Workforce Challenges in a Remade Approach to Care

Recalibrating the U.S. health care system for different performance will undoubtedly have a big impact on the health care workforce. Here are some of the workforce issues that will be important as we move forward.

The perennial question in health care is, “Will we have enough?” Before we can answer that question we must look at how much demand there will be and what form it will take. There is widespread pressure to increase educational capacity in preparation for the anticipated growth in demand for care services. This increase in demand is the result of several changes: the new legislation which makes it possible to move toward universal insurance coverage; an increase in demand for care services from an aging population; an increase of 20% in the U.S. population between 2000 and 2030, which means more people to provide with heath care; and shifts in disease affecting the nation (such as the growing obesity rate). Given the combination of these factors, it is easy to make a case that there will be tremendous increase in demand for service. While it is very difficult to quantify these changes at any meaningful level, it seems likely that these shifting demands will aggregate into an upward pressure of at least 20% over the next twenty years. How can we best meet this increased level of need? An increase of that amount in the nation’s health professional educational capacity would be a safe bet.

As we consider the need to grow our capacity, we must look from both a very broad and a very specific perspective. It is essential to maintain a broad horizon for growth because there will be temporary ups and downs in any specific labor market. Nursing is a good case in point. The reported nursing “shortage” of 2000 was exaggerated in part because of some short-term phenomena. The rapidly expanding economy of the time was attracting nursing graduates into other parts of health care or other fields entirely. The wage and practice reality of nursing at the time left nursing programs under enrolled, eventually reducing nursing enrollment by about 25% of what it should have been. Those who looked broadly at demand for nursing service didn’t like what they saw. They predicted that an aging population demanding more care, an aging nursing practice population and the trajectory of declining nursing enrollment would come to confluence around 2015 as demand for care increased at the very time that Baby Boomer RNs would retire. Nursing programs were expanded to attract potential students, and soon were filled to overflowing with the promise that nurses would always be in demand. So far so good: the nation enlarged the capacity of its nursing schools and colleges about 30% to meet the projected increase in demand.

But few expected the economic downturn of the past few years to be as deep or long-lasting as it has become. RNs who might have retired in the past are holding on to their jobs as retirement funds and plans have changed. Many more find that personal financial demands require four of five shifts a week and overtime when available to help make ends meet as partners lose jobs or transition to new positions. Over the past two years, hospitals have slowed or even stopped new hiring and some have even looked at lay-offs. A growing generation of new RNs is now finding that the promise was short lived. As each year passes, many of these trained nurses are lost to the profession.

Yet the reality is that we will need these newly minted RNs in the coming years. We probably need them today, just not in the specific roles into which they were expecting to be hired. This situation points to a much larger problem facing the nation’s health care system. We have too narrowly constructed health professional roles around a tight set of expected acts which produce very limited scopes for practice. Even when the law allows for a broader range of activities, traditions, professional prerogatives and financing patterns prevent the full range of practice for many professionals. Education programs follow this same narrow framework, restricting any meaningful cross-professional training or even awareness of these possibilities. Most young professionals leave such educational programs not only unaware of other professional work; they also fully expect to replicate their practice year after year using the framework learned in their professional programs. This lack of flexibility and understanding derails the ability of the care system to be innovative and responsive at the very moment when these qualities are most in demand.

The Center for the Health Professions at UCSF is often asked by policy makers, professionals and institutional leaders to predict how many health care professionals of this or that sort will be needed in the years ahead. We are not unsympathetic to the need for long-term planning, but we remind people that rethinking the future of the health care workforce is a complex undertaking that has proven to be highly unpredictable. In general we can say with the growth in numbers and demand, and the changing disease state of the nation, we will need more professionals than we now produce. Beyond this, we can say that the balance of needed nurses and physicians, specialists and primary care providers, this allied health profession and that, will continue to be a function of the practice models, traditions, technology, consumer expectations, and realities on the ground. I take some comfort from the fact that Connecticut has about twice as many physicians as does Iowa, yet this has not seemed to do any long-term disservice to the health of Iowans.

Like most human endeavors, the organization and delivery of health services is far more mercurial than we allow. If we cannot, with integrity, “predict” specifically how many health care professional will be needed, we should be willing and able to work toward a set of competencies that will be resourceful as the various practices change over a professional’s lifetime. Here are my suggestions of where we should begin the dialogue.

  • Educate and train in deep and meaningful cross-professional settings, so that an appreciation for the skills, competencies and perceptions of the major professions are shared.
  • Teach team skills overtly and generically. Working in a variety of settings with widely different types of teams will be one of the hallmarks of our emergent practice realities.
  • Leave all health professional students with the expectation that all things will change and give them the skills to direct and lead such changes in ways to rapidly improve the models of care.
  • Enshrine the core concept that health care is a knowledge-based undertaking and that accessing, assembling, sharing, advancing, and using that knowledge with other professionals, individuals and publics served is the most important aspiration of any profession. (As an aside, most of the students already know this and just need us to get out of the way.)
  • Enhance the creativity of every student leaving them with the expectation that they are responsible for continually improving the processes of care.
  • Give every student an opportunity to bring a critical capacity to the organization and financing of the care that they are charged to offer. Without such a perspective, we will have little hope of meaningfully changing the organization of care.

Clearly, these suggestions are not exhaustive. In fact, I would invite readers to forward their suggestions to me at the address below. Having such a dialogue might be an important first step to creating the health professionals we need for a different future.

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