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Nursing and
Nursing Education
Public Policies and
Private Actions
Division of Health Care Services
Institute of Medicine
NATIONAL ACADEMY PRESS
Washington, D.C. 1983
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NOTICE: The project that is the subject of this report was approved
by the Governing Board of the National Research Council, whose members
are drawn from the councils of the National Academy of Sciences, the
National Academy of Engineering, and the Institute of Medicine. The
members of the ~nmmitt-" -~^no;hl" F^_ The __ I._ ~A~ a__
~ ~ a: ~_ ~
_ _~ _~ At_ ·V~ DING ~CiJV-1_ tVGL C ill 1 AL
sneer special competences and with regard for appropriate balance.
This report has been reviewed by a group other than the authors
according to procedures approved bv a Renort Review Cnmmi tt--
consisting of members of the National Academy of Sciences, the
National Academy of Engineering, and the Institute of Medicine.
~r ~
The Institute of Medicine was chartered in 1970 by the National
Academy of Sciences to enlist distinguished members of the appropriate
professions in the examination of Policy matters Dertainin~ t~ the
health of the public.
A ~ _ I __ I ~ ~ ~ ~.
In this, the Institute acts under both the
^~au=.~ ~ boar congressional charter responsibility to be an adviser
to the federal government and its own initiative in identifying issues
of medical care, research, and education.
This study was supported by U.S. Department of Health and Human
Services Contract No. 282-80-0043, T.O. 7.
Library of Congress Catalog Card Number 83-60053
International Standard Book Number 0-309-03346-2
Available from
NATIONAL ACADEMY PRESS
2101 Constitution Avenue, N.W.
Washington, D.C. 20418
Printed in the United States of America
First Printing, January 1983
Second Printing, October 1983
Third Printing, August 1985
Fourth Printing, May 1988
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COMMITTEE ON NURSING AND NURSING EDUCATION
Arthur E. Hess, Chairman
Scholar-in-Residence, Institute of Medicine
Washington, D.C.
Ira Trail Adams, Dean and Professor, University of Tulsa, College of
Nursing, Tulsa, Oklahoma
Linda H. Aiken, Vice President for Research, The Robert Wood Johnson
Foundation, Princeton, New Jersey
Stuart H. Altman, Dean, The Florence Heller Graduate School for
Advanced Studies in Social Welfare, Brandeis University, Waltham,
Massachusetts
Karen W. Beaver, Director-Professor, Practical Nursing Program, Weber
State College, Ogden, Utah
Harry J. Bolwell, Chairman and Chief Executive Officer, Midland-Ross
Corporation, Cleveland, Ohio
Otis R. Bowen. Professor and Director, Undergraduate Family Practice
Education, Indiana University School of Medicine, Indianapolis, Indiana
Roger J. Bulger, President, University of Texas Health Science Center
at Houston, Houston, Texas
Saul J. Farber, Professor and Chairman, Department of Medicine, New
York University, New York, New York
William C. Fetch, Practicing Internist, Rye, New York
Charles D. Flagle, Professor and Head, Division of Operations
Research, Department of Health Services Administration, Johns Hopkins
University School of Hygiene and Public Health, Baltimore, Maryland
. · .
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David H. Jeppson, Executive Vice President, Intenmountain Health Care,
Inc., Salt Lake City, Utah
Carol Lockhart, Director, Division of Health Resources, Arizona State
.
Department of Health Services, Phoenix, Arizona
Gabrielle D. Martel, Vice President of Nursing, Northwestern Memorial
Hospital, Chicago, Illinois
Dorothy J. Novella, Vice President for Academic Affairs and Dean, Erie
Institute for Nursing, Villa Maria College, Erie, Pennsylvania
Virginia L. Olesen, Professor of Sociology, Department of Social and
Behavioral Sciences, University of California, San Francisco,
California
Edward B. Perrin, Director, Health and Population Study Center,
Battelle Human Affairs Research Centers, Seattle, Washington
Elliott C. Roberts, Sr., Director, Cook County Hospital, Chicago,
Illinois
Isabel V. Sawhill, Senior Fellow, Employment and Labor Policy, The
Urban Institute, Washington, D.C.
Edyth H. Schoenrich, Associate Dean, Johns Hopkins University School
of Hygiene and Public Health, Baltimore, Maryland
Stechen M. Shortell. A.C. Buehler Distinguished Professor of Hospital
and Health Services Management, J.L. Kellogg Graduate School of
Management, Northwestern University, Evanston, Illinois
Judy Solkovits, President, United Teachers--Los Angeles, Los Angeles,
California
John D. Thompson, Professor of Public Health and Chief, Division of
Health Services Administration, Yale University School of Medicine,
New Haven, Connecticut
Frances D. Tomokins. Director of Nursing, Union Memorial Hospital
Baltimore, Maryland
Robert A. Wallhaus,* Deputy Director for Academic and Health
Affairs, Illinois Board of Higher Education, Springfield, Illinois
*
From April 1981 to January 1982.
iv
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Ruby L. Wilson, Dean and Professor, School of Nursing, Duke
Durham, North Carolina
University,
Robert C. Wood,* Director of Urban Studies, Professor of Political
Science, University of Massachusetts, Boston, Massachusetts
From January 1982.
v
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INSTITUTE OF MEDICINE
Frederick C. Robbins
President
Study Staff
Katharine G. Bauer
Study Director and Senior Professional Associate
Michael Millman, Senior Staff Officer
Barbara Smith, Senior Research Associate
Julia Bander, Staff Officer
Sunny Yoder, Staff Officer
Ilissa Light, Research Associate
Deborah Parham, Research Associate
Jessica Townsend, Professional Associate
Sandra H. Matthews
Administrative Assistant
Virginia Ingram, Administrative Secretary
Patricia King, Administrative Secretary
Talitha Shipp, Word Processing Specialist
Principal Consultants
Eugene Levine
Judith Ottoson
Margaret D. West
Daniel I. Zwick
Hi
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Contents
PREFACE
ACKNOWLEDGMENTS
SUMMARY AND RECOMMENDATIONS
xv
XXI
1
CHAPTER I NURSING SERVICES AND NURSING EVOCATION: AN OVERVIEW 24
The Diversity of Registered Nurses' Responsibilities, 24
Variety of Nursing Service Personnel, 26
Variations in Nursing Service Staff Mix, 29
Education for Registered and Practical Nurses, 35
Relation of Type of Generalist Nurse Education
to Licensure and Practice, 37
Debate Over Appropriate Generalist Nurse Education, 41
Responsibilities of Advanced Level Nurses, 43
Education for Advanced Level Positions, 44
Federal, State, and Private Financing of Nurse
Education, 46
CHAPTER II MEETING CURRENT AND FUTURE NEEDS FOR NURSES
Current Supply and Demand, 52
Future Supply and Demand, 63
Supply of Registered Nurses Educated in the
Three Types of Generalist Programs, 7 7
State and Local Planning for Generalist Nurse
Education, 80
CHAPTER III THE EFFECTS OF EDUCATION FINANCING ON
GENERALIST NURSE SUPPLY
Student Decision Making, 90
State and Institutional Decision Making, 104
51
89
CHAPTER IV EDUCATION FOR GENERALIST POSITIONS IN NURSING 116
Attracting New Kinds of Students, 116
Opportunities for Educational Advancement, 119
Collaboration Between Education and Service, 126
· ~
VII
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CHAPTER V EDUCATION FOR ADVANCED POSITIONS IN NURSING
Advanced Education for Nursing Administration, 133
Advanced Education for Teaching and Research, 135
Advanced Education for Nurse Specialists, 138
Interrelationships Among Types of Advanced Education, 140
The Need for More Nurses With Graduate Education, 141
The Effect of Financing on Future Supply, 146
Statement of Exception to Recommendation, 151
CHAPTER VI ALLEVIATING NURS ING SHORTAGES IN
MEDICALLY UNDERSERVED AREAS AND AMONG
UNDERSERVED POPULATIONS
Some Reasons for Areas of Underservice, 158
The Nature and Consequences of Underservice, 158
Educational Outreach, 160
Education Opportunities for Minority Students, 164
Adequate Revenues for Inner-City Hospitals, 168
Nursing Education for Care of the Elderly, 171
Upgrading Existing Staff in Nursing Homes, 173
Adequate Payment for Long-Term Care, 175
Lowering Barriers to Expanded Nurse Practice, 178
Financing Recommended Actions, 182
CHAPTER VII IMPROVING THE USE OF NURSING RESOURCES
The Effects of Management Decisions on Supply
and Demand, 190
Job Turnover and Attrition in Nursing, 191
Improving Career Opportunities and Working
Conditions, 195
Inactive and Part-Time Nurses, 202
Accounting for Nursing Services, 209
CHAPTER VIII
ADVANCING RESEARCH IN NURSING AND GETTING
FACTS FOR MANPOWER PLANNING
Improving the Nation's Nursing Research Capacity, 215
Comparative Competencies of Registered Nurses WitI,
Different Educational Preparation, 217
Evaluation of Promising Management Approaches, 221
Information to Monitor Supply and Demand, 223
viii
133
157
190
215
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APPEND IXE: S
1 CONGRESSIONAL C~GE--E~RPTS FROM PUBLIC LAW 96-76
2 APPROPRIATIONS UNDER THE NURSE TWINING ACT
3 SUMMARY OF INFORMATION ON STATE REPORTS OF NURSING ISSUES
4 CERTIFICATES FOR SPECIALIST REGISTERED NURSES
5 PROJECTIONS OF REGISTERED NURSE SUPPLY
REQU IREMENTS
6 DOCTORAL PROGRAMS IN NURS ING: ILLUSTRATIVE
STATEMENTS OF PURPOSE FROM SCHOOL CATALOGS
7 MULTIV=IATE ANALYSIS OF DETERMINATION OF WOW
STATUS AND WAGE RATES
8 NURSING RESEARCH: DEFINITIONS AND DIRECTIONS
9 PARTICIPANTS IN THE STUDY' S WORKSHOPS AND
ADVISORY PANELS
LISTING OF BACKGROUND PAPERS
TABLE S
1 Examples of the Responsibilities of Hospital Nursing
Service Personnel
2 Percent Distribution of Registered Nurses Aged 35-39
Years in Selected Types of Employment According to
Their Highest Levels of Educational Preparation,
November 1980
ix
228
230
237
253
261
283
288
297
301
311
30
38
.,
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TABLES (continued)
Percent of Experienced Staff Nurses in Hospitals
Reporting Performing Activities That Indicate
Independent Judgment, by Highest Educational
Preparation, November 1980
4 Distribution of Registered Nurses Among Positions
in Nursing Service Management, Nurse Education,
and Clinical Specialties by Highest Educational
Preparation, November 1980
5 Median Annual Salaries for Full-Time Registered
Nurses, by Years of Experience and Highest
Educational Preparation, November 1980
6 Graduations From Basic Registered Nurse Programs,
1970, 1980, and 1981
7 Proportions of Graduations From Basic Registered
Nurse Programs at Age 25 or Older, by Program
Type, Selected Years
8 Beds, Inpatient Utilization, and Outpatient Visits
in Nonfederal Short-Term General and Allied Special
Hospitals, 1970 and 1980
9 Employed Registered Nurses, by Work Setting, 1977
and 1980
10 Registered Nurses and Licensed Practical Nurses
(FTE) in Hospitals, 1972 and 1980
11 Supply of Active Registered Nurses, Total and
FTE, 1980, and Study Projections for 1982 and 1990
12 Department of Health and Human Services Projections
of Requirements for Registered Nurses (FTE), Two
Models, January 1990
x
40
44
45
55
56
57
58
59
65
69
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13 Study's Illustrations of Projected Demand for
Registered Nurses, Total and FTE, 1990, Under Three
Sets of Assumptions
72
14 Study's Illustrations of Projected Demand for
Registered Nurses (FTE) in Selected Practice Settings,
December 1990, Under Three Sets of Assumptions 73
15 Summary of the Study's Alternative Projections of
the Supply of and Demand for Registered Nurses (FTE),
December 1990
16 The Supply of Employed Registered Nurses, 1980 and
Projected to 1990, by Highest Educational Preparation
(Study's Intermediate Projection)
17 Percent Distribution of Active Registered Nurses in
1990, by Highest Educational Preparation, Study's
Intermediate Projection, Compared With DHHS WICHE
Lower Bound Projection of Need
18 Expert Panels' Judgment of Required Nursing Staff
for Hospital Inpatient Services, U.S. and Eight
States, Using WICHE Methodology (Lower Bound)
19 Median Annual Tuition and Fees for Basic Nursing
Education Programs, by Type of Program and Public-
Private Control, 1981-1982 (dollars)
20 Average Annual Student Expenses for Books and
Education Supplies by Type of Institution and Public-
Private Control, Academic Year 1981-1982 (dollars)
21 Estimated Total Out-of-Pocket Education Expenses for
Full-Time Students in Basic Nurse Education Programs,
Academic Year 1981-1982, and Estimated Total Expenses
to Complete Each Type of Program for a Student
Entering in 1981-1982 (dollars)
xi
74
77
79
82
91
93
93
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TABLES (continued)
22 Estimated Annual Living Expenses for Resident,
Commuter, and Self-Supporting Students, by Type
of Education Institution, 1981-1982 Academic Year
23 Estimated Family Income Distribution of First-Time,
Full-Time Freshmen, Fall 1981
24 Sources of Financial Support for Nursing Students
Who Were First-Time, Full-Time Freshmen in 1981
25
Federal Appropriations for Higher Education,
Selected Programs, Fiscal Years 1981-1983 (in
millions of dollars)
26 Nurse Training Act Scholarship and Loan Funds
Awarded to Basic Nursing Education Programs, by
Type of Program, Fiscal Years 1965-1979
27 Current-Fund Revenues of Institutions of Higher
Education, by Source, Fiscal Year 1980
(in thousands of dollars)
28 Comparison of the Study's Projected Supply of
Employed Registered Nurses With Graduate Degrees in
1990 With DHHS Estimates of Need Derived From
Judgment-of-Need (WICHE) Model
29 Financial Support Received During Doctoral Study by
Nurses With Doctorates in 1980
30 Average Hourly Salaries of Selected Hospital Workers
in 21 SMSAs, 1975, 1978, 1981
31 Index of Average Hourly Salaries of Selected Hospital
Workers in 21 SMSAs Relative to General Duty Registered
Nurses' Salaries, 1975, 1978, 1981
· ~
X11
94
97
' 99
100
103
105
145
147
199
200
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32 Scores on the 1977 Licensure Examination of
Candidates from Diploma, Associate Degree, and
Baccalaureate Degree Programs
FIGURES
1 Where registered nurses worked in 1980
2 Mix of full-time equivalent personnel providing nursing
services in U.S. registered hospitals and in SNF nursing
homes
3 Trends in number of graduates of programs preparing for
registered nurse licensure, 1960-1981
4 The 1980 population of nurses graduated from basic
programs preparing for registered nurse kc ensure,
by age
5 Registered nurse labor force participation, by age,
1949, 1960, and 1980; all graduates of programs
preparing for registered nurse licensure
Employed registered nurses per 100,000 population by
regions of the United States, 1962, 1972, 1977, and
estimated 1980
~ Employed registered nurses and licensed practical
nurses (FTE) per 100,000 population, by state, 1977
8 Supply of active registered nurses (FTE), 1970-1980,
with study projections to 1990
9 Demand for registered nurses (FTE) 1970-1980 (actual)
with three illustrative study projections to 1990
10 Comparison of the projected supply of and demand for
registered nurses (FTE), 1980-1990, under alternative
study assumptions
· · ~
x~,
219
27
32
36
53
54
61
62
66
72
75
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FIGURES (continued)
11 Supply of active registered nurses, 1990, by age and
educational preparation (study's intermediate projection) 78
12 Contribution of educational mobility to the 1980 pool
of employed RNs with baccalaureate or higher degrees
Contribution of educational mobility to the 1980 pool
of employed RNs with master's and doctoral degrees
14 Characteristics of registered nurses not employed in
nursing, November 1980
x~v
122
123
192
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Preface
This is the final report of a two-year study of nursing and
nursing education undertaken early in 1981 by the Institute of
Medicine of the National Academy of Sciences. The study, contracted
by the Department of Health and Human Services, was mandated by Public
Law 96-76, the Nurse Training Act Amendments of 1979.
The study was prompted by controversy in the late 1970s as to
whether further substantial federal outlays for nursing education
would be needed to assure an adequate supply of nurses. The intent of
the congressional mandate as expressed in the legislative history was
to secure an objective assessment of the need for continued federal
support of nursing education programs, to make recommendations for
improving the distribution of nurses in medically underserved areas,
and to suggest actions to encourage nurses to remain active in their
profession.
Over an 18-year period beginning in 1965, more than $1.6 billion
was appropriated under the Nurse Training Act. Programs were
established and periodically revised with the primary intention of
expanding the supply of nurses but also to improve the quality and
distribution of this supply. This was accomplished by increasing the
capacity of educational institutions, providing student financial
assistance, and increasing the opportunities of nurses to obtain one
or another form of advanced training, such as that required to become
a clinical nurse specialist or a nurse practitioner. Actions by the
executive branch of four successive federal administrations suggesting
decreased support for nursing education have reflected a conviction
that these forms of federal support for nursing education generally
have outlived their usefulness, with the possible exception of small
amounts of support for selected objectives such as preparing particular
kinds of nurse specialists. Throughout the period, however, Congress
continued to urge more generous support of nursing education and to
express concern about the effects of withdrawal of federal support.
Authorizations for certain of the Nurse Training Act programs that
peaked in the 1970s have been continued, albeit at decreased levels of
support.
xv
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The Study Charge
The congressional charge embodied in Section 113 of the Nurse
Training Act Amendments of 1979 spelled out the purposes of this study
as follows:
(a)(l)(A) to determine the need to continue a specific
program of Federal financial support for nursing
education,
(B) to determine the reasons nurses do not practice
in medically underserved areas and to develop
recommendations for actions which could be taken
to encourage nurses to practice in such areas,
to determine the rate at which and the reasons
for which nurses leave the nursing profession and
to develop recommendations for actions which
could be taken to encourage nurses to remain in
or re-enter the nursing profession, including
actions involving practice settings conducive to
the retention of nurses.
The part of the study described in paragraph (a)(l)(A) shall
include consideration of the following:
(a)~2~(A) the need for nurses under the present health care
delivery system and under such system as it may be
modified by increased use of ambulatory care
facilities or as it may be changed by the enactment
of legislation for national health insurance.
Determination of such need shall include
determination of the need for nurses trained in
each type of school of nursing (as defined in
Section 853~2] of the Public Health Service Act) [a
diploma school of nursing, an associate degree
school of nursing, or a collegiate school awarding
baccalaureate or graduate degrees in nursing], for
nurses with graduate training in the varying nurse
practitioner clinical specialities, and for nurse
administrators and nurse educators.
(B.) The cost of nursing education and a comparison of
the cost of education at each type of school of
nursing (as so defined) and comparison of the costs
of each of the graduate programs of nursing.
(C) The availability of other sources of support for
nursing education, including support under general
programs of Federal financial support for
postsecondary education, under State and other
public programs, and from private sources.
xvi
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The statute also specified that final recommendations be made
after a two-year study of all the considerations described in the
subparagraphs, and that, if a need for continued federal financial
support for nursing is found, the study was to recommend the form it
should take and the basis for such recommendations. The study also was
instructed to recommend actions to encourage nurses to practice in
underserved areas, to remain in or re-enter the nursing profession, and
to make practice settings more conducive to the retention of nurses.
The study's recommendations on federal support of nursing education
are addressed principally to the Committee on Labor and Human Resources
of the Senate, the Committee on Energy and Commerce (previously the
Committee on Interstate and Foreign Commerce) of the House of
Representatives, and the Secretary of the Department of Health and
Human Services. However, the fact that Congress has directed the
study to consider the nation's need for various types of nurses and to
develop recommendations for actions that could be taken to encourage
nurses to practice in underserved areas and to remain in or re-enter
the nursing profession broadens the audience to include state
governments and the private sector. Nurses and nurse educators,
individually and through their organizations, are a vitally important
audience, as are the state commissions on higher education, many
health professional associations, and other groups with a stake in the
future of nursing education. Many remedial actions can be carried out
only by those who set organizational, management, and personnel
policies in hospitals, nursing homes, public health departments, and
other agencies that employ nurses.
Conduct of the Study
Under a preliminary contract awarded in 1980, the Institute of
Medicine established a broadly based planning committee to outline the
scope and identify the major issues for study. Upon receipt of the
final contract, a full study committee was constituted in 1981 to
establish specific policies and procedures for the study staff, to
carry on continuing deliberations, and to be responsible for the
study's recommendations. In line with established practice, the
committee was composed of Institute members and other nationally
recognized experts with experience in analysis and the formulation of
public policy as well as in other disciplines related to nursing
issues. Over the period of the projects the full study committee met
five times for a total of 11 days of deliberations. In addition,
individual committee members have spent countless days in preparation
for meetings, participation in the work of subcommittees, advisory
panels, and workshops.
The committee established a number of ad hoc advisory panels of
additional experts to assist in specific aspects of the study. It
also engaged consultants, commissioned working papers, and secured the
informal participation (through its workshops and other means) of a
broad selection of the nursing profession's representatives and of
others with authoritative knowledge in relevant fields. Although
xvii
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Institute and Academy policy precluded committee membership by official
representatives or employees of national organizations with a direct
interest in the outcome of the study, ample opportunity was afforded
in the course of the study to obtain information and opinions from
representatives of nursing and other organizations.
The study began with activities required to prepare an interim
report at the end of six months, as called for in the statutory
mandate. An extensive literature search was conducted; subsidiary
questions relating to the congressional charge were developed and
explored; an open meeting was held on May 18, 1981, at which
individuals and representatives of organizations concerned with
nursing testified; and written statements, data, and recommendations
were solicited and received from a wide range of groups and
individuals. Seventy-five recent state level studies of nursing were
identified, collected, and analyzed; working papers were prepared on
numerous issues pertinent to understanding nurses' satisfaction and
dissatisfaction with various conceptions of nursing roles; a detailed
review was conducted of survey and inventory data dealing with the
characteristics and requirements of education and employment settings
for both registered nurses and licensed practical/vocational nurses;
and an analysis was begun of the assumptions and methods employed by
the Department of Health and Human Services and by states to project
the future needs and the future supply of nurses.
On August 5, 1981, the study's interim report was transmitted to
the Congress and to the Secretary and was made available for public
consideration. Comments were received from numerous individuals and
organizations. These were reviewed by the committee and staff and
were taken into account during the conduct of subsequent study
activities.
Many activities begun earlier continued throughout the balance of
the study. In addition, major workshops were conducted on the
economics of nursing and graduate nursing education; ad hoc advisory
panels were appointed, and members participated in group meetings and
in individual consultations during the course of the study. The study
staff also kept in touch with new developments in the nursing field by
means of site visits in ten states and attendance at selected
conferences and meetings. In particular, close liaison was maintained
with the National Commission on Nursing, a study group of officials
and members of national health associations and organizations, which
concurrently was addressing crucial professional issues in nursing.
A Note About Data
The following advice from the former Committee for Interstate and
Foreign Commerce of the House of Representatives is included in its
report on the legislation in which the study was mandated:
It is the committee's intent that the required study
concentrate on review and analysis of ongoing studies
and available information respecting nursing education
xviii
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and the existing and potential supply and demand for
nurses, rather than a wholesale duplication of present
undertakings. . . .
unavailable in the detail
Thus, major new data collection efforts were explicitly
discouraged. Instead the study based its findings primarily on its
syntheses and interpretation of data secured from many existing
sources. We found certain important information to be outdated or
desired. Generally, there is a lag of
several years between the conduct of national nursing surveys and the
availability of their results. For example, both the study's interim
report of July 1981 and the Secretary's Third Report to Congress in
February 1982 had to rely on survey data collected in 1977.
Fortunately, for this final report we have been able to draw on the
results of a parallel survey of registered nurses, conducted in
November 1980, made available to us during the summer of 1982. Other
sources of data providing new information also became available during
the latter part of the study period.
In addition to the 1977 and 1980 sample surveys, the study's
analyses draw on data from a great variety of other sources,
referenced throughout the text. A few major ones deserve special
mention: American Hospital Association, Annual Survey of Hospitals;
American Nurses' Association, 1977 Inventory of Registered Nurses;
National Center for Health Statistics, National Nursing Home Survey
1977; and National League for Nursing Annual Survey of Schools of
Nursing, and Annual Survey of Newly Licensed Nurses.
Organization of the Report
After an introductory chapter that provides the reader with
background on the diversity both of nurses' roles and of nurse
education programs, the report focuses on the particular components of
the study charge.
Chapters II through V deal with various aspects of the first study
question: Is there a need for continued federal support for nurse
education? Chapter II reports the committee's findings on whether the
aggregate supply of generalist nurses will be sufficient to meet future
demand, and how changes that could occur in the health care system
might affect demand. Chapter III discusses how the current and future
supply of nurses may be influenced by the costs of nursing education
and the sources of education financing. Chapter IV discusses education
for generalist positions in nursing, and particularly the policies and
practices in nursing education that affect the future supply of new
nurses and the opportunities for educational and career advancement for
those already in the work force. Chapter V examines the supply and
demand situation for nurses educationally prepared for advanced
professional positions in nursing.
The second major study question--how to alleviate shortages of
nurses in underserved areas and for underserved populations--is dealt
with in Chapter VI. The third study question--how to improve retention
of nurses in their profession--is addressed In Chapter VII in
Ax
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conjunction with an analysis of how employer policies and management
practices in the utilization of nursing resources influence demand and
supply. The report concludes with an examination in Chapter VIII of
the nation's nursing research resources and needs. This chapter
identifies areas in which further data and studies are required to
improve capabilities for monitoring the nation's supply of and demand
for nurses, and to guide national and state planning for nursing
education.
The committee recognized a number of problems that, although
important, after further consideration seemed not to require
elucidation to answer the congressional questions and were not
otherwise within the scope of the report's intent. Also, in some
instances, where evidence was equivocal, we have presented data
without conclusions. Moreover, we were sensitive to the fact that we
should not address at a level of national policy those matters that
need to be resolved through the interplay of professional and market
forces. Examples include equal pay for comparable work; collective
bargaining for nursing; relationships between nurses and physicians;
jurisdictional and professional issues of credentialing, including
specialty certification; and questions of staffing substitution and
production function analysis. On the issue of what education pathways
provide appropriate preparation for entry into professional nursing
practice, we found ambiguity in the evidence about how well graduates
of the various nurse education programs that prepare students for
registered nurse licensure subsequently meet various employment needs,
and disagreement among those who are professionally and managerially
involved in the delivery of health care. We could reach no conclusions
on this issue. We do, however, present information bearing on the
question and present recommendations for research needed to enlighten
policymakers. It is our conviction that this issue essentially
involves matters for the profession, employers, and others to work out
through collaboration of national organizations as well as in the
marketplace and in the states--the arenas in which most resource
allocation decisions for health education programs take place.
The study has not considered the needs of the Veterans
Administration or the Department of Defense for nursing personnel. To
the extent that their present requirements are reflected in current
supply-demand data, their normal peacetime needs may be assumed in our
projections for the future. Additional requirements they may have,
however, for augmented numbers or special education of RNs are properly
within the purview of their manpower planning and appropriations.
A study of such scope and detail as this depends for its successful
conclusion on the good-spirited labors of many people. I hope that all
of them are named somewhere in these pages--the members of a superbly
dedicated study committee and study staff, the consultants, the work-
shop panels, and those in the agencies and professional organizations
who are listed on a separate page of acknowledgments. The strength of
this report borrows something from the devotion of each person who
worked on it.
Arthur E. Hess
Chairman
. .
xx
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Acknowled~nents
-
The committee and its staff are indebted to many individuals and
organizations for thoughtful contributions made to various aspects of
the study. The members of the committee's five advisory panels and the
participants in its two workshops (Appendix 9) gave generously of their
time to share their wisdom and experience. Special thanks are due to
Myrtle Aydelotte, who contributed an important background paper to the
project. She, Robert Derzon, Vernice Ferguson, Wayne Kirschling and
Donald Yett took part in two or more panels and workshops, bringing
insights that were particularly valued.
We also want to extend our appreciation to Walter Johnson, John
Vaughn, and Lucille Knopf at the National League for Nursing; to
Judith Yates and Pauline grimmer at the American Nurses' Association;
to Marian Murphy at the American Association of Colleges of Nursing;
to Eileen McQuaid Dvorak at the National Council of State Boards of
Nursing; to Gail Crossley at the National Association of Nurse
Recruiters; and to Lucille Etheridge, formerly at the National
Association for Practical Nurse Education and Service. At the
American Hospital Association, Ross Mullner and Jane Gibson were most
helpful. We have also enjoyed and profited from a continuing close
contact with the staff and members of the National Commission on
Nursing during the course of the study, for which we owe special
thanks to Robert Cathcart and to Marjorie Beyers.
Manv people in the Department of Health and Human Services Rave us
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valuable assistance. We are particularly grateful to Jo Eleanor
Elliott and her associates in the Division of Nursing for providing
background on the Nurse Training Act programs. We also want to thank
a number of people from the Division of Health Professions Analysis.
The director, Howard Stambler, was most helpful in ensuring our access
to many sources of information important to the study; Evelyn Moses
and William Spencer gave valuable technical advice on the use of the
1980 national sample survey data; John Drabek and William Losaw were a
great help in adapting the department's mathematical manpower model to
the committee's specifications. At the Department of Education,
Salvatore Corrallo guided us to useful sources of information on the
costs and sources of financing of education.
Finally, we would like to express special appreciation to Robert
Walkington, our project officer at the Department of Health and Human
Services, and to Karl Yordy, director of the Division of Health Care
Services at the Institute of Medicine, for their helpful suggestions
at every stage of the study.
Katharine G. Bauer
Study Director
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