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Visualizing the National Forum's Supply Minimum Data Set by State

Clark Ruttinger, MPA, MBA - National Forum 2019-2020 President

Director, Utah Nursing Workforce Information Center

Jana R. Bitton, MPA - National Forum 2020-2021 President

Executive Director, Oregon Center for Nursing

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The National Forum of State Nursing Workforce Centers

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MISSION

VISION

VALUES

The National Forum of State Nursing Workforce Centers

Mission

Lead a national network to ensure a robust and well-prepared nursing workforce.

Vision

The National Forum of State Nursing Workforce Centers will be the national leader for nursing workforce information.

Values

Collaboration, Inclusivity, Credibility, and Objectivity

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GOALS

The National Forum of State Nursing Workforce Centers

Collaborate to standardize and model core nursing supply, demand, and education information.

Implement dynamic and strategic nursing workforce long-range planning and policy

initiatives at the state and national levels.

Facilitate the establishment of sustainable workforce centers in every state by sharing resources, mentoring, and disseminating best practices.

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Forum History

2005 - California, Florida, Mississippi, New Jersey, North Carolina

2008 - Development of minimum data set (MDS) in Supply, Demand and Education

“Data collection practices varied substantially from state to state. Creation and adoption of standardized minimum nursing workforce data sets is suggested to bring states into alignment.”

2009 - Data Summit- finalization of MDS

2011 - 27 of the 30 Centers for Nursing reported that their state collected aspects of the supply minimum data set. The number of states in 2011 that collected demographic information (gender, age, and race) was higher than in 2008.

2020 - 37 states with a nursing workforce center recognized as a member of the National Forum

The initial steps of the Forum for National Nursing Workforce Centers Minimum Data sets project were funded by the Center to Champion Nursing in America (CCNA) along with in-kind contributions from forum subscribers.

“The responsibility for nurse workforce planning, however, rests largely with state governments (Salsberg, 2003). Without consistently collected state-level data and reliable national benchmarks, legislators and workforce planners at the state level have fewer resources to guide their use of scarce state funding."

At its annual subscribers meeting in June 2008, the National Forum of State Nursing Workforce Centers1 (Forum) developed a long-term goal of establishing a national reposi- tory of nurse workforce data based on state-level contribu- tions of data collected from nurses, employers, and nursing education programs. A national repository of state nurse workforce data would be advantageous for state and national nurse workforce analysts and planners. Consistently col- lected state-level data would permit state-to-state and state- to-region comparisons. When aggregated to the national level, such a repository would be the most exhaustive and accurate source of information ever assembled on the U.S. nursing workforce; it would be the first based on population- level (rather than sample) data. For this to be possible, states must collect the same information on nurse supply, demand, and education. A necessary first step is agreement among state data collection entities on the data elements and meth- ods to be used: establishment of National Minimum Nursing Workforce Datasets.

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Membership & Value of the Forum

If you’ve seen one nursing workforce center, you’ve seen ONE nursing workforce center.

Center Housed Within:
Professional org/trade assoc.	19%
State Agency	19%
Virtual Office	16%
Own unique space	11%
State Board of Nursing	11%
State College or University	8%

Funding:
License Fees	32%
Donations	19%
Federal	19%
State	11%
Membership	16%
Services	11%
Foundation	8%
Appropriations	5%

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Importance of state-level supply data

Healthcare workforce planning depends heavily on local and regional factors and rests with state governments.
National level sample surveys aren’t accurate enough to describe local conditions.
Supply data must be based in licensing data.
Licensing authority exists at the state level. Licensing data exists in every state.

^“Toward^{Standardization (Part 1): Assessment of State and National Nursing Workforce Data Sources”- 2010}

^{“Toward Standardization (Part 2): National Nursing Minimum Data Sets Consensus Building and Implementation Status”- 2012}

^Stand^ardiza^{tion (Part 1): Assessment of State and National Nursing Workforce Data Sources}

“The GAO (2001) concluded that “national data are not adequate to describe the nature and extent of nurse workforce shortages, nor are data sufficiently sensitive or current to compare nurse work- force availability across states, specialties, or provider types” (p. 1). More specifically, it was noted that “data on supply and demand for RNs are not adequate to determine the mag- nitude of any current imbalance between the two with any degree of precision” (GAO, 2001, p. 5) “

“The responsibility for nurse workforce planning, however, rests largely with state governments (Salsberg, 2003). Without consistently collected state-level data and reliable national benchmarks, legislators and workforce planners at the state level have fewer resources to guide their use of scarce state funding. “

Some researchers have found that state-specific forecasts based on the NSSRN do not seem to characterize the state situation accurately (Reinier et al., 2005; Nooney & Lacey, 2007). The data do not permit assessment of the nursing workforce within smaller geographic areas such as cities or counties. As nursing labor markets are inherently local, lack of data at the local level is disadvantaging.

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Complex Systemic Questions

What is the number and mix of nursing professionals to be trained to meet the growing future needs of the population?
What is the probability of entry/ retention into a nursing profession in a desired geographic area or for a given demographic?
Do we have a legitimately defined economic shortage of nurses, Or do we just have less than another state?
How do interstate compacts affect workforce migration and available supply?
What is the cost savings and quality improvement results of creating scope of practice laws that allow nurses to provide specific care?

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Forum Supply Minimum Data Set

Demographics:
Gender*
Ethnicity
Race
Year of birth*
Entry level nursing education
Highest level of nursing education
Highest level of education in another field

License/ Certification Information
License type*
Year of initial U.S. licensure
Country of initial RN/LPN licensure
License status*
Advanced Practice license/ certification*

Employment Information
Employment Status
Reason for being unemployed
Number of positions employed in
Hours worked per week
Employer zip code
Employment setting
Employment position
Employment specialty

*These should be available in every single state as part of a licensing file

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Supply Data- 2018 Forum Member Survey

Collection:
By other organization	49%
By center	14%
Collaborative effort	22%

Analyzed by center	49%

Method:
Embedded in the nurse licensure/relicensure application	51%
Collected in the nurse licensure/relicensure application via a link to an external survey	22%
Collected via one survey of a sample of nurses in the state	3%
Collected via one independent survey of the population of all nurses in the state	3%

Profession Collected:
LPN	76%
RN	84%
APRN	81%

Raw Data Housed:
Board of Nursing	49%
Department of Health	14%
University	8%
State Labor Dept.	3%
Forum Center	3%
Licensing Entity	3%
Other contracted entity	3%

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Supply Data Cont’d

Essential Variables:
Gender	81%
Ethnicity	73%
Race	73%
DOB	81%
Highest Education	84%
Employment Status	81%
Employers zip	65%

Barriers:
No political interest in collecting the data
Operational barriers to integration with license process
Responsible party won't collect MDS
Declining response rates to voluntary surveys
No entity with responsibility to collect

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Visualizing Supply Data

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What Is The Difference?

The books in the room are full of useful information.
People know where the books that they have found useful are located.
Others must rely on help or spend time looking for what they need without knowing if it’s even there.
Some are pretty good at knowing where the most useful books are or where the most helpful information is. They’re even willing to help others.
It is burdensome, inefficient and time consuming to maintain a room full of books without some tools.
Card Catalogue- to know what books are in the room
Indices- to know what is contained in the books
Dewey Decimal System- to know where to find the books you want.
Librarians- to help guide and shape your search for books and keep the books organized
A Library Card- to maintain the order and track access and use of the books.

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Problem

Data exists but within silo-ed systems

Limited information about other silos
Policy barriers to connection
Variables/ definitions/ metrics are not standardized

Workforce Tracking Limitations

Interstate Compact- Supply data collected by

resident states is not provided to non-resident states

False impressions of surplus/ shortage
May impact patient safety during disaster

management

Need for harmonized data among many health policy stakeholders/ government entities in order to swiftly and accurately track outcomes, progress toward goals and respond to emerging issues.

When nurses are licensed in one state but practicing in another, states aren’t sharing that migration data. (likely even legally restricted)

There are barriers in place to protect against sharing personally identifying Information

Institutional Review Boards

State data sharing policies

Knowledge of technology

Despite the existence of the MDS, there is still plenty of variation in how state entities calculate metrics based on the MDS variables

Ex: some states count total licenses, some count only those reporting that they work in a state

Some states calculate FTEs as 40 hours, some use 35, other use the method used by HRSA where 40 hours and above is 1 FTE but anything less than 40 hours is a percent of 1 FTE etc.

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Solution: Aggregated Flat File Template

Each state can fill in the data they can access or generate

States maintain control of their contributed aggregates

Complies with the most stringent data privacy restrictions

No sharing Personally Identifiable Information
No Institutional Review Board violation

Reduces the possibility a third-party using alternate data sources would produce and disseminate analyses inconsistent with data from each state
Avoids user error in case-selection filter, variable weighting
Allows for development of additional aggregates to be included as they are defined for future contributions.

A year ago the Forum formed a small workgroup of states interested in looking at this question of how to share data and create the data repository.

We quickly realized (already knew) that there was no way to share data sets containing individual level data because of IRB and PII sharing limitations.

We decided to create a set of aggregate categories based on the MDS categories or categories that we created that we found useful.

We found that we had to be careful with these categories because if a group was sliced too small we ended up with counts that were too small to be shared

This solution has it’s limitations in that if you need data in a different category you can’t easily just re code to those categories but it also allows for meaningful use. These categories are sufficient to use in modeling and projections of things like education or workforce flow

This last year, Forum members had an experience with a national foundation publishing some analysis of the best and worst states for nursing workforce. The counts they published were from data purchased from a marketing company. As we dug into this source the best any of us could figure was that this marketing company must have accessed old data from somewhere. The counts that they quoted were at least 10 years old in comparison to the data that each of our centers possessed and knew to be the current numbers. The problem is that these state level counts don’t exist in one centralized place. A person would need to contact each state in order to get the information they seek. This would be an onerous and time consuming task.

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Data Visualization Demo

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Forum Supply Minimum Data Set Toward Standardization (Part 2): National Nursing Minimum Data Sets Consensus Building and Implementation Status

(Policy, Politics and Nursing Practice, Moulton et al, 2012)

Next Steps:

Determining where the data will be housed and what entity/entities will assemble and maintain the data.

Data can continue to be housed and managed by states. The Forum can agree on aggregate extracts
States maintain full control over what is contributed to the Forum.

Getting buy in at the state level for both collecting the minimum data set and sharing it with the warehousing entity.

Centers have the opportunity to focus their work on coalition building and educating state level entities on the value of collecting the supply MDS and what it can be used for.

Mentoring states with fewer human and fiscal resources to begin minimum data set collection.

Participation in the Forum is valuable to get to know conditions in states and share best practices.

Determining how the data will be used and under what conditions it will be shared.

This can be the ongoing work of the Forum Research Committee/ Board.

Determining a stable funding source for collection, housing and analysis of data sets.

Data collection improvements at the state level may require funding but the Forum would not need to manage this data.

Need for standardized codebooks
Need for MOUs to exchange data
Need for understanding of ecosystem within each state
Need for stakeholdering
Need for “data trusts”

Lots of patient data standards, almost no workforce data standards.

““The crisis has highlighted the need to continue efforts to modernize the public health data systems that C.D.C. and states rely on,” Dr. Redfield told a Senate committee on May 12. “Timely and accurate data are essential as C.D.C. and the nation work to understand the impact of Covid-19 on all Americans.”

Federal Health Data Standards

https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/HRSA_BHW_NCHWA_Compendium_of_Federal_Data_Sources_092017.pdf

FHA- Federal Health Architecture

eHealth Exchange- Nationwide Health Information Network (NHIN)

The National Information Exchange Model (NIEM)

The Federated Health Information Model (FHIM)

connects participants in all 50 states, across four federal agencies, 65 percent of U.S. hospitals, 50,000 medical groups, 3,400+ dialysis centers, 8,300 pharmacies, supporting more than 100 million patients.

Driven by a non-profit entity using standards for communication and interoperability

(NIEM) is a common vocabulary that enables efficient information exchange across diverse public and private organizations. NIEM connects communities of people who share a common need to exchange information in order to advance their mission.

(FHIM) describes the health-related information required by health organizations to achieve interoperability both within and external to an organization.

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Special Thanks to:

Alyssa Mullins, Ph.D.- Florida Center for Nursing

Ashley Davis, MNSc- Arkansas Center for Nursing

Carrie M. Oliveira, Ph.D.- Hawaii Center for Nursing

Craig Donahue, MPA- Michigan Health Council

Lanelle Weems, MSN- Missouri Office of Nursing Workforce

Linda B. Roberts, MSN- Illinois Center for Nursing

Marcia B. Proto, M. Ed- Connecticut League for Nursing

Questions?

info@nursingworkforcecenters.org

https://nursingworkforcecenters.org