PERSPE C T I V E
a loss of status and income as
well as disdain from peers. Although leadership is making its
way into clinical training, the
workforce of the near future is
already practicing. How can senior leaders enable and encourage
front-line leadership among today’s clinicians?
Surveys suggest that clinicians
want a greater leadership role but
feel unprepared3 or disempowered.4 Institutional leaders can
encourage and support unit-level
and front-line clinical leadership
by framing the organizational purpose as value creation, giving local leaders the authority to make
microsystem changes, tolerating
the failure of some new delivery
ideas, and creating professional
pathways for clinicians who want
to make leadership a career option. But data remain the single
most important motivator and tool
for a clinical leader. High-quality,
LEADING CLINICIANS AND CLINICIANS LEADING
comparative, unit-level and individual-level clinical and financial
data5 can both create the need for
clinician leadership and be the
starting point for the four tasks.
Other critical resources include
protected time, training and mentorship (provided by many academic centers either in house or
through collaboration with professional societies and business
schools), and clear organizational
expectations of clinician performance.
CEOs may resist investing in
developing clinical leadership and
decentralizing control or may believe the process will be too slow
to address current pressures. But
the need is evident, the tasks are
clear, and the skills are at hand
— data orientation, the relentless pursuit of excellence, and a
habit of inquiry are all second
nature to clinicians. Ultimately,
investment in such leaders will be
essential to achieving the goals
of health care reform.
Disclosure forms provided by the author
are available with the full text of this article
at NEJM.org.
From Harvard Business School, Boston,
and the King’s Fund, London.
1. Curry LA, Spatz E, Cherlin E, et al. What
distinguishes top-performing hospitals in
acute myocardial infarction mortality rates?
A qualitative study. Ann Intern Med 2011;
154:384-90.
2. Beckman HB. Lost in translation: physicians’ struggle with cost-reduction programs.
Ann Intern Med 2011;154:430-3.
3. UnitedHealth Center for Health Reform
and Modernization. Farewell to fee-for-service? A “real world” strategy for health care
payment reform. Working paper no. 8. December 2012 (http://www.unitedhealthgroup.com/
~/media/UHG/PDF/2012/UNH-Working
-Paper-8.ashx).
4. Gilbert A, Hockey P, Vaithianathan R,
Curzen N, Lees P. Perceptions of junior doctors in the NHS about their training: results
of a regional questionnaire. BMJ Qual Saf
2012;21:234-8.
5. Lee TH. Turning doctors into leaders. Harvard Business Review. April 2010:50-8.
DOI: 10.1056/NEJMp1301814
Copyright © 2013 Massachusetts Medical Society.
The Nursing Workforce in an Era of Health Care Reform
David I. Auerbach, Ph.D., Douglas O. Staiger, Ph.D., Ulrike Muench, R.N., Ph.D., and Peter I. Buerhaus, R.N., Ph.D.
T
he foundation of the health
care delivery system is its
workforce, including the 2.8 million registered nurses (RNs) who
provide health care services in
countless settings. The importance of RNs is expected to increase in the coming decades,
as new models of care delivery,
global payment, and a greater
emphasis on prevention are embraced. These and other changes
associated with health care reform will require the provision of
holistic care, greater care coordination, greater adherence to
protocols, and improved management of chronic disease —
roles that are inherently aligned
with the nursing model of care.
1470
Will the nursing workforce be
ready to respond to these challenges? Just 10 years ago, the answer would have been far from
clear. The number of new entrants into nursing had fallen
sharply in the 1990s because the
generation of women born after
the baby boom was not only
smaller in size but had greatly
expanded career opportunities in
other professions. With fewer people becoming nurses, projections
from a decade ago indicated that
the size of the workforce would
begin declining by the middle of
the current decade, resulting in
shortages of 500,000 to 1 million
RNs by 2020. At the time, few
observers thought that interest in
n engl j med 368;16
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nursing would ever increase to
the level required to avert the
looming shortage.
Yet in a surprising turnaround,
merely a decade later, the shortages that were projected to be
under way by now have not materialized. In fact, reports indicate
that in some areas of the country
nursing graduates are experiencing growing delays in obtaining
employment.1 Long-term forecasts
now predict growth in the absolute number of RNs and strong
per capita growth under certain
scenarios.2 This turnaround is the
direct result of unprecedented
levels of entry into nursing over
the past decade (see graph). After
fluctuating at about 80,000 for
april 18, 2013
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PERSPECTIVE
160,000
140,000
Total No. of RN Graduates
two decades, the number of new
RN graduates more than doubled
from 74,000 in 2002 to 157,000
in 2010. If this surge in new RN
graduates continues, it will go a
long way toward reducing shortages that were projected for 2020
and beyond.
Two broad factors seem to
have contributed to this surge in
new RN graduates. First, there
has been an increase in interest
in nursing as a career. Despite
expanding enrollments, nursing
programs are turning away large
numbers of qualified applicants.1
Evidence of this growing interest
first appeared midway through
the 2000s, with a sharp increase
in the number of people in their
30s taking advantage of 2-year
associate’s degrees to enter nursing.2 More recently, the number
of people in their 20s entering
nursing has increased sharply,
particularly in baccalaureate degree programs.2 Nearly 5% of
first-year college students in 2010
reported that nursing was their
probable career choice — the
highest level of interest since
data were first collected in the
1960s.3
This remarkable growth in
interest appears to have arisen
from a confluence of factors.
There was an increase in media
attention to the nursing shortage, including a national campaign launched in 2002 by Johnson & Johnson, which continues
to inform the country about the
importance of the nursing profession, promote a positive image of
that profession, and entice a new
generation of men and women
into nursing careers. This effort
has been complemented by the
development of health workforce
centers in nearly three dozen
states that have similarly promoted the nursing profession. Final-
The Nursing Workforce and Health Care Reform
120,000
100,000
80,000
60,000
40,000
20,000
0
1985
1990
1995
2000
2005
2010
Total Number of Associate and Baccalaureate Degree RN Graduates, 1985–2010.
Data are authors’
calculations,
on annual completions
data from the Integrated
Revised
Staiger based
(Auerbach)
AUTHOR:
Postsecondary Education Data System (http://nces.ed.gov/ipeds).
FIGURE: 1 of 1
SIZE
ARTIST: ts
became
ly, the sluggish jobs recovery fol- tion, nursing 2education
col
TYPE: Line
Combo
4-C
H/T
increasingly
innovative in meetlowing the recession,
coupled
ingNOTE:
the growth in demand by dewith continued growth inAUTHOR,
healthPLEASE
Figure has been redrawn and type has been reset.
care spending and jobs, has
in-checkveloping
Please
carefully. new programs designed
creased the relative attractiveness to appeal to both younger and
JOB: 36816
ISSUE: 04-18-13
older students.
of nursing.
Although the combination of
A second contributor to the
surge of new RN graduates was growing interest in nursing cathe unanticipated dynamism of reers and the dynamic response
nursing education programs. Ac- of the educational sector has imcording to our research funded proved long-term workforce proby the Gordon and Betty Moore jections, the future is by no means
Foundation, using data from the secure. Four uncertainties threatIntegrated Postsecondary Educa- en the nursing workforce.
First, if demand for nurses
tion Data System (http://nces.ed
.gov/ipeds), the growth in new continues to expand at historical
RN degrees since 2002 resulted rates through 2030, entry into
from both the expansion of ex- nursing must continue to grow
isting nursing programs and the over the next two decades at a
opening of new programs; the rate of 20% per decade in order
total number of programs grew to meet that demand. This profrom about 1800 in 2002 to more jection highlights the need for
than 2600 in 2010. Growth has ongoing reinforcement of the
occurred in private and public in- message being sent by the media
stitutions, 2-year and 4-year uni- and others that nursing continversities, associate’s and bachelor’s ues to be an excellent career
degree programs, and especially in choice. The Affordable Care Act
private for-profit schools (which (ACA) will provide some support,
grew from fewer than 20 pro- with expanded grant programs
grams granting fewer than 1000 for training and education of RNs
degrees in 2002 to more than and advanced-practice nurses.
200 programs granting more than
A second uncertainty involves
12,000 degrees in 2010). In addi- the uneven distribution of the
n engl j med 368;16
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april 18, 2013
1471
The New England Journal of Medicine
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Copyright © 2013 Massachusetts Medical Society. All rights reserved.
PERSPE C T I V E
workforce. The per capita RN
supply in the Western and Northeast regions of the United States
has fallen behind that in the rest
of the country because these regions are home to a greater
number of older RNs who are
retiring. Per capita RN supply is
expected to decrease further in
these regions over the next de
cade, whereas the per capita supply is projected to grow at doubledigit rates in the Midwest and
the South.4
A third uncertainty is the lingering effect of the recession.
The slow jobs recovery swelled
the ranks of the nursing workforce, as many RNs chose to
work additional hours or delay
retirement to bolster their household’s economic security.5 This
temporary swelling of the workforce is expected to subside as
the jobs recovery accelerates. The
danger is that in the meantime,
employers, educators, and policymakers will reduce their investments in nursing when they observe that there’s a healthy
workforce, and people who
might otherwise be interested in
nursing may choose other career
paths because there are fewer
available jobs or temporarily depressed wages.
A final uncertainty concerns
The Nursing Workforce and Health Care Reform
the demand for RNs. The ACA
may stimulate additional demand
for RNs, with its increase in insurance coverage, expansion of
nurse-managed health centers,
and reform of the care delivery
system, in which payment is to
be linked to quality. However, it
is unclear to what extent RNs,
nurse practitioners, or other advanced-practice nurses will take
the lead in these new models of
care delivery and preventive care
approaches championed by the
ACA. It is also unclear whether
RNs will be prepared with the
skills needed for emerging roles in
leading and managing teams, implementing patient-centered care,
and adapting to other inevitable
changes in RN responsibilities.
Despite the projections of severe shortages made just 10 years
ago, a combination of policy efforts, a responsive education system, private-sector initiatives, and
the effects of the recession has
led to unexpected growth in the
nursing workforce. If this growth
continues, the nursing workforce
will be better able to respond to
the health care needs of Americans, including retiring baby
boomers, and to the many challenges and consequences of the
implementation of health care
reform. This outcome is not cer-
tain, however, and is less likely if
the surge in younger people entering nursing stalls, the workforce continues to grow unevenly
across the country, or the nursing
workforce is ill prepared to meet
the challenges of the fast-changing health care delivery system.
Disclosure forms provided by the authors
are available with the full text of this article
at NEJM.org.
From RAND, Boston (D.I.A.); the Department of Economics, Dartmouth College,
Hanover, NH (D.O.S.); the National Bureau
of Economic Research, Cambridge, MA
(D.O.S.); and the Vanderbilt University
School of Nursing (U.M., P.I.B.), the Center
for Interdisciplinary Health Workforce Studies (U.M., P.I.B.), and the Institute for Medicine and Public Health (P.I.B.), Vanderbilt
University, Nashville.
1. Auerbach DI, Buerhaus PI, Staiger DO.
Registered nurse supply grows faster than
projected amid surge in new entrants ages
23–26. Health Aff (Millwood) 2011;30:228692.
2. American Association of Colleges of Nursing. AACN releases preliminary data from
2012 annual survey (http://www.aacn.nche
.edu/news/articles/2012/enrolldata).
3. Pryor JH, Hurtado S, DeAngelo L, Palucki
Blake L, Tran S. The American freshman: national norms fall 2010. Los Angeles: UCLA
Higher Education Research Institute, 2010.
4. Buerhaus PI, Auerbach DI, Staiger DO,
Muench U. Projections of the long-term
growth of the registered nurse workforce:
a regional analysis. Nurs Econ 2013;31:13-7.
5. Staiger DO, Auerbach DI, Buerhaus PI.
Registered nurse labor supply and the recession — are we in a bubble? N Engl J Med
2012;366:1463-5.
DOI: 10.1056/NEJMp1301694
Copyright © 2013 Massachusetts Medical Society.
Complications of Mechanical Ventilation — The CDC’s New
Surveillance Paradigm
Michael Klompas, M.D., M.P.H.
E
arlier this year, the Centers
for Disease Control and Prevention (CDC) rolled out new surveillance definitions for patients
receiving mechanical ventilation
that promise to dramatically improve hospitals’ capacity to track
1472
clinically significant complications
in this population.1 The new definitions replace the CDC’s previous definition of ventilator-associated pneumonia (VAP) and are
designed to achieve two primary
goals: to broaden the focus of
n engl j med 368;16
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surveillance beyond pneumonia
to encompass other common complications of ventilator care, and
to make surveillance as objective
as possible in order to facilitate
automation, improve comparability, and minimize gaming.
april 18, 2013
The New England Journal of Medicine
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1/11/2019
WHO | Why do health labour market forces matter?
Bulletin of the World Health Organization
Why do health labour market forces matter?
Barbara McPake a , Akiko Maeda b , Edson Correia Araújo b ,
Christophe Lemiere b , Atef El Maghraby c & Giorgio Cometto
d
a. Institute for International Health and Development, Queen Margaret
University, Edinburgh, Scotland.
b. The World Bank, 1818 H Street, NW, Washington, DC, 20433, United
States of America.
c. African Development Bank, Tunis, Tunisia
d. Global Health Workforce Alliance, World Health Organization,
Geneva, Switzerland.
Correspondence to Akiko Maeda (e-mail: amaeda@worldbank.org).
(Submitted: 10 March 2013 – Revised version received: 12 June 2013 –
Accepted: 13 June 2013.)
Bulletin of the World Health Organization 2013;91:841-846. doi:
http://dx.doi.org/10.2471/BLT.13.118794
Health workforce challenges
Human resources for health are central to any health system insofar as
health workers perform or mediate most health system functions. They
make treatment decisions at the point of service and their actions
determine how efficiently other resources are used. 1 Health-care
delivery is highly labour intensive. To be effective, a health-care system
must have the right number and mix of health-care workers and it must
ensure that they possess the means and motivation to skilfully perform
the functions they are assigned. Many countries are facing a “crisis in
human resources for health” that involves three dimensions: availability,
which relates to the supply of qualified health workers; distribution, which
relates to the recruitment and retention of health workers where their
presence is most needed; and performance, which relates to health
worker productivity and to the quality of the care that health workers
provide.
Traditional approaches to resolving human resource constraints in the
health sector have relied primarily on workforce planning, i.e. the practice
of estimating health workforce requirements based on a country’s
epidemiological and demographic profile and of scaling up education and
training capacities to narrow the gap between the existing number of
health workers and the number required. However, focusing narrowly on
https://www.who.int/bulletin/volumes/91/11/13-118794/en/
1/10
1/11/2019
WHO | Why do health labour market forces matter?
the production of health workers results in the neglect of other important
factors that influence human resource capacity, such as labour market
dynamics and the behaviour and preferences of the health workers
themselves. Thus, despite the extensive published literature on the
human resource crisis in the health sector, few analyses have been
conducted using labour economic frameworks and the dynamics of
labour markets remain little known or understood, especially in low- and
middle-income countries.
The health status of a population, its health-care needs and its
requirements in the area of human resources for health are linked in
complex ways. 2 For example, the employment opportunities available to
health workers and the type of employment conditions that health
workers prefer are not always aligned with priority health-care needs.
Health workers may be attracted to positions that do not respond to such
needs or may choose to migrate in search of alternative employment
opportunities. Sometimes a paradoxical situation arises: vacancies in
high-priority positions in the public sector coexist with high
unemployment rates among health workers. This paradox is explained
by the labour market failure to match the supply and demand for health
workers. For instance, several African countries (e.g. Kenya, Mali and
Senegal) are experiencing acute under-employment among doctors and
nurses, yet they are simultaneously investing substantial public funds in
producing more health workers. This worsens underemployment and
reduces the efficiency of government expenditures. The system of
posting health workers to rural areas further illustrates the limitations of
traditional workforce planning. When health workers are officially
assigned to a remote rural area, they often find unofficial ways to evade
the assignment and find employment in an urban area. These examples
highlight the inadequacy of a human resource strategy focused
exclusively on the needs-based production of health workers. 3
Labour market conditions such as low salaries and a lack of other
economic benefits are known to influence employment processes, but
their influence on the planned allocation of resources is less widely
recognized. Thus, an analysis of the labour market is essential to
achieve a better understanding of the forces that drive health worker
shortage, maldistribution and suboptimal performance and to develop
policies and interventions tailored to different labour market conditions.
What is a labour market?
A market is any structure that allows buyers and sellers to exchange
goods, services or information of any type. A labour market is the
structure that allows labour services to ...
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