Addressing the Nursing Shortage:

Nurse Education, Expansion, and Development Act of 2007

Omar AbdelghanyFarida ReyesMandy ReynoldsMonica SchlaichMeghann Shannon

INTRODUCTION

The Nursing Shortage• The total number of nurses working in the field has decreased

from 2,669,603 in the year 2000 to 2,262,020 in year 2001.

FTE Supply Implications of Changes in Projected Number of New Graduates from U.S. Nursing Programs

www.aacn.nche.edu/Media/FactSheets/NursingShortage.htm

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OVERVIEW OF NURSING SUPPLY

MODEL

http://bhpr.hrsa.gov/healthworkforce/reports/behindrnprojections/2.htm

• Growing number of nurses with doctoral degrees are choosing careers outside of education

• Average age of nurse faculty at retirement is 63.1 years (2006)

• Master’s & doctoral programs aren’t producing a large enough pool of potential educators to meet projected demand

• According to 2004 Monthly Labor Review of the Labor of Statistics, more than 1 million new & replacement nurses will be needed by 2012

Congress Finds …

Congress Finds …

• While the Nurse Reinvestment Act helped to increase applications to schools, it has been unable to accommodate the influx because of insufficient numbers of educators

▫ 66.6% of schools had from 1 – 18 vacant faculty positions (2006-2007)

▫ 16.7% of schools needed additional faculty, but lacked resources needed to add more positions (2006-2007)

▫ 41,683 eligible candidates were denied admission due to insufficient faculty (2005)

OVERVIEW OF NEED

S. 446, the Nurse Education, Expansion, and Development Act of 2007, was introduced on February 1, 2007 to amend Title VIII of the Public Health Service Act, to authorize capitation grants.

Capitation grants: are formula grants based on the number of students enrolled. Administered by the Health Resources and Services

Administration (HRSA) grants may be used to hire new and retain current faculty,

purchase educational equipment, enhance clinical or audiovisual laboratories, repair and expand infrastructure, or recruit students.

Recipient institutions would receive the following for each student enrolled: $1,800 per year for master’s/doctoral students, $1,405 for bachelor’s or entry-level master’s students, and $966 for associate degree students. Currently ~ 40 programs that award competitive grants &

contracts

NEED ACT: Capitation Grants

http://www.ncsl.org/programs/health/forum/78grants.htm

NS93265010Go!

Capitation Grants From 1971 – 1978, Congress provided capitation grants funding

to schools of nursing in support of nursing education

Nurse Training Act of 1971 (P.L. 92-158) Nurse Training Act of 1975 (P.L. 94-63)

Capitation grants have had a stabilizing effect on past shortages.

Also recognized as a strategy to resolve the nursing shortage:

January 1974 – IOM cost study endorsed capitation grants as an appropriate federal undertaking to provide a stable source of financial support for nursing & other health profession schools.

March 2002 – HRSA’s Tenth Report to Congress on Health Personnel in the US recommended capitation grants funding as a strategy to expand the nursing workforce pipeline.

http://www.aacn.nche.edu/Government/pdf/07CapitationFS.pdf

Eligibility to Participate1) Accredited by a nursing accrediting agency

recognized by the Secretary of Education

2) Has a passage rate on the National Council Licensure Examination for Registered Nurses of not less than 80% for each of the 3 years preceding submission of grant application

3) Has graduation rate of not less than 80% for each of the 3 years preceding submission of grant application

Requirements1) Maintain passage rate of not less than 80% on the National

Council Licensure Examination for Registered Nurses2) Maintain graduation rate of not less than 80%3) The 1st year enrollment of full-time students will exceed

enrollment for the preceding year by 5% or 5 students, whichever is greater

4) Not later than 1 year are receipt of grant, school will formulate & implement plan to accomplish at least 2 of the following: Establish/significantly expand an accelerated baccalaureate

degree to graduate new nurses in 12-18 months Establish cooperative intradisciplinary education with a view

toward shared use of technological resources Establish cooperative interdisciplinary training between

schools of nursing & allied health, medicine, dentistry, etc Integrate core competencies on evidence-based practice,

quality improvements, & patient-centered care5) School will submit an annual report to the Secretary that

includes updated info on school with respect to enrollment, retention, graduate & passage rates, employment, & number accepted into graduate programs

6) School will allow Secretary to make on-site inspections & will comply with requests for info to determine extent to which school is complying

HISTORICAL LEGISLATION &

POLICY EFFORTS

II. Historic Legislation and Policy Efforts

•Nurse Reinvestment Act: Passed by President George W. Bush on August 1, 2002.

•The Reinvestment Act established:▫ Nurse Scholarships▫ Nurse Retention▫ Public Service Announcements▫ Faculty Loan Cancellation Program

•How does this tie in with the NEED Act of 2007?

Previous Legislative Efforts •While the Nurse Reinvestment Act helped

to increase applications to schools of nursing by 125 percent, schools of nursing have been unable to accommodate the influx of interested students because they have an insufficient number of nurse educators.

Previous Legislative Efforts• NEED Act of 2004▫ 61.5% of schools of

nursing had 1-15 vacant positions

▫ 18,105 eligible candidates denied admission

▫Average retirement age: 62.5; Average doctorally-prepared nurse age: 53.5

• NEED Act of 2007▫ 66.6% of schools of

nursing had 1-18 vacant positions

▫ 41,683 eligible candidates denied admission

▫Average retirement age: 63.1; Average doctorally-prepared nurse age: 54.7

KEY ISSUES FOR REPUBLICANS

Key Issues for Republicans Stance on governmental intervention on Educational/Workforce issues:

Belief that intervention should come from local & state

• Under American Constitutional system, education is a state, local, & family responsibility• > 90% public school funding is at the state & local level

Role of federal government must be limited in order to return control to parents, teachers, & local school boards

Key Issues for Republicans

Applicable Republican Principles: One of Republican principles states that “a

government must practice fiscal responsibility & allow individuals to keep more of the money they earn.”

Also that “the proper role of government is to provide for the people only those critical functions that cannot be performed by individuals or private organizations, & that the best government is that which governs least.”

Key Issues for Republicans

President Bush’s Budget for FY 2008 Requested 30% reduction in funding for Nursing

Workforce Development Programs (Title VIII of Public Health Service Act)

Funding went from $149.7 million to $105.3 million

Advanced education for nursing which provided support to ~ 12,000 graduate nursing students was completely eliminated

In area of nursing the only program whose funding was increased was in research

KEY ISSUES FOR DEMOCRATS

Key Issues for Democrats Two of the three sponsors of the NEED Act

are Democrats and 32 of the 34 cosponsors are Democrats.

The nursing shortage is a national problem so Democrats feel federal legislation and funding should be enacted to help alleviate the shortage.

Key Issues for Democrats There is not a lack of students, but a lack

of nurse educators to teach those students.

As Dr. Harriet Feldman, dean of the Lienhard School of Nursing at Pace University and a strong NEED advocate said: "Without a sufficient number of registered nurses, patient safety is constantly compromised.“

Key Issues for Democrats In 2004, more than 32,000 qualified students

were turned away from baccalaureate and higher degree nursing programs.

In 2006, 3,306 qualified applicants were turned away from master's programs, and 299 qualified applicants were turned away from doctoral programs. The primary reason for not accepting all qualified students was a shortage of faculty.

Democrats believe that government must take responsibility and interfere.

Key Issues for Democrats

•Congresswoman Nita Lowey: “My legislation will increase the number of available nurses by allowing nursing schools to invest in more instructors and improved equipment to increase their ability to enroll qualified applicants.”

POLICY & FISCAL IMPLICATIONS

Implications of the Various Approaches Scenario 1: If legislation addressing nursing education and shortages is

discouraged, we are left with market forces. A catch 22: The further a market stays from being perfectly competitive, the

more unlikely that “natural” market processes will adequately address supply and demand issues. Market-based solutions to the nursing shortage are unlikely to work because of the existence of government regulation in the health care market, and because of social views that it is a moral imperative that people receive care when they are ill.

Extra-market views about health care interfere with what market forces would provide, making government regulation of the health care market necessary.

In a True Market In U.S. Healthcare

If you don’t have money (insurance), you don’t receive care.

Our societal (extra-market) views have yielded safety nets, free clinics, emergent care without insurance, etc.

The price of a good or service attracts exactly as much demand as the market can currently supply.

There is an imperfect demand for services because consumers are dependent on health care plans, or in many cases have no coverage at all.

In economics, information asymmetry occurs when one party to a transaction has more or better information than the other party.

Consumers do not have perfect information about the services that are available or what is best for their specific needs.

Second best market in action, or maybe more appropriately

inaction. Increased regulations during the 1990s

Decreased Medicaid and Medicare reimbursements. Profits were determined by Health Maintenance Organizations (HMOs)

RNs were replaced by LPNs and Nurse Aides.

The remaining RNs had new burdens Many nurses left the profession.

Creation of a negative image of nursing as a profession. ------------------------------------------------------------------- Market Imperfections have exacerbated education pipeline issues.

There are a limited number of nurses working in hospitals, nursing schools. Trouble matching students with clinical supervisors in the hospital. Plays a role in how may students schools accept.

Implications of the Various Approaches Cont.

Scenario 2: For patient safety to be made a priority, legislation is needed to fund enrolling more qualified applicants and hiring more instructors. While significantly more spending will be required to help

reduce the problem of the nursing shortage, hospital administrators also must address all 3 dimensions of the problem before real progress can occur in increasing the nursing supply.

While NEED Act is a laudable step in the right direction, it explicitly does not address the fundamental issues of work conditions. These problems require that hospital administrators and state and national policymakers expand their vision beyond attracting more individuals into the profession.

The NEED Act neglects reducing the high turnover rate in this profession. The act must make sure the significant monetary and resource investment in training new nurses produces a lasting effect on the job market.

What Should We Regulate? The national nursing shortage is a 3 Dimensional problem:

1. A declining number of new nurses entering the workforce.2. Retention of nurses in hospitals.

Mechanisms to keep nurses in hospitals will address findings that 40% of nurses working in hospital jobs report being dissatisfied with their jobs, compared to other professions where 10% to 15% of workers report dissatisfaction.

As long as hospitals under-staff their nursing units, require nurses to float from unit to unit, require mandatory overtime, and disrespect their nurses in general, the constant high turnover in the nursing profession will continue.

3. Nurses retiring or leaving the workforce early. The physical nature of nursing influences early retirement.

Hiring more assistive staff to help nurses, or having less physical roles available to older nurses could keep nurses working longer.

If the various views were to meet in the Middle

We would have…

Lets Not Forget About Texas

Texas Nursing Reduction Act of 2001: Texas was one of the first states to address the

nursing shortage from a legislative perspective, specifically bolstering the nursing education infrastructure. The Texas Nurses Association (TNA)

wanted to develop a strategic plan for Texas TNA gathered partners

The Texas Nurses Foundation The Texas Hospital Foundation Texas Institute for Health Policy Research The Greater Houston Partnership (economic research

co.) The University of Texas at San Antonio’s, Center for

Health Economics and Policy (CHEP).

Describing the Problem Texas’ research data confirmed that there was

a shortage, and attributed the Texas shortage to these key factors: an aging nursing workforce an aging faculty workforce a growing and aging Texas population alternative employment opportunities for women

Intervention Arrives From Local & State Efforts

The legislation attempted to addressed the key issues found in the research conducted by CHEP. Legislation was responsible for:1. Amending the current Texas Higher Education Coordinating Board

financial aid program for nurses. 2. Allowed greater flexibility in using funds to provide the number

and types of nurses that Texas would need in the coming years.3. Provided nursing schools adequate resources to increase their

enrollments. 4. There was also a portion of the legislation aiming to encourage

innovation for recruitment and retention of students. 5. The policy provided sufficient faculty numbers by increasing the

salaries for nurse educators. 6. The policy planned to increase the number of nursing faculty by

providing two incentives for nurses to become nurse-educators: First, granting colleges the authority to allow out-of-state graduate

nursing students the opportunity to pay in-state tuition if they agree to teach at a Texas school of nursing after completion of their advanced degree.

Second, by expanding the financial aid for graduate students going into teaching .

Money, Money, Money An important part of the strategy by The Texas Nursing

Association was to identify money in the state budget to appropriate to the nursing shortage. Dramatic Growth Fund with $22.5 million was made available to

schools of nursing. To access this fund, nursing programs had to illustrate an adequate increase in student enrollment. These funds could be used to support faculty salaries and as operating funds for the nursing programs.

The legislation reallocated almost$4 million from the tobacco lawsuit, to be used exclusively for nursing education. Nursing Innovation Grants were created and funded through the

reallocation of tobacco settlements, which resulted in $2.4 million for competitive grants. These grants focused on the recruitment and retention of students.

A smaller fund of $1.5 million was generated to pay faculty who teach an over-load class

Legislation Impact In Texas

Texas public schools of nursing saw a 18.9% increase in their enrollments between the fall of 2000 and fall of 2002. This is particularly significant because the

national data during about this same time period indicated only an 8% increase in the enrollment in schools of nursing.

Health science centers proved to be even more successful by increasing their enrollment of nursing students by 26.9%.

Fiscal Implications If you agree with the democrats, that the nursing

shortage is a national problem so federal legislation and funding should be enacted to help alleviate the shortage. Then either Taxes or the deficit will increase

OR PayGo must be used, and funding will have to be cut

from somewhere else.

If you side with the republicans that intervention should come from local & state, and it likely would have to given the president’s 2008 budget for Nursing Workforce Development Programs, then There must be money to spare or costs to eliminate in

your state’s budget.

PROPOSED LEGISLATION

III. Proposed Legislation

•Amend the current NEED Act 0f 2007 to include that funding would be used to:▫Pay nurse educators more money. ▫Improve the work environment.▫Improve the physical options for older

nurses.

http://www.nursingadvocacy.org/media/commercials/jnj_2005.html#nurse_scientist

Rationale

•According to the Monthly Labor Review of the Bureau of Labor Statistics, more that 1,000,000 new and replacement nurses will be needed by 2012.

•Surveyed nurses agree that improving nurse-to-patient staffing will provide the best cost-effective patient safety intervention.

Target Groups•Nursing students▫Undergraduate ▫Graduate

•Nursing faculty & educators

•Nurses currently in workforce

•Universities/Institutions providing education to nurses

Mechanism

•New proposed legislation must focus on:

▫Keeping nurse educators out of direct care

▫Decreasing nurse turnover through having necessary equipment and high satisfaction

Mechanism

•Nurse Educators:

▫Entice nurse educators to work more in the classroom setting by allocating money specifically for their services

▫Nursing schools nationwide are struggling to find new faculty to accommodate the rising interest in nursing

Mechanism

•Nurse Educator Services:▫Designing, implementing, evaluating and

revising academic and continuing education programs for nurses

▫Assuring quality educational experiences that prepare the next nursing workforce

▫Advising students ▫Engaging in scholarly work (e.g., research) ▫ Participating in professional associations

Mechanism•Nurse Educator Services (cont):▫Speaking/presenting at nursing

conferences ▫Contributing to the academic community

through leadership roles ▫Engaging in peer review▫Maintaining clinical competence ▫Writing grant proposals ▫Evaluating learning ▫Documenting the outcomes of the

educational process.

Mechanism • Retaining Current Workforce:

▫ Between 200 and 300 doctoral-prepared faculty will be eligible for retirement each year from 2003 through 2012, and between 220-280 master's- prepared nurse faculty will be eligible for retirement between 2012 and 2018.

▫ The proportion of RNs with nursing doctorates who were employed in nursing schools with baccalaureate and higher degrees dropped from 68% in 1992 to 49% in 2000.

Mechanism•Retaining Current Workforce:

▫Clinical and audiovisual laboratories must be enhanced so that nursing faculty has the equipment and infrastructure they need

▫ Salaries must be raised because higher compensation in clinical and private-sector settings is luring current and potential nurse educators away from teaching

Financing The NEED ACT is an AUTHORIZATION

BILL, which provides the authority for a program or agency to exist and determines its policy. It recommends spending levels to

carry out the defined policy, but these levels are not binding.

$75 million for FY 2005, $85 million for FY 2006, and $95 million for FY 2007.

Without increased federal support, the potential for future growth in nursing education programs may be limited at a time when the demand for well-educated nurses is rising.

Summary• Our legislation wants to follow up the 2002

Reinvestment act, by correcting why it was not the end solution to the nursing shortage. because...

#1 To get more nurse educators, the pay must be more than those nurses can earn in the community.

#2 Fix the work environment so nurses stay working. That way the country will not need a brand new supply every couple years.  We must to beat the rate of retirement and career change in nursing with better conditions, not just new nurses.

Outcomes• The expectation is to see a dramatic improvement in the nursing deficit as a result of

our legislation. We hope for bypartisan support, as our legislation:

▫ Will ensure that the 2002 Reinvestment Act was money well spent, by keeping the nurses that act recruited and financed the education of happy and longevitious in their jobs. Our legislation will help to apply the funding already made available for nursing education, by creating enough teachers to expand school enrollment.

▫ Our legislation is justified in its national breadth because this is truly a nation wide problem that is not already, or adequately state legislated

According to the Department of Health and Human Services, the number of states with a shortage of RNs is expected to only grow from 30 states in 2000. By the year 2015, all 50 states will experience a shortage of nurses to varying degrees.

Presently, only four states have legislation to address the RN and nurse educator shortage over the next 5 to 10 years. Four more states, including Texas, have legislation for the shortage of nursing students and low nursing school capacity.

Finally, as of December 2002, eight states had implemented laws or regulations that ban or limit mandatory overtime.

QUESTIONS???

SourcesNurses for a Healthier Tomorrow. Nurse Educator. http://

www.nursesource.org/nurse_educator.htmlAmerican Associate of Colleges of Nursing. Dr. Harriet Feldman

Testifies Before Congress in Support of AACN’s Recommendations to Alleviate the Nurse Faculty Shortage. 2005 Press Release. http://www.aacn.nche.edu/Media/NewsReleases/2005/FeldmanTestimony.htm

American Association of Colleges of Nursing: Fact Sheet: Nursing Shortage. March 2007. http://www.aacn.nche.edu/Media/FactSheets/NursingShortage.htm

Health Resources and Services Administration. What is Behind HRSA’s Projected Supply, Demand, and Shortage of Registered Nurses? US Department of Health and Human Services. http://bhpr.hrsa.gov/healthworkforce/reports/behindrnprojections/2.htm

SourcesHenderson, Tim & Scanlon, Anna. Federal Title VII and Title VIII

Health Professions Training Grants: Their Importance in Improving Access to the Health Workforce in Arkansas, Minnesota and Texas. March 2002. http://www.ncsl.org/programs/health/forum/78grants.htm

Berliner, H. B., Ginzberg, E. “Why This Hospital Nursing Shortage Is Different”. JAMA. (2002) Vol.288:2742-2744. Available: http://jama.amaassn.org.lp.hscl.ufl.edu/cgi/content/full/28/21/2742

Wagner, E., Brown, A. F., & Miner, M. “Addressing the Nursing Shortage as a Market Failure”. December 7, 2005. Available: https://www.utexas.edu/research/cshr/pa393k/Previous_smesters/NursingShortage.report.rtf

American Associate of Colleges of Nursing. FY 2007 Recommendations: Support Capitation Grants Legislation. February 2006. http://www.aacn.nche.edu/Government/pdf/07CapitationFS.pdf

Sources:• Kaiser Family Foundation “Addressing the Nursing Shortage”

http://209.85.165.104/search?q=cache:SkGSv2CotWYJ:www.kaiseredu.org/topics_im.asp%3FimID%3D1%26parentID%3D61%26id%3D138+nursing+shortage,+states+with+legislation&hl=en&ct=clnk&cd=1&gl=us&client=firefox-a

• American Association of Colleges of Nursing. http://209.85.165.104/search?q=cache:Qq0Xyw8qkiIJ:www.aacn.nche.edu/Media/shortageresource.htm+nursing+shortage,+states+with+legislation&hl=en&ct=clnk&cd=2&gl=us&client=firefox-a

• www.thomas.loc.gov• www.beavoter.org• www.aacn.nche.edu• www.endonurse.com• www.nursezone.com• www.cspan.org• www.wikipedia.com• www.gop.com