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Four Challenges Facing the Nursing
Workforce in the United States
Peter I. Buerhaus, PhD, RN, FAAN, FAANP(h); Lucy E. Skinner, BA; David I. Auerbach, PhD; and Douglas O. Staiger, PhD
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.
Keywords: Nursing workforce, physician shortage, registered nurse retirements
O
ver the first 15 years of the 21st century, the size, education, and age of the nursing workforce changed considerably. The annual number of nursing graduates
increased rapidly. The growth of registered nurses (RNs) prepared
with bachelor’s degrees exceeded those prepared with an associate’s degree starting in 2011, and the number of RNs who have
obtained a graduate degree (master’s, PhD, or doctorate in nursing practice) increased fourfold. Moreover, the size of the workforce increased by approximately 1 million RNs, with employment
growth occurring in hospital and nonhospital settings. Since 2000,
the number of employed RNs older than age 50 years increased by
600,000, and these older RNs currently account for 30% of RNs
working in hospital settings and 40% of RNs working in nonhospital settings (Buerhaus, Skinner, Staiger, & Auerbach, In press).
These changes in the RN workforce occurred alongside
other forces. The new millennium began with a national shortage of more than 100,000 RNs that lasted until 2003, a brief but
sharp economic recession in 2001, and the development and spread
of the quality and safety movement. The Great Recession in 2007
to 2009 was followed by a slow and prolonged recovery, the implementation of health reforms created by the 2010 Patient Protection
and Affordable Care Act (ACA), and the release of the National
Academies Institute of Medicine Report, The Future of Nursing:
Leading Change, Advancing Health (Institute of Medicine, 2010).
The increasing educational preparation of RNs, the growth
in the size of the nursing workforce, and the ability to overcome
nursing shortages, recessions, and health reform implementation
establishes a strong foundation that can sustain the nursing profession as it faces new and unprecedented challenges that lie ahead.
This article discusses four challenges that RNs throughout the
country will face during the next 20 years. They include the aging
of the nation’s baby boom generation, physician shortages, the
retirement of RNs, and a new era of health reform implementation.
40
Journal of Nursing Regulation
These challenges will undoubtedly affect nursing regulation, particularly those rules concerned with patient care safety in
acute and non–acute care settings, use of technology, access to care,
scopes of practice for both nurse practitioners (NPs) and RNs, and
accreditation of nursing education programs. Regulators will need
to be alert for new regulations that may be needed or current regulations that may need to be examined and updated to help nurses
successfully respond to each of these challenges.
Aging of the Baby Boom Generation
An estimated 76 million people were born during the baby boom
from 1946 to 1964, far more than any generation born before them
(Colby & Ortman, 2014). By 2030, all baby boomers will be aged
70 years and older, and the number of U.S. seniors will be 55%
greater than that in 2015 (Kirch & Petelle, 2017). The U.S. population aged 85 years and older will double from 6.3 million in 2015
to nearly 13 million by 2035 (See Figure 1), and the number of U.S.
residents aged 100 years will triple between today and 2045 (U.S.
Census Bureau, 2014).
Currently, 54 million people are enrolled in Medicare, which
provides health insurance coverage to U.S. citizens aged 65 years
and older, people with end-stage renal failure, and people with
certain disabilities (Centers for Medicare and Medicaid Services
[CMS], 2017). As baby boomers age, Medicare enrollment is
projected to grow to 80 million in 2030 (CMS, 2016) and lead
to a substantial increase in demand for health care. Because the
demand for RNs is closely related to the factors that drive the
demand for health care, as the Medicare population increases, so
too will the demand for RNs.
The large numbers of aging baby boomers will also increase
the intensity and complexity of the nursing care required. Because
of advancements in medicine, more active lifestyles, and lower rates
of smoking, emphysema, and myocardial infarction, baby boomers
Volume 8/Issue 2 July 2017
FIGURE 1
Projections of Male, Female, and Total
Number of the U.S. Population Aged 85
Years and Older, 2015–2060
20,000,000
U.S. population aged 85+ years
are predicted to have longer life expectancies than previous generations and therefore will use more health care services financed by
Medicare (King, Matheson, Chirina, Shankar, & Broman-Fulks,
2013).
Alhough baby boomers may be living longer, the prevalence of chronic diseases among them is increasing. By 2030, 40%
of baby boomers are expected to have diabetes, 43% are expected
to have heart disease, and 25% are expected to have cancer.
Additionally, the percentage of Medicare beneficiaries with three
or more chronic conditions is predicted to increase from 26% in
2010 to 40% in 2030 (Goldman & Gaudette, 2015). Chronic disease management will stimulate an increase in the demand for
health care providers, the complexity of treatment regimens, the
use of prescription medications (with consequent untoward adverse
effects), the potential for conflicting medical advice, and the risks
of duplicative tests, hospitalizations, and emergency visits (Centers
for Disease Control and Prevention, 2013).
Approximately 11% of adults aged older than 65 years and
32% aged older than 85 years have Alzheimer disease (Alzheimer’s
Association, 2016). Degenerative and debilitating diseases will
require long-term care and challenge families, professional caregivers, and public resources. In the United States, the old-age dependency ratio (number of people aged 65 years and older per 100
people aged 20 to 64 years) will increase from 21 in 2010 to more
than 30 by 2030 (Ortman, Velkoff, & Hogan, 2014), increasing
pressures on health care providers and family caregivers.
Aging baby boomers are also expected to affect the geography of retirement. In 2010, states with the highest proportion of
their population aged older than 65 years were Florida (17%), West
Virginia (16%), Maine (16%), and Pennsylvania (15%) (West, Cole,
Goodkind, & He, 2014). In 2014, 32% of women and 18% of men
aged older than 65 years lived alone (Stepler, 2016). If baby boomers follow the pattern of past generations, the rural and smalltown population of 55- to 75-year-olds will increase to 14 million
by 2020. Much of this growth is reflected by “aging in place,” in
which older people have remained in rural communities, while
younger people have left for urban areas (Baernholdt, Yan, Hinton,
Rose, & Mattos, 2012). However, those living in rural areas have
access to fewer health and social resources than those in urban
areas, and they have higher rates of poverty, unemployment, substance abuse, and depression. Older people living in rural areas
often face a double jeopardy. In addition to the increased risk of
age-associated mental health problems and cognitive degenerative
diseases, those living in rural areas are more likely to experience
social isolation and inadequate or no access to mental health services (Administration on Aging, 2011).
The increased number of older people, the complexity of
their health conditions, their geographic location, and their need
for social services and family involvement will pose many challenges for nurses and health care delivery organizations in the coming years. Not only will the demand for nurses increase, but also
the intensity and types of nursing care required will rise.
15,000,000
10,000,000
5,000,000
0
2015 2020 2025 2030 2035 2040 2045 2050 2055 2060
Year
Female
Male
Total
Source: U.S. Census Bureau (2014).
Physician Shortages
The American Association of Medical Colleges estimates a shortage of between 40,800 and 104,900 physicians by 2030 driven
by decreasing working hours, retirement, and increasing demand,
particularly from aging baby boomers (Kirch & Petelle, 2017;
Association of American Medical Colleges, 2017). Separately, the
Health Resources and Services Administration (HRSA) projects
a shortage of 24,000 primary care physicians by 2025, mainly
because of the aging of the population and the overall population growth (HRSA, 2016). However, not all agree that physician shortages exist. For example, Gudbranson, Glickman, &
Emanuel (2017) argue that with improvements in the organization
of health care, gains in administrative efficiency, and technologic
advances in telemedicine and communication, the size of the physician workforce is more than adequate to meet current and future
demands of the U.S. population.
Despite discrepancies regarding the estimates on the size,
timing, and existence of primary care and specialty physician shortages, little disagreement exists regarding the uneven geographic
distribution of physicians (Gudbranson, Glickman, & Emanuel,
2017). Rural areas average 68 primary care physicians per 100,000
residents; urban areas average 80 per 100,000 (Champlin, 2013).
Residents of rural areas are already reporting long wait times and
difficulties accessing a physician (Kirch & Petelle, 2017). On the
eve of the ACA’s 2014 health insurance expansions, nearly 60 million people had inadequate access to primary care, and the HRSA
reported 5,900 health professional shortage areas in the United
States (Graves et al., 2016).
Current and projected shortages of primary care and specialty care physicians as well as the persistent uneven geographic
distribution mean that the nursing workforce will be increaswww.journalofnursingregulation.com
41
FIGURE 2
Years of Experience Lost to the RN Workforce, 1980–2030a
2,500,000
Years of experience lost
2,000,000
1,500,000
1,000,000
500,000
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
0
Year
a Years of experience is the product of the number of registered nurses (RNs) leaving the workforce and the average years of experience for each. The latter is
approximated based on data from the National Sample Survey of Registered Nurses, conducted by the Health Resources and Services Administration, in which
RNs were asked how many years they had worked as RNs. Source: Current Population Survey, 1980-2000, https://www.census.gov/programs-surveys/cps.html.
American Community Survey, 2001-2015, https://www.census.gov/programs-surveys/acs/.
ingly called on to provide some care that would otherwise be provided by physicians (DesRoches, Clarke, Perloff, O’Reilly-Jacob, &
Buerhaus, In press).
Retirement of Registered Nurses
Beginning in the early 1970s, career-oriented and primarily female
baby boomers embraced the nursing profession in unprecedented
numbers following large increases in health care spending resulting from the introduction of Medicare and Medicaid (Buerhaus,
Auerbach, & Staiger, 2017). By 1990, baby boomer RNs numbered nearly 1 million and accounted for about two-thirds of the
RN workforce (Buerhaus, Staiger, & Auerbach, 2000). As these
RNs aged over the next two decades, they accumulated substantial knowledge and clinical experience. The number of boomer
RNs peaked at 1.26 million in 2008 and, after a brief delay in
the early part of the current decade (likely associated with the
Great Recession), the baby boomer RN cohort began retiring in
large numbers (Auerbach, Buerhaus, & Staiger, 2014). Since 2012,
roughly 60,000 RNs have exited the workforce each year, and
by the end of the decade, more than 70,000 RNs will be retiring annually (Staiger, Auerbach, & Buerhaus, 2012; Auerbach,
Buerhaus, & Staiger, 2015). In 2020, baby boomer RNs will number 660,000, roughly half their 2008 peak.
The retirement of 1 million RNs between now and 2030
means the years of nursing experience and knowledge they have
42
Journal of Nursing Regulation
accumulated will be lost to the nursing workforce as these RNs
exit from the workforce. The authors estimate that in 2015, the
nursing workforce lost 1.7 million experience-years (the number of
retiring RNs multiplied by the years of experience for each RN),
double the number in 2005 (See Figure 2). This trend will continue to accelerate as the largest groups of baby boomer RNs reach
their middle to late 60s. The departure of such a large cohort of
experienced RNs means that patient care settings and other organizations that depend on RNs will face a significant loss of nursing
knowledge and expertise that will be felt for many years to come.
Health Care Reform
The 2016 elections gave Republicans control over the White
House and Congress and, as promised, they initiated efforts to
repeal and replace the ACA. As of this writing, they have not been
able to do so, and the main goals of the ACA remain: improving
the efficiency of health care delivery systems, expanding insurance coverage, increasing the number of certain health care professionals, emphasizing health education and disease prevention,
and replacing fee-for-service payment with a value-based system.
Determining the direct impact of these reforms on the nursing
workforce is difficult, but RN employment in both hospital and
nonhospital settings has continued to grow over the past several
years (Buerhaus, Skinner, Staiger, & Auerbach, In press).
However, the new administration and Congress now seek to
scale back and either modify or reform the ACA in several ways,
including eliminating personal and employer mandates to purchase health insurance, converting Medicaid to a block grant program, promoting health savings accounts, emphasizing greater
competition among insurers, and allowing states more flexibility
in determining what constitutes essential health benefits and coverage of pre-existing conditions (Antos & Capretta, 2017). Recent
Congressional Budget Office estimates suggest that these provisions would lead to large reductions in the number of people with
health insurance. If the Congressional Budget Office estimates are
reasonably accurate, the demand for health care would fall toward
pre-ACA levels, and hospitals would once again contend with a
larger portion of uncompensated care. Moreover, how an increasing portion of uninsured hospital patients will affect nurse employment is unclear, but greater financial pressure on hospitals could
lead to lower RN wages and hospital closures.
Meeting the Challenges
Each of these challenges is formidable and will significantly affect
the RN workforce. What is more, these challenges will occur
simultaneously and interact with each other, making the next 15
years perhaps the most important time in the nursing profession’s
history.
Aging Baby Boomers
Given the large number of baby boomers with multiple chronic
diseases, the nursing profession should realize that its clinical
workforce will be unable to provide all the care required. After
all, nursing education undergraduate and graduate programs offer
little focused content on geriatrics, and such content has never been
popular with nursing students. Thus, nurses should not count on
the education system to meet this challenge. Instead, nurses should
form partnerships with others—social workers, pharmacists, community health departments, primary care and other physicians,
community health workers, churches, home health care agencies,
long-term care facilities, and emerging health care delivery systems—to both understand the scope of need in their communities
and to determine how resources can best be organized to provide
a more coordinated and efficient system of care delivery. Such
partnerships can involve community housing planners; schools of
engineering, business, and architecture; developers of wearable digital sensors; and others who can contribute to modifying physical
environments, developing business ventures, and enabling digital
devices to ease the burdens on aging boomers and make better use
of professional and family caregivers.
Nurses in policy positions can urge state legislatures to recognize the health care implications of aging baby boomers and to
find nonpartisan public policy strategies that can help nurses and
others improve the care of the nation’s aging society. Similarly,
nurses can develop interprofessional models of care that go beyond
Volume 8/Issue 2 July 2017
physical care to provide mental and behavioral health support,
especially for patients with Alzheimer disease and other cognitive
degeneration conditions. Nurses, by themselves, are unlikely to be
able to provide all the needed care, but they can lead the development of new care models and interpforessional and interdisciplinary teamwork as well as increase their influence in shaping
private and public policies and removing barriers to appropriate
care delivery.
Shortages of Physicians
Although the magnitude of physician shortages is uncertain, little
doubt exists about their effect. They will impact nurses providing primary or specialty care, particularly in rural areas and for
vulnerable populations—women, low-income people, the uninsured, people who do not speak English as a first language, people with disabilities, people who are dually eligible for Medicare
and Medicaid, and Native Americans and African Americans
(DesRoches, Clarke, Perloff, O’Reilly-Jacobs, & Buerhaus, In press).
The expected increase in demand for primary care and the uncertainties associated with payment and delivery reforms have invigorated policymakers to address how to ensure the primary care
workforce can respond to the health needs of all U.S. individuals.
Efforts aimed at removing restrictive state-level scope-ofpractice laws and regulations governing NPs should continue.
Additionally, regulations promulgated at the local level (namely
by hospitals and insurers affecting NP hospital admitting privleges reimbursement, etc.) can also constrain NPs’ scope, often
more directly, even in states that do not impose state-level restrictions, will need to be carefully examined. Growing evidence on
the cost, quality, consumer satisfaction, and other contributions
of primary care NPs is stimulating policymakers and influential health organizations to increase the number of NPs and to
expand their scopes of practice (Donelan, DesRoches, Dittus, &
Buerhaus, 2013; DesRoches, Gaudet, Perloff, Donelan, Iezonni, &
Buerhaus, 2013; Buerhaus, DesRoches, Dittus, & Donelan, 2015;
Perloff, DesRoches, & Buerhaus, 2016). However, rather than viewing the lifting of scope-of-practice restrictions as a fight between
nurses and physicians, NP leaders could structure their public policy arguments around the opportunity (and evidence) that NPs
can increase access to care, especially to aging and medically complex baby boomers and people living in rural areas (which should
appeal to Democrats), and reduce costs and increase consumer
choice (which should appeal to Republicans).
Furthermore, NP leaders need to recognize that solutions
addressing the implications of physician shortages and the growing demand for care of older adults must acknowledge the complex
relationship between physicians and NPs. Beyond differences in
perspective (cure versus holism), education, training, and the ways
their roles have …
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