Marla E. Salmon, Sc.D., R.N., FAAN

Dean and Professor

Nell Hodgson Woodruff School of Nursing

Director

Lillian Carter Center for International Nursing

Emory University


DR. SALMON: It is very much a pleasure to be here this evening. It is also great to see people I know here who don’t look much older than they looked when worked together on workforce issues about ten years ago. I think it is telling that we didn’t solve those problems then and we still haven’t yet today.

My purpose this evening is twofold. I would like to revisit the numbers because that seems to be one of the things that people talk about most in terms of the nursing shortage. I will present this from a nursing perspective. I also want to reframe the shortage problem and propose some possible alternatives to addressing this challenge. I would like for you to listen to these alternatives with respect to where policy is and where policy needs to go.

So, let’s talk about the shortage. Essentially, the shortage numbers reflect four things: First, we have a failing demographic equation in nursing, and it is substantial. Second, the increasing demand for nursing is protracted, will continue, and will continue to increase. Third, we have a compromised production function, so the supply will continue not to be adequate. And fourth, we have an unstable national nursing workforce. That’s the good news.

Actually I do think, in some ways, that it is the good news. In short, in terms of our failing demographics, our workforce is fundamentally out of alignment with who we are as a country, who we are as a people, and who we are as a world. Nurses are basically white, middle-class women. The overall representation of minorities in nursing in the United States is about 10 percent, which is significantly less than the overall composition of



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Marla E. Salmon, Sc.D., R.N., FAAN ❧ Dean and Professor Nell Hodgson Woodruff School of Nursing Director Lillian Carter Center for International Nursing Emory Uniersity DR. SALMON: It is very much a pleasure to be here this evening. It is also great to see people I know here who don’t look much older than they looked when worked together on workforce issues about ten years ago. I think it is telling that we didn’t solve those problems then and we still haven’t yet today. My purpose this evening is twofold. I would like to revisit the num- bers because that seems to be one of the things that people talk about most in terms of the nursing shortage. I will present this from a nursing perspective. I also want to reframe the shortage problem and propose some possible alternatives to addressing this challenge. I would like for you to listen to these alternatives with respect to where policy is and where policy needs to go. So, let’s talk about the shortage. Essentially, the shortage numbers reflect four things: First, we have a failing demographic equation in nurs- ing, and it is substantial. Second, the increasing demand for nursing is protracted, will continue, and will continue to increase. Third, we have a compromised production function, so the supply will continue not to be adequate. And fourth, we have an unstable national nursing workforce. That’s the good news. Actually I do think, in some ways, that it is the good news. In short, in terms of our failing demographics, our workforce is fundamentally out of alignment with who we are as a country, who we are as a people, and who we are as a world. Nurses are basically white, middle-class women. The overall representation of minorities in nursing in the United States is about 10 percent, which is significantly less than the overall composition of 3

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4 TRANSFORMING TODAY’S HEALTH CARE WORKFORCE our U.S. population. And hovering at around 10 percent of the workforce, men are simply not well represented at all in nursing. This makes no sense given the economic opportunities nursing offers now and in the future. The overall aging of the workforce is also a very serious demographic issue. The average age of nurses is now more than 27 years old. And nurs- ing faculties are even older, with 72 percent of nursing faculties over age 45. The fact that we have fewer young nurses than ever is of great concern, as are the major changes in the work styles and work support needs of our existing nursing workforce. For example, older nurses experience age-related changes that necessitate workplace changes ranging from mechanical patient lifts to large-print monitor displays. There are two particular things that I want to draw to your attention to bring the aging issues into sharper focus. The first relates specifically to the decline in numbers of younger nurses. In 1980, nurses under 30 made up more than 25 percent of the workforce. By 2004, they represented less than 10 percent. Also in 1980, the majority of nurses were under 40 years old. By 2004, almost three-quarters of the workforce was over 40. We are looking at a supply of nurses that is fundamentally older than the overall population, making them demographically non-representative. While the demographics of the overall nursing population are of great concern, the situation in the academic setting is even more compromised. In about 8 years we will have half as many nursing faculty as we now have. There is no obvious source for replacements on the horizon. This has critical implications for the future production of nurses. Another dimension of our demographics relates to our increasing de- pendence on foreign-educated nurses. Between 1998 and 2004, we tripled the number of nurses coming to the United States to work (in total, about 60,000). This is the steepest increase we have ever experienced. While these numbers have important implications with respect to the United States, they also represent an enormous drain of capacity in some of the most resource-poor countries in the world. I know that Fitz is going to say some things about this in his presentation this evening. And, of course, the numbers: Projections of the nursing shortage con- tinue to be called into question. Rather than picking these apart, I think we can simply look at the range of estimates and get a feel for the grave challenges ahead. Our most conservative estimates say that by 2020 we will be short about 340,000 nurses. The Bureau of Labor Statistics thinks that the number will be as large as 1.4 million. But even if it is 340,000, that shortage number is three times greater than what we have experienced to date. The demand for nurses continues to expand, as do the variety of op- portunities that are available to them. Yet we still lose somewhere around a quarter of new nurses within their first few years of practice. So, from

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 MARLA E. SALMON a purely numeric perspective, this is not a picture that is very promising. Add to this the growth in the number of elderly and chronically ill people, which Kevin spoke about in his comments. Suffice it to say that for both populations, the need for nursing care is particularly intense. So also is the need for nurses by people who receive their care in the community, which will only continue to increase over time. At this point about 60 percent of people receive long-term care in their homes, generally by informal providers who have no professional preparation. About 36 percent receive services from a mixture of types of providers. Only about 7 percent receive care exclusively from formal care providers. Think about that in terms of the magnitude of the older population and the decline of a younger population to provide care in the home. I don’t think we are going to be able to meet our care needs just by trying to ramp up the numbers. While I’m not going to propose that we stop trying to produce nurses, I do think that we are focusing on the wrong things. We need to come to grips with the fact that numbers alone are not an answer. We’ve got to change the discourse that, at least in the mainstream, seems to be focused on quantity. How do we refocus our lens and look for fundamentally different ways of providing nursing services in the future? I think you have all heard that phrase about thinking outside the box. In this case, neither thinking outside nor inside has worked. Maybe the box is defective! I think that probably the first thing we need to do is re-look at nursing (and perhaps every other major type of health worker). The starting point needs to focus on preserving only those things that are nursing’s key roles and contributions. In doing this, we also need to identify what can be jet- tisoned, reengineered, or handed off. There are so many things that nurses do—and are relied on to do over and over again. And there are so many other things that nurses end up doing that keep them from doing the things that both matter to the patient and are rewarding to the nurse. I want to point out two of the re- ally important things that nurses do. One of them is that they serve as the gasket of the health care system. Nurses do what needs to be done to fill the gaps, which is critical to keeping things going despite what is often significant system dysfunction. We want to preserve this ability of nursing to expand and constrict its functions in times of need. If we look at the historical shortage of primary care providers and the development of the nurse practitioner role many years ago in response to that shortage, we can see the utility of this professional elasticity. Another important role relates to the involvement of nurses in health services innovation. Nurses have historically patched together care in innovative ways that have eventually become formalized. While nurses

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 TRANSFORMING TODAY’S HEALTH CARE WORKFORCE are well positioned to find answers to care problems, they are also not yet optimally utilized in finding system-level solutions. There is no question that our current contexts for care are not well thought out. We need to redesign virtually all of our care environments. I think that we also need to expand the definition of care environments. We focus a lot right now on the hospital care environment as the place that we need to redesign nursing care. Yet only about half of nurses work in hos- pitals. So when we think about where they are working, and the ways in which people are going to be cared for in the future, we know that people will not always be cared for in hospitals. What about the home as a care setting? We already know that people needing care in their homes are facing major challenges. How can we rede- sign both home care and the home environment to support and recapture wasted time for all providers, not just nurses? How can we also design that environment to support as much independence as possible for those aging in their own homes? We also need to engage patients and families productively in the care processes. Nurses have spent a long time in a state of ambivalence about wanting to encourage families to be involved in the care of patients and at the same time wanting to keep them as far away from patient care as possible. Families now, with patients, receive care out of self-defense many times, rather than out of support. So how can we prepare family members to be effective in care and engage nurses in redesign? I will just mention T-CAB (Transforming Care at the Bedside), an exciting example in the set of initiatives sponsored by the Robert Wood Johnson Foundation, that re- lates to creating supportive care environments. When you involve nurses in redesigning care, you can actually achieve success in terms of both outcomes for patients and the capturing of time that is so often wasted. Think about it: Somewhere between 25 percent and 50 percent of nurses’ time in hospitals is spent on things that are not nursing care. If we could only recapture that time, we would also retain nurses who leave the field because of the frustration that this causes. We also need to think about and actually create interdisciplinary teams. This does not mean that “interdisciplinary” in and of itself is the goal; it is actually just a part of the strategy for creating effective care teams. Not everybody needs to work together all of the time. We have to figure out when people need to work together and why they need to work together, educate them to do that, and actually use these teams in practice. We also look at another dimension of effective teams, one that we in nursing have had a problem with over the years. Claiming all of those who provide and support nursing is fundamentally important to truly effec- tive nursing care teams. We need to think seriously about how we involve ourselves in educating, and truly working with, those who are not nurses but who are involved in nursing care if we are to have optimally effec-

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7 MARLA E. SALMON tive care teams. I think part of our socialization and professionalization as nurses has, at times, encouraged us to distance ourselves from nursing assistants, technicians, and others who are part of the teams for which we actually have responsibility. So when we think about care teams, it is both across disciplines and within them that we should focus on the delivery of nursing care. Within teams, we need to make sure that we include those informal care providers, such as family members, who are so important to patient care. We also need to focus on technology that supports patients’ indepen- dence. Who are the best people to involve in the development of this tech- nology? Probably the patients themselves . . . and those who help support their self-care (the nurses and others). Technology is important in support- ing nurses as well. When it expands nursing capacity and moves nursing from being viewed as a cost to being an investment, there is a payoff for nurses as well as patients. Part of the reason we lose so many nurses in their first three years is that there is such a great need for evidence of their value, including (though not limited to) the technology that allows them to care in safe and high-quality ways. In terms of the technology that sup- ports independence of individuals, there is already a lot out there (though some is of questionable value). Having had an elderly father who looked for every possible gimmick to keep himself in his own home, I have seen that there is a great need for truly assistive and supportive technology that is of real value to elderly people. We need to think about technology that expands care capacity as well; robotics is one very promising avenue. In Japan, for example, in some of the settings where care is being provided for people with dementia, robotic puppies are being given to patients. These furry, active, tiny robots provide a source of comfort and entertainment. And the puppies themselves don’t require a lot of support except for being plugged in. We also need to attend to our educational capacity. Again, this is not just about turning out numbers of nurses. What I am talking about is being extremely targeted in how we develop and use our educational resources in the future. There are two examples I’d like to highlight in this regard. One is that we need to share our existing and future faculty. It is ridiculous how many institutions we have with people teaching redundant content— over and over again—things that could be shared across faculties. There are a variety of ways to do this, but it won’t happen without significant planning and lowering of barriers. The second example is that we must expand our nursing faculty to more extensively include people who aren’t nurses. (This would apply to other health professions’ education as well.) This requires planning and real attention to the barriers that prevent this from happening. Educational technology is probably obvious in enabling educational capacity. Less obvious, however, is our need to invest in shared educa-

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 TRANSFORMING TODAY’S HEALTH CARE WORKFORCE tional technology. For example, in the area of simulation, institutions often have multiple simulation laboratories rather than a shared facility for multiple programs. Simulation is incredibly expensive and requires the attention of real experts in simulated learning. Another area of great need is educational research and innovation. Since the federal government has pretty much ceased to fund educational research, there is not nearly enough educational innovation and develop- ment under way. I think that this is an area of policy that is extremely important if we are to actually figure out what works. Currently it is not funded, and the outcome of that is very apparent. Earlier I talked about the role of nurses as being somewhat fungible, expanding and contracting to fill gaps in our health care system. The nurse who enables this to take place both in the immediate and longer terms is the nurse who has received a university education (a bachelor of science in nursing). The national pool of baccalaureate-prepared nurses is the source of those who go on to earn graduate degrees and become advanced practice nurses, assume faculty positions, and—on a daily basis—serve in supervisory and leadership roles all across the health systems. We need to make sure that their education continues to be for the purpose of their elas- ticity; we need their generalist preparation and their broad perspective. And we need a greater proportion of these nurses in the overall workforce if we are going to expand our supply of nurses. I want to turn to what I see as the frontiers of innovation for nursing and patient care. I think that the triad of quality–technology–touch is where the most opportunities for real innovations lie for patients and for nurses. And I think that preparing nurses to be involved in process and systems innovation is extremely important in the same kinds of ways that Kevin was talking about with primary care physicians. Development of technology, not just working with it, is the key to enabling nurses to engage in the management of care quality and improvement. This clearly has implications for both the education and socialization of nurses and care teams. Another very promising area for future innovation relates to hybridizing the discipline in some key areas. I mentioned that nurses are being asked to do roles that far exceed—or are expanded beyond—what they have done traditionally. That is because there is a need, and nurses can certainly at least partially fill this need. I think that we ought to think about hybridizing education in the same way that we are hybridizing research. It is at the boundary of disciplines that we will find some of the most promising answers to the greatest challenges in health care and nurs- ing. This is also true in the educational arena. We have seen some very promising successes for nurses who have moved into engineering design informatics, architecture, and community design and planning. They think about care, redoing and reclaiming those care environments that

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 MARLA E. SALMON are not thought of as care environments. Nurses who have the knowledge and skills to engage in the neurosciences, genetics, and other predictive health fields may become nurses who will help to create a better future for patients, families, and providers. The field of rehabilitation sciences is another promising area where nurses should connect and engage; it is an area that is going to need to expand. In addition, as the many policy fellows here in the audience already know, health policy is a key area in which nursing needs to be involved. I have three final thoughts. The first is that our nursing shortage prob- lem has become the world’s problem. Not having enough nurses is not only deleterious to our health; it is also a disaster for the health of people around the world. We owe ourselves and the rest of the world our best efforts to find real solutions to the future of caring. The second thought is that real solutions will require significant investment, but perhaps more importantly, they will also require letting go and walking away from a lot of traditions that are embedded in the health professions and in nursing. And, lastly, policy is the key to developing the solutions and figuring out what really does work. My final comment is that having the opportunity to be with you this evening has been a great honor. Thank you very much for being here. DR. FINEBERG: Thank you very much, Marla. If we could have the lights up for a moment, we could ask for questions while we still have her with us. The floor is open for questions. QUESTION about whether, and to what extent, the Title VIII programs have helped. DR. SALMON: Title VIII programs have been incredibly important and also incredibly underfunded. I am going to give you an example. The benefits of Title VIII are most obvious when they are not there. One of the big contributors to the creation of this nursing shortage is the loss of Title VIII funding over a long period of time. We actually saw a 14-fold reduc- tion in funding for scholarships over the period from about 1980 through 2000. As a result, we saw a tremendous decrease in the number of people who were able to afford to go to nursing school. When Title VIII hasn’t been there, the public and nursing have suffered. When it has been there, Title VIII has been an important contributor. Also, because of the loss of Title VIII funding over this long period, we now have to reinvest in educational infrastructure. I think a number of people know that in the 1970s there were funds available for building schools, educational technology, and so on. Those funds have ceased to exist, and we now have to do what everybody is thinking about. The prob-

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20 TRANSFORMING TODAY’S HEALTH CARE WORKFORCE lems with bridges in Minnesota and elsewhere are essentially the same problems with education. We are so far behind in educational infrastruc- ture that it is ultimately having a huge impact on the health of people. Most people think that the $150 million to $200 million budget for nursing in Title VIII is a very small amount. I would agree; however, it is remarkable what is done with that amount when you think of the Carl Perkins money for example, when the Department of Education was at $2.1 billion or something like that for technical education. I think Title VIII is a little engine that could be incredibly important not only in terms of the impact it has had, but also in terms of the innovations that have come out of those dollars. I see that as the place where we need to think about really shaping the workforce in what we do in the future. I do have to say that I am really sad about Title VII, which has focused on other health disciplines and care for elderly people. It doesn’t make sense to me that Title VII has been so deeply eroded. QUESTION about what is the impact on the health of people in other countries due to our importation of nurses from abroad. DR. SALMON: I am going to defer to my colleague, Fitz Mullan, but I think that my biggest issue with this is that we are the largest consumer of human resources for health around the world, and we are probably the most stingy in terms of any reciprocity or any kind of capacity building for human resources in the countries that we import from. I think it is a human rights issue in terms of people having the choice to migrate, but I also think it is a global well-being issue. It is a humanitarian issue in terms of how we benefit from the resources of others but are not replenishing those resources or working to replenish them. QUESTION about what should be done to disinvest some of the en- trenched ways of doing things. DR. SALMON: This question is probably shared across all health profes- sions: What kinds of things might be done to encourage disinvestment or to actually embed it in a systematic fashion? I believe that we need to rethink the ways in which health profession education takes place, but I also believe that we probably need to think even more about how pre-health professions’ education takes place. There has been, in my opinion, an erosion of what would be called “lib- eral learning” or “basic liberal arts” as a foundation. I believe we need to think about that because there is this interest in specializing so early in the undergraduate experience. I would much rather see people specializing in societal issues and then thinking about health professions as ways of really aiming at those issues and making a difference in them.

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2 MARLA E. SALMON QUESTION about how we should use technology and interdisciplinary cooperation in light of the faculty and professional shortage. DR. SALMON: How should we use technology in the face of this incred- ible and growing shortage of faculty and the need to work across health disciplines to develop a new generation of professionals? I think that the answer lies in three areas. We need educational technology to expand educational capacities. One possibility is distance learning—the notion of opening up campuses as places where any degree might be offered. There is this conflict between community college systems and other systems of higher learning. I think that is really a shame because anybody should have access to those degrees that they are qualified for. We need to mix up higher education. I think the second thing is making the technology that is actually in practice available. Most nursing students do not experi- ence electronic medical records as part of their experience. I think that is incredibly important. The third thing relates to the interface between the design of technology and preparing health professionals to be involved in developing its design. I do not think that technology is truly effective if it is not user friendly. There is an enormous amount of time spent by nurses and others taking care of technology. Ultimately technology should sup- port the work of providers, not detract from it or waste their time. QUESTION about what the problems are related to viewing nurses and others as costs and rather than investments. DR. SALMON: I think this is a fairly pervasive issue in the health care arena, and it is at a systems level. There is a real lack of understanding that health care needs to invest in human resources in the way that any other enterprise invests. We have a lot to learn from the long history of investment in human resources in other sectors. It would have an enor- mous impact. When you look at why young nurses leave, it is often because they are thrown to the wolves in many settings. Because of staffing needs, in- experienced nurses are being placed into situations that they are not able to safely manage. This is a disaster for patients and, often, a life-changing experience for nurses. I saw this first hand with my own daughter, who is a nurse. She started out her career in an internship program at a major teach- ing hospital. She ended up quitting after six weeks because her mentor quit, she was left without supervision, and she was scheduled randomly for all shifts, which made her one of the only nurses on some shifts. She was being put in situations in which she was not a safe practitioner and was terrified that she would cause terrible harm to another. Also, the fact that she was a single mother was completely overlooked. So, despite her love for the area of nursing that she had started in, she ended up leaving.

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22 TRANSFORMING TODAY’S HEALTH CARE WORKFORCE She also ended up leaving hospital nursing and is now doing a great job as a school nurse in another county. It is really unfortunate. She loved that job but she knew that she was beyond her capacity to do it in a safe fashion. QUESTION about how the connections between practice and education have weakened over time in many places and about our need to look to nurses in practice for strengthening education. DR. SALMON: I think that this is a really important and promising area for improving the education and practice of nursing. In our own setting we are actually reclaiming our close connections with practice and commitment to clinical education. What we have said is that clinical education is extremely important, and there are ways that we can develop clinical partnerships in which practicing nurses can serve in mentoring and educational roles. As we look to practice for nurses to help us in our educational mission, we are also conscious that we want to make sure that they are prepared for this important role. We want to be sure they have the information that they need to do this and that it is enjoyable and rewarding to them. The other piece is that we somehow need to stop assuming that edu- cation ends at the time that a person completes his or her educational program. I think we are now entering a time in which education simply should always be a part of one’s life. QUESTION about why nurses aren’t seen as an investment. DR. SALMON: I think if you look at the mind-set relative to workforce, this is a global problem. Nurses are often seen as the easiest place to cut the budget during hard times. This nearsighted perspective precludes looking at the cost of losing a nurse and sees the loss of a nurse as a gain. The reality is that it costs an enormous amount when you lose a nurse. If we were more invested in developing that nurse in the first place and in helping him/her to be successful, and ultimately retained him/her, we would save a great deal more money and lives than when that investment does not take place. Those places that have really invested in their nurses have saved an enormous amount of money because they have retained them and because those nurses do a better job in caring for patients. The math works—but only when you think of nurses as an investment. DR. FINEBERG: Okay. Marla, thank you very much for being with us. We enjoyed both the comments and the question and answers. Thank you. We have already heard something about anticipating our third speaker

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23 MARLA E. SALMON tonight, Fitzhugh Mullan. Fitz is the Murdock Head Professor of Medicine and Health Policy at George Washington (GW) University School of Pub- lic Health and also professor of pediatrics at the GW University School of Medicine. What is interesting is that Fitz simultaneously serves at the Upper Cardozo Community Health Center here in Washington. He was commissioner in the Public Health Service in 1972 and was among the first to serve in the U.S. National Health Service Corp. Five years later he was tapped to serve as director of the U.S. National Health Service Corp here in Washington. He served for a time here at the IOM as a scholar in residence. He then went back to New Mexico, where he had started his career, to serve as the secretary of health and environment. He came back to Washington again and was on the Johns Hopkins faculty for a while as well as being appointed as director of the Bureau of Health Professions in the Health Resources and Services Administration. Subsequently, he has continued to be a leader in both thinking and action for health workforce issues. He currently serves on the editorial board of the Journal of Health Affairs, as a contributing editor and also as editor of the narrative matters section of that wonderful journal. He is the founding president of the National Coalition for Cancer Survivorship. He serves as the vice chair of the Board of Trustees of the National Health Museum and is a member of the IOM. Please join me in welcoming Dr. Fitz Mullan.