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A New Era in Nursing: Community Health and Aging Population Shift RN Employment

Sunday September 12, 2010
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The fastest-growing nursing jobs in coming years will require strong critical thinking skills, an ability to work independently and in cooperation with other providers, an understanding of how healthcare systems work, and familiarity with the needs of older adults. And they won’t necessarily be in hospitals.

“There will always be hospital jobs, but I think we should expect to see a lot more jobs in what we call community health,” says Linda Tieman, RN, MN, FACHE, executive director of the Washington Center for Nursing and board president of the Forum of State Nursing Workforce Centers.

The Statistics
Despite a slow period, due mostly to a sluggish economy, RN employment is expected to grow by 22% from 2008 to 2018, “much faster than the average for all occupations,” according to the 2010-11 edition of Bureau of Labor Statistics Occupational Outlook Handbook. But not all healthcare industries will be hiring nurses at the same rate. Though hospitals employ about 60% of all RNs, that share is expected to drop as healthcare reform, technological innovations and cost-cutting trends provide incentives to take care of more people in the community.

The fastest-growing RN jobs will be in physician offices (48% growth rate), home health (33% growth rate), and nursing care facilities (25% growth rate), according to federal projections. Hospital jobs will continue to increase as nurses get older and start to retire, but at a lower rate (17%) than other healthcare settings.

“While the intensity of nursing care is likely to increase, requiring more nurses per patient, the number of inpatients is not likely to grow by much,” the Labor Department report states, noting that earlier discharges and more outpatient procedures will keep hospital patient populations relatively stable.

Still, some nursing workforce researchers point out that an increasingly large aging population with multiple chronic conditions likely will mean an increase in hospital patients as well as patients in community care.

Healthcare Reform Effect
Healthcare reform, with its emphasis on prevention and coordinated care, also will help produce a shift from the hospital to the community, says Sheila A. Haas, RN, PhD, FAAN, a professor of the Niehoff School of Nursing at Loyola University Chicago and a past president of the American Academy of Ambulatory Care Nursing. “Much of the [newly passed Patient Protection and Affordable Care] Act isn’t about acute care, it’s about care in the community. The more I delve into the legislation, the more jobs I see.”

With a federal investment of $11 billion into community health centers — authorized by the healthcare reform legislation signed in May — the number of patients seen in the centers is expected to double in coming years, says Mary K. Wakefield, RN, PhD, FAAN, head of the Health Resources and Services Administration. Nurses make up the largest group of workers at the centers, and the need for primary care nurses at all educational levels will increase, she says.

Traditionally, nurses worked for at least a year or two in acute care before going into the community, say nurse leaders and educators, but the demand for nurses from all fields will mean new graduates should have expanding opportunities to go straight into community care areas such as ambulatory care, home health and public health. “The old bias was that you had to go to work in a hospital to be a real nurse,” says Geraldine Bednash, RN, PhD, FAAN, CEO and executive director of the American Association of Colleges of Nursing.

But new graduates can be hired directly into community care if they have the right education, training and support, say nurse leaders and educators. “I think it’s starting to change, but it just hasn’t changed enough yet,” says Beverly Malone, RN, PhD, CEO for the National League for Nursing. “I think it will continue to the point where you can graduate right into the community.”

To work in community health and hospitals, nurses need critical thinking skills and an ability to consider the needs of their patients in a variety of settings, not just when they are being seen in a clinic or hospital. For many nurse educators and nurse leaders, this means a bachelor’s degree or higher. “In baccalaureate programs, there’s more emphasis on leadership, care coordination and systems thinking,” Tieman says. “I think there’s a general agreement that nurses don’t need less education, they need more than they have. There’s more to understand with the complexity of the population.”

Physician Shortage Effect
Advanced degrees also will be in demand as a physician shortage is expected to produce more opportunities for nurses who can work in primary care, Bednash says. A federal plan to double the National Health Services Corps — which employs primary care practitioners in underserved areas — also will increase opportunities for nurse practitioners and nurse midwives, Wakefield says.

Most ambulatory care requires independence and the ability to know when and where to go for help, Haas says. “You may not see the patient for a couple of months, and if you’ve missed a chance for education or referral, you’ve missed it, and the patient doesn’t get the care,” she says.

Haas believes most nursing students are not exposed to ambulatory care as thoroughly as they should be. But many community health centers and long-term care facilities are working with nursing schools to provide places for new graduates to get clinical training. Federal funds for 10 nurse-run health centers have been allocated, with the intention that they serve as training grounds for students in nursing and other healthcare fields, in addition to providing care for underserved populations, Wakefield says.

New technology could allow instructors, using computers, phones and cameras, to monitor and support a number of students working in ambulatory or home care, Malone says.

Giving students a variety of experiences, perhaps through residency programs, would help reinforce the idea that care occurs in many places besides a hospital, Malone says. Patients and families need someone to help them navigate a network of providers, medications and information, whether they are in a hospital bed, a clinic, a long-term care facility or their homes. “That kind of systems thinking is what we really need nurses to have,” she says.

Aging Boomers Effect
Nursing students and new graduatesshould seek ways to work with elderly people, whether in long-term care, senior centers or home health, says Martha S. Anderson, DNP, CNS, FNGNA, associate professor at Jefferson College of Health Sciences in Roanoke, Va., and a National Gerontological Nursing Association board member. Once they begin to understand the needs of older adults, nursing students almost always enjoy working with them, she says. Though most nursing schools offer some instruction on older adults, many could expand in this area by offering specific education on aging and aging services taught by gerontological nurses or others who specialize in working with older adults, she says, and by working with skilled nursing facilities, home health agencies and other long-term care services to offer clinical experience.

“I think nurses have a huge responsibility and opportunity to become experts in geriatric care,” Anderson says. “That is the patient population, and it’s going to grow.”

Cathryn Domrose is a staff writer.


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