Differentiated levels of nursing work force demand

Differentiated Levels of Nursing Work Force Demand CHRISTINEW. KOVNER,PHD, RN, FAAN,* ANDJENNIFERSCHORE,MS, MSW'~

In addition to reviewing the literature about the extent to which basic nursing education is related to actual nursing practice, this article investigates the extent to which the relationship between nursing practice, education, and experience varies across specific health care settings. The literature presented no consistent or systematic association between type and amount of previous nursing experience and current nursing practice. However, the literature generally provided evidence of a consistent and systematic association between baccalaureate preparation and level of registered nurse (RN) practice. The review of practice and organizational differences across the hospital, nursing home, and ambulatory care sectors suggests that baccalaureate-prepared RNs in hospitals may have a more strongly differentiated role relative to those in nursing homes and ambulatory settings. If baccalaureate-prepared nurses continue to be perceived as capable of more complex and independent practice, and if employers believe that they can increase revenues by increasing the quality of nursing care or can save money by shifting to RNs some responsibilities now held by more costly personnel (such as physicians), then demand for baccalaureate-prepared nurses may increase. (Index words: Demand; Differentiated practice; Nurse education) J Prof Nurs 14:242-253, 1998. Copyright © 1998 by W.B. Saunders Company

URSING EDUCATORS and employers have had a long-standing interest in the relationship between registered nurse (RN) practice, level of RN educational preparation, and other types of practice qualifications (such as previous experience) and in

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how this relationship may vary across health care settings. Most recently this interest has been stimulated by changes in patient acuity in both institutional and noninstitutional settings and by debates about the need to recognize nursing as composed of differentiated levels of practice and about the ability of education programs (or on-the-job experience) to prepare RNs for these differences. For this article the authors reviewed the literature and questioned experts to assess the extent to which basic RN education is related to actual nursing practice and whether employers deem some types and amounts of previous nursing experience as a substitute for more advanced education in the workplace. Although a relatively small number of basic nursing programs operate at the master's and doctoral levels, this article focuses on the three most prevalent programs: associate (ADN), diploma, and baccalaureate (BSN). The article also investigates the extent to which the relationship between nursing practice, education, and experience varies across specific health care settings. To maintain the artide's focus, three settings were sdected: (1) short-term, acute care inpatient hospital, (2) nursing home, and (3) nonhospital ambulatory care. Ambulatory care induded care delivered by physicians and health maintenance organizations (HMOs). Neither public health nor community health nursing was included because the baccalaureate-level program is the current preferred preparation for nursing in those sectors. The article addresses the following questions:

*AssociateProfessor,Divisionof Nursing, Schoolof Education, New York University,NewYork,NY. tSenior Researcher,MathematicaPolicyResearch, Inc, Prince-

1. What are some major differences among baccalaureate, associate, and diploma programs?

ton, aJ.

2. What are the essential components of nursing practice, and how does practice relate to education and experience?

This article is based on work conducted for the Division of Nursing, BHPr under Health Resourcesand ServicesAdministration (HRSA), DHHS contract282-92-0044(13). The objectiveof that contract was to assess the feasibilityof differentiatingthe requirements for nursing personnel in the nurse demand based model based on nurse experienceand education.This paper does not representthe policyof HRSA.The viewsexpressedare thoseof the authors and no officialendorsementby HRSA is intendedor should be inferred. Address correspondenceand reprint requests to Dr Kovner: New YorkUniversity,Schoolof Nursing, Divisionof Nursing, 50 W 4th St, Room429, NewYork,NY 10012. Copyright© 1998 by W.B. SaundersCompany 8755-7223/98/1404-0012503.00/0 242

3. Does the relationship between practice, education, and experience differ across settings? Is this relationship likely to change in the near furore? Major Differences in Nursing Education Programs

An RN license can be obtained by one of three educational routes, each of which differs in terms of

JournalofProfessionalNursing, Vol 14, No 4 (July-August), 1998: pp 242-253

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DIFFERENTIATED NURSE DEMAND

the length of the program and the focus of the curriculum. As Table 1 shows, baccalaureate students spend an average of 68 per cent of their total clinical training time in acute care hospitals compared with approximately 85 per cent for associate's and diploma nursing students. In contrast, baccalaureate students spend an average of 23 per cent of clinical training time in community settings (ie, home, community, public health, and other ambulatory settings) compared with 6 per cent for associate's students and 8 per cent for diploma students (Rosenfeld & Kaufman, 1990). As of early I992, slightly more than 1.8 million RNs were employed as nurses in the United States. Roughly equal proportions of working RNs in i992 had obtained each of the three degrees. Among working RNs whose initial nursing degree was a diploma, approximately 20 per cent later received a baccalaureate or higher degree; among those whose initial degree was an associate's, approximately 15 per cent later received a higher degree (Moses, 1994). However, the proportion of newlygraduatedRNs with associate's degrees has been increasing steadily since 1973/1974, when they represented 43 per cent of graduates, to 1993/1994, when they represented 62 per cent (Alliance for Health Reform, 1996). Elements of Nursing Practice

Professional nursing organizations identify three broad areas of nursing practice: (1) direct patient care, (2) communication across disciplines on behalf of patients, and (3) professional awareness (American Association of Colleges of Nursing [AACN], 1986; National League for Nursing [NLN], 1992). Direct TABLE 1. Time Spent in Clinical Setting Percentageof Total Clinical Time Facility Acute care hospitals Nursing homes Home, community, public health Other ambulatory Other settings All settings

Diploma ADN 86.0 5.4 4.3 3.8 0.2 100

84.0 9.8

BSN

Hours of ClinicalTime

Diploma ADN

BSN

68.0 7.2

1,324 83

680 79

705 75

2.1 16.5 3.5 6.7 0.5 1.4 100 100

66 58 3 1,539

17 171 28 69 4 15 809 1,037

NOTE: Data from Rosenfeld and Kaufman (1990) based on the 1989 National League for Nursing Newly Licensed Nurse Survey. Hours, by degree and sector, were computed for this article, Abbreviations: ADN, associate degree in nursing; BSN, bachelor of science in nursing.

patient care includes such activities as assessing patients, planning care, and implementing nursing interventions. Communication across disciplines includes patient advocacy, coordinating with families and other members of the health team, and supervising care delegated to other nursing (or aide) staff. Professional awareness includes demonstrating accountability for nursing practice and practicing within the ethical framework of established nursing practice standards. The NLN adds two more practice areas: context and research. Context includes managing resources and technology cost-effectively and being aware of, or making use of, political issues that affect nursing. Research refers to the ability to realize the importance and practicality of research findings and, in some cases, to participate in research-oriented projects. The practice of RNs with different types of educational preparation and experience may differ in the emphasis placed on each of these broad practice areas. Such distinctions are the focus of differentiated nursing practice models. Boston (1990) described differentiated nursing practice as follows: Differentiated practice is referred to as a philosophy that focuses on the structuring of roles and functions of nursing according to education, experience, and competence. As a philosophy, differentiated practice establishes that the domain of nursing practice is broad, with multiple responsibilities of varying degrees and complexities. It assumes that nurses with different educational preparation, expertise, and background bring different competencies to the workplace. Based on the premise that individual practitioners with different types of education, competencies, and experiences should not be used interchangeably, differentiated practice seeks to ensure that the work of nurses is carried out by the most appropriate nurse in the most appropriate way. The AACN (1995) pointed out that differentiated practice results in an "effective and efficient utilization of human resources" because it maximizes costefficiency both directly by matching nurses with tasks on the basis of the nurses' specific abilities and indirectly by promoting nursing staffretention through increased job satisfaction. THE RELATIONSHIP BETWEEN PRACTICE AND EDUCATION

Theoretical models tend to differentiate levels of nursing practice in the three areas of direct patient care, communication across disciplines on behalf of patients, and professional awareness. The models typically draw a distinction between the practice of

244

baccalaureate-educated nurses and nurses with other types of educational backgrounds. Generally in these models, associate and diploma preparation are not viewed differently; however, the NLN model is a notable exception. Moreover, some model developers believed that diploma programs would soon cease to exist. In fact, in 1994 there were 124 diploma programs, down from 460 in 1974 (Alliance for Health Reform, 1996). Baccalaureate-prepared nurses typically are described as practicing in an administrative or other nondirect care role or, if described as engaging in direct patient care, as doing so with relatively complex or high-risk patients. Baccalaureateprepared nurses are expected to be able to practice independently in less structured (ie, noninstitutional) settings by virtue of the problem-solving skills and broad world view that baccalaureate programs provide. According to the models, associate and diploma nurses are expected to practice with established protocols in structured situations that are limited in time to a service encounter (such as a hospital admission) and with patients requiring relatively predictable care. These theoretical models are described by the AACN (1995), Forsey, Cleland, and Miller (1993), Koerner (1992), McClure (1991), NLN (1992), Newman (1990), and Primm (1987). Boonton and Lane (1985) and Friss (1994), among other researchers, have argued that separate licensing for baccalaureate-prepared RNs and for RNs with associate's degrees or diploma training should be used to differentiate practice because employers do not differentiate nursing skills and because the largest employers of nurses--hospitals--are oligopsonic.* Others argue that employers already distinguish between baccalaureate-prepared nurses and those with other types of education. Lehrer, White, and Young (1991) and Link (1988) made this argument after having conducted empirical analyses as did Johnson (1988), who performed a meta-analysis of research through 1985. However, on the basis of a literature review, Rose (1988) suggested that nurses with different educational degrees do have different levels of nursing skills, but that the differences in decisionmaking and leadership abilities--characteristics on which baccalaureate programs are thought to focus-are less striking. Similarly, the meta-analysis by Johnson found the differences between baccalaureate-prepared RNs and other RNs with respect to leadership abilities *An oligopsony is a situation in which a few employers control the labor market. In such a case, wage and employment levels may be below the levels that would exist under free competition among many employers.

KOVNER AND SCHORE

and autonomy to be less striking than those for other nursing skills. Some researchers describing applications of differentiated practice models have reported that some associate- and diploma-prepared nurses provide care for patients with relatively complex needs (see, for example, Allen&r, Egan, & Newman, 1995; Levi, Montgomery, & Hard, 1994; and Malloch, Milton, & Jobes, 1990). Malloch et al. also noted that nurses at these two levels were used somewhat interchangeably when the work environment was unstable (for example, when there were more admissions than expected or more nurse absences than usual), even with a differentiated practice model in place. Johnson (1988) affirmed the lack of distinction in practice of associateand diploma-prepared nurses; others have found that nurses who receive diploma degrees are better prepared for entry-level hospital work than are nurses with associate or baccalaureate degrees (Primm, 1987; Rose, 1988).

Baccalaureate-prepared nurses are expected to be able to practice independently in less structured settings...

Nursing regulations and accreditation criteria generally do not link nursing practice and education. Currently only North Dakota has legislated a twotiered nurse licensing system. In addition, California regulations specify that certification as a public health nurse requires a baccalaureate degree. Hospital accreditation criteria from the Joint Commission on the Accreditation of Healthcare Organizations do not address requirements of education or experience for RNs. As shown in Table 2, the literature reviewed generally supports the existence of a correlation between education and the complexity of RN practice. Theoretical models of differentiated practice suggest that baccalaureate programs, compared with associate's and diploma programs, prepare RNs for a greater degree of professional responsibility and more complex practice. A number of empirical studies of nursing practice generally have supported this correlation between educational preparation and level of practice; a few reported the correlation to be weak.

DIFFERENTIATEDNURSEDEMAND

245

TABLE2. Summary of Selected Study Conclusions on the Relationship Among Nursing Practice, Education, and Experience Nursing Education(BSNAssociated With MoreCompLexPractice/ More Responsibility)

PreviousNursingExperience (More Experience AssociatedWith MoreCompLex Practice/MoreResponsibility)

STUDY SUGGESTS RELATIONSHIP WITH PRACTICE/WAGES IS STRONG/MODERATE Discussions of differentiated practice models

Empirical studies and literature reviews

Boston (1990) Koerner (1992) National League for Nursing (1992) American Association of Colleges of Nursing (1995) Johnson (1988) Link (1988) Rose (1988) Lehrer et al. (1991) Young et al. (1991) Levi et al. (1994)

Boston (1990)

Lehrer et al. (1991) Levi et al. (1994)

STUDY SUGGESTS RELATIONSHIP WITH PRACTICE/WAGES IS WEAK/NONEXISTENT Empirical studies and literature reviews

Boonton & Lane (1985) Malloch et al. (1990) Friss (1994) Allender et al. (1995)

Young et al. (1991) Hackbarth et al. (1995)

NOTE: The National Council of State Boards of Nursing studies on role delineation (Yocum et al., 1995) and job analysis for newly licensed nurses (Chornick et al., 1993) each provide detailed information on the specific activities undertaken by nurses in different settings as well as descriptive statistics on the percentages of RNs with different types of educational preparation. The studies do not include analyses of the relationship between practice and type of education. The single exception is a cross-tabulation, by setting, in the study by Chornick et al. of newly licensed nurses' of type of education and whether practice includes administrative activities. Abbreviation: BSN, bachelor's of science in nursing; RNs, registered nurses. THE RELATIONSHIP BETWEEN PRACTICE AND EXPERIENCE

With the exception of the above-cited work by Boston (1990), the theoretical models of differentiated practice are notable for the absence of discussion of previous nursing experience and of how such experience may affect nursing practice level. The theoretical models reviewed relied almost exclusively on type of educational degree to distinguish between RNs who should fill positions requiring structured practice limited to service encounters and those who should fill relatively complex, independent practice positions that may involve following-up patients across health care settings. Nursing regulations for several states and accreditation criteria were also reviewed, and these did not mention a relationship between nursing practice and experience. However, researchers reporting on employers' efforts to implement differentiated practice models sometimes noted some effects of previous nursing experience on practice level. For example, Levi et al. (1994) found that many associate and diploma nurses provided care to patients with complex needs as a result aftheir experience and motivation to learn more highly developed skills. On the basis of a 1986 survey of RNs in Illinois (not restricted to those in settings who may have used differentiated practice models), Lehrer et al. (1991) found that as experience in-

creased, nurses with all educational backgrounds increasingly tended to move away from the relatively structured "staff nurse" position. The researchers reported that this tendency was more pronounced for baccalaureate-prepared nurses and was least pronounced for those with diploma degrees. According to Young, Lehrer, and White (1991), in theory, increased experience may be associated with either more responsibility and more complex practice (if longevity is associated with exposure to a wider array of tasks, which in turn leads to greater responsibility) or less responsibility and less complex practice (if more recent graduates with less experience have had a more complete or advanced education). Young's analysis of data from the 1986 survey of Illinois RNs, which was restricted to nurses engaged primarily in patient care, suggested the latter possibility. Hackbarth, Haas, Kavanagh, and Vlasses (1995) found, in their survey of ambulatory care nurses, of whom roughly 60 per cent had associate/diploma training and an average of 17 years of nursing experience, that the most frequently performed nursing tasks were those judged to be relatively unskilled. Hackbarth et al. and Young et al. both concluded that, at least for their samples, experience did not lead to positions of greater responsibility or practice complexity. Thus, the literature did not provide convincing evidence of any

246

KOVNER AND SCHORE

systematic relationship between nursing practice and previous nursing experience.

Variations Across Settings in the Relationship Between Nursing Practice, Education, and Experience At least in principle, the three practice areas delineated by professional nursing--direct patient care, communication, and professional awareness--can apply to nursing in any health care sector. However, practice patterns in hospitals, nursing homes, and ambulatory settings may place different emphases on each area. Moreover, area emphasis within a health care sector may differ depending on the philosophy of individual employers about the appropriate roles of nurses. In this section, for each health care sector, characteristics of nursing practice in the key areas of direct patient care and communications are discussed, as are employers' structural and financial characteristics that may affect nursing. The possible influence of these characteristics on the level of nursing practice and therefore on practice qualifications is also considered. Table 3 presents an overview of this discussion. HOSPITALS

Most RNs are employed by hospitals. During 1992, two thirds of the more than 1.8 million working RNs were employed by these organizations (Moses, 1994). In that same year, more than 90 per cent of newly licensed nurses worked in hospitals (Rosenfeld, 1994). According to Lehrer et al. (1991), even 20 years after graduating, nurses were still more likely to work in hospitals than in other settings, although the likelihood of their working in a hospital did decrease as the time since graduation increased. Compared with nursing home residents and ambulatory care patients, hospital patients are, on average, the most acutely ill and physiologically unstable, so their care generally is the most complex. Furthermore, as less acutely ill, more physiologically stable patients increasingly are discharged quickly to ambulatory and home settings or nursing homes, the average levels of acuity and instability of patients remaining in hospitals are likely to increase, relative to those of previous cohorts of hospitalized patients. Moreover, some procedures that formerly were routinely performed in hospitals are now performed in ambulatory settings. As fewer patients are hospitalized for less complex procedures or solely for "recuperation," nurses will be required to perform relatively simple monitoring tasks

less often, but more patients will require higher levels of assessment and monitoring. The ongoing introduction of high-technology medical and associated nursing procedures also has made hospital practice the most technically complex relative to that in other settings. For example, the successful care of lowbirthweight, preterm newborns relies heavily on recent technological developments. RNs working in hospitals traditionally have supervised licensed practical nurses (LPNs) and nurse's aides. Over the past few years, however, hospitals appear to be using fewer LPNs and aides. For example, the ratios of LPNs and aides to hospital beds has decreased from .17 and .33, respectively, in 1990 to .12 and .26 in 1994, respectively. At the same time, the ratio of RNs to beds has increased from .86 to 1.00 (Buerhaus & Staiger, 1996). Similarly, in comparing data from the American Hospital Association for 1985 and 1993, Berliner, Kovner, Goldman, and Balinsky (1994) observed an increase in the ratio of RNs to LPNs (from 3.3 to 5.2) and a decrease in the number of LPNs per patient day (from 0.25 to 0.19). On the other hand, although no hard data were available, anecdotal evidence suggests that hospitals increasingly are hiring technicians and other unlicensed staff to perform tasks once carried out by nurses and aides. Therefore, RNs working in hospitals may supervise fewer LPNs and aides but more technicians and other unlicensed staff. Because training of technicians and unlicensed staff is often minimal, hospitals might be induced to hire RNs with more education or supervisory experience.

. . . c a s e m a n a g e m e n t of patients with c o m p l e x care n e e d s . . , is e m e r g i n g a s an i m p o r t a n t role for R N s . . .

Finally, case management of patients with complex care needs both within and outside hospitals is emerging as an important role for RNs (Cohen & Cesta, 1994; Institute of Medicine, 1996). Arguably, case management requires more highly developed communication skills and a greater ability to make decisions and practice independently than do more traditional hospital nursing roles, and such skills and abilities generally increase with education and experience. Indeed, nurse case managers may require the type of training currently provided to advanced prac-

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tice nurses in postbaccalaureate programs (Institute of Medicine, 1996). The hospital industry continues to operate in a well-publicized state of flux that may well affect the mix of nursing, assistive, and technical staff that hospitals hire. Eight per cent fewer general hospitals were in operation in 1993 than in 1988 (5,342 v 5,810), and the number of hospital beds decreased by 6 per cent (American Hospital Association 1988, 1994-1995). Between 1994 and 1995, hospital mergers and acquisitions increased 44 per cent (Lutz, 1996). Furthermore, insurers, particularly managed care organizations and Medicare, continue to pressure hospitals to lower costs. In response to these financial pressures, hospitals have been investigating ways to increase efficiency through restructuring or reengineering. For example, they may hire greater numbers of unlicensed staff to assist nurses, presumably to carry out routine tasks under the supervision of RNs. They also may provide staff development, sometimes referred to as "cross training," to nurses so that the nurses can be used more flexibly in whatever role may be needed. Trends in the hospital industry that increase the supervisory responsibility assigned to RNs, that reduce their capacity to mentor more junior RNs, that increase the need for nurses who can care for physiologically complex and unstable patients, and that increase the need for nurses who can function well in a range of departments all suggest that hospitals increasingly will need more highly skilled RNs. However, economic imperatives are likely to move hospitals to develop the most cost-effective staffing strategy possible and, depending on relative wages, relative productivity, and available technology, to substitute among different types of staff. It is likely that hospitals will find the fewest staff able to substitute for the most highly skilled RNs in terms of judgment. Few substitutes means that hospitals will probably have to hire the most highly skilled RNs for positions that require judgment. It also seems likely that RNs with lower skill levels, perhaps those with the associate's or diploma degrees, may be hired less frequently or face declining relative wage offers because it is somewhat easier to substitute LPNs, technicians, or other unlicensed staff for some of the activities they carry out. Thus, the changing nature of hospital care may lead hospitals to opt for a mix of RNs comprising more highly skilled RNs and fewer less skilled RNs.

KOVNER AND SCHORE

NURSING HOMES

In 1992, only 7 per cent of RNs employed in nursing worked in nursing homes (Moses, 1994), whereas 5 per cent of newly licensed RNs worked in such a setting (Rosenfeld, 1994). In nursing homes, most nursing activities are carried out by LPNs and nurse assistants. Nurse assistants comprise 70 to 90 per cent of nursing home staff (Institute of Medicine, 1996). This staffing pattern is consistent with the lower average acuity/higher average physiological stability of traditional nursing home residents relative to hospitalized patients and with the fact that a large portion of nursing home care consists of assistance with personal care activities, such as bathing and eating. In nursing homes, RNs are employed primarily as directors or assistant directors of nursing. The Omnibus Budget Reconciliation Act of 1987 and its regulations require that directors of nursing in Medicare- and Medicaid-certified nursing homes be RNs and that an RN be on duty at least 8 hours per day, 7 days per week. (The same staff member can hold both the director and on-duty RN positions.) Rosenfeld (1994) found that more than half the newly licensed RNs employed in nursing homes held positions of head nurse or assistant head nurse. Similarly, approximately 75 per cent of newly licensed RNs working in long-term care facilities had some administrative responsibilities, regardless of educational preparation, compared with only about 30 per cent of newly licensed RNs working in all settings (Chornick, Yocum, & Jacobsen, 1993). In nursing homes the authors found no evidence of case management, similar to that in hospitals, designed to minimize length of stay or to promote a continuum of care for nursing home residents who move back to the community. As a result of pressures on hospitals to minimize lengths of stay, nursing homes increasingly are caring for residents with subacute needs (ie, providing care to stabilize patients after a hospitalization or to promote recovery from surgery). They also are caring for more residents who have dementia, acquired immunodeficiency syndrome or other special needs. In response to these trends, some nursing homes have developed special subacute or specialty care units. In 1995, more than 10 per cent of nursing facilities offered subacute care in more than 15,000 subacute beds. At the same time, 10 per cent of nursing facilities had special care units with a total of approximately 90,000 beds

249

DIFFERENTIATED NURSE DEMAND

(Institute of Medicine, 1996). An increase in these types of care would suggest the need for more RNs overall and perhaps for RNs with more education or experience. Alternatively, nursing homes might attempt to meet the needs of residents requiring subacute or specialty care by hiring more LPNs and aides to work under the supervision of RNs. In addition, the Institute of Medicine recommended that Congress increase the required daily presence of RNs in nursing homes from 8 to 24 hours by the year 2000 and that Medicare and Medicaid payment be changed commensurately. Like the rest of the health care industry, the nursing home industry is changing, producing a smaller number of nursing home beds relative to the elderly population. In 1991, the number of nonhospitalbased nursing homes in operation was 14,744, a decrease of 10 per cent since 1986. According to a 1995 study by the National Center for Health Statistics, the number of beds per 1,000 individuals age 85 years or older decreased during that period by 9 per cent, from 542 to 495. These decreases likely resulted at least in part from efforts during the last 10 to 15 years by state Medicaid programs, the largest payers of nursing home care, to tighten nursing home eligibility and shift long-term care from nursing homes to the community (DuNah, Harrington, Bedney, & Carrillo, 1995). In 1993, Medicaid was the source of more than half of all nursing home spending, and nursing home spending amounted to one fourth of Medicaid budgets (National Center for Health Statistics, 1995). Changes in the structure of or further limitations in funding for state Medicaid programs could have a major impact on the nursing home industry and potentially could shift more long-term care away from nursing homes. Residents who remained in nursing homes would be those deemed to be too difficult to maintain in the community (for example, individuals with dementia) or to be in need of a type or level of nursing care that they could not receive cost-effectively in their homes (for example, because they lack sufficient informal support, lack a safe home environment, or need more care than can be delivered costeffectively in the home). Thus, although RNs practicing in nursing homes are currently predominantly in supervisory roles, future practice may include more skilled clinical nursing roles to provide subacute and specialty care. The specific nature of future practice patterns and staffing mix will be determined by the interplay among the increasingly complex care needs of nursing

home residents, the wage levels paid to RNs and other health care workers, and the level of public funding for nursing home care. AMBULATORYCARE

Eight per cent (n = 144,110) of RNs employed in nursing in 1992 worked in ambulatory care settings, such as physician- and nurse-based practices and HMOs.* This percentage represented roughly a 100 per cent increase in the number of ambulatory care nurses since 1980, the largest proportionate increase during that 12-year period in the number of nurses in any health care sector (Moses, 1994). On the basis of a national 1992 survey of ambulatory care nurses, Hackbarth et al. (1995) described nursing practice in ambulatory care settings as falling into categories that were similar to the three broad areas in nursing--patient care, communication across disciplines, and professional awareness. In their study, the researchers defined ambulatory care settings to include hospital outpatient clinics, physician group practices, and HMOs. Hackbarth et al. found practice in ambulatory settings also to include "enabling activities," such as transporting patients, supplying rooms, recording vital signs, and maintaining traffic flow. They pointed out that nurses in ambulatory care settings most frequently performed tasks related to enabling operations, dient advocacy, and nursing process (for example, preparing clients for and assisting in procedures, witnessing the signing of consent forms, and collecting specimens) and performed care coordination and expert practice tasks least frequently. However, the frequency of task performance differed somewhat across ambulatory care settings. For example, nurses in HMOs conducted telephone commu*For the purposes of this article, ambulatory care included care provided in physicians' offices in the fee-for-service sector and care provided by HMOs. The terms HMO and managed care organization (MCO) sometimes are used interchangeably in everyday parlance. For this article, HMO refers to either a federally qualified HMO or an organization registered as an HMO in the state in which it operates. These organizations bear financial risk for providing health care services. HMOs usually follow one of four models that provide varying amounts of control over participating physicians or are a combination of models. The four models are: (1) the staff model, in which physicians are hired and employed by the HMO, practice in a location owned by the HMO, and see only HMO patients; (2) thegroup model, in which the HMO contracts with a single group of physicians (who may also see non-HMO patients) to care for HMO enrollees; (3) the network model, in which the HMO contracts with two or more groups of physicians to provide services; and (4) the fPA model, in which the H M O contracts with independent physicians or groups of independent physicians.

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nication, client advocacy, and client teaching tasks more frequently than they conducted enabling activities and nursing process, in part because some HMOs were delegating many of the latter activities to LPNs (Haas et al., 1995). Haas and Hackbarth (1995) predicted that to promote cost-efficient care delivery in the future, enabling and technical tasks increasingly would be delegated to less skilled ambulatory care workers. Nursing practice patterns in physicians' offices and HMOs seem to vary, although variations appear to be driven largely by employers' beliefs about how nurses should practice in their offices and organizations. During 1993, network- and IPA-model HMOs outnumbered Staff- and group-model HMOs by a ratio of three to One (Group Health Association of America, 1993). Thus, the H M O market is dominated by models in which physicians devote only a portion of their practice to a single HMO, and HMOs have relatively little control over physician practice. Consequently, a general H M O philosophy about RN practice would not likely affect most physicians practicing in HMOs.

Some HMOs . . . have developed innovative practice roles for RNs.

Some HMOs, presumably staff or group models primaril)~ have developed innovative practice roles for RNs. For example, RNs act as telephone advice nurses, answering patients' questions, providing patient education, and identifying patients who must see physicians. HMOs also are using RNs as case managers for special high-risk populations, such as enrollees with diabetes or AIDS. In their case manager role, RNs monitor preventive and primary care, coordinate different types of care, and provide health-related education. Some HMOs also use nurses to lead teams of LPNs and medical assistants or to carry out high-technology procedures (personal communications, H M O administrators). Reductions in the Medicare budget and pressures from all types of MCOs are likely to generate continued reductions in physician payments, thereby affecting physicians' practices and, potentially, the role of nurses in physicians' offices. In response to financial pressures, physicians are joining large physician group practices or physician management companies (Ginsburg & Grossman, 1995). To cut practice costs, they

may use fewer RNs or offer lower salaries to RNs. On the other hand, they may use more RNs if they believe that shifting some of their own activities to these nurses will increase the cost-efficiency of their practices.* Some evidence suggests that consolidation is occurring in the H M O industry, although managed care is expected to play an increasing role in health service delivery in the foreseeable future. During 1994, 540 HMOs were in operation compared with a high of 647 in 1987, although the number of enrollees in 1994 (42.2 million) was the highest ever (National Center for Health Statistics, 1995). In fact, between 1994 and 1995, merger and acquisition activity of HMOs decreasedby 24 per cent (Lutz 1996). In the future, H M O growth is expected to occur through geographic expansion and through expansion in the small-group market and among Medicare and Medicaid beneficiaries (Ginsburg & Grossman, 1995). During 1993, only seven per cent of Medicare beneficiaries and six per cent of Medicaid beneficiaries were enrolled in managed care plans (Health Care Financing Administration, 1995). In general, with the possible exception of some HMOs using RNs as advice nurses, leaders of teams of less skilled staff; or case managers for special populations, ambulatory care settings do not appear to make use of the different skills and abilities thought to be developed in the various RN education programs. It is unclear whether, or how, economic pressures on private practice physicians or the growth of HMOs and managed care more generally will affect nursing practice roles and thus practice qualification requirements for ambulatory care RNs. Conclusions

Different broad areas of practice apply to nurses with different educational backgrounds. Differentiated practice models make a strong argument that within these areas, baccalaureate-prepared nurses should hold positions associated with more complex practice and greater responsibility and that require better problem-solving, decision-making, and leader*Accordingto a 1993 study by the AmericanMedicalAssociation, solo practicephysicianswho employednonphysicianpractitioners (for example,clinicalnurse specialists,nurse practitioners, and physicians' assistants) had higher net income, were more productive, and were better able to expand the scale of" their practices than were physicianswho did not employnonphysician practitioners (Wozniak 1995). (Wozniakdid not discussthe effect of RNs on physicianpractice.)

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ship skills, whether in direct patient care or administrative roles. Although the description by Boston (1990) of differentiated practice discusses the structuring of nursing activities on the basis of education, experience, and competence, the models reviewed tended to differentiate activities only by education level, usually contrasting the practice of associate- and diplomaprepared nurses with that of baccalaureate-prepared nurses. According to many of the empirical studies (Lehrer et al., 1991; Levi et al., 1994), baccalaureate-prepared RNs held positions with more complex practice (or, as a proxy, providing higher wages) relative to associate'sor diploma-prepared RNs. However, a few studies showed this association to be weak (Allender et al., 1995). And state nursing practice regulations and JCAHO criteria did not mention any association between RNs' type of educational preparation and their practice level. Some researchers describing applications of differentiated practice models and nursing practice more generally noted that although experience did have an effect on practice levels, the direction and level of that effect were ambiguous. For example, in one study, some experienced or highly motivated associate- and diploma-prepared nurses provided care to patients with complex needs--patients whom differentiated practice models typically would assign to a baccalaureate-prepared nurse (Levi et al., 1994). According to another researcher, all nurses, regardless of educational preparation, tend to move away from "staff nurse" positions as they gain experience (Lehrer et al., 1991). However, Hackbarth et al. (1995) and Young et al. (1991) observed that nurses with the most experience and thus the longest time since schooling tended to perform less complex tasks or to hold positions with less responsibility. This may be so perhaps because their education did not prepare them for more complex tasks as well as did the education of more recent graduates or because the most competent nurses moved to administrative positions as they gained experience. Thus, the literature reviewed here presented no consistent or systematic association between type and amount of previous nursing experience and current nursing practice. However, the literature generally provided evidence of a consistent and systematic association between baccalaureate preparation and level of RN practice, although some empirical studies found this association to be weak, and the association was not reflected in current nursing practice regulations.

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The health care system is in a state of flux as hospitals, HMOs, and other entities merge, downsize, and reinvent themselves to continue providing services while remaining financially viable. Several changes in this system are likely to continue to have important impacts on the demand for RNs and on the type of skills that RNs will need in the coming years. Reductions in hospital length of stay have been particularly important: they have increased the proportion of acutely ill hospital patients. The increased average acuity of hospital patients suggests a need for RNs with more technical training and the ability to manage patients with more complex needs. The possible increase in the use of technicians and other unlicensed staff suggests a need for RNs with greater ability to supervise and mentor less skilled staff. At the same time, hospitals and other organizations recognize a need for nursing staff to monitor and coordinate care for patients across a continuum of care settings, suggesting that RNs should have knowledge about community resources and the ability to communicate with health care professionals in different settings. As nursing homes respond to reductions in hospital lengths of stay by providing more subacute care, nursing home care is likely to require more highly skilled nurses. Similarly, both ambulatory care and home care nursing have begun to provide the type of technologically sophisticated care once offered only in hospitals. Because the care is provided in homes and other noninstitutional settings, nurses lack the structure and support available in institutional settings (Institute of Medicine, 1996). This suggests a need for more RNs who are both more highly skilled and able to practice more independently. This review of practice and organizational differences across the hospital, nursing home, and ambulatory care sectors suggests that baccalaureate-prepared RNs in hospitals may have a more strongly differentiated role relative to those in nursing homes and ambulatory settings. RNs practicing in nursing homes hold primarily supervisory roles; the practice of those employed in ambulatory settings (physicians' offices and HMOs) is dominated by relatively less skilled activities, although the nature and complexity of activities delegated to nurses depends heavily on the approach of individual employers. However, increases in the complexity of RN practice, increases in the need for RNs to supervise other workers, and increases in the need to be able to practice independently all suggest that more nurses who are more highly skilled in these areas will be required in all health care settings.

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• Future changes in aggregate patient characteristics and ongoing pressures to cut costs in all three sectors could either increase or decrease differential education or experience requirements. If baccalaureate-prepared nurses continue to be perceived as capable of more complex and independent practice, and if employers believe that they can increase revenues by increasing the quality of nursing care or can save money by

shifting to RNs some responsibilities now held by more costly personnel (such as physicians), then demand for baccalaureate-prepared nurses may increase. The increase in demand will be mitigated, however, to the extent that wage differentials among RNs with differential qualifications or between RNs and other types ofstaffexceed the differentials in their relative productivity.

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