Assessing Progress on the Institute of Medicine Report The Future of Nursing (2016)

6

Improving Workforce Data Infrastructure

According to The Future of Nursing, there are major gaps in the available data on the health care workforce, and closing these gaps is critical to achieving a fundamental transformation of the health care system (IOM, 2011). Data are needed to understand the numbers and types of health professionals, where they are employed, and in what roles. To support the ongoing transformation of the health care system and the Triple Aim, data are essential to help answer such questions as how many providers the nation needs, what types of providers can be used to meet that need, and whether educational capacity is sufficient to prepare them. Accordingly, The Future of Nursing recommends that an infrastructure be built to improve the collection and analysis of data on the health care workforce (see Box 6-1). The Future of Nursing: Campaign for Action (the Campaign) has focused on this recommendation under the pillar “bolstering workforce data” (CCNA, n.d.-b).

The recommendation on workforce data in The Future of Nursing assumes the existence of the National Health Care Workforce Commission, and each of the recommendation’s bullet points calls on the Commission and the Health Resources and Services Administration (HRSA) to take steps to improve the infrastructure for collecting and analyzing these data. Although the Commission was authorized by the Patient Protection and Affordable Care Act (ACA), and commissioners were appointed in September 2010 (one nurse among them), it has yet to be funded by Congress and thus is not operational (Buerhaus and Retchin, 2013; GAO, 2015; IOM, 2011). While progress on a single, coordinated national data infrastructure has been limited, progress has been made by many different organizations over the past 5 years on the collection and analysis of health workforce data generally and nursing workforce data specifically. The

challenge going forward is to find a way to build on this progress by developing a national infrastructure that can synthesize, link, and support the multiple currently uncoordinated efforts. With an increasing emphasis on interprofessional collaboration and team-based care (see Chapters 2 and 5) in a health care system that is being redesigned, establishing a national infrastructure for collecting and analyzing robust and multidisciplinary data on the health care workforce is more important than ever.

ACTIVITY AND PROGRESS

Because the National Health Care Workforce Commission is nonoperational, recommendation 8 from The Future of Nursing cannot be implemented as it was written. As noted above, however, despite the absence of a formal national infrastructure and despite some setbacks, significant progress has been made in the past 5 years toward improving the collection and analysis of data on the nursing workforce for use in health workforce planning and policy relating to education, training, and practice.

HRSA has not administered the National Sample Survey of Registered Nurses (NSSRN) since 2008, a gap that runs counter to the recommendation of the Institute of Medicine (IOM) report and represents the loss of an important source of data on the nursing workforce. Still, HRSA’s National Center for Workforce Analysis continues to provide important data relating to the nursing workforce. In 2012, HRSA administered the first National Sample Survey of Nurse Practitioners (NSSNP), and in 2014, it issued a summary report on the survey findings and made a public use data file available to researchers (HRSA, 2014a). In October 2013, HRSA produced The U.S. Nursing Workforce: Trends in the Supply and Education (HRSA, 2013). In December 2014, HRSA published The Future of the Nursing Workforce: National- and State-Level Projections, 2012-2025, providing supply and demand projections for registered nurses (RNs) and licensed practical nurses/licensed vocational nurses (LPNs/LVNs) using data from HRSA’s Health Workforce Simulation Model (HRSA, 2014b). New projections of supply and demand at the national level and a Web-based platform are available that states can use to generate supply and demand models by entering their state-based data and other assumptions about attrition from or entrance into the profession (Zangaro, 2015a,b). These state-level data can inform workforce policy at the state level. Nursing workforce projections will be made again in 2016 and will be reported at the national, regional, and state levels. This type of resource and the information provided thereby directly address the IOM recommendation that efforts be made to “identify regional health care workforce needs, and establish regional targets and plans for appropriately increasing the supply of health professionals” (IOM, 2011, p. 284).

Progress has been made on other existing federal instruments for collecting health care workforce data. The National Ambulatory Medical Care Survey

(NAMCS), a comprehensive national survey of ambulatory care services administered annually by the National Center for Health Statistics, was expanded to include data on nurse practitioners (NPs) and other nonphysician clinicians in physician practices. This expansion occurred in part to determine “how advanced practice registered nurses (APRNs) and physician assistants (PAs) are utilized and whether they are used to the full extent of their licenses and training” (CDC, 2015b). Further, the Centers for Disease Control and Prevention (CDC) noted with regard to the NAMCS that “fueled in part by changes in the delivery system, there is strong interest in understanding the dynamics of practice redesign and how team-based medical care is actually delivered” (CDC, 2015b). The collection of data on more members of the health care team will help achieve that understanding. The National Health Interview Survey (NHIS) question “Did you see a general doctor, specialist, nurse practitioner/physician assistant or someone else?” was modified in 2012 to include NPs/PAs (CDC, 2015a; State Health Access Data Assistance Center, 2013). With the inclusion of NPs, certified nurse midwives (CNMs), and certified registered nurse anesthetists (CRNAs) in the Standard Occupational Classification (SOC) system in 2010 (OMB, 2009), data on these nursing professions are now available from the American Community Survey (ACS) and the Bureau of Labor Statistics (BLS, 2010; Watson, 2013). Prior to that update, NPs, CNMs, and CRNAs were classified in the SOC as RNs. The National Council of State Boards of Nursing (NCSBN) has developed the Nursys database, containing data on licensure, discipline, and practice privileges of licensed nurses, both RNs and LPNs/LVNs, in participating states (NCSBN, 2015a). Using licensure data from the 54 boards of nursing that provide this information through Nursys, NCSBN is developing a comprehensive census of nursing licensure statistics (currently, Alabama, Hawaii, and Oklahoma do not provide these data) (NCSBN, 2015b).

To fill the gap in national data on RNs left when the NSSRN was discontinued, NCSBN and the Forum of State Nursing Workforce Centers conducted the National Workforce Survey of more than 42,000 RNs in 2013 (Budden et al., 2013). The 2015 survey collected data from RNs and LPNs/LVNs through September 2015, and these data are expected to be published in spring 2016 (Alexander, 2015a,b).

In 2008, the National Forum of State Nursing Workforce Centers (National Forum) began efforts to develop national nursing datasets on supply, demand, and education, with the support of the Center to Champion Nursing (Moulton, 2015; Moulton et al., 2012; National Forum of State Nursing Workforce Centers, 2015b; Nooney et al., 2010). NCSBN, the National Forum, and HRSA have agreed on the data elements of the Minimum Data Set (MDS) (HRSA, n.d.). There are now 34 State Nursing Workforce Centers; 30 collect supply data, 20 demand data, and 31 education data (National Forum of State Nursing Workforce Centers, 2015a). Sixteen states do not have State Nursing Workforce Centers: Alabama, Alaska, Arkansas, Delaware, Kansas, Maine, Maryland, Massachusetts,

Nevada, New Hampshire, North Carolina, Pennsylvania, Tennessee, Virginia, West Virginia, and Wyoming (National Forum of State Nursing Workforce Centers, 2015b).

The Campaign measures progress on this recommendation of The Future of Nursing by tracking the number of recommended nursing workforce data items collected by states. The Campaign tracked states’ collection of 14 items about the nursing workforce identified as important by the National Forum (CCNA, 2015b, n.d.-a). The Campaign found that between 2010 and 2014, 23 states were making progress toward collecting all or most of these data items; 16 states were already collecting all or most of the items; and 11 still were collecting only between 1 and 11 of the items (CCNA, 2015b). Two supplemental indicators also show progress on this recommendation: state boards of nursing that participate in the NCSBN Nursys data system and states that collect race/ethnicity data on their nursing workforce. Not all state boards of nursing participate in NCSBN’s Nursys data system, but the number of participating states has increased in recent years (NCSBN, 2015c,d,e). Connecticut, Georgia, and Pennsylvania began providing licensure data to the system in 2013-2014 (NCSBN, 2014). The Campaign’s dashboard indicators reveal that progress also has been made on the number of states that collect race/ethnicity data on their nursing workforce. In 2013, 44 states collected such data, compared with 34 states in 2011 (information on Connecticut was not available) (CCNA, 2015b).

In the external evaluation conducted by TCC Group (2013), only Maine and New Hampshire indicated that improving data on the nursing workforce was the greatest priority for their state; nevertheless, 46 percent of state Action Coalitions noted that workforce data was a main focus of their work, and another 44 percent said they were doing some work to advance this recommendation. The National Forum reports significant involvement of data stakeholders, particularly State Nursing Workforce Centers, in the state Action Coalitions, stating that more than “70% of workforce centers are co-leads for their state’s Action Coalition” (National Forum of State Nursing Workforce Centers, 2015a, p. 2). And 76 percent of Action Coalitions indicated that they thought the availability of data on the nursing workforce was improving (TCC Group, 2013). Still, the Campaign indicated that just 2 percent of state Action Coalition funding was spent on advancing data collection (CCNA, 2015a).

The Campaign’s external evaluators made the following observation about state Action Coalitions’ perceived progress on issues around workforce data:

DISCUSSION

Barriers remain to the robust data collection and analysis needed to understand the nursing workforce and, especially, the health workforce more broadly. The Campaign has recognized limitations in the data available for measuring progress toward implementation of this IOM recommendation. These include the lack of national indicators providing consistent information across states, lag time in the collection and reporting of data, the lack of standardized databases with which to track ideal indicators of progress, and the need to use proxy measures to assess progress within such a short time frame (e.g., using student enrollment rather than graduations or changes in the nursing workforce) (CCNA, n.d.-a; Spetz, 2013b; Spetz et al., 2013).

Barriers to Data Collection and Analysis

Some nursing workforce demand models incorporate changing demographics and population characteristics (HRSA, 2014b; Spetz, 2013a), but they cannot include consideration of changes in the health care delivery system. As David Auerbach, Deputy Director for Research and Cost Trends at the Massachusetts Health Policy Commission, noted at the committee’s July 2015 workshop: “Some [nursing workforce demand] models match workforce with utilization today, projecting how the population is going to change, and then outputting what the implication of that is. And that gets us far down the road, but it doesn’t answer as well, and can’t, the question about what happens if the delivery system changes? How does that change the equation?” One method of addressing this gap is to look at how some of the leading organizations are using workforce data (Peikes et al., 2014; Pittman and Forrest, 2015).

New and greater opportunities for data collection exist now than was the case even 5 years ago, yet barriers still need to be addressed. As mentioned in Chapter 2, as more APRNs begin obtaining and using their own National Provider Identifier (NPI), opportunities may increase for collecting and analyzing data on the services these clinicians provide and the settings in which they work; however, because many NPs—particularly those that provide care in hospitals and those that work under the supervision of or under collaborative agreements with physicians—do not use their own NPIs, limitations remain to the use of this information to determine comprehensively the types of services provided by APRNs (Buerhaus et al., 2015; HRSA, 2014a).

The discontinuation of HRSA’s NSSRN left a gap in the collection of data from a national sample of nurses. As Spetz (2013b) points out, “Research on the employment decisions of RNs, their educational trajectories, specific subpopula-

tions, job satisfaction, future employment intentions, and migration across state lines will be severely limited by the lack of the NSSRN” (p. 6). Yet he notes that changes in the nation’s health care environment make this information more critical than ever. In addition to the National Workforce Survey of RNs in 2013 and of RNs and LPNs/LVNs in 2015, HRSA is considering reinstituting a national sample survey of nurses, although in modified form (Zangaro, 2015a,b). At the committee’s May 2015 workshop, George Zangaro, Director of the National Center for Health Workforce Analysis at HRSA, noted that he is working with the administration on this. The current thinking is to survey a sample of all licensed nurses and include a question asking respondents to identify their specialty (e.g., CRNA, NP), if applicable (Zangaro, 2015a). The survey is expected to continue to collect demographic and educational information, and also is expected to include questions on health care reform and on the roles of nurses and how they contribute within a team-based care environment (Zangaro, 2015a,b). By collecting this information, Zangaro said, HRSA hopes to go beyond describing the demographics of the nursing workforce to inform health policy. HRSA plans on convening leaders in 2016 to assist with the development of the new survey and provide feedback on the survey instrument, the sampling plan, and the implementation plan.

In addition to the lack of an overall infrastructure for the collection and analysis of data on the nursing or interprofessional health workforce, the existing sources of nursing workforce data have many gaps. For example, the American Association of Colleges of Nursing has extensive data on its members, but less on nonmembers. The American Association of Nurse Practitioners has invested considerable resources in building its databases, but the data are proprietary and are not readily shared with other organizations or researchers. Data on demand are limited. The U.S. Census Bureau collects valuable data through the ACS, but an important missing data element is whether the individual has or had a license or certification in a profession, data that would help identify nurses working in related but non-nursing positions, such as administration or research. The National Center for Health Statistics collects systematic data on physician practices and services to patients on the physician’s panel through the NAMCS, and it recently added collection of data on the role of nonphysicians in the practices. However, the survey does not sample records of patients on panels of NPs and PAs even in the physician offices that are surveyed, nor does it survey NPs not working in physician practices. The collection of these data would provide important information on the roles of and services provided by NPs and others. Actions are needed both to build the infrastructure for collecting the data and to fill the most serious gaps.

In addition to the ACS, robust data sources for assessing how the nursing workforce is changing include the NSSRN, which has not been conducted since 2008, and the U.S. Census Bureau’s Current Population Survey (CPS). Table 6-1 compares the characteristics of these sources. Compared with the ACS and the

TABLE 6-1 Comparison of Sources of Data on the Nursing Workforce

NOTE: ACS = American Community Survey; APRN = advanced practice registered nurse; CNM = certified nurse midwife; CPS = Current Population Survey; CRNA = certified registered nurse anesthetist; NP = nurse practitioner; NSSRN = National Sample Survey of Registered Nurses; RN = registered nurse.
SOURCE: Auerbach, 2015.

CPS, the NSSRN required a great deal of time to process and was conducted only every 4 years. It was, on the other hand, a nursing-specific survey, which allowed for more data collection on nurses’ work settings and education and more detail on APRNs. One challenge with both the ACS and the CPS data is that respondents need to indicate that their occupation is RN, which most, but not all, will do—particularly those who are not currently working or are working in non-nursing positions.

As noted above, the National Forum, in collaboration with NCSBN and HRSA, has developed and expanded the use of the MDS. Spetz (2013b) notes that legislation “may be required in some states to authorize such data collection, appropriate funds, and guarantee public reporting” (p. 6). In addition to legislative changes to allow the collection of data on license renewal, other barriers to state implementation of the MDS exist, including leadership’s unwillingness to contribute to national datasets and technological misalignment of the state and NCSBN data systems (Alexander, 2015b). A closer examination of these barriers could elucidate the most effective means for removing them. Speakers at the com-

mittee’s July 2015 workshop noted barriers to expanding the data infrastructure at the state level, including high fixed costs that prohibit small states from conducting surveys or adding the MDS to the license renewal process and also inhibit the collection of data from smaller ambulatory practices as opposed to large hospitals and health systems (Auerbach, 2015; Moulton, 2015).

These logistical and methodological shortcomings in the collection and use of nursing workforce data at the national level pose an issue for national workforce policy and planning. The National Forum (2015b) emphasizes this point and expands the call for support for comprehensive workforce data collection to legislators and planners at the state level: “Without current and accurate national data, best policy approaches for resolving the national shortage may not be implemented at the federal level. . . . Without consistently collected state-level data and reliable national benchmarks, legislators and workforce planners at the state level have fewer resources to guide their use of scarce state funding” (p. 2).

Yet little progress has been made on building a national infrastructure that could integrate the diverse sources of health workforce data; identify gaps; and improve and expand usable data not just on the nursing workforce but also on the entire health care workforce. Health professionals have worked to bolster data collection efforts within their professions and also have united around the need for comprehensive and interprofessional workforce data. For example, dozens of health professions associations have urged Congress to appropriate funds to allow the Commission recommended in The Future of Nursing to be operational.²

Data Needs for Assessing Progress

In assessing the landscape of the nursing and broader health care professions workforce, the committee identified a number of areas that require improved data collection, analysis, and availability to help in assessing progress toward implementing the recommendations of The Future of Nursing:

• National surveys of nurses need to continue to have sample frames that include licensed RNs with an associate’s degree in nursing (ADN), a bachelor of science in nursing (BSN), and a master of science in nursing (MSN) instead of conducting separate surveys for these populations (see above).

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¹ A November 29, 2012, letter to Senate and House leaders was signed by 33 health professions associations and organizations (https://www.aamc.org/download/343168/data/groupletterurgingfundingforthenationalhealthcareworkforcecommis.pdf [accessed September 24, 2015]).

² A May 21, 2013, letter to leadership of Senate and House Appropriation Committees was signed by 36 health professions associations and organizations (https://www.aamc.org/download/322424/data/groupletterregardingthenationalhealthcareworkforcecommission.pdf [accessed September 24, 2015]).

• Better data are needed on the settings where nurses are working (e.g., hospitals, ambulatory care, nursing homes, nurse-led practices, retail clinics) and what services they are providing in those settings (see Chapter 2).
• Better data are needed on the range and cost of services provided by APRNs and PAs in hospitals and other care settings (see Chapter 2 and the Barriers to Data Collection and Analysis section of this chapter).
• Better data are needed with which to assess whether there is a shift of baccalaureate-prepared RNs and NPs out of primary care and a subsequent shift of LPNs and associate’s degree–prepared RNs into outpatient and community care settings, including long-term care (see Chapter 2).
• A consistent way of measuring outcomes of RN and APRN transition-to-practice residencies, including retention, satisfaction, and support, as well as patient outcomes, is needed (see Chapter 3).
• Better data are needed on the diversity of the pipeline (see Chapter 4).
• The number of degrees obtained by nurses (bachelor’s, master’s, and doctorates) that are outside of nursing (e.g., business, public policy, public health, sociology, health care administration) needs to be quantified (see Chapter 3). The MDS may be one opportunity to collect these data. Particularly if these data were collected upon license renewal, it would be possible to take a longitudinal look at educational attainment and in what fields.
• The efforts of colleges and universities to develop interdisciplinary activities for students in the health professions need to be tracked (see Chapters 3 and 5).
• Expanded and more robust data need to be collected on leadership positions held by nurses (see Chapter 5).
• Nurse-related measures need to be included in demand-side surveys (e.g., surveys of employers, hospitals, government agencies, and trade associations) (see Chapters 2, 3, and 5).

FINDINGS AND CONCLUSIONS

The nursing community and other stakeholders, including nursing associations, state nursing workforce centers, and federal agencies, have made strides toward collecting more and more consistent and robust data on the nursing workforce. However, a broad, interprofessional infrastructure for the collection of these data is lacking and is more important now than ever.

Findings

This study yielded the following findings on improving the infrastructure for the collection of workforce data:

Conclusions

The committee drew the following conclusions about progress toward improving the collection and analysis of data on the nursing workforce and the health care workforce more broadly:

RECOMMENDATION

REFERENCES

Alexander, M. 2015a. Presentation to IOM Committee for Assessing Progress on Implementing the Recommendations of the Institute of Medicine Report The Future of Nursing: Leading Change, Advancing Health. Washington, DC, May 28, 2015.

Alexander, M. 2015b. Presentation to IOM Committee for Assessing Progress on Implementing the Recommendations of the Institute of Medicine Report The Future of Nursing: Leading Change, Advancing Health. Washington, DC, July 27, 2015.

Auerbach, D. 2015. Presentation to IOM Committee for Assessing Progress on Implementing the Recommendations of the Institute of Medicine Report The Future of Nursing: Leading Change, Advancing Health. Washington, DC, July 27, 2015.

BLS (U.S. Bureau of Labor Statistics). 2010. 2010 SOC user guide. http://www.bls.gov/soc/soc_2010_user_guide.pdf (accessed September 24, 2015).

Budden, J. S., E. H. Zhong, P. Moulton, and J. P. Cimiotti. 2013. Highlights of the National Workforce Survey of Registered Nurses. Journal of Nursing Regulation 4(2):5-14.

Buerhaus, P. I., and S. M. Retchin. 2013. The dormant National Health Care Workforce Commission needs congressional funding to fulfill its promise. Health Affairs 32(11):2021-2024.

Buerhaus, P. I., C. M. DesRoches, R. Dittus, and K. Donelan. 2015. Practice characteristics of primary care nurse practitioners and physicians. Nursing Outlook 63(2):144-153.

CCNA (Center to Champion Nursing in America). 2015a (unpublished). Future of Nursing: Campaign for Action biannual operations report, August 1, 2014-May 31, 2015. Washington, DC: The Center to Champion Nursing in America.

CCNA. 2015b. Future of nursing: Campaign for action dashboard indicators. http://campaignforaction.org/dashboard (accessed September 12, 2015).

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³ This text was revised since the publication of the final book to correct American Heart Association to American Hospital Association.

CCNA. n.d.-a. Frequently asked questions about the campaign for Action dashboard. http://campaignforaction.org/sites/default/files/CFA%20Dashboard%20FAQ%20FINAL.docx (accessed September 24, 2015).

CCNA. n.d.-b. Campaign progress. http://campaignforaction.org/campaign-progress (accessed September 23, 2015).

CDC (Centers for Disease Control and Prevention). 2015a. National Health Interview Survey, sample adult, document version date: 22-Jun-15. ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHIS/2014/samadult_layout.pdf (accessed September 24, 2015).

CDC. 2015b. Welcome NAMCS participants. http://www.cdc.gov/nchs/ahcd/namcs_participant.htm (accessed September 24, 2015).

GAO (U.S. Government Accountability Office). 2015. National Health Care Workforce Commission. http://www.gao.gov/about/hcac/nat_hcwc.html (accessed September 24, 2015).

HRSA (Health Resources and Services Administration). 2013. The U.S. nursing workforce: Trends in supply and education. Rockville, MD: U.S. Department of Health and Human Services.

HRSA. 2014a. Highlights from the 2012 national sample survey of nurse practitioners. Rockville, MD: U.S. Department of Health and Human Services. http://bhpr.hrsa.gov/healthworkforce/supplydemand/nursing/nursepractitionersurvey/npsurveyhighlights.pdf (accessed September 23, 2015).

HRSA. 2014b. The future of the nursing workforce: National- and state-level projections, 2012-2025. Rockville, MD: U.S. Department of Health and Human Services.

HRSA. n.d. Health professions minimum data set. http://bhpr.hrsa.gov/healthworkforce/data/minimumdataset/index.html (accessed September 24, 2015).

IOM (Institute of Medicine). 2011. The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press.

Moulton, P. 2015. Presentation to IOM Committee for Assessing Progress on Implementing the Recommendations of the Institute of Medicine Report The Future of Nursing: Leading Change, Advancing Health. Washington, DC, July 27, 2015.

Moulton, P., P. L. Wiebusch, B. L. Cleary, M. L. Brunell, D. F. Fapier, C. Bienemy, S. A. LeVasseur, and J. P. Cimiotti. 2012. Towards standardization (part 2): Status of implementation of national nursing workforce minimum data sets. Policy, Politics and Nursing Practice 13(3):162-169.

National Forum of State Nursing Workforce Centers. 2015a. National Forum member data collection. http://www.nursingworkforcecenters.org/minimumdatasets.aspx (accessed August 25, 2015).

National Forum of State Nursing Workforce Centers. 2015b. Report to the Committee for the Evaluation of the Impact of the Institute of Medicine report “The Future of Nursing: Leading Change, Advancing Health.” http://www.nursingworkforcecenters.org/Resources/files/Final_IOM_Future_of_Nursing_Evaluation_Committee_Report.pdf (accessed September 24, 2015).

NCSBN (National Council of State Boards of Nursing). 2014. 2013 Environmental scan: Annual review of emerging issues and trends that impact nursing regulation. https://www.ncsbn.org/NCSBN_2013-14_Environmental_Scan.pdf (accessed September 24, 2015).

NCSBN. 2015a. About Nursys. https://www.nursys.com/About.aspx (accessed September 24, 2015).

NCSBN. 2015b. The national nursing database. https://www.ncsbn.org/national-nursing-database.htm (accessed September 24, 2015).

NCSBN. 2015c. 48 nurse license verification boards of nursing. https://www.nursys.com/NLV/NLVJurisdictions.aspx (accessed August 28, 2015).

NCSBN. 2015d. 54 licensure QuickConfirm boards of nursing. https://www.nursys.com/LQC/LQCJurisdictions.aspx (accessed August 28, 2015).

NCSBN. 2015e. 53 Nursys e-Notify boards of nursing. https://www.nursys.com/EN/ENJurisdictions.aspx (accessed August 28, 2015).

Nooney, J., B. Cleary, P. Moulton, P. Wiebusch, J. Murray, M. Yore, and M. Brunell. 2010. Towards standardization (part 1): Assessment of state and national nursing workforce data sources. Policy, Politics and Nursing Practice 11(3):173-183.

OMB (Office of Management and Budget). 2009. 2010 Standard occupational classification (SOC)—OMB’s final decisions. Federal Register 74(12):3920-3936.

Peikes, D. N., R. J. Reid, T. J. Day, D. D. Cornwell, S. B. Dale, R. J. Baron, R. S. Brown, and R. J. Shapiro. 2014. Staffing patterns of primary care practices in the comprehensive primary care initiative. The Annals of Family Medicine 12(2):142-149.

Pittman, P., and E. Forrest. 2015. The changing roles of registered nurses in Pioneer Accountable Care Organizations. Nursing Outlook 63(5):554-565.

Spetz, J. 2013a. Forecasts of the registered nurse workforce in California. http://rn.ca.gov/pdfs/forms/forecasts2013.pdf (accessed September 24, 2015).

Spetz, J. 2013b. The research and policy important of nursing sample surveys and minimum data sets. Policy, Politics and Nursing Practice 14(1):33-40.

Spetz, J., T. Bates, L. Chu, J. Lin, N. W. Fishman, and L. Melichar. 2013. Creating a dashboard to track progress toward IOM recommendations for the Future of Nursing. Policy, Politics and Nursing Practice 14(3-4):117-124.

State Health Access Data Assistance Center. 2013. NHIS questionnaire changes addressing the Patient Protection and Affordable Care Act. http://www.shadac.org/files/shadac/publications/NHIS_ACA_Brief34.pdf (accessed September 24, 2015).

TCC Group. 2013. Future of Nursing: Campaign for Action: Action coalition survey. Philadelphia, PA: TCC Group.

Watson, A. L. 2013. Implementing the 2010 Standard Occupational Classification in the Occupational Employment Statistics program. Monthly Labor Review (May):36-49. http://www.bls.gov/opub/mlr/2013/05/art3full.pdf (accessed September 24, 2015).

Zangaro, G. 2015a. Presentation to IOM Committee for Assessing Progress on Implementing the Recommendations of the Institute of Medicine Report The Future of Nursing: Leading Change, Advancing Health. Washington, DC, May 28, 2015.

Zangaro, G. 2015b. Presentation to IOM Committee for Assessing Progress on Implementing the Recommendations of the Institute of Medicine Report The Future of Nursing: Leading Change, Advancing Health. Washington, DC, July 27, 2015.

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