REPORT ON NURSING IN VERMONT

December 1998

 The nation's health care system is in a period of dramatic transition driven by the need for cost-effectiveness. Major changes in structure, organization, financing and delivery have been underway since the early 1980s. The implications of these changes for the nursing workforce in terms of numbers, distribution and education are profound. What has changed for nurses in practice today? Or, how have nurses changed?

Dynamics of the RN labor force have always been difficult to understand - at least in part because of poor data regarding the composition of the workforce and its utilization. This lack of understanding becomes a particular liability during periods of nurse shortages and organizational restructuring.

The purpose of this report is to provide information that will enable decision-making about nursing and guide the most effective use of nurses. Its significance lies in the distinction between perception and fact.

 SUPPLY

In 1998, Vermont has 7583 registered nurses (RNs) - more than ever before. Yet four trends suggest that Vermont may soon be facing a nursing shortage.

1) Perhaps the biggest worry is the aging of Vermont's nurse population. In 1997, the median average age of Vermont RNs was 45 years old with 72 percent over 40. Studies (Buerhaus) show that nurses in their 50s begin to dramatically reduce their work hours. Within the next 10 years, large numbers of RNs will leave the workforce with inadequate replacements in the pipeline.

2) Vermont colleges are producing 36 percent fewer nurses today than five years ago despite growing demand for RNs in all sectors of health care. In 1997, Vermont graduated 176 RN students, compared to 240 students in 1993 - a drop largely due to the closing of UVM's Associate Degree program in 1996. A similar move is under discussion in at least one other school.

3) The utilization of nurses in all sectors of health care has grown. Hospitals, home health services, and nursing homes - the three largest nurse employers - all report record high numbers of RN staff.

4) Lastly, since the early 1990s, RN wages have stagnated while pay in other health care professions has grown. Candidates faced with better paying options may choose a career other than nursing.

The nursing shortage of the 1980s was not the result of a decline in the supply of nurses but an increase in the number of positions for nurses. With BOTH increasing demand and decreasing supply combining forces today, a serious nurse shortage is likely in the not-so-distant future.

 PRACTICE

The changing health care environment has given rise to much apprehension and concern about how the changes affect nursing practice and patient care. Most notable in this discussion is what HASN'T changed.

Work Setting

No shift in RN employment from acute to home care has occurred since 1995. Hospitals have not decreased their RN workforce and continue to employ almost half of the RNs in Vermont (46 percent). Home health is the second largest employer with 11 percent and nursing homes are third largest with 10 percent. Hospitals have not decreased their RN workforce and continue to employ almost half of the RNs in Vermont (46 percent). Home health is the second largest employer with 11 percent and nursing homes are third largest with 10 percent.

Within hospitals, however, changes have occurred in the practice setting. Staffed beds have decreased 36% in the past five years. Inpatient FTEs have dropped too, although to a much smaller degree (7%), while outpatient FTEs have almost doubled. This has resulted in some internal shifting of nurses. The extent and methods used to accomplish the internal shift of staff varies among hospitals. Cross-training has become a popular way to increase the cost-effectiveness of nurses and at the same time, provide nurses with additional work opportunities in the face of fluctuating inpatient census. Some studies, however, challenge the efficacy of cross-training. Aiken, et al. show in their article "Studying Outcomes of Organizational Change in Health Services" (1997), that nurses in specialized practice demonstrate enhanced performance in three general areas:

- Independent and timely clinical judgement
- Efficient utilization of resources
- Improved relationships with physicians which enhances the important exchange of patient information.

The degree of nurse specialization which small community hospitals can afford is a matter of speculation.

Within home health services, staff FTEs doubled between 1991-96 as did home visits. RN growth, however, has remained relatively flat - increasing in number but retaining about 35% of the work and 11% of the employed nurse population. The majority of growth in home health has occurred in Home Health Aide services.

Vermont nursing homes employ approximately 10% of the RN workforce - significantly more than the national norm of 7%.

Work Load

In a recent American Nurses' Association survey, 79% of hospital nurses questioned believed that patient care has suffered as a result of:

- decreased nurse/patient ratios
- decreased time for patient care.

This sentiment was echoed by an informal survey of nurses at Fletcher Allen Health Care which was reported by the Burlington Free Press in August of 1998:

- 67% said they experienced a significant increase in the number of patients assigned to them.
- 66% said their participation in direct patient care has decreased.

These statements are perplexing in light of current data which suggests that nurse/patient ratios are as strong as ever.
As the number of inpatient beds continue to fall, nursing FTEs in Vermont hospitals have remained relatively stable over the past five years. With fewer beds and the same number of nurses, it would seem that the RN workload has decreased - a notion supported by RN FTEs/staffed bed. However, studies (Aiken) show that factors which call for decreased nurse employment - such as fewer patients, are offset by factors which increase the need for nurses - such as increased patient acuity. From an inpatient perspective, it would seem that the workload of nurses has remained relatively unchanged.

Hospital nurses, however, do not care only for inpatients. When calculations are adjusted to include outpatient work, the nurse workload does indeed appear to increase slightly. But the calculation for adjustment has some inherent weaknesses, and when the adjustment is removed and acute admissions are related to inpatient staff, once again the result is a patient workload that has remained virtually unchanged for the past five years.

Current nurse/patient ratios for the hospital med/surg day shift are typically 1:4 with the range being 1:3-8 according to patient need and ancillary assistance. Home health nurses carry caseloads of 20-30 patients and generally make 5-7 visits per day.

Full Time vs. Part Time

Since 1995, the number of RNs working full time in Vermont has remained relatively stable. The same is true within Vermont hospitals. Much has been speculated about the negative effect of part-time employment on quality of care, staff morale and cost. In Vermont hospitals, full time RNs comprise about 39% of the nursing staff compared to a national average of 66%. Among individual hospitals, much variation occurs with the percentage of full time RNs ranging from 17% to 70%.

Shift Work

All Vermont hospitals use 8 hour shifts and all but two hospitals use 12 hour shifts to some degree - generally in specialty areas or on weekends. 10 hour shifts are used selectively but rarely.

In home health care, 8 hour shifts are the norm with an occasional 12 shift.

Wages

On a national scale, there has been no growth in the inflation-adjusted wages of RNs since 1991. In Vermont, the same is true with wages growing 11% over the past five years.

The current weighted average of RN pay in hospitals is:
    Vermont   $17.82/hour
    New Hampshire  $17.40
    combined    $17.53

In hospitals, RN wages increased 33% during the 1980s when the last nurse shortage occurred. Since then RN wages have remained essentially flat (11% in five years) and have been surpassed by gains in other health professions such as physical therapy, pharmacy or social service.

The current weighted average of RN pay in home health care is:

     Vermont      New Hampshire   combined

BSN        $17.55        $17.52       $17.53
diploma    $16.37      $16.60         $16.52
(No data available on ADN)

It is interesting to note that Home Health offers increased pay for a baccalaureate degree - presumably based on the demonstration of differentiated practice. Only five of Vermont's fourteen hospitals are aware of their educational mix. Nursing homes are also unaware of their educational composition.

No wage information was available from nursing homes.

Educational Preparation

While some areas of nursing practice have not changed, significant changes have occurred in the way RNs in Vermont are prepared for practice. RNs are prepared by one of three educational programs which involve two, three, or four years of training:

- Associate Degree 2 years
- Diploma (hospital-based)   3 years
- Baccalaureate Degree 4 years

All graduates, however, take the same licensing exam to qualify for practice - a matter of significant controversy within the nursing profession.

Last year, for the first time, the number of practicing Associate Degree RNs in Vermont exceeded the number of practicing Diploma RNs. This means that the majority of nurses in practice have been prepared with two years of education.

Changes have not only occurred in the type and amount of training received by Vermont's nurse workforce but also in the content of programs. Schools have attempted to adapt their curriculums to the changing health care environment as noted by the American Association of Colleges of Nursing:

- 68% have added course work dealing with managed care, health care economics, home care, health policy and chronic illness.
- 80% have extended clinical training into home care, outpatient clinics and community sites.

Vermont schools of nursing mirror these trends and report curriculum additions in five general areas: community, health promotion, high tech equipment, health assessment and management.

While these changes accurately reflect high growth areas of health care, the addition of new content provides a particular challenge for Associate Degree Programs which have only two years to offer an already demanding curriculum. If acute care content is curtailed as a result of this squeeze, a substantial burden is placed on both the new graduate seeking hospital employment and the hiring hospital.

In an interesting break from national trend, Vermont schools now graduate more Baccalaureate nurses than Associate nurses - signaling still another future shift in the skill mix of Vermont RNs.

Labor Mix

Nurses are a diminishing presence in hospitals. Since 1993, hospitals have increased their overall staff approximately 14%. Most of the growth has been distributed between ancillary, administrative and outpatient services. Even though RN FTEs are up slightly from five years ago, RNs now comprise approximately 22% of the total hospital staff compared with 24% in 1993. Similar trends exist nationally. In 1997, RNs comprised 24% of the workforce in US hospitals, compared with 37% in 1993 (Aiken). As hospitals increase the overall size of their workforce, the labor mix has changed to include a lower ratio of nurses to total. Since 1993, hospitals have increased their overall staff approximately 14%. Most of the growth has been distributed between ancillary, administrative and outpatient services. Even though RN FTEs are up slightly from five years ago, RNs now comprise approximately 22% of the total hospital staff compared with 24% in 1993. Similar trends exist nationally. In 1997, RNs comprised 24% of the workforce in US hospitals, compared with 37% in 1993 (Aiken). As hospitals increase the overall size of their workforce, the labor mix has changed to include a lower ratio of nurses to total.

In home health, RNs are retaining their presence at approximately 35% while at the same time Home Health Aides have increased their presence from 40% to 55% in five years.

 SERVICE and VALUE

Nurses are the largest group of health professionals and represent the primary clinical intervention in many settings. Much is known about the cost of nurses. Yet little examination has been directed toward nursing's contribution. While the relationship between nursing and quality patient care is quietly accepted, good analysis of variation is lacking. The reasons for this are varied. Much of nursing's work is preventative - an area historically difficult to quantify. Nursing has also lacked the political clout and academic "know how" to further their own outcomes research agenda. Lastly, poor data is available about the utilization and composition of the nursing workforce. Good studies are needed to affirm and further the relationship between nursing and patient outcomes. In their 1996 report on Nursing Staff in Hospitals and Nursing Homes, the Institute of Medicine concluded that "more rigorous research on the relationship between nursing variables, broadly defined, and quality of care would have significant payoffs for policymakers, nursing educators, and hospital administrators" (Wunderlich).

Some work already exists. Lower mortality rates in hospitals have been associated with an RN-rich skill mix (Hartz, et al.). Other work is underway on outcome indicators suspected to have a link with nursing practice, such as nosocomial infections, decubitus ulcers, medication errors and patient satisfaction. In Vermont, much of the information required to examine those relationships is not known to hospitals. More than half of the hospitals in Vermont have limited knowledge about the educational composition of their RN staff. The same situation exists in Vermont nursing homes. Only in home care, is there significant knowledge of skill mix against which patient outcomes can be compared.

 DISCUSSION

It appears inevitable that a nurse shortage is approaching. At the same time that supply is dropping, demand for RN services is growing. The situation is compounded by an aging general population with associated chronic illnesses, and a large wave of teenagers associated with risky behaviors such as smoking and drinking.

On the surface, nursing seems to have adjusted quite well to the challenges of the changing health care scene. Employment is up, nurse/patient ratios are stable, education is adapting, and more nurses have full-time employment than ever before.

But numbers do not reveal the whole story. Beneath this image of blue skies, several other less obvious factors have changed. Taken individually, none is particularly compelling. As a set of converging variables, however, their effect on nursing practice is substantial.

- Increased non-clinical responsibilities. In recent years, the institution of several new programs - many at the request of nurses - have increased nurse responsibilities, meeting time and paperwork. Examples of shared governance, quality improvement, and decentralized staffing naturally encroach on the time available for patient care and creates an added burden of work.

- 20% decrease in the number of hospital LPNs over a five year period. While RN/patient ratios have remained relatively stable, some of those patients were previously cared for by LPNs. Although the actual number of LPNs lost is fairly small (62 FTEs), the impact may be substantial in some pockets of Vermont.

- Increased intensity. Increased acuity and decreased length of stay combine to compress the work of nursing into a shorter time frame. Some studies (Aiken) show that this intensity is offset by fewer patients, but in Vermont, nursing's workload has not decreased.

- Decreased educational experience. In 1997, for the first time, Vermont's three year RNs which comprised the bulk of the workforce, were replaced by RNs with two years of education. Additionally, clinical experience which has traditionally focused on acute care, now includes community and outpatient components.

- Increased admissions. Even though inpatient care is down, there are indications that utilization of the system is up. Much of nursing care is front loaded - assessments, care plans, scheduling, education - all of which occur around the time of admission.

- Increasing age. The median age of Vermont RNs in 1997 was 45 years old and is part of a continuing trend of aging nurses since 1980.

- Increased information and technology. Mountains of information are thrust upon or demanded from health care workers on a daily basis. In addition, the rapidly growing technology constantly imposes new learning needs of a non-clinical sort. Both take time away from patient care and add to the stress of meeting expectations.

The actual impact of these changing variables requires further study.

 CLOSING

The changing health care environment has given rise to much apprehension and concern about how the changes affect nursing practice and patient care. In Vermont, we may take some comfort knowing that RN/patient ratios in hospitals have remained quite stable and that the number of nurses caring for patients has not diminished.

It is important to recognize, however, that other forces are present which not only may increase the overall workload of RNs but in some cases render nurses less prepared for the work they are expected to do. Further examination of these forces will enable the wise use of valuable nursing resources and benefit patients and providers alike.

 REFERENCES

Aiken L, Sochalski J, Lake E, Studying Outcomes of Organizational Change in Health Services, Medical Care 1997, 35:11, pp NS6-NS18.

Buerhaus P (published interview), Is a Nursing Shortage on the Way? Nursing98, August, pp 34-35.

Wunderlich G, Sloan F, Davis C, Nursing Staff in Hospitals and Nursing Homes: Is it Adequate? Institute of Medicine, National Academy Press, Washington DC 1996.

Aiken L, Sochalski J, Anderson G, Downsizing the Hospital Nursing Workforce, Health Affairs 1996, 15:4.

Hospital Statistics – 1998 Edition, Healthcare InfoSource, Inc., American Hospital Association, Chicago, Illinois.

Buerhaus P, Staiger D, Managed Care and the Nurse Workforce, JAMA, Nov 13, 1996, 276:18 pp 1487(7).

VAHHA Annual Statistical Report – 1996, Vermont Assembly of Home Health Agencies, Inc.

Hartz A, Krakauer H, Kuhn E, Young M, et al, Hospital Characteristics and Mortality Rates, New England Journal of Medicine, Dec 21, 1989, 321:25 pp 1720.

Vermont Community Hospitals Financial and Statistical Profiles 8/98, Division of Health Care Administration, Department of Banking, Insurance, Securities and Health Care Administration.

Bazilchuk N (news article), Nurses’ Survey: Care is Eroding, Burlington Free Press, 8/21/98.

Lumsdon K, Is There Life After Acute Care?, Hospitals & Health Networks, Dec 20, 1995, p 88.

RN Survey 1997, National Council of State Boards of Nursing, Vermont State Board of Nursing, 1998.

Wage Survey Report 1998, Foundation for Healthy Communities, Vermont Association of Hospitals and Health Systems, Vermont Assembly of Home Health Agencies, Home Care Association of New Hampshire.