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The Federal budget and the impact on nursing education, research, and innovative practice
SPECIAL EDITORIAL
Because it is so important to newborn and infant nurses to be involved in health policy, we have asked Joyce Hahn to review and give a brief synopsis of some of the more pertinent legislation.
Abstract The American health care system is facing a critical nursing shortage unprecedented in its complexity and future implications. The current and projected nursing shortage has presented an opportunity for the nursing profession to educate consumers to the vital role nurses play in the delivery of health care services while advocating and lobbying for federal legislation. The urgent need to fund nursing education programs and nursing research programs, and the immediate need to develop innovative practice models, has been heard in our nation’s capitol. This article will present the legislative activity and status of the appropriations and bills of the 107th Congress. Copyright 2003, Elsevier Science (USA). All rights reserved.
From the College of Nursing and Health Science, George Mason University, Fairfax, VA. Address reprint requests to Joyce Hahn, MSN, RN, CS, College of Nursing and Health Science, George Mason University, 4400 University Drive, Fairfax, VA 22030. Copyright 2003, Elsevier Science (USA). All rights reserved. 1527-3369/03/0301-0005$35.00/0 doi: 10.1053/nbin.2003.36087
The Federal Budget and the Impact on Nursing Education, Research, and Innovative Practice By Joyce Hahn, MSN, RN, CS
T
he nursing shortage impacts hospital-based patient care, causing emergency room overcrowding and diversions, cancellations and increased wait times for surgery, decreases in patient education programs, reductions in adequate patient care management, delayed discharges, and reduced service hours. In addition, nurses are the primary caregivers in many outpatient settings including clinics, home care, hospice, and long-term care. The services provided by nurses are vital to the ability of many patients to acquire basic preventative care, and in some circumstances, serve as the only access point to needed treatment. Nurses are an integral and necessary component of the nation’s health care system; they are working and standing watch 24 hours a day, 7 days a week. When nurses are not available to provide care, institutions limit patient care and services. From a nursing perspective, the halls of Congress have little in common with the hospital hallways of our daily practice. However, the time is now to rethink and expand our vision outward and hold our legislators accountable and responsive to our profession’s urgent needs. With more than 2.7 million nurses employed in health care, RNs are the largest group of health care professionals in the United States. We are a large voting block of legislative constituents in the eyes of our elected officials. This article will serve to provide information on legislative initiatives of the 107th Congress. Use this information to become grassroots advocates for our profession. Websites are listed where additional information can be obtained.
Background
A
s educational and employment opportunities for women have expanded over the past 2 decades, there has been a decline in younger women choosing a nursing career. The General Accounting Office reports a 20% Newborn and Infant Nursing Reviews, Vol 3, No 1 (March), 2003: pp 5–10
5
6
Joyce Hahn
decline in BSN enrollments, 11% decline in AD, and 42% decline in diploma nursing program admissions through the mid-to-late 1990s.1 This decline has been a consistent and dramatic drop. This shift has caused the average age of RNs to rise to 43.3 years, with a projected increase to 45.5 years in 2010.2 Men and racial minorities are poorly represented in today’s nursing population. Buerhaus et al2 project that by 2020 the demand for nurses will exceed supply by 20%. These authors cite more educational opportunities of choice and higher salaries as contributing factors to the nursing shortage. The Bureau of Labor Statistics estimates that 15% of the current workforce will retire between 1998 and 2008.2 This large-scale retirement is occurring at the same time as the aging and retirement of the baby boom generation and the resulting increase in demand for nursing services. As with every other sector of the nursing workforce, the aging of nursing educators is a significant factor that impacts nursing education. “The nationwide shortage of nursing faculty is severely and negatively impacting the profession of nursing during an era of enormous opportunity in health care. The implications could mean admitting fewer students or accepting less qualified instructors in schools of nursing.”3 Funding is necessary to prepare additional faculty to meet the current and anticipated increase in nursing enrollments. The cost-containment pressures within health care organizations have resulted in restructuring and workforce redesign with consequential decreases in staffing. Hospital patient acuity continues to increase while nursing shortages and decreases in staffing cause decreases in bed availability.4 The outlook for reversing the nursing workforce shortage and meeting the demand for nurse educators is bleak unless legislative action is taken now.
Budget Appropriations
T
he Health Resources and Services Administration (HRSA) fiscal year 2002 revised appropriation totals $6.23 billion, a $545 million increase over the fiscal year 2001 discretionary spending levels.5 The HRSA budget can be viewed at http://www.hrsa.gov/budget.htm.5 Maternal and child health has been appropriated $941 million for block grants, Healthy Start, universal newborn hearing, emergency medical services for children, trauma emergency medical services, poison control centers, adoption awareness, and abstinence education.5 Information and advice describing individual grant descriptions, purpose, funding, and application forms can be viewed at http:// mchb.hrsa.gov/grants/default.htm.6 Health Professions appropriations include multidisciplinary programs to include the National Health Service Corps, nursing and primary
care medicine, and dentistry totaled $533 million.7 Specific grant availability for nursing can be found on the web at: http://www.bhpr.hrsa.gov/grants2003/applictions.7 These grants are available for basic nurse education and practice, advanced education nursing, and nursing workforce diversity.
Legislation
L
egislation in the 107th Congress to address the nursing shortage included the Nurse Reinvestment Act (H.R.3487, S.1864); the Nursing Workforce Development programs under the Nurse Education Act (H.R.1436, S.706, S.721); the Department of Veterans Affairs Health Care Programs Enhancement Act (H.R.3447); and the Nurse Retention and Quality of Care Act of 2002 (H.R.4654, S.1594). The National Institute of Nursing Research (NINR), as one of the institutes at the National Institutes of Health (NIH), has requested increased funding. Nurse Reinvestment Act (H.R.3487, S.1864) The Nurse Reinvestment Act was the paramount piece of legislation addressing nursing issues in the 107th Congress. The House of Representatives and the Senate brought similar bills to their chamber floors and committees. Media interest in the nursing shortage was spreading the word, and lobbying from nursing interests was strong to support of these legislative bills. Both bills provided authority for scholarships and loan repayments for nursing students. Additionally, the bill funded public service announcements to promote nursing as a career choice. The bill supported grants for health career academic institutions to create partnerships between health care facilities, nursing schools, and high schools to introduce high school students to nursing curriculum. This bill also provided nursing recruitment grants to support nursing outreach programs in primary schools and junior and senior high schools. This bill established a new nurse corps designed to provide educational scholarships in exchange for commitment to serve in a health care facility. The Senate version also contained authority for stipends and other support for nursing students, grants to promote the Magnet criteria for best practices for nursing administration, funding for faculty development, career ladder programs, and funding for residencies for nursing specialties. The American Association of Colleges of Nursing (AACN) and the American Nurses Association (ANA) preferred the Senate-passed version of this legislation, which created a Fast-Track Nursing Faculty Loan and Scholarship Program that provided nurses seeking a mas-
Impact of the Federal Budget
7
Table 1. Summary of The Nurse Reinvestment Act (P.L. 107–205) Creation of Nurse Service Corps Expands the current nurse education loan and scholarship programs to allow nurses to satisfy their loan repayment and scholarships by working in a “health care facility with a critical nursing shortage.” Public Service Announcements Provides for the development of Public Service Announcements to highlight advantages and rewards of nursing and encourage individuals to enter the nursing profession. Nursing Faculty Loan Cancellation Program Establishes grants to schools of nursing for faculty load programs. Schools will be able to offer loans to advanced degree nursing students with the expectation that upon graduation they will join the nursing faculty. Loans will be cancelled when the students fulfill their teaching requirement. Career Ladder Grant Programs Provides grants to promote career advancement for nursing personnel (RNs, LPNs, CNAs, HHAs) to promote specialty training, to develop pre-entry programs, and to support mentoring and career counseling. Best Practice Grants Provides for best practice grants for nursing administration as modeled after ANA/ANCC’s magnet program. Geriatric Nurse Training Grants Establishes long-term care training grants to develop and implement gerontology curriculum into nursing programs. Data from reference 12.
ter’s or doctoral degree to receive financial assistance in exchange for teaching at a school of nursing.8,9 The Senate version also included the establishment of a National Nurse Service Corps Scholarship Program that provided scholarships to both part-time and full-time entry level nursing students. Grants for “best practice” Magnet Demonstration projects in nursing and the development of innovative strategies for retention and improvement in the practice of nursing are also found within the Senate bill.8 “The Nurse Reinvestment Act will go a long way toward attracting young people into the nursing profession and should help sidestep a looming shortage that may soon reach crisis proportions,” said American Nurses Association President Mary E. Foley, MS, RN. “This investment in the nursing workforce is crucial to the health and welfare of all Americans and will enhance the nation’s ability to respond to public health crises.”10 The American Organization of Nurse Executives (AONE) is on record supporting the Nurse Reinvestment Act. “AONE commends the bipartisan bicameral efforts of the sponsors of this legislation. This bill reflects many of the legislative goals of national nursing organizations who are working collaboratively to solve the nursing shortage. This bill represents an investment in nursing and in the health of all Americans.”11 Bill Status Both the House of Representatives and the Senate passed versions of the Nurse Reinvestment Act (H.R.3487 and S.1864) on December 20, 2001, just hours before the end of the congressional session. The bills were conferenced in early 2002. Conferencing the bill refers to reconciling the
differences and merging the House and Senate passed versions of the legislation to send to the President for signature. On August 1, 2002, President George W. Bush signed the Nurse Reinvestment Act into public law. This law sends a clear message to the nation that the President and our Congress recognize the national nursing shortage and support measures to remedy the situation. The new law authorizes grants and scholarships targeted to attract and retain nurses in the profession. The law authorizes loan repayment and scholarships to nursing students, nursing faculty loans, public service announcements, career ladder programs, and implementation of best practice (Table 1).12 The next step is to establish the funding to make the intent of the law a reality. The Nurse Reinvestment Act went to the appropriations committee for allocation of funds for the 2003 fiscal year. Nurse Education and Employment Development Act (S.706, S.721, H.R.1436) The Nursing Workforce Development programs under the Nurse Education Act (NEA) provided grant possibilities to schools of nursing, academic health centers, nursing centers, and state and local governments to support programs that provide nurse education. The funding priority was directed to programs providing nursing education targeted to practice in underserved areas. The NEA legislation provided for scholarship funds to go directly to disadvantaged nursing students. The ANA supported the innovative recruitment techniques, curriculum support, scholarships and loan repayments contained in these bills that would enhance all aspects
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Joyce Hahn
of nursing education. The AACN recommends increasing the fiscal year 2003 appropriations for the NEA Programs by $40 million.10 The NEA is the major federal statute providing authority for the Department of Health and Human Services to fund initiatives to expand or improve nursing education. Increased funding support is necessary to boost enrollments in nursing education programs supported by the NEA grants in the areas of Advanced Education Nursing, Nursing Workforce Diversity, and Basic Nurse Education and Practice. The AACN further recommends that both the Nursing Student Loan Program and the Nurse Education Loan Repayment Program receive an additional $10 million each for fiscal year 2003.10 Bill Status All three bills were sent to Committee and incorporated into the Nurse Reinvestment Act.
quality patient care and improve nurses’ working lives.”15 The ANA recognizes that the aging RN workforce and decreased enrollment in nursing school programs does play a role in the current staffing crisis, but ANA believes a major contributor is nurses’ dissatisfaction with their workplace. “This dissatisfaction is leading experienced nurses to leave the bedside, and it’s hindering efforts to recruit qualified men and women into the profession.”16 Senator Hilary Rodham Clinton was the sponsor of the Senate version of this legislative bill. Writing in AJN, Senator Clinton stated “The bill would foster long-overdue respect for nursing by giving hospitals seed money to implement practices that recognize and maximize the value of nursing, such as involving nurses in decisions affecting policy and patient care, and supporting nurses’ continuing education and advancement.”16 Bill Status
Department of Veterans Affairs Health Care Programs Enhancement Act (H.R.3447)
Both bills were referred out to Committees and incorporated into the Nurse Reinvestment Act.
This bill addressed many of the staffing related issues and concerns of the Veterans Affairs (VA) nurses. This legislation would require the VA to develop a nationwide policy on staffing standards that would consider the numbers and skill mix required of staff in specific medical settings. The bill enhanced the VA’s ability to recruit and retain qualified nurses. Also included within this legislation were required reports on the use of mandatory overtime by licensed nursing staff and nursing assistants in each facility and a required report on VA’s nurse qualification standards.13
NINR
Bill Status ANA was a strong supporter of this bill that was signed by President Bush on January 23, 2002. Nurse Retention and Quality of Care Act (S.1594, H.R.4654) These bills both address the amendment of the Public Health Service Act to direct the Secretary of Health and Human Services to award grants to eligible health care facilities to carry out demonstrations of model and best practices in nursing care with the purpose of developing strategies for nurse retention. These model demonstrations are required to promote nurse satisfaction, communication, collaboration in decision-making, professional advancement, and high-quality care.14 This bill encourages hospitals to adopt successful Magnet hospital practices. ANA has called the legislation “a real plan to ensure
The NINR is a Center within the NIH and is funded through the NIH within the annual appropriation laws. The NINR supports clinical and basic research by awarding grants to support new dimensions in nursing practice. The NINR supports comprehensive research training and career development programs to prepare nurses with the requisite skills to conduct nursing research in an interdisciplinary setting.17 The AACN supports providing the NINR with $145 million ($25 million increase) in fiscal year 2003. “NINR is vital to the creation of a science base for the profession of nursing and to communicate to potential students that nursing is an intellectual endeavor with a base of science for practice.”8 Status The NINR is awaiting funding through 2003 appropriation laws.
Professional Consequences of the Federal Budget
T
he Federal budget and current legislative initiatives can boggle the mind and leave you thinking that they can’t possibly have anything to do with your own daily practice. Think again. Have you ever wished there was more staff on your unit? Do you ever think that quality
Impact of the Federal Budget
Table 2. Legislative Information on the Internet • Go to the Thomas site which can be Internet accessed at http://thomas.loc.gov/home/legbranch/legbranch.html The Thomas site allows you to enter a bill number, word or phrase or click on Bill Summary and Status to track a bill in Congress. The complete text of the bill can be viewed or downloaded at this site. • Go to the American Nurses Association Website http:// www.nursingworld.org and click on Government Affairs to reach the menu Click on Legislative Activity to view fact sheets and links to text of nursing related legislation
patient care is being overlooked? Have you ever been pressured into working overtime? Called in to work an extra shift? Considered you might return to college to pursue an advanced practice degree? If you can answer “yes” to even 1 of these questions, then these legislative issues do affect your daily practice. For example, the inclusive combination of innovative recruitment techniques, scholarships, loan repayment, and nursing curriculum support that is found within the Nurse Reinvestment Act and the Nursing Education and Employment Development Act would work toward achieving a solution to the nursing shortage. The further development of our nation’s nursing workforce and the recruitment of the next generation of nurses will aide in addressing the present and future public health crisis arising from the nursing shortage.
at this point in the policy making process that lobbying and grassroots advocacy has the most impact. Proposed legislation on the floor of the House or the Senate can be amended and changed before congressional voting. The legislators need to be informed and educated not only about the growing need for knowledgeable, competent, and caring nurses, but also about the quality of health care that nurses provide. Individual contact with legislators to share stories and nursing experiences can go a long way to educating a legislator on the realities of nursing practice. Reaching the legislators at the early policy formation phase, otherwise known as “the window of opportunity,” is the best chance for nursing to have an impact on legislation and public law. All the legislation discussed in this paper is currently at that window of opportunity or has passed through the window. Some of the legislation was stalled in committee, whereas other pieces of legislation were waiting to be conferenced. Legislation that remains in committee once the Congress adjourns will be a dead issue. The Nurse Reinvestment Act is waiting for funding from the Appropriations Committee. As nursing professionals, we have the opportunity to be active participants at the window. Uncertain how to do that? Table 2 describes how to find legislative information on the Internet. The 3 members of Congress that are nurses can be found in Table 3. Table 4 explains how to identify and communicate with your congressional representatives.
Conclusion
Grassroots Involvement
P
ersonal contact with a telephone call, letter, or e-mail with your elected legislator can put the face of nursing priority and needs on a bill. With over 2.7 million nurses in the nation, that is a lot of faces, not to mention votes. Congress has been made aware of the nursing shortage through the lobbying efforts of nursing professional organizations. Individual and small group contact that describes the reality and impact of the nursing shortage on a daily basis will demonstrate the urgency and need to pass and fund legislation. Legislation commonly can become stalled in committees. A simple letter, phone call, or e-mail to your elected representative can help motivate and move the initiatives forward. Membership in your specialty professional organization and in the ANA can result in lobbying efforts on behalf of nurses nationwide. The message has been delivered but now must remain in front of our congressional representatives. Beaufort Longest has proposed a model of the public policy making process in the United States.18 Within this model, the policy formation phase can be found. This is the phase where the “window of opportunity” exists. It is
9
T
he Federal budget does have an impact on nursing education, nursing research, and innovative practice. Legislation determines the budget. The budget determines the dollar amount spent on educational grants and loans and will set the amount allocated for nursing research grants and for nurse retention and quality programs. Nurses are being heard in the congressional hallways. Continuing lobbying efforts from both our professional organizations and grassroots nursing advocacy representation will encourage legislators to sponsor, pass, and fund nursing legislation. National nursing organizations are working collaboratively on solutions for the nursing shortage. As nursing professionals, we also need to collaboratively work with our colleagues in grassroots advocacy movements. The Table 3. Nurse Representatives in Congress U.S. Representative Lois Capps (D-CA) U.S. Representative Carolyn McCarthy (D-NY) U.S. Representative Eddie Bernice Johnson (D-TX)
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Joyce Hahn
Table 4. Identifying and Communicating with Your Congressional Representative Identifying Your Representative Go to C-SPAN.org and follow the prompts to enter your zip code, member name, or state search. By Telephone Call the U.S. Capitol Switchboard at (202) 224-3121 and ask for your Senators and/or Representatives office. By Mail To write to a Senator: The Honorable (insert name) (name of) Senate Office Building United States Senate Washington, DC 20510 To write to a Representative: The Honorable (insert name) (name of) House Office Building United States House of Representatives Washington, DC 20515 By E-mail Use the titles as above Remember to include your home address on all correspondence. The voice of constituents matters to your elected officials.
first step is to belong to your professional organizations. Next begin to call, write, or e-mail your congressional representative. Be creative and write a piece for your local newspaper. Raise public awareness to the current and projected nursing shortage. Patients are constituents as well. Think of the possibilities. But act now. Our profession needs your help today. The passage of the Nurse Reinvestment Act, the omnibus nursing bill designed to address the current nursing shortage, is only the beginning of the need for funded programs to stem the current and projected nursing shortage.
References 1. United States General Accounting Office: Nursing Workforce: Emerging Nurse Shortages Due to Multiple Factors. Report to the Chair-
man, Subcommittee on Health, Committee on Ways and Means, House of Representatives, January 15, 2001 2. Buerhaus PI, Staiger DO, Auerback, DI: Implications of an aging registered nurse workforce. JAMA 283:2948 –2954, 2000 3. Kelly C: Investing in the future of nursing education: A cry for action. Nurs Educ Perspect 23:24 –29, 2002 4. Peterson CA: Nursing shortage: Not a simple problem---no easy answers. Accessed August 28, 2002. URL: http://www.nursingworld.org/ ojin/topic14/tpc14_1.htm 5. Health Resources and Services Administration: Budget and appropriations. Accessed June 6, 2002. URL: http://www.hrsa.gov/budget. htm 6. Health Resources and Services Administration: Grant guidance and forms. Accessed June 6, 2002. URL: http://mchb.hrsa.gov/grants/ default.htm 7. Health Resources and Services Administration: Bureau of health professions. Accessed June 6, 2002. URL: http://www.bhpr.hrsa.gov/ grants2002/applications 8. American Association of Colleges of Nursing: An overview of AACN[prime]s legislative vision and strategies. Government affairs. Accessed June 7, 2002. URL: http://www.aacn.nche.edu/Government/ shortagestrategies.htm 9. American Nurses Association: Funding recommendations for nurse education and research. Accessed June 7, 2002. URL: http:// nursingworld.org/gova/federal/legis/107/funding.htm 10. American Nurses Association: ANA commends house of representatives for passage of nurse reinvestment act. Accessed June 7, 2002. URL: http://nursingworld.org/pressrel/2001/pr1220b.htm 11. Thompson P: AONE press release: Statement of Pamela Thompson, executive director, the American Organization of Nurse Executives In Support of the Nurse Reinvestment Act. Accessed on June 5, 2002. URL: http://www.aone.org/news/thompson_nurse_reinvestment_actstmt. htm 12. American Nurses Association: Summary of the Nurse Reinvestment Act, P.L.107[hyphen]205. Accessed August 31, 2002. URL: http:/// www.nursingworld.org/gova/federal/news/nra.htm 13. American Nurses Association: Final Congressional action: House, Senate pass Nurse Reinvestment Act; VA Nurse Bill cleared for President’s signature. Accessed June 7, 2002. URL: http://nursingworld. org/gova/federal/news/reinvest.htm 14. U.S. Congress: Senate Bill S.1594. Nurse Retention and Quality of Care Act 2001. Accessed June 10, 2002. URL: http:// thomas.loc.gov 15. American Nurses Association: American Nurses Association endorses legislation addressing RN staffing shortage. Accessed June 11, 2002. URL: http://www.nursingworld.org/pressrel/2002/pr0506.htm 16. Clinton HR: Respect: The not-so-secret ingredient. Am J Nurs 102:11, 2002 17. National Institute of Nursing Research: Mission statement. Accessed June 11, 2002. URL: http://www.nih.gov/ninr/research/diversity/ mission.html 18. Longest BB: Health Policymaking in the United States (ed 2). Chicago, IL, Health Administration Press, 1998
Because it is so important to newborn and infant nurses to be involved in health policy, we have asked Joyce Hahn to review and give a brief synopsis of some of the more pertinent legislation.
Abstract The American health care system is facing a critical nursing shortage unprecedented in its complexity and future implications. The current and projected nursing shortage has presented an opportunity for the nursing profession to educate consumers to the vital role nurses play in the delivery of health care services while advocating and lobbying for federal legislation. The urgent need to fund nursing education programs and nursing research programs, and the immediate need to develop innovative practice models, has been heard in our nation’s capitol. This article will present the legislative activity and status of the appropriations and bills of the 107th Congress. Copyright 2003, Elsevier Science (USA). All rights reserved.
From the College of Nursing and Health Science, George Mason University, Fairfax, VA. Address reprint requests to Joyce Hahn, MSN, RN, CS, College of Nursing and Health Science, George Mason University, 4400 University Drive, Fairfax, VA 22030. Copyright 2003, Elsevier Science (USA). All rights reserved. 1527-3369/03/0301-0005$35.00/0 doi: 10.1053/nbin.2003.36087
The Federal Budget and the Impact on Nursing Education, Research, and Innovative Practice By Joyce Hahn, MSN, RN, CS
T
he nursing shortage impacts hospital-based patient care, causing emergency room overcrowding and diversions, cancellations and increased wait times for surgery, decreases in patient education programs, reductions in adequate patient care management, delayed discharges, and reduced service hours. In addition, nurses are the primary caregivers in many outpatient settings including clinics, home care, hospice, and long-term care. The services provided by nurses are vital to the ability of many patients to acquire basic preventative care, and in some circumstances, serve as the only access point to needed treatment. Nurses are an integral and necessary component of the nation’s health care system; they are working and standing watch 24 hours a day, 7 days a week. When nurses are not available to provide care, institutions limit patient care and services. From a nursing perspective, the halls of Congress have little in common with the hospital hallways of our daily practice. However, the time is now to rethink and expand our vision outward and hold our legislators accountable and responsive to our profession’s urgent needs. With more than 2.7 million nurses employed in health care, RNs are the largest group of health care professionals in the United States. We are a large voting block of legislative constituents in the eyes of our elected officials. This article will serve to provide information on legislative initiatives of the 107th Congress. Use this information to become grassroots advocates for our profession. Websites are listed where additional information can be obtained.
Background
A
s educational and employment opportunities for women have expanded over the past 2 decades, there has been a decline in younger women choosing a nursing career. The General Accounting Office reports a 20% Newborn and Infant Nursing Reviews, Vol 3, No 1 (March), 2003: pp 5–10
5
6
Joyce Hahn
decline in BSN enrollments, 11% decline in AD, and 42% decline in diploma nursing program admissions through the mid-to-late 1990s.1 This decline has been a consistent and dramatic drop. This shift has caused the average age of RNs to rise to 43.3 years, with a projected increase to 45.5 years in 2010.2 Men and racial minorities are poorly represented in today’s nursing population. Buerhaus et al2 project that by 2020 the demand for nurses will exceed supply by 20%. These authors cite more educational opportunities of choice and higher salaries as contributing factors to the nursing shortage. The Bureau of Labor Statistics estimates that 15% of the current workforce will retire between 1998 and 2008.2 This large-scale retirement is occurring at the same time as the aging and retirement of the baby boom generation and the resulting increase in demand for nursing services. As with every other sector of the nursing workforce, the aging of nursing educators is a significant factor that impacts nursing education. “The nationwide shortage of nursing faculty is severely and negatively impacting the profession of nursing during an era of enormous opportunity in health care. The implications could mean admitting fewer students or accepting less qualified instructors in schools of nursing.”3 Funding is necessary to prepare additional faculty to meet the current and anticipated increase in nursing enrollments. The cost-containment pressures within health care organizations have resulted in restructuring and workforce redesign with consequential decreases in staffing. Hospital patient acuity continues to increase while nursing shortages and decreases in staffing cause decreases in bed availability.4 The outlook for reversing the nursing workforce shortage and meeting the demand for nurse educators is bleak unless legislative action is taken now.
Budget Appropriations
T
he Health Resources and Services Administration (HRSA) fiscal year 2002 revised appropriation totals $6.23 billion, a $545 million increase over the fiscal year 2001 discretionary spending levels.5 The HRSA budget can be viewed at http://www.hrsa.gov/budget.htm.5 Maternal and child health has been appropriated $941 million for block grants, Healthy Start, universal newborn hearing, emergency medical services for children, trauma emergency medical services, poison control centers, adoption awareness, and abstinence education.5 Information and advice describing individual grant descriptions, purpose, funding, and application forms can be viewed at http:// mchb.hrsa.gov/grants/default.htm.6 Health Professions appropriations include multidisciplinary programs to include the National Health Service Corps, nursing and primary
care medicine, and dentistry totaled $533 million.7 Specific grant availability for nursing can be found on the web at: http://www.bhpr.hrsa.gov/grants2003/applictions.7 These grants are available for basic nurse education and practice, advanced education nursing, and nursing workforce diversity.
Legislation
L
egislation in the 107th Congress to address the nursing shortage included the Nurse Reinvestment Act (H.R.3487, S.1864); the Nursing Workforce Development programs under the Nurse Education Act (H.R.1436, S.706, S.721); the Department of Veterans Affairs Health Care Programs Enhancement Act (H.R.3447); and the Nurse Retention and Quality of Care Act of 2002 (H.R.4654, S.1594). The National Institute of Nursing Research (NINR), as one of the institutes at the National Institutes of Health (NIH), has requested increased funding. Nurse Reinvestment Act (H.R.3487, S.1864) The Nurse Reinvestment Act was the paramount piece of legislation addressing nursing issues in the 107th Congress. The House of Representatives and the Senate brought similar bills to their chamber floors and committees. Media interest in the nursing shortage was spreading the word, and lobbying from nursing interests was strong to support of these legislative bills. Both bills provided authority for scholarships and loan repayments for nursing students. Additionally, the bill funded public service announcements to promote nursing as a career choice. The bill supported grants for health career academic institutions to create partnerships between health care facilities, nursing schools, and high schools to introduce high school students to nursing curriculum. This bill also provided nursing recruitment grants to support nursing outreach programs in primary schools and junior and senior high schools. This bill established a new nurse corps designed to provide educational scholarships in exchange for commitment to serve in a health care facility. The Senate version also contained authority for stipends and other support for nursing students, grants to promote the Magnet criteria for best practices for nursing administration, funding for faculty development, career ladder programs, and funding for residencies for nursing specialties. The American Association of Colleges of Nursing (AACN) and the American Nurses Association (ANA) preferred the Senate-passed version of this legislation, which created a Fast-Track Nursing Faculty Loan and Scholarship Program that provided nurses seeking a mas-
Impact of the Federal Budget
7
Table 1. Summary of The Nurse Reinvestment Act (P.L. 107–205) Creation of Nurse Service Corps Expands the current nurse education loan and scholarship programs to allow nurses to satisfy their loan repayment and scholarships by working in a “health care facility with a critical nursing shortage.” Public Service Announcements Provides for the development of Public Service Announcements to highlight advantages and rewards of nursing and encourage individuals to enter the nursing profession. Nursing Faculty Loan Cancellation Program Establishes grants to schools of nursing for faculty load programs. Schools will be able to offer loans to advanced degree nursing students with the expectation that upon graduation they will join the nursing faculty. Loans will be cancelled when the students fulfill their teaching requirement. Career Ladder Grant Programs Provides grants to promote career advancement for nursing personnel (RNs, LPNs, CNAs, HHAs) to promote specialty training, to develop pre-entry programs, and to support mentoring and career counseling. Best Practice Grants Provides for best practice grants for nursing administration as modeled after ANA/ANCC’s magnet program. Geriatric Nurse Training Grants Establishes long-term care training grants to develop and implement gerontology curriculum into nursing programs. Data from reference 12.
ter’s or doctoral degree to receive financial assistance in exchange for teaching at a school of nursing.8,9 The Senate version also included the establishment of a National Nurse Service Corps Scholarship Program that provided scholarships to both part-time and full-time entry level nursing students. Grants for “best practice” Magnet Demonstration projects in nursing and the development of innovative strategies for retention and improvement in the practice of nursing are also found within the Senate bill.8 “The Nurse Reinvestment Act will go a long way toward attracting young people into the nursing profession and should help sidestep a looming shortage that may soon reach crisis proportions,” said American Nurses Association President Mary E. Foley, MS, RN. “This investment in the nursing workforce is crucial to the health and welfare of all Americans and will enhance the nation’s ability to respond to public health crises.”10 The American Organization of Nurse Executives (AONE) is on record supporting the Nurse Reinvestment Act. “AONE commends the bipartisan bicameral efforts of the sponsors of this legislation. This bill reflects many of the legislative goals of national nursing organizations who are working collaboratively to solve the nursing shortage. This bill represents an investment in nursing and in the health of all Americans.”11 Bill Status Both the House of Representatives and the Senate passed versions of the Nurse Reinvestment Act (H.R.3487 and S.1864) on December 20, 2001, just hours before the end of the congressional session. The bills were conferenced in early 2002. Conferencing the bill refers to reconciling the
differences and merging the House and Senate passed versions of the legislation to send to the President for signature. On August 1, 2002, President George W. Bush signed the Nurse Reinvestment Act into public law. This law sends a clear message to the nation that the President and our Congress recognize the national nursing shortage and support measures to remedy the situation. The new law authorizes grants and scholarships targeted to attract and retain nurses in the profession. The law authorizes loan repayment and scholarships to nursing students, nursing faculty loans, public service announcements, career ladder programs, and implementation of best practice (Table 1).12 The next step is to establish the funding to make the intent of the law a reality. The Nurse Reinvestment Act went to the appropriations committee for allocation of funds for the 2003 fiscal year. Nurse Education and Employment Development Act (S.706, S.721, H.R.1436) The Nursing Workforce Development programs under the Nurse Education Act (NEA) provided grant possibilities to schools of nursing, academic health centers, nursing centers, and state and local governments to support programs that provide nurse education. The funding priority was directed to programs providing nursing education targeted to practice in underserved areas. The NEA legislation provided for scholarship funds to go directly to disadvantaged nursing students. The ANA supported the innovative recruitment techniques, curriculum support, scholarships and loan repayments contained in these bills that would enhance all aspects
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of nursing education. The AACN recommends increasing the fiscal year 2003 appropriations for the NEA Programs by $40 million.10 The NEA is the major federal statute providing authority for the Department of Health and Human Services to fund initiatives to expand or improve nursing education. Increased funding support is necessary to boost enrollments in nursing education programs supported by the NEA grants in the areas of Advanced Education Nursing, Nursing Workforce Diversity, and Basic Nurse Education and Practice. The AACN further recommends that both the Nursing Student Loan Program and the Nurse Education Loan Repayment Program receive an additional $10 million each for fiscal year 2003.10 Bill Status All three bills were sent to Committee and incorporated into the Nurse Reinvestment Act.
quality patient care and improve nurses’ working lives.”15 The ANA recognizes that the aging RN workforce and decreased enrollment in nursing school programs does play a role in the current staffing crisis, but ANA believes a major contributor is nurses’ dissatisfaction with their workplace. “This dissatisfaction is leading experienced nurses to leave the bedside, and it’s hindering efforts to recruit qualified men and women into the profession.”16 Senator Hilary Rodham Clinton was the sponsor of the Senate version of this legislative bill. Writing in AJN, Senator Clinton stated “The bill would foster long-overdue respect for nursing by giving hospitals seed money to implement practices that recognize and maximize the value of nursing, such as involving nurses in decisions affecting policy and patient care, and supporting nurses’ continuing education and advancement.”16 Bill Status
Department of Veterans Affairs Health Care Programs Enhancement Act (H.R.3447)
Both bills were referred out to Committees and incorporated into the Nurse Reinvestment Act.
This bill addressed many of the staffing related issues and concerns of the Veterans Affairs (VA) nurses. This legislation would require the VA to develop a nationwide policy on staffing standards that would consider the numbers and skill mix required of staff in specific medical settings. The bill enhanced the VA’s ability to recruit and retain qualified nurses. Also included within this legislation were required reports on the use of mandatory overtime by licensed nursing staff and nursing assistants in each facility and a required report on VA’s nurse qualification standards.13
NINR
Bill Status ANA was a strong supporter of this bill that was signed by President Bush on January 23, 2002. Nurse Retention and Quality of Care Act (S.1594, H.R.4654) These bills both address the amendment of the Public Health Service Act to direct the Secretary of Health and Human Services to award grants to eligible health care facilities to carry out demonstrations of model and best practices in nursing care with the purpose of developing strategies for nurse retention. These model demonstrations are required to promote nurse satisfaction, communication, collaboration in decision-making, professional advancement, and high-quality care.14 This bill encourages hospitals to adopt successful Magnet hospital practices. ANA has called the legislation “a real plan to ensure
The NINR is a Center within the NIH and is funded through the NIH within the annual appropriation laws. The NINR supports clinical and basic research by awarding grants to support new dimensions in nursing practice. The NINR supports comprehensive research training and career development programs to prepare nurses with the requisite skills to conduct nursing research in an interdisciplinary setting.17 The AACN supports providing the NINR with $145 million ($25 million increase) in fiscal year 2003. “NINR is vital to the creation of a science base for the profession of nursing and to communicate to potential students that nursing is an intellectual endeavor with a base of science for practice.”8 Status The NINR is awaiting funding through 2003 appropriation laws.
Professional Consequences of the Federal Budget
T
he Federal budget and current legislative initiatives can boggle the mind and leave you thinking that they can’t possibly have anything to do with your own daily practice. Think again. Have you ever wished there was more staff on your unit? Do you ever think that quality
Impact of the Federal Budget
Table 2. Legislative Information on the Internet • Go to the Thomas site which can be Internet accessed at http://thomas.loc.gov/home/legbranch/legbranch.html The Thomas site allows you to enter a bill number, word or phrase or click on Bill Summary and Status to track a bill in Congress. The complete text of the bill can be viewed or downloaded at this site. • Go to the American Nurses Association Website http:// www.nursingworld.org and click on Government Affairs to reach the menu Click on Legislative Activity to view fact sheets and links to text of nursing related legislation
patient care is being overlooked? Have you ever been pressured into working overtime? Called in to work an extra shift? Considered you might return to college to pursue an advanced practice degree? If you can answer “yes” to even 1 of these questions, then these legislative issues do affect your daily practice. For example, the inclusive combination of innovative recruitment techniques, scholarships, loan repayment, and nursing curriculum support that is found within the Nurse Reinvestment Act and the Nursing Education and Employment Development Act would work toward achieving a solution to the nursing shortage. The further development of our nation’s nursing workforce and the recruitment of the next generation of nurses will aide in addressing the present and future public health crisis arising from the nursing shortage.
at this point in the policy making process that lobbying and grassroots advocacy has the most impact. Proposed legislation on the floor of the House or the Senate can be amended and changed before congressional voting. The legislators need to be informed and educated not only about the growing need for knowledgeable, competent, and caring nurses, but also about the quality of health care that nurses provide. Individual contact with legislators to share stories and nursing experiences can go a long way to educating a legislator on the realities of nursing practice. Reaching the legislators at the early policy formation phase, otherwise known as “the window of opportunity,” is the best chance for nursing to have an impact on legislation and public law. All the legislation discussed in this paper is currently at that window of opportunity or has passed through the window. Some of the legislation was stalled in committee, whereas other pieces of legislation were waiting to be conferenced. Legislation that remains in committee once the Congress adjourns will be a dead issue. The Nurse Reinvestment Act is waiting for funding from the Appropriations Committee. As nursing professionals, we have the opportunity to be active participants at the window. Uncertain how to do that? Table 2 describes how to find legislative information on the Internet. The 3 members of Congress that are nurses can be found in Table 3. Table 4 explains how to identify and communicate with your congressional representatives.
Conclusion
Grassroots Involvement
P
ersonal contact with a telephone call, letter, or e-mail with your elected legislator can put the face of nursing priority and needs on a bill. With over 2.7 million nurses in the nation, that is a lot of faces, not to mention votes. Congress has been made aware of the nursing shortage through the lobbying efforts of nursing professional organizations. Individual and small group contact that describes the reality and impact of the nursing shortage on a daily basis will demonstrate the urgency and need to pass and fund legislation. Legislation commonly can become stalled in committees. A simple letter, phone call, or e-mail to your elected representative can help motivate and move the initiatives forward. Membership in your specialty professional organization and in the ANA can result in lobbying efforts on behalf of nurses nationwide. The message has been delivered but now must remain in front of our congressional representatives. Beaufort Longest has proposed a model of the public policy making process in the United States.18 Within this model, the policy formation phase can be found. This is the phase where the “window of opportunity” exists. It is
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he Federal budget does have an impact on nursing education, nursing research, and innovative practice. Legislation determines the budget. The budget determines the dollar amount spent on educational grants and loans and will set the amount allocated for nursing research grants and for nurse retention and quality programs. Nurses are being heard in the congressional hallways. Continuing lobbying efforts from both our professional organizations and grassroots nursing advocacy representation will encourage legislators to sponsor, pass, and fund nursing legislation. National nursing organizations are working collaboratively on solutions for the nursing shortage. As nursing professionals, we also need to collaboratively work with our colleagues in grassroots advocacy movements. The Table 3. Nurse Representatives in Congress U.S. Representative Lois Capps (D-CA) U.S. Representative Carolyn McCarthy (D-NY) U.S. Representative Eddie Bernice Johnson (D-TX)
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Table 4. Identifying and Communicating with Your Congressional Representative Identifying Your Representative Go to C-SPAN.org and follow the prompts to enter your zip code, member name, or state search. By Telephone Call the U.S. Capitol Switchboard at (202) 224-3121 and ask for your Senators and/or Representatives office. By Mail To write to a Senator: The Honorable (insert name) (name of) Senate Office Building United States Senate Washington, DC 20510 To write to a Representative: The Honorable (insert name) (name of) House Office Building United States House of Representatives Washington, DC 20515 By E-mail Use the titles as above Remember to include your home address on all correspondence. The voice of constituents matters to your elected officials.
first step is to belong to your professional organizations. Next begin to call, write, or e-mail your congressional representative. Be creative and write a piece for your local newspaper. Raise public awareness to the current and projected nursing shortage. Patients are constituents as well. Think of the possibilities. But act now. Our profession needs your help today. The passage of the Nurse Reinvestment Act, the omnibus nursing bill designed to address the current nursing shortage, is only the beginning of the need for funded programs to stem the current and projected nursing shortage.
References 1. United States General Accounting Office: Nursing Workforce: Emerging Nurse Shortages Due to Multiple Factors. Report to the Chair-
man, Subcommittee on Health, Committee on Ways and Means, House of Representatives, January 15, 2001 2. Buerhaus PI, Staiger DO, Auerback, DI: Implications of an aging registered nurse workforce. JAMA 283:2948 –2954, 2000 3. Kelly C: Investing in the future of nursing education: A cry for action. Nurs Educ Perspect 23:24 –29, 2002 4. Peterson CA: Nursing shortage: Not a simple problem---no easy answers. Accessed August 28, 2002. URL: http://www.nursingworld.org/ ojin/topic14/tpc14_1.htm 5. Health Resources and Services Administration: Budget and appropriations. Accessed June 6, 2002. URL: http://www.hrsa.gov/budget. htm 6. Health Resources and Services Administration: Grant guidance and forms. Accessed June 6, 2002. URL: http://mchb.hrsa.gov/grants/ default.htm 7. Health Resources and Services Administration: Bureau of health professions. Accessed June 6, 2002. URL: http://www.bhpr.hrsa.gov/ grants2002/applications 8. American Association of Colleges of Nursing: An overview of AACN[prime]s legislative vision and strategies. Government affairs. Accessed June 7, 2002. URL: http://www.aacn.nche.edu/Government/ shortagestrategies.htm 9. American Nurses Association: Funding recommendations for nurse education and research. Accessed June 7, 2002. URL: http:// nursingworld.org/gova/federal/legis/107/funding.htm 10. American Nurses Association: ANA commends house of representatives for passage of nurse reinvestment act. Accessed June 7, 2002. URL: http://nursingworld.org/pressrel/2001/pr1220b.htm 11. Thompson P: AONE press release: Statement of Pamela Thompson, executive director, the American Organization of Nurse Executives In Support of the Nurse Reinvestment Act. Accessed on June 5, 2002. URL: http://www.aone.org/news/thompson_nurse_reinvestment_actstmt. htm 12. American Nurses Association: Summary of the Nurse Reinvestment Act, P.L.107[hyphen]205. Accessed August 31, 2002. URL: http:/// www.nursingworld.org/gova/federal/news/nra.htm 13. American Nurses Association: Final Congressional action: House, Senate pass Nurse Reinvestment Act; VA Nurse Bill cleared for President’s signature. Accessed June 7, 2002. URL: http://nursingworld. org/gova/federal/news/reinvest.htm 14. U.S. Congress: Senate Bill S.1594. Nurse Retention and Quality of Care Act 2001. Accessed June 10, 2002. URL: http:// thomas.loc.gov 15. American Nurses Association: American Nurses Association endorses legislation addressing RN staffing shortage. Accessed June 11, 2002. URL: http://www.nursingworld.org/pressrel/2002/pr0506.htm 16. Clinton HR: Respect: The not-so-secret ingredient. Am J Nurs 102:11, 2002 17. National Institute of Nursing Research: Mission statement. Accessed June 11, 2002. URL: http://www.nih.gov/ninr/research/diversity/ mission.html 18. Longest BB: Health Policymaking in the United States (ed 2). Chicago, IL, Health Administration Press, 1998