Question

What steps can Congress and state legislatures take to alleviate a serious national shortage of skilled providers? Research suggests medical errors have been linked to inadequate staffing (i.e., quantity and quality of skilled personnel). What steps would you take to mitigate shortages?

Answer 1

WHO has estimated there to be a total of 59·2 million fulltime paid health workers worldwide in 2006, of which about two thirds were health service providers, with the remaining third being composed of health management and support workers (WHO 2006).

WHO also calculated a threshold in workforce density below which consistent coverage of essential interventions, including those necessary to meet the health-related Millennium Development Goals (MDGs), was very unlikely. Based on these estimates, it reported that there were 57 countries with critical shortages equivalent to a global deficit of 2·4 million doctors, nurses and midwives. The proportional shortfalls were greatest in sub-Saharan Africa, although numerical deficits were very large in South-East Asia because of its population size. WHO also highlighted that shortages often coexist in a country with large numbers of unemployed health professionals: ‘Poverty, imperfect private labour markets, lack of public funds, bureaucratic red tape and political interference produce this paradox of shortages in the midst of underutilized talent’

In recent years, the nursing profession has been especially concerned about the nature of the transformation taking place in the health care sector. Reports of hiring freezes and layoffs of RNs in hospitals have led to increasing apprehension among them and their supporting organizations about the potential threat to the quality of patient care in hospitals as well as their physical and economic well-being. RNs have expressed concerns that hospitals are implementing a variety of nursing care delivery systems involving major staff substitutions, reducing the proportion of RNs to other nursing personnel by replacing them with lesser-trained (and at times untrained), and lower-salaried, personnel at a time when the increasing complexity of hospital inpatient caseloads calls for more skilled nursing care.

Regulation of hospitals is a long-standing part of government responsibility. States have had their own licensing requirements for hospitals and other facilities since the early part of the century. Regulation has taken many forms, such as certification, licensure, and accreditation.

Since Medicare and Medicaid legislation was passed in 1965, the Social Security Act has required that providers be certified as a condition of participation in the program. This is accomplished through mechanisms known as Conditions of Participation that are promulgated through specific standards in the Code of Federal Regulations. For hospitals to be so certified for participation, the Social Security Act requires that facilities be licensed and in good standing by the state. In addition, hospitals must meet all federal certification standards, and the federal HCFA is authorized to determine whether hospitals meet these federal requirements. HCFA may conduct on-site inspections to observe care and review records to determine compliance, or it may ask state agencies to carry out these surveys.

Under the Social Security Act, certification may also be based on accreditation, which is in turn based on a concept of deemed status . Hospitals found to meet accreditation standards by the JCAHO are deemed automatically to meet the federal Conditions of Participation in the Medicare program—in effect, they are considered to be certified to receive Medicare (and Medicaid) reimbursement. HCFA performs independent validation surveys of individual hospitals on a sample basis as an assurance that the federal government can rely on the JCAHO approach. In addition, accreditation by the JCAHO is a requirement for hospitals approved to conduct graduate medical education residency programs and is frequently a requirement for payment by health maintenance organizations (HMO) and health insurance companies

Regulation of hospitals is a long-standing part of government responsibility. States have had their own licensing requirements for hospitals and other facilities since the early part of the century. Regulation has taken many forms, such as certification, licensure, and accreditation.¹⁰

Since Medicare and Medicaid legislation was passed in 1965, the Social Security Act has required that providers be certified as a condition of participation in the program. This is accomplished through mechanisms known as Conditions of Participation that are promulgated through specific standards in the Code of Federal Regulations. For hospitals to be so certified for participation, the Social Security Act requires that facilities be licensed and in good standing by the state. In addition, hospitals must meet all federal certification standards, and the federal HCFA is authorized to determine whether hospitals meet these federal requirements. HCFA may conduct on-site inspections to observe care and review records to determine compliance, or it may ask state agencies to carry out these surveys.

Under the Social Security Act, certification may also be based on accreditation, which is in turn based on a concept of deemed status . Hospitals found to meet accreditation standards by the JCAHO are deemed automatically to meet the federal Conditions of Participation in the Medicare program—in effect, they are considered to be certified to receive Medicare (and Medicaid) reimbursement. HCFA performs independent validation surveys of individual hospitals on a sample basis as an assurance that the federal government can rely on the JCAHO approach. In addition, accreditation by the JCAHO is a requirement for hospitals approved to conduct graduate medical education residency programs and is frequently a requirement for payment by health maintenance organizations (HMO) and health insurance companies

Given the continued reliance of the federal government on this approach to certification for hospital reimbursement through federal health programs, the committee is encouraged by the evolution of JCAHO methods and standards in the past few years and by the more sophisticated attention being paid to the role of nursing care in those standards. It also takes note of a new initiative, the Council on Performance Measurement, which will serve as an advisory body for evaluation of performance measurement systems, especially with respect to considering whether they are suitable for incorporating into future accreditation processes.

First, addressing supply side issues: improving recruitment, retention and return- getting, keeping and keeping in touch with these relatively scarce nurses. Research indicates that nurses are attracted to work and remain in work because of the opportunities to develop professionally, to gain autonomy, and to participate in decision making, while being fairly rewarded. Factors related to work environment can be crucial, and there is some evidence that a decentralised style of management, flexible employment opportunities, and access to continuing professional development can improve both the retention of nursing staff and patient care. Some countries also have scope to widen the recruitment base by opening out access routes into nursing for a broader range of recruits, including mature entrants, entrants from ethnic minorities, and entrants who have vocational qualifications or work-based experience to compensate for fewer conventional academic qualifications. ‘Returners’ can also be attracted back into the profession. Most countries have relatively large pools of former nurses with the necessary qualifications to re-enter nursing.

Many countries need to enhance and align their workforce planning capacity across occupations and disciplines to identify the skills and roles needed to meet identified service needs. This is partly about longer term alignment between education supply, and funded demand. It is also about improving day-to-day matching of nurse staffing with workload. Flexibility should be about using working patterns that are efficient, but which also support nurses in maintaining a balance between their work and personal life.

Another critical area for policy intervention is to achieve effective skill mix-through clarity of roles and a better balance of registered nurses, physicians, other health professionals, and support workers. The evidence base on skill mix is developing, and many studies highlight the scope for effective deployment of clinical nurse specialists and nurse practitioners in advanced roles.

As noted earlier, the main challenge for policy makers is not to identify isolated or ‘one-off’ interventions to deal with nursing shortages, it is to develop a co-ordinated package of policies that provide a long term and sustainable solution.