National Nursing Workforce Workgroup Update: Responding to the IOM Future of Nursing 2015 Evaluation Patricia Moulton, PhD Executive Director, North Dakota Center for Nursing Past-President, National Forum of State Nursing Workforce Centers

National Nursing Workforce Minimum Data Sets Created by the National Forum of State Nursing Workforce Centers in 2009. There is a separate MDS for education, supply and demand data. http://nursingworkforcecenters.org/minimum-datasets/ Publications describing the creation of the datasets: https://www.researchgate.net/publication/49753660_Toward_Standardization_Part_1_Ass essment_of_State_and_National_Nursing_Workforce_Data_Sources https://www.researchgate.net/publication/233848400_Toward_Standardization_Part_2_N ational_Nursing_Minimum_Data_Sets_Consensus_Building_and_Implementation_Status The HRSA, National Center for Health Workforce Analysis also has a list of MDS for multiple professions and some FAQs about them at https://bhw.hrsa.gov/health-workforce-analysis/data

Institute of Medicine The Future of Nursing: Leading Change, Advancing Health October, 2010 http://www.nationalacademies.org/hmd/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx

Key Message #4: Effective workforce planning and policy making require better data collection and an improved information infrastructure. Planning for fundamental, wide-ranging changes in the preparation and deployment of the nursing workforce will require comprehensive data on the numbers and types of professionals currently available and required to meet future needs. Such data are needed across health professions if a fundamental transformation of the health care systems is to be achieved. Filling these gaps should be the priority for the National Health Workforce Commission and other structures and resources authorized under the Affordable Care Act. Page 255

Recommendation #8: Build an infrastructure for the collection and analysis of interprofessional health care workforce data. The National Health Care Workforce Commission, with oversight from the Government Accountability Office and the Health Resources and Services Administration, should lead a collaborative effort to improve research and the collection and analysis of data on health care workforce requirements. The Workforce Commission and the Health Resources and Services Administration should collaborate with state licensing boards, state nursing and workforce centers and the Department of Labor in this effort to ensure that the data are timely and publicly accessible.

The Workforce Commission and the Health Resources and Services Administration should coordinate with state licensing boards, including those for nursing, medicine, dentistry, and pharmacy to develop and promulgate a standardized minimum data set across states and professions that can be used to assess health care workforce needs by demographics, numbers, skill mix and geographic distribution. The Workforce Commission and the Health Resources and Services Administration should set standards for the collection of the minimum data set by state licensing boards, oversee, coordinate and house the data; and make the data publicly accessible. The Workforce Commission and the Health Resources and Services Administration should retain, but bolster, the Health Resources and Services Administration’s registered nurse sample survey by increasing the sample size, fielding the survey every other year, expanding the data collected on advance practice registered nurses and releasing survey results more quickly.

The Workforce Commission and the Health Resources and Services Administration should establish a monitoring system that uses the most current analytic approaches and data from the minimum data set to systematically measure and project nursing workforce requirements by role, skill mix, region and demographics. The Workforce Commission and the Health Resources and Services Administration should coordinate workforce research efforts with the Department of Labor, state and regional educators, employers, and state nursing workforce centers to identify regional health care workforce needs and establish regional targets and plans for appropriately increasing the supply of health professionals. The Government Accountability Office should ensure that the Workforce Commission membership includes adequate nursing expertise.

Assessing Progress on the Institute of Medicine Report: The Future of Nursing December, 2015 http://www.nationalacademies.org/hmd/Reports/2015/Assessing-Progress-on-the-IOM-Report-The-Future-of-Nursing.aspx

Improving Workforce Data Infrastructure (page 171-172) Finding 6-1 Improving Workforce Data Infrastructure (page 171-172) Finding 6-1. Many of the recommendations of the Future of Nursing call for the National Health Care Workforce Commission to work with HRSA on implementation. Established under the ACA, the Commission has yet to be funded and thus has not met. Finding 6-2. HRSA conducted the first ever National Sample Survey of Nurse Practitioners in 2012. Finding 6.3. HRSA has discontinued its National Sample Survey of Registered Nurses but is in talks to reinstate a modified version.

Finding 6-4. Other existing federal data collection instruments (National Health Interview Survey, Standard Occupational Classification, National Ambulatory Medical Care Survey) have been updated to provide opportunities for assessing the services and characteristics of nurses in the health care workforce. Finding 6-5. More APRNs have obtained NPIs, but not all bill for all of their services under their own NPI. Finding 6-6. Nursing and other health professions associations and organizations, including state board of nursing collect vast amounts of data on the nursing workforce. There has been a significant increase in the number of State Nursing Workforce Centers collecting data on supply, demand and education of nurses, and in those collecting all or most of the data items suggested by the National Forum of State Nursing Workforce Centers. NCSBN also has put great effort into developing and populating its Nursys data system and building a workforce database using the MDS through the participation of state boards of nursing.

Recommendation 10: Improve Workforce Data Collection Recommendation 10: Improve Workforce Data Collection. The Campaign should promote collaboration among organizations that collect workforce-related data. Given the absence of the National Health Care Workforce Commission, the Campaign can use its strong brand and partnerships to help improve the collection of data on the nursing workforce. (page 172-173) The Campaign should play a role in convening, supporting and promoting collaboration among organizations and associations to consider how they might create more robust datasets and how various datasets can be organized and made available to researchers, policy maker, and planners. Specifically, the Campaign should encourage Organizations and agencies to build national databases that could be shared and accessed by the Health Resources and Services Administration (HRSA) and researchers; States that implement the Minimum Data Set (MDS) and to share their data with the National Council of State Boards of Nursing (NCSBN) so they can build a national dataset on practicing nurses; and Nursing organizations that currently engage in independent data collection efforts (such as American Association of Colleges of Nursing, the National League for Nursing, NCSBN and the American Association of Nurse Practitioners) to collaborate and share their data to build more comprehensive datasets. Other organizations representing providers that employ nurses and other health professionals, such as the American Hospital Association, should be invited to participate in this collaboration.

The federal government and states should expand existing data collection activities to better measure and monitor the roles of registered nurses and advanced practice registered nurses. This expansion should include the collection of data on current and former licensees in the American Community Survey and a sampling of services provided by nurse practitioners and physician assistants for their own patient panels outside of physician offices in the National Ambulatory Medical Care Survey. HRSA should undertake a combined National Sample Survey of Registered Nurses and National Sample Survey of Nurse Practitioners that can be administered more frequently than once every 4 years. This effort should include the involvement of national and state nursing organizations. HRSA should continue to promote the use of the MDS and assist in and support its implementation.

National Nursing and Health Care Workforce Data Meeting May 9-10, 2016 Washington D.C. https://campaignforaction.org/wp-content/uploads/2016/11/May_2016_Nursing_Data_Workforce_Meeting-WhitePaper_11_2016.pdf

Priority Action Steps from Meeting Create a national repository of nursing workforce data. Create a nursing master file (sample frame of all RNs in the United States). Make data available in a de-identified public use files for research and policymaking. Implement data agreements with ACS, CPS, NSSRN, NCSBN and others. Make the case for nursing workforce data to the right people. Increase advocacy by the nursing organizations for the most helpful/complete data. Have HRSA administer a sample survey every four years using a revised sample including both RNs and NPs.

Workgroup #1: Work on first four action steps by 2021. Patricia Moulton, ND Center for Nursing hosting this group. Create a national repository of nursing workforce data. Create a nursing master file (sample frame of all RNs in the United States). Make data available in a de-identified public use files for research and policymaking. Implement data agreements with ACS, CPS, NSSRN, NCSBN and others.

Workgroup #1 Members Patricia Moulton, ND Center for Nursing Joanne Spetz, University of California, San Francisco Jean Moore, University of Albany, SUNY Edward Salsberg, George Washington University Pamela Lauer, National Forum of State Nursing Workforce Centers Cynthia Bienemy, National Forum of State Nursing Workforce Centers Mary Beth Bigley, National Organization of Nurse Practitioner Faculties Carey McCarthy, National Council of State Boards of Nursing Jill Budden, National Council of State Boards of Nursing Mary Anne Alexander, National Council of State Board of Nursing Nur Rajwany, National Council of State Board of Nursing Mark Huffman, National Council of State Board of Nursing Michael Berning, U.S. Census Bureau David Sheppard, U.S. Census Bureau Erin Fraher, University of North Carolina at Chapel Hill School of Medicine George Zangaro, Health Resources and Services Administration Michelle Cook, American Association of Nurse Practitioners

Goal 1: To build a National repository of nursing workforce data and a Nursing Master File to include all states and to make the data available for research and policy analysis. Determine where the National repository should be housed. Should it be at NCSBN or is there another organization that could house the repository? Determine how the data will be available. How are requests for data processed? Will there need to be revised MOUs with individual states submitting data to the repository? Will mailing lists be available or will data be de-identified for national research purposes? Determine the status/quality of Minimum Data Set Supply Data that is collected at the state level. How many state are collected MDS data? Is the data population or sample? IS the data collected as a part of licensure renewal or is it a separate survey? Is data collection mandatory or voluntary? Are all questions answered for all nurses in the state? Are the exact items from the Forum MDS being collected in each state?

Determine how many states are submitting data to the national repository. Are states submitting the data to the national repository? Which system is being used to collect and submit the data to the repository? How often will the data be submitted to the repository? Determine barriers for states that are not submitting data to the national repository. Are states unable to submit data due to: Ownership of the data and branch of state government that houses the data State law limiting collecting or sharing of data Multiple other possible barriers Work with states to have them added to the repository- utilize information from workgroup #2 to help make the case for collecting the data and working through the barriers. The end repository will probably not have all 50 states. The group has talked about how many is needed to be useful for national research purposes. Is 19 enough?

The group has compiled information on the current status of how many states are collecting supply MDS data from multiple sources: National Forum of State Nursing Workforce Centers annual membership survey- map of data collection for education, supply and demand data along with the MDS for each are available at http://nursingworkforcecenters.org/minimum-datasets-map/ - 29 states are collecting supply data

Health Workforce Technical Assistance Center Survey collects information on all health workforce data collection through their State Health Workforce Data Collection Inventory- http://www.healthworkforceta.org/resources/state-health-workforce-data-collection-inventory/ - 22 state are collecting supply data Robert Wood Johnson Foundation and the Campaign for Action collected information on the number of states collecting supply data for their dashboard- 42 states collect some supply data

National Council of State Board of Nursing National Council of State Boards of Nursing has a National Nursing Database: from their website “Valuing innovation, integrity and transparency, NCSBN is providing the first-ever comprehensive source of nursing licensure statistics for the U.S. and its territories. This data is compiled by NCSBN's database, NurSys, which is an electronic information system where boards of nursing enter licensure data on a frequent basis. Of NCSBN's 58 (RN and PN) member boards, 54 share licensure data” https://www.ncsbn.org/national-nursing-database.htm NCSBN has a list of the states that are currently submitting MDS data to the data repository and are working with additional states to add data through their existing licensure renewal system, ORBS or through e-notify- 20 states are submitting workforce data. Most states already submit basic licensure and discipline data through NurseSys. Five additional boards are working with NCSBN to have their data added to the repository. Examples of licensure systems: NurseTrack, CAVU (Iron Data), ALMS Licensing System, AMANDA Licensing System, DORIS(Thought span), the newest is ORBS Licensing System eNotify is a free license status push notification and electronic nurse workforce survey tool, which can be utilized by any board of nursing via a link from their website, free of cost. It provides the enrolled nurse with automatic license status notification updates of their license(s), free of cost, and also allows the board of nursing to collect the nurse work force data. There are currently 5 boards/states utilizing the eNotify tool specifically for collecting the nurse workforce data for their boards/states. Some states have paper surveys and sample surveys too.

Goal 2: Compile a list of national survey databases with nursing workforce data, how to access the data for research and the limitations. Compile into a document and then disseminate. This might be incorporated into the HWAC Health Workforce Analysis Guide http://www.healthworkforceta.org/wp-content/uploads/2016/10/Health-Workforce- Analysis-Guide_2016-Edition.pdf or a free-standing webpage or something. Identified National Surveys: National Nursing Workforce Study- National Council of State Boards of Nursing/National Forum of State Nursing Workforce Centers American Community Survey- U.S. Census Bureau National Sample Survey of Registered Nurses Data- Health Resources and Services Administration Area Health Resource File- Health Resources and Services Administration- not original data, but is pulled from other sources Current Population Survey – U.S. Census Bureau U.S. Bureau of Labor Statistics- https://www.bls.gov/

Integrated Postsecondary Education Data System- https://nces. ed American Association of Colleges of Nursing- Institutional Systems and Data Research Center- http://www.aacn.nche.edu/research-data NCLEX Exam Data- https://www.ncsbn.org/nclex-research-opportunities.htm Interagency Collaborative on Nursing Statistics-has a resource document on what organizations collect data and definitions- http://www.iconsdata.org/ American Association of Nurse Practitioners National NP Database and other research studies https://www.aanp.org/research/reports NCSBN also has a list of where you can obtain a mailing list for all of the states and will be on their website soon. If someone wanted to obtain all of the lists from each state, it would cost about $28,000. It would primarily include the addresses for a researcher to do their own mailed survey. https://www.ncsbn.org/research-resources.htm

Workgroup 2: Action Step 5. Make the case for nursing workforce data to the right people. Group Members: Jean Moore, University of Albany, SUNY- Group Host Carey McCarthy, National Council of State Boards of Nursing Cynthia Bienemy, National Forum of State Nursing Workforce Centers Pam Lauer, National Forum of State Nursing Workforce Centers Peter Buerhaus, Center for Interdisciplinary Health Workforce Studies Peter McMenamin, American Nurses Association

Convened a webinar series aimed at key state-level stakeholders including policy makers, planners, and researchers, among others. The webinar series was co- sponsored by the Health Workforce Technical Assistance Center and the Center for Interdisciplinary Health Workforce Studies. The webinars which include a two state panel presentation and individual “reactor” to facilitate group discussion: Best Practices for State-level Nursing Workforce Data Collection http://www.healthworkforceta.org/webinars/best-practices-for-state-level- nursing-workforce-data-collection/ Using Nursing Workforce Data to Inform State Policy http://www.healthworkforceta.org/webinars/using-nursing-workforce-data- to-inform-state-policy/ Two States’ Experiences Using HRSA’s Web-based Nursing Supply and Demand Model http://www.healthworkforceta.org/webinars/two-states- experiences-using-hrsas-web-based-nursing-supply-and-demand-model/ The group also started a blog at: http://www.healthworkforceta.org/making-the-case-for-state-level-nursing-data-collection/

Workgroup #3: work on action step #6 Ed Salsberg will host this group when it starts meeting. “increase advocacy of the nursing organizations working in collaboration with federal and state agencies for the most helpful/complete data,” emphasized the need for continuing communication and collaboration between the nursing organizations and those designing and implementing workforce datasets at the federal level. Examples of essential actions include: Raise awareness about the impact of “incident to” billing on availability of nurse practitioner data Define clear, consistent identifiers for nurses’ roles Work with the National Ambulatory Medical Care Survey to collect APRN data Work with federal data collection agencies to identify “low-hanging fruit” (e.g., collecting nurses in the Baccalaureate and Beyond survey) Begin a SOC (standard occupational classification) committee to address nursing workforce issues Inform HRSA sample survey components

An additional workgroup was not formed for action step 7, “HRSA will complete the sample survey every four years using a revised sample including both NPs and RNs”; in presenting the HRSA perspective earlier, Zangaro had said that HRSA will be implementing the NSS for RNs and NPs every four years. Although HRSA is not able to collect data more frequently, as the IOM recommended, it is committed to collaborating with nursing organizations in development, implementation, and analysis of the NSSRN and to encouraging the use of the MDS.

Contact Information: Patricia Moulton, PhD Executive Director North Dakota Center for Nursing 3523 45th Street South Fargo, ND 58104 701-639-6548 patricia.moulton@ndcenterfornursing.org www.ndcenterfornursing.org