Reimbursement Structures and Changes in RN Clinical Roles within Hospitals

Despite anticipation that registered nurses (RNs) will increasingly work outside traditional inpatient hospital settings, such a shift in employment settings is not reflected in U.S. Bureau of Labor Statistics (BLS) data. However, it is not clear that BLS data accurately measure RN employment in ambulatory settings that are owned or affiliated with hospital-based systems, which are on the rise as hospitals buy and expand ambulatory and outpatient practices. Moreover, the BLS does not provide information about the different clinical areas in which hospital-based RNs work. This study uses multiple sources of data from California to understand whether there have been changes in the roles of RNs employed in hospital and ambulatory settings.

California’s biennial Survey of Registered Nurses produces information describing the percentage of RNs working in the hospital industry, their job titles, and their areas of clinical focus. We use descriptive statistics to show the breakdown of hospital vs. non-hospital employment compared to BLS data and investigate areas of clinical focus for RNs, including those employed in hospitals. We also examine hospital-level data from the California Office of Statewide Health Planning and Development (OSHPD), which provides hours worked by type of hospital department. Regional trends in health maintenance organization (HMO) and accountable care organization (ACO) growth will be examined to assess whether these alternative payment structures are associated with changes in the roles of RNs.

Between 2006 and 2016, the share of employed RNs in California whose principal position was hospital-based rose from 62.7% to 68%. However, the share of these RNs reporting they work in an acute care department declined from 88.7% to 82.6%. There also were increases in the shares of RNs working in ambulatory care departments and “other” departments, which includes care management, utilization review, and other non-clinical functions, while the shares of RNs working in medical-surgical and intensive care units declined. In addition, there was growth in employment in non-patient-care departments and specialty care. Analyses of OSHPD data found that growth of RN hours in ancillary and ambulatory departments was more rapid than in inpatient units, which is consistent with declines in the number of inpatient days and increases in outpatient visits over this period. We are now estimating ordinary least squares regressions to assess whether there is an association between shifts in RN employment toward ambulatory services and HMO/ACO growth.

These findings indicate that hospitals are leveraging the skills of RNs as they engage in offering a broader array of services. BLS data are insufficient to assess trends in RN employment, as they do not provide any information about the different settings or clinical areas in which hospital-based RNs practice. These shifts in employment signal the need to pay greater attention to the skills required of RNs as they embrace a broader set of roles within the health care system.