Comparative analysis of urban and rural nursing workforce shortages in Nebraska hospitals

Characteristics of Medical Deserts and Approaches to Mitigate Their Health Workforce Issues: A Scoping Review of Empirical Studies in Western Countries

BACKGROUND

Medical deserts are considered a problematic issue for many Western countries which try to employ multitude of policies and initiatives to achieve a better distribution of their health workforce (HWF). The aim of this study was to systematically map research and provide an overview of definitions, characteristics, contributing factors and approaches to mitigate medical deserts within the European Union (EU)-funded project "ROUTE-HWF" (a Roadmap OUT of mEdical deserts into supportive Health WorkForce initiatives and policies).

METHODS

We performed a scoping review to identify knowledge clusters/research gaps in the field of medical deserts focusing on HWF issues. Six databases were searched till June 2021. Studies reporting primary research from Western countries on definitions, characteristics, contributing factors, and approaches were included. Two independent reviewers assessed studies for eligibility, extracted data and clustered studies according to the four defined outcomes.

RESULTS

Two-hundred and forty studies were included (n=116, 48% Australia/New Zealand; n=105, 44% North America; n=20, 8% Europe). All used observational designs except for five quasi-experimental studies. Studies provided definitions (n=171, 71%), characteristics (n=95, 40%), contributing factors (n=112, 47%), and approaches to mitigate medical deserts (n=87, 36%). Most medical deserts were defined by the density of the population in an area. Contributing factors to HWF issues in medical deserts consisted in work-related (n=55, 23%) and lifestyle-related factors (n=33, 14%) of the HWF as well as sociodemographic characteristics (n=79, 33%). Approaches to mitigate them focused on training adapted to the scope of rural practice (n=67, 28%), HWF distribution (n=3, 1%), support/infrastructure (n=8, 3%) and innovative models of care (n=7, 3%).

CONCLUSION

Our study provides the first scoping review that presents and categorizes definitions, characteristics, contributing factors, and approaches to mitigate HWF issues in medical deserts. We identified gaps such as the scarcity of longitudinal studies to investigate the impact of factors contributing to medical deserts, and interventional studies to evaluate the effectiveness of approaches to mitigate HWF issues.

Designing Policy Solutions to Build a Healthier Rural America

Disparities exist in the health, livelihood, and opportunities for the 46-60 million people living in America's rural communities. Rural communities across the United States need a new energy and focus concentrated around health and health care that allows for the designing capturing, and spreading of existing and new innovations. This paper aims to provide a framework for policy solutions to build a healthier rural America describing both the current state of rural health policy and the policies and practices in states that could be used as a national model for positive change.

Call to Action: Rural Health: A Presidential Advisory From the American Heart Association and American Stroke Association

Understanding and addressing the unique health needs of people residing in rural America is critical to the American Heart Association's pursuit of a world with longer, healthier lives. Improving the health of rural populations is consistent with the American Heart Association's commitment to health equity and its focus on social determinants of health to reduce and ideally to eliminate health disparities. This presidential advisory serves as a call to action for the American Heart Association and other stakeholders to make rural populations a priority in programming, research, and policy. This advisory first summarizes existing data on rural populations, communities, and health outcomes; explores 3 major groups of factors underlying urban-rural disparities in health outcomes, including individual factors, social determinants of health, and health delivery system factors; and then proposes a set of solutions spanning health system innovation, policy, and research aimed at improving rural health.

Hospital staff shortages: Environmental and organizational determinants and implications for patient satisfaction

Recent discussions and previous research often indicate that German hospitals are affected by a shortage of healthcare personnel on the labor market. However, until now, research has provided only limited insights into how environmental and organizational factors explain variations in staff shortages, how staff shortage measures relate to staffing ratios, and what relevance staff shortages have for patients. Regression analyses based on survey data of 104 German hospitals from 2015 to 2016, combined with labor market and patient satisfaction data, show that several environmental and organizational factors are significantly related to hospital staff shortages, measured by self-reports, vacancies, and turnover. These three measures of staff shortage do not correlate to the same degree for physicians and nurses, and none of the three significantly relate to nursing ratios, which indicates that the latter is a distinct concept rather than a direct consequence of staff shortage. The analyses further show that hospital staff shortages relate significantly to patient satisfaction with physician and nursing care. The findings suggest that hospitals are, to a certain extent, able to influence the degree to which they are affected by staff shortages and that hospitals' decisions about staffing levels depend on more than staff availability.

Explaining variations in hospitals' use of strategic human resource management: How environmental and organizational factors matter

BACKGROUND

Against the background of increasing workforce-related challenges such as staff shortages, strategic human resource management (SHRM) has gained importance in hospitals. Although the positive implications of SHRM for hospital performance are well known and commonly accepted in research and practice, hospitals still vary in its use. However, the sources of variations in hospitals' use of SHRM are largely unknown.

PURPOSE

Various organizational and environmental factors were used in this study to explain the variations in hospitals' use of SHRM for physicians and nurses.

METHODOLOGY

Data were obtained from a hospital survey (n = 172) on topics related to human resource management in hospitals and linked to different secondary data sets. We apply multiple linear regression modeling to investigate the association between organizational and environmental characteristics and hospitals' use of SHRM for nurses and physicians.

FINDINGS

Our results suggest that organizational factors such as private for-profit and nonprofit ownership (compared to public ownership), academic teaching status, and the strategic involvement of the human resource administration are positively associated with hospitals' use of SHRM. None of the environmental factors investigated in this study was significantly related to hospitals' use of SHRM.

PRACTICAL IMPLICATIONS

The study results increase our understanding of variations in hospitals' use of SHRM. Although organizational characteristics were found to explain variations in SHRM, environmental factors seem unrelated with hospitals' use of SHRM. Our results inform both hospital managers and policy makers about possible approaches to enhance SHRM use in hospitals. Furthermore, profound knowledge about factors associated with SHRM will help to enhance our understanding of anticipating changes in hospitals' use of SHRM through organizational- and environmental-oriented interventions.

Registered nurses' preferences for rural and urban jobs: A discrete choice experiment

BACKGROUND

Recruitment and retention of nurses is an ongoing challenge for employers in rural areas worldwide. There is limited information available regarding influences on nurses' job choice in the U.S. and little understanding of how nurses make trade-offs between desired and less desirable job characteristics when choosing between jobs.

OBJECTIVES

The purpose of this research was to examine the hospital job preferences of registered nurses in the U.S. The specific objectives of the study were: 1) To identify the relative importance of key job attributes on registered nurse job choice, and 2) To predict the impact of changes in the levels of attributes on the probability of registered nurses choosing one job over another.

DESIGN AND SETTING

A discrete choice experiment was developed and applied in the U.S. using California as a study site.

PARTICIPANTS

190 registered nurses currently working in nursing or intending to return to work in nursing from urban, large-, small- and isolated-rural communities.

METHODS

The survey instrument was developed through a literature review and semi-structured interviews with nurse experts, utilizing a hypothetical job in a hospital medical / surgical unit. Experimental design principles were applied to create a discrete choice experiment which was pilot tested with urban and rural nurses. The survey was mailed to a random sample of 1000 licensed registered nurses in California. A mixed logit model was used to estimate nurses' preferences for different levels of the job attributes. Willingness to pay estimates and simulations of job uptake rates were calculated.

RESULTS

Eight factors were identified as important to job choice: earnings, nursing voice in management, tuition reimbursement, scheduling, patient care team, leadership, location and nursing sensitive patient care outcomes. Respondents valued a cohesive patient care team (coefficient 1.95, [SE 0.23]) and a strong nursing voice in management (coefficient 1.56, [SE 0.22]) highest. A job in a large urban inland location was negatively valued (coefficient -0.69, [SE 0.25]). Around 72% of respondents chose to stay in their current job when this choice was offered. While earnings were important, nurses were willing to sacrifice earnings to secure other valued job characteristics when choosing between jobs.

CONCLUSIONS

Study findings provide information on how job characteristics are valued by nurses in California. Findings suggest job seekers may be 65-75 percent more likely to choose a job when valued job characteristics are present. Our findings are particularly relevant to rural hospitals with limited financial resources.

Associations of Provider-to-Population Ratios and Population Health by County-Level Rurality

PURPOSE

To explore the relationship between provider-to-population ratios, rurality and population health in the United States using counties as the unit of analysis.

METHOD

Population ratios for registered nurses (RNs), primary care physicians, and dentists were included in multivariable regression analyses. Population health indices assessed were premature death rate, self-rated health, teen birth rate, and mammography screening rate.

FINDINGS

County levels of health and health care providers per capita declined as rurality increased. In adjusted regression models, the highest RN-to-population ratio was associated with significantly better health measures in most urban/rural categories, with the magnitude of these associations generally increasing as rurality increased. In the smallest rural counties, the highest RN-to-population quartile was associated with 1,655 fewer years of potential life lost (YPLL), 2% lower rates of poor or fair health, 11/1,000 fewer teen births, and 6% more mammography screening relative to the lowest quartile. For primary care physicians, more significant associations were found in medium and small rural counties where the highest quartile was associated with 1,482 fewer YPLL, 3% lower rates of poor or fair health, 7/1,000 fewer teen births, and 4% more mammography screening. The highest quartile of dentist-to-population ratio was generally associated with lower rates of premature death and poor or fair health in urban, large-, and medium-sized rural counties, but not in small rural counties.

CONCLUSIONS

The consistency of the results by provider type suggests that the supply of health care professionals, particularly in rural areas, positively impacts the health of the population.

Demand for Temporary Agency Nurses and Nursing Shortages

There is an ongoing debate about the reasons for the growth of temporary employment of registered nurses (RNs). Some argue that efficiency incentives to increase flexibility and reduce labor costs are the principal cause, while others point to shortages of RNs as the stronger determinant. Using hospital-level data from California’s Office of Statewide Health Planning and Development, we find a significant trend of increasing demand for agency nurses during the years of RN shortage. Demand rose with inpatient days, patient demand fluctuation, and the level of fringe benefits. Competition between hospitals and unionization, however, did not affect hospitals’ demand for temporary RNs.

Nurse staffing in critical access hospitals: structural factors linked to quality care

Evidence links the amount of registered nurse care to improved patient outcomes in large hospitals, but little is known about registered nurse staffing in small critical access hospitals, which comprise 30% of all US hospitals. Our study findings show that the unique work environment of critical access hospitals means registered nurses are often overextended, reassigned from inpatient care, and/or interrupted creating potential safety and quality risks. Further research is needed to understand what critical access hospitals consider "safe" levels of nurse staffing and what processes are implemented to mitigate these risks.

Rural hospital nursing: results of a national survey of nurse executives

OBJECTIVE

The objective of the study was to describe nursing characteristics in small and larger rural hospitals and determine whether differences exist in market, hospital, and nursing characteristics.

BACKGROUND

A better description of nursing in rural settings is needed to understand the work context.

METHODS

A national sample of rural hospital nurse executives (n = 280) completed the Nurse Environment Survey and Essentials of Magnetism instrument.

RESULTS

Larger rural hospitals are more likely than small hospitals to have a clinical ladder (32.4% vs 19.4%), more baccalaureate-prepared RNs (20.8% vs 17.1%), greater perceived economic (mean, 9.5 vs 8.5) and external influences (mean, 41.1 vs 39.8), lower shared vision among hospital staff (mean, 18.4 vs 19.4), and higher levels of quality and safety engagement (mean, 16.9 vs 16.1). Most nurses employed in rural hospitals are educated at the associate degree (77.4%) level.

CONCLUSIONS

Contextual differences exist between small and larger rural hospitals. To promote the best patient outcomes, attention to contextual differences is needed to tailor nursing interventions to fit the resources, environment, and patient needs in a given healthcare setting.

The effect of work environment on intent to leave the nursing profession: a case study of bedside registered nurses in rural Florida

The purpose of this research was to explore the effect work environment has on the intent to leave the profession for rural hospital bedside registered nurses (RNs). Subscales of autonomy, control over the practice setting, nurse-physician relationship and organizational support were incorporated into the analysis to determine which aspects of work environment directly affect the intent to leave the profession. An explanatory cross-sectional survey was distributed to 259 direct care bedside RNs employed at a rural system-affiliated hospital in Central Florida between February 2007 and June 2007. Anonymity was assured. A questionnaire containing demographic questions, the Nursing Work Index-Revised and Blau's intent to leave scale was distributed to all direct care nurses. A 32.8% response rate was achieved for a total of 85 complete and usable surveys. Data analysis shows that the work environment in general is negatively related to intent to leave. In addition, each of the four subscales was also negatively related to the intent to leave the profession. The results of this study support several recommendations for practice and education, including the promotion of professional practice environments, fostering inter-departmental relationships, and increasing the managerial training of RN managers.

Partnering with rural communities to meet the demand for a qualified nursing workforce

The registered nurse (RN) shortage threatens rural health care quality and economic vitality. Educational institutions have the opportunity to collaborate with rural communities in building pipelines for a more highly educated, sustainable nursing workforce. Leaders from 19 Midwestern rural counties approached a university about their regional nurse workforce issues and a desire to locate a nursing campus in their community. This article describes the partnership between a university and a rural community and the process for addressing their concerns and determining program feasibility. A Task Force of faculty and community leaders used the Determining Program Feasibility model to frame data collection and analysis. The Task Force met regularly with a Community Advisory Board for problem-solving and formative feedback. The sound methodology and transparent process facilitated a successful collaboration and resulted in a final report outlining the significant opportunities and challenges to overcome. Plans are underway for a new rural nursing campus and the community has raised monies for the new facility. The state legislature will address needed start-up funds.

Making sense of competing nursing shortage concepts

Widespread and continuing discussions of nursing shortages frequently involve divergent concepts of shortage that can have differing policy implications. This article explains the shortage concepts used by economists, hospital administrators, and government policy makers. It discusses measurement problems and suggests possible improvements. It then sets forth the divergent policy implications of competing shortage concepts. The article's aim is to promote greater clarity in analyses of nursing shortages and more fruitful conversations among participants who use different notions of shortages.