by Laurie Larson

Peter Buerhaus, R.N.,  a health care economist and a professor of nursing at Montana State University, maintains a multifaceted research program analyzing nursing workforce economics, forecasting nurse and physician supply, and determining public and provider opinion on care delivery issues, among other areas of study. He does so in his role as director of the university’s Center for Interdisciplinary Health Workforce Studies.

Do we have a nursing shortage in this country?

BUERHAUS: Not necessarily, although some states, like California and Colorado, are experiencing nurse retirement sooner than others. Since 2002, there has actually been unprecedented growth in the number of nurses being produced in the United States. But there is a knowledge shortage in nursing. Experienced nurses are retiring, so we have more people, but less long-term experience. We’ve been warning the industry for the past five to 10 years about getting nursing graduates’ knowledge up to speed to deal with the upcoming retirement of 1 million nurses over the next decade.

Are we making the best use of our nursing workforce?

BUERHAUS: Right now, we are in the throes of a great experimentation, shifting around what nurses are doing to see what their best value could be — and that’s going to look very different in each hospital. There won’t be a “new normal,” but rather organization-specific new uses for nurses. It’s part of a search to get the most out of what all hospital staff can do, and for the states that restrict nurse practitioners’ scope of practice, that’s a tremendous loss.

Where do those scope-of-practice laws stand, and how do you see the nurse practitioner’s role evolving?

BUERHAUS: Twelve states still restrict scope of practice and 17 more reduce the ability of nurse practitioners to engage in at least one element of their practice, but patient care in a wide range of settings, such as nursing homes, demands that they have broader privileges. And nurse practitioners are more likely to work in rural areas where the need for health care services has grown because of expanded coverage under the Affordable Care Act. That’s also where there are fewer doctors compared with these providers. Nurse practitioners are 10 to 30 percent less expensive to employ than physicians, and are more likely to care for nonwhite, non-English-speaking Medicare and Medicaid beneficiaries, including those in rural areas, at a lower cost of care. To the extent that scope-of-practice laws don’t allow nurse practitioners to do all that they can, they are harming patient care.

Many states are in a battle over those laws, but the trajectory has been to open them up. It’s slow, but it’s not going to go away, because of the projected primary care and medical specialty shortages. Those shortages only will increase demands on state legislatures to give up scope-of-practice restrictions and, as they do, both registered nurses and nurse practitioners will move in to fill more of those provider roles. In addition, the Institute of Medicine, the National Governors Association and others have called for expanding the use of nurse practitioners, so there’s a growing policy force behind this as well.

How will the physician shortage affect the nurse workforce?

BUERHAUS: There is growing concern about how primary care will be provided in this country, and nurses are not doing as much as they could. The Association of American Medical Colleges estimates that by 2025, the demand for all doctors will exceed the supply by 62,000 to 95,000 clinicians, and primary care could account for a shortage of as many as 36,000 doctors. We need to get nurses more involved in managing certain types of patients, those with chronic conditions like diabetes, which they could do very well.

What competencies are most important for nurses going forward?

BUERHAUS: The nursing profession needs to make sure that the nurses coming out of school are savvy about health care reform and understand value-based care. Without that knowledge, I worry that the workforce will not be as prepared as it needs to be. [Nursing graduates] need to be extremely smart to step through and fulfill what is expected of them. We will expect nurses to be good team leaders and team members and to be more nimble and flexible. They need to have a mental framework that understands that their role may shift after a couple of years — that their career will be constantly changing. Our nurse educators need that same understanding, and work to form closer relationships with [hospital] employers so their graduates are better prepared and in line with change.

What are the biggest changes affecting the nursing profession today?

BUERHAUS: I see four major changes. First is the retirement of one-third of the nursing workforce over the next 10 years, which has never happened before and is going to take a lot of knowledge and know-how out of the workforce. Second, 70 million baby boomers will be retiring with multiple chronic and degenerative conditions, which will add to the complexity of care and increase the number of nurses needed to care for them. The third big change is health care reform. We will always need hospitals, but delivery systems are changing; there will be less hospital care, and everyone accepts that they will have greater accountability for cost and quality. And finally, there’s the physician shortage — and this will all be happening at the same time. It’s going to be challenging. Nurses will play a greater role in preventive care, patient education and [working with] the social determinants of health care — they will be more affected by that as access to care expands. More nursing work will be done electronically, and payment changes based on cost and quality also will affect them.

What must hospital and health system leaders do to address these changes?

BUERHAUS: Hospital leaders need to establish better communication with nursing schools. They can’t leave it to chance that nurses will have the skills to be accountable for cost and quality. They also need to talk with nursing leaders in their organization and ask them what they know about value-based care, striking up a whole new conversation with them. They need to discuss what’s going on in health care, and come up with strategies together that will define how nurses can continue to ensure the mission of the organization and the survival of hospitals. They need to ask, ‘How can we work together better to achieve what we all want?’ Experienced nurses know — talk to them before they retire. It could be a very productive conversation.