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In this 3rd part of our 6-part series on value-informed nursing practice-practice that focuses on both achieving desired patient outcomes and minimizing the use of costly resources to achieve these outcomes-we focus on the importance of nurses in improving environmental outcomes and reducing costly environmental waste. We also propose how nursing education needs to change to prepare the next generation of nurses to effectively address environmental problems through providing value-informed nursing practice.

Nurses make decisions about the use of costly resources in countless care delivery settings 24 hours a day. Consequently, nurses are inseparably connected to not only the quality and safety of care, but to the cost-of-care as well. This article is Part 1 of a 6-part series on value-informed nursing practice. It describes the concept of 'value-informed nursing practice'-practice that focuses not only on outcomes, but also on the cost of care-as a new way to envision nursing practice.

Background The U.S. health care system faces increasing pressures for reform. The importance of nurses in addressing health care delivery challenges cannot be overstated. Purpose To present a Nursing Health Services Research (NHSR) agenda for the 2020s. Method A meeting of an interdisciplinary group of 38 health services researchers to discuss five key challenges facing health care delivery (behavioral health, primary care, maternal/neonatal outcomes, the aging population, health care spending) and identify the most pressing and feasible research questions for NHSR in the coming decade. Findings Guided by a list of inputs affecting health care delivery (health information technology, workforce, delivery systems, payment, social determinants of health), meeting participants identified 5 to 6 research questions for each challenge. Also, eight cross-cutting themes illuminating the opportunities and barriers facing NHSR emerged. Discussion The Agenda can act as a foundation for new NHSR – which is more important than ever – in the 2020s.

Analysis of Current Population Survey data suggests a tightening labor market for registered nurses, licensed practical nurses, and nursing assistants, marked by falling employment and rising wages through June 2021. Unemployment rates remain higher in nonhospital settings and among registered nurses and nursing assistants who are members of racial and ethnic minority groups.

Different staffing configurations in primary and geriatric care practices could have implications for how best to deliver services that are essential for a growing population of older adults. Using data from a 2018 survey of physicians (MDs) and nurse practitioners (NPs) working in primary and geriatric care, we assessed whether different configurations were associated with better or worse performance on a number of standard process measures indicative of comprehensive, high-quality primary care. Practices with a large concentration of MDs had the highest estimated labor costs. Practices high in NPs and physician assistants (PAs) were most common in states that grant full scope of practice to NPs. The high-NP/PA configuration was associated with a 17-percentage-point greater probability of facilitating patient visits and a 26-percentage-point greater probability of providing the full bundle of primary care services compared with the high-MD model. Team-based configurations had a 27.7-percentage-point greater probability of providing the full bundle of primary care services. The complex needs of older adults may be best served by team-based practices with a broad provider mix that can provide a range of services in the office and the community.

Background Little is known about the extent of ordering low-value services by. Purpose To compare the rates of low-value back images ordered by primary care physicians (PCMDs) and primary care nurse practitioners (PCNPs). Method We used 2012 and 2013 Medicare Part B claims for all beneficiaries in 18 hospital referral regions (HRRs) and a measure of low-value back imaging from Choosing Wisely. Models included random clinician effect and fixed effects for beneficiary age, disability, Elixhauser comorbidities, clinician sex, the emergency department setting, back pain visit volume, organization, and region (HRR). Findings PCNPs (N = 231) and PCMDs (N = 4,779) order low-value back images at similar rates (NP: all images: 26.5%; MRI/CT: 8.4%; MD: all images: 24.5%; MRI/CT: 7.7%), with no detectable significant difference when controlling for covariates. Discussion PCNPs and PCMDs order low-value back images at an effectively similar rate.

Little is known about practice pattern differences between nurse practitioners (NPs) and physician assistants (PAs). We compared the rates of low-value back images ordered by NPs and PAs. For this comparison, we used 2012-2013 Medicare Part B claims for all beneficiaries in 18 hospital referral regions and a measure of low-value back imaging from the Choosing Wisely recommendations. Models included a random clinician effect and fixed effects for beneficiary age, disability, Elixhauser comorbidities, clinician type, the emergency department setting, and region. NPs ( N = 234) order low-value back images significantly less than PAs ( N = 204) (NPs 25.5% vs. PAs 39.2%, p < .0001). Controlling for relevant factors, NPs are 10.0 percentage points ( p < .0001) less likely to order a low-value back image than PAs. NPs and PAs have distinct patterns of low-value back imaging, which is likely a reflection of their different practice settings.

Supplemental Digital Content is available in the text., Objective: Applied to value-based health care, the economic term “individual productivity” refers to the quality of an outcome attributable through a care process to an individual clinician. This study aimed to (1) estimate and describe the discharge preparation productivities of individual acute care nurses and (2) examine the association between the discharge preparation productivity of the discharging nurse and the patient’s likelihood of a 30-day return to hospital [readmission and emergency department (ED) visits]. Research Design: Secondary analysis of patient-nurse data from a cluster-randomized multisite study of patient discharge readiness and readmission. Patients reported discharge readiness scores; postdischarge outcomes and other variables were extracted from electronic health records. Using the structure-process-outcomes model, we viewed patient readiness for hospital discharge as a proximal outcome of the discharge preparation process and used it to measure nurse productivity in discharge preparation. We viewed hospital return as a distal outcome sensitive to discharge preparation care. Multilevel regression analyses used a split-sample approach and adjusted for patient characteristics. Subjects: A total 522 nurses and 29,986 adult (18+ y) patients discharged to home from 31 geographically diverse medical-surgical units between June 15, 2015 and November 30, 2016. Measures: Patient discharge readiness was measured using the 8-item short form of Readiness for Hospital Discharge Scale (RHDS). A 30-day hospital return was a categorical variable for an inpatient readmission or an ED visit, versus no hospital return. Results: Variability in individual nurse productivity explained 9.07% of variance in patient discharge readiness scores. Nurse productivity was negatively associated with the likelihood of a readmission (−0.48 absolute percentage points, P

Care management programs have become more widely adopted as health systems try to improve the coordination and integration of services across the continuum of care, especially for frail older adults. Several models of care suggest the inclusion of registered nurses (RNs) and social workers to assist in these activities. In a 2018 national survey of 410 clinicians in 363 primary care and geriatrics practices caring for frail older adults, we found that nearly 40 percent of practices had no social workers or RNs. However, when both types of providers did work in a practice, social workers were more likely than RNs to be reported to participate in social needs assessment and RNs more likely than social workers to participate in care coordination. Physicians' involvement in social needs assessment and care coordination declined significantly when social workers, RNs, or both were employed in the practice.

Overuse and inappropriate use of emergency departments (EDs) remains an important issue in health policy. After implementation of Medicaid expansion, many states experienced an increase in ED use, but the magnitude varied. Differential access to primary care might explain such variation.To determine whether the increase in ED use among Medicaid enrollees following Medicaid expansion was smaller in states that allowed greater access to primary care providers by permitting nurse practitioners (NPs) to practice without physician oversight.Examining data on ED use by Medicaid beneficiaries, we estimated random effects models to examine changes in ED visits. Models for 8 different clinical conditions were estimated, with each model including a linear time trend, indicators for Medicaid expansion and for the absence of physician oversight requirements, and an interaction between these 2 indicators.States requiring physician oversight of NPs had a 28% increase in ED visits relative to the preexpansion period, while states allowing NP practice without physician oversight had only a 7% increase. The increase in the share of visits covered by Medicaid in no-oversight states was 40% of the size of the increase in oversight states.Allowing NPs to practice without physician oversight was associated with a reduction in the magnitude of increase in ED use following Medicaid expansion. States that restrict NP practice should weigh the costs of maintaining these restrictions against the potential benefits of lower ED use. States considering Medicaid expansion should also consider relaxing NP scope-of-practice laws.

Among the many trends influencing health and health care delivery over the next decade, three are particularly important: the transition to value-based care and increased focus on population health; the shift of care from acute to community-based settings; and addressing the vulnerability of rural health care systems in North Carolina.

Ensuring and Sustaining a Pandemic Workforce It seems clear that health care delivery organizations, educators, and government leaders all have to be willing to cut through bureaucratic barriers an...

Concerns about physician shortages have led policy makers in the US public and private sectors to advocate for the greater use of nurse practitioners (NPs). We examined recent changes in demographic, employment, and earnings characteristics of NPs and the implications of those changes. In the period 2010-17 the number of NPs in the US more than doubled from approximately 91,000 to 190,000. This growth occurred in every US region and was driven by the rapid expansion of education programs that attracted nurses in the Millennial generation. Employment was concentrated in hospitals, physician offices, and outpatient care centers, and inflation-adjusted earnings grew by 5.5 percent over this period. The pronounced growth in the number of NPs has reduced the size of the registered nurse (RN) workforce by up to 80,000 nationwide. In the future, hospitals must innovate and test creative ideas to replace RNs who have left their positions to become NPs, and educators must be alert for signs of falling earnings that may signal the excess production of NPs.

Highlights • MDs report that MDs are their team leaders in most circumstances; NPs are less likely to indicate that MDs lead their teams. • Less than half of MD or NP clinicians agree that they experience excellent team work in their units • Significantly more MDs than NPs agree their role in the care team is clear, Importance The delivery of emergency, trauma, critical and intensive care services requires coordination among all members of the care team. Perceived teamwork and role clarity may vary among physicians (MDs) and nurse practitioners (NPs). Objective To examine differences in perceived roles and responsibilities of NPs and MDs practicing in emergency, trauma, critical and intensive care. Main Outcome(s) and Measure(s) Key clinical activities, perceptions of role clarity, teamwork and preparedness to function as a team in disaster Design Secondary Analysis of the National Survey of Emergency, Intensive and Critical Care Nurse Practitioners and Physicians, a 2015 cross-sectional national survey of clinicians. Setting Mail survey of randomly selected stratified cross-sectional samples of MDs and NPs drawn from national lists of clinicians in eligible specialties working in emergency, trauma, intensive and critical care units in the United States. Participants 814 clinicians (351 NPs and 463 MDs) recruited from national by postal mail survey. Our initial sample included n=2063 clinicians, n=1031 NPs and n=1032 MDs in eligible specialties. Of these, 63.5% of NPs and 70.1% of MDs completed and returned the survey excluding those who were ineligible due to lack of current practice in a relevant specialty Results NPs in ICU/CCU are more likely to be female and report working fewer hours than do MDs and provide direct care to more patients. 55% of NPs and 82% of MDs agree that their individual role in their unit is clear (p

To describe physicians' and nurse practitioners' perceptions of the national and local PICU physician and other provider supply in institutions that employ PICU nurse practitioners, assess for differences in perceptions of supply, and evaluate the intent of institutions to hire additional nurse practitioners to work in PICUs.National, quantitative, cross-sectional descriptive study via a postal mail survey from October 2016 to January 2017.Institutions (n = 140) identified in the 2015 American Hospital Association Annual Survey with a PICU who employ PICU nurse practitioners.PICU physician medical directors and nurse practitioners.None.There were 119 respondents, representing 93 institutions. Responses were received from 60 PICU medical directors (43%) and 59 lead nurse practitioners (42%). More than half (58%) of all respondents reported the national supply of PICU physicians is less than demand and 61% reported the local supply of PICU providers (physicians in all stages of training, nurse practitioners, and physician assistants) is less than demand. Of the respondents from institutions that self-reported a local provider shortage (n = 54), three fourths (78%) reported plans to increase the number of PICU nurse practitioners in the next 3 years and 40% were likely to expand the nurse practitioner's role in patient care.Most PICU medical directors and lead nurse practitioners in institutions that employ PICU nurse practitioners perceived that national and local supply of providers to be less than the demand. Nurse practitioners are employed in PICUs as part of interdisciplinary models of care being used to address provider demand. The demand for more PICU nurse practitioners with expanded roles in care delivery was reported. Further evaluation of models of care and provider roles in care delivery can contribute to aligning provider supply with demand for care delivery.

Objective: To describe the members of pediatric intensive care unit interdisciplinary provider teams and labor inputs, working conditions, and clinical practice of pediatric intensive care unit nurse practitioners. Methods: A national, quantitative, crosssectional, descriptive postal survey of pediatric intensive care unit medical directors and nurse practitioners was administered to gather information about provider-team members, pediatric intensive care unit nurse practitioner labor inputs, working conditions, and clinical practice. Descriptive statistics, cross-tabulations, and χ2 tests were used. Results: Responses from 97 pediatric intensive care unit medical directors and 59 pediatric intensive care unit nurse practitioners representing 126 institutions were received. Provider-team composition varied between institutions with and without nurse practitioners. Pediatric intensive care units employed an average of 3 full-time nurse practitioners; the average nurse practitioner-to-patient ratio was 1 to 5. The clinical practice reported by medical directors was consistent with practice reported by nurse practitioners. Conclusion: Nurse practitioners are integrated into interdisciplinary pediatric intensive care unit teams, but institutional variation in team composition exists. Investigating models of care contributes to the understanding of how models influence positive patient and organizational outcomes and may change future role implementation.

The behavioral health workforce, which encompasses a broad range of professions providing prevention, treatment, and rehabilitation services for mental health conditions and substance use disorders, is in the midst of what is considered by many to be a workforce crisis. The workforce shortage can be attributed to both insufficient numbers and maldistribution of workers, leaving some communities with no behavioral health providers. In addition, demand for behavioral health services has increased more rapidly as a result of federal legislation over the past decade supporting mental health and substance use parity and by healthcare reform. In order to address workforce capacity issues that impact access to care, the field must engage in extensive planning; however, these efforts are limited by the lack of timely and useable data on the behavioral health workforce. One method for standardizing data collection efforts is the adoption of a Minimum Data Set. This article describes workforce data limitations, the need for standardizing data collection, and the development of a behavioral health workforce Minimum Data Set intended to address these gaps. The Minimum Data Set includes five categorical data themes to describe worker characteristics: demographics, licensure and certification, education and training, occupation and area of practice, and practice characteristics and settings. Some data sources align with Minimum Data Set themes, although deficiencies in the breadth and quality of data exist. Development of a Minimum Data Set is a foundational step for standardizing the collection of behavioral health workforce data. Key challenges for dissemination and implementation of the Minimum Data Set are also addressed. Supplement information This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.

To examine differences in the quality of care provided by primary care nurse practitioners (PCNPs), primary care physicians (PCMDs), or both clinicians.Medicare part A and part B claims during 2012-2013.Retrospective cohort design using standard risk-adjustment methodologies and propensity score weighting assessing 16 claims-based quality measures grouped into 4 domains of primary care: chronic disease management, preventable hospitalizations, adverse outcomes, and cancer screening.Continuously enrolled aged, disabled, and dual eligible beneficiaries who received at least 25% of their primary care services from a random sample of PCMDs, PCNPs, or both clinicians.Beneficiaries attributed to PCNPs had lower hospital admissions, readmissions, inappropriate emergency department use, and low-value imaging for low back pain. Beneficiaries attributed to PCMDs were more likely than those attributed to PCNPs to receive chronic disease management and cancer screenings. Quality of care for beneficiaries jointly attributed to both clinicians generally scored in the middle of the PCNP and PCMD attributed beneficiaries with the exception of cancer screening.The quality of primary care varies by clinician type, with different strengths for PCNPs and PCMDs. These comparative advantages should be considered when determining how to organize primary care to Medicare beneficiaries.

Background Studies suggest nurse practitioners are heavily represented among primary care providers for vulnerable Medicare beneficiaries. Purpose The purpose of this study was to compare quality indicators among three groups of vulnerable beneficiaries managed by MDs and nurse practitioners (NPs). Methods The methods include retrospective cohort design examining 2012 and 2013 Medicare claims for three beneficiary groups: (a) initially qualified for the program due to disability, (b) dually eligible for Medicare and Medicaid, and (c) both disabled and dually eligible. Validated quality indicators in four domains were analyzed. Discussion Gaps in outcomes suggest better performance for primary care nurse practitioners (PCNPs) in preventable hospitalizations and adverse outcomes. Outcome gaps suggesting better performance for primary care physicians in chronic disease management were diminished for beneficiaries who were both disabled and dually eligible suggesting improved performance for PCNPs within this subpopulation. Conclusion These findings add new evidence indicating the quality of primary care provided to vulnerable Medicare beneficiaries by PCNPs is generally consistent with clinical guidelines and the less intensive use of costly health care services.

Implications of an Aging Rural Physician Workforce As fewer younger physicians enter rural practice in the United States, the rural physician workforce is graying and nearing retirement. The uneven...

Background Little is known about the geographic distribution of the overall primary care workforce that includes both physician and nonphysician clinicians--particularly in areas with restrictive nurse practitioner scope-of-practice laws and where there are relatively large numbers of uninsured. Objective We investigated whether geographic accessibility to primary care clinicians (PCCs) differed across urban and rural areas and across states with more or less restrictive scope-of-practice laws. Research design An observational study. Subjects 2013 Area Health Resource File (AHRF) and US Census Bureau county travel data. Measures The measures included percentage of the population in low-accessibility, medium-accessibility, and high-accessibility areas; number of geographically accessible primary care physicians (PCMDs), nurse practitioners (PCNPs), and physician assistants (PCPAs) per 100,000 population; and number of uninsured per PCC. Results We found divergent patterns in the geographic accessibility of PCCs. PCMDs constituted the largest share of the workforce across all settings, but were relatively more concentrated within urban areas. Accessibility to nonphysicians was highest in rural areas: there were more accessible PCNPs per 100,000 population in rural areas of restricted scope-of-practice states (21.4) than in urban areas of full practice states (13.9). Despite having more accessible nonphysician clinicians, rural areas had the largest number of uninsured per PCC in 2012. While less restrictive scope-of-practice states had up to 40% more PCNPs in some areas, we found little evidence of differences in the share of the overall population in low-accessibility areas across scope-of-practice categorizations. Conclusions Removing restrictive scope-of-practice laws may expand the overall capacity of the primary care workforce, but only modestly in the short run. Additional efforts are needed that recognize the locational tendencies of physicians and nonphysicains.

Research has shown male registered nurses (RNs) outearn their female colleagues by approximately $5,000 annually. The aim of this study was to explore differences in characteristics of female and male fulltime employed RNs, and to examine whether these differences help account for the female-male earnings gap in nursing. Specifically, the researchers tested whether the gender earnings gap could be explained by differences in career aspiration, workplace experience, time taken out of the labor force for child-rearing, and physical strength. While some evidence suggested motivational differences in career aspirations between female and male RNs exist, evidence supporting other hypotheses was not found. Given the expansion of nurses' roles in health care delivery, serious deliberations of how to respond to the earnings gap in nursing is warranted.

To describe the extent to which organizational regulation of pediatric intensive care unit (PICU) nurse practitioner (NP) practice and prescriptive authority aligns with state scope-of-practice (SSOP) regulations, to examine differences between PICU medical directors' and NPs' report of regulation, and to describe organizational-level restriction of PICU NP practice.A 34-item national, quantitative cross-sectional descriptive survey of US PICU medical directors and NPs included demographic, institutional characteristics, and PICU NP regulation and role-related questions. Invitations to participate were sent between October 2016 and January 2017.Respondents (n = 121, 60 PICU NPs and 61 PICU medical directors) reported that 30% of PICU NPs have additional organizational restrictions beyond their SSOP practice authority and 11% have prescriptive authority regulations that exceed those required by the SSOP regulations. Medical directors and lead NPs showed agreement in reports of NP practice regulation. Variation in organizational-level restrictions of privileging, billing, and reporting structure practices were identified.As more states move to full SSOP regulatory environments, organizational regulation of NP practice can impede attainment of full practice authority. Future research is needed to determine whether variations in regulation of PICU NP practice influence patient outcomes, interdisciplinary collaboration, and NP role actualization.

Objective This study is designed to assess the cost of services provided to Medicare beneficiaries by nurse practitioners (NPs) billing under their own National Provider Identification number as compared to primary care physicians (PCMDs). Data Source Medicare Part A (inpatient) and Part B (office visit) claims for 2009–2010. Study Design Retrospective cohort design using propensity score weighted regression. Data Extraction Methods Beneficiaries cared for by a random sample of NPs and primary care physicians. Principal Findings After adjusting for demographic characteristics, geography, comorbidities, and the propensity to see an NP, Medicare evaluation and management payments for beneficiaries assigned to an NP were $207, or 29 percent, less than PCMD assigned beneficiaries. The same pattern was observed for inpatient and total office visit paid amounts, with 11 and 18 percent less for NP assigned beneficiaries, respectively. Results are similar for the work component of relative value units as well. Conclusions This study provides new evidence of the lower cost of care for beneficiaries managed by NPs, as compared to those managed by PCMDs across inpatient and office-based settings. Results suggest that increasing access to NP primary care will not increase costs for the Medicare program and may be cost saving.

Background Projections of physician shortages, an aging population, and insurance expansions have increased interest in expanding the number of primary care nurse practitioners (PCNPs) in the United States. Although information about the number and distribution of nurse practitioners is known, there is little information about the practice characteristics of PCNPs. The purpose of this study was to identify demographic and practice characteristics of PCNPs and compare these characteristics with primary care physicians (PCMDs). Methods From November 23, 2011, to April 9, 2012, we conducted a national postal mail survey of 972 clinicians (467 PCNPs and 505 PCMDs). Questionnaire domains included compensation and billing practices; characteristics of patients treated; PCNPs' use of their own National Provider Identification number to bill services; how PCNPs spend their time; clinical and nonclinical activities performed; and whether PCNPs have privileges to admit, round on (i.e., oversee the care provided to) patients, and write orders independently of physicians. The response rate was 61.2%. Discussion PCNPs are more likely than PCMDs to practice in urban and rural areas, provide care in a wider range of community settings, and treat Medicaid recipients and other vulnerable populations. Not only do most PCNPs work with PCMDs, but also the majority of both clinicians believe that increasing the supply of PCNPs will result in greater collaboration and team practice. Although PCNPs and PCMDs deliver similar services and spend their time in nearly identical ways, PCNPs work less hours and see fewer patients, and only a handful of PCNPs have their salary adjusted for productivity and quality performance. PCNPs cite government and local regulations as impeding their capacity to admit and round on patients in hospitals and long-term care facilities and write treatment orders without a physician cosignature. Conclusions Significant differences in demographic and practice characteristics exist between PCNPs and PCMDs. Whether working independently or with PCMDs, increasing the number of PCNPs can be expected to expand access to primary care, particularly for vulnerable populations, and for those gaining access to health insurance through the Affordable Care Act.

Patients can hold physicians directly or vicariously liable for the malpractice of nurse practitioners under their supervision. Restrictive scope-of-practice laws governing nurse practitioners can ease patients’ legal burdens in establishing physician liability. We analyze the effect of restrictive scope-of-practice laws on the number of malpractice payments made on behalf of physicians between 1999 and 2012. Enacting less restrictive scope-of-practice laws decreases the number of payments made by physicians by as much as 31%, suggesting that restrictive scope-of-practice laws have a salient extraregulatory effect on physician malpractice rates. The effect of enacting less restrictive laws varies depending on the medical malpractice reforms that are in place, with the largest decrease in physician malpractice rates occurring in states that have enacted fewer malpractice reforms. Relaxing scope-of-practice laws could mitigate the adverse extraregulatory effect on physicians identified in this study and could also lead to improvements in access to care.

Baby-boomer registered nurses (RNs), the largest segment of the RN workforce from 1981 to 2012, are now retiring. This would have led to nurse shortages but for the surprising embrace of the profession by millennials-who are entering the nurse workforce at nearly double the rate of the boomers. Still, the boomers' retirement will reduce growth in the size of the RN workforce to 1.3 percent per year for the period 2015-30.

Context: State scope of practice (SoP) laws impose significant restrictions on the services that a nurse practitioner (NP) may provide in some states, yet evidence about SoP limitations on the quality of primary care is very limited. Method: This study uses six different classifications of state regulations and bivariate and multivariate analyses to compare beneficiaries attributed to primary care nurse practitioners and primary care physicians in 2013 testing two hypotheses: (1) chronic disease management, cancer screening, preventable hospitalizations, and adverse outcomes of care provided by primary care nurse practitioners are better in reduced and restricted practice states compared to states without restrictions and (2) by decreasing access to care, SoP restrictions negatively affect the quality of primary care. Findings: Results show a lack of consistent association between quality of primary care provided by NPs and state SoP restrictions. Conclusion: State regulations restricting NP SoP do not improve the quality of care.

Numerous forecasts have predicted shortages of primary care providers, particularly in light of an expected increase in patient demand resulting from the Affordable Care Act. Yet these forecasts could be inaccurate because they generally do not allow for changes in the way primary care is delivered. We analyzed the impact of two emerging models of care--the patient-centered medical home and the nurse-managed health center--both of which use a provider mix that is richer in nurse practitioners and physician assistants than today's predominant models of care delivery. We found that projected physician shortages were substantially reduced in plausible scenarios that envisioned greater reliance on these new models, even without increases in the supply of physicians. Some less plausible scenarios even eliminated the shortage. All of these scenarios, however, may require additional changes, such as liberalized scope-of-practice laws; a larger supply of medical assistants, licensed practical nurses, and aides; and payment changes that reward providers for population health management.

A b s t r ac t Background The U.S. health care system is at a critical juncture in health care workforce planning. The nation has a shortage of primary care physicians. Policy analysts have proposed expanding the supply and scope of practice of nurse practitioners to address increased demand for primary care providers. These proposals are controversial. Methods From November 23, 2011, to April 9, 2012, we conducted a national postal-mail survey of 972 clinicians (505 physicians and 467 nurse practitioners) in primary care practice. Questionnaire domains included scope of work, practice characteristics, and attitudes about the effect of expanding the role of nurse practitioners in primary care. The response rate was 61.2%. Results Physicians reported working longer hours, seeing more patients, and earning higher incomes than did nurse practitioners. A total of 80.9% of nurse practitioners reported working in a practice with a physician, as compared with 41.4% of physicians who reported working with a nurse practitioner. Nurse practitioners were more likely than physicians to believe that they should lead medical homes, be allowed hospital admitting privileges, and be paid equally for the same clinical services. When asked whether they agreed with the statement that physicians provide a higher-quality examination and consultation than do nurse practitioners during the same type of primary care visit, 66.1% of physicians agreed and 75.3% of nurse practitioners disagreed. Conclusions Current policy recommendations that are aimed at expanding the supply and scope of practice of primary care nurse practitioners are controversial. Physicians and nurse practitioners do not agree about their respective roles in the delivery of primary care. (Funded by the Gordon and Betty Moore Foundation and others.)

Since the 1970s, a number of initiatives have attempted to increase the proportion of nursing graduates with a baccalaureate degree, but with little national effect. Now market forces, health reforms, and an Institute of Medicine report (2011) have combined to transform the educational composition of the nursing workforce. Today, there are considerably more graduates of baccalaureate nursing programs than associate degree programs. The educational transformation of the nursing workforce is not limited to baccalaureate education but includes the rapidly increasing numbers of registered nurses who have earned graduate degrees. These changes in nursing education are increasing the readiness of nursing professionals to capitalize on new opportunities, overcome challenges, and take on new roles and responsibilities as the nation's health care delivery and payments systems evolve in coming years.

The objective of this study was to examine RNs' experiences with health information technology (HIT) and their perceptions of the effect of this technology on quality of care and daily work. The adoption and use of HIT are expected to increase substantially over the next 5 years because of policy efforts at the federal and state levels. Given the size of the RN workforce and their critical role in healthcare delivery, their experiences with HIT could help adoption efforts. The method used was a nationally representative survey of 1500 nurses with a 56% response rate. Findings suggest wide variation in the availability of HIT functionality, with functions more likely available to hospital RNs. Overall, RNs perceived the effect of these technologies on quality of care and their daily work as positive. Ensuring that HIT systems are relevant to and usable for RNs will be a critical component in achieving the meaningful use of these systems.

Objective : The objective of the study was to compare perceptions of RNs employed in Magnet®, in-process (ie, hospitals seeking Magnet recognition), and non-Magnet hospitals using data from the 2010 National Survey of Registered Nurses (NSRN). Background : The NSRN is administered biennially and measures nurses' perceptions about their profession, workplace environment, and professional relationships. Methods : Self-administered mail survey to a national sample of 1,500 RNs was used. Bivariate statistical techniques were used to analyze responses from 518 nurses who indicated their employer's Magnet status and to examine associations between Magnet status and the nurses' perceptions of career satisfaction, the nursing shortage, work environment, opportunities to influence the workplace, and professional relationships. Results : Nurses employed in all 3 groups (Magnet, in-process, and non-Magnet hospitals) were uniformly satisfied with being a nurse, although significantly more Magnet and in-process nurses would recommend nursing as a career than would non-Magnet RNs. Views of workplace safety were similar across groups, with no significant differences in violence, verbal abuse, discrimination, or harassment; however, Magnet nurses reported significantly more musculoskeletal injuries. Magnet and in-process nurses rated opportunities to influence decisions about workplace organization and participate in shared governance and employer-paid continuing education, and relationships with advanced practice nurses and nursing faculty higher than did non-Magnet nurses; relationships with new nurses and physicians were not different across groups. Conclusions : The Magnet program continues to have a positive influence on nurses, their decision making, and their professional relationships. The paucity of other differences suggests that Magnet, in-process, and non-Magnet organizations are increasingly guided by a shared set of principles that define a positive professional environment derived not only by the Magnet program, but also by other professional organizations and forces.

Cross-sectional studies of hospital-level administrative data have shown an association between lower levels of staffing of registered nurses (RNs) and increased patient mortality. However, such studies have been criticized because they have not shown a direct link between the level of staffing and individual patient experiences and have not included sufficient statistical controls.We used data from a large tertiary academic medical center involving 197,961 admissions and 176,696 nursing shifts of 8 hours each in 43 hospital units to examine the association between mortality and patient exposure to nursing shifts during which staffing by RNs was 8 hours or more below the staffing target. We also examined the association between mortality and high patient turnover owing to admissions, transfers, and discharges. We used Cox proportional-hazards models in the analyses with adjustment for characteristics of patients and hospital units.Staffing by RNs was within 8 hours of the target level for 84% of shifts, and patient turnover was within 1 SD of the day-shift mean for 93% of shifts. Overall mortality was 61% of the expected rate for similar patients on the basis of modified diagnosis-related groups. There was a significant association between increased mortality and increased exposure to unit shifts during which staffing by RNs was 8 hours or more below the target level (hazard ratio per shift 8 hours or more below target, 1.02; 95% confidence interval [CI], 1.01 to 1.03; P0.001). The association between increased mortality and high patient turnover was also significant (hazard ratio per high-turnover shift, 1.04; 95% CI, 1.02 to 1.06; P0.001).In this retrospective observational study, staffing of RNs below target levels was associated with increased mortality, which reinforces the need to match staffing with patients' needs for nursing care. (Funded by the Agency for Healthcare Research and Quality.).

Key Points Question Is the growth of accountable care organizations associated with changes in physician work hours, probability of being self-employed, and probability of working in a hospital? Findings In this cross-sectional study including 49 582 physicians, a 10–percentage point increase in accountable care organization enrollment in a hospital referral region was associated with a statistically significant reduction of 0.82 work hours per week among male physicians. In addition, the 10–percentage point increase was associated with a decrease of 2% in the probability of all physicians being self-employed. Meaning These results suggest that accountable care organizations may affect physician employment patterns., Importance The share of the population covered by accountable care organizations (ACOs) is growing, but the association between this increase and physician employment is unknown. Objective To investigate the association between the growth of ACOs and changes in physician work hours, probability of being self-employed, and probability of working in a hospital. Design, Setting, and Participants A fixed-effects design was used in this cross-sectional study to compare changes in physician employment in hospital referral regions with high vs low ACO growth. A nationally representative 1% sample of all working US physicians obtained annually from 2011 through 2015 from the American Community Survey (N = 49 582) was included. Data analysis was conducted from March 28, 2017, to April 10, 2018. Main Outcomes and Measures Physician hours worked per week, probability of being self-employed, and probability of working in a hospital. Results Of the 49 582 physicians included in the study, 63.5% were men; the mean (SD) age of sampled physicians was 46.01 (11.59) years. In 2011, sampled physicians worked a mean (SD) of 52.2 (16.1) hours per week, 24.43% were self-employed, and 42.03% worked in a hospital. A 10–percentage point increase in ACO enrollment in a hospital referral region was associated with a statistically significant reduction of 0.82 (95% CI, −1.52 to −0.13; P = .02) work hours in men and a decrease of 2% (95% CI, −3.8% to −0.1%; P = .04) in the probability of all physicians being self-employed. The association with self-employment was strongest (−5.0%; 95% CI, −8.7% to −1.4%; P = .006) in physicians aged 50 to 69 years, who were also more likely (4.0%; 95% CI, 1.0% to 6.9%; P = .009) to work in a hospital. Conclusions and Relevance The growth of ACOs within hospital referral regions appears to be associated with a reduction in hours of work and self-employment among physicians. These results suggest that ACOs may affect physician employment patterns., This cross-sectional study evaluates the association between the expansion of accountable care organizations throughout the United States and changes in physician work hours, self-employment, and employment in hospitals.

Objective: This study explores the interactions among phases of team coordination, patient-related information, decision-making levels, and role holders in intensive care units (ICUs). Background: The effects of communication improvement initiatives on adverse patient events or improved outcomes have been difficult to establish. Conceptual inconsistencies and methodological shortcomings suggest insufficient understanding about clinical communication and care coordination. Method: Data were collected by shadowing a charge nurse, fellow, resident, and nurse in each of eight ICUs and recording each of their conversations during 12 hrs (32 role holders during 350 hrs). Results: Hierarchical log linear analyses show statistically significant three-way interactions between the patient information, phases of team coordination, and decision levels, χ2( df = 75) = 212, p < .0001; between roles, phases of team coordination, and decision levels, χ2( df = 60) = 109, p < .0001; and between roles, patient information, and decision levels, χ2( df = 60) = 155, p < .0001. Differences among levels of the variables were evaluated with the use of standardized parameter estimates and 95% confidence intervals. Conclusion: ICU communication and care coordination involve complex decision structures and role interactions across two information spaces. Different role holders mediate vertical and lateral process flows with goals and directions representing an important conceptual transition. However, lateral isolation within decision levels (charge nurses) and information overload (residents) are potential communication and care coordination vulnerabilities. Results are consistent with and extend the findings of previous studies. Application: The profile of ICU communication and care coordination provides a systemic framework that may inform future interventions and research.

Objectives To compare how registered nurses view the work environment and the nursing shortage based on the Magnet status of their organizations. Background The upsurge in organizations pursuing and obtaining Magnet recognition provides increased opportunities to investigate whether and how registered nurses who are employed in Magnet organizations and organizations pursuing Magnet status perceive differences in the nursing shortage, hospitals' responses to the shortage, characteristics of the work environment, and professional relationships. Methods A nationally representative sample of registered nurses licensed to practice in the United States was surveyed. The views of registered nurses who worked in Magnet organizations, organizations in the process of applying for Magnet status, and non-Magnet organizations were analyzed as independent groups. Results Significant differences were found. Although there is a clear Magnet difference, there are also identifiable differences that occur during the pursuit of Magnet recognition. Conclusion Many organizations in the process of applying for Magnet status rated higher than Magnet organizations, indicating that there is much to do to maintain the comparative advantages for Magnet hospitals.

The imposition of mandatory hospital nurse staffing ratios is among the more visible public policy initiatives affecting the nursing profession. Although the practice is intended to address problems in hospital nurse staffing and quality of patient care, this commentary argues that staffing ratios will lead to negative consequences for nurses involving the equity, efficiency, and costs of producing nursing care in hospitals. Rather than spend time and effort attempting to regulate nurse staffing, this commentary offers alternatives strategies that are directed at fixing the problems that motivate the advocates of staffing ratios.

Although the number of people entering nursing in their early to mid-twenties remains at its lowest point in forty years, large numbers of people are entering the profession in their late twenties and early thirties. And although it remains unclear why people are becoming nurses later, there is evidence that nursing is attracting interest from different segments of the potential workforce than it was in the 1970s and 1980s. We analyze these trends using data through 2005 and a revised forecast model that still predicts a nurse shortage by 2020, but a smaller one than previously forecast.

Providing regional projections of the RN workforce will allow underlying differences in the age structure of the RN workforce to become more visible. By providing regional-level projections, it will also be possible to identify those regions whose RN workforce is expected to grow at a slower rate relative to other regions. States in the South and Midwest have a greater supply of younger-aged RNs available to replace fewer numbers of older-age RNs compared to other regions. In contrast, the Northeast and West have fewer younger RNs currently in their workforce yet a relatively larger number of older age RNs to replace. These differences in age structure may be partly due to differences in nursing school enrollment and expansion in nursing education capacity across regions. This information can help guide national and state health workforce planners, employers, educators, and others in developing policies and initiatives that may impact nursing supply in their states.

Importance After forecasts made more than a decade ago suggested dire nursing shortages, enrollment in nursing schools doubled. The implications of this unprecedented change for the nursing workforce have not yet been fully explored. Objective To forecast the size and age distribution of the nursing workforce to the year 2030 and to compare to demand recently projected by the Health Resources and Services Agency. Design A retrospective cohort analysis of employment trends by birth year and age were used to project age and employment of registered nurses (RNs) through 2030. Setting Data on employed RNs from the United States Bureau of the Census Current Population Survey (1979-2000, N=72,222) and American Community Survey (2001-2013, N=342,712). Participants RNs between the ages of 23 and 69 years. Main outcome measure Annual full-time equivalent (FTE) employment of RNs in total and by single year of age. Results Annual retirements from the nursing workforce will accelerate from 20,000 a decade ago to near 80,000 in the next decade as baby boomer RNs continue to age. We project that this outflow will be more than offset by continued strong entry of new RNs into the workforce. Overall, we project that the registered nursing workforce will increase from roughly 2.7 million FTE RNs in 2013 to 3.3 million in 2030. We also find that the workforce will reach its peak average age in 2015 at 44.4. This increase in workforce size, which was not expected in forecasts made a decade ago, is contingent on new entry into nursing continuing at its current rate. Even then, supply would still fall short of demand as recently projected by the Health Resources and Services Agency in the year 2025 by 128,000 RNs (4%). Conclusions The unexpected surge of entry of new RNs into the workforce will lead to continued net growth of the nursing workforce, both in absolute FTE and FTE per capita. While this growth may not be sufficient to meet demand, such projections are uncertain in the face of a rapidly evolving health care delivery system.

Growth in the number of RN graduates from 2002-2012 has been dramatic and broad based, occurring between both associate and baccalaureate programs, and has included people from all racial and eth- nic backgrounds. This growth has occurred in all types of public, private not-for- profit, and proprietary institu- tions. The growth of RNs with gradu- ate degrees has also increased, particularly since 2004. Given the rapid production of nursing graduates, leaders in academic nursing education are urged to focus on the quality of nursing graduates, take steps to assure that graduates are well prepared for growth in nonhospital settings, ensure graduates are aware of the many challenges they will confront, and are well prepared to seize opportunities that will unfold during an era of health reform.

Roughly 40% of the nearly 3 million registered nurses (RNs) in the United States have an associate's degree (ADN) as their highest level of nursing education. Yet even before the recent Institute of Medicine report on The Future of Nursing, employers of RNs have increasingly preferred baccalaureate-prepared RNs (BSNs), at least anecdotally. Data from the American Community Survey (2003-2013) were analyzed with respect to employment setting, earnings, and employment outcomes of ADN and BSN-prepared RNs. The data reveal a divergence in employment setting: the percentage of ADN-prepared RNs employed in hospitals dropped from 65% to 60% while the percentage of BSN-prepared RNs employed in hospitals grew from 67% to 72% over this period. Many ADNs who would have otherwise been employed in hospitals seem to have shifted to long-term care settings.

We construct national estimates of the cost of increasing hospital nurse staffing and associated reductions in days, deaths, and adverse outcomes. Raising the proportion of nursing hours provided by registered nurses (RNs) without increasing total nursing hours is associated with a net reduction in costs. Increasing nursing hours, with or without increasing the proportion of hours provided by RNs, reduces days, adverse outcomes, and patient deaths, but with a net increase in hospital costs of 1.5 percent or less at the staffing levels modeled. Whether or not staffing should be increased depends on the value patients and payers assign to avoided deaths and complications.