It is hard to believe that in less than a decade much of that picture has changed. Hospital beds are being eliminated, patients are spending less time in acute care settings, professional staffing is being reduced, unlicensed assistive personnel are being hired in record numbers, and now, without a resume and good interviewing skills, a nurse applicant has little chance of success in today’s market.

Nursing, swept along in the tidal wave of healthcare reform, is having to redefine itself to remain an integral part of the new healthcare delivery system. Old solutions are obsolete. Each year more and more nurses look beyond staff nurse positions in traditional general hospitals for employment. Once the hub of healthcare, inpatient care is becoming far more specialized; and more treatment is delivered at home, in ambulatory care clinics, in hospices, and in the newly emerging hybrids called subacute care units.

According to the American Hospital Association, only 86 hospitals have closed across the country between 1993 and 1995; but more importantly, many hospitals have reduced their number of inpatient beds. During the same period, US hospitals eliminated almost 45,000 jobs, according to the Department of Health and Human Services, Division of Nursing. The number of lost nursing positions in hospitals isn’t identified.

Managed care has shortened inpatient hospital stays and helped shift the focus to the patient’s need for services at an affordable price. Every healthcare agency is now questioning how and where to best deliver these services.

What does this mean for nurses? It means that there will be fewer jobs in acute care hospitals, and that those RNs who remain in those positions will require specialized skills and perhaps advanced training and education. But it also means there will be more opportunities for nurses opening up in other settings, such as outpatient centers, home health care, and ambulatory clinics.

“Nurses are perfectly suited to provide the services that are needed because of shortened lengths of stay and increased ambulatory care,” says Bette Case, RN, PhD, author of Career Planning for Nurses. “There are plenty of places for nurses, but you need to look for them and find one that’s right for you.”

Here are some of the options available to nurses who are willing to step outside the hospital.

Home healthcare

Almost overnight, home healthcare has emerged to become a vibrant part of the mainstream. “Home healthcare is the center of the healthcare universe,” said Judith Gula, RN, BSN, at the national meeting of the Home Health Care Nurses Association, whose membership has jumped 65 percent in the last year alone. She is the executive administrator of Arcadia Health Care in Troy, Michigan. “We’re not the end of the care system – we’re the beginning and the center. We share our clients with hospitals.”

According to the National Association for Home Care, as of June 1995, there were 17,561 home care agencies in the United States, a 58 percent increase since 1989. Although the number of public agencies and not-for-profit organizations, such as the Visiting Nurses Association, have remained about the same, the number of for-profit and hospital-based agencies has doubled in the last 10 years.

The Bureau of Labor Statistics estimates that approximately 91,000 RNs worked in home healthcare in 1993. From 1988 to 1993, the total number of people employed in home healthcare almost doubled.

Recently, home healthcare nurses have seen a dramatic change in patients’ diagnoses and acuity. “We treat more acute cases now – patients with severe infections, patients who recently had surgery, and patients who need high-tech intensive nursing,” says Gabrielle Pro, RN, regional director of Housecall Home Healthcare of Tampa, Florida. Housecall, like many agencies, has developed programs to meet the needs of special patient populations. They have also increased the number of nurses with advanced clinical skills to act as consultants for other nurses within the agency concerning nursing care.

Pro has also seen an increase in services for the elderly, a trend she expects to continue.

“People are living longer and remaining more mobile. Consequently, they may not live near their families. This increases their need for home health nursing. They also stay home longer before entering skilled nursing facilities or they use skilled nursing facilities for temporary stays.” Home healthcare agencies in Florida are experiencing now what agencies in the rest of the country will face in the future. Within 20 years, almost every state will resemble Florida today in terms of services required by the elderly.

“Nurses with a background in critical care or the emergency room easily make the transition to home health-care,” says Pro. “They have good assessment skills, use critical thinking, and are accustomed to practicing autonomously.” For more information about home healthcare, call or write the Home Health Care Nurses Association at (800) 558-4462, 437 Twin Bay Drive, Pensacola, Florida 32534, or the National Association for Home Care at (202) 546-4759, 228 7th Street, SE, Southeast, Washington, DC 20003.

Subacute care

“It’s a booming field,” says Samantha Morgan, RN, BSN, director of rehabilitation services for Tendercare, a network of subacute facilities in Michigan. “As acute care hospitals downsize, long-term care is upsizing. The patient who used to be on a general medical-surgical floor is now at home or in a subacute unit.”

Subacute care bundles services for people with similar diagnoses or needs to provide them with more focused treatment. The average length of stay is 10 to 29 days. Patients are then transferred to home care or to traditional long-term care. Subacute units may be separately licensed units within a hospital or are more likely to be located in separate facilities. Freed of the need to underwrite expensive equipment and on-call personnel, subacute units have less overhead and operate leaner, typically charging 20 to 50 percent less than similar care delivered in an acute care hospital.

According to the American Subacute Care Association, subacute care has almost doubled in the last two years to become a $3.5 billion business. The Center for Health Care Information’s Case Management Resource Guide now lists over 2,000 programs. Insiders see the recent growth as just the tip of the iceberg. Most of the expansion has been fueled by private managed care rather than by federal reimbursement, leaving plenty of room for additional growth.

“It gives nurses a chance to be leaders in a new field and to polish their clinical skills,” says Morgan. “This is where we need the sophisticated nurse who is a skilled generalist, a nurse who thinks well on his or her feet and who has exceptional assessment skills. Subacute care nurses rely on assessment and judgment rather than equipment.”

For more information about subacute care, call or write the American Sub-acute Care Association at (305) 864-0396, 1440 Kennedy Cswy, Suite 421, North Bay Village, FL 33141.

Hospice care

In the last 15 years hospice care has blossomed. From 1984 to 1995, the number of Medicare-certified hospices skyrocketed from 31 to 1,857. According to the Hospice Association of America, 699 hospices are based in home health agencies, 679 are freestanding, 460 are hospital-based, and 19 are based in skilled care facilities. From 1988 to 1994, there was more than a five-fold increase in hospice patients to nearly a quarter-million. Almost three quarters of the patients are older than 65, and cancer is their most common diagnosis.

Hospices hire far more nurses than any other professionals. Long considered a haven for nurses with high-touch skills, hospice nurses also use technical skills as palliative treatment becomes more high-tech. At the Hospice of the Florida Suncoast, in Largo, Florida, Carol Hagans sees a special need for nurses with experience with infusion services and high-tech care. She expects hospices to continue to grow at 15 to 25 percent a year, fueled by the aging population. But as treatment becomes more complicated, the need for nurses may out pace the rate of patient growth.

For more information about hospice care, call or write the Hospice Association of American at (202) 546-4759, 228 7th Street, SE, Washington, DC 20003.

High-tech nursing care

Acute care hospitals will continue to grow smaller and fewer in number as less intensive services spin off to less expensive alternative organizations. The hospital of the future will concentrate on four areas – trauma, sophisticated diagnostics, critical care, and, operative procedures that are unsuitable for ambulatory care. In short, the general hospital will be replaced by an ultra high-tech hospital.

“More and more hospitals are looking for experienced critical care nurses,” says Paul Walden, RN, employment specialist at Columbia Michael Reese Hospital and Medical Center in Chicago. “The best candidate is a technically astute nurse with sound clinical skills.”

Experience counts. Increasingly, hospitals have scaled back their internship and training programs and expect critical care nurses to come fully trained. Critical care nurses, along with emergency department and operating room nurses, are some of the specialty nurses most in demand because of the highly clinical and technical skills required to work in those areas.

For information about critical care nursing, call or write the American Association of Critical-Care Nurses at (800) 899-2226, 101 Columbia, Aliso Viejo, CA 92656. For information about emergency nursing, call or write to the Emergency Nurses Association at (847) 698-9400, 216 Higgins Rd., Park Ridge, IL 60068. For information about operating room nursing, call or write to the Association of Operating Room Nurses at (303) 755-6300, 2170 S. Parker Rd., Suite 300, Denver CO 80231-5711.

Outpatient care

Outpatient care is becoming more high-tech and more corporate. According to the Journal of the American Medical Association, there has been a dramatic shift in the structure of physicians’ practice, as indicated in the table below.

This change means that nurses who were once employed as part of a three-person office now may be employed by national corporations. Their pay and benefits may improve, and they may be able to eliminate non-nursing tasks, but some nurses also lose flexibility and a sense of control.

Even the Veterans Administration (VA) system is changing. “As we treat more of our patients in outpatient primary care in specialty clinics, we rely on advanced practice nurses to provide primary care,” says, Ann Bures, RN, nurse recruiter, VA Maryland Health Care System. “The VA is committed to increasing the number of advanced practitioners by 200 percent nationwide within the near future.”

For more information about outpatient opportunities, call or write the American Academy of Ambulatory Care at (609) 256-2300, East Holly Ave., Box 56, Pitman, NJ 08071-0056, or the American Association of Office Nurses at (201) 391-2600, 109 Kinderkamack Road, Montvale, NJ 07654.

Entrepreneurs

Only two percent of nurses are self-employed, according to the Department of Health and Human Services, Division of Nursing. The growing emphasis on cost-effective care will create new opportunities for nurses willing to take risks. Because entrepreneurs have inherently lower overhead costs compared to expensively managed hospitals, they should be able to compete for patient education, staff training, and patient consultation services. For example, some hospitals already contract for staff CPR training and preparation for childbirth classes.

Entrepreneurs can also identify niches easier and fill them faster. In the future, more nurse entrepreneurs will make bids directly to insurers and managed care companies for patient education and services.

As healthcare continues to change, nurses will need to rely on their ingenuity and resilience to take advantage of the new opportunities. “I see nurses who have the skills, but they don’t have the heart or the guts to step outside of the familiar and be willing to fail,” says Esta Fox, RN, BSN, who counsels nurses about their careers and develops resumes from her home in Bellmore, New York. “A lot of nurses are angry about the changes in healthcare. They need to get beyond the anger and become part of the future.”

For more information about nursing and business, call or write the National Nurses in Business Association at (800) 331-6534, 56 McArthur Ave., Staten Island, NY 10312, or the American Nurses in Business at (713) 771-5016, PO Box 741384, Houston, TX 77274-1384.