AACN Issue Bulletin
July 1995

Even before hospital downsizings climbed to their current pace, the number of newly licensed nurses reporting "many jobs" available to them in summer 1993 had plummeted to just 6 percent, down from 37 percent in 1992 and 63 percent in 1990, according to the latest survey by the National League for Nursing. More than half (53 percent) reported "very few" jobs available, with 27 percent reporting a "fair number" of available positions.

Most new RNs (64 percent), however, found jobs before graduating from nursing school, and nearly 90 percent found employment within three months of graduation. However, while most (81 percent) secured hospital positions, that number was down from the 91 percent who did so two years earlier. Moreover, the ranks of graduates moving into community-based settings and long-term care continued to climb, to 5 percent and 11 percent, respectively, according to the survey of more than 61,000 new RNs who received their licenses in July 1993. Of those surveyed, 65 percent responded.

Giving Graduates a Jump Start

Falling inpatient volumes and a growing outpatient market have moved some hospitals to innovative steps to ensure their future nurse staffing. One such outlet is Boston's Beth Israel Hospital, which offers graduates from bachelor's- and graduate-degree nursing programs a two-year residency combining hands-on teaching with mentorship and career planning. The hospital's Clinical Entry Nurse Residency Program gives new nurses a structured first-work experience and on-going support not found in other facilities' more conventional six-week orientation periods.

"If we had not planned this program three years ago when the first class was admitted, we would have been like so many other hospitals in the area that are not taking new graduates," says Joyce Clifford, developer of the program and Beth Israel's vice president for nursing, in a recent interview in Syllabus, the newsletter of the American Association of Colleges of Nursing (AACN). "Because health care is in such a dynamic state of flux, you cannot put new people into any setting without more structure or help for them. We have an aging population of nurses in this country and at some point they're going to retire. We need to be sure we've got new graduates coming in who are well-prepared."

To allow for new residents, Beth Israel reorganized nurse staffing patterns in its medical, surgical, and high-risk OB-GYN units. Each resident is teamed with a clinical nurse sponsor and is guided beyond mere skill acquisition to become "socialized" to professional roles and values, such as how to work on interdisciplinary teams and follow a patient's illness throughout its course across hospital, home, and other settings.

Unique Needs

Once hired into managed care, however, graduates must manage far more than did new nurses just 10 years ago. "They have to manage other nurses, other personnel and resources -- really manage the whole environment -- and be accountable for the bottom line in ways they've not been in the past," says Mary Ann Parsons, dean of the College of Nursing at the University of South Carolina.

Indeed, an inpatient nurse would find it difficult to perform in most managed care settings without additional training, says Jan Wuorenma, nursing and reception services administrator for Health Partners, a Minneapolis-based HMO serving 250,000 clients in 24 centers. On a typical day, a Health Partners RN sees or talks to as many as 40 patients, compared to hospital nurses who may see five or six. "Nurses here need to deal with volume and speed" while still maintaining quality, and must have the communication skills and mindset that fit a service business. In particular, she says, new graduates and experienced acute-care nurses still lack vital skills in counseling and triaging patients by telephone, an activity central to HMOs and other managed care sites.

A Unified Curriculum

To adapt coursework for bachelor's-degree programs, educators and managed care leaders in a project funded by the Aetna Foundation have developed a model curriculum to prepare nursing graduates for managed care practice. Supported by a grant from Aetna to the American Nurses Foundation, the model's content gives students an overview of how nurses' roles fit within the overall scheme of managed care. The curriculum, which the course outline calls "essential" for all professional nurses prepared with the baccalaureate degree, has been endorsed by AACN and other nursing groups. The model provides students with a framework for carrying out managed care objectives in hospitals and increasingly dominant alternative sites, such as outpatient centers, day surgery facilities, home care, and hospices.

Users of the course have the flexibility to adopt it outright or incorporate pieces into existing curricula. Content focuses not only on new directions in health care -- such as community-based practice, interdisciplinary collaboration, and the shifting emphasis from illness care to prevention and health promotion -- but also on leadership and management roles, health care economics, cost-efficiency, health care payment plans, computerized information systems, total quality improvement methods, ethical issues in managed care, and steps for evaluating nursing staff performance. According to course materials, graduates learn to view the health system "as a multidisciplinary, multifaceted entity with a variety of entry and access points along a continuum of care."

Moreover, recent position statements by AACN urge nursing schools to include coursework on health care financing and to expand students' understanding of other economic factors such as reimbursement issues and the costs versus benefits of a patient's care. AACN also has called on deans to provide students with interdisciplinary experiences in the classroom and in clinical rounds.

What Schools are Doing

Starting in fall 1995, master's-degree students at the University of San Diego School of Nursing can elect a new specialty that prepares nurse case managers to care for vulnerable groups including high-risk patients, disadvantaged minorities, and the chronically ill. In addition to clinical training, students will work with nurse case managers in a variety of settings and take such core courses as health policy and the management and financing of health care systems. Graduates would be eligible to coordinate nursing care for patients in acute- and long-term care facilities, as well as in community and home health settings.

With their curricula contained within a fixed number of credit hours and semesters, schools that cannot add new courses are enhancing the content of what they already teach. Discussions of managed care have become part of undergraduate classes on professional issues and leadership at the University of Minnesota School of Nursing. At the master's-degree level, the school's nurse practitioner students are learning how prescription-writing privileges and other regulatory requirements can differ based on a nurse's practice setting or managed care organization, and how managed care influences work relationships with physicians and other colleagues. In addition, UM's courses in nursing administration and public health nursing are focusing on the ways managed care is shaping these specialties' organization, regulation, and financing.

Meanwhile, nursing administration students at the University of California- San Francisco will soon be provided with a managed care course being planned by two faculty members. The course also will be available to the school's other master's-degree candidates, such as nurse practitioner students who do clinical rounds at managed care clinics run by Kaiser Permanente and other agencies.

In some areas, managed care already is changing the way students learn traditional procedures. To keep up with shorter hospital stays, some as brief as 12 hours after delivery, nurse practitioner students in the obstetric/gynecological track at the University of Tennessee-Memphis are assessing mothers' and children's home environments, and assuring that mothers bring babies back to the school's nurse-managed clinic for blood tests that used to be performed in the hospital before the days of faster discharge. UT's teaching nursing home also has had to significantly alter drug therapy. Tenncare, the state's Medicaid plan, allows the home's residents only $57 per month for medications. "That's a single course of antibiotics," says nursing dean Michael Carter, citing one example of how students are focusing increasingly on cost-effectiveness issues.

At the University of Maine, where nursing students are going into homes to teach mothers about care of their newborns, curriculum planners are exploring ways to prepare students to perform patient assessments and triage by telephone.

Still, observers say, nursing education's chief focus -- preparing the individual nurse -- increasingly is at odds with one of managed care's unshakable realities. "In managed care, you're dependent on your group of co-providers to achieve the best incentive pools, best patient satisfaction, and most cost-effective operation. And yet, we don't give students much opportunity to interact, problem-solve, and work together as a group," says Vanderbilt University nursing dean Colleen Conway-Welch. "We need to look at how we deliver the message that sharing responsibility and accountability with your coworkers, including those in other disciplines, is absolutely essential, and then give students the tools to actually apply their classroom learning to working on interdependent teams." In addition, coursework should emphasize research on patient outcomes, she says. "Most nursing education to date has been focused on process, but managed care is inherently outcome-oriented."

Carving Out a New Niche for Faculty Practice

Schools that keep faculty engaged in active clinical practice help keep those educators' skills current. Moreover, the extra revenue from faculty practices not only bolsters a school's operating budget, but boosts faculty salaries, as well, helping to recruit additional educators and hold onto those already on staff.

With its state still "low - infiltrated" by HMOs, the College of Nursing at the University of South Carolina presently is not negotiating contracts with managed care companies, "though we're getting more and more requests from other clinical agencies to manage units for them," says dean Mary Ann Parsons. In August, the school's faculty will provide psychiatric care for nursing home patients, and nursing administration services for an acute-care facility, both under contract to the state's Department of Mental Health. Meanwhile, the school is also contracting with the state public health agency to provide nurse practitioners to deliver women's health services.

Of nine faculty practices that generate revenue for the School of Nursing at the University of California-San Francisco, some are being developed along managed care lines. Valencia Pediatric, a nursing-school-operated facility that treats 425 children a month, is negotiating with managed care firms to subcontract as one of their providers of primary care and to operate as a capitated plan, rather than the current fee-for-service system. To support its negotiations, the school is also gathering data on patient outcomes. "We will have to show how effective we've been in such areas as preventing emergency room visits," dean Jane Norbeck says.

Growing numbers of nursing schools, however, fear what may lie ahead as closed or downsized hospitals diminish the number of clinical training slots available for students. Profit-driven managed care companies and health care networks may not want to bear the expense of training students and may start turning them away, educators say. "Schools that are not moving into [faculty] practice arrangements as we speak," or that fail to have those practices based at or affiliated with managed care companies, are putting their students' clinical placements at risk, explains Vanderbilt University's Colleen Conway-Welch. Currently, she says, managed care organizations do not have budget lines for teaching and research.

"Everything is controlled by the mighty buck," adds Lea Acord, dean of the School of Nursing at the University of Maine. Still, she concedes, while some employers may be undervaluing students, viewing them -- many observers say inaccurately -- as not contributing to the bottom line, other agencies are realizing "that unless students train in managed care, there's no way for them to work in managed care." For example, in suburban Landover, Maryland outside Washington, D.C., the 31,000-member Kaiser Permanente Medical Center also serves as a training site for senior nursing students from Howard University who are paired with a nurse manager, sit in on nurse management meetings, and are supervised on clinical rounds by a staff preceptor.

In South Carolina, where "a lot of networks are forming, we haven't seen many facilities turning students away, but we anticipate it," says Mary Ann Parsons of the University of South Carolina. To secure training slots, "we stipulate in our contracts that we will bring students in." Whenever nurse practitioner faculty are contracted to manage a facility's care, undergraduate and graduate students are assigned, as well.

Investing in a Future Nurse Supply

With no managed care content in its curriculum, the University of Minnesota medical school has been exploring with nursing dean Sandra Edwardson a plan to establish a managed care course for all the university's health professions students. Discussions are underway with managed care firms to attract their support. In the meantime, with three large managed care companies already in the metro area, the nursing school and university hospital are assessing how they will figure in the larger picture. "The question now is will we join the competition and be part of a managed care conglomerate, or will be part of a public resource with the university receiving assistance from the state?," Edwardson says.

Elsewhere, nursing schools already are enlisting private assistance. Under a $550,000 grant from Kaiser Permanente, the School of Nursing at the University of California-San Francisco has begun a five-year effort to prepare more women's health nurse practitioners by hiring additional faculty and expanding its nurse practitioner curriculum. As pressures mount to balance federal spending, schools are eyeing closely this year's efforts to reauthorize the Nurse Education Act, the prime source of federal monies for undergraduate and graduate nursing education. Of equal concern, dean Jane Norbeck says, "state funding still isn't at the levels needed. We'd have to shrink our enrollments if we didn't get that private support."

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