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The Affordable Care Act, Nurse Supply, and Faculty Retention:
Predictors of Intent-to-Leave Academic Nursing
Linda Flynn, PhD, RN, FAANAssociate Dean & Professor
University of Colorado College of Nursing
Study Funded by …..
a research grant from the Robert Wood Johnson Foundation #66936 to………………….
Michael Yedidia, PhDRutgers Center for State Health Policy
Principal InvestigatorProject Director, Evaluating Innovations in Nursing Education
Increase of 16-34 million people insured (34 million by 2016) (Congressional Budget Office, 2012)
By 2019 increase of 15-25 million primary care visits per year (Hofer, Abraham, & Moscovice, 2011)
Shortage of approximately 12,000 – 41,000 primary care physicians by 2025 (AAMC)
Impact of Affordable Care Act
According to HRSA 2012….NO.
HRSA estimates that supply of NP will increase 30% by 2020 and PA supply will increase by 58% by 2020.
The increase in NP and PA supply will reduce PCP shortage from 20,000 PCPs to 6,000 PCPs.
Is there a Nurse Practitioner Shortage?
In Colorado…..
◦State graduates 125 new NPs per year◦A total of 140 NPs retire each year….(CCNE).
◦Supply not keeping up with demand from retirement NOT counting population growth nor impact of ACA.
Is HRSA Being a Bit Optimistic?
◦Only 18% of NPs practice in rural areas (American Academy of Nurse Practitioners)
◦Yet, 20-25% of residents live in rural areas
◦An additional 4,000 primary care providers needed in rural areas (National Conference of State Legislators).
Are Rural Areas Adequately Served?
BLS estimates RN demand up 26% (1 million RN increase) by 2020.
1/3 of increase in RN demand will come from ACA (333,333 RNs).
RNs needed in home health care will increase 55% between 2010-2020.
RNs needed for Primary Care Practices / Medical Homes = more training / education.
Impact of ACA on RN Demand(Spetz, 2014)
Increase in NP demand expected, especially for rural areas.
Demand for RNs will increase, particularly in outpatient settings and home health care.
RNs increasingly need skills as care coordinators, case managers, patient educators, and chronic care specialists.
Increased pressure on educational pipeline.
Summary: ACA Impact on Nurse Demand
….Unfortunately the goal to increase educational capacity is hampered by faculty shortages….
Total of 78,089 qualified applicants turned away in 2013.
Total of 1,358 existing faculty positions unfilled in 2013; an additional 98 new positions needed.
Faculty vacancy rates of over 8% nationwide.
Wave of faculty retirements expected.
Nurse Faculty Shortages (AACN, 2014)
Inadequate doctoral-prepared pool and pipeline.
Non-competitive salaries.
Aging faculty workforce.
Attrition of existing faculty for other than retirement (Fang & Bednash, 2014).
Contributors to Faculty Shortages (AACN, 2014).
But….does the faculty work environment contribute to faculty shortages?
Practice Environment• Resource Adequacy
• RN/MD Relationships• Foundations for Quality
• Input Into Affairs• Supportive Manager
Nurse Outcomes
Patient Outcomes
Processes of Care
The Nursing Organization & Outcomes Model
NurseStaffing
Surveillance
Facility Characteristics
(Aiken, et al., 1998; 2001)
Nurse Burnout◦ Aiken, Clarke, Sloane (2002); Aiken et al. (2008); Lang et al. (2012);
Flynn, Thomas-Hawkins, Clarke, 2009 Van Bogaert et al. (2010).
Job Satisfaction / Intent-to-Leave / Attrition ◦ Choi, Flynn, Aiken (2011); Flynn (2007); Flynn, Thomas-Hawkins, Clarke
(2009); Van Bogaert, et al. (2010).
Poor Patient Outcomes◦ Kutney-Lee, et al. (2009); Flynn, et al., (2012); Flynn, Liang, Dickson, &
Aiken, 2010; Jarrin, Flynn, Lake, Aiken (2014).
In Practice Settings……Work Environment Associated With
What are the modifiable aspects of work-life that are associated with burnout and intent-to-leave among nurse faculty?
Research Question:
Stratified random sample of full-time faculty.
Sample proportionately representative of all US programs by prelicensure offered (BS, AD); urban/rural; research intensity.
Total of 3,975 faculty invited to participate in survey; 78.5% response rate!
Final Sample = 3,120 faculty from 269 schools of nursing.
Methods: Sample
Characteristic Mean (SD) Percent
Age 51.4 (9.38)
Within 5 years of retirement
15.8%
Female 95%
White 88%
Education
Master’s 70.6%
Doctorate 19.7%
Research Institution 25%
Rank
Professor 16.7%
Associate Professor
19.4%
Assistant Professor 30.8%
Instructor 28.8%
Sample: Individual Characteristics
76% taught in Pre-Licensure Program 24% taught in Graduate Programs
46.2% taught in schools offering ADN 53.8% taught in schools offering BSN or > 21.4% taught in schools in rural areas
28.6% were tenured 20.8% on tenure track 24.4% NOT on tenure track 26.2% school does not offer tenure
Sample: Program Characteristics
Burnout (Emotional Exhaustion)◦ Maslach Burnout Inventory EE Subscale
Intent-to-Leave Academic Nursing◦ How likely to leave in next 5 years (4-point scale)
Demographics◦ Age, gender, race/ethnicity, highest degree◦ Health Status
Methods: Measures / Survey Items
Institutional Characteristics◦ Degree Programs Offered◦ Research Intensity◦ Urban/Rural Locale
Job Characteristics◦ Years in current institution◦ Rank◦ Tenure Status / Tenure Track/ Non-Tenure Track /
Tenure Opportunity◦ Teaching post-BSN students
Methods: More Measures / Items
Administrative Responsibilities
Salary Range
Certified APRN
Measures: Other Job Characteristics
Hours spent per week on….
◦ Didactic Teaching / Prep◦ Clinical Teaching / Prep◦ Committees / Meetings◦ Advising / Mentoring Students◦ All Work Activities
◦ Developed 1 Course / 1 Major Course Revision ◦ Developed 2 Courses/ 2 Major Course Revisions◦ Converted 1 or more courses to online format◦ Published 1 or more articles in p-r journal ◦ Prepared 1 or more grant proposals
Measures: Workload
Measures: Satisfaction with Work-Life Conditions of Work
◦ Workload◦ Salary◦ Benefits◦ Job Security◦ Resource Availability
Content of Work◦ Flexibility to balance
work/family◦ Autonomy/Independence◦ Relationship with Adm◦ Relationships with
Students◦ Relationships with
Colleagues◦ Meaningfulness of Work◦ Rewards for Innovations◦ Visibility in Job
Mean hours worked = 48.3 hrs / week.
34.2% Major revision of 2 or more courses
19.8% Published 1 or more p-r articles
28.3% Submitted 1 or more grants
67.7% >61 plan to retire in 5 years
85% Very – Somewhat Satisfied with their
work
Findings: The Good News…Sort Of
39% High Levels of Burnout! Higher than staff nurses in hospitals and
nursing homes!
20% Younger faculty intended to leave Academic Nursing within 5 years
31% 51-60 yrs old intended to leave Academic Nursing within 5 years
Findings: The Not So Good News
Faculty who were APRNs were 1.5X more likely to intend to leave!
OR = 1.56, (1.25, 1.95), p <.001.
Predictor OR CI p
Within 5 years of retirement age 6.41 (4.77,8.62)
<.001
Highest Degree BSN 2.70 (1.58,4.62)
<.001
Highest Degree Master’s 1.91 (1.42,2.56)
<.001
On Tenure Track but not Tenured 1.50 (1.08,2.08)
<.05
Not on Tenure Track 1.49 (1.02,2.16)
<.05
High Burnout (EE) 1.27 (1.00,1.61)
<.05
Dissatisfied with Workload 1.26 (1.08,1.47)
<.01
Dissatisfaction w/Teaching Support 1.19 (1.01,1.40)
<.05
Dissatisfaction with Salary 1.18 (1.02,1.35)
<.05
Dissatisfaction with Reward for Innovation
1.16 (1.04,1.29)
<.01
Other Predictors of Intent-to-Leave
Predictor OR CI p
Dissatisfaction with Workload 1.82 (1.55,2.13) <.001
>50% Administrative Role 1.73 (1.32,2.27) <.01
Dissatisfaction with Flexibility to Balance Work and Family Life
1.58 (1.37,1.82) <.001
Poor Health 1.46 (1.28,1.67) <.001
Dissatisfaction with Meaningfulness of Work
1.36 (1.14,1.63) <.01
Dissatisfaction with Direction of Department / School
1.27 (1.09,1.48) <.01
Hours Worked per Week* 1.02 (1.10,1.03) <.001
Race / Ethnicity Non-White 0.68 (0.49,0.93) <.05
*Increase from 40 hrs – 50 hours of work per week associated with 22% higher odds of burnout.
Predictors of Burnout
Constellation of Work-Life factors equal to retirement age in predicting intent-to-leave academic nursing!
◦ Burnout Workload / Hours per week worked Lack of flexibility to balance work / family life
◦ Dissatisfaction with Workload◦ Dissatisfaction with Salary / Reward for Innovation◦ Dissatisfaction with Teaching Support
Discussion
Monitor faculty workload / perceptions
Implement strategies to increase flexibility of schedules
Implement strategies to increase teaching support
Recommendations
Explore needs of APRN faculty
Explore needs of Non-Tenure Track Faculty
Explore needs of Academic Leaders
More Recommendations
Planning grant funded by RWJF
Schools invited to join as Members
Annual Faculty / Student Survey (electronic) for Member Schools / Outcome Driven
Large Database of De-identified Data / Schools own their data
Benchmarking Capabilities
www. NNERN.org (Under Construction)
National Nursing Education Research Network(NNERN)
Questions / Comments / Dialogue
