It is no secret that the U.S. has been struggling with a nursing workforce crisis for years, with healthcare organizations recruiting foreign nurses as a quick fix to fill swelling vacancies. During the pandemic, the influx of international nurses from the Philippines, Jamaica, India, Canada, and Africa increased significantly, up 44% from 2021 and 109% from 2018, according to the O’Grady Peyton International Inc. 2021 survey of International Nurses. Expected to continue in 2023, this trend may help to stem our national shortage in the short term but it also adds to nursing shortages felt abroad.
One country where we have seen a large number of nurses coming to the US to practice from is the Philippines. However, this has left the Philippines with a shortage of over 350,000 nurses, many who come to the U.S. for better wages and working conditions, explained Maria Rosario Vergiere, officer in charge for the Ministry of Health. These nurses who are looking to make an important change in their career raise a fundamental question: Is it ethical to take nurses from one country to fill the nursing shortage in another?
The migration of nurses from one country to another also exposes a larger issue: today’s nursing shortage is global, not just domestic. Countries and global nursing organizations need to work together to solve the nursing workforce crisis globally. The International Council of Nurses and the World Health Organization are recognized leaders in addressing the global nursing shortage; however, they need equitable support from all nations to ensure the shortage is addressed from a global perspective.
International nursing challenges
While recruiting internationally trained nurses may seem like a quick fix, it brings with it a host of challenges along with it that are not always immediately clear. One example is that international nurses must pass the NCLEX exam; and they must adjust to cultural and scope of practice differences. CGFNS International, an immigration-neutral, nonprofit organization, assists internationally educated healthcare professionals wanting to live and work in a desired country. They assess and validate their academic and professional credentials, educating them on language, culture, and practice differences (CGFNS, 2023). The work of this organization has been instrumental over the years in helping acute, long-term care, and other healthcare organizations fill vacant nursing positions with foreign candidates.
International nurses have traditionally struggled to pass the NCLEX exam compared to U.S. nursing graduates due to some of the roadblocks they encounter in their move. In 2021, the first-time pass rate for the NCLEX-RN exam was 82.48% for U.S.-trained nurses and 46.48% for internationally trained nurses (CGFNS, 2022). As nurses attempt to pass the exam again, health systems could experience a strain in their onboarding process for them. However, the bar raises in April when the National State Boards of Nursing releases the Next Generation NCLEX exam for RNs and LPNs. The new NCLEX exam, which assesses clinical judgment and readiness to practice for graduating nurses, could adversely impact the already tenuous flow of internationally trained nurses eligible to work in America.
Will nurses trained in foreign countries be able to pass the Next Generation NCLEX examination? Will their scores be better or worse than the results on the current NCLEX exam? Only time will tell what impact the test changes will have on the international nurse pipeline.
The healthcare system simply wasn’t ready for COVID-19, and the pandemic has exposed the system’s weak links. The situation has become exacerbated by an ongoing workforce shortage. Not only are a growing number of clinicians nearing retirement, but also burnout — already a problem prior to the pandemic — has become what many are calling a parallel pandemic.
And this isn’t surprising. Nurses have been working overtime week after week, seeing tremendous loss of life firsthand, and now are being asked to support the vaccine rollout – to the tune of 11 million doses per week.
The most pressing question for healthcare tech right now is how can we curb nursing burnout in 2021?
This is a question we’ve been asking since the early days of Health IT, but new responsibilities over the last few months and growing rates of nurses leaving the profession have raised the alarm for technology companies to do more.
Healthcare leaders, clinicians, and educators have responded by developing innovative workforce solutions and education strategies to keep pace with changing care-delivery models. Specifically, around the vaccine rollout, we can ensure nurses have access to rapid, virtual education around administration best practices and patient education.
We also need to streamline the alerts going to these providers so they only receive the most actionable and important information at the point of care. These providers do not have the time to review every new study that comes out around COVID treatment options. Instead, we can leverage digital tools to provide evidence-based information that is actionable and available at the point of care.
This helps eliminate confusion around what action should be taken, and ensures all members of the care team feel empowered to care for their patients. For on-the-job training, as artificial intelligence becomes more refined and its use expands, algorithms could surface insights much earlier that generate mini-lessons, clinical updates, remediation, and reminders within existing workflows.
By Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN, chief nurse, Wolters Kluwer, Health Learning, Research and Practice.
Anne Dabrow Woods
These are the days we never thought we’d see – unimagined times, pushing our nurses and healthcare workers to the brink with the demands of COVID-19. They’ve stepped up with unbelievable courage and resiliency. They’ve done so without many of the resources they’ve traditionally had, such as personal protective equipment (PPE) and medical equipment. But one thing that’s undoubtedly made a difference is technology.
Patients have been able to interact with their primary care provider and nurses via telehealth ensuring that patients are able to continue with the medications and treatment plans for chronic conditions and new issues.
In the acute care space, it has enabled patients to visit with their family through digital technology, and providers and nurses have been able to update the families on patients’ progress.
After patients are discharged with COVID-19, the patient is in daily contact with a nurse to make sure their condition isn’t worsening, and they understand how to care for themselves. This works to ensure patients have follow-up care and the family is supported. And those are just a few ways.
While the survey was taken prior to the pandemic, the results give insight into the role of technology as it applies to both next-generation nurses (those with less than 10 years of practice) and more experienced ones. The survey conducted by Wolters Kluwer aimed to explore the mindset of today’s nurses and healthcare workers, so hospitals can respond accordingly.
Digital natives versus techno-phobes
When looking at next-generation nurses, we should keep in mind that many of them grew up in a time with widespread use of the internet, social media, and mobile communication. Many nurses with longer tenure began their careers when the internet was in its infancy and computers weren’t an integral part of a hospital’s operations.
Next-generation nurses are, for the most part, digital natives. That comfort level does tend to influence their opinions: when care is better, next-generation nurses think it’s because of technology. 84% believe clinical-decision support systems at the point of care are making it easier to make the most informed, evidenced-based care decisions.
In addition, 84% feel specialized systems that provide treatment recommendations and integrate with electronic health records (EHRs) have a positive impact on how care is delivered.
Their understanding of technology may be a factor in them spending less time in EHRs than their more seasoned counterparts; 69% report spending too much time in EHRs, compared to 81% of more experienced nurses.
Next-generation nurses are fans of artificial intelligence (AI). 63% say they are optimistic that the use of AI will help providers get the information they need to make better care decisions.
Experienced nurses weren’t as convinced, with only half agreeing that AI will help in making better care decisions. (This insight should alert hospital leaders of the need to educate staff on how AI can improve clinical decision making so that implementation of AI will be viewed as a positive and not as a negative.)
Have you thanked a nurse today? Or any day, for that matter?
If not, you now have an entire week to make up for lost time. National Nurses Week 2019 runs May 6 through 12 and celebrates the innumerable contributions nurses make each day. This year’s theme is “4 Million Reasons to Celebrate,” pointing to the 4 million registered nurses licensed in the United States and the vast contributions they bring to care delivery.
Healthcare may be an ever-evolving industry, but the one thing that hasn’t changed is the integral role played by nurses. In fact, their skill set is more in-demand than ever before, especially as today’s healthcare organizations navigate the evolving value-based care landscape. For example, nurses must constantly absorb new information to keep up with rapidly-changing evidence in practice while simultaneously honing their critical thinking skills to stay current in a shifting healthcare model.
The reality is that the role of nurses is changing dramatically as healthcare organizations see increased demand for services and higher-acuity patients, many with more comorbidities than ever before. Today’s nurses are critical members of the multi-disciplinary care team. They need to be the collaborators and leaders, giving a voice not only to their patients but to other nurses and caregivers as well. This is a profession that needs to produce leaders with the savvy and acumen to feel as comfortable inside a boardroom as they do at a bedside.
Simply put, knowledge is power when it comes to producing the best possible patient outcomes. Forward-thinking healthcare organizations understand this dynamic and are designing workplaces that optimize and support a culture of learning that elevates nursing skills to align with healthcare initiatives related to chronic disease management and population health.
These strategies not only support nurses as they care for patients in today’s fast-paced healthcare environments, but they help clinical leaders address growing staffing challenges amid critical professional shortages. For example, turnover rates in 2017 shot up to nearly 17 percent as the industry faces growing challenges related to burnout and dissatisfaction. Hospitals pay dearly when nursing turnover is at its highest, and it isn’t only the quality of care that suffers. According to one survey, the average cost for the turnover of a bedside RN is between approximately $40,000 and $60,000. Each percent change in nursing turnover, the survey says, will either cost or save the average hospital more than $373,000.
Nurses who feel well-equipped and supported in their professional trajectory are much more likely to find satisfaction in their work. Consequently, healthcare organizations must provide that support from the outset—addressing education gaps during onboarding while continuing to educate new nurses on how to deliver the highest quality of care. It’s a difficult balance considering nurses are dealing with a growing number of patients and a plethora of complex diseases.
By Anne Dabrow-Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN and Dale Schumacher, MD, MPH
When nurses are armed with the latest evidence-based nursing procedures at the point of care and real-time step-by-step guides for clinical decision making at the bedside, Hospital Value-Based Purchasing (VBP) Program scores go up. That was the primary finding of a study undertaken by the Rockburn Institute in partnership with Wolters Kluwer Health, which found that hospitals where nurses used two specific evidence-based Clinical Decision Support (CDS) tools for two years had an average rank that was nearly 25 percent higher than their peers.
The findings are a rare instance where the intervention—in this case Lippincott Procedures and Lippincott Advisor from Wolters Kluwer—can be clearly associated with change in practice and quality improvement. In fact, the study’s findings clearly support the value and use of point-of-care CDS tools in a clinical setting to augment nurses’ substantial knowledge when needed. The results also demonstrate the close relationship between nurse, information, patient and performance improvement, which ultimately leads to improved quality and efficiency.
A VBP Primer
The Centers for Medicare and Medicaid Services (CMS), through its Hospital VBP Program, has incentivized hospitals to improve patient care and minimize costs by structuring its reimbursement system to reward care quality rather than service quantity. To fund the program, CMS reduces each hospital’s base operating payment by up to 2 percent, which hospitals can earn back (along with bonuses) by achieving high VBP performance scores.
In effect, VBP pits hospitals against each other and their own past performance to show achievement and improvement. Performance is currently assessed using four quality domains: 1) Clinical Care, 2) Experience and Coordination of Care, 3) Safety, and 4) Efficiency and Cost Reduction.
Each participating hospital receives an achievement and improvement score for each domain. The higher of the two is selected and weighted accordingly. All domain scores are then summed together to create the VBP Total Performance Score (TPS). This score is then converted into the hospital’s “adjustment factor,” a multiplier CMS applies to a hospital’s base payment covering each patient’s stay during a given time period.
Adjustment factors above 1.0 indicate that a hospital will receive back from CMS their full withholding plus a bonus. Hospitals with an adjustment factor below 1.0 will be assessed a penalty. For example, a hospital with a VBP adjustment factor of 0.9903 would be paid 99.03% of what Medicare usually reimburses for each service. It’s important to note that the VBP program is a mix of withholding repayment and bonus (or penalty) and required by law to be budget neutral.
The Study Methodology
To determine if and to what extent CDS could help hospitals improve performance on key metrics, the Rockburn Institute evaluated data compiled over a three-year period from all U.S.-based hospitals with a CMS Certification Number that participated in the VBP program. From this base of approximately 3,000 hospitals, 41 facilities were identified that utilized both Lippincott Procedures and Lippincott Advisor for the complete 2014 and 2015 calendar years.
The performance of hospitals using the CDS tools—which represented a mix of community-based clinics, hospitals serving large geographic regions and large university-based systems in 20 different states—was compared to the other hospitals that had received VBP scores for 2014 and 2015. Scores of the 41 CDS facilities were then evaluated for 2017 against their previous years’ results.
