Workforce
Call for Papers
Meeting the Workforce Needs in Rural America
Chair: Julie Sochalski, University of Pennsylvania
Sunday, June 25 • 8:30 am – 10:00 am
●US Rural Physician Workforce and Medical Education
Frederick Chen, M.D., M.P.H., L. Gary Hart, Ph.D., Meredith
Fordyce, Ph.D.
Presented By: Frederick Chen, M.D., M.P.H., Deputy Director,
Family Medicine, WWAMI Rural Health Research Center, 4311
11th Avenue NE, Ste. 210, Seattle, WA 98195; Tel: (206) 5437813; Fax: (206) 616-4768; Email: fchen@u.washington.edu
Research Objective: Among the most enduring problems
within rural America is the shortage and maldistribution of
rural health care providers. In addition, the dramatic decline
in U.S. medical graduates choosing generalist residency
positions, high malpractice costs, tight reimbursement
policies, and a shift within generalist disciplines to greater
proportions of women are creating an impending crisis in
access to physicians for rural populations, especially in the
smallest and most isolated rural communities. At the same
time, medical education policies have been unable to ensure a
continued commitment to the supply of rural physicians. We
sought to describe the training pathway of rural physicians in
the US. Research Objectives: 1. To describe the composition,
specialty distribution, and medical training of the rural
physician workforce. 2. To show that medical schools and
residencies vary dramatically in the number and proportion of
their graduates who practice in rural areas.
Study Design: We performed a national cross-sectional
analysis of the 2005 AMA and AOA Masterfile physician data.
The Masterfiles were linked with Rural-Urban Commuting
Area (RUCA) codes, Claritas demographic data, the Area
Resource File, HPSA designations, and ERS persistent poverty
counties. We identified physicians’ rural locations based on
ZIP codes and geocoded these to RUCA categories. Rural
physicans were aggregated to each medical school and
compared across the medical schools to show the percentage
of the rural physicians who are produced by the largest
producers and the lowest producers.
Population Studied: We examined a ten-year cohort of
allopathic and osteopathic physicians who graduated from
medical school 1988 through 1997.
Principal Findings: There were 175,649 physician graduates
between 1988 and 1997. 20,037 (11%) were currently
practicing in a rural RUCA location. 18% of osteopathic
physicians practice in a rural location but only 11% of
allopathic physicians were in a rural location. The specialty of
rural physicians varied widely. 23% of rural physicians are
family physicians, 16% are general surgeons, 11% are
internists, and 9% are pediatricians. The proportion of each
specialty that practices in a rural area remained fairly
consistent over the ten year period. The top 10 medical
schools placed between 21-36% of their graduates in rural
areas.
Conclusions: This national analysis shows that the proportion
and number of rural physicians has been stable, compared to
earlier analyses. Osteopathic physicians and primary care
physicians are much more likely to practice in rural areas. As
we expected, a small number of medical schools and
residency programs are responsible for training the majority of
rural physicians in this country. Recent trends that are not yet
reflected in these data, however, may adversely affect rural
physician supply and distribution.
Implications for Policy, Delivery, or Practice: This project
provides needed information on the specifics of the
production of physicians for the nation's rural communities.
Many federal and state programs are aimed at increasing the
supply of physicians within rural areas (e.g., the Medicare
Incentive Program and the National Health Service Corps).
The findings provide decision-makers with critically needed
information upon which to tailor federal and state programs
(e.g., GME funding alternatives, and NHSC scholarship and
loan repayment acceptance criteria). In addition, the project
provides comparative data that demonstrate how well medical
schools and states meet the rural needs of their respective
populations in comparison to other states and the nation at
large. At the state and local rural level, the results provide the
information needed as an impetus for change in medical
school and residency rural training activities.
Primary Funding Source: HRSA
●Health Care Employees’ Contributions to the Economy of
a Rural State: A study based on the Nebraska Rural Health
Works Project
Roslyn Fraser, M.A., Li-Wu Chen, Ph.D., Keith Mueller, Ph.D.
Presented By: Roslyn Fraser, M.A., data analyst, Preventive
and Societal Medicine, University of Nebraska Medical Center,
984350 Nebraska Medical Center, Omaha, NE 68198-4350;
Tel: 402-559-5260; Email: rfraser@unmc.edu
Research Objective: To examine the contribution of
employees of the health care sector to the state economy.
Study Design: Using an economic input-output analysis
model and IMPLAN software, we estimated the direct and
indirect impact of the health care sector on jobs, income, and
output on the state economy. Type SAM (Social Account
Matrix) multipliers were used because they adjust effects
based on spending patterns amongst different income
groups. This level of analysis is most accurate and allows us
to compare health care employees to employees of other
sectors. An aggregate model was built to compare the health
care sector to eight other economic sectors in Nebraska.
Sectors were ranked by overall impact on job creation, income
creation, total output, and contribution to gross state product.
We examined the direct effects (initial business spending),
indirect effects (businesses buying and selling to each other),
and induced effects (household spending based on income
earned) of the aggregated sectors. Particular attention was
paid to induced effects as a measure of employees’ spending
activity; this allowed us to examine their contribution to the
economy.
Population Studied: We used industry input-output data
from the 2002 Nebraska IMPLAN data supplemented with
employee and payroll data from the Nebraska Hospital
Association.
Principal Findings: The heath care sector ranks fourth in
overall (i.e., direct and indirect) impact on job creation in
Nebraska (161,140 jobs), third in overall impact on income
creation ($6.308 billion), fifth in overall impact on output
produced ($13.310 billion), and third in overall contribution to
gross state product ($8.024 billion) based on our statewide
analysis. When the specific spending activity of health care
employees is examined, the induced effects consistently rank
in second place. Within the healthcare sector, offices of
physicians, dentists, and other health professionals had the
highest induced effect, followed by employees of home health
care services.
Conclusions: Based on our findings, we see that the health
care industry provides high quality jobs with high incomes.
Health care employees have the second highest household
spending based on income earned and are more likely than
employees in any other sector, except one, to spend labor
income locally. Nebraska benefits from health care employees
not only because of the services they provide, but because
their income is relatively high and is spent locally.
Implications for Policy, Delivery, or Practice: The
population of 70 of Nebraska’s 93 counties is in decline. Given
out-migration trends, rural Nebraska is experiencing a rise in
its elderly population and a loss of well-educated people of
working age. Apprehension about the changing demographics
in rural areas places rural economic development at the top of
many policy agendas. As one of the strongest contributors to
overall economic activity, healthcare is a vital sector in
Nebraska. Rural Nebraska benefits from the draw of health
care professionals who provide necessary services, hold
professional degrees, earn higher incomes, and spend locally.
Because health care has the potential to increase jobs,
income, output, and attract educated professionals to an area,
investing in health sector development is one way to stimulate
rural economic development.
Primary Funding Source: State Office Of Rural Health
●Uses of Rural-Urban Commuting Areas (RUCAs) Version
2.0 in Health Workforce Research
Gary Hart, Ph.D.
Presented By: Gary Hart, Ph.D., Director and Professor, Rural
Health Research Center & Center for Health Workforce
Studies, Family Medicine, University of Washington, Box
354982, University of Washington, Seattle, WA 98195-4982;
Tel: 206-685-0402; Fax: 206-616-4768;
Email: garyhart@u.washington.edu
Research Objective: A key to performing quality research
regarding the health workforce is how the geography of
studies is measured. Generally, differences along the ruralurban continuum have been measured using county
definitions, with the Office of Management and Budget
(OMB) Metropolitan/Non Metro definition taking precedence.
Refinements to the OMB definition, such as the Economic
Research Service's Urban Influence Codes UICs) are often
used in studies. These county-based measures suffer from
lack of spatial specificity-they often grossly over and under
bound cities. The Census Bureau's Urban definition is based
on census tracts, which are not typically available in health
care data sets. This definition has only three categories and
often does not meet workforce analysis needs. The objective
of this study is to describe a new methodological geographic
tool upon which to base many health workforce and other
health services research studies: the ZIP code-based RUCAs.
In addition, it introduces the updated Version 2.0 of the
geographic taxonomy and demonstrates its use with national
physician workforce data. An additional tool (remoteness)
developed for use with the RUCAs is also introduced. The
remoteness tool provides the travel distance and time
between each ZIP code and the nearest edge of an Urbanized
Areas of 50,000 or more and/or the nearest edge of an Urban
Cluster of 10,000 to 49,999. This allows researchers to use
remoteness in combination with the RUCA geographic
taxonomy. The remoteness tool can be employed per
researcher specification to identify “frontier” areas.
Study Design: The new Version 2.0 of the RUCAs and the
new remoteness tool were utilized in combination with the
2005 American Medical Association (AMA) Masterfile and the
2005 American Osteopathic Association (AOA). Additional
environmental population data such as poverty were linked to
the ZIP code areas. Patient care physician supply by specialty
was examined by RUCA code aggregations (e.g., remote and
isolated small rural ZIP code areas) by state and Census
Bureau Division and poverty, for example. In addition,
findings were compared to results using the UIC county-based
taxonomy.
Population Studied: Population Studied: All the nation's
patient care allopathic and osteopathic physicians were
studied for the 50 states and the District of Columbia.
Principal Findings: The nation's remote isolated small rural
communities have extremely limited supplies of physicians,
especially in combination with poverty. The findings show this
to be much more true than previously reported using less
precise geographic measures.
Conclusions: The study results indicate that the RUCAs and
the remote tool provide much more meaningful results in a
basic workforce analysis than county-based alternatives. The
findings show that there are dramatic variations in physician
supply across the nation, even more so than previously
reported. The description of the study results and of the
RUCA taxonomy will help the audience understand the
importance of better methodological specification of study
geographic units and categories.
Implications for Policy, Delivery, or Practice: Better
geographic measurement of workforce supply is essential to
effective policy development in implementation. Defining
rural and urban must be a methodological priority for healthrelated workforce and other studies. Systematically dealing
with geographic problems can enhance the validity and
usefulness of health-related studies.
Primary Funding Source: HRSA
●Is Physician Supply in Rural Ohio Associated With
Unmet Need for Physician Visits?
Lars Peterson, David Litaker, M.D., Ph.D.
Presented By: Lars Peterson, Ph.D. candidate, Epidemiology
and Biostatistics, Case Western Reserve University School of
Medicine, 10900 Euclid Avenue, Cleveland, OH 44122; Tel:
216-407-0313; Email: lars.peterson@case.edu
Research Objective: Rural areas have fewer physicians per
capita compared to urban areas and rural residents receive
fewer health care visits than urban residents. Federal rural
health policy tends to focus on increasing availability of health
care but evidence from previous research is contradictory
about the effects of the local supply of physicians on
utilization of physician visits. The purpose of this study,
therefore, is to examine this issue further by assessing the
association between physician supply in rural Ohio counties
with a resident’s self-reported unmet need for physician visits.
Study Design: The current study is a cross sectional multilevel analysis of individual level data from the Ohio Family
Health Survey (OFHS) linked at the county level to the Area
Resource File, which supplied the data on per capita physician
supply. Our dependent variable is whether or not
respondents reported an unmet need for a physician visit. We
created random intercept models to examine the independent
association of contextual physician supply characteristics with
an individual’s report of an unmet need for physician visits.
Effects of increasing rurality were measured using rural urban
continuum codes (RUCC). Survey weights are incorporated in
our analysis to yield results that are representative of the
county population.
Population Studied: 11,255 residents residing in all 48 rural
Ohio counties in 2003-2004 obtained from the OFHS.
Principal Findings: After controlling for individual factors
often associated with unmet needs (female gender, minority
status, lower educational attainment, intermittent or
continuous absence of insurance coverage, having lower
income, lack of a usual source of care, unemployment, not
married, lower rating of physical health status) the weighted
multi-level model revealed that the primary care physician to
total physician (PCP/MD) ratio is associated with a lower
probability that an individual reports an unmet need for a
physician visit (OR = 0.25 (95% CI 0.07, 0.95)). Total MD’s
per capita (OR = 0.95 (0.89, 1.03)), PCP’s per capita (OR = 1.11
(0.98, 1.27)) and RUCC (OR = 1.05 (0.83, 1.32)) are all not
significantly associated with report of an unmet need for a
physician visit. Models restricted solely to contextual factors
demonstrated only the PCP/MD ratio is significantly
associated with an unmet need for a physician visit (OR =
0.28 (0.08, 0.93)).
Conclusions: Rural health policy has traditionally focused on
increasing the supply of physicians as a means of maintaining
the health of rural populations. Our results indicate, however,
that it is not the number of physicians but rather the
composition of the physician population in rural counties that
is associated with an unmet need for physician visits. These
results are consistent with other reports demonstrating the
population health benefits of health care systems with an
emphasis on primary care.
Implications for Policy, Delivery, or Practice: To meet
health care needs in rural areas, policy analysts should
consider workforce composition (the PCP supply relative to
overall supply) and not just the absolute number of
physicians.
Primary Funding Source: No Funding
Call for Papers
Does Structure Matter? Exploring the Impact of Physician
& Nursing Models of Care
Chair: Barbara Mark, University of North Carolina, Chapel Hill
Sunday, June 25 • 10:30 am – 12:00 pm
●Team Structure and Patient Outcomes: Predictors of
Adverse Events in Home Health Care
Penny Hollander Feldman, Ph.D.
Presented By: Penny Hollander Feldman, Ph.D., Vice
President, Research and Evaluation, Director, Center for
Home Care Policy and Research, Visiting Nurse Service of
New York, 107 East 70th Street, New York, NY 10021; Tel: 212609-1530; Email: PFeldman@VNSNY.org
Research Objective: To examine relationships between team
“structure” and adverse events in home healthcare. Structural
characteristics include variations in work volume, work
distribution, staff education and experience. The research
contributes to the empirical literature on predicting and
reducing adverse events, and to the theoretical literature on
how organizational characteristics such as staffing affect
patient outcomes.
Study Design: The study was conducted in a large home
healthcare agency with 86 structurally varied nursing teams.
Using clinical data for 56,346 patient care episodes delivered
over six months, we created an index of adverse events based
on 13 home care-specific measures classified by CMS as
potential adverse events. Then we used a comprehensive risk
adjustment technique to derive severity-adjusted quality
scores (Z-Score and FE-Score) for each team. Using detailed
administrative data, we captured information on staff age,
education and job tenure, and also constructed objective
measures of team structure – e.g., volume of episodes,
volume of weekend admissions, volume of weekend visits and
relative concentration of visits among nurses (HerfindahlHirschman index). Then we used multi-variate techniques to
examine the relationship between the team quality scores (i.e.,
team-attributable adverse event rates) and the selected
structural variables.
Population Studied: The 86 teams, which varied widely in
episode and visit volume, were staffed by group of core nurses
(8-24) plus assorted therapists, social workers and “float
nurses.” Average staff age was 44; average job tenure was 7.5
years. The patient population, averaging 71 years of age, was
two-thirds female and ethnically diverse (40% white, 26%
black, 24% Hispanic, 4% Asian, 6% other). Clinical diagnoses
varied widely, with the most common being diabetes (13%),
hypertension (8%) and congestive heart failure (5%).
Principal Findings: Controlling for patient case-mix severity,
the multivariate FE-score regressions found that adverse event
rates were significantly lower for teams with higher patient
volume (number of episodes) (P=0.01), greater workload
concentration (Herfindahl) (P=0.06) and more weekend visits
(p=0.02). Rates were significantly higher for teams with more
weekend admissions (p=0.01). Nurses’ age, education and
tenure at the agency were not significant (although tenure
reached a significance level of p=0.22, with fewer years
associated with higher adverse event rates).
Conclusions: The protective effect of patient volume suggests
that home healthcare teams may function more like hospital
surgical teams who can adjust their procedure load and
schedule to the available personnel, than like nurses on a
general hospital or nursing home unit, who have less control
over their workload or the resources to manage it. The
protective effect of concentrated workload may be due to the
narrower span of clinical managers’ control and/or to greater
expertise gained by nurses among whom care delivery is
concentrated.
Implications for Policy, Delivery, or Practice: The findings
underscore the riskiness of patient transitions, especially on
weekends when organizations are understaffed. Further, the
protective effect of weekend visits suggests that mobilizing
personnel for frequent “off-hours” visits may be a critical
safety factor in home care agencies, where weekend coverage
is often spotty. However, if busy, productive teams produce
better outcomes, care must be exercised to protect staff health
and safety and to guard against nurse burnout.
Primary Funding Source: AHRQ
●Does Increasing Hospital Nurse Staffing Lead to Better
Patient Outcomes?
R. Tamara Konetzka, Ph.D., R. Tamara Konetzka, Ph.D.,
Jingsan Zhu, M.B.A., Kevin G. Volpp, M.D., Ph.D.
Presented By: R. Tamara Konetzka, Ph.D., Assistant
Professor, Department of Health Studies, University of
Chicago; Tel: (773) 834-2202; Fax: (773) 702-1979;
Email: konetzka@uchicago.edu
Research Objective: Proposals to mandate minimum nurse
staffing levels are being debated in state legislatures across
the country, motivated by findings from cross-sectional
studies that link better outcomes with higher staffing levels.
This longitudinal study informs those debates by (1)
investigating the degree to which changes in hospital nurse
staffing influence patient outcomes; 2) determining the shape
of the staffing-outcomes relationship; and 3) identifying
subgroups of hospitals that benefit the most from increasing
staffing levels.
Study Design: Annual hospital financial data and patient
discharge data linked to death certificates for 1991 through
2001 from California’s Office of Statewide Health Planning
and Development were used in multivariate regression
models to determine whether changes hospital nurse staffing
levels (RN, LVN, and nurse aides) well as RN skill mix (i.e., the
percent of nursing personnel that are RNs) influenced
mortality. Four AHRQ inpatient quality indicators—30-day
mortality among acute myocardial infarction, stroke, hip
fracture, and gastro-intestinal hemorrhage patients—serve as
the outcome measures. We control for differences in the mix
of patients across hospitals and for secular changes over time
that could influence overall staffing levels. We use hospital
fixed effects to control for time-invariant differences between
hospitals and correct standard errors to account for clustering
of patients within hospitals. We characterize the shape of the
staffing-outcomes relationship by examining whether returns
to quality diminish as staffing levels increase and whether
thresholds exist in the relationship between staffing and
outcomes.
Population Studied: Patients with a primary diagnosis of AMI
(529,914), stroke (728,194), hip fracture (326,905) and GI
hemorrhage (464,919) in 450 short-term acute California
hospitals.
Principal Findings: Mortality declined significantly among
AMI and stroke patients as RN staffing levels rose, though the
effects were small: increasing RN staffing by one hour per
patient day resulted in a 1.4% reduction in mortality.
Increasing RN skill mix was associated with lower mortality
among AMI patients, but these effects were likewise small.
Changes in RN staffing levels and RN skill mix did not
contribute independently to mortality among hip fracture and
GI hemorrhage patients. Baseline staffing levels have an
inconsistent effect on the staffing-mortality relationship across
conditions.
Conclusions: Longitudinal analyses of the relationship
between nurse staffing levels and patient outcomes produce a
much more tempered portrait than the findings from crosssectional studies. They suggest that a more nuanced analysis
that investigates potential threshold effects in these
relationships may be more informative.
Implications for Policy, Delivery, or Practice: Determining
whether and how changes in nurse staffing affects patient
outcomes is critical to the current legislative debates over
mandatory minimum nurse staffing levels. Without this
information, staffing decisions based on cross-sectional
associations could result in significantly overestimating or
underestimating how much improvement in outcomes would
be realized by changing staffing levels, both of which could
have costly consequences.
Primary Funding Source: Doris Duke Charitable Foundation
●Resident Physician Team Workload and Organization
Effects on Patient Outcomes in an Academic General
Internal Medicine Inpatient Service
Michael Ong, M.D. Ph.D., Alan Bostrom, Ph.D., Arpana
Vidyarthi, M.D., Charles McCulloch, Ph.D., Andrew Auerbach,
M.D., M.P.H.
Presented By: Michael Ong, M.D. Ph.D., Assistant Professor
of Medicine, Medicine, UCLA, 911 Broxton Avenue, 1st Floor,
Los Angeles, CA 90024; Tel: 310-794-0154; Fax: 310-794-0766;
Email: michael.ong@ucla.edu
Research Objective: Resident physician work-hour
requirements have required residency programs to re-engineer
inpatient services. However, there is little research on how
resident physician workload or organization influences patient
outcomes. This study examined the effects of internal
medicine team workload and organization on patient
mortality, readmission, and resource utilization.
Study Design: Two-level mixed model analyses of patient
inpatient mortality, 30-day readmission, lengths of stay, and
total costs. Team structure and personnel information were
merged with patient-level data to create variables of interest.
Key adjusters included patient sociodemographic factors,
severity adjustment by DRG weights and ICU stays, hospitalist
supervision, discontinuities in care due to team personnel
switches. Additional controls included service census effects,
the academic quarter, year of admission, and if the admission
occurred on a weekend.
Population Studied: 5742 adults initially admitted to an
academic medical center general medical service between July
1998 and June 2001.
Principal Findings: Each increase in the admitting team’s
admissions on a patient’s admission day increased length of
stay (3.09%, 95% CI 2.22-3.96), total costs (2.31%, 95% CI
1.29-3.33), and risk of inpatient mortality (OR: 1.09, 95% CI
1.02-1.15). This mortality risk increase rises substantially when
admitting over 9 patients. However, each increase in the
admitting team’s average patient census during a patient’s
hospitalization reduced length of stay (5.30%, 95% CI 4.546.07) and total costs (5.11%, 95% CI 4.20-6.00). This increase
is concentrated in average censuses over 15 patients. Each
increase in teams working on the day of admission also
reduced length of stay (4.03%, 95% CI 0.96-7.01) and total
costs (4.68%, 95% CI 1.09-8.15). In addition, admission to a
team with two interns instead of one intern increased risk of
30-day readmission (OR: 1.41, 95% CI 1.05-1.89).
Conclusions: Our findings suggest that higher internal
medicine resident physician workload on admitting days
increases resource utilization and potentially inpatient
mortality risk. Higher team patient censuses are associated
with reduced resource utilization, which may reflect teams’
responses to higher workloads. Increasing the overall number
of GMS teams reduces resource utilization independent of
team admission and census counts, and may be related to
other benefits of workload reduction such as more time for
teaching and learning. Two-intern teams may experience less
supervision than one-intern teams, resulting in increased
readmission rates.
Implications for Policy, Delivery, or Practice: Programs
seeking to minimize total costs and lengths of stay may want
to find ways to reduce team admission loads. While teams
appear able to reduce total costs and lengths of stay through
internal mechanisms, these mechanisms may no longer be
available in an era of strict adherence to work hours
regulation.
Primary Funding Source: No Funding
Call for Papers
Beyond the Numbers: Innovations in National &
International Health Workforce Research
Chair: Chapin White, Congressional Budget Office
Monday, June 26 • 2:00 pm – 3:30 pm
●Physician Migration to the United States, Canada, United
Kingdom and Australia: Profiling the Source Countries
Onyebuchi A. Arah, M.D., M.P.H., Ph.D., Uzor C. Ogbu, M.D.
Presented By: Onyebuchi A. Arah, M.D., M.P.H., Ph.D.,
Assistant Professor, Department of Social Medicine,
Academic Medical Center of the University of Amsterdam,
Meibergdreef 9, PO Box 22700, Amsterdam, 1100 DE; Tel:
+31205665049; Fax: +31206972316;
Email: o.a.arah@amc.uva.nl
Research Objective: The World Health Organization has
earmarked its 2006 world health report, appropriately titled
“Working for Health”, for health workforce issues facing health
systems. Developed and developing countries both have
pressing shortages in nursing and physician workforces.
Unfortunately, such staffing shortages, lack of specialist
training positions in poorer countries, and the financial lure of
the rich west have resulted in the so-called ‘fatal flows’ of
physicians and nurses from the developing to the developed
countries. Between 23 and 28 percent of physicians in the four
large English-speaking countries, namely the United States,
Canada, the United Kingdom, and Australia, are international
medical graduates, 40 to 75 percent of whom come from lowto-middle income countries. It is not clear, however, whether
the poorest and most disadvantaged source countries suffer
more brain drain than other relatively poor countries.
Therefore, our study is aimed at profiling the low-to-middle
income countries that supply the most international medical
graduates to the United States, Canada, United Kingdom and
Australia.
Study Design: We used the most recent data from the World
Health Organization, World Bank and peer-reviewed articles to
relate country characteristics to the magnitude of physician
migration from source (low-to-middle income) countries to
the United States, Canada, United Kingdom, and Australia.
We examined the contemporaneous correlations between the
per capita number of source countries’ physicians working in
the four host countries and source countries’ characteristics
including gross domestic product, physician density, health
expenditure, percentage of population on less than one dollar
per day, urban population annual growth, density of nurses,
immunization rates, life expectancy at birth, under-five
mortality and infant mortality rates.
Population Studied: Thirty-six low-to-middle income
countries from eight regions of the world that supplied the
most international medical graduates to the United States,
Canada, United Kingdom, and Australia, between 1999 and
2002.
Principal Findings: We found that, among low-to-middle
income countries, those that supplied more physicians to the
United States, Canada, United Kingdom, and Australia were
relatively richer, healthier, with higher immunization rates, and
had higher physician density and health expenditure than their
fellow source countries. Higher physician migration was not
associated with unemployment rates, rural population density,
and receipt of workers’ remittances in source countries.
Conclusions: Even among poorer source countries, the
poorest may not be the ones losing the most physicians to the
wealthy countries. It is quite possible that as low-income
countries get marginally less poor, their meager facilities allow
them to train, but not retain or even sustain, quality physicians
who then migrate to take up residency positions in the United
States, Canada, United Kingdom, and Australia.
Implications for Policy, Delivery, or Practice: As
international medical graduates, we will like to see a more
sophisticated analysis of the current issues surrounding
physician brain drain, rather than the prevailing winners-andlosers and normative discussions that obscure the complexity
of the causes, consequences and solutions of the global
workforce problems. We hope our analysis will encourage
developing countries to contribute actively to the ongoing
debates and help craft intelligent solutions.
Primary Funding Source: No Funding
●Determinants of First Practice Location Choice by New
Physicians
Chiu-Fang Chou, MPA, Anthony T. LoSasso, Ph.D.
ensure that new physicians are prepared to meet the needs of
the neediest populations.
Primary Funding Source: HRSA
Presented By: Chiu-Fang Chou, MPA, Doctoral
Candidate/Research Assistant, The Division of Health Policy
and Administration, School of Public Health, Midwest Center
for Health Workforce Studies, University of Illinois at Chicago,
1747 W. Roosevelt Road, Room 558, M/C 275, Chicago, IL
60608-1264; Tel: (312)996-1792; Fax: (312)996-0065;
Email: cchou4@uic.edu
Research Objective: This study is aimed at understanding
how new physicians choose their initial practice locations. The
objectives of this study are to assess whether malpractice
premiums have an effect on new physicians' choice of practice
location and to examine how other local characteristics affect
where new physicians choose to practice.
Study Design: Statistical analysis involved conditional logit
models to examine the factors affecting the choice of initial
practice location by new physicians. Data are from a unique
survey of exiting medical residents acquired by the HRSAfunded New York Workforce Center at SUNY Albany. These
data are matched to data on malpractice premiums from
Medical Liability Monitor. Additional location information is
from the Area Resource File (ARF). The dependent variable is
the choice of location among the 357 metropolitan statistical
areas (MSAs) and non-metropolitan areas within each state in
the United States. Where appropriate, independent variables
have been weighted by area population. Other local market
characteristics include hospital beds, per capital income, and
the local unemployment rate.
Population Studied: The sample consists of 9,133 physicians
who just finished their residency training in New York and
California in 1998-2003 and who are beginning their careers in
patient care.
Principal Findings: Preliminary conditional logit results
indicate that malpractice premiums do not appear to be a
deterrent to locating in a particular area, even for high
malpractice specialties such as obstetrics and surgery.
Conclusions: Given that malpractice premiums do not
appear to be an important factor affecting new physician
location choices, our results suggest that other factors
outweigh anticipated malpractice concerns. These other
factors might include lifestyle variables that are difficult to
measure. Our results could also suggest that salaries for new
physicians might already compensate for high malpractice
costs.
Implications for Policy, Delivery, or Practice: Newly
graduated physicians represent a highly dynamic segment of
the supply of physicians, and their practice location decisions
can have a lasting impact on the future healthcare workforce.
Therefore, it is critical to have a better understanding of how
new physicians establish their careers, provide medical care,
and meet their own expectations in the 21st Century
healthcare market. Given the concerns about the distribution
of physicians relative to need, finding the most salient
characteristics associated with new physicians’ practice
location would help state and national healthcare
policymakers understand the needs of young physicians for
strategic workforce planning. This study can also help medical
education policymakers make future improvements in
recruitment and in the overall medical education system to
●An Economic Analysis of the Labor Market for Dental
Hygienists and Dental Assistants in California: 1997-2005
Tracy Finlayson, Ph.D., Timothy Brown, Ph.D., Richard M.
Scheffler, Ph.D.
Presented By: Tracy Finlayson, Ph.D., AHRQ Postdoctoral
Scholar, School of Public Health, UC Berkeley, 140 E Warren
MC7360, Berkeley, CA 94720-7360; Tel: 510-642-5652; Fax: 510643-4281; Email: tracyf@berkeley.edu
Research Objective: A perceived shortage of both registered
dental hygienists (RDHs) and dental assistants (DAs) was
documented among dentists in 1999 by an American Dental
Association Workforce Needs Assessment survey. This study
used an economic framework to examine whether or not there
was a labor market shortage for RDHs or DAs in California
anytime between 1997 and 2005.
Study Design: Labor shortages occur in a market economy
when demand for workers is greater than the supply of
workers who are qualified, available, and willing to do that job,
at a given market wage. We used rising average inflationadjusted wages as a measure of labor shortage. Data on the
demand for dental services, supply of RDHs and DAs, and
market-determined wages for each profession were examined
over time. The estimated numbers of and average hourly
wages for RDHs and DAs in each metropolitan statistical area
(MSA) in California were obtained from the U.S. Bureau of
Labor Statistics’ Occupational Employment Statistics Survey.
Trends in the number of candidates passing the California
Hygienist Licensing Exam were also explored. Demand for
dental services was assessed by the percent of adults with a
dental visit last year, percent with dental insurance, and state
dental expenditures. The numbers of RDHs and DAs were
adjusted for the California population using California
Department of Finance data, and wages were adjusted for
inflation using the Consumer Price Index.
Population Studied: This study focused on RDHs and DAs in
California.
Principal Findings: A clear rise in average inflation-adjusted
wages for RDHs started in 1999. Wages appear to have
peaked in 2002 and leveled off, at approximately 48% above
their 1999 levels. This indicates that a fairly severe shortage of
RDHs did occur during this period. There was no significant
supply response in the population-adjusted number of RDHs
to this increase in average inflation-adjusted wages. The
average inflation-adjusted wages of DAs increased by 13.9%
between 1997 and 2001. There was a large supply response in
the population-adjusted number of DAs to the increase in
average inflation-adjusted wages for DAs, and their numbers
rose by 28% from 1997 until their peak in 2003. This resulted
in the average inflation-adjusted wages for DAs returning to
1997 levels by 2005. Demand for dental services increased by
11.2% from 1997 to 2004. State dental expenditures rose
18.6% from 1995 to 2000. Between 1995 and 2003, the
percentage of Californians with dental insurance increased
18.1%.
Conclusions: Between 1997 and 2005, the demand for dental
services appeared to increase in California. Inflation-adjusted
wages increased for both RDHs and DAs, suggesting there
were labor shortages during this time period. Labor markets
for these professions behaved differently. Wages for RDHs
increased substantially then stabilized at a higher level, and
there was little supply response. DA’s wages increased
slightly before returning to the previous level, and the shortage
was corrected by an increase in DAs.
Implications for Policy, Delivery, or Practice: This study
provides information for understanding and responding to
changes in the labor market of RDHs and DAs. Results have
implications for future training, distribution and supply of the
dental auxiliary workforce in California.
Primary Funding Source: California Dental Association
Foundation and UC Berkeley Petris Center
●The Evidence Base for Diversity in the Health
Professions
Somnath Saha, M.D., M.P.H., Scott Shipman, M.D., M.P.H.
Presented By: Somnath Saha, M.D., M.P.H., Associate
Professor, Medicine, Oregon Health & Science University and
Portland VAMC, Portland VAMC (P3MED)/3710 SW U.S.
Veterans Hospital Rd., Portland, OR 97239; Tel: 503-220-8262
x55418; Fax: 503-721-7807; Email: sahas@ohsu.edu
Research Objective: Increasing the racial and ethnic diversity
of the health professions workforce is commonly cited as
essential to reducing racial/ethnic disparities in the quality of
health care. Programs promoting diversity, however, including
affirmative action policies, have become vulnerable in the last
decade. Sustaining such programs will increasingly require
documented evidence of the benefits of health professions
diversity. The most compelling argument for a more diverse
health professions workforce is that it will lead to
improvements in public health. We therefore examined the
evidence addressing the contention that health professions
diversity will lead to improved population health outcomes.
Study Design: Based on a conceptual model describing the
potential impact of health professions diversity on health care
access, quality, and outcomes, we conducted a systematic
review to identify studies addressing four hypotheses: 1) that
minority and non-minority health care providers serve
different populations; 2) that racial/ethnic and language
concordance between patients and health care providers is
associated with minority patients´ use of services and
adherence, quality of care, and health outcomes; 3) that
institutional workforce diversity is associated with minority
patients´ trust in health care institutions and use of services;
and 4) that minority and non-minority health care providers,
leaders, and researchers advocate for and implement different
programs, policies, and research agendas. We searched the
MEDLINE, HealthSTAR, CINAHL, and PsycINFO databases
using strategies tailored to each hypothesis. We also reviewed
the reference lists of included studies and relevant review
articles. One reviewer read and qualitatively summarized each
original study in terms of quality, characteristics (e.g.,
population, health profession category), and principal
findings.
Population Studied: Literature review.
Principal Findings: Our search retrieved 586 abstracts, and
we identified 55 original studies for inclusion. Seventeen
studies addressed the service patterns of physicians (16) and
dentists (1). These studies, many of them rated as highquality, uniformly found that minority providers
disproportionately served minority, poor, Medicaid, and
uninsured populations. Thirty-six studies addressed race and
language concordance between patients and physicians (20),
mental health providers (11), substance abuse counselors (4)
and medical students (1). These studies were mixed in their
results but generally found that both race and language
concordance were associated with higher interpersonal quality
of care (usually assessed with patient satisfaction surveys),
and to a lesser extent, utilization and adherence. No studies
directly addressed our hypotheses about institutional diversity
and patient trust, or about differential program, policy, and
research priorities between minority and non-minority health
professionals.
Conclusions: Current studies related to the impact of
healthcare workforce diversity on access, quality, and
outcomes are generally limited to those demonstrating that
minority physicians disproportionately serve underserved
populations, and that patient-provider race and language
concordance are associated with higher interpersonal quality
of care.
Implications for Policy, Delivery, or Practice: Further
research is needed to examine the service patterns of minority
and non-minority health professionals other than physicians;
the impact of race and language concordance on quality and
outcomes of care; the association between institutional
diversity and patient trust and use of services; and the
programmatic and policy priorities of minority and nonminority health professional leaders. Such studies may play an
important role in determining the fate of programs and
policies aimed at increasing the diversity of the health
professions workforce.
Primary Funding Source: HRSA
Related Posters
Workforce
Poster Session A
Sunday, June 25 • 2:00 pm – 3:30 pm
●Mental Illness, Employment, and Labor Force
Participation
Pierre Alexandre, Ph.D.; M.S.; M.P.H.
Presented By: Pierre Alexandre, Ph.D.; M.S.; M.P.H.,
Assistant Professor of Health Economics, Mental Health,
Johns Hopkins University - Bloomberg School of Public
Health, 624 n broadway, Ste 833, Baltimore, MD 21205; Tel:
410-502-2588; Fax: 410-955-9088; Email: pialexan@jhsph.edu
Research Objective: Previous studies based on labor market
effects of mental disorders using national representative
surveys did not distinguish the employed from those who
were in the labor force. This study investigates the differential
effects of mental illness on employment and labor force
participation.
Study Design: We merged survey years 2002 and 2003 of the
National Survey on Drug Use and Health (NSDUH), used
Kwallis-ranksum tests to test differences in outcomes and
control variables by mentally ill (SMIs) and non-mentally ill
(NSMIs)individuals. Multivariable stantard probits as well as
bivariate probit models that control for the potential
endogeneity of mental illness in the labor market
specifications were use to estimate the likelihood of
employment and labor force participation.
Population Studied: The study is based on individuals aged
25 to 64 from the 2002 and 2003 National Survey on Drug
Use and Health (NSDUH),formerly the National Household
Survey on Drug Abuse (NHSDA).
Principal Findings: The main findings of our analysis were
that mentally ill men and women were less likely to be
employed or in the labor market relative to their non-mentally
ill counterparts in both the univariate probit models and the
bivariate probit models. Test of endogeneity suggest that the
maximum likelihood estimates from the standard probit
models were consistent.
Conclusions: The findings of the present study are consistent
with other labor market studies in that mental disorders have
negative impacts on both men and women.
Implications for Policy, Delivery, or Practice: The main
policy implication of the study is that expansion of mental
health services as a means to improve quality-of-life may
promote economic benefits. Programs that prevent mental
illness or improve mental health may sustain or even enhance
work force productivity through avoiding the negative
consequences of mental illness on labor market outcomes.
Previous studies suggest that such programs were generally
cost-effective and increased employment and job retention.
Although these public health interventions may not lead to
overall increases in labor supply, they may be justified on
social welfare grounds.
Primary Funding Source: NIAAA
●Mentoring Function as a Workforce Retention Strategy:
Do mentoring needs change over time?
Mary K. Anthony, Ph.D., John M. Clochesy, Ph.D.
Presented By: Mary K. Anthony, Ph.D., Associate Professor,
College of Nursing, 113 Henderson Hall, Kent State University,
P. B. Box 5190, Kent, OH 44242; Tel: (330) 672-8824; Fax:
(330) 672-1564; Email: manthony@kent.edu
Research Objective: Hospitals struggle with the high
turnover in critical care. Mentored orientation programs have
been introduced as one way to improve retention and help
new nurses transition into ICU. Mentoring has been found to
be one of the most important relationships a novice can have,
enhancing satisfaction and effectiveness. As part of the larger
demonstration project to retain ICU nurses, the purpose of
this study is to compare and assess the change in nurses’
actual and perceived importance of key mentoring functions
over two time points during a 25 week ICU orientation
program.
Study Design: A descriptive comparative design using survey
methodology is used. Two cohorts of RN novice nurses were
hired into a 25 week mentored ICU orientation program into
one of four critical care units at a major university hospital.
Each novice nurse was assigned a mentor who met the criteria
for assuming a mentoring role and attended a workshop on
the responsibilities associated with mentoring. The 39-item 8dimension Fowler mentoring survey was distributed to novice
nurses at approximately 3 and 6 months after hire. For each
item, respondents were asked to rate both the importance and
the extent that the mentoring function actually occurred. Of
the 37 RNs hired into the program, 8 dropped out prior to
completing the first 3-4 months of orientation and one nurse
was on maternity leave, leaving a sample size of 26. Data is
reported on a sample of 22 nurses who returned their surveys.
Population Studied: The average age of nurses was 27.0
years, 86.4% had other healthcare experience, and 9.1% had
worked with a mentor in a job outside of nursing, while 13.6%
worked with a mentor in nursing.
Principal Findings: Data collection for Cohort 2 at 6 month
will be completed in February, 2006 and a new cohort (cohort
3) of nurses will be hired in March, 2006 and will be included
in future analyses. For the 8 mentoring functions: personal
and emotional guidance, coaching, advocacy, career
development, role modeling, advice on strategies for working
in a system, learning facilitation, and friendship, preliminary
data suggest that in general nurses place higher importance
on mentoring functions than they actually experience in the
mentoring relationships, creating gaps between what is valued
and what is received. Role facilitation, coaching and role
modeling were rated the highest in both importance and
actual occurrence.
Conclusions: Twenty–two percent of nurses who were hired
into ICU jobs left approximately 3-4 months after hire. At 3
months, novice nurses counted most on their mentor for
learning the role, role modeling and coaching. In our final
analysis, we will 1. compare whether the ordering of
importance changes and 2. whether the extent to which
nurses experience each mentoring function also changes.
Implications for Policy, Delivery, or Practice: Shortages in
the nursing workforce, particularly in critical care units, are
projected to worsen. Gaps in what nurses perceive to be
important and what they actually experience may be an
important predictor of job retention.
Primary Funding Source: HRSA
●Hospital Decision Making About Nurse Overtime
Barbara Berney, Ph.D., M.P.H.
Presented By: Barbara Berney, Ph.D., M.P.H., Assistant
Professor, Department of Urban Public Health, Hunter
College, 425 E. 25th Street Box 606, New York, NY 10010; Tel:
(212)481-5165; Fax: (212)481-5260;
Email: bberney@hunter.cuny.edu
Research Objective: Nurse overtime in hospitals has become
a contentious issue. Prior work done has found great variation
in the use of overtime across hospitals, but no prior studies
investigate management decision making in relation to use of
overtime versus alternative staffing strategies. This study
compares the use of overtime, agency, per diem, internal
swing staff and other staffing strategies for handling peak
staffing demand in hospitals.
Study Design: Structured interviews with hospital nurse
executives.
Population Studied: Ten New York State hospitals, five with
high overtime, five with low overtime.
Principal Findings: Preferences for overtime versus agency
staff depends on cost differentials and contract requirements.
Most nurse executives interviewed indicated they would prefer
to hire additional staff than use overtime or other alternative
staffing, but are unable to do so because of constrained
supply. Most overtime is worked as additional shifts, not
following a completed shift. Most nurse executives also feel
constrained to use twelve hour shifts because preferences of
nurses for such shifts make this an important recruiting tool.
They experess concern that nurses working fewer shifts per
week due to twelve hour shifts results in less continuity of care
for patients.
Conclusions: The level of overtime use by hospitals is a
management decision, with use of overtime influenced by
relative cost and contract requirements.
Implications for Policy, Delivery, or Practice: Results are
directly applicable for hospital managers, regulators, and
policy makers developing policy for controlling and regulating
nurse overtime. Further work is needed to study the impact of
twelve hour shifts on continuity of care.
Primary Funding Source: PSC-CUNY
●Satisfaction of Frontline Nursing Home Workers: Effect
of Organizational and Individual Factors and Impact on
Resident Well-being
Christine Bishop, Ph.D., Dana Beth Weinberg, Ph.D., Jody
Hoffer Gittell, Ph.D., Lisa Dodson, Ph.D., Walter Leutz, Ph.D.
Presented By: Christine Bishop, Ph.D., Professor and
Director, Ph.D. Program, Heller School for Social Policy &
Management, Brandeis University, 415 South Street Mailstop
035, Waltham, MA 02454-9110; Tel: 781-736-3942; Email:
bishop@brandeis.edu
Research Objective: To examine how workplace relationships
and the organization of work affect turnover of front-line
nursing home workers; and whether worker satisfaction is
related to resident satisfaction.
Study Design: Administrators and front-line supervisors were
interviewed in fifteen Massachusetts nursing homes to gather
information on human resources management and work
practices. Surveys concerning work-place relationships, job
satisfaction, and resident care were designed and
administered to all nurse supervisors (Response Rate: 89%)
and Certified Nurse Assistants (CNAs) (RR: 94%) on two
units in each nursing home. A resident satisfaction survey
was administered to a sample of five residents on each unit
(RR: 87%). The impact of organizational, relational, and
individual characteristics on intent to stay in current job was
estimated using statistical techniques that account for
clustering of the sample. Differences between general
attitudes of supervisory nurses toward CNAs and CNA
perception of own supervisor’s attitudes and practices were
explored for impact on satisfaction. The relationship between
CNA job satisfaction and resident satisfaction was
investigated.
Population Studied: 252 Certified Nurse Assistants (CNAs) in
15 Massachusetts nursing homes
Principal Findings: The quality of a CNA's relationship with
her/his own nursing supervisor is highly associated with
intent to stay in a job; staffing levels and sense of teamwork
with other CNAs also affect intent to stay, as do individual age
and education. Empowerment of CNAs to participate in care
planning does not appear to improve job satisfaction.
Statistical analysis suggests some linkage between CNA
satisfaction and resident well-being.
Conclusions: As has been found in other industries, quality of
supervision is critically important to job satisfaction of nursing
home workers. Task interdependency of the CNA-nurse
supervisor dyad may decrease the relevance of relationships
with other CNAs to job satisfaction. Difficulties in measuring
resident satisfaction can impede attempts to identify
organizational practices that support resident well-being.
Implications for Policy, Delivery, or Practice: Results
suggest that the supervisory skills, attitudes, and practices of
licensed nursing personnel are a key to reducing CNA
turnover and improving resident well-being, and are highly
relevant for transition to resident-centered care (“culture
change”).
Primary Funding Source: RWJF, Atlantic Philanthropies
●The Centers for Medicare and Medicaid Services (CMS)
Direct Service Workforce Demonstration Grants: Lessons
Learned and Preliminary Findings of 10 Grantees Working
to Improve Recruitment and Retention of Direct Service
Professionals
Carrie Blakeway, M.P.A., Karen Linkins, Ph.D., Lisa Alecxih,
M.P.A.
Presented By: Carrie Blakeway, Master of Public Affairs
(MPAff), Senior Associate, Applied Economics, The Lewin
Group, 3130 Fairview Park Drive, Suite 800, Falls Church, VA
22042; Tel: 703-269-5711; Fax: 703-269-5501;
Email: carrie.blakeway@lewin.com
Research Objective: To assess the preliminary outcomes of
the Centers for Medicare and Medicaid Services (CMS)
Demonstration to Improve the Direct Service Workforce
grants that were awarded in 2003 and 2004. Our purpose is
to inform policy makers and other stakeholders about the
progress that has been made by these grantees, and in what
areas, and the impact they have had on recruitment and
retention of direct service professionals after after almost
three years for the 2003 grantees and two years for the 2004
grantees.
Study Design: We reviewed data from the following sources
for this analysis: grantees’ work plans and evaluation plans,
grantees’ quarterly reports submitted to CMS, granteereported turnover and retention data at participating agencies,
grantees' requests for technical assistance and other grantee
communications with TA providers, and other grantee
materials. We present process findings and workforce
outcomes across all grantees and broken down by types of
interventions and year of grant award.
Population Studied: The ten CMS DSW grantees (state
agencies and private employers) working to improve
recruitment and retention of direct service professionals. Six
grantees are implementing interventions that provide or
promote health care coverage for direct service workers. The
North Carolina, New Mexico, and Virginia grantees pay for all
or part of workers’ health insurance in multiple participating
agencies. Maine and Washington are marketing and assisting
workers to enroll in state sponsored health insurance
programs, and the Indiana offers workers in one agency a
monthly cafeteria-style benefit that they can use to cover
health care expenses. Five of these six states are
implementing other interventions such as offering workers
peer mentorship programs, certificate programs, professional
networking opportunities, and participation in worker
registries. Four grant projects (in Delaware, Louisiana,
Arkansas and Kentucky) offer these kinds of expanded training
opportunities and workplace enhancements for workers
without a health insurance intervention.
Principal Findings: Overall, five of the ten grantees have
made some or significant progress toward their goals in all
major areas of grant activity. Some have demonstrated
reduced turnover and improved retention in participating
agencies. Grantees have reported the most challenges in the
area of intervention design, such as working out the details of
interventions or redesigning interventions when problems
were discovered upon implementation. Grantees have
reported successful strategies in many areas, including
designing workplace enhancements that are attractive to
agencies and workers - an area where significant challenges
had also been reported
Implications for Policy, Delivery, or Practice: As the
demand for long term support services increases, the Centers
for Medicare and Medicaid Services (CMS) recognizes the
importance of making informed decisions and building policy
in this area based on a strong groundwork of evidence. These
demonstrations will serve to better inform federal and state
policy makers, private employers, direct service workers,
consumers and other stakeholders about what kinds of
employee benefits, training, job structure, management,
recognition and rewards have a positive impact on
recruitment and retention in this field. In addition, the
experience of these grantees in implementing their grant
projects should help to inform others interested in
undertaking similar types of workplace interventions and
recruitment strategies.
Primary Funding Source: CMS
●Physician Stress and Life Satisfaction
Richard Bogue, BA, MA, Ph.D., Herdley Paolini, Psy.D., Brian
Fisak, Ph.D.
Presented By: Richard Bogue, BA, MA, Ph.D., Senior
Research Fellow and Director, Center for Health Futures,
Florida Hospital, 200 N. Lakemont Av., Winter Park, FL 32792;
Tel: 407-646-7119; Fax: 407-646-7146; Email:
richard.bogue@flhosp.org
Research Objective: Physician stress and satisfaction are
associated with quality, cost, job burnout and longevity.
Physician supply may be inadequate to future demand.
Helping "doctoring" be more satisfying may increase both the
supply and productivity of physicians. This research (1)
examines stress and satisfaction in physicians' professional
lives, and (2) learns why some physicians are more highly
satisfied.
Study Design: The study used survey and interview methods.
The survey gathered demographics, practice characteristics,
self-rated stress, and 17 self ratings on satisfaction. The single
stress item had reasonable reliability (r for matched
subsamples = .245, p < .001). The satisfaction scale had good
reliability (Cronbach's Alpha = .87). Quantitative analyses of
factors associated with stress were conducted with ANOVA
and hierarchical regression. Twenty-four semi-structured
interviews were conducted with physicians who (a) scored
very highly satisfied and (b) represented a variety of
specialties, career stages, and both genders. The interviews
identified and detailed "life practices" that the highly satisfied
physicians believe explain their higher satisfaction.
Qualitiative analyses included transcription and Q-Sorting.
Population Studied: 705 physicians participated from the
1,800 member staff of a southeastern US regional health
system.
Principal Findings: Age, hours worked per week, and an index
based on a subset of satisfaction items associated with
Personal and Family Issues were most strongly associated
with stress. Gender, number of children, and several workspecific issues were less strongly associated. Hierarchical
regression revealed that Personal and Family issues
accounted for 2.6 times more of the variation explaining stress
than hours worked per week, and three times more than age.
Q-Sorts of interviews with highly satisfied physicians revealed
10 types of Life Practices explaining higher satisfaction. The
three most common explanations were (a) Implementing
choices about how to organize the practice of medicine, (b)
Taking steps to create positive sentiments with patients, (c)
Observing one's own momentary stress responses and
intervening promptly.
Conclusions: Physician stress is most strongly associated
with satisfaction with Personal and Family Issues, rather than
work-specifc items. Results suggest that satisfaction around
Personal and Family Issues buffers doctors from stressful
work-related effects. Health systems, hospitals and physicians
themselves can take concrete steps improve physician
satisfaction.
Implications for Policy, Delivery, or Practice: More
productive business and personal relationships with
physicians could result from an appreciation of this study's
findings. Health system and physican leaders might consider
a more comprehensive approach to physician relations to find
ways to improve physicians' satisfaction beyond the business
and clinical relationship. Personal counseling services,
children's day care, free access to fitness centers, and other
concrete steps may contribute to stronger bonds with more
satisfied and productive physicians.
Primary Funding Source: Winter Park Health Foundation
●The Allied Health Workforce: Occupational Change in
International Context - A Comparative Study of Australia
and the UK
Rosalie A. Boyce, B.Sc., M.Bus., Ph.D., Susan Nancarrow,
Ph.D.
Presented By: Rosalie A. Boyce, B.Sc., M. Bus., Ph.D.,
Research Fellow, School of Health & Rehabilitation Sciences,
University of Queensland, University of Queensland, School of
Health & Rehabilitation Sciences, Brisbane, 4072; Tel: 61 7
3365 1048; Fax: +61 7 3365 4754; Email: r.boyce@uq.edu.au
Research Objective: International analyses of workforce
planning techniques advocate moving away from singleprofession models towards integrated inter-professional or
service-focused approaches. Lack of knowledge about the
allied health professions has been identified consistently as an
impediment to progressing new inter-professional workforce
planning and development models. As the health workforce is
increasingly perceived in global terms and trans-national
migration of workers is expected to expand, it is important
that we increase our understanding of the workforce in a range
of national contexts. The objective of this research is to add
to the limited body of international knowledge about the allied
health professions (non-physician, non-nursing). This
objective is achieved by focusing on Australia and the United
Kingdom and presenting results from a comparative study
that examines (a) trends in workforce supply, (b) key issues in
the national policy contexts of each country that underpin
workforce outcomes and (c) how senior profession managers
and clinicians perceive the relative importance of workforce
dilemmas in each national context.
Study Design: Data was gathered from official national
statistical agencies to chart trends in workforce change.
National policy documents were analyzed to identify key
issues in each national context and the organisational and
professional context were examined by reference to secondary
research sources. NVIVO qualitative thematic analysis
software was utilized on survey data (n=261) to identify issues
and barriers to workforce change in each country.
Population Studied: Senior profession managers and
clinicians in the allied health professions in Australia and the
United Kingdom. In these national contexts allied health does
not include nursing, medicine or dentistry. Professions
designated as core members of allied health in Australia and
/or the United Kingdom include physiotherapy, occupational
therapy, speech pathology, audiology, dietetics, social work
(Australia), pharmacy, podiatry, clinical psychology, medical
imaging, orthoptics and prosthetics and orthoptics.
Principal Findings: In Australia growth in allied health
significantly has exceeded that of medicine, nursing, all health
occupations and national population growth since the 1990s.
Strong growth patterns have also been observed in the UK
particularly since growth targets have been set as part of
recent policy positions. Australian’s rated ‘professional tribes’
and status and hierarchy highly as key issues in achieving
workforce change. UK respondents rated explicit Department
of Health policy initiatives and funding issues highly.
Respondents from both countries highlighted several issues
as shared concerns: recruitment and retention issues,
changing roles, lack of involvement in policy development and
a lack of research capacity.
Conclusions: Workforce change in allied health in the UK has
largely progressed as a result of top down policy initiatives.
Conversely, in Australia, the lack of an overarching federal
policy framework for achieving workforce change has resulted
in more diversity of approaches and more bottom-up
initiatives from the organisational level of health service
agencies and segments of the professions themselves.
Implications for Policy, Delivery, or Practice: The study
confirmed that the nature of allied health professions is
specific to the national context. As a result, making
assumptions about the homogeneity of allied health at the
level of international analysis is fraught with difficulty.
Development of Allied Health Workforce Investment
Strategies are recommended.
Primary Funding Source: Australian Research Council;
Univerisity of Queensland Research Fellowship Scheme
●Effect of RN Staffing on RN Workgroup Satisfaction
Diane K. Boyle, RN, Ph.D., Peggy A. Miller, RN, MS, Byron J.
Gajewski, Ph.D., Susan F. Klaus, RN, MSN, Nancy Dunton,
Ph.D.
Presented By: Diane K. Boyle, RN, Ph.D., Associate Professor,
School of Nursing, Univerisity of Kansas Medical Center, MS
4043, 3901 Rainbow Blvd., Kansas City, KS 66160; Tel: (913)
588-1686; Fax: (913) 588-1660; Email: dboyle@kumc.edu
Research Objective: To examine the effect of patient-to-RN
ratio on RN workgroup satisfaction in a national sample of
four adult, acute care unit types: step-down, medical, surgical,
and combined medical-surgical.
Study Design: We used cross-sectional analyses of linked
data from the 2004 National Database of Nursing Quality
Indicators’ (NDNQI) RN Satisfaction Survey and unit staffing
data. For each unit type, logistic regression models estimated
the effect of patient-to-RN staffing ratio on three RN
workgroup outcomes: low general job enjoyment, low
organizational satisfaction (including satisfaction with nurse
manager, nursing administration, professional development),
and low practice satisfaction (including satisfaction with
nurse-nurse interaction, nurse-physician interaction, task,
autonomy). Analyses controlled for hospital structural (e.g.,
Magnet status, size, ownership) and RN workgroup
characteristics (e.g., mean years on unit, mean years in
practice, percent full-time). To calculate staffing ratio, unit RN
care hours per patient day (RNHPPD) were divided by 24.
RNHPPD were collected according to National Quality Forum
specifications (limited to RNs with direct patient care
responsibilities). The NDNQI RN Satisfaction Survey
subscales exhibit individual and workgroup (unit) level
reliability and validity. NDNQI satisfaction scores are
calculated as T-Scores, with T-scores less than 40 (more than
one standard deviation below mean) considered low
satisfaction.
Population Studied: The sample included 206 NDNQI
hospitals in 44 states. A total of 801 patient care units met the
criteria of (a) participation in the RN Satisfaction Survey, and
(b) submission of RNHPPD for 3-months prior to the RN
Satisfaction Survey: 160 step-down (3,454 RNs), 234 medical
(4,621 RNs), 188 surgical (4049 RNs), and 219 combined
medical-surgical (4,278 RNs).
Principal Findings: Mean patient-to-RN ratios for the unit
types were: step-down 3.63:1, medical 5.14:1, surgical 4.89:1,
and combined medical-surgical 5.00:1. For medical units, an
increase of 1 patient per RN was significantly associated with
the likelihood of low RN workgroup satisfaction (T score < 40)
on all three outcomes: job enjoyment (OR 1.35), organizational
satisfaction (OR 1.39), and practice satisfaction (OR 1.58). For
step-down units, an increase of 1 patient per RN was
significantly associated with the likelihood of low RN
workgroup satisfaction on two outcomes: organizational
satisfaction (OR 1.40) and practice satisfaction (OR 1.61). For
combined medical-surgical units, only low practice satisfaction
was associated with an increase in 1 patient per RN (OR 1.30).
Patient-to-RN ratio was not associated with RN workgroup
satisfaction on surgical units.
Conclusions: Previous research on RN staffing and
satisfaction used state or regional samples and conducted
analyses at the hospital or total sample level. Using a sample
from 44 states, we were able to document staffing effects on
RN workgroup satisfaction when unit types were examined
separately. Our data indicate that RN workgroups with higher
patient workloads in step-down, medical, and combined
medical-surgical units are significantly more likely to
experience low satisfaction. For example, RN workgroups in
medical units with a patient-to-nurse ratio of 8:1 would be 3.94
times more likely (i.e., 1.58 taken to the 3rd power) to express
low practice satisfaction than medical unit RN workgroups
with a 5:1 ratio.
Implications for Policy, Delivery, or Practice: There is a
documented link between job satisfaction, burnout, and
turnover of RNs. Improvements in RN staffing may be
accompanied by improved RN satisfaction, and thereby
decreased burnout, turnover, and reduced replacement costs.
Primary Funding Source: American Nurses Association
●An Examination of RN Workforce Participation Over
Time
Carol S Brewer, Ph.D., RN, Christine T Kovner, Ph.D., RN,
William Greene, Ph.D., Yow-Wu-Wu, Ph.D., Ying Cheng, MA
Presented By: Carol S Brewer, Ph.D., RN, Assocaite Professor,
School of Nursing, University at Buffalo, 918 Kimball Tower,
Buffalo, NY 14214; Tel: 716-829-3241; Fax: 716-829-2021; Email:
csbrewer@buffalo.edu
Research Objective: We examine the time 1 factors that
influence Registered Nurses’ workforce participation (full-time
or part-time), conditional on choice to work or not work, at
time 2.
Study Design: Two wave panel survey design (one year
apart). The year 1 survey included demographic questions,
work setting variables, and movement constraints. Year two
included actual work status. We added county characteristic as
controls from Metropolitan Statistical Area data from
Interstudy, the Bureau of Labor Statistics, and the Area
Resource File.
Population Studied: A random sample of 4000 RNs from 40
MSAs in 29 states was randomly selected; we achieved a 48%
response rate in year one. In year 2, 1348 RNs responded to
both surveys (70.7% response rate). We selected female RNs
(N=1172).
Principal Findings: The data were analyzed using bivariate
probit regression with selection bias correction. The WK/NW
probit excluded work setting variables. The NW/Work and
PT/FT relationship (rho) is not significant unless intent to
work in the next 12 months is in the model. RNs with children
both under and over 6 reduced the probability of working in
year 2. Higher predicted wages, foreign graduate RNs or RN
intention to work increased the probability of working in year
2. In the FT/PT regression, RNs who were an APN, resided in
a small MSA or an MSA with higher inpatient per day ratios,
had a higher quantitative workload, paid time off or health
insurance increased the probability of working FT. If RNs were
a minority, had any children under 6, wanted to work more
hours, thought benefits were not important or worked in an
MSA with a higher RN ratio, the probability of working parttime (PT) in year 2 was increased.
Conclusions: As predicted by organizational theory, intent to
work was a major predictor of actual work status. Different
factors influence deciding to work or not versus working FT or
PT. Variables such as satisfaction and organizational
commitment, typically important in organizational turnover,
did not affect work status in year 2 although intent and
quantitative workload inventory did. MSA market level
variables influence RN work participation, and need to be
included in more RN work participation studies.
Implications for Policy, Delivery, or Practice: Wages
predicted whether or not nurses chose to work at all, but did
not impact FT/PT status, indicating that non-wage factors,
such as benefits that are under the control of employers, were
more important in predicting FT work status. There were no
differences between hospitals and non-hospitals, suggesting
that all employers need to work to attract nurses. The
consistent importance of children under 6 in reducing work
participation of RNs suggests this is an important target for
employers. Except for workload, traditional organizational
factors used in turnover models did not explain FT/PT
participation of the workforce. It is possible that variables used
in turnover studies to predict turnover may predict leaving a
particular organization, but not actual participation in the
workforce. Most measures of market forces have been ignored
in studies of RN workforce participation, but indicate that RNs
make work decisions in the context of opportunities in their
MSAs.
Primary Funding Source: AHRQ, R01 HS11320
●The Labor Supply of Advanced Practice Nurses
Timothy Brown, Ph.D.
Presented By: Timothy Brown, Ph.D., Associate Director of
Research, Petris Center - School of Public Health, University of
California at Berkeley, 140 Earl Warren Hall, MC7360, Berkeley,
CA 94720-7360; Tel: 510-643-4103; Fax: 510-643-4281; Email:
tbpetris@berkeley.edu
Research Objective: To determine the sensitivity of the
supply of labor of Advanced Practive Nurses (APNs) to
changes in earnings per hour. The labor supply behavior of
APNs has not been studied previously according to my
knowledge.
Study Design: The supply of labor is estimated as a function
of earnings per hour and unearned income. The model is
estimated as both a three-part supply model (labor
participation, hours per week, weeks per year) and a two-part
model (labor participation, annual hours). Control variables
include sex, age, the square of age, education, race/ethnicity,
children at home, and year dummies. Work setting is also
included in the sensitivity analysis. Selection corrections are
included as appropriate. Earnings per hour is adjusted to
include only after-tax earnings (estimated federal and state
income taxes are excluded). Separate models are run for
single and married APNs. A squared term for earnings per
hour is also included to pick up the effect of any backward
bend in the labor supply curve. Three waves of the National
Sample Survey of Registered Nurses (1992, 1996, 2000) are
combined with data from the Bureau of Labor Statistics, the
Area Resource File, and the National Bureau of Economic
Research. Labor participation equations are estimated using
two-stage probit models. Hours per week, weeks per year,
annual hours equations are estimated using two-stage
generalized least square models. Since earnings per hour are
endogenous, they are instrumented by the wages of non-APN
registered nurses, the lagged wages of registered nurses,
physicians per capita, hospital beds per capita, and
unemployment (all measured at the level of the Metropolitan
Statistical Area to proxy labor markets). The strength of the
instruments in the first stage are tested using the StaigerStock test. The exogeneity of the instruments is tested using
an overidentification test. The endogeneity of the earningsper-hour predictions is tested using a Hausman-type test. All
estimates also account for the complex survey design of the
data.
Population Studied: Advanced Practice Nurses in the U.S. for
the years 1992, 1996, and 2000 as sampled by the National
Sample Survey of Registered Nurses.
Principal Findings: The labor market for APNs is functioning
Conclusions: APNs do respond to economic incentives.
Implications for Policy, Delivery, or Practice: Economic
incentives should be the first line of response to perceived
labor shortages or labor surpluses of APNs.
Primary Funding Source: AHRQ
●Physical Therapy Education Programs in California:
Trends and Policy Implications
Susan Chapman, Ph.D., RN, Timothy Bates, M.P.P.
Presented By: Susan Chapman, Ph.D., RN, Assistant
Professor and Director of Allied Health Workforce Studies,
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:
schapman@thecenter.ucsf.edu
Research Objective: Although the decision was controversial,
the physical therapy profession is moving toward doctoral
level preparation for practice. The rationale is that clinical
scope, consumer recognition, interaction with medical
colleagues, and management skills will be enhanced. This
additional education is not required for licensure; graduates
from accredited BS, MPT, or DPT programs are all eligible to
sit for the licensure exam. The purpose of this project was to
assess how the move toward doctoral education shifted the
number and type of education programs available, the
number of degrees awarded at each educational level, and
thus the supply of licensed PTs in California. An additional
objective was to assess the impact on PT assistant (PTA)
programs and supply.
Study Design: The research was conducted in California as
part of a larger health workforce tracking project. The data
source used is a series of “Completions” surveys administered
through the Integrated Postsecondary Education Data System
(IPEDS), through the Department of Education.
Population Studied: Education/training programs for
Physical Therapists and Physical Therapy Assistants in the
state of California.
Principal Findings: Since 1998, there have been shifts in the
level and number of degree awards for professional programs
in both PT and PTA. Within Physical Therapy, the shift is away
from the Master of Physical Therapy (MPT) toward the Doctor
of Physical Therapy (DPT). In 1998, DPT awards were only
17% of the total number of awards; in 2004, their share was
31%. Additionally, whereas in 1998 only two schools offered
the DPT, in 2004 this number had grown to six in California.
In 2004, in California, 14 programs reported PT awards at the
Master’s or Doctoral level. Of these 14, 4 offered both the
DPT and the MPT, 8 offered only the MPT, 2 offered only the
DPT. Although the number of institutions offering PTA
Associate Degree programs has remained stable, there has
been a significant decline in the number of awards. In 1998,
there were 271 Associate Degrees awarded; in 2004, there
were only 95. In contrast to the declining numbers of
Associate Degree awards for the PTA, opportunities for
training as a Physical Therapy Aide (unlicensed) appear to be
on the rise. The Bureau of Private Postsecondary & Vocational
Education in the California Department of Consumer Affairs
lists approximately 35 different institutions offering training as
a Physical Therapy Aide.
Conclusions: The shift in program offerings in physical
therapy education is quickly moving to favor the doctoral
degree for entry level practice despite the lack of consensus
that it is clinically warranted. We expected to see an increase
in PTA awards yet data indicates a decrease in PTA degrees as
well. Further study is needed to determine whether a shortage
is practicing clinicians is perceived.
Implications for Policy, Delivery, or Practice: Will “degree
creep” happen in similar professions? Education costs will
increase for students and educational institutions. Potential
decrease in supply of practicing PTs as time in pipeline
increases. Will more unlicensed staff be used in practice?
Consumer confusion as to who is a PT.
Primary Funding Source: The California Endowment
●Estimates of Multiple Jobholding and Wages of
Registered Nurses in Metropolitan Statistical Areas
Ying Cheng, MA, Ph.D. Candidate, Carol S. Brewer, RN, Ph.D.,
Christine K. Kovner, RN, Ph.D., FAAN
Presented By: Ying Cheng, MA, Ph.D. Candidate, Research
Assistant, Economics, State University of New York at Buffalo,
924 Kimball Tower, Buffalo, NY 14214; Tel: 716-829-3611; Fax:
716-829-2021; Email: ycheng5@buffalo.edu
Research Objective: The effects on wages of demographic
characteristics, working conditions and geographic variation
have been studied. However, the relationships between
multiple jobholding (holding one or more secondary jobs),
wages and work hours have not been explicitly examined in an
endogenous framework. Our objective was to examine the
determinants of multiple jobholding and test whether
endogeneity exists in moonlighting behavior of registered
nurses (RNs) in metropolitan statistical areas (MSA).
Study Design: In spite of economic theory that suggests
endogeneity exists between wages and work hours,
researchers have not considered multiple jobholding as an
endogenous variable in this model. We address the explicit
relationship between multiple jobholding, wages and work
hours through endogenous equation models. The models
include demographic variables (age, education, gender, race,
marital status), MSA level variables, work variables (working
settings, positions, schedule, work benefits) and work attitude
measures (work family conflicts, work load, work motivation).
Two-step estimation and 2-stage conditional maximum
likelihood regression models are used to test the existence of
endogeneity.
Population Studied: The survey design had a randomly
selected sample of RNs from 40 MSAs in 29 states and 1907
RNs responded (48%). Of this sample, a subsample of
working RNs (n=1645) was used in the analysis. This survey
data was merged with the BLS (Bureau of Labor Statistics)
unemployment rate data, Interstudy Competitive Edge Part III
Regional Market Analysis data and the Area Resource File. The
final dataset includes RN demographic variables, RN work
setting variables and MSA market variables.
Principal Findings: Endogeneity exists in multiple jobholding
behavior (the chi-square test is significant at 5% level).
Education (Diploma), small MSA size and work hours are
negatively related to the probability of holding secondary job.
Race, partner’s income and marital status have no significant
effect. RNs with Master's or Doctoral degree, male, higher
work family conflicts and wages are more likely to hold
secondary jobs.
Conclusions: This study demonstrated the effects of wages
on RNs’ multiple jobholding behavior, as well as showed that
MSA level variables and demographic factors as well as work
attitudes were influential on RNs’ jobholding behavior. These
results indicated that RNs moonlight in a secondary job
because of market demand for more human capital, but not
for the need to meet regular household expenses, as workers
in other occupations reported in Current Population Survey.
Implications for Policy, Delivery, or Practice: The
differential pattern in the acquisition of secondary job by
gender, MSA size and education is consistent with the
persistent income gap in household between males and
females and across regions. RNs with more educational
human capital can respond to the demand for RNs by
accepting a secondary position.
Primary Funding Source: AHRQ
●Do Physicians and their Relatives have a Decreased Rate
of Caesarean Section? A 4-year Population-based Study in
Taiwan
Yiing-Jenq Chou, M.D, Ph.D., Cheng-Hua Lee, M.D, DrPH,
Nicole Huang, Ph.D., I-Feng Lin, Chung-Yeh Deng, Yi-Wen
Tsai, Long-Shen Chen,
Presented By: Yiing-Jenq Chou, M.D, Ph.D., Associate
Professor, Department of Social Medicine, National Yang
Ming University, 155, Li-Nong Street, Section 2, Taipei, 112; Tel:
886-2-28201458; Fax: 886-2-28261002; Email:
yjchou@ym.edu.tw
Research Objective: The increase in the rate of cesarean
deliveries may be due partly to a lack of consumer knowledge.
Assuming that physicians and their relatives are well informed
of the risks and benefits associated with the different methods
of delivery, our goal was to compare caesarean rates between
female physicians, female relatives of physicians, and women
with high socioeconomic status in Taiwan.
Study Design: A pooled cross-section time-series design.
Population Studied: Two subgroups of 588 female physicians
and 5,021 relatives of physicians aged 20-50 years were
compared with 96,104 with monthly wage?40,000 New
Taiwan (NT) dollars included from a nation-wide
representative sample of the general population of Taiwan
from 2000 to 2003.
Principal Findings: Female physicians (adjusted odds ratio
0.66; 95% CI 0.47, 0.93) and female relatives of physicians
(adjusted odds ratio 0.84; 95% CI 0.74, 0.95) were
significantly less likely to undergo a caesarean section than
other high socioeconomic status women, adjusted for clinical
and non-clinical factors.
Conclusions: In the study, the cesarean rate was lower
among women who may have greater access to medical
knowledge. However, the lower rates observed among female
physicians and physician relatives in Taiwan are still
considerably higher than the national averages of many
countries. This suggests that other than information, practice
pattern, social and cultural milieu, may play a role.
Implications for Policy, Delivery, or Practice: Debates about
the appropriate use, rates, and relative safety of caesarean
section are likely to continue. Using physicians and family
members of physicians as a reference may be reasonable in
the short term, but is perhaps not good enough. In the long
run, efforts must continue to contain the rising trend of
caesarean sections, and minimize the potentially
inappropriate use of this procedure. Sufficient and reliable
information must be made available to pregnant women, so
that they can make informed decisions. Also, in developing
countries, strategies to further reduce cesarean rates to an
acceptable global standard should take diverse social and
cultural factors into consideration.
Primary Funding Source: Taiwan's National Science Council
●The Professional Scope of Practice of Dental Hygienists
and Favorable Oral Health Outcomes for Children and
Adults: A Multi-level Model Analysis
Tracey Continelli, BA, Margaret Langelier, MS, Paul Wing, D
Engin
Presented By: Tracey Continelli, BA, Research Assistant,
Center for Health Workforce Studies, 7 University Place /
Room 334, Rensselaer, NY 12144-3458; Tel: (518) 402-0250;
Email: tac02@health.state.ny.us
Research Objective: Concern for the oral health status of
Americans was heightened with the 2000 publication of "Oral
Health in America: A Report of the Surgeon General." The
impact of poor oral health was a fundamental theme of the
report which presents the major economic and social issues
surrounding the effects on individuals and society of poor oral
health, and most importantly, the need to extend oral health
services to a variety of Americans with inadequate access to
fundamental dental services. One important way to improve
access is the expansion of the legally mandated scope of
practice for dental hygienists. Levels of legally prescribed
professional status differ widely from state to state, such as
requirements for differing levels of supervision, continuing
education, and actual services that can be provided. The tasks
permitted to dental hygienists in statute and regulation affect
the ability of the profession to provide preventive oral health
services to patients, particularly vulnerable population or rural
populations, which often encounter difficulty with access to
care. The goal of this analysis is to investigate whether or not
the professional scope of practice for dental hygienists can
exert an impact upon oral health outcomes in children and
adults within the United States.
Study Design: An index was created to quantify the
professional practice environment of dental hygienists. This
index summarizes the legal practice environment prescribed
by State law for the profession in each of the 50 States and the
District of Columbia for the year 2001. Four aspects of the
design emerged: a legal / regulatory environment, levels of
supervision, tasks permitted under varying levels of
supervision, and reimbursement. This index was factor
analyzed and found to be a single factor called the Dental
Hygiene Professional Index (DHPI). Higher scores on the
DHPI are associated with broader sets of tasks, more
autonomous practice environments, and greater opportunities
for direct reimbursement for services. Multi-level modeling is
employed estimating the effect of state level variables,
including the DHPI, upon oral health outcomes for individuals
nested within each state.
Population Studied: In addition to the DHPI, the supply of
dentists, dental hygienists, and dental assistants per capita are
utilized at the state level as well as the percentage of the
population on a fluoridated public water supply. Individual
level data are drawn from the Behavioral Risk Factor
Surveillance System (BRFSS) for adults, and the National
Survey of Children’s Health (NSCH) for children. The BRFSS
is a cross-sectional telephone survey conducted by state
health departments with technical and methodological
assistance provided by the CDC for all 50 States and the
District of Columbia. The dataset contains oral health
variables as well as a number of pertinent socio-demographic
factors. The National Survey of Children’s Health (NSCH),
also a telephone survey, was developed by the National Center
for Health Statistics of the CDC, and contains a number of
oral health as well as socio-demographic variables for
children. Both datasets contain large samples within each
state and are designed to be representative of the state
population.
Principal Findings: Both dental hygienists and the DHPI
exerted a positive and statistically significant effect upon
favorable oral health outcomes for both children and adults.
The final model suggests that it is the DHPI which is the most
important factor. The supply of dentists and dental assistants
per capita had no impact upon oral health outcomes.
Conclusions: The areas of health promotion, risk assessment,
and disease prevention are considered core competencies for
dental hygienists who function as preventive oral health
specialists. The findings of this analysis indicate that dental
hygienists play an important role in the prevention of dental
decay and disease.
Implications for Policy, Delivery, or Practice: The scope of
practice for dental hygienists has important implications for
the oral health of both children and adults within the United
States. Both children and adults living within States with less
restrictive legally prescribed practice environments for dental
hygienists have better oral health. The professionalization of
dental hygienists has important health implications for the
U.S. population.
Primary Funding Source: No Funding
●Physician Workforce: Rural vs. Urban
Pamela Dinkfelt, Ph.D., John M Westfall, M.D, M.P.H., Richard
G May, M.D, Kristina Wenzel, RN, MBA, Robin A Harvan, EdD
Presented By: Pamela Dinkfelt, Ph.D., Manager, Health
Workforce Analysis, Colorado Health Institute, 1576 Sherman
St, Denver, CO 80203; Tel: (303) 831-4200 x218; Fax: (303) 8314247; Email: dinkfeltp@coloradohealthinstitute.org
Research Objective: Of Colorado’s 64 counties, 47 (73%) are
considered rural. Many of these rural communities face a
shortage of physicians. This research compares demographic
and practice characteristics of physicians working in rural and
urban counties in Colorado in 2005.
Study Design: A one-page workforce-related questionnaire
was sent by the Colorado Board of Medical Examiners to all
physicians licensed to practice in the state. The survey form
was enclosed with materials required for license renewal in
2005, and respondents were asked to return the completed
survey form with their licensure documents. Of the 16,183
physicians who renewed their license, 7,694 (48%) completed
the questionnaire.
Population Studied: Survey respondents who indicated they
were currently practicing medicine, and also provided a
Colorado zipcode for the location of their primary practice
were included in the analysis. County designation of the
practice location zipcode was determined using a geomapping
software, and county designation of urban or rural was
determined using 2003 US Bureau of the Census
classifications. Of the 4,759 physicians practicing in Colorado
with identifiable counties, 4,245 (89%) practiced in urban
counties and 514 (11%) in rural counties.
Principal Findings: Findings from the 2005 physician survey
indicate rural physicians were significantly more likely to have
grown up in a rural location than urban physicians (Rural =
34%, Urban = 20%; p<0.001). Rural physicians did not,
however, differ from urban physicians in gender distribution
(R Females = 26%, U Females = 29%), nor in mean age (R =
50.4 years, U = 50.2 years). Rural physicians were significantly
more likely to designate their primary medical specialty as
family medicine, general medicine, internal medicine or
pediatrics than urban physicians (R = 49%, U = 41%;
p<0.001), and more likely to accept new Medicaid patients (R
= 66%, U = 55%, p<0.001) and new Medicare patients (R =
73%, U = 63%, p<0.001). In comparison to a similar 2001
survey, the 2005 findings show the mean age of physicians
increased, and the percentage of physicians accepting new
Medicaid and Medicare patients decreased.
Conclusions: The analysis showed differing demographic and
practice characteristics between physicians working in rural
counties and those working in urban counties. Given the
shortage of physicians in rural communities and the aging of
the physician workforce, further examination of rural physician
characteristics is imperative. The need for study is amplified
by a general population that is aging and will have increased
need for healthcare, and compounded by the decreased
acceptance of new Medicaid and Medicare patients.
Implications for Policy, Delivery, or Practice: According to
2003 US Census Bureau estimates, in year 2000, nonmetro
America comprised 2,052 counties and was the home to 17
percent (49 million) of the US population. A key, persistent
characteristic of the rural health landscape in Colorado and in
the nation is the uneven distribution and shortage of
healthcare providers. By better understanding the
demographic and practice characteristics of physicians who
choose to work in rural areas, recruitment and retention
strategies could be enhanced and more directed.
Primary Funding Source: The Colorado Trust
●Antecedents to Physician Retirement
Gaetano Forte, BA, David Armstrong, BA, Gaetano Forte, BA,
Jean Moore, MS
considered in future forecasts of physician supply and
assessments of the relationship between supply and demand.
Primary Funding Source: HRSA
Presented By: Gaetano Forte, BA, Director of Information
Management, Center for Health Workforce Studies, 7
University Place / Room 334, Rensselaer, NY 12144-3458; Tel:
(518) 402-0250; Fax: (518) 402-0250; Email:
gjf01@health.state.ny.us
Research Objective: After many years of concern about an
oversupply of physicians, there is a growing consensus that
the supply of physicians will soon be inadequate to provide
health care services to the population. To date, most efforts
to assess the adequacy of the supply of physicians in the U.S.
and forecast future requirements have focused on the pipeline
of new physicians, including medical school capacity and
graduate medical training. Surprisingly, very little attention
has been given to studying physician retirement rates, trends,
and the factors that may have influence on them. In order to
contribute to efforts to assess the adequacy of the physician
supply, the present study examines the antecedents of
physician retirement and plans to reduce patient care hours.
Study Design: The primary data source for the paper is the
2004 – 2006 New York State Physician Re-registration Survey.
Other data sources include 2000 – 2003 New York State
Resident Exit Survey and the Medical Liability Mutual
Insurance Company. The New York State Physician Reregistration Survey is conducted in cooperation with the New
York State Education Department. In 2004, over 77,000
physicians held licenses to practice medicine in New York. All
physicians are required to register with the State Education
Department every two years. The present registration cycle
began in January 2004 and will last until January 2006.
Included in each registration packet is a questionnaire that
requests responding physicians to provide information on a
number of personal, professional, and practice characteristics.
A logistic regression analysis was used to access the
antecedents of physician retirement. Apart from considering
demographic variables, indicators of practice setting, specialty
demand, and malpractice insurance premiums were also
included in the model.
Population Studied: Active, patient care physicians practicing
in New York between the years 2004 and 2006.
Principal Findings: There was substantial variation in
retirement rates across specialties. Further, several
demographic variables, including age, as well as solo practice
setting and high insurance premiums were significant
predictors of retirement.
Conclusions: Given the aging, baby-boom population,
physician retirement and plans to reduce work effort are
increasingly important pieces of the physician supply and
demand puzzle. Not only does the present study confirm that
retirement rates vary greatly by specialty, but it also highlights
a number of critical factors that affect retirement. Among
these factors are practice setting and insurance premiums.
Implications for Policy, Delivery, or Practice: We are just
beginning to understand the importance of physician
retirement patterns to the future supply of physicians. As a
result, additional research is needed in order to clarify their
implications. The findings of this present study suggests,
however, that the antecedents of retirement (such as: age,
race/ethnicity, practice setting, and premium rates) should be
●Nursing Compensation Policy and Health Care
Outcomes: The Relationship between Pay Level and
Coronary Survival Rates in California
Jonathon Halbesleben, Ph.D., Mark P. Brown, Ph.D., Anthony
R. Wheeler, Ph.D.
Presented By: Jonathon Halbesleben, Ph.D., Research
Assistant Professor, Department of Health Management &
Informatics, University of Missouri, Columbia, 324 Clark Hall,
Columbia, MO 65211; Tel: (573) 884-1723; Fax: (573) 882-6158;
Email: halbeslebenj@health.missouri.edu
Research Objective: In recruiting and managing nurses, a key
concern is the appropriate level of pay, relative to competitors,
to adequately attract and retain nurses to provide high quality
health care for patients. Efficiency wage theory predicts that
for some job categories (e.g., RNs) a lead pay policy (where
nurses are paid higher wages than average) will lead to better
outcomes for hospitals while a lag policy (where nurses are
paid lower wages than average) for other job categories (e.g.,
nursing aides and orderlies) will lead to better outcomes. The
objective of this study was to examine this predicted
relationship using a sample of hospitals from California.
Study Design: Data from state-mandated disclosure reports
to the state of California from 354 hospitals across nine years
were used to test the predictions. The reports included pay
data for nurses by job category (RN, LPN, and
aides/orderlies); pay level variables were calculated by
standardizing the average pay by job category for each
hospital; the resulting variables were scaled such that positive
scores indicated a lead policy, a zero score indicated a match
policy, and negative scores indicated a lag policy. The pay
level data were then compared to coronary survival rates for
each hospital after adjusting for common control variables.
Adjusted coronary survival rates were calculated by
subtracting the reported heart attack death rate from the riskadjusted expected heart rate (as estimated for each hospital by
the state of California) for each hospital.
Population Studied: Short-term-stay, acute care, general
hospitals in the state of California from 1991-1999.
Principal Findings: After controlling for profit status,
ownership status, hospital size, cost of living in the area where
the hospital was located, case mix, and unionization status,
we found that a lead pay policy among RNs was associated
with a higher adjusted coronary survival rate. On the other
hand, pay policy was not associated with higher adjusted
coronary survival rate for LPNs or aides and orderlies.
Conclusions: This study found a relationship between pay
policies of hospitals and patient outcomes. It suggests that by
paying employees in higher skill level job categories at a rate
that exceeds the market, patients benefit. This benefit may be
the result of attracting higher quality job candidates to these
jobs, which translates to better outcomes for patients. Future
research that replicates these findings with other patient
outcomes would provide greater credence to the conclusions.
Implications for Policy, Delivery, or Practice: This research
supports the notion of differentiating pay level strategy by job
category; specifically, the findings suggest utilizing a lead pay
policy for high skill jobs in order to recruit better qualified
candidates who can provide better care to patients. For lower
skill jobs, pay level is not related to patient outcomes; as such,
a lead policy is unlikely to lead to benefits in terms of patient
outcomes. As health care organizations struggle with
attraction and retention of nursing staff in light of
contemporary workforce shortages, understanding the
implications of pay level may be valuable in determining
compensation policy.
Primary Funding Source: No Funding
●Predictors of Home Healthcare Nurse Job Retention
Carol Hall Ellenbecker, RN, Ph.D., Frank Porell, Ph.D., Linda
W. Samia, RN, Ph.D.c
Presented By: Carol Hall Ellenbecker, RN, Ph.D., Associate
Professor, College of Nursing and Health Sciences, University
of Massachusetts Boston, 100 Morrissey Blvd, Boston, MA
02125; Tel: 617-287-7515;
Email: carol.ellenbecker@umb.edu
Research Objective: The purpose of this study was to test a
theoretical model of the direct and indirect effects of job
satisfaction, individual nurse characteristics, and intent to stay
on job retention for home healthcare nurses.
Study Design: This was a descriptive correlation study. A
second wave of self-report data was collected from nurses
using the Home Healthcare Nurses Job Retention
Questionnaire. The 14 item instrument measures home
healthcare nurse retention. This data was linked to nurse level
job satisfaction data collected one year earlier with the 30 item
HHNJS and Intent to Stay Instrument, nurse demographic
and descriptive agency level data.
Population Studied: A representative sample of 2,500 home
healthcare nurses was recruited from Certified Home
Healthcare Agencies throughout the New England region
from a probability proportionate to size random sample of 123
agencies. The 2,300 (96%) of nurses who agreed to future
contact during the first wave of data collection were recruited
to Phase II of the Retention Study using Dillman’s Tailored
Design Method. There was an 83% response rate to the
mailed self-report survey (N= 1900) and another 34% of nonrespondents (N=238) provided information via follow-up
phone call.
Principal Findings: The strongest predictor of job retention
was nurse job satisfaction. Fourteen percent of home
healthcare nurses left their jobs one year following the initial
wave of data collection and over 50% gave as their primary
reason for leaving “dissatisfaction.” Nurses describe reason
for dissatisfaction due to “overwhelming and stressful
demands,” and secondly because of relationships with
administration.
Conclusions: Nurses’ job retention is affected 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 provides the information necessary to
maintain nursing staff and assure access to quality home
healthcare services. Job satisfaction and retention 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, R01 # HS013477-02
●Evidence of Wage Discrimination Between Internationally
and US Educated Nurses
Sat Hayde, MSN, RN (HSA)
Presented By: Sat Hayde, MSN, RN (HSA), Doctoral Student;
UNCC Ph.D. Program, Public Policy,
Email: sahayden@uncc.edu
Research Objective: Is there evidence of wage discrimination
among nurses? Do wages paid to internationally educated
nurses (IENs) differ from wages paid to nurses educated in
the United States (USRNs) and can those differences can be
explained by productivity factors or do they provide evidence
of wage discrimination? 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. These studies have been done using a
variety of perspectives. The purpose of this study is to use an
economic perspective to explore differences in salaries
between these two groups of nurses as an explanation of the
growing use of IENs to alleviate domestic nursing labor
shortfalls.
Study Design: Wage differences will be investigated using an
Oaxaca wage decomposition formula along with a CottonNeumark extension. The current study builds on earlier work
by Kalist (2002) and Jones and Gates (2004) in which
evidence of gender related wage discrimination in nurses
responding to the year 2000 National Sample Survey of
Registered Nurses (NSSRN) was investigated. Once the data
from the 2004 National Sample Survey of Registered Nurses
is released, the current study will incorporate this latest data
for comparison purposes. To elucidate the relationships
between lifestyle and productivity factors, marital status,
children at home, work setting, primary job role, experience
and highest level of education attained were included in the
analysis.
Population Studied: The 2000 National Nurses Sample
Survey (NSSRN) contains information about 1291 foreign
educated nurses as well as information about 29000
domestically educated nurses. This study looks only at those
nurses who work full time in urban areas who responded to
the survey. Due to the limitations of the dataset, this study
was unable to further compare gender based differences
between IENs and USENs; with the release of the 2004
NSSRN dataset, it may be possible to expand the study to
include this important dimension.
Principal Findings: Analysis suggests that wage differences
between IENs and USENs exist in the US health care market.
These differences cannot be explained by differences in
experience, level of education, job role, job settings or job
function nor can they be explained by family status.
Implications for Policy, Delivery, or Practice: The
development this research can help health service researchers
and policy makers to identify a way to better understanding
the impact of international nurse migration on the United
States health care industry. For researchers the study
provides a platform for additional investigation of the impact
of nurse migration on health care market in general and
nursing labor shortages in particular. For policy makers the
study provides an economic lens through which to view
international nurse migration as a foreign policy issue or to
develop policy solutions to nurse shortages in their
jurisdictions locally. 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
●International Migration of Physicians to the United
States: Implications for US Workforce Policy
Peter Hussey, Ph.D.
Presented By: Peter Hussey, Ph.D., Associate Policy
Researcher, RAND, 1200 S. Hayes St. w6340, Arlington, VA
22202; Tel: (703) 413-1100 x5460; Email: hussey@rand.org
Research Objective: This study examines the characteristics
of visas obtained by physicians immigrating to the United
States. The objective is to determine how immigration rates
could potentially be changed and the implications of physician
immigration for the countries of origin.
Study Design: Descriptive analysis of Immigration and
Naturalization Service data on U.S. permanent resident visas
granted to physicians between 1994 and 2000. Data on
countries of origin were compiled from the World Bank, the
International Monetary Fund, and other sources.
Population Studied: All physicians receiving U.S. permanent
resident visas between 1994 and 2000.
Principal Findings: Two-thirds of physicians received
permanent resident visas on the basis of their family ties, not
through employment. Emigration rates were highest from
upper-middle-income countries: 11.2 emigrants per 1000
physicians in the country of origin per year, compared to 7.3
emigrants per 1000 physicians from low-income countries
and 4.4 per 1000 from lower-middle-income countries. The
absolute number of physicians migrating to the US from
poorer countries was substantial: 66%, or 19,761, physician
immigrants were from low-income or lower-middle income
countries. Emigration rates were also highest from countries
with the lowest average life expectancy: 9.8 per 1000 from
countries with average life expectancy <50 years, compared to
4.0 per 1000 for countries with life expectancy >70 years.
Conclusions: The brain drain of physicians was substantial
from both low- and middle-income countries and was most
common from countries with the lowest life expectancy. Most
physicians migrated based on their family ties to the US, not
based on agreements with employers. This is in contrast with
other professions such as scientists and nurses.
Implications for Policy, Delivery, or Practice: Efforts to
reduce physician immigration through immigration policy
would be most effective if focused on the one-third of
immigrants receiving employment-preference visas. The most
effective target for this type of policy would be temporary work
visas, particularly the H-1B visa, which could be replaced with
J-1 visas. Preventing family-based immigration would be more
to justify and difficult to target to physicians. There may be
large numbers of physicians living in the US who have
immigrated on family preference visas and are not practicing
as physicians. These individuals represent a potential
recruitment pool, assuming they are appropriately skilled;
efforts could be made to identify them and reduce the barriers
to licensure.
Primary Funding Source: AHRQ
●Medical Staff Availability and Nursing Home Quality
Orna Intrator, Ph.D.
Presented By: Orna Intrator, Ph.D., Assistant Professor
(Research), Center for Gerontology and Health Care Research,
Brown University, 2 Stimson Avenue, Providence, RI 02912;
Tel: 401-863-3579; Fax: 401-863-9219; Email:
Orna_Intrator@brown.edu
Research Objective: As the severity of illness of nursing
home residents continues to increase, the physician’s role in
their care will grow in importance. However, the scant existing
literature paints a picture of physicians as a shadowy presence
in most nursing homes1 suggesting that for many staff and
residents, the MD’s seem to be “missing in action”. The
limited involvement of physicians in nursing homes impedes
interdisciplinary communication and effective treatment, often
leading to deleterious resident outcomes, such as avoidable
hospitalizations, and inadequate pain management and
inadequate pressure ulcer care.2-6 This picture is complicated
by substantial variation among and within states in their
efforts to increase MD involvement and to utilize nurse
practitioners (NP) and physician assistants (PA).
Study Design: Proposed model of organizational behavior to
be tested using a survey of New York nursing homes in 1997
which captured organizational behavior, along with resident
performance as measured on the Minimum Data Set, and
nursing home characteristics as measured in the Online
Survey Certification And Reporting (OSCAR).
Population Studied: Long stay nursing home residents in
urban freestanding facilities.
Principal Findings: Multilevel models examining the
relationship between the availability of physicians and
separately the availability of nurse practitioners or physician
assistants (NP/PAs), controlling for many facility and resident
characteristics, reported that facilities with medical staff were
less likely to restrain residents, and were more likely to have
residents’ pain controlled. Moreover, using a novel method to
determine level of delirium, these facilities were also more
likely to diagnose sub-syndromal delirium.
Conclusions: The availability of medical staff enhances quality
of care for residents, yet it is not clear whether there is a
threshold effect, and whether there are other organizational
factors controlling medical staff that lead to the observed
effects.
Implications for Policy, Delivery, or Practice: More
attention needs to be given to considerations of the
organization of medical staff as evidence of its effectiveness
on resident quality is made apparent in the literature. Study of
medical staff is the next frontier of studies of the relationships
of staffing and quality in nursing homes.
Primary Funding Source: No Funding
●Preliminary Evaluation of a Unique K-12 Program
Designed to Prepare Underrepresented Minorities for
Scientific Careers
Micheala Jones, Ph.D., Marian Johnson-Thompson, Ph.D.
Presented By: Micheala Jones, Ph.D., Sheps Center for Health
Services Research, University of North Carolina at Chapel Hill,
4101 Five Oaks Drive Unit 33, Durham, NC 27707; Tel: 615289-9251; Email: mjones@schsr.unc.edu
Research Objective: The Bridging Education and Science
Technology K-12 Program (BEST), was established at Hillside
High School (HHS), in Durham, North Carolina as a
partnership between the National Institute of Environmental
Health Sciences (NIEHS), National Institutes of Health, and
Durham Public Schools. Its goals were to increase students’
enthusiasm for science, to increase opportunities for
motivated students to pursue science careers, and to assure
the availability of a well-trained scientific workforce. BEST
students received mentoring by NIEHS scientists and
participated in a molecular biology course taught at HHS.
Students also gained summer research experiences at local
and state institutions and participated in after-school
enrichment activities. BEST students have completed summer
research internships at UNC-Chapel Hill, Duke University, NC
State University, NIEHS, the US Environmental Protection
Agency and the Centers for Disease Control. After completing
research internships, students prepared research posters and
presented their research findings at various meetings (e.g. the
American Association for the Advancement of Science and the
NC Academy of Sciences Research Meeting). An
AcademyHealth Committee reported that minorities
represented 15.3% of public health students in 1990 and 19.5%
in 1999. Currently, the percentage of minorities is 25% and
this number is expected to double within the next 50 years.
Health experts suggest that if more minorities were involved
public health careers, the gap in health disparities could be
decreased. The objective of this study was to determine the
effectiveness of the BEST program in encouraging minorities
to pursue math/science disciplines that might prepare them
for public health related degrees.
Study Design: Data were collected via collegiate and internet
searches, personal references, and the project director. Data
were confirmed by phoning colleges and performing collegiate
and internet searches. Participants who have graduated
college were interviewed via phone and were asked to provide
their race, college attended and major, and post-college plans,
while, for those participants who were currently pursuing
undergraduate degrees, data were obtained from the program
director.
Population Studied: Sixty-two high school students who
participated in the BEST program from 1998-2005 that were
accepted into college.
Principal Findings: The percent of BEST students who were
minorities: Cohort 1998-2000 (100%), 2001 (90%), and
2002-2005 (97%). The percent of BEST students who
majored in a math/science discipline: Cohort 1998-2000
(100%), 2001 (88%), and 2002-2005 (90%). Of those, the
percent who received/are pursuing graduate degrees: Cohort
1998-2000 (60%), 2001 (30%), and 2002-2005 (N/A). Of
those, the percent of graduate degrees that are math/science
disciplines: Cohort 1998-2000 (95%), 2001 (67%), and 20022005 (N/A).
Conclusions: These findings demonstrate that 100% of the
BEST participants were accepted into college and more than
88% majored/are majoring in a math/science discipline. The
BEST program is partially responsible for preparing students
for math and science based disciplines.
Implications for Policy, Delivery, or Practice: The BEST
program could be implemented in school systems as a viable
mechanism for increasing the number of minorities who
pursue public health related careers. Potentially, these
students represent future health professionals who will play
significant roles in decreasing the health disparities gap.
Primary Funding Source: AHRQ
●Not on the Radar: Public Policy in Canada and Health
Human Resource Migration from Sub-Saharan Africa
Arminee Kazanjian, Dr. Soc., Lars Apland, MA
Presented By: Arminee Kazanjian, Dr. Soc., Professor, Health
Care & Epidemiology, University of British Columbia, 5804
Fairview Crescent, Vancouver, British Columbia, V6T 1Z3; Tel:
(604) 822-4618; Fax: (604) 822-4994; Email:
a.kazanjian@ubc.ca
Research Objective: Despite common acknowledgement that
the migration of health professionals from Sub-Saharan Africa
(SSA) and the resultant loss of capacity to deliver health
services are devastating for countries in that region, Canadian
public policy interest in, and consideration of, the “brain
drain” of health human resources (HHR) from SSA seems
cursory, at best. While memorandums of understanding and
other non-binding types of international agreements pay lip
service to ethical principals of recruitment, these seem to be
largely ignored or by-passed in the context of relations among
federal, provincial, and territorial levels of government in
Canada. The objectives of this research were to explore the
incongruity between public policy principles and objectives,
and to highlight a path whereby these may converge with
most effective overall results.
Study Design: This research was part of a larger study that
examined the scope, implications, and effects of the “brain
drain” of health professionals from SSA to Canada. Using
mixed methodology, it explored the conditions, primarily in
Canada but also in source countries of the developing world,
which allow, promote, and facilitate HHR migration and the
subsequent “brain drain” from countries that can least afford
to lose trained personnel. Telephone and face-to-face
interviews were the data collection methods for this paper.
Population Studied: A select sample of key Canadian
governmental and professional informants responsible for, or
involved in, HHR policy and recruitment in a number of
provinces were interviewed. They were asked to share their
views and understanding of issues, as well as their knowledge
of respective governmental or organizational policies,
surrounding the recruitment and migration of trained health
professionals from developing countries, particularly those of
SSA, to Canada.
Principal Findings: Canadian federal and provincial public
policy may be well-intentioned, but a number of factors
contribute to the incongruity between principle and policy and,
perhaps inadvertently and to an unnecessary extent,
undermine policy objectives and efficacy. These factors
include the nature of the division of constitutional powers
among federal and other levels governments in Canada, the
local conditions that variously force provincial and territorial
policy-makers to address pressing needs in their own
jurisdictions, as well as facilitative migration policies and the
often harsh realities of life in source countries that drive
citizens to seek opportunities internationally.
Conclusions: Broadly based domestic HHR and international
policy objectives invariably conflict, with inconsistent,
counterproductive and unsatisfactory results that continue to
work to the detriment of source countries of the developing
world.
Implications for Policy, Delivery, or Practice: A key
challenge for public policymakers, at all levels of government
in federal systems, is to co-ordinate and find common ground
whereby specific domestic HHR needs and “brain drain”
issues, as they affect source countries, can be simultaneously
and effectively addressed.
Primary Funding Source: No Funding
●Radiation Oncologists in the United States
Rebecca Lewis, Jonathan Sunshine
Presented By: Rebecca Lewis, American College of Radiology,
Email: rebeccal@acr.org
Research Objective: Given the increasing use of radiation
therapy in treatment of cancer, to provide an extensive and
detailed portrait of radiation oncologists, their professional
activities, the practices in which they work, and to assess
trends in the number of radiation oncologists over the past
decade.
Study Design: We analyzed data from the American College
of Radiology’s 2003 Survey of Radiation Oncologists, a
nationally-representative, confidential, stratified random
sample mail survey of radiation oncologists in the United
States, with a total of 479 useable responses. Data were
weighted to make them representative of all radiation
oncologists in the United States. Comparisons were made to
the results of the previous 2000 Survey.
Population Studied: Some analyses were performed on all
radiation oncologists, including those in-training and retired
(temporarily or permanently). Most of the analyses were
performed on post-training, professionally active radiation
oncologists.
Principal Findings: Approximately 39% of post-training
professionally active radiation oncologists were <45 years old
and 23% were women. Twenty-six percent of radiation
oncologists in training were women. The largest percentage
(33%) of radiation oncologists were located in the South. The
largest percentage (48%) of radiation oncologists are in nonacademic private radiation oncology practices. Of those
report a primary specialty, the largest percentages specialize in
prostate (23%), breast (18%), and brachytherapy (13%). Of
those who are involved in clinical practice in hospitals, the
mean percent of work time spent at it is approximately 83%
(compared to about 77% for diagnostic radiologists). Of
those involved in clinical practice in non-hospital sites, the
mean percent of work time spent at it is approximately 39%.
About one-third of radiation oncologists spend some time
teaching and about one-quarter spend some time in research.
Sixty-two percent of post-training, professionally active
radiation oncologists reported that their workload was about
right. Full-time radiation oncologists work on average 51
hours/week, about the same as the mean weekly hours
worked by diagnostic radiologists.
Conclusions: Most demographic, professional, and practice
characteristics remained relatively constant between 2000 and
2003. We do not have yet specific conclusions regarding
trends in the population of radiation oncologists, but expect to
have this data, along although with a comparison of U.S.
radiation oncologists to the number of patients who are
undergoing radiation oncology.
Implications for Policy, Delivery, or Practice: With radiation
therapy increasing as a treatment of cancer, and a potential
rise in overall incidence of cancer, sufficient numbers of
trained radiation oncologists are critical.
Primary Funding Source: No Funding
●Association Between Nurse Staffing and Length of Stay
in VHA
Chuan-Fen Liu, Ph.D., Ann E. Sales, Ph.D., Yu-Fang Li, Ph.D.,
Gwendolyn T. Greiner, M.P.H., Nancy D. Sharp, Ph.D., Elliot
Lowy, Ph.D.
Presented By: Chuan-Fen Liu, Ph.D., Investigator, VA Puget
Sound Health Care System (152), VHA, 1100 Olive, Suite 1400,
Seattle, WA 98101; Tel: (206)764-2587; Fax: (206)764-2935;
Email: Chuan-Fen.Liu@va.gov
Research Objective: Several large scale studies have found
associations between nurse staffing and length of stay for
hospitalized patients, aggregated to the facility level.
However, nurse staffing levels vary greatly across inpatient
units within a facility. In this study we provide the first largescale analysis using nursing unit-level data to examine the
association between staffing levels, skill mix, and patient
length of stay (LOS).
Study Design: Data came from several sources: VA nursing
labor files; VA National Patient Care Databases for data on all
patients admitted to VHA inpatient acute care between 2/036/03; and a national data file linking inpatients to nursing
units. We defined the nurse staffing level as nursing hours
per patient day by type of nurse provider (registered nurseRN, licensed practical nurse- LPN, nurse aide- NA). The skill
mix was defined as the proportion of RN hours to total
nursing hours. The dependent variable was natural log(LOS)
due to skewness and kurtosis. We developed a 2-step
multilevel regression model with patient, nursing unit and
hospital level data corrected for clustering at the unit and
facility levels. The first step predicted patient probability of
developing a serious complication using patient-level
predictors. The second step estimated log(LOS) on predicted
patient complications, nursing unit and facility-level
predictors. We stratified the analysis by whether or not the
patient received any intensive care (compared to those with
no intensive care). All analyses were conducted using the
xtmixed procedures in STATA with two levels of clustering
(unit and facility).
Population Studied: The study included 126,382 patients
from 463 nursing units in 119 VAMCs. 184 were intensive
care, and 279 non-intensive acute care units.
Principal Findings: The mean RN hours per patient day
(RNHPPD) was 8.4 (SD=6.6) and the proportion of RN hours
averaged 0.69 (SD=0.19). The average LOS was 11.5 days
(SD=37.1), with a median of 4 days. In all cases, patient risk
was the most significant factor associated with log(LOS). The
nurse staffing level measured by RNHPPD was positively
associated with log(LOS) for patients receiving any intensive
care (n=34,638) (coefficient=0.019, p<0.0001), while it was
adversely associated with log(LOS) for those receiving no
intensive care (n=91,744) (coefficient=0.061, p<0.0001).
There was no was no significant relationship between the
proportion of RN-hours and log(LOS) in both patient groups,
which may be due to the high collinearity between RNHPPD
and the proportion of RN hours (r=0.84).
Conclusions: This study shows that the relationship between
nurse staffing (RNHPPD) and LOS varies by patient group in
unit level analyses. Aggregating both patients and nurse
staffing to the facility level may result in biased estimates
through mixing very heterogeneous groups.
Implications for Policy, Delivery, or Practice: When
considering a change in nurse staffing to reduce patient LOS,
hospital managers need to examine the impacts separately for
patients with different risk profiles.
Primary Funding Source: No Funding
●Factors Affecting Physician Productivity in a
Proceduralist Specialty, Radiology
Cristian Meghea, Ph.D., Jonathan Sunshine, Ph.D.
Presented By: Cristian Meghea, Ph.D., Senior Researcher,
Research, American College of Radiology, 1891 Preston White
Drive, Reston, VA 20191; Tel: 703-648-8983; Email:
cmeghea@acr.org
Research Objective: There is only a small literature on the
production function of physicians. We seek to add to this
literature, making a number of new contributions,
methodological and substantive, such as: • We measure the
productivity of the physician group, the production unit of
medical services, while the focus of the previous literature was
the individual physician. • This study examines the effect of
technology, unlike previous work. • We account for the
measurement error generally present in inputs data. • This is
the first study of a procedure-centered medical specialty.
Previous literature focused on physician visits. • We control
for case mix in more detail than previous studies. Restraining
the growth of health expenses is a recurrent concern in almost
all developed nations, and identifying methods to improve
productivity may help ease the problem.
Study Design: We empirically investigate the determinants of
productivity of radiology practices, exploring the effect of
physician labor input, physician characteristics, purportedly
productivity-enhancing technologies and operational practices,
and other practice characteristics. Data are from the
American College of Radiology’s (ACR’s) 2003 Survey of
Radiologists, a nationally representative stratified random
sample survey of radiologists in the United States. We
estimate the production function via OLS with the outcome
being the logarithm of practice’s procedures per year. The
physician labor inputs -- full-time equivalent (FTE)
radiologists, weekly hours, weeks worked annually -- enter in
both linear and logarithmic forms allowing for the possibility
of non-constant input elasticities. To address the downward
bias introduced by measurement error in labor inputs, we
made various plausible estimates of the error size and then
used Monte Carlo methods to find what true elasticity
combined with each plausible estimate of measurement error
yields the elasticity observed in the regression.
Population Studied: Radiology practices in the US
Principal Findings: The FTE-radiologists elasticity of output
directly implied by the OLS is 0.8 (true elasticity between 0.850.90 if accounting for bias), the weekly hours elasticity is 0.4
(0.5-0.7, bias accounted) and the annual weeks elasticity is 0.4
(0.5-0.7, bias accounted). Three of eight techniques/practices
used in radiology practices have a positive independent
impact on productivity. Surprisingly, practices where
individual radiologists work in more locations have higher
productivity. Government owned practices are 18 percent less
productive than practices owned solely by members. Practices
in the Northeast and West census regions are more
productive than practices in the South.
Conclusions: Due to unaccounted measurement error,
previous studies probably underestimated the input
elasticities in the production function of medical services. To
increase output it is more efficient to add radiologists to the
practice than to increase the hours or weeks worked. Some
techniques used to improve radiologist productivity have less
than the generally believed effect.
Implications for Policy, Delivery, or Practice: There is a
growing consensus that U.S. faces (or will shortly face) a
shortage of specialist physicians. In that context, it is critical
to identify ways to increase productivity. We show which
technologies and operational practices increase productivity
and which do not. If one accepts the view that physicians
have an income goal, then enhancing productivity may
facilitate lower per-service prices than otherwise feasible,
thereby helping contain health costs.
Primary Funding Source: No Funding
●A Survey of Registered Dental Hygienists in California
Elizabeth Mertz, MA, Public Affairs, Dennis Keane, M.P.H.,
Kevin Grumbach, M.D.
Presented By: Elizabeth Mertz, MA, Public Affairs, Program
Director, Center for the Health Professions, University of
California, San Francisco, 3333 California Street, Suite 410, San
Francisco, CA 94118; Tel: 415-502-7934; Fax: 415-476-4113;
Email: bmertz@thecenter.ucsf.edu
Research Objective: To evaluate the current demographics,
practice settings, educational backgrounds, scope of work,
and opinions regarding professional issues of the registered
dental hygiene (RDH) workforce in California. The survey was
inspired by the need for data to inform policy debates
regarding an expanded role for RDHs within the context
increasing access to dental care and reducing the prevalence
of dental disease.
Study Design: The study was conducted in two phases,
development and implementation. Development consisted of
a relevant literature search, policy analyses, and over 25 expert
interviews, which were followed by a field test involving a six
person focus group of urban RDHS and five individual phone
interviews with rural RDHs. It was then revised for clarity in
order to focus around the key policy issues of adequacy of size
of the workforce, scope of practice, supervision requirements,
and alternative practice settings. The implementation phase
involved sending the survey to a random sample of 3802
licensed dental hygienists in California. RDHs with rural
addresses were over sampled, as were RDHs with certification
in alternative practice (RDHAP) or extended function
(RDHEF).
Population Studied: The dental hygienist workforce in
California with active licenses, both practicing and not
practicing.
Principal Findings: While there has been much written about
the potential of the RDH workforce to fill an important need in
delivering oral health care to those who have limited access to
a dentist, there is little research on the capacity and interest of
the existing workforce to expand into these new areas. In
addition, there have been few efforts to collect comprehensive
data on the RDH workforce - and particularly few focused on
practices in alternative or public health settings. The field
testing revealed a complex set of practice patterns of
respondents, varying career path expectations, and a mixed
interest of RDHs in practicing outside a dental office, primarily
due to concerns around quality of care. Preliminary survey
response is expected in May 2006.
Conclusions: The final survey results will inform policy
makers about the pipeline and attrition, practice realities,
patient populations, and professional ambitions of the RDH
workforce. In particular, the data will address the issues which
have a direct relationship to the profession’s ability to affect
access to care: scope of practice, supervision requirements,
and practice in alternative and public health settings.
Implications for Policy, Delivery, or Practice: Current dental
workforce policy discussions commonly focus on disputes
about the role of RDHs in meeting broader oral health system
goals. Dental hygienists are central to the discussion of the
capacity of the dental workforce to increase access to dental
care through alternative practice models and expansion of the
workforce in general. Yet these disputes and discussions are
rarely supported by good data. This study will reveal the
current demographics and practice patterns of dental
hygienists as well as examine the opinions and aspirations of
this workforce, all of which will directly impact educational,
regulatory and finance policy.
Primary Funding Source: UCSF/NIDCR(prime)/HRSABHPr/California Dental Association
●Supply of CRNA Faculty
Elizabeth Merwin, Ph.D., RN, FAAN, Steven Stern, Ph.D.,
Lorraine M. Jordan, Ph.D., CRNA
Presented By: Elizabeth Merwin, Ph.D., RN, FAAN, Madge M.
Jones Professor of Nursing, School of Nursing, University of
Virginia, McLeod Hall, Charlottesville, VA 22908; Tel: 434-9823286; Fax: 434-982-1809; Email: merwin@virginia.edu
Research Objective: Identify current issues regarding supply
and demand for faculty members in the nation’s academic
programs preparing Certified Registered Nurse Anesthetists.
Study Design: A mixed-methods quantitative and qualitative
study was conducted. A secondary analysis of a survey of over
16,000 CRNAs was used to compare and contrast supply
characteristics of CRNAs employed in colleges and
universities with other CRNAs including salary and retirement
plans. A random sampling of the nation’s CRNA program
directors were invited to participate in a qualitative interview
regarding faculty shortages. Twelve program directors were
interviewed. The results of the quantitative and qualitative
analyses were used to design an online survey to be
administered to 100% of faculty in the nation’s CRNA
programs during the Winter of 2006.
Population Studied: The nation’s population of CRNAs.
Program Directors and Faculty of Nurse Anesthetist
programs.
Principal Findings: Only 2.2% of CRNA’s are employed by
colleges or universities. CRNA educators are significantly older
(53.0 yrs) than other CRNAs (51.5 yrs) although in 2001 they
earned $10,000 a year less than other CRNAs on average (t
5.41, <.0001). Thirty-nine percent of this small group of CRNA
educators plan to retire by 2012. There is no difference in the
rate of planned retirement for educators versus other CRNAs
(36%). A logistic regression model reveals that men are less
likely to plan to retire by 2012 (odds ratio of 0.7), while older
individuals, part-timers an (odds ratio of 1.8) are more likely to
plan to retire and being an CRNA educator was not significant
in explaining plans for retirement. The qualitative interviews
reveal that the earnings differential is a major barrier to
recruitment to educator positions and makes retention
difficult as many faculty return to clinical positions. The
higher and more stressful workloads of faculty without
reimbursement for additional hours worked was a related
challenge in the retention of faculty. Many programs find it
difficult to fill faculty positions and some are unsuccessful in
recruiting efforts. Future challenges include planned
retirements, the lack of doctorally prepared faculty and
responding to policy changes and recommendations such as
the recent call by professional nursing for doctorate of nursing
practice programs for entry into specialty practice.
Conclusions: The high rate of planned retirements among all
CRNAs, the disparity in income with CRNAs in other
employment settings, and a small educator group will
continue to challenge the adequacy of educator workforce.
This study launches the beginning of a more detailed report
and analysis of the nurse anesthesia faculty workforce.
Implications for Policy, Delivery, or Practice: If many
schools choose to implement a doctorate of nursing practice
program there will be a need to increase the availability of
doctorally prepared CRNAs to teach in these programs. At the
same time the profession will be faced with a high number of
retirements, as well as disparities in income with other
settings, posing more serious workforce challenges than seen
in the past.
Primary Funding Source: American Association of Nurse
Anesthetists
●Determinants of Maternal Outcomes: The Impact of
Anesthesia, Nursing and Medical Care
Ann Minnick, Ph.D., RN, FAAN
Presented By: Ann Minnick, Ph.D., RN, FAAN, Chenault
Professor, School of Nursing, Vanderbilt Unviersity, 21st
Avenue, 424 Godchaux Hall, Nashville, TN 37240; Tel: 615 343
2998; Email: Ann.Minnick@vanderbilt.edu
Research Objective: (1) describe the relationship of
anesthesia, nursing, and medical provider models and staffing
practices in obstetrical settings in US hospitals and (2)
determine the extent to which anesthesia provider models and
other administrative variables predict maternal outcomes.
Health care policy makers and anesthesia providers have a
continuing interest in how privileges, supervisory laws, and
service accreditation policies should be crafted to improve
outcomes and if the interaction of provider models of
nursing, anesthesia and medicine explains outcomes.
Obstetrical care, the leading cause of US anesthesia
administration, produces enough cases to allow for a
statistically sound study of these knowledge gaps. This
project is the first to include labor and capital variables from
more than one discipline.
Study Design: Using a conceptual framework which specified
that maternal outcomes are the product of patient
characteristics, comorbidities, problem severity and treatment
(defined as what was done, timing, setting, provider training
and experience), a data base was developed that included (1)
information regarding patient characteristics, outcomes and
some institutional characteristics from the American Hospital
Association, state and federal agencies during 1999-2001 and
(2) data concerning anesthesia, nursing, and medical
practices acquired through a 2003-4 survey of all hospitals (n=
1124) that reported at least one live birth in 2002 in California,
Florida, Kentucky, New York, Texas, Washington and
Wisconsin. The states were chosen based on (1) data
availability (2) the combinations ability to represent US
demographic and population disbursement patterns and (3)
attainment of a data pool sufficient to meet statistical
requirements. Hospital survey development efforts included
content expert panels (anesthesia providers, registered nurses
and physicians) and two pilot tests to ascertain validity, data
availability, response burden and regional terminology
differences. Complication rates for each maternal outcome
(defined as all patients and as only those who had Caesarean
section) were estimated for each of the five anesthesia
provider models that emerged from the hospital survey. The
equality of the rate to the physician anesthesiologist only
model were tested using logistic regression with standard
errors adjusted for clustering.
Population Studied: 995 hospital years and 1,141,641
obstetrical events The survey response (rate=49%) reflects
national distributions by hospital type and size.
Principal Findings: Death, anesthesia complications, other
complications and obstetrical trauma rates were basically
unaffected by anesthesia provider model.. There was no
consistent pattern of other hospital, provider or patient
characteristics associated with the complications studied.
Conclusions: Unlike single state studies of specific adult
surgical conditions, the results provide no support for the
adoption of any one anesthesia provider model or changes in
other policies concerning delivery location or staffing based on
outcome differences.
Implications for Policy, Delivery, or Practice: Given
anesthesia providers serve many types of patients, a repetition
of this methodology with other outcomes is warranted before
any changes or additional rules are made in anesthesia
delivery. Policies which support this type of research as a part
of any rule change activity would provide a scientific basis for
future decisions.
Primary Funding Source: American Association of Nurse
Anesthetists
●Defining US Anesthesia Models in Labor and Delivery
Settings
Ann Minnick, Ph.D., RN, FAAN, Jack Needleman, Ph.D.
Presented By: Ann Minnick, Ph.D., RN, FAAN, Chenault
Professor, School of Nursing, Vanderbilt University, 21st
Avenue, 424 Godchaux Hall, Nashville, TN 37240; Tel: 615 343
2998; Email: Ann.Minnick@vanderbilt.edu
Research Objective: To describe the personnel models used
by US hospitals to provide obstetric anesthesia. Debates over
attempts to restrict or enlarge the conditions under which
anesthesiologists, nurse anesthetists, physicians and nurses
may provide anesthesia are continuing policy agenda points.
The traditional approach to defining provider models has been
to classify models in individual cases as “anesthesiologists
(ANES) only”, “certified registered nurse anesthetists (CRNA)
only” and “both types of providers used”. The resulting
variable is then used to study outcomes. The limitations of
this approach have been (1) its failure to account for
differences in models within an institution (e.g.. CRNA only in
obstetrics and ANES only in the operating room) outcomes
(2) reliance on billing codes to attribute individual provider
behaviors and (3) the inability to determine what duties are
required of and what support mechanisms are available to the
provider.
Study Design: Data concerning anesthesia, nursing, and
medical practices were acquired through a 2003-4 survey of all
hospitals (n= 1124) that reported at least one live birth in 2002
in California, Florida, Kentucky, New York, Texas,
Washington and Wisconsin. The states were chosen based on
(1) data availability (2) the combination’s ability to represent
US demographic and population disbursement patterns and
(3) attainment of a data pool sufficient to meet statistical
requirements. Hospital survey development efforts included
content expert panels (anesthesia providers, registered nurses
and physicians) and two pilot tests to ascertain validity, data
availability, response burden and regional terminology
differences.
Population Studied: The survey response (rate=49%) reflects
national distributions by hospital type and size.
Principal Findings: Five models emerged from the data: (1)
ANES only (33%) (2) CRNA only (24%) (3) both types of
providers with the ANES required to be present at the
beginning of every Caesarian section (C-section) regardless of
anesthesia type (ANES-CRNA I) (16%) (4) ANES not required
at the beginning of every C-section (25%) and (5 ) one model
used in the operating room and another in the obstetric area
(3%). In ANES-CRNAI institutions, 58% allowed the CRNA to
insert epidurals versus 85% at ANES-CRNAII. with similar
large differences for spinal privileges: 65% versus 93%.
Models were associated with hospital characteristics such as
location. Key obstetric resources (OR open for obstetric cases
at all times, anesthesia provider present at all times,
availability of C-section in labor and delivery, board certified
obstetricians, number of professionals at planned and
emergency C-sections) were least likely to be found in CRNA
institutions.
Conclusions: Although anesthesia models were largely
similar in the operating room and the obstetric area,
differences in actual ANES and CRNA roles indicate that the
use of the traditional three model typology is not warranted.
The CRNA only model may be a proxy for key resource
availability.
Implications for Policy, Delivery, or Practice: Studies
proposing to link outcomes to anesthesia models should be
evaluated in part on the precision of model delineation and
measures taken to determine the roles of obstetric resources.
Primary Funding Source: American Association of Nurse
Anesthetists
●Workplace Civility, Aggressive Behavior and Employee
Outcomes
David Mohr, Ph.D., Nicholas Warren, ScD, MAT, Michael
Hodgson, M.D, M.P.H.
Presented By: David Mohr, Ph.D., Investigator, Center for
Organization, Leadership and Management Research,
Department of Veterans Affairs, VA Boston Healthcare System
(152M) 150 S. Huntington Ave, Boston, MA 02130; Tel: 857364-5679; Email: david.mohr2@med.va.gov
Research Objective: To assess whether individual
perceptions of workplace civility are dependent on the source
of aggressive behavior in the workplace and how civility and
aggression perceptions influence employee outcomes.
Workplace aggression has been found to negatively relate
negatively to performance, satisfaction and retention.
Workplace civility may offer a way to reduce some of negative
effects. These are key issues in retaining a health care
workforce.
Study Design: Data were obtained from a census survey of
employees in a national health care organization. A total of
74,622 responses were obtained (36.5%). Workplace civility
was a factor constructed for this study, which consisted of
items relating to cooperation, diversity acceptance,
cooperation and coworker support. The survey also asked
respondents to report on frequency of active (as opposed to
passive) verbal aggressive behavior in the workplace. A
dichotomous measure of workplace aggressive behavior was
developed for each of six statements asking about the
frequency of behaviors employees experienced in the past
twelve months. These items included such behaviors as name
calling, provoking arguments, shouting, and intimidating
gestures. Individuals who had experienced 4 or more events
were categorized as working in an aggressive environment.
This variable was then regressed in a generalized linear mixed
model that included a measure of workplace civility and these
covariates: gender, race, age, tenure, job category
(administrative, clerical, professional, technical, wage grade),
level of supervisory status, pay grade, hours worked per pay
period, regular day shift status and field facility or office
location. Analyses were performed at the individual level with
individuals nested within facility. All models are crosssectional.
Population Studied: A census survey conducted in 2001 of
employees of a large national health care system.
Principal Findings: The strongest predictor (for all values p
<.001) was workplace civility (parameter estimate = -0.92).
Thus individuals who had higher perceptions of workplace
civility reported lower frequency of aggressive events as might
be expected. Also significant in the model were: hourly worker
status (est = .42), administrative employees (est = .32) being
male (est = .24), minority status (est =.32) and several of the
dummy coded variables were significant as well. In additional
models where civility and experience of aggressive behavior
was entered into a model, we found civility and experiences of
aggressive behavior significantly predicted individuals
workgroup performance assessment (civility est = .50,
aggression est = -.04), overall job satisfaction (civility est =
.64, aggression est = -.19) and intention to leave (civility est = .43, aggression est = .23). We found a very high rate of
reported aggressive behavior incidents of four or more times
(49%).
Conclusions: The strongest predictor of the frequency of
aggressive incidents in a health care setting is perceived
workplace civility rather than individual or job characteristics.
The influence of workplace civility was found to be a better
predictor than experiences of aggressive incidents for job
satisfaction, performance ratings, and intention to leave.
Implications for Policy, Delivery, or Practice: Workplace
civility was a strong predictor for key attitudinal outcomes that
may impact the satisfaction and retention rates of health care
employees as well as quality of work provided within the team.
Incidents of aggressive behavior in the workplace, given the
high reported frequency, should not be overlooked.
Primary Funding Source: VA
●Workplace Civility and Sick Leave Rate Usage over Time
David Mohr, Ph.D., Nicholas Warren, ScD, MAT, Michael
Hodgson, M.D, M.P.H., Mark Meterko, Ph.D., Richard Lin,
M.D.
Presented By: David Mohr, Ph.D., Investigator, Center for
Organization, Leadership and Management Research,
Department of Veterans Affairs, VA Boston Healthcare System
(152M), 150 South Huntington Ave, Boston, MA 02130; Tel:
857-364-5679; Email: david.mohr2@med.va.gov
Research Objective: The purpose of this study was to
examine the influence that increases in workplace civility have
on sick leave usage among administrative employees in a
health care setting. One way to get increased efficiency from
employees is to reduce sick leave rates.
Study Design: We sought to test the hypothesis that
increased civility would decrease sick leave usage rates. We
used data collected from a national health care system at two
different time points; 2001 and 2004. A census survey
designed to assess employee perceptions of their
organizations was conducted during both years which
obtained a response rate of 37% and 52% respectively. We
selected employees who were classified under “General
Service” as opposed to clinical staff. We examined an
independent data set for the facility-level sick leave usage for
employees for those two years as well. In the intervening
years, the system undertook systematic, though locally varied,
interventions to improve behavior among individuals. A
factor, “workplace civility” was constructed for this study from
items relating to conflict resolution, cooperation, respect,
diversity acceptance, and coworker support. We conducted
analyses using a mixed model with repeated measures for
group effects. We controlled for facility-level factors in the
model: number of hospital beds, teaching affiliation,
urban/rural location and geographical region).
Population Studied: Administrative data from a census
survey conducted in 2001 and 2004 with general service
employees of the Veterans Healthcare Administration.
Principal Findings: Workplace civility did predict sick leave
rate usage over time. System wide average sick leave usage
rates for 2004 (Mean = 68 hours, SD = 6.6) were statistically
higher by 1.75 days than 2001 (Mean = 54 hours SD = 6.4).
Workplace civility was significantly higher in 2004 (Mean =
3.60, SD = .13) than in 2001 (Mean = 3.39, SD = .16). We
tested ordinary least square regression models first to
ascertain if civility was a predictor of sick leave rates in 2001
and 2004 separately. Civility was a significant predictor in
both models. Next, in a mixed effects repeated measures
model, workplace civility was a significant predictor (estimate
= -16.78, p <.001) of sick leave rate usage. A one point change
in civility was associated with about two fewer sick leave days
per general service employee, if all other factors are held
equal. The variable of urban status also had a significant entry
in this model; individuals who work in rural locations were
less likely to use sick leave (est = -2.11, p <.001). There were
also small differences based on geographic region. If the
average cost per employee time included fringe benefits was
approximately $20 an hour, then improving the civility score
by 1 standard deviation (0.15) would lead to 2.5 fewer hours or
$50 in savings per employee or approximately $50,000 in a
typical facility with 1,000 employees. Adding in lost
productivity would also increase savings as well.
Conclusions: The study found that sick leave rates were
prospectively related to workplace civility. Covariates had a
much smaller influence on sick leave rates. The increase in
both sick leave usage and civility scores might be explained by
facility change efforts during the time period, but a closer
inspection at site specific strategies is warranted.
Implications for Policy, Delivery, or Practice: Over time,
some medical centers were able to improve civility which led
to substantial improvements going against the general trend.
These finding highlight the possible effects that workplace
civility may have among general service employees in terms of
reducing sick leave rate usage. Sick leave hours can be
converted to dollar amounts for lost time and lost
productivity.
Primary Funding Source: VA
●Nursing Representation and the Nursing Shortage in a
Rural State
Patricia Moulton, Ph.D., Karen Speaker, B.A.
Presented By: Patricia Moulton, Ph.D., Assistant Professor,
Rural Health, University of North Dakota, 501 N. Columbia
Road, Grand Forks, ND 58202-9037; Tel: (701)777-6781; Fax:
(701)777-6779; Email: pmoulton@medicine.nodak.edu
Research Objective: With the current and worsening shortage
of nurses throughout the United States, addressing the
workplace environment will be critical in retaining an adequate
workforce. The existence of formal nursing representation
structures has been advocated to help improve the workplace
environment. The Robert Wood Johnson Foundation Chief
Nursing Officer Study (Kimball & O’Neil, 2002) found that
76% of the hospital chief nursing officers reported some sort
of nursing representation structure in place.
Study Design: The North Dakota Nursing Needs Study, a
legislative-mandated study is designed to examine issues of
supply, demand, recruitment and retention. This study is
funded by the North Dakota Board of Nursing. Of the several
possible measurements for nursing shortages, vacancy and
turnover rates are the most common. Vacancy rates indicate
the number of vacant positions relevant to the number of
budgeted positions and a consistent vacancy rate above 6% is
thought to indicate a shortage (Prescott, 2000). Turnover
rates reflect fluctuation in staffing levels and can be another
indicator of the stability of a work environment. Between
2002 and 2004, turnover and vacancy rates have increased
throughout North Dakota. This study was designed to
determine whether there is a relationship between the
increase in turnover and vacancy rate, rurality and nursing
representation.
Population Studied: Surveys were sent to all hospitals and
long-term care facilities in North Dakota in the fall of 2002
and 2004. A total of 65 facilities (hospitals and long-term
care) completed the survey in both years which allows for a
comparison across the two years.
Principal Findings: In 2002, study results indicated that only
45% of hospitals and 38% of long-term care facilities reported
having a formal nurse representation structure with most of
these facilities located in urban areas. In 2004, 36% of
hospitals and 49% of long-term care facilities reported having
nurse representation. Despite the overall reduction in
representation, an increase was found in rural facilities with
55% of hospitals and 40% long-term care facilities indicating
nursing representation in 2004. This presentation will explore
possible relationships using regression between indicators of
shortage (vacancy and turnover) and the existence of nursing
representation structures in rural and urban hospital and longterm care facilities.
Conclusions: This presentation will explore possible
relationships using multiple regression between indicators of
shortage (vacancy and turnover) and the existence of nursing
representation structures in rural and urban hospital and longterm care facilities.
Implications for Policy, Delivery, or Practice: This
information will be useful for healthcare facilities as they look
at the many possible retention strategies including nurse
representation to prioritize those strategies which have the
largest possible impact on maintaining an adequate
workforce.
Primary Funding Source: North Dakota Board of Nursing
●Comparison of Young Adults' Perceptions of an Ideal
and a Healthcare Career
Mary Val Palumbo, DNP, APRN, Betty Rambur, DNSc
Presented By: Mary Val Palumbo, DNP, APRN, Director,
Office of Nursing Workforce, Department of Nursing,
University of Vermont, 106 Carrigan Drive, Burlington, VT
05405-0068; Tel: (802) 656-0023; Fax: (802) 656-8306; Email:
mpalumbo@uvm.edu
Research Objective: The purpose of this study was to
compare and contrast young adults’ (age 18-24 years of age)
perceptions of an ideal career versus their perceptions of six
health professions: nursing, medical laboratory science,
pharmacy, respiratory therapy, radiation technology, and
physical therapy.
Study Design: Design: Survey. Measures: Developed by
May et al 1991, the instrument measures 17 parallel items on a
5 point Likert scale and has been assessed for reliability
(coefficient alpha .81-.84) and content validity through a panel
of experts. Analysis: Descriptive statistics and paired t-tests,
with Bonferoni adjusted alpha significance at p < 0.0028.
Population Studied: Sample: A convenience sample of 720
18-24 year olds recruited from job fairs and community events
between Jan 2005 and Sept 2005. Setting: One metropolitan
statistical area within a rural, northeastern state and two less
urbanized adjacent communities.
Principal Findings: All six health professions were perceived
as significantly less desirable (p< 0.001) than the ideal career
in the area of “being respected”. All six health careers were
perceived as “working with high technology” more than was
desired in an ideal career. “Care for people” was the third
highest attribute of an ideal career and only pharmacy and
radiation technology were found to be statistically significantly
lower in this area (p<0.001). Only nurses were significantly
perceived (p<0.001 )as having job security that matched the
ideal. Additional similarities and differences are detailed.
Conclusions: Inaccurate perceptions of healthcare careers
may hamper the development of an adequate pipeline of new
recruits to these professions, which has the potential to
impact all health disciplines. Respect for the work of
healthcare professionals was not recognized by this sample.
Working with “high technology” was not seen as important in
an ideal career. Strategies to address these conclusions and
areas for further research are outlined.
Implications for Policy, Delivery, or Practice: A shrinking
pool of young adults will be tapped for careers in many
disciplines in the decade ahead. Quality healthcare in the
future will depend on a workforce of these young adults who
are adequately prepared for and interested in healthcare
careers. Healthcare is increasingly dependent on highly
collaborative multidisciplinary teams. Lessons learned from
the renewed interest in nursing careers (as evidenced by the
increased numbers of nursing students and applicants), may
need to be applied across the disciplines in order to prevent
future shortages.
Primary Funding Source: HRSA
●American Indians and Alaska Natives on the Path to
Physician Careers: Supports and Challenges
Davis Patterson, Ph.D., Walter Hollow, M.D, Apanakhi
Buckley, Ph.D., Polly Olsen, Laura-Mae Baldwin, M.D, M.P.H.
Presented By: Davis Patterson, Ph.D., Research Associate,
University of Washington Dept. of Family Medicine, WWAMI
Center for Health Workforce Studies, 4311 11th Ave NE, Suite
210, Seattle, WA 98105; Tel: (206) 616-6256; Fax: (206) 6164768; Email: dpatterson@fammed.washington.edu
Research Objective: American Indians and Alaska Natives
(AI/ANs) have persistent health status disparities compared
with the rest of the U.S. population. Addressing this problem
will require training more AI/AN physicians, who are more
likely to choose primary care, locate in underserved
communities, and deliver culturally appropriate care. Yet
AI/ANs have not achieved parity with whites in medical school
enrollment. The purpose of this study is to understand the
path to physician careers among matriculated American
Indian and Alaska Natives (AI/ANs), focusing on the
significant people and experiences that motivated or
supported students as well as challenges and barriers along
the way.
Study Design: This study used qualitative semi-structured,
one-on-one, confidential interviews. The research team used
grounded theory to content-analyze the interviews and arrive
at a consensus on salient support and barrier themes. Study
subjects were also invited to give feedback on the themes
identified in their own interviews.
Population Studied: The study is based on a sample of 10
AI/AN students at the University of Washington School of
Medicine.
Principal Findings: This research documented six major
supports and eight major barriers to AI/AN students’ paths to
medical school. The themes included students’ educational
experiences, competing career options and priorities, health
care experiences, financial factors, cultural connections, family
and friends, spirituality, and discrimination. Ties to Native
communities both supported students and created conflict
between Native culture and the culture of modern Western
medicine. Students also reported financial barriers severe
enough to constrain participation in the medical school
application process, a finding that has not been reported
elsewhere. Another unique finding of this study was that
spirituality played an important role in the lives of these
students as they pursued a medical career.
Conclusions: The AI/ANs in this study gained entry to
medical school by relying on important supports while facing
significant challenges. Their experiences suggest that
promoting greater AI/AN participation in medical careers can
be facilitated with strategies appropriate to the academic,
financial, and cultural needs of AI/AN students.
Implications for Policy, Delivery, or Practice: Several
strategies based on this study’s findings, and on the authors’
experience conducting programs to support AI/ANs pursuing
health professions, might improve recruitment and retention
of AI/AN medical students: (1) providing role models,
advisors, and mentors; (2) providing early research
opportunities by involving AI/AN communities in research on
Native health issues; (3) anticipating students’ traditional
Native spiritual practices; (4) providing professional
socialization opportunities for faculty and AI/AN medical
students; (5) creating and implementing rigorous curricula
that include indigenous perspectives; and (6) developing a
pro-diversity institutional mission statement to inform
admissions policies. Collaboration with AI/AN individuals,
organizations, and communities is critical to this effort but
not a familiar role for most academic medical centers;
suggestions for cross-cultural outreach and collaboration are
provided. The authors also identify organizations in a position
to fund and implement these strategies, along with a list of
resources. Increasing the numbers of AI/AN physicians is a
matter of social equity and basic fairness, but successful
collaborations will also enrich the medical community.
Primary Funding Source: HRSA
●Family Physicians in the Child Healthcare Workforce
Robert Phillips, M.D, M.S.P.H., Martey Dodoo, Ph.D., Andrew
Bazemore, M.D.
Presented By: Robert Phillips, M.D., M.S.P.H., Director, The
Robert Graham Center, 1350 Connecticut Ave NW, Suite 201,
Washington, DC 20036; Tel: 202-331-3360; Fax: 202-331-3374;
Email: bphillips@aafp.org
Research Objective: Studies of the child healthcare workforce
tend to focus exclusively on pediatricians. We sought to
understand the evolving role of the family physician (FP)
workforce in caring for children, and the potential causes of
this change. This included study of specific populations of
children and whether family medicine's role remains
important.
Study Design: We did a comprehensive literature review of
recent and past child health workforce analyses for trends and
potential explanations of an observed decline in visits to family
physicians by children. This review helped shape a secondary
analysis of data from the AMA Masterfile data from 1981
through 2004, Area Resource File, US Census (1980 – 2000),
Medical Expenditure Panel Survey (1996, 2002), and National
Ambulatory Medical Care Survey (1992-2002).
Population Studied: We studied the care of children from
birth to age 18, and the US physician workforce that cares for
them.
Principal Findings: In 2004, there was one pediatrician who
spends the majority of their time in direct patient care for
about every 1,570 children in the US, and about one FP for
every 3,200 people. Given the current contribution of family
physicians to children’s healthcare, there is one full time
equivalent physician for every 1000-1200 children. Visits by
children to family physicians have fallen by nearly 25% relative
to a 20% rise in visits to pediatricians over the last decade,
and a one-third reduction in average annual children’s visits
per FP. Erosion of family medicine’s role is due in large part
to a doubling of the general pediatrician workforce and a
decline in the crude birth rate since 1981. The decline in care
provided by family physicians to children has occurred largely
in more affluent urban and suburban areas as pediatricians
are less likely to locate in rural and low income areas. Both
specialties play an important role in caring for children reliant
on safety net programs; however community health centers
and the National Health Service Corps are more dependent on
FPs. Uninsured children and those on Medicaid are less likely
(than privately insured children) to have a pediatrician as their
usual source of care. FPs’ role in caring for adolescents is
more stable than for younger children (26% of visits vs 24% of
visits for pediatricians); however, half of adolescents are now
seen by other specialties.
Conclusions: The role of FPs remains important, particularly
to rural and underserved populations, despite a significant
erosion of their role in providing care to children. The growth
of the child healthcare physician workforce has outpaced the
birth rate in the US, producing a robust workforce for
children’s health that meets or exceeds sufficiency by
measures offered by the American Academy of Pediatrics.
Implications for Policy, Delivery, or Practice: Despite there
being one child healthcare physician for every 1200 children,
eight million children lack insurance and more than seven
million children lack a medical home. There are real
opportunities for pediatricians and FPs to turn from a period
of growth and competition to collaborate on resolving access
problems and tackling the family and community sources of
childhood morbidity and mortality.
Primary Funding Source: The American Academy of Family
Physicians
●Who Are the Dentists Who Provide Care to Publicly
Covered Patients?
Nadereh Pourat, Ph.D., Dylan Roby, Ph.D., Roberta Wyn,
Ph.D., Marvin Marcus, DDS
Presented By: Nadereh Pourat, Ph.D., Senior Research
Scientist, Health Services, UCLA Center for Health Policy
Research, 10911 Weyburn Ave, Suite 300, Los Angeles, CA
90024; Tel: 310/794-2201; Fax: 310/794-2686; Email:
pourat@ucla.edu
Research Objective: Public coverage of dental care is the
solution of choice to provide access to care for the low
income, yet, delivery of care may be negatively influenced by
parsimonious payment policies and program restrictions.
Such policies can impact providers’ decisions on the scope of
public patients in their practice, staffing, practice structure,
and patient care delivered. We examined the independent
association of demographic, business structure, and patient
care characteristics of dentists with the presence of publicly
covered patients in their practice to gain insights into potential
differences in delivery of dental care to these patients.
Study Design: A cross-section of dentists in private practices
in California was surveyed.
Survey topics included demographics, practice characteristics,
and patient care. Characteristics of dentists by presence of
publicly covered patients in their practice were examined in
bivariate and multiple logistic regression 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
51%. The sample consisted of approximately 3,800
respondents who were generalists or specialists who provided
general care.
Principal Findings: Preliminary analyses show that about half
of dentists had publicly covered patients in their practices, had
been in practice between 6-20 years, and accepted sliding
scale fees. The majority were generalists, in solo practice, and
spoke a language other than English or had staff that could do
so. Regression analysis revealed that dentists with publicly
covered patients were more likely to have a second language
capacity, accept sliding scale fees, or have multiple practice
locations than those who did not have any such patients.
Also, dentists with publicly covered patients were more likely
to practice in rural and less populated counties rather than
Los Angeles County. Dentists with publicly covered patients
were more likely to have fewer hygienists, spend less time in
preventive care, and had shorter appointment times than
dentists without any publicly covered patients. Dentists with
more than 5% publicly covered patients in their practice were
more likely to accept sliding scale fees and have multiple
practice locations than dentists with fewer publicly covered
patients. They also had fewer dentists and hygienists in their
practice.
Conclusions: Results suggest that dentists who provide care
to publicly covered patients work in different types of practices
such as multiple locations, have a possibly larger volume of
low income patients (as evidenced by accepting sliding scale
fees), employ fewer hygienists; and differ in some aspects of
their patient care, such as shorter appointment times and less
preventive care.
Implications for Policy, Delivery, or Practice: The delivery of
dental care to publicly covered patients may differ in content
and quality. Understanding the differences in care provided to
such patients is essential in examining the success of public
programs in improving delivery of care to low income
populations.
Primary Funding Source: California Dental Association
Foundation
●Supply and Demand Across Four Health Professions in a
Rural State
Betty Rambur, DNSc, Mary Val Palumbo, DNP, Robert Ross,
Ph.D., Burton Wilcke Jr., Ph.D., Barbara McIntosh, Ph.D.
Presented By: Betty Rambur, DNSc, Professor of Nursing and
Dean, College of Nursing and Health Sciences, University of
Vermont, 105 Rowell Building, Burlington, VT 05405-0068; Tel:
(802) 656-2216; Fax: (802) 656-2191; Email:
betty.rambur@uvm.edu
Research Objective: To explore rural healthcare workforce
demographics from the perspective of the individual and the
employer as a basis for evidence-based health workforce
planning.
Study Design: This two-part, survey design study utilized the
State of Vermont as a health workforce laboratory. In Part
One, the workforce minimum data set recommended by
Colleagues in Caring was used to analyze demographics, job
satisfaction, intention to leave current position and
profession, and reasons for such intention. These data were
gathered in spring 2005 from four healthcare professions:
medical laboratorians, radiographers, respiratory therapists,
and registered nurses. Part Two explored hospital vacancy and
turnover rates for these same professions at two points in
time, 2003 and 2005. This instrument was developed
following an extensive literature review, tested for content
validity through panel of experts, and pilot tested in the field
(detailed in Reinier, K., Palumbo, M, McIntosh, B., Rambur,
B., Kolodinsky, J., Hurowitz, L., & Ashikaga, T. (2005).
Measuring the nursing workforce: clarifying the definitions.
Medical Research and Review, 62(6), 741-755.)
Population Studied: The entire populations of registered
nurses, medical laboratorians, radiographers, and respiratory
therapists and all hospitals in the State of Vermont were
surveyed. Response rates for Part One were: respiratory
therapists 65% (n=100); medical laboratorians 51%, (n=241);
radiographers 58% (n=315); registered nurses, 65%, (n=5805).
Response rates for the employer-based surveys range were
94% (15 of 16 hospitals) in 2003 and 75% (12 of 16 hospitals)
in 2005.
Principal Findings: Radiographers were the youngest
profession (x= 43.8) and had the broadest age distribution.
RNs were the oldest (x= 48), followed by laboratorians (x= 45).
Seventy-six percent of laboratorians were over the age of forty,
and laboratorians also held the greatest proportion of
bachelor and higher degree (58%). Income, however, did not
parallel education. Radiographers and registered nurses
reported the highest albeit modest satisfaction, with 55% and
54% indicating they were “very satisfied” with their current
position, respectively. Nevertheless, 22% percent of the
radiographers and 23% of the registered nurses were
“somewhat likely” or “very likely” to leave their position within
the next year, as were a substantial number of the respiratory
therapists (28%) and medical laboratorians (23%). Of those
intending to leave their position, 21% of respiratory therapists,
16% of the radiographers, 13% of the RNs and 9% of the
laboratorians plan to leave their profession. The most
common reason given by medical laboratorians was “job
stress” at 45%. Vacancy and turnover rates for registered
nurses and laboratorians showed substantial but less
dramatic change than for respiratory therapists, who had a
hospital vacancy rate of 18% in 2003 and 5% in 2005, for
example, perhaps reflecting the 23% turnover rate in 2003 and
6% in 2005.
Conclusions: While the nursing shortage has received
growing attention, these data suggest that ongoing workforce
assessment across all health professions is necessary to
assess trends and develop appropriate strategies to ensure
adequate supply of these essential healthcare capacities.
Implications for Policy, Delivery, or Practice: Ongoing,
reliable, valid, and easily accessible health workforce data
across professions is essential to health planning and offers a
strategic use of state funds. This is particularly important in
rural states, where relatively small changes in absolute
numbers can mean dramatic changes in availability of
providers and essential services.
Primary Funding Source: HRSA
●Older Nurse Recruitment and Retention Initiatives
across Four Settings in a Rural State
Betty Rambur, DNSc, Mary Val Palumbo, DNSc, Barbara
McIntosh, Ph.D.
Presented By: Betty Rambur, DNSc, Professor of Nursing and
Dean, College of Nursing and Health Sciences, University of
Vermont, 105 Rowell Building, Burlington, VT 05405; Tel:
(802) 656-2216; Fax: (802) 656-2191; Email:
betty.rambur@uvm.edu
Research Objective: The aim of this study was to describe,
compare, and contrast recruitment and retention policies
directed toward older (age 50+) registered nurses (RNs)
across four settings: hospitals, home health agencies, long
term care facilities, and office practices in a rural state, as a
first step toward evidence-based nurse resource management.
Study Design: This study was part of a larger statewide survey
designed for the analysis of workforce patterns in hospitals,
home health agencies, long term care facilities, and office
settings. The instrument was developed following an
extensive literature review, tested for content validity through a
panel of experts, and pilot tested, as detailed elsewhere
(Reinier, K., Palumbo, M, McIntosh, B., Rambur, B.,
Kolodinsky, J., Hurowitz, L., & Ashikaga, T. (2005). Measuring
the nursing workforce: clarifying the definitions. Medical
Research and Review, 62(6), 741-755.) The survey was mailed
to the facility’s chief nursing officer, regardless of position
title.
Population Studied: The entire state population of hospitals,
home health agencies, long term care facilities and primary
care offices listed by the State Department of Health and/or
Area Health Education Center were surveyed, with the
following response rates: hospital, 75% (n = 12); home health
agencies, 83% (n = 10); long term care facilities, 42%; (n=18);
primary care offices, 40% (n=85).
Principal Findings: Only 10% of hospitals reported have
initiatives directed toward recruitment of the older RN,
compared to 40% of home health agencies, 35% of long term
care facilities, and 14% of primary care offices. Retention
initiatives directed toward older RNs were more commonly
reported by respondents, with 60% of hospitals, 70% of home
health agencies, 59% of long term care facilities, and 35% of
primary care offices reporting such strategies. The qualitative
data, however, suggests that existing practices vary in depth
and complexity. Moreover, comments reflected a varied
understanding of the purpose and value of such initiatives.
Conclusions: Facilities and agencies are not consistently
implementing meaningful strategies to recruit and retain the
older RN.
Implications for Policy, Delivery, or Practice: Older nurses
provide a pool of experience that the health system is ill
prepared to forego. In the study setting, for example, 39% of
working RNs are over age 50, and there are more working RNs
over the age of 60 than under the age of 30. Nurses who are
currently 50 -55 years old will likely be necessary to augment
the emerging nursing pipeline, thus recruitment and retention
is extremely important. Best practices for recruitment and
retention of older RNs should be developed and
disseminated.
Primary Funding Source: HRSA
●Changes in Physician Productivity 1993 – 2003
Mary Rimsza, M.D, Mark Speicher, MHA, Mary Ellen Rimsza,
M.D, William G. Johnson, Ph.D., Michael Grossman, M.D.
Presented By: Mary Rimsza, M.D, Professor, School of Health
Management and Policy, Center for Health Information and
Research Seidman Research Institute, Arizona State
University, PO Box 874506, Tempe, AZ 85287-4506; Tel: (480)
965 1622; Fax: (480) 965 6654; Email: mary.rimsza@asu.edu
Research Objective: Conventional wisdom holds that
physician workloads have changed, and not for the better.
Both patients and physicians believe that doctors have less
time for patients, and that physicians are seeing more patients
that ever. There has been recognition of a number of
workload issues as a cause for physician dissatisfaction, active
doctors leaving medicine and an inability to recruit new
physicians to certain areas or specialties. Reasons for this
change in workload may include population demographics,
the continuing increase in managed care, changes in access to
care caused by economic swings or levels of insurance
coverage, and physician lifestyle issues such as gender, worklife balance, choice of specialty and practice location (rural vs.
urban), etc.
Study Design: The Arizona Medical Board and the Arizona
Board of Osteopathic Examiners collect information on
physicians as a part of the license renewal process. This data
includes specialty, office location, education, age and other
information. Between 1992 and 1997, an Arizona State
University project added survey questions to the license
renewal packet. In 2003, the project was resumed as a joint
effort of Arizona State University and the University of
Arizona. The survey of practicing physicians from 2003 was
used to compare data on licensed allopathic and osteopathic
physicians practicing in Arizona in 1993, 1994, 1996, 1997, and
1998 and 2003 to determine the change in time spent in
practice as well as number of patients seen during the survey
periods. (Results for 1998 were self-reported by survey
respondents in 2003.) The direction and magnitude of
changes are reviewed by age group, specialty and geographic
location in Arizona.
Population Studied: All licensed allopathic and osteopathic
physicians were surveyed during the survey years. The survey
of practicing physicians is distributed and collected as a part
of the annual or biennial license renewal process for all
allopathic and osteopathic physicians through a cooperative
agreement with the physician licensing boards.
Principal Findings: As estimated by the survey respondents,
the number of patients seen for all practicing physicians
increased from 69 per week in 1994 (n=11,794) to 88 in 1997
(n=8,451) to 84 in 1998 and 84 in 2003 (both reported on the
2003 survey; n=7,675). Productivity (patients seen per week
and hours worked per week) increased across all specialty and
practice settings in roughly the same pattern; while patients
seen per week varied greatly between specialties. In 2004, for
example, anesthesiologists reported seeing an average of 37
patients per week, cardiologists 106, family practitioners 95,
internists 85, obstetricians 90, and surgeons 52.
Conclusions: The number of patients seen per week in rural
areas is significantly higher than in urban areas (though the
gap is narrowing over time) but hours worked per week do not
differ as greatly between urban and rural areas.
Implications for Policy, Delivery, or Practice: Models of the
need for health care providers are important for health
planning and policy decisions. The productivity of physicians
is an important but generally unknown component of
workforce planning models.
Primary Funding Source: Other Foundation, Flinn
Foundation, St. Luke's Health Initiatives, BHHS Legacy
Foundation
●Human and Social Capital of Nursing Personnel in
Magnet Hopitals and Long Term Care Organizations
Kent Rondeau, Ph.D., Terry Wagar, Ph.D., LLB
Presented By: Kent Rondeau, Ph.D., Associate Professor,
Public Health Sciences, University of Alberta, 13-103 Clinical
Sciences Building, Edmonton, Alberta, T6G 2G3; Tel: (780)
492-8608; Fax: (780) 492-0364; Email:
kent.rondeau@ualberta.ca
Research Objective: This reseach seeks to explore the
contribution of intellectual (human and social) capital of
nursing personnel towards magnet status in hospitals and
long-term care organizations.
Study Design: A mail survey questionnaire was sent to the
directors of nursing care in 2250 Canadian hospitals and longterm care organizations in late 2005. Approximately 600
hospitals and nursing homes constitute our study database.
Population Studied: Directors of nursing care in Canadian
hospitals and long-term care establishments are asked to
about their existing practices with respect to how they
organize and manage their nursing human resources.
Nursing unit goals and strategies, human resource
management practices, nursing recruitment/retention
approaches, magnet strength, nursing intellectual capital,
decision making culture, employee training and development
practices, labor-management relations, nursing workforce and
establishment characteristics are assessed in each
organization.
Principal Findings: Hospitals and nursing homes which have
strong magnet characteristics are more likely to have adopted
certain human resource practices, to have inculcated in their
nursing workforce highly progressive and participatory
decision making approaches, and to characterize their nursing
workforce as possessing higher levels of human and social
capital.
Conclusions: Health care organizations which want to
develop stronger magnet capacity with respect to recruiting
and retaining their nursing personnel will be more effective if
they develop nurse workforce human and social capital.
Implications for Policy, Delivery, or Practice: Investments in
increasing intellectual capital of nurses can have a significant
impact in improving the capacity of health care organizations
to recruit and retain nursing personnel.
Primary Funding Source: Private funding
●Residency Choice Among Women Medical Students-Effect of Economic and Time-Constraint Factors
Shuolun Ruan, B.S., Mythreyi Bhargavan, Ph.D., Victoria K.
Potterton, B.S., Kimberly E. Applegate, M.D., M.S., Jonathan
H. Sunshine, Ph.D., Howard P. Forman, M.D., M.B.A.
Presented By: Shuolun Ruan, B.S., M.D./Ph.D.-Health
Services Research & Policy, University of Rochester, 1323
Genesee St., Rochester, NY 14611-4201; Tel: 913-558-3547;
Email: shuolun.ruan@aya.yale.edu
Research Objective: To determine the extent to which
quantifiable measures of residency and in-practice lifestyle,
and also practice income, can explain differences and trends
in the percent of women in the entering residency class for 24
specialties over the 12 years 1993-2004.
Study Design: Annual data on the number of women and
men entering residency, by specialty, during the period 19932004 was collected from the American Medical Association
(AMA) and the Association of American Medical Colleges.
Data on residency lifestyle characteristics were obtained from
the Fellowship and Residency Electronic Interactive Database,
and median annual income was obtained from the Medical
Group Management Association. Data on in-practice hours
and hours worked per year were obtained from AMA
publications. Using the percentage of women among entrants
to each residency as the dependent variable, we applied
multivariate linear regression analysis to measure the effect of
number of years in residency, weekly duty hours in the first
year of residency, in-practice weekly hours, income per hour in
practice, and a time trend from 1993 to 2004 on the
percentage of women entering a specialty. In addition, we
regressed separate models for residency characteristics and
practice characteristics. All models included interaction terms.
Population Studied: Women entering the first year of
specialty-specific residency training.
Principal Findings: Longer years of residency, longer weekly
hours in practice, and higher in-practice income per hour were
inversely associated with percent women entering a specialty.
Conversely, longer hours per week in the first year of residency
was associated with more women. These factors explained
fully 61 percent of the variance across specialties and over
time in the proportion of residency program entrants who are
women. Dermatology and OB/GYN, however, have had
consistently much higher percentages of women entrants than
can be explained by these factors, and orthopaedic surgery has
consistently had a lower percentage. Including a control for
concordance between the gender of most patients and the
physician explained an additional 12 percent of the variance in
percentage of women in residency programs.
Conclusions: Residency and in-practice lifestyle
characteristics and income are important factors for women's
specialty choices. There remains, however, substantial
variation not explained by these factors including career
satisfaction of women in various specialties, presence of
mentors and role models, competitiveness of residencies,
discrimination, training program and practice flexibility. We do
not have data to address these in this study.
Implications for Policy, Delivery, or Practice: We find that
residency and in-practice lifestyle and in-practice income offer
much explanation for the percentages of women found
entering many specialties such as pediatrics, diagnostic
radiology, or general surgery. For specialties such as
dermatology and orthopaedic surgery, however, there are
other advantages and disadvantages, respectively, being
considered by women. These additional considerations
provide valuable interventional opportunities, including
providing mentors and greater practice flexibility, to attract
women into areas that have historically had few female
physicians. With documented incidences of some patients
preferring women providers, a lack of women in any specialty
undermines the goal of equal access to quality healthcare.
Primary Funding Source: No Funding
●How Do Physicians Perceive the Effect of Evidence-Based
Guidelines on Their Practice?
Christine Sammer, R.N., M.P.H., Kristine Lykens, MPA, Ph.D.,
Karan Singh, M.S., Ph.D.
Presented By: Christine Sammer, R.N., M.P.H., Doctoral
Candidate, Health Management and Policy, Unversity of
North Texas Health Science Center, 3500 Camp Bowie Blvd.,
Fort Worth, TX 76107; Tel: 817-568-5306; Fax: 817-735-2446;
Email: christine.sammer@ahss.org
Research Objective: The study explores physician and
practice characteristics that may contribute to the effect
practice guidelines have on their practice of medicine.
Study Design: Intercooled Stata 8.1® software survey
commands for binomial logistic and ordinal logistic
regression models were used for assessing the associations of
various factors on the perceived impact practice guidelines
have on a physician’s practice. For this analysis the restricted
data set of the Community Tracking Study (CTS) Physician
Survey was obtained from the Center for Studying Health
Systems Change. This data set included the sample design
variables necessary to make statistical adjustments for the
study design. Independent variables included demographics
such as gender; race; year of graduation from medical school;
specialty areas; practice types; and computer usage.
Population Studied: The study analyzes data from the third
round of the CTS Physician Survey, 2000-2001, a large-scale
investigation of changes in the health care system and their
effects on people. The survey was administered to physicians
in the 60 CTS sites and to a supplemental national sample of
physicians.
Principal Findings: Responses from 12,126 physicians were
included in the regression models. In the binomial logistic
regression, twelve of the 34 variables were significant at alpha
.05. The analysis showed that more recent (since 1996)
graduates from medical school were significantly more likely
to state practice guidelines had an effect on their practice.
Physicians who use computers to access information in their
practices were also strongly correlated with a perceived impact
of guidelines on practice. Other factors that positively
influenced the dependent variable and were significant at
alpha .05 were female gender, the specialty of Ob-Gyn, and all
non-solo practice types. An ordinal logistic regression was
also estimated to capture the full range of responses
regarding the perceived impact of practice guidelines from no
effect to a very strong effect. The results of this model were
consistent with the binomial logistic model.
Conclusions: Whereas the goal of EB guidelines has been to
provide a strong scientific framework and to improve
outcomes, many barriers have prevented wide acceptance and
impact among the medical community. We found year of
medical school graduation and practice setting correlates with
the perceived impact of evidence-based guidelines. In
addition, our findings indicate the importance of information
technology concepts in the effects of evidence-based
guidelines in medical education.
Implications for Policy, Delivery, or Practice: Our findings
regarding year of graduation from medical school and use of
technology would suggest that current medical school
practices, such as addressing guidelines during clinical
training and requirements that students purchase laptop
computers as an information resource, will have positive
effects on physician practice. The findings further suggest
research to identify other factors affecting the effect of practice
guidelines on physician practice. More research related to
behavior, attitudes, and perceptions related to loss of
autonomy would be a valuable addition to the body of
knowledge.
Primary Funding Source: No Funding
●Money, Planning and Outcomes: Three Critical Issues in
Continuing Medical Education
Sandra Schwanberg, Ph.D., RN
Presented By: Sandra Schwanberg, Ph.D., RN, Senior Clinical
Researcher, Medical Education, Lovelace Clinic Foundation,
2309 Renard Pl SE, Albuquerque, NM 87106; Tel: 505-2627568; Fax: 505-262-7598; Email:
Sandra.schwanberg@lcfresearch.org
Research Objective: The purpose of the paper is to discuss
three primary issues that influence the quality of continuing
medical education programs and to provide remedies for
program improvement. The issues include a lack of stable
funding for continuing education programs, a lack of formal
planning processes and structures in creating programs and a
dearth of ongoing effectiveness evaluation.
Study Design: Descriptive
Principal Findings: Funding- Approximately 62% of
continuing medical education activities is funded through the
pharmaceutical industry or other healthcare related
companies. Independence from industry influence on
continuing education content is an ongoing concern.
Continuing education programs may be informally planned to
secure funding rather than meet ongoing educational needs.
Funding sources for continuing education need to be
expanded and address programmatic issues rather than the
current piecemeal approach. Planning- Much of the planning
for continuing medical education is informal focusing on
limited interviews with practitioners, small group meetings,
surveys with low response rates and previous conference or
event evaluations. This process contributes to a “hodgepodge” of subjects for continuing education programs rather
than a needed formal curriculum that extends graduate
medical education to help clinicians maintain and improve
standards of care. A formal curriculum for continuing medical
education would require standardized data based needs
assessments, program planning and a formal evaluation
process. Health care professionals involved in graduate
medical education would be the best prepared to plan and
evaluate activities. Evaluation- Few continuing education
programs implement an actual evaluation plan. Most
“effectiveness” evaluation focuses on attendee reactions to
events, rather than ability to use the information, apply
standards of care or changes in patient health status
indicators. In addition, the evaluation of conference faculty
expertise and teaching ability also requires attention,
development and evaluation.
Conclusions: Continuing medical education is required for relicensure. Education is essential as medical information
changes rapidly. In addition, ongoing concerns about
healthcare quality and patient safety have focused on provider
education yet surprisingly little attention has been focused on
funding, planning and evaluation.
Implications for Policy, Delivery, or Practice: Continuing
medical education programs should be planned, evaluated
and funded through new approaches connected with
academic health sciences centers.
Primary Funding Source: No Funding
●The Role of Physician Supply in Determining Health Care
Services Utilization in Rural Canada
Lyn Sibley, BSc, M.H.A.
Presented By: Lyn Sibley, BSc, M.H.A., Student, Health Policy
& Management, Johns Hopkins Bloomberg School of Public
Health, 1418 West 37th Street, Baltimore, MD 21211; Tel: 443320-3239; Fax: 410-995-3781;
Email: lsibley@jhsph.edu
Research Objective: The goal of this research is to gain an
understanding of the degree to which the supply of general
and specialist physicians determines health care services
utilization among rural populations of Canada.
Study Design: This is a cross-sectional study of the
population of Canada using data from the 2003 Canadian
Community Health Survey (CCHS). Multilevel regression
models were constructed to identify the individual, community
and health system variables that are independent predictors of
health care services utilization. The models also indicate the
independent effect of level of community ruralness on
utilization of services.
Population Studied: The CCHS is a national survey designed
to gather health-related data at the health region level. The
study sample includes all survey respondents aged 18 and
older who resided in one of the ten provinces (N=119,104).
Using Statistic Canada’s Statistical Area Classification the
population is divided in to six cohorts based on the level of
rurality of their community.
Principal Findings: The main dependant variable, health care
services utilization, is indicated by four measures: had an
influenza immunization in the last two years, consulted a
family physician in the previous 12 months, consulted a
specialist in the previous 12 months, and had a mammogram
in the last two years (for woman aged 50 and above).
The independent variables are divided into three categories:
individual characteristics, community level social factors, and
health system characteristics. The community level social
factors were derived from the 2001 Census and aggregated at
the municipality level. Similarly health system characteristics
were derived from data collected by the Canadian Institute for
Health Information and aggregated at the health region level.
Conclusions: Universal health insurance coverage has
eliminated many barriers to receiving appropriate, high quality
health care in Canada, however, geography remains as a
obstacle to access. Rural populations, when compared to
those that are urban, have lower health care services
utilization rates even after adjusting for age, sex, and other
social factors.
Implications for Policy, Delivery, or Practice: This paper
presents the findings of the multilevel models described
above, with particular attention given to mutable health
system variables such has physician supply and distribution.
This research will help to inform policy makers on whether an
increase or change in physician supply will address the
reduced access to care in rural populations or if policies
aimed at social factors would be more appropriate.
Primary Funding Source: Canadian Institutes of Health
Research
●Does the Specialty of the Chemotherapy Provider
Inflence Outcome?
Jeffrey H Silber, M.D, Ph.D., Paul R. Rosenbaum, Ph.D., Daniel
Polsky, Ph.D., Richard N. Ross, Ph.D., Katrina Armstrong,
M.D, Thomas C. Randall, M.D
Presented By: Jeffrey H Silber, M.D, Ph.D., Professor of
Pediatrics and Director, The Center for Outcomes Research,
The University of Pennsylvania/The Children's Hospital of
Philadelphia, 3535 Market Street, Suite 1029, Philadelphia, PA
19104; Tel: 215-590-5635; Fax: 215-590-2378; Email:
Silberj@Wharton.UPENN.edu
Research Objective: Medical Oncologists (MOs) specialize in
administering chemotherapy while Gynecologic Oncologists
(GOs) specialize in the surgical management of gynecologic
cancers as well as providing chemotherapy. We asked whether
survival differed according to the type of specialist providing
the chemotherapy after ovarian cancer surgery. It is always
difficult to compare specialists due to selection bias. In this
case, it was especially difficult since the type of surgeon
influenced the stage of the patient, the stage of the patient
influenced outcome, and the chemotherapy provider was
associated with the type of surgeon.
Study Design: We identified patients who were diagnosed
with ovarian cancer after the age of 65 and who received
chemotherapy from a GO after surgery performed by any type
of surgeon. Using optimal matching and a propensity score
based on 35 prognostic characteristics, we identified similar
patients who were operated on, and staged, by nearly identical
types of surgeons but who received chemotherapy from an
MO.
Population Studied: Merged SEER-Medicare clinical and
administrative data from the years 1991 through 2001.
Principal Findings: We identified 344 patients who were
given chemotherapy for ovarian cancer by GOs after having
undergone surgery by either GOs (76%), Gynecologists (16%),
or general surgeons or other surgical specialties (8%).
Patients given chemotherapy by MOs were matched to these
patients. Both groups had nearly identical surgical specialists,
age, year of treatment, stage, tumor grade, race and 32 other
prognostic factors. There was no difference in overall survival
between the GO or MO groups (P = 0.45, paired PrenticeWilcoxon test). The 5 year survival was 35% (sd=2.6%) for the
GO group and 34% (sd=2.6%) for the MO group. However,
MOs administered chemotherapy over more weeks than did
the GOs (patient mean = 16.5 Vs 12.1 weeks, P < 0.0023,
Wilcoxon rank sum test) and MO patients had more weeks
that included at least one of the following chemotherapy
associated adverse events (neutropenia, anemia,
thrombocytopenia, diarrhea, dehydration or mucositis) than
did the GO group (patient mean = 16.2 Vs 8.9 weeks, P <
0.0001, Wilcoxon rank sum test).
Conclusions: Despite differences in training, specialty
emphasis, and practice style concerning the use of
chemotherapy (MO patients had more weeks of
chemotherapy and more weeks with chemotherapy associated
adverse events than GO patients), we found no difference in
survival between patients who received chemotherapy
administered by gynecologic oncologists and medical
oncologists.
Implications for Policy, Delivery, or Practice: From a policy
perspective, it would appear that specialists tend to use the
tools they were trained to use. The natural bias of the medical
oncologist was to treat more intensely with chemotherapy, not
realizing that less chemotherapy yielded identical outcomes.
From a research perspective, Health Services Researchers are
often asked to evaluate and compare specialty performance.
Multivariate matching can be a powerful tool in helping to
make these comparisons by more transparently addressing
potential confounders than the standard regression approach.
Primary Funding Source: NCI
●Where Have the Nurses Gone? An Exploratory Study of
RNs with Expired Licenses in Washington State
Susan Skillman, MS, Lorella Palazzo, PhC, L. Gary Hart, Ph.D.,
David Keepnews, Ph.D., J.D., RN, FAAN
●Measuring the Marginal Productivity of Financial Support
for Nursing Students
Joanne Spetz, Ph.D., Susan Chapman, Ph.D., RN, Jean Ann
Seago, Ph.D., RN
Presented By: Susan Skillman, MS, Deputy Director,
University of Washington, Family Medicine, Center for Health
Workforce Studies, 4311 11th Ave. NE, Suite 210, Seattle, WA
98105; Tel: (206)543-3557; Fax: (206)616-4768; Email:
skillman@u.washington.edu
Research Objective: To describe the characteristics of
Washington RNs who are no longer in nursing, the reasons
for leaving, and the circumstances under which they might
return to practice.
Study Design: We surveyed a 50% sample of Washington
RNs in 2002 and 2003 who did not renew their licenses and
conducted extensive followup on a sample of nonrespondents.
Population Studied: RNs in Washington state with expired
licenses.
Principal Findings: Our expectations that many of these RNs
with expired licenses had moved out of state was confirmed
by the low (20%) survey response rate, and subsequent
followup of a sample of nonrespondents. Of the survey
respondents, 70.1% were not working as nurses, citing
retirement, followed by health problems, domestic or family
reasons, and job stress as reasons for leaving the field. Nonworking RNs were almost evenly split between those reporting
being satisfied or dissatisfied with their last nursing position.
A minority of former RNs was employed in another
occupation, and even fewer were searching for RN work.
Change in personal situation was most often cited by workingage former RNs as an inducement to reenter nursing, but over
50% said that they would never practice nursing again.
Reflecting on their nursing careers, most respondents
reported changes in nursing practice: some conditions
improved (e.g. RN pay, variety of career opportunities in
available in nursing), others worsened (e.g. dangers and
physical demands of the job). Yet, a majority of non-practicing
RNs said they still considered themselves to be nurses and
would advise a young person to enter the profession.
Conclusions: This study suggests that most RNs who leave
active practice do so for personal reasons and while they may
still view themselves as nurses, they show little propensity for
rejoining the nursing workforce in the foreseeable future.
Implications for Policy, Delivery, or Practice: This study
adds to our understanding of why RNs leave nursing, and
contributes to formulating proposals to increase retention of
currently-practicing RNs.
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: 415-476-4113; Email:
jojo@alum.mit.edu
Research Objective: In response to the national shortage of
registered nurses, federal and state governments have
provided funding to nursing education programs to expand
the supply of RNs. Most of these programs either provide
financial support to currently-enrolled students, with the goal
of improving the productivity of education programs, or
expand the number of education slots available for students.
There has been no research of the relative effectiveness of
these strategies. This study compares the costs and results of
programs to provide financial support to nursing students and
expand nursing education slots, using new data from
California.
Study Design: Twenty-two regional groups were awarded a
total of $28 million to expand RN supply, with projects ending
in 2005. Some of these groups used the funds to provide
financial support to students, some expanded education slots,
and some did both. In addition, some programs received
private funds from hospitals and other local agencies to
support their regional efforts. We are using data provided by
the California Board of Registered Nursing, California
Community Colleges Chancellors Office, the funded groups,
and other state government agencies. To estimate the
effectiveness of the financial support programs, we estimate a
multivariate equation in which the graduation rate is the
dependent variable, and the key explanatory variable is the
percent of students receiving financial support. The
coefficients from this equation are then used to estimate the
net increase in graduating RNs resulting from the financial
support programs. To estimate the effect of the slotexpansion programs, we multiply the number of new slots by
the share of students expected to graduate. These two
numbers of “net new nurses” are compared with the costs of
each strategy.
Population Studied: All registered nursing education
programs in California.
Principal Findings: Over 1500 RN students received financial
support to improve program productivity, and over 1800 new
education spaces were created. Preliminary data suggest that
the programs providing financial support to students had a
substantial effect on student attrition. However, the programs
that used funds to expand slots have allowed for the
education of many additional nurses. It appears that the slot
expansion programs provide more nurses per dollar. Final
data are now being received by the research team and a final
report will be written by March 31, 2006.
Conclusions: Preliminary results indicate that slot expansion
programs provide more nurses per dollar.
Implications for Policy, Delivery, or Practice: Policymakers
should focus resources on expanding space in nursing
programs rather than financial support for current students.
Primary Funding Source: California Employment
Development Dept.
●The Impact of Obesity on Employment and Work
Limitations among U.S. Adults, 1986-1999
Kaan Tunceli, Ph.D., Kemeng Li, M.A., L. Keoki Williams, M.D,
M.P.H.
measured weight and height, the implications of obesity on
labor market outcomes are enormous for patients, families,
employers, and policy makers.
Primary Funding Source: No Funding
Presented By: Kaan Tunceli, Ph.D., Health Economist, Center
for Health Services Research, Henry Ford Health System, One
Ford Place, Suite 3A, Detroit, MI 48202; Tel: 313-874-5485; Fax:
313-874-7137; Email: ktuncel1@hfhs.org
Research Objective: To determine the relationship between
body mass index (BMI) and workforce participation and work
limitations in a U.S. working-age population.
Study Design: Individuals were classified into the following
weight categories: underweight (BMI <18.5), normal weight
(BMI >=18.5 but <25), overweight (BMI >=25 but <30) and
obese (BMI >=30). Using multivariable probit models, we
estimated the effect of obesity on the probability of
employment and work limitations. Analyses with work
limitation as the outcome were limited to respondents
working in 1999. In models, we controlled for smoking, selfreported health, age, race, marital status, level of education,
wealth, the number of children, and baseline employment
status. All analyses were stratified by sex. Because a number
of individuals (n = 1,991) did not respond to the survey in
1999 but were otherwise eligible, we assessed for potential
participation biases that could have affected our results.
Population Studied: The empirical analysis uses data from
the 1986 and 1999 panels of the Panel Study of Income
Dynamics (PSID), a nationwide prospective cohort. The selfreported height and weight information was collected for the
first time in 1986 and again in 1999. We restricted our study
population to those who participated in both interviews in
1986 (baseline) and 1999 (follow-up) and who were of working
age (i.e., age 18 years and older in 1986 and less than age 65
years in 1999). This resulted in a final study sample of 4,290
respondents (1,895 men and 2,395 women).
Principal Findings: After adjusting for baseline sociodemographic characteristics, smoking status, exercise, and
self-reported health, obesity was associated with reduced
employment at follow-up (men: marginal effect [ME] -4.8
percentage points [pp]; p < 0.05; women: ME -5.8 pp ; p <
0.10). Among employed women, being either overweight or
obese was associated with an increase in self-reported work
limitations when compared with normal weight individuals
(overweight: ME +7.7 pp; p < 0.01; obese: ME +20.1 pp; p <
0.01). Among men, the relationship between obesity and
work limitations was of borderline significance (ME +4.9 pp ;
p < 0.10). Adjusting for the propensity to participate in followup did not alter the previously described relationships
between obesity and either employment or work limitations.
Conclusions: Our findings suggest that obesity leads to
reductions in employment for both men and women after
thirteen years of follow-up. We also show that being
overweight or obese may contribute to work limitations at
follow-up, especially in women.
Implications for Policy, Delivery, or Practice: As the
prevalence of obesity in the U.S. has increased, so too have
associated economic burdens. The prevalence of obesity is
likely to escalate further. This implies that the number (and
proportion) of obese individuals among working age
population will be even greater in the future. Indeed, with as
many as 1 in 3 people already obese based on objectively
●Measuring the Potential Financial Impact of Mandatory
Nurse-Staffing Ratios on Hospitals in Massachusetts:
Initial Estimates and Methodological Challenges
Michael Tutty, M.H.A., Debra Hurwitz, M.B.A., BSN
Presented By: Michael Tutty, M.H.A., Senior Project Director,
Center for Health Policy and Research, University of
Massachusetts Medical School, 222 Maple Avenue, Higgins
Building, Shrewsbury, MA 01545; Tel: (508) 856-4350; Fax:
(508) 856-4456; Email: michael.tutty@umassmed.edu
Research Objective: To estimate the financial impact on
hospitals of proposed legislation requiring mandatory
minimum nurse-to-patient ratios in Massachusetts hospitals.
Study Design: Data from 2004 on registered nurse (RN)
staffing and inpatient utilization, broken out by hospital unit,
was collected from a convenience sample of Massachusetts
hospitals. Nurse-to-patient ratios were calculated for units
with usable data. The actual ratios were then compared with
the proposed minimum ratios, to determine whether hospital
units would have had to increase staffing, had the ratios been
in effect. For units with nursing shortfalls, the cost of
compliance with the staffing ratios was calculated. Nontransferability of nurses between hospital units was assumed.
Population Studied: Analysis was limited to a convenience
sample of nine hospitals. While not statistically representative,
the sample group included hospitals of different types
(community, teaching, state-owned, rehabilitation, and
psychiatric) and from different regions within the state.
Principal Findings: Analysis of unit staffing and utilization
data suggested that the proposed mandatory ratios’ potential
cost impact varied greatly by hospital type, and, to a lesser
extent, by region. Boston-area community and teaching
hospitals would have felt the least impact, while general
hospitals outside of the Boston area would have been more
strongly affected. Within the sample group, the one stateowned hospital and the two specialty hospitals (psychiatric
and rehabilitation) would have incurred the highest costs.
Serious deficiencies in currently available data limited our
ability to estimate the overall impact of mandatory nursestaffing ratios on hospitals in Massachusetts. No centralized,
statewide data repository on nurse staffing by unit is currently
available, and the hospitals in our sample group could not
provide unit-specific data for all units.
Conclusions: Among the sample group of hospitals examined
here, variation in actual staffing as compared with the
proposed mandates suggests several points. First, because of
the distinct models of care in rehabilitation and psychiatric
hospitals, which rely heavily on other health care disciplines
(such as physical therapists, mental health workers, or social
workers) rather than nurses, these specialty hospitals are likely
to encounter more serious financial impacts from mandatory
ratio proposals than are general acute care hospitals.
Psychiatric and rehabilitation units within general hospitals in
the sample group faced similar effects. Second, public (stateowned) hospitals, which often have fewer resources than other
sectors, may also face very high costs in meeting mandatory
staffing ratios. Third, regional variations are important; urban
and suburban general hospitals tend to be the most richly
staffed. Finally, the lack of systematic, statewide nurse staffing
data is a serious barrier to policy analysis of mandatory nursestaffing ratios.
Implications for Policy, Delivery, or Practice: Proposals for
regulating hospital nurse-staffing ratios should account for
different models of care in certain facility types, such as
specialty rehabilitation and psychiatric hospitals, and for other
relevant hospital characteristics. Mandated nurse-staffing
levels could disproportionately impact public hospitals as well.
Policymakers and researchers should collaborate to improve
data collection and analysis of hospital nurse staffing, as
recent trends suggest this will be an area of intense scrutiny in
the coming years.
Primary Funding Source: Commonwealth Medicine/UMass
Medical School
●State Level Changes in the Pharmacist Labor Market
between 1990 and 2000
Surrey Walton, Ph.D., Glen Schumock, MBA, Pharm D,
Katherine Knapp, Ph.D., Laura Miller, Ph.D.
Presented By: Surrey Walton, Ph.D., Associate Professor,
Pharmacy Adminstration, UIC, 833 S. Wood St (M/C 871) rm.
241, Chicago, IL 60612; Tel: (312) 413-2775; Fax: (312) 9960868; Email: Walton@uic.edu
Research Objective: The purpose of this study was to
examine long term changes in the US pharmacist labor
market across states. There were four specific objectives: 1) to
analyze in-state graduates, state level migration of
pharmacists between 1995 and 2000, and changes in the
number of pharmacists by state between 1990 and 2000; 2) to
examine pharmacist migration patterns by age; 3) to measure
long term changes in the wages of pharmacists, and variation
in wages across states; and 4) to examine state level
relationships between wages, migration, graduates, and
changes in the number of pharmacists across states.
Study Design: The majority of the analyses in this study were
based on the 5% Public Use Microdata Samples (PUMS) from
the 1990 US Census and the 2000 US Census. The 2000
PUMS data also contain information on where the individual
lived in 1995 which was used to define migration. Various
descriptive analyses were conducted to characterize state level
differences in the number of pharmacists and sources of
change in the number of pharmacists across states. Rates of
migration across age for all pharmacists were examined.
Descriptive statistics were also calculated for inflation
adjusted wages of pharmacists relative to inflation adjusted
wages of college educated workers in general.
Population Studied: The PUMS data were used to examine
pharmacists based on self reported occupation and also in
some instances to examine the number of pharmacists or the
level of pharmacist wages relative to the general population.
To complement the census data, information on the number
of graduates per state was also used. For wages, working
pharmacists between the ages of 21 and 65 with at least a
bachelor degree were used.
Principal Findings: Consistent with past findings, there is
substantial variance in the number of pharmacists and the
number of pharmacists per 100,000 population across states
according to the Census. Migration also varies significantly
across states. New graduates and net in migration were
negatively correlated after controlling for population.
However, neither the number of graduates, nor net in
migration were correlated significantly with the percent
change in the resident number of pharmacists. Pharmacists
are more likely to migrate at younger ages than the general
population, but less likely at older ages. In addition, there were
substantial increases in the wages of pharmacists relative to
similarly educated workers between 1990 and 2000.
Conclusions: As the country moves towards greater reliance
on the use of medications to manage medical conditions,
understanding of the market for pharmacists will continue to
be important. The general variance seen across states in
broad measures of supply remains unexplained, and detailed
consistent data at the state level remains scarce. Further,
changes in the number of pharmacists can come from a
variety of sources. Hence, there needs to be increased efforts
to measure and evaluate the labor market for pharmacists.
Implications for Policy, Delivery, or Practice: The shortage
has had a significant impact in terms of increased wages
which suggests value in policies geared towards promoting
increased supply. However, there remains wide variation in
the number of pharmacists across states and wide variation in
the patterns of migration and new graduates, the implications
of which has yet to be evaluated. Clearly there is ample room
for future research to better understand the underpinnings of
the market and to examine policy decisions surrounding the
pharmacist labor market.
Primary Funding Source: HRSA,
●Relationship Between State Nurse Aide Training
Requirements and Quality of Care
Alan White, Ph.D., Donna Hurd, R.N.
Presented By: Alan White, Ph.D., Senior Associate, Abt
Associates, 55 Wheeler Street, Cambridge, MA 02138; Tel:
(617) 349-2489; Email: alan_white@abtassoc.com
Research Objective: Federal regulations require that training
programs for nurse aides must be a minimum of 75 hours,
including 16 hours of supervised clinical training. There is
concern that this amount of training is insufficient for
adequately training nurse aides and that clinical training
should account for a higher proportion of total training time.
More than half of the states have additional training
requirements beyond the minimum federal training
requirement. This research has two primary objectives: 1) To
examine the relationship between state nurse aide training
requirements and resident quality of care; 2) To examine how
actual nurse aide training program length is related to state
requirements.
Study Design: A series of multivariate regression models
were estimated to explore the relationship between state nurse
aide training requirements and a subset of nursing home
quality measures that are most directly related to the care
provided by nurse aides. Independent variables also included
information on facility staffing, payor mix, and other
characteristics. Information on actual training program length
is based on interviews with state officials and the limited
amount of available data.
Population Studied: The study included most nursing homes
in the United States, excluding those with missing data. We
used data from 2003.
Principal Findings: We find a significant relationship between
higher state training requirements and better performance on
several resident outcome measures, including ADL decline,
urinary tract infection, mobility decline, pressure ulcers, and
indwelling catheter use. We found mixed evidence of a
relationship between clinical training requirements and
resident outcomes.
Our review of nurse aide training programs in several states
suggests that a substantial portion of training programs
exceed the state minimum requirement, even for states that
require more than the federal minimum number of hours.
Conclusions: While state requirements are not necessarily
reflective of the actual length of training programs in states,
our findings are consistent with the hypothesis that increasing
federal nurse aide training requirements can lead to
improvements in resident outcomes. Our results provide
empirical support for increasing nurse aide training
requirements, although it is not possible to know whether the
differences observed across states with different training
requirements are actually due to differences in training
requirements or other factors that may be correlated with
these requirements.
Implications for Policy, Delivery, or Practice: Since passage
of the 1987 Nursing Home Reform Act, the average acuity
level of nursing home residents has increased, but there have
been no changes in the federal training requirements for nurse
aides. Improving nurse aide training time may lead to
improvements in the quality of care furnished by nurse aides,
leading to better resident outcomes. The fact that, even in
states that have only the 75-hour minimum, there are many
programs that are longer reflects a belief among program
coordinators that it is not possible to cover all of the required
material in 75 hours.
Primary Funding Source: CMS
●Factorial Validity of the Transformational, Transactional
and Laissez-faire Leadership Constructs among Physician
Executives
Sudha Xirasagar, MBBS, Ph.D.
Presented By: Sudha Xirasagar, MBBS, Ph.D., Research
Assistant Professor, Health Services Policy and Management,
University of South Carolina, Arnold School of Public Health,
800 Sumter St., Columbia, SC 29208; Tel: (803) 576-6093; Fax:
(803) 777-1836; Email: sxirasagar@sc.edu
Research Objective: To verify the factor structure and validity
of transformational, transactional and laissez-faire leadership,
and their sub-constructs, among physician executives
Study Design: Exploratory factor analysis of cross-sectional
data on leadership behaviors of physician executives as rated
by their supervisors, using principal factor method to extract
the factors, followed by promax rotation. An adapted version
of Bass and Avolio’s Multifactor Leadership Questionnaire
Form 5X-Short was used, with items measuring leadership
behaviors (34 items) and effectiveness (9 items). Executive
directors of community health centers judged how frequently
each statement fit their medical director, on a 0-4 Likert scale
(0=Not at all, 4=Frequently, if not always).
Population Studied: A nation-wide anonymous mail survey of
executive directors of all 663 community health centers (CHC)
of the contiguous United States was conducted in fall 2002,
yielding 269 respondents (response rate=40.9%). Executive
directors responding to questions about their medical
director’s leadership style formed the study sample. Their
responses to the 34 leader behavior items were subjected to
exploratory factor analysis.
Principal Findings: The data support a 3-factor structure, with
21, 6, and 7 items, respectively, loading on the factors (=0.40),
with simple structure. Based on the content of items, the
factors were conceptually identified as transformational,
transactional and laissez-faire leadership, closely similar to
Bass and Avolio’s constructs. The data did not support the
factorial independence of Bass and Avolio’s subscales of
transformational leadership, (idealized influence, inspirational
motivation, individualized consideration, and intellectual
stimulation), and of transactional leadership, (contingent
reward, management-by-exception active, and managementby-exception passive). Reliability coefficients for all subscales
except management by exception passive ranged between 0.77
and 0.92. Anomalous loadings relative to Bass and Avolio’s
three leadership factors included the following: a) two
contingent reward items loaded on transformational
leadership, b) one item of contingent reward showed suboptimal factor loadings (<0.40) but highest loading on
transformational leadership, c) one item of idealized influence
loaded on transactional leadership, and d) all items of
management-by-exception passive loaded on laissez-faire (the
latter being well documented in the literature). Likely reasons
for the anomalous loadings are: a) Exclusion of two of Bass’s
original survey items from this survey, b) Measurement error
due to the (anomalously loading) items requesting
supervisors’ perceptions about the leader’s interactions with
subordinates, and c) Lack of construct distinction between
management-by-exception passive and laissez faire among
physicians, due to their (essentially) autonomous role
functioning.
Conclusions: This study empirically validates among
physician executives, a 3-factor leadership model that closely
approximates Bass and Avolio’s constructs of
transformational, transactional and laissez-faire leadership.
Implications for Policy, Delivery, or Practice: Factorial
validity of the transformational-transactional leadership
model, together with its predictive validity vis-a-vis objective
measures of clinical leadership effectiveness (impacting the
center’s clinical performance goals), documented in an earlier
paper, strengthen the case for refining this leadership
development model. New research studies should explore
physician provider perceptions and responses to the subconstructs of transformational and transactional leadership,
and variations in the salience of each sub-construct of
transformational and transactional leadership among a)
private versus public and non-profits, b) institutionallyemployed versus independent physicians, c) physicians versus
non-physician subordinates, and d) physician executives
versus non-physician managers and executives.
Primary Funding Source: No Funding
●Evaluation of Nursing Responses to Technology
Adoption in Home Health Agencies
Brye Yant, Ph.D., M.P.H., Kathryn Dansky, Ph.D.
Presented By: Brye Yant, Ph.D., M.P.H., Researcher,
Philadelphia VA Medical Center, 3615 Chestnut St,
Philadelphia, PA 19104; Tel: (215)573-9747;
Email: byant@mail.med.upenn.edu
Research Objective: The home health industry has been
exploring its potential to monitor patients in an environment
of shrinking financial and human resources by using
telehealth. Using the Technology Acceptance Model, this
study examines the relationship between technology adoption
and the use of telehealth technology with home health agency
nurse job satisfaction.
Study Design: Primary data was collected in June 2003 and
June 2004 by means of a questionnaire. Nurses were asked
about their previous experience with computer systems, use of
telehealth, length and intensity of use of the technology,
perceived value and ease of use associated with telehealth,
organizational support for telehealth, and job satisfaction.
Nurses were divided into four telehealth adoption groups
according to the existence and duration of telehealth adoption
within their organization. Analysis of Variance tests were
employed to examine differences in scores across time and
between adoption groups at one point in time. Factor analysis
was performed to examine ways in which telehealth was
perceived by nurses. Separate regression analyses were then
utilized to determine predictors of job satisfaction of nurses.
Population Studied: A sample of 580 nurses in June 2003
and 629 nurses in June 2004 from 36 participating home
health agencies in Pennsylvania.
Principal Findings: Results indicated that job satisfaction
levels were statistically similar among the adopters and non
adopters of telehealth and most of the nurses surveyed were
satisfied with their jobs. The results from this study provided
some evidence to support the Technology Acceptance Model
in forecasting the predictors of job satisfaction of nurses.
Positive significant predictors of job satisfaction included
previous nursing job satisfaction levels, user perception of
organizational support for telehealth, and to a lesser extent
the perception of telehealth as being useful. Telehealth
intensity was found to be a negative predictor of job
satisfaction. Computer experience, average hourly pay, patient
case mix, and the ease of use for telehealth were shown to not
significantly predict job satisfaction among nurses.
Conclusions: As the nursing shortage continues, home health
agencies must determine the optimal balance between
maintaining a nursing workforce while producing the most
sufficient level of nursing visits to uphold patient care and
health. The findings of this study indicate that nurses were
generally satisfied with their current job regardless of whether
or not their organization adopted telehealth. However, results
suggest that agencies choosing to adopt telehealth should pay
careful attention to the implementation stages following
adoption. Home health agencies must monitor not only how
nurses perceive the technology and the extent to which the
technology is being used as part of a nurse’s weekly activity,
but it is important to also encourage managers to offer
organizational support for the use of telehealth.
Implications for Policy, Delivery, or Practice:
Understanding the sources of nurses’ job satisfaction may
help to solve recruitment and retention issues faced in the
current and future nursing shortage. If telehealth becomes an
accepted way of handling workforce and reimbursement
issues, changes are likely to be needed regarding management
training and expressed support for telehealth, nursing
education, and monitoring the degree of its use in home
health practices.
Primary Funding Source: HRSA
●Satisfaction of US Radiologists: Findings from 2003 and
comparison to 1995
Hanna Zafar, Jonathan H. Sunshine, Mythreyi Bhargavan,
Rebecca S. Lewis
Presented By: Hanna Zafar, University of Pennsylvania,
Email: Hanna.Zafar@uphs.upenn.edu
Research Objective: Professional satisfaction can affect not
only work motivation but also career decisions, personal
health, and relationships with others. The dynamic and
sometimes unpredictable health care environment renders
physicians, including radiologists, particularly susceptible to
feelings of uncertainty and lowered professional satisfaction.
Specifically, increasing concern over self referral, malpractice,
and reimbursement have generated pressures within the field
of radiology. This paper ascertains what characteristics of
radiologists, their practices, and their work environment affect
their professional satisfaction and explains changes in
satisfaction since 1995.
Study Design: Data comes from the American College of
Radiology’s 2003 Survey of Radiologists, a nationallyrepresentative mail survey of radiologists in the United States
with a 63% response rate. The five answer options to
questions about level of current satisfaction with the radiology
profession were scored +2 (very satisfied), +1 (somewhat
satisfied), 0 (neither satisfied nor satisfied), -1 (somewhat
dissatisfied), and -2 (very dissatisfied). A similar question was
asked regarding the satisfaction compared to five years before
the Survey.
Univariate analysis and multiple regression analysis were
performed examine the associations between the level of
professional satisfaction and characteristics of the radiologists
and the main practice they work in. Comparisons were made
to the results of the 1995 Survey.
Population Studied: Professionally active radiologists in the
US.
Principal Findings: Although over 90% of radiologists enjoy
radiology “very much” or “somewhat,” there was a decrease in
mean satisfaction of post-training, professionally-active
radiologists from 1995 (1.62) to 2003 (1.47). Thirty two
percent of radiologists reported enjoying radiology more than
five years ago; 41% said they enjoyed it less. Excessive
workload reduced current satisfaction and satisfaction relative
to five years ago; working in the Midwest was associated with
both. Subspecialty and practice type had more varied effects.
In 2003, medico-legal climate, workload, and reimbursement /
financial pressures were the three most common reasons for
decreased satisfaction; in 1995, interference from managed
care, government regulations / control / red tape, and
increased administrative burden were most prominent.
Lifestyle/workhours and income were the most prominent
causes of increased satisfaction in 2003, but were also often
mentioned as causes of decreased satisfaction.
Conclusions: Other studies show that radiologists have
higher levels of professional satisfaction than other physicians.
However, as with physicians overall, their satisfaction has
decreased over time. The decrease in current satisfaction
between 1995 and 2003 continues a trend already seen for
1992-1995. The medico-legal environment, specifically the
increasing cost of medical malpractice insurance and
associated practice of defensive medicine have superseded
concerns of a decade ago regarding managed care as the
most prominent cause of decreased satisfaction.
Implications for Policy, Delivery, or Practice: Further policy
changes and reductions in radiology reimbursement seem to
be coming. Given increasing concern over self referral,
malpractice, and reimbursement and persistent levels of
dissatisfaction, the percent of radiologists reporting
dissatisfaction may continue to rise in the next few years.
Mammography is by far the leading source of malpractice
lawsuits against radiologists (a main source of
dissatisfaction), and a relatively low-revenue activity within
radiology. If fewer radiologists specialize in or interpret
mammograms, this may affect breast imaging and/or
exacerbate access problems.
Primary Funding Source: No Funding
●Hospital Staffing Decisions: Does Financial Performance
Matter?
Mei Zhao, Ph.D., Gloria J. Bazzoli, Ph.D., Jan P. Clement,
Ph.D., Richard C. Lindrooth, Ph.D., Askar Chukmaitov, Ph.D.,
Presented By: Mei Zhao, Ph.D., Assistant Professor, Public
Health, University of North Florida, 4567 St. Johns Bluff Road,
South, Jacksonville, FL 32224-2673; Tel: (904)620-1444; Fax:
(904)620-1035; Email: mzhao@unf.edu
Research Objective: Hospitals during the late 1990s
experienced many pressures, which led to declining financial
performance and efforts to shore up declining margins by
reducing hospital workforces and associated labor costs.
Given existing evidence on the relationship between quality of
care and the level of hospital staffing, the objective of this
paper is to assess how changes in hospital financial
performance affected the size and composition of a hospital’s
workforce.
Study Design: A panel study design is applied to data from
1995-2000 to examine the effect of incremental change in
hospital financial condition on staffing changes. Hospital total
FTE intensity, RN FTE intensity, LPN FTE intensity, and
RN/LPN skill mix were chosen as the staffing measures. The
dynamic panel econometric model of Arellano and Bond
(ReStud 1991) was used to examine these effects.
Population Studied: All nonfederal short term general
medical-surgical hospitals in operation between 1995 and
2000 were included in this study.
Principal Findings: We found that there is a significant
positive relationship between incremental change in financial
condition (cash flow and operating margin) and incremental
change in LPN FTE staffing intensity, after controlling for
hospital and market characteristics, and unobserved hospitalspecific effects. However, the effects of financial change on
total FTE and RN FTE staffing are inconclusive. Although the
cash flow models suggest a significant positive relationship
between cash flow changes and total FTE staffing intensity
(marginally significant for RN FTE staffing intensity), the
operating margin models do not find such an association. No
significant relationship was detected between financial
performance and RN still mix.
Conclusions: The findings of this panel study are consistent
with empirical studies and anecdotal reports about reductions
in hospital staffing due to hospital financial deterioration.
These findings also correspond to the previous study that the
least profitable hospitals limited the growth of their staffs
significantly below those of the most profitable group to
constrain their growth in total costs. However, the findings
suggest that hospitals do try to retain their core patient care
workforce, namely RNs, even when confronted with financial
difficulties.
Implications for Policy, Delivery, or Practice: The major
finding in this study—hospital financial performance is
positively related to LPN staffing decisions -- has significant
implications for hospital management. The reductions in LPN
staffing means that RNs and other professionals are likely
picking up the work that these lower skilled people previously
did, which likely leads to nursing burn out and dissatisfaction.
Therefore, a short-term financial fix for hospitals through LPN
staffing reduction could lead to staff morale and nurse
retention problems down the road. Thus, although reducing
the number of nurses may cut costs in the short term, such a
myopic approach may increase hospital costs in the long run.
Primary Funding Source: AHRQ