Good
afternoon, Mr. Chairman and Members of the Committee. Thank you for inviting me
to speak to you today on educating the future nursing workforce. I am Jean Bartels,
PhD, RN, Chair of the School of Nursing at Georgia Southern University in Statesboro,
Georgia. I am here presenting the views of the American Association of Colleges
of Nursing (AACN) which represents 556 baccalaureate and graduate schools of nursing
across the United States. I am heartened that the Congress is investigating the
nationwide shortage of nurses available to care for our citizens. I am hopeful
that Congress will invest in our health care education infrastructure, part of
which is the 2.7 million nurses that make up the backbone of the health care workforce.
The
Current Nursing Workforce
Registered
nurses (RN) are the nation's largest group of health care professionals that provide
up to 98% of all patient care in hospitals and other settings. With more than
four times as many RNs in the United States as physicians, nurses comprise the
largest single component of hospital staff and deliver most of the nation's long-term
care. Most health care services require some form of nursing care. Of the nation's
2.7 million registered nurses, 2.2 million or 81.7% report being employed in nursing.
The average age of the RN is 43; 12.3% come from racial/ethnic backgrounds; only
5.4% are men.
Approximately
60% of all RNs are employed in hospitals. This percentage has declined in recent
years as health care has moved beyond the hospital into a wide range of settings.
In addition to hospitals, today's nurse practices in health maintenance organizations,
public health agencies, primary care clinics, private practices, home health care,
nursing homes, outpatient surgicenters, nurse-managed health centers, insurance
and managed care companies, schools, mental health agencies, hospices, the military,
and private industry.
Nurses
practice in collaboration with physicians and health professionals from other
disciplines. The role of the professional nurse ranges from direct patient care
and case management to establishing nursing practice standards, developing quality
assurance procedures, and directing complex nursing care systems. The average
salary for an RN who was employed full-time in 2000 was $46,782.
According
to the first National Sample Survey of Registered Nurses prepared in 1980
by the Division of Nursing (DoN) within the Department of Health and Human Services,
almost 63% of RNs held a hospital diploma as their highest educational credential,
17.3% a bachelor's degree, and 19% an associate degree. According to the most
recent survey data released for the year 2000, a diploma was the highest educational
credential for only 29.6% of RNs, while the number with bachelor's degrees has
climbed to 29.3%, and the number of associate degrees to 40.3%.
The
Emerging Nursing Shortage
The
United States is in the midst of a nursing shortage that is projected to intensify
as baby boomers age and the need for health care grows. Compounding the problem
is the fact that the pipeline of new nurses is shrinking and a significant part
of the current nursing workforce is planning to leave the profession.
In
February 2001, the DoN reported that the nursing workforce in the United States
increased 5% in size since 1996 -- the smallest increase reported in the 20 years
in which this data has been collected. As the number of RNs is leveling off, the
demand for nurses is increasing. The U.S. Bureau of Labor Statistics projects
that the number of RNs needed to deliver care will grow by almost 22% by 2008,
with a projected need of 794,000 new RNs. This growth rate is faster than the
average of all other occupations.
The
Government Accounting Office reported in July 2001 that "a serious shortage
of nurses is expected in the future as demographic pressures influence both supply
and demand." Other federal projections indicate that by 2010, the demand
for RNs will begin to outstrip the anticipated supply, and that by 2020, demand
will grow nearly twice as fast as the expected increase in the RN workforce. By
the year 2020 the nation's health care system will experience a 20% shortage in
the number of nurses needed-a shortage of more than 400,000 RNs nationwide, according
to a June 2001 Journal of the American Medical Association report by Peter
Buerhaus, Phd, RN, FAAN. Although health care continues to shift beyond the hospital
to more community-based primary care and other outpatient sites, federal projections
say the rising complexity of acute care will see demand for RNs in hospitals climb
by 36% by 2020.
Projections
aside, our nation's hospitals need 126,000 nurses now, according to data published
in June 2001 by the American Hospital Association. Of all hospital vacancies today,
75% are for nurses.
A
factor contributing to the slow growth in the nursing workforce is the decline
in nursing schools enrollments over the past six years. According to annual data
collected by the American Association of Colleges of Nursing (AACN), enrollments
in entry-level baccalaureate nursing programs are down 21% since 1995.
The
number of students taking the national licensure examination to become RNs is
also decreasing. The National Council of State Boards of Nursing reports the number
of first-time, U.S. educated nursing school graduates who sat for the NCLEX-RN®
(National Council Licensing Examination for Registered Nurses) decreased by 26%
between 1995 and 2000. A total of 25,046 fewer students in this category of test
takers sat for the exam in 2000 as compared with 1995.
Data
also show a dramatic increase in nurses exiting the profession. Although half
of the nation's RNs will reach or near retirement age within the next 15 years,
one out of every five practicing nurses is considering leaving the patient care
field for reasons other than retirement within the next five years according to
an April 2001 report from the Federation of Nurses and Health Professionals. An
alarming report published in May 2001 by Linda Aiken, PhD, RN, FAAN, FRCN indicates
that more than 40% of nurses working in hospitals are dissatisfied with their
jobs, and one out of every three hospital nurses under the age of 30 is planning
to leave her or his current job in the next year.
The
Georgia Experience: Georgia's nursing shortage reflects what is happening
nationwide. In June 2001 the Governor's Health Care Workforce Technical Advisory
Committee reported that with a deficit of more than 2,000 RNs in hospitals and
nursing homes alone, Georgia risks potentially catastrophic shortages in the near
future if it does not act quickly to address the shortage. In addition, the data
show that vacancy rates for nurses in Georgia is 13% in hospitals, 15.4% in nursing
homes, and 17.4% in public health departments. While Georgia's demand for nurses
this year is 52,000, its projected supply of nurses is only 50,000. Equally troubling,
this deficit is expected to continue to grow rapidly as Georgia's population and
nursing workforce ages. The growth in Georgia's elder population is up 49.6% for
ages 50-59, 9.4% for ages 60-69, 17.4% for ages 70-79, and 34.2% for age 80 and
above. Comparably, the age distribution of nurses is rising. Only 25% of Georgia's
nurses are aged 30-39, while 35% are aged 40-49, 20% are 50-59, and 10% are over
60 years of age. If this pattern continues, by 2020 the supply of RNs is predicted
at best to be 60,000 with a demand of 72,000 nurses. The
number of new licenses awarded to RNs in Georgia is declining dramatically, as
are enrollments in undergraduate nursing programs. Georgia is in the bottom 10%
of states in the number of RNs per capita (712.5 nurses per 100,000 population
compared to U.S. average of 797.7 nurses per 100,000). Consequently, Georgia ranks
40th of the 50 states in terms of nursing workforce supply. Similarly, there are
20.7 per 100,000 Advanced Nurse Practitioners in Georgia compared with the U.S.
average of 26.3 per 100,000. Georgia ranks 34th of the 50 states in the delivery
of advanced practice nursing care.
In
fiscal year 2000, 1,000 fewer nurses received RN licenses in Georgia than in 1996,
which is directly tied to declines in student enrollment. The University System
of Georgia reports that enrollments in nursing programs have dropped significantly
since 1993 -- 8,000 in 2001 compared to 23,000 in 1993. Much of this drop in enrollment
is attributed to a decrease in associate degree program candidates as individuals
realize the necessity for a Bachelor of Science in Nursing (BSN) in today's health
care system coupled with the increases in time required for associate degree completion,
program credits required for an associate degree, and expenses associated with
attending an associate degree program. The number of graduations from all nursing
programs in Georgia has decreased from 1,671 in 1991 to 1,358 in 2000.
Nursing
Education Today
Today
there are approximately 1,666 schools of nursing educating more than half (52%)
of all health profession students in the United States. Of that total, 695 are
educating students at the baccalaureate and graduate level. For the sixth consecutive
year, enrollments in entry-level baccalaureate programs in nursing have declined
according to AACN data. Since 1995 enrollees have declined 21.1%; graduates have
declined 16.5%. On the average over the six-year period, the number of enrollees
and graduates have declined by 3,151 and 812 each year, respectively.
Nursing
educators look with trepidation at the six years of declining enrollments in baccalaureate
nursing programs and express doubts about the potential to turn that around. Students
express feelings of confusion that the professionals they seek to join encourage
them to change their majors expressing the view that to choose a nursing career
is a colossal mistake.
To
make matters worse, the current nursing shortage is creating calls to produce
more nurses from all entry-level programs with no focus on the varying competencies
of nurses from different educational programs. This short-term fix to bolster
the number of entry-level RNs fails to recognize its effects on efforts to recruit
baccalaureate-level students into nursing or the long-term impact on the profession.
During
a time of shortage of health care professionals, there is a predictable trend
to deregulate and substitute lesser-prepared persons. During previous nursing
shortages, Boards of Nursing have been pressured to reduce the requirements for
entry into the profession by decreasing the passing standard of the licensing
examination and/or waiving requirements for licensure. Other regulatory entities
have been pressured to lower agency staffing standards, for instance by allowing
unlicensed technicians to function in the emergency room without RN supervision
or by substituting unlicensed personnel for licensed nurses.
Lowering
educational standards is an inappropriate and potentially dangerous response to
a shortage of health care professionals. This short-term response will not help
to define the professional practice of nursing, will interfere with the delivery
of quality patient care, and is inconsistent with the long-term vision of what
nursing needs to look like.
Faculty
Shortages Contribute to the Nursing Shortage
Faculty
shortages at nursing schools across the country are contributing to the overall
decline in new enrollments. Data from AACN's 2000-2001 Enrollments and Graduations
in Baccalaureate and Graduate Programs in Nursing show nursing schools turned
away 4,967 qualified students across the United States due to insufficient number
of faculty, clinical sites, classroom space, clinical preceptors, and budget constraints.
More than a third (38.8%) of the schools surveyed pointed to faculty shortages
as a reason for not accepting all qualified applicants into entry-level baccalaureate
programs. In October 2000, AACN reported 336 vacancies from 209 responses to a
survey of 553 graduate schools of nursing. Sixty-four percent of these vacancies
were for individuals with the doctoral degree.
The
same factors that are affecting the nation's supply of practicing nurses are impacting
the supply of nurse educators. Nursing faculty are aging with nearly half (49.4%)
of new doctoral graduates being age 45-54; 6.5% are age 55 and older. With the
average age of full-time nursing faculty now 49, a wave of retirements is expected
to peak in just ten years. The pipeline of students planning to become educators
is inadequate to replace retiring nursing faculty with less than 1% of baccalaureate
nursing students indicating a desire to teach after graduation. Efforts to recruit
students into nursing programs must be complimented by initiatives to prepare
faculty and infrastructures to educate them.
Universities,
which generally pay less than private sector employers, must compete with expanded
opportunities that offer more lucrative benefits, less stressful work environments,
and 9-to-5 workdays to attract and keep nurses in teaching roles. Many educators
say faculty life presents a harder road than private practice or administration.
For clinical faculty in particular, hours are long and working conditions increasingly
arduous. RN staffing constraints and sicker patients have driven many hospitals
to limit or lower the number of nursing students they will accommodate for clinical
training. This reality forces faculty to scatter their charges more thinly over
several floors while still trying to provide adequate instruction and supervision,
as well as take responsibility for the students' assigned patients.
In
1998, 411 people graduated from doctoral programs in nursing, according to AACN
data. Of those, only 43% had an employment commitment to serve as nursing school
faculty. Another 17% had accepted non-academic positions. Compounding the problem
is the fact that once nurses begin working full-time, it is very difficult to
bring them back to study full-time for a doctoral degree. The majority of baccalaureate
graduates enter the workforce after an undergraduate program due to financial
need. The percentage of master's nursing students pursuing academic careers is
also on a steep decline, dropping 27.5% from 1997 to 1998 alone.
Colleges
and universities are caught up in a vicious cycle: lower enrollment equals less
revenue equals less faculty. Indeed, several schools report they have reduced
faculty numbers because of lower enrollments. Educators warn that while applicant
numbers inevitably will increase as word of the growing demand for nurses spreads,
enough educators simply will not be there to train the nursing workforce on which
the nation depends.
Georgia's
Faculty Shortage: To complicate the situation, serious shortages of nursing
faculty are causing Georgia schools to reduce or limit the number of students
admitted to nursing education programs. In Georgia, the average nursing faculty
age is just over 51 with 39% of current nurse educators planning to retire by
2005. If these retirees are not replaced, only 149 faculty will be left to cover
27 nursing programs representing an average of 5.5 faculty per program. Of note,
only four master's students graduating in 1998 from the Georgia University pipeline
indicated an interest in an academic career. A major reason cited for this lack
of interest is the fact that salaries for nursing faculty in Georgia are not competitive
with other states or with the practice environment.
Educational
Preparation and Necessary Skills for the Practicing RN
The
nursing profession has struggled for decades with concerns about educational preparation
and skill levels necessary for providing safe and appropriate nursing care. Educators
agree that nursing practice requires a strong background in the basic sciences
-- biology, anatomy, chemistry, pharmacology, pathophysiology. These basic sciences
lay the foundation for the assessment skills that allow for the formulation of
plans of care by nurses at the bedside. With patients in hospitals, long-term
care settings, and the home care arena having complex multi-system illnesses,
nurses must provide a critical level of assessment skills, employ highly complex
forms of health interventions, and use advanced technology. Sadly, the moments
available to provide gentle and personal care have been replaced more often than
not by technical tasks including monitoring blood gases, weening patients from
cardiac bypass pumps, and caring for a fragile, ventilated patient at home.
By
necessity nurses are becoming increasingly more knowledgeable in the assessment
and treatment of health systems problems. RNs are expanding their skill sets beyond
direct patient care to encompass the function and care of health systems. Nurses
continue to take on health systems roles in discharge planning, quality assurance,
utilization review, systems management, and information systems within different
health care settings. Nurses work in research settings on complicated protocols
in an effort to advance health science. Nurses bring their patient-centered, high
touch approach to these alternative nursing roles. Indeed, nursing practice and
care should expand beyond the bedside to allow for the growth of the professional
nurse and health care delivery. Currently,
there are three types of nursing programs that prepare students to sit for the
licensure exam, or NCLEX-RN®, to become registered nurses. Hospital-based
diploma programs offer a three-year education and were established in the 1800's
to educate nurses in the care of the hospitalized patient. Begun in the 1950's
in the wake of an earlier nursing shortage, associate degree nursing programs
offer a two-year curriculum focusing on the technical aspects of nursing care.
The four-year baccalaureate nursing programs were established at the turn of the
century to prepare nurse leaders to practice in hospitals and public health systems.
The
changing characteristics of the health care delivery system are resulting in dramatic
changes in the nature of education and may also require a reexamination of the
education required for nursing practice. AACN along with other leading nursing
organizations recognizes the Bachelor of Science degree in Nursing (BSN) as the
critical first step for a career in professional nursing and the minimum educational
requirement for professional nursing practice. While graduates can begin practice
as an RN with an associate degree or hospital diploma, the BSN degree is essential
for nurses seeking to perform at the case-manager or supervisory level or move
across employment settings.
The
BSN curriculum includes a broad spectrum of scientific, critical-thinking, humanistic,
communication, and leadership skills, including specific courses on community
health nursing not typically included in diploma or associate degree programs.
These abilities are essential for today's professional nurse who must be a skilled
provider, designer, manager, and coordinator of care.
A
recent report by the National Advisory Council on Nurse Education and Practice,
an advisory panel to the federal Division of Nursing, noted that baccalaureate
nursing programs are far more likely than other entry-level tracks to provide
students with on-site clinical training in non-institutional settings outside
the hospital. As a result, the BSN graduate is well-prepared for practice in such
sites as home health agencies, outpatient centers, and neighborhood clinics where
opportunities are fast expanding as hospitals focus more on acute care and health
services move beyond the hospital to more primary and preventive care throughout
the community.
Aware
of the expanding opportunities, RNs are seeking the BSN degree in increasing numbers.
Between 1975 and 2000, the number of RNs (with diplomas or associate degrees)
graduating from BSN programs rose from approximately 3,700 to 11,521 according
to AACN data. Indeed, enrollment of RNs who returned to school full-time in 2000
to pursue the BSN degree rose more than 7% above the previous year. Such numbers
indicate the high premium that nurses place on advanced education in today's growing
market, and the demand by employers for RNs who are baccalaureate-prepared.
Unfortunately,
in the nursing profession the question remains -- what makes a registered nurse?
-- a two-year associate degree education, a three-year diploma education, or a
four-year baccalaureate degree? The answer is that all levels and methods of educational
preparation allow students to sit for the patient care-focused NCLEX-RN® exam
and, if successfully completed, practice as a registered nurse. Confusing at best,
students are not prepared to make well-informed decisions regarding which educational
tract to pursue based on practice patterns or long-term career goals.
Creating
a Career Destination of Choice
The
current nursing shortage and the decreased interest in the profession are the
results of multi-faceted issues including the evolving health care delivery system,
the aging population, and the changing aspirations of young women who have traditionally
made up the bulk of new nursing students. In contrast with the 1970's, a nursing
career is not a desired option for most students.
The longitudinal American
Freshman Study indicates that an extremely small percentage of college freshmen
are choosing a nursing career. The J. Walter Thompson Company conducted a recent
national assessment comprised of ten focus groups with students in grades 2 through
10 found that young children, particularly those who plan to seek a college education,
do not see nursing as an attractive career option.
In
1995, a collaborative project of the AACN, the American Organization of Nurse
Executives, and the National Association of Associate Degree Nursing resulted
in a clear and bold statement of support for associate degree and baccalaureate
nurses. These organizations' collective view was that the health system required
nurses prepared at both levels of education and that graduates of these programs
hold different competencies and should be valued for those differences.
Unfortunately,
health systems employers have failed to clarify that different competencies are
acquired in the different educational paths to nursing which has created another
unexpected change in the educational system. Increasingly, anecdotal reports are
heard that the shape of associate degree nursing programs is changing dramatically.
A recent report from the Center for the Health Professions at the University of
California-San Francisco validated these anecdotal reports. In the report, Nursing
in California: A Workforce in Crisis, (2001) the authors revealed that California
associate degree programs have widely divergent curricular structures with required
credits ranging from 62 to 115 credits to graduate from a supposedly two-year
program. Moreover, the authors report that it is virtually impossible to graduate
from an associate degree program in three years and more frequently requires four
years. The "credit creep" reflected in these findings is also accompanied
by a growing tendency for associate degree educators to add community and public
health experiences to the curriculum for the students in these programs.
This
is a shift from the original intent of associate degree education as a two-year,
fast track preparation for nurses who would then be employed to provide care for
individuals with conditions that were both predictable and routine. One could
question whether this is actually a possibility in the current, complex environment
of health care. More likely, however, the diversification of the learning experiences
for associate degree students and the growth in the number of credits required
reflect the nature of the roles the graduates of associate degree programs are
expected to fill.
The
recruitment of young men and women into the nursing profession is at a critical
low point threatening the integrity of the entire health system. AACN and other
nursing leaders believe that to bring more students into the profession there
must be a vision for professional progression, a pipeline from all educational
levels of the registered nurse to alternative and advanced practice roles. The
failure of the nursing profession to clarify the role expectations and educational
outcomes for all levels of nursing will hinder efforts to recruit the best and
the brightest into the profession.
Make
Nursing Education More Accessible and Affordable
Nursing
schools across the U.S. turn away thousands of qualified students each year due
to an insufficient number of faculty, clinical sites, classroom space, clinical
preceptors, and budget constraints. In the face of declining enrollments, schools
are struggling to maintain current enrollment levels though an even greater influx
of students is needed to meet the projected demand for nurses in the coming decade.
Adding
to the problem is the fact that many of our nation's nursing schools are literally
crumbling since funding support for infrastructures has not been granted by Congress
since the mid-1970s. The cost to train nurses is comparatively high. Nursing schools
require a high ratio of faculty to students, sophisticated clinical equipment,
computer software, and simulated hospital units for student training. (State Boards
of Nursing recommend a ratio of one faculty member to eight-ten undergraduate
nursing students in clinical settings.) In addition, a nursing education is more
expensive for students since they must purchase uniforms, stethoscopes, and arrange
transportation to hospital and other practice sites. Federal
efforts to make nursing education more accessible and affordable occur primarily
through the Nurse Education and Practice Improvement Act of 1998 (Public Health
Service Act, Title VIII), known as the Nurse Education Act or NEA. Title VIII
grant programs increase the number of nurses in the workforce at every education
level as well as strengthen the ability of schools of nursing to educate students.
Congress provided $78 million for the three Title VIII programs in FY 2001, however
AACN and other members of the nursing community recommend an additional $25 million
as a good first step in meeting the needs of the evolving nursing shortage.
The
NEA focuses on three grant areas -- Advanced Education Nursing, Nursing Workforce
Diversity, and Basic Nurse Education and Practice. In an effort to recruit and
prepare disadvantaged students to become nurses, the NEA awards $4 million annually
to Workforce Diversity Grants. Awards go to schools of nursing, Nurse-Managed
Health Centers, academic health centers, state or local governments, and nonprofit
entities looking to increase access to nursing education for disadvantaged students
including racial and ethnic minorities under-represented among registered nurses.
In addition, the program provides stipends, pre-entry preparation, and retention
activities to enable students to complete nursing education programs. Although
a scholarship program for disadvantaged and minority students is authorized, Congress
has never appropriated the level of funding necessary to award these scholarships.
The
NEA funds two nursing loan programs from Title VIII. The Nurse Education Loan
Repayment Program (NELRP) was created to assist in the recruitment and retention
of full-time registered and advanced practice nurses working in areas with nursing
shortages. The NELRP provided loans of only 60% of the amount authorized to 50%
of nurses applying for program participation. The NELRP has operated on a static
budget of $2 million over the last five years. The Nurse Student Loan (NSL) program
was created to address nursing shortages. It operates on revolving funds received
through loan paybacks and returned funding received from nursing schools that
have closed down. Congress last appropriated funding to address nursing shortages
through the NSL program in 1983. AACN recommends an additional funding of $18
million for these two loan programs.
The
Georgia Southern University Experience: Existing federal efforts to address
nursing education involve the use of targeted grants and the dissemination of
loans and scholarships. However, the nursing shortage has stimulated states and
local areas to come up with creative solutions to recruit students into nursing
and to make education more accessible to busy students with family and full-time
jobs. Health care facilities, private industries, and schools of nursing are providing
scholarships and loan forgiveness for nursing education so that employees and
citizens will not go without basic nursing care. In addition, innovative public
and private partnerships are being formed to fund creative practice sites and
new educational facilities.
Recruitment
Efforts: Nursing faculty from Georgia Southern make numerous personal
recruitment visits to area grade and high school students. They conduct health
and career classes, emphasizing the academic requirements for and professionalism
of a career in nursing. On occasion, they partner with the Magnolia Coastlands
Area Health Education Center to recruit young people into the health professions.
Minority groups and men (particularly EMTs and military corpsmen) have also been
targeted. The School received U.S. Army Cadet Command Partnership in Nursing Education
(PNE) status in order to attract military candidates for admission to the undergraduate
program. Recruitment efforts, however, are limited by inadequate resources available
to support faculty release time and travel expenses.
Accelerated
Educational Programs for LPNs, RNs: Educational programs have been created
or Licensed Practical Nurses (LPNs) and RNs that offer these students an accelerated
pathway to obtaining the BSN and MSN degrees. The time required to achieve a degree
has been significantly reduced. Surrounding rural communities have requested that
the School bring these educational programs to distance sites where large numbers
of practicing nurses and ancillary personnel would be given tuition resources
to continue their education in nursing. At the present time, limited faculty resources
prohibit these initiatives from being implemented to their fullest potential.
Distance
Learning Options: Faculty created videoconference and WebCT courses that
increased access to educational offerings for students in both the baccalaureate
and graduate programs living in areas significantly isolated from campus. Additional
courses and entire on-line degree programs are being planned for development,
but currently lack sufficient faculty and equipment resources to be completed.
Increased
Scholarship Support for Students: The School awarded over $80,000 in scholarships
from its foundation monies to support students pursuing a degree in nursing. In
particular, funds were targeted to students willing to commit to working in rural,
underserved areas after graduation. Grant funds of $50,000 were awarded to LPN
and RN students seeking the baccalaureate or master's degree and $45,000 in Federal
Traineeship grant funds were given to graduate students pursuing an MSN. Faculty
are eager to secure grant funding for additional scholarship resources for both
graduate and undergraduate programs, but lack time and resources for writing these
grants.
Nurse-Managed Health Centers: Since 1994, the School
has operated a primary care nurse-managed health center in a rural community that
was without a health care provider. Primary care nurse-managed health services
are also provided to migrant populations in four surrounding rural counties. These
sites provide practice, service, and research opportunities for both graduate
and undergraduate students and faculty. They also provide health care services
to underserved areas. These activities, coupled with the Community Nursing Center
that will be located in a new Science and Nursing Building under construction,
have the potential to create a strong support base for economic development in
the region. Additional faculty with advanced practice certifications and research
agenda are needed to expand educational and practice experiences for both graduate
and undergraduate students in these outreach services.
Partnerships
with the State/Regional Initiative and Local Health Care Agencies: The
School of Nursing received a $400,000 gift from the Bulloch Health Care Foundation,
Inc. to establish an endowed scholar for rural nursing education. Matching funds
will be sought to build a $1 million endowment required for a Georgia Board of
Regents Eminent Scholar. This scholar will create educational offerings as well
as a research program that engages both graduate and undergraduate nursing students
in developing a better understanding of and expertise in treating the unique health
care needs of citizens in rural communities.
The
School of Nursing has been recognized as a probable partner in the Georgia Cancer
Initiative designed to improve and expand the delivery of cancer care to the state's
citizens. The role of the School of Nursing, with funding to support a faculty
position focused on oncology nursing care delivery and research, will be to increase
the educational opportunities for nursing students and practicing nurses at all
levels of education with a particular focus on the baccalaureate prepared nurse.
Faculty
partnerships with the local hospital, East Georgia Regional Medical Center, resulted
in the development of a program to train nurses as mentors to students and new
graduates. Faculty worked with the hospital to achieve magnet status by increasing
their involvement in committees and workgroups designed to improve working conditions
for nurses. Pending available resources, plans are underway to re-establish a
nurse extern program for new baccalaureate graduates and to develop joint leadership
training initiatives for practicing nurses and undergraduate students.
Critical
Infrastructure Needs: Georgia Southern University broke ground on a new
$24 million, 125,000 square foot Science and Nursing Building on June 5, 2001.
Funded by the state of Georgia and scheduled for completion in Fall 2003, this
facility will feature research and nursing skills laboratories, distance learning
classrooms, and a community nursing center. The facility will enable the School
of Nursing to attract increased numbers of students and qualified faculty to the
Southeast Georgia region by enhancing the resources available to provide the technologically
advanced learning experiences needed for educating the next generation of professional
nurses.
Transcultural
Experiences: Faculty have successfully created and offered international
learning opportunities for students at the graduate and undergraduate levels.
This summer, students from both programs traveled to Ghana, South Africa where
they had learning experiences in the direct delivery of nursing care in acute
care and rural community settings. While there, faculty and students also conducted
research in the areas of maternal-child care and HIV-AIDS care in Ghana. These
experiences were directly paralleled to learning experiences students have in
the School of Nursing's rural focused graduate and undergraduate curricula and
health care environment.
Federal
Response to Previous Nursing Shortages
To
address previous nursing shortages, Congress acted decisively by funding new initiatives
that effectively increased capacity in nursing schools and attracted new students
to the profession. In response to a nursing shortage in 1964, Congress created
the Nurse Student Loan program (Public Health Service Act, Title VIII, Section
836). Although the program increased opportunities for students to become nurses,
it no longer is authorized to receive new funding.
In
response to the nursing shortage of the 1970's, Congress created a capitation
program that provided per capita funding to schools of nursing for support of
nursing education programs from 1971-78. To qualify for capitation grants, schools
were required to increase their enrollments above the previous year's enrollment
level. Congress also required schools receiving these grants to pursue curriculum
development, increase educational opportunities for disadvantage students, increase
the supply of adequately trained nursing personnel, and promote the full utilization
of nursing skills.
Congress
has not addressed problems such as practice environments that hinder nurses' autonomy
over their own practice, licensure, and entry-level practice roles that have been
largely unrelated to education. Most efforts to deal with nursing shortages over
time focused on recruitment programs or image campaigns and did not get at core
problems that have plagued nursing for decades. Over the years Congress has authorized
new programs through the NEA in response to nursing shortages. Unfortunately,
there is no trigger mechanism to flip the on switch to reauthorize federal programs
that have been effective in addressing nursing shortages of the past when nursing
school enrollments begin to plunge.
Academic
Solutions to Strengthen Nursing Education
AACN
and the nursing community call for new initiatives in the areas of faculty preparation,
enrollment incentives, and a post-baccalaureate residency program to minimize
the impact the nursing shortage will have on our nation's health care system.
Create
a Fast-Track Nursing Faculty Scholarship and Loan Program: Providing scholarships
and loans to students to become nurses is ineffective if faculty do not exist
to educate them. To increase the number of nurse educators, a Fast-Track Nursing
Faculty Scholarship and Loan Program is needed to provide economic incentives
to master's and doctoral students to commit to serving as faculty members at baccalaureate-
or graduate-level nursing schools. Such a program should require participating
students to serve as a nurse educator at a college or university for a number
of years equivalent to the number of years the participant receives federal support.
With $30 million in FY 2002, a fast-track faculty program could provide non-taxable
scholarships, loans, and stipends to allow 1,500 nursing students to pursue full-time
graduate study. AACN recommends giving preference for the fast-track program to
doctoral students as the doctoral degree is the appropriate and desired credential
for nurse educators. In addition, preference should be given to minority and needy
students, allowing others to participate after requests from minorities and needy
students are filled.
With
federal support, nursing schools could recruit their most talented students from
a pool of over 103,000 baccalaureate students to enter the pipeline to become
faculty members. Without federal support, less than 1% of baccalaureate nursing
students are expected to become faculty members.
Establish a Capitation
Grant Program: Schools of nursing must have strong infrastructures equipped
with current technological equipment and labs to provide nursing students with
the complex level of education required to practice nursing in today's health
care system. A Capitation Grant Program is needed to strengthen the abilities
of nursing academia to recruit and retain students and faculty, enhance classroom/lab
space and support the nursing school infrastructure. AACN recommends creating
a capitation program to provide an incentive to recruit new students and retain
faculty with federal support of $1,200 for each full-time equivalent student enrolled
in a collegiate school of nursing. Schools of nursing should use capitation funding
to meet their individual program needs in increasing nursing students enrollments.
To
qualify for capitation grants, schools should be required to increase their enrollments
by 5% or five students -- whichever is greater -- above the previous year's enrollment.
In addition, they should be required to provide assurances that they would increase
their first-year enrollments over a base year, which was the average of the two
highest enrollments in the previous five school years, by 5% or ten students,
whichever is greater. The Secretary could waive this requirement if the school's
facilities limit it from enrolling additional students.
Note:
In January 1974, the Institute of Medicine Cost Study endorsed a capitation grant
program as an appropriate federal undertaking to provide a stable source of financial
support for the health profession schools, including nursing. It recommended that
capitation grants ranging between 25% and 40% of net educational expenditures
would contribute to the financial support for the stability of health profession
schools.
Create
a Post-Baccalaureate Nursing Residency Program: A Post-Baccalaureate Residency
program is needed to recruit and retain baccalaureate nurses in the profession.
In addition to insuring the successful transition of the newly licensed professional
nurse from student to expert nurse, a nursing residency will insure that our nation's
health care team includes nurses with a high level of education and clinical experience.
Stabilizing the health care team with well-educated nurses with bachelor or higher
degrees will also provide a positive image of nursing and attract more highly
qualified applicants to the profession.
Nursing
residencies should target specialty areas since nurses who have moved up the career
ladder to fill those roles are older and exiting the profession. These include
hospital emergency and operating rooms, acute and critical care units, and community
settings such as long-term care facilities.
A
residency program will minimize the burn-out associated with the stresses of under-preparation
for the nursing role, which is causing our young nurses to leave the profession.
In addition, a post-baccalaureate residency program will keep new baccalaureate-nurses
in the profession by providing them with socialization and cultural skills of
the practice site, knowledge of policies and procedures, and technical proficiencies
to cope with the reality and challenges of caring for the acutely and chronically
ill.
The
residency program would provide recognition of the enhanced value of the baccalaureate
degree at the federal level, on campuses, and in health care settings. Currently,
diploma, associate- and baccalaureate-prepared nurses are equally licensed as
RNs, equally compensated by employers, and often delegated identical responsibilities.
Needs
of the Georgia Southern University School of Nursing: The Georgia Southern
University School of Nursing requires additional support in four major areas:
recruit ten new faculty members, improve grant-writing initiatives, improve Internet
technology and distance education opportunities, and develop clinical laboratory
experiences for students.
Faculty
Support: In order to expand the capacity for educating entry-level and
advanced practice nurses, the Georgia Southern University School of Nursing requires
a minimum of five additional full-time tenure track faculty. At least three of
theses faculty should have advanced nurse practitioner credentials. In addition,
the School needs a non-tenure track faculty member to coordinate the clinical
skills of its laboratory and increase the number of adjunct faculty.
Opportunities
exist to bring an entire program of study to several counties in rural areas in
Southeast Georgia. For example, the School of Nursing has been approached by a
health care agency in Millen County requesting that the undergraduate program
be brought to their hospital campus. Over 30 potential students have expressed
a strong interest in pursuing a baccalaureate degree in nursing and the agency
has agreed to cover all tuition expenses. Similar requests have been received
from other regional communities. One to two additional faculty would be needed
to manage programs such as this.
An
opportunity exists for the School of Nursing to be an active participant in the
Georgia Cancer Initiative in the area of educational preparation of nurses skilled
in the delivery of oncology care. If the school can recruit a nationally known
oncology nurse specialist/educator/researcher, it will enhance the School's ability
to participate in this initiative.
An
opportunity exists to collaborate with the Georgia Washington University Adult
Nurse Practitioner to Family Nurse Practitioner Program that prepares adult nurse
practitioners to become family nurse practitioners. The School is considering
being the "southern
contingent" of this program. This collaborative
effort could begin as early as Fall 2000, but would require additional Family
Nurse Practitioner faculty.
Grant
Writing and Faculty Development Support: Support is needed to access the
monies available for curriculum development and research addressing rural and
underserved populations. At the current time, faculty are extremely limited in
their ability to attend state and national conferences related to health care
delivery and professional nursing initiatives. The School's current budget is
used to support faculty travel to distant clinical education sites ($10,000 this
past academic year). Increased travel support is necessary to expand the national
presence of faculty and the School. In turn, such exposure would positively impact
innovative instruction and curriculum redesign as well as stimulate continuing
interest in careers in academia.
Clinical
Laboratory and Technical Support: The School needs support for an array
of technology concerns such as providing technical personnel support and technology
resources to assist faculty in developing Internet based courses for both the
undergraduate and graduate programs. There is a nationwide need to increase the
availability of Internet courses and programs for BSN, RN-BSN, and graduate core/advanced
practice, which the School could develop. Additionally, reconfiguring the School's
Rural Community Health Nurse Specialist major to an on-line program would enhance
graduate applicants and would be a first for Georgia.
The
School needs support to upgrade and expand its clinical laboratory, media, software,
and Internet subscription resources -- particularly to maintain cutting edge curricula
and learning experiences and to expand offerings into distance learning and on-line
programming. A state-of-the-art laboratory facility will make continuing education
partnerships with community health care agencies possible. Additional personnel
in the clinical laboratory is critical to maintaining and expanding the use of
the lab as a simulated clinical environment and learning/assessment center.
Resources
are needed to increase the number of clinical learning environments for students
in both graduate and undergraduate programs and practice environments for faculty.
With the construction of the new Science and Nursing Building, the Community Nursing
Center in the building will provide expanded opportunities for outreach and service.
The School is also exploring the possibility of pursuing grant opportunities to
purchase a clinic van that could be used to deliver nursing care to rural communities,
thus impacting the economic development of the region.
Conclusion
Once
again, another cycle of nursing shortages is wreaking havoc in the health care
delivery system. Popular solutions focus on short-term strategies such as immigration,
sign-on bonuses, increased overtime, and pay raises. Market forces cause scarce
nursing resources to go for the best financial opportunity in an acceptable practice
environment.
As
the Congress investigates solutions to the current shortage, it must focus on
the long-range issues that affect the nursing profession. While concerns about
salary must be addressed, steps must also be taken to evaluate and improve the
practice environment. Simultaneously, schools of nursing must be adequately funded
to strengthen and expand the capacity to educate the nursing workforce for the
coming century. However, the nursing profession and other dedicated stakeholders
must take the bold step to define the education and training requirements and
practice competencies for all nursing care providers.
The
nursing profession must create a career pathway so that nurses can remain engaged
in the profession. Nurses must envision taking on different aspects of health
care delivery and alternative nursing roles. Though these opportunities may take
nurses away from the traditional practice at the hospital bedside, it creates
a positive career trajectory that will keep nurses in the field and attract fresh
talent to maintain staffing levels. The nursing profession will always need to
have a continuous flow of young new nurses to carry the burden of an intellectually
stimulating, physically challenging, but incredibly rewarding career.
