Online Exclusive: Nursing Professionals’ Roundtable

INSIGHT Into Diversity recently spoke with three nursing professionals about various issues within nursing education and practice. They offered insight into the increased demand for diversifying the profession, the call for more highly educated nurses, and more.

Cherie-RebarCherie Rebar, PhD, RN, is a professor in the Division of Nursing at Kettering College in Ohio, as well as an adjunct professor of nursing at Indiana Wesleyan University. She is also co-founder and co-president of RN2ED, an organization dedicated to bridging the gap between clinical nursing practice and education. She has written and edited many nursing textbooks and other resources.

Peter-McMenaminPeter McMenamin, PhD, is senior policy adviser for the American Nurses Association (ANA), where he serves as the organization’s health economist with expertise on the economic value of nurses and nursing services. He previously served as director of healthcare financing policy for the American Medical Association and has worked in or with a number of government civilian health agencies.

VlahovDavid Vlahov, PhD, RN, is a professor and dean of the University of California, San Francisco (UCSF) School of Nursing. He previously served as a professor at Johns Hopkins University and Columbia University, as adjunct professor at several prestigious nursing and medical schools, and as co-director of the Robert Wood Johnson Foundation’s Health and Society Scholars program.

Where have you noticed gaps, or disparities, in nursing — in regard to the types of communities and populations served, areas of nursing practice, and healthcare settings, among others? How do you recommend addressing these issues?

Rebar: Veterans are a population that we have not yet focused our full attention on within the profession of healthcare in general. Part of the reason I think we are seeing more of this is we have veterans right now from conflicts dating back to World War II who are still living, and not only do they have physical needs, but they also have many emotional and mental health needs that are so important to focus on. Many of our Vietnam veterans have mental health needs that, in my perspective, did not receive the same type of addressing that their physical needs did, and we are now seeing a very young generation coming back from Afghanistan and Iraq that is experiencing the same things as our Vietnam vets. So mental health and access to care for these folks is critical. … That is where I see the largest gap, in our availability to meet with them in a timely fashion.

How do I recommend addressing these issues? I think we need champions in healthcare for veterans care. Veterans can advocate for their care, veterans’ groups can advocate for their care, but we need champions within the profession of healthcare who recognize that on the front end and also advocate for this population.

McMenamin: In the short run, I have no idea. People ask me, “Where are they hiring?” We don’t have data that tell us that. I do know that registered nurse (RN) is the single most advertised position in the U.S., and it has been for several years.

What needs to be addressed is … more than 3 million people will age into Medicare every year, until at least the end of the century. That figure will be 4 million per year starting in 2050 and 5 million per year starting in 2085. On average, by 2019, 10,500 baby boomers will age into Medicare each day. Generation X is only 3 percent smaller than the baby boomer generation; they will be aging into Medicare at the rate of 10,124 per day. Millennials are only 10 percent larger and will be aging in at 11,521 per day. The generation after millennials will be aging in at 12,606 per day.

So, when nursing students ask, “What should I be specializing in?”, [I say] care for the elderly, care for people with multiple chronic conditions, end-of-life care. That is the gap that I worry about because of the dramatic increase in the number of deaths — the death rate is going to stay about the same, but the number of people dying will dramatically increase. And end-of-life care will become a much more significant part of what all clinicians have to deal with. … Those people are going to need care.

Vlahov: One could look at that as, “Do you have adequate data on the nursing workforce to identify where the shortages are?”

Right now, the kinds of data that are available, to really [be able to] authentically address the [issue], need to be supplemented. We need better data to be able to drill down on that question. But even if we did, it’s not like it is something that is centralized that we can address. I think nurses have to look within their own communities and see where the needs are.

If you were to ask me what is the overall trend of where there are going to be needs, particularly with healthcare reform, [I would say] it is going to be in transitional care, particularly in home health, as we help people to live independently in communities. How do we keep people out of the hospital, and then once they come from the hospital, how is it that we smooth that transition and enable them to live independently in communities and also assist with the family care burden? I see that as the biggest need overall, and certainly the fastest-growing profession in the U.S. is home healthcare; that is because the need is increasing — not just because of healthcare reform, but also because of the demographics in the United States.

Really getting better data to look at [regarding] where the different shortage areas are, that would certainly be helpful for schools of nursing in how we prepare; you know — what kinds of specialties should we be training in, what areas should we be concentrating on?

The demographics of the country are changing, and we want the profession to match the changing face of those demographics. We need diversity of thought, culture, and life experience.

In recent years, systemic issues within the U.S. Department of Veterans Affairs, specifically the Veterans Health Administration, have come to light, such as nine-month-long wait times for mental health treatments. What do you believe should be done to correct the system and provide our nation’s veterans better care?

Rebar: What I believe should be done to correct the system, first of all, is awareness; this should take place at a population level, but also at the pre-licensure level. … It is critical that we look at underserved populations when students are still in an educational setting and provide them with guidance for how to care for certain populations.

The reason I say this has to take place at a pre-licensure level is because students can learn to care for [veterans] in the community setting, but also hopefully we can inspire people who will want to go on to become nurse practitioners, who often are in underserved areas. So if they learn at the pre-licensure level that they could specialize in caring for veterans, then hopefully they will go straight on to a bachelor of science in nursing (BSN) and then onto a doctor of nursing practice (DNP) program. That would improve access, as well as [lead to] more practitioners.

McMenamin: The challenge that Veterans Administration (VA) Secretary Robert A. McDonald faces right now is … not only is there the current scandal about wait times, but if anything, it is likely to get worse because Vietnam vets are aging into Medicare, and their health needs are going to increase.

The other challenge is a little-known regulation that says that when a veteran is eligible for veterans health benefits, the VA is the primary payer; however, before veterans age into Medicare, the VA must bill any private insurance a veteran has to cover part or all of their bills; the VA can’t bill Medicare — unlike their bills to private insurance that might have covered some costs. The extra coverage from any private insurance disappears when a veteran turns 65 and enrolls in Medicare.

So the VA’s costs are going up because there are more people with more problems, and with this, no private insurance offset, … it needs more money. This should not be a hard lesson for Congress, but I think it is one that it should recognize. If the VA has more money, then it could hire more [nurses]. The VA is one of the largest, perhaps the largest, employer of RNs. It has something like 66,000 RNs and advanced registered nurses — as of July 2015 — and it should be hiring more.

Vlahov: I think one of the biggest issues is a shortage of providers, and so [how] can we work with the VA to help it recruit and retain high-quality clinicians?

I can tell you, at UCSF, we have built a very strong relationship with the VAs that are within the Bay Area, and the idea is to build what we call “academic nursing” — [looking at] how we can have closer links so that our faculty can work with VA nurses and nurse practitioners and also have a stream whereby they can come to the school. So how is it that we can increase capacity? How is it that we can have a farm system, if you will, where students become introduced to the VA, see the wonderful possibilities there, and the VA can look at them as they are going through school to develop a relationship through which [they] are able to recruit and retain high-quality nurses and nurse practitioners? I guess the magic word there is “pipeline.”

Alexandra Vollman is the editor of INSIGHT Into Diversity.