Appendix D

New Perspectives on the Workforce Crisis

Michael R. Bleich, Ph.D., R.N., C.N.A.A.
Associate Dean for Clinical and Community Affairs,
University of Kansas School of Nursing, Kansas City, Kansas

Peggy O'Neil Hewlett, Ph.D., R.N.
Associate Dean for Research and Director of the Doctoral Program,
University of Mississippi School of Nursing, Jacksonville, Mississippi

Thank you Dr. Miller for the kind introduction and to the Division of Nursing for the invitation to present our recently completed analysis of the major reports issued on the imminent workforce shortage. The knowledge we gained from this effort is exemplified in the title of our presentation, NEW PERSPECTIVES ON THE WORKFORCE CRISIS: Defining the Problem and Assuring and Adequate Response. As a result of our research, we strongly believe that­ while many thought and change leaders are striving to address the crisis­the magnitude of demand and the supply demographics are unrecognized, and the gap is severe enough to fundamentally alter health care delivery, the traditional roles of health care workers, and the overall health of the public. Too few are envisioning the severe realities of the problem and the social implications lurking ahead of us.

The presentation will cover these objectives:

• How the RWJ Executive Nurse Fellows Program served as a catalyst for this work; and,
• How the project component of the Fellowship is exemplified in the work that will be presented today by Dr. Cox­on the work environment, and by Dr. Hewlett and her team on the workforce shortage.
• As the individual charged by Dr. Hewlett with leading the research team, I will present the research methodology used, the problem/ solution themes uncovered, and the results of the gap analysis; and
• Dr. Hewlett will present a framework for a comprehensive strategy that addresses and could forestall the workforce crisis through a three-tiered, action-oriented list of "imperatives" to guide efforts and issue development.

The Robert Wood Johnson Executive Nurse Fellows Program is an advanced leadership program for nurses in senior executive roles in health services, public health, and nursing education who aspire to help lead and shape the US health care system of the future.

Since 1998, 15 to 20 Fellows per year have participated in this program, which consists of a core leadership curriculum, seminar and workshop session, pursuit of an individual learning plan, experience selecting and working with senior executive mentors, and the completion of a project jointly funded by fellowship resources and matching funds from the employing institution.

The mission of this program is to inspire experienced nurses in executive roles to continue the journey toward achieving the highest levels of leadership in the health care system of the 21st century. As Shirley Chater, the chair of the national advisory committee for the program states, "Leading is learning." And so, we build on nursing strength and capacity for leading change and­as Fellows­pursue learning.

Learning comes about in five competency domains:

• Interpersonal and communication effectiveness;
• Strategic vision (where we connect broad social, economic, and political changes to the strategic directions of institutions and organizations);
• Risk taking and creativity;
• Inspiring and leading change; and
• Self-knowledge and self-renewal.

Our cohorts span the health care industry and each of us in some way begins to transcend "self" to greater spheres of influence. Ultimately, each Fellow is supported through a collaborative process that involves the Core Resource Team, the National Advisory Committee, and Mentors/Consultants. Participating in this program is an opportunity that lasts a lifetime, and we are grateful to have had this experience!

The workforce project is an exemplar of the types of projects that Fellows use to grow in the competency domains. Supporting this effort have been Core Resource Team members Dr. Maryann Fralic and Dr. Jan Bellack; Mentors Sister May Roch Rocklage, RSM and Dr. Karen Miller; and a collaborator, Dr. Diana Mason, the editor-in-chief of the American Journal of Nursing (AJN), who we sought out early in our research and writing. Working with Dr. Mason and the staff of the AJN met two important goals of ours: to present a major workforce report in a nursing journal, and to reach a broad constituency­which AJN certainly does. Our research is featured in the April 2003 edition of AJN. We appreciate the permission given us to replicate the article and the handouts from the Journal.

In addition to Dr. Hewlett and me, our other primary author and systems researcher was Dr. Susan Santos, who is currently affiliated with the University of Missouri­Kansas City. Our secondary authors, who coded individual reports included: Drs. Rebecca Rice and Karen Cox, and a graduate student, Sheila Richmeier. We could not have done this work without the commitment of each of these individuals.

This work came about in several ways:

• during an RWJ seminar that addressed changing supply and demand demographics with social policy ramifications;
• in conversations with colleagues about workforce reports, where we realized that "many reports were cited, but few had actually been read;"
• and, significantly­through Dr. Hewlett¹s experience with Sr. Roch, who during this span of this work was the Chair of the American Hospital Association. During a board meeting, one of the members asked, "Who is looking at all of the workforce reports and what is common among them? And, who is doing what to solve the problem?"

In June, 2002, Dr. Hewlett convened a summit of leaders (RWJ Fellows that included Karen Cox, Fran Roberts, Catherine Garner, and me) and affiliates of the Colleagues in Caring workforce initiative (including Susan Santos, Rebecca Rice, Wanda Polen, Helen Connors, and Marge Bott). These participants were assigned to review and report on some 35 reports. By the end of the summit, an agenda emerged that included a decision to conduct a formal research analysis on the reports; a Phase II research team (that included Drs. Hewlett and Santos and me) then conducted the integrative review, prepared the analysis and framed the results for dissemination.

In January of 2003 our research was completed, and we believe our efforts have resulted in three major contributions to the profession: (a) a methodology that can be replicated for analyzing reports of this type in the future, (b) a thematic analysis of workforce problems and solutions expressed through a gap analysis, and (c) a framework around which a national comprehensive strategy to address the nursing shortage can be developed. Now, let's examine the methodology.

The methodology we chose was an integrative review, to guide the analysis and coding of data and subsequent theme generation. This method provided structure and analytical rigor to multi-document review, it promoted credibility through triangulation, peer debriefing, reflexive journaling, and purposive sampling and, it fostered dependability through dependability and confirmability audits and reflexive journaling. Interpret this to mean that we were scrupulous in the study of these reports and acknowledged this as serious work with important consequences.

Meta-synthesis is to the analysis of qualitative studies, as meta-analysis is to the comparison of multiple quantitative studies. Using the set of meta-synthesis principles was relevant because of the commonality of subject matter being pursued and the design of most of the documented workforce reports. Key principles helped us (from the very first summit and throughout the study) formulate the research questions, define the research outcomes, set the inclusion/exclusion criteria for reports, select data sources, and develop the coding system.

Further, these principles guided our categorization of the data, obtainment of intercoder consensus, the discussion and interpretation of findings, the identification of paradigms, the uncovering of assumptions, and relating results to a larger context. Finally, the research method and principles helped us to interpret the strengths and limitations of each workforce report, so we could examine paradoxes and contradictions within the reports; and determine gaps.

From the summit and after listening to the critical review of the workforce reports, three research questions were generated:

• What types of data were used to substantiate the health care workforce crisis?
• What descriptive themes expressed the scope and intensity of the workforce problems?
• To what extent did the solutions address the problems?

Although 35 reports were reviewed at the onset of the summit, 15 reports met the inclusion criteria we set for this study. A listing of these reports can be found in your handouts. To be included in the study, each of these reports had a national perspective; were issued between 2000-2002; represented a unique stakeholder perspective (our goal was to generate research outcomes that encompassed the broadest possible view of the workforce problem­so we intentionally examined reports that represented philanthropic organizations, professional and trade organizations, and government and accreditation agencies. These classifications are reflected in your handouts. While we sought the patient-consumer perspective, at that time, no such report could be identified. Also, the reports studied had a primary focus on nursing. Although we recognized that workforce shortages existed within other healthcare disciplines, statements about those disciplines were rare and issued subsequent to nursing reports. Excluded were reports that were limited to state groups, special interest groups, or individual agencies or persons. At this time, I would like to segue into the results of our study.

The first research question was, "What types of data were used to substantiate the health care workforce crisis?" Each of the 15 reports used data in some fashion­and some very extensively­to create the argument that a nursing shortage existed. Our interest was to explore the consistency of the data and to determine whether the sources were both valid and reliable. Turn to the handouts, where you will find our data definitions. Here is what we found: the data populating the reports included facts about nursing supply (current and projected), population demographics (relating primarily to the aging of the nursing workforce, and the number of baby-boomers about to retire), demand (current and projected), and an "other" category (for instance, data about nurse satisfaction with the work environment, or, intent to stay in nursing).

The data cited is valid and reliable, which is good news in terms of report credibility and the resources being expended to recruit and retain nurses. However, the sources of data are not widely dispersed in the reports. Three primary data sources exist: the government (Bureau of Labor Statistics and the National Center for Health Workforce Analysis), Buerhaus and his colleagues (who make strong references to supply and demand), and Aiken and her associates (who pursue nurse staffing and patient outcomes). Generally, a report made use of one of these three key sources as their reference point and then supplemented the report with citations of lesser-known or published authors. Of the data presented, the widest variation occurred associated with the projection of nurses needed, which ranged from shortfalls of 400,000 to 1.5 million by 2020.

The second research question addressed was: "What descriptive themes expressed the scope and intensity of the workforce problems?" The question was answered by coding each key concept and/or paragraph of each report and then grouping like- or related concepts across all reports into themes." From the narrative descriptions, we "teased out" what the various stakeholders saw as "the cause/causes" of the workforce problem. When all was coded, we found that problem themes fell into two categories: those that were national in scope and those that were institutional/organizational in nature. The themes that were identified in our study are also available in the handouts. To be included as a theme and to eliminate/ minimize the "noise" of a potential stakeholder's bias, a theme had to be present in five or more reports. For instance, looking at the handout you see that the theme "health care economics" is a national theme­meaning that stakeholders believe that the workforce problem has its roots in national economics­in 10 of the 15 reports we analyzed. Note the operational definition. In all cases, the operational definitions summarize what stakeholders described in their reports. Also, notice the bulleted sub-themes. A sub-theme was present in at lease three reports in order to be added to our typology. In the example of economics, the concepts "costs of labor" and "reimbursement for nursing services" are sub-themes present in at least three of the the ten reports that discussed health care economics. Take just a moment to examine the four national themes and the four institutional themes and the related sub-themes.

One final comment on these problem themes: Explicit problem statements were rare. We were able to ascertain the problem themes quite easily, but a pervasive clarity about exactly what the problem is, usually had to be inferred: if you are not close to/familiar with the subject, this makes communication about the nursing shortage to various constituencies difficult, to be sure.

We carefully reviewed each report, using the same procedures mentioned before, to identify strategies aimed at solutions to the problems. This answered the third research question: "To what extent did the solutions address the problems?" Because we coded for themes, we did not look for "problem-solution matches" within a single report. For instance, a report may have a solution statement about leadership, but may not have reported leadership as a problem. For our purposes, this was acceptable because we were looking thematically at total effort expended. Four reports stood out as exemplary in the clarity of their solution recommendations: those issued by the American Hospital Association, the Robert Wood Johnson Foundation (Kimball and O'Neil), the Joint Commission on the Accreditation of Healthcare Organizations and the American Organization of Nurse Executives.

Again, by dealing with themes across reports, we believed that we captured the magnitude and impact of problems and solutions getting the majority of effort. We found substantial solutions in the following categories: supply, work environment, research and data support, leadership, workforce development, and technology. Before moving on, recall that I mentioned that problem statements were not explicit. In fact, the text that described solutions was also somewhat problematic. Solutions tended to fall into two categories: they were either very broad (i.e., "increase the supply of nurses"), or were exceedingly specific to a stakeholder¹s interest, such that the "bigger picture" was overlooked.

Through the coding of problems and solutions, we were able to establish what is, to date, in a single snapshot, the most revealing perspective on the workforce crisis. It is presented in the form of a Gap Analysis and noted in the last remaining handout in your presentation materials.

We believe this slide is significant because it portrays the complexity of the workforce problem­noting the themes in the left hand column; and it shows where solutions are being recommended, in the right hand column. Notice, however, that there is not a congruent "mapping" of problems to solutions. Gaps in solutions exist. And, solutions are being reported that seem to be "searching for a problem." We surmise that this might reflect that additional problem areas exist that has not been fully documented.

This we know: the nursing workforce problem is more complex than we originally believed as evidenced by the problem themes. To communicate precisely what the problem areas are is a challenge yet to be solved. And, solutions strategies are not yet comprehensive enough to address the problems. The complexity reflected in the gap analysis sheds insight into why a comprehensive workforce plan may be beyond what could be defined and solved by any one stakeholder.

I will turn the presentation over now to my colleague, Dr. Peggy Hewlett, who will describe a framework that would further the development of a comprehensive workforce plan and a call to action.

Remarks by Peggy O'Neil Hewlett, Ph.D., R.N.
Associate Dean for Research and Director of the Doctoral Program, University of Mississippi School of Nursing
Jacksonville, Mississippi

Thank you, Dr. Bleich. You did a wonderful job discussing the gap analysis. From my perspective, this is the heart of our work.

What we set out to do was synthesize key national reports­trying to make some sense out of what they mean collectively. We accomplished that. However, it was at this point that we realized the need to develop a framework, based on our findings, that will help groups and individuals across the country address this problem. This is how it could work.

What we observe happening around the country are groups (at the national and state levels) making good efforts in attempting to address certain parts of the workforce problem. But the problem is far too complex and resources are scarce­therefore, it makes perfect sense for there to be some type of an orchestrated response from the healthcare industry. Groups could more judiciously use their resources and with greater impact such that the problems are more likely to be solved.

From our research, and based on the gap analysis that resulted, we have determined that a comprehensive workforce plan requires a multilevel approach that fosters national, institutional and nurse-specific efforts. We propose a three-tiered framework for action plans:

• National-level­requiring nationally orchestrated strategies;
• Regional/Institutional level­recognizing that shortages require localized strategies; and,
• Individual/Nurse-specific level­ recognizing that each nurse is called to involvement.

Each of these three tiers has associated with them what we have termed "imperatives" to drive the call for focused action planning. There are seven imperatives: a) three at the national level, b) two at the institutional level, and c) two at the individual level. I will discuss each of them briefly.

National Imperatives. The nursing shortage varies regionally and that is likely to continue. Yet there are overarching concerns, trends, and patterns that merit national consideration, especially around a comprehensive, collaborative approach to solutions. To be sure, national strategies will require public and private efforts. The government should not be expected to "fix" all of the problems, but obviously there are some areas that the government is better positioned to solve.

At the national level, there are three imperatives:

• Economic,
• Workforce Planning and Development, and
• Research and Data.

As we examine each, I will discuss the context of the imperative and share sample strategies that might be developed into action plans. The examples are not intended to be inclusive, but simply serve to give you a flavor of how we see action plans being developed from the problem themes mentioned earlier.

The first national imperative is Economic. The sheer numbers of nurses, compared to other health care professionals, make even slight incremental changes in the workforce potentially stressful on the economy. Therefore, we must develop action plans around sound economic strategies. Samples of these might be:

• Create and adopt public policy that favors fair reimbursement of basic and advanced nursing services, and secondly,
• Establish a venue for public-private sector discussions on the economics of socio-political issues impacting healthcare financing (i.e. re-examine social security regulations limiting employment for older professionals. We are losing large numbers of experienced health care providers from the workforce under current regulations)

The second national imperative considers workforce policy and planning. Nationally, there is a role for public and private sector cooperation in this area. We believe that the current and worsening supply/ demand imbalance will force the reinvention of all health care provider roles. Forums to create new work roles, innovate systems change and promote comprehensive national health care services will require a cooperative spirit among stakeholders. And leadership at the national level will be summoned to higher levels of creativity to influence these changes. Sample strategies to address workforce planning include:

• Increasing support for the six regional Centers for Health Workforce Studies. In fact, this is one of the top three recommendations our research team believes needs immediate action. HRSA¹s National Center for Health Workforce Analysis is charged to "collect, analyze and disseminate health workforce information and facilitate national, state and local workforce planning efforts." These six regional centers hold small HRSA grants to assist in meeting the charge. We understand that these centers will soon test the Nurse Supply Model and Nurse Demand Model datasets. Increased funding needs to be appropriated to support these centers in an effort to disseminate these data and educate healthcare leaders in every state in the use of the models.
• A second sample strategy would be a continued marketing and recruitment campaign, much like the one sponsored by Johnson & Johnson. The other component of this imperative relates to workforce development. From several of the reports it is clear that there is great sentiment toward education reform. This conversation must take place at the national level with key stakeholders at the table. But action must play out at the institutional and regional levels.
• Factors to consider in solving the development issue should focus on increasing the supply of nurses to meet the demand of the service sector, but the importance of the faculty shortage cannot be overlooked. It matters not how many students we can recruit into the pipeline if we don't have sufficient numbers of faculty teach them. Therefore, the second of the top three recommendations made by the research team for action is this: Recruitment into the teaching ranks and improving faculty compensation must become a top priority at the national level.
• A second sample strategy is to enhance continuing education to align with marketplace realities. With a rapidly changing technological workplace and a reduced supply of care providers, support for continuing education should increase accordingly.

The final national imperative I would like to discuss centers on Research and Data. Timely national data regarding the workforce and changing demographics are crucial. Data become increasingly important when the decision-making stakes are high. Without data, sound economic policy cannot be derived, changing workforce trends cannot be accurately projected, and program evaluation & effectiveness cannot be determined. The need will only increase for expanding national databases that include more frequent data collection, standardization and coordination of data, and more specific types of data going beyond supply and demand, to include, for instance, competency requirements. As strategies, we believe that:

• Both federal and non-federal agencies should be identified and charged with the authority and responsibility to collect valid and reliable workforce data; being careful not to duplicate­but to augment­the work of the National Center for Health Workforce Analysis. Public and private funding should be marshaled and provided to those selected entities. A clearinghouse of some sort should be developed to improve data accessibility. There might be more than one model, but the idea of using the six regional centers already mentioned is one viable suggestion.
• In spite of well-accepted recognition of, and funding for the role of research in promoting diagnosis and treatment of disease, that national support for systems and program evaluation research is desperately needed. The research and data imperative carries a high price tag, necessitating both public and private funding. It also demonstrates the need for a collaborative approach to the shortage, marking resources for specific action plans by specific groups­ and limiting duplication of efforts.

Regional and Institutional Imperatives. Not all strategies and action plans are best suited for national work. The role of entities at the regional and institutional level to address the workforce problem themes is supported by our findings. The major institutional strategy addressed in various reports was associated with the work environment. Additionally, the need for enhanced leadership was identified. Therefore, we have developed two imperatives at this level:

• Work climate and
• Leadership and innovation

From our research, the bulk of work and resources are currently being expended is on the work environment. By winnowing out the work that is better suited for national level action, institutions might be able to more clearly focus on these two charges, from which could rise the great demonstration projects so badly needed for education and practice reform. The first institutional level imperative is Work Climate. For multiple reasons, the work climate is in need of dramatic change in order to serve patients, families and care providers. Many providers have had a limited voice in organizational decision-making. As population demographics shift, as reimbursement issues create organizational hardships, when health conditions associated with chronicity add to high patient acuity, and as societal violence acts out in the health care setting, the effects are felt across all practice venues. Sample strategies for this imperative include:

• Ensuring that the basic satisfiers are in place for wages and working conditions; and, second,
• Integrating technology to help nurses work more efficiently and improve patient safety.
• The second institutional-level imperative is based on Leadership and Innovation. Without a doubt, one of the leading reasons that nurses leave the workforce is directly related to their relationship with their immediate supervisor. There is a true call for leadership development across all levels of management and administration. Further, we need leaders to identify and support academic/service partnerships to lead us toward innovative education and practice models. This was identified as a priority in many of the reports we studied. Innovation is often stifled by regulatory and accrediting constraints. Stakeholders must successfully lobby to obtain waivers for some of these guidelines in order to encourage and support creative and innovative solutions to the workforce problems.

This leads to the third "action recommendation" made by our research team: stakeholders must stimulate and support innovation in both education and practice. We must move toward redefining how we educate and utilize our nursing workforce and this will require broad-based involvement, support and acceptance. Turf issues must be set aside in the effort to adequately develop an action plan. ­Finally, under this imperative, we call for a reform in human resource practices, with human resource competencies built into critical job roles, and for human resource departments to take a leadership role in creating an enhanced workplace! We must encourage leadership to emphasize the need for healthy relationships within the workplace and value and reward those efforts.

Individual Imperatives. We would be remiss if we did not identify the critical role that each of us­as individual nurses­plays in resolving the workforce problems. Whether a nurse works in a hospital, clinic, or school of nursing­the business of nursing today is quite difficult. Nurses frequently have little time, energy or capacity to influence institutional change, whether at the national or local level. Yet the involvement of nurses with knowledge, skills and abilities to work effectively with other policy-makers, provider disciplines and consumers will be critical in influencing the transformation of the health care system.

We have two imperatives at the nurse-specific level: Involvement and Adaptive.

Strategies under the Involvement imperative include:

• Committing personal time to, and seeking a voice in, organizational and professional decision-making; second,
• Understanding pressure points within the economic and political systems to influence change at just the right level.

Individual nurses also need to make every effort to support colleagues actively involved in work around the shortage issues.

The second imperative at this level is being Adaptive. Change is the one certainty in what lies ahead:

• We must maintain consumer confidence in nursing through appropriate behaviors while system changes occur; and,
• We must reflect on our personal attitudes on change while respecting the complexities of transition in health care delivery.

In repeated surveys, nurses are consistently highly rated in holding the public's trust. The role we play in maintaining that trust cannot be overstated. Nursing will not be the only discipline experiencing change­it is our belief that education and healthcare delivery will evolve quickly into forms and models unfamiliar to us now. And it is our charge to work diligently to be part of the solution. The health and welfare of the people we serve will likely rest on the level of our involvement and our adaptability. The charge to each of us is clear.

We recognize that there have been emerging efforts and issues. Work has not stopped since these studies were issued. We acknowledge the efforts and initiatives that have been implemented. We also recognize the need for a comprehensive, three-tiered plan that addresses the gaps reflected in this study. Evolving issues include: a) faculty demographics and diminished supply is critical to workforce preparation; b) coordinated solutions are required; c) the problem complexity extends beyond supply, and d) the need for innovation is paramount. Nurse staffing and patient safety linkages are now public.

Based on our work, we have developed a clear Call to Action. A comprehensive workforce plan should include:

• Clear problem statements aligned to each theme;
• Agreement over desired outcomes based on the seven imperatives; and
• Focused, tiered strategies to achieve goals.

There is no longer any merit in groups or individuals claiming that they do not know the workforce problems and solutions from the broader view! Our work has focused both the issues and the charges and there is no longer any place for us to hide. There is also no credible reason for any one entity to approach the broader workforce issues in an effort to articulate them or solve them unilaterally. Our research has demonstrated the complexity of the problems and the unlikelihood that one group can adequately address them.

But, if all stakeholders work together, we can meet the challenges. However, if we choose not to respond­cooperatively ­working toward high-impact solutions ­we stand to compromise our mission of protecting and improving the health of the people we serve.

So, what do we do now? National leaders should convene key stakeholders who must:

• prioritize the imperatives;
• move quickly to fill in essential gaps;
• marshal resources to get work done; and
• be accountable for its completion.

This is our charge to "change leaders:"

• First, use the gap analysis framework. Until now, we have not had a synthesized "report on the reports." Our work has filled in that gap and provides leaders with the bigger picture.
• Second, stimulate innovation in practice. We cannot meet the challenges of this crisis until we grapple with system changes so badly needed.
• Third, respond to the nursing education crisis. Recruiting individuals into the profession must be a high priority and must be mirrored by equal efforts to recruit and retain talented nursing faculty
• Fourth, we must expand data capacity. The need for accessible, reliable and usable data is critical for workforce planning and development across all levels.
• Lastly, throughout each of these efforts, we must establish clinical, financial and operational outcomes.

In conclusion, we now have a road map. It is our job to use it, cite it, and put it into practice. If we do this we will meet the challenges of solving the nursing shortage head-on.

On behalf of Dr. Bleich, Dr. Santos and myself, I thank you for the opportunity to share our research results with you today.