With more than 2 million registered nurses nationwide, nursing is by far the nation’s largest health care profession. Due to the aging of the baby boomer generation, demand for RNs is expected to approach 3 million by 2020 while the population of RNs is expected to grow much more slowly, according to projections by the National Center for Health Workforce Analysis.

To fill the gap, the health care industry has stepped up efforts to educate and train more RNs. However, much of the enrollment growth has been in two-year associate programs, rather than the more comprehensive three- and four-year degree programs. As the graph below shows, two-year RNs comprise the largest group of direct-care workers in hospitals and nursing homes.

With technical training, two-year nurses are capable of providing direct care for patients within their experience base. However, they lack training in staff supervision and they have limited training on concepts and theories of patient care that facilitate competence in new and uncertain situations.

As the relative proportion of RNs with two-year degrees has increased, the demand for more thoroughly trained RNs has also grown. Over the past 20 years, the health care industry has focused on increasing productivity, which translates into more work being done in a shorter period of time. The industry has also grown in complexity, adding more technology, more medications, and more new treatment regimens to the mix with each passing year.

Recent studies have attempted to measure the impact of nurse staffing on patient outcomes, and California enacted strict nurse-to-patient staffing ratios in 2004 based on the research results. However, nearly all of the studies to date have been based on the assumption that “an RN is an RN,” without taking into account the potential impact of RN skill sets on outcomes and errors.

Treating RNs as a generic group can result in two-year nurses being placed in settings where they are expected to perform beyond their capabilities, as well as the underutilization of the capabilities of four-year nurses by assigning them to positions that involve routine or repetitive tasks.

Time for a Checkup?

Given the changing skill sets of RNs and the evolving needs of health care providers, it is important for organizations to review their care delivery structure periodically. An “environmental assessment” of internal and external factors that affect your organization can help ensure that your care delivery model maximizes staff potential and capabilities to deliver high-quality patient care while minimizing weaknesses.

External Factors for Environmental Assessment (partial list)

• Local availability of RNs by degree type
• Local availability of other health care providers by type (especially physicians by specialty type)
• Relationships with other health care providers, including referring and transferring agencies and partners
• Current patient/resident characteristics
• Desired patient/resident characteristics
• Acuity of residents
• Medicare reimbursement changes and other public-policy decisions that impact the market for health care
• Community perception of your health care facility
• Community affluence (wealth often equals health)

Internal Factors for Environmental Assessment (partial list)

• Physical layout of your facility
• Automation and equipment management utilization
• Clinical information system ease of use
• Key department and service adjacencies
• Programs and licensure requirements
• Levels of care offered and adjacencies
• Organizational culture (how well departments and services work together)
• Leadership capabilities within the staff
• Types and overall volume of general services provided
• Types and overall volume of specialized services provided

A care delivery model should be developed only after a comprehensive external and internal environment assessment has been completed.

Finding the Right Structure

Structural contingency theory states that an organization’s structure should fit the environment in which it operates. It also says that as organizations adapt to their structures, a close coupling evolves.

The grid below provides a model that health care organizations might use to determine which structural form is best suited to their unique circumstances.

The following examples demonstrate how the structure-environment grid can be applied to some typical health care environments.

Example 1: The Nursing Home

Residents in a nursing home are typically grouped by their clinical needs, which increases their homogeneity and reduces uncertainty. You can staff these areas with fewer RNs and more nursing assistants, increasing centralization as well as the need for detailed policies and procedures. Such a structure would increase the supervisory requirements of the RNs involved, so using staff with training in supervision of delegated nursing functions would be important.

Example 2: The Hospital Nursing Unit and/or Medicare Unit in a Skilled Nursing Home

Nursing units with high patient turnover rates require frequent nursing assessments and discharge planning. This is a turbulent, complex environment that requires more RNs and fewer nursing assistants. The ability of RNs to function independently in direct patient care, along with the reduced requirement for supervisory skills, makes such an environment ideal for RNs who have less formal training in supervision. Less administrative overhead is needed for these areas, and staff functions more as primary care teams.

Example 3: The Specialty Hospital or Clinic

Hospitals and clinics that have high volumes of specialty patients (orthopedic, diabetic, cardiac, etc.) have technically trained staff who have a depth of expertise in one area (orthopedic technicians, cardiac monitor techs, etc.) but who may lack a broad base of skills. When you increase the number of technically expert persons with focused skill sets, you increase the need for coordination of these services, which increases administrative overhead. This environment calls for a more centralized type of organization, and RNs or others who serve in the coordinating role should have training in the management and supervision of multidisciplinary services.

Example 4: The Hospital Emergency Room

Emergency room nurses are faced with uncertainty on a routine basis. RNs with strong conceptual backgrounds and/or extensive experience increase the likelihood of appropriate response in these new and untested situations.  If guidelines and protocols guide interventions, then a more technically trained individual is appropriate.

Example 5: The Small Hospital or Clinic

Low-volume health care operations have a need for practitioners with broad skill capabilities, including the ability to do both technical and professional work. In such environments, there is usually not enough patient volume to warrant a large support staff. Additionally, due to the lack of informational resources readily available to many low-volume providers, independent functioning based on an abstract, conceptual base of knowledge is necessary. Rural health care entities have a greater need for the more generalist physicians and nurses than their hierarchical urban counterparts. (This, along with a national shortage of rural physicians, is why specialty training programs for rural physicians have evolved.)

For assistance in determining the best structural form for your organization (or for any other health care management issue), please give your local Wipfli office a call or e-mail a note to wipfliinformation@wipfli.com.

Mary Jo Graham, R.N., M.S., is a director in Wipfli’s health care consulting group. She can be reached at 612.867.0121 or mgraham@wipfli.com.