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Preparing US Hospitals To Safely Manage Ebola Virus-Infected Patients: At What Cost?

December 11th, 2014

Since Ebola first reached US shores this summer, hospitals nationwide have attempted to prepare. National guidance has been helpful, but no such guidance can deal with the fastidious attention to every minute and mundane aspect of caring for a patient with Ebola virus infection that could place a healthcare worker at risk if a breach occurs. Simulation training has helped to uncover defects and to assess our capacity to mitigate those defects.

Additionally, innumerable hours of countless healthcare workers, hospital administrators, infection control staff, facilities and environmental services providers, communications specialists, security personnel and others have been brought to bear focused on the task at hand. Despite this effort, in the 30 years since becoming a physician, I have never witnessed a greater, more palpable level of stress and anxiety among my peers.

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Spreading Like A Wildfire: Interprofessional Education – The Vanderbilt Experience

November 20th, 2014

Well before the Affordable Care Act was passed in 2010, efforts to expand interprofessional education (IPE) were beginning to change the mindset that permeated much of health professional education in the US. One such example is the Vanderbilt Program in Interprofessional Learning (VPIL) that was established in 2010 with initial support from the Josiah Macy Jr. Foundation, and later from the Baptist Health Trust.

To learn about the challenges, successes, and surprises experienced by those who developed and lead IPE at Vanderbilt, I interviewed Linda Norman, Dean of Vanderbilt University School of Nursing, Bonnie Miller, Associate Vice Chancellor for Health Affairs and Senior Associate Dean for Health Sciences Education at Vanderbilt University Medical Center, and Heather Davidson, Director of Program Development for VPIL.

Peter Buerhaus: What were the key challenges faced when you started IPE at Vanderbilt?

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Revisiting Primary Care Workforce Data: A Future Without Barriers For Nurse Practitioners And Physicians

July 28th, 2014

With the full implementation of the Patient Protection and Affordable Care Act (ACA), there have been major concerns about the looming primary care provider shortage. The National Center for Health Workforce Analysis predicts shortages as high as 20,400 physicians by 2020, and increases in medical school graduates entering primary care residencies have been anemic.

Physician shortages can be addressed by the rapid growth of nurse practitioners (NPs), trained in primary care, along with the redesign of primary care to include teams that can be led by both physicians and NPs. But our nation’s primary care needs can only be met if states allow NPs to practice to the fullest extent of their training without unnecessary requirements for physician supervision.

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Health Affairs Web First: More US RNs Retire Later, Causing A Larger Workforce

July 16th, 2014

The size of the registered nurse (RN) workforce has surpassed forecasts from a decade ago, growing to 2.7 million in 2012 instead of peaking at 2.2 million as predicted. One less-noticed factor in this “nursing boom” is the decision by a growing number of RNs to delay retirement.

According to a new study being released today as a Web First by Health Affairs, among registered nurses working at the age of fifty from 1991 to 2012, 24 percent continued working as of the age of sixty-nine. This compared to 9 percent of RNs still working at the age of sixty-nine in the period from 1969 to 1990.

Authors David Auerbach, Peter Buerhaus, and Douglas Staiger also found that as RNs tend to shift out of hospital settings as they age, employers may welcome the growing numbers of experienced RNs seeking employment in other settings. Auerbach is affiliated with the RAND Corp. in Boston, Massachusetts; Buerhaus with Vanderbilt University’s Institute of Medicine and Public Health in Nashville, Tennessee; and Staiger with Dartmouth College in Hanover, New Hampshire.

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Asking The Wrong Question About Health Professionals

July 15th, 2014

I spent a significant part of my professional career pursuing “rational” policies to guide the numbers of health workers needed. I now understand that most of these moves on the policy side were fool’s errands, when measured against the powerful corrective forces of the labor and education markets.

In fact, the elasticity of these markets has been generally unanticipated by most of the workforce models. For instance, few recognized the shrinkage of incoming nursing classes in the waning years of the twentieth century. It was only in 2001, when the number of nurses passing the licensing exam fell to 28 percent, less than it had been just six years before, that alarm bells went off. New policies spurred the creation of schools, existing programs were expanded, and a raft of workplace changes were put in place to make nursing more attractive and sustainable. By 2005, more candidates passed the exam than in 1995, the previous high water mark. By 2009, the number had increased by 38 percent.

Similar unexpected market responses have been reflected in such trends as the growth of osteopathic medical colleges, expansion of proprietary allied health education, delayed retirement by many professionals, and a host of second-career entries into health professional work.

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Course Correction: Better Preparing Today’s Nurses For 21st Century Health Care Service

June 20th, 2014

Nursing has always been considered a highly established profession with solid job security for many, even in the midst of troubling economic conditions. In fact, a recent US News and World Report’s list of the Best 100 Jobs shows both nurse and nurse practitioner in the Top 10.  And it’s a respected profession as well: A 2013 Gallup poll showed 82 percent of Americans rate the ethical and honesty standards of nurses as “high or very high,” the highest of all professions.

Yet despite talk of an impending nursing shortage over the next few years, some believe there is an even bigger crisis looming, one that stems from the very heart of the career — education.  Quite simply, nursing students are not as prepared as they should be for the “real world” of nursing and patient care.

This skills deficit is all-encompassing. There is a lack of the basic technical skills, such as physical assessment and emergency response. But the equal lack of “soft skills,” such as critical thinking, problem recognition, prioritization and recognition of urgency, and communication with physicians, is just as alarming.

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Sharp Increases In The Clinician Pipeline: Opportunity And Danger

June 9th, 2014

The number of health care practitioners educated in the United States has grown dramatically over the past decade. This post presents data on four key health care clinicians: nurse practitioners (NPs), pharmacists, physician assistants (PAs), and registered nurses (RNs). In some cases, the pipeline for these clinicians has more than doubled in recent years. Even if there is no further growth in the educational pipeline today, the increases in educational capacity, if continued, will lead to an increase in the available supply each year for the next 30 to 35 years.

If these practitioners are fully integrated into the delivery system and allowed to practice consistent with their education and training, this growth can help assure access to cost effective care across the nation. On the other hand, because of the 30 to 35 year tail in the growth of practitioners, there is a danger that this rapid growth could also lead to significant surpluses, which would have many negative consequences.

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The Case For Global Health Diplomacy

April 14th, 2014

At the end of February, I had the pleasure of speaking about global health diplomacy at the Nursing Leadership in Global Health Symposium at Vanderbilt University. Nurses are one of the specialties that we support in the Frist Global Health Leaders program facilitated by Hope Through Healing Hands, a nonprofit dedicated to advancing peace by supporting health care services and education in some of the world’s most vulnerable communities. Nurses, including the men and women I met at Vanderbilt, have an enormous opportunity to affect health and global health diplomacy. Indeed, everyone in the medical profession can play a crucial role in health diplomacy.

Global Health Diplomacy And Foreign Policy

For several years now I’ve been thinking about—and speaking about—global health diplomacy. The term started appearing around 2000 and has many definitions, representing the complexity of the issue itself. Diplomacy, at the simplest level, is a tool used in negotiating foreign policy. Health diplomacy is different, though. As a physician, the overall goal of health is clear: improve quality of life by improving health and meeting overall patient goals of care. As a diplomat and policymaker, the goal is more complicated.

Foreign policy, in general, is a dance—a negotiation of shared goals and identification of conflicts between nations, always with inherent tension. For example, what we want for the government of Afghanistan may not align with their complex political and cultural ideologies.

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The Health Workforce: A Critical Component Of The Health Care Infrastructure

March 24th, 2014

Editor’s note: This is the first in a periodic series of Health Affairs Blog posts on health workforce issues by Edward Salsberg. Mr. Salsberg has spent over 30 years studying the health workforce, including nearly 20 years establishing and directing three centers dedicated to workforce data collection, analysis and research. The first center, at the University at Albany, was focused on state health workforce data collection and issues. The second, at the Association of American Medical Colleges, was focused on the physician workforce across the nation. The third, the National Center for Health Workforce Analysis, was authorized by the Affordable Care Act. Mr. Salsberg has now joined the faculty at George Washington University where they are establishing a new Center for Health Workforce Research and Policy.

In the post below, Mr. Salsberg provides an overview of workforce issues. Future posts will discuss more specific health workforce questions and developments.

It could be argued that the health workforce — the people who provide direct patient care, as well as the staff that support caregivers and health care institutions — is the most significant component of the infrastructure of the health care system. Yet as a nation we have invested very little in collecting and analyzing health workforce data or in supporting the necessary research to inform effective public and private decision making. The results of this lack of investment are surpluses and shortages, significant mal-distribution, and less efficient and effective care than would be possible with better intelligence on our workforce needs.

For many health care professions, it takes years to build education and training capacity to increase, supply, or to change curriculum and modify the profession’s skill set. For these professions, we need to not only assess today’s needs but to project our future needs.

What the nation needs is a system to provide data, research findings, and information to thousands of individual stakeholders. This includes individuals considering a health career; colleges, universities and training programs that will educate and prepare them; the health organizations who will employ them; policy makers who need to decide what, if any, programs and policies to support; and the private sector that needs to decide whether to invest in workforce development. The responsibility for assuring an adequate supply and a well prepared health workforce is shared between the public and private sectors at both the national and the state and local level. Regardless of who is making the decisions related to health professions education and training capacity and health professions preparation, accurate and timely data is extremely important to support informed decisions.

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The Dangers Of Quality Improvement Overload: Insights From The Field

March 7th, 2014

Editor’s note: This post is also co-authored by Ksenia O Gorbenko, Catherine van de Ruit, and Charles Bosk of the University of Pennsylvania.

Quality improvement (QI) and patient safety initiatives are created with the laudable goal of saving lives and reducing “preventable harms” to patients. As the number of QI interventions continues to rise, and as hospitals become increasingly subject to financial pressures and penalties for hospital-acquired conditions (HACs), we believe it is important to consider the impact of the pressure to improve everything at once on hospitals and their staff.

We argue that a strategy that capitalizes on “small wins” is most effective. This approach allows for the creation of steady momentum by first convincing workers they can improve, and then picking some easily obtainable objectives to provide evidence of improvement.

National Quality Improvement Initiatives

Our qualitative team is participating in two large ongoing national quality improvement initiatives, funded by the Agency for Healthcare Research and Quality (AHRQ). Each initiative targets a single HAC and its reduction in participating hospitals. We have visited hospital sites across six states in order to understand why QI initiatives achieve their goals in some settings but not others. To date, we have conducted over 150 interviews with hospital workers ranging from frontline staff in operating rooms and intensive care units to hospital administrators and executive leadership. In interviews for this ethnographic research, one of our interviewees warned us about unrealistic expectations for change, “you cannot go from imperfect to perfect. It’s a slow process.”

While there is much to learn about how to achieve sustainable QI in the environment of patient care, one thing is certain from the growing wisdom of ethnographic studies of QI: buy-in from frontline providers is essential for creating meaningful change. Front-line providers often bristle at expectations from those they believe have little understanding of the demands of their daily work. Requiring health care providers to improve on all mandated measures at once—in an atmosphere of reduced reimbursements and frequent staff shortages—is a goal that risks burnout, discouragement, and apathy – all signs of initiative fatigue.

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Examination Of Health Information Technology’s Disappointing Impact Leads Health Affairs 2013 Top-Fifteen List

January 21st, 2014

Years after promises of large gains from health information technology, evidence of the impact of health IT on efficiency and safety remain mixed, Arthur Kellermann and Spencer Jones report in the most-read Health Affairs article of 2013. Achieving health IT’s original promise will require standardized systems that are easier to use and more interoperable, and that provide patients with more control over their health information; providers must re-engineer care systems as well, Kellermann and Jones write. To celebrate the New Year, Health Affairs is making this piece and all the articles on the journal’s 2013 most-read list freely available to all readers for one week.

Second on the 2013 top-fifteen list is a report on 2011 health spending by analysts at the Centers for Medicare and Medicaid Services Office of the Actuary. Every year, Health Affairs publishes a retrospective analysis of National Health Expenditures by the CMS analysts, as well as their health spending projections for the coming decade. In the latest installment in this series, the analysts reported on 2012 health spending in our January 2014 issue and discussed their findings at a Washington DC briefing.

In the third most-read Health Affairs article of 2013, Linda Green and coauthors caution against projecting primary care physician shortages based on simple patient-physician ratios. They argue that increasingly popular strategies — such as the use of teams and nonphysicians, and better information technology and data-sharing — can potentially eliminate projected physician shortages.

The top fifteen articles for 2013 also include studies addressing the impact of states’ opting out of Medicaid expansion, the cost-shifting effects of some workplace wellness programs, and several other topics. The full list appears below. The list is based on online viewing statistics and covers all articles published in 2013.

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Review Of Accountable Care Organization Landscape Leads 2013 Health Affairs Blog Top Fifteen

January 17th, 2014

David Muhlestein’s comprehensive look at the growth of Accountable Care Organizations leads the list of most-read Health Affairs Blog posts for 2013. Muhlestein, Director of Research at Leavitt Partners, followed up this post later in the year with a discussion of why ACO growth was slowing.

Next on the top-fifteen list is a post by Tim Jost on exemptions from the Affordable Care Act’s individual mandate. Several posts in Jost’s extensive “Implementing Health Reform” series made the most-read list. Jost teaches law at Washington and Lee University and is a Health Affairs Contributing Editor.

Number three on our list is a post by Robert York, Kenneth Kaufman, and Mark Grube of Kaufman Hall on what declining inpatient utilization rates tell us about how health care is changing. At number four: an analysis of who will remain uninsured after the Affordable Care Act is implemented by Rachel Nardin, chief of neurology at Cambridge Health Alliance, and coauthors Leah Zallman, Danny McCormick, Steffie Woolhandler, and David Himmelstein,

The full list is below. (You can also review the 2013 most-read list for our sister publication, GrantWatch Blog.)

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Implementing Health Reform: Looking Ahead After A December Enrollment Jump

December 29th, 2013

Although enrollment for January 1, 2014 began with a whimper in October, 2013, it ended with a bang on December 24, 2013. According to Julie Bataille, Director of CMS’s Office of Communications, had 2 million visits on Monday, December 23, and 880,000 visits on Christmas Eve. The Marketplace call center received more than 250,000 calls on December 23rd and 317,000 calls on the 24th.

After 27,000 enrolled qualified health plans through the federal exchange in October and 110,000 in November, 975,000 enrolled in qualified health plans in December, despite the fact that it was a short month. Enrollment nearly doubled in the last few days of the enrollment period compared to earlier in the month. Hundreds of thousands more have enrolled through the state exchanges as well: about 400,000 in California, more than 188,000 in New York, almost 60,000 in Connecticut. And many more have been signed up for Medicaid.

Some of this heavy traffic is the predicted last minute rush of people who wanted coverage by January 1, 2014, at which time qualified health plan coverage with premium tax credits begins. But it is also due to the fact that the websites are at last up and running. It is now finally possible for consumers to sign up relatively quickly most of the time and to find the coverage they are entitled to. Now the massive planned enrollment efforts that have been on hold for months as the websites struggled can begin. Between now and March 31 we will see a continued surge as American’s uninsured get the coverage long denied them.

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A Policy Dialogue On Connected Health

December 19th, 2013

Editor’s note: In addition to Janet Marchibroda (photo and linked bio above), this post was coauthored by Chris Fleming, Health Affairs Blog Editor.

What is telehealth or “connected health”? What is driving the use of connected health and what are its benefits? To achieve its full potential, what key challenges must be overcome? What are the central policy issues that must be addressed?

These are some of the questions explored by a group of leaders representing providers, payers, research and philanthropic organizations, and technology companies (listed at the end of this post), convened by Health Affairs and the Bipartisan Policy Center (BPC) last month. The session was organized partly to prepare for an upcoming Health Affairs thematic issue on connected health, to which former Senate Majority Leader and BPC Health Project Co-Chair Bill Frist—who chaired the discussion—will contribute.

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Health Affairs Briefing Reminder And Twitter Hashtag: Redesigning The Health Care Workforce

November 12th, 2013

Amid constant debate over health delivery system reforms, insufficient attention has been given to the needs of the future US health care workforce in light of rapid changes. The November 2013 thematic issue of Health Affairs,”Redesigning The Health Care Workforce,” takes on the issue of how to create the optimal health care workforce for the 21st century.

Please join Health Affairs Founding Editor John Iglehart on Thursday, November 14, at the W Hotel in Washington, DC, for a briefing that features authors from the issue. In addition, Health Affairs is pleased to collaborate with Academic Medicine, the journal of the Association of American Medical Colleges, and its Editor-in-Chief David Sklar to feature several authors from Academic Medicine’s forthcoming thematic issue on training the future health care workforce.

The program will include a keynote address by Princeton Professor Uwe Reinhardt, and remarks by Representatives Allyson Schwartz (D-PA), and Aaron Schock (R-IL).

WHEN:…….Thursday, November 14, 2013
……………..8:30 a.m. – 12:45 p.m.

WHERE:…..W Hotel Washington
……………..515 15th Street NW (Metro Center), Washington, DC


Follow live Tweets from the briefing @HA_Events, and join in the conversation with the hashtag #HA_Workforce.

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New Health Affairs: Issues Facing The Health Care Workforce

November 4th, 2013

The November issue of Health Affairs, released today, discusses how the US health care workforce can respond to the Affordable Care Act’s expanded coverage and new models of care, as well as to an aging population. Some notable studies in the issue are described below, and the issue will be discussed at a Washington DC briefing on Thursday, November 14.

The aging population’s implications for specialty care and primary care.A study by Timothy Dall of IHS Inc. and coauthors forecasts future demand for health care services and providers based on projected demographics and other predictive changes, including the expected effects of expanded health insurance coverage under the Affordable Care Act. The authors project that demand for adult primary care services will grow by roughly 14 percent between 2013 and 2015, and demand for certain specialty care services will grow even faster at a high of 31 percent growth for vascular surgery. Cardiology (20 percent) and neurological surgery, radiology, and general surgery (each 18 percent) round out the list of the top five.

Dall and coauthors caution that failure to address the inadequate number and inappropriate mix of specialty care providers will further contribute to long wait times, reduce access to care, and decrease patients’ quality of life.

Diabetes patients in patient-centered medical homes are well served by nonphysicians and physicians alike. In this first study to compare the effectiveness of physician assistants (PA) and nurse practitioners (NP) roles to physician-only care for patients with chronic disease, Christine Everett of Duke University and coauthors found that patient outcomes were generally the same in thirteen comparisons. In four comparisons, PA and NP care was found to be superior; in three, the physician-only outcomes were higher.

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Health Affairs And Academic Medicine Briefing: Redesigning The Health Care Workforce

October 18th, 2013

Amid constant debate over health delivery system reforms, insufficient attention has been given to the needs of the future US health care workforce in light of rapid changes. The November 2013 thematic issue of Health Affairs,”Redesigning The Health Care Workforce,” takes on the issue of how to create the optimal health care workforce for the 21st century.

Please join Health Affairs Founding Editor John Iglehart on Thursday, November 14, at the W Hotel in Washington, DC, for a briefing that features authors from the issue. In addition, Health Affairs is pleased to collaborate with Academic Medicine, the journal of the Association of American Medical Colleges, and its Editor-in-Chief David Sklar to feature several authors from Academic Medicine’s forthcoming thematic issue on training the future health care workforce.

The program will include a keynote address by Princeton Professor Uwe Reinhardt, and remarks by Representatives Allyson Schwartz (D-PA), and Aaron Schock (R-IL).

WHEN:…….Thursday, November 14, 2013
……………..8:30 a.m. – 12:45 p.m.

WHERE:…..W Hotel Washington
……………..515 15th Street NW (Metro Center), Washington, DC


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October Health Affairs Issue: Economic Trends And Quality Trade-Offs

October 7th, 2013

Health Affairs’ October issue, released today, evaluates the successes, the costs, and the quality trade-offs of improving physical and mental health in the United States. As Founding Editor John Iglehart says in his October letter, “Medical advances…have extended life expectancy and reduced the prevalence of diseases that stalk modern society. Paradoxically, though, for every success, an equally difficult challenge remains.” Also, with multiple shootings and related incidents fresh in our collective memories, the issue contains a discussion about the cost barriers to mental health care.

Some of the notable articles in the issue are discussed below. The Goldman and Herrera articles will be discussed at a National Press Club briefing tomorrow, Thursday October 10, from 8:30-11:00 AM. The briefing is supported by the Alliance for Aging Research, MetLife Foundation, Aetna Inc., and the National Pharmaceutical Council.

Barriers to Mental Health Care. As American society knows all too well, many people with mental illness fail to seek treatment. Kathleen Rowan and coauthors at the University of Minnesota analyzed data from the Integrated Health Interview Series of working-age adults who were interviewed between 1999 and 2010. They found a significant increase in the percentage of the population classified as having moderate mental health problems, from 3.7 percent in 1999 to 5.1 percent by 2010. There was also a significant increase in the proportion of this group who had public health coverage (from 25.9 percent to 34.8 percent) and a decline in those with private coverage (from 50.2 percent to 39.8 percent.) The authors point out that public insurance typically provides coverage with limited to no out-of-pocket costs and fewer treatment limits than private coverage. Although the authors see the Affordable Care Act as an important opportunity to expand health insurance coverage to people with mental health disorders, they caution that those now eligible to purchase private insurance might still encounter financial hurdles to accessing care.

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Doctors And The Bully(ing) Pulpit

August 29th, 2013

For busy and opinionated physicians, online comments are both catharsis and a form of self-expression. After all, doctors are in the thick of it. We see how policies affect our patients. We know how politics affect our profession. While traditional editorials require time, editing, and an editor’s decision to publish the piece, online comments provide an easy and instantaneous way for even the most overworked and harried physicians to vent publicly. Seeing one’s opinion stream smoothly from brain to fingertips to computer screen feels good.

It is miraculously simple, but it can be problematic. Amid the stresses of patient care in an increasingly complex health care system, the temptation to unleash anger online can be hard to resist. Making sure our voices resonate with equanimity, with professionalism, with decorum, respect, and tolerance takes work.

In some online discussions, the voices have become ugly.

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Analysis Of Post-ACA Uninsured Leads Health Affairs Blog June Top Ten

July 11th, 2013

Who will be left uninsured under the Affordable Care Act? That’s the question addressed by Rachel Nardin and coauthors in the most-read Health Affairs Blog post for June.

Next on last month’s top-ten list: Joanne Pohl and coauthors’ look at the relative numbers of physicians and nurse practitioners choosing primary care specialties. The list also features Christine Cassel’s discussion of her priorities as she assumes the leadership of the National Quality Forum, and Robert Berenson’s proposals for improving quality measurement. Additionally, the top ten includes three posts in Tim Jost’s series on implementing the Affordable Care Act, as well as posts on lessons from early ACA Medicaid expansions, the growth of accountable care organizations, and health information technology for the accountable care era.

The full list appears below:

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