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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 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.

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 demographi...

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.

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.

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.

Four challenges face the nursing workforce of today and tomorrow: the aging of the baby boom generation, the shortage and uneven distribution of physicians, the accelerating rate of registered nurse retirements, and the uncertainty of health care reform. This article describes these major trends and examines their implications for nursing. The article also describes how nurses can meet these complex and interrelated challenges and continue to thrive in an ever-changing environment.

Growing Ranks of Advanced Practice Clinicians Nurse practitioners and physician assistants are providing an increasing share of health care services, and education programs have proliferated. These...

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.

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.

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.)

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.

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.

Registered nurse (RN) employment has increased during the current recession, and we may soon see an end to the decade-long nurse shortage. This would give hospitals welcome relief and an opportunity to strengthen the nurse workforce by addressing issues associated with an increasingly older and foreign-born workforce. The recent increase in employment is also improving projections of the future supply of RNs, yet large shortages are still expected in the next decade. Until nursing education capacity is increased, future imbalances in the nurse labor market will be unavoidable.

In 2006, JCAHO defined the second of its National Patient Safety goals as to “Improve the effectiveness of communication among caregivers”. The SBAR protocol gives practical guidelines for person-to-person communication but may not be appropriate in its current form for more complex contexts. This paper presents a case study showing communication processes in one ICU and illustrates important principles of complex clinical communication. The case study is based on observational and interview data from a bedside nurse, a charge nurse, a resident and a fellow over 12 hours each in a major trauma ICU. Artefacts were also collected and annotated. Five types of interconnected communication events are described in the sequence in which they occur. Each communication event is described in terms of its purpose, participants, process, and support tools. Four principles are defined.

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.

According to Lucian Leape, patient safety in hospitals is improving, and it is now possible to get to a level of zero defects. Growing recognition of the need for team training, use of trigger tools, improving the competency of physicians, and full disclosure and compensation to injured patients exemplify positive developments. Yet formidable barriers remain, including separatism in how doctors, nurses, and pharmacists learn; inadequate instruction in communication and team-building skills; poorly developed quality and safety curricula; lack of leadership among CEOs and hospital boards; physician apathy; absence of effective systems for accountability; and failure to believe in the possibility of eliminating medical errors and injuries.

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.

The study assessed perceptions about a career in nursing, the nursing shortage, decision to enroll in a nursing education program, and awareness and effect of the Johnson & Johnson Campaign for Nursing's Future. Data were obtained from a survey administered to a national sample of 496 nursing students. Although most students believe nursing is physically challenging and there is inadequate respect and recognition of nurses, most agree nursing is a good career for men and for people who have academic ability and want a secure job. Although the majority believes the nursing shortage will increase stress on nurses, lower the quality of care, and fail to improve working conditions, most students also expect the shortage will lead to higher pay and more job choices. Information and advice from practicing nurses was the most influential factor in deciding to become a nurse, and friends, parents, and other family members also had a positive influence. Two thirds are aware of the campaign, almost all said it made them feel good about becoming a nurse, and students who are White and enrolled in baccalaureate programs were more likely to be aware of the campaign. Future recruitment initiatives should strengthen the focus on men and minorities, parents and friends, and practicing nurses and nursing educators.

The importance of registered nurses is expected to increase under health care reform. Thanks to a surge in RN graduates, predicted workforce shortages have not materialized. But some uncertainties still threaten the sufficiency of the workforce in the future.

Purpose:To describe and discuss the status of patient safety in U.S. hospitals. Methods:Personal interview. This report is part of a series of discussions with a leading expert on patient safety. Findings and Conclusions:Some improvements have been made in the past 10 years. But changes have not been adequate. Continuing barriers include the punitive environment in hospitals, physicians' denial of the scope of the problem, lack of national leadership, and lack of systems thinking.

Hospital employment of registered nurses (RNs) increased dramatically during the recession, making it seem as if the decade-long national shortage of RNs had ended. But RN employment is countercyclical, and the bubble is likely to burst during the next several years.

Hospitals, nurses, the media, Congress, and the private sector are increasingly concerned about shortages of registered nurses (RNs) and the impact on safety and quality of patient care. Findings from a growing number of studies provide evidence of a relationship between hospital nurse staffing and adverse outcomes experienced by medical and surgical patients. These findings have policy implications for strengthening the nursing profession, monitoring the quality of hospital care associated with nursing, and improving the relationship between hospitals and the nursing profession.

The success of efforts to bolster the primary care workforce rests in part on how these clinicians view their professions and their willingness to recommend their careers to others. The authors sought to examine career and job satisfaction, perceptions of workforce shortages, and willingness to make career recommendations among primary care physicians (PCPs) and primary care nurse practitioners (PCNPs).In 2012, the authors mailed a national survey concerning the issues above to 1,914 randomly chosen clinicians found on national databases: 957 PCPs and 957 PCNPs.A total of 972 eligible clinicians (505 PCPs, 467 PCNPs) returned the survey. Using standard opinion research procedures, the authors estimated there were approximately 1,589 eligible clinicians in their sample (response rate, 61.2%). PCNPs and PCPs were more likely to recommend a career as a PCNP than as a PCP, despite the perception among all clinicians of a serious shortage of PCPs nationally and in their own communities. This finding held among PCNPs who reported low workplace autonomy and among PCPs reporting that they were satisfied with their own careers.Efforts to solve the primary care workforce shortage that ignore the significant dissatisfaction of PCPs with their own careers are unlikely to be successful. Simply adding training slots and increasing reimbursement rates will do little to solve the problem if PCPs continue to view their own careers as ones they cannot recommend to others.

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. Much of the difference is the result of a surge in new nursing graduates. However, the size of the RN workforce is particularly sensitive to changes in retirement age, given the large number of baby-boomer RNs now in the workforce. We found that in the period 1969-90, for a given number of RNs working at age fifty, 47 percent were still working at age sixty-two and 9 percent were working at age sixty-nine. In contrast, in the period 1991-2012 the proportions were 74 percent at age sixty-two and 24 percent at age sixty-nine. This trend, which largely predates the recent recession, extended nursing careers by 2.5 years after age fifty and increased the 2012 RN workforce by 136,000 people. Because many RNs tend to shift out of hospital settings as they age, employers seeking RNs for nonhospital roles may welcome (and seek to capitalize on) the growing numbers of experienced RNs potentially able to fill these positions.

Registered nurses (RNs) comprise the largest segment of the healthcare workforce, numbering more than 2.5 million in the US in 2010. The nursing workforce faces institutional rigidities – more so than with physicians but less so than with aides or medical assistants – and are thus not only somewhat responsive to typical market forces of supply and demand but also prone to temporary shortages. As most RNs are female and often part of two-income households, their labor supply decisions are particularly affected by childbearing decisions and the state of the economy. A growing segment of the workforce is advanced practice RNs, who have obtained additional education and perform work that overlaps substantially with physicians.

This article provides a comprehensive overview of nursing workforce studies, examines current efforts to investigate the relationship between hospital nurse staffing and patient outcomes that are sensitive to nursing, and discusses the implications for public and private policy making. Although the impact of hospital restructuring on nurses is generally well known, public policy making in this area has not resulted in significant changes. The lack of substantial policy is attributed to insufficient empirical evidence linking changes in hospital nurse staffing to adverse patient outcomes. Even though new studies are providing a rapidly expanding body of knowledge, readers are urged to use caution when using these findings to support mandated hospital nurse staffing levels. The level of sophistication that would allow precise estimates of minimal acceptable staffing levels and ratios will not be achieved. The authors suggest areas for future research that would further knowledge and policy development in this area.

In December 1998, I interviewed Lucian L. Leape, MD, a health policy analyst at the Harvard School of Public Health whose research has been focused on identifying and preventing errors in health care. As one of the major contributors to the application of scientific methods to identify and analyze errors, few are better suited to offer insights on a topic that is beginning to have a profound effect on improving health care.

Article-at-a-Glance Background Recent findings that variations in nursing workload may affect inpatient outcomes now highlight nurse workload management and the need for an updated analysis of the role of the charge nurse (CN). Methods Observational data for eight CNs, each at one of eight ICUs in a not-for-profit Level 1 Trauma Center, coded to capture interprofessional interactions, decision making, team coordination phases, and support tools. A researcher shadowed each participant for 12hours. Each shift began and ended with a face-to-face handoff that included summaries of each patient's condition; the current bed census; anticipated admissions, discharges, and transfers; and the number of nurses available to work the current and coming two shifts. The researcher, using a notebook, recorded the substantive content of all work conversations initiated by or directed to the CN from physicians, staff nurses, allied health workers, other employees, and patients/families. The tools used to support conversations were collected as blank forms or computer screen prints and annotated to describe how they were used, when, and for what purpose. Findings Statistically significant three-way interactions suggest that CNs' conversations with colleagues depend on the team coordination phase and the decision-making level, and that the support tools that CNs use when talking to colleagues depend on the decision-making level and the team coordination phase. Conclusions The role of ICU CNs appears to be continuing to evolve, now encompassing unit resource management in addition to supervising care delivery. Effective support tools, together with education that would enhance communication and resource management skills, will be essential to CNs' ability to support unit resilience and adaptability in an increasingly complex environment.

The U.S. health care system is facing a projected nursing shortage of unprecedented magnitude. Although military nursing services recently have been able to meet their nursing recruitment quotas, national studies have predicted a long-term nursing shortage that may affect future recruitment for the Nurse Corps of the three military services. Data are needed to plan for recruitment incentives and the impact of those incentives on targeted populations of likely future nurses.Data are drawn from three online surveys conducted in 2011-2012, including surveys of 1,302 Army, Navy, and Air Force personnel serving on major military bases, 914 nursing students at colleges with entry Bachelor of Science in Nursing programs located nearby major military bases, and a qualitative survey of 1,200 young adults, age 18-39, in the general public.The three populations are different in several demographic characteristics. We explored perceptions of military careers, nursing careers and barriers, and incentives to pursue military nursing careers in all populations. Perceptions differ among the groups.The results of this study may help to inform strategies for reaching out to specific populations with targeted messages that focus on barriers and facilitators relevant to each to successfully recruit a diverse Nurse Corps for the future.

The termination of the National Sample Survey of Registered Nurses (NSSRN) represents a loss of a key source of information on the nursing workforce that has been available for more than 30 years. At the same time, this loss presents new opportunities to address some of the biases associated with using licensing data to construct lists of RNs to construct a sampling frame. Given the loss of this key national data source on the nursing workforce, the NSSRN is compared to existing alternatives for nursing workforce data in two U.S. Census Bureaus surveys: the Current Population Survey and the American Communities Survey. The endeavor of workforce planning and a deeper understanding of whether we are equipped to meet the nation's changing health care landscape will benefit from a thoughtful consideration of how best to obtain accurate and comparable data from future surveys.

The vast preponderance of the nation's registered nurses are women. In the 1980s and 1990 s, a decline in the number of women ages 23-26 who were choosing nursing as a career led to concerns that there would be future nurse shortages unless the trend was reversed. Between 2002 and 2009, however, the number of full-time-equivalent registered nurses ages 23-26 increased by 62 percent. If these young nurses follow the same life-cycle employment patterns as those who preceded them--as they appear to be thus far--then they will be the largest cohort of registered nurses ever observed. Because of this surge in the number of young people entering nursing during the past decade, the nurse workforce is projected to grow faster during the next two decades than previously anticipated. However, it is uncertain whether interest in nursing will continue to grow in the future.

Massachusetts' experience with health care reform may be predictive of the effects of national health care reform. Data on employment in the health care industry were examined to determine the impact of the Massachusetts reform on the state's health care workforce.