The Affordable Care Act, Nurse Supply, and Faculty Retention:

Predictors of Intent-to-Leave Academic Nursing

Linda Flynn, PhD, RN, FAANAssociate Dean & Professor

University of Colorado College of Nursing

Greetings from the College of Nursing!

http://www.ucdenver.edu/academics/colleges/nursing/

Study Funded by …..

a research grant from the Robert Wood Johnson Foundation #66936 to………………….

Michael Yedidia, PhDRutgers Center for State Health Policy

Principal InvestigatorProject Director, Evaluating Innovations in Nursing Education

Increase of 16-34 million people insured (34 million by 2016) (Congressional Budget Office, 2012)

By 2019 increase of 15-25 million primary care visits per year (Hofer, Abraham, & Moscovice, 2011)

Shortage of approximately 12,000 – 41,000 primary care physicians by 2025 (AAMC)

Impact of Affordable Care Act

According to HRSA 2012….NO.

HRSA estimates that supply of NP will increase 30% by 2020 and PA supply will increase by 58% by 2020.

The increase in NP and PA supply will reduce PCP shortage from 20,000 PCPs to 6,000 PCPs.

Is there a Nurse Practitioner Shortage?

In Colorado…..

◦State graduates 125 new NPs per year◦A total of 140 NPs retire each year….(CCNE).

◦Supply not keeping up with demand from retirement NOT counting population growth nor impact of ACA.

Is HRSA Being a Bit Optimistic?

◦Only 18% of NPs practice in rural areas (American Academy of Nurse Practitioners)

◦Yet, 20-25% of residents live in rural areas

◦An additional 4,000 primary care providers needed in rural areas (National Conference of State Legislators).

Are Rural Areas Adequately Served?

BLS estimates RN demand up 26% (1 million RN increase) by 2020.

1/3 of increase in RN demand will come from ACA (333,333 RNs).

RNs needed in home health care will increase 55% between 2010-2020.

RNs needed for Primary Care Practices / Medical Homes = more training / education.

Impact of ACA on RN Demand(Spetz, 2014)

Increase in NP demand expected, especially for rural areas.

Demand for RNs will increase, particularly in outpatient settings and home health care.

RNs increasingly need skills as care coordinators, case managers, patient educators, and chronic care specialists.

Increased pressure on educational pipeline.

Summary: ACA Impact on Nurse Demand

….Unfortunately the goal to increase educational capacity is hampered by faculty shortages….

Total of 78,089 qualified applicants turned away in 2013.

Total of 1,358 existing faculty positions unfilled in 2013; an additional 98 new positions needed.

Faculty vacancy rates of over 8% nationwide.

Wave of faculty retirements expected.

Nurse Faculty Shortages (AACN, 2014)

Inadequate doctoral-prepared pool and pipeline.

Non-competitive salaries.

Aging faculty workforce.

Attrition of existing faculty for other than retirement (Fang & Bednash, 2014).

Contributors to Faculty Shortages (AACN, 2014).

But….does the faculty work environment contribute to faculty shortages?

Practice Environment• Resource Adequacy

• RN/MD Relationships• Foundations for Quality

• Input Into Affairs• Supportive Manager

Nurse Outcomes

Patient Outcomes

Processes of Care

The Nursing Organization & Outcomes Model

NurseStaffing

Surveillance

Facility Characteristics

(Aiken, et al., 1998; 2001)

Nurse Burnout◦ Aiken, Clarke, Sloane (2002); Aiken et al. (2008); Lang et al. (2012);

Flynn, Thomas-Hawkins, Clarke, 2009 Van Bogaert et al. (2010).

Job Satisfaction / Intent-to-Leave / Attrition ◦ Choi, Flynn, Aiken (2011); Flynn (2007); Flynn, Thomas-Hawkins, Clarke

(2009); Van Bogaert, et al. (2010).

Poor Patient Outcomes◦ Kutney-Lee, et al. (2009); Flynn, et al., (2012); Flynn, Liang, Dickson, &

Aiken, 2010; Jarrin, Flynn, Lake, Aiken (2014).

In Practice Settings……Work Environment Associated With

What are the modifiable aspects of work-life that are associated with burnout and intent-to-leave among nurse faculty?

Research Question:

Stratified random sample of full-time faculty.

Sample proportionately representative of all US programs by prelicensure offered (BS, AD); urban/rural; research intensity.

Total of 3,975 faculty invited to participate in survey; 78.5% response rate!

Final Sample = 3,120 faculty from 269 schools of nursing.

Methods: Sample

Characteristic Mean (SD) Percent

Age 51.4 (9.38)

Within 5 years of retirement

15.8%

Female 95%

White 88%

Education

Master’s 70.6%

Doctorate 19.7%

Research Institution 25%

Rank

Professor 16.7%

Associate Professor

19.4%

Assistant Professor 30.8%

Instructor 28.8%

Sample: Individual Characteristics

76% taught in Pre-Licensure Program 24% taught in Graduate Programs

46.2% taught in schools offering ADN 53.8% taught in schools offering BSN or > 21.4% taught in schools in rural areas

28.6% were tenured 20.8% on tenure track 24.4% NOT on tenure track 26.2% school does not offer tenure

Sample: Program Characteristics

Burnout (Emotional Exhaustion)◦ Maslach Burnout Inventory EE Subscale

Intent-to-Leave Academic Nursing◦ How likely to leave in next 5 years (4-point scale)

Demographics◦ Age, gender, race/ethnicity, highest degree◦ Health Status

Methods: Measures / Survey Items

Institutional Characteristics◦ Degree Programs Offered◦ Research Intensity◦ Urban/Rural Locale

Job Characteristics◦ Years in current institution◦ Rank◦ Tenure Status / Tenure Track/ Non-Tenure Track /

Tenure Opportunity◦ Teaching post-BSN students

Methods: More Measures / Items

Administrative Responsibilities

Salary Range

Certified APRN

Measures: Other Job Characteristics

Hours spent per week on….

◦ Didactic Teaching / Prep◦ Clinical Teaching / Prep◦ Committees / Meetings◦ Advising / Mentoring Students◦ All Work Activities

◦ Developed 1 Course / 1 Major Course Revision ◦ Developed 2 Courses/ 2 Major Course Revisions◦ Converted 1 or more courses to online format◦ Published 1 or more articles in p-r journal ◦ Prepared 1 or more grant proposals

Measures: Workload

Measures: Satisfaction with Work-Life Conditions of Work

◦ Workload◦ Salary◦ Benefits◦ Job Security◦ Resource Availability

Content of Work◦ Flexibility to balance

work/family◦ Autonomy/Independence◦ Relationship with Adm◦ Relationships with

Students◦ Relationships with

Colleagues◦ Meaningfulness of Work◦ Rewards for Innovations◦ Visibility in Job

Mean hours worked = 48.3 hrs / week.

34.2% Major revision of 2 or more courses

19.8% Published 1 or more p-r articles

28.3% Submitted 1 or more grants

67.7% >61 plan to retire in 5 years

85% Very – Somewhat Satisfied with their

work

Findings: The Good News…Sort Of

39% High Levels of Burnout! Higher than staff nurses in hospitals and

nursing homes!

20% Younger faculty intended to leave Academic Nursing within 5 years

31% 51-60 yrs old intended to leave Academic Nursing within 5 years

Findings: The Not So Good News

Faculty who were APRNs were 1.5X more likely to intend to leave!

OR = 1.56, (1.25, 1.95), p <.001.

Predictor OR CI p

Within 5 years of retirement age 6.41 (4.77,8.62)

<.001

Highest Degree BSN 2.70 (1.58,4.62)

<.001

Highest Degree Master’s 1.91 (1.42,2.56)

<.001

On Tenure Track but not Tenured 1.50 (1.08,2.08)

<.05

Not on Tenure Track 1.49 (1.02,2.16)

<.05

High Burnout (EE) 1.27 (1.00,1.61)

<.05

Dissatisfied with Workload 1.26 (1.08,1.47)

<.01

Dissatisfaction w/Teaching Support 1.19 (1.01,1.40)

<.05

Dissatisfaction with Salary 1.18 (1.02,1.35)

<.05

Dissatisfaction with Reward for Innovation

1.16 (1.04,1.29)

<.01

Other Predictors of Intent-to-Leave

Predictor OR CI p

Dissatisfaction with Workload 1.82 (1.55,2.13) <.001

>50% Administrative Role 1.73 (1.32,2.27) <.01

Dissatisfaction with Flexibility to Balance Work and Family Life

1.58 (1.37,1.82) <.001

Poor Health 1.46 (1.28,1.67) <.001

Dissatisfaction with Meaningfulness of Work

1.36 (1.14,1.63) <.01

Dissatisfaction with Direction of Department / School

1.27 (1.09,1.48) <.01

Hours Worked per Week* 1.02 (1.10,1.03) <.001

Race / Ethnicity Non-White 0.68 (0.49,0.93) <.05

*Increase from 40 hrs – 50 hours of work per week associated with 22% higher odds of burnout.

Predictors of Burnout

Constellation of Work-Life factors equal to retirement age in predicting intent-to-leave academic nursing!

◦ Burnout Workload / Hours per week worked Lack of flexibility to balance work / family life

◦ Dissatisfaction with Workload◦ Dissatisfaction with Salary / Reward for Innovation◦ Dissatisfaction with Teaching Support

Discussion

Monitor faculty workload / perceptions

Implement strategies to increase flexibility of schedules

Implement strategies to increase teaching support

Recommendations

Explore needs of APRN faculty

Explore needs of Non-Tenure Track Faculty

Explore needs of Academic Leaders

More Recommendations

Planning grant funded by RWJF

Schools invited to join as Members

Annual Faculty / Student Survey (electronic) for Member Schools / Outcome Driven

Large Database of De-identified Data / Schools own their data

Benchmarking Capabilities

www. NNERN.org (Under Construction)

National Nursing Education Research Network(NNERN)

Questions / Comments / Dialogue

linda.flynn@ucdenver.edu