Executive Summary

The National Advisory Council on Nurse Education and Practice (NACNEP) in this third report to the Secretary of Health and Human Services and the Congress focuses on the subjects of the meetings held in November 2002 and April 2003. This report, along with those dated November 2001 and 2002, fulfill the requirements under Section 845 of Title VIII of the Public Health Service Act as amended by the Nurse Education and Practice Improvement Act of 1998 (P.L. 105-392).

Throughout the period covered by the three reports, the country has been faced with a critical nursing shortage. This event coupled with the 9/11 act of terrorism and the concerns about medical errors as documented in various studies have provided the framework for NACNEP's work. This most recent report highlights two specific areas: the initiation and implementation of new provisions of Title VIII set forth in the Nurse Reinvestment Act (NRA) (P.L. 107-205) and the effects of the nurse work environment on patient safety and the retention of RNs in the workplace.

Mindful of the need to enhance Title VIII of the Public Health Service Act so that it could better serve to increase recruitment into nursing and retain those already in the field, Congress passed the NRA that was signed into law August 1, 2002. Its provisions included the expansion of the support for career enhancement and development, approaches to retaining nurses in the workforce through better job satisfaction and career advancement, the means for expanding clinical knowledge and skills to better qualify nurses to deliver care in today's complex health care arena, including geriatrics and support for nurses to obtain the necessary skills to become faculty members and students to become nurses. Following the appropriation of funds in February 2003, the Request for Applications was made available toward the end of April 2003 and the first grants for projects under the provisions of the NRA were made in September 2003.

The NRA responded to a number of the actions NACNEP had suggested in the first two reports forwarded to the Secretary and the Congress. NACNEP was pleased to be called upon to provide advice to the Division of Nursing (DN) staff within the Bureau of Health Professions (BHPr) of the Health Resources and Services Administration (HRSA) during the development of the implementation plans.

Building Career Ladders

In order to assist in retaining nursing personnel in the health care area, Section 831 of Title VIII was expanded to provide for grants that encourage nursing career ladders. The provisions of the Career Ladder Grant Program promoted career advancement for nursing personnel in a variety of training settings and across the spectrum of nursing occupational categories. As NACNEP reviewed the questions posed to it on implementing these provisions it agreed that the intent was to focus on both recruiting individuals in the nursing workforce and retaining those who have already shown an interest in working at some level with people in need of nursing interventions. When considering educational levels, NACNEP felt the focus should be on pathways and career mobility models that (1) further the achievement of its goal that by 2010 two-thirds of the RN workforce should have at least a baccalaureate degree and (2) help to develop those eligible to become faculty members. NACNEP believed that the ultimate accomplishment of these provisions should be that of articulation through the RN.

The response to the Career Ladder Program was overwhelming. In the relatively short time allowed, 276 applications considered eligible for review were received. Of these, 116 were approved through the peer review process. Because of limited funds available, only 11 could be funded.

Enhancing Patient Care Delivery Systems

As a means of assisting with nurse retention and with enhancing patient care, Section 831 was also amended to call for grants related to collaboration and communication among nurses and other health professionals, and to promote nurse involvement in decision-making in health care facilities. Considerable documentation exists that demonstrates the increased job satisfaction that comes from these practices. NACNEP saw these provisions as enhancing patient care through outcomes providing for consistency of care and continuity of care givers, good physician-nurse relations, interdisciplinary team standards of practice and acuity-sensitive staffing. A total of 108 applications out of the 125 received were considered eligible for review. Of the 35 approved grants under these provisions, 14 were funded. The entities involved in the activities to be carried out under these grants involved a variety of health care facilities including rural and disproportionate share hospitals and long-term care institutions.

Internships and Residencies

Another amendment to Section 831 focusing on the retention of nurses called for awards that would develop and implement internship and residency programs to encourage mentoring and the development of specialties. Given the focus for these awards, NACNEP advised that the interns and/or residents to benefit from these provisions be active members of the nurse workforce. With regard to the scope of the programs to be supported, NACNEP advised that the programs should contain both didactic and clinical aspects and that care should be taken that the individual is in a learner rather than a practitioner role.

Potential applicants for these awards were provided with three purposes for which awards would be granted: returning RNs to the workforce, providing graduate nurse transition in the first professional role, and changing a nursing specialty. Among the eligible applications, half covered more than one of these purposes. Of those with single purposes, only five had as their purpose returning RNs to the workforce. Of the 125 applications received, 98 were considered eligible and 52 were approved. However, limitation of funds available allowed for only 14 of those approved to be funded.

Comprehensive Geriatric Education

In recognition of the increasing number of the elderly among the country's population and the need for enhancing the health care of these individuals, the NRA also amended Title VIII to provide for support for training and educating individuals in providing geriatric care for the elderly (Section 855). NACNEP suggested that the focus of these grants be on continuing education, strengthening nurse faculty, and strengthening geriatric content in the nursing curricula. Of the 77 eligible grants reviewed, 30 were approved and 17 were funded. These grants will provide education/training for RNs providing care to older adults to enhance their leadership skills and increase their geriatric knowledge base. As geriatric nursing leaders, they will provide training for the licensed practical nurses and certified nursing assistants.

Nurse Faculty Loans

The NRA also added a loan program geared to increasing the pool of nurses prepared to be faculty members in schools of nursing (Section 846A). As NACNEP indicated in its Second Report, the lack of sufficient numbers of faculty members is a serious deterrent to attempts to expand the nursing student body. The agreement entered into with each institution under this program provides the base for a faculty loan fund for nurses to become full-time students to prepare as nurse faculty. Given the funding levels available, the 55 funded schools of nursing received only 29 percent of the total funds requested.

Nurse Scholarship Program

In addition, the NRA also amended Section 846 of Title VIII to provide for a scholarship program in addition to the loan repayment program. The Nurse Scholarship Program provides scholarships to nursing students in exchange for a service commitment at a health facility with a critical shortage of nurses. 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, 500 met the first preference (full-time students with no expected family contribution). 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.

It is anticipated that those projects funded under these initiatives will result in important contributions to the recruitment and retention of the nurse workforce. But the need is great and these limited funded projects can only address a portion of the issues involved in the critical nursing shortage.

Nurse Work Environment

The relationship between nurse staffing and patient safety has been demonstrated in numerous studies. The present climate of severe nursing shortages causes many health care provider organizations to experience significant levels of vacant nursing positions. However, others with positive work environments have been shown to have adequate nursing staff. Safe patient care resulting from declines in medical errors and decreases in adverse outcomes is an important goal of the health care system. Active attention to the nurse work environment is an important component of achieving this goal.

Creating a Positive Work Environment

Concerns about the work environment are uppermost in the minds of nurses as they discuss their careers. Nurses, in commenting about their heavy workloads and chaotic work environments, express concerns about the safety of their patients. An analysis of 26 studies of the relationship between nurse staffing and outcomes of patient care concludes higher nursing workload is associated with higher rates of non-fatal adverse outcomes and with higher incidence of medication errors. A recent Institute of Medicine (IOM) publication focusing on health professions education reinforces these conclusions and calls for limitations in nurse work hours and establishing programs within health care facilities to set nurse staffing according to the needs within each patient care unit per shift. It also calls for steps that would ensure nurse participation in the decision-making processes for staffing and patient care.

Nurse work environment issues directly impact patient safety. Research shows that hospitals having highly qualified nursing executives with participation in their top decision-making body and involvement of nurses in the operation and patient care decision-making at the unit level are "Magnets" in their ability to attract and retain nurses on their staff. Magnet hospitals have been shown to have better satisfied nursing staff and more positive patient outcomes than non-Magnet hospitals. The climate established by nurse leaders plays an important role in nurse satisfaction. Autonomy, team work and relationships with co-workers and supervisors, collaboration with physicians in decision-making about patient care and the reduction of job stress have been shown to be important to job satisfaction leading to retention of nurses.

The provision of a climate for collaborative practices in the work setting is crucial. But, in order for those practices to be successful, they must first be established in the disparate health care occupations' educational experience. The recognition of the need for such experiences was the crux of NACNEP's joint interest with the Council on Graduate Medical Education (COGME) in interdisciplinary health professions education. The first joint COGME/NACNEP interdisciplinary activities culminated in a joint meeting in 2000 that resulted in support for five interdisciplinary education projects centered on patient safety. Subsequently, NACNEP and COGME were involved in IOM's multidisciplinary efforts including serving on the committee guiding these efforts and participating in the National invitational summit held in June 2002. The IOM report stresses the importance of these activities and calls for biennial summits to further the efforts.

Creating a Positive Patient Environment

As documented in the report's data quality health care with positive patient outcomes can best be achieved with well-staffed nursing services with an organizational structure providing a positive role in the decision-making process for nurses. Basic to the achievement of a good working environment is creating an environment that recognizes the needs of today's diverse staff and patient population. In serving the patient population the disparities in the availability and delivery of health care need to be considered and active steps are needed to mitigate them. Studies show that racial and ethnic minorities experience lower quality and more limited health services than others within the country's population. Providing for cross-cultural education for health professionals and sensitizing providers are among the approaches to alleviating these problems. Through the recognition of its own staff needs and those of its patients, the leaders in a health care facility need to actively develop and carry out programs that provide for cultural competence and build a diverse workforce that reflects the population's diversity. As pointed out in an article on the development of such a program, a hospital's fiscal health depends on both an adequate supply of nurses and a nursing workforce that reflects the racial and ethnic diversity of its patient census.

Attracting individuals from diverse backgrounds into nursing is one of the means toward assuring an adequate nurse supply. A significant gap exists between the proportion of individuals with minority backgrounds in nursing and the proportion within the population as a whole. The development and implementation of specific strategies are needed to actively attract to and retain in nursing individuals from diverse backgrounds. In schools of nursing, faculty commitment in terms of contact and support, positive attitudes toward minority students and the integration of these students into the social and educational structure of the school are important to the accomplishment of these objectives.

Conclusions and Recommendations

During this year NACNEP turned its attention to those areas in both education and practice that would further the objective of providing an adequate nurse workforce to promote safety and quality in patient care and affect nurse recruitment and retention. In considering next steps it built on the broader actions recommended in its first two reports to the Secretary and the Congress bearing in mind actions taken by the Federal government in the NRA and the many others undertaken by the nursing community and other entities in working toward effecting the necessary changes. NACNEP recognizes that to solve the continuing critical nursing shortage requires cooperation from all segments. It sees a critical leadership role for the Federal government within these efforts through encouraging and fostering new creative and innovative approaches. To this end it recommends six actions designed to lead to improved access to and quality of the Nation's delivery of health care to its disparate population, as follows:

• Broaden the impact of the NRA initiatives by increasing funding appropriations consistent with National demand.
• Expand resources available to develop models to effectively recruit and graduate sufficient numbers of racial/ethnic students.
• Support continuing efforts toward fostering health professions interdisciplinary practice and education through implementation of the recommendations arising out of the IOM health professions summit.
• Foster development of working conditions providing for nurse involvement in operational and patient care decision-making within health care facilities and programs incorporating a diverse workforce at all levels of the organization.
• Support the development and evaluation of culturally competent interventions through demonstration projects using cooperative agreements.
• Develop survey mechanisms to create a database on the elements of the nurse work environment through cooperative agreements with professional hospital-affiliated organizations.

As NACNEP moves forward with its examination of the issues related to the nurse workforce it will continue to monitor the availability of an appropriate supply necessary to provide quality health care for the Nation's population. NACNEP will examine outcomes accomplished through support of the NRA and other aspects of Title VIII and suggest ways of building on these. It will also continue its particular focus on interdisciplinary education and practice with the effects on the improvement of patient safety, recruitment and retention of nurses, and educational costs.