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Testimony
of Mary D. Naylor, PhD, RN
On behalf of the American Association of Colleges of Nursing
on Fiscal Year 2000 Appropriations for Nursing
Research and Education
Before the House
Appropriations Committee
Subcommittee on Labor, Health and Human Services,
Education and Related Agencies
April
15, 1999
Good
morning Mr. Chairman and members of the subcommittee. I am Dr. Mary Naylor, Associate
Professor at the School of Nursing at the University of Pennsylvania. Today I
am presenting the fiscal year 2000 appropriations recommendations of the American
Association of Colleges of Nursing for nursing research and education. AACN represents
over 530 baccalaureate and graduate nursing education programs in senior colleges
and universities across the United States. First,
I want to thank the members of this subcommittee for the fiscal year 1999 funding
levels for the National Institute of Nursing Research (NINR) at NIH, the Nurse
Education Act (NEA) (Public Health Service Act Title VIII), Scholarships for Disadvantaged
Students (in PHSA Title VII), the Agency for Health Care Policy and Research (AHCPR)
and others. These needed funds are being well spent to improve the public health.
For NINR, AACN recommends an
increase of $18.523 million over the Administration's FY00 budget to $90.2 million,
the professional judgment budget. For AHCPR, AACN asks for funding of $188 million.
For FY00 for the NEA, AACN respectfully requests an increase to $74.6 million.
For SDS, we seek an increase to $21.3 million. AACN endorses the FY00 overall
NIH recommendation of 15% made by the Ad Hoc Group for Medical Research Funding.
AACN agrees with the recommendation of the Health Professions and Nursing Education
Coalition for FY00 of $316 million for PHSA Titles VII and VIII. AACN also advocates
appropriate FY2000 funding levels for Higher Education Act programs that serve
nursing students at the undergraduate and graduate levels, such as Pell Grants,
Perkins Loans, Federal Work-Study, TRIO, and GAANN. Please let me explain our
reasons. National
Institute of Nursing Research Funding
NINR at $90.2 million, the professional judgement budget level, would support
significant new research opportunities such as: enhancing adherence to diabetes
self-management behaviors; prevention of low birth weight in minorities; improved
care for children with asthma; managing symptoms in AIDS and cancer; and expanded
opportunities for pre- and post-doctoral training in nursing research. This is
not an extreme goal: For FY99, NIH's Center for Alternative Medicine received
a $30 million increase. Nursing
research contributes significantly to wellness and health outcomes. The National
Institute of Nursing Research performs a wide span of clinical research, developing
and testing interventions for promoting health and preventing disease. NINR research
has made a difference by identifying ways, for example, to reduce high blood pressure
in young urban African-American men at high risk for cardiovascular disease, to
help teach children how to prevent and manage their asthma symptoms and to identify
pain reducing drugs that work better for women. Nursing and its research are relevant
to virtually every condition and disease within the health care delivery system.
Indeed interdisciplinary research partially funded by NINR increases the value
of NIH research and is complementary to biomedical research. I
would like to share with you my own example of how NINR research improves outcomes
and cost effectiveness. Today's
shorter hospital stays may save money but they mean that patients are sicker at
discharge and need more support at home. NINR funded a project for comprehensive
discharge planning and follow-up programs using visits and telephone contact by
advanced practice nurses. The study improved patient outcomes and decreased the
cost of care and the likelihood of readmissions. Originally developed with a focus
on mothers and low birth weight infants, the model of care tested in this study
was expanded to elderly patients with complex medical and surgical conditions.
I was the principal investigator on this study, and the lead author on a paper
in the February Journal of the American Medical Association that described
the results. We used Advance Practice Nurses (APNs) to work with the patients,
family members, and other health care providers to plan the discharge from the
hospital and follow-up care for high risk patients (mean age 75) in the Philadelphia
Area. The objective was to increase patient and caregiver ability to manage unresolved
health problems. This study showed that compared to a control group that had standard
discharge planning and home follow-up, intervention group patients were less likely
to be readmitted to the hospital, have fewer multiple readmissions, and fewer
hospital days per patient. Impressive as the outcomes were, the study also showed
that Medicare saved $600,000 in the APN-managed intervention, a per-patient savings
of over $3,000. This study showcases the value of nursing research supported by
NINR: improved outcomes for high risk hospitalized elders and savings for the
Medicare system. You will not be surprised to learn that the JAMA article has
generated considerable interest from providers and managed care systems-all considering
this model for implementation. NINR
is one of only two National Institutes of Health (NIH) institutes since 1995 to
receive growing numbers of research proposals. Unfortunately, NINR is projecting
that it will only be able to fund 19% of its peer-reviewed, approved applications
in fiscal year 1999, compared to the NIH projected average of 33%. NINR has disproportionately
slow growth compared with NIH in general. Since 1986, NINR received only $55.5
million, or 0.5% of the total NIH growth of $10.3 billion. Low funding limits
NINR's ability to support research and training. NINR's small base operates as
a penalty and suppresses its rate of growth. NINR is the smallest institute at
NIH with $69.82 million (FY99). The next lowest funded institute (Deafness) receives
more than 3 times as much money ($229.8 million). This low funding base limits
NINR's ability to support research and training. NINR also received the smallest
budget increase (10%) in FY99. NIH received an increase of 14.7% with some institutes
receiving as much as 15.9% on much larger bases. That small percentage increase
on such a low base means a very small dollar increase for the science of nursing.
Given the importance of nursing research and the need for research training, as
shown by the earlier exciting clinical examples, this trend must be changed. The
following graph shows funding in dollars from inception of the National Institute
of Arthritis and Musculoskeletal and Skin Diseases, the Nation Institute on Deafness
and other Communication Disorders, and the National Institute of Nursing Research.
As you can see, the chart demonstrates
the way in which low initial funding and small percentage increases have adversely
affected NINR's ability to fund nursing research and training. NINR
has been designated as the lead institute at NIH to coordinate research on end-of-life
care. End-of-life issues are critically important to our aging patients
and their families. End-of-life care utilizes many of the skills of nursing such
as management of pain, handling of chronic conditions, and family counseling.
NINR must be able to increase
the number of nurse scientists to meet the Nation's health challenges.
In 1994, a National Research Council report urged a substantial increase in the
number of nurse researchers, but NINR has not reached even half of the proposed
figure. There is a scarcity of nurses with doctoral degrees compared to other
research professions. NINR supports minority and disadvantaged students and investigators.
In addition, there is a graying of nurse researchers and a strong need to prepare
and bring to maturity a sizable cadre of nurse scientists in the future. NINR
supports research in two Institute of Medicine high priority areas: clinical research
and behavioral research. Clinical research may be more expensive because
it involves working directly with patients (as opposed to laboratory research),
but it is just as important to the discovery of knowledge and its application
to specific conditions. Behavioral research is also a focus for nursing investigators
studying social support, health promotion, self-esteem, stress and others. NINR's
Core Centers focus on major concerns of nursing including symptom
management (University of California - San Francisco), care of the chronically
ill (University of Pittsburgh [PA] and University of North Carolina, Chapel Hill),
serious illness (University of Pennsylvania), gerontological nursing interventions
(University of Iowa), and women's health (University of Washington). The Core
Centers promote outreach activities to disseminate findings and implications.
While the Centers are relatively new, they have provided valuable knowledge on
patient care issues. NINR's
research agenda focuses on helping patients deal with pain, maximizing the
quality of life of people living with chronic conditions or the physical disabilities
of stroke, avoiding low birth weight babies, and maternal and child health. For
instance, a University of Illinois-Chicago NINR project is examining ways to strengthen
respiratory muscles in patients with chronic obstructive pulmonary disease. A
University of Arkansas NINR grant has produced ways to improve knowledge on the
ability of nursing home residents to achieve their activities of daily living
thus reducing their need for assistance. A Florida Atlantic University project
seeks to find ways to improve the quality of life and to reduce the care costs
for Alzheimer's disease patients by using exercise and special monitoring. A Johns
Hopkins University (MD) NINR project has investigated several interventions to
reduce the risk of high blood pressure in young black men, a common concern in
this population. A University of Mississippi Medical Center project funded by
NINR is supporting an interdisciplinary research team to examine treatment of
blood clots and tumors. NINR grants to schools in New York are examining childhood
asthma and the side effects of chemotherapy. A
number of major national nursing and other organization support better funding
for the National Institute of Nursing Research. The Tri-Council for Nursing (AACN,
American Nurses Association, National League for Nursing, American Organization
of Nurse Executives), the Coalition for Nursing Research Funding (29 members),
and the Doctoral Dean's Group for Nursing Research Funding (29 members) all advocate
a substantial increase in funding for the National Institute of Nursing Research.
The Nurse
Education Act
The Nurse Education Act programs serve critical public
health objectives. AACN seeks an increase in NEA for FY00 to $74.6 million.
NEA appropriations for FY99 were $67.855 million. Funding
for nursing education should be stable. Higher education programs for professional
nurses operate on the basis that a student will study for two, three or more years.
Highly trained faculty are hired in what has become a very competitive market
for people with the background needed to educate baccalaureate and advanced practice
nurses for primary care. Funding to run this type of system should be stable;
otherwise skilled faculty will be lost and students will face obstacles in completing
on time. In fact, AACN knows that there are shortages of nurses in parts of the
US right now. Funds for nursing
education should be sufficient. The Nurse Education Act (Public Health Service
Act Title VIII) was funded at $67.855 million in FY99. The NEA is important because
it supports innovations in education that enable schools to infuse their graduates
with skills needed by today's changing health care system with its emphasis on
primary care and health promotion. The NEA has supported over 50% of currently
operating nurse-managed centers. All 28 NEA supported centers are in medically
underserved areas, with 32,000 primary care service visits in 1995. The NEA helped
increase the number of minority nursing graduates by 24% over the past 5 years.
The New
Nurse Education Act Will Work for Better Health Care The
Nurse Education Act (Public Health Service Act Title VIII) helps schools of nursing
and nursing students prepare for a changing health care delivery system. The NEA
was reauthorized in 1998. The new NEA (P.L. 105-392) offers expanded flexibility
through: Advanced Education
Nursing Grants (Sec.811) - Grants to schools to train advanced practice
primary care nurse practitioners and nurse midwives. Also provides grants to educate
master's and doctoral students as clinical nurse specialists, public health nurses,
nurse administrators, faculty, nurse anesthetists, and non-primary care nurse
practitioners. Includes traineeships for master's and doctoral students with a
limit of 10 percent of appropriations for doctoral traineeships. Workforce
Diversity Grants (Sec.821) - Grants to increase opportunities for nursing
education for disadvantaged students including underrepresented minorities by
providing scholarships, stipends, pre-entry preparation, and retention activities.
Grantees are responsible for accomplishing the objectives of their grants. Basic
Nurse Education and Practice Grants (Sec.831) - Grants to schools of
nursing to strengthen basic nurse education and practice with seven priority areas:
expanding nursing practice in non-institutional settings to increase access to
primary health care; training for care of underserved and high risk populations,
education for managed care, developing cultural competency, expanding baccalaureate
enrollments, increasing nursing career mobility, and nursing education in informatics
and use of distance learning. Scholarships
for Disadvantaged Students
Scholarships for Disadvantaged Students is
a PHSA Title VII program (Sec.737) that provides funds to disadvantaged
and minority health professions students. Law directs 16% of the funds appropriated
to nursing students. This program is the major federal scholarship source for
undergraduate nursing students. The majority of SDS recipients are minority students.
AACN recommends that SDS be funded at $21.32 million for FY00, a 10% increase.
(There is also an education loan repayment program for nursing faculty from disadvantaged
backgrounds. (Sec.738) Agency
for Health Care Policy and Research
AACN recommends a 10% increase over
FY99 for AHCPR to $188 million in FY00. AHCPR's mission is critical to wise utilization
of health care dollars because it seeks to discover and to publicize the most
effective health care interventions. National
Health Service Corps
AACN suggests a 10% increase over FY99 for the National
Health Service Corps Scholarship and Loan Repayment programs (PHSA Title III)
to $85.8 million. This program seeks to attract health professionals to practice
in Health Professional Shortage Areas that lack such providers. Many of those
areas are rural, and have difficulty attracting and retaining caregivers. Conclusion
In summary, AACN respectfully recommends the following appropriations for FY2000:
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