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OCR for page 133
CHAPTER V
Educabon for Advanced
Positions in Nursing
The previous chapter described measures for strengthening the
nursing supply by enlarging the pool from which registered nurse
education programs draw students, reducing the barriers to educational
advancement, and improving the collaboration between nursing education
and nursing services. There is, however, another important dimension
to the problem of assuring adequate nursing services in the nation's
health care system.
Integral to the effectiveness of the nursing supply are such
matters as the quality of the education, the management of nursing
personnel and nursing services, the study of nursing practice for ways
to improve it, and the ability of nursing's advanced practitioners to
generate new knowledge and to translate it both into improved patient
care and into the education of other nurses. These leadership
functions are closely associated with the advanced education of nurses.
In this chapter, we examine the supply and demand for nurses with
advanced education in three areas: nursing administration, education
(including both research and teaching), and clinical specialty
practice.
Advanced Education for Nursing Administration
The committee found a widespread conviction among administrators
of hospitals and long-term care facilities that their nurse
administrator colleagues could make the delivery of care more cost
effective if they had better grounding in financial management and in
the human resource management required at all the levels of administra-
tion in which they currently serve, i.e., from head nurse positions
through nursing service administrators.* Reciprocally, testimony
indicated that nurse administrators should be able to contribute to
executive management decisions beyond nursing services. Because they
are familiar with almost all aspects of the daily operations of their
*In a number of medical centers, nursing service directors are now at
the vice-presidency level.
133
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134
institutions through the interactions between their own and other
departments, they are in a unique position to participate in
institution-wide decisions on ways to contain costs while maintaining
good standards of patient care.
Hospitals and other providers of health services need departmental
managers adept in the complex techniques of modern administration.
Today, administrators must deal with intricate problems in employment
policies, job design, resource allocation, intra-institutional negoti-
ation, and financial management. Many of the skills needed to handle
these problems can be acquired or enhanced through academic prepara-
tion. Nursing service administrators should be equipped with the same
fundamental knowledge of management practices as their colleagues in
other departments. Every departmental administrator will be competing
strongly for a share of revenue generated as cost cutting proceeds
further. Special seminars and workshops sponsored by professional
organizations and short training courses have often had to suffice
as
a means of upgrading middle managers and top administrators in nursing
services . Although these programs help, they are not sufficient to
prepare individuals for the responsibilities of high-level administra-
tive positions.
Among the more than 61,000 registered nurses (RNs) who reported in
the National Sample Survey of Registered Nurses, November 1980, that
they occupied a position in "top nursing administration," only 18
percent held a master's degree and 1.4 percent held a doctorate.!
However, it should be noted that this category did not distinguish
between persons who worked as administrators in large complex health
care settings with responsibilities for hundreds of staff and
multimillion dollar budgets and those who worked in small hospitals,
nursing homes, student health services, or physicians' offices and
were responsible for only a handful of staff and a small budget. It
is known that nursing service administrators with diploma preparation
are concentrated in hospitals with fewer than 100 beds; nursing
service administrators with associate degree (AD) preparation are
concentrated in hospitals with fewer than 200 beds. Nursing service
administrators with baccalaureate preparation are largely found in
hospitals of up to 300 beds; and, as could be expected, those with
master's degrees and doctorates are in the larger hospitals.2
Finally, it should be noted that the administrator category also
included 5,000 deans and directors of nursing education, the majority
of whom probably held a master's or doctoral degree. If this group
was removed from the computation of the proportion of individuals in
"top nursing administration" with advanced degrees, the proportion of
all "top nursing administrators" holding master's or doctoral degrees
might be appreciably less.
Although the committee would not argue that the majority of nurses
who work in supervisory or administrative positions need the skills and
knowledge acquired in formal graduate degree programs, there is general
agreement that a scarcity exists of nurses with advanced education.
The scarcity is felt most in larger hospitals. As health care settings
become increasingly complex, more highly skilled administrators of
nursing services will be needed.
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135
Because advanced clinical preparation has been the prime focus of
attention within the last 20 years, graduate programs in schools of
nursing have not been able to make a substantial direct contribution to
the pool of top nursing service administrators and nurses in middle
management positions. Students do not appear to be attracted. Between
1971 and 1980 only about 7 percent of all graduates of master's
programs in nursing had a concentration in administration. It seems
unlikely that graduate programs in administration in schools of nursing
can produce larger numbers and better quality of trainees soon. One
observer comments:
While programs in health care administration have
grown and changed, strengthening their residency in
line with needs of the field, nursing has come to a
fixed core, heavy on theory and light on the type
of experience a residency could provide. Too often
a major in administration and nursing has not
equipped that graduate with the skills or language
common to health care administration. It is not
uncommon for the new graduate to immediately enroll
for evening courses in business administration.3
The W.K. Kellogg Foundation has in recent years funded several
demonstrations of interdisciplinary preparation for nursing service
administration in university health care settings to assist nursing
schools to develop joint programs with schools of health administra-
tion, management, or business. The most recent example is that of the
University of Pennsylvania School of Nursing and the Wharton Graduate
School of Business. The study committee noted that there are still
too few opportunities for graduate nursing education in management
through such collaborative programs. We believe it is in the public
interest that the health care industry and nursing education encourage
and sponsor more such endeavors. Collaborative arrangements with
health services administration programs and/or with business schools
can, over the long run, build up nursing education's capabilities for
providing high-quality preparation for this very important aspect of
nursing leadership. Advanced education in management is one of the
few areas with substantial financial payoff for students, because
nursing service administrators in large institutions command the
highest salaries in nursing. This suggests that the financing of such
training be a cooperative endeavor in which greater weight is given
than in other fields of graduate education to the motivations for
institutions and individual nurses to share in costs.
Advanced Education for Teaching and Research
Many professional schools and university departments have little
difficulty in attracting faculty members in the numbers and at levels
of excellence required. This is not the case in schools and
departments of nursing, many of which were established in colleges and
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136
universities as recently as the late 1960s and 1970s. The relative
dearth of academic credentials among nursing faculty has been
aggravated by a great increase in the numbers of nursing education
programs in institutions of higher education and the consequent rapid
and large increase in nursing students. From 1968 to 1980 the number
of full-time faculty in nursing education programs increased by 36
percent and enrollments (basic and graduate) increased by 66
percent.4 State boards of nursing are increasingly requiring that
the deans and faculty of nursing education schools hold graduate
degrees. As of June 1982, 19 states required master of science
degrees in nursing as the minimal degree for senior faculty in all
programs, and two states required directors of schools of nursing to
hold a doctoral degree.5 If one agrees that the faculty required to
teach master's and doctoral students should hold doctoral degrees and
that those who teach baccalaureate students should also possess
advanced degrees, indications of scarcity are suggested by the fact
that of the approximately 20,000 full-time nursing faculty in 1980,
only 7 percent held a doctoral degree; 68 percent had a master's
degree.
The proportion of nursing faculty with doctorates does not compare
favorably with other disciplines. According to the Association of
Schools of Public Health, well over one-half of the faculty employed
by 20 schools of public health held at least one doctorate. Compared
with science faculties, nurses showed up even more unfavorably. A
National Science Foundation study of young and senior science and
engineering faculty found that in schools offering doctoral as well as
other degrees in departments of psychology, physical sciences,
biological sciences, mathematical/c~mputer sciences, engineering, and
social sciences, more than 90 percent held the doctoral degree.6 By
comparison, in the 22 nursing schools which enrolled nursing doctoral
students in 1981-1982, an average of only 35 percent of the faculty
had doctoral preparation.7
Recent surveys in 40 states in the Midwestern, western, and
southern regions found that among the 58 graduate programs in nursing
surveyed, respondents projected a need for 1,080 doctorally prepared
nurse faculty during the following 5 years. (Data were not obtained
on what proportion of such new faculty positions had been approved by
their respective institutions and assured of funding.) The schools
reported that their greatest need was for 371 nurse faculty with
doctoral preparation emphasizing research and theory development in
nursing. The second highest need was for 359 doctoral nurses with
formal preparation in clinical practice.8 To put this in the
perspective of the supply, in 1980 there were only about 4,000
doctorally prepared nurses. Although about one-half of the nurses who
earn doctorates take teaching positions after graduation, many later
gravitate to other types of activities. Among the respondents to a
survey of nurses with doctorates, conducted in 1980 by the American
Nurses' Association (ANA), 36 percent reported that their primary
function was in teaching, 33 percent reported that they were in
administration (mostly educational administration), and approximately
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137
6 percent were in research. Most of the remainder were performing
multiple activities.9
Research in nursing has been handicapped by inadequate levels of
support. Funding for nursing research fellowships, administered by
the Division of Nursing in the Health Resources and Services
Administration (HRSA), under the authority of Section 472 of the
Public Health Service Act, amounted to about $12 million for the
period 1971 to 1981; it has been averaging about $1 million per year
since 1977. During the same 10-year period, about $40 million was
awarded in research grants; between 1976 and 1981 the level has been
about $5 million per year. Over that same period the federal
government, through the National Institutes of Health, spent almost
$1.7 billion on general biomedical research training and almost five
times as much on dental research training as it did on nursing
research training.l0,11
Nurses with doctorates have earned them in many different fields.
Of the 6 percent of nurses with doctorates who reported in 1980 that
their primary function was research, about 65 percent had a Ph.D., and
slightly more than 40-percent had earned these degrees in the social/
behavioral sciences. Research as a primary function is most common
among nurses who received their doctorates in public health (about 17
percent of the total with these degrees) and in the biomedical
sciences (about 16 percent).12
The doctoral degrees in nursing (D.N.S. and D.N.Sc.) are granted
only by graduate programs located in schools or departments of
nursing. However, schools of nursing with doctoral programs also
offer other kinds of degrees. In 1982, 1 offered the Ed.D. and 16 the
Ph.D. (Appendix 6 contains descriptions of doctoral program offerings
in selected departments or schools of nursing). Mbst doctoral
programs in nursing departments are still relatively new. The number
of programs grew from 6 in 1970 to 24 in 1982.13 This expansion
brought sufficient problems to suggest that future increases should
proceed at a more measured pace. The National Research Council noted
in 1982 that a 40-percent increase in the number of doctorate-granting
nursing schools between 1977 and 1981 had detracted from efforts to
develop quality programs, and that unevenness in the quality of
committee's 1977 survey
been perpetuated rather than alleviated.14
In summary, the scarcity of nurse faculty with adequate academic
credentials in the nation's more than 1,000 academic nursing education
programs will not readily be alleviated. A long period appears to be
needed in which universities offering nursing doctorates can build
their capacity to produce greater numbers of high-quality graduates
likely to devote their careers to teaching and research. A key
feature of this strategy is the availability of targeted research
support and innovative programs to enhance the capability of nursing
faculty to compete effectively for research grants, including grant
funds not specifically earmarked for nursing.
In the short run, some nursing education programs may have to draw
on other kinds of academically and clinically qualified faculty from
their universities or elsewhere to collaborate in teaching and
research training programs evidenced in its
and site visits hnc1 horn nF,rn~t-d
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138
conducting research. As a corollary, nurses who do not find doctoral
nursing programs appropriate to their individual needs--in geographic
location as well as in substantive focus--should also be allowed to
compete for financial support to pursue an advanced degree in other
relevant disciplines. In time, as the number of nurses with
doctorates in nursing reaches a critical mass, increased financial and
organizational incentives may enable schools of nursing to attract
large numbers of faculty with these nursing degrees.
Advanced Education for Nurse Specialists
A growing interest developed in the 1960s to provide specialist
training to RNs that would enable them to respond to demands for
greater responsibilities than were found in their traditional roles
Acute care hospitals increasingly required nurses with highly
specialized skills. Community health settings highlighted the role of
nursing in preventive and primary care. In the 1970s, health
policymakers, seeking ways to help medically underserved populations,
encouraged the development of nurse practitioner programs.
In 1980, about 24,000 such specially trained nurses provided
clinical support to hospital nursing services, of whom about 5,700
were nurse practitioners. Approximately 7,000 other nurses with
clinical specialties were in same type of community health work, of
whom almost 4,500 were nurse practitioners or nurse midwives.15
Such nurses receive their special training in a variety of ways,
sometimes in staff development programs in an individual institution,
sometimes in joint cooperative programs between hospitals or other
health care institutions and schools of nursing, and sometimes in
graduate degree programs of schools of nursing with arrangements for
clinical experience at one or more practice institutions or with
practitioner preceptors.
Since 1976, under Nurse Training Act (NTA) appropriations, grants
and contracts have been awarded to schools of nursing, medicine, and
public health, as well as to hospitals and other public or nonprofit
organizations to develop and operate programs (certificate and
graduate degrees) to train nurse practitioners. The appropriations
began at $3 million per year and increased to $13 million by 1978.
However, by 1982 they decreased to $11.5 million. Recently, attention
has been directed toward the new potential of training to meet the
particular problems of geriatric and nursing home patients, as well as
training to provide primary care in homes, ambulatory facilities,
long-term care facilities, and other health care institutions.
In developing clinical specialist programs to produce all these
new kinds of nurses, the nursing profession responded to market
signals that indicated a demand for new services from nurses as well
as to federal policy expressed through funding. The educational and
experiential qualifications and job content in the market, however,
were not yet well defined. As a result, educational programs of
varying aims, length, content, and auspices proliferated (see Appendix
4~. Nurses who completed these programs are now employed in a wide
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139
range of capacities and hold a variety of position titles, for many of
which there is no commonly agreed upon definition of role.
The diffuse state of education and credentialing for nurses
holding clinical positions beyond the generalist level is illustrated
by the following data:
· In 1980, among the estimated 19,000 RNs who held the title of
clinical nurse specialist, 15 percent had the AD for their generalist
preparation, 36 percent had the diploma, and 21 percent had the
baccalaureate degree. Mbst are presumed to have completed same form
of clinical specialty training program; an unknown proportion hold
certificates in one or another nursing specialty. The remaining 27
percent (more than 5,000 nurses) had graduate preparation at the
master's or doctoral level, and many of them also held certificates.
In the same year, among the estimated 8,000 nurse clinicians, 14
percent had the AD as their highest educational preparation, 44
percent had the diploma, and 27 percent had the baccalaureate degree.
The remaining IS percent had graduate preparation.16
· Among the approximately 17,000 nurses who reported themselves
to be either nurse practitioners or nurse midwives in November 1980,
about 10 percent had the AD, and about 40 percent had the diploma as
their highest formal educational preparation; 30 percent had
baccalaureate degrees; and 19 percent had master's degree
preparation. Approximately 13,500 were certified (Appendix 4~.
· Among the approximately 15,000 nurse anesthetists reported in
the 1980 survey, only a small proportion had graduate preparation.
Again, in 1980, the majority were diploma prepared.17
Nurse practitioner education programs vary considerably in length
and content. For example, certificate programs generally require 8
1/2 months of additional nurse education and average about 6 months of
subsequent clinical preceptorship. Master's programs for nurse
practitioners require somewhat over 15 months of education and average
about 3 1/2 months of such preceptorship.18
Nurses pursuing graduate education in advanced clinical practice
usually choose an area of concentration. About 37 percent of those
enrolled full time in master's programs have concentrated in
medical/surgical nursing, 23 percent in maternal/child health, 19
percent in psychiatric and mental health, and 15 percent in public
health.l9 Among nurse practitioners (master's and certificate
combined), the most common types of specialists were in family nursing
(28 percent), pediatrics (about 20 percent), and adult nursing (16
percent).20
The forces that originally generated the demand for clinical
specialists and nurse practitioners have not abated. The rate of
growth in technological complexity of care has not declined. As will
be discussed in Chapter VI, there are many medically underserved
populations, such as the elderly, for whom the nurse practitioner is
well suited to help provide primary care.
In addition to the direct care they provide to patients, the areas
in which clinical nurse specialists with graduate degrees reportedly
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140
have made the most impact and have the most promise for the future
include the following:
· Translating research into practice: The advanced degree nurse
prepared to remain current in a specialty can use research findings to
develop appropriate nursing care interventions and, acting as a
teacher and role model, can ensure that the most efficacious regimens
are followed by the staff.
o Education/service collaboration: A critical need to bring
nursing education and service closer together (Chapter IV) puts the
nurse with advanced clinical practice preparation in a key position as
bridge between academic and bedside nursing as a person who
incorporates common sets of values.
· Facilitating managerial improvements: The nurse with advanced
clinical preparation can help guide management and staff to find more
efficient methods for delivering services without compromising quality
and can ease many of the frustrations and anxieties leading to
excessive staff turnover.
Nurses who have completed clinical education in certificate
programs also are needed to provide direct patient care at an advanced
level. However, the committee believes there is a need for greater
numbers of nurses with higher academic degrees in clinical areas
because, in principle, the master's level nurse is more likely to
provide the kinds of linkages set out above. Sultz has noted a trend
toward a greater proportion of nurse practitioners with master's
degrees and suggests that this trend will continue.21
Interrelationships Among Types of Advanced Education
The functional divisions of nursing--administration, teaching,
research, and clinical practice--interact and interrelate extensively.
Nurses with advanced degrees often perform several types of functions
during the course of a workweek. Also, over the length of a career it
is not uncommon for nurses and other similar professionals first to
engage in one kind of activity and later change to another. Educators
may engage in research or clinical practice; administrators may teach
or supervise students at an affiliated campus. The responses of nurses
with master's or doctoral degrees to the 1980 national sample survey
confirmed the occurrence of this phenomenon. Close to half of the
19,800 respondents who were employed in nursing education reported
that clinical practice had been the primary focus of their advanced
degrees. Conversely, roughly one-third of the 16,000 respondents with
graduate degrees who were employed by hospitals reported that education
had been their primary focus. There has been a marked shift of focus
in advanced degrees from education to clinical practice since 1971, but
it has not diminished the flow of nurses with advanced degrees going
into nursing education. Thirty percent of the 25,000 advanced clinical
practice graduates since 1971 were employed in nursing education in
1980--nearly as many as were employed by hospitalse
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As the recommendations in the previous chapter indicate, the
committee supports greater collaboration and shared responsibility
among the various segments of nursing. Because manpower planning is
not so precise as to be able to predict long-range shifts in health
system priorities and in consequent market demand for specialists,
flexibility in the advanced educational preparation of nurses clearly
is desirable. Coupled with efforts to provide sufficient economic and
noneconomic rewards in the work setting, investments in graduate
education can have a significant payoff in developing nurses who are
versatile in addressing deficiencies in the organization and delivery
of nursing care.
The Need for More Nurses With Graduate Education
Current Supply
Although the growth in the number of nurses with some form of
graduate training has accelerated in 1980, as noted earlier, only about
5 percent of all RNs in 1980 held master's or doctoral degrees. Marked
increases in the graduations from such programs cannot be expected in
the short run because, as with any other graduate education, it takes
considerable time to prepare a nurse with a master's or doctoral
degree. Furthermore, as we have seen, nursing schools depend on a
small supply of doctorally prepared nurses to teach in these and other
nurse education programs and to conduct research.
Nurses With Master's Degrees Among the approximately 80,000
nurses with master's as the highest degree in 1980, about two-thirds
(55,055) had earned the master's degree in nursing (M.S.N.~.22
About four-fifths of the nurses with M.S.N.s were employed in nursing,
as were three-fourths of the nurses with master's degrees in other
fields.23
The numbers and distribution of master's programs in nursing
education departments have increased substantially during the past 20
years--from 43 to 141. By 1981 all but four states had at least one
such program.24 Many, however, are quite small, and in 1980
one-half of all the graduations occurred in only seven states
(California, Illinois, Massachusetts, New York, Ohio, Pennsylvania,
and Texas).25,26
More than one-half of the approximately 15,000 nurses enrolled in
master's programs in the 1981-1982 academic year were part-time
students, a distinct change from the 1964-1965 academic year when
full-time outnumbered part-time students by three to two.27 The
current economic recession threatens to increase further the
proportion of students able to enroll on only a part-time basis. It
takes part-time students longer than full-time students to complete an
educational program. The increase in numbers of part-time students
would have to be much greater than the decline in numbers of full-time
students if a drop in graduates is to be avoided; how much greater
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142
cannot be estimated because it is not known how many part-time
students constitute one full-time student or how long it takes for the
average part-time master's degree student to complete a program.
Nurses With Doctorates According to the 1980 national sample
survey, approximately 4,100 nurses had doctoral degrees. Of these,
the survey estimated that close to 3,000 (72 percent) were employed in
nursing.28 The ANA survey of nurses with doctorates, conducted in
that same year, however, reported a much higher rate. Among their
approximately 2,000 respondents, 91 percent were employed, with almost
all of them working full time.29
Today, within the population of nurses with doctorates, there is a
varied mix of educational preparation--a mix that reflects the
historical development of nursing as a profession. The ANA survey
found that among their respondents, 17 different kinds of doctoral
degrees had been earned from 191 different institutions.30 Before
1965, the doctorate in education (Ed.D.) was the most common degree
for nurses with graduate training. Beginning in the mid-1960s,
education as the major field was challenged by a growing interest in
the social and biomedical sciences. The establishment of the Nurse
Scientist Training Grant programs in 1962 may have influenced the
subsequent change in preferred discipline. In any event, by 1980 the
Ph.D. had become the leading degree (54 percent). Another 3 percent
of nurse doctorates are in public health (Dr.P.H./Sc.D./D.S.Hyg.), and
2 percent are in law (J.D.~.
Doctorates in nursing (D.N.S. and D.N.Sc.) were first awarded in
the early 1960s. Again drawing on the ANA survey findings, in 1980
about 5 percent of nurses with doctorates held D.N.S. or D.N.Sc.
degrees. Assisted by Nurse Training Act funds, the number of doctoral
programs located in nursing schools or departments, where such degrees
are granted, grew rapidly during the decade of the 1970s.
The National League-for Nursing collects information about doctoral
education only from programs located in nursing education departments
or schools. In 1980, there were 125 graduations from such programs.
Enrollments have been growing, however, along with the numbers of
programs, which are now available in 18 states. In 1980-1981, slightly
more than 1~000 doctoral students were enrolled.31 In view of the
increase in the number of programs and enrollments, a higher proportion
of nurses can be expected in the future to earn the doctoral degree in
schools of nursing.
Nursing leaders do not always agree about the type of doctoral
education that would best prepare nurses for advancing the professional
development of nursing and the scientific base of nursing practice.
Those who advocate the doctorate in nursing (D.N.S., D.N.Sc.) argue
that while the nurse with a Ph.D. in a cognate discipline helps to
generate new knowledge, the nurse with the professional doctorate will
apply this knowledge. And among the advocates of the Ph.D., some
prefer a Ph.D. in nursing and others prefer a Ph.D. in a discipline
related to nursing.32
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Projections of Future Supply
To replenish or increase the size of the pool of Bus with advanced
education requires first that there be an adequate pool of RNs with
baccalaureate degrees eligible to enter advanced degree programs. As
noted in Chapter II, the number of annual graduations from
baccalaureate programs more than doubled between 1971 and 1981,
growing from about 11,000 to 25,000 during that period. Within the
study's intermediate projection total of 1,710,000 RNs at the end of
1990, the number with baccalaureate or higher degrees will have
increased by about one-quarter of ~ million. Unless baccalaureate
graduation rates were to fall dramatically, which is not anticipated
in our projections, baccaluareate nurses will continue to provide an
ample reservoir from which candidates for advanced degrees can be
drawn.
Given this basic premise, the c~mmittee's estimate of the future
supply of nurses with graduate education by 1990 is based on the
current capacity of the educational system to prepare them and on the
assumption that (1) increasing numbers of RNs will seek such education
in line with the trends of the 1970s, (2) current rates of labor force
participation by nurses with master's and doctoral degrees will
continue, and (3) financing of graduate nursing education from all the
major sources that have contributed in the past to increasing the
supply will also suffer no major dislocations.* To the extent that
these assumptions prove correct, a substantial growth is indicated
during the 1980s.
The committee estimates that by the end of 1990 there will be
124,200 employed nurses with master's preparation, of whom about
four-fifths will have M.S.N. degrees, and that there will be about
5,800 employed nurses with doctoral degrees. These projections were
derived as follows.
Nurses With Master's Degrees In 1980 there were 55,000 RNs with
master's degrees in nursing, of whom 44,700 (81 percent) were employed
in nurs~ng.33 In 1971, about 2,000 M.S.N. degrees were granted; by
1981, the number had risen to more than 5,000.34 The number of
graduations from M.S.N. programs represented about 2 percent of the
pool of eligible potential candidates for such nursing degrees--i.e.,
all employed nurses with the baccalaureate in nursing as their highest
degree.
If the proportion remains at 2 percent, the number of master's
degrees granted in nursing would continue to rise by some 500 per year.
This would result in a total of 9,500 such degrees granted in the year
1990, and would yield an additional 68,000 nurses with master's degrees
*As in the overall supply projections in Chapter II, estimates of
future supply are presented in terms of the numbers expected to be
employed in nursing--not the total numbers of nurses that have
obtained graduate degrees.
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146
In arguing the need for more nurses with master's and doctoral
degrees, the committee recognizes the concern, often expressed in
manpower discussions, about the cost to society of the general trend
in all professions toward overcredentialing. We have not been able to
quantify the necessary additions to supply in the various functional
areas of nursing. Nonetheless, in the committee's judgment, a
substantial increase in output of nurses with graduate degrees will be
required to achieve even modest goals in maintaining and improving the
leadership cadre of the nation's nursing resources.
The Effect of Financing on Future Supply
The success of efforts to lessen existing gaps will, in large
part, depend on the ability of students to afford advanced degrees.
Graduate students have higher tuition than undergraduate students.
Full-time graduate students in nursing education programs face 1-3
years with annual tuition costs of $1,000 to almost $10,000, depending
on whether the program is in a public or private institution of higher
education.38 Annual tuition charges generally are the same for all
graduate students, whether they are enrolled in master's or doctoral
programs. Graduate students tend to be self supporting (financially
independent of their parents) and thus have higher living expenses
than most undergraduates (see Table 22~. For a student who is a RN,
forgone earnings can be estimated to be over $17,000 annually,
according to data on average earnings from the 1980 national sample
survey.39 Such expenditures, particularly toward the higher end of
the range and when forgone earnings are included, can generally be
undertaken only by students willing to make large sacrifices or by
students having some private or public student aid.
Little information is available on the sources on which master's
degree candidates draw to finance their education. However, the 1980
ANA survey, referred to above, reports that nurses with doctorates
received financial support from a variety of sources (Table 29~.
Federal training grants were by far the most frequently reported
source. Federal loans and research grants also contributed a small
but important part. Universities, through fellowships and through
teaching and research assistantships, were reported to be another
important contributor. By contrast, state government support and
loans for doctoral students appear to have been negligible.
Federal Support Programs
Of the total $1.6 billion appropriated under the Nurse Training
Act and National Research Services Award Program between 1965 and
1981, $70 million went for general institutional support of advanced
nurse training and $206 million for nurse traineeships in master's and
doctoral programs (Appendix 2~. An additional $75.5 million was
granted to institutions to encourage the development of nurse
. .
practitioner programs.
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TABLE 29 Financial Support Received During Doctoral Study by Nurses
With Doctorates in 1980
Number of Nurses Reporting
Source of Support Receiving Support (Frequencies~a
No support
Federal government
Training grant
Loan
Research grant
University
Fellowship
Teaching assistantship
Research assistantship
State government
support or loans
442
983
118
90
185
174
132
101
a Not an unduplicated count of recipients, because a nurse may have
reported more than one source of support.
SOURCE: From ANA. Nurses with doctorates, Table 28, p. 76 (see
Reference 9 for complete citation).
Advanced nurse training grants and contracts are made to
collegiate schools of nursing to plan, significantly expand, or
maintain programs to prepare nurses at the graduate level--whether as
administrators, teachers, or clinical specialists. Special emphasis
is now given to three clinical specialties: geriatrics, community
health nursing, and maternal and child health. Between 1979 and 1981,
about 80 percent of the areas of concentration in these programs were
in clinical specialties and about 10 percent each in education and
administration.
Approximately 16 percent of master's level students are enrolled
in programs now supported in part at least by the NTA's advanced nurse
training program; 73 of the 141 schools currently offering master's
and/or doctoral degree education have received program support.
About 90 percent of the programs were at the master's level and 10
percent at the doctoral level. In 1981, about 2,500 FTE students were
enrolled in the programs assisted, of which approximately 1,500
students were full time.
Funding for student traineeships under the NTA began in fiscal year
1965 with $8 million, increasing to approximately $13 million in 1974.
It remained at that level until 1982, when the amount dropped to $9.6
million. The NTA traineeships provide grants to graduate schools of
nursing and to schools of public health, which in turn provide
traineeships for up to 36 months for students working full time toward
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a master's or doctoral degree. Nurses are prepared to serve as
teachers, administrators, and supervisors; as nurse practitioners; and
in other professional specialties determined by the DHHS Secretary to
require advanced training. These are the same specialties that have
been supported by the NTA's advanced training program.
The DHHS Division of Nursing estimates that during the 1979-1980
academic year 3,000 full-time students received assistance through
advanced nurse traineeships.40 In 1981, awards made to 126 schools
supported about 2,000 trainees at approximately $6,400 each. Without
these funds, in all likelihood the numbers of full-time students would
have been reduced, thus slowing the increase in the number of these
nurses coming into practice.
In addition to the advanced nurse training grants and the nurse
traineeship program, unknown proportions of the funds allocated under
the NTA to programs for nurse practitioners and special project
grants, as well as student loans, supported nursing students enrolled
In grac uate programs.
The National Institute of Mental Health has been another
substantial contributor to advanced nursing education, awarding more
than $105 million for teaching costs and stipends in the period
1970-1981. The vast majority of the more than 13,000 stipends awarded
went to students earning master's degrees; a few were granted to
undergraduate and doctoral students.41 The Veterans Administration
and the Department of Defense also provide advanced nurse training
stipends.
In summary, during the past 18 years the total amount of federal
aid for graduate education from various sources has been substantial,
probably more than $460 million--and the impact significant. During
the period 1971 and 1981, graduations from master's programs increased
40 percent and more than doubled in doctoral programs. This increased
the proportion of KNs holding master's and doctoral degrees from 4 to
more than 5 percent in the total population of RNs. Although it
cannot be argued that all who used these funds would not have
completed advanced education in their absence, certainly the growth in
the supply of these nurses would have been diminished, because the
funding went to build up program capacity as well as to support
students.
The committee believes that in the years ahead, the quality of
nursing services will depend directly on the extent to which growth is
sustained in the supply of nurses with higher degrees. Current
authorization and appropriations are insufficient to support such
growth. These graduate programs should be viewed as potentially cost
effective in promoting major positive impacts on the quality and
effectiveness of nursing services. Hence, they should be regarded as
strong elements in the total strategy of conservation of federal
outlays for health care.
Federal appropriations under NTA and related authorizations for
graduate education and other advanced nurse training were maintained
at about $40 million between 1978 and 1981, decreasing to about $34
million in 1982. Although we recognize the nation's current severe
federal and state budgetary straits, the committee is concerned that
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failure to maintain an adequate floor of support for master's and
doctoral education of nurses will cause long-term damage to the
quality of the nation 7 S nurse supply. Restoration of federal support
at least to the average 1980-1982 level of approximately $40 million
would help ensure that the foundation for further growth of
professional nursing will continue to be maintained.
As the capacity of the education system to graduate greater numbers
of postgraduate nurses expands and as costs of education increase, the
need for a higher level of federal support may follow. A number of
factors will require careful consideration: the capacity of the health
care and educational systems to use effectively the different types of
graduates; the levels of state support and of continuing federal
support needed to attract sufficient numbers of students into
postgraduate programs; and also the possibility that salaries of
nurses with advanced preparation may rise to the point that
prospective students will wish to make greater personal investments in
such education.
Conclusion
Unlike the situation with respect to basic supply of generalist
nurses, where we have found the likelihood of a general balance
between supply and demand in 1990, the committee concludes that there
is both a serious current and probable 1990 shortage of nurses
educationally prepared for administration, teaching, research, and
advanced clinical nursing specialties. The extent of the future
shortage cannot be estimated because various perceptions of need,
except possibly as regards faculty positions, may not necessarily
result in effective demand. Nevertheless, there is such an obvious
gap between the present supply and educational capacity of the system
on the one hand and even conservative estimates of future advanced
positions required on the other, that existing program capacity and
sources of student support at the graduate level should be expanded.
In examining the future need for nurses, the committee identified
problems that cannot be resolved merely by increasing the supply of
nurses with basic education, but may be alleviated by increasing the
supply of nurses with advanced education. First, the management of
nursing resources is less than optimal. The complexity of today's
health care settings demands nurse managers who are skilled not only
in nursing but also in the techniques of managing personnel and
budgets. Second, the quality of nurses delivering care at the bedside
and in the community to a great extent depends on the capabilities of
their teachers. They must within a relatively short period impart the
theoretical and clinical knowledge necessary to produce competent
professionals. The claims of nursing education leaders that the
current composition of the faculties of many nursing schools is
inadequate to accomplish this job properly is borne out by the
comments of employers as well as information comparing the preparation
of nursing faculty to that of other disciplines. A closely related
issue is the lack of research to inform nursing practice and to enhance
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nursing education--functions usually performed in health and sciences
by those in the discipline who are academically based (see Chapter
VIII). Third, although well qualified generalist nurses can deliver
care effectively, the growing complexity of services in many health
settings presents problems that also increasingly require the special-
ized knowledge and experience of nurses with advanced education.
In tomes of severe economic constraints, states may be more willing
to finance basic nursing education programs, which are perceived as
directly fulfilling local demand for nurses, than master's programs,
whose graduates can be expected to be more mobile. They have never
provided much financial assistance to nurses in doctoral programs. The
committee believes that RNs with high-quality graduate education are a
scarce national resource and that their education merits federal
support.
The demand for highly qualified nursing administrators, nurse edu-
cators, researchers, and clinical specialists prepared at the graduate
level has been increasing and is expected to continue to increase, but
to meet it only a small portion of nurse faculty are yet prepared at
the doctoral level. To increase the nation's supply of nurses with ad-
vanced degrees, public and private universities with graduate programs
must expand and strengthen their nursing education faculties. In the
face of the current shortage of academically qualified nurse faculty
with expertise in fields relevant to nursing, such as management, the
behavioral and basic sciences, and research methodology, deans of
schools of nursing could draw faculty from appropriate schools and de-
partments 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 arrange-
ments between university departments, such as schools of nursing with
business schools and/or health services administration programs, may be
found desirable. Programmatic support from the federal government can
help to improve graduate level nursing education in these and other
ways.
Lowering financial barriers to full-time enrollment of nurse gradu-
ate students will increase the supply more rapidly. Master's and doc-
toral students who must work to support their education take longer to
complete it. Financial assistance to nurses in master's programs
should be packaged with federal 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 program-
matic and accompanying student support for master's programs would be
available through competitive grants. In practice, master's programs
located in schools or departments of nursing would be in an excellent
competitive position to secure such grants, but arrangements in other
related programs should be possible, such as in health services
administration programs and schools of public health.
Federal doctoral level support should be targeted primarily to
strengthen existing programs in nursing, not to encourage the proli-
feration of new and possibly weak doctoral offerings. Until schools
of nursing have sufficient numbers of qualified faculty to meet the
range of RN doctoral students' scholarly interests and professional
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needs, financial aid programs to RN doctoral students should be
designed so that they 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 should
carry such service obligations. On the other hand, most committee
members believe that fellowships, awarded on the basis of scholarly
excellence and the promise of fundamental contributions to the
knowledge base, should not carry the same kind of obligation.
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 Lo 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.
Statement of Exception to Recommendation
As members of the nursing study committee of the Institute of Medi-
cine, we are most supportive of the general thrust of the committee's
recommendation, but take exception to the phrase in its first sentence:
"...and relevant disciplines." The rationale for not supporting this
aspect of the recommendation is presented in this minority position
statement.
The congressional charge to the nursing study committee was in part
"to determine the need to continue a special program of federal finan-
cial support for nursing education," (emphasis added) not education of
nurses in disciplines other than nursing. Nurses have the same freedom
as do other American citizens to pursue graduate study in their own
discipline or in an alternate one, and each discipline has the academic
prerogative to admit students of its choice regardless of their previ-
ous educational preparation. However, it is our belief that (1) nurses
admitted to graduate degree granting programs other than nursing, and
(2) programs in disciplines external to nursing that admit nurses for
graduate study should not be included under a "specific program of
Federal financial support for nursing education." Federal funds for
strengthening nursing education are already minimal and would be fur-
ther diluted if they were channeled to provide financial support to
programs and students (even though nurses) in disciplines other than
nursing.
Many portions of this report have focused on the urgent need for
nurses with graduate education in nursing (master's and doctoral
levels) to fill faculty and administrative positions in nursing. These
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nurses should be enrolled in graduate nursing programs so as to became
more knowledgeable in their own disciplines and, subsequently, to be
able to assist in the strengthening of nursing through the use of ad-
vanced nursing knowledge in clinical practice and teaching, and the
generation of new knowledge in nursing. This expectation is not dif-
ferent from that in other disciplines where advanced degrees or acade-
mic study are offered, i.e., psychology, sociology, physiology, medi-
cine, theology. Our stated belief does not preclude the opportunity
for nursing and other students to take courses in other disciplines
that have value to one's own, or in unusual situations perhaps to offer
a joint degree program. An example of this at the master's level is
the collaboration of schools of nursing and schools of business manage-
ment in the preparation of top level nursing service administrators.
However, we believe the nursing study committee is lacking in con-
science to support and document in this report the numerous reasons why
nurses should have advanced education in their own discipline and yet
approve a recommendation that endorses nurses to obtain graduate educa-
tion at either the master's or doctoral levels in fields other than
nursing and request federal funds for such. In reality nurses with
master's degrees in non-nursing disciplines will not be prepared, nor
will they meet the required qualifications of most clinical or
educational institutions for leadership positions in nursing, nor will
they be eligible for doctoral study in nursing. Thus, federal support
of nurses to obtain non-nursing graduate degrees will not assist in
meeting the intent of Recommendation 8 of this report or other
recommendat ions related to it.
Until recently, doctoral programs in nursing were limited in
number, and nurses had little option but to pursue doctoral degrees in
disciplines external to but related to nursing despite the additional
time and expense involved to make up course deficiencies. As would be
expected, there were the disadvantages of no nurse role models being
available for mentorship and the focus of one's research being in that
discipline rather then in nursing. In many cases nurses remained in
the discipline (not nursing) in which doctoral preparation was obtained
and were "lost" to nursing. It was because of this result that the
Doctoral Nurse Scientist Program, supported by the federal government,
was discontinued in the mid-70s. Moreover, faculty in schools of
nursing with preparation in disciplines external to nursing are often
not perceived as true colleagues in either these disciplines or in
nursing.
The general value of learning research methodology in either the
social or natural sciences has been recognized by nurses who have ob-
tained doctoral degrees in these disciplines, but in many instances
their study and research efforts have not focused on identification of
a body of sc lent if ic knowledge to provide a basis for the practice of
nursing and the control of that practice. The development of knowledge
and c~mpetencies unique to nursing must be produced by nurses with ad-
vanced education in nursing and whose research is focused on clinical
nursing practice. This preparation falls within the domain of doctoral
education in the discipline of nursing, and graduates of such programs
will (1) provide leadership in clinical practice and research; (2)
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teach in baccalaureate, master's, and doctoral programs in nursing; (3)
administer nursing service and nursing education programs; and (4) pro-
vide role models and mentors for future doctoral students in nursing.
Doctoral preparation in a discipline other than nursing deters the
socialization process and career expectations within one's peer group.
It also fosters an orientation to another field of knowledge and, in-
variably, the dissertation research, which often sets the focus of
future research, is unrelated to a nursing problem. Disciplines exter-
nal to nursing have had a much longer time to establish and add to
their knowledge base, and now nursing urgently needs federal funds,
especially fellowship support, to attract well-qualified nursing
students to continue the strengthening of doctoral nursing programs
and, ultimately, to add to the knowledge base of nursing. Nursing
doctoral students need the flexibility of obtaining fellowship support
to study with nursing faculty of their choice who can serve as mentors
within the students' specialization area. Many of these graduates with
advanced nursing preparation will in turn enter academic nursing to
teach nursing students, while also strengthening the theoretical and
clinical application bases of the discipline of nursing. Of about 1.7
million registered nurses in the United States in 1980, only about
4,000 (0.2 percent) held doctorates. Of these, fewer than 850 degrees
(21 percent) were earned in doctoral programs located in departments
or schools of nursing.
Thus, it is crucial that existing doctoral programs in nursing be
strengthened and expanded, and that scarce federal funds be channeled
to them rather than to doctoral programs of other disciplines. The
number of nurses making application to existing doctoral nursing
programs is significantly more than can be accommodated due to a lack
of faculty prepared at the doctoral level in the specialized areas of
nursing desired by these extremely well-qualified applicants. With
opportunities to serve as either a research or teaching assistant in
doctoral nursing programs these students will have early influence
from their nursing professors to be productive in scholarly activities
in the field of nursing. Such mentorship in nursing would not occur
If students were enrolled in doctoral programs of other disciplines.
In summary, "a specific program of Federal financial support for
nursing education" at the graduate level (master s and doctoral)
should be available only to nursing programs and students admitted to
those programs. Upon graduation these nurses with advanced nursing
preparation will quantitatively and qualitatively influence the genera-
tion of new nursing knowledge and the dissemination of nursing know-
ledge to future generations of nurses. Educated within the disciplines
of nursing, these leaders in nursing will join with colleagues of simi-
lar interests and be productive in bettering the health of society.
Ruby L. Wilson
Dorothy Novello
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REFERENCES AND NOTES
Department of Health and Human Services, Health Resources
Administration. The registered nurse population, an overview.
From national s amp le survey of registered nurses, November 1980
(Report 82-5, revised June 1982~. Hyattsville, Md.: Health
Resources Administration, 1982, Table 10, p. 18.
2. American Society for Nursing Service Administrators. Profile of
the nursing service administrator revisited: A report based on
an analysis of the data from the 1977 survey of nursing service
administrators in hospitals. Chicago, Ill.: American Hospital
Association, 1980, Table 4, p. 7.
3. Murphy, M.I. Master's programs in nursing in the eighties:
Trends and issues--Relationship to professional accreditation
(Publication No. 81-2~. Washington, D.C.: American Association
of Colleges of Nursing, 1981, pp. 11-12.
National League for Nursing. NLN nursing data book 1981
(Publication No. 19-1882~. New York: National League for
Nursing, 1982, pp. 60, 79, 86, 98.
National Council of State Boards of Nursing, Inc. Survey on
approval requirements for programs preparing students for the
registered nurse licensure examination. Unpublished, 1982.
6. National Science Foundation. Young and senior science and
engineering faculty, 1980 (Special Report No. NSF-81-319.
Washington, D.C.: National Science Foundation, 1981.
7. Murphy, M.I. Enrollment, graduations and related data:
Baccalaureate and graduate programs in nursing (Data Bank Series
82 No. 3~. Washington, D.C.: American Association of Colleges
of Nursing, 1982, p. 20.
8. McElmurry, B.J., Krueger, JeCe ~ and Parsons, L.C. Resources for
graduate education: A report of a survey of 40 states in the
midwest, west and southern regions. Nursing Research, 1982,
_ (1), 6.
9. American Nurses' Association.
City, Mo.: American Nurses' Association, 1981, p. 45.
10. National Institutes of Health. NIH data book 1982. Washington,
D.C. : U.S. Government Printing Office, 1982, Table 13, p. 22.
11. McElmurry, et al . Op . c it ., p . 6 .
12. American Nurses' Association. Nurses with doctorates. Op. cit.,
p. 44.
13. National League f or Nurs ing ~ Doc toral programs in nurs ing
1982-8 3 (Pub 1 ic at ion No ~ 15- 1448) . New York: National League
for Nursing, 1982.
14. Committee on a Study of National Needs for Biomedical and
Behavioral Research Personnel. Personnel needs and training for
biomedical and behavioral research. Washington, D.C.: National
Academy Press, 1980, pp. 131-138.
DHHS, HRA. The registered nurse population, an overview. From
national sample survey of registered nurses, November 1980. Op.
cit., Table 7, p. 15.
Nurses with doctorates. Kansas
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155
16. Ibid., Table 10, p. 18.
17. Ibid.
18. Sultz, H.A., Zielezny, M., Gentry, J.M., and Kinyon, L.
Longitudinal study of nurse practitioners, Phase III (DHEW
Publication No. HRA-80-2~. Washington, D.C.: U.S. Government
Printing Office, 1980, Table 22, pp. 56-57.
19. National League for Nursing. NLN nursing data book 1981. 2~.
cit., Table 84, p. 89.
20. DHHS, HRA. The registered nurse population, an overview. From
national sample survey of registered nurses, November 1980. 0~.
cit., Table 11, p. 19.
Sultz, H.A., et al. 0~. cit., p. 10.
22. DHHS, HRA. The registered nurse population, an overview. From
national sample survey of registered nurses, November 1980. Op.
cit., Table 3, p. 11.
23. Ibid.
24. National League for Nursing. NLN nursing data book 1982. In
press, 1982, Table 78.
25. Murphy, M. I. Enrollment, graduations and related data:
Baccalaureate and graduate programs in nursing. Op. cit., p.
26. National League for Nursing. NLN nursing data book 1981. Op.
cit., Table 87, p. 91.
27. Ibid., Table 79, p. 86.
28. DHHS, HRA. The registered nurse population, an overview. From
5~gG:~,~ ~2 ~e~ egistered nurses November 1980. Op.
cit., Table 3, p. 11.
29. American Nurses' Association.
Table 31, p. 79.
30. Ibid., p. 13.
31. National League for Nursing. NLN nursing data book 1982. Op.
cit., Table 73.
32. American Nurses' Association. Nurses with doctorates. Op. cit.,
p. 14.
33. DHHS, HRA. The registered nurse population, an overview. From
national sample survey of registered nurses, November 1980. Op.
cat., Table 3, p. 11.
34. National League for Nursing. NLN nursing data book 1981. Em.
cit., Table 86, p. 90.
35. DHHS, HRA. The registered nurse population, an overview. From
national sample survey of registered nurses, November 1980. Op.
cit., Table 3, p. 11.
36. National League for Nursing. NLN nursing data book 1981. 2~.
cit., Table 73, p. 79.
37. Ibid.
38. National League for Nursing. Master's education in nursing:
Route to opportunities in contemporary nursing 1982-83
(Publication No. 15-1432~. New York: National League for
Nursing, 1982.
39. DHHS, HRA. The registered nurse population, an overview. From
national sample survey of registered nurses November 1980.
~ ~ W~
5.
Nurses with doctorates. En. cit.,
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156
40. Elliott, J.E. Address to Workshop on Advanced Nursing Education,
Institute of Med ic ine Study of Nursing and Nursing Educ at ion,
March 1982.
41. Chamberlain, J. Nat tonal Institute of Mental Health. Personal
corr~nunication, February 17, 1982.
42. Secretary of Health and Human Services. Third report to the
Congress, February 17, 1982: Nurse Training Act of 1975 .
Hyattsville, Md.:
Health Resources Administration, 1982.
Representative terms from entire chapter:
doctoral degrees
