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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
OCR for page 8
- '
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
OCR for page 11
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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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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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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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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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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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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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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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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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. ~
Representative terms from entire chapter:
nursing services
