The American Association of
Colleges of Nursing (AACN) respectfully submits this statement
highlighting funding priorities for nursing education and
research programs in FY 2007. AACN represents over 590 senior
colleges and universities with baccalaureate and graduate
nursing programs that include over 210,000 students and
11,000 faculty members. These institutions are responsible
for educating almost half of our nation's registered nurses
(RNs) and all of the nurse faculty and researchers. Nursing
represents the largest health profession, with approximately
2.9 million dedicated, trusted professionals delivering
primary, acute, and chronic care to millions of Americans.
The Nationwide Nursing Shortage
Our country continues to be challenged by a shortage of
registered nurses that was first noted in 1998. This shortage
is showing no signs of diminishing and demographics reveal
that, unlike shortages in the past, it will affect health
care delivery for the foreseeable future. In 2005, the American
College of Healthcare Executives reported that 85% of hospitals
experienced a nursing shortage. The U.S. Bureau of Labor
Statistics (BLS) has projected that our country will require
an additional 1.2 million new and replacement registered
nurses by 2014. Nursing has been identified by BLS as the
fastest growing professional occupation in the country.
However, according to the Health Resources and Services
Administration (HRSA), the supply of RNs will drop 29% below
demand by 2020 unless deliberate action is taken to increase
the number of nurses graduating each year and entering the
workforce. Nursing vacancies exist throughout all health
care sectors, including long-term care, home care, and public
health. Among the nation's 5,000 community health centers,
the vacancy rate for RNs is 10% and 9% for nurse practitioners.
Even the Department of Veterans Affairs, the largest sole
employer of RNs in the U.S., has a 10% RN vacancy rate.
Research clearly documents that patient safety
is compromised without a sufficient number of RNs. In 2002,
the Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) noted that the nursing shortage contributed to nearly
a quarter of all unexpected incidents that adversely affect
hospitalized patients. Since RNs comprise the largest component
of a hospital workforce, shortages result in emergency room
overcrowding and diversions, increased wait time for or
cancellation of surgeries, discontinued patient care programs
or reduced service hours, and delayed discharges.
The nursing shortage also threatens homeland
security and disaster preparedness efforts. The Government
Accountability Office reported that local and state health
officials cited the nursing shortage as an impediment to
their preparedness efforts in 2003.
These alarming facts are coupled with
little change in contributing factors, such as the aging
of America's population, the aging nurse workforce, high
rates of RN retirement, and the increasing demand for high
acuity health care services by chronically ill, medically
complex patients. To ensure that every patient receives
the safest, highest quality health care, federal support
must continue to play an integral role in our nation's efforts
to address the nursing shortage.
Current Strategy: Nursing
Workforce Development Programs
Acknowledging the severity of the nation's
nursing shortage, Congress passed The Nurse Reinvestment
Act of 2002. This legislation created new programs and
expanded existing Nursing Workforce Development authorities.
Administered by HRSA under Title VIII of the Public Health
Service Act, these programs focus on the supply and distribution
of RNs across the country. Programs support individual students
in their nursing studies through loans, scholarships, and
loan repayment programs. Title VIII programs stimulate innovation
in nursing practice and bolster nursing education throughout
the continuum, from entry-level preparation through graduate
study. They are the largest source of federal funding
for nursing education assisting students, schools of
nursing, and health systems in their efforts to educate,
recruit, and retain RNs. In FY 2004, these programs helped
to educate over 50,000 student nurses through individual
and programmatic support.
Funding for these authorities is insufficient
to address the severity of the nursing shortage. Currently,
Nursing Workforce Development Programs receive $149.68 million,
down from $150.67 million in FY 2005. During the nursing
shortage in 1974, Congress appropriated $153 million for
nursing education programs. Translated into today's dollars,
that appropriation would total $615 million, more than four
times the current level. However, it will take billions
of dollars to resolve today's nursing shortage.
AACN respectfully requests $175 million
for Title VIII Nursing Workforce Development in FY 2007,
an additional $25.32 million over FY 2006. New monies would
expand nursing education, recruitment, and retention efforts
to help resolve the nursing shortage.
Colleges of Nursing Respond
The approximately 1,500 schools of nursing nationwide have
been working diligently to expand enrollments. AACN's 2005-2006
annual survey of 567 schools entitled, Enrollments and
Graduations in Baccalaureate and Graduate Programs in Nursing,
reveals that enrollments increased by 13% in entry-level
baccalaureate nursing programs. This makes the fifth consecutive
year of enrollment increases that can be attributed to a
combination of federal support through Nursing Workforce
Development Programs, private sector marketing efforts,
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. Despite intensive efforts
nationwide, AACN found that enrollments increased by a total
of 57.2% over the last five years in entry-level
baccalaureate programs. Moreover, only 8.1% of RNs are under
the age of 30, according to the 2004 National Sample Survey
of Registered Nurses.
Despite increasing enrollments and the escalating
demand for RNs, U.S. schools of nursing still are forced
to turn away eligible students. At least 41,628 qualified
applications were turned away despite the increase in enrollments.
This is a 21% increase from the over 32,797 denied admission
in 2004, according to AACN data. Reasons cited for this
denial are insufficient numbers of faculty, clinical sites,
classroom space, clinical preceptors, and budget constraints.
Over 73% of the schools surveyed cited the faculty shortage
as the primary barrier to increasing enrollments. Some of
these qualified students are placed on waiting lists for
two years or more, but many good students are lost to the
nursing profession.
Bottleneck: The Nurse Faculty Shortage
AACN believes that the most effective strategy to resolve
the nursing shortage is addressing the underlying faculty
shortage. HRSA reported in 2004 that just 13% of the RN
workforce holds either a master's or doctoral degree, credentials
required to teach. In 2003, there were 10,500 full-time
master's and doctorally prepared faculty 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 only represent present staffing requirements.
If the faculty vacancy rate holds steady, the deficit of
nurse faculty is expected to swell to over 2,600 unfilled
positions in 2012.
This situation will only worsen with time.
The number of productive years for nurse educators will
decrease as faculty age continues to climb, averaging 52
years in 2004. As such, significant numbers of faculty are
expected to retire in the coming years, but there are not
enough candidates in the pipeline to take their places.
An average of 410 individuals are awarded doctoral degrees
in nursing each year, but almost a quarter (23%) take jobs
outside of academic nursing. In 2005, AACN found a faculty
vacancy rate of 8.5%, which translates into an average of
approximately 2 faculty vacancies per school of nursing.
Of those vacancies, over half (52.6%) required a doctoral
degree. Higher compensation in clinical and private sector
settings lures current and potential nurse educators away
from the classroom. For example, the average salary of a
nurse practitioner in an emergency department was $84,835,
according to the 2005 National Salary Survey of Nurse Practitioners.
However, the average salary for a nurse practitioner in
academia was only $66,925, 26.8% less. Without sufficient
nurse faculty, schools of nursing cannot expand enrollments.
Reversing the Trend: Nurse Faculty Loan
Program (Sec. 846A) This trend can be reversed with
additional appropriations for the Nurse Faculty Loan Program.
Designed to increase the number of nurse faculty, schools
of nursing receive grants to create a loan fund. To be eligible
for these loans, students must pursue full-time study for
a master's or doctoral degree. In exchange for teaching
at a school of nursing, loan recipients will have up to
85% of their educational loans cancelled over a four-year
period. 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 2005, 66 new
grants were made to schools of nursing, and 26 grants were
continued, totaling 92. These funds will support an estimated
475 future nurse faculty members. In FY 2006, $4.77 million
was appropriated. However, if the current funding was
doubled to almost $10 million, based on FY 2005 projections,
colleges of nursing could educate over 900 future faculty.
Further, with an average faculty to student ratio of 1:10,
those 900 faculty could teach an additional 9,000 nurses
each year.
Advanced Education Nursing Program (Sec.
811) These grants support the majority of schools of
nursing preparing graduate-level nurses, some of whom become
faculty. Receiving $57.06 million in FY 2006, 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
88 applications reviewed for this program in FY 2005, 43
new grants were awarded, and 114 were continued. In addition,
422 schools of nursing received traineeship grants, which
in turn directly supported 9,000 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 registered nurses (APRNs). Mounting
studies demonstrate the quality and cost effectiveness of
APRN care. This is especially important for the 78 million
aging Baby Boomers, whose demand for health care services
will skyrocket in the near future. The rate of physician
office visits by Medicare beneficiaries jumped 20.5% from
1992 to 2001, according to the federal report Older Americans
2004: Key Indicators of Well-Being.
Workforce Diversity Program (Sec. 821)
These 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
those racial and ethnic minorities under-represented among
RNs. Scholarships or stipends, pre-entry preparation, and
retention activities are provided to enable students to
complete their nursing education. In FY 2005, 171 applications
were reviewed, from those 11 new grants were awarded and
48 previously awarded grants were continued. These program
funds assisted at least 6,344 students. Workforce Diversity
received $16.11 million in FY 2006.
At Risk: Nursing Student Loan Program
(Sec. 835) This revolving loan fund was established
in 1964 to specifically target nursing workforce shortages.
The Nursing Student Loan (NSL) program provides participating
undergraduate or graduate nursing students with a maximum
of $13,000 in loans at 5% interest. Schools of nursing participating
in the NSL select recipients and determine the level of
assistance provided, with a preference for those with financial
need. New loans are made as existing loans are repaid. This
program has not received additional appropriations since
1983. However, in FY 2005, the NSL provided financial
assistance to 17,240 nursing students. In FY 2005, Sec.
222 of the Consolidated Appropriations Act of 2005
(P.L. 108-447) included language which stated: "The
unobligated balance of the Nursing Student Loan program
authorized by section 835 of the Public Health Services
Act is rescinded." As a result, the NSL gave back $6.1
million to the U.S. Treasury in July 2005. In previous years,
those funds were redistributed among participating institutions,
increasing the amount of possible loans. A similar provision
in the FY 2006 appropriations law will force the NSL to
return even more funds to the Treasury that instead could
have assisted nursing students in completing their education.
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 $150 million in FY 2007,
an additional $12.66 million over the $137.34 million
NINR received in FY 2006.
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. 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 2005,
NINR training dollars supported 80 individual researchers
and provided 155 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 the cause, cure, and
prevention of disease, the Agency for Healthcare Research
and Quality (AHRQ) supports health systems research, 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
health care 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 health care. AACN joins the Friends
of AHRQ in recommending a funding level of $440 million
for FY 2007, an additional $121.3 million over the FY
2006 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 workloads, 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 as 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
AACN acknowledges the fiscal challenges
that the Subcommittee and the entire Congress must work
within. However, the health needs of our nation must be
addressed by a dedicated, long-term vision for educating
the new nursing workforce. Today, nurses must evaluate research
that promotes evidence-based practice and utilize technical
innovations in providing safe, high quality patient care.
Research shows that patient care suffers and mortality rates
increase in facilities without sufficient numbers of RNs.
Without highly educated nurses, who will care for us when
we must enter into our increasingly complex health care
system?
