New Nursing Minimum Datasets Represent “Bottom-Up” Approach to Standardizing Workforce Information
By Alex McEllistrem-Evenson
As far as resolving issues of health workforce supply and demand are concerned, standardized data practices are crucial. Without them, it becomes incredibly difficult to forecast workforce supply and demand with any degree of accuracy. Most workforce data is necessarily collected and processed at the state level, but unfortunately, states differ widely not only in terms of the kind of health workforce data they collect but also in their collection methods and rationale.
In 2000, the Health Resources and Services Administration (HRSA) released a State Health Workforce Data Resource Guide which illustrates this situation: “While there have been a number of efforts over the past several years by individual organizations to improve their data collection and analysis,” the preface to the 120-page Guide states, “these efforts have been sporadic and targeted more toward organizational needs than policy imperatives.” Although little has changed over the course of the subsequent decade, there is at least some reason for optimism. Later this month, representatives from the 29 states which subscribe to the Forum of State Nursing Workforce Centers, a national group of nurse workforce organizations, will more than likely ratify minimum datasets in the areas of nursing supply, nursing demand, and nursing education programs which have been in development by the Forum over the course of the last year.
Mary Lou Brunell, past chair of the Forum’s Steering Committee and Executive Director of the Florida Center for Nursing, recalls that “as several of us became more involved in establishing workforce centers in the states and looked nationally at what we knew or didn’t know about the nursing workforce, it became evident that we knew very little.” At the time, a recommended minimum dataset already existed for nursing, courtesy of the Robert Wood Johnson Foundation’s Colleagues in Caring program, which began in 1994 and lasted through 2003. But according to Brunell, “that minimum data set, while a wonderful, symbolic beginning was just that: a beginning.” The fact that states failed to adopt the Colleagues in Caring recommended minimum dataset is evidence that it fell short in key areas. Notably, the Colleagues in Caring dataset only focused on nursing supply information. “Those of us who began working in these workforce issues saw it as not adequate to really answer the questions we needed answered,” remarks Brunell. “That in turn led to the question of what is adequate and what do we need to collect.”
“Licensure,” Brunell goes on to state, “is an important regulatory component for protection of the public and safety of the public. But it strictly looks at licensed nurses, not whether or not they [nurses] are working, where they’re working, how much they’re working, nor does it look at what the needs are.”
According to Dr. Jennifer Nooney, chairperson of the Forum’s Research Interest Group and Associate Director for Research at the Florida Center for Nursing, “the National Forum realized in June 2008 that we needed to standardize this, the elements that are being collected. And not just with nurse supply information, which is what Colleagues in Caring had tackled, but also information about nurse demand—from our nursing employers such as hospitals, nursing homes, and home health agencies—and critically, nursing education programs as well, because their output of new graduates tells us about the size and characteristics of our future nurse supply.”
When it’s demonstrably difficult to get states to adopt a single dataset, it may seem counterintuitive to expand the effort to include three. Nooney acknowledges that the Forum’s effort is “ambitious,” but it becomes clear that the manner in which these datasets were created sets this apart from the “sporadic efforts” of years past. Rather than a typical top-down approach, wherein an organization or a committee conducts a study and autonomously develops a minimum dataset, the Forum proceeded in the opposite direction. “I would challenge someone to improve on our process,” asserts Nooney. “I feel like we put together a rigorous approach to reaching consensus. That’s really what this is all about.” Brunell elaborates, claiming that “the beauty of the process that we used here is that it was conducted by and involved those who are doing this work and those who are using the information. That’s the difference as opposed to what can happen when a think tank says ‘we really need to know this,’ and then they don’t ask the right questions.”
A Rigorous Process
The Forum’s committee members – all of whom are volunteers – began with support from the Center to Champion Nursing in America, an initiative of AARP, to develop the three datasets. The first step was to establish a research group with representation from all subscriber states; they then conducted an assessment of nursing data practices in each state. Dr. Nooney describes the process in detail: “The first question we needed to tackle was ‘what is everybody currently doing?’ So we sent out a call for each state to submit surveys or code books to me and I worked with a team to see what are the most popular elements, what are things that are uncommonly collected, hoping that would point us towards standardization. We sent that back to the group for corrections, as we wanted to make sure of accuracy, and following that we took all of those elements that are pretty commonly collected, by a handful or more states, and I constructed a survey which asked all of our participants to look at each of these items and rank them on a scale of 1 to 4 in terms of their importance.”
“When we got responses back from the survey,” she continues, “it became really clear which items were most important for our work and which ones we could live without. Our goal was truly to derive a minimum data set. Because the more items you add the more difficulty and expense the states will have if they try to implement it. We really wanted to drill down to those core items.”
Following that, the Forum committee members broke into separate drafting groups of five members. There were three groups, each in charge of drafting a minimum nursing dataset for a different area: supply, demand, and education. This culminated in a data summit, held in March 2009 in Biloxi, MS. “There were 23 states with representatives at that data summit,” states Nooney. “We went over the drafts item by item, discussing the pros and cons of different measurement approaches.”
The Forum then took their process further by instilling a public comment period and specifically soliciting input from experts and representatives from national organizations, both public and private. They used this input to revise the datasets once again, and submitted the drafts to each of the 29 states that subscribe to the Forum. By a process of voting, the Forum is likely to approve the collaboratively-created datasets by September 2009.
This is hardly the end of the line, however. Widespread adoption of the datasets faces a number of practical obstacles, as Brunell clarifies: “There are financial, political, and even data reasons why adopting these might be tricky for some states. The Forum Steering Committee will be moving forward to talk with other national groups and organizations who might be interested in supporting, funding, and participating in the process.” Nooney adds that while there are natural partners for promoting the supply and education program datasets, such as state-level boards of nursing or departments of education, the same is not true for the nursing demand dataset. “The departments of labor likely are already stretched thin within their budgets – it might be an uphill battle for them to collect special information for nursing. And at the same time individual centers for nursing may not have the resources to conduct a survey.”
The Larger Need
“The larger need is for accurate national forecasts of nurse supply and demand,” explains Nooney. “As wonderful as they are, HRSA’s forecasts have limitations related to the data they use and assumptions they’re making about projections. They use sample data from a national sample survey of registered nurses which is only conducted every four years and does not have great state level representation. Sources like that limit their ability to accurately forecast what’s going to happen nationwide. Having complete supply, demand, and education data from each of the states built up to the national level will really improve the accuracy of forecasts. It seems to me the onus is really largely on the states to deal with nursing shortage issues. If more accurate national information were available, it might be possible to increase the level of federal funding for combating the shortage.”
“Information is power,” states Brunell. “Really, that’s the key point. We need to be able to influence the policymakers and those who are in decision making positions, and we must have this data and information to influence those decisions. There’s always been a tendency within nursing and perhaps within other fields as well to really emphasize education. But in all candor, for this particular shortage, there needs to be a nearly equal if not equal emphasis on retention. Because of the aging of the nurse population, we’re looking at a glut of experiential knowledge that newly educated nurses are not going to be able to fill. We must emphasize lengthening the employment and retention of nurses within the profession as well, and that data really helps you demonstrate those issues to legislators and chief executives in the health system and so forth.
“The other piece that the data will really be valuable for,” she continues, “is evaluation. The government has committed a lot of money to nursing over the last few years, both in states and nationally. We don’t know if it’s made any difference. Having the ability to say ‘this process made a difference because we can see the change’ is crucial, and waiting for HRSA’s forecasts every four years is not timely enough to adjust strategies. Those same types of needs for data and information, of course, are relevant to other fields as well.”
Despite an intense focus on state-level data, the Forum has an eye on the national landscape of health care and health care reform as well. There is a concern among the research community that any national reform which results in a public health care option may lead to a situation where current health workforce supply and demand data becomes instantly outdated, due to the likelihood that more people will attempt to access health care. “There’s little doubt in my mind that health care reform is going to have an impact,” states Brunell. “It’s not taken into consideration in [nurse workforce] forecasting. I believe personally that if health care reform is enacted and we are providing services – be it preventative or curative – to larger numbers, we will see an additional increase in the demand for nurses. We’re in this blip period where the economy has given us a false sense that the shortage is lessening. Between recovery of the economy and the implementation of some degree of health care reform, I believe those two factors are going to have a significant impact on the demand for nursing workforce. At the same time, the faster we can implement these minimum data sets, the better we’ll be able to see what impact that’s having, project the need, and respond to it.”
Reform or no, the ultimate impact of these standardized nursing data sets will likely trickle down to the patients themselves. “I think that the literature has really exploded over the last ten years with articles looking at the impacts of nurse staffing levels on patient outcomes,” as opposed to other factors, adds Nooney.
Referring to nationwide adoption of the minimum datasets, Nooney estimates that “we’re a few years out from pulling this all together,” although it’s clear that the increased national emphasis on health care reform may increase the state-level impetus for accurate and standardized nursing workforce forecasts. “But the very first step is obviously reaching consensus on what it is we should be collecting and so I’m very proud that we’ve reached that point.”
Consensus seems to be the critical factor in the Forum’s successes thus far. “It’s a grassroots process,” states Nooney. “I’ve personally been interacting with folks in several states who have been working very hard in the last six months within their state—with nursing groups, with boards of nursing, with hospital associations—to really ramp up their data collection efforts. As we move forward realizing that care is coordinated across so many different disciplines, in hospitals and other places where health care is delivered, it’s going to be critical that all health care workforce fields do some work with standardizing data, potentially following some of the groundwork that the Forum has laid with nursing.”
“The leadership has come together,” continues Brunell. “I think a lot of our success reflects the nature of state nurse workforce centers – committed to assuring adequate, qualified supplies of nurses to meet the needs of their state while approaching their work through open, collaborative means. The fact that so many of our nursing workforce centers are state-based is important … we need to help state governments understand and value this work because that’s who the critical partners are going to be to help fund this project. The ongoing collection is going to have to be funded at some point at the state level.”
At a time when the debate surrounding health care in this country could not be more polarized and volatile, it is reasonable to believe that the Forum’s unique approach to standardizing data practices – built on collaboration and common ground—may find success. Dr. Nooney acknowledges this as well.
“The planets are aligned.”