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Tuesday, July 29, 2014

Health Workforce Research - The Priority for the Next 25 Years

Greetings from Coimbra, Portugal where I am attending the World Health Organization's (WHO) meeting of the Nursing and Midwifery Collaborating Centers. The purpose of the WHO-CC for Nursing and Midwifery is to his network works toward the maximization of the contribution of nursing and midwifery in order to advance Health for All in partnership with WHO and its Member States, member centres, NGOs, and others interested in promoting the health of populations. The network carries out advocacy and evidence based policy activities within the framework of WHA resolutions and the WHO programme of Work. An impressive amount of work, research, and capacity building is completed by the Nursing & Midwifery centers.

What's clear from this meeting is that the future of research in healthcare lies predominantly on the health workforce. We can develop lots of interventions, but if there are no health workers to implement them they will not matter nor be as effective as the randomized controlled trial proclaims them to be. If health care workers cannot get the supplies and medicines they need, they cannot be as effective in their roles and patient outcomes suffer. If management is poor, workers will leave their workplace or the professions all together.

WHO has made the healthcare workforce an essential part of achieving universal health care. In nursing, we have a major shortage of health services and workforce researchers. This kind of research looks at a variety of topics and is not all quantitative.  These can include but are not limited to:

  • Studying career trajectories and dynamics of healthcare professionals
  • Examining the link between the numbers and types (e.g. educational levels of staff) of healthcare professionals and patient outcomes (pick a disease or condition) in hospitals, primary care, home care, and long term care.
  • Developing organizational interventions to improve the quality of care provided and studying the impact on patient outcomes
  • Health workforce planning (national, regional, local)
  • Health labor market dynamics
  • Policy analyses of workforce policies
  • The impact of regulation, credentialing, and liscensure on the health workforce 

Health workforce research does require a PhD but there are a number of places around the world where you can study. If thinking about applying for a PhD to study health workforce, look for faculty members on the school's website that have a strong track record of scholarship in health services and workforce research. If we do not have more researchers in this field, the evidence-base and voices of nursing will not be able to effectively contribute to health policy that will help countries achieve universal health care.

Saturday, March 8, 2014

Turnover in Nursing Staff at the Unit Level: The Single Best Indicator of Manager Performance?

Recently I had lunch with a former student who was passing through town. Lisa graduated a little over two years ago and was one of the lucky ones who found a job fairly quickly.

What was most interesting about our conversation was the turnover rate on her unit. In 15 months, 15 nurses have left. The most recent was a group of five experienced night shift nurses, the kind any manager is loathe to lose. They left, according to the student, because they were tired of how they were treated.  Lisa is now the most experienced person on night shift at two years out of school. The loss of 15 nurses on one unit has also cost the organization nearly a million dollars. In an era of cost tightening, that is a steep price.

Acknowledging that this is only a report from one person, there is still something that rings true in her story: Well managed patient care units do not have high turnover rates of staff. So let's think about what constitutes turnover in nursing staff and it's causes.

Gilmartin provides an excellent review of the literature on nurse turnover in a 2012 study published in Medical Care Research and Review. If we consider turnover as a measure of manager performance, however, it needs categorization. Positive turnover might be staff who leave because they completed a higher degree and are moving into a new job that reflects their new level of education. It could also be termination of poor performing personnel who are likely toxic for unit culture and whose firing would likely improve retention overall. Internal transfers are a gray area because they could reflect poor management and a nurse "voting with her feet" to get away from it. Negative turnover, of course, is a situation like what Lisa described with the night staff.
Research by Kovner and Brewer on new graduate nurses adds another later of complexity to the performance equation because early career nurses may be more likely to leave due to life changes like marriage and child bearing. Rural locations may have high retention rates because there are fewer job options, but a proxy measure there could be staff burnout levels. Unhappy nurses make for unhappy patients as recent research out of the University of Pennsylvania shows.

If we move beyond borders to low and middle income countries, turnover grows still more complex. Poorly managed systems, for example, where staff do not get paid on time or as much as promised certainly drive people away and frontline managers do not always have control over those circumstances.

The take away message here is that turnover is complex, but it may be time to quantify it as a measure of manager performance. Turnover costs organizations too much to ignore any more. A million dollars in single unit turnover costs could be spent in much better ways.

Tuesday, January 14, 2014

Research Rankings - US Nursing Schools

The 2013 results are in!  Which US universities with research intensive nursing programs made the top ten in US National Institutes for Health Funding?  Here's the list:

1. UNIVERSITY OF CALIFORNIA SAN FRANCISCO
2. UNIVERSITY OF ILLINOIS
3. UNIVERSITY OF WASHINGTON
4. JOHNS HOPKINS UNIVERSITY
5. UNIVERSITY OF PITTSBURGH AT PITTSBURGH
6. NEW YORK UNIVERSITY
7. UNIVERSITY OF CALIFORNIA LOS ANGELES
8. UNIVERSITY OF PENNSYLVANIA
9. UNIVERSITY OF MARYLAND BALTIMORE
10. EMORY UNIVERSITY

So what does this mean? If you are a newly minted PhD or Post-Doc and you want to get your research career off the ground, applying for a job at one of those institutions will give you a good shot at developing your career.

If you are looking for a PhD program or a Post-Doctoral Fellowship, one of those schools would probably be the best place to look for opportunities and mentoring.  Nursing schools in universities that can consistently obtain funding mean that they have good research infrastructure overall to support a budding research career.

And yes, you better believe I'm proud as heck to be affiliated with the #6 ranked NYU College of Nursing!