived by nurses that often
impact recruitment, staff turnover, and retention. Once a
clearer understanding of these perceptions is gained,
management can focus on improving the aspects most
influential to that organization's working environment such as
overall quality of collaboration, professional respect, disruptive
behavior, patient outcomes, and conflict management.
• Measuring Nurse Staffing: The Good, The Bad, and The
Hope
H. Joanna Jiang, Ph.D., Cindy Wong, M.S.
Presented by: H. Joanna Jiang, Ph.D., Social Scientist, Center
for Delivery, Organization, and Markets, Agency for
Healthcare Research and Quality, 540 Gaither Road, Rockville,
MD 20850; Tel: 301.427.1436; Fax: 301.427.1430; E-mail:
jjiang@ahrq.gov
Research Objective: With mounting empirical evidence
showing the significant impact of nurse staffing on patient
outcomes, there is an increased demand for better data
systems to support monitoring and research activities on
nurse staffing. Significant efforts would be needed at the
national and state levels to improve existing or develop new
data systems in order to meet the needs. The purpose of this
study is to obtain a better understanding of the good and the
bad of two widely used data sources of nurse staffing
measures.
Study Design: Literature review and synthesis on nurse
staffing measures; and bivariate analyses to compare
measures derived from two sources – the American Hospital
Association (AHA) Annual Survey and the California Office of
Statewide Health Planning and Development (OSHPD)
Hospital Annual Financial Reports – in terms of relationship
with severity of illness proxies and risk-adjusted patient safety
events as well as discrepancy by hospital characteristics.
Population Studied: General, acute care, non-federal
hospitals in California
Principal Findings: For hospitals in California, OSHPD
reports total and productive hours by three nursing categories
(RN, LPN, Aide). AHA publishes number of FTE by RN and
LPN which can be converted to hours. Results consistent
between data derived from AHA and those from OSHPD
include: 1) significantly positive relationships of RN hours per
adjusted patient day and percent of RNs among licensed
nurses, respectively, with severity of illness proxies (i.e.,
percent of ICU beds, percent of Medicare days, being major
teaching hospital); and 2) significantly negative relationships
of these two nurse staffing measures with select patient safety
events (i.e., death in low mortality DRGs, decubitus ulcer).
The relationships are stronger for measures based on the
OSHPD data. RN FTEs per bed calculated from the AHA data
show inconsistent relationships with severity of illness proxies
and patient safety events. Total hours for licensed nurses per
adjusted patient day are comparable between the two sources
except for teaching, nonprofit hospitals for which the OSHPD
data show an average of 11% higher staffing level than the
AHA survey. Little discrepancy was found in the percent of
RNs among licensed nurses. The OSHPD data reveal
significantly higher percents of nurse aides for small, nonteaching, and public hospitals.
Conclusions: The OSHPD nurse staffing data demonstrate
more consistent and stronger relationships with severity of
illness proxies and patient safety events compared with the
AHA data. The AHA nurse FTE staffing is the least desirable
measure unless converted to hours and adjusted for inpatient
and outpatient care using financial data. Percent of RNs
among licensed nurses matches most closely between the two
data sources. Without data on nurse aides, the AHA survey
underreports the total nurse staffing which has a bigger
impact on small, non-teaching, public hospitals as these
hospitals have a higher percent of nurse aides.
Implications for Policy, Delivery or Practice: Understanding
the strengths and limitations of various nurse staffing
measures and data sources can help policy makers and
researchers better utilize existing data while contemplating for
potential improvement or development of new data systems.
Primary Funding Source: AHRQ
• Clinical Autonomy and the Rationalization of Clinical
Practice
Lei Jin, M.A., M.S.
Presented by: Lei Jin, M.A., M.S., Student, Sociology, The
University of Chicago, 5841 S. Maryland Avenue, MC2007,
Chicago, IL 60637; Tel: 773.834.1615; Fax: 773.834.2238; E-mail:
ljin@medicine.bsd.uchicago.edu
Research Objective: During the recent healthcare reform,
clinical practice has been increasingly been rationalized.
Measures have been implemented to standardize the context
and process of clinical decision-making, and physician
performance were quantified and evaluated with the intention
of influencing the decision-making process. Clinical practice
has traditionally been the exclusive domain of the medical
profession. This paper therefore examines the relationship
between rationalization of clinical practice and physician
perception of clinical autonomy and how this relationship vary
by physician cohorts and physicians’ elite status, and the
organizational context in which they work.
Study Design: Two rounds of the Community Tracking Study
Physician Survey, which is a nationally representative and
longitudinal study of physicians, are used. The dependent
variable is physicians’ assessment of their clinical autonomy at
round two of the survey; the independent variables are
changes in the impact of four rationalizing measures on
physicians’ practice of medicine between two rounds. We use
multivariable logistic regression models for binary responses
that comprise a first-order Markov chain. Interaction terms
are used to assess how the relationship between
rationalization of clinical practice and physician perception of
clinical autonomy vary by physician and organization
characteristics.
Population Studied: All doctors of medicine and osteopahty
practicing with the US. Specialists in fields without a primary
focus on patient care, federal employees, and those who
provided <20 hr/wk of patient care are excluded.
Principal Findings: Our study shows that rationalizing
measures that directly guide clinical decision-making are
perceived as more restrictive on clinical autonomy than those
measures that monitor and evaluate physician behavior. The
knowledge elite, defined as medical school faculty, physicians
whose practice is heavily influenced by electronic data entry,
and those working in large practice are more likely to have a
favorable view of the effect of guidelines on clinical autonomy.
Conclusions: Not all rationalizing measures negatively
influence physician assessment of their clinical autonomy.
Improving the use of clinical information technology and
implementing guidelines by physicians’ immediate
organizations may facilitate the introduction of guidelines.
Efforts are needed to minimize the gap between knowledge
elites and rank-and-file physicians in their understanding of
the implication of rationalization of clinical practice on clinical
autonomy.
• The Occupation of the Community Health Worker
(CHW) in the United States: A New Health Professional
Workforce?
Bita Kash, M.B.A., FACHE, Marlynn May, Ph.D., M.Div., Ming
Tai-Seale, Ph.D., M.P.H.
Presented by: Bita Kash, M.B.A., FACHE, Graduate Research
Assistant, Ph.D. Candidate, School of Rural Public Health,
Southwest Rural Health Research Center, Texas A&M
University, 3000 Briarcrest Drive, Suite 416, Bryan, TX 77802;
Tel: 979.458.0654; Fax: 979.458.0656; E-mail:
bakash@srph.tamu.edu
Research Objective: The goal is to analyze the history and
development of certification programs for CHWs in the United
States and to explore workforce implications. Results from a
national survey of CHW programs are analyzed following
economic perspective on market failure (initiation of CHW
programs), and Becker’s human capital theory (impact of
CHW training and certification).
Study Design: We surveyed 50 states in two phases: 1) initial
screening interviews, and 2) in-depth phone interviews with
selected programs. Screening interviews identified 19 states
at various stages of implementing CHW training or
certification programs. Telephone interviews included openended questions about history, structure, goals, curriculum,
evaluation, impact, and future of programs. State legislative
websites helped identify legislation concerning CHWs.
Qualitative data were coded and analyzed by substantive area
using Atlas.ti. Analysis of data based on emerging themes
resulted in a typology of CHW training and certification
programs.
Population Studied: Informants included public health
officials, healthcare associations, CHW networks, community
colleges, and service providers. Using the snowball process,
early respondents identified additional informants.
Principal Findings: All programs reported common reasons
for the initial creation of CHW programs, including lack of
access to healthcare services in culturally, economically, and
geographically isolated communities. Most training programs
for CHWs emerged in the 1990s. There are three prevalent
trends in the training and certification of CHWs: 1) Schooling
at the community college level provides career advancement
opportunities. 2) On-the-job training improves standards of
care, secures CHW income, and improves CHW retention. 3)
Certification at the state level recognizes the work of CHWs,
and enhances earnings and reimburseability.
Conclusions: The CHW initiatives can be described as steps
to correct dissatisfaction with the competitive equilibrium
achieved in the healthcare market. There is evidence of
disproportionate initial distribution of assets and skills in
minority communities due to language barriers, fear of
government authorities, and lack of access to health
insurance. Therefore minority communities are faced with
lack of purchasing power in the healthcare market, which is
one cause of “market failures”. CHW initiatives are attempts
to correct the unsatisfactory distribution of assets and skills,
and link people in need of medical services with providers and
payers. The three trends in training and certification parallel
the three factors associated with investing in human capital as
identified by Becker: schooling, on-the-job training, and health
(including emotional health). Participants report improved
self-esteem as a major outcome of certification. Therefore,
certification can be classified as a promoter of enhanced
earnings due to its ability to improve emotional health.
However, on-the-job training and certification programs
resulting in enhanced retention of CHWs can translate into
reduced vertical job mobility.
Implications for Policy, Delivery or Practice: State
departments of health and federal health agencies can
enhance career advancement of CHWs by subsidizing
education, or provide stable jobs and incomes by supporting
the reimbursement of trained and certified CHWs. Possible
issues with vertical job mobility have to be considered in labor
markets with shortages of health professionals such as nurses
and social workers. Study findings present significant
opportunities in reducing health care workforce shortages.
Primary Funding Source: HRSA
• Analyzing the Career Satisfaction of Minority Primary
Care and Specialist Physicians in California
William King, M.D., J.D., Kevin Grumbach, M.D., Andrew
Bindman, M.D., Terry Nakazono, Ph.D., William Cunningham,
M.D., M.P.H.
Presented by: William King, M.D., J.D., Clinical Instructor,
UCLA Department of Infectious Diseases, UCLA CARE Center,
10833 Le Conte Avenue, BH-140 CHS, Los Angeles, CA 90095;
Tel: 310.794.7569; Fax: 310.206.3311; E-mail:
wdking218@comcast.net
Research Objective: Although physician satisfaction is known
to impact long-term quality of care, few previous studies of
physician career satisfaction have focused on minority
physicians. As minority physicians are more likely to provide
care to minority and indigent patient populations, addressing
minority physician career satisfaction will help to ensure
underserved and diverse patient populations’ access to
primary and specialty health care. Our objectives were: 1) to
examine whether minority physicians are more satisfied in
their career than non minority physicians; and 2) to examine
the impact of provider demographics, patient characteristics,
and measures of provider autonomy on minority physician
career satisfaction.
Study Design: We analyzed a probability sample of
respondents to a 1998 survey of California specialists (n=978)
and primary care physicians (n=713). Minority physicians were
over sampled. The main dependent variable, career
satisfaction, was measured on a 4-point Likert scale from
strongly agree to strongly disagree. Independent variables
were career satisfaction covariates established by literature
review: provider demographics (race, age, gender, income),
provider autonomy (higher autonomy defined as not being
pressured to: see more patients, limit ordering of tests, or
limit discussion of treatment), and patient case mix
characteristics. We used multiple logistic regression to
examine the association of provider demographics and
autonomy, controlling for covariates. All analyses were
weighted to reflect the total population of specialist and
primary care providers within the thirteen largest counties of
California.
Population Studied: A representative sample of AfricanAmerican, Asian/Pacific Islander, Hispanic and Caucasian
primary care and specialist physicians in California.
Principal Findings: Approximately 55% of providers were
Caucasian, 22% were Asian/Pacific Islanders, 12% were
Hispanic and 8% were African-American. African-American
providers had higher percentages of Medicaid (22.2%) and
African-American patients than others (32.26%, p<.0001 for
both). Career satisfaction was greater than 70% for all groups,
but, in bivariate analysis compared to Caucasians, AfricanAmerican physicians (OR = 2.1, p < .001) were the most
satisfied, followed by Asian, (OR = 1.4, p < .001), and Hispanic
(OR = 1.3, NS) providers. In multivariate analysis including
provider and patient case-mix variables, the odds of AfricanAmerican provider’s satisfaction were reduced (OR = 1.5), but
were increased for Asian/Pacific Islander (OR = 2.5) and
Hispanic providers (OR = 1.8, all p<0.05). Providers who had
greater autonomy also were significantly more satisfied than
those with lower autonomy (no pressure to limit tests OR
=2.1, and discussion of treatment options with patients
OR=1.9, both p<0.0001).
Conclusions: African-American, Asian/Pacific Islander and
Hispanic physicians were more satisfied with their careers as
compared to Caucasian physicians. African-American provider
satisfaction was partly explained by provider demographics,
provider autonomy, practice settings, and the racial/ethnic
insurance mix of their patients.
Implications for Policy, Delivery or Practice: The high
satisfaction of minority physicians is an important component
of safety-net care in California, a state where historically
minority ethnic groups now out-number Caucasians. To
assure continued satisfaction of minority providers and
thereby maintain the safety-net for historically underserved
populations, policy should help to maintain minority
physician’s autonomy, patient and practice characteristics.
• The Pharmacist Shortage: Is Supply Catching up with
Demand for Community Pharmacists?
James Cultice, B.S., Katherine Knapp, Ph.D., Sharon Gershon,
Pharm.D.
Presented by: Katherine Knapp, Ph.D., Professor and Director
of the Center for Pharmacy Practice Research and
Development, College of Pharmacy, Western University of
Health Sciences, 309 E. Second Street, Pomona, CA 91766;
Tel: 909.469.5588; Fax: 909.469.5539; E-mail:
kkknapp@msn.com
Research Objective: There continues to be concern over the
shortage of community pharmacists in the U.S. and the
coming Medicare prescription drug benefit plan could worsen
the shortage. The demand for community pharmacists
continues to grow as prescription volume expands and
pharmacists are increasingly called upon to provide
nondispensing patient services. Although growth in retail
prescriptions abruptly dropped in the past year, the longer
term demand trend is upward and while the pharmacist
shortage appears to be abating, evidence still points to an
inadequate supply nationwide through 2010. Utilization
spurred by prescription drug coverage under Medicare will
likely widen the shortage. We estimate future demand for
community pharmacists based on prescription trends and the
probable impact of the Medicare drug benefit beginning in
2006, and estimate the extent of the shortage through
comparisons to projected full-time equivalent supply.
Study Design: We projected demand for community
pharmacists between 2003 and 2010 based on alternative
trends in prescription volume including the effects of
population growth and aging, and the expanded Medicare
drug benefit. We assumed a productivity level of 22,000
prescriptions per community pharmacist as observed in 1999
at the onset of the shortage. No change in the use of
pharmacist technicians, automation, or hours worked was
assumed. We used the Bureau of Health Professions'
Pharmacist Supply Model for comparable supply projections.
Principal data sources for the analysis are the American
Association of Colleges of Pharmacy, the Pharmacy Manpower
Project, the National Association of Chain Drug Stores, and
U.S. Census Bureau.
Population Studied: National community (retail) pharmacists
Principal Findings: New pharmacy schools and a slowdown
in prescription volume have helped relieve the shortage but
the overall demand trend is up and expected to continue
outstripping supply. The Medicare drug benefit could
aggravate the shortage but the impact on requirements may
be small based on new prescriptions alone. Projected
prescription trends indicate a widening shortage, presently at
11,000 community pharmacists, and exceeding 30,000 by
2010. Implementation of the Medicare drug benefit accounts
for about 1,500 of these pharmacists.
Conclusions: New schools and slower growth in prescription
volume has substantially reduced the size of the shortage as
estimated three years ago. But unfilled positions in
pharmacies and efforts to train and recruit new pharmacists
point to a stressed system. As prescription volume rebounds
with the expanding elderly population and improved insurance
coverage through Medicare, the shortage is expected to grow.
An increasing percentage of women pharmacists who tend to
work fewer hours than male counterparts may further widen
the shortage.
Implications for Policy, Delivery or Practice: The shortage is
foreseen to continue as demand for prescriptions and related
services outpaces growth in pharmacist numbers.
Introduction of a Medicare drug benefit could further
aggravate the shortage if pharmacists spend more time in
counseling and administrative activities. The new pharmacy
schools that have opened and prospective schools will expand
the supply and help relieve the shortage, as may greater use of
pharmacy technicians and automation.
Primary Funding Source: Authors' respective institutions
• Human Factors Engineering Assessment of Emergency
Departments
Scott Levin, B.S., Dorsey Rickard, Medical Student, Renee
Makowski, Medical Student, Dominik Aronsky, M.D., Ph.D.,
Kong Chen, Ph.D., Dan France, Ph.D., M.P.H
Presented by: Scott Levin, B.S., Biomedical Engineering
Graduate Student, Biomedical Engineering, Vanderbilt
University, 5824 Stevenson Center, Vanderbilt University,
Nashville, TN 37235; Tel: 301.404.7742; E-mail:
Scott.R.Levin@Vanderbilt.edu
Research Objective: To study and quantify the effects of
system and human factors on objective workload, subjective
workload and physiological stress in nurses, residents and
attending physicians working in an emergency department
(ED) at a Level I trauma center. In addition, a goal of the
study is to identify and assess inefficiencies in facility’s
physical layout, workflow, and communication processes that
contribute to increases in perceived provider workload and
physiological stress.
Study Design: The study design is a time-motion, task
analysis. A trained observer follows a single ED provider for
180-minute periods and continuously records the type,
frequency, and duration of all tasks and interruptions using a
handheld computer. Simultaneously, providers are equipped
with body worn devices to measure galvanic skin impedance,
upper body motion, center of mass motion, distance traveled,
and time in motion. The NASA – Task Load Index workload
assessment technique will be administered to all study
participants to retrospectively assess subjective workload
during the observational period. System level data including
ED occupancy, diversion status, patient acuity levels, patient
waiting times, patients lengths of stay and ED staffing are
obtained from the ED's electronic whiteboard. These
information sources are in the process of being independently
and conjointly analyzed. The study started September 8, 2003
and will end in February of 2004.
Population Studied: The study is being performed at a Level I
trauma center, in a large urban tertiary care hospital in
Tennessee. The ED receives approximately 70,000 visits per
year with a 20% admission rate. The population observed
consists of a convenience sample of 10 faculty physicians, 5
third-year residents, 5 second-year residents and 10 nurses all
working in the ED.
Principal Findings: Descriptive statistics of the independent
(i.e., work factors) and dependent (i.e., workload and stress)
variables will be calculated. The mean value and 95 percent
confidence interval of each variable will be tabulated. Chisquare analyses and Mann-Whitney U. tests will be used to
compare differences between faculty physicians, second-year
residents, third-year residents and nurses. A 0.05 level of
significance will be used for all statistical analyses.
Comparisons will be drawn between provider perceived
workload and objective workload. Time series analyses will be
performed on provider workload and physiological stress. The
time series analyses will be conducted to determine
relationships between system/human factors, inefficiencies
and increased workload and stress.
Conclusions: The study demonstrates the applicability of
human factors engineering to identify potential shortcomings
in system and provider level care in medicine. Human factors
engineering techniques may be used to advance our
understanding of factors that contribute to adverse patient
and provider outcomes.
Implications for Policy, Delivery or Practice: By identifying
work environment factors that lead to inefficiencies and create
high provider workload, educated decisions can be made to
improve medical systems and processes, which will lead to a
higher quality of care and improved patient and provider
safety.
• Developing Effective Physician Leaders: Transforming
Organizations
Ann McAlearney, Sc.D., David Fisher, M.D., Karen Heiser,
Ph.D., Darryl Robbins, D.O., Kelly Kelleher, M.D., M.P.H.
Presented by: Ann McAlearney, Sc.D., Assistant Professor,
Division of Health Services Management and Policy and
Department of Pediatrics, The Ohio State University, 1583
Perry Street, Atwell 246, Columbus, OH 43210-1234; Tel:
614.438.6869; Fax: 614.438.6859; E-mail:
mcalearney.1@osu.edu
Research Objective: Attempting to cross the quality chasm in
healthcare organizations requires transformational change. At
Columbus Children’s Hospital, Inc.--CCHI, our strategic plan
calls for the implementation of computerized order entry and
decision support, family-centered care, and a total focus on
quality. To attain these lofty goals and gain physician
partnership, we have addressed the need for transformational
change by improving leadership skills in our medical leaders,
which we feel is a requirement to achieve transformational
change. We did this by creating a medical leadership
development program--MLP. Our research objective was to
evaluate the MLP using quantitative and qualitative feedback
from both participants and program designers.
Study Design: Participants were surveyed before, during, and
after completion of a leadership development program
designed to promote transformational culture change.
Program designers were interviewed to obtain their
perspectives about issues in the design, implementation, and
acceptance of the MLP.
Population Studied: The study took place at CCHI, an
academic children’s hospital, located in Columbus, Ohio.
Physician participant respondents included both pediatric
generalists and specialists, in academic and community-based
practices. Program designers included physicians and
educators involved in developing the MLP.
Principal Findings: Our MLP was very well-received by
community-based and academic physicians who participated.
Nearly 90 percent of physicians remained active participants
in the two-year program. Program satisfaction was high, with
sessions evaluated on a 5-point scale ranked an average of 4.7
for satisfaction of needs, quality of information, and practice
impact. One year after program completion, participants
either agreed or strongly agreed that they were more effective
in their current leadership roles--mean 4.2, in working in
teams--mean 4.1, and in their ability to lead teams--mean 4.4.
Respondents also reported that they had had opportunities to
assume new or expanded leadership roles after participation-mean 4.0. Qualitative feedback showed that participants
perceived that the MLP had changed their leadership
behaviors, especially in decision-making, conflict resolution,
business planning, and managing people. The MLP also had
a strong effect on participants’ perceptions of CCHI, which
fulfilled the goals of program designers. Respondents agreed
that they were more aware of the CCHI resources available to
facilitate their leadership roles--mean 4.2, more motivated to
get involved in CCHI, the community, and professional
organizations--mean 3.9, and had greater confidence in the
strategic direction of CCHI--mean 4.3.
Conclusions: A targeted, locally developed medical leadership
program can be very effective at improving physicians’
leadership skills and knowledge. In addition, this type of
program can increase physician understanding of the strategic
goals and direction of the sponsoring organization. At CCHI,
the success of our transformational organizational change
effort has been demonstrated as both academic and
community physician program graduates become increasingly
involved in organizational leadership.
Implications for Policy, Delivery or Practice: The
transformational change required for physicians to develop
and appreciate business and leadership skills can be
supported and encouraged in a leadership development
program that includes the components of careful curriculum
design, program monitoring, and opportunities to apply new
skills in practice.
• Nursing Labor Markets of the U.S. States
Chang Park, Ph.D.
Presented by: Chang Park, Ph.D., Research Specialist, College
of Nursing, University of Illinois at Chicago, 845 S. Damen
Avenue, Chicago, IL 60612; Tel: 312.996.7058; Fax:
312.996.8945; E-mail: parkcg@uic.edu
Research Objective: This study investigated market
efficiencies of nursing labor markets in terms of temporal
convergence and spatial interaction.
First: examine the existence of dynamic structure changes
(spatial and temporal changes) in nursing labor markets.
Second: estimate spatio-temporal convergence models to
assess the existence of temporal convergence and spatial
interactions.
Third: evaluate existing long-term nursing employment
projections.
Study Design: Descriptive statistics, statistical convergence
tests, and exploratory spatial data analysis methods were used
to evaluate the characteristics of the regional nursing labor
markets. Spatial econometric methods were applied to assess
the existence of convergence with spatial interactions. Flexible
generalized least squares for cross sectional time series model
was also applied. Decomposition methods were applied to
estimate what to extent local factors contribute to the local
employment changes.
Population Studied: National Sample Survey of Registered
Nurse 1980, 1984, 1988, 1992, 1996 and 2000.
Principal Findings: descriptive convergence tests indicated
the existence of convergence in the regional nursing
employment markets during 1980-2000. The results of spatial
econometric model also indicated the existence of
convergence and strong spatial spillover effects in the regional
nursing labor markets. The results of decomposition method
indicated the substantial level of local factor in local
employment changes.
Conclusions: The evidences indicated the existence of spatiotemporal convergences in nursing labor markets during 19802000. Based on these findings more dynamic convergent
processes in nursing labor markets are expected to come for
the subsequent years. This implies that the higher level of
nursing labor market flexibility and market efficiencies are
expected.
Implications for Policy, Delivery or Practice: Long-term
projections without consideration of evolving dynamic nursing
labor market structure may not provide precise indicators for
the long term nursing policy making.
• Private Practice Dentists and Underserved Populations in
California
Nadereh Pourat, Ph.D., Roberta Wyn, Ph.D., Dylan Roby, M.
Phil., Marvin Marcus, DDS, M.P.H.
Presented by: Nadereh Pourat, Ph.D., Senior Research
Scientist, UCLA Center for Health Policy Research, 10911
Weyburn Avenue, # 300, Los Angeles, CA 90024; Tel:
310.794.2201; Fax: 310.794.2686; E-mail: pourat@ucla.edu
Research Objective: To assess the concordance of private
practice dentist characteristics with underserved population
characteristics in California
Study Design: Cross-sections of dentists in private practices
in California were surveyed on their demographics and their
practice characteristics. Survey data were merged with Census
level information on the characteristics of the population at
the census tract level. Survey topics included demographics,
practice setting, specialty of dentists, practice location,
employment status, patient care areas, patient characteristics,
and dental assistant and hygienist questions including size,
salary, benefits, work status and dentists’ perceptions of
availability of dental personnel. Concordance of dentists in
private practice with underserved groups including members
of racial/ethnic subgroups, limited English Proficient, and lowincome individuals were evaluated in bivariate analysis.
Population Studied: A cross-section of dentists in private
practice in all 58 California counties. About 4,300 dentists
participated in the mail survey with telephone follow up, with a
response rate of approximately 50%.
Principal Findings: Preliminary analysis shows that about two
in five of dentists were non-whites, and about three-fourths of
dentists or their staff members spoke languages other than
English. The majority (about 80%) of dentists were general
practitioners, owned their own practice and worked in only
one practice. Less than one in ten dentists reported that they
were unable to treat all patients requesting appointments
because their workload was too heavy. In areas with a high
concentration of limited English proficient population about a
third of private practice dentists did not speak languages other
than English or had staff members that speak other
languages.
Similarly, about a third of dentists working in areas with a high
concentration of Latinos did not speak Spanish or had staff
that speaks Spanish. About two in five dentists working in
areas with a high concentration of poor individuals did not
provide discounted fees for uninsured or low-income patients.
In areas with a high concentration of Asian Americans, about
one in five dentists reported to be Asian American. In areas
with a high concentration of African Americans, less than 2%
of dentists reported to be African American.
Conclusions: Preliminary results suggested that some degree
of mismatch exists between characteristics of dentists and the
population that resides in an area. This mismatch may result
in patients with limited English proficiency to have difficulty
finding dentists that can communicate with them. Similarly,
poor patients may have difficulty finding affordable dental care
in the private setting. In sum, limited English proficient and
poor populations may have a more limited choice of dentists
in private practice who can serve their dental needs.
Implications for Policy, Delivery or Practice: Access to
dental care is partially determined by supply of dentists.
Examining the link between the characteristics of underserved
populations and the characteristics of the dentists who serve
those communities would help shed light on potential barriers
to accessing dental care.
Primary Funding Source: California Dental Association
Foundation
• Nurse Perceptions of Hospital Care and Work
Environment: Comparison between VA RNs and RNs in a
Five-Country Study
Anne Sales, Ph.D., R.N., Gwendolyn Greiner, M.P.H., M.S.W.,
Yu-Fang Li, Ph.D. R.N., Nancy Sharp, Ph.D.
Presented by: Anne Sales, Ph.D., R.N., Research Scientist,
Health Services Research and Development, VA Puget Sound
Health Care System, 1660 S. Columbian Way, Seattle, WA
98108; Tel: 206.764.2068; Fax: 206.764.2935; E-mail:
ann.sales@med.va.gov
Research Objective: The Veterans Health Administration
(VHA) is one of the largest employers of RNs in the United
States, and has characteristics more like those of publiclyowned health systems in other countries than non-public
systems in the US. In this paper, we report on a study of nurse
perception and self-report of work environment and the quality
of care in VHA hospitals, and compare the VHA RN sample
with published reports of RN perceptions of hospital work
environment and quality of care from five countries, using
similar survey instruments.
Study Design: Study design was observational and crosssectional; we administered a survey to nursing staff at VHA
medical centers with inpatient services between February and
June 2003. The survey, adapted from an instrument developed
by the International Hospital Outcomes Consortium (IHOC),
obtained data on nursing work environment and nurse
perception of inpatient quality of care from RNs, LPNs, and
nurse aides providing clinical nursing care. To compare the
results of the VHA survey with a sample of RNs from five
countries reported by IHOC (US, represented by
Pennsylvania; Canada; England; Scotland; and Germany), we
identified RNs in the 124 VHA hospitals. We examined job
satisfaction, burnout, and several hospital and nurse
characteristics, comparing means and frequencies. Statistical
significance was not estimated, because we were using
published reports from the IHOC study rather than the
source data from that study.
Population Studied: We obtained survey responses from
7,445 RNs at 124 VHA Medical Centers with acute inpatient
services.
Principal Findings: Only 3% of VHA RNs were under 30,
compared to 41% in England, 34% in Germany, 32% in
Scotland, 19% in Pennsylvania, and 10% in Canada. VHA RNs
were similar to RNs in Canada and Germany in reporting
plans to leave their present jobs in the next year (all
approximately 17%), all lower than Pennsylvania (23%),
Scotland (30%), and England (39%). VHA RNs report lower
rates of job dissatisfaction (39%) than RNs in Pennsylvania
(41%), but higher than RNs in Canada (33%), England (36%),
Scotland (38%), and Germany (17%). VHA RNs fall in the
middle of the range in terms of the percent reporting high
burnout. VHA RNs reported the highest perception that the
quality of care provided on their unit was excellent: 40%
compared to 36% for Pennsylvania and Canada, 35% for
Scotland, 29% for England, and 12% for Germany.
Conclusions: RNs in the VHA are older than RNs in any of
the comparison countries or systems. However, they are
among the least likely to report plans to leave their jobs in the
next year. They appear to have positive perceptions of their
work environments, overall, compared with RNs in other
countries or systems, and they rate the quality of care on their
units higher, on average, than RNs in any of the other
countries/systems.
Implications for Policy, Delivery or Practice: Characteristics
of VHA related to the practice and organization of nursing
services may be useful as practices for adoption by other
health care systems, both in the US and in other countries.
Primary Funding Source: VA
• Tackling Nurse Shortages: Lessons from OECD
Countries
Steven Simoens, Ph.D., M.Sc., Peter Scherer
Presented by: Peter Scherer, Counsellor, Directorate of
Employment, Labour and Social Affairs, 2, rue Andre Pascal,
75775 Paris Cedex 16; Tel: 33.1.45.24.91.98; Fax:
33.1.45.24.90.98; E-mail: peter.scherer@oecd.org
Research Objective: The aim of this paper is to examine how
OECD countries are tackling nurse shortages. The paper
analyses international variability in nurse employment and
investigates the projected impact of nurse workforce ageing
on future nurse supply. Additionally, the paper compares and
evaluates policy levers that decision makers are using to
increase flows of nurses into the workforce, reduce flows out
of the workforce, and improve nurse retention.
Study Design: A desk review of material relevant to nurse
shortages in OECD countries was carried out. This was
supplemented by a secondary analysis of data from the
EUROSTAT Labour Force Survey and other data sources with
a view to gathering information on nurse employment
indicators. The OECD Secretariat also set up a network of
national correspondents who completed a quantitative
questionnaire and a policy questionnaire dedicated to nurse
workforce issues.
Population Studied: The nurse workforces in 19 OECD
countries.
Principal Findings: Faced with nurse shortages, OECD
countries have implemented a range of policies to increase
the number of practicing nurses. National advertising,
recruitment and incentive campaigns have had some success
in increasing sharply enrolments in nursing schools in some
countries, but these may be a slow and costly way of
increasing nurse numbers when subsequent attrition and
turnover is high. Additionally, many countries facilitate
international recruitment of nurses to sustain their nurse
workforce for two reasons: these nurses are available now and
are cheaper than increasing nursing school intake. Pay
increases appear to have raised nursing school enrolments
and increased participation of currently qualified nurses in the
workforce. Some success in retaining nurses has been
reported with improving conditions of service by offering
flexible work and retirement arrangements, setting up family
care initiatives, improving workforce management policies,
creating a supportive organizational culture and enhancing
career advancement prospects. Additionally, staffing levels
seem to play a role, with evidence emerging that minimum
nurse-to-patient ratios are associated with reduced nurse
turnover and increased nursing school intake. There is also
some research indicating that nurse shortages may be
reduced by employing fewer nurses, while raising the
proportion of nurses who are registered.
Conclusions: Although evidence about the effectiveness of
different policies designed to ensure an adequate supply of
nurses is emerging, to date little is known about the costs of
such policies on their own or in comparison with each other.
In recent years, a number of OECD countries have been able
to raise supply of practising nurses by enticing more people
into nursing schools, by attracting foreign nurses, and by
improving pay and working conditions of nurses.
Implications for Policy, Delivery or Practice: Traditional
policy responses that focus on one specific aspect of flows in
or out of the workforce or retention are unlikely to resolve
nurse shortages. Instead, this paper calls for the introduction
of comprehensive policies that initiate innovative approaches
to nurse education and training, offer strong incentives to
recruit domestic and foreign nurses, and make pay and
conditions of service attractive enough to retain nurses of all
ages.
• Organization of Nursing Services in the Veterans Health
Administration: Effects of Reorganization on Nursing
Management
Nancy Sharp, Ph.D., Gwendolyn Greiner, M.P.H., MSW, YuFang Li, Ph.D., RN, Anne Sales, Ph.D., R.N.
Presented by: Nancy Sharp, Ph.D., Research Health Sciences
Specialist, Health Services Research and Development, VA
Puget Sound Health Care System, 1660 S Columbian Way
(HSRD 152), Seattle, WA 98108; Tel: 206.277.3584; Fax:
206.764.2935; E-mail: nancy.sharp@med.va.gov
Research Objective: The Veterans Health Administration
(VHA) has extensively reorganized patient care services at the
regional and facility level over the past 5-7 years. We examined
changes in key nurse executive roles and responsibilities that
have accompanied reorganization, and nurse executive
perceptions of the effects of organizational changes on
nursing management and patient care.
Study Design: The research reported here is part of a larger
observational, cross-sectional study of nurse staffing, nursing
care processes, and patient outcomes in the VHA, the “Nurse
Staffing and Patient Outcomes in VA” study. Data were
obtained through structured telephone interviews with key
nurse executives conducted from December 2002 to May
2003. Interviews included questions about current hospital
organization, organizational changes in the past 5-7 years, and
the effects of reorganization on nursing care and patient
outcomes, and included open-ended responses regarding
changes in authority and responsibility in the nurse executive
role.
Population Studied: Participants were nurse executives at 124
VHA facilities in the Nurse Staffing and Patient Outcomes in
VA study. Seven other VHA facilities offering acute inpatient
care were not included due to human subjects review issues
(n=5) or because the nurse executive declined to be
interviewed (n=2).
Principal Findings: Most nurse executives (89%) described
organizational changes that affected the key nurse executive
role. Of the 112 acute care facilities that reorganized patient
care services in the past 5-7 years, 110 implemented service
lines at the facility or regional level. Nurse executives have
been key players in transitioning VHA hospitals to new
organizational structures, and 65 of 69 nurse executives who
reported a change in overall responsibility took on broader
management roles in service line organizations. At the same
time, more than half of these nurse executives (60%) reported
a decrease in their authority with respect to nursing services,
direct supervision of nurses, and their ability to monitor
nursing practice and implement practice changes. In hospitals
with service line organizations, 88% of nurse executives report
that service lines had a mixed or negative effect on integration
of patient care, degree of patient-centered care, delivery of
nursing care, or nurse workloads.
Conclusions: Nurse Executives described significant impacts
on the nurse executive position and nursing services due to
changes in facility organization. Fragmentation of nursing
services has created new challenges for nursing supervision
and implementation of nursing practice changes.
Implications for Policy, Delivery or Practice: Understanding
the impact of organizational change at both management and
staff levels is essential for maintaining quality nursing care,
improving nursing staff recruitment and retention, and
achieving optimal nurse-sensitive patient outcomes.
Primary Funding Source: VA
• Effects of the Workforce Investment Act of 1998 on
Health Workforce Development in the States
Susan Skillman, M.S., Joshua Sadow-Hasenberg, M.A., L. Gary
Hart, Ph.D.
Presented by: Susan Skillman, M.S., Deputy Director,
University of Washington, Center for Health Workforce
Studies, 4311 11th Avenue, N.E., Suite 210, Seattle, WA 98195;
Tel: 206.543.3557; Fax: 206.616.4768; E-mail:
sskillman@fammed.washington.edu
Research Objective: To identify ways in which the Workforce
Investment Act (WIA) of 1998 provides opportunities for
states and local regions to develop their health workforce.
Study Design: State and local workforce boards were
contacted to identify health workforce development activities
supported with WIA resources through the U.S. Department
of Labor. The study examines these state and local efforts and
compares activities among states. The study also describes
characteristics of the WIA program and related U.S.
Department of Labor programs that can be used to support
health workforce development.
Population Studied: State and federal health workforce
development programs funded by WIA.
Principal Findings: WIA resources have been used by many
(but not all) states and local regions to support health
workforce planning, increase educational capacity, promote
health career ladders, improve health sector employee
retention, and provide direct educational support for health
care education. Comparative matrices and specific examples
are provided in this presentation. Compared with its
predecessor programs, WIA was designed to give states and
local regions more decision-making flexibility in how these
federal funds are used. Because of administrative
requirements, these WIA programs tend to target the
professions that can be trained on-the-job and in technical
and community colleges. Exceptions include nursing, where
some WIA-supported programs provide avenues for
baccalaureate-level training of registered nurses. A structural
requirement of WIA is to include business and other key
stakeholders in planning how the resources will be used. The
majority of the WIA-funded health workforce programs involve
collaborations among public and private entities, which has
leveraged both additional direct funding and in-kind support.
Conclusions: The WIA program has been a useful source of
resources for health workforce development in many states
and local regions. The intentional flexibility of the program
has allowed its resources to be targeted to the needs of
specific sectors of the workforce, such as the health sector.
WIA, however, has administrative barriers to addressing some
of the most pressing health workforce needs in states and
local regions.
Implications for Policy, Delivery or Practice:
Reauthorization of the WIA program is under review.
Findings from this study show that the health workforce has
benefited from the resources WIA has brought to states and
local areas. Development of this sector could expand if the
program were modified through reauthorization to make WIA
resources more readily available to meet specific health sector
needs, such as professional training that requires two or more
years of education.
Primary Funding Source: HRSA
• Survey of US Chiropractors
Monica Smith, DC, Ph.D.
Presented by: Monica Smith, DC, Ph.D., Associate Professor,
Palmer Center for Chiropractic Research, 741 Brady Street,
Davenport, IA 52803; Tel: 563.884.5173; Fax: 563.884.5227;
E-mail: monica.smith@palmer.edu
Research Objective: Growing interest in the role of
complementary/alternative medicine in U.S. healthcare
delivery and policy mandates have accelerated the CAMrelated health services research agenda. The DVA Health Care
Programs Enhancement Act directs the DVA to provide
chiropractic care and services to veterans through DVA
medical centers and clinics. The Health Care Safety Net
Improvement Act now makes Doctors of Chiropractic, DCs,
eligible to participate in the National Health Service Corps
program. Research is needed to guide the integration of
evidence-based CAM into mainstream health care, at the
levels of clinical practice, health system organization and
delivery, and policy. This project studies actual or potential
contributions of chiropractors in meeting this nation’s
healthcare workforce needs, and factors for integration of
chiropractic providers into extant health care systems.
Study Design: Cross-sectional mail survey of US
chiropractors: Original mailing, two follow-up mailings, and a
final phone follow-up.
Collected demographic data, self-identified practice markets,
clinical and practice patterns for primary and coordinated
care provision, differential diagnosis, monitoring patients for
adverse pharmaceutical events, referral, practice volume, wait
times, and provision of uncompensated care.
Population Studied: Three samples drawn from 68,000 statelicensed U.S. chiropractors: simple random sample, clustered
random sample from sites of the Community Tracking Study,
stratified random sample from 3 strata of Health Professional
Shortage Areas representing whole, part, and no shortage
counties.
Data linked by chiropractor’s market service area to HRSA
Area Resource File for measures of practice market
environments. Sampling frame allows future linkage of CTS
sub-sample to public-use data from the Community Tracking
Study.
Principal Findings: Results from separate analyses of each
sampling frame were consistent and reported here as
summary findings.
Final response rate 50%.
Most DCs are new practitioners: 38% graduated within the
last 10 years, 72% within the last twenty.
Many, 60%, serve whole or part-shortage counties, 15% serve
whole-county shortage areas.
Most DCs, 79%, perform both differential diagnosis and
chiropractic analysis, 14% only chiropractic analysis, and 7%
only differential diagnosis. Approximately 80% generally agree
that chiropractors should attempt to differentially diagnose a
patient’s condition before referring a patient for medical care.
Most, 85%, report experience being the first provider to
identify a patient condition necessitating referral for medical
care. This experience occurs less than 5 times a year for 50%,
5-20 times/year for 40%, and more than 20 times/year for
10%.
Many, 60%, identified an adverse pharmaceutical event
occurring in one of their patients. Such events occur less than
5 times a year for 50%, 5-20 times/year for 30%, and more
than 20 times/year for 20%.
Conclusions: The chiropractic profession encompasses a
heterogeneous group of practitioners varying considerably as
to disciplinary foci, clinical attributes, and practice
characteristics.
Implications for Policy, Delivery or Practice: Strategies for
integrating chiropractic care provision into healthcare delivery
systems will be better informed and more truly directed by
considering the existence and implications of professional
heterogeneity, and the extent to which chiropractic
intraprofessional differences might be related to fundamental
differences in training, personal practice preferences,
characteristics of their practice environments, or other
possible factors.
Primary Funding Source: Intramural funding
• Chiropractic and Medical Interprofessional Relationships
Monica Smith, DC, Ph.D., Barry Greene, Ph.D., Mitchell Haas,
DC, M.A., Junlin Liao, M.B.A., M.H.A., M.S.
Presented by: Monica Smith, DC, Ph.D., Associate Professor,
Palmer Center for Chiropractic Research, 741 Brady Street,
Davenport, IA 52803; Tel: 563.884.5173; Fax: 563.884.5227;
E-mail: monica.smith@palmer.edu
Research Objective: Evidence points to increased utilization
of complementary and alternative medicine services, although
little knowledge exists about the coordination or integration of
CAM with conventional health care. This project explores two
dimensions of the relationship between chiropractors and
conventional allopathic primary care physicians in the U.S.,
using two modes of data collection.
Study Design: All chiropractors and medical primary care
providers in Iowa were surveyed to measure patterns of
referrals/consults and bidirectional communication between
the two practitioner types. In addition, nine focus groups
made up of both academic and community leaders in their
respective fields were convened to gather information about
the conceptual formulation and barriers and facilitators of the
design, delivery and implementation of practice-based
research networks, PBRNs, that would include both CAM and
medical providers.
Population Studied: Chiropractors and medical primary care
providers.
Principal Findings: Based on survey response rate of 40%,
most MDs report that a patient had asked them for
information about chiropractic (86%), or for referral to a
chiropractor (74%). Over 99% of respondent DCs have
recommended that a patient seek medical care and 90% of
DCs have formally referred to MDs. Significantly less MDs
have ever recommended to a patient that they try chiropractic
(64%), usually recommending that the patient contact the
chiropractor on their own (88%) rather than initiating a formal
referral (30%). When MDs formally refer to MD peers 70%
will always/usually exchange patient records, reports or other
clinical information, and 98% will always/usually send a
reason for referral. When MDs formally refer to DCs 42% will
always/usually send patient clinical information to the DC and
83% will send a reason for referral.
Content analysis of the focus group transcripts reveals a
number of factors related to the feasibility and formulation of
multidisciplinary Practice Based Research Networks, PBRNs.
Factors align along general themes of: Professionalism and
Challenges to Professional Status, Communication, Base
Knowledge about the Other Profession, Mutual Education and
Training Experiences, Good Medicine and Patient-Centered
Care as a Unifying Concept, and issues surrounding Primary
Care Roles and Functions.
Conclusions: Medical doctors most typically refer patients
within profession via formal referrals to a specific MD,
whereas those MDs that do recommend chiropractic to a
patient are as likely to recommend a specific chiropractor as
they are any chiropractor in general, and to essentially handle
it as a “lay referral”. The exchange of shared patient clinical
information during inter-professional formal referrals and
follow-ups to referrals exhibited similar disparate patterns,
with MDs sharing pertinent clinical information with their
medical colleagues much more frequently than with DCs.
The focus groups further examined the interprofessional
relationships between chiropractic practitioners and medical
primary care providers, to provide direction to the formulation
of PBRNs where both academics and clinicians in the
community might participate in research of mutual interest to
advance the knowledge of health services research.
Implications for Policy, Delivery or Practice: Information
from this project will serve as a foundation for setting
scientific research agendas of mutual interest and benefit to
the interprofessional fields and the communities of health
services research science.
Primary Funding Source: NIH-National Center for
Complementary and Alternative Medicine (NCCAM)
• How Do Scope of Practice Regulations Affect Demand
for Licensed Practical Nurses?
Joanne Spetz, Ph.D., Jean Ann Seago, Ph.D., Wendy Dyer,
M.A.
Presented by: Joanne Spetz, Ph.D., Assistant Professor,
Community Health Systems, University of California, San
Francisco, 3333 California Street, Suite 410, San Francisco, CA
94118; Tel: 415.502.4443; Fax: 415.502.4992; E-mail:
jojo@alum.mit.edu
Research Objective: Nurses can have two types of licenses:
Registered Nurse (RN) licenses, which are conferred after 2-4
years of study and passage of an examination, and Licensed
Practical Nurse (LPN) licenses, which are conferred after 1-2
years of study and passage of an examination. The scope of
practice for LPNs vares state-to-state. During nursing
shortages, healthcare administrators and policymakers are
turning to LPNs as a source of labor that might be able to help
meet the needs of patients. This study examines whether
scope of practice regulations affect demand for LPNs.
Study Design: This study provides a comprehensive overview
of the LPN workforce, the scopes of practice for LPNs in
various states, the potential for LPNs to substitute for RNs,
and the effect of scope of practice on demand for LPNs. Scope
of practice information was collected from every state's
nursing board, using our own survey instrument. We
categorized scope of practice along two scales; the breadth of
scope of practice, and the specificity with which scope of
practice rules are written. Demand for LPNs is estimated
using multivariate regression with panel data from all
hospitals in the U.S. collected by the American Hospital
Association. Scope of practice is an explanatory variable in
this demand equation. We use instrumental variables to
address the potential endogeneity of scope of practice with
employment levels of LPNs.
Population Studied: All acute care hospitals in the United
States
Principal Findings: Scope of practice regulations have a small
effect on the demand for LPNs, generally reducing their
employment levels.
Conclusions: There are many common elements in the
scopes of nursing practice across states. Because the
education and practice of LPNs is limited, hospitals have
relatively little latitude to substitute LPNs for RNs. This is
increasingly true as the acuity of patients has risen.
Implications for Policy, Delivery or Practice: Policymakers
should not rely on increases in the supply of LPNs to abate
the shortage of RNs.
Primary Funding Source: HRSA
• Do Professional Obligations Affect Ethical Conflict? A
Survey of Non-Physician Healthcare Professionals in the
United States
Connie Ulrich, Ph.D., R.N., Christine Grady, Ph.D., R.N.,
Marion Danis, M.D., Ezekiel Emanuel, M.D., Ph.D., Elizabeth
Garrett, Ph.D., Deloris Koziol, Ph.D.
Presented by: Connie Ulrich, Ph.D., R.N., Assistant Professor,
School of Nursing and Center for Bioethics, University of
Pennsylvania, 420 Guardian Drive, Room 357 NEB,
Philadelphia, PA 19104; Tel: 215.898.0898; E-mail:
culrich@nursing.upenn.edu
Research Objective: To determine the frequency of ethical
conflict and to improve our understanding of the factors that
influence practitioners’ ethical conflict.
Study Design: A self-administered mailed questionnaire of a
national stratified random sample of 3900 primary care nurse
practitioners (NPs) and physician assistants (PAs) in the
United States.
Population Studied: Nurse Practitioners and Physician
Assistants
Principal Findings: Among 1536 respondents (50.6%
adjusted response rate), 72% of practitioners report that
insurance constraints have interfered with their ability to
provide quality care for their patients and more than half
(55.9%) reported daily-weekly interferences. Nearly half of
respondents (47%) have been asked by a patient to mislead
insurers to assist them in receiving appropriate care yet 27.3%
responded that they were unsure if they would be willing to
comply with a patient’s request to mislead. A perceived
obligation to advocate for patients even if it means
exaggerating the severity of a patient’s condition was the
single most significant predictor of ethical conflict explaining
26% of the variance. Slightly more than 50% of respondents
agree that sometimes it is necessary to bend the rules or to
exaggerate (39.9%) the severity of a patient’s condition to
third parties in order to advocate for the patient’s best
interest.
Conclusions: NPs and PAs are experiencing ethical conflict
often associated with their perceived professional obligations
to advocate for patients. Ethics strategies are warranted to
assist clinicians to balance the ethical complexities and
demands of meeting patients’ needs within a constrained
healthcare system.
Implications for Policy, Delivery or Practice: To keep costs
down as well as to improve access to care, an increasingly
larger proportion of American patients are receiving healthcare
services from nurse practitioners and physician assistants,
referred to here as nonphysician clinicians. By the year 2005,
nurse practitioners will equal family physicians and by 2015; it
is estimated that there will be more than 275,000
nonphysician clinicians in clinical practice in the US. This
group of providers represents an integral and economically
desirable component of the healthcare system with
implications for cost effective, quality care. With physician
pressures to contain costs unlikely to diminish, we expect
similar concerns for nonphysician providers as they become
more fully integrated into multidisciplinary teams with cost
effectiveness expectations.
Primary Funding Source: Department of Clinical Bioethics,
National Institutes of Health
• The Quiet Revolution in Workforce Policy in the English
National Health Service
Elizabeth West, Ph.D., Anne Marie Rafferty, Ph.D.
Presented by: Elizabeth West, Ph.D., Lecturer, Public Health,
London School of Hygiene and Tropical Medicine, Keppel
Street, London; Tel: 01865512938; E-mail:
elizabeth.west@LSHTM.ac.uk
Research Objective: The shortage of health care workers has,
in England, prompted a raft of policy interventions designed
to rationalise workforce planning and make the National
Health Service (NHS) a more attractive place to work. This
paper describes the underlying political themes, identifies key
ideas, organisations and tools, and draws out some of the
possible implications of recent policy innovations.
Study Design: A descriptive and critical analysis of the
content of recent policy documents in relation to the future
workforce in the NHS (England).
Principal Findings: The political stance of “New Labour”
emphasises the importance of funding the NHS from general
taxation. It also emphasises that the NHS--the largest
employer in Europe--has a major role to play in the wider
economy, drawing disadvantaged groups into the labour
market, education and training, and acting as a model of good
human resource management practice.
The publication of the NHS Plan (2000) initiated structural
reform of the health service combined with increased
investment. Key principles included reorganising services
around the needs of the patient, and devolution of power to
increase responsiveness to local labour market conditions and
enable jobs redesign.
A new organisational infrastructure has been established.
New tools, such as the skills escalator, pay reform, and a new
job evaluation scheme were introduced. Many of the ideas
draw on current human resource management practice, and
are revolutionary in their scope, coherence and potential
implications.
Conclusions: The NHS programme on Service Delivery and
Organisation has a significant budget for research on
workforce issues; their challenge will be to commission
research that can evaluate the implications of current
workforce policy on service delivery, clinical outcomes and
relationships among professional groups.
Implications for Policy, Delivery or Practice: The future
workforce in England will be more diverse, in terms of age,
ethnicity and social class than it has been in the past.
Although laudable, this could lead to an increase in the
number of (professionally) unqualified staff in the NHS, at the
same time as the government plans to decrease the number
of admissions to acute hospitals and to limit length of stay,
could have a detrimental effect on the quality of care. The new
tools provided for evaluating jobs and matching these to pay,
combined with the empowerment of local employers means
that career trajectories will be more diverse and professional
boundaries will be more permeable, particularly between
health care assistants and nurses. Nurses are also being
asked to take on more clinical and managerial responsibilities
suggesting that this profession in particular will experience
more pressure.
In sum, recent reforms have transformed the aims and
apparatus of workforce planning in England. It is crucial that
the new research agenda on workforce issues focuses on the
potential impact on patient outcomes, on health care workers
experience of work life and on relationships among
professional and occupational groups.
Primary Funding Source: Macmillan Cancer Relief funded
the policy review but the views expressed are those of the
authors
• Impact of Medical Staffing Patterns on Community
Health Center Operations and Practices
Dylan Roby, M.Phil., Sara Wilensky, J.D., Sara Rosenbaum,
J.D.,
Presented by: Sara Wilensky, J.D., Assistant Research
Professor, GWU Department of Health Policy, Center for
Health Services Research and Policy, 2021 K Street, N.W.,
Suite 800, Washington, DC 20006; Tel: 202.530.2359; Fax:
202.296.0025; E-mail: wilensky@gwu.edu
Research Objective: To examine workforce and staffing
issues and their relation to financial deficits and operations in
federally funded Community and Migrant Health Centers.
Study Design: This study employs Uniform Data System
(1999-2001) data from the Bureau of Primary Health Care in
an attempt to establish an association between various
demographic variables, health center characteristics, staffing
models, and financial deficits. Both bi-variate statistics and
multi-variate regression modeling are used in order to predict
the relationship between high physician staffing levels and
financial revenues and costs, as well as high Nurse Practioner,
Nurse midwife, and Physician Assistant (NP/PA/CNM)
staffing levels and financial revenues and costs. Logistic
regression was the primary method of analysis for this study,
using staffing levels and financial deficits as the dependent
variables.
Population Studied: Approximately 800 federally funded
health centers from 1999-2001. These centers are located
throughout the country, in both urban and rural settings, and
provide care to over 10 million Americans of varying
race/ethnicity, gender, income level and insurance status.
Principal Findings: 1) Health centers with high deficits
appear to be linked to significantly lower patient and nonpatient related revenues per encounter. They are also more
reliant on grant revenues and have a greater proportion of
physician staffed encounters.
2) High NP/PA/CNM encounter centers tend to be less likely
to incur deficits, have fewer charges per FTE, and are smaller
than centers with high physician encounters.
3) Health center staffing patterns do not seem to be related to
patient outcomes (as defined by proportion of low birthweight
and access to prenatal care).
4) Staffing patterns and deficit ratios were not correlated with
being located in an urban or rural area.
5) There are differences between health center patients served
at centers with high physician staffing levels and centers with
high NP/PA/CNM staffing. High physician centers tend to
care for more minorities and more patients with chronic
disease than centers with high NP/PA/CNM staffing levels.
Conclusions: Smaller centers with higher proportions of
NP/PA/CNM staff are able to provide care without relying on
BPHC grants and without incurring deficits. However, larger
physician staffed centers are more likely to care for minority
patients, chronic disease patients, and provide more specialty
services. The health center program has space for both types
of staffing models, with smaller, streamlined centers providing
much needed primary care in a wide range of locations, while
larger, physician staffed centers are able to provide needed
care to minorities and patients with special needs.
Implications for Policy, Delivery or Practice: Centers with
high physician staffing and high NP/PA/CNM staffing levels
are both an integral part of America's safety net. Health center
expansions and further investment into the program will help
to provide care to many uninsured and underserved
individuals.
Primary Funding Source: HRSA
• Are Chinese Nurses a Viable Source to Relieve the U.S.
Nurse Shortage?
Yu Xu, Ph.D.
Presented by: Yu Xu, Ph.D., Assistant Professor,
Community/Mental Health Nursing, University of South
Alabama, 1504 Springhill Avenue, Mobile, AL 36688; Tel:
251.434.3454; Fax: 251.434.3995; E-mail: yxu@usouthal.edu
Research Objective: This paper examines the viability of
recruiting Chinese nurses to ease the current U.S. nurse
shortage within the global context using the “push-pull”
theoretical framework. China has the world’s second largest
nursing workforce (2.2 million). The increasingly global market
for nurses has aroused enormous excitement among Chinese
nurses as China is facing a relative “over-supply” of nurses,
declining socioeconomic status of nurses, and the underdevelopment of nursing as a recognized profession.
Study Design: Analytic review and synthesis based on “pushpull” theoretical framework, research literature and first-hand
field experience and data.
Principal Findings: Chinese nurses as a group have excellent
clinical skills and work ethic. However, language skills,
differences in professional values, interpersonal relationship at
the workplace, and deficiency in mental health nursing are
some of the challenges Chinese nurses face in order to survive
and thrive on the U.S. market.
Conclusions: With more focused training and an effective
social support network, Chinese nurses could prove to be a
viable source to relieve the U.S. nurse shortage, especially in
light of the recent opening of first CGFNS (Commission on
Graduates of Foreign Nursing Schools) test center in Beijing
in 2003. China is likely to replace the Philippines as the
country that exports the largest number of nurses to the U.S.
in the foreseeable future. Recruiting foreign nurses to relieve
U.S. domestic nurse shortage remains a pragmatic alternative,
at least for now and the foreseeable future.
Implications for Policy, Delivery or Practice: The practice of
“importing” nurses into the U.S. from other countries raises
legal issues regarding the complexity of immigration and
licensing, ethical issues regarding the “brain drain” of talent
from other nations, and quality of care issues related to
adequate educational and language training. U.S. employers,
government agencies, and professional regulatory
organizations need to get prepared for the coming waves of
Chinese nurses in the years ahead. Although foreign nurses
have eased the U.S. nurse shortage many times in the past, it
is unrealistic to entirely rely on them. U.S. policy-makers need
to develop a long-term socially responsible nursing workforce
policy in order to eliminate the cyclic nurse shortage.
Invited Papers
Migration & the Global Health Care Workforce:
Balancing Competing Demands
Chair: Linda Aiken, Ph.D., R.N.
Tuesday, June 8 • 9:15 a.m.-10:45 a.m.
• Panelists: James Buchan, Queen Margaret University
College, Scotland; Richard Cooper, Medical College of
Wisconsin; Barbara Stilwell, World Health Organization,
Geneva (no abstracts provided)