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Nursing in the 21st century: An introduction
C O N F E R E N C E RR©CEED
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Nursing in the 21st Century: An Introduction CLEMENT BEZOLD,
PHD,* AND
HAT WILL THE typical nurse do in the year 20107 How many nurses will there be? Where will they work? What ate the major forces likely to shape the future of nursing? What are the future implications of current choices for nurses and nursing organizations? These are among the questions addressed by the July 1985 conference on Nursing in the 21st Century. This background paper focuses on some of the existing forecasts for nursing and health care and provides a common frame of reference for the authors of the five papers prepared for the conference. The use of a conference to explore the future of nursing has a long and rich tradition. Since at least the 1930s in the United States, conferences have been held for this purpose.~ This 1985 conference on Nursing in the 21st Century goes beyond past conferences in two ways. First, some of the more systematic approaches to thinking about the future developed in the field of futures studies were utilized, reaching out further than most such efforts and considering a wider set of concerns. Second, the conference did not seek to set goals for the nursing profession. Rather, it allowed participants to explore the future of nursing in light of a host of potential changes in the health care system that pose both threats and opportunities for nursing. Participants at the conference have developed their image of optimal ap-
W
* Executive Director, Institute for Alternative Futures, Alexandria, Virginia. t Consultant and Author, Old Snowmass, Colorado. Presented at the AACN/AONE conference on Nursing in the 21st Century. Aspen, Colorado, .July 9-11, 1985. The opinions expressed herein are those of the authors, and do not necessarily reflect those of the AACN or AONE. Address correspondence and reprint requests to Dr. Bezold: Executive Director, Institute for Alternative Futures, 1405 King Street, Alexandria, VA 22314.
RICK CARLSON,
JD~
proaches for nursing and set goals in the context of forecasts made by futurists and leading thinkers in health care. The major benefit of a conference such as this is to infuse that goal setting with imagination and creativity. The remainder of this paper will summarize some of the major U.S. government forecasts for nursing; review alternative forecasts for nursing personnel, aspects of nursing and other segments of the health care system; and develop the questions that were addressed at the conference. The Official Future DEMAND FOR NURSES
In most fields of business or government work there are plans based on certain forecasts. These forecasts typically have been a single projection of past experience (generally growth) into the future. History is used as the basis for forecasting the future. History is not a bad place to start, but things can and do change, and in the 1980s health care is changing with surprising rapidity. A relevant question asked, therefore, is "What is the official future for nursing?" There are several government forecasts for nursing. The major set of forecasts is developed by the Bureau of Health Professions in the Department of Health and Human Services every other year for the President and Congress. The most recent, delivered in May 1984, sets out a range of forecasts for the supply and demand for nurses. The general growth trend among all of the major forecasts for registered nurses is shown in Figure 1. The supply and requirements for nurses are compared in Table 1. The supply forecast assumes that the age group activity rates for nurses in November 1980 remain constant. The demand or requirements
NURSING IN T H E 21ST CENTURY: INTRODUCTION
BEZOLD A N D CARLSON
3
2,200,000
03
z
2,000,000
.>
1,800,000
hE _o Clr O O
E -L
,k
--
. .. ~
..............
-II-A -AIt.-III -II-B
..... • 1,600,000
--
1,400,000
--
~,
.............
...!~
~
- I-A "AIt.-II
"6 .IQ
E "'1 7 1,200,000
--- S
1,000,000
__
I 1980
v,....~.~;.::.;:.~.,;,.-AIt.oll Historical Trend-Based Req.-Alternative I ,.o,...~..,. . . . . . . . . . AIt.-III Historical Trend-Based Req.-Alternative II -"-':"" •...... I-A Supply Projection Assumption I-A ..... I-B Supply Projection Assumption I-B ~ II-A Supply Projection Assumption II-A . . . . . . II-B Supply Projection Assumption II-B Criteria Based Lower Bound Req. for 1990 and 2000
I 1982
I
I 1984
I
I 1986
I
I 1988
I
I 1990
I
I 1992
I
I 1994
I
I 1996
I
I 1998
I 2000
Year
Figure I. Forecasted trends in the requirement for and supply of registered nurses through the year 2000, Source: Department of Health and Human Services: Status of Health Personnel in the U.S., Vol. 1, C-2-9, May 1984.
forecast assumes that RN utilization rates grow at a decreasing rate until 1990; thereafter, there is no increase. Also, the forecasts such as those shown in Figure 1 and Table 1 are often based on data and assumptions made some years earlier. The Department of Health and Human Services (DHHS) has updated the figures shown in Table 1, but will not release these figures until 1986. Thus, using what was available at the time of the conference, the supply of nurses is predicted to grow to 1,986,400 and the supply of nursing full-time equivalents to 1,675,800 in the year 2000 as shown in Table 1. During the same period the demand or requirement for nurses will grow to 1,768,060. The 1984 DHHS report contained another estimate of potential demand, this one called the "criteria-based" model. Criteria for adequate nursing staff by location and type of service were developed. This model suggests a much higher requirement for nurses in 1990 and 2000 than the historical trend model. The two stars above the trend line in Figure I represent the estimate of demand for nurses if all care facilities were staffed adequately, based
on the criteria developed by a 1980 expert panel. These 1980 criteria were updated and, except for nursing skill levels in nursing homes, were generally increased in 1984. SUPPLY OF NURSES
In terms of supply the number of registered nurses is forecast by the 1984 DHHS Report to t/se President and Congress on Healtb Care Personnel to grow to between 1.85 million and 2.16 million by the year 2000.2 This variation is due to different assumptions about the entering rate for new students and the activity level of nurses (the percentage actually seeking nursing work). Series 1A assumes a 75 per cent activity level with a growing number of students. Series 1B assumes a 75 per cent activity level with no growth in new students. Series 2A assumes a 78 per cent activity level with a growing number of students. Series 2B assumes a 78 per cent activity level with no growth in new students. This range is identified in Table 2 by type of nursing education program. The supply of nursing personnel is based on the
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JOURNAL OF PROFESSIONAL NURSING
TABLE 1.
Projections of National Active Supply of Registered Nurses and Requirements for Registered Nurses, 1980-2000 Supply
Year
1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Total Number of Nurses
1.272.900 1,317.800 1,362,300 1,410,200 1,457,700 1,507,400 1,551,900 1,593,600 1,636,200 1,675,300 1,713,800 1,745,900 1,776,200 1,807,900 1,838,300 1,868,600 1,892,600 1,915,200 1.938.300 1,961.800 1,986.400
Full-time Equivalents (FTE)
1,068,000 1,t05.000 1,140,700 1,179,600 1,218,700 1,260,000 1,297,000 1,332,100 1,367,500 1,400,500 1,432,800 1,460,200 1,486,600 1,514,400 1,541,500 1,568,200 1,589,900 1,610,900 1,631,900 1,653,600 1,675,800
TABLE 2.
JANUARY-FEBRUARY1986
Nursing Supply Forecasts for 1990 and 2000
Requirements Total FrEs Nurses p e r per 1 0 0 , 0 0 0 100,000 Population Population
560 572 586 601 615 629 641 653 665 675 685 692 698 706 712 719 724 728 732 736 740
470 480 490 502 514 526 536 545 555 564 572 578 584 591 597 603 608 612 616 620 624
Number of Nurse FTEs Required
1,068,000 1.126,270 1,180,380 1.232,730 1,281,310 1,329,140 1,374,420 1,414,450 1,448,980 1,480,060 1,507,990 1,532,660 1,557,050 1,581,580 1,606,900 1,632,750 1,658,330 1,685,160 1.712.320 1.740,010 1,768,060
Source: Departmentof Healthand HumanServices(DHHS): Status of Health Personnel in the United States, Vol. 2, Supply, Series 1-A Table C-12; Requirements,AlternativeIII, Table C-21.
existing stock of potential nursing workers: the number of new graduates or entrants into the field, including immigrants, and the labor force participation rates. In considering the variables affecting new entrants, the Institute of Medicine (IOM) report identified five major factors. 1. Availability of educational opportunities; 2. Costs of education; 3. Level of public and private support for the financing of nursing education; 4. The relative attractiveness of nursing as a career in terms of job satisfaction and economic incentives; 5. Immigration laws and regulations that influence inflows of foreign graduates.3 Labor force participation, IOM argues, is influenced by: 1. General conditions of the nation's economy; 2. Compensation rates; 3. Other factors, including improved career opportunities, better working conditions, child care benefits, flexible scheduling, fringe benefits, reentry education opportunities.3
1980 °
RNs per 100,000 population Total Associate/Diploma Baccalaureateand Higher Baccalaureate Master's/Doctorate Unknown
NO.
o~
1,272,900 901,700 364,400
100.0 70.8 28.6
6,800
.5
RNs per 100,000 population Total Associate/Diploma Baccalaureateand Higher Baccalaureate Master's/Doctorate
In thinking about the future, this conference focused primarily on factors within the health care system. The papers identify many of the larger forces, such as reorganization of the health care delivery system, that will in turn affect nurses' compensation rates and working conditions. An Alternative to the Official Future
The above forecasts provide the best thinking of the federal government on the most likely future. Other approaches use expert judgment, often from a single expert. The health care personnel forecasts of Eli Ginzberg are relevant examples, particularly his forecasts for nursing in 19814 and for health care personnel in 1984.~ These forecasts provide one comparative approach to speculation about the future of nursing. In 1981, Ginzberg argued that hospitals and nursing homes that employed four out of five nurses were prime sources of data. Yet these institutions were likely to face increasingly difficult times in the 1980s, including a shrinking number of hospital beds. This would affect the traditional goals within the nursing community of increasing the percentage of baccalaureate and higher degree nurses, providing greater income, and giving nurses more authority. Ginzberg argued that the goal of a substantial increase in the number of baccalaureate level nurses is unlikely to be realized in the years ahead because hosp!tals are not seeking substantially more baccalaureate level nurses, there is a levelling or declining of nursing students, and educational costs are rising. Also, he speculated that the goal of greater responsibilities for nurse practitioners will be diffi-
BEZOLD AND CARLSON *
NURSING IN THE 21ST CENTURY; INTRODUCTION
5
1990 HHS Forecasts"1:
IOM Intermediate Forecast1"
No. 1,710,000 1,089,000 621,000
% 100.0 63.7 36.3
Series IA
NO: 685 1,713,800 1,146,300 567,500 443,700 123,800
SeriesIB
%
NO.
100.0 66.9 33.1 25.9 7.2
661 1,654,100 1,083,500 570,700 446,900 123,800
100.0 62.1 37.9 27.1 10.8
688 1,847,300 1,088,200 759,100 544,800 214.300
SeriesIIA
%
No.
100.0 65.5 34.5 27.0 7.5
738 1,846,800 1,245,700 601,100 471,200 129,900
100.0 58.9 41.1 29.5 11.6
8O6 2,164,200 1,356,100 808,100 582,500 225,600
Serieslib
%
No.
%
100.0 67.5 32.5 25.5 7.0
713 1,784,200 1,178,900 605,300 475,400 129,900
100.0 66.1 33.9 26.6 7.3
100.0 62.7 37.3 26.9 10.4
751 2,015,400 1,197,500 817,800 592,300 225,500
100.0 59.4 40.6 29.4 11.2
2000
74O 1,986,400 1,233,900 752,400 538,000 214,400
Sources: * Registered Nurses per 100,000 population from Status of Health Personnel, Vol. 2, pp. C-12, C-13; t Nursing and Nursing Education, Division of Health Care Services, Institute of Medicine, Washington, D.C., National Academy Press, 1983, p 77; and t Status of Health Personnel in the United States, U.S. Department of Health and Human Services, DHHS Publication No. HRS-P-OD 84-4, Washington, D.C., GPO, May 1984.
cult to realize due to the growing surplus of physicians concerned about declines in income and increased lobbying pressure from state medical societies. Governments may be reluctant to agree to reimburse nurse practitioners despite a "considerable and growing n u m b e r of studies (which) have concluded that nurse practitioners do as well and sometimes better than physicians in providing first encounter care; that they tend to elicit a positive response from patients they serve; and that they are generally cost-effective.''4 However, Ginzberg notes that Health Maintenance Organizations (HMOs) may be the place where nurse practitioner cost-effectiveness will be appreciated. Ginzberg notes that the progress for professional emancipation for nurses "has been slow because of the difficulties they have experienced in defining their area of expertise, in differentiating who among the 2.5 million individuals engaged in nursing and nursing support services are to be treated as professionals; '4 and a host of other factors. By 1984, Ginzberg's forecasts were more focused but still in the same direction. For the hospital sector, he forecast "hospital-based employment to decline over the rest of the century. This will affect lower level hospital workers such as LPNs, aides and orderlies and technicians, more acutely than higher level workers, such as physicians, RNs, technologists and therapists. ''5 He notes that declines of 15 to 20 per cent in hospital personnel are commonly fore-
cast as hospitals adjust from a system that rewards inefficiency to one that rewards efficiency, favors technology over people, favors part-time workers over fulltime workers, and seeks alternative and less costly and intensive therapies. W i t h declining occupancy rates, length of stay and utilization, hospitals will hav~ less need for nurses. In some cases, RNs may be used to substitute for less flexible LPNs.
The nursing profession will be polarized between those nurseswith BA or Master'sdegreeswho workin high technology/high intensity areas of acute care hospitals and remain high in demand, and other nurses assigned to general care who will probably have less autonomy and responsibilityand for whom there will be fewerjobs . . . . It seems likely that the trend towards employing nurses on a part-time basis will continue over the remainder of the century.~ Regarding LPNs (licensed practical nursing, with the exception of dietitian, is the major field of skilled employment for black women in the health field), while the n u m b e r of hospital-based LPNs may decline, the prospects for LPNs in nursing homes and home health care seem brighter. Ginzberg suggests that moves to change LPN training from one year to I8 months are likely to be fought by RNs. Nurse practitioners and physician assistants (physician extenders in Ginzberg's terms) currently are used "largely in group practice model HMOs and military and other government hospitals, where relatively low salary levels discourage the recruitment and retention of physicians. With an increasing n u m b e r of
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JOURNAL OF PROFESSIONAL NURSING
physicians, we expect extenders to be displaced from these jobs.''~ Ginzberg's summary statements include: • Hospitals will lose between 10 and 15 per cent of their current job complement (400,000-600,000 positions) over the next decade. Much of this loss, however, will be absorbed by other components of the delivery system. • Convalescent services will have the greatest growth in this period, particularly home health care services. While the cost of home care borne by families will remain at about 70 per cent of all convalescent care, the number of jobs will escalate as the number of those over 75 years of age grows. We expect an additional 500,000-800,000 jobs to be created in home health care services over the next 10 years, with approximately 70-75 per cent in personal care services (personal care and housework) and 25 to 30 per cent in medically related jobs (nursing, therapy, etc.) • Ambulatory care settings will also experience rapid growth--with a total of between 825,000 and 1,050,000 more jobs over the next 10 years than at present. • The job categories where we expect to see the largest decreases in employment are LPNs and technicians.~ Ginzberg's forecasts in 1981 were fairly accurate. Will his 1984 forecasts hold up? What other factors need to be considered in thinking about the future of nursing? One possibility is the future of other health care workers. Physicians, other professionals, and health care support personnel will compete with nurses even more in the years ahead. After considering the size and nature of the health care workforce, the following sections will return to a consideration of where nurses work, what they do, and in this round-about fashion, what nursing is. There has been a dramatic rise from 1975 to 1982 in the number of health care workers. For example, nurses, dietitians, and therapists increased from 1,143,000 in 1975 to 1,736,000 in 1982, and health administrators increased from 154,000 in 1975 to 228,000 in 1982.6 Few health care occupations declined in the period from 1970 to 1982. The number of persons working in dentist offices, hospitals, convalescent institutions, physicians' and chiropractors' offices, and other health service sites almost doubled. The population
•
JANUARY-FEBRUARY1986
during that period increased from 205 million to 232 million, thus, per capita service rates at all care delivery sites increased. 7 Will they increase in the years ahead? The discussion of the criteria-based model above suggests they should. The thrust of the various trends discussed in the conference papers suggests otherwise. How will other health care providers fare in the years ahead? One possible forecast, summarized in Table 3, is provided by Ginzberg. Questions About Nursing Where do nurses work? Given the forecasts of Eli Ginzberg above and those of Sarah Detmer and the other conference authors, are the DHHS projections likely to be accurate? What does a nurse do? Will this change over the next twenty years and if so, why? Answers to these questions will vary widely depending upon the type of nurse and work setting being considered. The intensity of nursing care varies widely from site to site. Given the changes in therapies, delivery systems, licensure, and telematics, how will these intensities change in the years ahead? What will nurses be in the 21st century? What will nursing have become? Having considered forecasts for nursing, where nurses work and what they do, it is relevant to ask, what are nurses? Given any current definition, what changes will take place in that definition in the years ahead? Styles, in On Nursing: TowardaNew Endowment, notes that to answer the question of nursing we must look at the theorists and conceptualizers in the nursing field, at legal definitions, and at the personal goals of those who are now nurses. In regard to the first area, Styles presents Sister Callista Roy's comparison of five conceptualizations of nursing in the context of the conceptualizers' views of humanity, the goal of nursing, and nursing activities. 7 For this meeting on Nursing in the 21st Century, it is relevant to ask how these conceptions might evolve. A comparison of Florence Nightingale's mid-19th century model of nursing with others developed more recently by nurse theorists shows a clear progression in nursing's concern for the environment and its effects on health and in the growing focus on health as well as illness. Over the next 25 years, how will this evolving conception change? Styles notes that the legal definition of nursing is also changing, at least in some states. Compare for example, the definitions below from Oklahoma
BEZOLD AND CARLSON
NURSING IN THE 21ST CENTURY: INTRODUCTION
TABLE 3.
A Plausible Forecast for Health Care Personnel*
Physicians. By 1990 there will be about 600,000 physicians. Medical schools forecast about 16,000 new students each year. The supply of physicians will continue to expand throughout the rest of this century. This will have a chilling effect on the practice options of nurse practitioners, physician assistants, and midwives.
Dentists. Unless the demand for dental care picks up substantially there will be a depressed market for both dentists and dental hygienists. Dentists delegated tasks to their allied health workers in periods of growth and are now usurping those tasks when growth is slow or declining. Registered Nurses. Supply of RNs will increase but employment opportunities will shift- more in outpatient and home care, less in hospitals (see text). Part-time employment for nurses will continue over the remainder of the century. Post-baccalaureate-trained nurses will be in greater demand as supervisors and for work on high technology units and will have more flexibility shifting between clinical and administrative needs. Licensed Practical Nurses (LPNs). LPNs will lose hospital jobs more quickly than RNs but the prospects for LPNs in nursing homes and home health care are brighter (see text). Other Health Practitioners. These include about 200,000 other practitioners, 60% of whom are pharmacists. Growth in the number of podiatrists and chiropractors has been tied to third party reimbursement and changes in reimbursement may affect demand for their services. The growth of chain pharmacies and optometric services will continue to reduce the number of independent pharmacists and optometrists. Physician Extenders (sic). There are about 1,000 nurse midwives and their number is not likely to grow. Nurse practitioners and physician assistants (there are about 15,000 of each) are threatened by the increase and surplus of physicians. Job prospects for physician extenders will decrease over the next 15 years. Even in HMO settings and military and other government hospitals where relatively low salary levels have discouraged the recruitment and retention of physicians, the physician surplus will reverse this condition, displacing physician extenders.
Administrators. This group has risen from 8600 in 1960 to almost 230,000 by 1982. Even with government policies encouraging competition the need for health administrators should continue for some time because of the need to tighten hospital operating systems, to manage entrepreneurial ventures, to do strategic planning, and to have the managerial superstructure necessary for an industry financed increasingly on the private debt market. Assistants, Technicians and Technologists and Other Allied Health Workers. From 1950 to 1980 this group grew 700%, and in 1978 represented nearly 20% of all health workers. This spectrum goes from assistants with on the job training or one year of school, to technicians with 2 years, and technologists with a formal 4-year training program. Therapists, such as physical or respiratory therapists, have additional training beyond the bacheZors degree and are required to be certified or licensed. Many of these jobs are tied to specific technologies. As these technologies are automated jobs will be lost. If financing limits the use of certain tests and technologies more jobs are likely to be lost. As jobs move out of hospitals many of these workers will follow. Job creation at the lowest end of the skill spectrum will be more constrained than at the technologist or therapist level. Job obsolescence through technological change will require flexible skills including rapid retraining. Emergency Medical Service Workers. There were 269,000 Emergency Medical Technicians in 1978, yet only one third were employed full time, the rest being volunteers on rescue squads or fire departments. The numbers of EMS workers will increase and an increasing proportion will have full time positions over the next 15 years. Other Health Workers. In 1978 these workers, primarily nurse aides, orderlies, attendants and other unskilled or Iowskilted occupations accounted for 40% of the entire health labor force, primarily in hospitals and nursing homes. In the years ahead they will increasingly be employed in home health care services and other community-based settings. At the bottom of the status hierarchy, often paid on an hourly basis, they are the most expendable of health workers. in summary: 1. There will be a shift away from hospital based employment for all nonprofessional health workers. 2. People at lower skill levels will be in greater jeopardy than those at higher skill levels. 3. Nursing homes, home health care and other modalities of care for the elderly and chronically ill will become important sources of employment. 4. While employment in the health field will continue to increase, it will do so at a slower rate than in previous years. * Data from Ginsberg E, etal: Employment in the Health Care Delivery Sector. Draft of Report Submitted to the U.S. Office of Technology Assessment by Conservation of Human Resources, Columbia University, New York, 1984.
7
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JOURNAL OF PROFESSIONAL NURSING
(the more conservative definition here dates back to 1953) and the 1978 New York State Statute: The practice of professional nursing means the performance for compensation of any acts, in the observation, care and counsel of the ill, injured or infirm, or in the maintenance of health or prevention of illness of others, or in the supervision and teaching of other personnel, or the administration of medications and treatments, as prescribed by a licensed physician or dentist, requiring substantial specialized judgment and skill based on knowledge and application of the principles of biological, physical, and social science. The foregoing shall not be deemed to include acts of diagnosis or prescription of therapeutic or corrective measures. (Oklahoma statute) 7 "Diagnosing" in the context of nursing practice means that identification of and discrimination between physical and psychosocial signs and symptoms essential to effective execution and management of the nursing regimen. Such diagnostic privilege is distinct from a medical diagnosis. "Treating" means selection and performance of those therapeutic measures essential to the effective execution and management of the nursing regimen, and execution of any prescribed medical regimen. "Human responses" means those signs, symptoms, and processes which denote the individual's interaction with an actual or potential health problem. The practice of the profession of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or
restorativeof life and well-being,and executivemedical regimens prescribed by a licensed or otherwise legally authorizedphysicianor dentist. A nursingregimenshall be consistentwithand shallnot varyanyexistingmedical regimen. (1978 New York State Statute)7 In her conference paper, Lori Andrews reviews the question of credentialling and licensure, noting the various options facing policy-makers and the profession. What approaches could or should nurses take? How will developments in therapeutics discussed by Bezold, Carlson, and Fries, telematics by Milio, and health care delivery systems by Detmer and Andrews affect these approaches?
JANUARY-FEBRUARY 1986
the care itself are likely to change in the years ahead. A major question for the conference was: "What changes will occur in the pattern of conditions and their treatment that will alter the work of the hospital-the place where 60 to 65 per cent of nurses work?" While a much lower percentage of nurses work in physician's offices, an appropriate question to ask is, what brings people to the doctor and how will that change and, to what extent might nurses or nurse practitioners become the focus of these visits? Data from the National Ambulatory Medical Care Survey provide information on the reasons for visits to physicians. Some of the most common reasons, in descending order of frequency, are as follows: general medical examination; prenatal examination; postoperative visits; throat referable symptoms; back symptoms; earache or ear infection; headache; and abdominal pain. 8 A number of factors may affect the fiequency with which people act in response to these conditions, such as self-care software; nurse midwives; less surgery; less weight and more exercise; meditation; and autonomic control. Given the self-limiting nature of most conditions, increasing awareness of the efficacy of various treatments, better capability to self-diagnose particular symptoms, and to home-test, physician visits (which have not grown since the last 1970s) may well decline in the years ahead. When care is given, how will it be delivered in the years ahead? Lori Andrews points out in her paper that 50 to 80 per cent of primary care complaints can be handled by protocols. A typical listing of complaints taken during HMO care showed that 63 per cent were handled by protocols.9 Given Clem Bezold's forecast for a "hospital on the wrist," as well as those by Nancy Milio in her conference paper, how will software protocols and related therapeutic delivery technologies adjust the need for health care personnel, particularly nurses?
Health Care Needs Relevant for Nurses
Review of Selected Literature on the Future of Nursing
Before moving on to other issues it is relevant to consider the basic demands patients put on hospitals and physicians that involve nurses. The primary function of hospitals has traditionally been acute care, although the leading categories are for acute episodes of chronic conditions, namely, heart disease and cancer. James Fries' paper identifies how both the conditions that give rise to the need for care and
In preparing a meeting on the future of any given topic, it is useful to review the literature focusing on the future in that field. Unfortunately for anyone doing research on the future, articles are not always categorized appropriately. Titles including the term "future" often deal only with certain aspects of the field. Overview articles that include forecasts may not appear as such in relevant index volumes.
BEZOLD AND CARLSON
"
NURSING IN THE 21ST CENTURY: INTRODUCTION
Yet, most fields have some literature on the future. For this project, an initial search of the Library of Medicines' collection of resources on articles on the future of nursing was made. Another source of information on the future of nursing are works that deal with the future of health care or its major pieces. These include trend summaries of forces shaping the health care system, '0.'' forecasts for the future of hospital utilization, such as the recent studies for the American Hospital Association, and the American College of Nurse Administrators, aggregation of key trends into scenarios on the future of health care, t2 and exploration of the implications of health care change for specific professions.'3.'4
References I. Gortner SR: The history and philosophy of nursing science and research. Adv Nuts SciJanuary: 1-8, 1983 2. Department of Health and Human Services (DHHS): Report to the President and Congress on the Status of Health Personnel in the United States, Volumes land 2. Government Printing Office, Washington, D.C., 1984 3. Institute of Medicine, Nursing and Nursing Education: Public Policies and Private Actions. Washington, D.C., National Academy Press, 1983
9
4. Ginzberg E: The economics ofheahh care and the future of nursing. Nurse Educator May-June: 29-32, 1981 5. Ginzberg E, et ah Employment in the Health Care Delivery Sector. Draft of report submitted to the U.S. Office of Technology Assessment by Conservation of Human Resources, Columbia University, New York, 1984 6. U.S. Department of Labor: Handbook of Labor Statistics. Washington, D.C., U.S. Department of Labor, 1983 7. Styles M: On Nursing: Toward a New Endowment. St. Louis, C. V. Mosby, 1982 8. McLemore T, Koch H: 1980 Summary: National Ambulatory Medical Care Survey. Advanced Data No. 77. Rockville, Maryland, National Center for Health Statistics, 1982, p 4 9. Greenfield S: Protocols as analogs to standing orders, in Bullough B (Ed.): The Law and the Expanding Nursing Role. East Norwalk, Connecticut, Appleton-CenturyCrofts, 1980, pp 186-187 10. The Health Central System, 1985-89. The Restructuring Health Industry: Progress Through Partnerships, March 1984 11. Bezold C, Carlson R, Peck J. The Future of Workand Health. Boston, Auburn House, 1985 12. Bezold C: The Uncertain Future: Ahemative Futures for the U.S. and Health Care. Pharmacy in the 21st Century. Alexandria, Virginia, Institute for Alternative Futures, and Project Hope, 1985, pp 19-28 13. Bezold C, HalperinJ, Binkley H, et al. Pharmacy in the 21st Century. Alexandria, Virginia, Institute for Alternative Futures, and Project Hope, 1985 14. National Mental Health Association: Project on the Future of Mental Health. Alexandria, Virginia, NMHA, 1985
NG8
Nursing in the 21st Century: An Introduction CLEMENT BEZOLD,
PHD,* AND
HAT WILL THE typical nurse do in the year 20107 How many nurses will there be? Where will they work? What ate the major forces likely to shape the future of nursing? What are the future implications of current choices for nurses and nursing organizations? These are among the questions addressed by the July 1985 conference on Nursing in the 21st Century. This background paper focuses on some of the existing forecasts for nursing and health care and provides a common frame of reference for the authors of the five papers prepared for the conference. The use of a conference to explore the future of nursing has a long and rich tradition. Since at least the 1930s in the United States, conferences have been held for this purpose.~ This 1985 conference on Nursing in the 21st Century goes beyond past conferences in two ways. First, some of the more systematic approaches to thinking about the future developed in the field of futures studies were utilized, reaching out further than most such efforts and considering a wider set of concerns. Second, the conference did not seek to set goals for the nursing profession. Rather, it allowed participants to explore the future of nursing in light of a host of potential changes in the health care system that pose both threats and opportunities for nursing. Participants at the conference have developed their image of optimal ap-
W
* Executive Director, Institute for Alternative Futures, Alexandria, Virginia. t Consultant and Author, Old Snowmass, Colorado. Presented at the AACN/AONE conference on Nursing in the 21st Century. Aspen, Colorado, .July 9-11, 1985. The opinions expressed herein are those of the authors, and do not necessarily reflect those of the AACN or AONE. Address correspondence and reprint requests to Dr. Bezold: Executive Director, Institute for Alternative Futures, 1405 King Street, Alexandria, VA 22314.
RICK CARLSON,
JD~
proaches for nursing and set goals in the context of forecasts made by futurists and leading thinkers in health care. The major benefit of a conference such as this is to infuse that goal setting with imagination and creativity. The remainder of this paper will summarize some of the major U.S. government forecasts for nursing; review alternative forecasts for nursing personnel, aspects of nursing and other segments of the health care system; and develop the questions that were addressed at the conference. The Official Future DEMAND FOR NURSES
In most fields of business or government work there are plans based on certain forecasts. These forecasts typically have been a single projection of past experience (generally growth) into the future. History is used as the basis for forecasting the future. History is not a bad place to start, but things can and do change, and in the 1980s health care is changing with surprising rapidity. A relevant question asked, therefore, is "What is the official future for nursing?" There are several government forecasts for nursing. The major set of forecasts is developed by the Bureau of Health Professions in the Department of Health and Human Services every other year for the President and Congress. The most recent, delivered in May 1984, sets out a range of forecasts for the supply and demand for nurses. The general growth trend among all of the major forecasts for registered nurses is shown in Figure 1. The supply and requirements for nurses are compared in Table 1. The supply forecast assumes that the age group activity rates for nurses in November 1980 remain constant. The demand or requirements
NURSING IN T H E 21ST CENTURY: INTRODUCTION
BEZOLD A N D CARLSON
3
2,200,000
03
z
2,000,000
.>
1,800,000
hE _o Clr O O
E -L
,k
--
. .. ~
..............
-II-A -AIt.-III -II-B
..... • 1,600,000
--
1,400,000
--
~,
.............
...!~
~
- I-A "AIt.-II
"6 .IQ
E "'1 7 1,200,000
--- S
1,000,000
__
I 1980
v,....~.~;.::.;:.~.,;,.-AIt.oll Historical Trend-Based Req.-Alternative I ,.o,...~..,. . . . . . . . . . AIt.-III Historical Trend-Based Req.-Alternative II -"-':"" •...... I-A Supply Projection Assumption I-A ..... I-B Supply Projection Assumption I-B ~ II-A Supply Projection Assumption II-A . . . . . . II-B Supply Projection Assumption II-B Criteria Based Lower Bound Req. for 1990 and 2000
I 1982
I
I 1984
I
I 1986
I
I 1988
I
I 1990
I
I 1992
I
I 1994
I
I 1996
I
I 1998
I 2000
Year
Figure I. Forecasted trends in the requirement for and supply of registered nurses through the year 2000, Source: Department of Health and Human Services: Status of Health Personnel in the U.S., Vol. 1, C-2-9, May 1984.
forecast assumes that RN utilization rates grow at a decreasing rate until 1990; thereafter, there is no increase. Also, the forecasts such as those shown in Figure 1 and Table 1 are often based on data and assumptions made some years earlier. The Department of Health and Human Services (DHHS) has updated the figures shown in Table 1, but will not release these figures until 1986. Thus, using what was available at the time of the conference, the supply of nurses is predicted to grow to 1,986,400 and the supply of nursing full-time equivalents to 1,675,800 in the year 2000 as shown in Table 1. During the same period the demand or requirement for nurses will grow to 1,768,060. The 1984 DHHS report contained another estimate of potential demand, this one called the "criteria-based" model. Criteria for adequate nursing staff by location and type of service were developed. This model suggests a much higher requirement for nurses in 1990 and 2000 than the historical trend model. The two stars above the trend line in Figure I represent the estimate of demand for nurses if all care facilities were staffed adequately, based
on the criteria developed by a 1980 expert panel. These 1980 criteria were updated and, except for nursing skill levels in nursing homes, were generally increased in 1984. SUPPLY OF NURSES
In terms of supply the number of registered nurses is forecast by the 1984 DHHS Report to t/se President and Congress on Healtb Care Personnel to grow to between 1.85 million and 2.16 million by the year 2000.2 This variation is due to different assumptions about the entering rate for new students and the activity level of nurses (the percentage actually seeking nursing work). Series 1A assumes a 75 per cent activity level with a growing number of students. Series 1B assumes a 75 per cent activity level with no growth in new students. Series 2A assumes a 78 per cent activity level with a growing number of students. Series 2B assumes a 78 per cent activity level with no growth in new students. This range is identified in Table 2 by type of nursing education program. The supply of nursing personnel is based on the
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JOURNAL OF PROFESSIONAL NURSING
TABLE 1.
Projections of National Active Supply of Registered Nurses and Requirements for Registered Nurses, 1980-2000 Supply
Year
1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Total Number of Nurses
1.272.900 1,317.800 1,362,300 1,410,200 1,457,700 1,507,400 1,551,900 1,593,600 1,636,200 1,675,300 1,713,800 1,745,900 1,776,200 1,807,900 1,838,300 1,868,600 1,892,600 1,915,200 1.938.300 1,961.800 1,986.400
Full-time Equivalents (FTE)
1,068,000 1,t05.000 1,140,700 1,179,600 1,218,700 1,260,000 1,297,000 1,332,100 1,367,500 1,400,500 1,432,800 1,460,200 1,486,600 1,514,400 1,541,500 1,568,200 1,589,900 1,610,900 1,631,900 1,653,600 1,675,800
TABLE 2.
JANUARY-FEBRUARY1986
Nursing Supply Forecasts for 1990 and 2000
Requirements Total FrEs Nurses p e r per 1 0 0 , 0 0 0 100,000 Population Population
560 572 586 601 615 629 641 653 665 675 685 692 698 706 712 719 724 728 732 736 740
470 480 490 502 514 526 536 545 555 564 572 578 584 591 597 603 608 612 616 620 624
Number of Nurse FTEs Required
1,068,000 1.126,270 1,180,380 1.232,730 1,281,310 1,329,140 1,374,420 1,414,450 1,448,980 1,480,060 1,507,990 1,532,660 1,557,050 1,581,580 1,606,900 1,632,750 1,658,330 1,685,160 1.712.320 1.740,010 1,768,060
Source: Departmentof Healthand HumanServices(DHHS): Status of Health Personnel in the United States, Vol. 2, Supply, Series 1-A Table C-12; Requirements,AlternativeIII, Table C-21.
existing stock of potential nursing workers: the number of new graduates or entrants into the field, including immigrants, and the labor force participation rates. In considering the variables affecting new entrants, the Institute of Medicine (IOM) report identified five major factors. 1. Availability of educational opportunities; 2. Costs of education; 3. Level of public and private support for the financing of nursing education; 4. The relative attractiveness of nursing as a career in terms of job satisfaction and economic incentives; 5. Immigration laws and regulations that influence inflows of foreign graduates.3 Labor force participation, IOM argues, is influenced by: 1. General conditions of the nation's economy; 2. Compensation rates; 3. Other factors, including improved career opportunities, better working conditions, child care benefits, flexible scheduling, fringe benefits, reentry education opportunities.3
1980 °
RNs per 100,000 population Total Associate/Diploma Baccalaureateand Higher Baccalaureate Master's/Doctorate Unknown
NO.
o~
1,272,900 901,700 364,400
100.0 70.8 28.6
6,800
.5
RNs per 100,000 population Total Associate/Diploma Baccalaureateand Higher Baccalaureate Master's/Doctorate
In thinking about the future, this conference focused primarily on factors within the health care system. The papers identify many of the larger forces, such as reorganization of the health care delivery system, that will in turn affect nurses' compensation rates and working conditions. An Alternative to the Official Future
The above forecasts provide the best thinking of the federal government on the most likely future. Other approaches use expert judgment, often from a single expert. The health care personnel forecasts of Eli Ginzberg are relevant examples, particularly his forecasts for nursing in 19814 and for health care personnel in 1984.~ These forecasts provide one comparative approach to speculation about the future of nursing. In 1981, Ginzberg argued that hospitals and nursing homes that employed four out of five nurses were prime sources of data. Yet these institutions were likely to face increasingly difficult times in the 1980s, including a shrinking number of hospital beds. This would affect the traditional goals within the nursing community of increasing the percentage of baccalaureate and higher degree nurses, providing greater income, and giving nurses more authority. Ginzberg argued that the goal of a substantial increase in the number of baccalaureate level nurses is unlikely to be realized in the years ahead because hosp!tals are not seeking substantially more baccalaureate level nurses, there is a levelling or declining of nursing students, and educational costs are rising. Also, he speculated that the goal of greater responsibilities for nurse practitioners will be diffi-
BEZOLD AND CARLSON *
NURSING IN THE 21ST CENTURY; INTRODUCTION
5
1990 HHS Forecasts"1:
IOM Intermediate Forecast1"
No. 1,710,000 1,089,000 621,000
% 100.0 63.7 36.3
Series IA
NO: 685 1,713,800 1,146,300 567,500 443,700 123,800
SeriesIB
%
NO.
100.0 66.9 33.1 25.9 7.2
661 1,654,100 1,083,500 570,700 446,900 123,800
100.0 62.1 37.9 27.1 10.8
688 1,847,300 1,088,200 759,100 544,800 214.300
SeriesIIA
%
No.
100.0 65.5 34.5 27.0 7.5
738 1,846,800 1,245,700 601,100 471,200 129,900
100.0 58.9 41.1 29.5 11.6
8O6 2,164,200 1,356,100 808,100 582,500 225,600
Serieslib
%
No.
%
100.0 67.5 32.5 25.5 7.0
713 1,784,200 1,178,900 605,300 475,400 129,900
100.0 66.1 33.9 26.6 7.3
100.0 62.7 37.3 26.9 10.4
751 2,015,400 1,197,500 817,800 592,300 225,500
100.0 59.4 40.6 29.4 11.2
2000
74O 1,986,400 1,233,900 752,400 538,000 214,400
Sources: * Registered Nurses per 100,000 population from Status of Health Personnel, Vol. 2, pp. C-12, C-13; t Nursing and Nursing Education, Division of Health Care Services, Institute of Medicine, Washington, D.C., National Academy Press, 1983, p 77; and t Status of Health Personnel in the United States, U.S. Department of Health and Human Services, DHHS Publication No. HRS-P-OD 84-4, Washington, D.C., GPO, May 1984.
cult to realize due to the growing surplus of physicians concerned about declines in income and increased lobbying pressure from state medical societies. Governments may be reluctant to agree to reimburse nurse practitioners despite a "considerable and growing n u m b e r of studies (which) have concluded that nurse practitioners do as well and sometimes better than physicians in providing first encounter care; that they tend to elicit a positive response from patients they serve; and that they are generally cost-effective.''4 However, Ginzberg notes that Health Maintenance Organizations (HMOs) may be the place where nurse practitioner cost-effectiveness will be appreciated. Ginzberg notes that the progress for professional emancipation for nurses "has been slow because of the difficulties they have experienced in defining their area of expertise, in differentiating who among the 2.5 million individuals engaged in nursing and nursing support services are to be treated as professionals; '4 and a host of other factors. By 1984, Ginzberg's forecasts were more focused but still in the same direction. For the hospital sector, he forecast "hospital-based employment to decline over the rest of the century. This will affect lower level hospital workers such as LPNs, aides and orderlies and technicians, more acutely than higher level workers, such as physicians, RNs, technologists and therapists. ''5 He notes that declines of 15 to 20 per cent in hospital personnel are commonly fore-
cast as hospitals adjust from a system that rewards inefficiency to one that rewards efficiency, favors technology over people, favors part-time workers over fulltime workers, and seeks alternative and less costly and intensive therapies. W i t h declining occupancy rates, length of stay and utilization, hospitals will hav~ less need for nurses. In some cases, RNs may be used to substitute for less flexible LPNs.
The nursing profession will be polarized between those nurseswith BA or Master'sdegreeswho workin high technology/high intensity areas of acute care hospitals and remain high in demand, and other nurses assigned to general care who will probably have less autonomy and responsibilityand for whom there will be fewerjobs . . . . It seems likely that the trend towards employing nurses on a part-time basis will continue over the remainder of the century.~ Regarding LPNs (licensed practical nursing, with the exception of dietitian, is the major field of skilled employment for black women in the health field), while the n u m b e r of hospital-based LPNs may decline, the prospects for LPNs in nursing homes and home health care seem brighter. Ginzberg suggests that moves to change LPN training from one year to I8 months are likely to be fought by RNs. Nurse practitioners and physician assistants (physician extenders in Ginzberg's terms) currently are used "largely in group practice model HMOs and military and other government hospitals, where relatively low salary levels discourage the recruitment and retention of physicians. With an increasing n u m b e r of
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JOURNAL OF PROFESSIONAL NURSING
physicians, we expect extenders to be displaced from these jobs.''~ Ginzberg's summary statements include: • Hospitals will lose between 10 and 15 per cent of their current job complement (400,000-600,000 positions) over the next decade. Much of this loss, however, will be absorbed by other components of the delivery system. • Convalescent services will have the greatest growth in this period, particularly home health care services. While the cost of home care borne by families will remain at about 70 per cent of all convalescent care, the number of jobs will escalate as the number of those over 75 years of age grows. We expect an additional 500,000-800,000 jobs to be created in home health care services over the next 10 years, with approximately 70-75 per cent in personal care services (personal care and housework) and 25 to 30 per cent in medically related jobs (nursing, therapy, etc.) • Ambulatory care settings will also experience rapid growth--with a total of between 825,000 and 1,050,000 more jobs over the next 10 years than at present. • The job categories where we expect to see the largest decreases in employment are LPNs and technicians.~ Ginzberg's forecasts in 1981 were fairly accurate. Will his 1984 forecasts hold up? What other factors need to be considered in thinking about the future of nursing? One possibility is the future of other health care workers. Physicians, other professionals, and health care support personnel will compete with nurses even more in the years ahead. After considering the size and nature of the health care workforce, the following sections will return to a consideration of where nurses work, what they do, and in this round-about fashion, what nursing is. There has been a dramatic rise from 1975 to 1982 in the number of health care workers. For example, nurses, dietitians, and therapists increased from 1,143,000 in 1975 to 1,736,000 in 1982, and health administrators increased from 154,000 in 1975 to 228,000 in 1982.6 Few health care occupations declined in the period from 1970 to 1982. The number of persons working in dentist offices, hospitals, convalescent institutions, physicians' and chiropractors' offices, and other health service sites almost doubled. The population
•
JANUARY-FEBRUARY1986
during that period increased from 205 million to 232 million, thus, per capita service rates at all care delivery sites increased. 7 Will they increase in the years ahead? The discussion of the criteria-based model above suggests they should. The thrust of the various trends discussed in the conference papers suggests otherwise. How will other health care providers fare in the years ahead? One possible forecast, summarized in Table 3, is provided by Ginzberg. Questions About Nursing Where do nurses work? Given the forecasts of Eli Ginzberg above and those of Sarah Detmer and the other conference authors, are the DHHS projections likely to be accurate? What does a nurse do? Will this change over the next twenty years and if so, why? Answers to these questions will vary widely depending upon the type of nurse and work setting being considered. The intensity of nursing care varies widely from site to site. Given the changes in therapies, delivery systems, licensure, and telematics, how will these intensities change in the years ahead? What will nurses be in the 21st century? What will nursing have become? Having considered forecasts for nursing, where nurses work and what they do, it is relevant to ask, what are nurses? Given any current definition, what changes will take place in that definition in the years ahead? Styles, in On Nursing: TowardaNew Endowment, notes that to answer the question of nursing we must look at the theorists and conceptualizers in the nursing field, at legal definitions, and at the personal goals of those who are now nurses. In regard to the first area, Styles presents Sister Callista Roy's comparison of five conceptualizations of nursing in the context of the conceptualizers' views of humanity, the goal of nursing, and nursing activities. 7 For this meeting on Nursing in the 21st Century, it is relevant to ask how these conceptions might evolve. A comparison of Florence Nightingale's mid-19th century model of nursing with others developed more recently by nurse theorists shows a clear progression in nursing's concern for the environment and its effects on health and in the growing focus on health as well as illness. Over the next 25 years, how will this evolving conception change? Styles notes that the legal definition of nursing is also changing, at least in some states. Compare for example, the definitions below from Oklahoma
BEZOLD AND CARLSON
NURSING IN THE 21ST CENTURY: INTRODUCTION
TABLE 3.
A Plausible Forecast for Health Care Personnel*
Physicians. By 1990 there will be about 600,000 physicians. Medical schools forecast about 16,000 new students each year. The supply of physicians will continue to expand throughout the rest of this century. This will have a chilling effect on the practice options of nurse practitioners, physician assistants, and midwives.
Dentists. Unless the demand for dental care picks up substantially there will be a depressed market for both dentists and dental hygienists. Dentists delegated tasks to their allied health workers in periods of growth and are now usurping those tasks when growth is slow or declining. Registered Nurses. Supply of RNs will increase but employment opportunities will shift- more in outpatient and home care, less in hospitals (see text). Part-time employment for nurses will continue over the remainder of the century. Post-baccalaureate-trained nurses will be in greater demand as supervisors and for work on high technology units and will have more flexibility shifting between clinical and administrative needs. Licensed Practical Nurses (LPNs). LPNs will lose hospital jobs more quickly than RNs but the prospects for LPNs in nursing homes and home health care are brighter (see text). Other Health Practitioners. These include about 200,000 other practitioners, 60% of whom are pharmacists. Growth in the number of podiatrists and chiropractors has been tied to third party reimbursement and changes in reimbursement may affect demand for their services. The growth of chain pharmacies and optometric services will continue to reduce the number of independent pharmacists and optometrists. Physician Extenders (sic). There are about 1,000 nurse midwives and their number is not likely to grow. Nurse practitioners and physician assistants (there are about 15,000 of each) are threatened by the increase and surplus of physicians. Job prospects for physician extenders will decrease over the next 15 years. Even in HMO settings and military and other government hospitals where relatively low salary levels have discouraged the recruitment and retention of physicians, the physician surplus will reverse this condition, displacing physician extenders.
Administrators. This group has risen from 8600 in 1960 to almost 230,000 by 1982. Even with government policies encouraging competition the need for health administrators should continue for some time because of the need to tighten hospital operating systems, to manage entrepreneurial ventures, to do strategic planning, and to have the managerial superstructure necessary for an industry financed increasingly on the private debt market. Assistants, Technicians and Technologists and Other Allied Health Workers. From 1950 to 1980 this group grew 700%, and in 1978 represented nearly 20% of all health workers. This spectrum goes from assistants with on the job training or one year of school, to technicians with 2 years, and technologists with a formal 4-year training program. Therapists, such as physical or respiratory therapists, have additional training beyond the bacheZors degree and are required to be certified or licensed. Many of these jobs are tied to specific technologies. As these technologies are automated jobs will be lost. If financing limits the use of certain tests and technologies more jobs are likely to be lost. As jobs move out of hospitals many of these workers will follow. Job creation at the lowest end of the skill spectrum will be more constrained than at the technologist or therapist level. Job obsolescence through technological change will require flexible skills including rapid retraining. Emergency Medical Service Workers. There were 269,000 Emergency Medical Technicians in 1978, yet only one third were employed full time, the rest being volunteers on rescue squads or fire departments. The numbers of EMS workers will increase and an increasing proportion will have full time positions over the next 15 years. Other Health Workers. In 1978 these workers, primarily nurse aides, orderlies, attendants and other unskilled or Iowskilted occupations accounted for 40% of the entire health labor force, primarily in hospitals and nursing homes. In the years ahead they will increasingly be employed in home health care services and other community-based settings. At the bottom of the status hierarchy, often paid on an hourly basis, they are the most expendable of health workers. in summary: 1. There will be a shift away from hospital based employment for all nonprofessional health workers. 2. People at lower skill levels will be in greater jeopardy than those at higher skill levels. 3. Nursing homes, home health care and other modalities of care for the elderly and chronically ill will become important sources of employment. 4. While employment in the health field will continue to increase, it will do so at a slower rate than in previous years. * Data from Ginsberg E, etal: Employment in the Health Care Delivery Sector. Draft of Report Submitted to the U.S. Office of Technology Assessment by Conservation of Human Resources, Columbia University, New York, 1984.
7
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JOURNAL OF PROFESSIONAL NURSING
(the more conservative definition here dates back to 1953) and the 1978 New York State Statute: The practice of professional nursing means the performance for compensation of any acts, in the observation, care and counsel of the ill, injured or infirm, or in the maintenance of health or prevention of illness of others, or in the supervision and teaching of other personnel, or the administration of medications and treatments, as prescribed by a licensed physician or dentist, requiring substantial specialized judgment and skill based on knowledge and application of the principles of biological, physical, and social science. The foregoing shall not be deemed to include acts of diagnosis or prescription of therapeutic or corrective measures. (Oklahoma statute) 7 "Diagnosing" in the context of nursing practice means that identification of and discrimination between physical and psychosocial signs and symptoms essential to effective execution and management of the nursing regimen. Such diagnostic privilege is distinct from a medical diagnosis. "Treating" means selection and performance of those therapeutic measures essential to the effective execution and management of the nursing regimen, and execution of any prescribed medical regimen. "Human responses" means those signs, symptoms, and processes which denote the individual's interaction with an actual or potential health problem. The practice of the profession of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or
restorativeof life and well-being,and executivemedical regimens prescribed by a licensed or otherwise legally authorizedphysicianor dentist. A nursingregimenshall be consistentwithand shallnot varyanyexistingmedical regimen. (1978 New York State Statute)7 In her conference paper, Lori Andrews reviews the question of credentialling and licensure, noting the various options facing policy-makers and the profession. What approaches could or should nurses take? How will developments in therapeutics discussed by Bezold, Carlson, and Fries, telematics by Milio, and health care delivery systems by Detmer and Andrews affect these approaches?
JANUARY-FEBRUARY 1986
the care itself are likely to change in the years ahead. A major question for the conference was: "What changes will occur in the pattern of conditions and their treatment that will alter the work of the hospital-the place where 60 to 65 per cent of nurses work?" While a much lower percentage of nurses work in physician's offices, an appropriate question to ask is, what brings people to the doctor and how will that change and, to what extent might nurses or nurse practitioners become the focus of these visits? Data from the National Ambulatory Medical Care Survey provide information on the reasons for visits to physicians. Some of the most common reasons, in descending order of frequency, are as follows: general medical examination; prenatal examination; postoperative visits; throat referable symptoms; back symptoms; earache or ear infection; headache; and abdominal pain. 8 A number of factors may affect the fiequency with which people act in response to these conditions, such as self-care software; nurse midwives; less surgery; less weight and more exercise; meditation; and autonomic control. Given the self-limiting nature of most conditions, increasing awareness of the efficacy of various treatments, better capability to self-diagnose particular symptoms, and to home-test, physician visits (which have not grown since the last 1970s) may well decline in the years ahead. When care is given, how will it be delivered in the years ahead? Lori Andrews points out in her paper that 50 to 80 per cent of primary care complaints can be handled by protocols. A typical listing of complaints taken during HMO care showed that 63 per cent were handled by protocols.9 Given Clem Bezold's forecast for a "hospital on the wrist," as well as those by Nancy Milio in her conference paper, how will software protocols and related therapeutic delivery technologies adjust the need for health care personnel, particularly nurses?
Health Care Needs Relevant for Nurses
Review of Selected Literature on the Future of Nursing
Before moving on to other issues it is relevant to consider the basic demands patients put on hospitals and physicians that involve nurses. The primary function of hospitals has traditionally been acute care, although the leading categories are for acute episodes of chronic conditions, namely, heart disease and cancer. James Fries' paper identifies how both the conditions that give rise to the need for care and
In preparing a meeting on the future of any given topic, it is useful to review the literature focusing on the future in that field. Unfortunately for anyone doing research on the future, articles are not always categorized appropriately. Titles including the term "future" often deal only with certain aspects of the field. Overview articles that include forecasts may not appear as such in relevant index volumes.
BEZOLD AND CARLSON
"
NURSING IN THE 21ST CENTURY: INTRODUCTION
Yet, most fields have some literature on the future. For this project, an initial search of the Library of Medicines' collection of resources on articles on the future of nursing was made. Another source of information on the future of nursing are works that deal with the future of health care or its major pieces. These include trend summaries of forces shaping the health care system, '0.'' forecasts for the future of hospital utilization, such as the recent studies for the American Hospital Association, and the American College of Nurse Administrators, aggregation of key trends into scenarios on the future of health care, t2 and exploration of the implications of health care change for specific professions.'3.'4
References I. Gortner SR: The history and philosophy of nursing science and research. Adv Nuts SciJanuary: 1-8, 1983 2. Department of Health and Human Services (DHHS): Report to the President and Congress on the Status of Health Personnel in the United States, Volumes land 2. Government Printing Office, Washington, D.C., 1984 3. Institute of Medicine, Nursing and Nursing Education: Public Policies and Private Actions. Washington, D.C., National Academy Press, 1983
9
4. Ginzberg E: The economics ofheahh care and the future of nursing. Nurse Educator May-June: 29-32, 1981 5. Ginzberg E, et ah Employment in the Health Care Delivery Sector. Draft of report submitted to the U.S. Office of Technology Assessment by Conservation of Human Resources, Columbia University, New York, 1984 6. U.S. Department of Labor: Handbook of Labor Statistics. Washington, D.C., U.S. Department of Labor, 1983 7. Styles M: On Nursing: Toward a New Endowment. St. Louis, C. V. Mosby, 1982 8. McLemore T, Koch H: 1980 Summary: National Ambulatory Medical Care Survey. Advanced Data No. 77. Rockville, Maryland, National Center for Health Statistics, 1982, p 4 9. Greenfield S: Protocols as analogs to standing orders, in Bullough B (Ed.): The Law and the Expanding Nursing Role. East Norwalk, Connecticut, Appleton-CenturyCrofts, 1980, pp 186-187 10. The Health Central System, 1985-89. The Restructuring Health Industry: Progress Through Partnerships, March 1984 11. Bezold C, Carlson R, Peck J. The Future of Workand Health. Boston, Auburn House, 1985 12. Bezold C: The Uncertain Future: Ahemative Futures for the U.S. and Health Care. Pharmacy in the 21st Century. Alexandria, Virginia, Institute for Alternative Futures, and Project Hope, 1985, pp 19-28 13. Bezold C, HalperinJ, Binkley H, et al. Pharmacy in the 21st Century. Alexandria, Virginia, Institute for Alternative Futures, and Project Hope, 1985 14. National Mental Health Association: Project on the Future of Mental Health. Alexandria, Virginia, NMHA, 1985