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.
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 4 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.
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 this year's 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.
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, the Workforce Diversity program, and the
Nurse Education, Practice, and Retention 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.
The Nurse Education, Practice and Retention
program helps schools of nursing, academic health centers,
nurse-managed health centers, state and local governments,
and health care facilities strengthen programs that provide
nursing education, facilitate innovations in nursing practice,
and retention of the nursing workforce. Education grants
are made to enable schools to expand enrollments in baccalaureate
nursing programs, develop internship and residency programs,
and provide for new technology. Practice grants are made
to expand arrangements in non-institutional settings to
improve primary health care in medically underserved communities,
provide care for underserved populations, enhance practitioner
skills, and develop cultural competencies. Retention grants
are made to the Career Ladder program, which supports efforts
to assist people to obtain the necessary education to either
enter the profession or to advance within it; enhance patient
care delivery systems through incorporation of best practices,
and improved communication. In FY 2004, 336 applications
were submitted, from those, 40 new grants and 85 continuation
grants were awarded. Nurse Education, Practice, and Retention
received a total of $36.48 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.
AHRQ Research Demonstrates that Nurse
Education Affects Patient Outcomes
Another AHRQ study found that by employing a greater proportion
of more highly educated nurses reduced the mortality and
failure to rescue rates from life threatening complications.
This extensive study in the September 2003 issue of the
Journal of the American Medical Association found
that surgical patients have a "substantial survival
advantage" if treated in hospitals with higher proportions
of nurses educated at the baccalaureate or higher degree
level. In hospitals, a 10% increase in the proportion of
nurses holding BSN degrees decreased the risk of patient
death and failure to rescue by 5%.
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.
