The
American Association of Colleges of Nursing (AACN) respectfully
submits this statement highlighting funding priorities for
nursing education and research programs in fiscal year 2006.
AACN represents over 580 senior colleges and universities
with baccalaureate and graduate nursing programs, and over
190,000 students and 10,000 faculty members. These institutions
are responsible for educating about half of our nation's
registered nurses (RNs) and all of the nurse faculty and
researchers. Nursing represents the largest health profession
in the nation, with approximately 2.7 million dedicated,
trusted professionals delivering primary, acute, and chronic
care to millions of Americans daily across the spectrum
of settings.
The Nationwide Nursing Shortage
Our country continues to be plagued by a shortage of nurses
that is only expected to intensify in the future. While
AACN is cognizant of the difficult budget environment in
which the Subcommittee and the entire Congress must operate,
patient safety is compromised without a sufficient number
of RNs. Indeed, the American College of Healthcare Executives
reported in 2004 that 72% of hospitals were experiencing
a nursing shortage. Furthermore, the Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) found
in 2002 that the nursing shortage contributes to nearly
a quarter of all unexpected incidents that kill or injure
hospitalized patients. Since nurses comprise the largest
component of hospital staffs, shortages also result in emergency
room overcrowding and diversions, increased wait time for
or outright cancellation of surgeries, discontinued patient
care programs or reduced service hours, and delayed discharges.
The U.S. Bureau of Labor Statistics (BLS) has projected
that by 2012, our nation will need an additional 1.1 million
new and replacement registered nurses. Despite nursing being
identified by BLS as the fastest growing occupation, according
to the Health Resources and Services Administration (HRSA),
the U.S. still will be roughly 800,000 nurses short in 2020,
unless there is a significant and sustained increase in
the number of nurses graduating each year and entering the
workforce. There are nursing vacancies throughout all sectors
of health care, including long-term care, home care, and
public health. These alarming predictions are coupled with
little change in the multitude of contributing factors such
as the aging of America's population, the aging nurse workforce,
high numbers of RN retirements, and the increasing demand
for more intensive health care services by chronically ill,
medically complex patients. It is clear that federal support
must continue to play a critical role in the nation's effort
to address the nursing shortage.
Current Strategy:
Nursing Workforce Development
Acknowledging the situation, Congress
passed The Nurse Reinvestment Act of 2002. This legislation
reauthorized and expanded Nursing Workforce Development
programs, administered by HRSA under Title VIII of the Public
Health Service Act, to address the inadequate supply
and distribution of RNs across the country. These authorities
fund nursing education and retention programs as well as
support individual students in their nursing studies. The
seven Title VIII grant and student programs stimulate innovation
in nursing practice and bolster nursing education throughout
the continuum, from entry-level preparation through graduate
study. Thoughtful and well-written authorities, Title VIII
programs are the largest source of federal funding for nursing
education. In FY 2004, these programs provided loan and
scholarship support to over 28,000 student nurses.
Given the demonstrated need for these outstanding programs,
past funding levels have been insufficient, receiving only
$150.67 million in FY 2005. AACN respectfully requests
$175 million for Title VIII Nursing Workforce Development
in FY 2006, an additional $24.33 million over FY 2005.
New monies would support these crucial Title VIII programs
designed to help resolve the nursing shortage through education,
recruitment, and retention efforts for the nursing workforce.
During the last serious nursing shortage in 1974, Congress
appropriated $153 million for nursing education programs.
Translated into today's dollars, that appropriation would
total $592 million, almost four times the current level.
Colleges of Nursing Respond
The approximately 1,500 schools of nursing nationwide have
been working diligently to expand enrollments. In fact,
AACN found in a recent study that enrollments increased
in 2004 by 15.5% for entry-level baccalaureate, master's,
and doctoral nursing programs, over the 9.1% increase experienced
in 2003. These increases are attributed to intensive marketing
efforts by the private sector, public-private partnerships
providing additional resources to expand capacity of nursing
programs, and state legislation targeting funds towards
nursing scholarships and loan repayment.
While impressive, these increases still cannot meet the
demand. In the November 2003 issue of Health Affairs,
Dr. Peter Buerhaus reported that nursing school enrollments
would have to increase by at least 40% annually just to
replace those nurses who retire, due to declining numbers
of young RNs over the past 20 years. It is important to
note that in spite of protracted efforts by colleges nationwide,
AACN found that enrollments have increased only by a total
of 53.5% over the last five years in entry-level baccalaureate
programs.
In spite of increasing enrollments and the demonstrated
need for RNs, U.S. colleges of nursing must still turn away
eligible students. In 2004, AACN found that at least 32,797
qualified applicants were turned away, up sharply from over
18,000 in 2003. These students were turned away due to insufficient
numbers of faculty, clinical sites, classroom space, clinical
preceptors, and budget constraints. Over 75% of the schools
surveyed cited the faculty shortage as the primary barrier
to increasing enrollments. Some of these qualified students
are being placed on waiting lists that may be as long as
two years.
Bottleneck: The Coexisting Faculty Shortage
AACN strongly believes that the most effective strategy
for the resolution of the nursing shortage is addressing
the underlying faculty shortage. HRSA reported in 2000 that
just 9.6% of the RN workforce holds master's degrees, while
only 0.6% holds doctorates. AACN found that more than half,
53.4%, of the nurse faculty vacancies in 2004 were for faculty
positions requiring the doctoral degree. In 2003 AACN reported
there were 10,500 full-time master's and doctorally prepared
faculty teaching in baccalaureate and graduate nursing programs.
Projections through 2012 show that the faculty pool will
shrink by at least 2,000 as compared to 2003, even after
accounting for retirements, resignations, and additional
entrants. Note that these figures do not take into account
the need for faculty in new or expanded programs, but represent
only present staffing requirements. If the faculty vacancy
rate holds steady, it is expected the deficit of nurse faculty
will swell to over 2,600 unfilled positions in 2012.
Harriet R. Feldman, PhD, RN, FAAN, Dean and Professor, Lienhardt
School of Nursing, Pace University (NY), recently shared
her struggle with the faculty shortage. "In 2001 there
were five qualified applicants for each of the four vacant
full-time nursing faculty positions at Pace University.
In 2002, there were five applicants for two positions. In
2003, there was just one applicant for two positions, and
in 2004 I hired one doctorally prepared individual for a
full-time tenure track position although five positions
were advertised." Dr. Feldman's experience is shared
by the vast majority of the schools of nursing across the
nation.
The situation is only expected to worsen with time. Faculty
age continues to climb, narrowing the number of productive
years nurse educators can teach. Significant numbers of
faculty are expected to retire in the coming years, as the
average age is 52. Likewise, there are not enough candidates
in the pipeline to take their places. For example, an average
of 410 individuals are awarded doctoral degrees in nursing
each year, but almost a quarter, 23%, take jobs outside
of academic nursing. Higher compensation in clinical and
private sector settings lures current and potential nurse
educators away from the classroom. The average salary of
a nurse practitioner in an emergency department was $80,697,
according to the 2003 National Salary Survey of Nurse Practitioners.
In contrast, AACN found that the average salary for a nurse
faculty member was $60,357 in 2003. Without sufficient nurse
faculty, schools of nursing will not be able to expand their
capacities to educate new generations of the nurses.
Reversing the Trend: The Nurse Faculty Loan Program
This trend can be reversed - with your help. Additional
appropriations for the Nurse Faculty Loan Program, Section
846A of Title VIII, will provide targeted assistance. Designed
to help increase the number of nurse faculty, grants are
provided to colleges of nursing in order to create a loan
fund. To be eligible for these loans, students must be pursuing
either a master's or doctoral degree on a full-time basis.
Loan recipients will have up to 85% of their educational
loans cancelled over a four-year period, if they agree to
teach at a school of nursing. The loan is cancelled at a
rate of 20% for the first three years, increasing to 25%
in the final year. A student may receive a maximum loan
award of $30,000 per academic year for tuition, books, fees,
laboratory expenses, and other reasonable educational costs.
In FY 2004, 61 grants were made to schools of nursing, which
in turn supported a projected 419 future nurse faculty members.
In FY 2005, $4.83 million was appropriated.
For example, if the current funding was doubled to almost
$10 million, based on FY 2004 projections, colleges of nursing
could educate over 800 future faculty. Though the student
to faculty ratios vary by state, a common average is one
faculty member for every ten students. Then one could surmise
from that estimate that the doubled funding could help to
educate over 8,000 future nurses.
Prospective Strategy:
Capitation Grants Program
Another effective strategy for rectifying
both the nurse and nurse faculty shortages is capitation
grants for schools of nursing, as illustrated by the
Nurse Education, Expansion, and Development Act (NEED).
The NEED Act will be reintroduced in the near future by
Reps. Nita Lowey (D-NY) and Lois Capps (D-CA). Similar to
the successful Nurse Training Act of 1971, P.L. 92-158,
which provided capitation grants to schools of nursing from
FY 1972 through FY 1981, the NEED Act would provide accredited
schools of nursing with a fixed dollar amount per enrolled
student. Schools of nursing could then focus these funds
on their areas of greatest need whether it would be hiring
additional faculty, expanding infrastructure, purchasing
educational equipment and software, improving clinical laboratories,
or augmenting student recruitment. While schools of nursing
would have flexibility on how to spend these funds, certain
quality, training, reporting, and data collection requirements
would have to be met. Capitation grants not only have a
proven track record for stimulating enrollment growth in
schools of nursing across the country, as at least 940,000
students enrolled from 1972 to 1981, but also were recommended
by the Institute of Medicine as an appropriate federal undertaking.
If authorized once again, capitation grants could play a
key role in eradicating the current nursing shortage.
Other Sources of Relief
AACN would like to highlight the following
programs in addition to the Nurse Faculty Loan Program:
the Advanced Education Nursing program, and the Workforce
Diversity program.
The Advanced Education Nursing
program supports the majority of colleges of nursing that
prepare graduate-level nurses to be primary care providers,
some of whom become faculty. Receiving $58.17 million in
FY 2005, this grant program helps schools of nursing, academic
health centers, and other nonprofit entities improve the
education and practice of nurse practitioners, nurse-midwives,
nurse anesthetists, nurse educators, nurse administrators,
public health nurses, and clinical nurse specialists. Out
of the 149 applications received for this program in FY
2004, 82 new grants were awarded to institutions and 75
previous awarded grants were continued. In addition, 408
schools of nursing received traineeship grants, which in
turn directly supported 8,925 individual student nurses.
The health system's increasing demand
for primary care, increased utilization of case management-
particularly for chronic illnesses, prevention and cost-efficiency,
and a shortage of physicians are driving the nation's need
for nurse practitioners, certified nurse-midwives, and other
RNs with graduate education and advanced clinical skills,
known as advanced practice nurses (APNs). Mounting studies
demonstrate the quality of APN care is at least equal to,
and at times better than comparable physician services rendered
by physicians, and often at lower cost. This is especially
important, as the 78 million Baby Boomers age, their demand
for health care services will skyrocket. AARP reported that
the rate of physician office visits by those 65 and older
jumped 22% from 1985 to 1999.
Workforce Diversity grants prepare
disadvantaged students to become nurses. As the United States
becomes ever more heterogeneous, it is imperative that the
composition of our nursing workforce mirrors this shift.
According to the U.S. Census Bureau, roughly 30% of the
population was reported as a racial or ethnic minority in
2000, but by 2050 that percentage will jump to over 52%.
This program awards grants to schools of nursing and other
entities seeking to increase access to nursing education
for disadvantaged students, including racial and ethnic
minorities under-represented among RNs. The program provides
scholarships or stipends, pre-entry preparation, and retention
activities to enable students to complete their nursing
education. In FY 2004, 144 applications were submitted,
from those 27 new grants were awarded and 35 previously
awarded grants were continued. Under the scholarship program
alone, 473 students each received $7,000 scholarships. Workforce
Diversity received $16.27 million in FY 2005.
National Institute
of Nursing Research
One of the 27 Institutes and Centers
at the National Institutes of Health (NIH), the efforts
of the National Institute of Nursing Research (NINR) improve
patient care and foster advances in nursing and other health
professions' practice. These practices must be must constantly
updated and validated based on rigorous, peer-reviewed research.
The outcomes-based findings derived from NINR research are
important to the future of the health care system and its
ability to deliver safe, cost-effective, and high quality
care. Through grants, research training, and interdisciplinary
collaborations, NINR addresses care management of patients
during illness and recovery, reduction of risks for disease
and disability, promotion of healthy lifestyles, enhancement
of quality of life in those with chronic illness, and care
for individuals at the end of life. To advance this research,
AACN requests a funding level of $160 million in FY 2006,
an additional $21.91 million over the $138.09 million NINR
received in FY 2005.
NINR Addresses the Need for Translational and Clinical Research
NINR emphasizes translational research, the means by which
basic findings relating to behavior, molecules, and genes
are tested in the clinical setting and translated into innovative
medical practices and improvements in public health. This
effort is incorporated into the NIH Roadmap for Medical
Research. Under the framework of the Roadmap Initiative,
NINR and nurse researchers are addressing the development
of new interdisciplinary research teams and enhanced clinical
research to move the overall NIH portfolio of social, behavioral,
and medical research forward in this coordinated and cohesive
effort.
NINR Addresses the Shortage of Nurse
Researchers and Faculty
NINR allocates 8% of its budget, a high proportion when
compared to other NIH institutes, to research training to
help develop the pool of nurse researchers. In FY 2004,
NINR training dollars supported 88 individual researchers
and provided 186 institutional awards, which in turn supported
a number of nurse researchers at each site. Since nurse
researchers often serve as faculty members for colleges
of nursing, they are actively educating our next generation
of RNs.
Agency for Healthcare
Research and Quality
While NIH supports biomedical research
that improves health care by focusing on disease cause,
cure, and prevention; the Agency for Healthcare Research
and Quality (AHRQ) supports research from a systems perspective,
collecting evidence-based information on health care outcomes.
AHRQ research findings are used by patients, clinicians,
health system decision makers, and public policymakers to
guide healthcare delivery systems and patient care. The
research supported by AHRQ not only improves the quality
of health care services, but also helps people make more
informed decisions about their healthcare. AACN joins
the Friends of AHRQ in recommending a funding level of $440
million for FY 2006, an additional $121 million over
the FY 2005 level of $318.7 million.
Health Systems Research at AHRQ
Addresses Nurses' Role in Patient Safety
AHRQ research has demonstrated that inefficient work processes,
overwhelming work loads, extended work hours, and poor workplace
designs create obstacles to providing patients safe, cost-effective,
and high quality health care. The New England Journal
of Medicine published a study of over 6 million patients
in May, 2002 that found hospitalized patients had better
outcomes when the majority of their nursing care was provided
by RNs. Decreased hours of RN care, stemming from the nursing
shortage, correlated with longer hospital stays, increased
incidence of urinary tract infections and gastrointestinal
bleeding, as well higher rates of pneumonia, shock, and
cardiac arrest. When patients received additional hours
of RN care, the death rates dropped for pneumonia, shock
or cardiac arrest, upper gastrointestinal bleeding, sepsis,
and deep venous thrombosis.
Conclusion
Nurses can no longer simply give care
to a patient at the bedside. They must evaluate research
that promotes evidence-based practice and utilize technical
innovations to provide quality patient care. To achieve
this level of excellence, AACN recognizes that our nation
desperately needs a dedicated, long-term vision for educating
the new nursing workforce. Strategies must encompass state
support, public-private sector initiatives, and increased
federal funding for nursing education and research. Title
VIII Nursing Workforce Development programs enable colleges
of nursing to innovate and prepare students for the realities
of caring for our nation's diverse population in many health
care settings across the lifespan. NINR, NIH, and AHRQ provide
the research that supports the evidence base for safe practice
and quality care delivery. We ask the Subcommittee to graciously
consider our appropriations requests for FY 2006.
