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IiPPE N DrX Congressional Charge Excerpts From Public Law 96-76 Sec. 113.(a)~1) The Secretary of Health, Education, and Welfare (hereinafter in this section referred to as the "Secretary") shall arrange, in accordance with subsection (b), for the conduct of a study- (A) to determine the need to continue a specific program of Federal financial support for nursing education, (B) to determine the reasons nurses do not practice in medically underserved areas and to develop recommendations for actions which could be taken to encourage nurses to practice in such areas, and (C) to determine the rate at which and the reasons for which nurses leave the nursing profession and to develop recommendations for actions which could be taken to encourage nurses to remain or re-enter the nursing profession, including actions involving practice settings conducive to the retention of nurses. (2)The part of the study described in paragraph (1~(A), shall include considerations of the following: (A) The need for nurses under the present health care delivery system and under such system as it may be modified by increased use of ambulatory care facilities or as it may be changed by the enactment of legislation for national health insurance. Determination of such need shall include determination of the need for nurses trained in each type of school of nursing (as defined in section 853~2) of the Public Health Service Act), for nurses with graduate training in the varying nurse practitioner clinical specialties, and for nurse administrators and nurse educators. (~) The cost of nursing education and a comparison of the cost of education at each type of school of nursing (as so defined) and comparison of the cost of each of the graduate programs of nursing. (C) The availability of other sources of support for nursing education, including support under general programs of Federal financial support for postsecondary education, under State and other public programs, and from private sources. 228
229 (b)(l) The Secretary shall first request the National Academy of Sciences (hereinafter in this section referred to as the "Academy"), acting through the Institute of Medicine, to conduct the study, required by subsection (a), under an arrangement whereby the actual expenses incurred by the Academy directly related to the conduct of such study will be paid by the Secretary. If the Academy agrees to such request, the Secretary shall enter into such an agreement with the Academy. (2) If the Academy declines the Secretary's request to conduct such study under such an arrangement, then the Secretary, after consulting with the Committee on Labor and Human Resources of the Senate and the Committee on Interstate and Foreign Commerce of the House of Representatives, shall enter into a similar arrangement with another appropriate public or nonprofit private entity to conduct such study. (3) Any arrangement entered into under paragraph (1) or (2) of this subsection for the conduct of a study shall require that such study be completed and reports thereon be submitted within such period as the Secretary may require to meet the requirements of subsection (c). (4) The Secretary shall undertake such preliminary activities as may be necessary to enable the Secretary to enter into an arrangement for the conduct of the study at the earliest possible date. (c) Not later than six months after the date the arrangement for the conduct of the study is entered into under subsection (b), the Secretary and the entity conducting the study shall each report to the Committee on Human Resources of the Senate and the Committee on Interstate and Foreign Commerce of the House of Representatives their respective preliminary recommendations respecting the matters described in subparagraphs (A), (B), and (C) of subsection (a)(l) and, if a need for continued Federal financial support for nursing is found, the form in which the support should be provided. Not later than two years after such date, the Secretary and the entity which conducted the study shall each report to such Committees recommendations respecting such matters (including the form of Federal financial support for nursing) and the basis for such recommendations. as
liPPE N DrX 2 Appropriations Under the Nurse liaising Act Appropriations under the Nurse Training Act (NTA) of 1964 and subsequent amendments are listed in Table 1. The listing provides information through Fiscal Year (FY) 1982. The latest amendments, which were part of the Omnibus Budget Reconciliation Act of 1981, extended nurse training provisions of the Public Health Service Act through FY 1984. The NTA and subsequent amendments authorized funds for a number of programs of institutional support and student support. In addition, support for research activities has been provided under other provisions of the Public Health Service Act. The data in this appendix were secured from various sources in the Department of Health and Human Services (DHHS) and Health Resources and Services Administration (HKSA). Formula and Capitation Grants Capitation grants provided support to basic nursing education programs from FY 1972 through FY 1981. About 1,000 schools received assistance annually. In 1980, 1,075 schools participated, including 386 baccalaureate programs, 554 associate degree (AD) programs, and 135 diploma programs. About 190,000 students were enrolled in these schools. The amount of capitation support varied among schools according to the type of program and number of full-time students. In 1980, the average level of support per student counted for capitation purposes was 3221 for students in baccalaureate programs, $152 for students in AD programs, and $138 for students in diploma programs. Participating schools were required to increase enrollment of first-year students or to strengthen program activities in at least two specified programs. The program options were (1) training of nurse practitioners, (2) encouraging enrollment and retention of students from disadvantaged backgrounds, (3) providing clinical training at sites geographically remote from the school, and (4) extending continuing education opportunities. 230
231 of 1 En C) em 00 So o So C) _1 C~ S~ E~ cn z S~ o U) o o S~ P~ 'm ¢ ~ O O S~ ~ O O tn ~rl ~ O ~rl e~ <; a~ E~ _' o S 0 Pt o JJ u31 o ce C U' C ~a tn - S U) L Ct o' o S ~rl ~ s cn °e a) , - =, Ct · - s~ s ~1 cn c ca o . - a eq C) o ~ ~. - Z ~ ~ o ~ oo. - C) 5 ¢ Z S~ U] ~ ~ O O ~ C.) JJ o~ O ·- O O U~ P~ ,/ O ~.- o ~ ~ ca - ct o E~ o o ~ ~ ~ . · ~ c~ ~ ~ ~ - - ~ O C~ C~ ~ ~ ~ ~ ~ ~O O O O O ~ · . . · . · . · . · ·· · · . . . ~ C~ C~ C~4 C~ ~ C~ ~ ~ C~ _~ ~ U~ ~ U~ ~ c ~l u) z o u~ o u~ c~ o ~ ~ ~ o o ~ o o o · · · . · · · . · . · . . . O u~ _ cr~ ~ ~ ~ o~ - - c~ ~ - O O O O u~ ~ u~ ~ u~ O O O O O O O O sD · · · · · · · · . · . · . · . · . ~ ~ ~ o o o o o ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ - - ~ ~ - ~ - ~ - - - O O d" ~ U~ U~ O · · · · · · · · · ~ . · · · . . . ~ oo ~ ~ a~ ~ ~ _ ~ ~ ~ ~ ~ ~ ~ ~ ;t ,_ ~ - - ~ cN c~ ~ c~ ~ c~ cN - - - o o o o o o ~ ···.·.·- ~ ~ ~ ~ ~ ~ -u~ - .- o o o o o o ~ ···.·.·~ c~l =\ ~ ~ c~ ~ -o ~ _ _ _ _r_ o o o o o ~ ~ o o o o u~ · · · · · · · · · · · - ~ ~ ~ ~ oo ~ ~ ~ o o - ~ ~ ~ ~ - c~ ~ ~ o o o o o ~ ~ o o o o o o o o o o ~q . · . · . .· ·· · · · · · · · . . ;t - ~ - ~ - - - - - - o ~ o o o · · · · - ~ c~ ~ ~ ~ ~ Lr, ~ ~ o o o o o o · · . · · · . . · ~ ;t ~ ~ o o ~ ~ o ~ ~ ~ ~ ~ ~ ~ ~ c~ - oo ~ r~ 00 u~ ~ ~ ~ C~ ~D ~ ~ O ~ ~ ~ ~ oO ~ · · · · . · · · · · · · · · ~ ~ ax _ U~ ~ U~ ~ o~ oo O ~ c~ r- ~ ~ ~ ~ 0 0 ;t ~ ~ ~ ~ ~ ~ ~ ~ ~ c~ c~ cN - - - - - - - - - oo o~ 0 _ c~ ~ ;' ~ ~ ~ ~ a~ 0 _ c~ ~D ~ r~ ~ ~ ~ r~ ~ ~ ~ ~ ~ oo oO oO o~ ~ ~ ~ o~ o~ ~ o~ ~ ~ o~ ~ ~ a~ ~ o~ - ~ - - - - - - - - - - - - - - - - o v s~ u) .,1 e .,, cn c ca U) o U' - x ~o C .,, ~C r ~O · O 0 · - ~C) u, a _ ~_ _ C) O . ~C) _ ~ · C cn Ct 0 c :^ a _ ~ ~ · 0 ~ :^ 0- U) U' ~ .,, ~ C 0 _ ~ Ct · ~ 0 _ ~D O - ~. ¢ r=, E ~E~ 0 0 ~Z CO 00 _ C) ~ C Cd | D | U) C) ,1 U, X S - ~a o e . . r~ o CD
232 Special Project Grants and Contracts Special projects to improve the availability and quality of nursing education are assisted under this funding program. There are currently five specified purposes: 1. 2. 3. 4. 5. to increase educational opportunities for individuals from disadvantaged backgrounds; to provide continuing education; to provide retraining opportunities for nurses reentering active practice; to increase the supply or improve the distribution of nurses by geographic area and speciality field; and to upgrade the skills of licensed vocational and practical nurses and other paraprofessional personnel. At least 20 percent of available funds must be used for item 1, 20 percent for item 4, and 10 percent for item 5. Three other purposes were specified for support prior to 1982. They were the following: 6. to assist mergers and other cooperative agreements among hospitals and academic institutions; 7. to develop new or modify existing training programs, develop research in nursing education, and improve curricula; and 8. to assist short-term training fin' Ale ~ A; ~_A ^ -1~ -1 '__ ~ @ In nursing homes. ~^o _~. & ~e ~;7~= c&~;> O.ll ~ULUt:~1 BUS In recent years, about 100 projects received assistance annually In 1981, assistance was awarded to 98 projects at 84 nursing schools and 14 other agencies. About 40 percent of the projects related to item 7, 30 percent to item 2, 20 percent to item 4, and 10 percent to item 1. Construction Assistance Grants Program--Nursing Funds were appropriated under NTA as extended and amended, to aid the construction and equipping of nursing education facilities over a 12-year period beginning in 1966. Altogether, assistance was provided to 301 programs, of which 52 were diploma programs, 90 AD programs, 105 baccalaureate programs, 43 graduate degree programs, and 11 continuing education programs. About 70 percent of the projects were for the expansion or renovation of existing schools and 30 percent for the construction of new schools. Schools expanding facilities were required to expand first-year enrollment by at least 5 percent or 5 students, whichever was greater. Local funds financed at least 25 percent of the construction costs. Over 50,000 student places benefited from this activity, of which over 12,000 were increased f irst-year student places. Of the total,
233 about 16 percent were in diploma programs, 23 in AD programs, 54 percent in baccalaureate programs, and 7 percent in graduate degree programs. Advanced Nurse Training Grants and Contracts Assistance is made available to collegiate schools of nursing to (1) plan, develop, and operate, (2) significantly expand, or (3) maintain programs to prepare nurses at the graduate level. Educational programs offering master's and doctoral degrees are supported to help develop clinical nurse specialists, teachers, administrators, and supervisors. Special emphasis is now given to three clinical specialties: maternal and child health, geriatrics, and community health nursing. In recent years, about 90 projects have been supported annually. Between 1979 and 1981, about 80 percent of the areas of concentration in these programs were focused on clinical specialties and about 10 percent each on education and administration. Among the clinical areas, maternal and child health and medical/surgical care were the most frequent, followed by geriatric and community health nursing. About 90 percent of the programs were at the master's level and 10 percent at the doctoral level. In academic year 1981, about 2,500 full-time equivalent students were enrolled in assisted programs, of which approximately 1,500 were full tome. During that period, there were about 700 graduations, approximately 14 percent of the estimated national total. Nurse Practitioner Grants and Contracts Support is provided to (1) plan, develop and, operate, (2) significantly expand, or (3) maintain programs to train nurse practitioners. Emphasis is given to training to improve care to geriatric and nursing home patients and to strengthen primary health care in homes, ambulatory care facilities, long-term care facilities, and other settings. In recent years, about 70 projects have been funded annually. In 1981, 75 projects were assisted, involving 103 training programs; 33 focused on family care, 21 on pediatrics, 15 on adult care, 14 on geriatrics, and 11 on midwifery. About 1,900 students were enrolled in these projects, of which 41 awaided master's degrees and 34 awarded certificates. About 80 percent of the projects were at nursing schools, 8 percent at medical schools, 6 percent at hospitals, and 5 percent at other participating institutions. Traineeships have also been provided to selected nurse practitioner students who agree to serve after graduation in designated primary medical care shortage areas. Eligibility was limited to students from health manpower shortage areas through 1981; thereafter, the legislation, although not limited to residents of these areas, provided that special consideration be given to them.
234 Payback commitments equal the months of educational support. Traineeships were made through participating schools; 36 schools received support initially in 1978, and same of them have received subsequent continuation awards. A total of 361 eligible trainees were appointed between FY 1978 and FY 1981. Student Loans Low-interest loans up to $2,500 a year--to a total of $10,000--are made to assist students in basic registered nursing education programs (including diploma, AD, and baccalaureate programs) and in graduate programs. Students may be on a full-time or half-time basis. Funds are awarded to participating schools on a formula based on the relative number of full-time nursing students. The schools make and monitor the loans and must contribute at least 10 percent of the total federal dollars awarded. Participating schools may retain the amounts repaid by students and make new loans from a revolving fund made up of collections. Loans are repayable over 10 years following completion of training; repayment may be deferred during advanced professional education in nursing, study as a nurse anesthetist, or service in the uniformed services or Peace Corps. About 1,150 schools have participated in this program annually. In 1982, about 24,000 students received loans--about 8,200 from newly appropriated funds and 15,600 through the revolving funds. The average loan was approximately $800. Loans incurred under this program prior to September 29, 1979, may be canceled in part for service of more than one year as a nurse in a public or nonprofit hospital, health center, or other health care agency for more than one year. Since 1971, cancellations may be up to 85 percent for 5 years of service; previously, cancellations were up to 50 percent or 100 percent, depending on the location and length of work as a nurse. Through 1979, a portion of about 150,000 loans had been canceled; the number of individual nurses benefiting is not known because many students received multiple loans from these funds. Funds have also been available to repay portions of loans of nurses who serve in designated shortage areas. For those completing years of such service, 60 percent is repaid; for 3 years, 85 percent. Between 1973 and 1982, about 130 nurses had benefited from this loan repayment option. Professional Nurse Traineeships Grants are made to graduate schools of nursing and to schools of public health, which in turn provide traineeships for up to 36 months to students working toward a master's or doctoral degree. Nurses are prepared to serve as teachers, administrators and supervisors, nurse practitioners, and in other professional specialities determined by DUNS to require advanced training. These are the same clinical 1 2
235 specialties that have been supported by the Advanced Nurse Training Program: maternal and child health, geriatric nursing, community health, acute care, adult care, and medical/surgical nursing. Priority in the award of traineeships to nurse practitioner trainees Is given to nurse midwife trainees. In recent years, between 2,000 and 3,000 trainees have received support annually. In 1981, awards made to 126 schools supported about 2,000 trainees at approximately $6,400 each. Scholarships Scholarships up to $2,000 a year were made available to selected students with exceptional financial need in basic and graduate nursing education programs during a 14-year period beginning in 1967. Funds were allocated to participating schools on a formula based on the relative number of full-time nursing students. The schools selected the scholarship recipients. About 1,300 schools participated in this program annually. In 1981, 1,328 schools received funds, including 603 AD programs, 418 baccalaureate programs, 213 diploma programs, and 94 graduate programs. That year, over 8,900 students received benefits, about 4 percent of the total student body. During the program's operation, over 200,000 scholarships were made available. It is estimated that in excess of 67,000 students benefited. The average annual scholarship was about $1,000. Research Fellowships Fellowships are awarded for full-time predoctoral and postdoctoral education in nursing and related behavioral and biological sciences under the authority of the Section 472 of the Public Health Service Act. Support is aimed at preparing nurses to conduct and direct research, collaborate in interdisciplinary research, and strengthen faculties in nursing schools. Support may be provided up to 5 years for predoctoral programs and up to 3 years for postdoctoral programs. Payback agreements require participation in research or teaching activities for periods commensurate with the educational support received. In recent years, an average of about 115 predoctoral and 3 postdoctoral fellowships have been supported each year. In 1981, 47 new fellowships were awarded, of which 22 were in nursing, 11 in behavioral sciences, 3 in biomedical sciences, and 11 in other fields. Fellowships are sometimes referred to as National Research Service Awards.
236 Research Grants Grants are made to schools of nursing and other public and private institutions to support high-quality research projects, under the authority of Section 301 of the Public Health Service Act. Basic and clinical research related to patient care and clinical therapy, as well as to nursing education, manpower, and administration, is emphasized. In recent years, about 50 awards have been made annually. At the end of lY 1981, 58 projects were ongoing, of which 23 were focused on nursing practice and 11 on fundamental issues on which nursing practice research is based; 13 were institutional projects designed to enhance the research capabilities of schools of nursing with doctoral programs; 6 were concerned with such issues as stress, parenting, and health promotion; and 5 dealt with the delivery of nursing services and professional issues, such as nursing staff turnover. Other Between 1972 and 1975, funds were available for specific other programs. These included aid to nursing schools experiencing financial distress, start-up grants to initiate new nursing programs and funds to encourage recruitment of groups underrepresented in nursing, including minorities. Authority for financial distress grants was reinstated in 1981, but no funds have been appropriated under the new provision.
AiPPE N DrX 3 Summary of ~formabon on State Reports of Nursing Issues Nursing issues have been studied in almost every state of the nation during the past few years. Reports of recent studies have been identified from 45 states. More than 75 such studies were completed between 1977 and 1982. As indicated in Table 1, many agencies--both public and private-- have sponsored and published studies of nursing issues in recent years. In many states, more than one agency undertook such reviews. In same cases, the multiple state studies were complementary, focusing on different aspects of the subject; in others, they present different perspectives and conclusions. A majority of the recent state nursing studies have been sponsored by public agencies. Altogether about two-thirds were by official bodies. State higher education agencies were the most frequent sponsors. Other public agencies that were active along these lines in many states were nursing or other schools at a state university, state health planning agencies, and governors' commissions and legislative committees. In other cases, health departments, education departments, and nursing boards took the lead. Private agencies assumed responsibilities for reviews of nursing issues in about one-third of the states. State hospital associations often conducted studies of nursing problems being experienced by their member hospitals. State nurses' associations carried out such studies directly in many states and participated actively in others. There has been broad participation in many of these efforts. Committees composed of representatives of the many parties concerned with nursing matters were reported to have been involved in about one-half of the studies. In some cases, they were responsible for directing the work, and in others they had advisory roles. In many cases, public hearings provided opportunities for other concerned parties to participate. In about one-half of the states, the studies involved detailed analyses. In the past 2 years, for example, reports of extensive studies were issued in Alaska, Arizona, Arkansas, Georgia, Indiana, Maryland, Michigan, Ohio, South Carolina, and Wyoming. About 40 of the studies addressed educational issues and a similar number focused on employment aspects. Approximately 25 studies presented projections of future requirements and resources and about 237
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240 20 studies included information on current shortages of nursing personnnel. Many reports covered various aspects of the subject. As would be expected, studies conducted by higher education agencies, state universities, and education departments tended to focus on educational issues. Those undertaken by hospital associations tended to concentrate on employment topics. Those initiated by governors' commissions, legislative committees, planning agencies, and nursing associations often addressed a broad range of subjects. In reviews of educational issues, the most common topics that were considered in these reports were extension of continuing education programs, extension of programs to help nurses to advance from one educational level to the next, and expansion of graduate programs. Other matters receiving considerable attention were the relation of education to practice, preparation of faculty, increases in enrollment, coordination of educational programs, strengthening of clinical experiences, and development of off-campus courses. Reviews of employment issues often focused on the nature of working conditions, salary levels and ranges, and opportunities for career advancement. Other subjects along this line that were frequently discussed were the effect of vacancies, the impact of new technology, changes in nursing roles and responsibilities, problem of geographical distribution, and difficulties in staffing particular shifts. Reports of future nursing requirements and resources are commonly based on local efforts to apply the forecasting methodology developed by the Western Interstate Commission for Higher Education (WICHE). The essential characteristic of this forecasting approach is the use of panels of experts to Estimate, by means of professional judgments and criteria, the numbers and types of staffing and the nursing service utilization ratios that are believed to be necessary to meet desirable health care goals. In some cases, other approaches were taken. In a few reports, the results of projections based on different methods are compared. The "target" year varied considerably among the studies, ranging from 1982 to 1995. In most reports, the projections indicated desired changes in the mix of nurses that would result in estimated shortages of registered nurses (RNs), particularly those with baccalaureate degrees and surpluses of licensed practical nurses (LPNs). Studies of current shortages of nursing personnel were usually made by state hospital associations among their member institutions. While hospitals were the usual respondents, long-term institutions were sometimes included also. Estimated shortages of RNs during 1980 tended to be in the range of 10-15 percent overall; especially serious problems were often reported in filling positions for intensive care units, on certain shifts (e.g., night and weekends), in rural areas, and in inner cities. More recent reports indicate less pressure in some situations but continuing problems in other areas. The state studies suggest that two types of nursing shortages are of major concern. On the one hand, many are concerned about the availability of nurses to assume full-time positions in hospitals and
241 sometimes in nursing homes. On the other hand, others are concerned about the supply of nurses with what is considered adequate preparation, usually at or above the baccalaureate level, to handle increased responsibilities. Many reports also identified other issues of importance. Common among them were the numbers and responsibilities of LPNs, inadequacies of available data, and needs for additional research. Other topics that were often discussed were the roles and responsibilities of nurse practitioners, the number of minority nurses, the effect of migration, and the impact of changes in health care financing. The state studies tend to concentrate on local and state actions to address identified problems. They often focus on needs and opportunities to make more effective uses of already available resources and to recognize the increasing restraints on new public spending. Some reports, however, recommend expansion of state funds for scholarships and institutional support. Only about one-quarter of these studies included references to federal grant programs for nursing, and almost all of these statements are descriptive in nature. Actions to implement the recommendations of these studies have been initiated in many states. Commonly, those such activities have been slowed or delayed by the economic and fiscal difficulties being experienced in many parts of the country. In some states, detailed implementation schedules have been formulated assigning specific responsibilities to designated agencies and groups. In many states these reports have resulted in efforts to establish continuing mechanisms to oversee the development of nursing resources and issues. These arrangements have included representatives of the many public and private agencies with interests in these topics, including personnel from educational institutions, employers, and professional associations. They have been aimed at making more effective use of available resources as well as facilitating implementation and monitoring changes. For the convenience of the reader the sources of major state reports of nursing issues are presented in Table 2. -
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AiPPE~nDrX 4 Certificates for Specialist Registered Nurses This study has identified 13 certifying organizations reporting special certification for 69,140 registered nurses (RNs), of whom 13,593 are nurse practitioners and nurse midwives. The following tables list these organizations together with relevant information. Table 1 lists all identified nurse certifying organizations. Tables 2 and 3 contain information on two organizations that certify RNs in specialty areas. In all tables, certification for nurse practitioners/ nurse midwives is underlined. The information was obtained from members of the National Federation for Specialty Nursing Organizations and American Nurses' Association publications in November 1982. TABLE 1 Al 1 Ident if fed Nurse Cert if ying Organizations Year Began Certifying Organizat ion Total Number Certified Eligibility Requirements for Certification American Nurses' Association (ANA) American Associa- tion of Critical Care Nurses (AACN) American Associa- tion of Nurse Anesthetists (AANA) American College 1971 of Nurse Midwives (ACNM) 1974 1976 10,269a 12,101 1946 ~19,000 (detail in Table 2) -RN licensure -1 year of critical care experience within past 3 years -RN licensure -graduation from approved program in nurse anesthesia 2,598 -RN licensure -graduation from approved program in nurse midwifery 253
254 TABLE 1 (continued) Total Year Began Number E1 igibility Requirements Organization Certifying Certified for Certification Association of 1979 3,770 -RN licensure Operating Room -2400 hours of practical Nurses (AORN) experience in operating room within the last 2 years -must be recertified every 5 years Emergency Depart- 1980 6,000 -RN licensure ment Nurses -2 years of emergency room Association experience is recommended Nurses Associa- 1975 3,968 (detail in Table 3) Lion of the American College of Obstetrics and Gynecology (NAAOOG) American Board of 1977 1,120 -RN kc ensure Neurosurgical -2 years of experience Nurses preferably in the field American Associa- 1972b 2,406 -RN licensure Lion of Occupa- -5 years of experience . .. . tional Health in occupational health Nurses (AADHN) nursing -60 contact hours of con tinuing education within last 5 years -currently employed full time in occupational health nursing American Board of 1972 ~500; -RN or LPN or physician's Urologic Allied "a few" -assistant kc ensure Health Profes- LPNs employed in urology for signals at least 1 year prior to examination
255 TABLE 1 (continued) Organization Year Began Certifying Total Number Certified Eligibility Requirements for Certification International Association for accredited Enterostomal Therapy Board of Nephrology field Examiners National Board of 1977 . Pediatric Nurse Practitioners and Associates 1979 608 1977 ~ 4,000 2,800 -RN licensure -graduate of a 6 to 8-week enterostomal therapy course -practice as an RN for at least 2 years prior to attending enterostomal course -RN licensure -currently employed in -1 year of clinical experience in field -RN licensure -graduation from a formal pediatric nurse practitioner program ADoes not include those jointly certified with NAACOG, but does include nurse practitioners. bThe AAOHN began certifying occupational health nurses in 1972. Fran 1972 until 1974, those nurses desiring certification were "grandfathered" in. The first occupational health nursing certifying exam was given in 1974.
256 TABLE 2 American Nurses i Association Specialty Certif ication Title of S pee ia lLy Area Total Number Certified Eligibility Requirements for Certification - Adu tt c linic al 731 specialist (psychiatric and mental health nursing) Child and adolescent specialist ~ psychiatric and mental health nursing) 66 P sychiatr ic 633 and mental health nurs ing Medical-surgical 437 nurs 1ng Medical-surg ice 1 154 clinical spec tall sts MAN in psychiatric and mental health nursing -currently employed in direct patient care at least 4 hours each week -post-MSN practice in field at least 8 hours per week for 2- years or 4 hours per week for 4 years -experience in at least 2 different treatment modalities -100 hours post-MSN supervision -access to clinical supervision or consulation -as above -currently practicing in field giving direct patient care at least 4 hours per week -have practiced 24 of the last 48 months in the field -have access to supervision or consultation -currently practicing in field giving direct patient care at least 16 hours per week -have practiced 24 of last 36 months in field an average of at least 16 hours per week -MSN -currently practicing in field giving direct patient care an average of at least 4 hours per week -have practiced 12 of last 24 months as clinical specialist (post MSN) giving direct patient care an average of at least 16 hours per week
257 TABLE 2 (continued) - Title of Total Nwmber Specialty Area Certified Eligibility Requirements for Certification Child and adolescent nursing 95 Gerontology 492 nursing Nurse administration 1,119 Nurse admini- 413 Stratton advanced Community health 218 nursing High-risk perinatal nursing -1,500 hours of direct patient care in maternal and child health -provided at least 200 hours of direct nursing care to children and adolescents 2 of last 3 years -30 contact hours of continuing education in field within last 3 years -2 years of practice as a gerontological nurse -currently in middle management or executive nursing administrative position -have been in middle or executive level nursing administrative position at least 24 months within last 5 years -documentation of administrative responsibilities -master's degree -currently in executive level nursing administration or providing consultation in same -have worked in executive level nursing position or provided such consultation at least 36 months within last 5 years -documentation of administrative responsibilities -have practiced 2 of last 5 years as a community health nurse -1,500 hours of direct patient care in maternal and child health nursing practice -have provided at least 300 hours of direct nursing care in field for 2 of last 3 years (time spent in formal program for advanced study may count for 1 year) -have 30 contact hours of continuing field within last 3 years education in
258 TABLE 2 (continued) Title of Specialty Area Total Number Certified Eligibility Requirements for Certification Maternal and Child Health (MCH) nursing Pediatric nurse 450 practitioner School nurse 272 practitioner oa Adult nurse 2,468 practitioner Family nurse 2,630 practitioner -2,100 hours of direct patient care in MCH nursing -30 contact hours of continuing education in field within last 3 years -completed program of study that meets criteria identified by ANA and American Academy of Pediatrics "Guidelines on Short-Term Continuing Education Programs for Pediatric Nurse Associates" or "Guidelines for Nurse Practitioner Training Programs" -completed formal education program affiliated with an institution of higher learning of at least 9 months or 1 academic year of full-time study including didactic and clinical components as outlined in the "Certification Guidelines for Educational Preparation of School Nurse Practitioners" -completed formal educational program affiliated with institution of higher learning of at least 9 months or 1 academic year of full-time study including didactic and clinical components as outlined in the "Certification Guidelines for Educational Preparation of Adult Nurse Practitioners" -completed formal educational program affiliated with an institution of higher learning of at least 9 months or 1 academic year of full-time study including didactic and clinical components as outlined in "Certification Guidelines for Educational Preparation of Family Nurse Practitioners"
259 TABLE 2 ~ cant inued ~ - Title of Total Number Eligibility Requirements Specialt Area Certif fed for Certif ication Y Gerontolog ical 91 nurse practitioner -completed formal program of study that prepares nurses to function as adult, f amity, or gerontolog ical nurse practitioners as out lined in "Guide line s f or Nurse Pract it loner Training Programs" NOTE: Taken from American Nurse s ' As soc fat ion. 198 3 cert if ic at ion catalog. Kansas City, Mo.: American Nurses' Association, 1982. first examination was given in October 1982. available. Re suits not yet
260 TABLE 3 Nurses' Association of the American College of Obstetrics and Gynecology (NAACOG) Specialty Certification Title of Total Number Specialty Area Certified Eligibility Requirements for Certification Inpatient obstetric nurse Neonatal intensive care nurse 865 405 Neonatal nurse Ma clinician/ practitioner OB/GYN nurse 2,284 practitioner Maternal, gynecologic, and neonatal nursing (joint certification with ANA) 414 -2 years of experience in field -employment in field within last 2 years -2 years of experience in field -employment in field within last 2 years . -2 years of experience in field or certification as an NICU nurse -graduation from neonatal nurse clinician/practitioner program that is at least 12 weeks long and ace eptable to NAACOG, or 4 years of RN employment in NICU with at least 2 years as a neonatal nurse practitioner or clinician -completion of formal nurse practitioner progam that has at lest 3 months of OB/GYN content, is at least 12 weeks in length, and is found acceptable to N. M COG no longer offered first examination will be offered in 1983.
GRIPPE N DIX 5 Projections of Registered Nurse Supply and Requirements The projections of the supply and demand for registered nurses (RNs) made by the study committee are based on and developed from earlier work supported by the Department of Health and Human Services (DHHS), Health Resources Administration (BRA). This appendix describes in some detail the methods contributing to both the DHHS projections and those of our study, discusses methods and findings of the study, and makes some comparison of the study conclusions with those made most recently by the DHHS, contained its Third Report to Congress.1 As is indicated in Chapter II, supply and requirement models are based on assumptions about future population dynamics, health service delivery patterns, and nurse utilization trends. Different assumptions about any of these factors will affect resulting RN projections. Because it is difficult to anticipate how these factors may change and interact in the future, some caution must be exercised in using model projections. Current Supply of Registered Nurses The best data available on the current supply of RNs in the United States are those contained in The Registered Nurse Population, an . . . . . Overview. From the National Sample Survey of Registered Nurses, . . . ~ . _ . . .. _ . November, 1980.2 Those figures, in final form, were released by the BRA in July 1982. The report estimated that 1,272,900 RNs were employed in nursing--a sharp and unexpected increase of about 30 percent over the 1977 Sample Survey, which had led to an estimate of a total of 987,200 in that year. Projections of the Supply of Registered Nurses The DHHS and its predecessors over a long period have made or sponsored a number of projections of the supply of RNs. These projections were made on the basis of either the total number of living graduates of nursing schools, or the number of RNs currently licensed, the latter being the basis for the projections contained in 261
262 the recent Third Report to Congress.3~4~5~6 Only the most recent projections of the DHHS are discussed below. DHHS Projections These projections responded to the requirements of Section 951 of P.L. 94-63, which directed that the adequacy of the supply of RN~ for the future be considered according to level of educational preparation, within each state as well as nationally. Projections were made to the year 2000 and were included in the Third Report to Congress.7 The following description of the projection methods is abstracted from that report. Three types of projections were made on a state-by-state basis: · the RN population--those with current licenses to practice · the RN supply--all those practicing nursing · the full-time equivalent (FTE) supply--RNs practicing full time plus one-half of those practicing part time. The projections were divided into three levels of highest educational preparation: associate degree (AD) or diploma, baccalaureate, and master's and doctorate. The projections show the RN population and supply on an annual basis as a function of three characteristics of that population: (1) the 50 states and the District of Columbia, (2) three levels of highest educational preparation, and (3) age groups. The projections were initiated from a data set based on the 1977 National Sample Survey of Registered Nurses amplified by data from the 1972 Inventory of Registered Nurses.8~9 (The Third Report to Congress noted that data from the National Sample Survey of Registered Nurse, November 1980 survey would be used to update the data base, when it became available.) For "current estimates," graduation data were taken from the annual surveys made by the National League for Nursing (NLN).10 Separate models were developed that project the number of graduates from the varying types of programs. Other data inputs included migration factors, mortality rates, licensure phenomena, age distributions, and activity rates. With the exception of the assumptions regarding graduations, only one set of assumptions was used for all projection series. In all series, assumptions were based on the following data and considerations. · Mortality rate To determine the losses through death, age-specific mortality rates based on 1976 life tables for white females were used throughout the projection period. · "Net loss" rates In addition to mortality, changes in the RN - population result from lapsed and reinstated licenses. A factor providing for an "age-specific net loss" in licenses was derived from data obtained from the American Nurses' Association's annual licensure statistics, the 1972 Inventory of Registered Nurses, and the 1977
263 National Sample Survey of Registered Nurses.11,12 The same rate was used throughout the projection period. ~ New licensees The number of new licensees from United States - nursing education programs was determined from 1977 state board examination passage rates. These rates were kept constant throughout the projection period. To account for the new licensees graduated elsewhere than in the United States, a constant total of 3,700 foreign nurses per year was included. This estimate was based on 1976 licensing data. The age distribution of both the United States and foreign new licensees was based primarily on data from 1977 National Sample Survey of Registered Nurses.l3 · Activity rates (employed KNs/all RNs currently licensed) Current activity rates were maintained throughout the projection period on the assumption that the rates have nearly peaked for the younger nurses and that the overall rate was the highest it has been. The rates used are age specific. Assumptions about nursing education graduations for each DHHS series were as follows: ~ Series A was developed as a "middle" level projection. It represents a "baseline," considering recent trends. In Series A, diploma program admissions continue at a rate consistent with the prior data, if it is assumed that some programs will operate throughout the projection period. Associate degree admissions are assumed to be most likely for 17- to 34-year-old females, and future admissions to these programs would decline slightly as a proportion of this population group. Baccalaureate and diploma admissions are assumed to come basically from new thigh school graduates and together, these two groups are examined as a proportion of new high school graduates. This proportion continues the negative trend it has shown in the late 1970s. The graduation rates applied to these admissions data were 73 percent for diploma, 69 percent for AD, and 63 percent for baccalaureate. Post-RN baccalaureates from generic programs are a function of the basic graduates from these programs, with an additional fixed factor for those graduating from nongenetic programs. Master's degree graduates were determined from the maintenance of the linear trend in the number of programs, maintenance of the increases in average enrollments per program, and the stabilization at 50 percent of the proportion of full-time students. Graduations were determined to be 35 percent of enrollments, the proportion noted for the 2 years the full-time enrollment rate was 50 percent. To account for the master's graduates from non-NLN-counted nursing programs, an additional fixed factor was applied to the graduate totals. · Series B is the "higher" series. It is based on the assumption that current concerns about RN shortages would lead to reversals in the present admissions trends to basic programs, to increased higher level educational opportunities, and to an increased number of students. Specifically, assumptions made define diploma program trends as the same as those in Series A, but reverse AD program trends
264 in that series. Thus, in Series B. the decreasing trend in the proportion of 17- to 34-year-old females entering AD programs would reverse so that, about 1985-1986, it would become the proportion it was in the mid-1970s and remain at that level through the rest of the projection period. Also, the trend of the combined baccalaureate and diploma admissions would reverse and by 1985-1986 become the proportion it was In the early 1970s and remain at that leve the projection period. The proportion graduating from Norm wait 1 d her ~m" fi ~ 1 through baccalaureate programs would become 65 percent, the estimate for the latest data, while the rates for the other programs would remain the same as those in Series A. In addition to these higher levels of basic nursing graduates, it was assumed that the number of master's degree programs would increase to 328 by the end of the projection period. It was further assumed that the trend toward part-time enrollment would - reverse so that by the end of the projection period, 75 percent of the enrollees would be full time. The increase in the availability of "nursing" master's programs would offset, to same extent, the number of students attending "non-nursing" programs. o Series C is based on the premise that present concerns about the baccalaureate degree as the entrance level into practice would lead to a sharp decline in the proportion of 17- to 34-year-old females entering AD programs and a sharp increase in the number of baccalaureate programs available. Admissions to diploma programs were determined as in Series A, and the master's degree assumptions as in Series B. · Series D is the most constrained set of projections, combining diploma and baccalaureate projections from Series A and the AD projection from Series C. In essence, it assumes that current discussions about the entrance level into practice will lead to a sharp decline in admissions to AD programs, but with no offsetting increase in baccalaureate admissions. Series D also maintains the type of trends noted in the master's degree programs in Series A. In all of the above series, it is projected that the number of graduations by the year 2000 will be lower than the 77,000 being graduated currently. Series B. the most "optimistic" of the graduation projections, shows only a moderate decline following an increase in the 1980s. Series A, which provides for no changes in recent trends, shows a continual decrease until total graduations reach the 1971-1972 level of 51,300. Series D projects even further decreases in the overall number of graduates to levels prevalent in the latter half of the 1960s (Table 1~. Graduates of the academic year 1989-1990 are shown in Table 1. The national active supply as of January 1, 1991, which includes the 1990 graduates, under the four DHHS series is shown in Table 2.
265 TABLE 1 Four DHHS Projections of the Number of Graduates of Basic Programs Preparing Registered Nurses, 1990 Graduates 1990 Graduates--DHHS Projection Series A B C D Associate degree 34,200 41,500 24,400 24,400 Diploma 7,100 7,100 7,100 7,100 Baccalaureate 20,800 30,000 31,800 20,800 TOTAL 62,100 78,600 63,300 52,300 - SOURCE: Secretary, DHHS. Third report to the Congress, February 17, 1982, Table 22, p. 153 (see Reference 1 for complete citation). TABLE 2 Four DHHS Projections of the Supply of Employed and Full-Time Equivalent Registered Nurses, January 1, 1991 MA Registered Nurses Projection Series Active _ Full-Time Equivalents A B (high) C D (low) 1,493,700 1,580,400 1,458,400 1,445,900 1,264,100 1,340,500 1,260,400 1,223,700 Third resort to the Con~r~.~. F~bruarv 17. SOURCE: Secretary, DHHS. 1982, Tables 24, 25, 26, and 27, pp. 155-158 (see Reference 1 for complete citation). The Study's Projections These projections were developed both to utilize the new data on the supply of RNs, which became available with the National Sample Survey of Registered Nurses, November 1980, and to explore the effect of alternative assumptions as to graduations and activity rates. Because the committee believed it reasonable to view the future in terms of the time elapsing from the present to the end of the year 1990, the estimates take into account the classes graduating in that year. The projections are national only and are made at five levels of highest educational preparation: associate degree, diploma, baccalaureate, master's degree, and doctorate.* *For a more detailed discussion, see West, M.D. The projected supply of registered nurses, 1990: Discussion and methodology (see Reference 30 for complete citation).
266 Three series of projections were made. They used as a population base the number of living graduates of nursing schools in the United States in 1980. This number, by age group, was calculated by applying appropriate mortality rates for white females to the graduates of each class from 1928 to 1980, by program type. To this total was added the number of graduates of foreign schools who have been licensed in the United States. This base population was updated to 1990, using appropriate age-specific death rates based on 1978 life tables for white females. Activity rates for November 1980 were computed by calculating the ratio of the number of employed RNs in each age group, as reported in the National Sample Survey of Registered Nurses, November 1980, to the number of living nurses in that age group.14 Alternative assumptions as to future activity rates were the following: 1. Because labor force participation rates of all women have been rising for many years, as have such rates for RNs, RN activity rates will rise by 3 percent between 1981 and 1990; or 2. Nursing labor force participation rates will remain constant from 1980 to 1990. The Study's Inte'~ediate Projection Prepared for normative purposes, this projection assumed that the states would continue financial support of nursing education and that general federal aid to postsecondary students would continue at levels adequate to maintain present educational opportunities; that nursing would continue to draw new students from a wide age range at rates that represent the average of the years 1978 to 1980; and that graduations as a proportion of admissions would stay constant. Under these assumptions, graduations in 1990 would total 70,000, or 6.5 percent fewer than in 1981. Within this total, graduates of AD progress, after some rise, would return to the 1981 level; while baccalaureate graduates would decline by 6.3 percent and diploma graduates by one-third (see Table 3~. TABLE 3 Number of Graduates of Basic Registered Nurse Programs, 1981 Actual, and Study Intermediate Projections 1990 and 1981-1990, Cumulative Total Program Type 1981 1990 1981-1990 Associate degree 37,183 37,600 Diploma 12,903 8,500 Baccalaureate 24,804 23,900 388,900 111,300 246,500 TOTAL 74,890 70,000 746,700 SOURCE: West, M.D. Projected supply of nurses, 1990: Discussion and methodology, Tables 6, 7, 8, 9 (see Reference 30 for complete citation).
267 Study's Low Projection It was assumed that nursing schools will not continue to prepare students at the rates shown in the intermediate projections, but that there will be a 10-percent drop below the intermediate level. The number of graduates in 1990 would then fall to 63,000, as shown in Table 4. TABLE 4 Number of Graduates of Basic Registered Nurse Programs, Study's Low Projections, 1990 and 1981-1990 _ . . Program Type 1990 1981-1990 Associate Degree 33,400 337,200 Diploma 8,500 111,300 Baccalaureate 21,100 242,300 TOTAL 63,000 730,800 SOURCE: West, M.D. Projected supply of nurses, 1990 : Discussion and ~ ~ - a a ~ methodology, Tables 6, 7, 8, and 9 (see Reference 30 for complete citation). Since the potential graduates of baccalaureate programs who will complete their program in 1986 are already enrolled, it is assumed that the greatest change would be in the shorter AD programs. In this low projection it is also assumed that labor force participation rates will remain at 1980 levels. The Study's High Projection It was assumed that admissions to nursing schools will continue to rise during the 1980s, so that total graduations would reach 76,900 by 1990, 2.7 percent above the 1980 level (see Table 5~. TABLE 5 Number of Graduates of Basic Registered Nurse Programs, Study's High Projections, 1990 and 1981-1990 Program Type 1990 1981-1990 Associate 42,600 406,400 Diploma 8,500 111,300 Baccalaureate 25,800 250,800 TOTAL 76,900 768,500 SOURCE: West, M.D. Projected supply of nurses, 1990: methodology, Tables 6, citation). Discussion and and 9 (see Reference for complete
268 Within this total there would be, compared to 1981, a 4-percent increase in baccalaureate graduates and a 15-percent increase in AD graduates. It is assumed that labor force participation rates will r i se as in the int ermed fat e pro j ec t ion . To project the highest educational level attained by RNs, the following assumptions were used in each of the three pro jection series: · Post-RN baccalaureate degrees There were 8,416 RNs with diplomas or ADs who completed requirements for the baccalaureate in 1981, compared to 2, 200 in 1971. It is assumed that the will continue to grow, reaching 14, 000 graduates per year by degree number 1990. · Master's degrees In 1971, there were 2,100 master's degrees granted in nursing; by 1981, the number had risen to 5, 000. It is assumed that the number will continue to grow, reaching 9,500 in 1990. Smaller numbers of RNs will receive master's degrees in other f ields . · Doctoral degrees The number of doctoral degrees in nursing granted rose from 41 in 1971 to 125 in 1980. It is assumed that the number will reach 400 in 1990. The number receiving doctoral degrees in other f ields is also assumed to increase. Total Projected Supply The total number of active As under each of these three study projections, together with the corresponding f igures for FTE RNs, are shown in Table 6. TABLE 6 Study' s Pro jections of the Supply of Employed Registered Nurses and Full-Time Equivalents, December 31, 1990 Registered Nurses Study Group Proj ec t ion Emp toyed High Intermed i ate Low Ful 1-Time Equivalenta 1, 728, 000 1 ,451 ,000 1,710,000 1,436,000 1, 643, 000 1, 379, 000 lithe number of full-t ime equivalent (FTE) nurses is calculated by adding half of the number of part-time nurses to the actual number of full-time nurses, assuming that the ratio of full-time to part-time workers wi 11 remain as in 1980 . SOURCE: West, M.D. Projected supply of nurses, 1990: Discussion and me thodo 1 ogy ~ see Ref erenc e 30 f or c omp le t e c it at ion) .
269 The effects of the projected changes in number of graduates by highest educational preparation are illustrated in Table 7, which compares the findings of the 1980 RN Sample Survey with the study's intermediate projection for 1990.15 TABLE 7 Estimated Employed Registered Nurses, 1980, and Study's Intermediate Projection, 1990 Highest Employed RNs Educational a b Preparation November 1980 December 1990 Difference Associate 256,200 475,000 +218,800 Diploma 645,500 614,000 - 31,500 Baccalaureate 296,200 491,000 +194,800 Ilasterts 65,200 124,200 ~ 59,000 Doctorate 3,000 5,800 ~ 2,800 Unknown 6,800 - - 6,800 TOTAL 1,272,900 1,710,000 +437,100 a SOURCE: DHHS, ELAo The registered nurse population, an overview. From national sample survey of registered nurses, November, 1980, Table 3, p. 11 (see Reference 2 for complete citation). b SOURCE: West, M.D. Projected supply of nurses, 1990: Discussion and methodology, Table 16 (see Reference 30 for complete citation). Comparison of the DHHS and the Study Supply Projections The projections of the study are considerably higher than those made by the DHHS. The reasons for these differences are found primarily in the differing bases used for the two sets of projections-- that of DHHS being the 1977 National Sample Survey of Registered Nurses and that of this study group being the 1980 RN Sample Survey. The effect of the use of the newer base is to raise the study projections by 109,100 over those of the DHHS. Comparing projections for the two sets for December 1990 to January 1991, the total number of active RNs projected by the study's intermediate projection is 1,710,000 while the DHHS Series A totaled 1,493,700. The major elements of the difference between the totals of the two projections are shown in Table 8. The difference is primarily due not to methodology but to differences in assumptions, particularly the underestimated increase in employment between 1977 and 1980, differences in projected rates of labor force participation, which are assumed to rise in the study group's series, but not in that of the DHHS; and differences in projected numbers of graduates. The differences between the study's intermediate and the DHHS Series B are smaller (1,710,000 and 1,580,000) because the Series B projects higher graduation levels.
270 TABLE 8 Study Group Intermediate Supply Projection and DHHS Supply Projection (Series A) Study's intermediate projection Dec. 1990a DHHS projection (Series A) Jan. l99Lt Difference Elements of Difference . 1977-1980 employment estimate increase Higher labor force participation Higher new graduates, 1981-1990 Other 1,710,000 1,493,700 216,300 109,100 50,200 52,100 4~900 a SOURCE: West, M.D. Projected supply of nurses, 1990: Discussion and methodology (see Reference 30 for complete citation). . _ ~SOURCE: Secretary of Health and Human Services. Third report to the Congress, February 17, 1982, Table 24, p. 155 (see Reference 1 for complete citation). The study's intermediate projections also include a higher proportion of employed RNs with baccalaureate and higher preparation than do those of the DHHS. These differences are also related to the sharp increase in the number with higher levels of preparation that was reported for 1980 as compared to 1977 (see Table 9~. TABLE 9 Number of Employed Registered Nurses by Highest Nursing-Related Educational Preparation, 1977 and 1980 Educational Preparation 1977a 1980b Percent Increase Increase Less than baccalaureate752,600 901,700149,100 19.8 Baccalaureate180,500 296,200115,700 64.1 Master's and above43,300 68,20024,900 57.5 Not reported1,900 6,8004,900 - TOTAL978,200 1,272,900294,700 30.1 a.RnlJRcE. DHHS. HRA. Source book--nursinz Personnel. Table 11, p. 19 (see Reference 31 for complete citation). b SOURCE: DHHS, HRA. The registered nurse population, an overview. From national sample survey of registered nurses, November, 1980, Table 3, p. 11 (see Reference 2 for complete citation).
271 The differences between the DHHS Series A for January 1, 1991, and the study's intermediate projection for December 31, 1990, by highest level of educational preparation, are shown in Table 10. TABLE 10 Supply of Active Registered Nurses by Highest Level of Educational Preparation, Projections of DHHS and Study Group, December 1990 to January 1991 Highest Educational DHHS Preparation Series Al Associate and diploma 999,200 Baccalaureate 380,600 Master's and doctorate 113,800 Study's Intermediate Projectiont 1,089,000 491,000 130,000 TOTAL 1,493,700 1,710,000 aSOURCE: Secretary, DHHS. Third report to the Congress, February 17, 1982, Table 24, p. 155 (see Reference 1 for complete citation). , ~ . ~SOURCE: West, M.D. Projected supply of nurses, 1990: Discussion and methodology, Table 16 (see Reference 30 for complete citation). Registered Nurse Requirement Projections DHHS Projections For many years the DHI~ and its predecessor, the Department of Health, Education, and Welfare, have made studies of projected require- ments for RNs. In looking at future requirements, this agency has supported the development of models that provide tools for the explora- tion of factors that must be taken into account in examining future requirements. The two most useful of these are the "historical trend- based demand model," which provides techniques for examining trends in the provision of nursing service in major work settings, and the "criteria-based" or "judgment-of-need model," which proposes staffing and educational preparation standards--in great detail--for essentially the same work settings. The two techniques can be used to consider both state and national requirements. The Historical Trend-Based Demand Model* This model was first developed in 1974, with several series of projections to 1985. These projections were based on scenarios that *Abstracted in part from the Third report to the Congress, February 17, 1982, pp. 91-102 (see Reference 1 for complete ci
272 included assumptions as to introduction of national health insurance, increased HdO enrollment, and RN role reformulation.16 The assumptions of the model were updated in 1980, taking into account new data from the 1977 National Sample Survey of Registered Nurses.l7 The figures from that update, projected to the year 2000, are discussed in the Third Report to Congress.l8 (Now that figures from the 1980 Sample Survey are available, further updates by the HRSA are expected.) The model includes three major components, or modules: population, demand for services, and nurse manpower requirements. The Population Module This module used projections of the civilian population of the United States (Series II) made by the Bureau of the Census.l9 The population was projected to grow from 214.6 million in 1977 to 220.0 million by 1980 and to 241.4 million by 1990. A separate projection series was developed for the population enrolled in health maintenance organizations (HMOs). The Demand for Services Module This module directly calculated per capita utilization rates for six areas of health services--hospital inpatient units, hospital outpatient units, nursing homes, ambulatory care at HOD "clinics," physicians' offices, and hare health. Per capita patient utilization rates were projected on the basis of 1972-1977 trend data, and the projected population was multiplied by the appropriate projected per capita utilization rate to obtain the total service demands for each of the six settings. The Nurse Manpower Requirement Module This module calculated aggregate RN requirements based on utilization trends of RN per unit of service and the total service demands calculated in the service module in each of the above service areas. Requirements for nurse educators, community health nurses, private duty nurses, and RNs in other settings were calculated on the basis of historical time trends rather than specific utilization rate projections. The major data source was the 1977 National Sample Survey of Registered Nurses.20 Independent data for hospitals, nursing homes, and public health services were also used. The RN utilization rates so derived, with historical growth rates appropriately adjusted for assumed future trends, were considered requirements for the purposes of projections. Model Projections The total January 1990 FTE RN requirements under the above assumptions were projected by the DHHS to be 1,245,400. This total and its major components by employment setting are shown in Table 11.
273 TABLE 11 DHHS Historical Trend-Based Demand Model Full-Time Equivalent Registered Nurses Requirements, January 1990 Area of Practice January 1990 Hospital Nursing home Community health Physician's office Nursing education Other TOTAL 899,900 93,300 101,100 71,900 47,100 32,000 1,245,400 SOURCE: From Secretary, DHHS. February 17, 1982, Table 37, p. 174 (see Reference 1 for complete citation). The Criteria-Based Model Third report to the Congress, A second major set of projections in the Third Report to Congress is derived from a model officially referred to as the "criteria-based model" developed by the Western Interstate Commission on Higher Education (WICHE).21 The study group refers to this as the "judgment-of-need" model. It was designed to establish a framework for developing RN and LPN requirements making use of professional staffing and educational preparation criteria for nurses in a wide variety of work settings. A national panel of consultants, including nurses involved in service and education, hospital administrators, and other leaders in the health field, was established in 1977 to develop such assumptions and criteria for 1985. Staffing and educational criteria for optimal patient care were established in accordance with a consensus of professional judgment, by unit of service, by detailed field of employment. In 1980 a new workshop was held to augment, review, and revise existing criteria for hospitals, nursing homes, and community health services. An adjusted 1990 lower bound was proposed as a level that all states could meet by that year, while an upper bound represented a goal to be met by states exceeding the lower bound. The translation of these professional criteria into nursing ~ was a separate undertaking. This translation was made by WICHE criteria to the health service utilization and population trends used by the historical trend-based model. The criteria thus applied resulted in 1990 FTE nursing personnel requirements, as shown in Table 12. requirement s applying the
274 TABLE 12 DHHS Judgment-of-Need Full-T=me Equivalent Registered Nurse Requirement Projections, January 1990 PersonnelLower BoundUpper Bound Registered nurses1,784,0002,373,000 Associate degree/diploma(767,700)(834,200) Baccalaureate(747,500)(1,165,100) Master's/doctoral(269,200)(373,300) Licensed practical nurses331,000334,000 Aides524,000589,000 SOURCE: Secretary of Health and Human Services. Third report to the Congress, Table 40, p. 177 (see Reference 1 for complete citation). ~ _ _ ~ Comparison of Historical Trend-Based Demand and Judgment-of-Need Lower Bound Projections The lower-bound projection of the judgment-of-need model for 1990 was 43 percent higher than that of the historical trend-based demand model, as shown in Table 13.22 The requirement projections of the two models are approximately the same for hospitals and physicians' offices; however, there were major differences in those for nursing homes and community health services. These differences reflect the view of the WICHE national panel that present RN staffing patterns in nursing homes and community health settings are grossly inadequate.23 TABLE 13 DHHS Projections of Full-Time Equivalent Registered Nurses Required Under Two Sets of Staffing Assumptions, January 1990 Trend-Based Judgment-of-Need Area of Practice Demand Model Model, Lower Bound Difference Hospital899, 900 935, 70035, 800 Nursing home93, 300 469, 900376, 600 Community health101,100 240,500139,400 Physician's office71,900 66, 700- 5, 200 Nurs ing educat ion47, 100 37, 000-10, 100 Other32, 000 34, 6002, 600 TOTAL1, 245, 400 1, 7 84, 400538, 6 00 SOURCE: Secretary, DHHS. 1982, Table 37, p. 174; and Table 49, p . complete citation). Third report to the Congress, February 17, 176 (see Reference 1 for
275 The Study's Illustrative Demand Projections To determine the impact of several possible health care changes on future RN requirements, the study committee developed specifications for three demand illustrations which were computed for the study by the DHHS, using adjustments to the existing historical trend-based demand model. Assumptions and resulting projections are the responsibility of the study, not of the DHHS. The present structure of the model was discussed earlier in this appendix. In developing the study illustrations, original scenarios incorporated by Vector Research, Inc. in the first set of published results of the historical trend-based model were reviewed.24 The forecasting exercise that the study undertook was intended to respond to the congressional charge to determine the future need for nurses. We have emphasized in Chapter II the importance of examining approaches for predicting "demand" as a means of understanding future "needs." The historical trend-based demand model that the study committee selected as the most practical for its purposes is driven by two important sets of variables. These are, first, changes over time in the utilization of health services by the population and, second, the rates at which RN services are used in various components of the health care system.* There are many complex forces at work that affect these two sets of variables now, and policy changes can be expected to influence them in the future. In its charge, Congress recognized the potential impact of demand on financing changes like national health insurance and new utilization patterns that might resul as an increased use of ambulatory fnnilitie~. t from such developments ~ _ It is well beyond the scope of this study to posit to what extent basic health policies might change in the next few years and the multivariant results that might arise from an interaction of these new policies. Rather, the study group believed it could provide insight into the future by three relatively simple illustrations that would test how much the demand for RNs might be altered by the assumed effects of certain changes in the financing climate, which, in turn, would tend to produce changes in how patients use health care and how programs and institutions utilize RNs. In making illustrative projections using the historical trend-based demand model, time, resource, and technical limitations permitted only surrogate adjustments compatible with the model structure. No general population adjustments could be made in the model owing to the unavailability of 1980-1990 population projections based on the 1980 census. For each illustration, the model baseline was updated to approximate FTE RN estimates derived from the 1980 RN - ~A fuller discussion of this model and the modifications in the variable model components adopted for purposes of the study illustrations is found in Bander, J. Methodologies for projecting the nation's future nurse requirements (see Reference 25 for complete . . CItatlOT1 e
276 Sample Survey.26 Alsoj the first two illustrations were updated to reflect HMO enrollment projections made by the Department of Health and Human Services' Office of Health Maintenance Organizations for the period 1980-1990. This update projects slightly more than 9 percent of total population enrolled in 1990.27 The third illustration, as noted below, was characterized by an assumption that this increase would rise to 30 percent by the end of 1990. Under all three illustrations, the HMO population is assumed by the model to use 44 percent of the per capita hospital inpatient days of the non-HMO population. This rate is based on the experience of traditional HMO s (prepaid group practice plans).28 To the extent that this rate may be considered too low for future HMO experience with a larger enrollment population, the results of the illustrations may understate somewhat the volume of short-term inpatient utilization and the resultant demand for nurses in this sector (see Table 18~. The assumptions for the projections are described in Chapter II. The specifications and results are summarized in Table 14. TABLE 14 Illustrations of 1990 Registered Nurse Requirements (FTE) Under Three Series of Study Group Assumptions RNs FTE) Required Illustration Specifications December 1990 I. National Health Insurance Updates RN utilization data and HMO enroll- 1,471,600 ment projections; assumes continued upward health service utilization trends as in the projections for the Third Report to Congress. II. Cost Containment Updates RN utilization data and HMO en- rollment as in Illustration I; holds ICU beds and non-ICU patient days, outpatient visits, and nursing home resident days at projected 1985 rates until 1990; however, allows ratio of RNs to non-ICU inpatient days to rise as in Illustration I. III. Increased Use of Ambulatory Care Updates RN utilization data; shifts to less use of hospital inpatient care and increased ambulatory services as the population's use of HMOs or similar services increases to 30 percent by 1990; doubles per capita home care visit rate. 1,348,000 1,297,600 SOURCE: Bauder, J. Methodologies for projecting the nation's future nurse requirements (see Reference 25 for complete citation).
277 The adjustments made by the illustrations in the per capita health service utilization rates of the historical trend-based model are shown in Table 15.* The significant difference in per capita service rates for non-ICU inpatient days in Illustration III result from differences in the internal treatment by the model of assumed reduced utilization by HMO-type populations. In the original model, because HMO enrollment was not a major influence, inpatient per capita savings attributable to TABLE 15 Comparison of Per Capita Health Service Rates, Historical Trend-Based Demand Model and Study's Illustrative Projections, December 1990 Practice Setting DHHS Projections Per Capita Service Historical Model Study Group Illustrative ProjectionsC ICU bed day 0.134271 0.129987 0.104286 0.104286 Non-ICU inpatient day 1.224304 1.224305 1.224305 1.001157 Hospital out patient visit 1.065468 1.065468 1.005471 0.745550 Physician' s office visit 5.029299 5.029302 5.029302 3.529225 HMO clinic visit (per enrolled member) 4. 329707 4.329700 4.329700 4.329711 Nursing home re ~ ident day Type L! 2.318763 2.318764 2.318764 2.318762 Type 2b 0.376272 0.376273 0.376273 0.376273 Home Visit 0.151145 0.151145 0.151145 0.309846 2Type 1: One or more RNs or LPNs employed and 50 percent or more of the residents receiving nursing care. bType 2: Less than 50 percent of residents receiving nursing care, irrespective of nurse employment. RESOURCE: "Inpatient Health Facilities as Reported From the 1973 MFI Survey," Vital and Health Statistics Series No. 14, No. 16, NCHS. C SOURCE: DHHS, BRA. Unpublished computer runs 100, 110, 120, and 140 on RN state and national requirements model, revised and updated, July and August 1982, p. 3. *In this table and the two following, all model variables are carried Out to four or more decimal places in order to show areas of differ- ences. The distinctions may result in small differences in RN require- ments in those settings where nurse utilization is small, but in signi- ficant differences in practice settings such as short-term inpatient non-ICU and ICU hospital service where RN requirements are large.
278 HMO members was compensated for by increasing the rates of non-HMO patients on grounds that existing data showing per capita utilization in the total short-term hospital system appear to have shown no net decrease in overall utilization. The model also operated this way for the first two illustrations. In the third illustration, however, the study specified that the hospital utilization savings attributable to the part of the population using HMO-type modes of care should not be absorbed and distributed over the entire population, but should be netted out, the result being a significantly lower per capita factor. RN service ratios in the model under the three sets of assumptions the study group chose to illustrate are shown for selected settings in Table 16. TABLE 16 Comparision of Selected Registered Nurse Per Service Ratios, Historical Trend-Based Demand Model and Study's Illustrative - Projections, December 1990 Practice DHHS Projec Setting Lions Histori Ratio of RNs Cal Model Study Group Illus trat ive Proj ec Lions I II III ICU bed day 2.45471 2.45471 2.43832 2.43832 Non-ICU in patient day 0.63026553 0.74969667 0.65011829 0.74969667 Hosp ital out pat lent visit 0.00039008 0.00042960 0.00042675 0.00042960 Phy s ic fan ' s office visit 0.2785 0.2693 0.2693 0.098~ HMO visit 0.000099 0.000099 0.000099 0.000099 Nurs ing home resident dayb Type 1 0.05766 0.06035 0.06027 0.06035 Type 2 0.02457 0.02801 0.02802 0.02801 Home visit 0.0005335 0.0008259 0.0008259 0.0008259 Was noted in Chapter II, the deep drop in nurse per service ratio and in resulting nurse requirements in physicians' offices under Illustration III can be discounted; it appears to be only partially attributable to a shift in patient utilization by HMO services. It may also be due, in part, to the fact that the existing model was not designed to accommodate such large increases in assumed HMO enrollments, which cause correspondingly large decreases in non-HMO physicians' offices. The resulting population may reflect the manner in which model components interact in the treatment of the nurse Productivity factor in ambulatory care. _See Table 15 footnote for explanation of Type 1 and Type 2 SOURCE: DHHS, unpublished computer runs 100, 110, 120, and 140 on RN state and national model requirements model, revised and updated, July and August 1982, pp. 53-54.
279 In order to visualize how these model variables interact to produce FTE RN requirements, the variables dealing with ICU utilization are,set out in Table 17. TABLE 17 Comparison of Output Regarding Intensive Care Units Made by the BRA Historical Trend-Based Demand Model and the Study's Three Illustrations, January, 1980, 1985, 1990 Study Group Illustrative DHHS Projections BRA Historical Projections Model Output Model Projections I II III Per capita demand 1980 0.096401 0.091662 0.091662 0.091662 1985 0 . 1 14 5 1 1 0 . 1 099 93 0 . 0 1 9 99 3 0 . 10 9 9 93 1990 0.134271 0.129987 0.104286 0.104286 RNs per ICU bed 19 80 2. 1 1045 2. 1 1045 2. 1 1045 2. 1 1045 1985 2.43832 2.43832 2.43832 2.43832 1990 2.45471 2.45471 2.43832 2.43832 FTE RN requirements 1980 122,636 116,600 116,600 116,600 1985 176, 508 169, 500 169, 500 169, 500 1990 219, 7 59 212, 700 169, 500 169, 500 SOURCE: DHHS, ~ A. Unpublished computer runs, 110, 120, 140 on RN state and national model, revised and updated, July and August 1982, pp. 38-40. As illustrated above, the per capita ICU demand rates and RNs per ICU bed ratios were held constant between 1985 and 1990 in Illustrations II and III. This resulted in ICU FTE RN requirements being held at 169,500 in both illustrations--a 45 percent increase over 1980. In contrast, Illustration I did not hold per capita demand rates or RNs per ICU bed ratios constant between 1985 and 1990. As a result FTE RN requirements rose from 116,600 in 1980 to 212,700 in 1990--a 92-percent increase. Comparison of Historical Trend-Based Model and Illustrative Projections The study's December 1990 demand projection totals were moderately higher in the aggregate than the historical trend-based demand model's projection, as is shown in Table 18. Illustrations I, II, and III were 16, 6, and 2 percent higher, respectively. These differences
280 were primarily due to the incorporation of the more up-to-date 1980 RN Sample Survey data in the three illustrations.29 Striking differences were found, however, in comparing the practice area projections of the illustrations and the historical trend-based model. For example, a 30 percent increase in HM()-type services in Illustration III resulted in decreased RN requirements for non-ICU inpatients, outpatients, and physicians' offices, and increased requirements for HMO clinics. The doubling of the per capita rate of home health visits as an independent variable in Illustration III resulted in substantially increased home care RN requirements. As is discussed in Chapter II of this report, the three RN supply projections made by the Committee all fall within the wider range of the demand projected by the illustrations. December 1990 supply projections range from 1.38 million to 1.45 million, while requirement projections for the same period range from 1.30 million to 1.47 million. Cautions were expressed in that chapter as to model limitations and the combinations of assumptions. TABLE 18 Comparison of Historical Trend-Based Demand Model Projections With Study's Three Illustrative Projections, Registered Nurses (FTE) December 1990 DlIHS Hist orical Model Practice Setting Projections Study Group Illustrative Projec Lions I II III Short-term hospital Inpatient 713,500 799,700 688,100653,300 ICU (219,800) (212,700) (169,500)(169,500) Non-ICU inpatient (476,500) (569,800) (501,300)(466,600) Nursing administra tion (17,200) (17,200) (17,200)(17,200) Hospital outpatient 100,800 111,400 104,40077,900 Other hospital 106,000 113,000 113,000113,000 Nursing homes 95,300 100,300 100,200100,300 Corr~nunity health 82,500 123,000 123,000123,000 Home care 19,600 30,400 30,40062,300 Physicians' offices 66,300 64,000 64,00022,500 H6X)-type organizations 6,900 10,300 10,30032,400 Nursing education 48,000 56,500 51,70049,800 Private duty and other 32, 600 63, 000 63, 00063, 000 TOTAL 1,271,600 1,471,600 1,348,1001,297,600 NOTE: Detail may not add to totals because of rounding. SOURCE: DHHS, BRA. Unpublished computer runs 100, 110, 120, and 140 on RN state and national model requirements model, revised and updated, July and August 1982, pp . 38-40.
281 REFERENCES AND NOTES 1. 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. 2. Department of Health and Human Services, Health Resources Administration. The registered nurse_population, an overview. From national sample survey of registered nurses, November, 1980 (Report 82-5, revised June 1982~. Hyattsville, Md.: Health Resources Administration, 1982. Secretary, DHHS. Third report to the Congress, February 17, 1982, 9~ cit. 4. U.S. Bureau of the Census. Projections of the population of the United States: 1977 to 2050 (Publication Series P-25, [704~. Washington, D.C.: U.S. Government Printing Office, 1977. Secretary of Health, Education, and Welfare. Toward quality in nursing--Needs and goals report of the Surgeon General's Consultant Group on Nursing (PHS Publication No. 992~. Washington, D.C.: Public Health Service, 1963. 3. - 6. Altman, S.H. Present and future supply of registered nurses (Dam Publication No. (NIH) 73-134~. Washington, D.C.: U.S. Government Printing Office, 1972. 7. Secretary, DHHS. Third report to the Congress, February 17, 1982. Op. cit. _ 8. Roth, A., Graham, D. and Schmittling, G. 1977 national sample survey of registered nurses: A report on the nurse population - and factors affecting their supply (NTIS Publication No. HRP-0900603~. Kansas City, Mo.: American Nurses' Association, 19 79. 9. Roth, A.V., and Walden, A.R. The nation's nurses: 1972 inventory of registered nurses. Kansas City, Mo.: American Nurses' Association, 19 74. 10. National League for Nursing. NLN nursing data book 1981 (Publication No. 19-1982~. New York: National League for Nursing, 1982. Roth, A.V., and Walden, A.R. The nation's nurses: 1972 inventory of registered nurses. Kansas City, Mo.: American Nurses' Association, 1974. Roth, A. et. al., Op. cit. 11. 12. 13. Ibid. 14. DHHS, HRA. The registered nurse population, an overview. From national sample survey ot registered nurses, November, Emu. up. cit., Table 1, p. 9. _. 15. Ibid. 16 . ~ ^ ^-^ ~ _ ~A _ I LLOYD. He ~e . ~U~JVt:~-. En- By-, all" Illume OULI' ^. Ax- The impact of health system changes on the nation's requirements for registered nurses in 1985 (DHEW Publication No. HRA-78-9). Washington, D.C.: U.S. Government Printing Office, 1978. 17. Roth, A., et. ale
282 18. Secretary, DHHS. 1982. Op. _t. 19. U.S. Bureau of the Census. Third report to the Congress, February 17, Projections of the population of the United States: 1977 to 2050. OP. cit. 20. Roth, A., et. al., Op. cit. 21. Secretary, DHHS. 1982. Op. cit., pp. 91-102. 22. Ibid. 23. Department of Health and Human Services, Health Resources Administration. Evaluation and updating of the criteria established by the WICHE panel of expert consultants (DHPA Report _ No. 81-19~. Hyattsville, Md.: 1981. 24. Doyle, T.C., et al., OP. cit. 25. ~ , Bauder, J. Health Resources Administration, , _ , is, _ _ Methodologies for projecting the nation's future nurse requirements. Background paper of the Institute of Medicine Study of Nursing and Nursing Education. Available from Publicatinn-on-Demand Program, National Academy Press, Washington, D.C., 1983. 26. DHHS, HRA. The registered nurse population, an overview. From national sample survey of registered nurses, November, 1980. Op. cit., Table 9, p. 17. 27. Secretary of Health and Human Services. National HMO census of prepaid plans (DHHS Publication No. DHS 80-50159~. Washington, D.C.: U.S. Government Printing Office 1980. 28. Department of Health and Human Services, National Center for Health Statistics. Current estimates from the National Health Interview Survey: U.S. 1980 (DHHS Publication No. PHS-82-1567). Washington, D.C.: U.S. Government Printing Office, 1981. 29. Secretary, DHHS. Third report to the Congress, February 17, 1982, Op. cit. _ 30. West, M.D. Projected supply of nurses, 1990: Discussion and methodology. Background paper of the Institute of Medicine Study of Nursing and Nursing Education. Available from Publication-on-Demand Program, National Academy Press, Washington, D.C., 1983. 31. Health Resources Administration. (DHHS Publication No. HRA-81-21~. Government Printing Office, 1981. Source book--nursing personnel Washington, D.C.: U.S.
IdPPE N DIX 6 Doctoral Programs in Nursing: frustrate Statements of Purpose From School Catalogs A recent study by the American Nurses' Association (ANA), Nurses with Doctorates, notes that the development of knowledge and skills that are unique to nursing requires that certain of its members be able to produce new knowledge through research, to disseminate or communicate this knowledge, and to apply it in the nursing arena. A major purpose of doctoral education is to develop skills in the conduct of such activities.] Doctoral programs are expected to prepare students committed to becoming productive researchers, educators, and clinicians. The ANA study also observes that doctorally prepared nurses are both cause and effect in the continued professional development of nursing. "They have been and continue to be instrumental in developing a knowledge base unique to nursing. They are also the major faculty resource for doctoral programs in nursing, where they are expected to prepare students who are committed to becoming productive researchers, educators, and clinicians. Growth in the numbers of doctorally prepared nurses may meet the need for research-qualified faculty with ongoing research and for faculty who are actively engaged in practice. Such faculty can serve as mentors and role models for students."2 To illustrate the stated purposes and scope of doctoral programs in nursing, our study selected the following examples from catalogs of seven schools of nursing. The programs were chosen to represent a broad range of geographic distribution. Descriptions are quoted verbatim. University of Arizona The purpose of the program leading to the Ph.D. degree with a major in nursing is to prepare clinical nurse researchers who will: · Add to the body of nursing knowledge through the: synthesis of knowledge from nursing and the related sciences, development of nursing theory, conduct of research; and ~ Evaluate the application and utilization of new knowledge in nursing practice; and 283
284 o Contribute to the solution of society's health problems through communication with the broader health community. University of Alabama in Birmingham The D.S.N. degree program is oriented toward the science of nursing with a triple emphasis on professional practices research and preparation for the candidate's functional role as an educator, administrator or consultant. The D.S.N. degree program is planned to produce nurse scientists. Post-master's study is offered in nursing service administration in collaboration with the School of Business and the School of Community and Allied Health, and in advanced oncology nursing in collaboration with the School of Medicine. The School of Nursing's Center for Nursing Research provides M.S.N. and D.S.N. students with assistance in planning, conducting, analyzing, writing and securing financial support for nursing research. The Center houses a research planning conference roam and a large data analysis laboratory equipped with a CRT Terminal, Deswriter, keypunch and calculators. Faculty research interests include cognitive development, nursing diagnoses, adjustment to widowhood, pain, cultural aspects of health, sleep, history of nursing education in Alabama, benefits and attitudes toward exercise, curriculum issues, parent-infant relationships, energy expenditure and moral development of nurses. Boston University The D.S.N. program emphasizes nursing science and the development of intellectual skills and abilities in scholarly analysis related to nursing practice and research. Graduates of the program are prepared to provide leadership in the development of nursing knowledge and practice, and in organization and improvement of health care. The University of California, San Francisco The aim of the D.S.N. program is to prepare scholars in nursing who are trained in research and who have attained a depth of knowledge in a substantive area of nursing practice. Graduates of the program are prepared to assume complex leadership roles in the health care system. Courses of study have been developed in various fields within Mental Health and Community Nursing, Nursing in Biolog ical Dysfunction, Family Health Care Nursing, and Social and Behavorial Sciences. Appropriate courses offered by other schools on the San Francisco and Berkeley campuses are used to enhance and support the aims of the program.
285 The objective of the program for the student is to achieve a high level of comprehension of practice and research in a specialized area of nursing. Prospective D.N.S. candidates pursue a program of course work in four major areas: research theory and methodology, theory development, social and political aspects of health care, and a nursing focus. Students, with the guidance of advisers, outline specific programs of study that assist them in meeting their professional-academic goals and the requirements for the degree. A program of independent research, developing from initial course work, culminates in the preparation and defense of the dissertation. Doctoral students may have primary affiliation with any department in the School of Nursing. University of Michigan The Ph.D. degree has traditionally been viewed as the degree enabling professionals of many disciplines to conduct research, develop theories, and expand their knowledge base; it is not designed explicitly to develop more advanced clinical practitioners. The focus of a doctorate in clinical nursing is the attainment of professional and scholarly knowledge sufficient for graduates to pursue research on the delivery of health care by nurses. Moreover, doctorally prepared nurses can address themselves to generalized problems of promoting health in the population and maintaining mental and physical abilities during periods of acute or chronic illness, and at all stages of the life cycle. Nursing, with its emphasis on a big-psycho-social model of care, has great potential for enhancing the distribution and quality of patient care, encouraging health protection and promotion, and creating cost effective improvements in the organization and delivery of health services. To pursue excellence in research and theory development in clinical nursing, graduates must be clinically proficient and have extensive preparation in the biophysical and/or behavorial sciences and in research methods and data analysis. As an integrative and applied endeavor, the program draws on the curricular and research resources of other disciplines and institutes within the University. The purposes of the Ph.D. Program in Nursing are to prepare the graduate to: 1) conduct clinical nursing research, 2) expand the boundaries of nursing knowledge, and 3) provide leadership in the development of nursing theories.
286 Doctoral study in nursing is designed to prepare scholars who are capable of developing an empirical base for nursing practice in both current and emerging health care systemse A unique strength of the Ph.D. program in nursing is the opportunity to study the interrelationships of physiological, psychological, and social variables as they influence health outcomes. The program is predicated on professional preparation in nursing and includes a strong clinical knowledge base that integrates scientific theory with practice. To pursue research and theory development in clinical nursing, graduates will be clinically proficient and have advanced preparation in the biophysical and/or behavioral sciences and in research methods and data analysis. As an integrative and applied endeavor, the program draws on the curricular and research resources of other disciplines and institutes within the University. To best meet the diverse needs of the field of nursing and the goals of the student, the course of study is highly individualized. The overall purpose of the program is to prepare nurses competent in research design, data analysis, and inferential processes, and thus capable of pursuing research related to the delivery of patient care by nurses, and of developing theory oriented toward applications of nursing practice. University of Maryland The purpose of the Ph.D. program in nursing is to prepare scholars and researchers who will advance nursing science, thereby making more effective the practice of nursing, and who will provide innovative leadership to the profession. The program will prepare graduates who: 1) Construct, test and evaluate conceptual models and nursing theories which reflect synthesis, reorganization and expansion of knowledge from nursing and related disciplines; 2) Evaluate and apply appropriate research designs, measures and statistics to the study of nursing phenomena; 3) Conceptualize practice phenomena from the perspective of nursing frameworks and theory; 4) Design, conduct and communicate research relevant to nursing practice; 5) Facilitate the incorporation of new knowledge into nursing practice; and 6) Initiate, facilitate and participate in collaborative endeavors related to the theoretical, conceptual arid practical aspects of health care with clients, nurses and scholars from related disciplines.
287 Univer.~iLv of Washington The Ph.D. in nursing science program offered by the University of Washington is designed to prepare scholars and researchers for a vital mission--that of developing and expanding the body of scientific knowledge upon which the practice of nursing must ultimately rest. The program provides for rigorous research training related to five fields in nursing science: · Individual adaptations to health and illness; · Family adaptations to health and illness; · Environments: supporting and nonsupporting, o Clinical therapeutics: interpersonal; and · Clinical therapeutics: physical. - . Those who successfully complete the program are fully prepared to answer the national need for doctorally prepared nursing school faculty. They are equally well qualified to serve in leadership positions in many service agencies requiring nursing scientists to research and advance the state of the art of modern health care delivery. The doctoral degree is the highest degree conferred by the university. All requirements and regulations leading to the doctoral degree are devices whereby the student may demonstrate present capacities and future promise for scholarly work. The degree is not conferred merely as a certificate to a prescribed course of study and research, no matter how long or faithfully pursued. The program of study for each student will be developed collaboratively by the student and his/her supervisory committee, as appropriate to the student's research interest. REFERENCES AND NOTES 1. American Nurses' Association. Nurses with doctorates. Kansas City, Mo.: American Nurses' Association, 1982, p. 13. 2. Ibid., p. 14.
ACPPE N DIX 7 Mul~variate Analysis of Determ~nabon of Work Status and Wage Rates Introduction The discussion in Chapter VII of nurses' work status in the labor force and factors influencing salary levels incorporated results of multivariate analyses of data from the National Sample Survey of Registered Nurses, November 1980. The methodology and detailed findings of the analyses are presented in the technical notes that follow. Work Status To ascertain the simultaneous effects of a number of independent variables thought to influence nurses' work status--full time, part time, or inactive--data from the National Sample Survey of Registered Nurses, November 1980,* were analyzed using multivariate regression techniques. In this survey sponsored by the Health Resources Administration, Department of Health and Human Services, 30,596 registered nurses currently holding licenses (approximately 80 percent of a probability sample) responded to a questionnaire during the period August 16 to November 2, 1980. The model employed in the multiple regression analysis is of the form Y = a + blXi + b2Xi + · + bnYi + ei, where Yi takes the value 1 if the nurse is employed full-time and 0 otherwise, and the X's represent the following categorical independent variables: highest level of nursing education, marital status, presence of children in the home, student status (i.e., whether the respondent is currently pursuing further formal education), sex, race, age, *Department of Health and Human Services, Health Resources Administration. The registered nurse population, an overview. From national sample of registered nurses, November, 1980 (Report 82-5, Revised June 1982~. Hyattsville, Md.: Health Resources Administration, 1982. 288
289 residence in a non-SMSA geographic region, and years of experience as a nurse. The b's are coefficients that represent the change in Y that can be attributed to the value of the X's relative to the omitted category. Because Y only assumes the value O or 1, the expectation of Y. E(Y), may be interpreted as the probability that Y = 1, or the probability that, for example, a nurse is employed full time. Separate models were used to explain part-time and inactive status. The intercept, a, is interpretable as the probability that Y = 1 for the nurse who has all the omitted attributes. The ei represents random variation in Y not explained by the linear relationship between Y and the X's; it is assumed to have an expected value of zero. Tables 1-3 present the results of the regression analysis for the probability of full-time, part-time, and inactive status, respectively. TABLE 1 Regression Estimates of Determinants of Full-Time Work Status for Licensed Registered Nurses Regression Coefficient Independent Variable (t Statistic) _ Age less than 25 Age 25-34 Age 35-44 Level of Significance Omitted - -.1406 (-11.83) -.3070 .0001 (-22.90) .0001 Age 45-54 -.3645 .0001 Age 55-64 Age 65 and Experience less than 1 year Experience 1 year Experience 2 years Experience 3-5 years Experience 6-10 years .0016 (.06) .0250 (1.79) .0250 (2.10) .0634 (5.25) Experience 11-15 years .1670 (12.70) .2726 (19.07) .3487 (22.44) Experience 16-20 years Experience 21-25 years (-25.88) -.5382 .0001 (-36.45) -.9427 (-50.60) Omitted .0001 .9503 .0731 .0358 .0001 .0001 .0001 .0001 Experience of 26 years and more .3724 .0001 (25.33)
290 TABLE 1 (continued) Regression Coefficient Level of Independent Variable (t Statistic) Significance Diploma Omitted __ Associate degree .1514 .0001 (18.98) Baccalaureate degree .0902 .0001 (12.79) Graduate degree .1175 .0001 (9.38) Single .1888 .0001 (28.58) Male .2126 .0001 (13.13) Children younger than 6 -.3052 .0001 (-37.14) Children 6 and over -.0798 .0001 (-10.82) Student .0237 .0072 (2.69) White Omitted - Black .2417 .0001 (16.67) Hispanic .0935 .0001 (3.93) Other minority .2741 .0001 (15.05) Non-SMSA .0057 .3810 (.88) Northeastern region Omitted -~ Western region -.0190 .0182 (-2.36) North central region .0164 .0205 (2.32) Southern region .0892 .0001 (12.55) Intercept 0.6082 .0001 (43.61) R2 .25 Dependent variable (full-time) mean .5254 Number of Observations 27,331
291 TABLE 2 Regression Estimates of Determinants of Part-Time Work Status for Licensed Registered Nurses Regression Coefficient Level of Independent Variable (t Statistic) Significance Age less than 25 Omitted - Age 25-34 -.0072 .5223 (-.64) Age 35-44 -.0458 .0003 (-3.61) Age 45-54 -.0818 .0001 Age 55-64 Age 65 and over (-6.14) -.1047 (-7.50) -.0584 (-3.31) Experience less than 1 year Omitted .0001 .0009 _ _ Experience 1 year .0313 .1862 (1.32) Experience 2 years .0069 .6010 (.52) Experience 3-5 years .0438 .0001 (3.90) Experience 6-10 years .1061 .0001 (9.29) Experience 11-15 years .1584 .00001 (12.74) Experience 16-20 years .1370 .0001 (10.14) Experience 21-25 years .1182 .0001 (8.05) Experience 26 years and more .1191 .0001 (8.57) Diploma Omitted - Associate degree -.0056 .4541 (-.75) Baccalaureate degree -.0486 .0001 (-7.29) Graduate degree -.1052 .0001 (-8.88) Single -.1082 .0001 (-17.34) Male -.1267 .0001 (-8.28)
292 TABLE 2 (continued) Regression Coefficient Level of Independent Variable (t Statistic) Significance Children younger than 6 .1967 .0001 (25.32) Children 6 and over .0955 .0001 (13.71) Student .0147 .0766 (1.77) White Omitted - Black -.1366 .0001 (-9.97) Hispanic -.0290 .1982 (-~.29) Other minority -.1931 .0001 (-11.22) Non-SMSA -.0199 .0013 (-3.22) Northeastern region Omitted - Western region .0221 .0036 (2.91) North central region .0196 .0033 (2.94) Southern region -.0785 .0001 (-11.69) Intercept 0.2002 .001 (15.18) R2 . 1 1 Dependent variable (part-time) mean .2541 Number of Observations 27,331
293 TABLE 3 Regression Estimates of Determinants of Inactive Work Status for Licensed Registered Nurses - Regression Coefficient Level of Independent Variable (t Statistic) Significance - Age less than 25 Omitted - Age 25-34 . 1036 .0001 (11.09) Age 35-44 .2520 .0001 ~ 23. 90) Age 45-54 .3322 . 0001 (29.99) Age 55-64 .5147 .0001 (44. 31) Age 65 and over . 8892 .0001 (60.67) Experience less than 1 year Omitted - Experience 1 year Experience 2 years Experience 3-5 years Experience 6-10 years -.0234 (-1. 19) -.0199 (-1. 81) -. 0520 (-5. 55) -.1308 (-13. 76) -. 2569 (-24. 83) -.3084 (-27. 41) -. 3538 (-28. 93) Experience 26 years and more -. 3700 ( -31. 99) Omitted Experience 11-15 years Experience 16-20 years Experience 21-25 years Diploma .2341 .0700 .0001 .0001 .0001 .0001 .0001 . 000 1 .0001 Associate degree -.1223 .0001 (-19.48) Baccalaureate degree -. 0447 .0001 (-8. 06) Graduate degree -.0390 (-3.95)
294 TABLE 3 (continued) Regression Coefficient Level of Inde endent p Single -.0811 .0001 (-15.60) Male -11.06 .0001 (-a. 69) Children younger than 6 .1146 .0001 (17.74) Children 6 and over -.0134 .0175 (-2. 38) Student -. 0173 .0127 ~ -2. 49) White Omitted - Black -.0886 .0001 (-7. 7) Hispanic -.0603 .0013 (-3. 21) Other minority -. 0754 .0001 (-5. 26) Non-SMSA -.0019 .7133 (-.37) Northeastern region Omitted - Western region .0011 .8625 ~ . 17) North central region -. 0276 .0001 (-4.96) Southern region -.0009 .8734 (-.16) Intercept .1565 .0001 (14.26) R2 .21 Dependent variable (inactive) mean .1696 Number of Observations 27,331
295 Wage Analysis A multivariate regression was performed to assess a number of factors that are believed to influence differences in nurses' wages. The 1980 Sample Survey data were used to examine the effect of the following independent variables on the dependent variable, monthly wage of full-time nurses: highest education, years of experience in nursing, job position, age, sex, race, geographic region, and residence in a non-SMSA. The estimated equation takes the form Yi = a + blXi + b2Xi + + bnXi + ei' where Y is monthly gross earnings as reported in the survey, and the X's represent the independent variables listed above. Each b represents the change in monthly earnings (Y.) attributed to a change in a given Xi variable, all other X's held constant. The results of the regression are presented in Table 4. In general, the relatively small value of R2 (0.2) suggests that factors such as local labor markets, the personal attributes of individual nurses, and individual employer characteristics predominate as wage determinants. TABLE 4 Regression Estimates of Determinants of Monthly Wage Rates for Full-Time Licensed Registered Nurses Regression Coefficient Level of Independent Variable (t Statistic) Significance Diploma Omitted Associate degree85.04 .0451 (2.00) Baccalaureate degree131.72 .0005 (3.49) Graduate degree 379.74 .0001 (5.71) Years of experience 11.36 .0001 (4.29) Age -1.84 .3918 (-0.86) Job position Staff nurse Omitted - Administrator Supervisor 400.33 .0001 (6.55) 120.36 (2.04) .0411 Head nurse157.27 .0017 (3.13)
296 TABLE 4 (continued) Regression Coefficient Level of Independent Variable(t Statistic) Significance Educator130.28 .0666 (1.83j Clinical specialist255.14 .0001 (3.85) Other position140.09 .0267 ~ 2.22) Male217.90 .0033 (2.94) WhiteOmitted - Black359.86 .0001 (5.46) Hispanic103.67 .3787 (0.88) Other minority243.88 .0040 (2.88) Non-SMSA-138.49 .0002 (-3.76) Northeast regionOmitted - North central region120.99 .0022 (3.06) Southern region84.44 .0274 ~ 2.21) Western region282.90 . oooi (6.26) Intercept1148.58 .0001 ~ 16.74) R2.02 Dependent variable (monthly wage) 1472.52 Number of Observations 14,166 REFERENCES AND NOTES 1. Feldstein, M.S. A binary variable multiple regression method of analy sing factors affecting pert-natal mortality and other outcomes of pregnancy. Journal of the Royal Statistics Society, Series A' 1966, 129, 61-73. Goldberger$ A.S. Econometric theory. New York: John Wiley and Sons, 1964, pp. 248-230.
IOPPE N DIX ~ Nursing Research: Defin~hons and Direchons In order to provide further insight into the need for, philosophy, and scope of nursing research this appendix presents a position statement issued by the Commission on Nursing Research of the American Nurses' Association. It is quoted here in its entirety:* Recent years have seen a growing awareness among the public that valuable resources are finite and their use must be carefully considered. In this context, increasing attention is being given to the relative cost of various strategies for utilizing health care resources to meet the present and emerging needs of the nation. Concurrently, nurses are assuming increased decision-making responsibility for the delivery of health care, and they can be expected to continue to assume greater responsibility in the future. Therefore, the timeliness and desirability of identifying directions for nursing research that should receive priority in funding and effort in the 1980s is apparent. The priorities identified below were developed by the Commission on Nursing Research of the American Nurses' Association, a nine member group of nurses actively engaged in research whose backgrounds represent considerable diversity in preparation and experience. The priorities represent the consensus of the commissioners, developed through a process of thoughtful discussion and careful deliberation with colleagues. Accountability to the public for the humane use of knowledge in providing effective and high quality services is the hallmark of a profession. Thus, the preeminent goal of scientific inquiry by nurses is the ongoing development of knowledge for use in the practice of nursing; priorities - *American Nursest Associatione Research priorities for the 1980s: Generating a scientific basis for nursing practice (Publication No. D-68. Kansas City, Mo.: American Nurses' Association, 1981. 297
298 are stated in that context. Other guiding considerations were the present and anticipated health problems of the population; a historic appreciation of the circumstances in which nursing action has been most beneficial; nursing's philosophical orientation, in which emphasis is on a synthesis of psychosocial and biomedical phenomena to the end of promoting health and effective functioning; and projections regarding the types of decisions nurses will be making in the last decades of the twentieth century. New, unanticipated problems will undoubtedly confront the health care resources of the country; yet it is clear that many of the problems of the future are already manifest today. New knowledge is essential to bring about effective solutions. Nursing research directed to clinical needs can contribute in a significant way to development of those solutions. Definition of Nursing Research Nursing research develops knowledge about health and the promotion of health over the full lifespan, care of persons with health problems and disabilities, and nursing actions to enhance the ability of individuals to respond effectively to actual or potential health problems. These foci of nursing research complement those of biomedical research, which is primarily concerned with causes and treatments of disease. Advancements in biomedical research have resulted in increased life expectancies, including life expectancies of those with serious injury and those with chronic or terminal disease. These biomedical advances have thus led to growth in the numbers of those who require nursing care to live with health problems, such as the frail elderly, the chronically ill, and the terminally ill. Research conducted by nurses includes various types of studies in order to derive clinical interventions to assist those who require nursing care. The complexity of nursing research and its broad scope often require scientific underpinning from several disciplines. Hence, nursing research cuts across traditional research lines, and draws its methods from several fields. Directions for Research Priority should be given to nursing research that would generate knowledge to guide practice in: 1. Promoting health, well-being, and competency for personal care among all age groups;
299 2. Preventing health problems throughout the life span that have the potential to reduce productivity and satisfaction; 3. Decreasing the negative impact of health problems on coping abilities, productivity, and life satisfaction of individuals and families; 4. Ensuring that the care needs of particularly vulnerable groups are met through appropriate strategies; 5. Designing and developing health care systems that are cost-effective in meeting the nursing needs of the population. Examples Examples of research consistent with these priorities include the following: · Identification of determinants (personal and environmental, including social support networks) of wellness and health functioning in individuals and families, e.g. avoidance of abusive behaviors such as alcoholism and drug use, successful adapation to chronic illness, and coping with the last days of life. · Identification of phenomena that negatively influence the course of recovery and that may be alleviated by nursing practice, such as, for example, anorexia, diarrhea, sleep deprivation, deficiencies in nutrients, electrolyte imbalances, and infections. o Development and testing of care strategies to do the following: Facilitate individuals' ability to adopt and maintain health enhancing behaviors (e.g. alterations in diet and exercise). Enhance patients' ability to manage acute and chronic illness in such a way as to minimize or eliminate the necessity of institutionalization and to maximize well-being. Reduce stressful responses associated with the medical management of patients (e.g. surgical procedures, intrusive examination procedures, or use of extensive monitoring devices). Provide more effective care to high-risk populations (e.g. maternal and child care service to w lnerable mothers and infants, family planning services to young
300 teenagers, services designed to enhance self-care in the chronically i 11 and the very old ~ . Enhance the care of clients culturally different from the majority (e.g. Black Americans, Mexican-A,nericans, Nat ive Americans ~ and c lients with spec ial problems (e . g. teenagers, prisoners, and the mentally ill), and the underserved ~ the elderly, the poor, and the rural) ~ Design and assessment, in terms of effectiveness and cost, of models for delivering nursing care strategies found to be effective in clinical studies. . All of the foregoing are directly related to the priority of developing the knowledge and information needed for improvement of the pract ice of nursing. While priority should be given to this form of clinical research, there is no intent to discourage other forms of nursing research. These would include such investigations as those utilizing historical and philosophical modes of inquiry, and studies of manpower for nursing education, practice, and research, as well as studies of quality assurance for nursing and those for e stabl ishment of criterion measures f or prac Lice and educat ion.
AiPPE N DrX 9 Parbapants in Me Study's Workshops and Advisory Panels The committee was privileged to draw on the knowledge of many distinguished people during the course of the study; they are listed in this appendix. Many leaders in the nursing profession gave generously of their time. Their contributions to consideration of issues in nursing education, in nursing research, and in nursing services were invaluable. In addition, as the listings illustrate, the study's advisory panels and workshops drew on participants representing a broad range of other professional backgrounds and experience. Their assistance, also, was invaluable in consideration of issues related to identification of data required for the study, trends, and projection methodologies; the cost and financing of nursing education; and the economics of nurse supply and demand. Members of each of the five advisory panels usually met together twice. The advice of individual members was solicited more frequently, on an informal basis. The Economics Workshop was a day-long meeting; sessions of the Workshop on Advanced Nurse Education covered 2 days. Advisory Panel on Nursing Education Costs and Financing to the TOM Study of Nursing and Nursing Education * Roger J. Bulger, chair President, University of Texas Health Science Center at Houston Eileen Alessandro Executive Director, Association of Diploma Schools of Professional Nursing Steven D. Campbell Director, Financial Management Center, National Association of College and University Business Officers * Member--IOM Study Committee on Nursing and Nursing Education. 301
302 Joseph Paul Case Director of Program Administration, College Scholarship Service, College Board Salvatore B. Corrallo Director, Student and Institutional Financing Division, Office of Program Budgeting and Evaluation, Department of Education Joseph C. Czerwinski President, The Czerwinski Group, Inc., Milwaukee, Wisconsin Ruth S. Hanft Consultant Gladys Chang Hardy Program Officer in Charge, Education and Culture Program, The Ford Foundation Rose Muscatine Hauer Director of Nursing Service, Dean, School of Nursing, Beth Israel Medical Center, New York City Robert Kinsinger Vice President, W.K. Kellogg Foundation Wayne R. Kirschling Deputy Commissioner, Indiana Commission for Higher Education Lucille Knopf Division of Research, National League for Nursing Mary Nell Lehnhard Executive Washington Representative, Federal Financing and Tax Legislation, Blue Cross and Blue Shield Association Lawrence S. Lewin President, Lewin and Associates, Washington, D.C. * Robert A. Wallhaus Deputy Director for Academic and Health Affairs, Illinois Board of Higher Education * Ruby L. Wilson Dean and Professor, School of Nursing, Duke University
303 Advisory Panel on Data Needs for the TOM Study of Nursing and Nursing Education * Edward B. Perrin, chair Director, Health and Population Study Center, Battelle Human Af f airs Re search Centers Myrtle Aydelotte Executive Director, American Nurses' Association (retired December 1981), Consultant (January 1982) Walter Johnson Director of Research, National League for Nursing Wayne R. Kirschling Deputy Commissioner, Indiana Commission for Higher Education Evelyn B. Moses Acting Chief, Data Development and Evaluation Section, Division of Health Professions Analysis, Health Resources Administration, Department of Health and Human Services Now with Division of Nursing, Bureau of Health Professions Analys i s, HRSA, DHHS Carol S. Weisman Assoc late Professor, School of Hygiene and Public Health, Johns Hopkins Univers ity Advisory Panel on Intervention Strateg ies to the TOM Study of Nursing and Nursing Education * Robert C. Wood, chair (November 1981-January 1982) Direct or of Urban Stud ies, Prof e s sor of P o l it ical Sc ienc e, Univers ity of Massachusetts Harbor Campus * Arthur E. Hess, chair (February 1982-April 1982) Scholar-in-Residence, Institute of Medicine, National Academy of Sciences * Otis R. Bowen Professor and Director, Undergraduate Family Practice Education, Indiana University School of Med icine Shirley S. Chater Vice Chancellor, Academic Af fairs, University of California, San F ranc i sc o Robert A. Derzon Vice President, Lewin and Associates, Inc., Washington, D . C .
304 Vernice D. Ferguson Director, Nursing Service, Veterans Administration Central Off ice Wayne R. Kirschling Deputy Commissioner, Indiana Commission for Higher Education Nan S. Robinson Vice President for Administrat ion, Rockef eller Foundat ion F rank A. S loan Professor of Ec onomics, Vanderbilt University Nathan J. Stark Senior Vice Chancellor, Health Sc fences, University of Pittsburgh Advisory Panel on Nursing Education/Nursing Service to the ION Study of Nursing and Nursing Education * Edyth H. Schoenrich, chair Assoc late Dean, Johns Hopkins University School of Hygiene and Pub 1 ic Hea 1 th Virginia Allen Director of Accreditation, National League for Nursing Myrtle Aydelotte Executive Director, American Nurses' Association (retired December 1981), Consultant (January 1982) Madeline A. Bohman Executive Director, Bellevue Hospital Center, New York City Rose Marie Chioni Dean, School of Nursing, University of Virginia Barbara A. Donaho Corporate Director of Nursing, Sisters of Mercy Health Corporation Sister Rosemary Donley Dean, School of Nursing, Catholic University of America * David H. J eppson Executive Vice President, Intermountain Health Care, Inc., Salt Lake C ity, Utah Patric ia Perry Dean, Bishop Clarkson Memorial Hospital College of Nursing, Omaha, Nebraska
305 Doris L. Wagner Chief Nurse, Bureau of Public Health Nursing, Division of Public Health, The Health and Hospital Corporation of Marion County, Indianapolis, Indiana Advisory Panel on Trends and Projections to the IOM Study of Nursing and Nursing Education Charles D. Flagle, Chair Professor and Head, Division of Operations Research, Department of Health Services Administration, Johns Hopkins University School of Hygiene and Public Health John Drabek Chief of Supply and Requirements, Forecasting Branch, Health Resources Administration, U.S. Department of Health and Human Services Hesook Susie Kim College of Nursing, University of Rhode Island * * Carol Lockhart Director, Division of Health Resources, Arizona Department of Health Services, Phoenix William Lo saw Statistician, Health Resources Administration, Department of Health and Human Services Scott A. Mason President, National Health Advisors, Ltd., McLean, Virginia Edward B. Perrin Director, Health and Population Study Center, Battelle Human Affairs Research Centers -- John D. Thompson Professor of Public Health and Chief, Division of Health Services Administration, Yale University School of Medicine Richard F. Tompkins Deputy Director, Study of the Costs and Financing of Graduate Medical Education, Arthur Young and Company Donald E. Yett Professor of Economics and Director, Human Resources Research Center, University of Southern California
306 Economics Workshop of the IOM Study of Nursing and Nursing Education October 16, 1981 Part ic ipant s * Isabel V. Sawhill, chair Senior Fellow, The Urban Inst itute -- Linda H. Aiken Vice President for Research, The Robert Wood Johnson Foundation -- Stuart H. Altman Dean, The Florence Helter Graduate School for Advanced Studies in Social Welfare, Brandeis University Myrtle Aydelotte Ex ecut ive Direc tar, American Nurse s ' As sac fat ion (ret ired De cember 1981), Consultant (January 1982) Haro Id Cohen Executive Director, Maryland Health Services Cost Review Commission * Charles D. Flagle Professor and Head, Division of Operations Research, Department of Health Services Administration, Johns Hopkins University School of Hygiene and Public Health Lois Friss Assistant Professor, Graduate Program in Health Services Admini s trat ion, S chool of Pub 1 ic Admini s trat ion, Univers ity of Southern Calif ornia He id i I. Hartmann Assoc late Executive Director, Commission on Behavioral and Social Sciences, and Education, National Academy of Sciences Jesse S. Hixson Chief, Modeling and Research Branch, Division of Health Professions Analysis, Hea 1th Resources Adminis trat ion ·: David H. Jeppson Executive Vice President, Intermountain Health Care, Inc., Salt Lake C ity, Utah Charles R. Link Professor, Department of Ec onomics, University of De [aware Russell F. Sett le Assoc late Professor, Department of Economics, University of Delaware
307 Frank A. Sloan Prof es sor of Ec anomie s, Vanderb i It Univers ity Gary S. . Syke s NIE Assoc late, National Institute of Education * John D. Thompson Professor of Public Health and Chief, Division of Health Services Admi ni s t rat ion, Yale Univers ity S choo 1 of Med ic ine William White Associate Professor, Department of Economics, University of Illinois at Chic ago Donald E. Yett Professor of Ec anomies and Director, Human Resources Research Center, University of Southern California Advanced Nurse Education Workshop of the ION Study of Nursing and Nursing Educ at ion March 9-10, 1982 * Edyth H. Schoenrich, chair Assoc late Dean, School of Hygiene and Public Health, Johns Hopkins Univers ity Faye G. Abdellah Deputy Surgeon General and Chief Nurse Officer, U.S. Public Health Service * Ira Trail Adans Dean and Professor, College of Nursing, University of Tulsa Kathleen C. Andreoli Executive Director of Academic Services, Office of the President, School of Nursing, The University of Texas Health Science Center Myrtle Aydelotte Executive Director, American Nurses' Association (retired December 1981), Consultant (January 1982) Madeline A. Bohman Ex ec ut ive Di rec t or, Be 1 revue Ho sp it al Center, New York C i ty Pauline F. grimmer Director, Research and Policy Analysis Department, American Nurses' As s oc i at ion
308 Joan E. Caserta Assistant Commissioner of Health for Personal Health Services, Westchester County Department of Health Rose Marie Chioni Dean, School of Nursing, University of Virginia Luther Christman The John L. and Helen Kellogg Dean, College of Nursing, Rush University Anna B. Coles Dean and Professor, College of Nursing, Howard University Verla Collins Director of Nursing Education and Education Information, Intenmountain Health Care, Inc. Peter Dans Associate Professor and Director, Office of Medical Evaluation, Johns Hopkins University School of Hygiene and Public Health Robert A. Derzon Vice President, Lewin and Associates, Inc. Donna Diers Dean, School of Nursing, Yale University Barbara A. Donaho Corporate Director of Nursing, Sisters of Mercy Health Corporation Sister Rosemary Donley Dean, School of Nursing, Catholic University of America Jo Eleanor Elliott Director, Division of Nursing, Bureau of Health Professions Analysis, Health Resources and Services Administration, Department of Health and Human Services Eunice K. M. Ernst Director, Cooperative Birth Center Network--Maternity Center Association, Perkiomenville, Pennsylvania Geraldene Felton Dean, College of Nursing, University of Iowa Vernice D e Ferguson Director, Nursing Service, Veterans Administration Central Office
30-9 Cynthia Freund Director, Nursing Administration Program, School of Nursing, Univers ity of Pennsylvania He ten Grac e Dean, College of Nursing, University of Illinois Medical Center John R. Hogness President, As sac fat ion of Ac ademic Health Centers Ada K. Jacox Prof essor of Nurs ing and Direc tar, Center f or Re search, School of Nursing, University of Maryland Jean E. Johnson Professor in Nursing and Associate Director of Oncology Nursing in Cancer Center, University of Rochester Medical Center Jean A. Kelley Assistant Dean, Graduate Program, School of Nursing, University of Alabama at Birmingham Jerri Laube Dean and Professor, School of Nursing, University of Southern Mis sis sippi Barbara J. Lee Program Director, W. K. Kellogg Foundation (retired October 1982) * Carol Lockhart Director, Division of Health Resources, Arizona Department of Health Services, Phoenix Barbara tiertman Lowery Associate Professor, School of Nursing, University of Pennsylvania Jannetta MacPhail Dean and Professor, School of Nursing, University of Alberta Kathleen McCormick Assistant for Research to the Chief, Nursing Department, National Inst itutes of Health Maurice I. May Chief Executive Officer, Hebrew Rehabilitation Center for the Aged Clarion I. Murphy Executive Director, American Association of Colleges of Nursing
310 Patricia Perry Dean, College of Nursing, Bishop Clarkson Memorial Hospital, College of Nursing, Omaha, Nebraska Jessie M. Scott Associate Professor, School of Nursing, University of Maryland F rank A. Shaf f er Director, Continuing Education Service and Director, National Forum of Administrators of Nursing Services, National League for Nursing Barbara J. Stevens Director, Division of Health Services, Sciences, and Education, Teachers College, Columbia University Frances D. Tompkins Director of Nursing, Union Memorial Hospital, Baltimore, Maryland Rheba de Tornyay Dean and Professor, School of Nursing, University of Washington Debbie Turner Professional Staff Member, Committee on Labor and Human Resources, United States Senate Patric ia L. Valoon Director of Nursing, University Hospital, New York University Medical Center Doris L. Wagner Chief Nurse, Bureau of Public Health Nursing, Division of Public Health, The Health and Hospital Corporation of Marion County, Ind ianapo l i s, Ind iana The lma We 11 s As s oc fat e Prof e ssor, Schoo 1 of Nurs ing, Univers ity of Michigan Carolyn Wil limes Assoc late Professor of Nurs ing and Ep idemiology, School of Public Health, University of North Carolina Ruby L. Wi lson Dean and Professor, School of Nursing, Duke University
