THIS IS THE FEEDBACK I RECEEIVED. Only one patient responded to my.docx

THIS IS THE FEEDBACK I RECEEIVED. Only one patient
responded to my post. Hope this helps
Ryan,
Inadequate levels of nursing professionals were first discussed
more than 80 years ago (Whelan, n.d.). Recently, scholars have
opined many reasons for the shortage of nurses. Factors such as
work stress, burnout, violence against healthcare professionals,
a lack of qualified nursing instructors, and nurses unable to
adapt to changing technology or clinical environments have
been addressed (Haddad & Toney-Butler, 2019). As many
nurses may attest, doing more with less can lead to mistakes and
dissatisfaction with a nursing career. Ultimately, patient care
suffers.
Organizations employ various tactics to help strengthen nurse
retention. Halter et al. (2017) suggest strong nursing leadership
and assigning preceptors to new nurses can help minimize
nursing resignation rates. At the writer’s employment, hospital
administrators use several ways to retain nurses. Each quarter, a
nurse is recognized for outstanding achievement by receiving a
certificate, gift card, and editorial mention on the hospital’s
intranet. Moreover, the hospital caters lunch for all employees,
dayside and nighttime staff, twice a year for meeting quality
targets. Also, the hospital uses various national celebration days
such as ice cream, donuts, coffee, bagels, and candy to reward
all employees. Creating a level of goodwill and institutional
collaboration can help retain nurses and improve job
satisfaction (Kurnat-Thoma et al., 2017).
Reference
Haddad, L.M., & Toney-Butler, T.J. (2019). Nursing shortage.
StatPearls Publishing.
Halter, M., Pelone, F., Boiko, O., Beighton, C., Harris, R.,

Gale, J., Gourlay, S., & Drennan, V. (2017). Interventions to
reduce adult nursing turnover: A systematic review of
systematic reviews. The Open Nursing Journal, 11, 108-123.
https://doi.org/10.2174/1874434601711010108
Kurnat-Thoma, E., Ganger, M., Peterson, K., & Channell, L.
(2017). Reducing annual hospital and registered nurse staff
turnover: A 10-element onboarding program intervention. SAGE
Open Nursing, 3. https://doi.org/10.1177/2377960817697712
Whelan, J.C. (n.d.). Where did all the nurses go? Retrieved
from https://www.nursing.upenn.edu/nhhc/workforce-
issues/where-did-all-the-nurses-go/
By Thomas C. Ricketts and Erin P. Fraher
Reconfiguring Health Workforce
Policy So That Education,
Training, And Actual Delivery
Of Care Are Closely Connected
ABSTRACT There is growing consensus that the health care
workforce in
the United States needs to be reconfigured to meet the needs of
a health
care system that is being rapidly and permanently redesigned.
Accountable care organizations and patient-centered medical
homes, for
instance, will greatly alter the mix of caregivers needed and
create new
roles for existing health care workers. The focus of health
system
innovation, however, has largely been on reorganizing care
delivery
processes, reengineering workflows, and adopting electronic
technology

to improve outcomes. Little attention has been paid to training
workers
to adapt to these systems and deliver patient care in ever more
coordinated systems, such as integrated health care networks
that
harmonize primary care with acute inpatient and postacute long-
term
care. This article highlights how neither regulatory policies nor
market
forces are keeping up with a rapidly changing delivery system
and argues
that training and education should be connected more closely to
the
actual delivery of care.
H
ealth care professionals are be-
ing challenged to find new ways
to organize care and develop
systems that hold providers ac-
countable for the quality, cost,
and patient experience of care.1 The once in-
cremental pace of change is accelerating, and
there is evidence that long-standing paradigms
are dramatically shifting.2 For example, the rela-
tively slow acceptance of prepaid and managed
care systems is being replaced by the rapid adop-
tion of bundled and risk-based payment mod-
els.3,4 Early adopters of accountable care organi-
zations (ACOs) are finding that their workforce
is shifting from acute care to community- and
home-based settings with increasing roles for
physicians, nurses, social workers, patient navi-
gators and outreach coordinators, and other
clinicians in providing enhanced care coordina-

tion, better medication management, and im-
proved care transitions.5
The training of health professionals, however,
lags behind these reforms because it remains
largely insulated from change behind the walls
of schools of medicine, dentistry, pharmacy, and
nursing. Medical training is done primarily in
hospitals, while the greatest challenges are
found in coordinating care in multiple out-
patient settings. This article describes how
health workforce policy was done in the past.
It illustrates some of the specific changes under
way and how they are changing the health care
workforce. Further, it suggests that closer links
should be built between the day-to-day caring for
patients and the training of the people who de-
liver that care.
Workforce Policy Center Stage Again
Health workforce policy took center stage in an
earlier Health Affairs thematic issue in 2002.6
Articles in that issue described future efforts to
doi: 10.1377/hlthaff.2013.0531
HEALTH AFFAIRS 32,
NO. 11 (2013): 1874–1880
©2013 Project HOPE—
The People-to-People Health
Foundation, Inc.
Thomas C. Ricketts (tom_
[email protected]) is the
deputy director of the Cecil G.
Sheps Center for Health

Services Research and a
professor in the Departments
of Health Policy and
Management and Social
Medicine at the University of
North Carolina at Chapel Hill.
Erin P. Fraher is an assistant
professor in the Departments
of Family Medicine and
Surgery, University of North
Carolina at Chapel Hill.
1874 Health Affairs November 2013 32:11
Overview
Downloaded from HealthAffairs.org on February 23, 2020.
Copyright Project HOPE—The People-to-People Health
Foundation, Inc.
For personal use only. All rights reserved. Reuse permissions at
HealthAffairs.org.
shape the clinical workforce as a “dream”7 or
subject to “hand-to-hand” combat.8 The “hands”
in thiscase weredescribedby KevinGrumbach as
the “heavy hand” of government regulation and
the “invisible hand” of market forces that con-
stantly pushed the United States into a rolling
series of surpluses followed by shortages.8 The
“dream,” as Uwe Reinhardt saw it, was that reg-
ulation and control could actually work. He of-
fered in its place a change in policy to expose

physicians to the actual costs of their training
while pushing them to the right places and spe-
cialties with judiciously targeted tax-financed
loan repayment.7
In much of the rest of the world, coordinated
workforce planning that develops national and
regional goals has long been accepted as a legiti-
mate policy exercise. This work is achieved by
pairing technical workforce experts and policy
makers with clinicians and patients to guide the
structure of the health workforce—in both num-
bers and skill mix—to meet the needs of delivery
systems and thepopulation.9 IntheUnited States
a mix of government policies and professional
guidelines combine with strong market forces to
shape the health care workforce; the latter al-
most invariably dominates but with a recogni-
tion among most stakeholders that regulation is
necessary.10
As a result, the United States has forgone any
substantial investment in workforce planning
except for the veterans’ health system.11 The
United States has left it up to states, professional
associations, employers, payers, and other
stakeholders to negotiate their interests via the
market and the political process. The result is a
complex and uncoordinated web of training in-
stitutions efforts, licensing board rules, place-
ment programs such as the National Health
Service Corps, and payment regimes. These are
not compared or evaluated to determine if they
are producing the right people for the right work
to meet patients’ needs.
With many observers asking if there will be

enough providers to meet the needs of rapidly
innovating systems, this laissez-faire system is
now in flux. The Centers for Medicare and
Medicaid Services has funded numerous pilots
to identify new models for workforce develop-
ment and payment to support health system in-
novation. These pilots, however, are relatively
isolated and have not been linked in any system-
atic way to broader systems or structures that
govern the way we train, regulate, or deploy
the health workforce.
The earlier Health Affairs thematic issue raised
many familiar, unanswered questions, including
a fundamental one: How many of what kinds of
professionals with what competencies are need-
ed to care for our population? This issue asks the
same questions but adds another: What has
changed over the past ten years?
The Affordable Care Act has created a new
vocabulary to describe networks of providers
tied together to offer enhanced care coordina-
tion. The ACO and the patient-centered medical
home have become seemingly ubiquitous mod-
els for holding systems accountable for the care
provided to patients across community, ambula-
tory, and acute care settings. These emerging
models of integrated care have been abetted by
increasing market concentration in health care
delivery systems.
ACOs, which take on risk by having a portion
of their reimbursements tied to the outcomes of

care for a predetermined Medicare population,
are seeking to reduce costs and improve care by
ramping up screening and preventive care and
the coordination of services. This restructuring
will have far-reaching implications for how clin-
ical work is organized and compensated, with
more work shifting to lower-paid and allied
health workers who provide care in less costly
community- and home-based settings.
Teams And Workforce
Almost all of the new arrangements include
plans or structures that call for more “team-
based care” and make use of “enhanced” roles
for various professions, despite a lack of consen-
sus on what those two terms really mean. Teams
have been described as groups of people whose
roles continuously shift in response to internal
and external forces, including patient expecta-
tions; policy and payment changes; organiza-
tional factors; geographic proximity of other
providers; and professional regulation, training,
and attitudes.12,13 Broadly conceptualized, roles
within teams fall into two categories: lower-cost
health professionals acting as substitutes for
higher-cost ones (for example, nurse practi-
tioners for physicians), or lower-cost health
professionals functioning as supplements who
extend and enhance the work of others (for
example, navigators to coordinate care or dis-
charge planners to help patients make the tran-
sition from acute to postacute care). Despite the
numerous calls for more team-based models of
care, relatively little attention has been given to
how to prepare physicians, nurses, therapists,
technicians, and others already in the workforce

to practice in accountable or reformed teams.
Health care professionals have been seen more
as parts of a puzzle that need to be carefully fit
together into a transformed system of care than
as fungible resources that can be crafted or re-
made to help build a truly reformed and more
November 2013 32:11 Health Affairs 1875
Foundation, Inc.
HealthAffairs.org.
effective health care delivery system. For exam-
ple, although the use of electronic health records
(EHRs) has burgeoned with the implementation
of the federal program to certify and reward the
meaningful use of health information technolo-
gy, there is limited understanding of how health
professionals can work with EHRs to change the
flow of work or how work should be reconfigured
and reallocated among team members. EHRs are
shaping the work of clinicians as much as they
are being adopted for and adapted to current
practices. To be optimally effective, EHRs re-
quire broad and rapid adoption, practitioners
must pay constant attention to data entry, and
care patterns have to be reengineered to accom-
modate EHRs’ use.14,15
Projecting Supply, Demand, Need,

And Requirements
That workforce projections are controversial
should come as no surprise; any projection will
inevitably be ambushed by unknown or un-
expected factors and events that affect future
workforce supply and demand. The surprising
thing is that projections, whether based on em-
pirical models or “expert” opinion, are criticized
for not correctly predicting the future when their
purpose is almost always to change policies and
practices. Projections, when accepted as roughly
correct, are often followed by policy shifts that,
in turn, change the future supply or pipeline of
workforce production.
Projections turn out to be wrong either be-
cause it is not known how many physicians there
are16 or because there is a lack of understanding
of the true relationship between physician
supply and health outcomes.17 They are, in one
sense, “projectiles” shot across the bows of
policy makers to stimulate action; they paint a
picture of what is likely to happen if some desir-
able policy is not implemented. If a policy is
changed, then the projection is likely to turn
out wrong because it helped cause changes in
the factors that drove the model.
For example, the Graduate Medical Education
National Advisory Committee’s 1980 projection
of a physician surplus was used to justify cut-
backs in federal support to medical education,
thus changing medical school growth trends.
That policy shift reduced production and even-
tually led to a perceived shortage.18 The more
recent Association of American Medical Colleges

forecasts of shortages of physicians have similar-
ly prompted the expansion of existing and the
opening of new medical schools and have put
strong pressure on the debate over how to sup-
port graduate medical education to provide the
additional training necessary to produce practic-
ing physicians.19
Recent work has focused on developing dy-
namic projection models that are amenable to
changes in the assumptions on which they are
based and that allow policy makers to simulate
the effects of potential policy scenarios20 on
workforce supply and demand. This type of work
is supported by the National Center for Health
Workforce Analysis in the Department of Health
and Human Services, but the center struggles
with a lack of both up-to-date inventories of ex-
isting health professionals and a common data
set to measure practitioner capacity or simply
identify the location of practice.21,22
The modeling field in the United States and
other countries23 is moving toward using projec-
tions not as a method for generating one “right”
answer but as a way to educate health profession-
als and their associations, policy makers, and
other workforce stakeholders about the com-
plexity of projecting future workforce needs
and the effects of the policy options they have
at hand. Engaging stakeholders—particularly
clinicians—in themodeling process cangenerate
numerous desirable results, including a better
understanding of how rapid health system
change affects workforce deployment and im-

proved communication between the professions
and policy makers. Having clinicians involved in
modeling can also serve as a check on the “face
validity” of model outputs and can generate clin-
ical input in areas where data inputs are weak.
Stakeholders engaged in modeling can also help
identify ways to redesign care processes to ad-
dress workforce shortfalls or surpluses.
Models and projection thus cannot provide a
single “right” answer in a system that is rapidly
changing. The important thing is to have a model
that can be used to simulate the effect of policy
change and educate stakeholders about the
effects of policy options. For example, a model
might show that increasing graduate medical
education slots will likely have a relatively small
effect on the overall match of supply to need
compared to increasing productivity and delay-
ing retirement.
Efforts to model the nursing workforce have
been complicated by nursing’s persistent sine-
wave pattern of shortages prompting policy ac-
tions that, in turn, stimulate rapid growth lead-
ing to surpluses.24 Analyses of nurse supply and
demand remain doggedly unconnected to physi-
cian workforce projections. There are no exam-
ples of national models that simultaneously
project the supply of both professions despite
their substantial overlap in providing care.
Combining the two in projections is now an im-
perative given nurses’ complementary and sup-
plementary roles in delivering or supporting
Overview

Foundation, Inc.
HealthAffairs.org.
many of the new services required by ACOs and
patient-centered medical homes, such as care
coordination, patient navigation, transition
care, and population health management.
An obvious link would be in the production
and deployment of nurse practitioners and their
impact on the “effective supply” of primary care
practitioners,25,26 but including “nonphysicians”
in physician supply-demand calculations has
proved difficult. For example, in the develop-
ment of an index to identify shortage areas for
federal support, an intense battle was fought in a
special “negotiated rulemaking” committee
mandated by the Affordable Care Act over how
to count nurse practitioners and physician assis-
tants in a formula for proposed new Health
Professional Shortage Areas and Medically
Underserved Populations.27 Advocates from the
nurse practitioner and physician assistant pro-
fessions felt strongly that they should be as-
signed a weight of at least 0.75 full-time-equiva-
lent of a primary care physician to account for
their contribution to community-based primary
care. Counting them would often increase the

local supply above a shortage threshold, making
the community or population lose its designa-
tion and thus its eligibility for federal support.
Productivity In The Health Care
Workforce
The promise of technology as the way to improve
the quality of care and lower costs, especially via
the EHR, has been promoted on the basis of its
potential to improve productivity in the system
by making care more efficient and effective.28
This is essentially an economic calculus: Can
more be done and done better and at lower cost?
That question remains to be answered.
What the United States has done is rapidly
increase the number of people and types of work-
ers who are delivering care. Employment in the
health care sector grew rapidly between 2000
and 2010—at a rate of greater than 3 percent
annually—and even faster growth has been
projected for the following decade, but there
are signs of a slowdown in that growth.29 This
is in contrast to overall employment, which
shrank by 0.2 percent per year in the first decade
of this century and is projected to grow by only
1.3 percent during 2010–20.
Employment growth in ambulatory health
services has been strong at 3.3 percent per year,
with an anticipated increase to 3.7 percent.
These labor inputs may be growing faster than
patient care needs, thus making the overall
workforce less productive and efficient. On the
other hand, that same expanding workforce may

be generating greater value by improving out-
comes through better coordination and greater
intensityof care.Whetherthesystem isbecoming
more or less efficient in terms of value for money
because of the addition of new specialties or new
professions has seldom been asked30 and even
less often answered.31
Professions Unto Themselves
The United States accepts in policy and practice
the idea of “sovereign” and self-regulating pro-
fessions that have substantial control over their
place in the health care system. This approach
has meant that workforce policy has been largely
shaped around the demands of the professions
and not around the needs of the patients. The
question of whether the professions should con-
trol entry into their respective realms through
self-regulation remains largely out of the main-
stream of debate but is raised from time to time
by libertarian thinkers.32 There are very intense
battles over scope-of-practice rules, with ad-
vanced-practice nurses making strong claims
on primary care, nurse anesthetists being chal-
lenged over their contributions by anesthesiolo-
gists, and the development of dental therapists’
work being challenged by dentists. These con-
flicts are becoming sharper despite a body of
evidence that shows that most of these work
and professional roles are effective in saving
money and maintaining or improving quality.33
New and different types of health profession-
als—community health workers, patient navi-
gators, health coaches, care coordinators, and

more—are attempting to create their own space
in the health care delivery system as their con-
tributions to the new payment and organiza-
tional models become more apparent. The
emergence of new professions runs counter to
theories of how health care workers should func-
tion in teams adapting and “upskilling” existing
professional or paraprofessional roles to meet
patients’ needs.34
The progressive division of labor and the crea-
tion of specialized labor categories that are able
to do one focused job more efficiently than a
range of work has been the pathway to greater
productivity in manufacturing and other sectors
but to a lesser extent in health services. In the
health care realm, increasing specialization is
reflected in the growing complexity of how a
hospital is staffed to care for patients—a process
that has given us hospitalists, intensivists, noc-
turnalists, and other types of practitioners who
are defined by their functional role as much as by
their disciplinary specialization.35 The prolifera-
tion of new professions and professional roles
does not necessarily lead to greater efficiency
because, as David Meltzer and Jeanette Chung
◀
3%
Employment growth
Employment in the health
care sector grew more
than 3 percent a year
during 2000–10, compared
to a 0.2 percent annual

shrinkage in overall
employment growth in the
same decade.
Foundation, Inc.
HealthAffairs.org.
point out, there are real costs associated with
coordination.35 Those costs have not been calcu-
lated or even anticipated in most of the calls for
reorganization using teams.
The rise of additional specialists and profes-
sions within the health care “team” in new mod-
els of care have made Irving Zola and Stephen
Miller’s description of long-term care common-
place:“In thecourse of…long term disorders, the
doctor recedes further and further into the back-
ground, eventually assuming the role of occa-
sional medical consultant.With this, the physio-
therapist, visiting nurse, dietician, prosthetist
becomes essentially ‘the doctor’ not only in
terms of primary day-to-day management, but
in terms of the transference relationship as
well.”36
The career paths for physicians, nurses, and
even dentists are multiplying. They involve serial
training in fellowships to acquire new techni-

ques and skills; adapt to shifts in practice focus;
and, more often, prepare them for a return or
to introduce them to a type of practice that is
more flexible—essentially a return to a generalist
role.37 At the simplest level of care, the nature of
laborfordirect careworkerswho feed,move,and
clean patients has become dominated by part-
time jobs with fewer and fewer benefits.38 To
achieve true integration, teams must accommo-
date the multiple needs of the people working
around the patient, including highly trained
physicians who seek professional satisfaction
andhigh rewards aswell as unlicensed personnel
whose formal connection to the system is tenu-
ous but whose practical training and skills are
often crucial in generating quality care and pa-
tient satisfaction.
The pressure to coordinate, or perhaps simply
serve as a traffic cop controlling, the flow of
practitioners around the patient, has emerged
as a true challenge. Atul Gawande’s description
of hismother’s careduring her knee replacement
gives a sense of what a contemporary hospital-
based team is like: It is large, potentially irratio-
nal, and likely to grow.39 We know far less about
what makes for an effective team of ambulatory
caregivers when it comes to managing transi-
tions for patients with complex chronic illnesses
from community to acute care settings and back.
If the workforce needs of the future are to be
adequately assessed, it is necessary to first get
a better handle on who will make up the work-
force in each setting in the future.
Training And Education As Field Of

Reform
Training professionals for the future of team-
based care has been recognized as a real chal-
lenge. The Institute of Medicine is currently
supporting a committee, the Global Forum on
Innovation in Health Professional Education, to
explore how best to promote “transdisciplinary
professionalism.” The group recognizes the
challenges of integrating the diverse cultures
and skill sets of the various professions, the
problem of teaching “followership” and leader-
ship, and the practical problem of measuring
how well a team works.
The National Center for Interprofessional
Practice and Education has been funded by the
Health Resources and Services Administration
to do similar work. These efforts follow on a
series of precursor programs in interdisciplinary
training that never quite found traction in for-
mal policy or in health professions training.40
Thecentraltask for reformedhealth care delivery
may indeed be to create and sustain teams of
different professional pedigrees. The question
is whether teams can be constructed around a
template or whether it must happen in practice
with ad hoc teams forming around the patient
and their needs.
Innovations In Training And
Education
The ways in which health care professionals are
taught are changing rapidly. Additionally, there
is pressure to streamline pathways into profes-

sions.41 Online courses, clinical simulators, and
learning teams have made education more flexi-
ble. Still, little is known about what constitutes
efficient and effective clinical training.42 The true
costs of preparing health professions are being
revealed by the rapid growth in the number of
private, including for-profit, health professions
institutions that have sprung up to meet demand
from prospective students.43 These include oste-
opathic medical schools and physician assistant
programs and umbrella “Health Science”
schools that provide training for nurses, thera-
pists, and technicians. Public community col-
leges in some states fill this niche, but the market
Training professionals
for the future of
team-based care has
been recognized as a
real challenge.
Overview
Foundation, Inc.
HealthAffairs.org.
has also responded vigorously to train workers,
especially allied health workers, for reformed, if
not fully coordinated, systems.44

The “safety net” of public clinics, hospitals,
and private charity caregivers is one place where
innovation in role assignment and integration of
multiple professions has been welcomed,45 but
the benefits are difficult to calculate. Community
health centers (also known as federally qualified
health centers) have become testing grounds for
a new approach to graduate medical education
through the Teaching Health Centers Program.46
Through this program, the new centers are
funded as temporary demonstrations whose
long-term outlook depends on future appropria-
tions.47 They do offer a new approach to meeting
the growing need for locations to provide grad-
uate medical education given the recent rapid
rise in the number of US medical school gradu-
ates and the apparent “bottleneck” that has
slowed growth in residency training and thus
physicians’ progression into the workforce.
Revolutionary changes in the nature and form
of health care delivery are reverberating back-
ward into medical education as leaders of the
new practice organizations demand that the ed-
ucational mission be responsive to their needs
for practitioners who can work with teams in
more flexible and changing organizations. In
the face of this pressure, the traditional response
of health educators—that they should have au-
tonomy in defining the educational mission—is
no longer viable. Instead, more explicit, formal,
and systemic linkages between practice and ed-
ucational institutions that are coordinated with
maintenance of certification and licensing are

inevitable.48 There are proposals to base certifi-
cation and licensure on actual performance and
patient care outcomes instead of on simply meet-
ing additional education and training require-
ments. 49 This new pressure to make medical
education at all levels more accountable to public
and patient needs means that we must measure
how medical education affects medical care out-
comes, not just the outputs of the programs and
institutions.
Conclusion
We often hear how the United States has a non-
system of health care—a faircharacterization of a
very adaptable sector of the economy that com-
bines rigid professional norms, rapid shifts in
staffing and deployment of workers to capture
funding streams, and the constant creation of
new work roles and employment opportunities.
It is largely these characteristics of the workforce
that have both constrained the coordination of
health care and allowed the system to grow very
rapidly. To blunt rising costs, it seems necessary
to find ways to temper this professional and oc-
cupational exuberance to achieve both greater
efficiency and effectiveness.
To anticipate these changes and prepare the
workforce for new roles, it will be necessary to
invest in workforce planning but not solely at the
macro level of overall supply. Investments are
needed in research and implementation studies
to help foster greater understanding about the
actual content of care that is required in the new
systems. Investments in research are also needed

to identify how best to allocate new caring roles
among a set of professions and disciplines that
are trained and deployed in a coordinated fash-
ion. Workforce planning needs to be more “bot-
tom up” as it seeks to identify the “right kind”
and the “right number” of workers. ▪
This work was supported in part by
contracts with the American College of
Surgeons and the Physicians Foundation.
The authors thank Laura Trude and Kelly
Quigley of the Health Workforce
Information Center at the University of
North Dakota for their assistance.
NOTES
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HealthAffairs.org.
Removing restrictions on nurse practitioners’ scope of practice
in New York State: Physicians’ and nurse
practitioners’ perspectives
Lusine Poghosyan, PhD, RN, FAAN1, Allison A. Norful, PhD,
RN, ANP-BC2, & Miriam J. Laugesen, PhD3

ABSTRACT
Background and purpose: In 2015, New York State adopted the
Nurse Practitioners Modernization Act to remove
required written practice agreements between physicians and
nurse practitioners (NPs) with at least 3,600 hours of
practice experience. We assessed the perspectives of physicians
and NPs on the barriers and facilitators of policy
implementation.
Methods: Qualitative descriptive design and individual face-to-
face interviews were used to collect data from
physicians and NPs. One researcher conducted interviews,
which were audio-taped and transcribed. Twenty-six
participants were interviewed. Two researchers analyzed the
data.
Results: The new law has not yet changed NP practice. Almost
all experienced NPs had written practice agreements.
Outdated organizational bylaws, administrators’ and physicians’
lack of awareness of NP competencies, and phy-
sician resistance and lack of knowledge of the law were
barriers. Collegial relationships between NPs and physicians
and positive perceptions of the law facilitated policy
implementation.
Conclusions: Policy makers and administrators should make
efforts to remove barriers and promote facilitators to
assure the law achieves its maximum impact.
Implications for practices: Efforts should be undertaken to
implement the law in each organization by engaging
leadership, increasing awareness about the positive impact of
the law and NP independence, and promoting rela-
tionships between NPs and physicians.
Keywords: Nurse practitioners; scope of practice; primary care;
policy.
Journal of the American Association of Nurse Practitioners 30
(2018) 354–360, © 2018 American Association of Nurse
Practitioners

DOI# 10.1097/JXX.0000000000000040
Background
Physicians, nurse practitioners (NPs), and physician
assistants currently provide the bulk of primary care in
the United States (U.S.) to meet the demands of an
aging population and expansion of insurance coverage
(Agency for Healthcare Research and Quality, 2014; Col-
will, Cultice, & Kruse, 2008; DeVol & Bedroussian, 2007;
Patient Protection and Affordable Care Act of, 2010). One
projection suggests an additional 52,000 physicians will
be needed by 2025 to meet the primary care demand
(Petterson et al., 2012); however, the supply of these
providers is expected to decrease (Association of Medical
Colleges Center for Workforce Studies, 2015). Conversely,
NP workforce is expected to grow. In 2013, NPs comprised
about 19% of the U.S. primary care provider workforce,
and the number of NPs will increase by 93% by 2025
(Health Resources and Services Administration, 2016),
potentially expanding the primary care capacity (Auer-
bach, et al., 2013; Green, Savin, & Lu, 2013).
However, the ability of NPs to care for patients has
been limited by state-level scope of practice (SOP) reg-
ulations that determine the services NPs provide. Nurse
practitioner state-level scope of practice laws vary across
states. In 2017, 22 states and the District of Columbia au-
thorize NPs to deliver care according to their competen-
cies (Robert Wood Johnson Foundation, 2017). The
remaining states impose restrictions, including the re-
quirement of NPs to have supervisory or collaborative
relationships with physicians. Some states require NPs to
1Columbia University School of Nursing, New York, NY

2Columbia
University School of Nursing, Columbia University Medical
Center
Irving Institute for Clinical and Translational Research
3Department
of Health Policy & Management, Columbia University Mailman
School
of Public Health
Correspondence: Lusine Poghosyan, PhD, RN, FAAN, Columbia
University School of Nursing, 630 W. 168th Street, Mail Code
6, New
York, NY 10032. Tel: 212-305-7081; Fax: 212-305-0722; E-
mail: [email protected]
columbia.edu
Received: 9 August 2017; revised 30 October 2017; accepted
20 November 2017
354 June 2018 · Volume 30 · Number 6 Journal of the American
Association of Nurse Practitioners
Qualitative Research
� 2018 American Association of Nurse Practitioners.
Unauthorized reproduction of this article is prohibited.
have such relationships both for delivering care and
prescribing medication and services, other states impose
restrictions only on one aspect. The Federal Trade Com-
mission, the National Governors Association, and the
National Academy of Medicine have criticized these laws
and recommend removal of these restrictions to improve
access to care (Federal Trade Commission, 2014; Institute
of Medicine, 2010; National Governors Association, 2012).
Indeed, states granting NPs greater SOP authority expe-

rience expanded health care utilization (Kuo, Loresto,
Rounds, & Goodwin, 2013; Xue, Ye, Brewer, & Spetz, 2016).
In 2015, New York State (NYS) implemented the Nurse
Practitioners Modernization Act (New York State De-
partment of Education, 2015). The law removed the re-
quired written practice agreement between NPs and
physicians for experienced NPs with more than 3,600
hours of practice. New NPs with less than 3,600 hours of
practice still are required to have this agreement. The
outdated policy requiring NPs to have a written practice
agreement with physicians limited NPs’ ability to in-
dependently care for their patients and practice in un-
derserved areas with shortage of primary care physicians.
This policy change aimed to promote NP independent
practice and address the misdistribution of primary care
services across NYS by allowing experienced NPs to
practice independently in underserved areas (Center for
Health Workforce Studies, 2013). In this study, we
assessed the perspectives of physicians and NPs on the
barriers and facilitators of implementing the NP Mod-
ernization Act 18 months after the policy adoption.
Methods
We used a qualitative descriptive design as described by
Sandelowski (2010) to collect data from physicians and
NPs because we know little about the law’s implementa-
tion. Participants were recruited through purposive
snowball sampling (Sandelowski, 2007). We contacted
several practices in NYS, through our professional network
in primary care, and informed practice managers or
providers about the study and asked for assistance with
recruitment. Both managers and providers distributed
flyers about the study which included information about
study’s risks and benefits, and the contact information of
the researchers. Participants were eligible for inclusion if

they practiced as a primary care NP or physician and spoke
and understood English. Interested participants contacted
the researchers to schedule a convenient time and place
(e.g., primary care office) for the face-to-face interview.
Using the snowball sampling method, we also asked par-
ticipants to refer colleagues as potential participants.
One researcher (AN), an experienced NP in NYS with
expertise in qualitative designs, conducted all interviews
using a semistructured interview guide that allowed for
probing for additional information. The researcher kept
a reflexivity journal prior to and during the interviews to
reduce bias. We developed the questions from existing
evidence. Interviews started with questions regarding the
practice, participants’ roles, and then about the NP
Modernization Act. Table 1 presents key questions.
Each interviewee signed a consent form. Interviews
and data analysis were conducted concurrently (DiCicco-
Bloom & Crabtree, 2006). As interviews progressed,
participants provided information, which was further
explored in subsequent interviews. All interviews were
conducted in the participant’s practice office with no
others present during the interview. Interviews were
audio-taped and lasted between 25 and 45 minutes. The
interviewer took notes. Demographic and practice char-
acteristic information was also collected. Data collection
took place in the summer-fall of 2016.
Twenty-three interviews were completed initially (12
NPs and 11 physicians) and analyzed to identify codes and
themes (Miles & Huberman, 1984). To further explore the
codes and themes and develop an exhaustive de-
scription, we conducted three additional interviews with
two NPs and one physician. In alignment with qualitative

research principles (Sandelowski, 2007), data collection
ended when interviews were not producing new in-
formation. This was reached after the 26th interview.
Interview audio-recordings were transcribed verbatim
by a transcriptionist. We imported the data into the
qualitative software package, Atlas, and using iterative
content analysis (Bradley, Curry, & Devers, 2007), we an-
alyzed the data. Two researchers independently read and
reread transcripts for overall understanding and in-
ductively coded the data (Hsieh & Shannon, 2005). We
reviewed data line-by-line and when a concept became
apparent, we assigned a code. We used constant com-
parison to refine codes and had regular in-person
meetings to review discrepancies and achieve consensus.
After identifying all concepts, we linked them to develop
themes relating to barriers and facilitators of the law’s
implementation. We also conducted a comparative
analysis in two groups (physicians and NPs) by retrieving
data coded with both conceptual and participant codes.
This comparison showed whether certain concepts were
Table 1. Examples of interview questions
Key Questions
•Can you describe the Nurse Practitioners Modernization Act?
What does it state?
•Can you talk about how your organization has adopted the
Nurse Practitioners Modernization Act?
•How has the Nurse Practitioners Modernization Act impacted
your practice?
•What organizational barriers exist to adopt the Nurse
Practitioners Modernization Act?

Journal of the American Association of Nurse Practitioners June
2018 · Volume 30 · Number 6 355
L. Poghosyan et al.
reported differently between two groups. Findings were
shared with participants to obtain feedback. De-
mographic data were analyzed using SPSS v24.
Results
Table 2 includes information about the 14 NP and 12
physician participants. The mean age was 41 years for NPs
and 45 years for physicians. The mean years of experience
for NPs was about 7 years and for physicians was 13 years.
Twelve of 14 NPs (85.7%) were experienced NPs with at
least 3,600 hours of clinical practice. The majority of NPs
and physicians worked in practices affiliated with
hospitals or medical centers. We identified four barriers
and two facilitators toward the law’s implementation
(Table 3), which emerged both in NP and physician
interviews; thus, findings are combined.
Barriers
The following barriers emerged: stagnant organizational
policy; lack of awareness of NP competencies; lack of
knowledge about the NP Modernization Act; and physi-
cian autonomy and resistance to change.
Stagnant organizational policy. Almost all NPs reported

that the law change did not affect their practice because
Table 2. Nurse practitioner (NP) and physician characteristics
Characteristics NPs (N = 14) Physicians (N = 12)
Age, mean (SD), years 41.36 (3.4) 45.78 (2.7)
Female, No. (%) 13 (93) 7 (58)
Highest degree, No. (%)
Master’s 5 (36) —
Post-Master’s 3 (21) —
MD — 11 (92)
Doctorate (PhD; DNP; PhD/MD) 6 (43) 1 (8)
Years of experience, mean (SD) 7.21 (1.8) 13 (2.4)
Main practice site, No. (%)
Private practice 2 (14) 3 (25)
Academic medical center-affiliated
practice
5 (36) 6 (50)
Hospital-affiliated practice 7 (50) 2 (17)
Community health center — 1 (8)
Geographical location, No. (%)

Urban 9 (64) 8 (67)
Suburban 5 (36) 3 (25)
Rural — 1 (8)
Table 3. Barriers and facilitators for implementing the nurse
practitioners modernization act
Barriers
•Stagnant Organizational Policy
•Lack of Awareness of NP Competencies
•Lack of Knowledge about the NP Modernization Act
•Physician Autonomy and Resistance to Change
Facilitators
•NP and Physician Collegiality
•Positive Perceptions of the benefits of NP Independence and
the Law
356 June 2018 · Volume 30 · Number 6 www.jaanp.com
Removing restrictions on NPs’ scope of practiceQualitative
Research
the organizational bylaws were not reformed to accom-

modate the change, particularly in practices affiliated
with hospitals or medical centers. Eighty-six percent of
NPs (12 out of 14), regardless of experience, had a written
practice agreement with physicians. One NP employed in
a hospital-affiliated practice for seven years described,
“The bylaws…state that you have to have a collaborating
physician…I still have a collaborating physician.” She
continued, “They (administrators) have not kind of come
with the times yet…my collaborating physician in
particular totally agrees with the Modernization Act and
does not feel that she needs to oversee me in any way,
shape, or form.” Most NPs reported that their
organizations do not plan to change their bylaws because
of lack of advocates in the leadership to encourage
change.
Practices sold to hospitals found that new owners
were less supportive of expanding NP SOP. Hospitals not
only did not promote NP independent practice, but they
even restricted the practice of those NPs who had
a broader SOP in a standalone practice prior to the hos-
pital acquiring their practice. One NP with 15 years of
experience provided an example:
Before (hospital) took over, I was comfortable, and the
physician that owned the practice was very comfortable
with me doing initial physical examinations, doing med-
ical clearances, doing worker’s compensation. All that has
gone away since (hospital) bought the practice.
Physicians also confirmed that their organizations did
not conform to the law. They saw this as a reflection of
their organizations, which they perceived as out of touch
with new policies. One physician practicing with NPs for
20 years stated, “I really think that the organization that
I’m working for is just not up with the times. I don’t think

they’re astute enough to… know what’s out there.”
Lack of awareness of NP competencies. Most participants,
both NPs and physicians, perceived that some physicians
and administrators are not familiar with NP competen-
cies or the care NPs can deliver. One NP said, “I also don’t
think that all providers, like physicians, know what nurse
practitioners can do and the extent we can do it, too.”
Physicians’ comments confirmed NPs’ concerns. One
physician said, “I’m not really sure what their (NPs’)
training entails.”
Physicians had conflicting views about NPs’ abilities
when speaking about NPs more generally compared with
NPs they worked with directly. Most physicians viewed the
quality of care of NPs in their practices positively, “The
nurse practitioner that works here I feel is exceptional. So,
if she went out on her own independently, I would have
no hesitation about it.” However, viewed as a group, the
same physician’s perception of NPs was not as positive, “I
don’t feel that way across the board for most NPs.”
Awareness of NP competencies and support for NP in-
dependent practice was higher among physicians who
worked with NPs; however, that awareness and support
was individualized to the NPs they worked with. Physi-
cians often perceived that these NPs are uniquely skilled
and their competencies are not generalizable to the
overall NP workforce.
Lack of knowledge about the NP Modernization Act.
Awareness of the policy change varied across the two
groups. Although most NPs were familiar with the law,
only a few physicians had heard about it. One physician
stated, “I heard it is’ something like they (NPs) can
practice individually? Without any presence of any

doctors?” Another physician said, “I don’t know about
NPs going independent. I have not seen that in any of my
practices.”
Even though most NPs knew the law had passed, they
were not well informed about its details. One NP sum-
marized as, “It is (NP Modernization Act is) basically pro-
moting NP autonomy”. Also, both physicians and NPs
reported that their organizations are unfamiliar with the
law or they do not keep informed about the state policy
changes.
Physician autonomy and resistance to change. Two
physicians reported resistance toward surrendering
some of their rights despite recognizing that the law’s
implementation would reduce delays for patients by
allowing NPs to bypass physician signing off on forms.
One physician provided an example, “Ideally, I would
hope that we (NPs and physicians) would be completely
equal. But I know that after being in, like, 20 years of
practice where I am sort of the final say, I might have
a hard time giving up that.” The same physician said,
“Then you would have to sort of negotiate between the
two providers.” Another physician said, “not that they
(NPs) don’t know and they don’t have any experience, but
I feel still that I think there has to be some kind of com-
munication with the doctor…”
Facilitators
Two factors emerged as facilitators: NP and physician
collegiality and positive perceptions of the benefits of NP
independence and the law.
Nurse practitioner and physician collegiality. Both NPs
and physicians identified favorable collegial relations as
facilitating the law’s implementation. In practices where

NPs and physicians had positive relationships, NPs were
more likely to practice independently. Furthermore, in
these practices, NPs were key members of the team. One
NP said, “A lot of our physician colleagues…see me as
a warrior with them…” Similarly, some physicians spoke
about NPs being equal team members and in-
dependently delivering care to patients. One physician
said, “the NP certainly is seeing patients on her own… she
has her own panel.” Other physicians emphasized the
importance of having collegial relationships with NPs
because it would benefit patients.
2018 · Volume 30 · Number 6 357
L. Poghosyan et al.
Positive perceptions of the benefits of NP independence and
the law. Physicians were supportive of the law when they
perceived that NP independence benefitted their practice
by expanding its capacity. Nurse Practitioners could help
practices meet the increased care demand and attract
more patients. One physician with over 20 years of ex-
perience owning his practice said:
Expansion (NP SOP) is like if I have two “me’s…because
the NP is going to be doing the same thing that I do, it is’
just that we are able to get as many patients as possible…I
just want to make the office bigger.”
Physicians who found the NP collaboration re-

quirement burdensome were also more likely to support
the law’s implementation. One physician said, “I’ve asked
that many times, ‘Why am I signing for a nurse practitioner
who has a Ph.D. and has been working with me since
1998?’ I have absolutely no clue.” Similarly, NPs perceived
that environments where physicians and administrators
had positive attitudes toward NP independence were
more likely to adopt the law.
Discussion
Our study represents one of the first comprehensive
assessments of the NYS NP SOP policy change imple-
mentation. Despite the attention on the NP workforce and
the regulatory trend of loosening NP SOP restrictions
nationwide (Robert Wood Johnson Foundation, 2017), no
study has assessed how these laws are implemented. The
response to policy change is important to understand
because translation from policy into practice is a neces-
sary step in realizing the law’s goals. Our study reveals
some important barriers toward the law’s implementa-
tion, which should be addressed by policy makers and
administrators to assure NPs in NYS practice according to
the law. Despite that NP SOP is different in NYS, our
findings may inform policy makers in other states con-
sidering reform of NP SOP laws. New York State has had
a slow response to SOP law change compared with other
policies. Research on other state policy changes has
shown immediate and measurable responses (Gresenz,
Edgington, Laugesen, & Escarce, 2012; Gresenz, Laugesen,
Yesus, & Escarce, 2011; Laugesen et al., 2014; Sabik &
Laugesen, 2012). Both NPs and physicians believe that
their organizations lack the ability to embrace policy
innovations and no efforts are undertaken to implement
the law. These findings are consistent with previous re-
search showing how implementation is frequently over-
looked after legislation is passed (Pressman & Wildavsky,

1984).
Most practices had not changed their bylaws in ac-
cordance with the law. These findings contribute to new
knowledge that legislative change alone is not adequate
to maximize the contributions of the NP workforce to our
health care system. For the NP Modernization Act to
achieve maximum impact, many stakeholders, including
physicians and administrators, should get involved in
efforts to embrace the law at the organizational level.
With more NPs employed in practices associated with
hospitals or medical centers, it is particularly important
to work with leadership because these organizations
seem to be more resistant to expanding NP SOP. Cur-
rently, about 32% of NPs in NYS practice in such settings
(Poghosyan, Boyd, & Knutson, 2014). Supporting NP
practice according to the state laws promotes patient
safety (O’Grady, 2008).
Although NPs gained legal SOP in NYS in 1988 (Elwell &
Ferrara, 2014), there remains a lack of awareness among
some physicians about NP competencies. Evidence is
clear that NPs deliver high-quality care (Kurtzman &
Barnow, 2017; Newhouse et al., 2011). Therefore, increasing
awareness about NP competencies could promote the
implementation of the NP Modernization Act. Also, al-
though the law affects both NPs and physicians, many
physicians are unfamiliar with it. Raising awareness
about the law, particularly how it can positively affect the
practice of NPs and physicians, patient care, and the
overall health care system may motivate its
implementation.
Nurse practitioner and physician collegiality and
leadership’s positive perceptions of NP independence

and the law facilitate the law’s implementation. Physi-
cians speak favorably about the NPs they work with and
support NP independent practice if they already have
favorable relationships. Our findings suggest that physi-
cians’ greater familiarity with NPs increases support for
NPs. These findings are consistent with research showing
that physicians practicing with NPs have positive atti-
tudes toward them (Street & Cossman, 2010). As the
number of NPs grows, it may lead to improved relation-
ships between NPs and physicians and subsequently to
a better implementation of laws aimed at loosening
restrictions on NP SOP.
Our findings reinforce existing research showing that
support for NPs depends on organizational leadership
(Poghosyan et al., 2013). In organizations where leader-
ship does not share resources with NPs and/or do not
communicate with NPs, teamwork between NPs and
physicians suffers, thereby inhibiting state policy
adoption (Poghosyan & Liu, 2016). Efforts should pro-
mote the relationship between NPs and leadership to
aid the implementation of the policy at the practice
level.
The study has limitations. The study was conducted in
NYS and the findings might not be applicable to other
states. A purposive sample of participants was inter-
viewed. Other NPs and physicians, especially from dif-
ferent geographic areas, might have different
perspectives. Participants might not be truthful during
the interviews. Future large-scale studies are needed.
Studies might track how the law affects the supply of NPs

Research
in underserved areas over time. Also, it is important to
collect data from leadership.
Conclusion
The NP Modernization Act is a major policy accomplish-
ment in NYS. Policy makers and administrators should
make efforts to remove the barriers and promote facili-
tators of the law’s implementation to assure the law
achieves its maximum impact.
Presentation: The study was presented as a poster at
Annual Research Meeting at AcademyHealth in June 2017.
Authors’ contributions: Lusine Poghosyan (data analysis;
manuscript writing; editing and revisions); Allison A.
Norful (interviewer; data analysis; manuscript writing;
editing and revisions); Miriam J. Laugesen (manuscript
writing; editing and revisions).
Competing interests: The authors report no conflict of
interests.
Funding: The study was funded by the Robert Wood
Johnson Foundation, the National Institute of Nursing
Research (T32NR014205), and the National Institute of
Health (TL1TR001875).
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Research
RESEARCH Open Access
Workforce planning and development in
times of delivery system transformation
Patricia Pittman1* and Ellen Scully-Russ2
Abstract
Background: As implementation of the US Affordable Care Act
(ACA) advances, many domestic health systems are
considering major changes in how the healthcare workforce is
organized. The purpose of this study is to explore
the dynamic processes and interactions by which workforce
planning and development (WFPD) is evolving in this
new environment.
Methods: Informed by the theory of loosely coupled systems
(LCS), we use a case study design to examine how

workforce changes are being managed in Kaiser Permanente and
Montefiore Health System. We conducted site
visits with in-depth interviews with 8 to 10 stakeholders in each
organization.
Results: Both systems demonstrate a concern for the impact of
change on their workforce and have made
commitments to avoid outsourcing and layoffs. Central
workforce planning mechanisms have been replaced
with strategies to integrate various stakeholders and units in
alignment with strategic growth plans. Features
of this new approach include early and continuous engagement
of labor in innovation; the development of
intermediary sense-making structures to garner resources,
facilitate plans, and build consensus; and a whole system
perspective, rather than a focus on single professions. We also
identify seven principles underlying the WFPD processes
in these two cases that can aid in development of a new and
more adaptive workforce strategy in healthcare.
Conclusions: Since passage of the ACA, healthcare systems are
becoming larger and more complex. Insights from
these case studies suggest that while organizational history and
structure determined different areas of emphasis, our
results indicate that large-scale system transformations in
healthcare can be managed in ways that enhance the skills
and capacities of the workforce. Our findings merit attention,
not just by healthcare administrators and union leaders,
but by policymakers and scholars interested in making WFPD
policies at a state and national level more responsive.
Keywords: Workforce planning and development, Human
resources in health, Healthcare delivery reform, System
change, Loosely coupled systems, Labor-management
partnerships, US Affordable Care Act

Background
As the implementation of the 2010 Affordable Care Act
(ACA) advances in the United States, many healthcare
organizations are taking bold measures to reorganize
their delivery systems and finding that in order to do so,
changes must be made to the healthcare workforce [1].
While different healthcare organizations in the United
States, be they public or private, are at very different
points in this process, commonly popular concepts in-
clude moving staff to new ambulatory and home care
settings [2]; creating new jobs relating to care coordin-
ation and outreach to the sickest patients [3]; designing
new modes of delivering care in response to consumer-
ism [4]; adopting team-based care and task shifting
based on the principal of practicing at the top of license
and education [5]; requiring new roles and skills as part
of the adoption of health information technologies
(HIT); and the use of data for decision-making [6].
Understanding what workforce changes are occur-
ring and how they are being managed is key not just
for healthcare leaders but for policymakers as well.
Traditional methods of projecting provider shortages
and justifying the allocation of public funding to
expand various professional pipelines are giving way
* Correspondence: [email protected]
1Milken Institute School of Public Health, The George
Washington University,
2175 K Street, NW, Suite 500, Washington, DC 20037, United
States of
America
Full list of author information is available at the end of the
article

© 2016 The Author(s). Open Access This article is distributed
under the terms of the Creative Commons Attribution 4.0
International License
(http://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate
credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were
made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to
the data made available in this article, unless otherwise stated.
Pittman and Scully-Russ Human Resources for Health (2016)
14:56
DOI 10.1186/s12960-016-0154-3
http://crossmark.crossref.org/dialog/?doi=10.1186/s12960-016-
0154-3&domain=pdf
mailto:[email protected]
http://creativecommons.org/licenses/by/4.0/
http://creativecommons.org/publicdomain/zero/1.0/
to the notion that there are many models of care delivery
and that they have vastly different staffing configurations.
For example, several studies have demonstrated that
including advanced practitioners in primary care medical
homes allows practices to expand panel sizes [7, 8].
Choices about staffing, therefore, can have enormous im-
plications for productivity, making assumption about the
demand for certain health professions a moving target.
The policy question then becomes not just how will
these changes alter the national demand for certain
types of health workers at an aggregate level but how
are organizations making choices about ways to recon-

figure their workforce and, ultimately, what kinds of
local, state, and federal policies are most supportive of
workforce transformations that advance both workers’
well-being and the value of their services.
We know from the literature reviewing the hospital re-
structuring of the 1990s that workforce change manage-
ment faces many challenges. The critiques of this era
were many, but chief among them, according to Walston
and colleagues, were the following: goals for change
were not clear, too many changes were implemented too
quickly, there was a lack of communication with em-
ployees, a lack of engagement with physicians and
unions, there was a poor understanding of the local
site differences by management leading to a one-size-
fits-all approach, and, lastly, that training needs were
not anticipated [9].
In a review of the international literature on workforce
planning and development (WFPD), Curson and col-
leagues suggest that the problem goes deeper. They
argue that workforce policies lack the capacity to re-
spond to new demands for system change [10]. The
reason, they point out, is that most workforce planning
do not take account of political dynamics among the
range of stakeholders outside the control of human re-
source administrators, be they at the organizational or
the policy level.
It is with these critiques in mind that we are interested
in understanding how two leading health systems in the
United States, with a historic commitment to developing
and retaining their workforce and to managing change
through labor-management partnerships, are responding
to the demands of the post-ACA environment. The aim
is to explore how they are determining what changes are

needed and how they are implementing those changes in
practice. Their experiences may provide insights for
other organizations, as well as for policymakers charged
with ensuring that the healthcare workforce is able to
meet population needs.
Our first case focuses on Kaiser Permanente (KP), an
integrated system that has historically served the em-
ployer market on the West Coast. It has been at the
forefront of systems that emphasize value over volume
and among the organizations most advanced in the use
of HIT to improve the patient care process. In addition,
KP has one of the most successful models of labor-
management partnerships (LMP) in the nation.
The second system is the Montefiore Health System,
headquartered in the Bronx, NY, an organization with al-
most 20 years of experience with shared risk contracts
with payers. Like KP, they have extensive experience with
care coordination, they are in the process of expanding
to new markets, and they have a LMP. They differ from
KP in that their patient population is predominantly
poor and Spanish speaking, and an extraordinary 80 %
of their revenue is coming from Medicaid and Medicare.
Conceptual framework
The objective of this study is to go beyond descriptive
groupings of health workforce changes to explore the dy-
namic processes and interactions by which staffing models
emerge. To frame our inquiry, we draw on the literature
on health workforce planning and development and the
theory of loosely coupled systems (LCS) [11].
For the purposes of this paper, we define WFPD as the
macro level processes and practices that enable the sys-

tem to change and adopt new staffing arrangements and
respond with timely and appropriate education, training,
and certification programs. Schrock has suggested that
WFPD policies span the continuum of skill formation,
employment networks, and career advancement [12].
This means not simply examining the supply and distribu-
tion of personnel in different categories but also under-
standing educational and training pathways, management
of performance, and the regulation of working conditions.
Dussault and Dubois argue that the traditional ap-
proach to WFPD is a linear, sequential, and protracted
skill formation process through which healthcare pro-
viders hand off demand projections to education institu-
tions and certifying bodies that in turn, supply the
requisite workforce [13]. Weick reasons that this form of
sequential task interdependence induces rule-based
action and cognitive processes that are not equipped to
tackle ambiguous problems like providing a skilled
workforce for care models that are in a constant state of
flux [14]. This and other complex, non-routine problems
require controlled cognition or slow, deliberative, and
explicit thinking that is more often associated with
reciprocal interdependence coordinated by an iterative
process of negotiation and mutual adjustment among
relatively autonomous units and subsystems. [14]
Dussault and Dubois describe an alternative approach
that is emerging in healthcare that coordinates the
efforts of a diverse range of institutional actors through
adaptive processes that respond to specific, local polit-
ical, economic, cultural, and social contexts where
healthcare is delivered [13]. This approach is understood
14:56 Page 2 of 15

as a political exercise in which values and differences are
made explicit, compromises are made, and actions are
justified. Orton and Weick further suggest that there is a
need to move beyond the traditional focus on static
organizational elements, like structure, resource alloca-
tion, and technology, and turn instead to a focus on the
dynamic relationship among them [15].
Organizational scholars developed the concept of
“loose and tight coupling” as one way to examine com-
plex organizational structures and relationships [16–19].
The focus of this approach is on hierarchy and inter-
dependence among elements within and between organi-
zations and how variability in these features enables
different operational strategies and responses to shifts in
the external environment [17]. In tightly coupled sys-
tems, individual units and organizations are linked to-
gether through formal structures and procedures and
they respond to change through centralized control
mechanisms that reduce variation and close the system
off from the effects of external forces. In loosely coupled
systems, on the other hand, the links among the compo-
nents are weak and a high level of autonomy exists
among the interdependent parts of the system [20].
While the variation in the way similar functions are or-
ganized and managed may make it difficult to integrate
activities, theorists argue that it enables flexibility and
openness to change in the environment [15].
According to the theory of LCS, all systems are both
tightly and loosely coupled because there is variation in
how subunits are linked and rely on each other (couple-
d)—as well as in the number and strength of their con-

nections (lose or tight) [15, 17, 21]. Therefore, any
subsystem may be closed to outside forces to ensure for
stability (tight), while another subsystem may remain
open to outside forces to enable flexibility (loose) [15].
This paradoxical nature of LCS makes it difficult for
researchers to conceptualize and study [16], yet we
would suggest that its application to the US healthcare
system during this period of intense transformation
holds explanatory potential. Healthcare systems are sim-
ultaneously being asked to expand coverage and access,
while being financially incentivized to extend the con-
tinuum of care to address the social determinants and
provide ongoing care management. As a result, there
are significant pressures on traditional care models and
staffing arrangements, leading in turn to the emer-
gences of new patterns of “coupling,” both within and
across healthcare organizations. Further, we submit that
the effectiveness of the transformation occurring in
healthcare today may hinge on new, more adaptive
methods to prepare the healthcare workforce to
perform in a more complex system of care, where job
tasks, team interactions, and work locations are con-
tinuously changing.
To analyze changes in WFPD, we borrow from Weick’s
typology of strategies for changing LCS [11] and from the
descriptions on a new approach to WFPD in healthcare
put forth by Curson et al. [10] and Dussault and Dubois
[13] to identify a set of principles that together, may serve
as a new adaptive WFPD framework aligned with the
needs of a rapidly changing deliver system.
Methods
We use a case study design to explore how two major
health systems undergoing significant system transform-

ation are managing the process of workforce change. We
selected Kaiser Permanente (KP) and Montefiore because
they are well known for their innovative approaches to in-
tegrating healthcare yet they are significantly different
from each other with regard to their organizational histor-
ies, structures, and patient populations.
We conducted site visits to both organizations in the
spring and summer of 2015, conducting interviews with
8–10 people at each site including executives, human re-
source managers, the heads of innovation and care coord-
ination programs, and union and LMP representatives.
Some interviews were held in group settings, while others
were individual. We also conducted planning and follow-
up phone calls with some of the participants. Interviews
were taped and transcribed. We also reviewed current
organizational documents, including training plans, re-
ports, and collective bargaining agreements, as well as
prior studies on each system [9, 22, 23].
Data analysis proceeded through several steps. First,
the research team conducted a review of each case,
including the historic development of the system and
significant drivers of change, as well as the strategies,
structures, and resources informants reported as being
central to the competiveness of the system and the
sustainability of the workforce in the post-ACA environ-
ment. To support this analysis, the research team devel-
oped a series of inductive and deductive codes, which
we used to extract relevant data from the case docu-
ments and interview transcripts. Next, the researchers
jointly analyzed the coded data to developed individual
case profiles. These profiles were validated by key infor-
mants from each case. Finally, we conducted a constant
comparative method to identify cross-cutting themes
and principles to explain the workforce planning and de-

velopment strategy emerging within the two systems.
Results
Case study 1: Kaiser Permanente
Kaiser Permanente (KP) was established in 1938 as a
comprehensive medical system for the workers and their
families at Kaiser steel mills and shipbuilding facilities
across California and in Portland, OR. In 1945, after
WWII ended and many shipyards closed, KP opened
14:56 Page 3 of 15
membership to the general public. The KP unions played
an instrumental role in this expansion by helping KP
market to unionized employers in areas where the com-
pany had a presence. Today, it operates as a Health
Maintenance Organization (HMO) with 8.3 million
health plan members in seven regions: Northern and
Southern California, Colorado, Georgia, Hawaii, Mid-
Atlantic, and the Northwest. Each region is made up of
two separate entities, the Kaiser Foundation Health Plans
and the Permanente Medical Group (PMG), a physician-
owned corporation that owns and operates KP’s medical
facilities. The PMG contracts with the Foundation to
serve KP health plan members. A key feature in this
model is that physicians are employed by KP. The na-
tional program office includes a variety of support func-
tions, including human resources, labor relations,
information technologies (IT), finance, and patient care
services (nursing).
The KP Labor-Management Partnership (LMP) was
formed in 1997. At the time, KP faced competitive

pressures leading executives to demand deep union
concessions. In response, many of the KP unions of-
fered the company a choice: continued harsh labor-
saving tactics and escalating labor strife, including a
strike, or a partnership to address the fiscal crisis and
improve the quality of care at KP. The company
agreed to the partnership [24]. The governance struc-
ture consists of the LMP Strategy Group, with one
representative from each of three sectors: Physicians,
Management and Labor, and each region maintains
its own tripartite LMP council.
By 2015, the LMP included 12 international and 28
local unions representing 105 000 KP employees or
about half of the total KP workforce, across six of the
seven regions. Hawaii is not part of the partnership, and
not all KP unions are involved in the partnership, most
notably absent is the California Nurses Association.
KP also has a network of functional units to support
the design and management of change and WFPD
strategies. The LMP staff is integrated into these units,
and labor representatives are highly engaged in their
activities. These units include the following:
� National Workforce Planning and Development
(housed in national human resources (HR))
provides opportunities to the KP workforce to
optimize skills and competencies and manages two
LMP education trusts: the Ben Hudnall Memorial
Trust and SEIU/UHW Joint Employer Education
Fund.
� National Innovations Network including patient care
services, workforce planning, and IT functions as a
loosely coupled “future-sensing” group that

examines technology trends, creates proof of
concepts and proof of technology, and develops
pilots.
� Unit-based teams (UBT) are natural work groups of
frontline workers, physicians, and managers who
solve problems and enhance quality.
Drivers of change
KP’s history of pre-paid, member-based service is critical
to understanding the company’s current competitive
situation. KP is well positioned to grow in a post-ACA
era in which policies to advance integration has prolifer-
ated. Growth has been especially dramatic in the South-
ern California Region, where new individuals that joined
via the Health Exchange grew by 4 % per year (from 2 to
6 %). This rapid influx of new members has been most
pronounced among younger and healthier individuals as
compared to members in KP’s traditional employer-
based plans.
KP leadership knew that they needed to understand
the implications of this shift in demand and have held
focus groups with their newest members. Results have
led the company to reorient business strategy around
three priorities, as follows:
1. Convenience. Millennials are demanding “care
anywhere and how we want it.” Increased access,
convenience, and enhanced experience of healthcare
are therefore major priorities for the organizations.
2. Affordability. Because the individual market is more
price sensitive than the group market, there is a
heightened awareness that they must reduce the

cost of care in order to continue to expand in this
market.
3. Value. At the same time, new healthcare consumers
expect more value or increased and enhanced
services, and this is driving a number of efforts
focused on the care experience.
Change strategies
Three strategic initiatives have emerged in response to
these drivers. The LMP and the national innovation
units are integrated into all three, as are KP members’
views, as represented through surveys, focus groups, and
ethnographic studies.
� Perform, Grow, Lead is KP’s strategic plan. It
emphasizes affordability targets, meeting rising
customer expectations, and transforming care.
Guiding principles include the following: One KP,
which calls for a common care experience across all
regions, and the KP people strategy, which
articulates the desired characteristics of the KP
workforce as “innovative, engaged, change ready,
healthy, and accountable.”
14:56 Page 4 of 15
� Vision 2025 is an ongoing initiative to understand
what healthcare consumers will look like and how
KP can position itself to meet needs in a rapidly
changing healthcare market. It develops care models
and offers strategic road maps to guide planning and
change. Health information technologies are central

to this strategy, including the use of social media to
keep its members informed and healthy and new
mobile technologies to enhance staff communication
and reporting. Remote diagnostic tools will also be
more available to patients for common ailments like
strep throat, to allow self-testing and more rapid
recoveries. In the next 5 to 7 years, they see
increased use of remote monitoring technology,
sensors, and virtual care, as well as health analytics
to enhance the nurse role in triage and care
management [23]. As one interviewee put it, “…if it
can be automated, it will be.”
� Reimagining Ambulatory Design (RAD) is an
initiative of the Southern California Region that may
spread across KP. Its goal is to design a new
ambulatory care delivery model aligned to the
principles of consumerism. In extensive research
with members, the leads of this effort discovered
that “…people wanted access to care in a much
more radically different way… It has to do with
much more embedding of services into the
community, into the home, into work…and much
more local access for simple things.” This “life-
integration vision” has sparked several experiments
to redesign and relocate KP clinical operations in
Southern California.
Workforce planning and development strategies
Human resource (HR) leaders and the Coalition of
Kaiser Permanente Unions (CKPU) staff report that early
on the focus of WFPD was on creating consistent work-
force metrics and analytics to help the regions forecast
future staff and skill needs. They now view these tools
as necessary but insufficient. A regional HR leader
described the change:

So, at first…we forecasted membership growth,
utilization, supply, turnover, retirement, we looked at
the local labor markets, we connected with a
university for economic analysis of the projected
nursing workforce, and the fluctuations around the
economy. And then we realized that most forecasting
is based on the previous year, or the previous three, or
the previous five years, projecting forward. But if
you’re in the midst of complete transformation of
how you’re providing care, how accurate are those
numbers? …We need to understand what kinds of
jobs (are coming); we need to understand how work is
transforming. So, it really started in 2012 to 2013, (we
have been) trying to get a movement towards a kind
of qualitative approach to understanding change.
Key to this new approach is that it is integrated with
KP’s strategic growth initiatives. As one HR leader ex-
plained, “workforce development is being driven by the
business need.” Part of this emanates from the “affordabil-
ity” imperative, which both HR and labor representatives
agree has given finance a larger role in the company. At
the same time, HR leaders describe the emerging WFPD
approach as “maturing,” by which they mean that finance
is one important player but that they also take into ac-
count other interests. Indeed, HR leaders view themselves
as “intermediaries” who help senior leaders understand
the strategic value of the workforce in the context of the
drive toward labor-cost-saving solutions.
The LMP, which was further strengthened in the 2015
National Agreement, has several mechanisms that inte-
grate labor and innovative WFPD strategies into the
strategic change processes. First, for collective bargain-

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