- Email: [email protected]
Health policy thoughtleaders' views of the health workforce in an era of health reform
Health policy thoughtleaders’ views of the health workforce in an era of health reform Karen Donelan, ScD Peter I. Buerhaus, PhD, RN, FAAN Catherine DesRoches, DrPH Sheila P. Burke, RN, MPA, FAAN
Although registered nurses rank similarly with physicians in the public’s esteem, physicians are more visible than nurses in media coverage, public policy, and political spheres. Thus, nursing workforce issues are overshadowed by those of other health priorities, including Medicare and health reform. The purpose of this research was to understand the visibility and salience of the health workforce in general, gain an understanding about the effectiveness of messages concerning the nursing workforce in particular, and to understand why nursing workforce issues do not appear to have gained more traction in national health care policymaking. The National Survey of Thoughtleaders about the Health Workforce was administered via mail, telephone and online to health workforce and policy thoughtleaders from August 2009-October 2009. Of 301 thoughtleaders contacted, 123 completed questionnaires for a response rate of 41%. Thoughtleaders agree that nurses are critical to the quality and safety of our healthcare system, that there are current nursing shortages, and that nursing shortages will be intensified by health reform. Thoughtleaders reported that while they do hear about
Karen Donelan, ScD, is Senior Scientist in Health Policy at Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, MA. Peter I. Buerhaus, PhD, RN, FAAN, is Valere Potter Professor of Nursing, Director Center for Interdisciplinary Health Workforce Studies, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN. Catherine DesRoches, DrPH, is Assistant Professor of Medicine, Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, MA. Sheila P. Burke, RN, MPA, FAAN, is Faculty Research Fellow and Adjunct Lecturer, John F. Kennedy School of Government, Harvard University, Cambridge, MA. Corresponding author: Dr. Karen Donelan, Massachusetts General Hospital, Mongan Institute for Health Policy, 50 Staniford Street, 9th Floor, Boston, MA 02114. E-mail: [email protected] Nurs Outlook 2010;58:175-180. 0029-6554/$ - see front matter ª 2010 Mosby, Inc. All rights reserved. doi:10.1016/j.outlook.2010.06.003
nursing issues frequently, they do not view most sources of information as proposing effective policy solutions. This study highlights a critical gap in effective policy advocacy and leadership to advance nurse workforce issues higher on the national health agenda.
A
n estimated 3.1 million registered nurses are employed throughout the United States healthcare system, more than 3 times the number of active physicians.1 For decades, public opinion surveys have documented that registered nurses rank similarly with doctors in the public’s esteem, including measures of honesty, ethical standards, trust, and as a desirable and respected profession.2-7 Yet there is little question that physicians are far more visible in media coverage and in public policy and political spheres than are nurses. A LexisNexis search for major stories in major US newspapers conducted in January 2010 using the search terms ‘‘nurses’’ and ‘‘health reform’’ revealed 278 major stories during the past 6 months. In contrast, using the terms ‘‘physicians’’ and ‘‘health reform’’ yielded 753 major stories in the same time period. Searches using the terms ‘‘doctors’’ and ‘‘health reform’’ yielded 107 major stories in the past month alone, and more than 1000 in the past 6 months. While a few television advertisements and White House press conferences mentioned nurses in the recent and continuing health reform debate, attention to the care delivery roles of nurses (namely, the increased use of nurse practitioners to provide primary care) and the profession’s attempts to influence the shape of the health reform debate have been largely overshadowed by media coverage of Medicare physician payment, possible cuts in Medicare payment to hospitals, and other issues associated with health reform. A large shortage of nurses is projected to develop during the next decade.8 Since 2004, it has been widely recognized that the constrained capacity of nursing education programs is a major stumbling block to J
U L Y
/ A
U G U S T
N
U R S I N G
O
U T L O O K
175
Health policy thoughtleaders’ views of the health workforce in an era of health reform
and followed by telephone. During the study period, 123 thoughtleaders completed the survey for a 41% response rate. No monetary incentives were offered or provided to respondents. Differences in the demographics of respondents and non-respondents could not be analyzed due to our having only basic contact and job title information in our sample. The major goal of this research was to understand the visibility and salience of the health workforce in general, gain an understanding about the effectiveness of messages concerning the nursing workforce in particular, and to understand why nursing workforce issues do not appear to have gained more traction in national health care policymaking. Survey items included: national and health policy priorities, the role of nurse workforce issues in those priorities, perceptions of and sources of information about health workforce supply, trust in sources of information, and the most effective ways for nursing workforce issues to gain traction among policymakers. The questionnaire was developed by the researchers and a team of national advisors expert in health policy making, journalism and health services research. Several questions were taken from other national surveys of the public or key stakeholders. The survey instrument had 17 questions (62 items) and took approximately 10 minutes to complete depending on mode of administration. The questionnaire will be made available by the corresponding author upon request. Due to the comparatively small sample size in this study, most analyses reported are descriptive in nature. Bivariate comparisons of respondents with nursing degrees (n ¼ 37) to those with other advanced degrees (n ¼ 82) were made using 2-tailed z-tests. We report the results of significant differences by professional degree in the text where appropriate.
achieving an adequately sized nursing workforce to meet increasing demands.9 Recently enacted expansions of health insurance coverage in the United States are likely to increase the demand for health care and hence the demand for healthcare professionals, particularly registered nurses and physicians. The new legislation does include provisions to expand the capacity of nursing education programs to begin to close the gap in the supply of nurses. Still, debates and discussion continue about the best approaches to educate nurses for current and future roles in acute and long-term care, as well for meeting the future demand for primary care providers. As the healthcare reform debate was underway in the United States, we asked how effectively issues of concern to the nursing profession were being communicated to those who were shaping the nation’s health policy agenda. In the latter half of 2009, we conducted a survey of key health care and health workforce thoughtleaders to understand the relative positioning of nursing workforce issues amidst other key health priorities. Developing a sample from several publicly available sources, we posed questions about federal health policy priorities, health workforce supply, sources of information dissemination, effective advocacy about nursing workforce issues, and barriers to legislative progress.
SURVEY DATA AND METHODS The National Survey of Thoughtleaders about the health workforce was administered by mail, telephone, and online to a sample of health workforce and policy thoughtleaders during the period from August 2009October 2009. The survey was administered by Social Science Research Solutions (SSRS) for the Johnson & Johnson Campaign for Nursing’s Future, an 8-year philanthropic effort to promote the nursing profession, increase nurse recruitment and retention, and address problems in the capacity of nursing education programs in an effort to avert the projected long-term national shortage of Registered Nurses (RNs). De-identified data were provided to the research team for analysis in order to protect the privacy of individual respondents. ‘‘Thoughtleaders’’ were defined as leadership representatives of key stakeholder groups on health workforce policy. The sampling frame was constructed using nationally published lists of influential leaders in health care organizations (hospitals, medical, and nursing schools, health plans, trade, and membership organizations), Washington ‘‘think tank’’ organizations, foundations concerned with health care, health workforce policy agencies, academia, health workforce experts within research organizations, and authors who have published about health workforce supply. Initial contact with a sample of 301 was attempted by mail, then by mail or email (if address was publicly available), 176
V
O L U M E
5 8
N
U M B E R
4
N
U R S I N G
Donelan et al
STUDY RESULTS More females (57%) than males (43%) completed the survey, and nearly 9 in 10 were > 50 years of age (33% > 65 and 55% aged 50-64). We did not measure significant differences in response by age or gender. Half of respondents worked in academic settings while the other half was divided among hospitals, professional or trade organizations, foundations, and other settings. Virtually all respondents had multiple postgraduate professional degrees; 15% were Medical Doctors (MDs) and 30% had at least one nursing degree (21% had nursing degrees at the masters and/or doctoral level) though many of those had gone on to pursue graduate degrees outside of nursing. Overall, experience with political activity and legislative matters included 21% who had served as a legislative aide, 21% as a lobbyist, 36% as healthcare campaign advisor and 14% as a candidate for state or federal office. Roughly 1 in 10 of respondents (8%) worked in government positions at the time of the survey. O
U T L O O K
Health policy thoughtleaders’ views of the health workforce in an era of health reform
Health Workforce Supply in an Era of Health Reform Respondents were asked to describe, in their own words, the top 2 most important issues for this Congressional term, along with the 2 most important health policy issues for their organizations to address in the next 2 years. By a wide margin, respondents identified health reform (91%) and issues associated with insurance coverage and health care costs as the 2 most important issues for Congress, dominating the economy (47%) and foreign policy (15%). When asked to constrain their responses to health issues for their organization to address, priorities were divided among a range of insurance coverage (35%), health costs (23%), workforce (25%), and quality of care (20%). Nurses were significantly more likely than other respondents (including physicians and respondents with other non-nursing higher degrees) to indicate that the issue of workforce was one of the 2 most important health issues for their organization to address (51% nurses vs. 11% other respondents, P < .001). Respondents were asked their perceptions of the current adequacy of the supply of nurses, primary care physicians, medical specialists, and surgical specialist physicians. Nearly all respondents (94%) indicated that the nation has a very or somewhat serious shortage of primary care physicians, and 92% reported a very or somewhat serious shortage of nurses (Figure 1). One third or fewer respondents reported shortages of both medical and surgical specialists. A similar proportion of nurses and respondents with other non-nursing degrees say that that there was a very serious or somewhat serious shortage of registered nurses in the United States (97% vs. 88%, P ¼ .189). When asked if there would be a sufficient supply of physician and nurses if universal health insurance coverage were enacted, only 10% and 13% of thoughtleaders, respectively, agreed there were sufficient numbers of primary care physicians and nurses to care for patients if universal coverage was provided. To gauge the relative importance of the ‘‘predicted future shortage of nurses,’’ respondents were asked to rate Do you think there is currently a shortage of each of the following in the US? Primary Care Physicians
66
R i t d Registered Nurses
28
46
Surgical specialist MDs
25
8
Medical 2 specialist MDs 0%
Very serious
46
20%
5 3
59
8
65
26 40%
Somewhat serious
60%
No shortage
42
7 80%
100%
Don’t know
Figure 1. Thoughtleader Perceptions of Current Health Workforce Shortages, 2009.
Donelan et al
Considering the many health policy issues our nation has to address in the next 2 years, how would you rank the importance of the predicted future shortage of nurses relative to each of the following? Health fraud and abuse
49
Bioterrorism
43
37
Primary Care MD shortage
27
Rising health costs
12
Solvency of Medicare
12 0%
21
48
36
42
46
51 20%
Shortage is more important Less important
2
16
57
16
Uninsured
71
40
37
40%
60%
80%
100%
Neither more nor less Don't know
Figure 2. Thoughtleader Perceptions of the Relative Importance of Predicted RN Shortages, 2009.
the importance of the predicted future shortage in comparison with 6 other issues using a response scale of ‘‘nursing issue is more important,’’ ‘‘neither more nor less important,’’ ‘‘nursing issue less important’’ (Figure 2). Overall, looking at the data one way, the projected nursing shortage was seen by a majority of respondents as being more important than—or neither more nor less important than—each issue we inquired about, including health fraud and abuse, bioterrorism, primary care physician shortages, solvency of Medicare, rising health care costs, and number of Americans without health insurance. Focusing solely on the ‘‘more important,’’ nearly half of respondents thought the predicted shortage was more important than health fraud and abuse. Forty-six percent of respondents thought the predicted shortage was less important than the number of Americans without health insurance. Nurses were more likely than respondents with other non-nursing higher degrees to think that the predicted shortage of nurses was more important than the predicted shortage of primary care MDs (51% vs. 17%, P < .001), and rising health costs (35% vs. 9%, P ¼.001). There were no significant differences in the proportions of nurses and other respondents who thought that the RN shortage was more important than the threat of bioterrorism, the solvency of Medicare, the number of Americans without health insurance or healthcare fraud and abuse.
Do Nurses Matter? Importance of Nurses in Health Care Delivery and Health Reform Policymaking Respondents were asked about their perceptions of the importance of nurses on several dimensions of health care delivery and policymaking. A strong majority of respondents (82%) said nurses were very important to assuring the overall quality of health services, and 89% said the same about patient safety (Figure 3). Only about half of respondents indicated that they thought nurses were very important to improving patient access (50%) or to slowing the rate of growth of the costs of J
U L Y
/ A
U G U S T
N
U R S I N G
O
U T L O O K
177
Health policy thoughtleaders’ views of the health workforce in an era of health reform
Johnson Foundation) are both reported by R 70% of respondents as having a ‘‘great deal’’ of trust. Health policy journals and the Bureau of Health Professions have the trust of approximately half of respondents. Multiple nursing, medical, and hospital trade associations rank lowest on the list, with major newspapers and the American Medical Association least trusted by respondents. The American Association of Retired Persons (AARP) shows mixed support of respondents in its efforts to provide trusted information and analysis.
How important do you think nurses are to…? 89
Assuring safety Assuring overall quality
9 2
82
Assuring access
16
50
Slowing growth of health costs
36
46 0%
20%
40%
Very important Not very/not at all important
14
60%
2
13 1
39 80%
Donelan et al
1 100%
Somewhat important Don’t know
Roadblocks to Workforce Policymaking We asked respondents to reflect on the ‘‘major barriers to the passage of legislation that would fund increasing capacity of registered nurse education programs.’’ The overwhelming response from 86% of thoughtleaders indicated that ‘‘budget and cost’’ issues were major barriers. However, a majority also pointed to the priority of the issue and the effectiveness of advocates as barriers. One in 6 (16%) questioned the evidence of a shortage, and some indicated opposition from other groups or infighting among nursing groups. Finally, we asked thoughtleaders to rate the effectiveness of 10 groups in ‘‘putting forth solutions to nursing workforce shortages.’’ Few respondents assigned the rating of ‘‘very effective’’ to any of the 10 organizations or groups, the highest being 11% for foundations. Combining ‘‘very’’ and ‘‘somewhat’’ effective, foundations (72%), nursing professional organizations (61%), academic institutions (61%), and think tanks (59%) rated highest. Thirty-five percent rated nursing organizations as ‘‘not very’’ or ‘‘not at all’’ effective (Figure 5). Nurses were more likely than respondents with other nonnursing degrees to report that RN professional organizations were very or somewhat effective in proposing solutions to RN shortages (76% vs. 55%, P ¼ .05).
Figure 3. Thoughtleader Perceptions of the Importance of RNs in Health Service Delivery.
health care (46%). We then asked about the importance of nurses in the policy sphere in the current health reform debate, asking if nursing organizations were essential to the passage of health reform legislation. We compared the perception of the role of nurse versus physician organizations: 95% of respondents ‘‘strongly or somewhat’’ agreed (50% strongly) that physician organizations are important to the passage of reform while 79% said nurse organizations were important (37% strongly). To appraise public messages that thoughtleaders hear and read about the nursing workforce, respondents were asked about the frequency with which they heard from various sources and to assess the information and analysis provided by those sources. By a wide margin, thoughtleaders reported hearing frequently or often from nursing organizations (79%) more than any other source, including hospitals (59%), healthcare foundations (47%), the media (46%), universities (40%), federal agencies (31%), private industry (11%), and physician organizations (11%). Figure 4 shows data about the degree of trust held in several organizations that provide information about the RN workforce. The Institute of Medicine and Foundations (specifically noting the Kaiser Family Foundation and Robert Wood
DISCUSSION Although nursing achieved certain successes in the recent healthcare reform debate, including the inclusion
For each of the following, indicate to what degree you trust the information and analysis it provides about nurse workforce issues in the U.S. How effective are each of the following when it comes to putting forth solutions to nursing workforce shortages?
IOM Foundations
Foundations
H lth policy li journals l Health Bureau Health Professions
HHS
Nursing journals
RN professional organizations
AONE
Academics
AARP
Think tanks
ANA
Hospitals
Medical journals
State government C Congress
AHA
MD organizations
Major newspapers
Private Companies
AMA 0% A great deal
Some trust
20%
Little or no
40%
Don’t Know
60%
80%
0%
100%
Very effective
Source does not provide info on RNs
Figure 4. Trusted sournces of information and analysis about RN workforce. 178
V
O L U M E
5 8
N
U M B E R
4
N
U R S I N G
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Somewhat effective
Not very/not at all
Don't Know
Figure 5. Thoughtleader Perceptions of the Effectiveness of Organizations in Proposing Solutions to RN Shortages. O
U T L O O K
Health policy thoughtleaders’ views of the health workforce in an era of health reform
of substantial funding for nurse education, this data points to a critical gap in effective policy advocacy and leadership to move nurse workforce issues higher on the national health agenda. Thoughtleaders who responded to this survey are in clear agreement that nurses are critical to the quality and safety of our health delivery system, that there are current shortages of nurses, and that those shortages will be intensified by the passage of health reform. Thoughtleaders are also clear that while they do hear about nursing issues on a frequent basis, they do not view most sources of this information as proposing very effective policy solutions. While they thought nursing organization support was important to the passage of health reform, only 7% said these organizations were ‘‘very effective’’ in proposing solutions. With respect to trusted sources of information about the nursing workforce and organizations viewed as relatively effective in developing solutions, the Institute of Medicine (IOM) and healthcare foundations rated highest among thoughtleaders. These findings are prescient given that the Robert Wood Johnson Foundation is currently supporting an IOM Commission on the Future of Nursing. Thus, the high opinions of thoughtleaders about both the IOM and healthcare foundations should not be lost on the nursing profession and others who seek to increase the influence of nurses in health policy and to increase policy attention to the many issues that will face the nursing profession over the coming decade. Depending on the content of the IOM commission’s recommendations, the visibility they garner, and the health policy climate that prevails when the recommendations are made public, this IOM initiative could propel nursing issues higher on the national health policy agenda. Given the planned expansion of insurance coverage and increasing pressure to constrain federal health care expenditures, and to reform the delivery of care, it will be important to ensure the full productive potential of the nursing workforce. Conducted during a time when the healthcare reform debate was becoming increasingly contentious and the national economy was losing hundreds of thousands of jobs each month, it is not entirely unexpected that for most thoughtleaders, even for some nurses, the salience of nursing issues was relatively low. Thus, it is somewhat surprising that health workforce issues appear on the broad agenda for the leaders we surveyed. The nurses among our respondents place workforce issues high on organizational agendas in the coming years. While the current shortage of nurses appears as less important to our respondents than that of primary care physicians, greater concerns are seen about a future projected shortage. This also suggests that the importance of the nursing workforce is likely to be heightened if shortages escalate over time against a backdrop of expanded insurance coverage and increasing demand for nurses. The recently enacted legislation contains provi-
Donelan et al
sions calling for studies of health workforce needs, a new National Health Work Force Commission, increased funding of nursing education, grants for advanced nursing education, and funding for nursemanaged clinics and health centers. These are all steps in the right direction. What can nurses and nurse leadership do to exert greater influence on health policy in this time of change? The results of this and other surveys seem to point to public and thoughtleader perceptions that nurses are critical voices on issues of quality and safety in health care. The public trusts nurses’ honesty and integrity and values the profession, and that places nurses in a position to be a critical voice for the patient in the public sphere. Where are those voices of nurses in the public sphere? Are they heard in the media, in highly ranked research journals that are covered by the media, and on Capitol Hill? Nurses and nursing professional associations need well-honed messages and they need to master the tools of communication—news media, research publication, surveys, advertising; these are all ways of bringing the voices, value and importance of nursing to the public sphere. They are tools that are used far more often by the medical profession than the nursing profession. Foundations have played major roles in making visible the many issues involved in health reform—how much of that attention included nurses? How much of the funds devoted to research included research on nursing? How many nurses are publishing their research in highly visible journals and how many of those journals are making the nursing research visible to the media? The findings from this survey point to the expected report from the IOM as a window of opportunity to put nursing issues on the national agenda and the national stage. It will be critically important that nurses follow the release of that report with research, new strategies for change, and further inquiry. Few respondents to our survey see policy analysis about nursing as highly visible from any source—lessons must be drawn from those who have had success in these spheres as to how to make nursing research and practice more visible. National efforts such as the Campaign for Nursing’s Future, the IOM commission, the Robert Wood Johnson AARP initiative—these can all make nursing visible in the short run. Nursing needs a more coordinated strategic effort that puts the profession in the public eye as a valued and participating part of the leadership of the profession and the care team of the patient. Although national nursing associations have developed many alliances with organizations that care for and about patient safety and quality health care, going forward, it is time to develop new alliances with hospitals and physicians. Working together in clinical and policy settings will lessen the challenges that lie ahead as health reform measures are implemented and evaluated. J
U L Y
/ A
U G U S T
N
U R S I N G
O
U T L O O K
179
Health policy thoughtleaders’ views of the health workforce in an era of health reform This project was funded by an unrestricted grant from the Johnson & Johnson Campaign for Nursing’s Future to the Vanderbilt University School of Nursing. The authors gratefully acknowledge the advice of Dr. Paul Feldstein and Mr. John Iglehart in the development of our survey and survey sample, the support and assistance of SSRS in data collection (Dr. David Dutwin) and the assistance of Johanna Mailhot, MSc, in manuscript preparation.
4. Gallup Organization. Honesty/ethics in professions: poll conducted 11/20/07–11/22/09. Available at: http://www. gallup.com/poll/124625/honesty-ethics-poll-finds-congressimage-tarnished.aspx. Accessed on June 2, 2010. 5. Harris Interactive. The Harris Poll #37, May 10, 2006: doctors, dentists and nurses most trusted professional to give advice. Harris Interactive; 2006 Available at: http://www. harrisinteractive.com/harris_poll/index.asp?PID¼661. Accessed on April 24, 2008. 6. Tai-Seale M, Pescosolido B. The public’s opinions of physicians: Do perceived choice and exercised choice matter? Am J Manag Care 2003;9:631-8. 7. Harris Interactive. The Harris Poll #77, August 1, 2007: firefighters, scientists and teachers top list as ‘‘most prestigious occupations’’. Harris Interactive; 2007 Available at: http:// www.harrisinteractive.com/harris_poll/index.asp?PID¼793. Accessed on April 24, 2008. 8. Buerhaus PI, Auerbach DI, Staiger DO. The recent surge in nurse employment: Causes and implications. Health Aff 2009;28:657-68. 9. Buerhaus PI, Donelan K, Ulrich BT, Norman L, DesRoches C, Dittus R. Impact of the nurse shortage on hospital patient care: Comparative perspectives. Health Aff 2007;26:853-62.
REFERENCES 1. Health Resources and Services Administration, U.S. Department of Health and Human Services. The Registered Nurse Population: Initial Findings from the 2008 National Sample Survey of Registered Nurses, March 2010. Available at: http://bhpr.hrsa.gov/healthworkforce/rnsurvey/initialfindings 2008.pdf. Accessed on June 2, 2010. 2. Donelan K, Buerhaus P, DesRoches C, Dittus R, Dutwin D. Public perceptions of nursing careers: The influence of the media and nursing shortages. Nurs Econ 2008;26:143-50. 3. Balkrishnan R, Dugan E, Camacho F, Hall M. Trust and satisfaction with physicians, insurers, and the medical profession. Medical Care 2003;41:1058-64.
180
V
O L U M E
5 8
N
U M B E R
4
N
U R S I N G
Donelan et al
O
U T L O O K
Although registered nurses rank similarly with physicians in the public’s esteem, physicians are more visible than nurses in media coverage, public policy, and political spheres. Thus, nursing workforce issues are overshadowed by those of other health priorities, including Medicare and health reform. The purpose of this research was to understand the visibility and salience of the health workforce in general, gain an understanding about the effectiveness of messages concerning the nursing workforce in particular, and to understand why nursing workforce issues do not appear to have gained more traction in national health care policymaking. The National Survey of Thoughtleaders about the Health Workforce was administered via mail, telephone and online to health workforce and policy thoughtleaders from August 2009-October 2009. Of 301 thoughtleaders contacted, 123 completed questionnaires for a response rate of 41%. Thoughtleaders agree that nurses are critical to the quality and safety of our healthcare system, that there are current nursing shortages, and that nursing shortages will be intensified by health reform. Thoughtleaders reported that while they do hear about
Karen Donelan, ScD, is Senior Scientist in Health Policy at Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, MA. Peter I. Buerhaus, PhD, RN, FAAN, is Valere Potter Professor of Nursing, Director Center for Interdisciplinary Health Workforce Studies, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN. Catherine DesRoches, DrPH, is Assistant Professor of Medicine, Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, MA. Sheila P. Burke, RN, MPA, FAAN, is Faculty Research Fellow and Adjunct Lecturer, John F. Kennedy School of Government, Harvard University, Cambridge, MA. Corresponding author: Dr. Karen Donelan, Massachusetts General Hospital, Mongan Institute for Health Policy, 50 Staniford Street, 9th Floor, Boston, MA 02114. E-mail: [email protected] Nurs Outlook 2010;58:175-180. 0029-6554/$ - see front matter ª 2010 Mosby, Inc. All rights reserved. doi:10.1016/j.outlook.2010.06.003
nursing issues frequently, they do not view most sources of information as proposing effective policy solutions. This study highlights a critical gap in effective policy advocacy and leadership to advance nurse workforce issues higher on the national health agenda.
A
n estimated 3.1 million registered nurses are employed throughout the United States healthcare system, more than 3 times the number of active physicians.1 For decades, public opinion surveys have documented that registered nurses rank similarly with doctors in the public’s esteem, including measures of honesty, ethical standards, trust, and as a desirable and respected profession.2-7 Yet there is little question that physicians are far more visible in media coverage and in public policy and political spheres than are nurses. A LexisNexis search for major stories in major US newspapers conducted in January 2010 using the search terms ‘‘nurses’’ and ‘‘health reform’’ revealed 278 major stories during the past 6 months. In contrast, using the terms ‘‘physicians’’ and ‘‘health reform’’ yielded 753 major stories in the same time period. Searches using the terms ‘‘doctors’’ and ‘‘health reform’’ yielded 107 major stories in the past month alone, and more than 1000 in the past 6 months. While a few television advertisements and White House press conferences mentioned nurses in the recent and continuing health reform debate, attention to the care delivery roles of nurses (namely, the increased use of nurse practitioners to provide primary care) and the profession’s attempts to influence the shape of the health reform debate have been largely overshadowed by media coverage of Medicare physician payment, possible cuts in Medicare payment to hospitals, and other issues associated with health reform. A large shortage of nurses is projected to develop during the next decade.8 Since 2004, it has been widely recognized that the constrained capacity of nursing education programs is a major stumbling block to J
U L Y
/ A
U G U S T
N
U R S I N G
O
U T L O O K
175
Health policy thoughtleaders’ views of the health workforce in an era of health reform
and followed by telephone. During the study period, 123 thoughtleaders completed the survey for a 41% response rate. No monetary incentives were offered or provided to respondents. Differences in the demographics of respondents and non-respondents could not be analyzed due to our having only basic contact and job title information in our sample. The major goal of this research was to understand the visibility and salience of the health workforce in general, gain an understanding about the effectiveness of messages concerning the nursing workforce in particular, and to understand why nursing workforce issues do not appear to have gained more traction in national health care policymaking. Survey items included: national and health policy priorities, the role of nurse workforce issues in those priorities, perceptions of and sources of information about health workforce supply, trust in sources of information, and the most effective ways for nursing workforce issues to gain traction among policymakers. The questionnaire was developed by the researchers and a team of national advisors expert in health policy making, journalism and health services research. Several questions were taken from other national surveys of the public or key stakeholders. The survey instrument had 17 questions (62 items) and took approximately 10 minutes to complete depending on mode of administration. The questionnaire will be made available by the corresponding author upon request. Due to the comparatively small sample size in this study, most analyses reported are descriptive in nature. Bivariate comparisons of respondents with nursing degrees (n ¼ 37) to those with other advanced degrees (n ¼ 82) were made using 2-tailed z-tests. We report the results of significant differences by professional degree in the text where appropriate.
achieving an adequately sized nursing workforce to meet increasing demands.9 Recently enacted expansions of health insurance coverage in the United States are likely to increase the demand for health care and hence the demand for healthcare professionals, particularly registered nurses and physicians. The new legislation does include provisions to expand the capacity of nursing education programs to begin to close the gap in the supply of nurses. Still, debates and discussion continue about the best approaches to educate nurses for current and future roles in acute and long-term care, as well for meeting the future demand for primary care providers. As the healthcare reform debate was underway in the United States, we asked how effectively issues of concern to the nursing profession were being communicated to those who were shaping the nation’s health policy agenda. In the latter half of 2009, we conducted a survey of key health care and health workforce thoughtleaders to understand the relative positioning of nursing workforce issues amidst other key health priorities. Developing a sample from several publicly available sources, we posed questions about federal health policy priorities, health workforce supply, sources of information dissemination, effective advocacy about nursing workforce issues, and barriers to legislative progress.
SURVEY DATA AND METHODS The National Survey of Thoughtleaders about the health workforce was administered by mail, telephone, and online to a sample of health workforce and policy thoughtleaders during the period from August 2009October 2009. The survey was administered by Social Science Research Solutions (SSRS) for the Johnson & Johnson Campaign for Nursing’s Future, an 8-year philanthropic effort to promote the nursing profession, increase nurse recruitment and retention, and address problems in the capacity of nursing education programs in an effort to avert the projected long-term national shortage of Registered Nurses (RNs). De-identified data were provided to the research team for analysis in order to protect the privacy of individual respondents. ‘‘Thoughtleaders’’ were defined as leadership representatives of key stakeholder groups on health workforce policy. The sampling frame was constructed using nationally published lists of influential leaders in health care organizations (hospitals, medical, and nursing schools, health plans, trade, and membership organizations), Washington ‘‘think tank’’ organizations, foundations concerned with health care, health workforce policy agencies, academia, health workforce experts within research organizations, and authors who have published about health workforce supply. Initial contact with a sample of 301 was attempted by mail, then by mail or email (if address was publicly available), 176
V
O L U M E
5 8
N
U M B E R
4
N
U R S I N G
Donelan et al
STUDY RESULTS More females (57%) than males (43%) completed the survey, and nearly 9 in 10 were > 50 years of age (33% > 65 and 55% aged 50-64). We did not measure significant differences in response by age or gender. Half of respondents worked in academic settings while the other half was divided among hospitals, professional or trade organizations, foundations, and other settings. Virtually all respondents had multiple postgraduate professional degrees; 15% were Medical Doctors (MDs) and 30% had at least one nursing degree (21% had nursing degrees at the masters and/or doctoral level) though many of those had gone on to pursue graduate degrees outside of nursing. Overall, experience with political activity and legislative matters included 21% who had served as a legislative aide, 21% as a lobbyist, 36% as healthcare campaign advisor and 14% as a candidate for state or federal office. Roughly 1 in 10 of respondents (8%) worked in government positions at the time of the survey. O
U T L O O K
Health policy thoughtleaders’ views of the health workforce in an era of health reform
Health Workforce Supply in an Era of Health Reform Respondents were asked to describe, in their own words, the top 2 most important issues for this Congressional term, along with the 2 most important health policy issues for their organizations to address in the next 2 years. By a wide margin, respondents identified health reform (91%) and issues associated with insurance coverage and health care costs as the 2 most important issues for Congress, dominating the economy (47%) and foreign policy (15%). When asked to constrain their responses to health issues for their organization to address, priorities were divided among a range of insurance coverage (35%), health costs (23%), workforce (25%), and quality of care (20%). Nurses were significantly more likely than other respondents (including physicians and respondents with other non-nursing higher degrees) to indicate that the issue of workforce was one of the 2 most important health issues for their organization to address (51% nurses vs. 11% other respondents, P < .001). Respondents were asked their perceptions of the current adequacy of the supply of nurses, primary care physicians, medical specialists, and surgical specialist physicians. Nearly all respondents (94%) indicated that the nation has a very or somewhat serious shortage of primary care physicians, and 92% reported a very or somewhat serious shortage of nurses (Figure 1). One third or fewer respondents reported shortages of both medical and surgical specialists. A similar proportion of nurses and respondents with other non-nursing degrees say that that there was a very serious or somewhat serious shortage of registered nurses in the United States (97% vs. 88%, P ¼ .189). When asked if there would be a sufficient supply of physician and nurses if universal health insurance coverage were enacted, only 10% and 13% of thoughtleaders, respectively, agreed there were sufficient numbers of primary care physicians and nurses to care for patients if universal coverage was provided. To gauge the relative importance of the ‘‘predicted future shortage of nurses,’’ respondents were asked to rate Do you think there is currently a shortage of each of the following in the US? Primary Care Physicians
66
R i t d Registered Nurses
28
46
Surgical specialist MDs
25
8
Medical 2 specialist MDs 0%
Very serious
46
20%
5 3
59
8
65
26 40%
Somewhat serious
60%
No shortage
42
7 80%
100%
Don’t know
Figure 1. Thoughtleader Perceptions of Current Health Workforce Shortages, 2009.
Donelan et al
Considering the many health policy issues our nation has to address in the next 2 years, how would you rank the importance of the predicted future shortage of nurses relative to each of the following? Health fraud and abuse
49
Bioterrorism
43
37
Primary Care MD shortage
27
Rising health costs
12
Solvency of Medicare
12 0%
21
48
36
42
46
51 20%
Shortage is more important Less important
2
16
57
16
Uninsured
71
40
37
40%
60%
80%
100%
Neither more nor less Don't know
Figure 2. Thoughtleader Perceptions of the Relative Importance of Predicted RN Shortages, 2009.
the importance of the predicted future shortage in comparison with 6 other issues using a response scale of ‘‘nursing issue is more important,’’ ‘‘neither more nor less important,’’ ‘‘nursing issue less important’’ (Figure 2). Overall, looking at the data one way, the projected nursing shortage was seen by a majority of respondents as being more important than—or neither more nor less important than—each issue we inquired about, including health fraud and abuse, bioterrorism, primary care physician shortages, solvency of Medicare, rising health care costs, and number of Americans without health insurance. Focusing solely on the ‘‘more important,’’ nearly half of respondents thought the predicted shortage was more important than health fraud and abuse. Forty-six percent of respondents thought the predicted shortage was less important than the number of Americans without health insurance. Nurses were more likely than respondents with other non-nursing higher degrees to think that the predicted shortage of nurses was more important than the predicted shortage of primary care MDs (51% vs. 17%, P < .001), and rising health costs (35% vs. 9%, P ¼.001). There were no significant differences in the proportions of nurses and other respondents who thought that the RN shortage was more important than the threat of bioterrorism, the solvency of Medicare, the number of Americans without health insurance or healthcare fraud and abuse.
Do Nurses Matter? Importance of Nurses in Health Care Delivery and Health Reform Policymaking Respondents were asked about their perceptions of the importance of nurses on several dimensions of health care delivery and policymaking. A strong majority of respondents (82%) said nurses were very important to assuring the overall quality of health services, and 89% said the same about patient safety (Figure 3). Only about half of respondents indicated that they thought nurses were very important to improving patient access (50%) or to slowing the rate of growth of the costs of J
U L Y
/ A
U G U S T
N
U R S I N G
O
U T L O O K
177
Health policy thoughtleaders’ views of the health workforce in an era of health reform
Johnson Foundation) are both reported by R 70% of respondents as having a ‘‘great deal’’ of trust. Health policy journals and the Bureau of Health Professions have the trust of approximately half of respondents. Multiple nursing, medical, and hospital trade associations rank lowest on the list, with major newspapers and the American Medical Association least trusted by respondents. The American Association of Retired Persons (AARP) shows mixed support of respondents in its efforts to provide trusted information and analysis.
How important do you think nurses are to…? 89
Assuring safety Assuring overall quality
9 2
82
Assuring access
16
50
Slowing growth of health costs
36
46 0%
20%
40%
Very important Not very/not at all important
14
60%
2
13 1
39 80%
Donelan et al
1 100%
Somewhat important Don’t know
Roadblocks to Workforce Policymaking We asked respondents to reflect on the ‘‘major barriers to the passage of legislation that would fund increasing capacity of registered nurse education programs.’’ The overwhelming response from 86% of thoughtleaders indicated that ‘‘budget and cost’’ issues were major barriers. However, a majority also pointed to the priority of the issue and the effectiveness of advocates as barriers. One in 6 (16%) questioned the evidence of a shortage, and some indicated opposition from other groups or infighting among nursing groups. Finally, we asked thoughtleaders to rate the effectiveness of 10 groups in ‘‘putting forth solutions to nursing workforce shortages.’’ Few respondents assigned the rating of ‘‘very effective’’ to any of the 10 organizations or groups, the highest being 11% for foundations. Combining ‘‘very’’ and ‘‘somewhat’’ effective, foundations (72%), nursing professional organizations (61%), academic institutions (61%), and think tanks (59%) rated highest. Thirty-five percent rated nursing organizations as ‘‘not very’’ or ‘‘not at all’’ effective (Figure 5). Nurses were more likely than respondents with other nonnursing degrees to report that RN professional organizations were very or somewhat effective in proposing solutions to RN shortages (76% vs. 55%, P ¼ .05).
Figure 3. Thoughtleader Perceptions of the Importance of RNs in Health Service Delivery.
health care (46%). We then asked about the importance of nurses in the policy sphere in the current health reform debate, asking if nursing organizations were essential to the passage of health reform legislation. We compared the perception of the role of nurse versus physician organizations: 95% of respondents ‘‘strongly or somewhat’’ agreed (50% strongly) that physician organizations are important to the passage of reform while 79% said nurse organizations were important (37% strongly). To appraise public messages that thoughtleaders hear and read about the nursing workforce, respondents were asked about the frequency with which they heard from various sources and to assess the information and analysis provided by those sources. By a wide margin, thoughtleaders reported hearing frequently or often from nursing organizations (79%) more than any other source, including hospitals (59%), healthcare foundations (47%), the media (46%), universities (40%), federal agencies (31%), private industry (11%), and physician organizations (11%). Figure 4 shows data about the degree of trust held in several organizations that provide information about the RN workforce. The Institute of Medicine and Foundations (specifically noting the Kaiser Family Foundation and Robert Wood
DISCUSSION Although nursing achieved certain successes in the recent healthcare reform debate, including the inclusion
For each of the following, indicate to what degree you trust the information and analysis it provides about nurse workforce issues in the U.S. How effective are each of the following when it comes to putting forth solutions to nursing workforce shortages?
IOM Foundations
Foundations
H lth policy li journals l Health Bureau Health Professions
HHS
Nursing journals
RN professional organizations
AONE
Academics
AARP
Think tanks
ANA
Hospitals
Medical journals
State government C Congress
AHA
MD organizations
Major newspapers
Private Companies
AMA 0% A great deal
Some trust
20%
Little or no
40%
Don’t Know
60%
80%
0%
100%
Very effective
Source does not provide info on RNs
Figure 4. Trusted sournces of information and analysis about RN workforce. 178
V
O L U M E
5 8
N
U M B E R
4
N
U R S I N G
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Somewhat effective
Not very/not at all
Don't Know
Figure 5. Thoughtleader Perceptions of the Effectiveness of Organizations in Proposing Solutions to RN Shortages. O
U T L O O K
Health policy thoughtleaders’ views of the health workforce in an era of health reform
of substantial funding for nurse education, this data points to a critical gap in effective policy advocacy and leadership to move nurse workforce issues higher on the national health agenda. Thoughtleaders who responded to this survey are in clear agreement that nurses are critical to the quality and safety of our health delivery system, that there are current shortages of nurses, and that those shortages will be intensified by the passage of health reform. Thoughtleaders are also clear that while they do hear about nursing issues on a frequent basis, they do not view most sources of this information as proposing very effective policy solutions. While they thought nursing organization support was important to the passage of health reform, only 7% said these organizations were ‘‘very effective’’ in proposing solutions. With respect to trusted sources of information about the nursing workforce and organizations viewed as relatively effective in developing solutions, the Institute of Medicine (IOM) and healthcare foundations rated highest among thoughtleaders. These findings are prescient given that the Robert Wood Johnson Foundation is currently supporting an IOM Commission on the Future of Nursing. Thus, the high opinions of thoughtleaders about both the IOM and healthcare foundations should not be lost on the nursing profession and others who seek to increase the influence of nurses in health policy and to increase policy attention to the many issues that will face the nursing profession over the coming decade. Depending on the content of the IOM commission’s recommendations, the visibility they garner, and the health policy climate that prevails when the recommendations are made public, this IOM initiative could propel nursing issues higher on the national health policy agenda. Given the planned expansion of insurance coverage and increasing pressure to constrain federal health care expenditures, and to reform the delivery of care, it will be important to ensure the full productive potential of the nursing workforce. Conducted during a time when the healthcare reform debate was becoming increasingly contentious and the national economy was losing hundreds of thousands of jobs each month, it is not entirely unexpected that for most thoughtleaders, even for some nurses, the salience of nursing issues was relatively low. Thus, it is somewhat surprising that health workforce issues appear on the broad agenda for the leaders we surveyed. The nurses among our respondents place workforce issues high on organizational agendas in the coming years. While the current shortage of nurses appears as less important to our respondents than that of primary care physicians, greater concerns are seen about a future projected shortage. This also suggests that the importance of the nursing workforce is likely to be heightened if shortages escalate over time against a backdrop of expanded insurance coverage and increasing demand for nurses. The recently enacted legislation contains provi-
Donelan et al
sions calling for studies of health workforce needs, a new National Health Work Force Commission, increased funding of nursing education, grants for advanced nursing education, and funding for nursemanaged clinics and health centers. These are all steps in the right direction. What can nurses and nurse leadership do to exert greater influence on health policy in this time of change? The results of this and other surveys seem to point to public and thoughtleader perceptions that nurses are critical voices on issues of quality and safety in health care. The public trusts nurses’ honesty and integrity and values the profession, and that places nurses in a position to be a critical voice for the patient in the public sphere. Where are those voices of nurses in the public sphere? Are they heard in the media, in highly ranked research journals that are covered by the media, and on Capitol Hill? Nurses and nursing professional associations need well-honed messages and they need to master the tools of communication—news media, research publication, surveys, advertising; these are all ways of bringing the voices, value and importance of nursing to the public sphere. They are tools that are used far more often by the medical profession than the nursing profession. Foundations have played major roles in making visible the many issues involved in health reform—how much of that attention included nurses? How much of the funds devoted to research included research on nursing? How many nurses are publishing their research in highly visible journals and how many of those journals are making the nursing research visible to the media? The findings from this survey point to the expected report from the IOM as a window of opportunity to put nursing issues on the national agenda and the national stage. It will be critically important that nurses follow the release of that report with research, new strategies for change, and further inquiry. Few respondents to our survey see policy analysis about nursing as highly visible from any source—lessons must be drawn from those who have had success in these spheres as to how to make nursing research and practice more visible. National efforts such as the Campaign for Nursing’s Future, the IOM commission, the Robert Wood Johnson AARP initiative—these can all make nursing visible in the short run. Nursing needs a more coordinated strategic effort that puts the profession in the public eye as a valued and participating part of the leadership of the profession and the care team of the patient. Although national nursing associations have developed many alliances with organizations that care for and about patient safety and quality health care, going forward, it is time to develop new alliances with hospitals and physicians. Working together in clinical and policy settings will lessen the challenges that lie ahead as health reform measures are implemented and evaluated. J
U L Y
/ A
U G U S T
N
U R S I N G
O
U T L O O K
179
Health policy thoughtleaders’ views of the health workforce in an era of health reform This project was funded by an unrestricted grant from the Johnson & Johnson Campaign for Nursing’s Future to the Vanderbilt University School of Nursing. The authors gratefully acknowledge the advice of Dr. Paul Feldstein and Mr. John Iglehart in the development of our survey and survey sample, the support and assistance of SSRS in data collection (Dr. David Dutwin) and the assistance of Johanna Mailhot, MSc, in manuscript preparation.
4. Gallup Organization. Honesty/ethics in professions: poll conducted 11/20/07–11/22/09. Available at: http://www. gallup.com/poll/124625/honesty-ethics-poll-finds-congressimage-tarnished.aspx. Accessed on June 2, 2010. 5. Harris Interactive. The Harris Poll #37, May 10, 2006: doctors, dentists and nurses most trusted professional to give advice. Harris Interactive; 2006 Available at: http://www. harrisinteractive.com/harris_poll/index.asp?PID¼661. Accessed on April 24, 2008. 6. Tai-Seale M, Pescosolido B. The public’s opinions of physicians: Do perceived choice and exercised choice matter? Am J Manag Care 2003;9:631-8. 7. Harris Interactive. The Harris Poll #77, August 1, 2007: firefighters, scientists and teachers top list as ‘‘most prestigious occupations’’. Harris Interactive; 2007 Available at: http:// www.harrisinteractive.com/harris_poll/index.asp?PID¼793. Accessed on April 24, 2008. 8. Buerhaus PI, Auerbach DI, Staiger DO. The recent surge in nurse employment: Causes and implications. Health Aff 2009;28:657-68. 9. Buerhaus PI, Donelan K, Ulrich BT, Norman L, DesRoches C, Dittus R. Impact of the nurse shortage on hospital patient care: Comparative perspectives. Health Aff 2007;26:853-62.
REFERENCES 1. Health Resources and Services Administration, U.S. Department of Health and Human Services. The Registered Nurse Population: Initial Findings from the 2008 National Sample Survey of Registered Nurses, March 2010. Available at: http://bhpr.hrsa.gov/healthworkforce/rnsurvey/initialfindings 2008.pdf. Accessed on June 2, 2010. 2. Donelan K, Buerhaus P, DesRoches C, Dittus R, Dutwin D. Public perceptions of nursing careers: The influence of the media and nursing shortages. Nurs Econ 2008;26:143-50. 3. Balkrishnan R, Dugan E, Camacho F, Hall M. Trust and satisfaction with physicians, insurers, and the medical profession. Medical Care 2003;41:1058-64.
180
V
O L U M E
5 8
N
U M B E R
4
N
U R S I N G
Donelan et al
O
U T L O O K