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State Legislative Initiatives to Address the Nursing Shortage

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State Legislative Initiatives to Address the Nursing Shortage

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Resolving the U.S. nursing shortage will require the collective effort of stakeholders at the national, state, and local levels. Federal legislators have demonstrated a commitment to addressing this health care crisis by nearly doubling the amount of funding for Nursing Workforce Development programs (Title VIII of the Public Health Service Act) from $78.8 million in FY 2001 to $149.7 million in FY 2006. With the nursing community struggling to maintain funding levels in the current fiscal year, future increases in federal programs promising nursing shortage relief may not be realized.

To help bridge this gap and more fully address local needs, many state initiatives are underway to increase the number of new nurses entering the workforce and pursuing faculty careers. These efforts generally center on the creation of new legislation to remove financial barriers to pursuing a nursing degree, mostly at the graduate level, and often result from a collaborative push by representatives from both the education and practice communities.

In recent years, the number of new statewide legislative initiatives to address the nursing shortage seems to be multiplying. This year, Illinois, Kansas, Maryland, and Utah were among the states that enacted sweeping legislation to address the shortage of Registered Nurses (RNs) and nurse educators over the next five to ten years. States including Colorado, Georgia, Nebraska, Minnesota, and Texas have focused efforts on alleviating the shortage of nurse educators, the primary obstacle faced by schools of nursing looking to expand student capacity. Other states, including Massachusetts, Missouri, and Pennsylvania, are working inside and outside of the legislative arena to launch programs involving strong collaborations between education, practice, and community stakeholders.

To assess the efforts underway at the state level, the Government Affairs Committee (GAC) of the American Association of Colleges of Nursing (AACN) conducted a survey of our nation's senior nursing colleges and universities. This Issue Bulletin will share details about some efforts that have proven successful at strengthening the nursing workforce and bridging resource gaps at schools of nursing looking to expand student enrollments and meet supply expectations.

"The success stories featured in this Issue Bulletin serve as a blueprint for those wishing to pursue legislative solutions to the shortages of RNs and nurse educators at the state level," said Dr. Jane Kirschling, dean of the University of Kentucky College of Nursing and GAC chair. "While AACN is committed to increasing the nurse faculty population and securing funding for nursing education, much more can be done at the state and local levels to address these important concerns."

Comprehensive Statewide Strategies

Several states are leading the way by pursuing comprehensive strategies to address the nursing shortage on several fronts. In April 2006, Maryland's Health Services Cost Review Commission (HSCRC) awarded grants to seven academic institutions totaling $6 million over five years as part of the first round of funding through the newly created Nurse Support Program (NSP). The NSP was created through legislation proposed by Governor Robert L. Ehrlich, Jr., the Nurse Support Program Assistance Fund (SB 230/HB 322), that was vigorously supported by Maryland nurse educators.

The NSP aims to expand the pool of nurses in Maryland by increasing the capacity of nursing programs in two phases. The first statewide initiative provides funding for graduate nursing faculty scholarships and living expenses, new nursing faculty fellowships, and state nursing scholarship and living expenses grants. The second program, the competitive institutional grants initiative, expands the state's nursing capacity through shared resources, enhancing nursing student retention, and increasing the pipeline for nurse faculty.

Through this innovative program, HSCRC generates funding by levying a 0.1% increase to the rate structure of all Maryland hospitals retroactive from July 1, 2005. This change will generate approximately $8.8 million annually to be awarded to the state's schools of nursing. The projected outcomes of this first round of seven institutional grants are is an increase of 500 nursing students in undergraduate programs and 250-300 students in graduate programs.

"This state initiative is unprecedented," says Dr. Janet D. Allan, dean of the University of Maryland School of Nursing. "This funding comes at a time when the state and the nation are experiencing a severe shortage of nurse faculty. Maryland needs nurses, and to get more nurses, we need the nurse faculty to educate them. This program couldn't have come at a better time."

In May 2006, the Kansas Board of Regents approved a ten-year, $30 million initiative aimed at increasing nursing capacity in the state by 25%. Of the $30 million total cost, $22 million will come from state appropriations while $8 million will be committed through matching funds by the participating educational institutions. Funding from this initiative is divided into three main areas, including: 1) Nursing Equipment and Facility Upgrades; 2) Nursing Faculty Salaries and Supplies; and 3) Nurse Educator Scholarships. Each of these grants requires matching funds from the applying institution or other sources. Once the proposals funded by these grants are fully implemented, the state's nursing programs will be able to increase their capacity by over 500 additional nursing students and realize the potential for additional nurse educators.

"Every nursing program in the state is turning down applicants. We don't have the faculty to teach them; that is the main pipeline breakdown," said Dr. Karen Miller, dean of the University of Kansas School of Nursing. "This is a proactive move on the part of the Board of Regents which includes some very forward thinking about our state's healthcare system."

To address the severe nursing shortage facing Illinois, Governor Rod R. Blagojevich unveiled a plan to increase the number of faculty available to educate nurses, provide financial assistance to nursing students, and develop a long-term nursing workforce plan. In July 2006, the Illinois General Assembly enacted the Nurse Educator Assistance Act which provides up to $5,000 in loan repayment and $10,000 in scholarship funds to nursing students enrolled in graduate nursing programs. This legislation was designed to attract capable and promising students to the nurse educator role, increase employment and retention of individuals who are working towards or who have received a master's or doctoral degree in nursing, and provide opportunities for persons making mid-career decisions to enter the nurse educator profession.

This law also created the Illinois Center for Nursing to address issues of supply and demand in the nursing profession, including recruitment, retention, and utilization of nurses. "The Governor's proposal recognizes the need to address critical issues in nursing for the state of Illinois. It is very difficult to project nursing workforce needs when there is no central data bank in the state," said Dr. Nancy Ridenour, dean of the Mennonite College of Nursing at Illinois State University. "The Center for Nursing will provide opportunities to centralize workforce related issues and assist colleges of nursing in coordinating and collaborating with each other to provide comprehensive nursing education throughout the state. In addition, the Nurse Educator Scholarship and the addition of merit to the Nursing Scholarship criteria both support the need to increase the numbers of nursing faculty."

Last year, a coalition of seven state-supported nursing programs in Utah were successful in obtaining designated 'nursing initiative' funding from the state legislature. Two million dollars was provided by the legislature with a $1 million match from the hospitals in the state represented by the Utah Hospital Association. "This $3 million in support is to be continued for 5 years and is to be used to hire and retain nursing faculty to allow for nursing program expansion," said Dr. Maureen Keefe, dean of the University of Utah College of Nursing. "State officials expect that nursing graduates in Utah will increase by over 600 within the next five to six years."

Expanding the Nurse Faculty Population

Efforts to address the shortage of registered nurses will fall short unless sufficient numbers of faculty are available to prepare the next generation of RNs. Armed with this understanding, many state initiatives are underway to offer loan repayment or forgiveness programs for nurse educators.

In 2006, Colorado's state legislature passed two nurse faculty shortage bills which addressed both the financial barriers to graduate education and the salary differential for nurses working in academia versus practice. Modeled after an existing program for teachers in other disciplines, the Nursing Teacher Loan Forgiveness Program (SB 136) provides up to $20,000 in loan forgiveness for students pursuing master's or doctoral degrees in exchange for a five-year teaching commitment at a Colorado school of nursing. The Nursing Faculty Fellowship Program(HB 1269) was created to assist nursing schools in filling faculty vacancies by providing fellowship payments of up to $10,000 a year for three years. Though implementation of the fellowship program is planned for 2007-2008, funding has not yet been appropriated.

Other states are moving in the same direction. The Nebraska Legislature passed the Nurse Faculty Student Loan Act which created a program to provide loans and loan waivers to nurses enrolled in master's or doctoral programs who intend to teach after graduation. The North Dakota State Board of Nursing operates a program called the Nursing Education Loan Program which is available to nursing students in graduate and undergraduate programs. Doctoral students and nurses pursuing refresher courses may also apply for funding which can be repaid via nursing service in North Dakota after the program's end.

For links to other nurse loan repayment/forgiveness programs offered in the states of Georgia, Illinois, Minnesota, Vermont and Texas, see the online companion to this Issue Bulletin found at www.aacn.nche.edu/government-affairs/resources/state-advocacy-resources.

Working in Coalitions at the State Level

Working within state legislatures, and sometimes outside of this arena, many nursing institutions and organizations at the state level have joined forces to launch joint nursing shortage relief strategies. These collaborations vary from state to state and typically involve a number of stakeholders, including schools of nursing, state higher education agencies, centers for nursing, hospital associations, foundations, and businesses.

In some instance, the state higher education authorities are fully engaged in collaborating with academic and practice leaders. In January 2006, the Connecticut Health and Educational Facilities Authority (CHEFA) established a targeted investment grant program to increase the number of faculty in the state's schools of nursing. The authority made a commitment to make $240,000 available annually for two years, and awards will be made on a competitive basis. The Massachusetts Board of Higher Education (BHE) has been working with the Massachusetts Hospital Association and other stakeholders to develop the Massachusetts Public Higher Education Initiative on Nursing Education. The partnership was created to increase the nursing faculty population and launch programs to rapidly augment the number of skilled nurses.

In an effort to increase the number of new faculty at area nursing schools, the Kansas City Metropolitan Healthcare Council (KCMHC) has created the Graduate Nursing Faculty Financial Assistance Program which will provide approximately $193,000 throughout 2007 and 2008 to nurses from Kansas or Missouri who have completed no more than 12 credit hours towards a master's degree. Nurses receiving financial assistance through this program must work either full- or part-time as a clinical faculty member at a local nursing school after graduation.

Another Kansas City area initiative, OneKC WIRED, further demonstrates the power of partnering among diverse stakeholders. "The OneKC WIRED Grant is the result of collaboration among manufacturing, life sciences, health care, nursing education, and the public workforce system," explained Dr. Susan Fetsch, dean of the Avila University School of Nursing. "The focus on the healthcare component of this larger initiative is the expansion of the nursing workforce in the Kansas City region."

With more than $1.75 million in funding, OneKC WIRED is supporting several innovative programs, including three Clinical Faculty Academies to (1) develop educational materials and standardized curriculum, (2) educate mentors and preceptors on how to promote retention of new graduates, and (3) facilitate expansion of nurse re-entry programs. Funding was also used to purchase patient simulators to enhance clinical training for all nursing programs in the Kansas City metropolitan area and provide stipends to clinical staff to enable them to pursue graduate study full-time.

As part of continuing efforts to alleviate the state's nursing shortage, the Pennsylvania Higher Education Foundation in cooperation with The Hospital & Healthsystem Association of Pennsylvania launched new Nursing Education Capacity Initiatives in March 2006. These programs are designed to boost capacity in all of the state's nursing programs with initiatives developed to encourage practicing nurses to return to school, earn their graduate degrees, and teach the next generation of nurses. Included among these initiatives were:

  • The Nurse Educator Loan Forgiveness Program which forgives up to $50,000 of qualified loan debt, provided that the applicant agrees to work three to five years as a nurse educator at an approved Pennsylvania nursing school.

  • The Graduate Nurse Education Grant Program which awards funding for scholarships to graduate nursing programs with the goal of increasing enrollments and improving retention for students seeking teaching roles.

  • The Nurse Faculty Lines Program which provides funds annually to non-profit, tax-exempt schools of nursing to underwrite nursing faculty positions. The initial round of awards, subject to available funding, will provide $50,000 per line, renewable for a minimum of three years, to increase teaching faculty at an institution.

Resources to Support Advocacy at the State Level

AACN encourages schools of nursing to fully explore the success stories contained in this Issue Bulletin and to consider launching new statewide initiatives. To support the advocacy efforts of member schools, AACN offers the following advice on getting started:

  • Contact your State Grassroots Liaison - www.aacn.nche.edu/Government - or deans at other schools of nursing to find out what state initiatives are underway and/or to propose new legislative solutions.
  • Consult with your colleagues around the country who have had success launching their own state legislative initiatives to see what strategies work and what to avoid.
  • Begin conversations with practice partners and contacts at the state board of nursing, higher education authority, nurses association, hospital association, and center for nursing to assess interest in a collaborative venture.
  • Visit the AACN Web site for data and information that will help you make your case at the state level. There resources include:

Last Update: October 25, 2006