Preparing for Health Reform: The Federal Government and the Nursing Workforce
The nation's health care delivery and financing systems are facing strong public and private sector pressures to improve quality, safety, access, and efficiency (i.e., value). While often overlooked, the foundation of the health care delivery system is its workforce. Unless the nation's health workforce is adequately sized, better configured, and prepared with the right skills, the goal of improving value will be unlikely to be achieved.
The federal government has long been involved with the nursing profession, the largest component of the health care workforce. For decades, federal entities have helped shape the size, composition, and distribution of the nursing workforce, as well as help advance the scientific foundation of the profession through the work of agencies such as the National Institute of Nursing Research, the Veterans Administration, and the Agency for Healthcare Research and Quality. But, in the face of the rapidly changing organization and financing of health care delivery, the dramatic expansion of insurance coverage, the aging of the baby boomer generation, and the burgeoning population with multiple chronic care conditions, the question of how to prepare the nursing workforce has taken on a new urgency.
It would be impossible to chronicle all of the federal initiatives focused on the nursing workforce in a single article. Therefore, this overview focuses primarily on those currently under way at the Health Resources and Services Administration (HRSA). These initiatives are aimed at helping prepare the number of nurses needed to match expected demand, and to prepare nurses to take on new roles, interact with other caregivers differently, and navigate challenges to their professional boundaries.
To gather data on the roles and practice patterns of nurse practitioners (NPs), especially their contribution to the provision of primary health care, HRSA's National Center for Health Workforce Analysis is currently administering a nationally representative survey of approximately 22,000 NPs. The survey will obtain information on the utilization of NPs, their distribution across medical and surgical specialties, the location of employment settings, and other descriptive data. With its large sample size and rigorous study design, the 2012 National Sample Survey of Nurse Practitioners (NSSNP) will provide the National Center and workforce analysts with a much needed understanding of the current NP supply, and with data needed to project future NP supply and demand. A report of results will be available in early 2013, with a public use data file available shortly thereafter.
The Center is also working to revitalize HRSA's modeling of the future supply and demand for registered nurses (RNs). For more than a decade, HRSA had maintained models projecting RN supply and demand, but rapid changes in economic conditions, health care delivery, and forecasting technology have prompted the Agency to redesign the models. Center staff and contractors have conducted research to improve model parameters and scenarios and engaged nursing stakeholder groups (including educators, employers, researchers, policy leaders, and others) to understand the type of models that will best meet the needs of workforce planners and analysts. Projection results (including state-by-state demand) and description of projection models should be released in late 2013.
To better inform decision making on health workforce policy, a priority of the Center is to develop and implement a national uniform minimum data set (MDS) for the health professions. The MDS includes basic data on the demographic, education, employment, and practice characteristics of most health professionals. The Center is working closely with leading national organizations in 13 professions, including the National Council of State Boards of Nursing (NCSBN).
A fourth Center activity involves the production of Nursing Facts and Figures. This report will compile a wide range of data on the nursing workforce. Data will be obtained from federal sources, such as the American Communities Survey and the Bureau of Labor Statistics, as well as from national organizations. The Center plans to publish the report on a biennial basis beginning in late 2012.
Beyond the Center's agenda, other HRSA initiatives are underway that support the nursing workforce, particularly as the agency carries out its health care delivery activities. For example, the National Health Services Corp has grown tremendously—from fewer than 4000 people in 2009 to approximately 10,000 today. The Corp now employs roughly 1900 NPs and certified nurse midwives (CNMs). Similarly, the Community Health Center program has added more than 3000 nursing positions since 2009, including 800 advanced practice registered nurses (APRNs). Funds from the Affordable Care Act are being used by the Nurse-Managed Clinics to train nearly 1000 nurses by 2014, when the clinics are expected to serve nearly 100,000 patients. The Affordable Care Act also created a $1.5 billion maternal and child home visitation program, emphasizing pregnant women and interventions to improve health outcomes.
HRSA has a growing focus on interprofessional education and collaborative practice, illustrated by the new public–private partnership with foundations that led to the creation of the Coordinating Center for Interprofessional Education and Collaborative Practice. The goal of the Coordinating Center is to promote an integrated health system in which coordinated, collaborative, team-based practice becomes the national norm.
Finally, this overview of the federal government's involvement with the nursing profession would be incomplete without highlighting a new initiative under way at the Center for Medicare and Medicaid Services (CMS). In March 2012, CMS issued a call for applications for a new initiative to increase the nation's primary care workforce by supporting facilities that train APRNs. Under this initiative, CMS will distribute tens of millions of dollars to eligible hospitals to help them offset the costs of clinical training for APRN students. Students will acquire new skills in primary care, preventative care, transitional care, chronic care management, and other services needed by Medicare beneficiaries.
In the future, nurses will be called on increasingly to both participate and lead changes that are needed to improve the delivery system and improve the health of the nation. These examples illustrate the federal government's recognition that an adequately sized and well-prepared nursing workforce is vital to the success of public and private sector reforms aimed at increasing the value of health care services.
Peter I. Buerhaus, PhD, RN
Valere Potter Professor of Nursing Director, Center for Interdisciplinary Health Workforce Studies Institute for Medicine and Public Health Vanderbilt University Medical Center