Journal of Nursing Education

Changing Trends in Healthcare: Implications for Baccalaureate Education, Practice and Employment

Patricia Manuel, EdD, RN, CS; Lena Sorensen, PhD, RN

Abstract

ABSTRACT

The authors surveyed 96 hospitals and agencies in Massachusetts to determine: 1) the effect of the changes in health care delivery on RN utilization, particularly baccalaureate nurses, and 2) to identify educational changes necessary to prepare baccalaureate nursing graduates for employment and practice in the future. An analysis of the results of the survey of the 50 nurse executives who responded to the study identifies the projected needs and requirements of the service sector for delivering nursing care, and translates them into suggestions for revisions of the baccalaureate curriculum.

Abstract

ABSTRACT

The authors surveyed 96 hospitals and agencies in Massachusetts to determine: 1) the effect of the changes in health care delivery on RN utilization, particularly baccalaureate nurses, and 2) to identify educational changes necessary to prepare baccalaureate nursing graduates for employment and practice in the future. An analysis of the results of the survey of the 50 nurse executives who responded to the study identifies the projected needs and requirements of the service sector for delivering nursing care, and translates them into suggestions for revisions of the baccalaureate curriculum.

Introduction

The rapidly occurring changes in health care delivery have effected nursing practice, employment and education. Changing skill mix, with increased use of unlicensed caregivers, a shortened length of hospital stay, institutional downsizing, increased acuity in acute care hospitals, and a shift in the locus of care to outpatient and homecare, all have significant implications for the employment of nurses. These trends will continue to reorder patterns of nursing practice and will necessitate revision of current curriculum in colleges of nursing.

Significant staff changes have been documented across the country. The University of Chicago Hospital is threatening to convert 150 RN FTEs to technicians and LPNs, and at California Pacific Medical Center 321 RN positions were cut (American Journal of Nursing, April 1994). California's Kaiser Permanente Hospital and Clinics recently projected their RN staffing will be as low as 30% of the present inpatient workforce in a massively restructured patient care delivery system. They plan to reduce unit size to between 24 and 30 patients with one RN supervising a group of lower skilled or unlicensed personnel (American Journal of Nursing, May 1994). In Tennessee, Vanderbilt Hospital has gone UOm 90% RN staff in 1992 to 79% in 1994 and anticipate reducing the ratio of RNs to 65% in the near future (American Journal of Nursing, April 1994). At Mercy Medical Center in Coon Rapids, Minnesota, plans call for cutting RN PTEs by 24%, adding LPNs and aides, and creating a "unit support person" to handle housekeeping, dietary and transport tasks, and assist with ADL and orthopedic activities (American Journal of Nursing, April 1994). In Massachusetts, Framingham Union Hospital and Leonard Morse Hospital in Natick, have joined to form MetroWest Medical Center and are piloting a new unlicensed position which will ultimately reduce the number of RN positions needed to deliver care to patients (American Journal of Nursing, April 1994). Boston's Carney Hospital nurses narrowly defeated the hospital's plan to reduce the RN ratio to 50% with the creation of a new healthcare worker called "patient care associate*. The new worker had a job description which Usted 103 duties, among them unstable blood gases, applying catheters and changing Foley bags and feeding tubes, all previously documented nursing duties (American Journal of Nursing, April 1994). In the past year, there has been an active discussion on the Internet listserv NURSENET about the significant layoffs and lack of jobs for nurses and new graduates across the U.S. and Canada. Similar changes are occurring in the community. The American Nurse (Ketter, 1994) reported that public health agencies are using fewer professional nurses and increasing their use of unlicensed assistive personnel in homes.

Recently, both the American Nurses Association and the National League for Nurses have criticized hospitals' restructuring practices in their appeal to the public and the Clinton Administration. The president of ANA, Virginia Betts, stated that "hospitals, at the advice of outside consultants, are focusing on labor costs as a quick method to reduce costs and increase reserves" (The American Nurse, June 1994, p. 1). The ANA suggests that hospitals' practice of reducing RNs and replacing many nursing positions with unlicensed staff is actually "using health care reform as a scapegoat for saving money, often with little regard for patient care" (The American Nurse, June 1994, p. 1).

We are noticing similar changes in Massachusetts as graduating nursing students are unable to find jobs in acute care and even long-term care settings. Feedback from colleagues informs us that downsizing, layoffs and restructuring are occurring in the majority of hospitals statewide. As a result of these findings, this study was designed to: 1) determine the effect of the changes in healthcare delivery on RN utilization, particularly baccalaurate nurses, in Massachusetts, and 2) to identify educational changes necessary to prepare future graduates to remain both marketable and functional in hospitals or other practice settings. Nursing education has never professed to teach neophyte nurses all they need to know for the duration of their careers. However, in the 90s and beyond, it is imperative that nursing education and service work together to identify and develop the core essential skills nurses must have for beginning practice. This study is a step in this direction: gathering the needs/requirements from the service sector and translating them into the baccalaureate curriculum to prepare nurses for practice in the future.

Literature Review

Two primary issues influencing the healthcare system are cost and quality of care. In terms of cost, many factors have contributed to the rising ticket on healthcare. Probably the least significant, economically, is the cost of nursing care when compared with other services and hospital charges. One recent study estimates that the average hospital spends only 31 cents of its labor dollar on direct patient care (Curtin, 1994). Many studies have documented findings that indicate hospitals with higher ratios of nurses to patients have lower mortality rates, shorter lengths of stay, fewer complications and thus lower costs than those with fewer nurses and lower nurse-patient ratios. Paradoxically, however, because hospital nursing care generates no direct revenue, and is accorded the status of a "cost center" rather than a "profit center," there is a dangerous assumption that rapidly rising costs of hospital care are due in part to increased nursing salaries (McCloskey, 1989; Philips, Castorr, Prescott, & Soeken, 1992; Walker, 1983).

Hospitals have attempted to address their cost and quality concerns by developing new care delivery models and redefining job functions. Many institutions have created an integrated, cross-trained, multifunctional worker who may or may not be licensed in a healthcare discipline. Most of the new models have been designed in such a way that the professional nurse retains the responsibility and accountability for patient care prescription and for highly skilled tasks, while delegating other functions to a variety of assistive personnel. The goal of these new models is to lower costs of care per patient day and to increase productivity. The underlying assumption is that the use of assistive personnel will save money as they require lower salaries than the professional nurse (Manuel & Alster, 1994).

Based on the assumption that non-professional assistive personnel receive lower salaries, many hospitals have dramatically changed the ratio of skill mix with a reduction in professional nursing staff A recent study (Barter, McLaughlin, & Thomas, 1994) of chief nurse executives at 234 hospitals in California found that the restructuring and reduction of RNs with the substitution of unlicensed assistive worker is happening without any supporting evidence that quality of care will be maintained or that any systematic evaluation of outcomes will occur. This study also showed that costs to train one unlicensed assistive personnel exceeds $3,000 for on-thejob training. This does not account for the continuing costs of supervision by RNs.

Some nursing professionals believe that nursing education programs have failed to prepare students for the new practice arena in which assistive personnel play a larger role. Outdated curriculum models focus on primary nursing but lack content in supervision and delegation and computer literacy (Andredi, 1992). Educators are urged to identify these critical skills and include them in the curriculum (Kennerly, 1990; Mantel, 1990; McMurray, 1992). For example, Metcalfe (1992) has suggested that new nurses with little experience cannot be expected to delegate tasks proficiently when they are still trying to master the tasks themselves and frequently need supervision from more experienced nurses. Nurses must be educationally and experientially prepared to meet the legal obligations that the act of delegation entails as nurses are negligent if they fail to recognize potential problems or fail to take steps to prevent them (Mantel, 1990).

Some authors have addressed this deficit by suggesting that the responsibility of staff education departments should be to assist the nursing staff to develop leadership and management skills necessary for effective delegation (Spitzer-Lehmann & Yahn, 1992; Hansten & Washburn, 1992). This may be easier said than done. A study examining the use of nurse extenders found that even after 2 years of education related to a care delivery model that included the use of assistive personnel, nurse managers in one hospital required continuing education utilizing the model and making assignments, and staff nurses required more education and training on defining their role in the model (Garfink, Kirby, & Bachman, 1992).

Another strategy that hospitals are using is the use of management and nursing information systems to increase nursing productivity, thus saving dollars. Simpson (1994) discusses the current state of computer systems and reports that they do not adequately meet nursing's needs for gathering and reporting nursing outcomes. He urges that nurses become more involved in the development of systems that gather, report and compare outcomes to ensure that the impact of nursing service outcomes will be recognized. What nursing must keep in mind, with our focus on technologically defined productivity, is what Kirk (1990) calls the "productivity wall," the point where quality outcomes risk compromise for the sake of productivity, profit, and staff availability.

Table

TABLE 1Breakdown of the Distribution of Hospitals in the Sample (n = 46 Acute and Long-Term Care Hospitals)

TABLE 1

Breakdown of the Distribution of Hospitals in the Sample (n = 46 Acute and Long-Term Care Hospitals)

Methodology

The purpose of this descriptive study was to determine:

What are the hiring trends for the professional nurse and unlicensed assistive personnel in hospitals and agencies in Massachusetts?

What are the skill expectations for professional nursing staff?

How are baccalaureate nurses utilized now and how will they be utilized in the future?

What nursing skills will be necessary for the future?

A list of all Massachusetts acute and long-term care hospitals and community agencies was developed using the Massachusetts Organization of Nurse Executives' membership list and the Greater Boston telephone directories. This convenience sample consisted of 96 institutions and agencies across Massachusetts. A packet that included a letter of introduction, the questionnaire, and a stamped, self-addressed return envelope, was mailed to the chief nursing officers at each of the 96 hospitals and agencies identified on this list.

A survey instrument consisting of 18 questions was used to identify the hiring and practice trends of nursing personnel. The content and construct validity was established by a group of four nurse administrators and hospital educators selected from teaching hospitals in the greater Boston area. Data were analyzed using descriptive statistics.

The questions (scaled and open-ended) were developed from themes raised in the current literature reporting healthcare restructuring and from experiential feedback from graduating undergraduate and graduate students from University of Massachusetts/Boston over the past 18 months who have been having an increasingly difficult time finding jobs. Some of the graduate students themselves have lost positions as clinical nurse specialists and staff educators. The survey questionnaire was developed with the consultation of the Center for Survey Research at University of Massachusetts/Boston.

The questionnaire was designed to identify staffing trends, staff mix and nursing skills needed from 1992, presently (at the time of the survey), and projected through to 1996. Due to a somewhat guarded atmosphere resulting from restructuring and unionization efforts at a number of hospitals, questions were phrased in a style that allowed the nurse executive to share past, present and future trends without disclosing specific information that could render the institution vulnerable. For example,"rIow do your hiring practices in 1993 compare with 1992?" allowing the respondent to check a box indicating "More, Less and the Same" to estimate the nursing staff mix. Many of the questions focused on how different levels of nursing staff were being utilized. Five open-ended questions encouraged the respondents to report their own hospital and/or agency practice priorities and needs. For example:

"List three of the most important skills for new graduates at your facility."

"What procedures are new nurses presently not adequately prepared to perform?"

"List skills needed by new nurses now and for the future."

The questionnaire also solicited data on each institutions demographics, past, present and future; hiring trends of licensed and unlicensed nursing staff; nursing practice models used now and those planned for the future, and present and future utilization of Management Information Systems (MIS) and Nursing Information Systems (NIS).

Results

Fifty completed questionnaires were returned: 41 hospitals, 4 home care agencies, and 5 long-term care facilities. This represents an overall 52% return rate (57% from hospitals, 36% from home care agencies, and 38% from long-term care facilities). Thirteen respondents were from the Boston area and 37 were from other areas in Massachusetts. The mean size of the hospitals was 278 beds, ranging from 57 to 900 beds. Table 1 summarizes the distribution of the hospitals by size to their location.

Hiring Trends

The majority of the institutions reported that they would be increasing their hiring of unlicensed assistive personnel (UAPs). The hiring of registered nurses would stay the same or decrease (Table 2). Many hospitals reported laying off nurses in the past year.

There was a relatively equal distribution of educational levels of practicing nurses reported by the 37 hospitals (33.5% diploma, 28.5% associate degree, 32.1% baccalaureate degree, and 5.5% master's degree). The hospitals with the greatest percentage of diploma degree nurses were located outside of Boston, while hospitals located within the greater Boston area had the highest percentage of baccalaureate prepared nurses. There was a similar distribution in the long-term care facilities (34.6% diploma, 27.4% associate degree, 29.6% baccalaureate degree, and 8.4% master's degree). There was a slightly higher percentage of baccalaureate degree nurses in three of the four home care agencies (HCAs) that responded (22% diploma, 32.3% associate degree, 38.3% baccalaureate degree and 7.3% master's degree).

Table

TABLE 2Anticipated Hiring Trends of Staff by Hospital Size

TABLE 2

Anticipated Hiring Trends of Staff by Hospital Size

Nursing Skills Expectation - Present & Future

In response to an open-ended question, "What are the three most important skills needed for practice by new RNs in your facility?" the skills most frequently identified were: 1) assessment, 2) clinical technical skills and 3) organizational skills. "Organizational skills" is a construct created by the authors to incorporate the responses: leadership, critical thinking, delegation and supervision, and communication (Table 3). When asked, "Do you think there are skills new graduates in 1996 will need that are different from the present skills?" the most frequently mentioned response was delegation and supervision. One respondent wrote that new graduates in 1996 need to have "greater preparation in supervision of non-professional caregivers and greater emphasis on physical assessment skills." Another respondent wrote that the future graduate needs "more clinical experience before entering the work force and to be able to think creatively and delegate care to others" (Table 4).

Utilization of Baccalaureate Nurses

Respondents were asked to rate the degree of anticipated change in the utilization of UAPs, BSNs and need for work experience (will increase, decrease, no change). The majority of the facilities stated that in the future, if they hire nurses, they would prefer hiring experienced BSN nurses. However, the majority of the respondents reported plans to increase hiring and utilization of unlicensed caregivers (Table 2, Figure). When asked if BSN nurses were more likely than ADN or diploma nurses to get more complex assignments, promotions and/or be utilized in leadership positions, most respondents reported that BSNs were promoted and assigned to leadership positions significantly more, but were not given more complex patient care assignments than other nurses. In addition, the majority of the midsize and large hospitals reported that they either preferred or required RNs to have a baccalaureate degree to practice and were promoted more readily than others. The educational preparation of nurses is not a factor at the majority of hospitals (60% + ) in consideration of the clinical complexity of assignments. Respondents went on to explain this preference with comments like "BSNs have the ability to see the big picture of health care and the ability to assess and plan patient care, as well as an eagerness to be involved professionally in collaborative committee work." "BSNs have better problem solving ability and have a broader based education and a more global perspective." One nurse executive wrote "A bachelor's degree enhances the skills of an individual to look at the continuum of care requirements and challenge the 'rote' ways of practicing once they gain more clinical experience."

Figure. Anticipated utilization of BSNs.

Figure. Anticipated utilization of BSNs.

Information Technology

The majority of the hospitals (82%) reported having management information systems (MIS) with 62% using it for staffing, 82% for measuring productivity, and 73% for acuity levels. Many of those who do not presently have MIS in place planned to do so in the future. Of the 43 hospitals that have nursing information systems (NIS), only fourteen (27%) reported systems that supported nursing documentation, although their NIS had programs for connecting with other departments: ordering, pharmacy, laboratory data, census and information retrieval. Seventy-three percent (73%) of all hospitals planned to include nursing documentation in the future. Thirty-eight of these computers were located at the nurse's station, with no hospital using bedside computers.

Conclusion

This study supported the trends that nurses in other areas of the country are reporting. Hospitals and agencies in Massachusetts are decreasing the hiring of RNs and increasing UAPs. In the past year, fewer nurses were hired by all types of institutions across the state and most were looking for experienced nurses. It is apparent that for at least the short term, employment will be problematic and extremely competitive for all new graduates. Because hospitals and agencies prefer hiring experienced BSN nurses, there will be a dilemma for new graduates who may find themselves in a prolonged state of unemployment due to their inexperience and ineligibility for hire into positions in acute and community nursing. "How do you gain experience without a job?" is a question many new graduates are already asking and one that colleges of nursing need to address through curriculum redesign.

Table

TABLE 3Most Important Nursing Skills Needed Now by New Graduates (n = 50 Nurse Executives)

TABLE 3

Most Important Nursing Skills Needed Now by New Graduates (n = 50 Nurse Executives)

Table

TABLE 4Nursing Skills Needed for the Future (n = 36 Nurse Executives)

TABLE 4

Nursing Skills Needed for the Future (n = 36 Nurse Executives)

Colleges of nursing cannot meet the demand for clinically experienced new graduates. They cannot produce "expert clinical practitioners" at the baccalaureate level as nursing is a skill based profession and requires extensive practice to achieve competence. However, what appears to be problematic is the practice setting's employment of new graduates with deficient clinical skills while demanding expert clinicians for jobs. The hospitals and agencies surveyed emphasized the importance of clinical skills for all nurses, but value baccalaureate nurses for their ability to problem solve and see the "broad picture" of patient care. While the respondents continue to emphasize the need to prepare clinically skilled practitioners, they envision a future that will increasingly demand nurses' ability to also provide leadership and organizational competence, particularly supervision and delegation.

Recommendations

We recommend that colleges of nursing redesign their curriculum to include the following changes:

1) Emphasize the development of critical thinking and independent decision-making throughout the curriculum. This process must begin in the first baccalaureate nursing course and be incrementally developed throughout the curriculum. In the past, nursing education has fostered student dependency on structure in the classroom and clinical settings by emphasizing factual information and procedures. In the future faculty must encourage students to participate in their learning process both individually and as a group. Coursework and strategies for teaching need to encourage students to think actively, explore situations and open their minds to new ideas and different perspectives. Faculty must deemphasize structured learning where the teacher lectures and the students listen. Students must learn to think conceptually and translate concepts into practical problem-solving. For example several strategies for fostering critical thinking are using case methods for presenting materials, role playing, group activities that encourage problem-solving, and using the debate forum for examining new ideas. Strategies for fostering independent thinking might include having students develop portfolios that incorporate their own goals and objectives for learning within each course and clinical setting, and developing their own topics for discussion that incorporate clinical problems from practice. Students come with a variety of experience and knowledge and we need to build on these differences. By having the students take an active role in defining their own learning needs, the learning experience incorporates the diversity of abilities and encourages the active sharing of knowledge. Faculty can then become facilitators of learning instead of "feeders."

2) Teach leadership and organizational skills, such as delegation and supervision. These concepts and theories must be presented in an experiential context both within the classroom and in the clinical setting. Historically, leadership and organizational skills have been assigned to upper-level courses. The development of these skills must begin in the entry level courses and strengthened throughout the program. For example, students need to learn leadership skills through the case study method that requires analysis and clinical decision-making. Each case should present a problem scenario and students, in small groups, use scientific problem solving methods to identify the problem, generate a fist of alternatives, choose the best alternative (make a decision) and do follow-up evaluation on the outcome of their decision. This method generates class discussion, fosters active participation from all students and encourages students to take risks in making decisions. For delegation and supervision, students need to learn through the use of patient vignettes that focus on patient problem identification and identification of nursing tasks. Then they need to decide what type of nursing staff is required to provide nursing care. Students must then learn the responsibilities involved in the supervision of delegation for ensuring quality of care within the ethical and legal framework of each state's nurse practice act. A precepted clinical experience should accompany this learning so that students have an opportunity to practice the skills of delegation and supervision prior to graduation.

3) Improve clinical skills in specialty areas to increase students' employability in alternate settings, such as community, ambulatory settings and long-term care. A senior year precepted clinical experience would provide students an opportunity to improve their clinical skills and synthesize learning. Alternative clinical sites must be developed for student learning as healthcare shifts from acute care hospitals to ambulatory and long-term care settings and homecare. Levels of learning can be incorporated within each setting that allow the students to build on their knowledge and experience. Evaluation tools for assessing clinical competence must be developed for self-paced learning that will enable each student to identify and address skill deficits. Faculty must also shift their attitudes that value acute care inpatient settings as the most esteemed practice for nursing.

4) Teach students to assess and provide patient care across the continuum. For example, clinical sites need to be arranged to allow for multi-level learning experiences. This would enable the student to remain in one setting and build on their expertise from pre-admission through post-discharge (homecare/community interventions). The model of case management is an excellent one for this framework.

5) Educate students to develop an understanding of healthcare costs and fiscal management, politics/policy development and ethics. Classes need to provide opportunities for analyzing current nursing and healthcare issues and their implications for the future. A political awareness must be instilled while they are students in order for them to become involved in the political and policy development process. Opportunities for professional nurses in all areas of the healthcare spectrum must be explored, such as the insurance industry, health maintenance organizations, professional organizations, such as political action committees and grass roots community groups.

In conclusion, this study, although limited by its small sample, raises several important issues: 1) the need to reexamine nursing curricula that will increase students' knowledge and competence in clinical assessment and technical skills in an efficient and cost effective framework; 2) the need to develop an awareness in students of financial and political considerations of healthcare delivery in the future and nurses' role in that future; and 3) the need for nursing faculty to address the politically difficult topic of how many nurses we should be producing during these difficult times of healthcare reorganization and the significant decrease in job opportunities for new nursing graduates.

Healthcare is changing rapidly and will continue to change in the foreseeable future. Colleges of nursing cannot wait for the "dust to settle" and for the healthcare system to finish its "restructuring". They must be proactive and move quickly to prepare nurses who think creatively and critically and who are prepared to enter all practice arenas as leaders. New graduates must have the skills to enter the profession as competent and knowledgeable caregivers and as active participants for legislating future changes in healthcare that ensure the quality and status of professional nursing. As educators, we can no longer depend on practice to provide these skills, but must instill them at all levels of the educational process.

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TABLE 1

Breakdown of the Distribution of Hospitals in the Sample (n = 46 Acute and Long-Term Care Hospitals)

TABLE 2

Anticipated Hiring Trends of Staff by Hospital Size

TABLE 3

Most Important Nursing Skills Needed Now by New Graduates (n = 50 Nurse Executives)

TABLE 4

Nursing Skills Needed for the Future (n = 36 Nurse Executives)

10.3928/0148-4834-19950901-04

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