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In 2003, the Colorado Permanente Medical Group (CPMG), a 780-member, multispecialty physician group that provides ambulatory and hospital care principally in metropolitan Denver and Boulder, embarked upon a multifaceted program to leverage physician leadership to address the nursing shortage. Designated as the “Preferred Clinical Partner Program” (the PCP Program), CPMG sought to participate in solving the nursing shortage by engaging in a number of initiatives. Through an initial fund of $1 million, over $350,000 was used to fund nursing scholarships, over $150,000 was used to provide advanced training to a select group of health care professionals in a program that may be the first physician-partnered MA-to-LPN and RN-to-BSN initiative, and over $500,000 was devoted to building and expanding nursing simulation laboratories. Currently, the accelerated nursing program graduates approximately 32–35 nurses each year and has admitted its seventh cohort of students. Student retention has been excellent.
In 2003, the Colorado Permanente Medical Group (CPMG), a 780-member, multispecialty physician group that provides ambulatory and hospital care principally in metropolitan Denver and Boulder, embarked upon a multifaceted program to leverage physician leadership to address the nursing shortage. Designated as the “Preferred Clinical Partner Program” (the PCP Program), CPMG sought to participate in solving the nursing shortage by: a) funding nursing scholarships, b) building nursing education capacity by funding and developing educational programs, c) utilizing physicians as faculty and mentors, d) clarifying leadership and partnership expectations for physicians, and e) developing physician-nurse relationship training programs. The strategy of the PCP Program was to be comprehensive and innovative in the drive to stimulate interest, develop capacity, and offer opportunities for nurses and other future health care team members. The development of the PCP Program is explained more fully in Physician as Healer, Leader and Partner: Tackling the Nursing Shortage.1 Six years later, we look back to assess the impact of the PCP Program in helping to address the nursing shortage in Colorado.
The shortage of nurses has severe implications for affordability, accessibility, and the quality of health care. In 2000, the US Department of Health and Human Services (DHHS) identified Colorado as one of 30 states with a nursing shortage. The 2000 supply-versus-demand comparisons by DHHS projected a shortage of 11% (3656 nurses) by 2007 compared with the national nursing shortage trend at 6%. The shortage was expected to grow slowly until 2010, at which time demand was expected to accelerate and exceed supply in 2020 by 31%. DHHS anticipated a 40% increase in demand for RNs between 2000 and 2020 with growth of this labor pool at a modest 1.7% annually.
In 2000, CPMG physicians began to experience the effects of an acute and, in some situations, crippling shortage of nurses—aggravated by local geography. Patients were being diverted away from CPMG's urban partner hospitals and four new hospitals under construction on Denver's periphery posed an additional challenge as they vied for nurses who preferred to work closer to home. Classified advertisements in local newspapers showed some urban hospitals were offering an additional per diem of $50—simply for driving to work. This impending crisis caused CPMG to take action to maintain high-quality, affordable care.
Rather than sit back and let others “fix” this increasingly severe problem, CPMG decided to be a part of its solution. CPMG's Board of Directors authorized a contribution of $250,000 to provide scholarships and other financial assistance to help prospective nursing students and to build the educational infrastructure necessary to accommodate them.
With this commitment in hand, matching grants were obtained from Kaiser Foundation Health Plan of Colorado and Exempla Healthcare. Thus, what began as a relatively small scholarship program grew into a fund of more than $1 million. Funds obtained through the generosity of these institutions have been put to good use over the past six years. See Table 1 for a summary of the disposition of the funds.
Over $350,000 was used to fund nursing scholarships. These scholarships were awarded to an ethnically diverse and deserving population of prospective nurses. More than 130 individuals who might not have had the opportunity to pursue nursing careers have been able to do so because of these scholarships. In addition, the recognition and publicity that these students obtain in connection with the award of these scholarships has generated interest in nursing well beyond the scholarship recipients alone.
Over $150,000 was used to provide advanced training to a select group of health care professionals. In a program that may be the first physician-partnered MA-to-LPN and RN-to-BSN initiative, professionals who already had dedicated themselves to the health care field were able to advance their skills, increase their scope of practice, and obtain higher paying jobs. The ability to envision a robust career path has led to improved career satisfaction, which will lead to lower nurse turnover and fewer nurses abandoning the health care field. Thus far, this program has seen 128 nursing students receive BSN degrees, and 32 MAs receive LPN licenses.
Currently, the number of graduates from the accelerated nursing program has stayed consistent at approximately 32-35 graduates each year. The program has admitted its seventh cohort of students. Student retention has been excellent. To date, a total of two students did not complete the program; a third is returning this spring following withdrawal last year. Consequently, the program has generated an impressive attrition rate of only approximately 1.5%.
In 2007, US nursing schools turned away 40,285 qualified applicants due to lack of faculty resources and funding.2 Educational capacity is one of the chief obstacles to entry into the nursing profession. There are simply not enough teachers, educators, or facilities to train the number of nurses needed. And every time a nurse steps away from the bedside and into a classroom, a critical hospital bed may become unavailable for patient care. Funds must be used in creative ways to provide needed infrastructure without “stealing from Peter to pay Paul.”
By devoting over $500,000 to build and expand nursing simulation laboratories, the PCP Program accomplished this end. Nurses can learn how to insert an IV or a chest tube or practice birthing procedures using this simulation equipment. Such equipment enables more students to practice needed skills, and requires fewer educators to supervise the training. This, in turn, enables our most senior nurses to remain at the bedside, caring for our most critically ill patients.
Finally, the funds were used to help open the Colorado Center for Nursing Excellence (the Center) and a CPMG physician leader was on the founding Board of Directors. Today, the Center creates public awareness of the nursing workforce shortage and stimulates attraction to the profession, ensures statewide access to capacity-building, lifelong learning opportunities for nursing personnel, promotes innovation that increases workforce retention and professional satisfaction, and provides a sustainable resource for the public and the health care community. It works to expand and enhance nurse recruitment and retention efforts, expand the capacity of the academic nursing education system, strengthen the collaboration between practice settings and education systems, and consistently monitors, reports, and evaluates the status of the nursing workforce. Working in partnership with the Center, CPMG established a clinical nurse scholar program that aims to increase the number of qualified nurse educators in the Region. CPMG continues to provide in-kind support annually. To date, these efforts have introduced hundreds of new nurses into the profession and touched thousands more who receive state-of-the-art training and education made possible by physician partnerships.
Although financial support and community partnerships are critical to expanding the supply of qualified nurses and the capacity of the nursing educational infrastructure, another key component of the PCP Program was to drive a cultural change in the work environment for nurses in order to enhance the likelihood that nurses would remain satisfied in their work environments over time. The PCP Program commenced with evidence-based education for physicians on the impact of their behavior on their nursing partners. This work also included the funding of new positions, including a manager for the physician-supported nursing program, a director of program development who oversaw orientation and communication training, and a CPMG board-certified physician “coach” who consulted one-on-one with physicians who struggled with staff interactions. In addition, CPMG adopted a “zero-tolerance” policy—backed by a robust performance management system that included an annual review, with feedback provided by nursing colleagues. The combination of agreement on a set of principles and a rigorous management system to support those principles helped CPMG achieve its goals—nursing satisfaction increased, and nursing turnover declined. At the same time, overall physician satisfaction improved, and patient satisfaction scores reached all-time highs.
CPMG is continuing to support the formation and use of multidisciplinary clinical teams. Chronic care nursing coordinators, clinical pharmacists, and physicians work side-by-side to help chronically ill patients in a variety of disease management programs. Having these teams embedded in clinics is critical to improving overall quality, nurturing respect, creating a positive work environment, and building collaboration among professionals.
Like many persons of a certain age, I became a caregiver—not just to my patients—but also to my parents. As I sat at their bedsides in a Denver hospital, I had the bittersweet opportunity to see the art of healing that my nursing colleagues bring to their patients and to their profession. Now, each summer, my family gathers in the auditorium of that hospital to celebrate the lives of my parents, and to award a scholarship to a nurse in the oncology unit. I share this personal story to illustrate a much larger point. Let's not wait until we watch a loved one suffer to value our nursing colleagues for their exceptional skills in carrying us through these painful experiences. Let's recognize the leadership, education, and power we represent as physicians and not remain silent on the subject of the nursing shortage. CPMG's initial physician prescription for the nursing shortage suggests there are three key ingredients—financial investments, community partnerships, and a focus on physician behavior—that may offer a lasting cure. Let's opt in, fix ourselves, fix our systems, and extend a hand of support to our partners in the nursing profession. Our patients' lives depend on it.
The trained nurse has become one of the great blessings of humanity, taking a place beside the physician and the priest, and not inferior to either in her mission.
— Nurse and Patient, William Osler, MD, 1849-1919, physician, professor of medicine, and author