Roundtable: An aging nursing workforce confronts rapid healthcare industry change

Nurses have always played a central role in delivering healthcare.

Hospital patients typically spend far more time with several nurses over the course of their stay than with the physicians who are in charge of their care. Nurses are an indispensable part of the services delivered in every physician's office.

But, today, nurses are being asked to take on new jobs. As the healthcare payers demand greater value for their healthcare dollars, delivery systems must learn how to care for their patients more safely, with higher quality and in a less costly manner. That's led health system leaders to ask the nation's 3.1 million nurses to play a greater role in coordinating care.

Are they up to the task? The nation's nursing workforce is growing older, with the average age approaching 50. About a quarter of current nurses are slated to retire in the next decade. Given the aging of the population — 10,000 baby boomers are retiring every day — the government projects the nation will need to train and employ a million new and replacement nurses between now and the middle of the next decade.

Throughout 2017 Modern Healthcare will conduct a series of roundtable discussions with C-suite leaders drawn from many of the nation's leading hospital systems, large physician practices and the organizations representing groups that make up the healthcare landscape. We decided to launch the series with a chief nursing officers roundtable, moderated by Modern Healthcare reporter Maria Castellucci, because of the increasingly important role that nurses must play as the nation drives toward better coordinated, value-based care.

Participating in a conversation that took place early this month were Kim Henrichsen, vice president of clinical operations and chief nursing officer at Intermountain Healthcare, based in Salt Lake City; Linda Burnes Bolton, vice president for nursing and chief nursing officer at Cedars-Sinai in Los Angeles; Janice Walker, senior vice president and chief nurse executive for the central division of Baylor Scott & White, based in Texas; and Pamela Cipriano, president of the American Nurses Association. The following transcript has been edited for brevity and clarity.

Modern Healthcare: How is the role of the nurse changing? How are they becoming a more important part of the care team?

Pamela Cipriano: The role of the nurse has been changing dramatically as nurses have not only become more educated, but have assumed roles as partners in transforming healthcare. If we think about some of the important changes that came about with the Affordable Care Act, nurses have jumped in and embraced value-based reimbursement. Similarly, they have been instrumental in affecting positive and successful transitions of care across numerous locations and have key roles in the coordination of care.

Kim Henrichsen: It's very energizing to watch this transition and the ongoing evolution of the role of the nurse in healthcare. Our nurses who work in all different walks of healthcare have a lot of respect, and are taking on leadership roles in places that we haven't had the opportunity to take on before.

It's also been fun to watch and to participate in not only the expansion of the opportunities for nurses but the skill sets that they are developing. There are so many opportunities for nurses to work in hospitals, ambulatory settings, education, IT and the home. Telehealth services are (also) growing and expanding, and nurses are playing a key role in delivering care through electronic means.

MH: What are your concerns about the nursing shortage, and how can it be addressed?

Cipriano: We're graduating about 150,000 nurses per year, and we expect those numbers to go up. (But) we also know the demand is going to go up. Our biggest concern right now is that in pockets across the country many nurses are telling us that they are very understaffed, and we know that that creates a serious risk for patients.

Our goal is to make sure that regardless of setting and geography we're able to have nurses in positions that keep patients safe and provide the right care they need.

Also, we have clinical nurses who are beginning to age out of the workforce, so we know we have a lot to do as a profession to make sure that our supply stays in place over the next decade as more baby boomers live longer.

Linda Burnes Bolton: This nursing shortage is different than the other nursing shortages that have preceded it. Individuals who graduated from nursing schools in the late '60s, '70s and early '80s are reducing the hours that they want to work, so we have to create environments that retain nurses and provide them with opportunities to deliver meaningful work.

One of the things that keeps me up at night is how am I going to assist in preparing nurses to work outside the walls of hospitals? So, population health management is something that we are chasing.

Janice Walker: Part of any strong system's strategic nursing plan is to continue to funnel nurses into their organization. Many students make the decision to enter healthcare in their sophomore or junior year, so at Baylor Scott & White we have partnered with schools of nursing to do summer camps. And one thing that we have found to be very intriguing is when we reach out to the children of our employees. They have a calling and a need to enter healthcare. We have found a talent pool there. But we cannot ever lose focus on building our infrastructure and our workforce planning as part of our strategic plan. (Nurses) are retiring faster than they are entering, and we have to have a good solid foundational plan around that.

MH: A big part of this retention and recruitment of nurses will involve millennial nurses. What are your systems doing to encourage or prepare for nurses that will increasingly include millennials?

Walker: As millennials enter our workforce they are really looking for that work-life balance, so we've had to get creative with our schedules. We've also had to get creative with our innovation around IT and infrastructure.

I think everyone would agree that when we went to nursing school we were not trained with the technology that they are trained at. When our students come out, and enter the workforce, they are looking for that technology. Hospitals struggle to stay up with that, so we are looking at any way that we can deploy technology to take the burden off of the nurse at the bedside.

Bolton: One of the things about the millennials is you have to keep it interesting for them. The days of a nurse working in obstetrics for 25 or 30 years are gone. You have to have multiple programs that allow nurses to transition into different roles. I mentioned earlier the need to help nurses transition from acute-care settings to population-health settings. The use of nurse practitioners in nursing homes, which has dramatically decreased the admissions from those facilities to the hospital, is an example of creating that value proposition (and) supporting nurses to advance their knowledge and expertise, and then deploying them in settings where they can be able to act at the top of their license.

Cipriano: One of the unique aspects that we're seeing with the younger generation — and I wouldn't want to just pigeonhole millennials because I think we have a lot of second-career entrants in nursing as well — is that we've done a good job of educating nurses to say everyone can be a leader. But I'm not sure we've actually created those opportunities.

One of the traditional problems with nursing is that we've not always supported young people moving ahead rapidly, and that's something this generation wants. They want to know that they're not going to be held back. I see this as a cultural shift that is beginning to happen, but will have to happen more rapidly.

If we think back to our conversation on shortage, we have to make sure that we are retaining nurses. Their skills and knowledge are so essential, so we can't afford to lose any educated nurse to a system that doesn't support their professional growth and development.

MH:There were a number of nursing strikes in 2016. What do you think is driving nurses to take organized labor actions?

Cipriano: In today's world, what we see is that nurses really care about taking care of their patients, and in order to do that, staffing is one of the most important issues to them. So, as we hear reports across the country, that is one of the key provisions.

It's a wake-up call to be mindful of the fact that nurses really have to have a good working relationship with the leaders in their organization in order to be sure that they have provided the right resources and structure to care for patients.

MH: How can healthcare organizations improve occupational safety and health for nurses?

Cipriano: One of the key areas where staff can be very helpful is making sure that they're following the most current guidelines for safe patient handling and mobility. Nurses originally were educated to think that body mechanics were the answer. We now know that's really not true at all. Particularly as patients are getting heavier, we know that nurses really are at risk. They're the fourth highest occupational category that misses days from work because of musculoskeletal injuries, so this is a key area.

Henrichsen: To get better visibility into what nurses are dealing with every day, we've started huddles on our units at Intermountain Healthcare that address nurse safety. (It's) a place where we talk about quality metrics (and) patient-safety topics. We also ask if there have been any injuries or anything that appears to be unsafe for our staff, whether it's staffing issues or whether somebody had a needle stick. We're watching those injuries always.

MH: Why have nurses faced difficulty in raising the educational bar for continued practice?

Bolton: I'm going to put on the hat of both the system chief nursing executive here at Cedars-Sinai but also the hat as one of the directors at the Robert Wood Johnson Foundation, which has funded academic progression that has been going on for the last several years. The good news is that through that work, many states, including Texas and California, and some rural states, have seen an increase in the number of graduates holding bachelor's and master's degrees. The programs in the rural states that have been very successful include the junior colleges granting bachelor's degrees.

Henrichsen: We are seeing the same thing here in Utah. We talked with the schools of nursing across the state of Utah and we have been working together to create opportunities for nurses to move seamlessly through an associate's program into a bachelor's program. We are beginning now to see the fruits of those labors. When we started the work, at least 75% of our new nursing graduates were graduating from associate degree programs. It's been a pretty big hurdle.

MH: Are there any efforts your systems are making to encourage a more diverse workforce of nurses?

Henrichsen: We don't have a very diverse workforce at Intermountain Healthcare at this point, and it is something that is very important to us. We've got such a great partnership with our schools of nursing, and we've been supporting some scholarships for nurses who come from diverse backgrounds.

Our goal is really to increase the number of nurses that come from a diverse background and move more of them into the nursing workforce, whether it's within our own organization or just somewhere within the state because we do have a growing diverse population. It's important for us to be able to meet the needs of our patients.

Bolton: This is lifelong work for me. Under funding from the Robert Wood Johnson Foundation and its Center to Champion Nursing in America we have been successful in creating a task force to expand the diversity of the nursing workforce across all areas. It's not just staff nurses, but the nurses in executive positions, faculty positions and nurses who sit on boards. We want it to be a more inclusive workforce.

We have worked with the National Coalition of Ethnic Minority Nurse Associations as well as the American Assembly for Men in Nursing to support their programs that they have had. We've seen a dramatic increase in the number of men in nursing, African-American nurses and Hispanic nurses. The one area that we have not been as successful in terms of a national effort is Native American nurses. But North Dakota, South Dakota and Idaho have a coalition underway to try to work with their populations to try to increase it, and we're supporting some of that work.