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Commentaries on health services research
Abstract
Computer modeling was used to assess the pediatric NP workforce and to investigate the effect of potential policy changes to address forecasted shortages. Modeling included the admission of students into nursing bachelor's programs and followed them through advanced clinical programs. Prediction models were combined with optimal decisionmaking to determine best-case scenario admission levels. Two measures were computed: (1) the absolute shortage and (2) the expected number of years until the pediatric NP workforce will be able to fully satisfy pediatric NP demand (self-sufficiency). A shortage of pediatric NPs is predicted over the next 13 years. Under the best-case scenario, at least 13 years are needed for the workforce to fully satisfy demand. Analysis of potential policy changes revealed that increasing the specialization rate for pediatric NPs and increasing the certification examination passing rate to 96% would lead to self-sufficiency in 11 years. In addition, increasing the annual growth rate of master's programs to 36% from the current maximum of 10.7% would result in self-sufficiency in 5 years. Forecasts of demand for pediatric NPs indicate that the current workforce will be incapable of satisfying the growing demand.1.
Traditional workforce planning methodologies and interprofessional education (IPE) approaches will not address the significant challenges facing health care systems seeking to integrate services, eliminate waste and meet rising demand within fixed or shrinking budgets. This article describes how New Zealand’s workforce planning approach could be used as a model by other countries to move toward needs-based, interprofessional workforce planning. Such an approach requires a paradigm shift to reframe health workforce planning away from a focus on shortages toward assessing how to more effectively deploy and retrain the existing workforce; away from silo-based workforce projection models toward methodologies that recognize professions’ overlapping scopes of practice; and away from a focus on traditional health professions toward including both health and social care workers. We propose that IPE must develop new models of learning that are delivered in the context of practice. This will require a shift from today’s predominant focus on preparing students in the pipeline to be collaboration-ready to designing clinical practice environments that support continuous learning that benefits not just learners, but patients, populations, and providers as well. We highlight the need for improved data and methods to evaluate IPE and call for better collaboration between health workforce planners and IPE stakeholders.
Increased demand for expensive intensive care unit (ICU) services may contribute to rising health-care costs. A focus on appropriate use may offer a clinically meaningful way of finding the balance. We aimed to determine the extent and characteristics of perceived inappropriate treatment among ICU doctors and nurses, defined as an imbalance between the amount or intensity of treatments being provided and the patient's expected prognosis or wishes.
This was a cross-sectional study of doctors and nurses providing care to patients in 56 adult ICUs in California between May and August 2013. In total, 1,363 doctors and nurses completed an anonymous electronic survey.
Thirty-eight percent of 1,169 respondents (95% confidence interval (CI) 35% to 41%, 51.1% of physicians and 35.8% of nurses) identified at least one patient as receiving inappropriate treatment. Respondents most commonly reported that the amount of treatment provided was disproportionate to the patient's expected prognosis or wishes-325 out of 429 (76%, 95% CI 72% to 80%)-and that treatment was 'too much' in 93% of cases. Factors associated with perceived inappropriateness of treatment were the belief that death in their ICU is seen as a failure (odds ratio (OR) 5.75, 95% CI 2.28 to 14.53, P = 0.000), profession (doctors more than nurses) (OR 2.50, 95% CI 1.58 to 3.97, P = 0.000), lack of collaboration between doctors and nurses (OR 1.84, 95% CI 1.21 to 2.80, P = 0.004), intent to leave their job (OR 1.73, 95% CI 1.18 to 2.55, P = 0.005), and the perceived responsibility to control health-care costs (OR 1.57, 95% CI 1.05 to 2.33, P = 0.026). Providers supported formal communication training (90%, 95% CI 88% to 92%) and mandatory family meetings (89%, 95% CI 87% to 91%) as potential solutions to reduce the provision of inappropriate treatment.
Doctors and nurses working in California ICUs frequently perceive treatment to be inappropriate. They also identified measures that could reduce the provision of inappropriate treatment.
Little is known about the perspectives and experiences of family members of very elderly patients who are admitted to the intensive care unit.
To describe family members' perspectives about care provided to very elderly critically ill patients.
Multicenter, prospective, cohort study.
In total, 535 family members of patients aged 80 years or older admitted to 22 intensive care units for more than 24 h.
Family members reported that the "patient be comfortable and suffer as little as possible" was their most important value and "the belief that life should be preserved at all costs" was their least important value considered in making treatment decisions. Most family members (57.9%) preferred that life support be used for their family member, whereas 24.1% preferred comfort measures only, and 14.4% were unsure of their treatment preferences. Only 57.3% reported that a doctor had talked to them about treatment options for the patient. Overall, 29.7% of patients received life-sustaining treatments for more than 7 days and 50.3% of these died in hospital. Families were most satisfied with the skill and competency of nurses and least satisfied with being included and supported in the decision-making process and with their sense of control over the patient's care.
There is incongruity between family values and preferences for end-of-life care and actual care received for very elderly patients who are admitted to the intensive care unit. Deficiencies in communication and decision-making may be associated with prolonged use of life-sustaining treatments in very elderly critically ill patients, many of whom ultimately die.
© The Author(s) 2015.
To assess the current pediatric nurse practitioner (PNP) workforce and to investigate the impact of potential policy changes to address forecasted shortages.
We modeled the admission of students into nursing bachelor's programs and followed them through advanced clinical programs. Prediction models were combined with optimal decision-making to determine best-case scenario admission levels. We computed 2 measures: (1) the absolute shortage and (2) the expected number of years until the PNP workforce will be able to fully satisfy PNP demand (ie, self-sufficiency).
There is a forecasted shortage of PNPs in the workforce over the next 13 years. Under the best-case scenario, it would take at least 13 years for the workforce to fully satisfy demand. Our analysis of potential policy changes revealed that increasing the specialization rate for PNPs by 4% would decrease the number of years required until there are enough PNPs from 13 years to 5 years. Increasing the certification examination passing rate to 96% from the current average of 86.9% would lead to self-sufficiency in 11 years. In addition, increasing the annual growth rate of master's programs to 36% from the current maximum of 10.7% would result in self-sufficiency in 5 years.
Current forecasts of demand for PNPs indicate that the current workforce will be incapable of satisfying the growing demand. Policy changes can result in a reduction in the expected shortage and potentially improve access to care for pediatric patients.
Copyright © 2015 by the American Academy of Pediatrics.
Now that the Affordable Care Act (ACA) has expanded health care coverage and made it affordable to many more Americans, we have the opportunity to shape the way care is delivered and improve the quality of care systemwide, while helping to reduce the growth of health care costs. Many efforts have already been initiated on these fronts, leveraging the ACA's new tools. The Department of Health and Human Services (HHS) now intends to focus its energies on augmenting reform in three important and interdependent ways: using incentives to motivate higher-value care, by increasingly tying payment to value through alternative payment . . .
Regulation and licensure of health professionals-nurses, physicians, pharmacists, and others-currently falls to the states. State laws and regulations define legal scopes of practice for these practitioners. Concern is growing that this system cannot support workforce innovations needed for an evolving health care system or for successful implementation of the Affordable Care Act. Existing state-based laws and regulations limit the effective and efficient use of the health workforce by creating mismatches between professional competence and legal scope-of-practice laws and by perpetuating a lack of uniformity in these laws and regulations across states. State laws limit needed overlap in scopes of practice among professions that often share some tasks and responsibilities, and the process for changing the laws is slow and adversarial. We highlight reforms needed to strengthen health professions regulation, including aligning scopes of practice with professional competence for each profession in all states; assuring the regulatory flexibility needed to recognize emerging and overlapping roles for health professionals; increasing the input of consumers; basing decisions on the best available evidence and allowing demonstration programs; and establishing a national clearinghouse for scope-of-practice information.
There is growing consensus that the health care workforce in the United States needs to be reconfigured to meet the needs of a health care system that is being rapidly and permanently redesigned. Accountable care organizations and patient-centered medical homes, for instance, will greatly alter the mix of caregivers needed and create new roles for existing health care workers. The focus of health system innovation, however, has largely been on reorganizing care delivery processes, reengineering workflows, and adopting electronic technology to improve outcomes. Little attention has been paid to training workers to adapt to these systems and deliver patient care in ever more coordinated systems, such as integrated health care networks that harmonize primary care with acute inpatient and postacute long-term care. This article highlights how neither regulatory policies nor market forces are keeping up with a rapidly changing delivery system and argues that training and education should be connected more closely to the actual delivery of care.
Physician assistants (PAs) are licensed to practice with physician supervision. PAs do not specialize or subspecialize as part of their formal standard training; consequently, their license is not limited to a specific specialty. As such, PAs can, and do, change their practice settings at will. Some researchers have projected plans for the future use of the pediatric PA workforce. However, the information on which those projections have been based is limited.
To provide information regarding the current status of pediatric PAs and to inform future workforce deliberations, we studied their current distribution and scope of practice.
Data from the American Association of Physician Assistants and the US Census Bureau were used to map the per-capita national distribution of pediatric PAs. We conducted a mail survey of a random sample of 350 PAs working in general pediatrics and 300 working in pediatric subspecialties.
Most states have <50 pediatric PAs, and there is significant variation in their distribution across the nation. The overall survey response rate was 83.5%; 82% (n = 359) were female. More than half of the respondents (57% [n = 247]) reported that they currently are working in pediatric primary care, mostly in private-practice settings.
PAs can, and do, play an important role in the care of children in the United States. However, the impact of that role is limited by the relative scarcity of PAs currently engaged in pediatric practice.
The utility of idealised patient journeys as a centre-piece on health workforce planning.
- Gorman