Older adults with serious mental illness (SMI) often have multiple comorbidities and complex medication schedules. Shortages of behavioral health specialists (BHSs), especially in rural areas, ...frequently make primary care providers (PCPs) the only clinician managing this complex population. The aim of this study was to describe rural/urban psychiatric medication prescribing in older adults with SMI by PCPs and BHSs, and by clinician type.
This retrospective descriptive analysis used 2018 Medicare data to identify individuals with a bipolar, major depression, schizophrenia, or psychosis diagnosis and examined medication claims for antianxiety, antidepressants, antipsychotics, hypnotics, and anticonvulsants. Descriptive statistics summarized percentage of medications provided by PCPs and BHSs stratified by rural and urban areas and by drug class. Additional analyses compared psychiatric prescribing patterns by physicians, advanced practice registered nurses (APRNs), and physician assistants (PAs).
In urban areas, PCPs prescribed at least 50% of each psychiatric medication class, except antipsychotics, which was 45.2%. BHSs prescribed 40.7% of antipsychotics and less than 25% of all other classes. In rural areas, percentages of psychiatric medications from PCPs were over 70% for each medication class, except antipsychotics, which was 60.1%. Primary care physicians provided most psychiatric medications, between 36%-57% in urban areas and 47%-65% in rural areas. Primary care APRNs provided up to 13% of prescriptions in rural areas, which was more than the amount prescribed by BHS physicians, expect for antipsychotics. Psychiatric mental health APRNs provided up to 7.5% of antipsychotics in rural areas, but their prescribing contribution among other classes ranged between 1.1%-3.6%. PAs provided 2.5%-3.4% of medications in urban areas and this increased to 3.9%-5.1% in rural areas.
Results highlight the extensive roles of PCPs, including APRNs, in managing psychiatric medications for older adults with SMI.
Rural primary care shortages may be alleviated if more nurse practitioners (NPs) practiced there. This study compares urban and rural primary care NPs (classified by practice location in urban, large ...rural, small rural, or isolated small rural areas) using descriptive analysis of the 2012 National Sample Survey of NPs. A higher share of rural NPs worked in states without physician oversight requirements, had a DEA (drug enforcement administration) number, hospital admitting privileges, and billed using their own provider identifier. Rural NPs more often reported they were fully using their NP skills, practicing to the fullest extent of the legal scope of practice, satisfied with their work, and planning to stay in their jobs. We found lower per capita NP supply in rural areas, but the proportion in primary care increased with rurality. To meet rural primary care needs, states should support rural NP practice, in concert with support for rural physician practice.
Health information technology (HIT) is increasingly adopted by nursing homes to improve safety, quality of care, and staff productivity. We examined processes of HIT implementation in nursing homes, ...impact on the nursing home workforce, and related evidence on quality of care. We conducted a literature review that yielded 46 research articles on nursing homes’ implementation of HIT. To provide additional contemporary context to our findings from the literature review, we also conducted semistructured interviews and small focus groups of nursing home staff (n = 15) in the United States. We found that nursing homes often do not employ a systematic process for HIT implementation, lack necessary technology support and infrastructure such as wireless connectivity, and underinvest in staff training, both for current and new hires. We found mixed evidence on whether HIT affects staff productivity and no evidence that HIT increases staff turnover. We found modest evidence that HIT may foster teamwork and communication. We found no evidence that the impact of HIT on staff or workflows improves quality of care or resident health outcomes. Without initial investment in implementation and training of their workforce, nursing homes are unlikely to realize potential HIT-related gains in productivity and quality of care. Policy makers should consider creating greater incentives for preparation, infrastructure, and training, with greater engagement of nursing home staff in design and implementation.
Objectives. To determine whether nurse staffing in California hospitals, where state‐mandated minimum nurse‐to‐patient ratios are in effect, differs from two states without legislation and whether ...those differences are associated with nurse and patient outcomes.
Data Sources. Primary survey data from 22,336 hospital staff nurses in California, Pennsylvania, and New Jersey in 2006 and state hospital discharge databases.
Study Design. Nurse workloads are compared across the three states and we examine how nurse and patient outcomes, including patient mortality and failure‐to‐rescue, are affected by the differences in nurse workloads across the hospitals in these states.
Principal Findings. California hospital nurses cared for one less patient on average than nurses in the other states and two fewer patients on medical and surgical units. Lower ratios are associated with significantly lower mortality. When nurses' workloads were in line with California‐mandated ratios in all three states, nurses' burnout and job dissatisfaction were lower, and nurses reported consistently better quality of care.
Conclusions. Hospital nurse staffing ratios mandated in California are associated with lower mortality and nurse outcomes predictive of better nurse retention in California and in other states where they occur.
Research Objective
During the first months of the COVID‐19 pandemic, numerous concerns about the nursing workforce were reported. Nursing education programs have reported that their students were not ...able to continue their clinical education due to worries about infection risks within hospitals and some have cancelled or reduced entering cohorts. At the same time, anecdotal reports suggested that some RNs near retirement chose to retire early to reduce the risk of infection with SARS‐Cov2. These changes, if true, could undermine the progress made over the past 20 years toward a balanced nursing labor market and lead to shortages of RNs in the near future.
Study Design
This study uses data from two surveys conducted in California to assess the current and future supply of RNs, and to learn how the coronavirus pandemic is affecting this essential workforce. Early data from two surveys have been analyzed to provide a rapid assessment of the workforce: (1) the biennial Survey of California Registered Nurses, and (2) the Board of Registered Nursing Annual Schools Survey. Data from the Survey of California RNs, which is based on a stratified sample of the state's nurses, are weighted to represent the total population of nurses. Analysis methods include tabulating means and frequency distributions for the 2020 surveys and comparing the results to prior years. The data from these surveys are then used in a stock‐and‐flow supply projection model to learn the extent to which RN shortages might emerge in the future.
Population Studied
Registered nurses and nursing education programs in California.
Principal Findings
Approximately 2000 RNs responded to the biennial Survey by November 2020. The data indicate that: (1) employment rates of older nurses dropped substantially: 6 percentage points for RNs 60‐64 years old and 10 percentage points for RNs 65 years and older. Employment rates for nurses younger than 30 years also dropped, but not significantly. Employment of nurses 30‐49 years increased approximately 6 percentage points, making up for the decreases of older RNs. Among RNs 55‐64 years old, the percent reporting they intend to retire or leave nursing within two years increased from 11.4% in 2018 to 24.5% in 2020.
The survey of RN education programs finds that 16 of California's 147 nursing programs skipped a cohort of students in 2020 and another 18 programs enrolled fewer students than the prior academic year. The estimated decrease in students statewide is approximately 350 ‐ 2.3% of ~15,000 new enrollments in 2018‐2019.
Conclusions
Although RN enrollments decreased only negligibly, the rapid decrease in employment of older nurses and increase in projected retirements suggest that RN shortages may rapidly emerge.
Implications for Policy or Practice
Over the past five years, hospitals have been increasingly uninterested in hiring newly‐graduated nurses, even while reporting shortages of experienced RNs. Hospitals need to rapidly hire newly‐graduated RNs in order to compensate for the rapid outflow of older RNs from the labor supply.
Background The COVID-19 pandemic led to important indirect health and social harms in addition to deaths and morbidity due to SARS-CoV-2 infection. These indirect impacts, such as increased ...depression and substance abuse, can have persistent effects over the life course. Estimated health and cost outcomes of such conditions and mitigation strategies may guide public health responses. Methods We developed a cost-effectiveness framework to evaluate societal costs and quality-adjusted life years (QALYs) lost due to six health-related indirect effects of COVID-19 in California. Short- and long-term outcomes were evaluated for the adult population. We identified one evidence-based mitigation strategy for each condition and estimated QALYs gained, intervention costs, and savings from averted health-related harms. Model data were derived from literature review, public data, and expert opinion. Results Pandemic-associated increases in prevalence across these six conditions were estimated to lead to over 192,000 QALYs lost and to approach $7 billion in societal costs per million population over the life course of adults. The greatest costs and QALYs lost per million adults were due to adult depression. All mitigation strategies assessed saved both QALYs and costs, with five strategies achieving savings within one year. The greatest net savings over 10 years would be achieved by addressing depression ($242 million) and excessive alcohol use ($107 million). Discussion The COVID-19 pandemic is leading to significant human suffering and societal costs due to its indirect effects. Policymakers have an opportunity to reduce societal costs and health harms by implementing mitigation strategies.
Objective. To compare alternative measures of nurse staffing and assess the relative strengths and limitations of each measure.
Data Sources/Study Setting. Primary and secondary data from 2000 and ...2002 on hospital nurse staffing from the American Hospital Association, California Office of Statewide Health Planning and Development, California Nursing Outcomes Coalition, and the California Workforce Initiative Survey.
Study Design. Hospital‐level and unit‐level data were compared using summary statistics, t‐tests, and correlations.
Data Collection/Extraction Methods. Data sources were matched for each hospital. When possible, hospital units or types of units were matched within each hospital. Productive nursing hours and direct patient care hours were converted to full‐time equivalent employment and to nurse‐to‐patient ratios to compare nurse staffing as measured by different surveys.
Principal Findings. The greatest differences in staffing measurement arise when unit‐level data are compared with hospital‐level aggregated data reported in large administrative databases. There is greater dispersion in the data obtained from publicly available, administrative data sources than in unit‐level data; however, the unit‐level data sources are limited to a select set of hospitals and are not available to many researchers.
Conclusions. Unit‐level data collection may be more precise. Differences between databases may account for differences in research findings.
Objective
To determine whether, following implementation of California's minimum nurse staffing legislation, changes in acuity‐adjusted nurse staffing and quality of care in California hospitals ...outpaced similar changes in hospitals in comparison states without such regulations.
Data Sources/Study Setting
Data from the American Hospital Association Annual Survey of Hospitals, the California Office of Statewide Health Planning and Development, the Hospital Cost Report Information System, and the Agency for Healthcare Research and Quality's Health Care Cost and Utilization Project's State Inpatient Databases from 2000 to 2006.
Study Design
We grouped hospitals into quartiles based on their preregulation staffing levels and used a difference‐in‐difference approach to compare changes in staffing and in quality of care in California hospitals to changes over the same time period in hospitals in 12 comparison states without minimum staffing legislation.
Data Collection/Extraction Methods
We merged data from the above data sources to obtain measures of nurse staffing and quality of care. We used Agency for Healthcare Research and Quality's Patient Safety Indicators to measure quality.
Principal Findings
With few exceptions, California hospitals increased nurse staffing levels over time significantly more than did comparison state hospitals. Failure to rescue decreased significantly more in some California hospitals, and infections due to medical care increased significantly more in some California hospitals than in comparison state hospitals. There were no statistically significant changes in either respiratory failure or postoperative sepsis.
Conclusions
Following implementation of California's minimum nurse staffing legislation, nurse staffing in California increased significantly more than it did in comparison states' hospitals, but the extent of the increases depended upon preregulation staffing levels; there were mixed effects on quality.
•Despite growth in entry-level Bachelor of Science in Nursing (BSN) education and Registered Nurse (RN)-to-BSN graduations, the Institute of Medicine recommendation that 80% of RNs have a bachelor's ...degree or higher by 2020 will not be attained.•Based on current patterns of entry-level and RN-to-BSN education, approximately 66% of RNs are projected to have BSN+ education by 2025.•To reach the 80% goal by 2025, changes in the mix of entry-level education and/or an increase in the number of RN-to-BSN graduates will be required.•Employers can support tuition costs and offer rewards to RNs who complete baccalaureate degree, as many do now.•Programs that support entry-level BSN education should be expanded, including collaborative agreements between community colleges and universities and community colleges offering bachelor's degrees in nursing.
In 2011, the Institute of Medicine recommended that 80% of RNs have a bachelor's degree or higher by 2020. Progress toward this recommendation has been slow.
This paper presents a model that projects whether the 80% recommendation can be met within a 10-year period and estimates the impact of education changes that might accelerate progress.
A projection model for 2016 to 2026 was created using a “stock-and-flow” approach. Secondary data were extracted from multiple sources for the projections. The model includes the option to enter alternative values of key parameters to estimate the impact of changes.
Based on current patterns of entry-level and RN-to-BSN education, approximately 66% of RNs are projected to have BSN+ education by 2025.
To reach the 80% goal by 2025, changes in the mix of entry-level education and/or an increase in the number of RN-to-BSN graduates will be required.
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