VOLUME 100, NUMBER 5 OCTOBER 2012

Public Policy Forum 633 West Wisconsin Avenue, Suite 406 Milwaukee, Wisconsin 53203 414.276.8240 www.publicpolicyforum.org

Research funded by: The Faye McBeath Foundation Partners Investing in Nursing’s Future: The Robert Woods Johnson Foundation & Northwest Health Foundation

Aurora Healthcare Foundation Greater Milwaukee Foundation Rogers Memorial Hospital United Way of Greater Milwaukee

Research by: Anneliese Dickman, Research Director Rob Henken, President Survey support by: Kathie Eilers, Nursing’s Voice Project Manager Sue Schuler, Wisconsin Center for Nursing, Nursing’s Voice Project Consultant

Mental Health Nurses and their Employers See Enhanced Role for Nursing in Milwaukee County’s Mental Health System

The Forum surveyed 120 mental health nurses and 34 employers this year as part of the Nursing’s Voice project, intended to better understand the capacity and capabilities of the local mental health nurse workforce and gather the insights of nurses to inform mental health redesign planning in Milwaukee County. The findings highlight the potential for an enhanced role for nurses in the county’s mental health care delivery system. In addition, Nursing’s Voice survey data will help public and private sector employers gauge the challenges associated with securing an appropriately trained nursing workforce for Milwaukee’s outpatient settings, hospitals, and rehabilitation centers.

Mental health nurses in Milwaukee County and their employers agree that among the nursing skills most important for treating patients with mental illness is an understanding of dual or co-occurring disorders, in which mental health issues are accompanied by substance abuse and/or addiction. The importance of understanding treatment options and protocols also is important, but understanding the individual patient’s needs is seen as perhaps more important. Both the nurses and their employers also agree that the nurse workforce in the county requires more training in dual or co-occurring disorder treatments. Nurses see their understanding of patients’ and clients’ needs in this area to be among their greatest strengths, however, while employers see opportunities for greater understanding of those needs (Table 1).

Table 1: Important nursing skills most frequently cited by both nurses and nurse employers

Nurses Nurse employers

Frequency of respondents citing... Among own

greatest strengths

In need of more training

Among most important

skills

Among most commonly

lacking skills

Understands the needs of persons with mental illness, co-occurring disorders, and complex biopsychosocial and spiritual issues

77% 75% 35%

Understands dual disorder treatment/recovery and the impact of substance abuse on a person’s mental health

36% 40% 59%

2

Data and methodology

The survey of nurse employers was conducted in April and May 2012. Agencies holding contracts with the Milwaukee County Behavioral Health Division were phoned to determine whether they provided services of the type a mental health nurse might provide and to establish a contact name. Paper surveys with 16 questions were mailed to 51 health care providers and agencies with facilities in Milwaukee County. Following the initial mailing, at least one reminder was made to each agency, either by phone, mail, or email.

The survey of mental health nurses was conducted on-line in July and August 2012. Emails were sent to contacts at the 21 health care providers previously surveyed that indicated they employ nurses. Each employer was emailed a customized link to a online survey, hosted by Survey Monkey. The customized links allowed us to maintain an anonymous survey while also counting the number of respondent nurses from each employer, to ensure the nurse survey sample was representative of the employer survey sample. Reminder emails were sent up to four times per employer.

Determination of response rates and representativeness is difficult due to a lack of data about the county’s population of mental health nurses. To ensure the employer survey is representative of all mental health nurse employers in Milwaukee County, the distribution of responses was compared to the distribution of mental health nurses working in Milwaukee County, as enumerated in the 2010 nurse census conducted by the Wisconsin Department of Workforce Development in cooperation with the Wisconsin Center for Nursing (WCN). The sample of respondents is fairly representative in this way, lacking participation from only one employer thought to have a significant number of mental health nurses on staff (Table 2).

Because the WCN nurse survey does not enumerate employers, however, we cannot

calculate a response rate in comparison to all nurse employers in the county. As compared to the 51 employers to which surveys were mailed, our 34 responses equal a response rate of 66%.

Table 3 shows the representativeness of the nurse survey sample. The distribution of responses from the nurse survey is compared to the number of nurse employees reported on the

Milwaukee County zip

code

Mental health nurses working

in zip code (DWD census)

Employers in zip code responding

to nurse employer survey

53110 13 53132 * 53172 * 53202 7 1 53203 * 53204 12 1 53205 N/A 1 53206 * 1 53207 * 1 53208 * 2 53209 5 53210 * 2 53211 24 1 53212 * 53213 56 1 53214 16 4 53215 12 1 53216 6 2 53217 * 1 53218 7 2 53219 * 53220 * 53221 * 53222 5 2 53223 9 53224 * 53225 * 53226 151 4 53227 47 1 53228 * 53233 19 4 53234 N/A 1 *Suppressed data, cells having a value of less than 5.

Table 2: Representativeness of nurse employer sample

3

employer survey, as well as the nurses enumerated in the WCN census. As compared to the WCN data, our 120 mental health nurse respondents represent a 25% response rate.

Both the nurse employer survey and the nurse survey were field tested prior to launch. The nurse employer survey was tested by six

employers of mental health nurses in Milwaukee and Waukesha Counties. The nurse survey was tested by 11 mental health nurses working in the greater Milwaukee metro area.

In addition, during the survey instrument drafting stage, input was sought from academic experts in the field of psychiatric nursing, mental health nurses and other practitioners, as well as current and former county administrators. The list of nursing skills and competencies we tested was developed based on competencies identified by nurse accreditation bodies, research studies, Milwaukee County redesign plans, and interviews with local nursing experts and academics.

The Nursing’s Voice Project

Nursing’s Voice is a collaborative partnership designed to enhance the role of nurses in Milwaukee County's adult mental health delivery system. Nursing's Voice reflects the strong role that needs to be assumed by mental health nurses in both the design and implementation of the system. It will provide research and ideas to help support the mental health system redesign currently underway in Milwaukee County.

Key project activities include extensive data collection to establish the current and future need for mental health nurses and acquire nurses' own insights on their utilization in a redesigned system; development of strategies to educate nursing students about the rewards of a career in mental health service, and to prepare both students and current mental health nurses with the knowledge and skills needed to be successful in the field; and activities to amplify the voice of nurses to ensure that their skill sets are optimized in the new delivery system.

The Nursing’s Voice project is led by the Faye McBeath Foundation of Milwaukee and Partners Investing in Nursing’s Future, a national funding cooperative. Other local funders include Aurora Healthcare Foundation, Greater Milwaukee Foundation, Rogers Memorial Hospital, and United Way of Greater Milwaukee.

Milwaukee County zip

code

Mental health nurses (DWD)

Mental health nurses

(employer survey)

Nurses responding

to nurse survey

53110 13

53132 *

53172 *

53202 7 53203 *

53204 12

53206 * 3 1

53207 * 2

53208 * 1 4

53209 5

53210 * 1

53211 24 11

53212 *

53213 56 67 16 53214 16 14 4

53215 12 6 3

53216 6 2

53217 *

53218 7 24 2 53219 *

53220 *

53221 *

53222 5 6 53223 9

53224 *

53225 *

53226 151 88 59

53227 47 45 13 53228 *

53233 19 34 7 *Suppressed data, cells having a value of less than 5.

Table 3: Representativeness of nurse sample

4

Key findings and implications

Taken together, results from both surveys have significant implications for local health care employers and county administrators planning the redesign of Milwaukee’s mental health system.

There is a need for nurses with an interest in mental health now and in the future.

Implication: Incentives for increasing the mental health workforce might be necessary. In addition, the mental health system redesign process should anticipate the need for more nurses.

In general, employers are satisfied with the mental health nurse applicant pool, including recent graduates. However, very few nurses are nationally certified or advanced practice nurses.

Implication: Schools of nursing are providing nurses with a basic foundation in mental health issues. Deeper knowledge among nurses is lacking; explanations for this gap should be explored.

There is a role envisioned for more nurses in mental health outpatient/community settings, although it is unclear exactly what their roles should be. Currently, most nurses work with adults in inpatient settings.

Implication: As the mental health system is redesigned, planners should explicitly consider the optimal roles of nurses in community health settings.

Mental health nurses’ job satisfaction comes from work with patients; dissatisfaction comes from pay.

Implication: If nurses’ responsibilities under a redesigned system are more administrative or policy-oriented, the reduction in patient contact may not be desirable, particularly if wages do not change.

Employers and nurses have more

disagreement than agreement about the most important skills and competencies for patients’ recovery.

Implication: This suggests either a lack of clear communication between employers and nurses or differing expectations as to the job objectives. More clarity is needed if the role of nurses is to change under a redesigned system.

Employers and nurses have more agreement about the specific skills that need strengthening.

Implication: These areas should garner the most attention and resources for professional development.

Understanding dual/co-occurring disorder treatment and the needs of patients with dual disorders were seen both as important and in need of strengthening.

Implication: As the county shifts its focus to dual/co-occurring disorder treatment, the need for improved training for nurses will be imperative.

Over the next two years, the Nursing’s Voice project intends to grapple with several of these implications, including those for training and professional development, the size of the workforce, interest among nursing students, and clarity regarding job expectations.

5

Table 4: Mental health nurses in Milwaukee County in 2011 and position openings in 2012

Full-

time

Part-

time

Head-

count

FTEs Full-

time

Part-

time

Direct care, inpatient 125 5 150 4 15 22 51 7.1 16 17

Direct care, outpatient 54 35 34 5 6 1 14 10.5 5 2

Indirect care 10 6 0 0 0 0 3 3 2 0

Total 189 46 184 9 21 23 68 20.6 23 19

Separations*

between

1/1/11 and

12/31/11

New

positions in

2012

2- or 4-

year

degree

Advanced

degree in

nursing or

other field

2- or 4-

year

degree

Advanced

degree in

nursing or

other field

Full-time RNs on

12/31/11

Part-time RNs on

12/31/11

Vacant

positions

being

actively

recruited on

12/31/11

Supply and demand for mental health nurses in Milwaukee County

Twenty agencies report employing a total of 428 full- and part-time mental health nurses in Milwaukee County (Table 4). As shown in the table, most of these nurses (66%) are in inpatient settings working directly with patients. Roughly a third of nurses (30%) work with patients in outpatient settings. Just 16 mental health nurses hold administrative or other positions in which they do not work directly with patients.

Table 4 also shows that few nurses (13%) hold advanced degrees in nursing or another field. Nurses with these advanced degrees are much more likely to work in outpatient settings than inpatient and are also more like to work full-time. Among nurses with either 2– or 4-year degrees, half work full-time and half work part-time.

Turnover among these employers is relatively low, with just 20.6 full-time equivalent positions having turnover during 2011, which is a turnover rate of less than 10%. These full-time equivalent positions represent 68 individual nurses, or 16% of all mental health nurses employed last December, however. The recession has been the driving force behind the low 2011 turnover rates, according to 53% of employers.

The low turnover rate may also be due to high levels of commitment among nurses to their patients and clients; 43% of the nurses surveyed anticipate continuing to work as a mental health nurse for at least 10 more years (Chart 1 on next page).

Despite the low turnover rate, 44 full– or part-time positions were open at the end of last year. Coupled with the 42 new positions anticipated in 2012, these openings indicate a needed mental health workforce growth rate of 20%.

In addition, because the average age of respondents is 50 years (median is 52 years), retirements can be expected to create openings over the long run.

The need for growth in the workforce is also apparent from employers’ experiences in trying to fill open or new positions. Even though most employers (53%) feel the recession has resulted in more applicants per vacancy, more (65%) say staff nurse positions are difficult positions to recruit and about half (47%) feel similarly about advanced practice nurses. Third shift is reported to have the most problems in recruitment and turnover, by 64% of respondents. Many employers (63%) find too few nurses have an interest in mental health positions, which may explain these difficulties.

6

While employers report some difficulties filling positions, in general they feel the applicant pool is well-qualified. Just 16% of nurse employers feel the applicant pool is low-quality. More, 37%, feel the applicant pool is not well-prepared for mental health nursing, yet more than two-thirds (68%) hire recent nursing program graduates.

Employers reported higher quality within the applicant pool during the recent recession, both in general and among psychiatric/mental health nurses in particular (Chart 2).

Demand for nurses also may be shaped by perception. For example, health care agencies not currently employing mental health nurses are more likely to perceive the cost of nurse wages as a barrier to greater utilization of nurses in mental health care than agencies that do employ nurses. In addition, they are significantly less likely to perceive a lack of interest in mental health among nurses as a barrier. Chart 3 illustrates the gap between the perceptions of employers without nurses and those with nurses.

Finally, when asked whether a redesign of the mental health care system should anticipate a larger or smaller role for mental health nurses, the majority of both types of employers see a need for nurses to play a larger role in outpatient mental health care. About half also see a need for nurses to play a larger role in inpatient care under a new system (Chart 4).

18%

21%

18%

43%

0% 10% 20% 30% 40% 50%

Less than 2 years

2 to 4 years

5 to 9 years

10 or more years

Chart 1: How much longer do you plan to work in mental health nursing?

53%

24%

18%

53%

6%

0% 20% 40% 60%

Fewer vacancies/less recruiting needed

Higher quality applicant pool generally

Higher quality psych applicant pool

Larger applicant pool

Other

Chart 2: What has been the impact of the recession on psychiatric/mental health nurse recruitment?

0% 10% 20% 30% 40% 50% 60% 70% 80%

Too costly to employ RNs

Applicant pool is low quality

Applicant pool is inadequately prepared

No added benefit to patient care

Too few RNs with interest

Other

No nurses Employing nurses

Chart 3: Are any of the following barriers to greater utilization of nurses in psychiatric/mental health care?

7

Taken as a whole, these findings have implications for the county as it plans for a system redesign. A new system with greater reliance on outpatient care providers may require even more mental health nurses than providers anticipate having a need for today. Coupled with low turnover and a perceived lack of interest in mental health nursing among nurses, this may require incentives to increase the mental health nursing workforce. At a minimum, county planners may wish to further investigate the need for more mental health nurses and the anticipated growth in the workforce. Nursings’ Voice will work over the next two years to increase awareness of and interest in mental health care among nursing students in Milwaukee.

Workforce snapshot

Surveying nurses in the mental health field provides a snapshot of their background, qualifications, and other descriptive attributes. Chart 5 shows that among our sample of 120 nurses, slightly more entered the field with Associate degrees (43%) than with Bachelors degrees (40%). As illustrated in Chart 6, however, a large majority of nurse respondents have at least a Bachelors degree at this point in their career.

Very few nurses in the sample are advanced practice nurses (6%) or have national board certification in psychiatric nursing (10%) or any

70%

50%

79%

42%

0% 20% 40% 60% 80% 100%

outpatient care

inpatient care

employing nurses no nurses

Chart 4: If the mental health care system in Milwaukee County were to be redesigned, what size role would you prefer nurses to play in the delivery of [each type of] care? Percent answering “larger”

Diploma in nursing,

13%

Associate degree in nursing,

43%

Bachelors degree in nursing,

40%

Masters degree in nursing,

5%

Associate degree or

below

32%

Bachelors degree

49%

Masters degree or

higher

19%

Associate degree or

below

38%

Bachelors degree

46%

Masters degree or

higher

16%

Chart 5: Degree held at time of entry into field of nursing

Chart 6: Highest degree earned: Nursing-related Non-nursing

8

other specialty (10%). The average experience in mental health nursing is 14.1 years and the average age is 50 years. Nearly all of our respondents are female (87%) and white (81%). The next most represented racial group is African-American (12%).

With respect to positions held in their organizations, most are staff nurses (64%), working in inpatient settings (60%) with adults (84%). The average work week among the sample is 38.5 hours. Chart 7 shows the various positions held by survey respondents.

Table 5 shows that the nurse survey sample is quite representative of the nurses employed by the agencies in the employer sample.

The relatively small proportion of mental health nurses having advanced degrees or national certification, as well as the small number of advanced practice nurses, may indicate a lack of deeper knowledge of mental health care advancements or promising practices. The fact that the nurses in the survey have an average of 14 years experience in the field indicates a level of expertise that may not be reflected in academic

Employer survey

Nurse survey

Inpatient 66% 60%

Outpatient 30% 26%

Masters degree or above 13% 16%

Full-time 55% 70%

Table 5: Nurse survey representativeness

1%

16%

3%

3%

6%

64%

8%

0% 20% 40% 60% 80% 100%

Administrator

Nurse manager

Staff education

Quality improvement

Advanced practice nurse

Staff nurse

Case manager

Chart 7: Job title in primary position

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

psychotherapy

medication management

inpatient

community support

crisis services

counseling

case management

protective payee

supportive housing

other

nurses employers without nurses employers of nurses

Chart 8: Services provided by mental health nurses, nurse employers, and mental health care providers without nurses

9

credentials, however. Employers may wish to investigate why experienced nurses are not seeking national certification or other opportunities to demonstrate advanced expertise. One explanation may be few academic programs in the Milwaukee area focused on mental health nursing.

Finally, the fact that most mental health nurses in Milwaukee are staff nurses in inpatient settings calls into question whether or not their skills are transferable to outpatient settings and/or community-based organizations, should most delivery of mental health care in the county move to those settings. Chart 8 shows there is a distinct difference between the services provided by mental health care providers employing nurses

and those without nurses, as well as between the services the nurses report they help to provide. Crisis services tend to be provided by nurses, for example, while supportive housing does not.

Nurse competencies and job satisfaction

As noted previously, most mental health nurse employers feel the workforce is adequately prepared for mental health nursing positions and the applicant pool is qualified. Most employers also say they hire recent nursing school graduates.

When asked about specific mental health nursing competencies, employers tended to vary in opinion, however. For example, when asked to identify the skills most commonly lacking among

Of the specialized skills and competencies listed in the box to the right, please rank below the five most important for a psychiatric/mental health nurse in your facility: (percent of all responses)

Understands the needs of persons with mental illness, co-occurring disorders, and complex biopsychosocial and spiritual issues 15%

Applies physical assessment skills with persons (adults and elderly) with mental illness including the identification of medical issues and provision of needed nursing interventions 8%

Utilizes assessment data to identify and prioritize problems and validates with client and family 8%

Demonstrates proficiency in evidenced-based nursing practice, as applied to medication teaching and symptom management strategies, to promote recovery and community reintegration 8%

Understands dual disorder treatment/recovery and the impact of substance abuse on a person’s mental health 8%

Of the specialized skills and competencies listed in the box to the right, please rank the five that are most commonly lacking among your new psychiatric/mental health nursing hires: (percent of all responses)

Understands dual disorder treatment/recovery and the impact of substance abuse on a person’s mental health 12%

Demonstrates effective managerial, supervisory, and leadership skills in psychiatric/mental health practice 11%

Applies principles of trauma-specific care 10%

Demonstrates cultural competence for the identification and response to race, culture, ethnicity, and language 7%

Utilizes motivational interviewing and client engagement strategies 7%

Understands the needs of persons with mental illness, co-occurring disorders, and complex biopsychosocial and spiritual issues 7%

Understands the needs of persons with a mental illness to be successful in their community, evidenced by knowledge of community resources/contacts and supports essential for seamless transitions between services and providers 7%

Table 6: Employers’ views of important and lacking nurse competencies

10

their mental health nursing staff, three skills were mentioned most frequently (at least 10% of the time), but four other skills each garnered significant responses, as well (Table 6).

There was even less consensus among employers when asked to name the most important skills for mental health nurses, with only one skill mentioned more than 10% of the time and opinions otherwise split among four other skills.

For the most part, the skills deemed lacking were not the most important skills, although understanding dual disorder treatment/recovery and the impact of substance abuse on a person’s mental health was a skill thought to be both important and in need.

Nurses also were asked about important skills and competencies. They, too, lacked consensus as to importance of specific skills and the need for greater proficiency in specific areas (Table 7). In addition, none of the skills nurses deemed most important for their patients’ recovery also was deemed most in need of more training.

Interestingly, when nurses were asked about

their own greatest strengths and their own skills in need of more training, greater consensus emerged. A large majority (79%) of nurses said their greatest strengths included being able to conduct a “psychosocial assessment of the client to identify and prioritize problems and validate the concerns with the client and family.”

When asked to identify the skill they were most in need of strengthening through additional training, 36% said, “Knowledge of community resources, contacts, and supports for seamless transitions between services and providers.”

To the extent nurses and employers agree on the skills and competencies most commonly lacking among the mental health nurse workforce, county planners might wish to investigate whether those skills and competencies are among those which would be most in demand under a community-based mental health delivery system. If so, they may wish to work with nurse educators

Of the skills listed, which three do you feel are the most important in the recovery of your patients? (percent of all responses)

Psychosocial assessment of the client to identify and prioritize problems and validate the concerns with the client and family. 14%

Person-centered care planning to create meaningful life options, informed choices, and to promote stigma reduction. 13%

Understanding the needs of persons with mental illness, co-occurring disorders, and complex biopsychosocial and spiritual issues. 13%

Crisis management, including relationship development and medication management 11%

Of the skills listed, which three do you feel are the most important for you to receive more training? (percent of all responses)

Knowledge of community resources, contacts, and supports for seamless transitions between services and providers. 13%

Proficiency in evidence-based nursing practice, as applied to medication teaching and symptom management strategies, to promote recovery and community reintegration 11%

Proficiency in dual disorder treatment/recovery and the impact of substance abuse on a person's mental health. 10%

Table 7: Nurses’ views of important and lacking competencies

Note: All skills and competencies included as part of the surveys can be found on the final page of this Research Brief.

11

to improve training opportunities and access.

Because so many nurses expect to stay in the field for at least 10 more years, understanding the satisfactory aspects of their current jobs is important, especially if those aspects might change considerably in a redesigned mental health system. Not surprisingly, the skills and competencies nurses see as among their greatest strengths, and most important to their patients, are reflected in the aspect of their job that provides the most satisfaction: interactions with patients (Chart 9). Most nurses also are satisfied with the quality of care they provide and the hours they work.

Sources of dissatisfaction are not related to patient care, but to other aspects of the job, such as pay and the potential for advancement. Overall, however, more nurses report job satisfaction than dissatisfaction.

Taken together, it seems that nurses feel they have developed competencies in areas that are among the most important to their patients, and they get satisfaction from those skills. They do see a need to strengthen their proficiency in other skills areas, but they may be encountering barriers to obtaining that training.

Conclusion

These two surveys provide health care planners and nursing schools with considerable data on the demand for mental health nurses currently and in the near future. More research is likely to be needed once the mental health care system redesign process is further along, so that nurses and their employers can provide perspective on the potential demands of the new system.

Until then, the Nursings’ Voice project will work to help clarify job expectations and core competencies, expand opportunities for training, and encourage nursing students to consider careers in mental health care.

44%

35%

35%

25%

62%

63%

70%

Pay

Employer-supported education options

Potential for advancement

Job security

Hours/shift availability

Quality of care you provide

Interactions with patients

% Dissatisfied % Satisfied

Chart 9: Aspects of mental health nursing leading to greatest job satisfaction and dissatisfaction

12

Specialized skills and competencies needed by psychiatric/mental health nurses

A. Demonstrates cultural competence for the identification and response to race, culture, ethnicity, and language

B. Applies physical assessment skills with persons (adults and elderly) with mental illness including the identification of medical issues and provision of needed nursing interventions

C. Utilizes assessment data to identify and prioritize problems and validates with client and family

D. Integrates family assessment and interventions into client education

E. Applies principles of person-centered care planning to create meaningful life options, informed choices, and to promote stigma reduction

F. Implements consumer-centered/care-driven models including recovery principles guided by evidenced–based practices in hospitals and community settings

G. Implements crisis management including relationship development and medication management

H. Demonstrates proficiency in evidenced-based nursing practice, as applied to medication teaching and symptom management strategies, to promote recovery and community reintegration

I. Applies principles of trauma-specific care

J. Utilizes motivational interviewing and client engagement strategies

K. Understands the needs of persons with mental illness, co-occurring disorders, and complex biopsychosocial and spiritual issues

L. Demonstrates understanding of team development and participation skills and a collaborative approach to care, evidenced by delegation and interdisciplinary fluency

M. Utilizes principles of group process in providing client education and support

N. Understands dual disorder treatment/recovery and the impact of substance abuse on a person’s mental health

O. Understands the needs of persons with a mental illness to be successful in their community, evidenced by knowledge of community resources/contacts and supports essential for seamless transitions between services and providers

P. Demonstrates knowledge of legal and ethical issues relevant to the practice of psychiatric/mental health nursing

Q. Identifies own beliefs about persons with mental illness and creates environments that promote mental health recovery

R. Demonstrates effective managerial, supervisory, and leadership skills in psychiatric/mental health practice

S. Examines the practice environment and quality of nursing care in relation to existing evidence so as to identify opportunities for quality improvement

This list of mental health nursing skills and competencies was developed by Sue Schuler of the Wisconsin Center for Nursing based on competencies identified by nurse accreditation bodies, research studies, Milwaukee County redesign plans, and interviews with local nursing experts and academics.