1. Kennedy, Maureen Shawn MA, RN, FAAN


By the time they graduate, nursing roles and settings may be vastly different.


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I remember my first day of nursing school vividly. I was excited to begin the journey to becoming an RN, and disappointed that my first class-the fundamentals of nursing-was taught in the school's mock hospital unit. We didn't venture onto a real unit until the end of the second semester; but when we did, it was much like what our learning had prepared us for. While a few of my classmates went into community and public health after graduation, the majority became employed in hospitals. I wonder, given the changes that are occurring now in our health care system, what the first workplaces will be like for today's students?

Figure. Maureen Shaw... - Click to enlarge in new window Maureen Shawn Kennedy

We know that the population is aging and will need more care. At the same time, a significant portion of the nursing workforce is poised to retire, taking with them years of experience and expert knowledge and creating a nursing shortage. Working short-staffed may become the norm in some areas-Texas and Missouri, for example, are already reporting shortages. Some forecasters, however, have softened the initial dire predictions. Using data from the Bureau of Labor Statistics, the American Nurses Association estimates that, between 2014 and 2024, "689,200 RNs/APRNs will retire or otherwise leave the labor force[horizontal ellipsis]. [Thus,] 1,182,000 vacancies will emerge for RNs/APRNs. Since the country is producing 150,000 new RNs per year (NCLEX passers), there should be sufficient numbers of new nurses to fill all of those vacancies." However, this depends on continued federal funding for education and adequate numbers of faculty.


We also know that care is moving out of the hospital. Initiatives to control the cost of care, reduce readmissions and lengths of stay, and better manage chronic diseases-along with an increase in alternative settings like freestanding surgical centers and retail clinics and the use of newer technologies like telehealth-have enabled the increased provision of care at home or in ambulatory settings. According to the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project, between 2005 and 2014 inpatient stays for all conditions decreased (with the exception of mental health/substance abuse, which increased by 12%). Roughly 61% of RNs are currently employed in hospitals; and while hospitals will undoubtedly remain a primary workplace for nurses, there will be a significant need (and opportunity) for RNs, not just NPs, to step into roles in primary care settings.


At the National Forum of State Nursing Workforce Centers conference held in June, nursing leaders, along with researchers and economists, gathered to review the current state of the nursing workforce and how best to plan for the future. And while workforce planners may look to predict how many and what kind of health professionals are needed, that's the wrong focus, according to Erin P. Fraher, assistant professor in the University of North Carolina School of Medicine at Chapel Hill, who spoke at the conference. Fraher says the question should be, "What should the workforce look like to best meet patients' needs for health care?" and that we should be "planning for a workforce for health, not a health workforce." As an example, she cited Community Aging in Place-Advancing Better Living for Elders (CAPABLE), a community health model developed at Johns Hopkins University, where the collaborative health care team charged with keeping older adults healthy includes a nurse, an occupational therapist, and a handyman. (For more information, see our upcoming profile on Sarah L. Szanton, the program's director.)


Yet by and large, the majority of student learning experiences are still focused on acute care. A report by the Josiah Macy Jr. Foundation, Registered Nurses: Partners in Transforming Primary Care, notes that "RN education continues to emphasize inpatient hospital nursing and many nursing faculty are unfamiliar with primary care nursing," and calls for "rebalancing nursing education to encourage RNs to become leaders in primary care teams."


Where and how care is delivered, by whom, and importantly, how it is financed, will vastly change the landscape for those entering the workforce in four years. Let's hope they're ready for this brave new world.