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 nejm.org 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 The New England Journal of Medicine Downloaded from nejm.org at Himmelfarb Health Sciences Library on February 1, 2019. For personal use only. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved. 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 nejm.org april 18, 2013 1471 The New England Journal of Medicine Downloaded from nejm.org at Himmelfarb Health Sciences Library on February 1, 2019. For personal use only. No other uses without permission. 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 nejm.org 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 Downloaded from nejm.org at Himmelfarb Health Sciences Library on February 1, 2019. For personal use only. No other uses without permission. Copyright © 2013 Massachusetts Medical Society. All rights reserved. 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 ...
Purchase answer to see full attachment