Leadership in Nursing Education:
Challenges and Opportunities in the U.S.
Symposium on Nursing Leadership Across the Care Continuum
Penn Wharton China Center
Beijing, China
June 30, 2015
Antonia M. Villarruel, PhD, RN, FAAN
Professor and Margaret Bond Simon Dean of Nursing
Greetings from
PENN
2
Overview
• Healthcare trends
• Nursing trends
• Challenges and opportunities in
nursing and nursing education
Health Care Trends



Aging Population
The Affordable Care Act平价医疗法案
Culture of Health
Population Aging in the U.S.
 The United States is an aging society
‒ population of age 65+ will double in 20 years (35M → 72M)
‒ population of age 65+ will account for 20% of U.S. by 2030
(1 out of every 5)
 Major shift from infectious diseases and
acute illnesses to chronic diseases and
degenerative illnesses退化性疾病
 Shift from one-time interventions to ongoing
management of multiple diseases and disabilities残
疾
‒
more than 60% of older adults will manage 1+ chronic
condition by 2030
Population Aging in the U.S.
 Older adults rely on health care services
exceedingly more than other segments of the
population
 Huge impact on the organization and delivery of
health care
‒
‒
‒
‒
increasing need for patient education, care coordination,
and interdisciplinary care
increasing demand for home care and long term care
increasing need for health care workforce trained in
gerontology老年病
increasing complex health needs outpaces
number of health care providers to care for
older adults
Affordable Care Act – Key Features
 Improve quality of health
care
 Reform health care
system to reduce health
care costs
 Increase access to all
Americans
 32 million+ newly insured
 Increase supply of health care
workers卫生保健工作者
Affordable Care Act –
Access to Primary Care



Increases access and cost to preventive
care services and counseling
Provides free annual wellness checkups年度健康检查 for seniors
Supports the training of new primary
care providers and nurses
Affordable Care Act - Quality
 Improve health care quality and patient safety
‒ Reimbursements报销 are tied to the quality of care and
service
 Accountability
‒
Hospital Value-Based Purchasing Program
pays for performance
• rewards high quality care for patients
• measured through 12 clinical quality measures
and patient experience (e.g., scores rating heart failure
心脏衰竭, pneumonia, and healthcare-associated
infections)
• aims to reduce readmission rates and prevent hospital
and surgical errors
•
Affordable Care Act - Community
 Greater community care and coordination
‒ Primary and preventive care linked with community
prevention services
‒ Improve care transitions from hospital to other settings
to reduce readmissions重新入院
‒ Improve health outcomes by increasing focus on social
and physical determinants of health
 Increased access to Community Health Centers
‒ Increase of over 5M patients served
annually since 2010
‒ Increase of health center employees
by 40% since 2010
A Culture of Health – Why We Need It
 Because being healthy means more than just not
needing to seek health care;
 Because our population’s health is unduly过度and
unequally influenced by income, education,
ethnicity种族, and location;
 Because healthcare must extend beyond the walls
of medical offices医护办公室 to the places where
people live, learn, work, and play;
 Because we need to enable everyone in a diverse
society to lead healthier lives.
A Culture of Health is one in which:
Good health flourishes across geographic, demographic and social sectors.
2.
Attaining the best health possible is valued by the entire society.
3.
Individuals and families have the means and the opportunity to make choices that
lead to the healthiest lives possible.
4.
Business, government, individuals, and organizations work together to build healthy
communities and lifestyles.
5.
Everyone has access to affordable, quality health care because it is essential to
maintain, or reclaim, health.
6.
No one is excluded.
7.
Health care is efficient and equitable.
8.
The economy is less burdened by excessive and unwarranted health care spending.
9.
Keeping everyone as healthy as possible guides public and private decision-making.
10. Everyone understand that we are all in this together.
1.
www.rwjf.org
Nursing Trends in the U.S.
Nursing Workforce
Nursing Education
Future Aspirations
The Nursing Workforce
The nursing profession is the largest segment of
the health care workforce in the United States
319 million
U.S. population
3 million nurses
1150 nurses
per 100,000
population
Distribution (Settings)
Rural settings - 17%
Urban settings - 83%
Distribution (Age)
 The nursing workforce is aging
‒
‒
Average age of the U.S.
nursing workforce is 45 years
About 33% of the nursing
workforce is older than
50 years
Distribution (Settings)
Distribution (Diversity)
Ethnicity
 White – 75.4%
 Black – 9.9%
 Hispanic/Latino – 4.8%
 Asian – 8.3%
 Other – 1.7%
Gender
 Males make up 9.1% of
the nursing workforce
Distribution (Education)
55% of nurses
hold a BSN
degree or
higher
• 44.6% - BSN
• 10.3% - Masters degree
• 0.4% - Doctorate
44.8% of
nurses hold an
Associate
degree or
diploma
• 37.9% - Associate degree
• 6.9% - Diploma
(HRSA, 2013)
Nursing Education – Current Trend
 Increase in enrollment in BSN, masters and
doctoral programs (from 2013-2014)
‒
‒
‒
‒
4.2% increase in entry level BSN
10.4% increase in AD-BSN
6.6% increase in masters programs
29.4% increase in doctorate programs
 Need to develop skills to meet employer
demands and patient care needs
(AACN, 2014)
Advanced Practice Roles (APRN)
 Master’s level education – focuses on clinical
specialties versus education, research, or
administration
 Approximately 8.2% of nurses are educated as
Advanced Practice Registered Nurses (APRN)
‒
‒
‒
‒
Nurse Practitioner
Clinical Nurse Specialist
Nurse Midwife助产护士
Nurse Anesthetist麻醉护士
Doctor of Nursing Practice (DNP)
 Practice doctorate degree for nurses; highest level
of academic preparation for nursing practice
 Prepares nurses for advanced clinical practice,
leadership, management of health care delivery
systems, and to influence health policy
 DNP临床护理博士 prepared nurses help meet the
need for more primary care providers, nurse faculty,
and nurse leaders
DNP prepares nurses for advanced
practice and the application of
research into practice
vs.
PhD prepares nurses for careers as
nurse scientists and researchers who
generate new knowledge
Growth in DNP Programs 2006-2014
(AACN, 2015)
Projected National Supply/Demand
(2012-2025)
Estimated supply growth = 952,000
Estimated demand growth = 612,000
Supply in Excess of Demand by 2025 = 340,000
BUT..
1/3 of states are expected to experience
shortages.
Most of these states are in Western,
Southern, or Northeastern United States.
Factors Affecting Nursing Supply/Demand
 Population growth
 Aging of the nation’s population
 Economic conditions
 Aging of the nursing workforce
 New care delivery models
 Changes in health care
reimbursement
Nurse Faculty Shortage

Average age of nurse faculty is 53
years
 Over 1200 current vacancies;
90% require or prefer doctorallyprepared faculty members
‒
‒

there are not enough nurses with
PhDs to fill this need
in 2013, only 336 graduates were
prepared to become educators
Major obstacle to increasing
student capacity
‒
‒
nearly 80,000 qualified applicants
turned away from baccalaureate
or graduate programs
over 1000 qualified applicants
turned away from doctoral
programs
(AACN, 2010,2014)
The Future of Nursing
 Need to address
challenges facing nursing
to address challenges
facing our health system
 High-quality, patientcentered health care for
all will require a
transformation of the
health care delivery
system
Health Care System Challenges
Education
Why a BSN Degree?
“An increase in the percentage of
nurses with a BSN is imperative as the
scope of what the public needs from
nurses grows, expectations
surrounding quality heighten, and the
settings where nurses are needed
proliferate and become more
complex.”
(IOM Future of Nursing Report, 2010)
Quality patient care hinges on having a welleducated nursing workforce.
Positive patient outcomes are linked to nurses
prepared at the baccalaureate and graduate
degree levels.
(AACN, March 2015)
Practice
 All practitioners should practice to
full extent of their education and
training
‒
equivalent patient outcomes when
care is provided by APRN or MD for
certain services
 Optimal care
‒
‒
team-based model of care delivery
maximize time on appropriate role
Practice
Collaboration
 Integrated, collaborative,
patient-centered health care
teams enhance patient care
quality and safety
 Foster interprofessional
education, training and
practice
Opportunities for Leadership in
Nursing Education
 ACA
 Focus on evidence-based practice
 Interprofessional Education
 Teaching Innovations
Nurses Leading in the Community
Hispanic Nurses Educating Communities on the Affordable Care Act
 Goal: Train nurses using the ACA as a
platform to teach communities about the
protections, benefits and health insurance
options under the law.
Nurses Leading in the Community
Hispanic Nurses Educating Communities on the Affordable Care Act
 Nurse Outcomes
‒ Leadership
‒ Education
 Individual & Family Outcomes
‒ Needs assessment
‒ Attendance/Enrollment
 Community Outcomes
‒ Partnerships
‒ Messaging/Social Media
‒ over 1200 multicultural residents
were educated through 60 town
hall meetings
Graduate Nurse Education Demonstration Project
GOAL: increase the nation’s primary care
workforce by supporting facilities that train APRNs
 Mandated by the Affordable Care Act
 Hospitals partner with accredited
schools of nursing and non-hospital
community-based care settings
 Reimbursements made to hospitals
for training APRN students
GNE – University of Pennsylvania
 Graduate Nurse Education
Network of Greater
Philadelphia
 Encompasses 9 local schools
that offer APN education.
 The Hospital of the University
of Pennsylvania (HUP) is the
largest of the Federally funded
projects to facilitate an
increase in the numbers of
APRNs educated in the
GNE – Penn Outcomes
 2 year data
‒ 78% increase in APRN graduates from baseline
‒ 108% increase in NP graduates from baseline
 Alumni Data
‒ 20.7% hired at sites where students had clinical training
‒ 83% of NP graduates working in primary care
‒ 19% of NP graduates working in rural settings
‒ 40% of NP graduates working with underserved populations
 Partnered with over 1000 clinical training sites in the Tri-state
area including:
‒
‒
‒
‒
‒
Academic Medical centers
Private practices
Community-based clinics
Federally qualified health centers
Retail clinics
Focus on Evidence-Based Practice
 Important strategy for improving quality of
care, patient safety and outcomes
 Integration of best research evidence with
clinical expertise and patient values
 Uses the current best evidence in making
decisions about the care of the individual
patient
 Examples:
‒
‒
Transitional Care Model (TCM)
Penn LIFE
Patient-Centered Transitions
Project Achieve
 ‘Achieving Patient-Centered Care and Optimized
Health in Care Transitions by Evaluating the Value of
Evidence’
‒
Penn is a lead site
‒
$15M multi-site 3-year PCIORI consortium study
‒
identify the transitional care services and outcomes that
matter most to patients and their family caregivers
‒
compare how evidence-based transitional care services are
meeting these needs
‒
develop recommendations to spread highly effective,
patient-centered care transitional care programs
Transitional Care Model – Dr. Mary Naylor



Interdisciplinary program of research
‒ designed program to improve outcomes and reduce costs of care for
vulnerable community-based elders
‒ Completed 3 NINR-funded RCT
Developed EBI -Transitional Care Model
‒ identifies patients’ health goals, coordination and continuity of care throughout
acute episodes of illness
‒ streamlined plans of care
‒ prepares patient and family caregivers for implementation of care plan
‒ translation of research to practice with Aetna and Kaiser Permanente Health Plan
Impact of TCM
‒
‒
‒
‒
‒
Increased time to first readmission or death
Improved physical function and quality of life
Increased patient satisfaction
Decreased total all-cause readmissions
Decreased total health care costs
Penn LIFE
(Living Independently for Elders)
 A nursing perspective produced Penn LIFE.
 Build by primary nurses and Nurse Practitioners, who
maximize nursing contributions made to LIFE members.
 Specifically:
‒
‒
‒
‒
Nurse Practitioners (NPs) lead 5 interdisciplinary teams and
panels of members, providing both primary care and intensive
care coordination (NP to member ratio is 1:90);
NPs to function at the full scope of practice (i.e. make all primary
care visits except for those to a skilled nursing facility or hospital
that specifically require a physician’s visit);
Each interdisciplinary team and member panel includes a
baccalaureate prepared nurse who works closely with the NP;
Integration of an interdisciplinary mix of professional students
Nurse Practitioner-Led LIFE Program
17 years of
successful NP
model of care for
multimorbid dualeligible older
adults
Social Services
Nursing
Expert NP Clinicians
Physicians
Pathways to Excellence
Transportation
High Member
Satisfaction
Holistic Care
Rehabilitation Services
PT/OT/Recreation
Biopsychosocial
Environmental focus
Collaborative
coordination of care
Leadership in Education
Mentorship of Students
& Colleagues
Transitional care
LIFE Member
Change Agent & Quality
Improvement
Research &
Scholarship
Pharmacy
International & National
Recognized Model of Practice
Consultants
Geropsychiatry
Eye, Dental
Podiatry
NPs lead the
interdisciplinary team
with low use of consultants
Nutrition
Spiritual Care
Low rehospitalization rates:
9.7% (2013), 14.3% (2014);
9.1 (2015)
Interprofessional Education
 Collaborate to advance high-quality integrated




healthcare delivery
Transform the patient experience
Share learning experiences among health
profession students across disciplines
Build strong clinical teams and improve health
outcomes
Enhance the preparation of the healthcare
workforce and optimize care delivery
Penn’s Interprofessional Pain
Course
• NIH Center for Excellence in Pain
Education in 2012 – only 12 in the US
 Collaboration with 4 schools
 5-day intensive course; 140 students; 20
faculty
 Uses innovative teaching and learning
methods:
–
–
–
Interprofessional collaborative team-based
Problem-based and team simulation
Reflective, situated and interactive
 Apply pain evidence-based practice
guidelines to patient cases
 Teaches national and global defined
interprofessional competencies
Teaching Innovations
 Conceptualize and envision new approaches to the
teaching and learning process in nursing education
 Think differently about the curriculum, instructional
methods, and clinical experiences
 Take risks and a non-traditional approach to create new
approaches to teaching and learning
 Examples:
‒ Flipped classrooms
‒ Online education
‒ Simulation
Simulation

Safe and controlled environment resembling
clinical practice

Integrates knowledge, skills and critical thinking

Provides both a participative and an interactive
environment

Valuable tool for initial training and continued
competence verification

Enhances both acquisition and retention of
knowledge, sharpens critical-thinking and
psychomotor skills

Better equipped to respond to real-world events
“I hear and I forget ~ I see and I remember ~ I do and I understand”
Confucius
Simulation at Penn Nursing
The
Helene
Fuld
Pavilion
for
Innovative
Learning
Online Education
 The number of online nursing programs is




increasing rapidly
Online courses increase access
Currently, there are 400 nursing
programs offered at least partially
online
There are 133 schools offering
online nursing master’s degree
programs
Some programs are totally online, others are
low-residence (part online, part on campus)
 Coursera an online education platform that partners with
universities worldwide
 Penn’s partnership with Coursera started in 2012
‒
‒
‒
‒
46 non-credit Massive Open Online Courses (MOOCs)
3.9 million enrollments and 151,000 completions
Each of Penn’s 12 schools participates
Penn Nursing has offered two titles so far:
•
•
Growing Old Around the Globe (2013, 2014)
Vital Signs: Understanding What the Body
Tells Us (2014)
 China has the second largest enrollment next to the U.S.
‒
1.1 million enrollments across 5 universities since 2013
Penn Wharton China Center
Hospital Nursing in China (Study)

Premier comprehensive study of nursing and
patient outcomes in hospitals in China
‒
‒
‒
‒
38% of nurses were experiencing burnout
45% of nurses were dissatisfied with their job
36% of nurses rated patient safety as low
61% of nurses rated the quality of care as poor

Better work environments and higher nurse-assessed safety
grades showed less incidence of burnout, job dissatisfaction,
and poor quality patient care
 Higher patient-to-nurse ratios are associated with poorer nurse
outcomes
 Greater percentages of baccalaureate nurses are strongly
related to better patient outcomes
 Continued expansion of baccalaureate education in China is
imperative
(You, Aiken, Sloane, et al, 2012)
Hospital Nursing in China (Study)
Policy recommendations for maximizing nurses’
contributions to improved hospital care in China:

Improve patient-to-nurse ratios, and move to more patient-centered
organization of nursing care;

Focus on improving hospital work environments, including introducing
evidence-based best practices in human resource management
‒

Include greater participation of nurses in decision-making, greater
responsiveness of management to correct system problems in patient
care, and good working relationships among health professionals
Increase proportion of patients’ care from baccalaureate-qualified
nurses by transitioning to a more educated nurse workforce
(You, Aiken, Sloane, et al, 2012)
Hospital Nurse Employment in China

Economic and health system reforms in China have transformed nurse
employment in Chinese hospitals

Employment of ‘bianzhi’ nurses is decreasing; contract-based nurse
employment is increasing

Hospital-level utilization of contract-based nurses averages 51%.

Contract-based nurses were significantly more dissatisfied with their wages
and benefits than ‘bianzhi’ nurses who have more job security

Contract-based nurses who were dissatisfied were more likely to leave their
current positions

High utilization of contract-based nurses in Chinese hospitals may
adversely affect both nurse and patient satisfaction in hospitals

‘Equal pay for equal work’ policy (China Ministry of Health) calls for efforts
in Chinese hospitals to eliminate the disparities between ‘bianzhi’ and
contract-based nurses.
(Shang, You, Ma, Sloane, & Aiken, 2014)00
Access/Affordability of Nursing Education

Affordability – cost of nursing education is a major barrier
‒
‒

changes in federal loan programs (mandated by ACA) allow more
nursing students to attend full-time
online programs can be more affordable than onsite
Access
‒
‒
‒
‒
‒
‒
provide seamless academic progression
through nursing education system
faculty shortages decreases access and
student capacity
provide incentives to nurses to pursue further
education
adapt to changes in science, technology and
population demographics that shape the delivery of care
modify approach to bring teaching/learning into 21st century ways for
delivering care
online programs provide convenience