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Testimony
of the American Association of Colleges of Nursing
on Fiscal Year 2003 Appropriations
For
theNational Institute of Nursing Research and the
Bureau of Health Professions,
Nursing Division and other Programs for the
House Appropriations Subcommittee
on Labor, Health and Human Services, and Education The
American Association of Colleges of Nursing (AACN) respectfully submits this testimony
to the Subcommittee with our requested funding priorities for nursing research
and education programs. This federal support will play a critical role in the
nation's effort to overcome the nursing shortage. AACN represents over 560 baccalaureate
and graduate nursing education programs in senior colleges and universities across
the United States. The
country is in the midst of an emerging nursing shortage unlike any that the nation
has experienced over the past 30 years. Since 1995, AACN noted declining enrollments
in baccalaureate nursing programs that reached a low point of 21.1% in 2000. In
the fall of 2001 enrollments increased by 3.7%. This slight increase is
attributed to intensive marketing by health care facilities in high schools and
colleges, public-private partnerships creating additional faculty positions to
expand capacity of nursing programs, and state legislation targeting funds to
scholarships and nursing loan repayment programs. Potentially the start of a hopeful
trend, this increase is inadequate to provide over one million new and replacement
nurses that will be needed by 2010, according to the Bureau of Labor Statistics. Still,
employers are reporting crisis level shortages of nurses in all health care settings
including long-term care, home care, and public health. An aging workforce, with
the average age of registered nurses (RNs) up to 45.2 years, compounds the shortage.
Clearly the lack of appropriately educated RNs and skilled is adversely changing
the face of the health care delivery system. Despite
the need to expand the nursing workforce, a lack of nursing faculty has had an
impact on the shortage. The majority of AACN member schools report great difficulty
filling budgeted faculty positions. The small percentage of doctorally prepared
nurses in this country and the lengthy completion time of a doctoral degree have
limited the availability of nurses prepared to function in a faculty role. Doctoral
nursing students usually attend classes while maintaining a full-time clinical
position. Expanding the number of full-time doctoral students would greatly facilitate
the production of available faculty. AACN members also report difficulty recruiting
master's prepared nursing personnel for faculty roles because of the great disparity
between clinical and faculty salaries. Schools would benefit from initiatives
that provide resources to augment salaries for specialized faculty needed to support
the entire program. AACN
recognizes that strategies to meet the growing nursing shortage must encompass
state legislation, increased federal support, and private and public sector initiatives.
We are asking the Subcommittee to graciously consider these requests and the effect
that an unresolved RN shortage of this magnitude will have on the future of health
care in America. NATIONAL
INSTITUTE OF NURSING RESERACH (NINR) We
thank you for your support of the National Institute for Nursing Research (NINR).
AACN respectfully requests a Fiscal Year 2003 funding level of $145.45 million,
which reflects an increase of $25 million for NINR. At this funding level,
NINR will support significant new research findings for the nation's largest profession
of health care providers-registered nurses. This new funding will support the
following new research: - Enhance
adolescent health promotion by addressing risk behaviors such as smoking, substance
abuse, unsafe sexual activity, and nutrition. Culturally appropriate interventions
for ethnic minorities are needed for this population.
- Improve
the care of more than 1.6 million residents of nursing homes and many others in
assisted living facilities and board-and-care homes. NINR hopes to fund studies
that focus on residents' functional mobility, their adjustment to loss of independent
living, and prevention of falls and depression.
- Partner
with communities to design ways to eliminate health disparities in those communities.
- Focus
on end-of-life care and research to address the public's concern with issues at
the end-of-life, including symptom management, family burden, and decision-making.
Directions for this research include palliative care models and, timed to the
release of an upcoming Institute of Medicine report, pediatric end-of-life care.
- Increase
the pool of investigators to conduct nursing research and direct special emphasis
toward facilitating early entry into doctoral training and career development
programs.
As
the primary sponsor of nursing research in the country, NINR attracts new students
to the profession by providing opportunities for nurse-researchers to solve important
clinical problems and make a difference in patients' lives. The Institute initiates
studies on the relationship between staffing mix and patient outcomes, which is
vital to understanding patient safety and the skill set required of health care
providers to reach optimal patient outcomes. Nursing
research makes a difference in quality of life and patient outcomes. It helps
people make wise health choices that prevent disease and promote health and provides
the scientific base for the nation's 2.7 million registered nurses and others
who provide patient care. The NINR supports investigators who are conducting a
broad range of clinical research, developing and testing interventions to improve
patient care, treating disease, managing chronic conditions, and addressing the
physical and emotional concerns that are important to a diverse American public. The
National Institute for Nursing Research increases the number of nursing faculty
and researchers. In an effort to develop the pool of nurse faculty and researchers,
NINR directs 9% of its budget to research training. FY 2002 research training
dollars supports approximately 190 pre-doctoral nurse researchers and 70 post-doctoral
researchers. A $25 million funding increase would substantially increase the pool
of pre-doctoral researchers to 280 and post-doctoral researchers to 90. However,
under the Administration's proposed budget for FY 2003, the number of funded nurse
researchers would remain at FY 2002 levels. Additionally,
AACN's 2001-2002 Report on Enrollments and Graduations shows that 3,312
nurses are enrolled in doctoral programs. Through the NINR, the National Institutes
of Health will continue to expand its emphasis in FY 2003 on clinical research,
the means by which basic findings relating to behavior, molecules, and genes can
be tested and translated into medical practice and improvements in public health.
NINR will extend its clinical trial networks nationwide in an effort to evaluate
new prevention strategies, drugs, and vaccines in large numbers of patients. The
Subcommittee investment in NINR is well justified as nursing research contributes
extensively to wellness and health choices that prevent disease. There is growing
evidence of advances made possible by NINR research, but we will highlight just
four recent success stories. AACN believes that based on these and numerous other
examples, it is clear that nursing research is making a difference in health outcomes.
For example, NINR research has made a difference by identifying interventions
or other studies to:
Cesarean
deliveries increase the risk of uterine rupture in future pregnancies. Labor
and delivery records of nearly 20,000 women who gave birth to a second single
child after an earlier cesarean delivery were analyzed to assess the risk of uterine
rupture. Compared to the very low risk of rupture during a scheduled repeat c-section,
the risk during uninduced labor increased three-fold, and the risk during labor
induced using prostaglandins increased fifteen-fold. Though more research is needed
to establish cause-and-effect, since 60% of women with prior cesarean deliveries
attempt labor with the next pregnancy, these women need to be aware of the risk
of uterine rupture. Childrens'
learning deficits after aggressive treatment for acute lymphoblastic leukemia.
Today many more children survive after treatment for acute lymphobolastic leukemia
and are declared disease free. However, long-term consequences of the aggressive
treatments (whole brain irradiation and high dose chemotherapy) used to treat
the disease include learning difficulties that impair academic performance. Diminished
arithmetic skills, verbal fluency, and visual and motor-related skills are observed
for up to four years after treatment is ended. An early intervention with remedial
math has shown positive results, and a larger study to test the intervention is
now in progress. Reducing
the risk of a second cardiac arrest. Nursing research also examines ways to
lower the risks that may precede disease. Preliminary results of a biobehavioral
intervention on patients who had cardiac arrest showed that there was an 86% reduction
of risk of mortality from subsequent cardiac arrest in these patients for up to
two years. The intervention consisted of training in physiological relaxation
using biofeedback; coping skills for depression, anxiety, and anger; and health
education about cardiovascular risks. Further study is needed to affirm that decreases
in psychological distress subsequently improve the prognosis of those with cardiac
disease. The study underscores the importance of biobehavioral approaches for
survivors of cardiac arrest. Hospital
restructuring makes a difference. Hospital restructuring has taken place across
the nation, typically concurrent with reduced numbers of nurses providing care
for patients. Within 29 academic health centers, patient outcomes were measured
before and after restructuring. Many health outcomes were affected by the reduction
in registered nurse hours: more RNs lead to diminished numbers of patient falls
and urinary tract infections and higher satisfaction with pain control. Research
such as this helps validate the concerns expressed by nurses across the country
and helps the health care system measure its effectiveness in terms of patient
safety and health promotion. NURSE
EDUCATION ACT (NEA) AACN
recommends an increase in the NEA for FY 2003 to $122.5 million. This increase
is $40 million over current funding. NEA appropriations for FY 2002 were $82.5
million. Central to increasing the availability of a well-trained nursing workforce
is the availability of educational grants and scholarships. Current demand for
nursing student loan support significantly exceeds the resources available. In
addition, scholarship support is a major incentive to enter the profession and
facilitates full-time study. Title
VIII of the Public Health Service Act (PHSA), the NEA, is the major federal statute
providing authority for the Department of Health and Human Services to fund initiatives
to expand or improve nursing education. Authorities under Title VIII provide for
support of advanced practice nursing education, special initiatives for nursing
clinics, support of innovations in the delivery of nursing care, expansion of
enrollments in baccalaureate nursing programs, and development of initiatives
to expand minority nursing enrollments. Several of the programs assist schools
with their efforts to bring more students into baccalaureate nursing programs.
In addition, the program for loans to nursing students allows students to acquire
low interest rate loans that can be repaid through service in high need areas.
Advanced
Education Nursing Grants (Sec. 811) - The initiative provides grants
to schools to train advanced practice primary care nurse practitioners and nurse
midwives. It 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. It includes traineeships
for master's and doctoral students with a limit of 10% of appropriations for doctoral
traineeships. Nursing
Workforce Diversity Grants (Sec. 821) - To increase opportunities for
nursing education for disadvantaged students, including underrepresented minorities,
this initiative furnishes 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) - This initiative disseminates
grants to schools of nursing to strengthen basic nurse education and practice
with seven priority areas. The areas are: 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. Nursing
Student Loan Program (NSL) (Sec. 836) - AACN recommends an appropriation
of $10 million for the NSL for FY 2003. Administered by the Division of Health
Careers Diversity and Development, this program was created to address nursing
workforce shortages. Academic institutions select students enrolled in nursing
programs for participation in the program based on financial need. The program
operates on revolving funds received through student loan paybacks and returned
funding received from nursing schools that close down. In FY 2002, only 347 out
of almost 1,600 eligible collegiate schools of nursing participate in the program
because of reluctance to compete for the limited funding. This loan program has
received no new funding since 1983. Nursing
Education Loan Repayment Program (NELRP) (Sec. 846) - AACN requests
an additional $10 million for this program in FY 2003. The NELRP, administered
by the Bureau of Health Professions, provides loans to registered nurses, nurse
anesthetists, certified nurse midwives and nurse practitioners in exchange for
practicing in designated Health Profession Shortage Areas (HPSAs). The NELRP received
$10.24 million in FY 2002. AACN is grateful for this funding which included an
additional $5 million allocated by Secretary Tommy Thompson as part of a "tap"
in July 2001. Scholarships
for Disadvantaged Students (SDS)
AACN recommends that SDS be funded
at $52 million for FY 2003, a $6 million increase. Current FY 2002 funding
is at $46.20 million. Scholarships for Disadvantaged Students is a PHSA Title
VII Program (Sec. 737) that provides funds to disadvantaged and minority health
professions students. The statute directs 16% of the funds appropriated to nursing
students. This program is the major federal scholarship source for undergraduate
nursing students and eliminates or reduces the financial barriers that may prevent
these students from enrolling. The majority of SDS recipients are minority students.
National
Health Service Corps (NHSC)
AACN recommends increasing funds for the
NHSC to $203.5 million for FY 2003. The National Health Service Corps Scholarship
and Loan Repayment programs (PHSA Title III) seek to attract health professionals
to practice in HPSAs that lack such providers. Many of those areas are rural,
and have difficulty attracting and retaining caregivers. Nursing has a 10% set
aside that provides funding for certified nurse midwives, nurse practitioners,
physician assistants, and psychiatric clinical nurses specialists. In
summary, AACN respectfully recommends the following appropriations for FY2003: National
Institute of Nursing Research - $145.45 million
Nurse Education Act - $122.00
million
Nursing Student Loan Program - $10.00 million
Nursing Education
Loan Repayment Program - $20.24 million
Scholarships for Disadvantaged Students
- $52.00 million
National Health Service Corps Scholarship/Loan - $203.50
million
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