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Objectives: In times of heightened population health needs, the health workforce must respond quickly and efficiently, especially at the state level. We examined state governors’ executive orders related to 2 key health workforce flexibility issues, scope of practice (SOP) and licensing, in response to the COVID-19 pandemic. Methods: We conducted an in-depth document review of state governors’ executive orders introduced in 2020 in all 50 states and the District of Columbia. We conducted a thematic content analysis of the executive order language using an inductive process and then categorized executive orders by profession (advanced practice registered nurses, physician assistants, and pharmacists) and degree of flexibility granted; for licensing, we indicated yes or no for easing or waiving cross-state regulatory barriers. Results: We identified executive orders in 36 states containing explicit directives addressing SOP or out-of-state licensing, with those in 20 states easing regulatory barriers pertaining to both workforce issues. Seventeen states issued executive orders expanding SOP for advanced practice nurses and physician assistants, most commonly by completely waiving physician practice agreements, while those in 9 states expanded pharmacist SOP. Executive orders in 31 states and the District of Columbia eased or waived out-of-state licensing regulatory barriers, usually for all health care professionals. Conclusion: Governor directives issued through executive orders played an important role in expanding health workforce flexibility in the first year of the pandemic, especially in states with restrictive practice regulations prior to COVID-19. Future research should examine what effects these temporary flexibilities may have had on patient and practice outcomes or on permanent efforts to relax practice restrictions for health care professionals.

Supplemental Digital Content is available in the text., Objective: The objective of this study was to addresses the basic question of whether alternative legislative approaches are effective in encouraging hospitals to increase nurse staffing. Methods: Using 16 years of nationally representative hospital-level data from the American Hospital Association (AHA) annual survey, we employed a difference-in-difference design to compare changes in productive hours per patient day for registered nurses (RNs), licensed practical/vocational nurses (LPNs), and nursing assistive personnel (NAP) in the state that mandated staffing ratios, states that legislated staffing committees, and states that legislated public reporting, to changes in states that did not implement any nurse staffing legislation before and after the legislation was implemented. We constructed multivariate linear regression models to assess the effects with hospital and year fixed effects, controlling for hospital-level characteristics and state-level factors. Results: Compared with states with no legislation, the state that legislated minimum staffing ratios had an 0.996 (P

BACKGROUND: As coronavirus disease 2019 (COVID-19) rapidly progressed throughout the United States, increased demand for health workers required health workforce data and tools to aid planning and response at local, state, and national levels. OBJECTIVE: We describe the development of 2 estimator tools designed to inform health workforce planning for COVID-19. RESEARCH DESIGN: We estimated supply and demand for intensivists, critical care nurses, hospitalists, respiratory therapists, and pharmacists, using Institute for Health Metrics and Evaluation projections for COVID-19 hospital care and National Plan and Provider Enumeration System, Provider Enrollment Chain and Ownership System, American Hospital Association, and Bureau of Labor Statistics Occupation Employment Statistics for workforce supply. We estimated contact tracing workforce needs using Johns Hopkins University COVID-19 case counts and workload parameters based on expert advice. RESULTS: The State Hospital Workforce Deficit Estimator estimated the sufficiency of state hospital-based clinicians to meet projected COVID-19 demand. The Contact Tracing Workforce Estimator calculated the workforce needed based on the 14-day COVID-19 caseload at county, state, and the national level, allowing users to adjust workload parameters to reflect local contexts. CONCLUSIONS: The 2 estimators illustrate the value of integrating health workforce data and analysis with pandemic response planning. The many unknowns associated with COVID-19 required tools to be flexible, allowing users to change assumptions on number of contacts and work capacity. Data limitations were a challenge for both estimators, highlighting the need to invest in health workforce data and data infrastructure as part of future emergency preparedness planning.

Hospitals have increasingly relied on nurse assistants to support nurses in the provision of patient care, yet knowledge about their contributions to the patient experience in U.S. hospitals is limited. We address this issue by exploring the impact of nurse assistants and registered nurses on an array of patient satisfaction measures from the Medicare Hospital Consumer Assessment of Healthcare Providers and Systems. Using linked data for 2,807 hospitals from 2008 to 2016, we employ a production function approach to estimate and plot marginal impact curves for both nurse assistants and registered nurses. We find that although registered nurses are more impactful, nurse assistants are the more underdeployed staffing category. We also find that after meeting certain thresholds for minimal hours, nurse assistants have a comparative advantage in improving patient satisfaction scores in the housekeeping and patient support domain. Given their lower labor costs, further employment of nurse assistants may be warranted.

Background and purpose Expanding state scope of practice (SOP) for nurse practitioners (NPs) and physician assistants (PAs) can boost productivity and improve access to health care services. Existing analyses on regulatory policies in NP or PA SOP have primarily focused on the direct effects on their own professions but have not fully considered the potential cross-professional effects. This study examines the impact of expanded state SOP for NPs and PAs on primary care utilization by NP, PA, and primary care physician (PCP) in community health centers (CHCs). Methods We conducted a difference-in-differences approach using the Uniform Data System for 739 CHCs from 2009 to 2015. During our study period, 12 states liberalized NP SOP laws and 14 states changed their PA SOP regulations. The number of visits per full-time equivalent clinician (NP, PA, and PCP) per year was the outcome of interest and was linked to the degree of state SOP restriction for NPs and PAs in a given year. Conclusions Granting independent practice and prescriptive authority for NPs resulted in statistically significant increases in NP visits, and decreases in both PA and PCP visits, for those CHCs with a high proportion of NPs and PAs along with the increased provision of support staff. PA SOP liberalization had no statistically significant effect on PA visits. Implications for practice As the NP and PA workforce continues to grow, and as SOP laws continue to be liberalized, it is important to advance evidence on how to most efficiently deploy these staff.

Background: There is variation in nursing education quality, measured as first-time NCLEX (National Council Licensure Examination)-RN pass rates (FTPR), both across and within the United States. Current research examines program-level characteristics associated with performance. Method: This study examines state-level policies and their relationship to FTPR (both associate and baccalaureate nursing degrees) to identify policies that enhance nursing program quality. Ordinary least squares regression analyses were conducted for state and program levels, and tests for interactions of variables were conducted between the two levels. Results: Accredited for-profit programs were associated with a 24% higher FTPR than nonaccredited for-profit programs. In addition, for-profit programs in more business-friendly states were associated with an 11.8% lower FTPR. Conclusion: National standards for licensure pass rates, a mandate that all programs be accredited, and better enforcement could help improve the quality of RN programs nationwide. States with pro-business policies should be aware of the effect of their policies on the proliferation of for-profit schools. [ J Nurs Educ . 2022;61(5):242–249.]

The nurse practitioner (NP) workforce in community health centers (CHCs) increases access to primary care for underserved populations. Working with medically complex patients, high workloads, and low resources in the CHC setting, CHC NPs may be susceptible to poor workforce outcomes. This study uses NP survey data collected from 6 US states to describe and assess the relationship between CHC NP practice environment and burnout, job satisfaction, and turnover intention. CHC NPs rated their practice environments favorably, and more than 89% of CHC NPs reported satisfaction with their job. Better rating of NPs' relationship with CHC administration was associated with improved job satisfaction and decreased turnover intention.

Supplemental Digital Content is available in the text., Objective: Prior studies of community health centers (CHCs) have found that clinicians supported by the National Health Service Corps (NHSC) provide a comparable number of primary care visits per full-time clinician as non-NHSC clinicians and provide more behavioral health care visits per clinician than non-NHSC clinicians. This present study extends prior research by examining the contribution of NHSC and non-NHSC clinicians to medical and behavioral health costs per visit. Methods: Using 2013–2017 data from 1022 federally qualified health centers merged with the NHSC participant data, we constructed multivariate linear regression models with health center and year fixed effects to examine the marginal effect of each additional NHSC and non-NHSC staff full-time equivalent (FTE) on medical and behavioral health care costs per visit in CHCs. Results: On average, each additional NHSC behavioral health staff FTE was associated with a significant reduction of 3.55 dollars of behavioral health care costs per visit in CHCs and was associated with a larger reduction of 7.95 dollars in rural CHCs specifically. In contrast, each additional non-NHSC behavioral health staff FTE did not significantly affect changes in behavioral health care costs per visit. Each additional NHSC primary care staff FTE was not significantly associated with higher medical care costs per visit, while each additional non-NHSC clinician contributed to a slight increase of $0.66 in medical care costs per visit. Conclusions: Combined with previous findings on productivity, the present findings suggest that the use of NHSC clinicians is an effective approach to improving the capacity of CHCs by increasing medical and behavioral health care visits without increasing costs of services in CHCs, including rural health centers.

The National Health Service Corps (NHSC) is a federal program to increase the supply of health professionals in underserved communities, but its role in enhancing the capacity of community health centers (CHCs) has not been investigated. This study examined the role of NHSC clinicians in improving staffing and patient care capacity in primary, dental, and mental health care in CHCs.Using 2013-2016 administrative data from CHCs and the NHSC, we used a generalized estimating equation approach to examine whether NHSC clinicians [staff full-time equivalents (FTEs)] complement non-NHSC clinicians in CHCs and whether their productivity (patient visits per staff FTE) was greater than that of non-NHSC clinicians in primary, dental, and mental health care.Each additional NHSC clinician FTE was associated with a significant gain of 0.72 non-NHSC clinician FTEs in mental health care in CHCs and an increase of 0.04 non-NHSC FTEs in primary care in CHCs with more severe staffing shortages. On average, every additional NHSC clinician was associated with an increase of 2216 primary care visits, 2802 dental care visits, and 1296 mental health care visits per center-year. The adjusted visits per additional staff for NHSC clinicians were significantly greater in dental (difference=992) and mental health (difference=423) care, compared with non-NHSC clinicians.The NHSC clinicians complement non-NHSC clinicians in primary care and mental health care. They help enhance the provision of patient care in CHCs, particularly in dental and mental health services, the 2 major areas of service gaps.

Objectives The current study adds to the literature on vape shops by evaluating vape shop growth in an urban community over a 3-year period, assessing similarities and differences across the vape shop context, and addressing whether socialization spaces within vape shops are associated with a vape shop's ultimate success - remaining operational. As e-cigarette/vaping use enters its second decade in the US market, its regulation and status as a novel form of substance use is evolving; accordingly, it is unknown whether the presence of vape shops has changed as well. Methods In this study, we tracked and observed 19 vape shops over a 3-year period in Long Beach, California. Results Vape shop presence declined by 53% between September 2015 and September 2018. A comparison of vape shops remaining open versus those closing in the 3-year period indicated that shops with designated socialization spaces (lounges/tasting bars) were more likely to remain operational. Conclusions The substantial decline in vape shop presence in this community may reflect an entrepreneurial response to increased regulation, as well as a dynamic market for e-cigarette/vape products. Findings suggest vape users support Electronic Nicotine Delivery Systems (ENDS) retailers that promote community-building or recreational activity.

The COVID-19 pandemic has reset the table for a dialogue about health equity, public health, and the future of nursing. Experts anticipated that payment reforms would lead to a much-needed increase in community and public health nursing. Despite calls for the profession of nursing to take a leadership role in addressing the social determinants of health and health equity, data show that jobs for nurses in community-based clinics and public health have actually declined in the last decade. This article offers background on the ongoing decline in public health infrastructure in the United States, an analysis of workforce data on nursing jobs using the National Sample Survey of Registered Nurses from the years 2000, 2004, 2008, and 2018, and the National Association of County and City Health Officials from 2008 to 2019, as well as a discussion of why these findings are so troubling. We discuss policy implications for nurse educators related to curricula and clinical experiences, and for professional nursing organizations as they set goals to increase and improve nursing jobs in community clinics and public health settings. In conclusion, we note that the federal investments in community health centers and public health nursing provide a short window of opportunity to reverse the historic and ongoing decline and rebuild a stronger community and public health nurse workforce.

The health workforce has been greatly affected by COVID-19. In this commentary, we describe the articles included in this health workforce research supplement and how the issues raised by the authors relate to the COVID-19 pandemic and rapidly changing health care environment.

This study asks how much and why the productivity of advanced practice clinicians (APCs; nurse practitioners and physician assistants) varies across community health centers (CHCs), as measured in their marginal contribution to overall patient visits. We found APCs in the 90th percentile CHCs provide about 1,840 adjusted-visits per year, whereas APCs in the 10th percentile CHCs provide about 978 adjusted-visits per year. We interviewed leadership at 14 high APC and 16 low APC productivity CHCs to elicit organizational conditions that could explain the difference. Using content analysis and then qualitative comparative analysis, we found several important conditions were more common among high productivity CHCs, including scheduling APCs and physicians for the same number of visits, parity in terms of any financial incentives, and formal education programs for new APCs during onboarding/transition to practice.

Background To prepare new graduate nurse practitioners (NPs) for transition to practice, postgraduate residency or fellowship programs have been spreading across the nation in the past decade. Purpose We examined the effects of completing a postgraduate residency or fellowship program on role perception, practice autonomy, team collaboration, job satisfaction, and intent to leave among primary care NPs (PCNPs). Methods We analyzed 8,400 PCNP respondents, representing a total of 75,963 PCNPs nationwide, to the 2018 National Sample Survey of Registered Nurses. We conducted multivariate logistic regression analyses to examine whether completing a postgraduate training program was associated with increased role perception, greater practice autonomy, improved team collaboration, increased job satisfaction, and decreased intent to leave in their work, controlling for NP personal and practice characteristics. Results About 10% of PCNPs completed some form of postgraduate training. Primary care NPs who had completed a residency or fellowship program were more likely to have a minority background (e.g., non-White and male) and also see more underserved populations (e.g., minority background, with limited English proficiency) than those without residency training. We found that PCNPs with residency training were more likely to report enhanced confidence in independent roles, greater practice autonomy, improved team collaboration, increased job satisfaction, and decreased intent to leave than those without residency training. Implications for practice This study supports further expansion of such programs, which would have positive effects for NPs, health care organizations, and patients, necessitating a long-overdue conversation about real public funding for primary care graduate nursing education.

OBJECTIVE This study examines the use of temporary providers in federally qualified health centers (FQHCs) in recent years and identifies associated factors. METHODS Using 2013-2017 federal administrative data of 1,028 FQHCs, we describe trends in the number and percentage of FQHCs that used temporary primary care physicians and advanced practice providers (nurse practitioners, physician assistants, and certified nurse midwives). We employed descriptive statistics to compare facility and patient characteristics between FQHCs that used and did not use temporary providers and constructed multivariate linear probability models to identify factors associated with their use. FINDINGS Slightly over one-third of FQHCs used temporary primary care providers during 2013-2017. During this period, fewer FQHCs used temporary family physicians, while more FQHCs used nurse practitioners and physician assistants. Centers that used temporary providers were larger and less rural. Multivariate regression analysis showed that neither Health Professional Shortage Area facility scores (a measure of provider shortage), nor the county primary care provider-to-population ratio, was a predictor of temporary provider usage in FQHCs. Instead, facility regular primary care staff-to-patient ratio was positively associated with use of temporary providers. CONCLUSION Temporary providers tend to be used in FQHCs where measure of underservice appears to be less severe. Future research should use qualitative interviews or other data sources to explore further the underlying reasons for using temporary providers in FQHCs.

Introduction Since 2002, there has been dramatic growth in the number of registered nurse (RN) graduates from nursing programs in all types of institutional settings, with the largest increases in the for-profit sector. Aim To document trends in the growth of nursing programs and to compare their outcomes, as measured in first-time NCLEX® pass rates, by ownership type and degree, including bachelor of science in nursing, associate degree in nursing, and practical nurse. Methods We used 10 years of data (2007-2016) from the Integrated Postsecondary Education Data System (IPEDS) to track the number of programs and graduates by ownership type. We obtained 5 years of data (2011-2015) from state boards of nursing on first-time NCLEX pass rates by degree. We constructed a multivariate regression model with pass rates as the dependent variable and school ownership status as the independent variable. Covariates included a broad range of institution-level covariates obtained from IPEDS and county-level data on poverty obtained from the Area Health Resource File. Results From 2007-2016, there was a five-fold increase in the total number of for-profit nursing programs and a 14-fold increase in the number of graduates of for-profit nursing programs. Graduates of public nursing programs declined as a percentage of total graduates, whereas for-profit programs' share grew from 1.7% to 14.2 %. After controlling for demographic and socioeconomic factors, for-profit ownership was a significant predictor of lower NCLEX pass rates for all three degree programs. Conclusions Additional research is needed to understand why ownership status affects performance, but it is incumbent upon nursing leaders to review federal, state, and accreditation oversight to ensure minimum performance standards for all nursing programs.

Ensuring and Sustaining a Pandemic Workforce It seems clear that health care delivery organizations, educators, and government leaders all have to be willing to cut through bureaucratic barriers an...

Unethical International Nurse-Staffing Agencies A bill in the U.S. Congress would remove caps on employment-based visas for immigrants from any one country and may include a carve-out for nurses. T...

Modernizing Scope-of-Practice Regulations Many health care organizations are experimenting with new ways of unleashing their workforce’s potential. Such approaches require reconfiguring of provider...

This cross-sectional study uses national medical claims data set to examine the workforce providing abortion care and management of pregnancy loss.

Background Contraception care is essential to providing comprehensive healthcare; however, little is known nationally about the contraception workforce. Previous research has examined the supply, distribution, and adequacy of the health workforce providing contraception services, but this research has faced a series of data limitations, relying on surveys or focusing on a subset of practitioners and resulting in an incomplete picture of contraception practitioners in the United States. Objective This study aimed to construct a comprehensive database of the contraceptive workforce in the United States that provides the following 6 types of highly effective contraception: intrauterine device, implant, shot (depot medroxyprogesterone acetate), oral contraception, hormonal patch, and vaginal ring. In addition, we aimed to examine the difference in supply, distribution, the types of contraception services offered, and Medicaid participation. Study Design We constructed a national database of contraceptive service providers using multiple data sets: IQVIA prescription claims, preadjudicated medical claims, and the OneKey healthcare provider data set; the National Plan and Provider Enumeration System data set; and the Census Bureau’s American Community Survey data on population demographics. All statistical analyses were descriptive, including chi-squared tests for groupwise differences and pairwise post hoc tests with Bonferroni corrections for multiple comparisons. Results Although 73.1% of obstetrician-gynecologists and 72.6% of nurse-midwives prescribed the pill, patch, or ring, only 51.4% of family medicine physicians, 32.4% of pediatricians, and 19.8% of internal medicine physicians do so. The ratio of all primary care providers prescribing contraception to the female population of reproductive age (ages, 15–44 years) varied substantially across states, with a range of 27.9 providers per 10,000 population in New Jersey to 74.2 providers per 10,000 population in Maine. In addition, there are substantial differences across states for Medicaid acceptance. Of the obstetrician-gynecologists providing contraception, the percentage of providers who prescribe contraception to Medicaid patients ranged from 83.9% (District of Columbia) to 100% (North Dakota); for family medicine physicians, it ranged from 49.7% (Florida) to 91.1% (Massachusetts); and for internal medicine physicians, it ranged from 25.0% (Texas) to 75.9% (Delaware). For in-person contraception, there were large differences in the proportion of providers offering the 3 different contraceptive method types (intrauterine device, implant, and shot) by provider specialty. Conclusion This study found a significant difference in the distribution, types of contraception, and Medicaid participation of the contraception workforce. In addition to obstetrician-gynecologists and nurse-midwives, family medicine physicians, internal medicine physicians, pediatricians, advanced practice nurses, and physician assistants are important contraception providers. However, large gaps remain in the provision of highly effective services such as intrauterine devices and implants. Future research should examine provider characteristics, programs, and policies associated with the provision of different contraception services.

As hospitals’ interest in nurse practitioners (NPs) and physician assistants (PAs) grows, their leadership is eager to know how their medical staffing privileging policies for these professionals compare to peer hospitals. This study assesses the extent of variation of these policies in four clinical areas and examines whether the differences are associated with state scope of practice laws for NPs and PAs. We also examine the relationship of NP and PA privileging policies to each other. Our analysis finds no evidence that hospital privileging is associated with state scope of practice, and indeed within-state variation is more significant than cross-state variation. We also find a strong correlation between NP and PA privileging in all four clinical areas. These results suggest the need for additional research to understand the institutional-level variables and human dynamics at the level of medical staffing committees that may explain the dramatic variation in privileging policies and, ultimately, the effects of different privileging levels on costs and quality.

Background Care coordination is generally viewed as a key to success for health systems seeking to adapt to a range of new value-based payment policies. Purpose This study explores care coordination staffing in four health systems participating in new payment models, including Medicaid payment reform and Accountable Care Organizations. Methods Comparative case study design is used to describe models of care coordination. Analysis of 43 semi-structured interviews with leadership, clinicians, and care coordination staff at four health systems engaged in value-based contracts. Discussion Each of the sites engaged in significant task shifting of low-complexity care coordination activities to licensed practical nurses, medical assistants, and other unlicensed personnel freeing up registered nurses and social workers for more complex patients. Few have care coordination experience, requiring a significant investment in on-the-job training. Conclusion Payment reform is leading to a greater investment in the care coordination workforce. However, demonstrating the return on investment remains a challenge.

By the 1920s, Lillian Wald's model of care, with nurses working side by side with social workers at the intersection of medicine and society, had become an important component of the U.S. health care system. Over subsequent decades, however, a confluence of historic forces resulted in its marginalization. Today, people are recognizing that medical cures alone, although important, will not reduce the epidemic of diseases of despair or the growing challenges involved in achieving health equity. Wald's approach, extended to a broader range of settings in which nurses work today, could be the missing ingredient.To provide background for the National Academy of Medicine Committee on the Future of Nursing 2020-2030, as it develops its follow-up to the Institute of Medicine's 2010 Future of Nursing: Leading Change, Advancing Health, the Robert Wood Johnson Foundation commissioned a report on nursing's historic role in advancing health. This article summarizes that report, which can be found in its entirety at www.rwjf.org/content/dam/farm/reports/reports/2019/rwjf452706.

Objective To assess how medical staffing mix changed over time in association with the adoption of electronic health records (EHRs) in community health centers (CHCs). Study Setting Community health centers within the 50 states and Washington, DC. Study Design Estimated how the change in the share of total medical staff full-time equivalents (FTE) by provider category between 2007 and 2013 was associated with EHR adoption using fractional multinomial logit. Data Collection 2007–2013 Uniform Data System, an administrative data set of Section 330 federal grant recipients; and Readiness for Meaningful Use and HIT and Patient Centered Medical Home Recognition Survey responses collected from Section 330 recipients between December 2010 and February 2011. Principal Findings Having an EHR system did significantly shift the share of workers over time between physicians and each of the other categories of health care workers. While an EHR system significantly shifted the share of physician and other medical staff, this effect did not significantly vary over time. CHCs with EHRs by the end of the study period had a relatively greater proportion of other medical staff compared to the proportion of physicians. Conclusions Electronic health records appeared to influence staffing allocation in CHCs such that other medical staff may be used to support adoption of EHRs as well as be leveraged as an important care provider.

This study investigated how years of experience with an electronic health record (EHR) related to productivity in community health centers (CHCs). Using data from the 2012 Uniform Data System, we regressed average annual medical visits, weighted for service intensity, as a function of full-time equivalent medical staff controlling for CHC size and location. Physician productivity significantly improved. Although the productivity of all other staff types was not significantly different by years of EHR experience, the trends showed lower productivity among nurses and other medical staff in CHCs with fewer years of EHR experience versus more years of experience.

INTRODUCTIONWith the expansion of coverage and preventive care facilitated by the Affordable Care Act, primary care facilities are facing increased demand for services. At the same time, new payment incentives linked to patient-centered medical homes (PCMHs) are encouraging the adoption of team-based care (Auerbach et al., 2013; Bitton et al., 2012). Team-based care may help contain costs and improve productivity and patient outcomes in primary care facilities (Altschuler, Margolius, Bodenheimer, & Grumbach, 2012; Bodenheimer & Smith, 2013; Ku, Frogner, Steinmetz, & Pittman, 2015). However, most studies of primary care teams examine team-based care or teamwork as a variable associated with certain outcomes, with little attention given to the question of how leaders of primary care facilities determine the composition of primary care teams and the staffing configurations that best serve patient populations given their local policy and market contexts (Chen & Bodenheimer, 2011; Chesluk & Holmboe, 2010).Understanding how leaders make staffing configuration decisions in the context of the current system transformations is important because it may help build knowledge about how ground-level choices in primary care facilities mediate policy outcomes. In addition, such information may help inform national and state health workforce planners as they grapple with the challenge of projecting demand for different types of healthcare workers, some of whom have overlapping roles. Such projections have traditionally measured supply and demand for just one profession, but interest is increasing in more sophisticated models that consider alternative team configurations (Auerbach et al, 2013). Furthermore, organizations such as the Association of American Medical Colleges are particularly interested in identifying variables that can be used to develop local workforce planning tools (Dill, 2015).Researchers have argued for a complexity perspective on primary care, with greater attention given to how leaders manage competing goals and values, leam from their environment, and create emergent organizational forms (Felix-Bortolotti, 2009; Sweeney, 2006). In this study, we use a qualitative approach to explore how leaders of community health centers (CHCs) make complex medical staff configuration choices in their role as safety-net providers for 22 million low-income patients in the United States (Health Resources and Services Administration, n.d.). CHCs are a good venue for studying complexity in primary care because they require leaders to use tightly constrained resources to provide high-quality primary care to patients, regardless of their ability to pay (Rosenblatt, Andrilla, Curtin, & Hart, 2006). CHCs are seen as "in the vanguard of flexible staffing" because their leaders make tradeoffs and adapt to the environment to maximize resources in a difficult funding environment (Ku et al, 2015).METHODSParticipantsWe used the 2012 Uniform Data System (UDS), an annual administrative reporting system for CHCs that receive federal funding (Section 330 grantees), to identify a maximum variety sample (Patton, 1990) of CHCs with unusually high proportions of advanced practice providers (APPs) (i.e., nurse practitioners [NPs], physician assistants [PAs], and certified nurse midwives), nurses (registered nurses [RNs] and licensed practical nurses [LPNs] or vocational nurses), medical assistants (MAs), case managers, and community health workers. We selected three to five sites from each of these ftve categories for variety with regard to urban versus rural location, NP scope of practice (SOP), Medicaid expansion states versus Medicaid non-expansion states, and large versus small. We determined size (the last variable) on the basis of whether they reported more or less than 9,844, the median number of patients. This maximum variety sampling approach allowed us to analyze a wide range of ideas pertaining to staffing (Patton, 1990). …

As globalization advances, the governance challenges relating to cross-border labor recruitment have also grown. Transnational companies that manage the employment-based migration process often take advantage of individuals seeking work abroad. While some states have implemented recruitment regulations, a combination of jurisdictional constraints and economic interests have limited states' capacity and political will to take action. Supplemental strategies are emerging led by international organizations, non-governmental organizations (NGOs), labor unions, and corporate trade groups. This paper reviews the strengths and weaknesses of strategies led by each of these different types of actors and explores potential synergies among them. [ABSTRACT FROM AUTHOR]

Although numerous studies have shown that child obesity is associated with internalizing symptoms, relatively few studies have examined the role of parenting behaviors on this relationship. Youth meeting obesity status may be at higher risk of psychosocial maladjustment when exposed to more vulnerable parenting contexts. The current study interviewed mothers with a history of substance abuse to assess whether parenting behaviors moderated the relationship between obesity and internalizing symptoms among adolescents ( N = 160; 51% girls; M = 12.76 years). Hierarchical regression analyses identified physical discipline as a moderator; girls meeting obesity status displayed higher levels of internalizing symptoms when exposed to higher versus lower levels of physical discipline. Prevention/intervention efforts targeting mothers with substance abuse histories should aim to not only improve physical and emotional health but also highlight the connections between physical and emotional health and the influence of parenting behaviors on associations.

BACKGROUND Few studies have looked under the hood of practice redesign to understand whether and, if so, how staffing changed with the adoption of patient-centered medical home (PCMH), and whether these staffing changes impacted utilization. OBJECTIVES To examine the workforce transformation occurring in community health centers that have achieved PCMH status, and to assess the relationship of those changes to utilization, as measured by the number of visits. RESEARCH DESIGN, SUBJECTS, MEASURES Using a difference-in-differences approach, we compared staffing and utilization outcomes in 450 community health centers that had adopted a PCMH model between 2007 and 2013 to a matched sample of 243 nonadopters located in the 50 states and the District of Columbia. RESULTS We found that adopting a PCMH model was significantly associated with a growth in use of advanced practice staff (nurse practitioners and physician assistants) [0.53 full-time equivalent (FTE), 8.77%; P

Objectives This study focuses on whether and how Pioneer Accountable Care Organization (ACO) leaders believe the deployment of the registered nurse workforce is changing in response to the shared savings incentives. Methods Semistructured phone interviews with leaders from 18 of the original 32 Pioneer ACOs were conducted. Results Narrative analysis suggests that all of the organizations are developing new and enhanced roles for registered nurses across the continuum of care. Overall, eight types of changes were reported: enhancement of roles, substitution, delegation, increased numbers of nurses, relocation of services, transfer of nurses from one setting to another, the use of liaison nurses across settings, and partnerships between nurses coordinating care in primary and acute care settings. Conclusions This exploratory study suggests that Pioneer ACO leaders believe that payment models are affecting the deployment of the health workforce and that these changes are, in turn, driving outcomes.

Here, we present a case of a 31-year-old man with progressive cognitive decline, ataxia, and dystonia. Extensive laboratory, radiographic, and targeted genetic studies over the course of several years failed to yield a diagnosis. Initial whole exome sequencing through a commercial laboratory identified several variants of uncertain significance; however, follow-up clinical examination and testing ruled each of these out. Eventually, repeat whole exome sequencing identified a known pathogenic intronic variant in the NPC1 gene (NM_000271.4, c.1554-1009G>A) and an additional heterozygous exonic variant of uncertain significance in the NPC1 gene (NM_000271.4, c.2524T>C). Follow-up biochemical testing was consistent with a diagnosis of probable Niemann–Pick disease Type C (NP-C). This case illustrates the potential of whole exome sequencing for diagnosing rare complex neurologic diseases. It also identifies several potential common pitfalls that must be navigated by clinicians when interpreting commercial whole exome sequencing results.

The objective of this study was to assess the implementation of recommendations of the Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health.In 2010, the IOM made a series of recommendations aimed at transforming the role of nurses in healthcare delivery.We conducted a multiyear survey, in 2011 and 2013, with nurse leaders who were members of the American Organization of Nurse Executives, the National Nursing Centers Consortium, or the Visiting Nurses Association of America.When comparing 2013 to 2011, we find progress in instituting the IOM's recommendations in 3 areas: (1) raising the proportion of employed RNs with at least a bachelor's degree; (2) expanding the proportion of healthcare institutions with nurse residency programs; and (3) offering opportunities for continuing nurse educationOur findings suggest that healthcare organizations are transforming to support the recommendations of the IOM.

Community health centers are at the forefront of ambulatory care practices in their use of nonphysician clinicians and team-based primary care. We examined medical staffing patterns, the contributions of different types of staff to productivity, and the factors associated with staffing at community health centers across the United States. We identified four different staffing patterns: typical, high advanced-practice staff, high nursing staff, and high other medical staff. Overall, productivity per staff person was similar across the four staffing patterns. We found that physicians make the greatest contributions to productivity, but advanced-practice staff, nurses, and other medical staff also contribute. Patterns of community health center staffing are driven by numerous factors, including the concentration of clinicians in communities, nurse practitioner scope-of-practice laws, and patient characteristics such as insurance status. Our findings suggest that other group medical practices could incorporate more nonphysician staff without sacrificing productivity and thus profitability. However, the new staffing patterns that evolve may be affected by characteristics of the practice location or the types of patients served.

Objectives In recent years, electronic tobacco (e-cigarette/vaping) use among young adults has grown exponentially. Given past research linking obesity and cigarette smoking, assessing whether this relationship extends to electronic tobacco use is warranted. The current study examined weight status as a correlate of substance use patterns reflecting electronic tobacco use. Methods Survey data were collected from a convenience sample of 452 (59% female) undergraduates attending a large, public university during the 2015-2016 academic year. Latent class analysis (LCA) was conducted to identify substance use classes and examine weight status as a covariate of class membership. Results LCA analyses identified 4 classes: High Substance Use (19%), Risky Alcohol Use (14%), Cigarette/Electronic Tobacco Use (17%), and Low Substance Use (50%). Both obesity status and greater deviation from one's group body mass index (BMI) norm were associated with a higher likelihood of belonging to the Cigarette/Electronic Tobacco Use class. Conclusions Findings suggest that electronic tobacco use may fit well into previously established relationships between higher weight status and tobacco use. Future research should examine the longitudinal processes and pathways underlying the relationship between weight status and electronic tobacco use.

Although nursing education pathways have expanded access to the profession, fragmentation accompanying these entry points has created uncertainty among students about the desired end point, questionable efficiency and effectiveness of reaching career goals, and unclear merging mechanisms to enable seamless, linear progression. In response to these challenges and in anticipation of greater demands on nurses due to health reform, the Institute of Medicine (IOM) examined the capacity of the nursing workforce and proposed a transformative blueprint for change that relies on an education system to promote seamless academic progression. Despite support for this recommendation, little research exists regarding the best way to achieve the IOM’s vision. This study examined the most promising practices in design and implementation of alternative pathways for academic progression in nursing. Four case studies are presented that explore the challenges of designing alternative pathways and identify performance measures to assist with developing such programs. [ J Nurs Educ. 2014;53(6):329–335.]

The Institute of Medicine’s report, “The Future of Nursing: Leading Change, Advancing Health,” calls for “transition-to-practice” residencies for new nurses and nurses transferring to new types of settings. In this study, we examine the current residency landscape for home health and hospice nurses and compare it with responses from their peers in hospitals and nurse-led primary care clinics. We find that just 2% of surveyed home health and hospice settings offer residencies, while almost 49% of hospitals and 11% of nurse-led primary care clinics provide them. Major barriers cited include lack of available preceptors and financial costs. We discuss ways in which the federal government could help spur the development of residencies in this sector.

Objective: To determine whether foreign-educated nurses (FENs) perceived they were treated equitably in the U.S. workplace during the last period of high international recruitment from 2003 to 2007. Background: With experts predicting that isolated nursing shortages could return as soon as 2015, it is important to examine the lessons learned during the last period of high international recruitment in order to anticipate and address problems that may be endemic to such periods. In this baseline study, we asked FENs who were recruited to work in the United States between 2003 and 2007 about their hourly wages; clinical and cultural orientation to the United States; wages, benefits, and shift or unit assignments; and job satisfaction. Methods: In 2008, we administered a survey to FENs who were issued VisaScreen certificates by the Commission on Graduates of Foreign Nursing Schools International between 2003 and 2007. We measured four outcomes of interest (hourly wages, job satisfaction, adequacy of orientation, and perceived discrimination) and conducted descriptive and regression analyses to determine if country of education and recruitment model were correlated with the outcomes. Results: We found that 51% of respondents reported receiving insufficient orientation and 40% reported at least one discriminatory practice with regard to wages, benefits, or shift or unit assignments, FENs educated in low-income countries and those recruited by staffing agencies were significantly more likely than other FENs to report that they receive inequitable treatment compared with their U.S. counterparts. Conclusions: These findings raise both practical and ethical concerns that should interest those striving to create positive health care workplace environments and to ensure staff retention. Health care leaders should take steps to ensure that FENs are, and perceive that they are, treated equitably

The 2010 recommendation that the proportion of registered nurses with BSN (bachelor of science in nursing) degrees in the nursing workforce should increase from the current 40% to 80% by the year 2020 has shifted the focus on nurses educational progression from state legislatures-where changes in entry-level requirements were debated for decades-to the executive suites of large healthcare providers. The recommendation, contained in the report titled The Future of Nursing: Leading Change, Advancing Health, by the Robert Wood Johnson Foundation Initiative on the Future of Nursing at the Institute of Medicine, suggests that human resources policies for nurses have the potential to double the rates of college degree completions (IOM, 2010). We surveyed 447 nurse executives in hospitals, nurse-led clinics, and home and hospice companies to explore the current practices of healthcare employers with regard to this recommendation. Almost 80% of respondents reported that their institution either preferred or required newly hired nurses to have a bachelor's degree, and 94% of the facilities offered some level of tuition reimbursement. Only 25%, however, required their nurses to earn a BSN or offered salary differentials on the basis of educational attainment (9%). We conclude that if employers are serious about wanting a more highly educated nurse workforce, they need to adopt requirements for degree completion and wage differentials in the coming years. The likelihood that such policies will be widely adopted, however, is dramatically affected by the dynamics of nursing supply and demand.

The objective of this study was to determine the prevalence of hospital RN residencies and the associated factors.The 2010 Institute of Medicine/Robert Wood Johnson Foundation report, The Future of Nursing: Leading Change, Advancing Health, recommends the adoption of nurse residency programs.Members of the American Organization of Nurse Executives were surveyed, and covariates were identified.We found approximately 36.9% of all hospitals in our study offered a nurse residency in 2011. Associated covariates included not-for-profit status, midsize, and location in the South. Hospitals that offer residency programs were more likely to have other training programs.Findings suggest that residencies have been widely supported even in times of economic recession. It is important to track the expansion of these programs and to initiate research to examine the long-term impacts of residencies on nurse retention and clinical outcomes.

Objective This study examines nurse-related clinical nonlicensed personnel (CNLP) in U.S. hospitals between 2010 and 2014, including job categories, trends in staffing levels, and the possible relationship of substitution between this group of workers and registered nurses (RNs) and/or licensed practical nurses (LPNs). Data Source We used 5 years of data (2010–2014) from an operational database maintained by Premier, Inc. that tracks labor hours, hospital units, and facility characteristics. Study Design We assessed changes over time in the average number of total hours worked by RNs, LPNs, and CNLP, adjusted by total patient days. We then conducted linear regressions to estimate the relationships between nurse and CNLP staffing, controlling for patient acuity, volume, and hospital fixed effects. Principal Findings The overall use of CNLP and LPN hours per patient day declined from 2010 to 2014, while RN hours per patient day remained stable. We found no evidence of substitution between CNLP and nurses during the study period: Nurse-related CNLP hours were positively associated with RN hours and not significantly related to LPN hours, holding other factors constant. Conclusions Findings point to the importance of examining where and why CNLP hours per patient day have declined and to understanding of the effects of these changes on outcomes.

Objective To examine what different types of employers value in hiring community health workers (CHWs) and determine what new competencies CHWs might need to meet workforce demands in the context of an evolving payment landscape and substantial literature suggesting that CHWs are uniquely qualified to address health disparities. Study Design We used a multimethod approach, including a literature review, development of a database of 76 programs, interviews with 24 key informants, and a qualitative comparison of major CHW competency lists. Principal Findings We find a shift in CHW employment settings from community-based organizations to hospitals/health systems. Providers that hire CHWs directly, as opposed to partnering with community organizations, report that they value education and training more highly than traditional characteristics, such as peer status. We find substantial similarities across competency lists, but a gap in competencies that relate to CHWs’ ability to integrate into health systems while maintaining their unique identity. Conclusions As CHW integration into health care organizations advances, and as states move forward with CHW certification efforts, it is important to develop new competencies that relate to CHW–health system integration. Chief among them is the ability to explain and defend the CHW's unique occupational identity.

Background Despite the large numbers in health care industry, little is known about the clinical nonlicensed personnel (CNLP) in U.S. hospitals and how their staffing has changed over time. Purpose The purpose of this analysis is to better understand the conformation and recent trends in CNLP staffing in U.S. hospitals from 2010 to 2015. Methods Using Premier's OperationsAdvisor database, we examined trends in staffing of 25 CNLP jobs and graduate nurses (GNs) in U.S. hospitals and by hospital units, including medical–surgical units, outpatient units, and emergency departments, from 2010 to 2015, based on their skill levels. We measured CNLP and graduate nurse staffing using the average number of full-time equivalents (FTEs) in each hospital. We performed statistical analysis to compare the changes in the number of FTEs between 2010 and 2015. Discussion Over the 6-year period from 2010 to 2015, we observed declining trends in the average number of high-skill and middle-skill CNLP FTEs by 22% and 7%, respectively, and increases in the average number of low-skill and graduate nurse FTEs by 38% and 117%, respectively. This skill mix shift appears to be most pronounced in emergency departments. Conclusion Changes in staffing levels and the skill mix of the hospital workforce warrant further study to understand both the reasons behind the observed changes and their effects on health outcomes. Although labor efficiency is an important goal, it is also critically important to assess whether reductions and/or the skill mix shifts among support staff impact nurse workload and, by extension, patient safety.

OBJECTIVES Despite an increase in the number of foreign-educated nurses (FENs) working in U.S. hospitals and nursing homes, very little is known about the industry that brought them here. Our objectives were to learn more about the size and scope of the international nurse recruitment industry, its business models, and the range of countries where companies actively recruit. Based on reports from focus groups of FENs in New York City, we also sought to identify some of the problems that have occurred in the areas of contracting and clinical orientation. METHODS We used a combination of qualitative methods and secondary data sources, which included U.S.-based international nurse recruitment company Web sites, interviews with 20 executives from international nurse recruitment companies, two focus groups with FENs in New York City, and letters sent to the Philippine Nurses Association of America by FENs seeking legal advice. RESULTS Through a July 2007 Internet search, we found that at least 273 U.S. companies were actively recruiting FENs. While most such companies focused on the Philippines and India, about 20 companies were active in Africa. (A second search revealed that, as of January, at least 211 U.S. companies were actively recruiting FENs abroad.) Within the industry there is growing use of the staffing-agency model, which typically requires nurses to sign 18-to-36-month contracts and imposes high breach-of-contract fees. The focus group discussions with FENs in New York City revealed inadequate orientation programs and several types of labor abuses. CONCLUSIONS Concerns about recruitment practices, which were expressed by many industry executives and FENs, reveal the need for accountability within the industry.

Health insurance systems in Central and Eastern Europe have evolved in different ways from the centralized health systems inherited from the Soviet era, but there remain common trends and challenges in the region. Health spending is low in comparison to the spending of pre-2004 European Union members, but population aging, medical technology, economic growth, and heightened expectations will generate major spending pressures. Social health insurance is the dominant model in the region, but coverage is uneven. Key3reform issues include identifying ways to encourage additional investment in the health sector; and defining formal benefit packages, copayments, and the role of private insurance.