Physicians
as Leaders
Physician as Healer, Leader and Partner: Tackling the Nursing Shortage
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By
John H Cochran, Jr, MD; Patricia K Fahy, MD; Jill C Bansek, MBA, MSHA
Contributor: Linda Smith, RN, MSN, MSHA
Abstract
Context:
Physicians have been notably silent on the nursing shortage in spite
of articles that have suggested that physician behavior is one of the
causes of job dissatisfaction among professional nurses. In addition
to the role of healer, the physicians of the Colorado Permanente Medical
Group (CPMG) are expected to have the additional responsibilities of
being both leaders in health care and strong clinical partners with
the nursing staff. CPMG has embarked upon a program to leverage physician
leadership to address the nursing shortage through multiple avenues.
We expect not only to increase the number of nurses in the future, but
also to enhance their careers by being their "Preferred Clinical
Partner."
Objective: To describe a model for engaging physicians in becoming
active participants in solving the nursing shortage through leadership
and partnering.
Results: The Preferred Clinical Partner Program has been developed
to address the nursing shortage in multiple ways. We have significantly
increased the number of scholarships available for nursing students
as well as funding and developing additional educational programs to
meet the needs of nurses entering from various points in their lives
and educational journeys. We have also enhanced programs around physicians
serving as teachers and mentors in the education and long-term development
of health care team members. And finally, we are clarifying leadership
and partnership expectations for physicians and developing very specific
physician-nurse relationship training programs to try to solidify the
long-term sustainability of careers of these important members of our
health care team.
Conclusions: Physician groups that take an active role by "opting-in"
to nursing shortage issues will benefit by having an engaged, professional,
compassionate nurse on their health care team.
Physician Stakes are High
Could
there be a group of professionals with any greater stake in solving
the nursing shortage than physicians?
- Nurses
assure the quality and safety of care delivered to patients through
their scope of practice and technical skills, their culture of empathy
and advocacy, and their participation in the development and execution
of the patient care plan.
- Nurses
extend physician influence and leverage physician time through their
expertise in patient education and their
management of other health care team members.
- Nurses
partner with physicians: anticipating difficulties in patient care,
offering options, working with family members, and optimizing communication
in the care of patients.
Where Have all the Nurses
Gone?
Local
and National Nursing Trends
Increasing
evidence shows that the shortage of nurses has severe implications for
affordability, accessibility, and quality of health care. In 2000, the
US Department of Health and Human Services
(DHHS)1 identified Colorado as one of 30 states with a nursing
shortage. The 2000 supply-versus-demand comparisons by DHHS projected
a shortage of 11% (3656 RNs) for Colorado by 2007 compared with the
national nursing shortage trend at 6%.2 The shortage is expected
to grow slowly until 2010, at which time demand will accelerate and
exceed supply in 2020 by 31% (16,926 RNs) in Colorado.2 DHHS
anticipates a 40% increase in demand for RNs between 2000 and 2020 with
growth of this labor pool at a modest 1.7% annually (Figure 1).2
On a national level, there will be more than one quarter of a million
unfilled nursing positions by 2010.1
Factors driving demand include population growth, a larger proportion
of elderly with more chronic diseases, new approaches to care that leverage
RN talent (eg disease management and group visits), and medical advances
that heighten the need for RNs. Growth in supply is expected to peak
by 2011 and then begin to decline as the number of nurses leaving the
profession exceeds the number who enter.
According
to the Spring 2003 Colorado Department of Labor Job Vacancy Survey,3
there were 951 open registered nursing positions in the Denver area.
Last year, the State of Colorado higher education system turned away
between 500 and 1000 qualified students from nursing programs because
of lack of capacity. Colleges that offer nursing programs have had their
funding cut and cannot afford to add qualified faculty to accommodate
student interest. The even bigger capacity issue and the true bottleneck
in the system is in the provision of clinical sites for nursing students.
Hospitals that are understaffed already have their nursing workforce
precepting large numbers of student nurses. To take on more students
compromises patient care and overburdens nurses further.
Nursing Shortage: CPMG's
Wake-Up Call
The
Colorado Permanente Medical group (CPMG) is a 700 member, multispecialty
physician group that provides care in metropolitan Denver and Boulder
to Kaiser Permanente patients. CPMG physicians work with nurses and
other health care team members in a variety of settings: primary care
clinics, ambulatory surgical centers, partner hospitals, specialty clinics,
and a variety of other clinical and administrative venues.
In 2000,
CPMG began to experience the effects of an acute and, in some situations,
crippling shortage of nurses. Patients were being diverted away from
Kaiser Permanente's (KP) primary partner hospital to other community
hospitals. KP patients and members were unable to receive care by CPMG
because of a shortage of staffed beds in the hospital and in the emergency
department.
Four new
hospitals being built on the periphery of Denver pose an additional
challenge. These more suburban facilities will be vying for nurses who
choose to work in the inpatient setting closer to their homes. There
is a significant concern that these new suburban hospitals will be able
to market themselves more effectively to the shrinking talent pool of
nurses and other health care professionals. This may put KP's older,
urban, partner hospitals at even greater risk of ongoing nursing shortages.
Classified advertisements in Denver newspapers show that some urban
hospitals have resorted to offering an additional per diem of up to
$50 for simply driving to work.
An overall
shortage of health care workers, the addition of new hospital beds without
commensurate increased staffing visible anywhere on the horizon, and
the threat to inner-city hospitals, meant CPMG needed to take action
to insure that Permanente Medicine4 would be available to
our patients in the future.
"Physician Tyrant"--a
Role in the Nursing Shortage?
A
recent VHA study5 found that disruptive physician behavior
and verbal abuse was a strong contributing factor to diminished nurse
satisfaction and morale. When asked whether they had ever observed abusive
behavior by a physician toward a nurse, 96% of nurses said yes. Nearly
30.7% of nurses, physicians, and hospital executives said they knew
of nurses who had left a hospital as a result of being berated, harassed,
or abused by a doctor.5 An all too revealing necessity is
the universal adoption of "abuse-free" policies in medical
settings. Nurses' expectations for collaboration, acknowledgement, and
respect is a long way off when "abuse-free" policies are considered
a real step forward (and they are) in managing the work environment.
Although CPMG has a "zero-tolerance" policy for abuse, some
nurses state they don't have a voice and are not respected in spite
of years of experience.
Figure 1. Nursing Trends in Colorado2
Preferred Clinical Partner
Program
"PCP"
Program--the Origins
CPMG's
leadership team and Board of Directors were determined not to simply
stand on the sidelines and document the deterioration of health care
teams. The need for action became a vision that led to the development
of the "Preferred Clinical Partner" (PCP) Program. The PCP
Program articulates the breadth and significance of the partnership
between physicians and nurses (Table 1). The PCP vision is for physicians
to pick up the mantle of leadership and participate in solving the nursing
shortage. The strategy of the PCP Program is to be comprehensive and
innovative in the drive to stimulate interest, develop capacity, and
offer opportunity for nurses and other future health care team members.
In addition
to the financial commitment to building programs, physicians can affect
the nursing shortage by enhancing the work-lives of nurses. Physicians
have a legally based, nontransferable leadership role within a medical
team or department. Physicians can affect the nursing shortage by using
their leadership role in their care teams to support nurses, purposefully
investing in the relationship, and acknowledging and respecting their
nursing colleagues.
Consistent
with a dedication to be "physician leaders" on all issues
that affect our patients and the health care industry, CPMG developed
a response to the nursing shortage. What were CPMG's motives?
First,
to ensure that every place a Permanente physician treats patients and
KP patients receive care, there is a health care team fully staffed
with excellent professionals. With high-quality, intact teams, we can
ensure that our patients get all of the benefits of KP care.
The second,
more audacious motive is to help solve this shortage globally by demonstrating
that an accountable physician group can play a leadership role in solving
one of the most problematic issues in health care today. If we can demonstrate
success in our own local area of influence, it may be a model for medical
groups, medical staffs, and all physicians to be leaders in trying to
address and make a major contribution in solving this critical shortage.
Preferred Clinical Partner
Program "Nuts & Bolts"
To
launch the PCP Program, the physicians of CPMG contributed $250,000
to help fund scholarships and build nursing capacity at community colleges
and universities.
A project
manager for Nursing and Community Relations was hired by the Medical
Group to manage the PCP Program.
The PCP
Program includes the following components:
Nursing
scholarship program: distribution of scholarships; solicitation
and fostering of potential recipients at every educational level; engagement
of community leaders and hospital leaders to raise money, to support
the program, and to facilitate people and systems to identify recipients.
The PCP Program seeks to foster interest in health careers in school-age
children, and to offer opportunities for health care workers, both inside
and outside KP, to attain more advanced degrees.
Create
educational capacity: Extensive collaboration with community and
hospital leaders. Leaders of the Catholic high school system serving
the urban area (CPMG's partner hospital is an urban Catholic hospital)
and college leaders has resulted in extraordinary interest and cooperation
in the PCP Program. In addition to scholarships, a core need is more
educational capacity at the local colleges as well as within our hospitals
for clinical precepting and clinical experience. CPMG's physicians sponsor
these programs and will also provide additional faculty for the training
programs.
Changing
the nursing work environment: A key component of the PCP Program
is driving a cultural change in the work environment for nurses. Dissemination
of information about the role physicians play in nursing work life has
been accomplished through the Executive Medical Director's monthly communication
to physicians as well as discussion and repetition in more informal
sessions. Results of the VHA study on disruptive physician behavior
and its effect on nurses was sent to all physicians. The attached introductory
comments by the Executive Medical Director included the following statement:
"Every day we should seek opportunities for inclusion, feedback,
personal recognition, and 'Thank yous!' for the nurses caring for our
patients."
Current Status and Next
Steps
The Dollars
The
CPMG Healthcare Education Fund (the "Fund") has continued
to grow through additional donations and grants and has expanded to
$950,000. CPMG is collaborating with educational institutions to determine
what type of "hands-on," "front-of-classroom" support
our physicians and other professionals might be able to offer. Additionally,
we are seeking to expand the involvement of CPMG in mentoring and teaching
health care professionals in the hospital and clinic settings.
To date,
the Fund has granted money to Metropolitan State College to provide
staffing for a newly developed accelerated BSN program and a nursing
laboratory. The Fund has also committed financing over the next two
years to partner with KP to provide matching funds to support an onsite
"MA to LPN" program. These two-year programs, taught by the
Community College of Denver, will provide evening and weekend training
for 32 KP employees with no out-of-pocket cost to them. CPMG has also
agreed to match existing Kaiser Foundation Health Plan nursing scholarships
during the next three years, which resulted in ten additional nursing
scholarships this year.
Early Evidence of Success
When
the Director of Nursing at KP proposed a structure to reenergize nurses
and focus on the importance of nursing, physician-leaders agreed to
partner in every way. Fifteen physicians are actively involved: many
as co-chairs of the task forces that were created to address issues
such as quality of nursing care, career ladders, and nursing education.
Physician-leaders have helped coach nurse-leaders on the development
of appropriate peer review processes, collaborative nurse-physician
educational projects, quality assurance efforts, and have helped with
nursing orientation programs.
The Colorado
Region People Pulse Survey is evidence that physicians are making a
difference internally. The 2003 survey showed that 84% of nurses say
MDs treat them with respect compared with 81% in 2002. Positive nurse
response to the question "MDs support me in providing quality service"
increased from 78% to 86%. Perhaps the most important question, in an
era of severe nursing shortage, is "I would recommend KP as a place
to work." Eighty-nine percent of nurses agreed compared with 73%
just a year ago. In the last year, when newly hired nurses were asked
for the top 10 reasons they joined KP, one of the top reasons cited
was their ability to have long-term collegial, respectful relationships
with an outstanding medical group. These data are consistent with national
studies showing that positive, collaborative relationships with physicians
help to recruit and retain nurses.
The Mantle of Leadership
Clearly,
the stakes are high for physicians as the increasing reality of a nursing
shortage unfolds. Despite the leadership, education, and power represented
by physicians, they are rarely mentioned as playing a role in solving
the nursing shortage. Given the legal responsibilities and leadership
roles of physicians in health care, it is incomprehensible and unacceptable
for physicians to be "silent" on this subject. The physicians
of CPMG have "opted in." The PCP Program represents physicians
picking up the mantle of leadership and extending a hand of support
to our partners in the nursing profession.
References
- US
Department of Health and Human Services, Health Resources and Services
Administration, Bureau of Health Professions, National Center for
Health Workforce Analysis. Projected supply, demand, and shortages
of registered nurses: 2000-2020, July 2002. Available from: http://bhpr.hrsa.gov/healthworkforce/reports/rnproject/
(accessed January 26, 2004).
- Miller
ME. The nursing workforce in Colorado: educating registered nurses
to meet Colorado's healthcare needs. [Denver (CO): Colorado Center
for Nursing Excellence]; 2003. Available from: www.coloradonursingcenter.org/PDF/study.pdf
(accessed January 26, 2004).
- Colorado
Department of Labor & Employment. Denver Metro Region job vacancy
survey, Spring 2003. Denver (CO): Colorado Department of Labor &
Employment; 2003. Available from: www.coworkforce.com/LMI/WRA/SMFVS7.pdf
(accessed January 26, 2004).
- Weissberg
J. A conversation with Jed Weissberg, MD, on defining Permanente Medicine.
Perm J 2000 Winter;4(1):41-4.
- Rosenstein
AH. Original research: nurse-physician relationships: impact on nurse
satisfaction and retention. Am J Nurs 2002 Jun;102(6):26-34.
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