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CHAPTER V Educabon for Advanced Positions in Nursing The previous chapter described measures for strengthening the nursing supply by enlarging the pool from which registered nurse education programs draw students, reducing the barriers to educational advancement, and improving the collaboration between nursing education and nursing services. There is, however, another important dimension to the problem of assuring adequate nursing services in the nation's health care system. Integral to the effectiveness of the nursing supply are such matters as the quality of the education, the management of nursing personnel and nursing services, the study of nursing practice for ways to improve it, and the ability of nursing's advanced practitioners to generate new knowledge and to translate it both into improved patient care and into the education of other nurses. These leadership functions are closely associated with the advanced education of nurses. In this chapter, we examine the supply and demand for nurses with advanced education in three areas: nursing administration, education (including both research and teaching), and clinical specialty practice. Advanced Education for Nursing Administration The committee found a widespread conviction among administrators of hospitals and long-term care facilities that their nurse administrator colleagues could make the delivery of care more cost effective if they had better grounding in financial management and in the human resource management required at all the levels of administra- tion in which they currently serve, i.e., from head nurse positions through nursing service administrators.* Reciprocally, testimony indicated that nurse administrators should be able to contribute to executive management decisions beyond nursing services. Because they are familiar with almost all aspects of the daily operations of their *In a number of medical centers, nursing service directors are now at the vice-presidency level. 133

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134 institutions through the interactions between their own and other departments, they are in a unique position to participate in institution-wide decisions on ways to contain costs while maintaining good standards of patient care. Hospitals and other providers of health services need departmental managers adept in the complex techniques of modern administration. Today, administrators must deal with intricate problems in employment policies, job design, resource allocation, intra-institutional negoti- ation, and financial management. Many of the skills needed to handle these problems can be acquired or enhanced through academic prepara- tion. Nursing service administrators should be equipped with the same fundamental knowledge of management practices as their colleagues in other departments. Every departmental administrator will be competing strongly for a share of revenue generated as cost cutting proceeds further. Special seminars and workshops sponsored by professional organizations and short training courses have often had to suffice as a means of upgrading middle managers and top administrators in nursing services . Although these programs help, they are not sufficient to prepare individuals for the responsibilities of high-level administra- tive positions. Among the more than 61,000 registered nurses (RNs) who reported in the National Sample Survey of Registered Nurses, November 1980, that they occupied a position in "top nursing administration," only 18 percent held a master's degree and 1.4 percent held a doctorate.! However, it should be noted that this category did not distinguish between persons who worked as administrators in large complex health care settings with responsibilities for hundreds of staff and multimillion dollar budgets and those who worked in small hospitals, nursing homes, student health services, or physicians' offices and were responsible for only a handful of staff and a small budget. It is known that nursing service administrators with diploma preparation are concentrated in hospitals with fewer than 100 beds; nursing service administrators with associate degree (AD) preparation are concentrated in hospitals with fewer than 200 beds. Nursing service administrators with baccalaureate preparation are largely found in hospitals of up to 300 beds; and, as could be expected, those with master's degrees and doctorates are in the larger hospitals.2 Finally, it should be noted that the administrator category also included 5,000 deans and directors of nursing education, the majority of whom probably held a master's or doctoral degree. If this group was removed from the computation of the proportion of individuals in "top nursing administration" with advanced degrees, the proportion of all "top nursing administrators" holding master's or doctoral degrees might be appreciably less. Although the committee would not argue that the majority of nurses who work in supervisory or administrative positions need the skills and knowledge acquired in formal graduate degree programs, there is general agreement that a scarcity exists of nurses with advanced education. The scarcity is felt most in larger hospitals. As health care settings become increasingly complex, more highly skilled administrators of nursing services will be needed.

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135 Because advanced clinical preparation has been the prime focus of attention within the last 20 years, graduate programs in schools of nursing have not been able to make a substantial direct contribution to the pool of top nursing service administrators and nurses in middle management positions. Students do not appear to be attracted. Between 1971 and 1980 only about 7 percent of all graduates of master's programs in nursing had a concentration in administration. It seems unlikely that graduate programs in administration in schools of nursing can produce larger numbers and better quality of trainees soon. One observer comments: While programs in health care administration have grown and changed, strengthening their residency in line with needs of the field, nursing has come to a fixed core, heavy on theory and light on the type of experience a residency could provide. Too often a major in administration and nursing has not equipped that graduate with the skills or language common to health care administration. It is not uncommon for the new graduate to immediately enroll for evening courses in business administration.3 The W.K. Kellogg Foundation has in recent years funded several demonstrations of interdisciplinary preparation for nursing service administration in university health care settings to assist nursing schools to develop joint programs with schools of health administra- tion, management, or business. The most recent example is that of the University of Pennsylvania School of Nursing and the Wharton Graduate School of Business. The study committee noted that there are still too few opportunities for graduate nursing education in management through such collaborative programs. We believe it is in the public interest that the health care industry and nursing education encourage and sponsor more such endeavors. Collaborative arrangements with health services administration programs and/or with business schools can, over the long run, build up nursing education's capabilities for providing high-quality preparation for this very important aspect of nursing leadership. Advanced education in management is one of the few areas with substantial financial payoff for students, because nursing service administrators in large institutions command the highest salaries in nursing. This suggests that the financing of such training be a cooperative endeavor in which greater weight is given than in other fields of graduate education to the motivations for institutions and individual nurses to share in costs. Advanced Education for Teaching and Research Many professional schools and university departments have little difficulty in attracting faculty members in the numbers and at levels of excellence required. This is not the case in schools and departments of nursing, many of which were established in colleges and

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136 universities as recently as the late 1960s and 1970s. The relative dearth of academic credentials among nursing faculty has been aggravated by a great increase in the numbers of nursing education programs in institutions of higher education and the consequent rapid and large increase in nursing students. From 1968 to 1980 the number of full-time faculty in nursing education programs increased by 36 percent and enrollments (basic and graduate) increased by 66 percent.4 State boards of nursing are increasingly requiring that the deans and faculty of nursing education schools hold graduate degrees. As of June 1982, 19 states required master of science degrees in nursing as the minimal degree for senior faculty in all programs, and two states required directors of schools of nursing to hold a doctoral degree.5 If one agrees that the faculty required to teach master's and doctoral students should hold doctoral degrees and that those who teach baccalaureate students should also possess advanced degrees, indications of scarcity are suggested by the fact that of the approximately 20,000 full-time nursing faculty in 1980, only 7 percent held a doctoral degree; 68 percent had a master's degree. The proportion of nursing faculty with doctorates does not compare favorably with other disciplines. According to the Association of Schools of Public Health, well over one-half of the faculty employed by 20 schools of public health held at least one doctorate. Compared with science faculties, nurses showed up even more unfavorably. A National Science Foundation study of young and senior science and engineering faculty found that in schools offering doctoral as well as other degrees in departments of psychology, physical sciences, biological sciences, mathematical/c~mputer sciences, engineering, and social sciences, more than 90 percent held the doctoral degree.6 By comparison, in the 22 nursing schools which enrolled nursing doctoral students in 1981-1982, an average of only 35 percent of the faculty had doctoral preparation.7 Recent surveys in 40 states in the Midwestern, western, and southern regions found that among the 58 graduate programs in nursing surveyed, respondents projected a need for 1,080 doctorally prepared nurse faculty during the following 5 years. (Data were not obtained on what proportion of such new faculty positions had been approved by their respective institutions and assured of funding.) The schools reported that their greatest need was for 371 nurse faculty with doctoral preparation emphasizing research and theory development in nursing. The second highest need was for 359 doctoral nurses with formal preparation in clinical practice.8 To put this in the perspective of the supply, in 1980 there were only about 4,000 doctorally prepared nurses. Although about one-half of the nurses who earn doctorates take teaching positions after graduation, many later gravitate to other types of activities. Among the respondents to a survey of nurses with doctorates, conducted in 1980 by the American Nurses' Association (ANA), 36 percent reported that their primary function was in teaching, 33 percent reported that they were in administration (mostly educational administration), and approximately

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137 6 percent were in research. Most of the remainder were performing multiple activities.9 Research in nursing has been handicapped by inadequate levels of support. Funding for nursing research fellowships, administered by the Division of Nursing in the Health Resources and Services Administration (HRSA), under the authority of Section 472 of the Public Health Service Act, amounted to about $12 million for the period 1971 to 1981; it has been averaging about $1 million per year since 1977. During the same 10-year period, about $40 million was awarded in research grants; between 1976 and 1981 the level has been about $5 million per year. Over that same period the federal government, through the National Institutes of Health, spent almost $1.7 billion on general biomedical research training and almost five times as much on dental research training as it did on nursing research training.l0,11 Nurses with doctorates have earned them in many different fields. Of the 6 percent of nurses with doctorates who reported in 1980 that their primary function was research, about 65 percent had a Ph.D., and slightly more than 40-percent had earned these degrees in the social/ behavioral sciences. Research as a primary function is most common among nurses who received their doctorates in public health (about 17 percent of the total with these degrees) and in the biomedical sciences (about 16 percent).12 The doctoral degrees in nursing (D.N.S. and D.N.Sc.) are granted only by graduate programs located in schools or departments of nursing. However, schools of nursing with doctoral programs also offer other kinds of degrees. In 1982, 1 offered the Ed.D. and 16 the Ph.D. (Appendix 6 contains descriptions of doctoral program offerings in selected departments or schools of nursing). Mbst doctoral programs in nursing departments are still relatively new. The number of programs grew from 6 in 1970 to 24 in 1982.13 This expansion brought sufficient problems to suggest that future increases should proceed at a more measured pace. The National Research Council noted in 1982 that a 40-percent increase in the number of doctorate-granting nursing schools between 1977 and 1981 had detracted from efforts to develop quality programs, and that unevenness in the quality of committee's 1977 survey been perpetuated rather than alleviated.14 In summary, the scarcity of nurse faculty with adequate academic credentials in the nation's more than 1,000 academic nursing education programs will not readily be alleviated. A long period appears to be needed in which universities offering nursing doctorates can build their capacity to produce greater numbers of high-quality graduates likely to devote their careers to teaching and research. A key feature of this strategy is the availability of targeted research support and innovative programs to enhance the capability of nursing faculty to compete effectively for research grants, including grant funds not specifically earmarked for nursing. In the short run, some nursing education programs may have to draw on other kinds of academically and clinically qualified faculty from their universities or elsewhere to collaborate in teaching and research training programs evidenced in its and site visits hnc1 horn nF,rn~t-d

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138 conducting research. As a corollary, nurses who do not find doctoral nursing programs appropriate to their individual needs--in geographic location as well as in substantive focus--should also be allowed to compete for financial support to pursue an advanced degree in other relevant disciplines. In time, as the number of nurses with doctorates in nursing reaches a critical mass, increased financial and organizational incentives may enable schools of nursing to attract large numbers of faculty with these nursing degrees. Advanced Education for Nurse Specialists A growing interest developed in the 1960s to provide specialist training to RNs that would enable them to respond to demands for greater responsibilities than were found in their traditional roles Acute care hospitals increasingly required nurses with highly specialized skills. Community health settings highlighted the role of nursing in preventive and primary care. In the 1970s, health policymakers, seeking ways to help medically underserved populations, encouraged the development of nurse practitioner programs. In 1980, about 24,000 such specially trained nurses provided clinical support to hospital nursing services, of whom about 5,700 were nurse practitioners. Approximately 7,000 other nurses with clinical specialties were in same type of community health work, of whom almost 4,500 were nurse practitioners or nurse midwives.15 Such nurses receive their special training in a variety of ways, sometimes in staff development programs in an individual institution, sometimes in joint cooperative programs between hospitals or other health care institutions and schools of nursing, and sometimes in graduate degree programs of schools of nursing with arrangements for clinical experience at one or more practice institutions or with practitioner preceptors. Since 1976, under Nurse Training Act (NTA) appropriations, grants and contracts have been awarded to schools of nursing, medicine, and public health, as well as to hospitals and other public or nonprofit organizations to develop and operate programs (certificate and graduate degrees) to train nurse practitioners. The appropriations began at $3 million per year and increased to $13 million by 1978. However, by 1982 they decreased to $11.5 million. Recently, attention has been directed toward the new potential of training to meet the particular problems of geriatric and nursing home patients, as well as training to provide primary care in homes, ambulatory facilities, long-term care facilities, and other health care institutions. In developing clinical specialist programs to produce all these new kinds of nurses, the nursing profession responded to market signals that indicated a demand for new services from nurses as well as to federal policy expressed through funding. The educational and experiential qualifications and job content in the market, however, were not yet well defined. As a result, educational programs of varying aims, length, content, and auspices proliferated (see Appendix 4~. Nurses who completed these programs are now employed in a wide

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139 range of capacities and hold a variety of position titles, for many of which there is no commonly agreed upon definition of role. The diffuse state of education and credentialing for nurses holding clinical positions beyond the generalist level is illustrated by the following data: In 1980, among the estimated 19,000 RNs who held the title of clinical nurse specialist, 15 percent had the AD for their generalist preparation, 36 percent had the diploma, and 21 percent had the baccalaureate degree. Mbst are presumed to have completed same form of clinical specialty training program; an unknown proportion hold certificates in one or another nursing specialty. The remaining 27 percent (more than 5,000 nurses) had graduate preparation at the master's or doctoral level, and many of them also held certificates. In the same year, among the estimated 8,000 nurse clinicians, 14 percent had the AD as their highest educational preparation, 44 percent had the diploma, and 27 percent had the baccalaureate degree. The remaining IS percent had graduate preparation.16 Among the approximately 17,000 nurses who reported themselves to be either nurse practitioners or nurse midwives in November 1980, about 10 percent had the AD, and about 40 percent had the diploma as their highest formal educational preparation; 30 percent had baccalaureate degrees; and 19 percent had master's degree preparation. Approximately 13,500 were certified (Appendix 4~. Among the approximately 15,000 nurse anesthetists reported in the 1980 survey, only a small proportion had graduate preparation. Again, in 1980, the majority were diploma prepared.17 Nurse practitioner education programs vary considerably in length and content. For example, certificate programs generally require 8 1/2 months of additional nurse education and average about 6 months of subsequent clinical preceptorship. Master's programs for nurse practitioners require somewhat over 15 months of education and average about 3 1/2 months of such preceptorship.18 Nurses pursuing graduate education in advanced clinical practice usually choose an area of concentration. About 37 percent of those enrolled full time in master's programs have concentrated in medical/surgical nursing, 23 percent in maternal/child health, 19 percent in psychiatric and mental health, and 15 percent in public health.l9 Among nurse practitioners (master's and certificate combined), the most common types of specialists were in family nursing (28 percent), pediatrics (about 20 percent), and adult nursing (16 percent).20 The forces that originally generated the demand for clinical specialists and nurse practitioners have not abated. The rate of growth in technological complexity of care has not declined. As will be discussed in Chapter VI, there are many medically underserved populations, such as the elderly, for whom the nurse practitioner is well suited to help provide primary care. In addition to the direct care they provide to patients, the areas in which clinical nurse specialists with graduate degrees reportedly

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140 have made the most impact and have the most promise for the future include the following: Translating research into practice: The advanced degree nurse prepared to remain current in a specialty can use research findings to develop appropriate nursing care interventions and, acting as a teacher and role model, can ensure that the most efficacious regimens are followed by the staff. o Education/service collaboration: A critical need to bring nursing education and service closer together (Chapter IV) puts the nurse with advanced clinical practice preparation in a key position as bridge between academic and bedside nursing as a person who incorporates common sets of values. Facilitating managerial improvements: The nurse with advanced clinical preparation can help guide management and staff to find more efficient methods for delivering services without compromising quality and can ease many of the frustrations and anxieties leading to excessive staff turnover. Nurses who have completed clinical education in certificate programs also are needed to provide direct patient care at an advanced level. However, the committee believes there is a need for greater numbers of nurses with higher academic degrees in clinical areas because, in principle, the master's level nurse is more likely to provide the kinds of linkages set out above. Sultz has noted a trend toward a greater proportion of nurse practitioners with master's degrees and suggests that this trend will continue.21 Interrelationships Among Types of Advanced Education The functional divisions of nursing--administration, teaching, research, and clinical practice--interact and interrelate extensively. Nurses with advanced degrees often perform several types of functions during the course of a workweek. Also, over the length of a career it is not uncommon for nurses and other similar professionals first to engage in one kind of activity and later change to another. Educators may engage in research or clinical practice; administrators may teach or supervise students at an affiliated campus. The responses of nurses with master's or doctoral degrees to the 1980 national sample survey confirmed the occurrence of this phenomenon. Close to half of the 19,800 respondents who were employed in nursing education reported that clinical practice had been the primary focus of their advanced degrees. Conversely, roughly one-third of the 16,000 respondents with graduate degrees who were employed by hospitals reported that education had been their primary focus. There has been a marked shift of focus in advanced degrees from education to clinical practice since 1971, but it has not diminished the flow of nurses with advanced degrees going into nursing education. Thirty percent of the 25,000 advanced clinical practice graduates since 1971 were employed in nursing education in 1980--nearly as many as were employed by hospitalse

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141 As the recommendations in the previous chapter indicate, the committee supports greater collaboration and shared responsibility among the various segments of nursing. Because manpower planning is not so precise as to be able to predict long-range shifts in health system priorities and in consequent market demand for specialists, flexibility in the advanced educational preparation of nurses clearly is desirable. Coupled with efforts to provide sufficient economic and noneconomic rewards in the work setting, investments in graduate education can have a significant payoff in developing nurses who are versatile in addressing deficiencies in the organization and delivery of nursing care. The Need for More Nurses With Graduate Education Current Supply Although the growth in the number of nurses with some form of graduate training has accelerated in 1980, as noted earlier, only about 5 percent of all RNs in 1980 held master's or doctoral degrees. Marked increases in the graduations from such programs cannot be expected in the short run because, as with any other graduate education, it takes considerable time to prepare a nurse with a master's or doctoral degree. Furthermore, as we have seen, nursing schools depend on a small supply of doctorally prepared nurses to teach in these and other nurse education programs and to conduct research. Nurses With Master's Degrees Among the approximately 80,000 nurses with master's as the highest degree in 1980, about two-thirds (55,055) had earned the master's degree in nursing (M.S.N.~.22 About four-fifths of the nurses with M.S.N.s were employed in nursing, as were three-fourths of the nurses with master's degrees in other fields.23 The numbers and distribution of master's programs in nursing education departments have increased substantially during the past 20 years--from 43 to 141. By 1981 all but four states had at least one such program.24 Many, however, are quite small, and in 1980 one-half of all the graduations occurred in only seven states (California, Illinois, Massachusetts, New York, Ohio, Pennsylvania, and Texas).25,26 More than one-half of the approximately 15,000 nurses enrolled in master's programs in the 1981-1982 academic year were part-time students, a distinct change from the 1964-1965 academic year when full-time outnumbered part-time students by three to two.27 The current economic recession threatens to increase further the proportion of students able to enroll on only a part-time basis. It takes part-time students longer than full-time students to complete an educational program. The increase in numbers of part-time students would have to be much greater than the decline in numbers of full-time students if a drop in graduates is to be avoided; how much greater

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142 cannot be estimated because it is not known how many part-time students constitute one full-time student or how long it takes for the average part-time master's degree student to complete a program. Nurses With Doctorates According to the 1980 national sample survey, approximately 4,100 nurses had doctoral degrees. Of these, the survey estimated that close to 3,000 (72 percent) were employed in nursing.28 The ANA survey of nurses with doctorates, conducted in that same year, however, reported a much higher rate. Among their approximately 2,000 respondents, 91 percent were employed, with almost all of them working full time.29 Today, within the population of nurses with doctorates, there is a varied mix of educational preparation--a mix that reflects the historical development of nursing as a profession. The ANA survey found that among their respondents, 17 different kinds of doctoral degrees had been earned from 191 different institutions.30 Before 1965, the doctorate in education (Ed.D.) was the most common degree for nurses with graduate training. Beginning in the mid-1960s, education as the major field was challenged by a growing interest in the social and biomedical sciences. The establishment of the Nurse Scientist Training Grant programs in 1962 may have influenced the subsequent change in preferred discipline. In any event, by 1980 the Ph.D. had become the leading degree (54 percent). Another 3 percent of nurse doctorates are in public health (Dr.P.H./Sc.D./D.S.Hyg.), and 2 percent are in law (J.D.~. Doctorates in nursing (D.N.S. and D.N.Sc.) were first awarded in the early 1960s. Again drawing on the ANA survey findings, in 1980 about 5 percent of nurses with doctorates held D.N.S. or D.N.Sc. degrees. Assisted by Nurse Training Act funds, the number of doctoral programs located in nursing schools or departments, where such degrees are granted, grew rapidly during the decade of the 1970s. The National League-for Nursing collects information about doctoral education only from programs located in nursing education departments or schools. In 1980, there were 125 graduations from such programs. Enrollments have been growing, however, along with the numbers of programs, which are now available in 18 states. In 1980-1981, slightly more than 1~000 doctoral students were enrolled.31 In view of the increase in the number of programs and enrollments, a higher proportion of nurses can be expected in the future to earn the doctoral degree in schools of nursing. Nursing leaders do not always agree about the type of doctoral education that would best prepare nurses for advancing the professional development of nursing and the scientific base of nursing practice. Those who advocate the doctorate in nursing (D.N.S., D.N.Sc.) argue that while the nurse with a Ph.D. in a cognate discipline helps to generate new knowledge, the nurse with the professional doctorate will apply this knowledge. And among the advocates of the Ph.D., some prefer a Ph.D. in nursing and others prefer a Ph.D. in a discipline related to nursing.32

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143 Projections of Future Supply To replenish or increase the size of the pool of Bus with advanced education requires first that there be an adequate pool of RNs with baccalaureate degrees eligible to enter advanced degree programs. As noted in Chapter II, the number of annual graduations from baccalaureate programs more than doubled between 1971 and 1981, growing from about 11,000 to 25,000 during that period. Within the study's intermediate projection total of 1,710,000 RNs at the end of 1990, the number with baccalaureate or higher degrees will have increased by about one-quarter of ~ million. Unless baccalaureate graduation rates were to fall dramatically, which is not anticipated in our projections, baccaluareate nurses will continue to provide an ample reservoir from which candidates for advanced degrees can be drawn. Given this basic premise, the c~mmittee's estimate of the future supply of nurses with graduate education by 1990 is based on the current capacity of the educational system to prepare them and on the assumption that (1) increasing numbers of RNs will seek such education in line with the trends of the 1970s, (2) current rates of labor force participation by nurses with master's and doctoral degrees will continue, and (3) financing of graduate nursing education from all the major sources that have contributed in the past to increasing the supply will also suffer no major dislocations.* To the extent that these assumptions prove correct, a substantial growth is indicated during the 1980s. The committee estimates that by the end of 1990 there will be 124,200 employed nurses with master's preparation, of whom about four-fifths will have M.S.N. degrees, and that there will be about 5,800 employed nurses with doctoral degrees. These projections were derived as follows. Nurses With Master's Degrees In 1980 there were 55,000 RNs with master's degrees in nursing, of whom 44,700 (81 percent) were employed in nurs~ng.33 In 1971, about 2,000 M.S.N. degrees were granted; by 1981, the number had risen to more than 5,000.34 The number of graduations from M.S.N. programs represented about 2 percent of the pool of eligible potential candidates for such nursing degrees--i.e., all employed nurses with the baccalaureate in nursing as their highest degree. If the proportion remains at 2 percent, the number of master's degrees granted in nursing would continue to rise by some 500 per year. This would result in a total of 9,500 such degrees granted in the year 1990, and would yield an additional 68,000 nurses with master's degrees *As in the overall supply projections in Chapter II, estimates of future supply are presented in terms of the numbers expected to be employed in nursing--not the total numbers of nurses that have obtained graduate degrees.

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146 In arguing the need for more nurses with master's and doctoral degrees, the committee recognizes the concern, often expressed in manpower discussions, about the cost to society of the general trend in all professions toward overcredentialing. We have not been able to quantify the necessary additions to supply in the various functional areas of nursing. Nonetheless, in the committee's judgment, a substantial increase in output of nurses with graduate degrees will be required to achieve even modest goals in maintaining and improving the leadership cadre of the nation's nursing resources. The Effect of Financing on Future Supply The success of efforts to lessen existing gaps will, in large part, depend on the ability of students to afford advanced degrees. Graduate students have higher tuition than undergraduate students. Full-time graduate students in nursing education programs face 1-3 years with annual tuition costs of $1,000 to almost $10,000, depending on whether the program is in a public or private institution of higher education.38 Annual tuition charges generally are the same for all graduate students, whether they are enrolled in master's or doctoral programs. Graduate students tend to be self supporting (financially independent of their parents) and thus have higher living expenses than most undergraduates (see Table 22~. For a student who is a RN, forgone earnings can be estimated to be over $17,000 annually, according to data on average earnings from the 1980 national sample survey.39 Such expenditures, particularly toward the higher end of the range and when forgone earnings are included, can generally be undertaken only by students willing to make large sacrifices or by students having some private or public student aid. Little information is available on the sources on which master's degree candidates draw to finance their education. However, the 1980 ANA survey, referred to above, reports that nurses with doctorates received financial support from a variety of sources (Table 29~. Federal training grants were by far the most frequently reported source. Federal loans and research grants also contributed a small but important part. Universities, through fellowships and through teaching and research assistantships, were reported to be another important contributor. By contrast, state government support and loans for doctoral students appear to have been negligible. Federal Support Programs Of the total $1.6 billion appropriated under the Nurse Training Act and National Research Services Award Program between 1965 and 1981, $70 million went for general institutional support of advanced nurse training and $206 million for nurse traineeships in master's and doctoral programs (Appendix 2~. An additional $75.5 million was granted to institutions to encourage the development of nurse . . practitioner programs.

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147 TABLE 29 Financial Support Received During Doctoral Study by Nurses With Doctorates in 1980 Number of Nurses Reporting Source of Support Receiving Support (Frequencies~a No support Federal government Training grant Loan Research grant University Fellowship Teaching assistantship Research assistantship State government support or loans 442 983 118 90 185 174 132 101 a Not an unduplicated count of recipients, because a nurse may have reported more than one source of support. SOURCE: From ANA. Nurses with doctorates, Table 28, p. 76 (see Reference 9 for complete citation). Advanced nurse training grants and contracts are made to collegiate schools of nursing to plan, significantly expand, or maintain programs to prepare nurses at the graduate level--whether as administrators, teachers, or clinical specialists. Special emphasis is now given to three clinical specialties: geriatrics, community health nursing, and maternal and child health. Between 1979 and 1981, about 80 percent of the areas of concentration in these programs were in clinical specialties and about 10 percent each in education and administration. Approximately 16 percent of master's level students are enrolled in programs now supported in part at least by the NTA's advanced nurse training program; 73 of the 141 schools currently offering master's and/or doctoral degree education have received program support. About 90 percent of the programs were at the master's level and 10 percent at the doctoral level. In 1981, about 2,500 FTE students were enrolled in the programs assisted, of which approximately 1,500 students were full time. Funding for student traineeships under the NTA began in fiscal year 1965 with $8 million, increasing to approximately $13 million in 1974. It remained at that level until 1982, when the amount dropped to $9.6 million. The NTA traineeships provide grants to graduate schools of nursing and to schools of public health, which in turn provide traineeships for up to 36 months for students working full time toward

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148 a master's or doctoral degree. Nurses are prepared to serve as teachers, administrators, and supervisors; as nurse practitioners; and in other professional specialties determined by the DHHS Secretary to require advanced training. These are the same specialties that have been supported by the NTA's advanced training program. The DHHS Division of Nursing estimates that during the 1979-1980 academic year 3,000 full-time students received assistance through advanced nurse traineeships.40 In 1981, awards made to 126 schools supported about 2,000 trainees at approximately $6,400 each. Without these funds, in all likelihood the numbers of full-time students would have been reduced, thus slowing the increase in the number of these nurses coming into practice. In addition to the advanced nurse training grants and the nurse traineeship program, unknown proportions of the funds allocated under the NTA to programs for nurse practitioners and special project grants, as well as student loans, supported nursing students enrolled In grac uate programs. The National Institute of Mental Health has been another substantial contributor to advanced nursing education, awarding more than $105 million for teaching costs and stipends in the period 1970-1981. The vast majority of the more than 13,000 stipends awarded went to students earning master's degrees; a few were granted to undergraduate and doctoral students.41 The Veterans Administration and the Department of Defense also provide advanced nurse training stipends. In summary, during the past 18 years the total amount of federal aid for graduate education from various sources has been substantial, probably more than $460 million--and the impact significant. During the period 1971 and 1981, graduations from master's programs increased 40 percent and more than doubled in doctoral programs. This increased the proportion of KNs holding master's and doctoral degrees from 4 to more than 5 percent in the total population of RNs. Although it cannot be argued that all who used these funds would not have completed advanced education in their absence, certainly the growth in the supply of these nurses would have been diminished, because the funding went to build up program capacity as well as to support students. The committee believes that in the years ahead, the quality of nursing services will depend directly on the extent to which growth is sustained in the supply of nurses with higher degrees. Current authorization and appropriations are insufficient to support such growth. These graduate programs should be viewed as potentially cost effective in promoting major positive impacts on the quality and effectiveness of nursing services. Hence, they should be regarded as strong elements in the total strategy of conservation of federal outlays for health care. Federal appropriations under NTA and related authorizations for graduate education and other advanced nurse training were maintained at about $40 million between 1978 and 1981, decreasing to about $34 million in 1982. Although we recognize the nation's current severe federal and state budgetary straits, the committee is concerned that

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149 failure to maintain an adequate floor of support for master's and doctoral education of nurses will cause long-term damage to the quality of the nation 7 S nurse supply. Restoration of federal support at least to the average 1980-1982 level of approximately $40 million would help ensure that the foundation for further growth of professional nursing will continue to be maintained. As the capacity of the education system to graduate greater numbers of postgraduate nurses expands and as costs of education increase, the need for a higher level of federal support may follow. A number of factors will require careful consideration: the capacity of the health care and educational systems to use effectively the different types of graduates; the levels of state support and of continuing federal support needed to attract sufficient numbers of students into postgraduate programs; and also the possibility that salaries of nurses with advanced preparation may rise to the point that prospective students will wish to make greater personal investments in such education. Conclusion Unlike the situation with respect to basic supply of generalist nurses, where we have found the likelihood of a general balance between supply and demand in 1990, the committee concludes that there is both a serious current and probable 1990 shortage of nurses educationally prepared for administration, teaching, research, and advanced clinical nursing specialties. The extent of the future shortage cannot be estimated because various perceptions of need, except possibly as regards faculty positions, may not necessarily result in effective demand. Nevertheless, there is such an obvious gap between the present supply and educational capacity of the system on the one hand and even conservative estimates of future advanced positions required on the other, that existing program capacity and sources of student support at the graduate level should be expanded. In examining the future need for nurses, the committee identified problems that cannot be resolved merely by increasing the supply of nurses with basic education, but may be alleviated by increasing the supply of nurses with advanced education. First, the management of nursing resources is less than optimal. The complexity of today's health care settings demands nurse managers who are skilled not only in nursing but also in the techniques of managing personnel and budgets. Second, the quality of nurses delivering care at the bedside and in the community to a great extent depends on the capabilities of their teachers. They must within a relatively short period impart the theoretical and clinical knowledge necessary to produce competent professionals. The claims of nursing education leaders that the current composition of the faculties of many nursing schools is inadequate to accomplish this job properly is borne out by the comments of employers as well as information comparing the preparation of nursing faculty to that of other disciplines. A closely related issue is the lack of research to inform nursing practice and to enhance

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150 nursing education--functions usually performed in health and sciences by those in the discipline who are academically based (see Chapter VIII). Third, although well qualified generalist nurses can deliver care effectively, the growing complexity of services in many health settings presents problems that also increasingly require the special- ized knowledge and experience of nurses with advanced education. In tomes of severe economic constraints, states may be more willing to finance basic nursing education programs, which are perceived as directly fulfilling local demand for nurses, than master's programs, whose graduates can be expected to be more mobile. They have never provided much financial assistance to nurses in doctoral programs. The committee believes that RNs with high-quality graduate education are a scarce national resource and that their education merits federal support. The demand for highly qualified nursing administrators, nurse edu- cators, researchers, and clinical specialists prepared at the graduate level has been increasing and is expected to continue to increase, but to meet it only a small portion of nurse faculty are yet prepared at the doctoral level. To increase the nation's supply of nurses with ad- vanced degrees, public and private universities with graduate programs must expand and strengthen their nursing education faculties. In the face of the current shortage of academically qualified nurse faculty with expertise in fields relevant to nursing, such as management, the behavioral and basic sciences, and research methodology, deans of schools of nursing could draw faculty from appropriate schools and de- partments in their universities or neighboring institutions both to fill immediate needs and to help build future teaching and research capabilities. Joint programs and other forms of collaborative arrange- ments between university departments, such as schools of nursing with business schools and/or health services administration programs, may be found desirable. Programmatic support from the federal government can help to improve graduate level nursing education in these and other ways. Lowering financial barriers to full-time enrollment of nurse gradu- ate students will increase the supply more rapidly. Master's and doc- toral students who must work to support their education take longer to complete it. Financial assistance to nurses in master's programs should be packaged with federal funds for programmatic support. The committee would expect, in line with the objective of strengthening the nursing profession as well as nursing education, that such program- matic and accompanying student support for master's programs would be available through competitive grants. In practice, master's programs located in schools or departments of nursing would be in an excellent competitive position to secure such grants, but arrangements in other related programs should be possible, such as in health services administration programs and schools of public health. Federal doctoral level support should be targeted primarily to strengthen existing programs in nursing, not to encourage the proli- feration of new and possibly weak doctoral offerings. Until schools of nursing have sufficient numbers of qualified faculty to meet the range of RN doctoral students' scholarly interests and professional

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151 needs, financial aid programs to RN doctoral students should be designed so that they are not precluded from pursuing doctoral studies in nursing-related disciplines. To encourage graduate students to return to nursing when they have earned their degrees, loans should carry such service obligations. On the other hand, most committee members believe that fellowships, awarded on the basis of scholarly excellence and the promise of fundamental contributions to the knowledge base, should not carry the same kind of obligation. RECOMMENDATION 8 The federal government should expand its support of fellowships, loans, and programs at the graduate level to assist in increasing the rate of growth in the number of nurses with master's and doctoral degrees in nursing and relevant disciplines. More such nurses are needed Lo fill positions in administration and management of clinical services and of health care institutions, in academic nursing (teaching, research, and practice), and in clinical specialty practice. Statement of Exception to Recommendation As members of the nursing study committee of the Institute of Medi- cine, we are most supportive of the general thrust of the committee's recommendation, but take exception to the phrase in its first sentence: "...and relevant disciplines." The rationale for not supporting this aspect of the recommendation is presented in this minority position statement. The congressional charge to the nursing study committee was in part "to determine the need to continue a special program of federal finan- cial support for nursing education," (emphasis added) not education of nurses in disciplines other than nursing. Nurses have the same freedom as do other American citizens to pursue graduate study in their own discipline or in an alternate one, and each discipline has the academic prerogative to admit students of its choice regardless of their previ- ous educational preparation. However, it is our belief that (1) nurses admitted to graduate degree granting programs other than nursing, and (2) programs in disciplines external to nursing that admit nurses for graduate study should not be included under a "specific program of Federal financial support for nursing education." Federal funds for strengthening nursing education are already minimal and would be fur- ther diluted if they were channeled to provide financial support to programs and students (even though nurses) in disciplines other than nursing. Many portions of this report have focused on the urgent need for nurses with graduate education in nursing (master's and doctoral levels) to fill faculty and administrative positions in nursing. These

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152 nurses should be enrolled in graduate nursing programs so as to became more knowledgeable in their own disciplines and, subsequently, to be able to assist in the strengthening of nursing through the use of ad- vanced nursing knowledge in clinical practice and teaching, and the generation of new knowledge in nursing. This expectation is not dif- ferent from that in other disciplines where advanced degrees or acade- mic study are offered, i.e., psychology, sociology, physiology, medi- cine, theology. Our stated belief does not preclude the opportunity for nursing and other students to take courses in other disciplines that have value to one's own, or in unusual situations perhaps to offer a joint degree program. An example of this at the master's level is the collaboration of schools of nursing and schools of business manage- ment in the preparation of top level nursing service administrators. However, we believe the nursing study committee is lacking in con- science to support and document in this report the numerous reasons why nurses should have advanced education in their own discipline and yet approve a recommendation that endorses nurses to obtain graduate educa- tion at either the master's or doctoral levels in fields other than nursing and request federal funds for such. In reality nurses with master's degrees in non-nursing disciplines will not be prepared, nor will they meet the required qualifications of most clinical or educational institutions for leadership positions in nursing, nor will they be eligible for doctoral study in nursing. Thus, federal support of nurses to obtain non-nursing graduate degrees will not assist in meeting the intent of Recommendation 8 of this report or other recommendat ions related to it. Until recently, doctoral programs in nursing were limited in number, and nurses had little option but to pursue doctoral degrees in disciplines external to but related to nursing despite the additional time and expense involved to make up course deficiencies. As would be expected, there were the disadvantages of no nurse role models being available for mentorship and the focus of one's research being in that discipline rather then in nursing. In many cases nurses remained in the discipline (not nursing) in which doctoral preparation was obtained and were "lost" to nursing. It was because of this result that the Doctoral Nurse Scientist Program, supported by the federal government, was discontinued in the mid-70s. Moreover, faculty in schools of nursing with preparation in disciplines external to nursing are often not perceived as true colleagues in either these disciplines or in nursing. The general value of learning research methodology in either the social or natural sciences has been recognized by nurses who have ob- tained doctoral degrees in these disciplines, but in many instances their study and research efforts have not focused on identification of a body of sc lent if ic knowledge to provide a basis for the practice of nursing and the control of that practice. The development of knowledge and c~mpetencies unique to nursing must be produced by nurses with ad- vanced education in nursing and whose research is focused on clinical nursing practice. This preparation falls within the domain of doctoral education in the discipline of nursing, and graduates of such programs will (1) provide leadership in clinical practice and research; (2)

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153 teach in baccalaureate, master's, and doctoral programs in nursing; (3) administer nursing service and nursing education programs; and (4) pro- vide role models and mentors for future doctoral students in nursing. Doctoral preparation in a discipline other than nursing deters the socialization process and career expectations within one's peer group. It also fosters an orientation to another field of knowledge and, in- variably, the dissertation research, which often sets the focus of future research, is unrelated to a nursing problem. Disciplines exter- nal to nursing have had a much longer time to establish and add to their knowledge base, and now nursing urgently needs federal funds, especially fellowship support, to attract well-qualified nursing students to continue the strengthening of doctoral nursing programs and, ultimately, to add to the knowledge base of nursing. Nursing doctoral students need the flexibility of obtaining fellowship support to study with nursing faculty of their choice who can serve as mentors within the students' specialization area. Many of these graduates with advanced nursing preparation will in turn enter academic nursing to teach nursing students, while also strengthening the theoretical and clinical application bases of the discipline of nursing. Of about 1.7 million registered nurses in the United States in 1980, only about 4,000 (0.2 percent) held doctorates. Of these, fewer than 850 degrees (21 percent) were earned in doctoral programs located in departments or schools of nursing. Thus, it is crucial that existing doctoral programs in nursing be strengthened and expanded, and that scarce federal funds be channeled to them rather than to doctoral programs of other disciplines. The number of nurses making application to existing doctoral nursing programs is significantly more than can be accommodated due to a lack of faculty prepared at the doctoral level in the specialized areas of nursing desired by these extremely well-qualified applicants. With opportunities to serve as either a research or teaching assistant in doctoral nursing programs these students will have early influence from their nursing professors to be productive in scholarly activities in the field of nursing. Such mentorship in nursing would not occur If students were enrolled in doctoral programs of other disciplines. In summary, "a specific program of Federal financial support for nursing education" at the graduate level (master s and doctoral) should be available only to nursing programs and students admitted to those programs. Upon graduation these nurses with advanced nursing preparation will quantitatively and qualitatively influence the genera- tion of new nursing knowledge and the dissemination of nursing know- ledge to future generations of nurses. Educated within the disciplines of nursing, these leaders in nursing will join with colleagues of simi- lar interests and be productive in bettering the health of society. Ruby L. Wilson Dorothy Novello

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154 REFERENCES AND NOTES Department of Health and Human Services, Health Resources Administration. The registered nurse population, an overview. From national s amp le survey of registered nurses, November 1980 (Report 82-5, revised June 1982~. Hyattsville, Md.: Health Resources Administration, 1982, Table 10, p. 18. 2. American Society for Nursing Service Administrators. Profile of the nursing service administrator revisited: A report based on an analysis of the data from the 1977 survey of nursing service administrators in hospitals. Chicago, Ill.: American Hospital Association, 1980, Table 4, p. 7. 3. Murphy, M.I. Master's programs in nursing in the eighties: Trends and issues--Relationship to professional accreditation (Publication No. 81-2~. Washington, D.C.: American Association of Colleges of Nursing, 1981, pp. 11-12. National League for Nursing. NLN nursing data book 1981 (Publication No. 19-1882~. New York: National League for Nursing, 1982, pp. 60, 79, 86, 98. National Council of State Boards of Nursing, Inc. Survey on approval requirements for programs preparing students for the registered nurse licensure examination. Unpublished, 1982. 6. National Science Foundation. Young and senior science and engineering faculty, 1980 (Special Report No. NSF-81-319. Washington, D.C.: National Science Foundation, 1981. 7. Murphy, M.I. Enrollment, graduations and related data: Baccalaureate and graduate programs in nursing (Data Bank Series 82 No. 3~. Washington, D.C.: American Association of Colleges of Nursing, 1982, p. 20. 8. McElmurry, B.J., Krueger, JeCe ~ and Parsons, L.C. Resources for graduate education: A report of a survey of 40 states in the midwest, west and southern regions. Nursing Research, 1982, _ (1), 6. 9. American Nurses' Association. City, Mo.: American Nurses' Association, 1981, p. 45. 10. National Institutes of Health. NIH data book 1982. Washington, D.C. : U.S. Government Printing Office, 1982, Table 13, p. 22. 11. McElmurry, et al . Op . c it ., p . 6 . 12. American Nurses' Association. Nurses with doctorates. Op. cit., p. 44. 13. National League f or Nurs ing ~ Doc toral programs in nurs ing 1982-8 3 (Pub 1 ic at ion No ~ 15- 1448) . New York: National League for Nursing, 1982. 14. Committee on a Study of National Needs for Biomedical and Behavioral Research Personnel. Personnel needs and training for biomedical and behavioral research. Washington, D.C.: National Academy Press, 1980, pp. 131-138. DHHS, HRA. The registered nurse population, an overview. From national sample survey of registered nurses, November 1980. Op. cit., Table 7, p. 15. Nurses with doctorates. Kansas

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155 16. Ibid., Table 10, p. 18. 17. Ibid. 18. Sultz, H.A., Zielezny, M., Gentry, J.M., and Kinyon, L. Longitudinal study of nurse practitioners, Phase III (DHEW Publication No. HRA-80-2~. Washington, D.C.: U.S. Government Printing Office, 1980, Table 22, pp. 56-57. 19. National League for Nursing. NLN nursing data book 1981. 2~. cit., Table 84, p. 89. 20. DHHS, HRA. The registered nurse population, an overview. From national sample survey of registered nurses, November 1980. 0~. cit., Table 11, p. 19. Sultz, H.A., et al. 0~. cit., p. 10. 22. DHHS, HRA. The registered nurse population, an overview. From national sample survey of registered nurses, November 1980. Op. cit., Table 3, p. 11. 23. Ibid. 24. National League for Nursing. NLN nursing data book 1982. In press, 1982, Table 78. 25. Murphy, M. I. Enrollment, graduations and related data: Baccalaureate and graduate programs in nursing. Op. cit., p. 26. National League for Nursing. NLN nursing data book 1981. Op. cit., Table 87, p. 91. 27. Ibid., Table 79, p. 86. 28. DHHS, HRA. The registered nurse population, an overview. From 5~gG:~,~ ~2 ~e~ egistered nurses November 1980. Op. cit., Table 3, p. 11. 29. American Nurses' Association. Table 31, p. 79. 30. Ibid., p. 13. 31. National League for Nursing. NLN nursing data book 1982. Op. cit., Table 73. 32. American Nurses' Association. Nurses with doctorates. Op. cit., p. 14. 33. DHHS, HRA. The registered nurse population, an overview. From national sample survey of registered nurses, November 1980. Op. cat., Table 3, p. 11. 34. National League for Nursing. NLN nursing data book 1981. Em. cit., Table 86, p. 90. 35. DHHS, HRA. The registered nurse population, an overview. From national sample survey of registered nurses, November 1980. Op. cit., Table 3, p. 11. 36. National League for Nursing. NLN nursing data book 1981. 2~. cit., Table 73, p. 79. 37. Ibid. 38. National League for Nursing. Master's education in nursing: Route to opportunities in contemporary nursing 1982-83 (Publication No. 15-1432~. New York: National League for Nursing, 1982. 39. DHHS, HRA. The registered nurse population, an overview. From national sample survey of registered nurses November 1980. ~ ~ W~ 5. Nurses with doctorates. En. cit.,

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156 40. Elliott, J.E. Address to Workshop on Advanced Nursing Education, Institute of Med ic ine Study of Nursing and Nursing Educ at ion, March 1982. 41. Chamberlain, J. Nat tonal Institute of Mental Health. Personal corr~nunication, February 17, 1982. 42. Secretary of Health and Human Services. Third report to the Congress, February 17, 1982: Nurse Training Act of 1975 . Hyattsville, Md.: Health Resources Administration, 1982.