Statewide Strategic Plan for Nursing in the State of Arizona Prepared by: The Arizona Governor’s Task Force on the Nursing Shortage - 2004 2004 Nursing Statewide Strategic Plan Table of Contents Table of Contents Acknowledgements 3 Executive Summary 4 Introduction 5 Background 6-7 Vision and Mission 8 Strategic Themes 9 Concurrent Efforts Goals and Objectives Strategic Map Table 10-14 15 16-20 2004 Nursing Statewide Strategic Plan 2 Acknowledgements This strategic plan would not be in existence without the vision and leadership of Governors Hull and Napolitano in appointing a statewide taskforce to address the nursing shortage in Arizona. Thanks to the professional nursing community and key stakeholders who served as members of the Governor’s Task Force on the Nursing Shortage (listed below). Members represented all areas of nursing as well as geographic regions throughout the state. A special thanks to Marla Weston and Fran Roberts for providing leadership in the development of this report, and to Dan Anderson of the Arizona Board of Regents who provided data on the economic impact of Arizona’s healthcare industry. Members and their representative organizations included: Daniel Chafetz, Staff nurses, Tucson Rose Conner, Public Health Policy Barbara Durand, Arizona State University Marty Enriquez, University Medical Center Amy Franciscus, Staff nurses, Phoenix Susan Gerard, Governor’s Office Colleen Hallberg, Thunderbird Hospital Patricia Harris, Maricopa Community Colleges Sandy Hughes, AZ Healthcare Human Resources Association Linda Hunt, St. Joseph’s Hospital, Phoenix Marjorie Isenberg, University of Arizona Jack Jewett, Tucson Medical Center, Board of Regents Charlotte Kelly, Nurse supervisors, Flagstaff Raymond Kronebitter, Staff nurses, Yuma Robert Lucero, ASU graduate student Peggy MacMacken, Carondelet Health Network Kathy Malloch, Nursing consultant Linda Maschner, Public health nurses Melinda Miller, Staff nurses, Phoenix Doris Milton, University of Phoenix Joanne Motley, Staff nurses Margaret Mullan, The Beatitudes Campus, Phoenix Richard Patze, Pima Community College Joey Ridenour, Arizona State Board of Nursing Fran Roberts, Arizona Hospital and Healthcare Association Carol Robinson, Staff nurses and nurse supervisors, Phoenix Judith Sellers, Northern Arizona University Bertha Sepulveda, Hispanic Nurses Association Margaret Taylor, Yavapai Regional Medical Center Patricia Torrington, Handmaker Jewish Services for the Aging, Tucson Marla Weston, Arizona Nurses Association Jayne Swinford Wilkins, Staff nurses, Show Low 2004 Nursing Statewide Strategic Plan 3 Executive Summary Although national in scope, the nursing shortage is particularly problematic in Arizona. Nationwide there are 782 registered nurses (RNs) for every 100,000 people, whereas in Arizona there are only 628 RNs per 100,000 people. The Governor’s Task Force on the Nursing Shortage was charged with developing a statewide strategic plan to ensure that the State of Arizona has the nursing resource necessary to met the healthcare needs of its citizens. The work of the Governor’s Task Force on the Nursing Shortage was organized around four strategic themes that categorize the factors that contribute to the nursing shortage and recommendations to counter those factors. The themes are: · · · · Attracting People to the Profession Educating More Nurses Improving the Work Environment Removing Regulatory Barriers This report summarizes work done to date and identifies specific goals, strategies and responsible parties for impacting the nursing shortage in the short and long term. The goals relate to the themes and are: GOAL 1. Strategies are implemented for forecasting the changing nursing workforce demand and attracting people to the profession. GOAL 2. Strategies are implemented to double the capacity of Arizona’s registered nursing education programs over 2003 levels by the year 2007. GOAL 3. Strategies are implemented to improve the work environment of Arizona’s registered nurses. GOAL 4. Strategies are implemented to remove regulatory barriers to nursing practice and education. The Governor’s Nursing Shortage Task Force recommends the appointment of an Oversight Committee to assure implementation of the strategic plan. 2004 Nursing Statewide Strategic Plan 4 Introduction The state of Arizona is facing a shortage of registered nurses (RNs) that is reaching a crisis of critical proportion. In 2001, in recognition of this crisis, Governor Hull appointed the Governor’s Task Force on the Nursing Shortage. Now, under the leadership and administration of Governor Janet Napolitano, the Task Force has been charged with the development of a statewide strategic plan targeting the multiple and complex factors involved with the shortage of RNs. 2004 Nursing Statewide Strategic Plan 5 Background Since the turn of the century, the country and state have experienced repetitive and cyclical nursing workforce shortages. The conventional wisdom was that these supply and demand swings were an inevitable part of the dynamic system of healthcare delivery in America. However, today’s nursing crisis is fundamentally different from past shortages. The coupling of fewer people entering the profession along with increasing demand related to statewide population growth, a disproportionate increase in the elderly population, and medical and technological advances, has created an unprecedented and persistent shortage. Although national in scope the shortage is particularly problematic in Arizona. In acute care settings in the United States the average number of RNs is 3.3 for every 1,000 people. In Arizona the ratio is 1.9 RNs per 1,000 people. Nationwide there are 782 RNs per 100,000 people; in Arizona there are only 628 RNs per 100,000 people. In the United States between 1996 and 2000 there was a 2% decline in the ratio of RNs to the population; in Arizona there was a 12.9% decline. Number of Nurses per 1000 People in Acute Care Settings Acute Care Nursing Shortage in Arizona 3.5 3 3.3 2.5 2 1.9 1.5 1 0.5 0 Nation Arizona 2004 Nursing Statewide Strategic Plan 6 Background Number of Nurses per 100,000 People Nu r s in g Sh o r tag e in A r iz o n a 900 800 700 782 600 628 500 400 300 200 100 0 Nation A r iz ona At the same time, the growth of the healthcare industry has been unprecedented. Since the 1990’s, healthcare employment has grown 20% faster than total Arizona jobs. Furthermore, the healthcare industry is responsible for 8.6% of jobs in Arizona and 10% of wages. Investment in ensuring a stable and responsive healthcare infrastructure not only serves the healthcare needs of Arizona citizens, but also contributes to the strength of the economy. For every dollar invested in the industry about 2.2 total dollars are added to the local economy. 2004 Nursing Statewide Strategic Plan 7 Vision for Nursing in AZ The health and well being of residents of Arizona will be supported and enhanced through the provision of accessible, high quality care and services by the nursing profession. Mission of the Governor’s Task Force The mission of the Governor’s Task Force on the Nursing Shortage is to ensure that the State of Arizona has the nursing resources necessary to meet the healthcare needs of its citizens. The Governor’s Nursing Shortage Task Force shall develop a statewide strategic plan to address the nursing shortage in Arizona for both the short and long term. To achieve this end, the Governor’s Task Force on the Nursing Shortage will facilitate comprehensive planning and policy development to strengthen the nursing workforce in Arizona, as well as identify potential funding for strategic initiatives. In addition, the Task Force will study and make recommendations on new and emerging issues upon the request of Task Force members. 2004 Nursing Statewide Strategic Plan 8 Strategic Themes The work of the Governor’s Task Force on the Nursing Shortage was organized around four strategic themes that categorize the factors that contribute to the nursing shortage and recommendations to counter those factors. The factors are: · · · · Attracting People to the Profession Educating More Nurses Improving the Work Environment Removing Regulatory Barriers Attracting people to the profession focuses on limited public knowledge about the profession of nursing and what nurses do to enhance people’s lives related to wellness, renewed health, or the inevitability of dying. Educating more nurses focuses on the need to expand the capacity of programs of nursing education in the state, and programs of higher education leading to more advanced practice nurses and nurse educators. Improving the work environment focuses on issues in settings where nurses practice that contribute to satisfaction, the desire to continue to practice and the quality of patient care. Removing regulatory barriers focuses on examining any statute or rule that currently prevents nurses from proficiently providing high quality care and services to the residents of Arizona. 2004 Nursing Statewide Strategic Plan 9 Concurrent Efforts A number of concurrent efforts have been undertaken while the taskforce has been in progress (Table 1). Funding, assistance, and collaboration by hospitals, foundations, and professional associations have been organized through the leadership and direction of the Arizona Hospital and Healthcare Association (AzHHA) in creating and implementing the “Campaign for Caring”, a statewide initiative aimed at increasing interest in healthcare professions, supporting an increased capacity in the state’s nursing education programs, and addressing problems related to healthcare workplaces. Universities and community colleges have responded to the shortage by creatively enhancing the capacities of their programs (See table below). Extended course hours into evenings and weekends have maximized availability of teaching space and clinical rotations. New programs, including second career programs, school and hospital partnerships, and on-line courses have accommodated more learners. Arizona Nursing Program Admissions and Capacity 2500 2083 Number of Students 2000 1773 1614 2160 1652 1701 1500 Admits Capacity 1000 500 0 2001 2002 2003 Year Data obtained from the Arizona State Board of Nursing website 2004 Nursing Statewide Strategic Plan 10 Concurrent Efforts The Arizona Legislature in 2002 passed Senate Bill 1260 charging the “Arizona board of regents and the president or chancellor of each community college district or their designee and one member of the state board of directors for community colleges appointed by the chairman, in conjunction with private educational institutions that provide nursing education programs, hospitals and private hospitals and healthcare organizations, shall develop a caregiver and resource expansion program. The caregiver and resource expansion program shall be a five-year plan to increase the number of nurses who enter and graduate from nursing education programs in this state.” The bill also provides more specific direction regarding the development of a plan to double the capacity of Arizona’s registered nursing education programs by 2007. Healthcare organizations that employ nurses have initiated plans to create work environments that facilitate the work of nursing. Many have implemented programs to financially support faculty and programs to educate more nurses, and nearly all have enhanced scholarship and loan programs. The Arizona Nurses Association (AzNA) has provided leadership and direction by educating nursing employers on the characteristics of environments that are attractive and supportive to nurses. In addition, a program was initiated by AzNA to enhance leadership skills of nursing supervisors in partnership with the University of Arizona Colleges of Business and Nursing. AzNA spearheaded legislation in 2003 concerning reporting of patient safety issues. The passage of Senate Bill 1178 established reporting policies and procedures prohibiting retaliation against health professionals working at health care institutions when they in good faith report any unsafe practices or violation of law that put patients’ health or safety at risk. In addition, AzNA worked with the Arizona Organization of Nurse Executives (AzONE) on a project that would eliminate the use of mandatory overtime by hospitals within the state. 2004 Nursing Statewide Strategic Plan 11 Concurrent Efforts Regulatory initiatives by the 2004 Arizona Legislature included the passage of House Bill 2256, which provides for piloting a study of medication technicians passing medications to custodial patients in long-term care facilities. The adoption of rules by the Arizona State Board of Nursing (ASBN) related to the multistate compact for nurse licensure and the application process for foreign-educated nurses. These new rules have ensured that nurses moving into the state meet educational and competency standards. The Department The Department of Health Services (DHS) has proposed rules which will strengthen nurse staffing requirements, including an acuity plan that is reviewed and evaluated annually, with results reported to the governing authority. In addition, the DHS is proposing the acuity plan include an assessment of a patient’s need for nursing services be made by a registered nurse who is providing nursing services directly to that patient. The Task Force acknowledges that these many efforts have not been sufficient to address the shortage of nurses in Arizona. As evidence mounts demonstrating that nurses are critical in ensuring patients receive quality health care, the need to address the nursing shortage in Arizona becomes even more critical. Unfortunately, there is no easy or simple solution. The Task Force acknowledges reasons for this shortage are multiple and complex and must be addressed in a comprehensive manner through public and private partnerships. Since much time, funding and energy has been directed to this shortage, the Task Force has identified key priorities as well as gaps in current initiatives, and focuses this strategic plan on those areas needing current and future attention. 2004 Nursing Statewide Strategic Plan 12 Concurrent Efforts Strategic Theme Attracting People to the Profession Educating More Nurses Table 1: Concurrent Efforts Activity Status Campaign for Caring Across the state there are reports of waiting lists for entry into nursing programs 1. Student admissions are 1. Universities and near or exceed capacity. Community Colleges Capacity has been increasing capacity. increased at universities and community colleges. Enrollment in nursing programs (RN & PN) increased 26% from 2001 to 2003. See Board of Nursing Website. 2. Estimated cost to double 2. Nursing Education capacity is $125 million; Program and $14 million has been Expansion Plan (plan to identified. double enrollment by 3. New programs are 2007). entering the market using new educational approaches. 4. Legislation introduced to allow Community Colleges to prepare nurses at the baccalaureate level. 5. Changing community demand for advanced practice nurses including NPs as intensivists and CNSs. 2004 Nursing Statewide Strategic Plan 13 Concurrent Efforts Strategic Theme Improving the Work Environment Removing Regulatory Barriers Table 1: Concurrent Efforts (continued) Activity Status 1. One hospital in Arizona 1. “Magnet” Work Magnet Credentialed. Environment Seven more are in development. 2. Eliminating mandatory 2. Staffing overtime. 3. Two hospitals in Arizona implemented 1:4 ratios on med-surg. DHS implementing 1:2 ratios in ICU, requiring an acuity system and requiring that staff have knowledge of the staffing plan. 1. Legislation on pilot 1. Legislation introduced medication technician to pilot med tech role in passed. long term care. 2. Licensure compact 2. Multistate licensure adopted by 20 states. enacted. 3. Foreign educated nurses 3. State Board added continuing to experience flexibility to application delays at the national process for foreignlevel. educated nurses while maintaining educational and competency standards. 2004 Nursing Statewide Strategic Plan 14 Goals and Objectives With the intent of focusing statewide efforts on those activities that would most dramatically impact the nursing shortage in the short-term while simultaneously creating an infrastructure for addressing future demands for nursing care, the Governor’s Task Force on the Nursing Shortage prioritized suggested activities. Four goals were identified, and strategies, expected outcomes, and responsible parties were identified. Table 2 details a strategic map for addressing priority strategies. Goal 1: Strategies are implemented for forecasting the changing nursing workforce demand and attracting people to the profession. Goal 2: Strategies are implemented to double the capacity of Arizona’s registered nursing education programs over 2003 levels by the year 2007. Goal 3: Strategies are implemented to improve the work environment of Arizona’s registered nurses. Goal 4: Strategies are implemented to remove regulatory barriers to nursing practice and education. The Governor’s Nursing Shortage Task Force recommends the appointment of an Oversight Committee to assure implementation of the strategic plan. 2004 Nursing Statewide Strategic Plan 15 2004 Nursing Statewide Strategic Plan 16 Theme Attracting People to the Profession Joey Ridenour Marketing campaign developed and implemented for attracting diverse populations and bilingual individuals to nursing by 2006. Annual report to nursing community by December 2004. Adda Alexander Plan developed to counsel individuals currently on education program waiting lists. Design strategy for retaining people on waiting list. Determine, through a longitudinal study, if people on waiting lists remain interested in pursing a career in nursing or have changed career paths. Identify strategies for attracting a more diverse population and more bilingual individuals to nursing. Continue to monitor number of individuals entering programs and number on waiting lists. Pat Harris, Joey Ridenour, Jean Stengel Available nursing education openings routinely listed on website by August 2004. Joey Ridenour Responsible Party Rose Conner, Kathy Malloch, Peggy Mullen, Fran Roberts, Marla Weston, Lynn Maschner Implement centralized information for students on waiting lists to access information on openings in schools through ASBN website. Table 2: Strategic Map Activity Expected Outcome/Date Identify the number of nurses and Report on number of nurses and nursing nursing assistants needed in various assistants needed geographically, and by practice settings by geographical educational preparation, by December location, educational preparation and 2004. ethnicity. 2004 Nursing Statewide Strategic Plan 17 Theme Educating More Nurses Develop a plan for attracting nurses to faculty positions including (1) outline for adjusting salaries to meet market demands and (2) prediction of number of faculty needed based on growing demand and retirement projections. Program graduates first class by August 2005. Marla Weston, Kathy Nursing community recommendation for increasing baccalaureate nursing education Malloch in Arizona. Evaluate the merits of baccalaureate nursing education through the state’s community colleges. Bertha Sepulveda Pat Harris, Jayne Wilkins, Fran Roberts, Marty Enriquez, Richard Patze Marjorie Isenberg, Pat Harris, Fran Roberts, Judy Sellers Implement program to assist foreign educated nurses to successfully complete NCLEX. Strategies identified for increasing Explore strategies for increasing alternatives for educating more nurses alternatives for educating more nurses while maintaining current standards. while maintaining current standards. Address the faculty shortage and the non-competitive salary structure of nursing faculty to meet current and future faculty demands. Table 2: Strategic Map Responsible Party Expected Outcome/Date Activity Monitor and collaborate on fundraising Plan developed to identify $111 million over Fran Roberts, Marjorie Isenberg the next five years for increasing and plan development for Nursing educational capacity. Education Program and Expansion Plan. 2004 Nursing Statewide Strategic Plan 18 Theme Educating More Nurses Identify excellent preceptors as future faculty. Establish practices for transitioning new graduates into competent RNs. Clarify and enhance the work of preceptors. Enhance support in the work environment to orient and mentor students, new graduates, new employees traveling nurses, and programs to transition experienced nurses to new settings. Delineate criteria for selecting preceptors as future faculty and disseminate to clinical professors. Evaluate a national pilot residency program and a change in hours worked from 12 hour down to 8 hour shifts. Evaluate pilot residency program and incorporate into model precepting/residency program. Create and disseminate template for model orientation, precepting, residency and mentoring programs. Table 2: Strategic Map Activity Expected Outcome/Date Explore HRSA, WIA (workforce Apply for a grant that enhances recruitment investment act) and other funding for and retention of nurses. enhancing preceptor development. Linda Hunt, Fran Roberts, Lynn Maschner Sandy Hughes, Marjorie Isenberg, Marty Enriquez Responsible Party Mardy Taylor, Adda Alexander, Marty Enriquez, Rose Conner Sandy Hughes Theme Improving the Work Environment Develop materials to help HCOs implement desirable nursing practice environments (repository of information) Modify program based upon pilot and expand to statewide implementation by December 2004. Promote leadership education for clinical nursing supervisors. Development of process and reports for reliable data about the need for nursing including projections for practice and education. Establish an Arizona Center for Nursing as a venue for data collection on nursing to serve as a centralized repository of information on nursing and to provide resources for assisting nurses to navigate regulatory agencies. Communicate information to Arizona nurses Expand existing award program to increase participation in nominations and recognitions. Establish reward mechanisms for best practice facilities, including AzNA recognition and nomination by clinical nurses. Continue to monitor activities in other states related to initiatives. Increase presentations to clinical nurses, emphasizing the important contributions of nursing’s voice and expertise. Promote educational session by AzNA on “what it means to be a professional nurse.” Activity Focus on improving the work environment in three areas where most nurses work: hospitals, longterm care, home health/hospice. Table 2: Strategic Map Expected Outcome/Date Share best practices on creating a positive work environment from different employment settings. Factors Influencing the Healthcare Industry 2004 Nursing Statewide Strategic Plan 19 University of Arizona College of Nursing and Business, Marla Weston Marla W eston Marla W eston, Kathy Malloch Marla W eston Marty Enriquez, Marla W eston Responsible Party Jayne W ilcox, Adda Alexander, Peggy McMacken, Peggy Mullan, Judy Sellers 2004 Nursing Statewide Strategic Plan 20 Theme Removing Regulatory Barriers Implement medication technician pilot study. Continue to monitor for other regulatory barriers. Peggy Mullen Joey Ridenour Barriers identified on ongoing basis. Responsible Party Bertha Sepulveda Implemented by August 2005. Table 2: Strategic Map Activity Expected Outcome/Date Evaluate data collected on barriers to Data evaluated at the end of the first cohort foreign educated nurse licensure. completing the program by August 2005.