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Congress reacted to the pervasive nursing
shortage and its implications for provision
of health care to the Nation's population
by passing legislation in 2002 designed
to stimulate the growth of the nursing
profession and to enhance the attractiveness
of nursing as a profession. The Nurse
Reinvestment Act (NRA), Public Law 107-205,
was signed August 1, 2002. While retaining
the provisions of Title VIII as set forth
in Public Law 105-392, the NRA enhanced
several of those provisions and established
new initiatives to further the recruitment
and retention of nurses. At its November
2002 meeting NACNEP focused its attention
on the provisions of the NRA and on providing
advice to the Division of Nursing, BHPr,
HRSA in implementing these provisions.
In passing the NRA, Congress was looking
toward both increasing recruitment into
nursing and retaining those already in
the field through providing support for
career enhancement and development. In
order to retain nurses in the workforce
through better job satisfaction and career
advancement, it provided the means by
which nurses could expand their clinical
knowledge and skills to better qualify
them to deliver care in the complex arena
of today's health care. In recognition
of the role that the involvement in decision-making
plays in increased nurse job satisfaction
and improved patient care, Congress provided
for support to programs that enhance collaboration
and communication among nurses and other
health care professionals and promote
nurse involvement in health facilities'
organizational and clinical decision-making.
Mindful of the need to take care of an
aging population, Congress specifically
provided for educational programs for
nurses in providing geriatric care for
the elderly.
Staff of the Division of Nursing, charged
with the responsibility for carrying out
the NRA provisions, made a detailed analysis
of each aspect of this new legislation
and developed key questions relevant to
the interpretation of these legislative
mandates. NACNEP's advice, along with
that of professional organizations with
membership from and interests in the nursing
community, was used in devising the implementation
plans pertinent to these new initiatives.
All concerned with the critical issues
facing nursing, Congress, the Department
of Health and Human Services, NACNEP and
the nursing community at large, felt the
need to implement these new initiatives
as rapidly as possible. Funds were appropriated
in February 2003. The Request for Applications
was made available toward the end of April
2003 and the funding of grants was accomplished
in September 2003.
Building Career Ladders
As a means of retaining personnel in
the health care area the NRA added to
Section 831 of Title VIII provisions for
grants to encourage nursing career ladders.
The career ladder grant program had two
aspects to it: promoting career ladders
and assisting individuals. As indicated
in the legislation Congress saw this program
as one that would "promote career
advancement for nursing personnel in a
variety of training settings, cross training
or specialty training among diverse population
groups, and the advancement of individuals
including to become professional nurses,
advanced education nurses, licensed practical
nurses, certified nursing assistants,
and home health aides." NACNEP agreed
with the interpretation that the intent
of these provisions was to focus on both
recruiting individuals into the nursing
workforce and to retain in nursing those
who have already shown an interest in
working with people in need of nursing
interventions.
In response to questions about the educational
levels to be considered, the Council stressed
that the focus should be on pathways and
career mobility models that would further
the achievement of NACNEP's goal that
by 2010 two-thirds of the RN workforce
should have at least a baccalaureate degree
and, also, help to develop those eligible
to become faculty members. As shown in
the First and Second Reports of NACNEP
to the Secretary and Congress, both these
objectives are critical to the assurance
of an adequate, appropriately qualified,
nurse workforce. A recent study carried
out by researchers in the school of nursing
in the University of Pennsylvania provided
additional support for NACNEP's educational
goal. The authors of this study of staffing
in surgical units in hospitals concluded
that surgical patients had greater survival
advantages and were more likely to survive
serious complications if higher proportions
of the direct-care RNs had baccalaureate
or higher degrees. (Aiken, 2003)
The Council recommended that the new
career ladder projects should be based
on existing models of articulation and
"accelerated" tracks. The Council
felt that individual projects should not
be required to include multiple educational
levels. However, the Council indicated
that the overall goal to be accomplished
was that of articulation through the RN.
NACNEP itemized several outcome measures
that it felt would appropriately reflect
the intent of these legislative provisions.
Among these were: progress within individual
projects; numbers graduating and obtaining
licensure as a result of funded programs;
the future advancement through the nursing
educational levels and the retention within
the workforce of those attending the funded
programs, and the impact of these programs
in increasing the capacity for providing
health care to reduce health disparities
of the population.
The overwhelming response to the request
for applications for the Career Ladder
Program with 301 applications in the little
over one month's time given for response
demonstrated the potential for the program
to make a difference in increasing the
nurse supply. Of the applications received,
276 were eligible for review and 116 were
approved through the peer review process.
But, because of the limited amount of
money available for the program, only
11 of the approved applications could
be funded. (See Chart 1.) Five of the
11 funded grants were for articulation
of education programs for nursing personnel.
Of the six others, three provided accelerated
pathways for RN education for second-degree
students; two related to increasing access
to specialty education for the preparation
of nurse faculty, and one covered multiple
purposes.
Chart 1: Number
of Applications in New NRA Initiatives,
FY 2004
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Enhancing Patient
Care Delivery Systems
Another amendment to Section 831 of Title
VIII designed to assist with nurse retention,
as well as assist in enhancing patient
care, called for grants related to collaboration
and communication among nurses and other
health professionals and to promotion
of nurse involvement in the organizational
and clinical decision-making processes
of a health care facility. Considerable
documentation exists in the literature
about the increased job satisfaction leading
to improved nurse retention and better
patient care that comes from increased
collaboration, including good physician-nurse
relations, and nurse involvement in the
institutional structure and decision-making
process. These organizational characteristics
are key variables in "Magnet"
hospitals, those identified as having
good success in recruiting and retaining
their nurse workforce.
NACNEP, in reviewing the considerations
for implementation, discussed whether
there should be differing funding levels
based on the size and scope of the services
of the institution in which the program
was to be carried out. Consistent with
its continuing support of interdisciplinary
education and practice NACNEP defined
"collaboration" for purposes
of this provision as activities among
the variety of health care disciplines
such as physician-nurse interaction.
Since the main purpose for including
provisions related to collaboration and
communication and nurse involvement in
organizational and clinical decision-making
was to improve the retention of nurses
so that the quality of patient care would
be increased, the Council itemized the
outcome measures needed to accomplish
enhanced patient care. These included
consistency of care and continuity of
the caregivers; evidence-based practice;
good physician-nurse relations; interdisciplinary
team standards of practice; nursing's
involvement in institutional structure;
use of standardized instruments to measure
outcomes, and acuity-sensitive staffing.
Out of the 125 submitted applications
108 were considered eligible for review.
Among those, 35 were approved and 14 of
the approved applications were funded
under the provisions of this program.
These funded grants all spoke to improving
team communications, patient care and/or
patient safety, and nursing governance.
The entities directly involved in the
activities to be carried out within these
grants reflect an interesting mix of institutions
and consortiums including 103 rural hospitals,
22 disproportionate share hospitals, 105
acute care hospitals and 100 long-term
care institutions.
Internships and Residencies
Section 831 was also amended to provide
for awards for the purpose of "developing
and implementing internship and residency
programs to encourage mentoring and the
development of specialties." The
Council considered the questions posed
to it in the light of the intent of this
legislative provision to enhance the ability
to retain nurses.
Of particular importance to the interpretation
of this provision was the scope of its
coverage. Should it encompass programs
designed for students prior to graduation
from the nursing educational program or
those designed for nurses who are reentering
practice? Given the focus on retention
of nurses, the Council advised that awards
under this provision should benefit nurse
graduates and registered nurses. They
should be helpful in assisting the transition
of nurses into the workforce setting;
provide the means to better deal with
the complex health care arena, and assist
with the transition into specialty areas.
Although several Council members spoke
positively about including student internships
in the implementation, NACNEP was mindful
of this provision's legislative intent
to educate nurses to remain in the workforce
or to change nurse specialties with its
implication that the nurse interns and/or
residents be active members of the workforce.
The scope of the programs to be supported
also engendered considerable discussion.
It was agreed that the programs should
contain both didactic and clinical aspects
but questions arose as to how much should
be learning and how much service. In terms
of the latter, it was agreed that care
needs to be taken that the individual
is in a learner rather than a practitioner
role. Questions of length, minimum requirements
or standardization were addressed with
the overall consideration of allowing
for creativity and flexibility.
The Council considered the outcomes to
be sought in determining the success of
the program in retaining nurses. Among
these were the reduction in turnover (except
promotion, considered "good"
turnover); reduction in vacancy rates
in high-need clinical areas, and increased
job satisfaction. For the programs, it
was important that needed resources including
people, time, expertise, and training
for the mentors be provided and that there
be an overall plan for retention of nurses.
Of the 125 applications submitted for
funding under this program, 98 were eligible
and reviewed and 52 were approved. However,
again, the limited amount of funds available
resulted in only 14 of the 52 approved
submissions being funded. Half of the
98 applications considered appropriate
for review included more than one of the
three purposes for which it was determined
that grants would be made. Among those
submitted for a single purpose, only five
were to implement the purpose of returning
RNs to the workforce. The purpose of providing
graduate nurse transition into the first
professional role attracted 26 of the
98 applications and that of changing a
nursing specialty, 18 applications. Both
of these latter purposes are critically
important to creating a nurse workforce
capable of quality patient care and enhancing
patient safety. Studies show that newly
graduated nurses have considerable uncertainties
about their role and ability to function
effectively in the health care setting.
Comprehensive Geriatric
Education
Title VIII was further amended by the
NRA to include Section 855 calling for
"programs and initiatives to train
and educate individuals in providing geriatric
care for the elderly." Eligible entities
to receive grants under this provision
were schools of nursing, programs leading
to certification as a certified nurse
assistant (CNA), health care facilities,
and partnerships between a facility and
a school or a CNA program. Section 855
provided that the purposes for which the
grants were to be awarded in connection
with geriatric care were to provide training
to individuals giving care; develop and
disseminate curricula; train faculty members,
and provide continuing education to those
providing care.
In determining coverage of the provision,
NACNEP advised that individuals providing
care should have a broad interpretation
within the nursing community. It suggested
that, among the purposes for these grants,
the focus should be on continuing education,
strengthening nursing faculty, and strengthening
geriatric content in nursing curricula.
The Council thought that programs under
these grants could appropriately include
English-as-a-second-language/linguistic
competence and multidisciplinary training.
As required in the legislation, the Council
suggested effective and efficient coordination
should be demonstrated with local/State
Geriatric Education Centers, where appropriate.
NACNEP also thought that the proposed
programs should be required to demonstrate
that recipients had achieved competency
in geriatrics.
A total of 98 applications were received
for this initiative of which 77 were eligible
and reviewed. Thirty of those reviewed
were approved with 17 of these funded.
These grants will provide education/training
for RNs providing care to older adults
to enhance their leadership skills and
to increase their knowledge base in geriatrics.
As leaders in geriatric nursing, the RNs
will provide training in geriatrics for
licensed practical nurses and CNAs.
Nurse Faculty Loans
In addition to the new competitive grant
programs described earlier, the NRA also
included another new program of particular
significance. The Nurse Faculty Loan Program
(Section 846A) is specifically geared
to increasing the pool of nurses prepared
to be faculty members in schools of nursing.
As described in Chapter I, NACNEP focused
the work of its prior year on the critical
shortage of nurse faculty members noting
that "a well-qualified faculty is
the foundation of a well-qualified nurse
workforce." The current lack of sufficient
numbers of faculty members serves as a
serious deterrent to attempts to expand
the nursing student body. The agreement
entered into with each institution carrying
out a loan program under this NRA provision
provides for the recruitment of nurses
to become full-time students to prepare
as nurse faculty with loans up to $30,000
per year for 5 years which may be used
for full tuition, fees, books and other
educational expenses. Retention of loan
recipients as faculty members is encouraged
through a loan cancellation provision
that would cancel 85 percent of loan and
interest for working full-time as a faculty
member in a school of nursing. Of the
65 applications received from institutions,
55 were complete and eligible for funding.
However, once again, the limited funds
available meant that the 55 schools of
nursing received only 29 percent of the
almost $10,000,000 in total funds they
requested.
Nurse Scholarship
Program
The NRA also amended Section 846 of Title
VIII to provide for a scholarship program
in addition to the loan repayment program.
This program provides scholarships to
nursing students in exchange of a service
commitment of at least two years on a
full-time basis, or the equivalent on
a part-time basis, at an eligible health
facility with a critical shortage of nurses.
Eligible individuals could be those enrolled
or accepted for enrollment in a school
of nursing on a full or part-time basis.
Congress specifically provided that preference
be given to qualified applicants with
the greatest financial need.
The Council in its review of this program
suggested that enrollment should be considered
full-time in accordance with the individual
school's definition and that part-time
enrollment should be half that of full-time.
It recommended that priority be given
to entry-level students to increase the
nurse supply. The Council also considered
the service provisions and recommended
that a four-year time frame be established
for completion of the service requirements.
Given the intent in awarding scholarships
to increase the nurse supply, it was determined
that preference be given to full-time
students and in undergraduate programs.
The scholarships include an amount for
tuition, fees and other reasonable educational
costs. Full-time students also receive
a monthly stipend of $1,098. Of the approximately
4,400 eligible applications received,
about 500 met the first preference (full-time
students with no expected family contributions).
Of these 500, 81 recipients received awards
totalling $3,308,016. Given the total
request, about $15 million additionally
would have been required to fund the remaining
eligible applications with first preference.
Looking Toward the
Future
The addition of the initiatives in the
NRA to those already in Title VIII is
seen by NACNEP and other segments of the
nursing community as important steps toward
overcoming the critical nursing shortage.
Given the relatively short period of time
allowed, the large response of the nursing
community to these new initiatives documented
the need. However, as the data in Chart
2 show, only a relatively small proportion
of the submitted projects that were considered
worthwhile could be funded with the appropriations
available.
Chart 2: Requested Finding in
Approved Applications and Awards in NRA
Initiatives, FY 2004
[D]
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