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Summary and Recommendations . Our study estimates that there are more than 1.3 million registered nurses employed in the United States today. They are the largest single professional component of a health care system that represents almost 10 percent of the gross national product. Their responsibilities are diverse. Two-thirds work in the nation's hospitals, providing or supervising the care of patients. Others care for patients in their homes, in nursing homes, community health centers and public health clinics, physicians' offices, and health maintenance organizations. Still others work in schools, industry, and public administration. They are involved not only in care of those acutely ill, but also in preventive services and in care of the chronically ill and disabled. The leadership component of this nurse population also has highly differentiated functions. Top nurse administrators manage large and complex nursing services in hospitals where they often are responsible for multi-million dollar budgets. In all the varied institutional and community settings of patient care, they manage services provided by approximately 915,000 staff level registered nurses, more than 500,000 licensed practical nurses, and an estimated 850,000 aides. Faculty in schools of nursing educate future nurses and conduct research to improve the care of patients through the practice of nursing. An increasingly important part of the advanced nursing cadre are specialists, such as nurse practitioners, nurse midwives, and variety of clinical nurse specialists in hospitals. During the late 1970s, when this study was mandated by Congress, concern about nursing shortages was strong and was expressed publicly in terms of the need for more generalist "bedside" nurses. The study was, in effect, asked to respond to the following kinds of questions: Will there be enough registered nurses (RNs) of the types needed to ensure an adequate future supply of the various types of nurses? Should the federal government continue its specific support of generalist nursing education in order to assure the adequacy of their supply? What are the means to bring better nursing services to underserved populations in rural and inner city areas, as well as to elderly and minority populations who generally lack adequate access to nursing care? Finally, what is the true extent of kN dropout, and what are the means for retaining such nurses in their profession? The last question arose from a widespread opinion that investment of public funds to train RNs was wasteful because they would soon leave for higher paying, less stressful occupations. 1

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2 Because concern for all these aspects of current and possible future nurse shortages appeared to be a motivating force for the study, the committee examined the various aspects of nursing and nursing education in that general framework. In our analysis, we found reasons to distinguish sharply between shortages or maldistribution of nurses prepared as generalists to provide direct care to patients, and shortages of nurses in leadership and specialty nursing. The problems and the possible solutions are quite different for these two groups. The Committee's Recommendations Our recommendations are framed not only in the general context of the provisions of the Nurse Training Act (NTA) of 1965 and its subse- quent amendments, but also in the context of other federal, state, and local government and private sector actions that influence both the demand for and the supply of RNs and LENS. Many factors enter into the alleviation of current numerical and distributional scarcities of nurses and in the prevention of future scarcities. In most instances, the responsibilities of the various public and private sectors interact. In consequence, the c~mmittee's recommendations generally involve shared funding to stimulate the kind of collaborative approaches most likely to ensure desired results. This section presents the committee's specific responses to the three congressional questions of its study charge. Each recommenda- tion addresses a topic that is, in effect, a subset of the overall study question under consideration. The recommendation under each of these topics is accompanied by an abstract of the conclusions that led to its formulation. The congressional questions and the topics and recommendations are set forth in the sequence in which they appear in the statutory charge and in the chapters of the full report. Congressional Question One: IS THERE A NEED TO CONTINUE A SPECIFIC PROGRAM OF FEDERAL FINANCIAL SUPPORT FOR NURSING EDUCATION? Meeting Current and Future Needs for Nurses* RECOMMENDATION 1 No specific federal support is needed to increase the overall supply of registered nurses, because estimates indicate that the aggregate supply and demand for generalist nurses will be in reasonable balance during this decade. However, federal, state, and private actions are recommended throughout this report to alleviate particular kinds of shortages and maldistributions of nurse supply. *When the term "nurse" is used without qualification, it refers to a person licensed as a nurse, whether holding the license as a registered nurse or a practical nurse.

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3 During the 1970s, increasing sophistication of medical technology and growing complexity of health services continuously increased the demand for more and better prepared nurses. Supply fell behind explosive demand, and local labor markets for nurses during most of that decade manifested obvious scarcities in numbers and types of nurses whom hospitals and other health facilities wanted to employ. Nonetheless, in the short time between two official surveys in 1977 and 1980, the supply of active registered nurses (RNs) jumped by 30 percent, a figure well in excess of prior predictions. Four out of five of these additional RNs were employed by hospitals, where two- thirds of all RNs and almost two-thirds of all licensed practical nurses (LPNs) work. The number of practical nurses also has grown, but at a slower rate. On the basis of all evidence it has been able to study, the committee concluded that, as of the fall of 1982, in the aggregate there was not a significant national shortage of generalist RNs or of LPNs. We have, however, identified shortages that occur unevenly throughout the nation in different geographic areas, in different health care settings--especially those that serve the economically disadvantaged--within institutions, and in specialty nursing. The resolution of such particular shortages depends both on the operation of market forces and on concerted actions by the federal, state, and private sectors following the lines of this study's recommendations. State and Local Planning for Generalist Nursing Education by Program Type RE00MMENDATION 2 The states have primary responsibility for analysis and planning of resource allocation for generalist nursing education. Their capabilities in this effort vary greatly. Assistance should be made available from the federal government, both in funds and in technical aid. - Most decisions affecting the allocation of resources for the education of generalist nurses take place at state and institutional levels. Shortages are often viewed by members of the nursing profession, employers, and others in terms of the need for RNs specifically prepared in one or more of the three different types of basic nursing education programs--diploma, associate degree, and baccalaureate in nursing--and of the additional need for LPNs. The committee concluded that there was no evidential basis for making national recommendations on the desired proportions of RNs to be prepared in each basic educational pathway, or on the distribution of RN and LPN nursing service personnel within and among diverse nurse employment settings. In the past, these settings have sustained market demand for the output of each type of basic nursing education program.

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4 The committee analyzed a large number of state reports dealing with efforts to disaggregate future state RN supply according to educational preparation. It is apparent that issues of educational differentiation are squarely on the agenda of nursing education policy. It also is apparent that state studies estimating future supply and need mainly on the basis of professional judgments of numbers and kinds of nursing personnel needed (by type of educational preparation) produced widely different estimates in levels and mix of staffing (and of amounts of time required by nursing service personnel per patient day) for similar practice settings from one state to another. Many states appear not to be well organized to deal with nursing issues and nursing education policy on a continuing basis. The committee noted the apparent inefficiency of ad hoc, short-tenm efforts as states struggled to ascertain their current and future needs for KNs and LPN s and to identify related nursing education priorities. In many cases, the follow-through on these attempts has not been coordinated or appears not to have led to consensus building on goals for basic nursing education. Finally, projections of needed future supply of nurses appear to be hampered by the absence of balanced methodological alternatives for estimating anticipated future market demands. A relatively small outlay of federal technical assistance dollars is necessary to assist states in developing a more consistent methodology for their estimates of future demand and to promote ongoing state planning for nurse supply. Federal Education Financing to Help Sustain the Basic Nurse Supply RECOMMENDATION 3 The federal government should maintain its general programs of financial aid to postsecondary students so that qualified prospective nursing students will continue to have the opportunity to enter generalist nursing education programs in numbers sufficient to maintain the necessary aggregate supply. The assessments of future supply on which our first recommendation is based were made in the face of concern that current levels of federal financing of education might not be maintained. Limited available evidence suggests that nursing students are substantially dependent on general higher education student aid programs. Considerations that go into making projections at both federal and state levels do not reveal the complex decision making processes and the great variety of influences that ultimately determine, locally, the size and composition of the future pool of RNs. The committee has attempted to answer the congressional questions on comparative educational costs and on sources of financing to the extent that data

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5 could be found or developed. Estimates of student and institutional costs for various programs, however, permit only cautious comparisons among programs. Conclusions as to the societal utility or professional value of one type of program or another should not be made on cost considerations alone. Students' education costs have risen rapidly over the past few years and increases are projected to continue. Nursing students, who are predominantly women, finance their tuition and living costs from a combination of sources: the very limited funding remaining under the Nurse Training Act scholarship and loan programs; general federal programs of financial aid for all postsecondary students; state and collegiate grant programs; earnings; and personal and family savings. Higher education--and nursing education in particular--is entering a period in which resources will be more constrained than in the past. Nursing students tend to come fray families with moderate incomes or to count heavily on their own resources to finance their education. They bear the cost without the assurance of earnings comparable to those of students in other fields who make similar educational investments. General federal financial aid programs for postsecondary students, designed to improve equality of access to education, have been a major source of financing for students in basic nursing education programs. Reductions in these programs could curtail the number of students entering basic nursing education or seriously limit students' choices among educational programs. Such reductions were not presupposed in any of the assumptions that led to our estimates of future supply; their impact would be unpredictable. Continued State and Private Support of Nursing Education RECOMMENDATION 4 Institutional and student financial support should be maintained by state and local governments, higher education institutions, hospitals, and third-party payers to assure that generalist nursing education programs have capacity and enrollments sufficient to graduate the numbers and kinds of nurses commensurate with state and local goals for the nurse supply. State tax dollars appropriated for higher education represent the largest source of governmental and institutional support for nursing education. Local governments and private donors are important financing sources for community colleges and private educational institutions, respectively. Hospitals support nursing education by offering diploma programs in nursing and/or staff development programs, providing educational fringe benefits, and subsidizing nurse employees who are advancing their level of education in college-based programs

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6 in return for service commitments. These costs principally through third-party reimbursements. Fiscal pressures on state and local governments, as well as cost containment efforts in hospitals, threaten to reduce funds available from these sources for nursing education. This would, in turn, increase the cost burden on students and diminish their educational opportunities. These considerations link this recommendation and the preceding ones, because it is essential to maintain a monitoring capacity at both national and state levels to track current supply and demand and to refine at the level of each state the continuing adjustments necessary in resource allocation to assure continuing adequate accretions to the pool of generalist nurses. Attracting New Recruits to Nursing RECOMMENDATION 5 are financed To assure a sufficient continuing supply of new applicants, nurse educators and national nursing organizations should adopt recruitment strategies that attract not only recent high school graduates but also nontraditional prospective students, such as those seeking late entry into a profession or seeking to change careers, and minorities. Actions taken by the administrators and faculty of nursing education programs can strongly influence both the numbers and types of applicants to their programs. Because changes in the nation's demography have led to a shrinking pool of high school graduates, and because of the attractions of other careers for women, nurse educators must recruit students from new sources in order to maintain the~output of their programs. So-called nontraditional candidates are likely to respond to special arrangements made to facilitate their entry into nursing. These candidates include mature women first entering the labor market, men, minorities, and people seeking career changes. In the latter category, people who have completed other education or have embarked on other careers may wish _ _ =_ __ nursing. Additionally, there may be people who find their careers disrupted by technological changes, industrial dislocations, or altered priorities in public expenditures. . ~ courses of to Johnny to

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7 Improving Opportunities for Educational Advancement RE ~MMENDAT ION 6 Licensed nurses at all levels who wish to upgrade their education so as to enhance career opportunities should not encounter unwarranted barriers to admission. State education agencies, nursing education programs, and employers of nurses should assume a shared responsibility for developing policies and programs to minimize loss of time and money by students moving from one nursing education program level to another. It is essential that annual accretions to the nurse supply from new graduates be maintained, but it also is increasingly important to improve the opportunities of nurses already in the work force to attain higher levels of education. Although pursuit of higher education by large numbers of RNs already licensed will not necessarily augment overall numbers in practice, over time it can significantly change the characteristics of the supply, enhance individual opportunities for career advancement, and provide candidates for employment in categories that employers may find in short supply. Advancement of diploma and associate degree graduates to the baccalaureate level not only produces a result consistent with a goal espoused by many leaders in the profession but also enlarges the pool from which graduate nursing education can draw. Educational progression from less than a baccalaureate degree to higher degrees has been characteristic of the careers of many nurses who now hold advanced degrees. In 1980, one in every ten RNs was enrolled in some form of educational program intended to advance his or her credentials. Although many educational programs have responded to the need of nurses for educational advancement by facilitating credit transfers or providing for advanced placement credits, many others still do not actively-pursue this objective. Upward mobility for both LPNs and RNs has been hindered in many places by past failures of educational systems and individual institutions to plan their programs to make successive stages of nursing education "articulated," so that academic credits obtained can contribute maximally toward admission and progression in the next stage. Many state studies have identified educational advancement as a high priority, and in some states significant progress has been made toward this goal. Educational institutions will inevitably incur some added costs for steps taken to ease students' transitions from one educational program to another. On the other hand, where experienced nurses successfully challenge clinical requirements, educational institutions may also benefit from proportionately fewer enrollments in the more expensive clinical components of their nursing education programs. Motivation is growing ever stronger for KNs and LPNs to pursue further education. Professional pressures on the individual come in

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- ' part from the growing complexity and variety of nursing responsibili- ties and in part from anticipation that future career and promotional opportunities may rest on qualifications that differentiate nurses by academic credentials. Although not an approach preferred by some educators in terms of time and cost, attainment of future supply goals may well depend on a continual upgrading of the quality of a pool of nurses that is primarily nourished by streams of new entrants whose initial career objective may have been merely to secure nursing employment at minimum personal cost. Improving Collaboration Between Nursing Education and Nursing Services RECOMMENDATION 7 Closer collaboration between nurse educators and nurses who provide patient services is essential to give students an appropriate balance of academic and clinical practice perspectives and skills during their educational preparation. The federal government should offer grants to nursing education programs that, in association with the nursing services of hospitals and other health care providers, undertake to develop and implement collaborative educational, clinical, and/or research programs. Many employers tend to believe that newly graduated nurses from academic programs are inadequately prepared to assume the responsi- bilities of clinical nursing. Many nurse educators, on the other hand, believe that employers do not offer their graduates-- especially those with baccalaureate preparation--the opportunity to practice at the level of professional skills for which they have been prepared. There is increasing concern and attention among nursing leaders to reduce this discord. Some few prototypes exist of organizational structures that provide unified nursing accountability, and to bring together the perspectives of educators and employers of nurses for the mutual benefit of patients, students, and nursing staffs. Other kinds of increased collaboration between nurse educators and nursing service staffs are found across the country. The development of practical arrangements for improving communica- tion and collaborative efforts between nurse educators and nursing service administrators requires the solution of a great many logisti- cal, organizational, and financial problems among a large variety of institutions that do not have close affiliations. It is difficult and time consuming to provide incentives to test untried relationships and new patterns of accountability. Further experimentation and demonstra- tions are needed to guide institutions of all types in moving toward appropriate goals. Modest grants should be available to demonstrate innovative ways of implementing collaborative arrangements, including

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9 those that emphasize clinical and research appointments for faculty. Although the financial burden of developing new collaborative arrange- ments should fall primarily on those to whom benefits will accrue, some federal support would indicate a strong national interest in the problem and would provide impetus for wider experimentation. A reconciliation of differences between the goals and expectations of leaders in nursing practice and in education must occur to improve both the education of students and the care of patients. Increasing the Supply of Nurses With Graduate Educat ion to Fi 11 Advanced Positions in Nurs ing RECOMMENDATION 8 The federal government should expand its support of fellowships, loans, and programs at the graduate level to assist in increasing the rate of growth in the number of nurses with master's and doctoral degrees in nursing and relevant disciplines.* More such nurses are needed to fill positions in administration and management of clinical services and of health care institutions, in academic nursing (teaching, research, and practice), and in clinical specialty practice. In examining the future need for nurses, the committee identified a wide range of problems that can be alleviated only by increasing substantially the supply of nurses with advanced education. The nation's cadre of professional nurses is short of persons who have been educationally prepared for advanced positions in the administration of nursing services and nursing education programs, in education (including research), and in clinical specialty areas. The complexity of today's health care settings demands managers who are skilled not only in nursing but in the techniques of human resource management, decision making, and budgetary management. Also, the competencies of nurses delivering care at the bedside depend to a great extent on the capabilities of their teachers, who must, within a relatively short period, guide and facilitate the students' acquisition of the theoretical knowledge and clinical experiences necessary to produce competent professionals. The claim of nursing education leaders that many members of current nursing school faculties are inadequately prepared to accomplish this purpose is borne out by the comments of employers of nurses as well as by comparisons of the academic preparation of nursing faculty to that of faculty in other disciplines. A closely related problem is the short supply of faculty *Two members of the committee wished to delete the words "and relevant disciplines." Their statement of exception is in Chapter V.

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10 engaged in research--a function performed in most disciplines by those who are academically based. Finally, although well qualified generalist nurses can deliver care effectively, the growing complexity of care in many health settings presents problems that increasingly require the specialized knowledge and experience of nurses with advanced nursing degrees, both to provide direct care and to provide consultation and training to less highly prepared staff nurses caring for patients with complex illnesses. In times of severe economic constraints, states may be more willing to finance basic nursing education programs that are perceived as directly fulfilling local demand for nurses rather than to support master's and doctoral programs, whose graduates may leave a given state labor market because they have more opportunities. The committee believes that kNs with high quality graduate education are a scarce national resource and that their education merits continued federal support. Although the demand for highly qualified nursing administrators, faculty members, researchers, and clinical specialists prepared at the graduate level has been increasing and is expected to continue to increase, the evidence of a scarcity of nurse educators is most apparent. Only a small portion of nurse faculty is prepared at the doctoral level. To increase the nation's supply of nurses with advanced degrees, public and private universities with graduate programs in nursing must expand and strengthen their nursing faculties. In the face of the shortage of academically qualified faculty with expertise in nursing-related disciplines, such as management, the behavioral and basic sciences, and research methodology, deans of schools of nursing have opportunities to attract faculty from relevant schools and departments in their universities or neighboring institutions both to fill immediate needs and to help build future teaching and research capabilities. Joint programs and other forms of collaborative arrangements between university academic units, such as with business schools, health administration programs, and social science departments (e.g., psychology, anthropology, and sociology), may be found desirable. Programmatic support from the federal government can help to improve graduate level nursing education in these and in other ways. Lowering financial barriers through loans and grants to encourage full-time enrollment of RN graduate students will increase the supply more rapidly, because master's and doctoral students who must work to support their education take longer to complete it. Federal financial assistance to students in master's programs should be packaged with funds for programmatic support. The committee would expect, in line with the objective of strengthening the nursing profession as well as nursing education, that such programmatic and accompanying student support for master's programs would be available through competitive grants. In practice, nursing programs would be in an excellent competitive position to secure such grants, but arrangements in other programs should be possible. Federal doctoral level support should result primarily in the strengthening of existing programs in nursing and not in the proliferation of new and possibily weak doctoral offerings. However, until schools of nursing have sufficient numbers of qualified faculty

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to meet the full range of scholarly interests and professional needs of doctoral students, financial aid in the form of fellowships to RN doctoral students should be designed so that such students are not precluded from pursuing doctoral studies in nursing-related disciplines. To encourage graduate students to return to nursing when they have earned their degrees, loans based on need should carry such service obligations. On the other hand, most committee members believe that fellowships awarded on the basis of scholarly excellence and promise of a fundamental contribution to the knowledge base should not carry the same kind of obligation. Congressional Question Two: WHAT ARE THE REASONS NURSES DO NOT SERVE IN MEDICALLY UNDERSERVED AREAS AND WHAT ACTIONS COULD BE TAKEN TO ENCOURAGE NURSES TO PRACTICE IN SUCH AREAS? An important exception to the generalization that there is a sufficient existing supply of generalist nurses for direct patient care was noted in the discussion following Recommendation 1. That exception arises from the fact that the labor market cannot function properly when there are financial, geographic, and other barriers to the provision of medical care and other health services for disadvantaged segments of the population. Lack of access to preventive and primary care services by residents of rural and inner-city areas remains one of our nation's most pressing health problems. The committee has found, not surprisingly, that there are serious shortages of nurses who are willing or able to work in such areas, and to care for patients in public hospitals and nursing homes. The shortages largely coincide with the lack of adequate medical facilities and services for many low-income people and the elderly. Many of the root causes lie in the nation's health care financing arrangements. Possible solutions to this overriding national health care problem are beyond the scope of the committee's assignment, but we have, nonetheless, identified actions closely related to the committee's charge that would help to encourage nurses to practice in underserved areas and to work with the elderly and other underserved populations. Alleviating the Maldistribution of Nurses by Educational Outreach RECOMMENDATION 9 To alleviate nursing shortages in medically underserved areas, their residents need better access to all types of nursing education, including outreach and off-campus programs. The federal government should continue to cosponsor model demonstrations of programs with states, foundations, and educational institutions, and should support the dissemination of results.

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13 service co~itments to shortage areas, although some members questioned the effectiveness or the equity of such provisions. Strategies to develop minority manpower to provide more adequate nursing services in medically underserved areas have been stated as goals, though inadequately supported by past legislation. These goals require re-emphasis and new approaches through a redirection of authorization and funding available under the Nurse Training Act. Thus, in addition to general educational outreach efforts, nurse educators and health care employers should jointly develop programs to ensure that students are recruited from these special groups, that they will be given employment preference, and that they will gain clinical experience in shortage area facilities, e.g., rural and inner-city hospitals, nursing homes, and public health clinics. We believe that educational programs and health care facilities by working together in consortia can be successful in designing programs to recruit well .~,otivated students who will be attracted by improved prospects of future employment. The facilities themselves may benefit by work-study arrangements that will assure a future continuing supply of newly graduated nurses who live in the vicinity and are already familiar with their operations. Patients will benefit under the care of nursing service personnel who are more likely to be familiar with their health needs and life styles. Adequate Revenues for Inner-City Hospitals RECOMMENDATION 11 Differential allowances in payment should take into account the special burdens on inner-city hospitals that demonstrate legitimate difficulties in financing services because of disproportionate numbers of uninsured or Medicaid and Medicare patients. Federal, state, and local governments and third-party payers should pay their fair shares of amounts necessary to prevent insolvency and to support acceptable levels of service, including nursing care. Many inner-city public hospitals (that is, county-, city-, or state-owned), and some inne~-city voluntary hospitals bear a primary burden of serving the unsponsored poor. They generally also serve disproportionately large numbers of Medicare and Medicaid patients for whose care they may not recover full payment of necessary expenditures. Many of these hospitals are teaching institutions affiliated with academic health centers and serve as regional referral centers for very sick patients requiring extraordinary inpatient medical and nursing attention. On an outpatient basis, they also provide a heavy volume of episodic primary care and emergency room services to otherwise medically underserved persons.

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14 Failure of federal and state governments to cover certain services, or to allow payment sufficient to recover necessary outlays for services that are covered, threatens the existence of this essential part of the nation's health services structure. It stands in the way both of good patient care and of improving poor physical plant and general working conditions that contribute to the traditional difficulties these institutions encounter in recruiting and retaining nurses. The service missions of some inne~-city hospitals may result in justifiably higher costs and lower revenues than those in institutions classified as comparable in size or scope of-service. Differential payments should take these factors into account. Although differential payments cannot assure an adequate nursing supply, they may be necessary to maintain institutional solvency. When new methods of payment are developed, it will be important to allow for the expense of service and management improvements to redress past deficiencies. By making service improvements possible, such payments may promote attainment of more competitive salary structures and better staffing ~ . . or nursing services. RE COMMENDATION 12 Nursing Education for Care of the Elderly The rapidly growing elderly population requires many kinds of nursing services for preventive, acute, and long-term care. To augment the supply of new nurses interested in caring for the elderly, nursing education programs should provide more formal instruction and clinical experiences in geriatric nursing. Federal support of such efforts is needed, as well as funding from states and private sources. The most rapidly growing segment of the population--the elderly-- is a group particularly in need of the many services that nurses can provide. Those among the elderly who are age 75 and older are the most prone to multiple disabilities and chronic diseases. They use hospital, nursing home, and home care services at rates double or triple those of the population as a whole. Elderly patients are found in almost all health care settings. Their needs for care range from preventive, acute care, and rehabilitative services that help them maintain maximum independent functioning to care that eases the course of terminal illness and its impact on both patient and family. Nursing students need realistic preparation to dispel common misconceptions about the problems of the elderly, including attitudinal orientation that will enable them to provide the most effective care in all institutional settings and in patients' homes. Neither basic nor advanced nursing education programs yet focus sufficiently on academic preparation and clinical experiences in geriatrics.

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15 Upgrading Existing Staff in Nursing Homes RE COMMENDATION 13 Nursing service staffs in nursing homes certified as "skilled nursing facilities" and in other institutions and programs providing care to the elderly often lack necessary knowledge and skills to meet the clinical challenges presented by these patients. Such facilities, in collaboration with nursing education programs and other private and public organizations, should develop and support programs to upgrade the knowledge and skills of the aides, LPNs, and kNs who work with elderly patients. States should assist vocational and higher education programs to respond to these needs. Federal support~of such programs should be maintained. Today in nursing homes there are large numbers of licensed nurses as well as aides and orderlies whose education and training did not provide them with the special knowledge needed to care for elderly patients who require skilled nursing. A cost effective way to improve the quality of care for the close to a million patients in these settings would be to provide staff already engaged in their care with additional in-service training or continuing education in geriatric nursing. However, in many localities adequate financing, program, and faculty resources are lacking and must be developed. Adequate Payment for Long-Term Care RECOMMENDATION 14 The federal government (and the states, where applicable) should restructure Medicare and Medicaid payments so as to encourage and support the delivery of long-term care nursing services provided to patients at home and in institutions. For skilled nursing facilities, such payment policies should encourage the continuing education of present staffs and the recruitment of more licensed nurses (RNs and LPNs), and should permit movement toward a goal of 24-hour RN coverage. Private insurance rarely offers benefits to cover the costs of health services that patients require for long-term illnesses and disabilities, either in their homes or in nursing homes. Medicare benefits, too, are almost entirely limited to acute care services. While Medicaid provides extensive benefits for the destitute elderly in nursing homes, in most states restrictive payment practices appear to discourage the employment of licensed nurses (RNs and LPNs).

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16 Among the nursing homes certified for payment under the Medicaid and Medicare programs, slightly less than two-thirds of the patients are in homes certified either as a skilled nursing facility (SNF) only, or as some combination of SNF and intermediate care facility (ICF). Patients in such institutions usually are severely disabled and frequently are disoriented. Their conditions often require expert nursing services. By far the largest proportion of nursing service personnel in SNFs and combined SHF/ICFs are aides. Licensed nurses (RNs and LPNs) are responsible for their supervision, as well as for the direct care of patients, for recordkeeping, and for decisions about emergency situations that usually must be made with no physician in immediate attendance. Federal certification requirements call for only minimal RN staffing, i.e., in SNFs a full-time KN on the day shift every day of the week. Facilities have few incentives to exceed minimal staffing standards because such standards are likely to influence strongly the basis on which payment levels are calculated in the Medicaid program. Given the magnitude of nursing responsibilities for SNF patients, the committee believes that regulations and payment systems should be modified to advance toward a goal of 24-hour RN coverage. Legal and Reimbursement Barriers to Expanded Nursing Practice RECOMMENDATION 15 There is a need for the services of nurse practitioners, especially in medically underserved areas and in programs caring for the elderly. Federal support should be continued for their educational preparation. State laws that inhibit nurse practitioners and nurse midwives in the use of their special competencies should be modified. Medicare, Medicaid, and other public and private payment systems should pay for the services of these practitioners in organized settings of care, such as long-term care facilities, free-standing health centers and clinics, and health maintenance organizations, and in joint physician-nurse practices. (Where state payment practices are broader, this recommendation is not intended to be restrictive.) Nurse practitioners (NPs) are nurses whose education extends beyond the basic requirements for licensure as an RN and prepares them for expanded nursing functions in diagnostic and treatment needs of patients, as well as in primary prevention and health maintenance measures. At the beginning of 1983, there were about 20,000 NPs, of whom about 2,600 were nurse midwives. Many of them serve in rural and inner-city communities, especially with underserved populations, such as migrant workers, low-income mothers and children, and the elderly. The provisions of same state practice acts have slowed or prohibited this expanded nursing practice, and varying degrees of limitation on payment for their services by Medicaid, Medicare, and third-party payers often prevent payment even for legally authorized

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17 services. Approximately half the states now provide some type of reimbursement under their Medicaid programs for physician extender services provided both by NPs and physician assistants. Since 1977, the Rural Health Clinic Services Act waives payment restrictions in the Medicare and Medicaid programs under defined safeguards if such physician extenders practice in certified rural health clinics located in designated underserved areas. When they are employed in organized settings, NPs and nurse midwives have been shown to contribute to productivity gains and cost reductions. Even with the anticipated ample increases in physician supply, it is likely that NPs will be needed to serve hard-to-reach populations, to facilitate new organizational arrangements for providing health care in cost effective ways, especially in practice settings that operate within fixed budgets, and to augment the quality of care provided in nursing homes. Continued funding is needed for NP training, weighted toward supporting the preparation of RNs most likely to practice in underserved areas, in nursing homes, and in caring for the elderly in other settings. Thus, special attention should be directed to training as nurse practitioners RNs who already live in underserved areas or who work in long-term care settings. Congressional Question Three: WHAT IS THE RATE AT WHICH AND THE REASONS FOR WHICH NURSES LEAVE THE NURSING PROFESSION? WHAT ACTIONS COULD BE TAKEN TO ENCOURAGE NURSES TO REMAIN OR RE-ENTER THE NURS ING PROFESSION, INCLUDING ACTIONS INVOLVING PRACTICE SETTINGS CONDUCIVE TO THE RETENTION OF NURSES? Improving the Use of Nursing Resources RE COMMENDATION 16 The proportion of nurses who choose to work in their profession is high, but examination of conventional management, organization, and salary structures indicates that employers could improve both supply and job tenure by the following: providing opportunities for career advancement in clinical nursing as well as in administration ensuring that merit and experience in direct patient care are rewarded by salary increases assessing the need to raise nurse salaries if vacancies remain unfilled encouraging greater involvement of nurses in decisions about patient care, management, and governance of the institution identifying the major deterrents to nurse labor force participation in their own localities and responding by adapting conditions of work, child care, and compensation packages to encourage part-time nurses to increase their labor force participation and to attract inactive nurses back to work.

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18 The committee found that the problems of retention in the profession and high turnover in hospitals are less severe today than commonly believed. More than three out of every four RNs holding current licenses are actively engaged in nursing. Only about 5 percent have left nursing for other types of employment. A major reason labor force participation rates are high--having risen 6 percentage points in the last 3 years--may be that the profession affords the option of part-time and evening or night work for nurses with family responsibilities. However, the committee believes that many institutions have opportunities to further increase the effective participation of nurses in the part-time and inactive supply. Investments in measures to accomplish this goal are especially pertinent in areas of local shortage. Turnover rates apparently are lower today than in the past. Although precise data are not systematically and comprehensively available, the average turnover in RN positions does not appear to be very much higher now than it is for women in any other stressful occupation. Much of the recent improvement has came about because employers engaged in strenuous recruitment campaigns and in the use of temporary nursing agencies have come to realize that strategies for retention are essential. Frequently they are more cost effective than alternatives that reinforce competition between hospitals for nurses inclined to change jobs in their search for better career opportunities, better working conditions, or better compensation. Congress asked this study to suggest actions involving practice settings that would be conducive to the retention of nurses. Our conclusions focus on the responsibility of health care management to engage in analysis of the effect of its decisions--its actions and its lack of action--that cause nurses to enter and leave employment. Of particular concern is the necessity for employers to retain experienced nurses. In light of the growing complexity of hospital care, their contributions should not be undervalued. Despite recent gains in the earnings of nurses, continuing activity is required to improve career opportunities and work environment. RNs earn significant promotions in hospitals today largely by moving into supervisory and management positions. Attention must also be given to promotions and salaries progressively adjusted to reward merit and experience in direct patient care. Cost Accounting for Nursing Services REOOMMENDATTON 17 Lack of precise information about current costs and utilization of nursing service personnel makes it difficult for nursing service administrators and hospital managers to make the most appropriate and cost effective decisions about assignment of nurses. Hospitals, working with federal and state governments and other third-party payers, should conduct studies and experiments to determine the feasibility and means of creating separate revenue and cost centers for direct nursing care units within the institution for case nix costing and revenue setting, and for other fiscal management alternatives.

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19 As cost containment pressures force hospital management to become more skilled at using resources productively, it becomes important that managers have the tools to identify nursing revenue and to allocate nursing costs accurately and that systems be developed especially to-enable nurse management to accept responsibility for using nursing service staffs most effectively. To achieve these goals, management needs to develop much more accurate methods for disaggregating revenue and costs associated with nursing. In the absence of greater operational experience and evaluation of effects, the committee can only conditionally endorse the concept of separate cost/revenue centers for nursing activities, but strongly recommends federal sponsorship and assessment by the hospital industry (with third-party payer encouragement) of experiments with methods potentially applicable to different types of providers under varying payment arrangements. This will require studies to determine the information requirements, costing procedures, effects on the delivery of nursing services, and cost impact of such developments. A Center for Nursing Research REOOMMENDATION 18 The federal government should establish an organizational entity to place nursing research in the mainstream of scientific investigation. An adequately funded focal point is needed at the national level to foster research that informs nursing and other health care practice and increases the potential for discovery and application of various means to improve patient outcomes. A substantial share of the health care dollar is expended on nursing care, and yet there is a remarkable dearth of research in nursing practice. The federal government's principal nursing research initiative--$5 million annually--is not at a level of visibility and scientific prestige to encourage scientifically oriented kNs to pursue careers devoted to research of direct applicability to the problems that nurses confront in patient care. The lack of adequate funding for research and the resultant scarcity of talented nurse researchers have inhibited such investigation. The committee believes that a center of nursing research is needed at a high level in the federal government to be a focal point for promoting the growth of quality nursing research. Such an organiza- tional base, adequately funded, would provide necessary leadership to expand the pool of experienced nurse researchers who can become more competitive for general health care research dollars. It would also promote closer interaction with other bases of health care research.

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JO Studies of ache Competenc ies of RNs Prepared in Different Types of Education Programs RECOMMENDATION 19 Federal and private funds should support research that will provide scientifically valid measurements of the knowledge and performance competencies of nurses with various levels and types of educational preparation and experience. Many different pathways in nursing education lead to initial licensure as an RN. Nurse educators, nursing service administrators, and other nurse employers often have different perceptions about the outcomes from these different educational inputs and, more fundamentally, on the outcomes that should be expected, both in the short and long term. As with most other kinds of postsecondary education, there is little empirical evidence on the performance differences of the graduates of these different types of nursing education programs according to established measurable criteria of knowledge, skills, and range of co~upetencies. This creates problems for nurse educators planning curricula to encourage educational advancement, for nursing service administrators trying to utilize Pus and LPNs most efficiently, and for the various organized groups within nursing who are seeking to establish new levels of kc ensure or to retain the current ones. The current lack of consensus on objectives and performance measures and evidence seriously handicaps the efforts of higher education bodies and state university systems attempting to allocate resources for nursing education in ways that will best match demand or needs for nurses with different kinds of competencies. Evaluation of Promising Management Approaches RECOMMENDATION 20 As national and regional forums identify promising approaches to problems in the organization and delivery of nursing services, there will be a need for wider experimentation, demonstration, and evaluation. The federal government, in conjunction with private sector organizations, should participate in the critical assessment of new ideas and the broad dissemination of research results. Although individual health care institutions often develop better approaches to problems in the organization and delivery of nursing

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21 services, there is a dearth of systematic information on their generalizability. The committee recommends that the hospital industry and the professions of nursing and medicine develop a concerted effort to continue the work begun by the National Commission on Nursing to identify and assess existing experience with proposed innovative solutions. We also conclude that there is a federal role in stimulating innovation by disseminating information, by according national recognition to model solutions, and by supporting more rigorous evaluation than is likely to be employed by the industry itself. By focusing federal attention on these areas of research, the effect will be to draw the interest of other sources of support in the private sector. Information for Future Monitoring of the Nation's Nurse Demand and Supply RECOMMENDATION 21 To ensure that federal and state policymakers have the information they need for future nurse manpower decisions, the federal government should continue to support the collection and analysis of compatible, unduplicated, and timely data on national nursing supply, education, and practice, with special attention to filling identified deficits in currently available information. In order to maintain the necessary capability for monitoring the future balance between the nation's demand and perceived needs for licensed nurses (RNs and LPNs) and the supply, analysts depend on continuing streams of reliable national information from many sources. Some is collected periodically, some occasionally. Some is badly outdated, as in the instance of survey information concerning LPNs. Data collection and analysis require the continued support of the federal and state governments and/or professional associations. The collection of new data to yield information not now available may require some rearrangement of priorities within available funding. In the course of this study, we have identified serious gaps in such areas as the costs and sources of financing of nursing education, nursing education curricula, the supply and distribution of LPNs, and the staffing of nursing homes. The federal government, in cooperation with the nursing profession' nursing organizations, health care institutions, and state governments, should continue to provide leadership in nurse manpower data collection in order to maintain and improve definitional conformity, to provide a sense of priorities, and to minimize duplicative efforts.

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22 Costs and Financing to Implement the Recommendations The committee has kept in mind the ever increasing economic pressures on public budgets and the concomitant emerging constraints on health care providers and educational institutions. We have culled from many desirable proposals those of less than urgent priority. We believe that each recommendation presented would require financial support for implementation. In combination, they represent a concerted public-private strategy for the effective use of the nation's health care resources. They build on solid foundations of policy reassessment and, thus, are designed to obtain maximum return from investments in nursing education and nursing services. Three sources of federal support for the recommendations are discussed below: continued funding under the NTA, as amended; continued funding of student support for general higher education; and payment for services under Medicare and Medicaid. Specific costs of recommendations to the federal government are assessed only for the first source, the one that deals exclusively with nursing. The committee has not attempted to estimate expenditures needed to support recommendations concerning aid to secondary education or improvement in Medicare and Medicaid. Support for recommended activities within the scope of the NTA objectives can be accommodated with modest additional sums, assuming continued authorization of the NTA and redirection of some of its ~ ~ e existing provisions. We estimate that our various recommendations for the strengthening and redirection of NTA programs could be implemented if funding for the NTA is restored to a level of about $80 million--the approximate average of annual appropriations between 1980 and 1982. This includes restoration of federal support for graduate education and other advanced nurse training to the average 1980-1982 level of $40 million. It also includes the added costs of improving access of the disadvantaged to nursing care and nursing education, of special project grants or contracts to support demonstrations and encourage new programs of educational and clinical collaboration, of outreach to minorities, of off-campus programs, of improvements in curricula to increase students' abilities to serve the elderly, of continuing education programs to upgrade skills of nursing home personnel, and of certain employer experiments in the better management of nursing resources. The costs of implementing the committee's recommendations for stronger federal support of research and data collection involve modest increments in expenditures. For example, an increase on the order of $5 million per year for research could have a substantial impact in stimulating growth of capacity for research on nursing-related matters. A similar amount would greatly strengthen federal-state planning efforts for manpower studies and resource allocation. Many such activities primarily would entail redirection of effort. Levels of expenditure for non-NTA programs are beyond the capacity of this study to quantify, except in terms of existing general levels

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23 of effort. We examined some problems, for example, those of inner-city hospitals and of nursing care for the elderly, that we felt unable to ignore but whose solutions would require substantial resources not fairly attributable to nursing even though nursing improvements indirectly may be at stake. The committee also has presented strategies that private sector groups and institutions should pursue, such as improving the management of nursing personnel, attracting to a career in nursing students from nontraditional sources, and improving collaboration between nursing education and nursing service. To encourage such efforts, we recommend modest federal demonstration, evaluation, and dissemination expenditures under the NTA authority in the range of $1-2 million per year. Of course, there will be costs to others engaged in implementing these recommendations, but we expect that anticipation of either commensurate long-run savings or associated benefits to patients and to educational and employing institutions will be considered worth the cost. In summary, the budgetary impact of the committee's recommendations entails (1) modest increases in essential expenditures under the NTA directed at resolving certain particular nurse shortages, (2) holding the line against possible erosion of outlays for higher education generally at both federal and state levels, and (3) modifying payment systems of public and third-party payers to permit providers of service to the poor and elderly to become financially secure and, thus, to increase the quality of their nursing services. ~