Commentary A Physician Prescription for the Nursing Shortage

John H Cochran, MD, FACS

nursing shortage trend at 6%. The Abstract shortage was expected to grow In 2003, the Colorado Permanente Medical Group (CPMG), a 780-mem- slowly until 2010, at which time ber, multispecialty physician group that provides ambulatory and hospital demand was expected to accelerate care principally in metropolitan Denver and Boulder, embarked upon a and exceed supply in 2020 by 31%. multifaceted program to leverage physician leadership to address the nurs- DHHS anticipated a 40% increase in ing shortage. Designated as the “Preferred Clinical Partner Program” (the demand for RNs between 2000 and PCP Program), CPMG sought to participate in solving the nursing shortage 2020 with growth of this labor pool by engaging in a number of initiatives. Through an initial fund of $1 million, at a modest 1.7% annually. over $350,000 was used to fund nursing scholarships, over $150,000 was In 2000, CPMG physicians began used to provide advanced training to a select group of health care profes- to experience the effects of an acute sionals in a program that may be the first physician-partnered MA-to-LPN and, in some situations, crippling and RN-to-BSN initiative, and over $500,000 was devoted to building shortage of nurses—aggravated and expanding nursing simulation laboratories. Currently, the accelerated by local geography. Patients were nursing program graduates approximately 32-35 nurses each year and has being diverted away from CPMG’s admitted its seventh cohort of students. Student retention has been excellent. urban partner hospitals and four new hospitals under construction Introduction in the drive to stimulate interest, on Denver’s periphery posed an In 2003, the Colorado Perma- develop capacity, and offer oppor- additional challenge as they vied for nente Medical Group (CPMG), a tunities for nurses and other future nurses who preferred to work closer 780-member, multispecialty physi- health care team members. The to home. Classified advertisements cian group that provides ambula- development of the PCP Program in local newspapers showed some tory and hospital care principally in is explained more fully in Physi- urban hospitals were offering an metropolitan Denver and Boulder, cian as Healer, Leader and Partner: additional per diem of $50—simply embarked upon a multifaceted Tackling the Nursing Shortage.1 Six for driving to work. This impending program to leverage physician lead- years later, we look back to assess crisis caused CPMG to take action to ership to address the nursing short- the impact of the PCP Program maintain high-quality, affordable care. age. Designated as the “Preferred in helping to address the nursing Clinical Partner Program” (the PCP shortage in Colorado. Program), CPMG sought to partici- The Preferred Clinical pate in solving the nursing shortage Background Partner Program in by: a) funding nursing scholarships, The shortage of nurses has severe Action b) building nursing education ca- implications for affordability, acces- Rather than sit back and let oth- pacity by funding and developing sibility, and the quality of health ers “fix” this increasingly severe educational programs, c) utilizing care. In 2000, the US Department problem, CPMG decided to be a physicians as faculty and mentors, of Health and Human Services part of its solution. CPMG’s Board of d) clarifying leadership and partner- (DHHS) identified Colorado as one Directors authorized a contribution ship expectations for physicians, of 30 states with a nursing shortage. of $250,000 to provide scholarships and e) developing physician-nurse The 2000 supply-versus-demand and other financial assistance to help relationship training programs. The comparisons by DHHS projected a prospective nursing students and to strategy of the PCP Program was to shortage of 11% (3656 nurses) by build the educational infrastructure be comprehensive and innovative 2007 compared with the national necessary to accommodate them.

John H Cochran, MD, FACS, is the Executive Director of The Permanente Federation; formerly a plastic surgeon with Kaiser Permanente Colorado and Executive Medical Director of the Colorado Permanente Medical Group. E-mail: [email protected].

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With this commitment in hand, Table 1. Contributions to the CPMG Education Fund between matching grants were obtained from 2003 and 2008 to support nursing education Kaiser Foundation Health Plan of Physician-supported Contributions Impact Colorado and Exempla Healthcare. nursing education 2003-2008 Thus, what began as a relatively Student scholarships $ 351,500 133 scholarships awarded small scholarship program grew Nursing education $529,560 Four nursing simulation labs into a fund of more than $1 million. simulation equipment constructed or expanded Funds obtained through the gener- and construction osity of these institutions have been Colorado Center for $95,000 Opened center and supported Nursing Excellence general operations put to good use over the past six Accelerated nursing $160,312 128 nursing students received years. See Table 1 for a summary of degree programs BSN degrees; the disposition of the funds. 32 MAs received LPN licenses Funds recently donated $250,000 To be determined Scholarships but not yet allocated Over $350,000 was used to fund Total $1,386,372 nursing scholarships. These scholar- CPMG = Colorado Permanente Medical Group ships were awarded to an ethnically diverse and deserving population of approximately 32-35 graduates each learn how to insert an IV or a chest prospective nurses. More than 130 year. The program has admitted its tube or practice birthing procedures individuals who might not have had seventh cohort of students. Student using this simulation equipment. the opportunity to pursue nursing retention has been excellent. To Such equipment enables more careers have been able to do so date, a total of two students did students to practice needed skills, because of these scholarships. In not complete the program; a third and requires fewer educators to addition, the recognition and pub- is returning this spring following supervise the training. This, in turn, licity that these students obtain in withdrawal last year. Consequently, enables our most senior nurses to connection with the award of these the program has generated an remain at the bedside, caring for our scholarships has generated interest impressive attrition rate of only ap- most critically ill patients. in nursing well beyond the scholar- proximately 1.5%. ship recipients alone. Colorado Center for Over $150,000 was used to pro- Nursing Education Nursing Excellence vide advanced training to a select Infrastructure Finally, the funds were used to group of health care professionals. In 2007, US nursing schools help open the Colorado Center for In a program that may be the first turned away 40,285 qualified appli- Nursing Excellence (the Center) physician-partnered MA-to-LPN and cants due to lack of faculty resources and a CPMG physician leader was RN-to-BSN initiative, professionals and funding.2 Educational capacity is on the founding Board of Directors. who already had dedicated them- one of the chief obstacles to entry Today, the Center creates public selves to the health care field were into the nursing profession. There awareness of the nursing workforce able to advance their skills, increase are simply not enough teachers, shortage and stimulates attraction to their scope of practice, and obtain educators, or facilities to train the the profession, ensures statewide higher paying jobs. The ability to number of nurses needed. And access to capacity-building, lifelong envision a robust career path has every time a nurse steps away from learning opportunities for nursing led to improved career satisfaction, the bedside and into a classroom, personnel, promotes innovation which will lead to lower nurse turn- a critical hospital bed may become that increases workforce retention over and fewer nurses abandoning unavailable for patient care. Funds and professional satisfaction, and the health care field. Thus far, this must be used in creative ways to provides a sustainable resource program has seen 128 nursing stu- provide needed infrastructure with- for the public and the health care dents receive BSN degrees, and 32 out “stealing from Peter to pay Paul.” community. It works to expand MAs receive LPN licenses. By devoting over $500,000 to and enhance nurse recruitment Currently, the number of gradu- build and expand nursing simula- and retention efforts, expand the ates from the accelerated nursing tion laboratories, the PCP Program capacity of the academic nursing program has stayed consistent at accomplished this end. Nurses can education system, strengthen the

62 The Permanente Journal/ Spring 2010/ Volume 14 No. 1 Commentary A Physician Prescription for the Nursing Shortage

collaboration between practice set- and communication training, and hospital, I had the bittersweet op- tings and education systems, and a CPMG board-certified physician portunity to see the art of healing consistently monitors, reports, and “coach” who consulted one-on- that my nursing colleagues bring to evaluates the status of the nursing one with physicians who struggled their patients and to their profession. workforce. Working in partnership with staff interactions. In addition, Now, each summer, my family gath- with the Center, CPMG established CPMG adopted a “zero-tolerance” ers in the auditorium of that hospital a clinical nurse scholar program policy—backed by a robust per- to celebrate the lives of my parents, that aims to increase the number formance management system that and to award a scholarship to a nurse of qualified nurse educators in included an annual review, with in the oncology unit. I share this per- the Region. CPMG continues to feedback provided by nursing sonal story to illustrate a much larger provide in-kind support annually. colleagues. The combination of point. Let’s not wait until we watch To date, these efforts have intro- agreement on a set of principles a loved one suffer to value our nurs- duced hundreds of new nurses into and a rigorous management system ing colleagues for their exceptional the profession and touched thou- to support those principles helped skills in carrying us through these sands more who receive state-of- CPMG achieve its goals—nursing painful experiences. Let’s recognize the-art training and education made satisfaction increased, and nursing the leadership, education, and power possible by physician partnerships. turnover declined. At the same we represent as physicians and not time, overall physician satisfaction remain silent on the subject of the Behavioral Issues improved, and patient satisfaction nursing shortage. CPMG’s initial Although financial support and scores reached all-time highs. physician prescription for the nursing community partnerships are critical CPMG is continuing to support shortage suggests there are three key to expanding the supply of quali- the formation and use of multidis- ingredients—financial investments, fied nurses and the capacity of the ciplinary clinical teams. Chronic community partnerships, and a focus nursing educational infrastructure, care nursing coordinators, clinical on physician behavior—that may another key component of the PCP pharmacists, and physicians work offer a lasting cure. Let’s opt in, fix Program was to drive a cultural side-by-side to help chronically ill ourselves, fix our systems, and extend change in the work environment patients in a variety of disease man- a hand of support to our partners in for nurses in order to enhance the agement programs. Having these the nursing profession. Our patients’ likelihood that nurses would remain teams embedded in clinics is critical lives depend on it. v satisfied in their work environ- to improving overall quality, nur- ments over time. The PCP Program turing respect, creating a positive References 1. Cochran JH, Fahy PK, Bansek JC, Smith commenced with evidence-based work environment, and building L. Physician as healer, leader, and education for physicians on the collaboration among professionals. partner: Tackling the nursing shortage. impact of their behavior on their Perm J 2004 Winter;8(1):89-92. nursing partners. This work also Our Personal Stake 2. Nursing faculty shortage [mono- included the funding of new po- in this Issue graph on the Internet]. Washington sitions, including a manager for Like many persons of a certain age, DC: American Association of Col- leges of Nursing; 2008 [cited 2008 the physician-supported nursing I became a caregiver—not just to my Oct 1]. Available from: www.aacn. program, a director of program de- patients—but also to my parents. As nche.edu/Media/factsheets/Facul- velopment who oversaw orientation I sat at their bedsides in a Denver tyShortage.htm.

Inferior to None The trained nurse has become one of the great blessings of humanity, taking a place beside the physician and the priest, and not inferior to either in her mission. — Nurse and Patient, William Osler, MD,1849-1919, physician, professor of medicine, and author

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