Meeting of the Board of Regents | April 2003

THE STATE EDUCATION DEPARTMENT / THE UNIVERSITY OF THE STATE OF NEW YORK / ALBANY, NY 12234

TO:	The Honorable the Members of the Board of Regents
FROM:	Johanna Duncan-Poitier
COMMITTEE:	Professional Practice
TITLE OF ITEM:	Horizon Issue: Update on Activities to Address Nursing Workforce Shortage
DATE OF SUBMISSION:	April 10, 2003
PROPOSED HANDLING:	Discussion
RATIONALE FOR ITEM:	To inform the Regents about continued work to support the Regents Task Force on the Future of Nursing and to address the nursing shortage
STRATEGIC GOAL:	Goal 3
AUTHORIZATION(S):

SUMMARY:

This report is the third in a series that updates the Regents on progress made by the Department and our partners on initiatives to address the nursing shortage � a shortage that if not alleviated can affect thousands of New Yorkers at all stages of their lives�as they are born, as they recover from illnesses, and as they care for elderly family members, or sit with dying friends and loved ones.

Activities and initiatives described in this report are a direct result of the work of the Regents Blue Ribbon Task Force on the Future of Nursing, the State Board for Nursing, and the Department. New data describing the continuing intensity of the nursing shortage presented in this report include:

Two additional studies are cited that clearly demonstrate the relationship between registered nurse staffing and both patient outcomes and job satisfaction. These studies combined with continuing evidence of the severity of the shortage, both now and in the future, demonstrate the importance of the Department�s efforts to continue to collaborate with our partners to carry out the recommendations of the Regents Blue Ribbon Task Force on the Future of Nursing.

Since September 2002, the Department has taken the lead on numerous initiatives to support the work of the Task Force to address the nursing shortage. Major activities include:

Nursing Survey

• The Department mailed a comprehensive survey to 31,890 randomly selected registered nurses. The survey responds to the Task Force recommendation to: Develop a reliable central source of data on the future need for nurses in the work force upon which employers, policymakers, futurists, researchers and legislators may base public policy and resource allocations. In addition to identifying characteristics of the state�s nursing workforce, this study closely examines work conditions and organizational "climate" factors known to be critical in creating a positive culture of retention -- a workplace that empowers and is respectful of nursing staff. Results of the survey will be presented to the Regents in September 2003.

Abandonment Memo

• Collaborated with our partners to develop a guidance memo to clarify the Department�s position on patient abandonment and mandatory overtime. The memo that was mailed to over 320,000 currently registered and licensed RNs and LPNs clarifies that, in most cases, the following situations are not examples of unprofessional conduct or automatic violations of the Regents Rule:
• • Refusing to accept responsibility for a patient assignment(s) when the nurse has given reasonable notice to the proper agent that the nurse lacks competence to carry out the assignment.
  • Refusing the assignment of a double shift or additional hours beyond the posted work schedule when proper notification has been given.

Practice Guidelines

• In response to the Task Force�s recommendation, practice guidelines to clarify the legal scope of practice of nursing, including those tasks that do not require licensure, are under development. These guidelines will reaffirm the individual practitioner's responsibility for patient care, even within demanding workplace settings.

Revised Nursing Guide to Practice

• Beginning in October 2002, a revised version of the Nursing Handbook, titled the Nursing Guide to Practice, has been mailed with licensure parchments to all newly licensed nurses. The Guide serves as a compendium of information to assist nurses to understand legal and ethical principles of practice.

Enhanced Web-site

• All information in the Guideto Practice is also featured on an enhanced nursing page of the Office of the Professions Web site at www.op.nysed.gov/nurse.htm

    The Web site made its debut in September 2002 and includes many unique features:

Clearinghouse

• The Department has developed a web-based Clearinghouse of initiatives and strategies that address the nursing shortage. The Clearinghouse serves to highlight best practice activities by members of the Task Force, our partners and others.

The report concludes with a series of next steps including an announcement of The Empire Promise Nurse Opportunity Corps. This innovative program is a four-year pilot project designed to prepare world-class nurses who are dedicated to investing their talents in New York State. The program targets students from Liberty Partnerships Programs (LPP) located in urban, rural and suburban communities across the State. Activities such as pre-professional orientation and workshops, summer residential programs on college campuses, and tutoring will help to prepare students for rich and rewarding careers in the nursing profession. Upon high school graduation, students will be guaranteed admission to four New York State baccalaureate nursing programs. It is hoped that this initiative will address the need for additional faculty for the future education of New York State nurses.

We look forward to continued work with our partners to carry out the recommendations of the Regents Task Force.

INTRODUCTION

In April 2001, the Board of Regents issued a revealing policy report concerning the nursing shortage in New York State. That report was the eighth in a major series designed to target critical policy horizon issues in professional regulation. The analysis offered compelling evidence of the nursing shortage projected in coming years; highlighted the root causes of the nursing shortage; described how the current shortage differed from previous shortages; and identified this issue as a serious challenge to the Regents public protection mission.

Former Chancellor Carl T. Hayden called for the immediate formation of a Blue Ribbon Task Force on the Future of Nursing and tapped nurse educator and former Vice Chancellor, Regent Diane O�Neill McGivern to chair the Task Force. Regent McGivern invited 26 influential leaders in health care, education and government to participate in the Task Force. Members were selected based on their ability to represent significant areas of responsibility and being uniquely positioned to contribute to the resolution of the shortage. The Task Force included members of the Board of Regents, Chief Executive Officers of the New York University Medical Center, the Visiting Nurse Service of New York, the Healthcare Association of New York State, the Greater New York Hospital Association, the Commissioners of Health and Education, the President of the New York State Nurses Association, members of the New York State Assembly and Senate, members of the State Board for Nursing, and the Deputy Commissioner for the Professions.

Members assembled for two meetings, on June 28 and September 7, 2001, in New York City to address the nursing shortage. The Task Force confirmed the factors leading to the shortage, detailed the complexities of the shortage in diverse health care settings, agreed upon the severity of the problem and developed recommendations to address the problem. Their report, Protecting the Public: The Future of Nursing in New York State: Addressing the Nursing Shortage can be found on the Office of the Professions web site at www.op.nysed.gov/nurse.htm. The recommendations identified in that report are summarized below:

• Retention: Support initiatives to retain current nursing work force, including pursuit of best practice principles, such as the magnet hospital model.
• Recruitment: Expand the nursing work force by recruiting additional numbers of men, minorities, non-practicing nurses, and recent high school graduates.
• Education: Provide additional academic and financial support systems to increase the pool of nursing school graduates and create career ladders.
• Technology: Increase the application of labor saving technology to eliminate unnecessary, duplicative paperwork and improve access to and communication of patient information, thereby improving workplace conditions.
• Data Collection: Develop a reliable central source of data on the future need for nurses in the work force upon which employers, policymakers, futurists, researchers and legislators may base public policy and resource allocations.

 

• Clarify Existing Laws and Regulations:

This report is the third in a series of updates to inform the Regents on actions taken by the Department to meet those recommendations.

Impact of the Nursing Shortage

In the past several months two major research studies have been published pointing to the fact that patients in hospitals with low numbers of registered nurses are more likely to have complications, stay in the hospital longer and even die from treatable conditions than patients in hospitals with more registered nurses. The first study, conducted by Buerhaus, Nettleman and Associates from the Harvard School of Public Health and the Vanderbilt School of Nursing, analyzed the discharge records of more than six million patients at 799 hospitals in 11 states during 1997. The study, published in the May 30, 2002 issue of the New England Journal of Medicine, found that:

• Patients in the highest-staffed hospitals experienced cardiac arrest and shock 9.4 percent less often than patients in the lowest-staffed hospitals.
• Patients in the highest-staffed hospitals had 9 percent fewer urinary tract infections, 6.4 percent fewer cases of hospital-acquired pneumonia and 5 percent fewer episodes of stomach or intestinal bleeding than patients in the lowest-staffed hospitals.
• Patients in the highest-staffed hospitals spent on average four hours less in the hospital than those in the lowest-staffed hospitals.
• Surgical patients in the highest-staffed hospitals were 6 percent less likely to die from surgical complications, including shock and sepsis, than surgical patients in the lowest-staffed hospitals.
• The "failure to rescue" death rate -- patients who died from conditions that might have been reversed, including pneumonia, shock, cardiac arrest, upper gastrointestinal bleeding, sepsis or a blood clot -- for patients in the lowest-staffed hospitals was 2.5 percent higher than for medical patients in the highest-staffed hospitals.

The study also analyzed patient outcomes such as length of stays and complications based on the number of licensed practical nurses and nursing aides employed by the research facilities. In hospitals with higher numbers of registered nurses, patient hospital stays were 3 to 5 percent shorter and complication rates were 2 to 9 percent lower than hospitals with fewer registered nurses. The level of practical nurses and nurses aides did not affect patient outcomes.

The second highly publicized study conducted by Aiken and her colleagues at the University of Pennsylvania, documented three exceptionally important points:

• Substantial decreases in patient mortality could result from increasing registered nurse staffing � especially for patients who develop complications. For example, had the average patient-to-nurse staffing ratio (found to range from 4:1 to 8:1 in the 168 hospitals studied by Aiken and her colleagues) been held statistically to the more favorable 4:1 standard across the board, roughly 1,000 deaths could have been prevented in the time period and hospitals studied.
• Higher emotional exhaustion and greater job dissatisfaction were strongly and significantly associated with higher patient to nurse ratios, i.e., the higher those patient-nurse staffing ratios, the greater the level of burnout and job dissatisfaction experienced.
• Very pronounced relationships were found between job satisfaction and intentions to leave. For example, among nurses who reported high burnout and job dissatisfaction, 43 percent indicated that they intended to leave within 12 months; in stark contrast, among those not experiencing burnout and job dissatisfaction, the comparable intent-to-leave percentage dropped to 11 percent, a 32 percentage point difference.

A recent analysis of the 2000 National Sample Survey of Registered Nurses data for New York State finds that the State has a current 11 percent shortfall of supply versus demand that is predicted to worsen by 2020 to 23.6 percent. These findings are depicted in the table below.

Ample reports and evidence such as hospital vacancy rates and turnover rates for registered nurses point to the continuing intensity of the nursing shortage in New York State and throughout the nation. Unfortunately, a February 2003 report on Trends in Registered Nursing Graduations in New York, 1996-2002, conducted by the Center for Health Workforce Studies, School of Public Health, at the State University at Albany, finds that every New York State region had fewer RN graduations in 2002 than in 1996. The report concludes that despite projected increases in graduations for all regions by 2004, that number will be insufficient to meet the future demand for new registered nurses in New York.

New York State RN Graduations by Degree Type, 1996 to 2004

(Used with Permission from the Center for Health Workforce Studies)

What is perhaps most sobering is that the report states that nearly half of the RN programs in the State that participated in the annual survey reported turning away qualified applicants. The Center estimated that over 1,000 qualified candidates were denied admission to programs. The three major reasons for turning away qualified applicants were: lack of faculty, limited number of clinical sites and the lack of classroom space. Of the programs that identified lack of faculty as the reason for turning away faculty, 75 percent were RN programs in State University of New York (SUNY) or City University of New York (CUNY).

Given the findings of the previously cited studies that clearly demonstrate the relationship between registered nurse staffing and both patient outcomes and job satisfaction, and continuing evidence of the severity of the shortage, both now and in the future, it becomes imperative for the Department and our partners to continue to collaborate to address the recommendations of the Regents Blue Ribbon Task Force on the Future of Nursing.

The State Education Department Responds to the Regents Task Force Recommendations

The Department has recently taken the lead on a number of major initiatives to support the recommendations of the Regents Task Force. We have collaborated with multiple partners, sometimes on a daily basis, to seek out opinions, feedback and suggestions. The Department took advantage of all opportunities to bring key issues to the attention of our partners and include them in strategic planning and problem solving. For example, clarification of patient abandonment and mandatory overtime included significant input from Department staff as well as members of the State Board for Nursing, in consultation with the Department of Health, the New York Organization of Nurse Executives, the New York State Nurses Association and the Healthcare Association of New York State. When the document clarifying the law and related practice regarding abandonment was completed, our partners eagerly shared the resulting memorandum with their staff, membership and other interested parties. Staff and members of the Board for Nursing continue to promote this and other initiatives as they lecture and provide information about the nursing shortage to groups throughout the State and nation.

Task Force Recommendation:

Data Collection: Develop a reliable central source of data on the future need for nurses in the work force upon which employers, policymakers, futurists, researchers and legislators may base public policy and resource allocations.

During the summer of 2002, a large-scale survey of registered nurses was designed by the Department in partnership with key stakeholders. Like five previous statewide studies of the New York State registered nursing population undertaken by the Department, the study is best described as a comprehensive, quantitative, descriptive study of the currently licensed registered nurses in New York State. Unlike any of the previous studies, however, this study closely examines work conditions and organizational "climate" factors known to be critical in creating a positive culture of retention, that is, a workplace that empowers and is respectful of nursing staff. Also, unlike earlier studies, respondents in this study were asked to directly evaluate a variety of policy initiatives intended to improve the attractiveness of the profession. In summary, the survey was designed to pursue six discrete research objectives:

• To describe the major demographic, occupational, and educational characteristics of registered nurses in New York State (as of September, 2002);
• To examine important conditions of the work setting, with particular attention to certain conditions of the work climate (e.g., professional autonomy, cooperation, job satisfaction, organizational commitment, promotional opportunity, etc.);
• To determine the net impact and relative importance of these climate factors upon nurses� overall job satisfaction and organizational commitment;
• To determine as well the net effects of global job satisfaction and organizational commitment upon actual job-search behaviors, leave-taking decisions, and recommendations to others about a career in the nursing profession;
• To highlight nurses� level of support for a variety of policy initiatives of interest to the Regents Blue Ribbon Task Force and the Board of Regents; and
• To synthesize briefly current findings concerning projected nursing supply and demand, and to describe nurses' own views about supply and demand issues in their particular settings and geographic locales.

The findings of this study will help to inform and advance important policy recommendations of the Regents and our partners.

Survey Methodology

Registered nurses were randomly selected to receive the study from the New York State Education Department licensure database of registered nurses as of August 28, 2002. The sample extract of 31,890 survey recipients was drawn based upon systematic, disproportionate stratified sampling techniques. Major strata were defined based on each licensee�s Health Service Area (HSA). Sampling fractions were thus not uniform across all Health System Areas; rather, higher sampling rates were applied to more thinly populated HSAs to ensure an adequate number of respondents in the various regions of the State.

The random sample of registered nurses received the survey in early October, together with a postage-paid, return-address envelope. The useable response rate is 45.6 percent. Survey responses have been "cleaned" and scanned. Preliminary data analysis has begun.

Because of the magnitude of the results, and the depth of the analysis, the findings of the report will be published in two separate volumes. The primary research objectives of the Volume I report are demographic. In this report we will:

• Describe with precision the major demographic, occupational, and educational characteristics of registered nurses in New York State (as of September, 2002);
• Compare, where possible, current demographic findings with earlier nursing studies conducted in New York State;
• Synthesize briefly current findings concerning projections of nursing supply and demand; and
• Describe nurses' own views about supply and demand issues in their particular settings and geographic locales.

The primary research objectives of the Volume II report are far more analytic in character. The second report volume is designed to:

• Examine important conditions of the work setting, with particular attention to certain conditions of the work climate (e.g., professional autonomy, cooperation, job satisfaction, organizational commitment, promotional opportunity, etc.);
• Determine the net impact and relative importance of these climate factors upon nurses� overall job satisfaction and organizational commitment;
• Determine, in turn, the net effects of global job satisfaction and organizational commitment upon actual job-search behaviors, leave-taking decisions, and recommendations to others about a career in the nursing profession; and
• Highlight nurses� level of support for a variety of policy initiatives of interest to the Regents Blue Ribbon Task Force and the Board of Regents.

The findings of this comprehensive survey are scheduled to be presented at the September 2003 meeting of the Regents as was outlined in the Timeline presented at the March 2002 Regents meeting [see Attachment 1]. After the report has been shared with the Regents, the Department expects to provide the survey data to other researchers for their independent analysis.

Task Force Recommendation:

Clarify Existing Laws and Regulations:

Patient Abandonment: Familiarize field with existing Regents regulations, which describe patient abandonment - clarifying that refusal to work a double shift, or other mandatory overtime in ordinary circumstances does not necessarily constitute professional misconduct.

The legal definition of abandonment as found in Section 29.2(a) of the Rules of the Board of Regents states that unprofessional conduct includes:

Abandoning or neglecting a patient or client under and in need of immediate professional care, without making reasonable arrangements for the continuation of such care, or abandoning a professional employment by a group practice, hospital, clinic or other health care facility, without reasonable notice and under circumstances which seriously impair the delivery of professional care to patients or clients.

As the nursing shortage becomes more severe, some employers are mandating nursing overtime and assigning nurses to patient units where the nurse lacks competence to carry out the patient assignment. When nurses refuse these assignments, many employers have threatened to report nurses to the Education Department stating that such "abandonment" would lead to charges of unprofessional conduct against a nurse�s license. The State Board for Nursing office received hundreds of letters from nurses asking for the Department�s clarification and direction on this issue.

As part of their work to ensure a strong future for the nursing profession, the Regents Blue Ribbon Task Force on the Future of Nursing recommended that the Department clarify its position on abandonment. We are pleased to report that a guidance memo was developed and mailed to over 320,000 currently registered and licensed RNs and LPNs in Fall 2002. The memo resulted from the significant contributions of the State Board for Nursing, in consultation with our partners in the Department of Health, the New York Organization of Nurse Executives, the New York State Nurses Association and the Healthcare Association of New York State.

The memo states that the decision to charge a nurse with abandonment will depend on an examination of all of the circumstances surrounding a particular situation as assessed by State Education Department staff in consultation with a member of the State Board for Nursing. Key questions considered include:

• Did the nurse accept the patient assignment, which established a nurse-patient relationship?
• Did the nurse provide reasonable notice when severing the nurse-patient relationship?
• Could reasonable arrangements have been made for continuation of nursing care by others when proper notification was given?

An investigation by the Department of abandonment charges would consider whether managerial or supervisory personnel made adequate provisions for competent staffing to ensure necessary patient care in routine situations. The Department and the nurse may obtain a copy of the nurse's written notice of patient assignment refusal in the event of such an investigation.

In most cases, the following situations are not examples of unprofessional conduct or automatic violations of the Regents Rule:

• Refusing to accept responsibility for a patient assignment(s) when the nurse has given reasonable notice to the proper agent that the nurse lacks competence to carry out the assignment.
• Refusing the assignment of a double shift or additional hours beyond the posted work schedule when proper notification has been given.

The memo has been posted on the Office of the Professions� web site at www.op.nysed.gov. In addition, a section on Frequently Asked Questions and Answers on patient and employer abandonment has also been added to the web site based on a request from the organizations that partnered with us on this initiative.

Clarify Existing Laws and Regulations:

Scope of Practice for Nurses: Issue practice guidelines to clarify the legal scope of practice of nursing, including those tasks which do not require licensure. These guidelines will reaffirm the individual practitioner's responsibility for patient care, even within demanding workplace settings.

In October 2002 a revised version of the Nursing Handbook was completed. The new Nursing Guide to Practice is mailed with the licensure parchment to all newly licensed nurses. It serves as a compendium of information to assist nurses in understanding legal and ethical principles of practice. The Guide to Practice includes:

• Full-text excerpts of Education Law, Rules of the Board of Regents and Regulations of the Commissioner of Education important for nursing practice;
• A self-administered jurisprudence exam that tests nurses� knowledge of New York State law;
• Frequently asked practice questions;
• The American Nurses Association Code of Ethics; and
• A complete list of contacts in the Education Department offices for assistance regarding practice and professional conduct questions.

All information included in the Guideto Practice is also provided on an enhanced nursing page of the Office of the Professions Web site at www.op.nysed.gov/nurse.htm

The Web site page includes many unique features such as:

• Licensure statistics by counties for Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Nurse Practitioners (NPs);
• Licensure and limited permit application forms for RNs, LPNs and NPs;
• Descriptions of licensure requirements for RNs, LPNs, and NPs;
• The self-administered jurisprudence exam mentioned above, that tests nurses� knowledge of New York State law and that will provide an immediate score on the exam and answers to all questions;
• A list of NYS registered nursing programs; and
• All reports of the Regents Blue Ribbon Task Force on the Future of Nursing and reports to the Regents on the nursing shortage.

Recognizing opportunities for benchmarking and collaboration, the State Education Department has developed a Web-based Clearinghouse of initiatives and strategies that address the nursing shortage. The Clearinghouse serves to highlight best practice activities by members of the Task Force, the Department�s many partners and other interested stakeholders. The goal of the Clearinghouse is to stimulate creative thinking and encourage further activity and collaboration to ensure a strong future for the nursing profession. Initiatives and strategies are categorized by Task Force recommendation. Contact information is provided so individuals using the site can obtain details for more information on each initiative directly from individuals carrying out the initiative.

Many organizations, eager to have their initiatives included on the Clearinghouse, have contacted the Department to share their activities. The Web-based Clearinghouse is becoming recognized as a valuable resource.

Additional examples of Department activities to follow up on the recommendations include:

Next Steps

The work of the Board of Regents and the Department to address the nursing shortage continues to make a difference as evidenced by some of the following examples:

• The report of the Task Force is used throughout the country as a model for taking action in dealing with the nursing shortage.
• Leaders in health care express appreciation about the availability of comprehensive information included in the Nursing Clearinghouse on the Office of the Professions� Web site.
• The survey of New York State Registered Nurses is the largest data collection conducted to date and should prove to be an invaluable document for making sound decisions about addressing the nursing shortage.
• Actions are on target with the timeline provided at the March 2002 Regents meeting.

In addition to continuing our outreach and finalizing the analysis of the nursing survey, the Department is pleased to announce one new next step in our goal to address the nursing shortage � The Empire Promise Nurse Opportunity Corps. This innovative program is a four-year pilot project designed to prepare world-class nurses who are dedicated to investing their talents in New York State.

The program targets students from Liberty Partnerships Programs (LPP) located in urban, rural and suburban communities across the State. Activities such as pre-professional orientation and workshops, summer residential programs on college campuses, and tutoring will help to prepare students for rich and rewarding careers in the nursing profession. Upon high school graduation, students will be guaranteed admission to baccalaureate nursing programs at Mount Saint Mary College in Newburgh, The Sage Colleges in Troy, the State University of New York at Binghamton, and Utica College of Syracuse University.

LPP seeks to improve the abilities of at-risk youth to graduate from high school and prepare for competitive entry into postsecondary education and the workforce. The Empire Promise component of the Liberty Partnerships Program also seeks to prepare students to view themselves as investors in New York�s social and economic development agenda. The annual student/school persistence rate among LPP students is 98 percent. Over 1,200 graduating seniors enter higher education through LPP each fall and, over 86 percent of these students choose to pursue undergraduate study in New York. Through a competitive process, the New York State Education Department awards funding to degree-granting postsecondary education institutions in collaboration with public and non-public schools, parents, the business community, local government agencies, community organizations and other stakeholders to develop and implement comprehensive year-round programs and services to students enrolled in grades 5 through 12.

The Empire Promise Nurse Opportunity Corps is a collaborative venture of the State Education Department, the Foundation of the New York State Nurses Association, the New York State Nurses Association and the four participating baccalaureate nursing programs.

Addressing professional workforce shortages requires a comprehensive approach that includes professional education, opportunity programs, and profession regulation. This program exemplifies the power of connections across the State Education Department and among our many partners.