1. © The George Washington University. Do not cite, quote, or distribute without permission What Do You Know About….. Nursing in the U.S.? Test your knowledge… 1.Describe the U.S. nursing workforce and its composition 2.Detail recent trends in the preparation and practice of nurses, generally, and advanced practice nurses, specifically 3.Discuss current and emerging policy issues that influence (and are influenced by) this workforce

2. TRUE FALSE There are more than 3 million RNs in the U.S. 2

3. Nursing Today—3.1 Million Largest Health Care Workforce 3

4. What is Nursing? The art and science of promoting the health and well being of patients, families, and communities. 4

5. History of Nursing Expression of Christianity Florence Nightingale (1820-1910)  British social reformer and statistician  Crimean War  Reduction in mortality rates  Contributions to sanitation and hygiene  Established 1st secular nursing school Sick care provided in the home Civil War—casualties; Clara Barton  hospitals US nursing schools open—Nightingale model WWI and WWII—Army Nurse Corps; military nurses Specialization; rising technical expertise  APRNs Opportunities under the Affordable Care Act 5 Nursing in the U.S.

6. A.54% B.78% C.94% D.100% What is the composition of the RN workforce? The percent of nurses who are women….. 6

7. Growing Number of Male RNs 7

8. TRUE FALSE Hospitals remain the primary setting of practice for RNs. 8

9. Where Do RNs Practice? Source: 2008 National Sample Survey of Registered Nurses, HRSA 9

10. Today’s Nursing Workforce Remains largely female 17% minority Mean age 47 65-70% of RNs 30-59 yoa work full-time >80% are very satisfied or satisfied In hospitals, 19% are unionized Inpatient settings—nursing costs billed as “room and board” Mean annual RN salary $66,973 (FT) Source: 2008 National Sample Survey of Registered Nurses, HRSA 10

11. What Do RNs Do? Source: 2008 National Sample Survey of Registered Nurses, HRSA 11

12. TRUE FALSE What does it take to become a nurse? Becoming an RN requires 4 years of didactic and clinical education. 12

13. Nursing Education— Multiple Pathways Doctoral preparation—PhD, DNP, DNSc Advanced Practice RNs and other master’s prepared nurses Nursing Practitioner Clinical Nurse Specialist Certified Nurse Midwife Certified Registered Nurse Anesthetists 2 year – associate degree--45% RN 3 year – diploma--20% 4 year – bachelor degree--34% Licensed Practical Nurse/Licensed Vocational Nurse—I+ year technical Certified Nursing Assistant—75 hours of training 13

14. Source: 2008 National Sample Survey of Registered Nurses, HRSA Nursing Education— Pursuing Higher Degrees 14

15. TRUE FALSE Nursing schools currently cannot meet the demand among qualified applicants. 15

16. Shortage of Nurse Faculty >8% national nurse faculty shortage Age and retirements of nurse faculty  Average age at professor rank >61 yoa  Average age of at retirement = 62.5  200-300 faculty eligible for retirement annually Time to produce doctoral-level faculty More competitive salaries in clinical settings  $83K (NP) vs. $65K (bachelor’s program) Impact—qualified candidates denied admissions, insufficient pipeline  shortage 16

17. A.Are in the process of becoming “registered” B.Have advanced education and specialized clinical training C.Must be employed and supervised by a physician D.Are independent practitioners The term “advanced practice nurse” refers to nurses who… 17

18. APRNs—Preparation Broad classification—nurse practitioners, nurse midwives, nurse anesthetists, and clinical nurse specialists Prepared with advanced education and specialized clinical training  National certifying boards currently require a minimum of a master’s degree Licensed to deliver care consistent with their area of expertise and state laws that govern scope of practice 250,000+ APRNs in U.S. (2008) 18

19. NPs—Largest Group of APRNs Source: 2008 National Sample Survey of Registered Nurses, HRSA 19

20. NPs—Fastest Growing Primary Care Workforce From 2008- 2025, 94% increase  ~250,000 “NPs will likely fulfill a substantial amount of future demand for care.” (Auerbach, Med Care, 2012) 20

21. NPs—Practice Source: 2008 National Sample Survey of Registered Nurses, HRSA 21

22. Many states require physician oversight of NPs NPs are reimbursed at 90% of the physician fee schedule under Medicare Which is true? 22  Incentivizes “Incident to” Billing

23. Restrictions in NP Scope of Practice Key: = fully independent = reduced practice = restricted practice Source: AANP; http://www.aanp.org/images/documents/state-leg- reg/stateregulatorymap.pdf

24. Factors Contributing to Easing of State NP Restrictions Increased demand for primary care  Growing elderly population  Insurance expansion under ACA Worsening shortage of primary care physicians Rising costs Inadequate access especially among underserved and vulnerable populations Evidence of equivalent quality—clinical outcomes, patient experience  “Match” with ACA’s new/emerging models— e.g., readmissions, transitional care 24

25. Where do APRNs fit in the health care system? Nurse Practitioner Physician Well Care Critical Care Acute and Chronic Unstable Acute Limited/ Stable Chronic Acute Limited/Stable Chronic Illness Well Care Acute and Chronic Unstable Critical Care 25

26. Which of the following policy issues affect nurses? A.Faculty shortage B.System transformation under the ACA C.Availability of sites for clinical placement D.Restrictions in scope of practice 26

27. Transformation of the health care delivery system in response to new demands on/roles for nurses  Practice  Education & academic progression  Leadership  Effective workforce planning via improved information infrastructure Current and Emerging Policy Issues for Nursing 27 Institute of Medicine Future of Nursing (2010)

28. Summary of Key Points Workforce that is growing and changing Multiple avenues for entry into practice Rising demand in response to demographic, labor market, and economic factors Alignment between nurses’ expertise and priorities under health reform Regulatory restrictions in practice and payment limit potential Opportunities for interprofessional collaboration and partnership 28

29. Reflect on the following…. 1.How does the preparation and composition of the current nursing workforce impact you in your practice? 2.What do you think nursing can learn from medicine? Conversely, what do you think medicine can learn from nursing? 3.What are your views about the boundaries/limits on APRN practice? How might these be re- fashioned to meet the nation’s needs? 4.How might partnerships among all health care practitioners be strengthened? 29

30. Ellen T. Kurtzman, PhD, MPH, RN, FAAN Associate Professor The George Washington University School of Nursing 2030 M Street, NW, Suite 300 Washington, DC 20036 Email: etk@gwu.edu 30