Trends in Ambulatory Care/Community Health Nursing in Vermont

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1 Trends in Ambulatory Care/Community Health Nursing in Vermont Mary Val Palumbo DNP, APRN University of Vermont Department of Nursing AHEC Nursing Workforce Research and Development Betty Rambur PhD, RN University of Vermont Department of Nursing Acknowledgements Victoria Hart, PhD, Statistician Vermont AHEC Nursing Workforce Research, Planning and Development Future of Nursing State Implementation Program Vermont Board of Nursing and Vermont Legislature Background One key element of health reform is payment reform Volume to value transition is accelerating ACO Next Gen Medicare s January 2015 announcement of an accelerated pace toward value based payments Medicare s bundled payment initiative for joint replacement Unlike ACOs, is not voluntary Medicare s actions significant Large payer in and of themselves Medicaid and commercial insurers often follow Medicare s lead. 1

2 Background Shift away from fee for service expected to remove barriers to care coordination across the care continuum Theoretically catalyzes management of individuals and populations in the least intensive setting Reasonable to conclude that registered nurses, the largest health care workforce segment, would demonstrate a corollary shift in employment setting. Preparation for RN licensure has two routes, AD and BS, the latter of which must the meet accreditation criteria include preparation in population health, community health, and care outside the acute care/long term care setting. Purpose of Study The study will investigate decadal changes in ambulatory care and community health nurse employment in a small state undergoing payment and delivery reform. Rationale and Significance Understanding shifts in work settings is an important first step toward clarifying emerging gwork roles as well as knowledge and skills less essential to individual and population health. A large proportion of nurses are educated at the AD level Understanding work setting shifts is important to: Nursing educators Employers of nurses Nurses who may require updated skills in a reformed health care system Policymakers 2

3 Hypotheses When comparing nursing workforce survey data pre reform (2005) and post reform (2015) there will be: 1. An increase in the proportion of nurses who report working in ambulatory care/community settings. 2. A decrease in the proportion of nurses who report working in hospitals. 3. A decrease in the proportion of associate degree nurses who report employment in ambulatory care/community settings, and an increase in the proportion of nurses educated at the baccalaureate and higher degree level. Methods This secondary analysis design study compared the nursing workforce at an interval of one decade using the Vermont Board of Nursing Relicensure Surveys from 2005 and In 2005 (n =4,075; 65% response rate) In 2015 (n= 6,723; 97% response rate). Subjects Subset Surveys of registered nurses who reported working in Vermont in setting of ambulatory care and community health at the time of the surveys were also analyzed: In 2005, n= 318 and In 2015, n= 667 3

4 Analysis Limited to descriptive statistics followed by nonparametric tests as appropriate. Independence assumption for parametric statistics likely violated. Findings Findings Demographics Demographics 2005 all n = a/c n= all n= 6, a/c n=668 Gender 94% Female 99% Female 91% Female 94% Female Mean age 48 years 49 years 48 years 49 years Caucasian 95% 96% 93% 94% Other races (AND MISSING) 2.8% 2.2% (missing) 0.3% 4% (missing) 3.5% 4% (missing) Hispanic 1% 0% 4% 1% 3% 4% (missing) 4

5 Findings Demographics Demographics 2005 all n = a/c n= all n= 6, a/c n=668 Gender 94% Female 99% Female 92% Female 95% Female Mean age 48 years 49 years 48 years 49 years Caucasian 95% 96% 93% 94% Other 2% <1% 3% 1% races Missing 3% 4% 4% 5% Hispanic 1% 0% 4% 1% There is a significant decrease in the proportion of females in the A/C setting from 2005 to 2015 (p=0.01, chi square test) Findings Setting Setting 2005 n (%) 2015 n (%) Ambulatory/ 318 (8.0%) 667 (10.0%)* Community Health Hospital 1986 (50.0%) 0%) 3482 (51.9%)** Other 1677 (42.0%) 2556 (38.0%) Missing 1 (<0.1%) 19 (0.1%) Total 3982 (100%) 6724 (100%) * p=0.001, **p=0.049 Findings Education Education 2005 all n = a/c n= all n= 6, a/c n=665 Diploma 849 (21%) 92 (29%) 621 (9%) 73 (11%) ADN 1576 (39%) 109 (34%) 3,159 (47%) (48%) BSN 1321 (32%) 101 (32%) 2,505 (37%) 235 (35%) MSN 187 (5%) 3 (1%) 382 (6%) 39 (6%) Doctorate 6(<1%) 3 (1%) 30 (0.4%) 4 (0.6%) Missing 131 (3%) 12 (4%) 5

6 Findings Education Education 2005 all 2005 a/c 2015 all 2015 a/c Currently enrolled in a nursing program 233 (6%) 15 (5%) 596 (9%) 38 (6%) Position/ Major activity Findings Position 2005 all n = a/c n= all n= 6, a/c n=668 Patient care 2554 (63%) 227 (71%) 4,697 (70%) 485 (73%) Nurse Executive 168 (4%) 6 (2%) 194 (3%) 15 (2%) Nurse 217 (5%) 15 (5%) 195 (3%) 6 (1%) Faculty/teaching Nurse Manager 354 (9%) 29 (9%) 738 (11%) 80 (12%) Other 762(19%) 41 (18%) 754 (11%) 69 (10%) The increase in proportion of RNs in patient care in the A/C setting is not a significant change (p=0.66, chi square test) Findings Hypothesis 1: An increase in the proportion of nurses who report working in ambulatory care/community settings In 2005, 8.0% of respondents worked kdin Ambulatory Care/Community Health settings. This compares to 10.0% in This represents a significant increase from 2005 to 2015 (p=0.001, chi square test) 6

7 Findings Hypothesis 2: A decrease in the proportion of nurses who report working in hospitals. In 2005, 50.0% 0% of respondents worked in a Hospital setting. This compares to 51.9% in This is not a statistically significant increase, but is approaching significance (p=0.049, chi square test). The data do not support this hypothesis. Findings Hypothesis 3: (1) a decrease in the proportion of associate degree nurses who report employment in ambulatory care/community settings; and (2) an increase in the proportion of nurses educated at the baccalaureate and higher degree level. In the Ambulatory Care/Community Health setting, 65.7% had a diploma or associates nursing degree in This compares to 58.8% in This represents a significant decrease from 2005 to 2015 (p=0.040, chi square test) In the Ambulatory Care/Community Health setting, 34.3% had a BSN or higher in This compares to 41.2% in This represents a significant increase from 2005 to 2015 (p=0.010, chi square test) These data suggest that although there has not been a decrease in the proportion of nurses employed in hospitals, there has been a fairly dramatic increase in the proportion of nurses employed in ambulatory and community settings 7

8 Despite baccalaureate education s inclusion of a focus on community health and population health, the proportion of nurses in ambulatory/community setting with baccalaureate degrees actually decreased, while associate degree increased. The settings in which nurses are employed is important for many reasons. 1. The N CLEX, serving as the gateway to nursing practice test for competency in common practice settings and has historically been acute care oriented. 2. Nurses are being encouraged to practice to the fullest extent of their education by the IOM (2010), therefore, more nurses with bachelor and masters degrees employed in the study settings might have a significant impact on care delivery. The increase in nurses who have obtained the bachelor s degree in nursing or higher h in the ambulatory care setting is encouraging, as is the more than doubling of in the actual number of ambulatory care nurses who are currently enrolled in an educational program (15 in 2005 and 38 in 2015). 8

9 The skill set for the ambulatory care/community health nurse is evolving and the attention of employers, nurses, and educators is key to assuring a match between nurses knowledge and skills and workforce needs. Additional questions to consider: There is an increase in reported nurse manager positions in ambulatory care Is that administrative or patient care related? Do nurses doing care management perceive this to be administrative or patient care particularly if the responsibility is for population health? How is this different from the case manager/case coordinator role for nurses which has been well documented since 1986 (Reimanis, Cohen, Redman, 2001)? What new technical and interprofessional skills are needed? 9

10 What About Lifelong Learning? The Institute of Medicine The Future of Nursing report underscored lifelong learning as an essential nursing responsibility in this era of change and societal need. Although the proportion of overall nurses enrolled in a nursing program increased, the proportion in ambulatory care/community care was largely stable. Arguably, these nurse are in areas of potential greatest flux, change, and redesign. Is a focus on education warranted? Can nurses maximally contribute to care redesign without understanding changing financial and reimbursement incentives? Limitations All secondary analyses are limited by use of data gathered for another purpose. The data looked only at setting, not work role. Further work in this area is essential. Response rate in 2015 was very robust, 2005 less so. Are responders different than non responders? Recommendation for Future Study Nurses, nurse educators, and other providers have largely been educated in a fee for for system world. An assessment of the new/renewed skills desired by ambulatory care/community health nurses and valued by their employers and payers offers an important strategy by which to inform curriculum development, continuing education, and further prepare nurses to serve societal need. 10

11 Evidence Based References California Institute for Nursing and Health Care. (CINHC, 2013) Nurse Role Exploration Project: The Affordable Care Act and New Nursing Roles, retrieved on August 31, 2015 from Kaunonen M, Salin S & Aalto P (2015) Database nurse staffing indicators: explaining risks of staff job dissatisfaction in outpatient care. Journal of Nursing Management 23, Reimanis CL1, Cohen EL, Redman R. (2001) Nurse case manager role attributes: fifteen years of evidence based literature. Lippincotts Case Manag Nov Dec;6(6):230 9; quiz Schmitt N. (2005). Role transition from caregiver to case manager, part 1. Lippincotts Case Manag Nov Dec;10(6): Better Results When Nurses Manage Care of Outpatients With Chronic Diseases. (2014). AACN Bold Voices, 6(10), Retrieved from live Ioli, J. G. (2015). Basic social processes of primary care outpatient staff registered nurses. (Ph.D.), Widener University. Retrieved from live Available from EBSCOhost cin20 database. Morissette, A. (2015). Succeeding as a primary care nurse. American Nurse Today, 10(7), Retrieved from live New Care Coordination and Transition Management Core Curriculum Launched. (2014). MEDSURG Nursing, 23(6), Retrieved from live. 11

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