Workforce
Call For Papers
Health Workforce Studies - A Profession-Specific
Perspective
Chair: Jean Moore, State University of New York, Albany
Sunday, June 26 • 8:30 am – 10:00 am
●Physician Gender, Physician Marriage and the Supply
and Distribution of Medical Services
Ann Boulis, Ph.D.
Presented By: Ann Boulis, Ph.D., Postdoctoral Fellow,
Department of Sociology, University of Pennsylvania, 3718
Locust Walk, Philadelphia, PA 19104; Tel: (215)898-7665; Fax:
(215)573-2081; Email: aboulis@pop.upenn.edu
Research Objective: To understand how changes in the
personal lives and demographic characteristics of US
physicians have affected the supply and distribution of
medical services.
Study Design: Data from the 1980, 1990 and 2000 Census 5
percent samples were used to assess how changes in the
representation of women, and changes in the characteristics
of physicians’ spouses has affected both overall work effort
and the tendency to locate outside of metropolitan areas.
First, we track trends in the overall population of physicians in
the study years. Then, we create a file of married physicians
and their spouses to assess the influence of spousal
characteristics on physicians’ work effort and general location.
Population Studied: This study focuses on individuals who
identify themselves as physicians in the Census and who
indicate that they have at least three years of graduate level
education.
Principal Findings: Although female physicians are less likely
than their male colleagues to work for pay, the gender
difference in employment is negligible. Between 1980 and
2000, the labor force participation rates of female physicians
are consistently over 90 percent and never less than 95
percent of comparable rates for male physicians. Further,
while employed women physicians continue to work less per
week than their employed male colleagues, the gap in average
work effort is closing over time. Between 1980 and 2000,
employed female physicians went from working 85 to 90
percent of the average male physicians’ work week. Similarly,
over time, the disproportionate tendency for male physicians
to locate outside of metropolitan areas is declining. Between
1980 and 2000, male physicians went from being 59 to 35
percent more likely than their female colleagues to locate in
rural areas. While the influence of gender per se on the
supply and distribution of medical manpower is declining, the
effect of marital characteristics on physician work effort is
increasing. I find that the total work effort of married
physicians is constrained by the labor force participation of
their spouses and that, over time, the effect of spousal
employment on physician work effort is increasing. In 1980,
male physicians with employed spouses worked 0.9 hours
less per week and female physicians worked 4.8 hours less per
week. By 2000, these differences had grown to 2.3 hours less
work for married men and 8.1 hours less work for married
women. Similarly, I find a significant and increasingly
negative association between spousal education and the
tendency to locate outside of a metropolitan area for married
male physicians. In 1980, married male physicians whose
wives had graduate level education were 81 percent as likely as
men whose spouses did not have a bachelor’s degree to
locate outside of a metropolitan area. By 2000, men with
highly educated wives were only 58 percent as likely as their
peers with less educated wives to live in a rural area.
Comparable figures for married women physicians were 29
percent in 1980 and 33 percent in 2000. Finally, the
frequency with which the spouses of male physicians work for
pay increased from 44 percent in 1980 to 58 percent in 2000.
The frequency with which male physicians' spouses reported
graduate level education also increased significantly during
the study period from 24 percent in 1980 to 42 percent in
2000.
Conclusions: Increases in the representation of women in the
US medical workforce are associated with a decline in the
overall supply of medical labor and with a more skewed
distribution of medical professionals but over time the extent
of these associations is declining. One potential explanation
for the declining significance of gender may be the increasing
salience of marriage to the work effort and location decisions
of male physicians.
Implications for Policy, Delivery, or Practice: Although
family life issues continue to affect the work related decisions
of female physicians more than the decisions of their male
colleagues, the spouses of male physicians are having an
increasing influence on the location and work effort of male
doctors. Greater effort needs to be made to understand the
effects of family life on the work effort and location of
physicians, and ultimately to incorporate this knowledge into
health workforce planning and policy.
Primary Funding Source: Macy Foundation
●Applying a Public Policy Approach to Issues of Global
Nurse Migration
Sat Ananda Hayden, MSN, RN, HSA, Lutchmie Narine, Ph.D.
Presented By: Sat Ananda Hayden, MSN, RN, HSA, Doctoral
Student in Health Policy, Ph.D. Program in Public Policy,
University of North Carolina, Charlotte, 9201 University City
Boulevard, Charlotte, NC 28223; Tel: (704)687-6272; Fax:
(704)583-4467; Email: sahayden@uncc.edu
Research Objective: To identify implicit or explicit policy
models that may have shaped current discourse, policies, and
practices related to the importation of nurses into the US
health care system. Using a variety of perspectives, a number
of studies and reports have been done on the phenomenon of
nurse shortages and importation of nurses to alleviate
projected supply and demand imbalances. In this study we
describe these approaches, identify common themes and
elements, and develop a comprehensive research model that
incorporates the various perspectives. The model can be used
to apply and evidenced-based approach to policy decisions.
Study Design: This research is a meta-synthesis of existing
studies. Studies were identified using major key search terms
on Medline, CINHAL, social science citation index, and other
health care databases. Published and unpublished papers
addressing ethical recruitment of nurses by national and
international professional nursing organizations and major
institutions were also reviewed.
Population Studied: Previous studies on the phenomenon of
global nurse migration.
Principal Findings: Few studies on global nurse migration
have indicated a policy perspective or theoretical approach.
However, a number of approaches or views of nurse
migration were implicitly apparent in these studies. These
included looking at nurse migration as a supply of labor issue,
as a moral and ethical dilemma, as perpetuating north versus
south human and social capital inequities, as a feminist issue,
as a function of migratory push and pull factors, as a free
trade issue, as an organizational issue involving work design
and work force diversity challenges, as a threat to established
professional standards and norms, and as a basic human
right issues. The key variables associated with each
perspective were identified along with their relevant measures.
These were then organized according to context, population,
themes and put into a broad model that elucidated their
interrelationships.
Conclusions: The plethora of existing studies on international
nurse migration while being influenced by particular
perspectives are not informed by theory and lack a common
theoretical research framework. Studies are predominately
descriptive rather than analytical. This has in turn limited the
usability and applicability of study findings.
Implications for Policy, Delivery, or Practice: The
development of our comprehensive research can help
researchers and policy makers identify a way to better
understanding the phenomenon of international nurse
migration. For researchers the model provides a common
platform from which they can study the impact of nurse
migration on health care delivery in general and nursing
practice in particular. For policy makers the existence of a
common framework or lens through which they can look at
international nurse migration can help them to make better
sense of the findings from the research literature and so
develop policy solutions to nurse shortages in their
jurisdictions. For health services administrators the
framework can assist in nurse recruitment and retention
decision making within their organizations and in particular
managing the impact of increasing diversity in their nurse
work forces due to international nurses.
Primary Funding Source: No Funding
●Who’s Overworked and Who’s Underworked Among
Radiologists?
Cristian Meghea, Ph.D., Jonathan Sunshine, Ph.D.
Presented By: Cristian Meghea, Ph.D., Senior Researcher,
Research, American College of Radiology, Email:
cristianm@acr.org
Research Objective: Concerns about physician shortage or
surplus are recurrent in developed nations and we seek to
empirically investigate the situation. Typically the “market” for
physician services does not clear. For radiology in the United
States reasons include: prices are set administratively by
insurers; the number of entrants to any given specialty is
relatively rigid because all physician training programs tend to
guard their trainee slots even when the demand for their
graduates is low; and the demand for radiology work is
relatively inflexible in the short term because it is not ethical
for radiologists to postpone requested work. Similar
situations characterize other physician fields and other
countries. Also, the usual measure of labor market imbalance,
the unemployment rate, is often of little relevance because it is
essentially zero. We analyze the radiology labor market using
a new measure of shortage/surplus, namely the desire for
more or less work if accompanied by a proportional change in
income. The desire for less work is an indicator of a shortage,
while the desire for more work suggests a surplus.
Study Design: Data are from the American College of
Radiology’s (ACR) 2003 Survey of Radiologists, a nationally
representative stratified random sample survey of all
radiologists in the United States. Responses were weighted to
make the data representative of all radiologists in the United
States. We present overall descriptive statistics and also use
multiple OLS regression analysis.
Population Studied: All radiologists in the United States.
Principal Findings: The net average workload change sought
was approximately 0.1 percent of the current workload and not
significantly different from zero, indicating that the overall
total workload is what is desired. However, radiologists
working in academic or government practices were seeking,
respectively, 4% and 12% more work while those in private
practices sought 2% less work, although radiologists in
government practices worked similar hours to radiologists in
private groups and those in academic practices worked more
hours. In addition, radiologists working in non-metropolitan
practices were seeking 3% less work relative to those in large
metropolitan areas. Regression results showed that an
additional hour worked was associated with a desire for only
0.1 hour greater reduction in workload.
Conclusions: There was an overall balance between the
demand and the supply of radiologists in 2003. We found
some imbalances, including surpluses in academic and
government-owned practices, a shortage of radiologists in
private radiology groups, and a shortage of radiologists in
non-metropolitan areas. There were differences in radiologists’
desired workload by gender, age, and type and location of
practice.
Implications for Policy, Delivery, or Practice: Concern about
whether the supply of physicians in the U.S. is excessive or
inadequate is again becoming prominent, with the concern
now focusing on a shortage of physicians. Thus it becomes
important to have good measures of the surplus or shortage
situation, but there are no agreed-upon measures. We
introduce what should be a sound and particularly realistic
measure, namely, physicians’ desire for change in workload if
accompanied by a proportional change in income. We also
show that it is a useful and illuminating measure.
Primary Funding Source: No Funding
● Title: Supply and Demand in the LPN Workforce: Effects
of Scope of Practice, Demographics, and Local Markets
Joanne Spetz, Ph.D., Wendy Dyer, MS, Susan Chapman,
Ph.D., RN, Jean Ann Seago, Ph.D., RN
LPNs in the United States would remedy the national nursing
shortage, unless substantial expansions of the scope of
practice of LPNs were implemented.
Primary Funding Source: HRSA
Presented By: Joanne Spetz, Ph.D., Associate 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; Email:
jojo@alum.mit.edu
Research Objective: Registered Nurse (RN) licenses are
conferred after 2-4 years of study and passage of an
examination, and Licensed Practical Nurse (LPN) licenses are
conferred after 1-2 years of study and passage of an
examination. The scope of practice for LPNs varies state-tostate, and this scope of practice affects demand for LPNs.
The demographic characteristics of LPNs are different from
RNs. This study examines how scope of practice,
demographics, and local market characteristics affect demand
for and supply of LPNs.
Study Design: Scope of practice information was collected
from every U.S. state nursing board and was categorized
scope of practice according to the breadth of scope of
practice, and the specificity with which scope of practice rules
are written. Data on employment levels of LPNs and other
nursing personnel were obtained from the 2000 American
Hospital Association’s Annual Survey of Hospitals. Demand
for LPNs was estimated using multivariate regression
equations, using instrumental variables to address the
potential endogeneity of scope of practice and wages.
Multivariate models of the supply of LPNs were estimated
using data from the Current Population survey, with supply
being a function of individual and family demographics,
employment setting, and market factors. The labor supply
equations were estimated using two-stage least squares
regression to address the potential endogeneity of wages.
Population Studied: All hospitals in the United States, and
LPNs who responded to the US Current Population Survey.
Principal Findings: Demand for LPNs is lower when scope of
practice regulations are more restrictive, and to a lesser
degree when scope of practice regulations are specific. LPN
wages have a negative effect on demand for LPNs, but this
effect is not significant when instrumental variables are used
to control for the endogeneity of LPN wages. Hospitals with a
higher share of Medicaid inpatient days have greater demand
for LPNs, as do district and government hospitals. Employed
licensed nurses who are male, non-white, or foreign-born work
more hours per week and are more likely to work full-time.
The presence of children in the household has a negative
effect on labor supply. The effect of age is convex. Employed
LPNs respond to changes in their own wage by working
additional hours per week until a certain wage, after which
further increases induce LPNs to work less.
Conclusions: Because the education and practice of LPNs is
limited, hospitals have relatively little latitude to substitute
LPNs for RNs. Many of the same demographic, family and
market factors influence LPNs’ and RNs’ decisions of how
much to work once working.
Implications for Policy, Delivery, or Practice: Employers
have limited ability to use LPNs as substitutes for RNs, and
LPN decisions on how much labor to supply are similar to
those of RNs. Thus, it is unlikely that increasing the supply of
●Can Wage Increases End Nursing Shortages? A
Reexamination of the Supply Curve of Registered Nurses
Lynn Unruh, Ph.D., RN, Joanne Spetz, Ph.D.
Presented By: Lynn Unruh, Ph.D., RN, Health Services
Administration Program, University of Central Florida,
University of Central Florida, Orlando, FL 32816; Tel: (407)8234237; Fax: (407)823-6138; Email: lunruh@mail.ucf.edu
Research Objective: The United States and many other
nations are experiencing a severe shortage of registered
nurses (RNs), and the shortage is predicted to persist for the
foreseeable future. Economic theory indicates that a labor
shortage should be accompanied by wage increases, and
these wage increases will reduce demand and increase supply,
thus bringing the labor market into balance. However, a
variety of factors might prevent this neoclassical prediction
from occurring: demand may not adjust due to regulations,
long-term supply may not increase due to barriers to entry,
and short-term supply might not rise if the labor supply curve
is backward-bending. This study examines the relationship
between the supply of RNs and wages using standard labor
supply models and data from the 2000s. The question of
whether and to what extent nurses’ labor supply is backwardbending is examined.
Study Design: We estimate the supply of registered nurses
using the National Sample Survey of Registered Nurses
(NSSRN) and the United States Census Bureau – Bureau of
Labor Statistics Current Population Survey (CPS). We
estimate the equations for all years of the NSSRN (19772000) and ten years of the CPS. We estimate simple supply
equations using ordinary least squares regression, controlling
for RN and market characteristics. This analysis suffers from
two problems. First, the supply of RNs is endogenous with
wages, and thus instrumental variables regression must used
to correct this problem. Second, the number of hours worked
by a RN is predicated on the RN’s decision to work, and thus
a correction for this selection should be considered in the
analysis. We estimate regression equations using
instrumental variables and Heckman selection corrections to
address these problems. We pay particular attention to
changes in the labor supply function that have occurred over
time and the importance of family characteristics.
Population Studied: RNs in the United States.
Principal Findings: Preliminary equations estimated using
the Current Population Survey demonstrates that there is
some backward bend in the labor supply of RNs.
Conclusions: If the labor supply of RNs is backward-bending,
wage increases may not increase the short-term supply of
nurses. The extent to which this might be true depends on
the exact relationship between wages and supply. However,
the long-term supply of RNs might be positively affected by
wage increases. Thus, although the short-term effect of wage
increases might not be an abatement of the shortage of RNs,
the long-term effect could be resolution of the disequilibrium
in this labor market.
Implications for Policy, Delivery, or Practice: In the short
term, policymakers and employers should not expect wage
increases to improve the national shortage of RNs. However,
in the long term these wage increases will induce more people
to enter the nursing profession, thus remedying the shortage.
Primary Funding Source: California Employment
Development Department
Call for Papers
Health Workforce Studies: An Organizational Perspective
Chair: Bob Konrad, University of North Carolina, Chapel Hill
Sunday, June 26 • 3:30 pm – 5:00 pm
●Clinical Staffing on Labor and Delivery Units in California
Ida R. Shihady, MPH, Linda Burnes Bolton, DrPh, RN, FAAN,
Moshe Fridman, Ph.D., Lisa M. Korst, Ph.D., Paula Broussard,
RN, RDMS, Kimberly D. Gregory, M.D., MPH
Presented By: Kimberly D. Gregory, M.D., MPH, Director,
Maternal Fetal Medicine, Obstetrics and Gynecology, CedarsSinai Medical Center, 8700 Beverly Boulevard, Suite 160W,
Los Angeles, CA 90048; Tel: (310) 423-5420; Fax: (310) 4230140; Email: gregory@cshs.org
Research Objective: Mandated nurse-to-patient ratios have
been put forth as key ingredients for improving the quality and
safety of care. The majority of these directives are based on
data obtained from medical/surgical, and critical care units.
While obstetrical admissions are the most common cause of
hospital admissions in the United States, literature on the
application of staffing standards and the organization of care
on L&D is limited. The current study describes the clinical
staffing and organizational structure employed by L&D units
in California, and utilizes a measure of unit activity to describe
variation in nurse staffing among hospitals.
Study Design: We interviewed L&D nurse managers at
hospitals reporting more than 50 deliveries during 2002 in a
structured telephone interview. Information collected included
daily patient flow, number of nurses and hours per shift,
staffing models, clinical management of low and high-risk
patients, and type of health care personal available. We
measured unit activity by combining same day patients,
admissions, discharges/transfers, and midnight census.
Nurse-to-patient ratios were calculated by comparing the unit
activity measure to a self-reported average number of RNs per
12-hour shift. We classified hospitals into low (first quartile),
average (middle quartiles), and high (fourth quartile) staffing
levels. We present summaries of staffing patterns,
organizational factors, and clinical policies by delivery volume,
stratified into quartiles (Q1 = <750, Q2 =750-1699, Q3 = 17002759, and Q4 = >2760 deliveries per year). Staffing level
association to hospital characteristics (region, delivery
volume, ownership, and teaching status) are examined.
Population Studied: California hospital L&D nurse managers
Principal Findings: We surveyed 225 (84%) out of 268
eligible hospitals. Most hospitals use 12-hour nursing shifts,
and budget staffing based on acuity; however high volume
hospitals are more likely to use both 8- and 12-hour shifts.
Almost all hospitals use a call system or rely on supplemental
staff to meet staffing ratios. About 50% of hospitals were
staffed with a 1:2 nurse-to-patient ratio or better; 18% had a
ratio of 1:3 or worse. Northern CA hospitals and low volume
hospitals were significantly higher staffed compared with
Southern CA and Los Angeles area hospitals (p=0.003) and
high volume hospitals (p<.0001), respectively. Ownership
and teaching status were not associated with nurse staffing
ratios. High-risk patients are more likely to be managed on
L&D, except in high volume hospitals where a “special” unit is
common. High volume hospitals are more likely to have >10
MD’s and access to a Maternal Fetal Medicine specialist.
Availability and use of unit secretaries, scrub techs, doulas,
midwives, residents, and anesthesiologists varies widely.
Conclusions: L&D units in California approach nurse staffing
in a consistent manner. Other structural variables such as use
of ancillary personnel and clinical setting for different levels of
patient acuity vary and are associated with hospital volume, as
is nurse staffing by unit activity.
Implications for Policy, Delivery, or Practice: Staffing
patterns and organization of care on L&D units vary.
Additional research is needed to understand whether this
variation is associated with birth outcomes, and to determine
best practices for ideal outcomes.
Primary Funding Source: AHRQ
●The Impact of Organizational Changes on Supply and
Demand for Intensivist Services
Atul Grover, M.D., Ph.D., Tim Dall, MS, Jim Cultice, MS
Presented By: Atul Grover, M.D., Ph.D., Senior Consultant,
The Lewin Group, 3130 Fairview Park Drive, Suite 800, Falls
Church, VA 22042; Tel: (301)526-3883; Fax: (301)897-5810;
Email: HealthPolicy@jhu.edu
Research Objective: The aging and expansion of the
population will increase demand for health care in the US,
including demand for critical care (intensivist) physicians. A
growing body of literature supports the use of intensivists as a
way to improve patient outcomes in intensive care units.
This model of care has been encouraged by public and private
organizations whose goal is to improve quality of care.
Subsequent changes to the delivery and organization of care
in the ICU will significantly alter the current and future
demand for physicians trained in critical care. Our study
assesses the adequacy of the supply of practicing intensivists
through 2020.
Study Design: The Physician Supply and Demand Models of
the National Center for Health Workforce Analysis were
adapted to project the supply of, and demand for, adult
intensivists. The number of practicing intensivists is projected
based upon new entrants and losses from the critical care
workforce. Demand projections are modeled using
information about population growth and aging, insurance
status, and changes in science and technology. In addition,
changes in the organization and delivery of critical care
services are modeled based upon the literature linking
intensivist staffing patterns to quality of care.
Population Studied: Practicing US intensivists from 20002020, including domestic and international medical
graduates. Practice data obtained from AMA Masterfile and
physician surveys.
Principal Findings: Based on evidence supporting intensivistdirected care for ICU patients, two thirds of patients may be
receiving less than optimal care today. Even if only half of ICU
patients are cared for by full time intensivists, it implies a
current shortage of 1,200 intensivists, about 25% of current
supply. This is projected to exceed 2,000 by 2020 if current
trends continue.
Conclusions: The evolving standard of care for ICU patients
indicates that utilization patterns are changing towards greater
use of intensivists, moving the US closer to an optimal
standard of care, and suggesting that applying current
utilization patterns to future populations underestimates the
growth in demand for intensivists. After taking this into
account, the projections suggest an inadequate supply of
physicians trained in critical care at the present time with a
growing shortage over the coming decade.
Implications for Policy, Delivery, or Practice: While the
proportion of hospitals whose critical care is directed by
intensivists has doubled over the last several years in
response to studies linking staffing to quality of care, many
hospitals and communities will not be able to achieve this
standard of organization of care because of an inadequate
supply of intensivists. This shortage is likely to be severe by
2020, when the aging population will consume a far greater
volume of critical care services. Moreover, the lack of
practicing intensivists will disproportionately affect patients
who are already underserved. Major changes will need to
occur to ensure an adequate supply of intensivists and their
ability to deliver the highest quality of care in the ICU.
Primary Funding Source: HRSA
●Staffing Patterns and Vacancy Rates of the Nation’s
Federally Funded Rural Health Centers
Gary Hart, Holly Andrilla, Roger Rosenblatt
Presented By: Gary Hart, Director and Professor, Department
of Family Medicine, Rural Health Research Center & Center
for Health Workforce Studies, University of Washington,
University of Washington, Box 354982, Seattle, WA 981954982; Tel: (206)685-0402; Fax: (206)616-4768; Email:
ghart@fammed.washington.edu
Research Objective: Federally funded health centers (HCs)
have been at the core of the U.S. federal government’s safety
net system. The current administration has made a
commitment to expand the size and number of HCs. The
level of success of this expansion will depend on the ability of
these centers to recruit and retain qualified health care
providers. The objective of this study is to describe the
staffing patterns of federally funded HCs and to determine
which types of rural clinics have the highest vacancy rates.
Study Design: A 2004 survey of HC grantees yielded an
overall response rate of 79%, with a rural center response rate
of 98%. Survey data were linked to BPHC Uniform Data
System and other demographic and provider data. Weights
were created to make the respondents nationally
representative. SUDDAN was applied to adjust standard
errors.
Population Studied: All the 846 federally funded 330 health
clinic grantees (e.g., community health clinics and migrant
health clinics) that were clinically operational during 2003
constitute the study population (over 4,800 sites).
Principal Findings: HCs vary greatly in their size and the
complexity of their workforces. Family physicians (FPs)
(3,072) represent half of all HC physicians. There are 3,286
NPs and PAs; 1,491 dentists; and 3,389 RNs employed by
HCs. HC vacancy rates vary greatly by their location and
characteristics. Rural rates are higher for most professions
than for their urban counterparts, with RNs being an
exception. Vacancy rates are highest for physicians, dentists
and RNs. Vacancy rates for FPs are 12% for urban, 12% for
large rural, 19% for small rural, and 18% for isolated small
rural locations while the comparative rates for NPs are 9%,
7%, 8%. Rural HCs located in persistent poverty counties had
dentist vacancy rates that were about 10 percentage points
higher than those who were not so located.
Over a quarter of the physician staffing of HCs (over a third in
rural HCs) is made up of NHSC scholarship, NHSC loan,
state loan, and J-1 physicians who are currently working off
their program obligations. Rural high vacancy rate HC
directors indicate that expansion of programs that increase
NHSC slots, residency slots, visibility of HCs during training,
and minorities graduating will help them recruit and retain
providers better.
Conclusions: This study shows that many of the nation’s
HCs, especially rural HCs, face substantial challenges in
recruitment of provider staff. High vacancy rates are strongly
associated with their locations and characteristics. HC
staffing is heavily dependent on federal programs such as the
NHSC and J-1 visa waivers.
Implications for Policy, Delivery, or Practice: This study is
important to help identify the barriers to recruitment and
retention of HC workforce. The study results can be used to
identify and target appropriately tailored therapeutic
interventions to those HCs where they are needed most. The
results are not only relevant to federal policy makers and
program managers but to those at the federal and state level
who are responsible for planning and provider training.
Primary Funding Source: No Funding
●The Influence of Organizational Culture on Physician and
Nurse Resignation Rates
David Mohr, Ph.D., Mark Meterko, Ph.D., Gary Young, JD,
Ph.D., Martin Charns, DBA
Presented By: David Mohr, Ph.D., Health Services
Researcher, VA Boston Healthcare System (152M),
Department of Veterans Affairs, 150 South Huntington
Avenue, Boston, MA 02116; Tel: (617)232-9500-5679; Email:
david.mohr2@med.va.gov
Research Objective: The influence of organizational culture
was examined as it related to facility-level resignation rates for
physicians and registered nurses. Numerous studies have
used employee attitudes to explain individual turnover
intention and behavior, however, few studies have examined
the influence of group-level factors such as organizational
culture on actual facility-level resignation rates in health care
organizations.
Study Design: A job satisfaction survey was administered to a
census of employees of the Veterans Health Administration
(VHA) during the spring of 2004, this included a battery of 14
items based on the Zammuto and Krakower model of
organization culture. This measure yields culture dimension
scores for: group, entrepreneurial, bureaucratic and rational.
Following common practice, we combined the scores for the
group and entrepreneurial dimensions. Nation-wide 5,485
(38%) physicians and 18,954 (49%) registered nurses
responded to the survey. Culture scores for these respondents
were aggregated to the facility-level for both the physician
(n=112) and nurse (n=127) cohorts. These scores were then
matched to a database containing facility-level resignation
rates for the fiscal year the survey was conducted. Separate
doctor and nurse hierarchical regression analyses were then
conducted to examine the ability of group/entrepreneurial and
bureaucratic culture to explain the resignation rates for the
two professional groups. Because resignation data was
proportional with a restricted range, an arcsine transformation
was applied for regression models. In each analysis, four
dichotomous control variables were entered into the model
first: large hospital staff size, small hospital staff size, teaching
status, and urban location.
Population Studied: Physician and registered nurses in a
cross-national sample from The Veterans Health
Administration.
Principal Findings: The median facility-level resignation rate
was 7% for physicians and 5% for registered nurses.
Group/entrepreneurial culture significantly improved the
percent of variance accounted in facility-level resignation rates
in a stepwise regression models for both professional groups.
For physicians, the combined group/ entrepreneurial culture
scale explained an additional 3% of the variance (p<.05) in
turnover rates above the organizational covariates (model
adjusted r2 = .10). In the model with nurses,
group/entrepreneurial culture explained an additional 4% of
the variance (p<.05) beyond that accounted for by the
organizational covariates (model adjusted r2 = .06).
Bureaucratic culture did not explain incremental variance in
resignation rates for either professional group. For covariates,
teaching affiliation was positively related to resignation rates
for physicians and a large hospital characteristic was
negatively associated with nurse resignation. The difference in
resignation rates at facilities with the highest 25% and lowest
25% combined group/entrepreneurial culture was 1% (p =.18)
for nurses and 3% (p<.01) for physicians.
Conclusions: Group/entrepreneurial culture was negatively
related to facility-level resignation rates after controlling for
size, teaching affiliation and urban status. Organizations with
higher scores on this culture dimension experienced lower
resignation. A difference in turnover rates of 3% for
physicians and 1% for nurses between facilities at the highest
and lowest quartiles for group/entrepreneurial culture can be
a source of significant costs in recruitment for highly skilled
professions.
Implications for Policy, Delivery, or Practice: Physicians and
nurses are less likely to resign at facilities with higher levels of
group/entrepreneurial culture. Efforts to increase
group/entrepreneurial-oriented organizational culture may
yield benefits to skilled workforce retention.
Primary Funding Source: VA
●Increasing the Supply of Certified Nursing Assistants
Holly Rodin, Doctoral Candidate, M.P.A.
Presented By: Holly Rodin, Doctoral Candidate, M.P.A., 2997
Chatsworth St N, Roseville, MN 55113; Tel: (651)490-5035;
Email: rodi0016@umn.edu
Research Objective: To estimate the effect of wages increases
and availability of Employer Sponsored Insurance on the
probability of working age adults choosing work as Certified
Nursing Assistants and on the number of hours worked as a
Certified Nursing Assistant in healthcare.
Study Design: A maximum likelihood probit estimation with
selection is used to estimate the probability of working as a
Certified Nursing Assistant as annual wages and offers of
Employer Sponsored Insurance change. A Heckman selection
model is used to estimate how hours worked as a Certified
Nursing Assistant change based on changes in annual wages
and availability of Employer Sponsored Insurance. Recycled
probability methods are used to estimate adjusted rates of
change as wages and offers of Employer Sponsored Insurance
increase. Selection corrected wages are predicted for all
observations. A two-sample estimation method is used to
predict the probability of being offered Employer Sponsored
Insurance, using the Medical Expenditure Panel SurveyHousehold Component for the years 1996-2001.
Population Studied: Current Population Survey-Annual
Demographic Survey respondents, age 15 to 64, who are
employed as well as those respondents not working for
reasons other than disability or retirement. A pooled dataset
(1996 to 2002 of the Current Population Survey-Annual
Demographic Survey) with a sample size of 628,290 is used
for this analysis.
Principal Findings: Findings indicate that Certified Nursing
Assistants have a positive, inelastic response to wage
increases, increasing the probability of working as a Certified
Nursing Assistant between .3% and 1.1. Hours worked would
decrease as wages increase, ranging from –1.6% to -4.8%.
Increasing offers of Employer Sponsored Insurance would
increase the probability of working as a Certified Nursing
Assistant by 2.3% as well as increasing hours worked by 6.4%.
Conclusions: Increasing the offer of Employer Sponsored
Insurance would have the largest positive impact on
increasing the probability that workers will work as Certified
Nursing Assistants in healthcare, as well as increasing the
number of hours worked. Wage increases would increase the
probability that workers will become Certified Nursing
Assistants, but hours worked would decrease, resulting in a
net decrease of Certified Nursing Assistants working in
healthcare. A combination of wages and offers of Employer
Sponsored Insurance would result in the largest net gain in
the number of Certified Nursing Assistants, although the
estimates of the percentage increase in workers is still far
below the number projected to meet the increased demand
for these services.
Implications for Policy, Delivery, or Practice: State Medicaid
agencies and the federal Centers for Medicare and Medicaid
Services are devoting resources to address the current
shortage of Certified Nursing Assistants, especially in long
term care. This analysis provides policy makers with a set of
estimates that indicate that a combination approach of wage
increases and offers of Employer Sponsored Insurance could
out perform policies that only consider wage increases. As the
demand for these health services increases in the future, and
the potential pool of workers decreases, additional resources
will need to be devoted to ensure adequate staffing in order to
provide quality care for the elderly.
Primary Funding Source: AHRQ
Related Posters
Poster Session A
Sunday, June 26 • 2:00 pm – 3:15 pm
●Public Perception of Adequacy of Physician Supply
Holly Biola, M.D., Donald E. Pathman, M.D., MPH
Presented By: Holly Biola, M.D., NRSA Primary Care
Research Fellow, Family Medicine, UNC- Chapel Hill, 2507
West Woodrow Street, Durham, NC 27705; Tel: (919)843-4818;
Fax: (919)966-0536; Email: hollyrose@unc.edu
Research Objective: Increasing physician supply may not
enhance people’s sense of their access to health care if
perception of physician supply is based on factors other than
number of physicians in their area. Our aim is to assess how
closely people’s perceptions about the adequacy of the local
physician supply relate to actual numbers of physicians in
their county, and to identify which other factors are associated
with perception of an adequate physician supply.
Study Design: A telephone survey consisting of 89 questions
about demographic, attitudinal, care utilization, and access-tocare measures was fielded from November 2002 to July 2003
in 150 rural counties of 9 states in the U.S. Southeast as part
of the evaluation of the Robert Wood Johnson Foundation’s
Southern Rural Access Program. These analyses focus on the
question, How much do you agree with the statement:“I feel
that there are enough doctors in my community.” and its
association with demographic, attitudinal and county
variables. Bivariate logistic regression and multivariable
logistic regression analyses were used. All analyses were
weighted to adjust for demographic group response
likelihood.
Population Studied: Participants were English- or Spanishspeaking adults 18 years and older who had lived for at least a
year at their current residence. They were reached via
random-digit dialing to exchanges within study counties. The
overall response rate to the survey was 51.0%, with 4,879
participants and 4,682 refusals.
Principal Findings: About half (54.4%) of respondents felt
there were enough doctors in their communities.
Respondents in areas with lower physician densities (1
physician per > 3,999 people) were significantly less likely to
feel that there were enough doctors in their community than
people in areas with high physician densities (1 physician per
< 1,000 people) (49.2% vs. 59.4%; p= .006). Although
physician-to-population ratios were significant correlate of
perceived physician supply adequacy, other characteristics had
stronger associations. People significantly more likely to feel
there were enough physicians in their communities were
those over 65 years old, male, white, in good health, had more
confidence and satisfaction in their physicians, did not find
cost of care a problem, typically traveled less than 30 minutes
to care, and lived in counties with lower proportions of racialethnic minorities and poverty. The strongest correlate of
believing that there are enough doctors in one’s community
was the attitude that people should not go to doctors except
as a last resort (p <.001; O.R.=2.03; CI95=1.63-2.53).
Conclusions: People who live in areas with lower physician
densities are more likely to perceive that there are too few
physicians; however people’s attitudes about and experiences
with health care are also strongly correlated with perceived
doctor shortages.
Implications for Policy, Delivery, or Practice: Current efforts
to increase physician supplies in rural areas might succeed in
increasing physician numbers but still not eliminate the
perception that there are too few physicians. If the goal is for
people to feel that there are enough physicians locally,
interventions will also need to address people’s satisfaction
with and confidence in their physicians, cost, and other
barriers to care.
Primary Funding Source: HRSA
●RN Satisfaction: Evidence from the National Database of
Nursing Quality Indicators
Diane K. Boyle, Ph.D., Peggy A. Miller, MS, Byron Gajewski,
Ph.D., Nancy Dunton, Ph.D.
Presented By: Diane K. Boyle, Ph.D., Associate Professor,
School of Nursing, University of Kansas, 3901 Rainbow
Boulevard, MS 4043, Kansas City, KS 66160; Tel: (913)5881686; Fax: (913)588-8737; Email: DBOYLE@kumc.edu
Research Objective: Job satisfaction is crucial to retention of
RNs and therefore provision of quality patient care. Given the
growing shortage of RNs, hospital executives, policy makers,
and regulatory bodies are challenged to improve the work
environment for nurses. We examined the differences among
types of patient care units in acute care hospitals on
Registered Nurse (RN) job satisfaction, satisfaction with work
environment, perceived quality of care, and intent to stay on
the job.
Study Design: Data for this descriptive correlational study
were collected in a 2004 RN survey, which was primarily webbased. Hierarchical linear models were used to assess
differences across unit types. A random effect for hospital
was included, which allowed units within the same hospital to
be correlated.
Population Studied: The population studied was RNs
working as direct care providers in acute care hospitals in the
United States. The sample included >75,000 RNs in >5,000
nursing care units in 206 hospitals across the country.
Member hospitals of the American Nurses Association’s
National Database of Nursing Quality Indicators choose to
participate in the annual survey. Eligibility criteria included full
or part-time RNs, regardless of job title, who spend a
minimum of 50% of their time in direct patient care and have
been employed a minimum of 3 months on the current unit.
RNs working on all types of patient care units were eligible,
including critical care, step-down, medical-surgical, maternalnewborn, neonatal, pediatric, psychiatric, rehabilitation,
surgical services, ambulatory care, and the emergency
department. The hospitals represented 44 states, 90% are
general hospitals, 43% have achieved Magnet designation by
the American Nurses Credentialing Center.
Principal Findings: Significant differences existed among
types of patient care units on RN satisfaction with specific job
aspects, including task, RN-RN interaction, RN-MD
interaction, decision-making, autonomy, professional status,
and pay; on RN satisfaction with aspects of the work
environment, including professional development, nursing
management, and nursing administration; and on general job
enjoyment. Significant differences were also found among
types of patient care units on perceived quality of care
delivered and intention to stay on the job.
Conclusions: Unit environment significantly impacted RN job
satisfaction. It is important to go beyond the hospital level to
a unit level analysis to understand RN job satisfaction, quality
of care, and intention to remain on the job.
Implications for Policy, Delivery, or Practice: These results
will assist policymakers and hospital administrators design
targeted, effective interventions to improve RN work
environments of different types of units.
Primary Funding Source: No Funding Source
●Does the Market Value Racial and Ethnic Concordance in
Timothy Brown, Ph.D., Richard M. Scheffler, Ph.D., Sarah
Tom, MS, MPH, Kevin Schulman, M.D., MBA
Presented By: Timothy Brown, Ph.D., Associate Director of
Research, Petris Center - School of Public Health, University of
California at Berkeley, 2150 Shattuck Avenue, Suite 525,
Berkeley, CA 94720-7380; Tel: (510)643-4103; Fax: (510)6434281; Email: tbpetris@berkeley.edu
Research Objective: To determine if the market places an
economic value on racial/ethnic concordance in potential
physician-patient relationships.
Study Design: Using SUDAAN, population-averaged
regression models with area fixed effects were used to
estimate the determinants of earnings per hour for physicians
in a two-period panel (12,886 observations). Controls for
physician characteristics and area population characteristics
were included. Various interactions between the
race/ethnicity of the physician and the race/ethnicity of the
local population were performed.
Population Studied: Physicians from the 1998-1999 and
2000-2001 Community Tracking Study Physician Surveys
Principal Findings: Black physicians are paid approximately
5.6% more in earnings per hour than non-Black physicians for
every percentage point increase in the percentage of the
population that is Black and insured by Medicaid or other
public insurance. Hispanic physicians are paid 1.2% more in
earnings per hour than non-Hispanic physicians for every
percentage point increase in the difference between the
percentage of the population that is Hispanic and the
percentage of physicians who are Hispanic.
Conclusions: While neither Black nor Hispanic physicians
earn more than non-Black or non-Hispanic physicians when
comparing simple means, both Black and Hispanic physicians
earn more when practicing in areas where the degree of
potential racial/ethnic concordance between physicians and
patients is lower than the potential demand for such
relationships. This suggests that there are shortages of Black
and Hispanic physicians in such areas.
Implications for Policy, Delivery, or Practice: Additional
Black and Hispanic physicians should be trained in order to
reduce current shortages.
Primary Funding Source: WKK
●A Geographic Analysis of Dental Schools, Dental
Graduates, and Residential Status of Dental School
Enrollees
Gayle Byck, Ph.D., Linda M. Kaste, DDS, Ph.D.
Presented By: Gayle Byck, Ph.D., Deputy Director, Midwest
Center for Health Workforce Studies, University of Illinois at
Chicago, 1747 West Roosevelt Road, Room 558, Chicago, IL
60608; Tel: (312)355-4761; Fax: (312)355-2801; Email:
gbyck1@uic.edu
Research Objective: The purpose of this study is to provide
descriptive data on the presence of dental schools, dental
school graduates, in-state enrollment and interstate dental
education agreements for states in the United States. This
information about the dental education pipeline may be
helpful to states deciding to open or maintain a dental
school., as well as to policy makers addressing dentist
workforce, supply and education.
Study Design: Using data from the American Dental
Association, American Dental Education Association, and US
Census Bureau, cross-sectional comparisons were made for
dental schools (presence of, public versus private), graduates
(1990-2000), and residential status of dental school enrollees
(1998-2000) for the following geographic levels: state, Census
division, and Census region.
Population Studied: Dental school enrollees (1998-2000),
and dental graduates (1990-2000) by state and Census
division and region.
Principal Findings: In 2000, there were 54 dental schools, in
35 states. There were 43,289 dental school graduates during
1990-2000, with little fluctuation by year. Over half (56%) of
the graduates were from public schools. The distribution of
schools and graduates differed by geographic region. The
South had the largest unadjusted number of graduates;
however, the Northeast graduated the largest number of
dentists per capita. Over 80% of residents in most Census
divisions stayed in their division for dental school, while
residents in the Mountain division/West region needed to
look outside their geographic area for dental school
opportunities. The Mid-Atlantic schools were the most
“national” in terms of student enrollment, while the West
South Central and Pacific schools attracted enrollees mainly
from their geographic areas. Schools and states without
dental schools varied considerably in their reliance on
interstate agreements. There appeared to be an inverse
relationship between dentist supply and in-state enrollment.
Conclusions: US states vary widely on the number of dental
schools, dentists, dental school graduates, and residential
status of first year dental school enrollees. Further
assessment on additional factors such as dental health
provider shortage areas and state oral health status is needed
to more fully view the impact of these factors.
Implications for Policy, Delivery, or Practice: With many
states facing dentist shortages in many counties and an aging
dentist workforce, the importance of having an in-state dental
school and/or interstate agreements on the future supply of
dentists for a state is an area of interest. The state and
regional-level data presented here on dental school enrollees
and graduates, and dentist supply, contribute to current
ongoing discussions about the dental workforce, the future of
dental education, and access to oral health care.
Primary Funding Source: HRSA
●The Allied Health Workforce: Out of the Shadows and
into the Spotlight
Susan Chapman, Ph.D., RN, Edward H. O'Neil, Ph.D., MPA,
Wendy Dyer, MS, Vanessa Lindler, MA
Presented By: Susan Chapman, Ph.D., RN, Assistant Adjunct
Profesor, Social & Behavioral Sciences and Center for Health
Professions, University of California, San Francisco, 3333
California Street, Suite 410, San Francisco, CA 94118; Tel: (415)
502-4419; Fax: (415) 476-4113; Email: susanac@itsa.ucsf.edu
Research Objective: The health care industry’s focus on the
nursing shortage has overshadowed a growing and significant
shortage of allied health workers. These workers provide the
bulk of diagnostic, therapeutic and direct care in hospitals,
nursing homes and in the home. Position vacancy rates range
between 8% -15% although there is inconsistent measurement
and variability in demand by geographic and health care
setting. Previous studies have documented the supply of and
demand for allied health professionals but they have been
largely regionally or profession-specific. The objective of this
project was to use secondary data to identify supply and
demand trends nationally and to assess state and regional
variations in the production of and need for greater numbers
of workers now and in the next decade.
Study Design: Data were collected, summarized, and trended
using a variety of secondary sources. The Current Population
Survey (CPS) 1998-2003 was used to assess demographic
characteristics; the BLS (OES) and Census for the number of
workers per population in each state and the U.S., the AMA
Health Professions Education Directory (1997-2003) for the
number of program graduates, the BLS for quarterly job
openings, and a review of literature, previous HRSA workforce
reports, and key informant interviews.
Population Studied: (1) Allied health occupations ranging
from entry level nurse aides to masters prepared physical and
occupational therapists (2) Accredited allied health
educational programs in the U.S.
Principal Findings: The U.S. average number of allied health
workers to population is 21.4/1000, with state averages
ranging from 16.7 to 30/1000. Graduation rates have been flat
for 8 years. Many states produce too few graduates to meet
demand for open positions e.g., California graduates 500
radiologic technologists for over 700 new positions per year.
Key informants indicate that recruitment suffers due to
relatively low wages and lack of career advancement
opportunities.
Conclusions: An aging population and the pending
retirement of current allied workers will create a greater
demand for increased production of allied health workers.
The technical fields continue to grow and specialize as new
technology in imaging and the clinical lab have created the
need for new technicians. A new infusion of support for
community colleges and baccalaureate programs is critical to
maintain access for entry level and career ladder students.
Implications for Policy, Delivery, or Practice: Increased
funding support is needed at the community college and
baccalaureate level to increase the capacity of allied health
educational programs. Labor-management partnerships to
promote career development for incumbent workers may be a
successful approach to reduce turnover and encourage new
entrants to the allied health field.
Primary Funding Source: The California Endowment and the
CaliforniaHealthcare Foundation
●Advanced Practice Nurses in Genetics: A Workforce That
Can Increase Access to Genetics Services
Judith Cooksey, M.D., MPH, Dale H. Lea, RN, MPH, CGC,
APNG, FAAN, Gaetano Forte, BA, Patricia A. Flanagan, MA,
Janet Williams, RN, CGC, NP, Ph.D., Miriam Blitzer, Ph.D.
Presented By: Judith Cooksey, M.D., MPH, Faculty,
Department of Epidemiology and Preventive Medicine,
University of Maryland School of Medicine, 660 West
Redwood Street, Baltimore, MD 21201; Tel: (410) 706-1277;
Email: jcookseyumuic@aol.com
Research Objective: Despite new genomics advances each
year, the US has few genetics specialists, and limited capacity
to produce new professional entrants. Advanced practice
nurses (APNs) in genetics are one of only three recognized
genetics specialty groups; the others are medical geneticists
(1,600 MDs and PhD geneticists) and genetic counselors
(about 2,000). Nurses in genetics are the least studied and
smallest group. An ongoing problem is limited genetics
content in general nursing educational curricula; and the
paucity of master’s or doctoral level nurse education
programs in genetics. The major organization for APNs in
genetics is the International Society of Nurses in Genetics
(ISONG); membership is open to all nurses. ISONG has
advanced the profession and recently developed a new
credential for nurses with demonstrated competency in
genetics. This study describes the professional roles of
ISONG members in an effort to better inform overall genetics
workforce planning.
Study Design: Confidential written survey of all US members
of ISONG, conducted in July 2004. The survey included 49
questions on demographics, education and credentials,
professional activities, patient care, and perspectives. The
study had IRB approval by UMB and NYSDOH.
Population Studied: All US nurses who were ISONG
members in July 2004. Response rate was 72% (211 of 293
ISONG members); results reported for 201 professionally
active nurses.
Principal Findings: Respondents are predominantly women
(98%), white (94%) with a median age of 51 years. There is
high educational attainment, almost 40% have a doctoral
degree and 95% have a master’s degree. Primary work
settings are diverse: colleges of nursing 32%,
hospitals/associated clinics 18%, government 17%, academic
health centers 16%, clinics/physician offices 7%, and other
settings 12%. In aggregate, professional time is distributed
among teaching 26% of time, direct patent care 24%, research
23%, administration 17%, public health/community health
10%, and other activities 2%. About 67% of respondents have
direct patient care in clinical areas of genetics 26%, oncology
22%, pediatrics/neonatal 13%, family/adult 13%, womens
health 8%, and other areas 18%. Genetics-related services
include family history & analysis, genetic counseling, physical
exam, psychosocial counseling, and care coordination.
Average genetic-related patient care volume is 180 new and
220 follow-up patient visits per year. About 20% of
respondents list their primary position as a researcher or
research coordinator, with varied research fields. A majority of
respondents had no formal genetics courses or clinical
rotations during their graduate studies; often undertaken in
the 1970s and 1980s. A majority rate current genetics
educational opportunities for advanced nurse education as fair
or poor.
Conclusions: APNs in genetics have divers roles and
responsibilities, with almost equal time distributed among
teaching, research, and patient care. There are and have been
insufficient genetics-specific advanced educational
opportunities for nurses, possibly contributing to small
numbers of younger APNs in genetics.
Implications for Policy, Delivery, or Practice: APNs in
genetics provide complementary professional roles and
patient care services to those provided by physicians, medical
geneticists, and genetic counselors. Expansion of this nurse
specialty workforce could help impprove access to genetic
services. However, there is a serious need to expand geneticsspecific training and educational programs for nurses.
Primary Funding Source: HRSA, NHGRI - ELSI Program
●Evaluating Variations in Individual Nurse Workload
Perceptions in Relationship to Regulatory Mandates
Karen Cox, Ph.D, Shelly C. Anderson, MSN MBA, Susan L.
Teasley, BSN, Cathryn A. Carroll, Ph.D.
Presented By: Karen Cox, Ph.D., Senior Vice President,
Patient Care Services, Children's Mercy Hospitals and Clinics,
2401 Gillham Road, Kansas City, MO 64108; Tel: (816)2343933; Fax: (816)346-1333; Email: kcox@cmh.edu
Research Objective: To evaluate (1) state specific variations
in individual nurse workload perceptions and (2)compare
workload perceptions for nurses employed in states with and
without regulatory mandates.
Study Design: A cross-sectional evaluation of individual nurse
workload perceptions. Data specific to demographic and
institutional information was obtained in addition to nurse
workload perceptions through the completion of the validated
Individual Workload Perception Scale. Univariate statistics
were used to compare mean values of workload perceptions.
Population Studied: A convenience sample of over 4,000
nursing professional located throughout the United States.
Principal Findings: State variations were observed in
individual nurse workload perceptions with nurses employed
in some states having worse perceptions of workload than
nurses employed in other states. The adoption of regulatory
strategies to improve nurse workload appear to have been
effective with statistically significant differences in workload
perceptions being observed in states with and without
mandatory ratios, mandatory staffing plans, mandatory
overtime and right to work states.
Conclusions: State specific variations in nurse workload
perceptions do occur and regulatory tools used to improve
nurse workload do appear to have some effect. Nurse
managers must be aware of regional variations in workload
perceptions.
Implications for Policy, Delivery, or Practice: As nurse
professionals advocate for the adoption of regulatory
interventions to improve nurse workload, specific
consideration should be given to the adoption of mandatory
staffing plans prior to the adoption of alternative regulatory
interventions such as mandatory ratios, right to work
legislations, etc.
Primary Funding Source: No Funding Source
●All Physicians are not Created Equal: Supply and
Demand Projections for 19 Physician Specialties
Tim Dall, MS, Atul Grover, M.D., Ph.D., Jim Cultice, MS
Presented By: Tim Dall, MS, Vice President, Applied
Economics, The Lewin Group, 3130 Fairview Park Drive, Falls
Church, VA 22042; Tel: (703) 269-5743; Fax: (703) 269-5503;
Email: tim.dall@lewin.com
Research Objective: Recent reports have reflected a growing
concern over the potential shortage of physicians in the US.
However, analyses and commentaries have focused on the
adequacy of the aggregate number of physicians; more
specific studies usually examine total numbers of specialists
or generalists, but not particular specialties. This study
attempts to assess the adequacy of the physician workforce for
nineteen individual physician specialties through 2020.
Study Design: The Physician Supply and Demand Models of
the National Center for Health Workforce Analysis were used
to project the supply of, and demand for, 19 physician
specialties. The number of practicing physicians is projected
based upon new entrants and losses from the workforce while
demand projections are modeled using information about
population growth and aging, insurance status, and changes
in science and technology. Specialty-specific physician-topopulation ratios are also examined which reflect trends in
provider availability.
Population Studied: Practicing US physicians from 20002020, including domestic and international medical
graduates. Physician practice and utilization data were
obtained from the AMA’s Physician Masterfile, their
Socioeconomic Characteristics series, and the National center
for Health Statistics. Population projections came from the US
Census Bureau. Other supply and demand determinants were
incorporated based upon findings from the physician
workforce literature.
Principal Findings: Aggregate physician supply is likely to
meet the demands of a growing and aging population until
close to 2017, when the number of exits from the physician
workforce will begin to exceed the number of new physicians
under current conditions. However, the number of physicians
in some specialties, particularly those serving the elderly, will
be inadequate to meet demand for physician services given
current utilization patterns. Physician-to-population ratios
adjusted by primary population served (e.g., OB/Gyn to
female ratio) reveal widely varied results. The ratio of
OB/Gyns to target population will grow by 21% and for
general pediatricians will increase by 15%, which may indicate
a future surplus of these specialists. However, the ratio of
cardiologists to target population will fall by 28%; the provider
to population ratio for other internal medicine subspecialties
will also decline by 23%, which point to a shortage of these
providers in the next 15 years.
Conclusions: While some authors have suggested that there
will be national shortage of physicians or of all physician
specialists, this is not likely to occur given current practice and
utilization patterns. However, those specialties which care
primarily for elderly patients may not be able to meet demand
for their services given current conditions. Other specialties,
particularly those caring mostly for younger patients, are
unlikely to experience significant shortages in the next 15 years.
Implications for Policy, Delivery, or Practice: Aggregate
physician workforce projections do not reflect potential
specialty imbalances between supply and demand. The calls
for increasing the total numbers of physicians in the US do
not account for specialty-specific practice patterns and may
ignore the ability of the physician workforce to meet future
demands by changes in specialization rates and practice
patterns by new physicians. More specialty-specific research
on the physician workforce is necessary to ensure that
physician workforce policy is well-informed on future trends in
specialty requirements.
Primary Funding Source: HRSA
●Nurse Staffing and Quality of Care: Findings from the
Economic Value of Nursing Model
Tim Dall, MS, Peggy J. Maddox, RN, Ph.D., Juliette Chen,
MPH, Paul F. Hogan, Ph.D. (abd)
Presented By: Tim Dall, MS, Vice President, Applied
Economics, The Lewin Group, 3130 Fairview Park Drive, Falls
Church, VA 22042; Tel: (703) 269-7543; Fax: (703) 269-5503;
Email: tim.dall@lewin.com
Research Objective: This study models the implications of
alternative nursing systems of care on patient risk of
nosocomial complications, and the implications in terms of
premature mortality, excess length of stay, and excess medical
costs.
Study Design: By combining findings from the literature with
original empirical analysis, we developed the Economic Value
of Nursing Model (EVNM) that can be used to quantify
changes in patient risk of nosocomial complication under
alternative nursing systems of care.
Population Studied: RNs providing tertiary care in general,
acute care hospitals, as well as the patients for whom they
provide care.
Principal Findings: Over 7 million cases of nosocomial
complication occur each year in general, acute care hospitals.
These complications are directly responsible for 450,000
premature deaths, 20 million additional inpatient days, and
$53 billion in excess medical costs. Improved nurse staffing—
whether defined in terms of higher staffing levels or higher
skill mix—has the potential to reduce (but not eliminate) the
incidence of nosocomial complications and the mortality,
additional length of stay, and additional medical costs
attributed to these complications.
Conclusions: A growing body of research documents the
impact of improved nurse staffing on patient outcomes, but
more research is needed. Moreover, future research will prove
more valuable if the findings are estimated and presented in
such a way that they can be combined with the findings of
other researchers into a systematic model of the economic
and quality of care implications of nurse staffing decisions.
Implications for Policy, Delivery, or Practice: It is in the
interest of all parties—employers, patients, insurers, policy
makers and nurses—to gain a better understanding of the
contribution of professional nursing care as this knowledge
will contribute to the improved efficacy and efficiency of
healthcare services. Such information will help inform
operational decisions regarding appropriate systems of
nursing care.
Primary Funding Source: Nursing's Agenda for the Future
and its sponsoring associations
●A Comprehensive Model to Project the Primary Care
Physician Workforce
Martey Dodoo, Ph.D., Robert L. Phillips, M.D., MSPH, Jessica
L. McCann, MA, Ginger Ruddy, M.D., Larry A. Green, M.D.,
Lisa S. Klein
Presented By: Martey Dodoo, Ph.D., Senior Economist, The
Robert Graham Center, 1350 Connecticut Avenue N W, Suite
201, Washington, DC 20036; Tel: (202)331-3360; Fax: (202)3313374; Email: mdodoo@aafp.org
Research Objective: To assess prior models to forecast the
adequacy of the Primary Care Physician Workforce, develop a
comprehensive model with both demand and supply
segments, and use the model to project the primary care
physician workforce to 2020.
Study Design: We critically reviewed recent models to
forecast the adequacy of the Primary Care Physician
Workforce. We developed a comprehensive physician
workforce model with demand and supply segments. Demand
was based on need and supply was simulated from
production components and training cohorts. Key variables
were identified using regression techniques. We estimated the
model using 20 months of data. Tested the model with 20
additional months of data. Used the model to project the
primary care physician workforce to 2020.
Population Studied: The US primary care physician
population
Principal Findings: The medical training pipeline is relatively
supply inelastic. The results of the best-fit regression analysis
identified three out of six variables that were strongly related
to the size of the primary care physician workforce. These were
the real GDP three years prior, the civilian resident population
and the percentage of the population that is insured. In
evaluations the model accounted for more than 95 percent of
the historical primary care physician workforce. In a status quo
projection the physician workforce of general internists grows
at a higher rate than that of family physicians. The projection
results were 97,000 family physicians, 90,000 general internal
medicine physicians, and 48,000 general pediatricians in
2010; and 151,000 family physicians, 173,000 general
internists, and 89,000 general pediatricians in 2020.
Conclusions: This analysis identified significant relationships
between key variables in both the supply and demand
segments of the primary care physician workforce market. The
primary care physician workforce is sensitive to growth in the
GDP, population and proportion of the population insured.
These relationships and variables appear to determine the
level of the primary care physician workforce within the shortrun 5-year period.
Implications for Policy, Delivery, or Practice: There should
be concerns about the relative inelasticity of the medical
training pipeline, and whether a physician workforce driven
mainly by economic factors will sufficiently provide the needed
health care. This analysis illustrates that analytical rigor could
be effectively employed in projecting the physician workforce.
Primary Funding Source: No Funding Source
●Home Healthcare Nurse Job Satisfaction and Intent to
Stay
Carol Ellenbecker, RN, Ph.D., Carol Ellenbecker, RN Ph.D.,
James Byleckie, Ph.D., Linda Samia, RN, MS
Presented By: Carol Ellenbecker, RN, Ph.D., Associate
Professor, Nursing, University of Massachusetts Boston, 100
Morrissy Boulevard, Boston, MA 02125; Tel: 617-287-7515;
Email: carol.ellenbecker@umb.edu
Research Objective: The purpose of this study was to
examine the relationship of job satisfaction and individual
nurse characteristics to intent to stay in home healthcare
nurses and to test a theoretical model of nurse job satisfaction
and intent to stay.
Study Design: This was a descriptive correlation study. Selfreport data were collected from home healthcare nurses using
the Home Healthcare Nurses Job Satisfaction (HHNJS) scale.
The 30 item HHNJS measures job satisfaction of home
healthcare nurses and has demonstrated validity and
reliability.
Population Studied: A representative sample of 2,500 home
healthcare nurses was recruited from Certified Home
Healthcare Agencies throughout the New England region.
First, a probability proportional to size sample of 150 agencies
was generated from the Medicare provider file. Second, the
selected agencies were contacted and asked to participate in
the study by allowing researchers access to nurses employed
at their agency. All nurses at participating agencies meet the
criteria for inclusion and were asked to participate in the study
Principal Findings: Global job satisfaction mean scores
varied from 2.42 to 4.97 and were highly correlated with intent
to stay. Demographic variables were not related to job
satisfaction. Factors most strongly correlated with intent to
stay were Professional Pride and Relationship with
Administration, Autonomy and Independence; follow by Salary
and Benefits, Stress and Workload, Relationship with Peers,
Relationship with Patients, and Relationship with Physician in
that order. There was a greater variability among the factors
hypothesized as intrinsic and extrinsic than in global job
satisfaction. Nurses’ relationship with Administration had the
greatest amount of variability, while nurses’ relationship with
patients the least.
Conclusions: Nurses’ job satisfaction and their desire to stay
at their jobs may be effected most by the organizational
environment and other extrinsic factors over which
administrators and policy makers have control. The theoretical
model developed from an integration of the findings of
empirical research related to job satisfaction and retention, in
institutional settings, may not be a good fit for home
healthcare settings. The results of this research suggest that
characteristics viewed as extrinsic, i.e. Autonomy and
Independence of hours and work activities for the home
healthcare nurse may actually be perceived by home
healthcare nurses to be intrinsic to job of the home health
care nurse. Likewise, the previously hypothesized intrinsic
characteristics of Relationship with Administration while
intrinsic to the job for nurses in institutional settings may be
extrinsic to the role of the home healthcare
Implications for Policy, Delivery, or Practice: Predicted
severe nursing shortages and an increasing demand for home
healthcare services have made the retention of experienced,
qualified nursing staff a priority for healthcare organizations.
Knowledge of variables that contribute to job retention in
home healthcare will provide the information necessary to
maintain nursing staff and assure access to quality home
healthcare services. Job satisfaction for home healthcare
nurses is dependent on factors over which agencies have
control. This suggests avenues for intervention that will
improve job satisfaction with implications for higher retention,
greater access, and improved patient care.
Primary Funding Source: AHRQ
●Determining User Satisfaction with Online Public Health
Preparedness Training
Jennifer Horney, MA, MPH, Erin Rothney, MPH, Lorraine
Alexander, DrPH, Pia MacDonald, Ph.D., MPH
Presented By: Jennifer Horney, MA, MPH, Assistant Project
Director, Director of Training and Education, North Carolina
Center for Public Health Preparedness, University of North
Carolina, Campus Box 8165, Chapel Hill, NC 25799-8165; Tel:
(919) 843-5566; Fax: (919) 843-5563; Email:
jen.horney@unc.edu
Research Objective: The North Carolina Center for Public
Health Preparedness, in the North Carolina Institute for Public
Health at the University of North Carolina at Chapel Hill
School of Public Health, works to improve the capacity of the
public health workforce to prepare for and respond to
terrorism and other emerging public health threats.
NCCPHP’s Training Website offers more than 100 free
Internet-based training modules on surveillance, bioterrorist
agents, emerging/re-emerging diseases, and other topics.
Each 30- to 60-minute module offers free continuing
education units. For continuous improvement of training
services and marketing, NCCPHP surveyed the Training
Website’s registered users to determine module effectiveness,
suggest topics for new modules, and gather demographic
data.
Study Design: A survey was designed to assess use of and
satisfaction with the training modules. Registered users of the
training website were sent an e-mail asking them to participate
and providing a link to the online survey. Responses were
anonymous.
Population Studied: The survey was distributed to all 2752
registered users of the NCCPHP Training Website.
Principal Findings: Four hundred sixteen registered users
participated in the survey, a 15 percent response rate. The two
largest occupational groups of respondents were
epidemiologists: 68, and public health nurses: 61. Twentyseven percent of respondents discovered the website through
an Internet search; a colleague referred 22 percent to the site.
Most public health nurses learned about the training site
through the North Carolina Public Health Workforce
Development System, a learning management system
available from NCCPHP. Fifty-four percent completed at least
one training module in the last year. Of those who did, 98
percent said the module provided them with the information
they were seeking, 92 percent said the module made them feel
better equipped to do their jobs, 62 percent recommended the
website to colleagues, and 61 percent bookmarked the website
on their computers. Fifty-four percent said the website is one
of the first three places they look online for training related to
terrorism and other emerging health threats. Sixty-four
percent of epidemiologists and 54 percent of public health
nurses completed a training module in the last year; 96
percent of epidemiologists and 100 percent of nurses said the
module provided the information they needed. More than half
of all respondents desired more training in
emerging/reemerging diseases, outbreak investigation,
epidemiology methods, and surveillance. Epidemiologists
requested additional training in epidemiology methods,
surveillance, geographic information systems, and
biostatistics. Public health nurses desire additional training in
outbreak investigation, emerging/reemerging diseases, and
public health law.
Conclusions: Online training modules from NCCPHP provide
most users with needed information and help equip them to
do their jobs. This website is one of the first places that users
look for preparedness training; many bookmark this site and
have recommended it to others. A limited population
completed this survey, so results cannot be generalized to a
larger population without additional research.
Implications for Policy, Delivery, or Practice: Short, online
modules are a highly effective way to provide necessary
information to public health workers for public health
preparedness topics. Distance learning is useful for
bioterrorism preparedness because it allows quick access to
just-in-time training.
Primary Funding Source: CDC
●Direct Care (DC) Staffing and Turnover in Nursing
Homes: An Attempt to Identify Instrumental Variables
Bita A. Kash, MBA, FACHE, Charles D. Phillips, Ph.D., MPH,
Catherine Hawes, Ph.D.
Presented By: Bita A. Kash, MBA, FACHE, Graduate Research
Assistant, Health Policy and Management, School of Rural
Public Health, Texas A&M University Health Science Center,
3000 Briarcrest Drive, Suite 300, Bryan, TX 77802; Tel:
(979)458-0652; Fax: (979)458-0656; Email:
bakash@srph.tamhsc
Research Objective: 1) To identify firm-specific variables
related to DC staff turnover, and 2) to test the usefulness of
identified instrumental variables in the construction of 2SLS
models of DC staffing, where staff turnover has been identified
as endogenous.
Study Design: We used an economic framework of human
capital and on-the-job training (OJT) to test potential
predictors of staff turnover. We also tested other potential
variables related to staff mix, benefits, and management
capacity which could affect turnover, and therefore may be
useful in the development of a 2SLS model of DC staffing.
These potential instrumental variables (IVs) were tested for
significant covariation with staffing versus turnover using
Pearson correlation methodology. Next, staffing regression
models were developed to predict direct care (DC) staff hours
per resident day. We then analyzed the usefulness of the
identified IVs for 2SLS regression modeling.
Population Studied: The population of nursing homes
originated from the 2002 Texas Medicaid Nursing Facility
Cost Report (1,016 facilities). This study did not include
hospital based facilities. Texas is unique due to the large
number of facilities allowing for a large sample size, and a
well-established Medicaid cost report process allowing for a
thorough examination of expense categories.
Principal Findings: We tested five potential IVs and identified
only one - expense ratio - as a unique indicator of staff
turnover. This IV was DC Staff Training Expense Ratio, as
proposed in the human capital framework. All other proposed
IVs were either significantly correlated with both staff levels
and staff turnover, or only related to staffing. The direction of
the relationship between staff turnover and staff training
expense was negative as expected. The results from the OLS
and 2SLS regressions were expected and consistent: percent
Medicaid had a significant negative effect on staffing, while
average case mix complexity (CMI) demonstrated a significant
positive effect. The size of the facility proved to be a
significant positive predictor of staffing levels. Although staff
training expense ratio was identified as an IV for staff turnover
rates, and the hypothesized relationship of specific training
and turnover was accepted, we did not see enough support for
the use of 2SLS models in DC staffing prediction models.
Conclusions: Both OLS and 2SLS models are consistent in
identifying the significant predictors of nursing home DC
staffing levels. Most predictors of staffing are organizational
characteristics, making DC staffing supply less dependent on
market factors and more sensitive to ownership status and
facility resources. OTJ training does matter when looking at
staff turnover. Our process of IV identification assumed that
all resident care staff training expenses were strictly for longterm care “specific training.” In order to improve this
approach to analyzing DC staff turnover, one would need
more detailed information on the type of training received
(e.g., general versus specific OJT).
Implications for Policy, Delivery, or Practice: As we are able
to explain turnover rates with a growing number of unique
predictor variables, opportunities for developing effective
retention practices and supportive public policies will emerge.
Primary Funding Source: No Funding Source
●Physician-Patient Race Concordance May Reduce Risks
of Potentially Avoidable Maternity Complications for
African American Medicaid Beneficiaries
Sarah Laditka, Ph.D., James Laditka, DA, Ph.D.
Presented By: Sarah Laditka, Ph.D., Associate Professor,
Dept. Health Services Policy and Management, University of
South Carolina, HESC Building, 800 Sumter Street, Columbia,
SC 29208; Tel: (803)777-1496; Fax: (803)777-1836; Email:
sladitka@gwm.sc.edu
Research Objective: There is evidence that minority patients
prefer treatment by minority physicians, and that minority
physicians are more likely to treat minority patients and those
whose insurance status limits access to health services.
Communication, understanding, and trust may be enhanced
with greater physician cultural competence. Patients who
understand and trust their physicians may be more likely to
adhere to recommended behaviors and health care regimens.
We examined associations between physician-patient race
concordance and pregnancy outcomes associated with the
accessibility and success of prenatal care, for African American
Medicaid beneficiaries. We used an indicator of prenatal care
access and quality, Potentially Avoidable Maternity
Complications (PAMCs). This indicator uses hospital
discharge data to identify pregnancy complications that may
often be prevented through successful prenatal care. We
defined PAMCs with an expert panel including obstetricians,
with external physician review. PAMCs are defined by
combinations of primary and secondary diagnoses, such as a
delivery hospitalization with both a urinary tract infection and
a complication known to be associated with such infections.
Study Design: Data were obtained from the South Carolina
Budget and Control Board. The data included de-identified
records of all deliveries covered by Medicaid in year 2000, all
health care encounters for the mothers in the 12 months
preceding delivery, and provider information that included
patient-physician race concordance. PAMC risk was estimated
using multilevel logistic regression. Individual-level controls
included age, education, marital status, income, and
comorbidities. Area-level controls included rurality, median
income, physician supply, and the availability of either a
community or rural health center.
Population Studied: 10,687 year 2000 delivery hospital
discharges for African American women whose pregnancy
care was provided by Medicaid in South Carolina.
Principal Findings: Women in the study received treatment
from a total of 3,776 physicians who were not African
American, and 136 physicians who were African American. Of
all deliveries, 3.2% included PAMCs; 23% of African
Americans had at least one race concordant prenatal care
visit, whereas only 3.7% had race concordance in more than
one-third of their visits. In adjusted results, each 1% increase
in the proportion of prenatal care visits that were race
concordant was associated with a 3.2% decrease in PAMC risk
(p=.001). The odds of having a PAMC for those with any race
concordant prenatal care visit were only 45% of the odds for
those having no race concordant visits (p=.002). The odds of
having a PAMC for women with at least two-thirds of visits
being race concordant were only 28% of those for others
(p=0.013). Race concordance had a larger effect on model fit
than any other predictor.
Conclusions: Pregnant African American Medicaid
beneficiaries have notably improved pregnancy outcomes
when they obtain prenatal care from African American
physicians.
Implications for Policy, Delivery, or Practice: United States
policies encourage physician training for African Americans
and other minorities. Although our results could be influenced
by selection effects, they suggest these policies should be
supported and expanded. Results also suggest the need for
additional cultural competence for majority physicians who
treat vulnerable minority Medicaid beneficiaries.
Primary Funding Source: HRSA, Office of Rural Health Policy
●Breast Imagers
Rebecca Lewis, MPH, Mythreyi Bhargavan, Ph.D.
Presented By: Rebecca Lewis, MPH, Researcher, American
College of Radiology, 1891 Preston White Drive, Reston, VA
20191; Tel: (703)295-6771; Fax: (703)264-2443; Email:
rebeccal@acr.org
Research Objective: Much has been discussed recently in
popular media and in academic literature about breast
imaging, specifically mammography and its effectiveness,
effect of low reimbursement and lawsuits on potential access
to mammography, and the quality of mammography in the
country, particularly in the context of the Mammography
Quality Standards Act (MQSA) which was reauthorized in
2004. Little is written about those radiologists who interpret
mammograms, such as measures of their training and
experience, practice patterns, and the volume of work. This
study seeks to fill that gap.
Study Design: This paper uses data from the American
College of Radiology’s 2003 Survey of Radiologists.
We quantify the pool of available breast imagers using a
variety of definitions of breast imagers: based on training,
volume of mammograms, percentage of time spent in breast
imaging, and self-identification. We document the average
level of training and experience that they have relative to other
radiologists. We measure if there are any differences in access
to mammographers across geographic locations (census
regions) and types (e.g., urban versus rural). We use the age
distribution across physicians and other practice
characteristics to estimate the available supply of
mammographers in the future.
Population Studied: All analyses were performed on posttraining, professionally active radiologists, and were weighted
to be representative of all radiologists in U.S.
Principal Findings: Roughly 58% of those radiologists who
perform any mammograms, interpret >=480 mammograms
per year, which is an approximation of the current MQSA
requirement of 960 mammograms across two years. 55% of
radiologists interpret fewer than 1000 mammograms per year.
Of those who perform any mammograms, 98% are boardcertified, and 4% have a fellowship in breast imaging, while
57% have a fellowship of any type. Most mammographers are
located in the Midwest and South, work in private radiology
(50%) or multi-speciality private practices (32%), and practice
in the main city of smaller metropolitan areas. Statistically
significantly more women than men report having a specialty
in breast imaging, and report breast imaging or women’s
imaging as their primary specialty. Significantly more women
than men report spending 30% or more of their clinical time
in breast imaging and women perform significantly more
mammograms than men.
Conclusions: The large majority of mammographers are welltrained in that they are board-certified, and/or have a
fellowship in breast imaging. There is no obvious evidence
that women in rural areas or in certain census regions have
lower access to mammography than others.
Implications for Policy, Delivery, or Practice: Women
predominately undergo training in and exhibit a preference for
breast imaging subspecialties, and the number of women
going into radiology is not increasing; the combination of
these factors could affect the access to breast imaging in the
future. A large number of radiologists perform low volumes of
mammograms per year. As a result, any changes in
regulations related to volume requirements must take into
account the effect on patient access to qualified
mammographers.
Primary Funding Source: No Funding Source
●Survey of Nursing Work Environment: a Confirmatory
Factor Analysis of the Nursing Work Index-Revised
Yu-Fang Li, Ph.D., RN, Anne Sales, MSN, Ph.D., RN, Nancy
Sharp, Ph.D., Gwen Greiner, MS, MPH, Elliott Lowy, Ph.D.
Presented By: Yu-Fang Li, Ph.D., RN, Research Health
Science Specialist, HSR&D, VA Puget Sound Health Care
System, 1100 Olive Way, Suite 1400, Seattle, WA 98101; Tel:
(206) 768-5383; Fax: (206) 764-2935; Email:
yufang.li@med.va.gov
Research Objective: Associations between perception of work
environment, nurse retention and recruitment, and patient
outcomes have been supported by previous studies, although
their properties are not fully assessed. The objective of this
study was to assess properties of three different factor
solutions for the Nursing Work Index-Revised (NWI-R).
Study Design: Data came from 6650 staff registered nurses
who participated in the Nurse Staffing and Patient Outcomes
in VA project nursing staff survey conducted by mail in 2003.
Reliabilities of the NWI-R and its subscales were evaluated
using Cronbach’s alpha. We conducted confirmatory factor
analyses (CFA) using 50% of the sample to examine the
goodness-of-fit of one-, three-, and five-factor models of the
NWI-R. Unidimensionality of individual factors was examined
if a model revealed a poor fit to the data. The modified models
were cross-validated using the other half of the sample.
Population Studied: Registered Nurses working at VHA
Medical Centers with acute inpatient units.
Principal Findings: Cronbach’s alphas ranged from .90 to .95
for the three solutions of the NWI-R and .80 to .88 for the
subscales. None of the original models tested provided good
overall fit to the data. Items underlying nurse-physician
relations and adequacy of support appeared to be consistent
across models. Large standardized residuals between items
suggested that these items may reflect constructs other than
those previously described. Five new models were created by
including additional factors, dropping ambiguous items, or
allowing correlated error covariance and items to cross-load
on multiple factors. Results from cross-validations suggested
that an alternative five-factor model representing the areas of
career advancement, adequate support, nurse-physician
relationships, supportive management, and foundations for
quality care might be most stable in repeated samples.
Conclusions: Effective measurement of nurses’ perceptions
of their work environment requires that researchers are
assured of the reliability and validity of the instrument used in
their studies. Results suggested that the three forms of the
NWI-R examined in this study required adjustments to
strengthen their psychometric properties.
Implications for Policy, Delivery, or Practice: Despite the
increased interest in job satisfaction of nursing staff, VHA has
not standardized an instrument to investigate this construct
systematically. This study presented a form of the NWI-R, a
commonly used nursing job satisfaction instrument, to serve
as a starting point toward this effort.
Primary Funding Source: VA Health Services Research and
Development
●America's Health Workforce: Larger and More Complex
Than We Thought
Ana Maria T. Lomperis, MA, Ph.D.
Presented By: Ana Maria T. Lomperis, MA, Ph.D., Associate
Professor of Health Management and Policy, Department of
Health Management and Policy, Saint Louis University, 3545
Lafayette Avenue, Salus Center, Suite 300, St. Louis, MO
63104-1314; Tel: (314)977-3236; Fax: (314)977-1674; Email:
lomperat@slu.edu
Research Objective: Today two-thirds of health care costs are
generated by labor. Yet, as many have argued, the health
workforce continues to be largely neglected as a focus of
health policy research (e.g., McLaughlin 1994; Iglehart).
Reliable, systematic data on the health workforce are rare.
Moreover, there is no agreement in the literature on how to
define America's health workforce, and by extension, how
large it really is. Estimates range from the 10 million
"conventional" health care workers, such as physicians and
nurses, to the roughly 12 million jobs in "conventional" health
delivery industries, such hospitals and physician offices. But
these approaches overlook millions in other settings from
mental and public health workers to those employed by
pharmaceutical firms, health insurance companies and in the
health policy research field. The main objective of this study is
to identify the range of occupations and industries that should
be included in a definition of the health workforce and provide
an estimate of the total number of individuals employed in
them that reflects their full contribution to the health sector in
the United States today
Study Design: Michael Grossman's seminal work in 1972 on
the production of health provides the theoretical basis for this
study. According to Grossman, consumers produce "good
health" by combining their own time with a wide variety of
health care and other goods and services. Thus, the health
workforce should include everyone whose livelihood
contributes to the production of health - from the
conventional health care occupations typically studied to the
"other health" occupations typically overlooked.
The study develops a matrix that identifies both such
"conventional" and "other health" occupations and industries
based on the federal government's classification systems.
Detailed unpublished data from the U.S. Bureau of Labor
Statistics' 2000-10 National Industry-Occupation Employment
Matrix are then used to fill the matrix to produce estimates of
the total number of jobs in these health occupations and
industries in 2000, as well as those projected for 2010.
Population Studied: The population studied includes
members of the U.S. labor force, whatever their occupation
and wherever they work.
Principal Findings: This study finds that America's health
workforce is much more complex and far larger than
commonly understood. Specifically, it identifies 343 more
occupations and 17 additional industries that are overlooked
in previous works. It also estimates that the U.S. health
workforce, broadly defined, represented nearly 16 million jobs
and 11 percent of the overall U.S. labor force in 2000 -considerably more than the 9.6 million jobs and 6.6 percent of
the overall workforce in the conventional health care
occupations and the 11 million jobs and 7.6 percent of the
total in the conventional health services industries typically
counted.
Conclusions: The health workforce is more complex and far
larger than most previous studies have suggested. This study
provides a first step in reaching this understanding and
suggests avenues for future research.
Implications for Policy, Delivery, or Practice: The findings
of this study should be of broad interest to health policy
researchers and practitioners seeking ways to more effectively
utilize the skills and talents of the millions of individuals
employed in the health sector.
Primary Funding Source: University funding
●The Impact of Nosocomial Complications on Patient
Mortality: Findings from the Economic Value of Nursing
Model
Peggy Maddox, RN, Ph.D., Tim Dall, MS, Juliette Chen, MPH,
Paul F. Hogan, Ph.D. (abd)
Presented By: Peggy Maddox, RN, Ph.D., Director, School of
Nursing, Center for Health Policy and Research, Fairfax, VA ;
Tel: (703) 993-1982; Email: pmaddox@mason.gmu.edu
Research Objective: This study quantifies the additional
mortality risk attributed to each of 10 nosocomial
complications acquired in general, acute care hospitals. These
nosocomial complications are recognized as nursing sensitive
outcomes—i.e., patient outcomes that are sensitive to the
quality of nursing care received. This research is part of a
larger effort sponsored by the Nurses’ Agenda for the Future
(NAF) to quantify the patient care and economic implications
of alternative nursing systems of care.
Study Design: Using patient-level discharge data from the
2002 National Inpatient Sample (NIS), we use regression
analysis to isolate the contribution of each nosocomial
complication on patient mortality controlling for patient acuity
and other risk factors. The 10 nosocomial complications
modeled are urinary tract infection (UTI), decubitus ulcer,
pneumonia, deep vein thrombosis/pulmonary embolism
(DVT/PE), upper gastrointestinal tract infection (UGI), central
nervous system (CNS) complications, sepsis, shock/cardiac
failure, postoperative infection, and pulmonary failure. Using
the Economic Value of Nursing Model (EVNM), we quantify
the relationship between RN staffing and patient risk of
complications, and the relationship between complications
and mortality risk to estimate the relationship between
nursing systems of care and patient mortality.
Population Studied: Patients admitted to general, acute care
hospitals. Separate analyses are conducted for patients
admitted for major surgery (i.e., the surgical pool), and all
other patients (i.e., the medical pool).
Principal Findings: In 2002, an estimated 450,000
premature deaths are directly attributed to nosocomial
complications. The increase in mortality risk attributed to
patient complications differs by type of complication and
differs among patients in the medical and surgical pools. The
three leading complications in terms of the attributed (i.e.,
after controlling for patient acuity) number of deaths are
shock/cardiac failure (167,600 deaths), pulmonary failure
(69,600 deaths), and hospital-acquired pneumonia (60,500
deaths). When these mortality risk estimates are incorporated
into the EVNM, the estimated relationship between nurse
staffing and patient risk of in-hospital mortality is similar to
estimates in the literature of the relationship between nurse
staffing and failure to rescue.
Conclusions: Patients who experience complications are at
increased risk of mortality. This fact highlights the importance
of providing adequate nurse staffing levels and skill mix that
can help prevent the occurrence of nosocomial complications.
Implications for Policy, Delivery, or Practice: These findings
on the mortality risk attributed to nosocomial complications
are useful to hospitals, clinicians and researchers developing
new methods and practices to improve patient care.
Clinicians tracking the incidence of nosocomial complications
as part of initiatives to improve patient care can apply these
attributed mortality risks to quantify the effects of their
initiatives on patient mortality.
Primary Funding Source: Nurses' Agenda for the Future and
contributing associations
●Are We There Yet? Distance to Pediatric Subspecialty
Providers in the United States
Michelle Mayer, Ph.D., MPH, RN
Presented By: Michelle Mayer, Ph.D., MPH, RN, Rsearch
Fellow, Sheps Center for Health Services Research, University
of North Carolina at Chapel Hill, CB #7590, Chapel Hill, NC
27599-7590; Tel: (919)966-7666; Fax: (919)966-3811; Email:
michelle_mayer@unc.edu
Research Objective: There is currently widespread concern
that the supply of pediatric subspecialists is not adequate to
meet the needs of children. To date, no one has estimated
the distances that children must travel to obtain pediatric
subspecialty services in the United States. Our objective was
to estimate the distance between pediatric populations in the
United States and identify county characteristics that are
associated with greater distances to pediatric subspeciality
care.
Study Design: Using physician data from the American Board
of Pediatrics and county level data from the Bureau of Health
Professions Area Resource File (ARF), we calculated the
straight line distance between each county in the United
States and the nearest pediatric subspecialty provider. For
each county and pediatric medical subspecialty, we calculated
the shortest straight-line distance to the nearest physician.
We merged 2003 estimates of the under-18 population from
the United States Bureau of the Census. Using distance and
population data, we calculated the percentage of the pediatric
population living within 10, 11-50, 51-100, 101-200, and 200 or
more miles of a provider for each specialty. Using county level
observations for all pediatric subspecialties simultaneously,
we performed random effects logit to identify county
characteristics associated with living more than 50 miles from
a pediatric subspecialty provider.
Population Studied: United States Counties (n=3141).
Principal Findings: Across all counties in the United States,
the population-weighted average distance to a board-certified
pediatric subspecialist ranged from 12.6 miles for neonatology
to 76.7 miles for pediatric sports medicine. For most pediatric
subspecialties, more than 75% of the pediatric population lives
within 50 miles of a certified physician. Adolescent medicine,
developmental and behavioral pediatrics, pediatric
rheumatology, and pediatric sports medicine are exceptions.
Non-metropolitan counties and those in the Pacific and
Mountain regions of the United States were significantly more
likely to be located more than 50 miles from a pediatric
subspecialist.
Conclusions: For most pediatric subspecialties, more than
75% of the under-18 population lives within 50 miles of a
provider. Pediatric subspecialists in adolescent medicine,
developmental pediatrics, rheumatology, and sports medicine
are less widely available. These results suggest that the
practice locations of pediatric subspecialists parallel the
geographic distribution of children in the United States.
Nonetheless, children from non-metropolitan counties and
those in selected regions of the United States face significant
geographic barriers to receipt of pediatric subspecialty care.
Implications for Policy, Delivery, or Practice: Future studies
should identify ways to improve access for those children
living in areas without a nearby provider and should evaluate
the extent to pediatric subspecialist supply is adequate to
meet patient demand in the areas that currently have
providers.
Primary Funding Source: AHRQ
●Progress and Potential of Women and Minorities in
Health Care Management: Results of Two Nationwide
Studies
Ann Scheck McAlearney, Sc.D., MS
Presented By: Ann Scheck McAlearney, Sc.D., MS, Assistant
Professor, Health Services Management and Policy, The Ohio
State University, 1583 Perry Street, Atwell 246, Columbus, OH
43210; Tel: (614)292-0662; Fax: (614)438-6859; Email:
mcalearney.1@osu.edu
Research Objective: Despite a sense that women are making
effective strides in achieving higher ranks in health care
management, objective evidence shows considerable
disparities still existent, slow growth of numbers over time,
and appallingly few numbers of minorities of either gender in
health care leadership roles. This research was designed to
explore these issues in greater depth, combining results of
both quantitative and qualitative studies to improve our
understanding of how health care is or is not supporting and
promoting women and minorities, and how far we have to go.
Study Design: Results of two nationwide studies were
analyzed to assess issues of inclusion and development for
women and minorities in health care management. First, a
nationwide survey of all U.S. hospital chief executives,
conducted between August and December 2004, asked about
leadership experiences, perspectives about leadership impact,
and plans for the future. Analyses included descriptive
statistics, chi-squared analyses, linear regression, and logistic
regression. Second, an extensive qualitative study, consisting
of expert interviews and organizational case studies, was
completed between September 2003 and December 2004.
Hour-long in-person and telephonic interviews included topics
such as inclusion, opportunities for mentoring, and
perspectives about the challenges faced by women and
minorities in health care management. All interviews were
transcribed and analyzed using both deductive and inductive
methods.
Population Studied: Our nationwide survey had 844 chief
executive respondents (response rate =17.2 percent).
Consistent with other studies, our respondents were
overwhelmingly white (96 percent), making analysis by race
infeasible. The qualitative study included 60 organizational
case studies and 35 expert interviews. A total of 160
informants were interviewed across the country, including
organizational representatives with titles such as Chief
Executive Officer (CEO), Director of Human Resources, and
Director of Organizational Development. Informants from
expert interviews included consultants, recruiters, association
leaders, and academic researchers.
Principal Findings: Our survey showed that female and male
chief executives do not share the same experiences, nor the
same perspectives. Controlling for age, women respondents
were statistically significantly less likely to have previously
been CEOs (41 percent vs. 61 percent, p<.005), had shorter
tenures in their current chief executive positions (9.2 years vs.
13.5 years, p<.005), and were less likely to lead health systems
percent vs. 19 percent, p<.005) than men. Further, women
respondents rated themselves lower than men on several
measures of leadership effectiveness, including meeting their
goals with respect to management team functioning and
financial performance. Women were also significantly more
likely than men to strongly agree that offering internal
leadership programs, permitting flexibility in job assignments,
and targeting women and minorities for leadership
development should be an organizational priority. From the
qualitative study, three major themes emerged around these
issues: 1) barriers hindering progress; 2) strategies to
overcome barriers; and 3) opportunities and concerns about
targeting women and minorities as special cases in health
care leadership development.
Conclusions: Organizations aiming to increase the
representation and visibility of women and minorities in
health care leadership must acknowledge the disparities that
exist, and take active steps toward greater inclusion.
Incorporating suggested strategies such as establishing
participation metrics for senior leadership and board roles,
consciously broadening women’s and minorities’ experiences
and promoting their successes, and supporting formal
mentoring can help health care organizations by promoting
greater diversity in management so that senior leadership can
become more reflective of both the employee population and
communities that health care organizations typically serve.
Implications for Policy, Delivery, or Practice: By
understanding differences between women’s and men’s
experiences and perspectives and by considering potential
opportunities to help women and minorities advance,
organizations can make informed decisions about
investments in leadership development strategies and
successfully maximize the potential for these
underrepresented groups to attain higher ranks in health care
leadership.
Primary Funding Source: Center for Health Management
Research
●Evaluation of the introduction of US-trained Physician
Assistants to the UK NHS
Hugh McLeod, BSc, MSc, Ph.D., Juliet Woodin, Ph.D., Richard
McManus, MBChB, Ph.D., Kim Jelphs, MSc
Presented By: Hugh McLeod, BSc, MSc, Ph.D., Research
Fellow, Health Services Management Centre, University of
Birmingham, Park House, 40 Edgbaston Park Road,
Birmingham, B15 2RT; Tel: 0044 21 414 7620; Fax: 0044 21
414 7620; Email: h.s.t.mcleod@bham.ac.uk
Research Objective: US physician assistants (PAs) are
professionals licensed to practice medicine with physician
supervision. In 2003 and 2004, US-trained PAs were recruited
to the UK NHS, in family practice and emergency department
settings. The initiative was a local response to a shortage of
medical staff in a deprived area. This study assessed the
impact of the PAs in terms of: their clinical workload
compared to physician and nurse colleagues; the views of staff
and patients; and lessons for development of new UK-trained
practitioner roles.
Study Design: The clinical workload of the PAs was compared
with their physician and nurse colleagues using consultation
data recorded by the clinicians both for the study and
routinely. Data on consultations’ presenting problem(s) were
coded using the International Classification of Primary Care
(ICPC). Data on emergency department attendees were
coded using International Classification of Diseases (ICD10)
codes. Data from PAs, supervising physicians and a range of
nursing and support staff were collected using semistructured interviews. Data from patients were collected using
focus groups. Our analysis used Pawson and Tilley’s (1997)
‘context, mechanism, outcome’ conceptual framework.
Population Studied: The study included all 15 PAs employed
in the NHS in the West Midlands. Seven PAs worked in family
practices, four in two emergency departments, two in both
settings. Three PAs returned to the US. Five of the remaining
12 PAs had more than 10 years’ PA experience.
Principal Findings: The PAs in family practices increased
medical capacity by seeing a range of undifferentiated acutely
presenting patients similar to their supervising physicians.
The PAs’ contributions were influenced by factors including
consultation duration (10 to 20 minutes), practices’ clinic
arrangements, and supervising physicians’ and PAs’
preferences. The PAs were positively regarded by clinical
colleagues, and noted for strong interpersonal and
communication skills, and a team-working ethos. The
contribution made by the PAs working in the emergency
departments varied with the extent of their previous
experience and perceptions of the available supervisory
support. Patients were overwhelmingly positive in their
response to the PAs. The inability of the PAs to prescribe
medicines without a physician’s signature was the key
limitation to the PAs’ practice.
Conclusions: The PA profession has made a successful
transition from the US and has effectively increased medical
capacity in an under-doctored area. However, like physicians,
PAs contribute in a range of ways and fulfilment of a PA’s
potential requires that their skills are well matched to a
specific local need.
Implications for Policy, Delivery, or Practice: Interest in UStrained PAs is increasing in the NHS, and recruitment is
expanding. The experience of the PAs included in this study is
informing the Department of Health’s current development of
a Medical Care Practitioner (MCP) role, which is likely to be
similar to the PA role in certain respects. In the future,
registration of PAs as MCPs may resolve the key prescribing
issue. However, the PAs’ supervisory relationship with
physicians explicitly facilitates patient-centred care, an
attribute which may be lost if the MCP role is granted
independent status.
Primary Funding Source: UK Department of Health
●Physician Assistant Workforce Research Using Existing
National Health Surveys: Trials and Tribulations
Perri Morgan, MS, PA-C, Justine Strand, MPH, PA-C, Truls
Ostbye, M.D., MPH, MBA, Ph.D., FFPH
Presented By: Perri Morgan, MS, PA-C, Physician Assistant
Research Fellow, Physician Assistant Division, Duke
University, DUMC 3848, Durham, NC 27710; Tel: (919) 681
3161; Fax: (919)-681-9666; Email: perri.morgan@duke.edu
Research Objective: Given the expanding role of
nonphysician clinicians (NPCs) in the health workforce, high
health care costs, and predicted physician shortages, there is a
pressing need for research detailing the current and potential
activities, quality of care, and costs of NPCs such as physician
assistants (PAs). Although this research is inherently
interdisciplinary, research resources are often disciplinespecific. This study details strengths and weaknesses of
existing national healthcare surveys for research on physician
assistants and proposes remedies for existing barriers
Study Design: This paper is based on a critical literature
review and an analysis of existing large nationally
representative health surveys. The methodologies of several
of these surveys (Medical Expenditure Panel Survey, National
Health Interview Survey, National Ambulatory Medical Care
Survey, and Community Tracking Study) are scrutinized for
appropriateness for research on PAs. As an example, we
compare national estimates of NPC patient encounters from
each survey
Population Studied: Health workforce of the United States
and the population that uses health services.
Principal Findings: Although research has generally found
that PAs provide high quality, cost-effective care, PA workforce
analysts face several unique problems. First, since PAs are by
definition dependent providers who work under the
supervision of a physician, studies would ideally focus on care
provided by the team. National surveys, however, do not
support analysis at the team level. Second, PA practice is
extremely heterogeneous, with scope of practice carved out at
the individual level between a PA and a physician, subject to
constraints of varying state regulations. This variation
complicates any analysis of PA practice, but especially limits
the generalizability of local studies in which practice patterns
may be expected to be more homogeneous. National surveys,
however, have frequently under-represented PA practice and
have often phrased survey questions to apply to physicians
only. Third, research comparing PA to physician performance
is frequently criticized for failing to account for potential
differences in complexity of patients. Analyses that take these
issues of case mix into account require data that can be
evaluated both at the individual and at the team level. Again,
existing national surveys lack this level of detail.
Conclusions: With the looming need to expand the health
workforce, there is a critical need for information about the
viability of alternative types of healthcare providers. Existing
evidence documenting the high quality and cost-saving care
provided by NPCs has prompted workforce analysts to
advocate development and evaluation of team models of care.
Modifications in data collection and analysis techniques are
required to support conduct of high-quality, generalizable
research at the team level. For example, health care provider
data could be collected at both the individual provider and
team levels, with variables linking team members added to the
national survey datafiles.
Implications for Policy, Delivery, or Practice: Funding
agencies and researchers should pursue analyses of team
approaches to healthcare provision. Toward this end, national
workforce data collection and research methodology should
1)integrate physician and nonphysician surveys and analyses,
2)promote evaluation of team practice, and 3)support
examination of both separate and joint contributions of
physicians and nonphysicians.
Primary Funding Source: Duke University Physician Assistant
Research Fellowship
●Measuring Change in Obstetrical Provider Supply at the
Hospital Level: MA 2002-2004
Angela Nannini, FNP, Ph.D., Emily Lu, MPH, Wanda Barfield,
M.D., MPH, Donna Johnson, MSW
Presented By: Angela Nannini, FNP, Ph.D., Assistant
Professor, School of Nursing, Northeastern University, 106D
Robinson Hall, Huntington Avenue, Boston, MA 02115; Tel:
(617) 373-3112; Fax: (617) 373-8675; Email: a.nannini@neu.edu
Research Objective: 1. Measure change in supply of
obstetrical providers by perinatal hospital level and geography
in Massachusetts from 2002 to 2004. 2. Report reasons for
loss of providers. 3. Compare change in supply of providers
among Level I, II and III perinatal hospitals with trends in
numbers of deliveries at each level of perinatal care.
Study Design: A survey adapted from MA ACOG was sent to
Obstetrical Chiefs in all MA maternity hospitals (n=50) with a
88% response rate overall and 88% by each level of hospital.
The survey assessed obstetrical providers from 2002 to 2004;
the number and type of obstetrical providers [OB, family
practitioner (FP), and certified nurse midwife (CNM)], number
of recruited providers, and number who stopped obstetrical
practice and why. Percent change in obstetrical providers by
type and overall were reported by perinatal hospital level
(I,II,III) and geographic area. Trends in numbers of births at
each hospital and level of perinatal care from 2001 to 2003
were calculated and compared to losses or gains of providers.
Population Studied: Obstetricians, certified nurse midwives
and family practitioners who perform deliveries at perinatal
hospitals in Massachusetts.
Principal Findings: Overall, 7.6% of all OB providers and
10.7% of OBs were loss in MA between 2002 to 2004. Level I,
II and III lost 14.6%, 5.8 % and 9.4% of OBs respectively.
Western MA lost 1 in 4 OBs but other areas lost only 1 in 18.
50% of Level I hospitals had <= 4 OBs and 18% had <= 4 OB
providers. Cost of liability insurance accounted for nearly 40%
of loss of OBs. Other major issues related to provider loss
were recruitment, retention, retirement and change of practice
patterns.
Conclusions: Loss of obstetricians was greater than loss of
other providers. Hospitals designated as Level I perinatal
facilities or located in western MA suffered the greatest losses.
OB services in hospitals with <=4 providers may be in
jeopardy of closing. This survey at the hospital level yielded
better response rates than previous surveys to individual
providers.
Implications for Policy, Delivery, or Practice: Overall
statewide estimates of obstetrical provider loss may obscure
geographic and hospital level losses. The disproportionate
loss of providers at Level I hospitals and in Western MA may
encourage women to seek care at more costly facilities and
travel longer distances to get care. The relationship of these
losses to the ability of women to access prenatal care needs to
be monitored.
Primary Funding Source: No Funding Source
●The Canadian Contribution to the US Physician
Workforce
Robert Phillips, M.D., MSPH, Georger Fryer, Jr., Ph.D., Walter
Rosser, M.D., Jessica McCann, MS, Martey Dodoo, Ph.D.
Presented By: Robert Phillips, M.D., MSPH, Director, The
Robert Graham Center, American Academy of Family
Physicians, 1350 Connecticut Avenue NW, Suite 201,
Washington, DC 20036; Tel: (202)331-3360; Fax: (202) 3313374; Email: bphillips@aafp.org
Research Objective: To understand the net emigration of
Canadian physicians to the United States in the context of a
physician shortage in Canada. We measure the size of effect of
this emigration and consider its repercussions for the
physician workforce in other developing countries.
Study Design: We performed a cross-sectional analysis of the
2004 AMA Masterfile, the 2002 Area Resource File, and
reported data from the Canadian Institute for Health
Information, the Canadian Medical Association, and the
Association of Canadian Medical Colleges to produce a count
of Canadian graduates who have ever come to the US, those
in the US as of 2004, those in active practice, those in rural or
underserved areas, and their net, annual contribution to the
US physician workforce. We also examine the immigration of
other foreign-trained physicians to Canada compared to
physician emigration to test whether retention of émigrés
could achieve physician workforce self-sufficiency for Canada.
Population Studied: US physician workforce, Canadian
physician workforce
Principal Findings: Two-thirds of the 11,912 Canadianeducated physicians living in the US spend the majority of
their time in direct patient care and are more likely than US
graduates to practice in rural areas (p<0.001). From 19601997, an average of 184 Canadian-educated physicians from
each graduating class joined the US physician workforce and
spend the majority of their time in direct patient care. This
migration appears to be slowing; however Canada still realized
a net loss of 80 physicians in 2003. There are 13,286 foreigntrained, licensed physicians in Canada excluding those in
training. This contrasts with 8,665 to 9,852 (depending on
status of non-classified physicians) similarly active Canadiantrained physicians in the United States.
Conclusions: In the midst of a physician shortage, Canada
has been a net supplier of physicians to the United States.
This physician export is equivalent to having nearly two,
average-sized Canadian medical schools dedicated to
producing physicians for the US. This trend may be waning
but requires more longitudinal observation. There are just
402 US-trained physicians practicing in Canada. The net
migration of Canadian-trained physicians working in the
United States represents 65%-75% of the current foreigntrained physician workforce in Canada. The foreign-trained
physicians in Canada come predominantly from lessdeveloped countries, with South Africa as the leading donor.
Implications for Policy, Delivery, or Practice: Workforce
policies that promote physician supply self-sufficiency in the
United States could reduce the draw for Canadian-trained
physicians and support workforce needs there. Likewise,
polices that promote retention of Canadian-trained physicians
within Canada could reduce reliance on foreign physicians.
Policies in both countries that support self-sufficiency would
further benefit the, largely, less-developed countries, which fill
the gaps to the detriment of their own health workforce needs.
Primary Funding Source: American Academy of Family
Physicians
●Shortage of Dental Hygienists in Private Practices of
General Dentists
Nadereh Pourat, Ph.D., Roberta Wyn, Ph.D., Dylan Roby,
MPhil, Marvin Marcus, DDS, MPH
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; Email: pourat@ucla.edu
Research Objective: Data on capacity for dental care is scant
and less is known on the adequacy of supply of dental
personnel such as hygienists in dental practices.
Nevertheless, a perception of shortage of such personnel has
been documented. We examine the perceptions of shortage
of dental hygienists, the concordance between perceived
shortage and delays in hiring of dental hygienists, and
predictors of perceptions and delay in hiring of these
personnel.
Study Design: A cross-section of dentists in private practices
in California was surveyed. Survey topics included
demographics, practice setting, and specialty of dentists;
practice location; dental assistant and hygienist questions
including size, salary, benefits, work status and dentists’
perceptions of availability of dental personnel. Concordance
of dentists’ perception of shortage and experienced delays in
hiring of dental hygienists were evaluated in bivariate and
multivariate analysis. Analyses were weighted to account for
disproportionate sampling of dentists in rural and less
populated counties and adjusted for the clustering of dentists
by county.
Population Studied: A cross-section of dentists in private
practice in all California counties with licensed dentists.
About 4,300 eligible dentists participated in the mail survey
with telephone follow up, with an adjusted response rate of
52%.
Principal Findings: Preliminary analysis shows that 52% of
dentists reported having an opening for hygienists currently or
in the past year. Of these dentists, 47% experienced delays in
hiring hygienists defined as more than 1.5 months time to hire
hygienists. Dentists who experienced delays more frequently
offered dental care and vacation benefits to their full time
hygienists and offered higher salaries to the hygienists
currently employed in their practices. Those experiencing
delays were more frequently clustered in larger urban areas in
northern and southern California and had a lower average
ratio of full-time equivalent (FTE) hygienists to FTE dentists in
their county of practice. Ninety-seven percent of dentists who
had experienced delays in hiring believed that there was a
shortage of hygienists in their area. Examining the predictors
of delays in hiring in a logistic regression model only revealed
geographic region of practice and gender to be significant
predictors of delays. Examining predictors of having an
opening for hygienists revealed that dentists with more
hygienist turnover, those owning their practice, and those
reporting being too busy or overworked were more likely to
have openings for hygienists. Geographic region was also a
significant predictor of having an opening. Examining
predictors of perceived shortage of hygienists revealed that
dentists who offered more benefits, paid higher salaries, and
had higher turn over of hygienists were more likely to perceive
a shortage of hygienists. In contrast, those not experienced
delays or not having hired hygienists in the past year, younger
dentists and those within five years of graduation from dental
school, and those of Latino or African American decent were
less likely to perceive a shortage of hygienists.
Conclusions: Results suggest that delays in hiring of
hygienists are tied to geographic location of the practice and
so are openings for these personnel. Both factors suggest a
possibility of differential supply of hygienists by geographic
region in California counties. Dentists’ perception of hygienist
shortage are seemingly dependent on experienced delays in
hiring these personnel but not exclusively so. Other
experiences of dentists also play a role in this perception,
suggesting additional differential in experiences of dentists in
relation to their employment of hygienists.
Implications for Policy, Delivery, or Practice: Access to
dental care is partly determined by capacity of dentists to
provide care and this capacity is dependent on adequate
supply of essential personnel such as hygienists. Examining
the issues in hiring and retention of dental hygienists in dental
practices would illuminate the pathways to insuring a
sufficient supply of allied dental personnel.
Primary Funding Source: California Dental Association
Foundation
●Comparing Characteristics of Dentists and their Practices
in California and the U.S.
Dylan Roby, M.Phil, Nadereh Pourat, Ph.D., Roberta Wyn,
Ph.D., Marvin Marcus, DDS
Presented By: Dylan Roby, M.Phil, Senior Research Associate,
Center for Health Policy Research, UCLA, 10911 Weyburn
Avenue, Suite 300, Los Angeles, CA 90024; Tel: (310)794-3953;
Email: droby@ucla.edu
Research Objective: To examine the characteristics of
dentists and dental practices in California and how they
compare to national data.
Study Design: A cross-section of general dentists in private
practice in California was surveyed by mail in 2003. Survey
topics included demographics, practice setting, and specialty
of dentists; practice location; staffing questions on size of the
practice, salary for assistants, hygienists, and front office
personnel, benefits, work status and dentists’ perceptions of
availability of dental personnel. The information generated
from this survey is the first of its kind in the state, and allows
us to compare the California dentists’ and their practices to
nationwide data using 1998 and 2001 reports of American
Dental Association (ADA) data, the latest data available
Population Studied: A cross-section of general dentists in
private practice in all California counties with licensed
dentists. About 4,300 dentists participated in the mail survey
with telephone follow up, with an adjusted response rate of
52%.
Principal Findings: Preliminary analysis shows that dentists
in private practice in California have different characteristics
when compared to the entire nation. More tend to practice
general dentistry (90% vs. 84%), work in larger practices
(48% vs. 32% have two or more dentists), less frequently
employ hygienists (88% vs. 73% have no full-time hygienists)
but they employ more dental assistants (7% vs. 32% have no
full-time dental assistants), pay higher hourly salaries to
hygienists ($42 vs. $29) and dental assistants ($16 vs. $13)
than dentists nationally. California dentist less often own the
practice that they work in (82% vs. 90%), and spend less time
in patient treatment activities (92% vs. 88%) than dentists
nationwide. In their demographic characteristics, California’s
dentists are more often women (27% vs. 10%) than in the rest
of the country and tend to be slightly older (86% vs. 80% are
between 30-59 years old). More than half (53%) of California
dentists are white, 34% are Asian, 6% are Latino, other races
make up 6% of the dentists, and only 1% are AfricanAmerican. Over half (53%) of dentists practice in Southern
California, with 27% concentrated in the Bay Area. Lastly,
60% of dentists in the state speak a language other than
English, while 68% of the dental practices have staff members
that speak another language as well. There are no comparative
national data for these demographic characteristics.
Conclusions: Findings suggest that California’s dentists differ
from the rest of the nation in a number of demographic and
practice characteristics. Due to these differences, national
policies on dental personnel and access to care may influence
California dentists differently or in unexpected directions.
Implications for Policy, Delivery, or Practice: A true
understanding of the dental care personnel and delivery of
dental care in California is more likely to be achieved using
California specific data. Policies to improve access to care or
to insure adequate supply of dental personnel may not
otherwise achieve their intended effects.
Primary Funding Source: California Dental Association
Foundation
●Advancement of Minorities in Nursing: Is There
Discrimination?
Jean Ann Seago, Ph.D., RN, Joanne Spetz, Ph.D.
Presented By: Jean Ann Seago, Ph.D., RN, Associate
Professor, Community Health Systems, University of
California, San Francisco, Box 0608, San Francisco, CA 94143;
Tel: (515)402-6340; Email: jean.ann.seago@nursing.ucsf.edu
Research Objective: America’s diverse population is not
reflected in its nursing workforce, especially at senior and
executive levels. The purpose of this study was to provide
baseline data on the experiences of registered nurses who selfidentify as members of ethnic minority groups. We examine
how the experiences of ethnic minority nurses are similar or
different from majority nurses as they seek such positions or
work to resolve issues in the workplace.
Study Design: A survey of 6000 registered nurses across
California was conducted. Ethnic minority groups were oversampled. The survey focused on (1) the career paths of nurses
of different ethnic backgrounds and (2) the barriers which
minority nurses may face. The survey data were analyzed both
univariate and multivariate methods. Multivariate regression
equations were used to examine the independent
contributions of race, ethnicity, and age.
Population Studied: 6000 Registered Nurses in California in
2004.
Principal Findings: Two-thirds of the Filipino nurses in the
survey believe they have the opportunity to advance in their
workplace. White nurses were the least likely to believe that
they have the opportunity to advance in their workplace.
However, only 18.3% of white nurses reported that there were
barriers to the advancement of their careers in the workplace
in contrast to about 40% of Filipino nurses who perceived
barriers to the advancement of their career. While African
American nurses applied for promotions more often than
nurses from other ethnic groups, 42.8% of them feel that they
have been denied a promotion that they were qualified for.
Most of these nurses felt that favoritism and race were the
primary factors responsible for the denial of their promotion.
Only 29.6% of white nurses felt that they have been denied a
promotion that they felt they were qualified for. Most white
nurses (57%) believed that they do not have a good working
relationship with other nurses in their workplaces. However,
when asked about feelings of isolation, African American and
Other Asian nurses, more than nurses of other ethnicities,
expressed that they felt isolated by other nurses in their
workplaces. Filipino and African American nurses reported
that nurses of their ethnicities were not treated equally in their
workplaces. Eighty-four Filipino nurses, the highest number
among all groups, have been criticized by coworkers or their
supervisors for speaking a language other than English at
work. Multivariate analyses indicate that age is a factor
affecting satisfaction and promotion opportunities. Since
white nurses are older, on average, than minority nurses, they
are particularly dissatisfied. Once age has been controlled in
multivariate analyses, the differences between ethnic groups
are smaller.
Conclusions: The most surprising finding was the profound
dissatisfaction of the majority nurses in our sample compared
to the minority nurses. That they were dissatisfied was not a
surprise, but the large percent differences toward the negative
for most items was startling.
Implications for Policy, Delivery, or Practice: The
encouragement of larger numbers of minority persons to
enter and remain in nursing can be supported because the
minority nurses are more satisfied with their work.
Primary Funding Source: Impact Fund
●Nurses in VHA Hospitals: Results from the Nurse
Staffing and Patient Outcomes in VA Nursing Staff Survey
Nancy Sharp, Ph.D., Anne E. Sales, Ph.D., RN, Gwendolyn T.
Greiner, MPH, MSW, Yu-Fang Li, Ph.D., RN, Pamela Mitchell,
Ph.D., RN, Julie Sochalski, Ph.D., RN
Presented By: Nancy Sharp, Ph.D., Health Sciences Research
Specialist, Health Services Research & Development, VA
Puget Sound Health Care System, 1100 Olive Way, Suite 1400,
Seattle, WA 98101; Tel: (206) 277-3584; Fax: (206) 768-5343;
Email: nancy.sharp@med.va.gov
Research Objective: The nursing workforce, including
registered nurses (RNs), licensed practical or vocational
nurses (LPNs or LVNs), nurse aides (NAs), and health
technicians (HTs), makes up the largest group of health care
providers in the VHA. We report on demographic
characteristics of nursing staff working in VHA hospitals and
their self-report of perceptions of work environment and
quality of care, and compare VHA RNs to RN responses
reported by a recent study of nurses in five countries.
Study Design: The nursing staff survey was part of an
observational, cross-sectional study examing associations
between nurse staffing, nursing outcomes, and patient
outcomes in VHA. The survey instrument, adapted from a
survey developed by the International Hospital Outcomes
Consortium (IHOC), included questions about workload,
working environment, job satisfaction and quality of care in
addition to demographic data.
Population Studied: We administered a survey to 46,277
nursing staff in 125 VHA facilities with acute inpatient services.
Principal Findings: We received responses from 11,378 VHA
nurses for a response rate of 24.6% overall. RNs, LPN/LVNs
and combined NA/HTs showed significant differences in
demographic characteristics, with a higher proportion of men
and racial and ethnic minorities among NAs/HTs than in
other nursing categories. Perceptions of the nursing work
environment also differed. RNs reported more positive
perceptions of salaries, while NA/HTs reported more positive
perceptions of management response to nurses’ concerns,
participation by nurses in policy decisions, opportunities for
advancement, and adequacy of support staff. LPNs were more
likely than other nurses to report an increase in the number of
patients assigned to them in the past year. Compared to RNs
described by the IHOC study, a higher proportion of VHA RNs
perceived that there were enough staff to get the work done
and enough staff to provide high quality care, and fewer VHA
RNs reported a decrease in the number of nurse managers
over the past year than the IGIC groups. Overall, VHA RNs
looked more like respondents in countries other than the US,
represented in the IHOC study by RNs in Pennsylvania, and
painted a relatively positive picture by comparison with RNs in
other countries and health care systems.
Conclusions: VHA nurses report different levels of job
satisfaction and different perceptions of their working
environment and quality of care depending on their job type.
In general, RNs appear least satisfied, and to have the lowest
perceptions of the quality of the work environment of the three
types of personnel. However, VHA RNs compare favorably on
many measures to RNs from non-VHA hospitals in the U.S.
and other countries.
Implications for Policy, Delivery, or Practice: VHA facilities
compete for personnel in all categories with other health care
organizations and providers in local, regional, and national
markets. Understanding how nurses’ perceptions of their
working environment and quality of care differ across job type
and health care system is important for developing successful
recruitment and retention initiatives in VHA.
Primary Funding Source: VA
●Professional Liability Issues and Practice Patterns of
Obstetrical Providers in Washington State
Susan Skillman, MS, Thomas Benedetti, M.D., MHA, LauraMae Baldwin, M.D., MPH, Elise Bowditch
Presented By: Susan Skillman, MS, Deputy Director, Center
for Health Workforce Studies, University of Washington, Box
354982, Seattle, WA 98195; Tel: (206) 543-3557; Fax: (206) 6164768; Email: sskillman@fammed.washington.edu
Research Objective: To describe Washington State obstetrical
providers’ (obstetrician/gynecologists (OBs), family practice
physicians (FPs), certified nurse midwives (CNMs) and
licensed midwives (LMs)) clinical practice organization, recent
changes in their obstetrical practice patterns, and the potential
relationship between practice changes and liability insurance
factors.
Study Design: Mailed four-page questionnaire to obstetrical
providers asking about demographic and practice
characteristics, type and amount of liability insurance, practice
changes and limitations due to liability insurance issues,
extent of obstetrical services provided, and future plans for
providing obstetrical care.
Population Studied: All OBs (n=828), rural FPs (n=579),
CNMs (n=255), LMs (n=92), and a 45% random sample of
urban FPs (n=1,157), identified from Washington state
professional associations and licensing files.
Principal Findings: Response rates were 55% (OBs), 41%
(urban FPs), 55% (rural FPs), 68% (CNMs), and 71% (LMs).
Significantly fewer FPs (28% of urban FPs and 46% of rural
FPs) provide obstetrical services than OBs (79%) , CNMs
(85%), and LMs (100%). The median age of OBs (47) and
CNMs (48) is greater than FPs (43) and LMs (43). Median
annual number of deliveries among obstetrical providers is
120 (OBs), 20 (FPs), 70 (CNMs) and 25 (LMs). Liability
insurance premiums for obstetrics providers have increased
by 58% (OBs), 108% (FPs), 153% (CNMs), and 31% (LMs)
from 2002 to 2004. Tail coverage costs affected practice for
more OBs (45%) than FPs (27%), CNMs (17%) or LMs (13%).
Practitioners reported reducing compensation; reducing
liability coverage; and raising cash through loans, liquidating
assets or using savings as the most common monetary
responses to liability insurance issues. The most common
practice changes in the past two years were increasing the
number of deliveries (reported by 57% of LMs and 42% of
CNMs), increasing the number of C-sections (53% of OBs and
46% of CNMs), increasing OB consults (50% of FPs and 43%
of CNMs), and decreasing high-risk OB procedures (49% of
FPs). The majority (90-100%) of obstetrical practices accept
new obstetrical patients, and plan to increase or maintain the
number of obstetrical patients in the coming year (73-98%).
Conclusions: Liability insurance premiums have risen
dramatically in the past three years for providers practicing
obstetrics in Washington state. The cost of tail coverage has
affected practice decisions for many providers. Among these
practitioners there have been numerous recent practice
changes that may represent “defensive medicine”. The effects
of liability insurance on obstetrical access for patients in
Washington is not clear, but the aging of the OB workforce is
a risk for the near future.
Implications for Policy, Delivery, or Practice: Many
providers have needed to make difficult adjustments to rising
liability insurance premiums, leading to the policy question
“can further increases be tolerated?” The mean age of
Washington’s OB workforce, the highest volume provider
group, is nearing the mean age for providers leaving
obstetrical practice. If providers leave obstetrical practice,
whether because of aging or liability insurance costs, rural
areas are most vulnerable because FPs, who are less likely to
do obstetrical care and can most easily drop that component
of their practices, provide much of the obstetrical care in rural
areas.
Primary Funding Source: HRSA
●Access in Oregon: An Initial Analysis of Primary Care
Physicians from the 2004 Oregon Physician Workforce
Survey
Jeanene Smith, M.D., MPH, Janne Boone, MPH, Charles
Gallia, MS, Tina Edlund, MS
Presented By: Jeanene Smith, M.D., MPH, Deputy Director,
Office for Oregon Health Policy and Research, 255 Capitol
Street NE, 5th floor, Salem, OR 97310; Tel: (503) 378-2422
x420; Email: jeanene.smith@state.or.us
Research Objective: Physician workforce adequacy and
acceptance of public payers are critical to access to care for
low-income, vulnerable populations. The initial analysis of a
subset of statewide survey results assesses Oregon’s current
capacity to deliver primary care and identifies the barriers to
physician participation in public programs.
Study Design: A mail-return survey of all licensed physicians
in the state. Information was gathered regarding
demographics, career satisfaction, anticipation of changes in
physician’s practices, acceptance and perceptions of payers
and issues regarding the Oregon Health Plan, Oregon’s
Medicaid program.
Population Studied: The study population of 10,354
physicians, from a database updated quarterly by the Oregon
Medical Association (OMA) and the Board of Medical
Examiners, were mailed a unique survey instrument designed
collaboratively by the OMA with the state’s Medicaid and
health policy offices. The response rate was 24% representing
2,419 physicians. Physicians not involved in direct patient
care or from hospital-based specialties were excluded from
this analysis.
Principal Findings: The focus of this analysis includes those
in primary care (44% of the respondents) and those in
medical and surgical subspecialties (32% of the respondents).
Differences between subgroups were tested using chi-square
tests of independence. Primary care and specialist
satisfaction was similar (86% and 87% somewhat or very
satisfied); older providers were more likely to be “very
satisfied”, with urban providers more satisfied. Less satisfied
physicians were less likely to accept public payers. Patient
relationships are the greatest source of satisfaction (59%)
while income was a much less important satisfier (4.7%). Cost
of doing business emerged as the most important practice
issue and public payers’ (Medicaid and Medicare)
reimbursement and cost of liability insurance followed.
Increased referral of complex cases was the most often noted
anticipated change in their practices (37%) in the next two
years. Reducing patient care hours, increasing diagnostic
procedures performed, and retiring from practice were major
changes under consideration. Nineteen percent of primary
care providers and 27% of specialists plan to retire in the next
five years; this retirement rate is greater than the influx of new
physicians into the state. Physicians balance acceptance of
public payers with commercial payers, and practices limiting
Medicare were more likely to limit Medicaid. Increasing
referral of more complex cases (26%) was the most
commonly reported reaction to rising liability premiums.
Conclusions: Physician response to rising cost pressures and
medical liability include increasing referral of complex cases
and decreasing hours. These actions further reduce access to
primary care. Physicians balance payer types to counter rising
costs, and the decision to accept or limit Medicare directly
impacts the decision to accept or limit Medicaid.
Implications for Policy, Delivery, or Practice: National
Medicare reimbursement policy influences physicians’
acceptance of Medicaid as a payer. State Medicaid policy
options to stabilize physician participation are limited by this
interaction between public payers. Opportunities open to state
policymakers to increase physician participation in Medicaid
include reduction of administrative costs and support of
patient-physician relationships.
Primary Funding Source: Oregon Medical Association
●Employment-Based Benefits of Nurses
Joanne Spetz, Ph.D.
Presented By: Joanne Spetz, Ph.D., Associate 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; Email:
jojo@alum.mit.edu
Research Objective: A large share of the workforce of the
United States receives non-wage benefits in addition to a wage
or salary. The principal objective of this study is to provide an
overview of what benefits are available to nurses as compared
with the general workforce, how health care leaders are
approaching the provision of employment-based benefits for
nurses, and what nurses have to say about the employmentbased benefits they receive and do not receive.
Study Design: The research team analyzed the US Current
Population Survey, reviewed the literature, conducted
interviews with health care leaders, and conducted focus
groups with RNs in two states.
Population Studied: Registered Nurses and Licensed
Practical Nurses in the United States, and their employers.
Principal Findings: RNs are more likely to be enrolled in
health and retirement benefits than are U.S. workers in general
and those with some college education. LPN enrollments in
employer-provided benefits are similar to those of other
workers with some college education, but higher than the
general workforce. The demographic patterns of enrollment in
benefits among LPNs are similar to those of other collegeeducated workers. All the key informants representing
employers said their organizations provide a wide range of
benefits to their nursing staff. The underlying reasons for
offering these benefits included a desire to invest in staff, the
need to competitively recruit and retain qualified employees,
and the consideration of benefits as part of a total
compensation package. Most interviewees who represented
employers said their firm offers benefits to nurses working 20
or more hours per week. Focus group participants agreed that
the most important benefit is health insurance. Most RNs
who do not have benefits work per diem and part-time, and
value the flexibility associated with these employment
arrangements. These RNs generally received health insurance
through their spouses’ employers. Attitudes toward the
benefits received at work varied greatly, with some RNs
believing that they are very important to overall job
satisfaction and others viewing them as less important.
Conclusions: Nurses value the benefits they receive as part of
their employment. Relatively high shares of RNs receive
benefits from their employers, as compared both to the
general workforce and those workers who have some college
education. LPNs are enrolled in health and retirement
benefits at rates similar to those of other college-educated
employees. Health care leaders must tread carefully when
considering changes to the benefits offered to nurses. It is
essential that nurses be consulted about the benefits they
want and need, through surveys and focus groups.
Implications for Policy, Delivery, or Practice: Improved
benefits packages, and higher wages, will not magically solve
the problem of recruiting and retaining qualified nurses.
Employers must recognize that the financial wages and
benefits received by staff must match the market, but that the
overall satisfaction of nurses, and their ability to provide highquality care, depends on developing holistic approaches to
improving the workplace. While fringe benefits play a role in
this holistic approach, they should not be the sole focus of
human resource managers.
Primary Funding Source: RWJF
●Working Conditions and Organizational Climate in ICUs
Patricia Stone, Ph.D., Cathy Mooney-Kane, MS, Elaine Larson,
Ph.D., Teresa Horan, MPH, Jack Zwanziger, Ph.D., Andrew
Dick, 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; Email: ps2024@columbia.edu
Research Objective: The purpose was to identify factors
related to working conditions that influence the organizational
climate (OC) perceived by intensive care unit (ICU) nurses.
Study Design: A cross-sectional design was used. Nurses
employed in ICUs were surveyed using the Perceptions of
Nurse Work Environment Scale to measure OC. Market- and
hospital-level characteristics were identified using American
Hospital Association, hospital zip code and Bureau of Labor
statistics data. A random effects GLS regression model was
developed and respondents were grouped by ICU.
We controlled for hospital neighborhood characteristics (i.e.,
proportion of population in hospital zip code living in poverty
and median income). Independent main effects of nurses’
income (actual mean wages adjusted by region and ratio of
nurses’ wages to teachers’ wages by region), nurses’ workload
(staffing ratios, Nursing Intensity Weights [NIW] and
proportion of overtime), setting characteristics (teaching
status, Magnet accreditation, National Nosocomial Infections
Surveillance [NNIS] affiliation, bedsize and ICU type) and
nurses’ characteristics (gender, education, full versus parttime, and ICU experience) were entered into the model.
Population Studied: The sample consisted of 647 nurses
(response rate 47%) employed in 27 ICUs from 17 hospitals
across the nation. The majority of hospitals (n=10) were large
(>=400 beds), affiliated with NNIS (n=13) and located in
either the Central (n=7) or Pacific (n=7) region. The average
respondent was 38.5 years old (SD =9.41), had 9.8 years
(SD=9.40) ICU experience, and had worked in their current
position for 7.5 years (SD= 7.21).
Principal Findings: Approximately 20% of the variance in OC
(p <0.05) was explained. Both measures of nurses’ income
had significant independent positive effects (RN wages
relative to teachers wages [ß = 0.69, 95% CI 0.03, 1.35] and
nurses’ mean actual wages [ß = 0.73, 95% CI 0.17, 1.35]) as did
NIW (ß = 0.63, 95% CI 0.16, 1.10). Significant setting
characteristics included NNIS affiliation (ß = 0.20, 95% CI
0.001, 0.40) and hospital teaching status (ß = -0.28, 95% CI 0.41, -0.14). Nurses with ICU experience less than 1 year
perceived the OC more positively than those with more than
12 years experience (ß = 0.19, 95% CI 0.05, 0.33).
Conclusions: Controlling for use of overtime and staffing,
nurses working in ICUs with more complex patients as
measured by the NIWs perceive a more positive OC. The
positive relationship between OC and complexity of patients
may be related to nurses’ finding rewards in challenging tasks
given enough staff. Hospitals active in the NNIS system and
paying nurses higher wages have ICU nursing staff who
perceive a more positive OC.
Implications for Policy, Delivery, or Practice: Many of the
factors we found to be independently related to OC are
amenable to change. Market solutions (e.g., wage increases)
may help, but they are not the only solutions. Designing wellstaffed but challenging workloads may improve the OC. While
the model presented is not causal, results may help hospitals
to develop and implement strategies aimed at improving the
OC in their setting, which may ultimately result in improved
patient and institutional outcomes. These findings are
important in context of the reports of nurse dissatisfaction
and workforce shortages.
Primary Funding Source: AHRQ
●Service Requiring Scholarship and Loan Repayment
Programs for Nurses in the Southeastern U.S.
Samir Thaker, Barbara A. Mark, RN, Ph.D., FAAN, Donald E.
Pathman, M.D., MPH, Dennis Zaenger, MPH
Presented By: Samir Thaker, Graduate Research Assistant,
Cecil G. Sheps Center for Health Services Research, 725
Airport Road, Chapel Hill, NC 27516; Tel: (919) 966-7445; Fax:
(919) 966-5764; Email: thaker@unc.edu
Research Objective: States and the federal government use
service-requiring scholarships and loan repayment incentives
to entice nurses into rural and underserved areas. These
programs have grown rapidly since the early 1990s when
states created many new support-for-service programs for
licensed practical nurses, registered nurses, advanced-practice
nurses, nurse practitioners and nurse midwives. Relatively
little, however, is known about the combined size and
operations of these programs, the ways state and federal
programs interact, and the optimal design of such programs.
In this study, we: (1) identify all programs in the southeastern
U.S. that provide financial support for training costs to entice
nurses to underserved areas and describe the basic operations
of these programs; (2) identify and characterize federal
programs operating in this region; (3) describe the region’s
nursing support-for-service programs, their combined
workforce composition, new program directions, and
challenges; and (4) clarify how federal and state programs
augment and/or duplicate one another.
Study Design: We identify eligible programs through an
iterative approach. An initial list of potentially eligible
organizations is generated by searching available compendia
of nursing and state health professions support programs and
by contacting personnel at state nursing boards and schools
of nursing. We then conduct semi-structured telephone
interviews with program directors to verify program eligibility,
obtain program information, and learn of other potentially
qualifying programs. Program directors will next be asked to
complete surveys about their programs, participants, key
challenges, and new directions.
Population Studied: Data are being collected from all state
and federal scholarship, loan repayment and similar supportfor-service programs intended to entice RNs, LPNs, NPs,
CRNAs, CNMs, or CNSs to work in rural and/or underserved
regions of eight southeastern states: Alabama, Florida,
Georgia, Kentucky, Mississippi, North Carolina, South
Carolina, and Texas. We exclude initiatives whose primary
purpose is to attract nurses to specific hospitals and
communities as well as those that do not make financial
support contingent on practice in underserved areas.
Principal Findings: We have found that states and intra-state
entities employ a wide variety of strategies to entice nurses
into needy areas through subsidization of nursing education
costs. We will describe this group of programs, their
operations and workforces, and greatest strength and
weakness. We expect to find that the combined workforce of
these state and federal programs is substantial, representing a
major thrust in public efforts to maintain an adequate nursing
workforce in underserved communities.
Implications for Policy, Delivery, or Practice: The findings
of this study will help clarify the nature and contributions of
these programs and help states and the federal government
improve current and future support-for-service programs.
Enhancing the effectiveness of nuring support-for-service
programs will be an important step toward remedying the
geographic maldistribution of health care workers in the
southeastern U.S. and other regions.
Primary Funding Source: HRSA,
●Dental Hygiene Professional Practice Index
Paul Wing, DEngin, Ann Battrell, MA, Margaret Langelier, MS
Presented By: Paul Wing, DEngin, Deputy Director, Center for
Health Workforce Studies, 1 Discovery Way, B334, Rensselaer,
NY 12144; Tel: (518)402-0250; Fax: (518)402-0252; Email:
pow01@health.state.ny.us
Research Objective: To create a numerical index that rates
the legal practice environment of DHs in the 50 states and
DC, and to explore the relationship of this index to access to
dental services and oral health outcomes.
Study Design: A Dental Hygiene Professional Practice Index
(DHPPI) is described that defines the professional status,
supervision, tasks permitted, and reimbursement options for
DHs in each of the 50 states and DC as of December 31, 2001.
Spearman rank order correlations between the DHPPI and
numbers of oral health professionals, utilization of oral health
services, and oral health outcomes in the 50 states are also
presented.
Population Studied: This study involves cross-sectional
analyses of statistics for the 50 states and DC.
Principal Findings: 1) There are significant differences in the
legal practice environment (as reflected in the DHPPI) across
the 50 states and DC. 2) Between 1990 and 2001 the numbers
of DHs per capita increased by 46% in the US, while the
number of dentists per 100,000 population increased by only
10%. 3) The DHPPI was not significantly correlated with the
numbers of DHs or dentists in the 50 states in 2001.
4) The DHPPI was significantly positively correlated with the
salaries of DHs in 2001. 5) The DHPPI was also significantly
and positively correlated with a number of indicators of
utilization of oral health services and oral health outcomes.
Implications for Policy, Delivery, or Practice: Both access to
oral health services and oral health outcomes are positively
correlated with the DHPPI. This suggests that states with low
DHPPI scores would be logical candidates for revised DH
practice statutes and regulations to accomplish these
objectives.
Primary Funding Source: HRSA
●Characteristics of Internationally Educated Nurses in the
U.S.
Yu Xu, Ph.D., Chanyeong Kwak, Ph.D.
Presented By: Yu Xu, Ph.D., Associate Professor, School of
Nursing, University of Connecticut, 231 Glenbrook Road, U2026, Storrs, CT 06269; Tel: (860)486-0593; Fax: (860)4860001; Email: Yu.Xu@uconn.edu
Research Objective: To profile and analyze characteristcs of
internationally educated nurses in the U.S. nurse workforce.
Study Design: Secondary analysis of the 2000 National
Sample Survey of Registered Nurses (the latest available
survey)
Population Studied: internationally educated nurses in the
U.S. in 2000.
Principal Findings: Out of an estimated 2.7 million U.S.
registered nurse workforce in March 2000, 3.7% were
internationally educated nurses from other countries.
Internationally educated nurses tended to be younger,
unmarried females from the Philippines, Canada, India, or the
United Kingdom in their 40s and 30s living or working in
urban areas; they had more years of experience as registered
nurses, and were more likely to have completed diploma or
baccalaureate nursing programs as their basic nursing
preparation; they tended to work in hospitals as staff nurses in
direct patient care on medical/surgical units and intensive
care units; a disproportionately higher rate were employed in
long-term care facilities; they were more likely to work full time
in nursing, worked more hours, and earned more.
Conclusions: 1. Internationally educated nurses have
distinctive demographical, educational, and employment
characteristics when compared to U.S.-trained nurses.
2. Internationally ucated nurses as a group were not only more
likely to be in the labor workforce, but also participated to a
greater extent. Based on these findings, it can be inferred
that, given the same number of nurses, internationally
educated nurses appear to have a greater effect on relieving
the current nurse shortage because they had a longer and
more productive working career.
Implications for Policy, Delivery, or Practice: Although U.S.
healthcare industry has traditionally recruited foreign nurses to
relieve periodic nurse shortages, it is unrealistic and
impossible to depend solely on foreign nurses to resolve the
issue. Policy-makers need to develop a long-term socially
responsible workforce policy in order to eliminate the cyclic
nurse shortage. However, until then, recruiting foreign nurses
to relieve U.S. domestic nurse shortage remains a pragmatic
alternative, at least for now and the foreseeable future.
Primary Funding Source: No Funding Source