Is Nursing in Jeopardy?

For 16 years, nursing has occupied the highest position on Gallup’s annual survey of the public’s trust in occupations---above pharmacists, doctors, lawyers, bankers and the rest. This week, on the anniversary of Florence Nightingale’s birthday (May 12), the nation celebrates National Nurses Week.

The centrality of nursing to the U.S. health system cannot be overstated. Many of our hospitals were founded by nurses. In wars, nurses were on the frontline. It’s a profession rich in tradition that’s now in jeopardy:  

Scope of Practice Limitations: Nurses can do more than they’re allowed. State laws restrict their activities in deference to physicians. Health reformers espouse that allowing mid-level clinicians including advanced practice nurses, nurse practitioners and other mid-level professions to practice at their highest level of training could alleviate shortages in primary care and many other physician specialties. But credentialing permitting nurses to practice at the highest level of their training is rare in hospitals, clinics, and other traditional settings.

Job Related Stress: Nursing is stressful, especially in hospital, post-acute and large medical group settings. Nurses are targets of hostile patients, abusive physicians and bullying by the old guard in their ranks. The hours are predictable, compensation attractive and patient appreciation gratifying, but each new wrinkle on cost-containment, quality measurement, patient safety, data capture and technology integration means the day-to-day work done by nurse’s changes. Studies show nurses in patient care roles at higher risk for sleep disorders, depression, fatigue and other maladies. And rates of occupational burnout (40%) and emotional exhaustion (43.2%) in nursing rival rates of physicians and have been proven to result in medical errors and suboptimal patient outcomes.

Shortages: there are 3.1 million nurses in the U.S. A third are over 50 and three in four say they’ll retire in the next 10-15 years. Thus, the Bureau of Labor Statistics estimates a shortage of 1.1 million nurses by 2022 with no remedy in sight.

None of this is news to veteran industry watchers. Nursing is a profession in jeopardy. Its trade groups have successfully lobbied state and federal officials for minimum staffing standards in the licensing of health facilities. Accreditation agencies recognize nurse staffing levels in their assessments and the correlation between the quality and quantity of nursing care and patient outcomes is widely accepted. So, the significance of nursing is well-known. But remedies to these issues have been slow.  

Every trend in healthcare delivery points to expanded roles for nurses empowered to use their skills to improve the efficiency and effectiveness of care. Consider the skills and scope of practice implicit in these definitions from leading nursing associations: they envision nurses doing much more than their allowed in most traditional settings.

“Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people..”— International Council of Nurses

“The use of clinical judgment in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems, and to achieve the best possible quality of life, whatever their disease or disability, until death.”— Royal College of Nursing (2003)

“Nursing is the protection, promotion, and optimization of health and abilities; prevention of illness and injury; alleviation of suffering through the diagnosis and treatment of human responses; and advocacy in health care for individuals, families, communities, and populations.”— American Nurses Association

Little wonder, non-traditional competitors like CVS, Optum, Kroger, and others are recruiting nurses away from their conventional settings.  They’re betting nurses will play a key role in four areas where the current system falls short:

1-Primary and Preventive Health: Today, 1941 retail clinics and 1200 community health centers dispense treatment and counsel to populations requiring attention. They’re the frontline for primary care in most underserved populations and a convenient alternative to office visits for minor emergencies and treatment. Thus, the numbers of locations and scope of services provided in these settings is increasing as is acceptance by insurers, employers and consumers. They’re run by nurses; physicians oversee medical policies and referrals but it’s the nurses who do the bulk of the work.

2-Health Coaching: 70% of health costs are the result of unsafe environments where individuals live and unhealthy behaviors they adopt. The science of behavior change is advancing in tandem with techniques and technologies that allow targeting and interventions that pre-empt unnecessary emergency room visits, tests, medications and procedures. Health coaching is a blossoming career path in nursing and a central feature in every population health management program.

3-Waste, Fraud and Abuse: Nurses know which physicians are prone to unnecessary testing and procedures. They know which hospitals, nursing homes, home care agencies and other providers cut corners potentially harmful to patient care. They recognize their peers who have become insensitive to patients and bullies to their co-workers. And they share their insight in cultures that are safe.

4-Chronic Care Management: Chronic care consumes 80% of health spending in the U.S. the health system but the majority is untreated. Example: Half of adults with arthritis and overweight or obesity do not receive counseling from their physician (Morbidity and Mortality Weekly Report May 4, 2018). Per the CDC, 84 million U.S. adults are pre-diabetics but 90% are unaware. Patients look to nurses to help them manage their chronic condition and often consult them for help in modifying their treatments.

The themes of consumerism, cost containment, value-based purchasing, disruptive innovation, consolidation, affordability, accessibility and transparency revolve around nursing care that’s effective, engaged and energized.

My take:

I’ve studied healthcare systems in the U.S. and elsewhere for 40 years. The stature of nursing has not changed: it is highly respected and vital to each system’s effectiveness. I know many healthcare leaders who draw on their early training as nurses in leading prominent organizations like Carillion Clinic (Nancy Agee), AtlantiCare (Lori Herndon) and others. I have watched my daughter, Erin, matriculate through two degrees, the pursuit of her DNP in nursing while managing a university’s health clinic.

Nurses are national treasures. They ply their skills to serve patients. They rarely seek the spotlight nor are sit on the boards that make big decisions impacting the future of their organizations.

Stress, burnout and career frustration are legitimate issues in healthcare. They’re not exclusive to physicians. Perhaps it’s time to reflect on the role our nurses play, the cultures in which they work, and the emerging opportunities they have.

Perhaps it’s time to engage nurses more actively in leadership and board roles.

Perhaps it’s time elected officials reflect on the values and motivation of nurses (whose lobbying expenditures pale in comparison to other health professional groups).

Perhaps it’s time for states to permit nurses to practice at the highest level of their training.

Perhaps it’s time to reflect on the public’s respect and trust in nursing. It’s deserved.

Paul

P.S. Last week, CMS recommended changes many consider a positive response to industry concerns for less regulation and greater freedom to innovate: CMA announced it will make 2015 Medicare Advantage data accessible to researchers this year and Medicaid data next year. CMS also announced a new model of payment for primary care: Direct Primary Care allows Medicare beneficiaries “to receive convenient, accessible primary care from a physician they know at a predictable and affordable cost.” HHS Secretary Alex Azar is steering the health industry toward greater accountability and transparency promising more changes to come.

 Fact file: Nursing

Staffing Ratio Recommendations: Range from 1 nurse per 1 patient in the operating room and 1:2 in intensivist settings to 1:6 in the well-baby nursery. As of 2017, California is still the only state to have a safe patient ratio law (ANA)

Lobbying activity 2017: Total for all health professionals ($91 million) including #1 American Medical Association ($22 mil), #31 American Association of Nurse Anesthetists ($700,000), #34 American Association of Nurse Practitioners ($660,000), #37 Academy of Physician Assistants, and #40 Association of Nurse Executives ($600,000) Open secrets.org

States with Acute Nurse Shortages 2017: The top 5 states that are feeling the nursing shortage are California, Florida, New York, Ohio, North Carolina (BLS)

Factors driving Nurses to Leave the Profession: Retirement 54%, age 39%, nurse staffing ratio 17%, job satisfaction 16%, unsafe environment 12%, career change 6% (2017 Nurse Salary Survey allnurses.com)

Nurse Education: The national faculty vacancy rate in nursing programs is over 7% or a shortage of 1,565 teachers. Faculty pay is an issue: the average salary of a nurse practitioner is $97,000 compared to an average salary of $78,575 for a nursing school assistant professor (American Association of Nurse Practitioners)