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CHATTIER VI ADev~ahng Nursing Shortages in Medically Underserved Areas and Among Underserved Populations In earlier chapters this report has dealt with issues of aggregate supply and demand for nursing as a whole and for nurses with different levels of educational preparation. Another distributive aspect of the supply problem was posed in the second of the congressional questions that occasioned this study: "What are the reasons nurses do not serve in medically underserved areas and what actions could be taken to encourage nurses to practice in such areas?" The committee viewed these issues as being more extensive than would be implied by statutory or regulatory definitions of the term "medically under- served areas." We believed that this question called for an exploration of the problems of maldistribution as they affect certain geographic areas, certain population groups, and certain types of facilities that experience chronic nurse shortages resulting in underservice to large numbers of patients. This chapter focuses on availability of the services of nurses to residents of inner cities and rural areas, to minority ethnic groups and elderly citizens, and to patients in public hospitals and nursing homes. There are commonalities among the geographic areas, population groups, and institutions identified as suffering from the maldistribution of nursing personnel. For all of them, indications of severe unmet nursing needs persist and are not likely to be self-correcting under foreseeable market conditions. The magnitude of the problem is suggested by estimates that 20 million residents of inner city and rural areas are without a regular source of primary care,1 and that approximately 12-15 million Americans are "structurally underserved"--that is, their difficulties of access to nursing services are tougher and more complicated than those of the rest of the population.2 This chapter first describes the nature and consequences of underservice and examines recent attempts to attract nurses to underserved areas and increase the representation in nursing of economically disadvantaged individuals. Nursing service problems of the inner cities and the elderly are then discussed. The chapter concludes with a look at the functions of nurse practitioners in alleviating problems of underservice. 157

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158 Some Reasons for Areas of Underservice Lack of access to preventive, primary, and acute care services by people living in inner cities and in rural communities remains one of the nation's most pressing health problems. It ranks with the lack of access to effective preventive and maintenance care of the nation's elderly, large numbers of whom may as a result become untimely afflicted with worsening chronic conditions that lead to long-tenm institutionalization. Among all underserved populations, barriers to care are created by lack of adequate financing, transportation problems, lack of health care facilities, and lack of health manpower to staff facilities or provide services outside health care institutions. The obvious explanation of nursing and other health manpower shortages lies in the nature of the nation's health care financing arrangements. Inadequate public or private coverage to pay for services to very large numbers of low-income people results in lack of programs or lack of access to programs and facilities that can meet their medical and other health care needs. Inadequate financing and the resulting inappropriate services make it unlikely that nurses will seek or be able to find employment, even though they may wish to work in an underserved area or with underserved people. We believe that solutions to the problems of medical underservice eventually will require a long-range restructuring not only of the nation's health care financing, but also of health services delivery arrangements. Other public commissions and studies have come to similar conclusions. While it was not within our purview to address these fundamental problems, the study necessarily became concerned with their implications as principal factors in the maldistribution of nursing personnel. In this context, the committee has responded to the request for suggestions likely to help alleviate existing nurse shortages in medically underserved areas. The Nature and Consequences of Underservice Many rural and semi-rural areas, where 30 percent of the nation's population lives, are characterized by low population density, disproportionate numbers of poor and elderly, vast distances, and small hospitals.3 Providing health care in these circumstances presents multiple problems. Most nurses are employed by hospitals, nursing homes, physicians, and health departments. Therefore, most nursing care depends on the presence of such employers, but they are not found in many remote communities. Approximately 500 of the nation's more than 3,000 counties currently have no hospital.4 The economics of supplying adequate levels of health services to poor and remote populations and the heavy workload associated with being a solo practitioner make remote and poor rural areas unattractive to physician practice. In

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159 1979, 143 counties had no active physician, federal or non-federal, engaged in patient care.5 These and~other factors result in employed nurse-to-population ratios that are usually much lower for rural than for urban areas. The 1977-1978 Inventory of Registered Nurses showed that the ratio of employed registered nurses (RNs) per 100,000 population ranged from a low of 268 in Arkansas, a largely rural state, to 885 in urban District of Columbia. Moreover, such comparisons fail to reveal the often substantial pockets of underservice that frequently exist in a state. Among the areas alone that were not standard metropolitan statistical areas (SMSAs), this ratio ranged from a low of 162 in Louisiana to a high of 892 in New Hampshire. Vacancy rates for nurses in hospitals are not markedly different in small and large institutions, but hospitals in non-SMSAs have more recruitment problems than do their urban counterparts.6 State studies and testimony from hospital representatives have noted the special difficulties associated with nurse shortages in rural areas. In testimony before the Senate Finance Committee, one witness commented that there was an immediate need for at least 300 RNs in 61 Montana hospitals, most of which are in rural areas. He also noted that while a nurse vacancy in a large hospital may not be really crucial, "when a small facility loses one nurse, that's a crisis situation."7 Further, he observed that Montana's small rural hospitals consistently upgrade their salary and fringe benefits to meet and, in same cases, exceed those of the larger facility in order to attract nurses to their hospitals. Other testimony suggests some factors that detract nurses from rural service. "Rural nurses are asked to assume greater responsibility, are often on call 24 hours a day. . . . Rural public health nurses find their salaries and working conditions determined by county commissioners who are often more concerned with building and maintaining roads and bridges than quality health care. Feeling frustrated...they leave their chosen profession."8 Additionally, fluctuations in patient census tend to make some rural hospitals unreliable employers. And where the absence of other providers puts major responsibility for health care on public health nurses 5 the level of funding may support only a minimal number.9 These problems and others lie behind the fact that in rural areas 21 percent of black children and 14 percent of white children had no physician visits in 1981 compared with 10 percent and 9 percent, respectively, of children in SMSAs.10 Residents of non-metropolitan areas are also less likely to have preventive care and more likely to spend more than 30 minutes traveling to a physician visit and to experience longer waits once there. Seventeen percent of physician visits by residents of non-SMSAs occurred in metropolitan areas. Nursing shortages in rural areas are only one aspect of the problem of underservice. Minority, immigrant, and other low-income populations in many urban areas of the nation also can lack access to health care. Large concentrations of these people are found in inner city areas, where nursing and other health care services present

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160 particular problems.* Although the gap in utilization of health care between the poor and nonpoor in both urban and rural areas that existed quite generally prior to the 1960s almost closed between the mid-1960s and 1980, serious problems of access nevertheless remain, particularly in the settings where poor and minority people--notably blacks and Hispanics--receive care.12 For example, a study in Boston found a 4 percent decline in the number of inner-city residents who had a personal physician between 1975 and 1981, despite a 7 percent increase in the nationwide physician-to-population ratio during this period.13 Differences between the health status of underserved populations (whether rural, urban, poor, or minority) and better served groups also indicate unmet needs for health care. Household interview surveys conducted by the National Center for Health Statistics in 1979 found that consistently greater proportions of residents outside of the standard metropolitan statistical areas than SMSA residents reported health conditions that made them unable to carry on major activities of daily living. More than 14 percent of the non-SMSA residents rated their health as only fair or poor, compared with 11.4 of the SMSA residents.14 People in federally designated medically underserved rural areas have 24 percent higher hospital utilization, 33 percent more disability days, and 22 percent more chronic limitations than do those in rural areas not so designated.+ Mexican-American migrant agricultural workers are said to have a much lower life expectancy and higher rates of illness than does the population as a whole, but scant data are yet available to describe their health status. Educational Outreach Since the mid-1960s the federal government, the states, and higher education systems have adopted various strategies designed to alleviate identified nurse shortages in medically underserved areas. . ~Currently, blacks constitute 28 percent of the population of large central cities compared with 12 percent of the total United States population, and Hispanics constitute It percent as opposed to 5 percent. A disproportionate number of inner-city residents have incomes below the poverty level, 17 percent versus 12 percent of the total United States population.15 Cover the years the federal government has defined geographic areas of underservice using a variety of criteria. The areas have been variously delineated as Medically Underserved Areas, Health Manpower Shortage Areas and Nurse Shortage Areas. Many technical problems have been encountered in attempting to define these areas of underservice so as to accomplish program objectives. This report does not address these technical issues but notes that discussions concerning definitions of underservice are continuing.

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161 One such strategy has been to offer financial incentives through educational loan repayment arrangements designed to attract nurses to serve in such areas. The strategy implies a hope that an appreciable proportion of such nurses will remain in the shortage area after their service obligation has been met, but there is no evidence either At the federal level, examples include programs under the Nurse Training Act (NTA) of 1964 and subsequent amendments, and National Health Service Corps authorizations. The NTA Nursing Loan Repayment Program offers repayment of a portion of an RN's educational loan in return for 2 or 3 years of service in a designated nurse shortage area (Appendix 2~. Between 1974 and 1981 approximately 219,000 nurses received educational loans but only 128 accepted the option of service in return for loan repay- ment. The failure of the program has been commonly attributed to the more favorable teems offered by the Federal Nursing Loan Cancellation Program, which allowed cancellation of up to 85 percent of an - education loan for practicing nurses working in a public or nonprofit hospital, health center, or other health care agency for more than 1 year, regardless of location or population served.16 The National Health Service Corps Scholarship Program also used the incentive of repayment of educational loan in return for a service obligation. Of the 564 nurses awarded scholarships, almost all met not collected to indicate the service obligations, but data were whether any were staying in the shortage area after their obligated service e The Nurse Practitioner Traineeship Program under NTA described in Chapter V also offered payback incentives for service in shortage areas. Again, because the current status of 50 percent of the traineeship recipients is unknown, the program cannot be evaluated. Nurse education programs are not required to keep records or report on where their graduates practice. A second strategy--facilitating nurse education for those most likely to work in underserved areas--is built on the assumption that people who already live in such areas are more likely to remain than are those attracted for a limited tour of service. Evidence supports this hypothesis. Feldbaum's 1977-1978 survey found that nurses who grew up in rural areas were the most likely to return to work in such areas, and that a large proportion of nurses who work in inner cities had grown up in large cities.17 Another recently completed nursing study, in North Carolina, found that nurses cited living in the areas as a prime reason for remaining employed in rural areas and in long-term care institutions. The very high response rate--95 percent for hospitals, 75 percent for long-term care facilities, and 93 percent for health departments--makes these findings credible.18 Local access to education appears to be important in determining where newly licensed nurses will work. For example, the National League for Nursing's (NLN) 1980 survey of newly licensed nurses frog associate degree (AD), diploma, and baccalaureate programs found that more than 61 percent of AD graduates reported their residence at kc ensure as being in the same county as the location of their schools, and that 75 percent of these graduates had the same residence at licensure as the location of their employer 6 to 8 months after

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162 licensure. Corresponding rates in a similar period for diploma graduates were 53 percent and 69 percent. Baccalaureate graduates were more mobile, presumably because programs were not so widely dispersed geographically. Their county residence at licensure was the same as the location of their schools for only 41 percent of the graduates. However, about 65 percent of these baccalaureate graduates reported that the location of their employer 6 to 8 months after licensure was in the county in which they had lived at the time of licensure. No county residence data are available to show geographic mobility of nurses over the longer run of their practice. However, 10 years after kc ensure, 63 percent of AD and 41 percent of baccalaureate graduate nurses reported having practiced in only one state.l9 Thus, there is some evidence to indicate that the location of the nursing education program is a determinant of where a licensed nurse chooses to work. Practical nurses also tend to live and work in the areas where they receive their nurse education. The NLN 1980 survey of newly licensed practical nurses reported that at the time of licensure, over 60 percent of new LPNs were living in the same county where their nurse education program was located. Less than 5 percent had obtained their education in a different state.20 Improvements in the accessibility of nursing programs are needed to encourage residents of underserved areas to enter nursing. Many potential students from such areas--especially those in rural c~mmunities--are unable to avail themselves of nursing education. Programs are not likely to be locally available and family responsibilities, costs, and travel distances often combine to prevent potential students from moving to communities where such programs are located. These factors, together with past experience, suggest that locating nursing education programs directly in or near medical underservice areas is a useful strategy in addressing nursing supply problems. At the federal level, the Area Health Education Center program (AHEC) has in several states mounted more narrowly focused attempts to bring nurse education to residents of underserved areas. AHEC programs encourage training for a wide range of health occupations, and also provide continuing education. The programs are offered through arrangements with existing educational and health care institutions to increase courses and to offer training experiences at hospitals and other sites in and near rural and urban underserved areas. Nursing education has received special attention in the AHEC programs in California, North Carolina, Massachusetts, and Colorado.21 In most states, community college systems have made considerable progress in developing locally accessible programs to prepare RNs and LPNs e However, where populations are not sufficiently dense to yield sufficient numbers of students, and where local educational resources are inadequate to provide an institutional base and faculty for the types of nurse education programs that prospective students may require, it is not economically or educationally feasible to provide

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163 local nurse education programs. Outreach nursing education programs from state universities or from large schools of nursing offering generalist nursing education, continuing education, and even graduate education can provide an alternative to the proliferation of autonomous, inadequately staffed new schools. Outreach programs also can upgrade the education of nurses already practicing in these areas. Several programs funded under the NTA are demonstrating that nursing education programs can be offered at off-campus locations to students unable to travel or to relocate. In some instances, such as at Weber State College in Ogden, Utah, nursing faculty pay regular visits to rural countries to teach basic nursing education courses. Their students come to Ogden for short, intensive clinical experience at an affiliated community hospital. There are several variants of this type of outreach. Examples include California State University at Fresno, Montana State University, the University of Maryland (offering baccalaureate degree training to RNs with ADs or diplomas), and Wayne State University (offering master's degree preparation to RNs in remote areas of Michigan). Television,-videotapes, and other technical advances are expanding the possibilities for reaching students in remote areas or areas that lack access to schools of nursing. Today, thousands of non-nursing students are enrolled in televised courses. Several hundred colleges are members of a network working in collaboration with local television stations to offer courses.22 All these various types of programs, on and off the main campus, that offer flexibility and career mobility at various levels of nurse education appear to be sufficiently promising to merit continued support for their further development, evaluation, and dissemination of results. Conclusion There is little evidence about the success of federal efforts to relieve nursing shortages in underserved areas by financial incentives to attract nurses to move there. In many instances it appears they stay for only a limited period of service. Another approach, however--attracting residents of shortage areas into nursing--appears to have a greater potential for success. The committee notes that: o RNs and LPNs tend to practice in or near their places of origin; for rural areas that implies attracting into practice rural residents; for inner-city urban areas it implies attracting to nursing inner-city residents who are often poor and of minority racial or ethnic groups o RNs and LPN s tend to practice in the areas in which they received their nursing education many potential candidates for nursing education are unable to relocate to gain access to nursing education new forms of communication technology offer opportunities to develop outreach and satellite nurse education programs.

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164 However, it is unrealistic to expect that access to nurse education by residents of underserved areas will occur without special targeted efforts. State and federal governments need to continue to provide special initiative grants to schools of nursing to make their educational programs available to residents of these areas through various kinds of outreach programs. New forms of communication technology that offer opportunities for outreach and satellite nurse education programs have not been sufficiently exploited. Such programs can be designed to suit the requirements and convenience of prospective students who, for reasons of family, residence, or the need to continue employment while studying, cannot readily attend existing campus educational programs. RECOMMENDATION 9 To alleviate nursing shortages in medically underserved areas, their residents need better access to all types of nursing education, including outreach and off-campus programs. The federal government should continue to cosponsor model demonstrations of programs with states, foundations, and educational institutions, and should support the dissemination of results. Education Opportunities for Minority Students In the same way that minority racial and ethnic groups frequently lack access to health care and have more illness than many others, members of these groups also have inadequate access to opportunities for nursing education.23~24 Although there are no easy solutions to the access problems of minority groups, studies by Sloan and Feldbaum suggest some strategies for improvements. Recruiting black and other minority people to join the nursing profession may help to increase the number of practical and registered nurses willing to practice in inner-city areas serving minority and underserved populations. This is consistent with the evidence that nurses tend to practice where they grew up. According to Feldbaum's studies of work location, black nurses are more inclined to work in the inner city (41.1 percent) than are their white colleagues (18.4 percent). Further, 30.8 percent of black nurses spend more than one-half of their RN working years in these locations, compared with only 8.1 percent of whites.25 Most nurses do not want to work in the inner-city environment, which is widely perceived to be not only stressful but also unsafe. Sloan reported that 72 percent of RN respondents to a survey were not willing to work in poor sections of cities, even for higher earnings--compared with 42 percent who were unwilling to work in rural

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165 areas .26 However, the obverse of Sloan's findings about unwillingness to work in inner cities is that for 28 percent of nurses that was not the case. Sloan also found that black nurses are more willing to work in inner city areas than white nurses--and that baccalaureate trained nurses are less adverse to working in central cities than AD nurses.*27 The National Sample Survey of Registered Nurses, November 1980, found that minorities have high labor force participation rates, so that increasing their access to nurse education appears to be a good investment.28 The rate for whites was 76 percent, for blacks 90 percent, for Hispanics 86 percent, and for Asian and Pacific Islanders 91 percent.29 Minority nurses, both RNs and LPNs, constitute a large percentage of the nursing staffs in public general hospitals in the inner city, which serve large numbers of minority patients. Another major advantage of increasing minority representation in the nursing labor force would be that minority patients could be served by those best able to understand minority cultures and languages. The language problem is particularly acute in states with large Hispanic populations, many of whom do not speak English. Hispanic RNs are scarce. In 1974 a California study found that although Hispanics constituted over 15 percent of the population of the state they were only 1.1 percent of California RNs.30 In Arizona in 1981, Hispanics were 16.2 percent of the state's population, but only 2.5 percent of the state's RNs and 6.6 percent of its LPNs.31 The relative poverty of minority groups, closely associated with their poor health status and lack of access to care, also creates barriers to their attaining nurse education. A number of federal programs have tried to help disadvantaged individuals gain access to nursing education by offering scholarships and loans. Federal programs to facilitate nurse education for those with disadvantaged backgrounds and to help alleviate shortages in underserved areas include the Special Project Grants and Contracts Program to improve nurse training, authorized by NTA and its various amendments. Currently, two of the five stated purposes of these special grants are to (1) increase nursing education opportunities for individuals from disadvantaged backgrounds and (2) help to increase the supply or improve distribution by geographic area or by specialty group of adequately trained nursing personnel (including nursing personnel who are bilingual) needed to meet the health needs of the nation. The DHHS Division of Nursing awards grants to public and non-profit private schools of nursing and other education organizations. How the educators are to achieve the goals of the program is not specified. *Despite the tendency for minority nurses to work in these areas, a sizable proportion do not. The Feldbaum survey, which overs~mpled for black nurses, showed that 76 percent of respondents had never worked in inner-city areas.32

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166 Since 1965, almost 1,000 projects have been funded under the special grants program. (Further detail is provided in Appendix 2.) The current authorization stipulates that (1) not less than 20 percent be obligated for assistance to the disadvantaged and (2) not less than 20 percent go to projects to increase the supply or improve the distribution of adequately trained nursing personnel by geographic area or by speciality group. Again, however, data are not available to show how many students have been assisted by this program.* The Nursing Student Scholarship Program, although not designed as an effort to improve access to education for those likely to serve in shortage areas, may have assisted that effort more than the programs specifically designed for that purpose. The program was first authorized in the Allied Health Professions Personnel Training Act of 1966 and continued in the Health Manpower Act of 1968, the Nurse Training Acts of 1971 and 1975, and the Nurse Training Act Amendments of 1979. As noted in Chapter III, this program is currently authorized but not funded. Nursing schools administered the program, and could award up to $2,000 per academic year to needy students. Since FY 1970, the program has awarded a total of $139.1 million to nursing schools to provide an estimated 180,502 scholarships.33 During fiscal year 1974, 79 percent of the 23,700 scholarships awarded went to students from families with incomes of less than $10,000. Of these students, 21 percent were black and 5 percent were other minorities.34 The NTA may have had a significant impact on increasing the supply of black KNs. Smith notes that "the number of blacks enrolled in KN programs began to increase dramatically after the enactment of the Nurse Training Act of 1964. . . . From 1965 to 1971, black enrollment increased by about 2,000 students each year compared to an annual increase of about 400 from 1962 to 1965.-35 Nonetheless, by 1980 only 8 percent of the employed nurse population was black and other minority.36 The committee believes that low income minority students continue to need both general and specific financial assistance to enable them to enter basic, advanced, and continuing nurse education programs, and that the net effect would be to alleviate the maldistribution of nurses. Because hospitals and other nursing employers control many of the factors that can attract or discourage nurses seeking employment, *Another program, now discontinued, was the Full Utilization of Educational Talent for the Nursing Profession. It provided incentives for special recruitment of minorities and for remedial education. Operational from 1968 to 1974, it was intended to attract students from disadvantaged backgrounds to the nursing profession, and to help alleviate shortages of fins in underserved areas. Grants were awarded to many types of organizations. The diversity of the approaches used by participating organizations made it difficult to evaluate the program. A substantial number of the targeted individuals now work in underserved areas. Most of the problems addressed by the Full Utilization Program, however, remain unsolved.

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167 and because they suffer when they are unable to fill staff vacancies, it is important that they participate in future targeted programs to increase the supply of new nurses in underserved areas. When such nurse employers work closely with nurse education programs in providing clinical experiences for students, they stand to gain a cadre of graduates familiar with the operations of their institution. To the extent that they can offer some assurance that they will hire number of these graduates, they help create an attractive situation for potential students. Conclusion Certain segments of the population are particularly disadvantaged both in their access to health services and in their access to educational opportunities in nursing. Prominently included are minority groups and new immigrant residents of rural and inner-city areas. Strategies to develop manpower to provide more adequate nursing services under these conditions require targeted approaches. Special efforts must be made to reduce financial barriers to nursing education for residents of such areas, to offer reasonable opportunities for future employment in these areas, and to accustom students to the situations they are likely to encounter in providing nursing services in these areas. In addition to general educational outreach efforts, nurse educators and health care employers can improve access to nursing education in underserved areas by cooperating to develop programs to ensure that students are recruited from minority groups, that they will be given special consideration for employment, and that they gain clinical experience in shortage area facilities, e.g., rural and inner-city hospitals, nursing homes, and public health clinics. Consortia of educational programs and health care facilities may be successful in recruiting such students, attracted by improved prospects of future employment. The facilities themselves may benefit by improved prospects of a continuing supply of newly graduated nurses who live in their area and are already familiar with their operation. Patients will benefit because these nurses are more likely to speak their language and to be familiar with their health needs. The federal government should, therefore, encourage consortia of nurse educators and nurse employers by offering institutional and student support for educational programs targeted, though not limited, to members of minority and ethnic groups. Opportunities for nurse education at all levels could be offered. The programs should be designed to ensure that the students, the prospective employers, and the educational institutions all have incentives for making the program successful in recruiting and retaining students most likely to practice in underserved settings, whether urban or rurale After initial funding, the continued support of the programs could be contingent on the success of institutions in reaching shortage areas and encouraging their graduates to serve in inner-city or rural areas. The committee believes that performance

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179 . . . even with the prod ected increase in the supply of physic fans, physic fan assistants and nurse practitioners have an important role to play in the de livery of primary care. Their role in those rural communities unable to support a physician is of part icular importance. In the opinion of the conuT~ittee, rural communities with populations of 4, 000 or less may be adequately and economically served by a physician assistant or nurse practitioner with physician backup. Even in more populated rural communities, they can augment the care provided by the physician so that the patient can obtain needed primary care on a 24-hour basis. In addit ion, new health pract itioners can improve access to primary care in urban settings, especially in hospitals, nursing homes, and as part of a team in a group practice. Moreover, the committee views these providers as enhancing the delivery of primary care by educating patients to lead more healthful lives. . . By concentrat ing on c ommunic at ion with pat lent s, ~ they ~ might help pat tents to adhere more closely to prescribed reg imens and t o a s sure inc rea sed re span s i hi 1 ity f o r their own health. . . 69 The use of NPs in the care of the elderly has potential for improving the health states of this group. A study reports that an adult health nurse practitioner/physician team delivering primary health care to the elderly reduced hospital days and the use of diagnostic and therapeutic procedures.70 A Rand study predicts a need for 12,000 to 20,000 geriatric nurse practitioners by the year 2010, depending on the amount of responsibility delegated by physicians. 71 The study indicates that geriatric nurse practitioners could play a signif ic ant role in caring for elderly people. Much larger numbers of geriatric NPs have been predicted to be needed by that date in estimates being submitted to the National Institute on Aging.72 Two major factors control the extent to which NPs can furnish primary care to underserved populations: (1) NP practice is regulated by state practice acts that define the scope of nursing practice, (2) payment for NP services by federal programs determines the economic feasibility of using NPs. In recent years, many states have amended physician and nurse practice acts to allow new health practitioners to perform some medical procedures under various conditions.* Most nurse prac t ic e ac t s re qu ire phy s ic fan sup ervi s ion of NP ac t iv it ie s; *See Habibi, M. Legal issues influencing nursing practice. Background paper of the Study of Nursing and Nursing Education. Available from Publication-on-Demand Program, National Academy Press, Washington, D. C., 1983.

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180 therefore the presence of NPs in underserved areas depends not only on their own interest, but on their ability to make arrangements with hospitals or physicians . Nurse midwives, many of whom practice in rural and urban underserved areas, also must make such arrangements. In recent years, state laws have become increasingly supportive of midwifery practice. The number of states with statutes or regulations allowing nurse midwives to practice is reported to have increased frog 16 in 1977 to 32 in 1980.73 The level at which nurse practitioners can be used is directly related to the licensing provisions in any given state. State legislators, in considering changes in nurse practice acts and related legislation, usually confer with representatives of the medical profession as well as with nursing groups. There are differences of viewpoint as to practice proposals. For example, physician supervision of NPs may be defined as requiring the presence of the physician at the site of practice. Same critics of organized medicine have observed that economic concerns may influence the attitudes and actions of some medical practitioners, especially in the face of the increasing supply of physicians. However, there also are genuine concerns about the quality of care that might be given by NPs in the absence of a physician. The committee did not attempt to resolve these questions because its recommendation deals only with nurse practitioners functioning in organized settings and in joint physician-nurse practices. Medicaid and Medicare payment policies affect the ability of ambulatory clinics, physicians, and health care institutions to employ NPs. The Medicaid programs in approximately one-half the states specifically provide some type of reimbursement for physician extender services such as those by nurse practitioners or physician assistants.74 Federal reimbursement policies in the Medicare and Medicaid programs allow institutions to include physician extender compensation in their calculation of reasonable costs. But federal payments for primary care services, provided by physician extenders outside of institutions, have been restricted. In most cases, services traditionally performed by physicians are not reimbursable under federal programs when provided by physician extenders.75 The Rural Health Clinic Services Act of 1977 (Public Law 95-210) eliminated such restrictions in the Medicare and Medicaid programs for physician extenders practicing in certified rural health clinics in designated underserved areas. The Act provides payment for physician extender services even if not directly supervised by a physician. However, where state practice laws require on-site physician supervision, their provisions often appear to govern. Studies confirm that NPs are willing to provide primary care in parts of rural and inner-city underserved areas where physicians at present do not practice. There is, however, considerable debate on the long-term prospects for using substantial numbers of such practitioners in ambulatory care in view of the increasing supply primary care physicians. Physicians are increasingly moving into small communities. It is not possible now to project how many nurse practitioners will be needed in the future and where they will of

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181 practice. GMENAC estimated that the supply of NPs will rise to 39,000 by 1990.76 Conclusion Continued federal funding is needed for nurse practitioner training. It should, however, be weighted toward supporting the training of RNs most likely to practice in underserved areas, in nursing homes, and in caring for the elderly in other settings. funding can profitably be directed at training RNs already living in underserved areas or already working in long-term care settings, since they are most likely to continue practicing there. The legitimate role for nurse practitioners is hampered in many instances by state laws and third-party reimbursement practices. Their services in organized settings and in joint physician-nurse practices should be covered by Medicaid, Medicare, and third-party payers. This does not, however, imply an intention to restrict payment for services that states already authorize. Approximately half the states now provide same Medicaid reimbursement for physician extender services provided by NPs or physician assistants. Since 1977 the Rural Health Clinic Services Act has waived payment restrictions in the Medicare and Medicaid programs under defined safeguards where such physician extenders practice in certified rural health clinics located in designated underserved areas. There are examples of the use of NPs and nurse midwives in organized health care settings contributing to productivity gains and cost reductions. Even with the anticipated future increases in physician supply, it is likely that NPs will be needed, especially to serve hard-to-reach populations, to facilitate new organizational arrangements for providing health care in cost effective ways, and augment the quality and amount of care provided to the elderly in their own homes and in nursing homes. RECOMMENDATION 15 to There is a need for the services of nurse practitioners, especially in medically underserved areas and in programs caring for the elderly. Federal support should be continued for their educational preparation. State laws that inhibit nurse practitioners and nurse midwives in the use of their special competencies should be modified. Medicare, Medicaid, and other public and private payment systems should pay for the services of these practitioners in organized settings of care, such as long-term care facilities, free-standing health centers and clinics, and health maintenance organizations, and in joint pl~ys~ciar~-nurse practices. (Where state payment practices are broader, this recommendation is not intended to be restrictively

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182 Financing Recommended Actions The committee has presented recommendations in this chapter that would involve redirection and reauthorization of a number of NTA programs designed to alleviate chronic nursing shortages for various geographic areas, population groups, and institutions. These approaches can be grouped as (1) manpower distribution policies to facilitate the education and employment of individuals most likely to work in rural and inner-city areas, including nurse practitioners; (2) payment changes to enable skilled nursing facilities and inner city hospitals to support acceptable levels of service, including more adequate nursing care in such institutions, and to facilitate the employment of nurse practitioners to care for rural and elderly patients; and (3) policies to improve nursing care for the elderly through incentives to educational institutions and health care providers, first by enhancing the geriatric component of educational programs so that new graduates will be more likely to want to work with the elderly and be more skilled in doing so, and second by improving the skills and knowledge of all levels of nursing personnel who already care for elderly people in long-term care institutions. Manpower Distribution Policies The principal recommendation in this category suggests incentives to states, educational institutions, and health care providers to develop consortia and model demonstrations that address specific shortage problems in medically underserved areas. A key strategy is to bring educational opportunities to potential students who already live in those areas. The committee is not suggesting a large-scale program of diffuse student and institutional support as occurred in the past, but rather carefully targeted aid for local initiatives that will attract added local resources. Past federal expenditures to address nursing maldistribution problems were included among the Nurse Training Act authorizations for loans and scholarships for disadvantaged people, special project grants, and training for nurse practitioners. These loan appropriations peaked at $33.5 million in 1976, at which time $12 million was also available in scholarships. By 1982, the loan program had been reduced to $7.5 million and the scholarship program discontinued. However, many nursing schools still have large cash balances in the loan program, totaling $54 million nationwide, and substantial amounts are owed in delinquent loan repayments, some of which may be repaid.77 These funds presumably could be retargeted to support a substantial number of loans through 1986 (the end of the period during which the money may be reloaned). In addition, a relatively small amount of new funds for loans targeted to educational activities in underserved areas would speed improved geographical distribution. Federal capitation (no longer authorized) and special project funds (authorized in 1981 at about $12 million), which had many purposes,

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183 have also been used to address problems of underservice. Same of these funds have been used to develop innovative outreach and collaborative programs, recruit disadvantaged students, and improve the distribution of nurses. In sum, many of the committee's objectives and strategies have been stated among the objectives of past federal efforts, but the impact has at~times been lost because of diffuse funding arrangements. Furthermore, inadequate data and poor institutional records have frustrated the evaluation of their impact on the intended problem areas. In view of federal budget constraints, the committee believes that levels of funding as high as in the past may not be feasible or even necessary. Rather, smaller but more carefully targeted expenditures would be effective to develop concentrated approaches to the problems of recruiting minority and other students who are likely to work in underserved settings. The recommended activities to stimulate consortia for underserved areas could be supported by appropriations for special project grants and contracts at about the 1981 level. In addition to the need for generalist RNs to care for underserved populations, the committee sees a need for nurse practitioners to care for elderly clients and provide primary care in underserved areas. Specific federal support for nurse practitioner education programs has been authorized under the NTA since 1976. Funding was at the $13 million level between 1978 and 1981. Although in recent years special consideration has been given to institutions that prepare nurse practitioners to deal with the special problems of geriatric patients at home and in nursing homes and to serve in health manpower shortage areas, many NPs subsequently find employment elsewhere. NP students have also been assisted by Traineeships for Advanced Training of Professional Nurses. This program supports a whole range of advanced nurse education. It was also funded annually at about $13 million between 1979 and 1981. The committee endorses continued funding at present levels for the education of nurse practitioners, but with stronger program incentives for them to work in underserved areas and in the care of the elderly. Payment Changes Manpower policies address only part of the underservice problem Perhaps the most important obstacle to adequate nursing care for residents of skilled nursing facilities and patients in inner-city hospitals is in the lack of financial resources in these institutions. The committee has placed no explict price tag on these recommendations because they are part and parcel of major program reforms required in Medicare and Medicaid payment systems to assure that cost constraints are balanced by broad equity considerations. Any added costs are not fairly attributable to nursing, although nursing improvements are intended as one of the results of more adequate payment for total care.

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184 Improving Nursing Care for the Elderly Training of all levels of nursing personnel, including aides, LPNs, and RNs, has failed to pay sufficient attention to the special problems of caring for the elderly. We have recommended that educational institutions in collaboration with providers strengthen their curricula to remedy this situation by encouraging more nurses to pursue careers in geriatric nursing. We also see a need for continuing education to upgrade the skills and knowledge of those currently employed in long-term care. Providers and educational institutions should take the lead and primarily bear the costs of developing both these types of educational programs, with additional financing from state agencies and foundations. The federal contribution to such improvement and to efforts to upgrade the skills of LPNs, aides (nursing assistants), and other nursing personnel has been expressed in the past primarily through the NTA special projects grant program. In the Omnibus Reconciliation Act of 1982, Congress stipulated that not less than 10 percent of special project funds be devoted to upgrading the skills of vocational or practical nurses, nursing assistants, or other paraprofessional nursing personnel. At the same time, however, Congress eliminated from the authority support for curriculum improvements and short-tenm in-service training for aides and orderlies. The provisions that remain could nevertheless allow for greater federal participation to implement the committee's reco~u~ended actions to improve geriatric nursing care. The committee believes that if special project grants were funded at a level equivalent to the average of 1980-1982 appropriations ($11 million), the federal share of the committee's recommendations could be accommodated. REFERENCES AND NOTES 1. 4. Davis, K. Primary care for the medically underserved: Public and private financing. Paper presented at the American Health Planning Association and National Association of Community Health Centers, Inc., Symposium on Changing Roles in Serving the Underserved, Leesburg, Va., October 1981. 2. Blendon, R.J. Untitled testimony presented to the Subcommittee on Health and the Environment of the House Committee on Interstate and Foreign Commerce, March 4, 1981. 3. Murrin, K. Laying the groundwork: Issues facing rural primary care. In G. Bisbee (Ed.), Management of rural primary care--Concepts and cases. Chicago, Ill.: The Hospital Research and Educational Trust, 1982. Mullner, R. American Hospital Association. Personal communication, July 2, 1981. Center for Health Services Research and Development. Physician distribution and medical licensure in the United States. Chicago, Ill.: American Medical Association, 1979, unpublished data.

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185 6. Roth, A., and Patchin, N. Geographic distribution of nurses in relation to perceived recruiting difficulties and economic conditions. In 11. Millman (Ed.), Nursing personnel and the changing health care system. Cambridge, Mass.: Ballinger Publishing Co., 1978. Rural Health Care: Hearing before the Subcan. on Health of the _ Comm. on Finance, 97th Cong., 1st Sess. 55 1981 statement of William Leary, Montana Hospital Association) Rural Health Care: Hearings before the Subcom. on Health of the - Comm. on Finance, 97th Cong., 1st Sess. 40(1981) (statement of Jo Anne Dodd, Montana Nurses' Association) 9. Rural Health Care: Hearing before the Subcomm. on Health of the Corr=. on Finance, 97th Cong., 1st Sess. Op. cit., p. 62. 10. Secretary of Health and Human Services. Health' United States, 1981 (DHHS Publication No. PHS-82-1232~. Washington, D.C.: U.S. Government Printing Office, 1982, p. 90. 11. Ibid., p. 93. 12. Davis, K., and Schoen, C. Health and the war on poverty: A ten~ear appraisal. Washington, D.C.: The Brookings Institution, 1978. 13. Blendon, R.J. Op. cit., p. 7. 14. Secretary of Health and Human Services. Health. United States ~ 1 h 8. Washington. D. C. The Brooking 1981, Op. cit. Table 27, p. 15. Ostow, M., and Millman, M. The demographic dimensions of health manpower policy. Public Health Reports, 1981, 96~4), 304-309. 16. Vector Research, Inc. Hospital nursing shortage designation criteria: Analysis and revision (DHPA Report No. 80-45~. Hyattsville, Md.: Health Resources Administration, 1980, pp. 10-11. 17. Feldbaum, E.G. Registered nurses at work. A report to administrators of health facilities. College Park, Md.: Bureau of Governmental Research, University of Maryland, 1980, p. 32. 18. North Carolina Area Health Education Centers Program. North Carolina AHEC 1982 nurse manpower survey: Final report. Chapel Hill, N.C.: N.C. AHECs Program, 1982. 19. Knopf, L., and Vaughn, J.C. Work-life behavior of registered nurses: A report to the nurse career-pattern study (Appendix, Final Report) (NTIS No. HRP-0900631~. Hyattsville, Md.: Health Resources Administration, 1979, p. 124. 20. National League for Nursing. NLN nursing data book 1981 (Publication No. 19-1882~. New York: National League for Nursing, 1982, Table 184, p. 185. 21. Secretary of Health, Education, and Welfare. An assessment of National Area Health Education Center Program (DHEW Publication No. HRA-80-33~. Washington, D.C.: U.S. Government Printing Office, 1980, pp. 11-46. 22. Cross, K.P. Living in the learning society. Paper presented at the Quality in Off-Campus Prograns Annual Conference, Nashville, Tenn., October 1981. Secretary of Health, Education, and Welfare. Health, United States, 1979 (DHEW Publication No. PHS-80-1232~. Washington, D.C.: U.S. Government Printing Office, 1979, Table 14, pp. 96-99. 23.

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186 24. Blendon, R.J. Op. cit., p. 7. 25. Feldbaum, EeGe Ope cit., p. 19. 26. Sloan, F.A. The geographic distribution of nurses and public policy (DREW Publication No. HRA-75-53~. Washington, D.C.: U.S. Government Printing Office, 1975, pp. 150-155. 27. Ibid. 28. Department of Health and Human Services, Health Resources Administration. The registered nurse population, an overview. From national sample survey of registered nurses, November 1980 (Report No. 82-5, revised June 1982~. Hyattsville, Md.: Health Resources Administration, 1982, Table 1, p. 9. 29. Ibid. 30. California State Functional Task Analysis Study. General characteristics of nurses licensed in California, JanuarY 1975. Sacramento, Calif.: State of California Department of Health, 1977. 31. Eastwell Research Associates, Inc. Nursing manpower study--The status of nursing in Arizona. Phoenix, Ariz.: Arizona Department of Health Services, 198' 32. Feldbaum, E.G. Op. cit., p. 20. 33. Department of Health and Human Services, Health Resources Administration. Nursing scholarship program: Fiscal years 1970 through 1977, academic years 1977-78 through 1980-81. Unpublished manuscript, 1981. 34. Congressional Budget Office. Nursing education and training: Alternative federal approaches. Washington, D.C.: U.S. Government Printing Office, 1979. 35. Ibid. 36. DENS, HRA. The registered nurse population, an overview. national sample survey of registered nurses November 1980. Op. _ , cit., Table 1, p. 9. 37. Oversight on Financially Distressed Hospitals: Hearings before the Subcomm. on Health and Scientific Research of the Senate Comm. on Labor and Human Resources, 96th Cong., 2d Sess. 74~1980) (Statement of Henry E. Manning, Cuyahoga County Hospital) 38. Commission on Public-General Hospitals. The future of the public-general hospital (HRET Publication No. 9202). Chicago, Ill.: Hospital Research and Education Trust, 1978. 39. National Association of Public Hospitals. NAP H white paper: The situation of urban public hospitals in America today. Washington, D.C.: National Association of Public Hospitals, 1982. 40. Rogers, D.E., Blendon, R.J., and Maloney, T.~. Who needs Medicaid? New England Journal of Medicine, 1982, 307~1), 13-18. 41. Balz, D. Medicaid cuts put urban, public hospitals at the crunch point. The Washington Post, August 29, 1982, p. A4. 42. National League for Cities. Preliminary findings, municipal general hospital survey. Unpublished manuscript, 1981. 43. New York City Health and Hospitals Corporation. HHC nurse staffing: The numbers speak for themselves. New York: Consumer Commission on the Accreditation of Health Services Inc.' 1980, p. 8.

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187 44. Rice, D. Morbidity, mortality, and population trends in the United States. Paper presented at the Annual Spring Meeting of - the Council~ of Teaching Hospitals, Atlanta, Gal, May 1981. 45. Gurel, L., Linn, Lid., and Linn, B.S. Patients in nursing homes. Journal of the American Medical Association, 213~1), 73-77. 46. Kayser-Jones, J.S.A. Gerontological nursing research revisited. Journal of Gerontological Nursing, 1981, _44), 217-223. 47. grower, H. A study of graduate programs in gerontological nursing. Journal of Gerontological Nursing, 1977, 3~6), 40-46. 48. Kayser-Jones, J.S. Op. cit., p. 218. 49. Reif, L., and Estes, C.L. Long-term care: New opportunities for professional nursing. In L. H. Aiken (Ed.), Nursing in the 1980s: Cries, opportunities, challenges. Philadelphia, Pa.: J. B. Lippincott Company, 1982. 50. Department of Health, Education and Welfare, Administration on Aging. ADA Occasional papers in gerontology, No. 1, Human resources issues in the field of aging: The nursing home industry (DHEW Publication No. OHDS-80-20093~. Washington, D.C.: Office of Human Development Services, 1980. 51. National Center for Health Statistics. The national nursing home survey: 1977 summary for the United States (DHHS Publication No. P B-79-1974~. Washington, D.C.: U.S. Government Printing Office, 1979. 52. Beaver, Kid. Task analysis of nursing personnel: Long-term care facilities in Utah (Doctoral dissertation, Brigham Young University, 1978) (University Microfilm NOe BKK78-16191~. Dissertation Abstracts International, 1978, 39/03-B, 1208, Table 6, pp. 96-100; and Table 7, pp. 102-106. 53. Department of Health, Education and Welfare, Administration on Aging. ADA Occasional papers in geronotology, No. 1, Human resources issues in the field of aging: The nursing home industry. Ad. cit., p. 8. 54. Department of Health and Human Services, Health Resources Administration. The registered nurse population, an overview. From national sample survey of registered nurses, November 1980. Op. cit., Table 9, p. 17. 55. Somers, A. R. Long-term care for the elderly and disabled. A new health priority. New England Journal of Medicine, 1982, 307~4), 221-225. 56. Ibid., p. 222. 57. American Association of Homes for the Aging. Survey of subcommittee on program performance recommendations regarding proposed conditions of participants for SNFs and ICFs. Washington, D.C.: American Association of Homes for The Aging, July 1982. 58. Nurse shortage and its impact on care for the elderly: Hearings before the Subcomm. on Health and Long-Term Care of the House Select Comm. on Aging, 96th Cong., 2d Sess. 50~1980) (Statement of Jack MacDonald, National Council of Health Centers)

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188 59. American Nurses r Association. Facts about nursing 80-81. New York: American Journal of Nursing Company, 1981, p. 77. 60. Reif, L., and Estes, C.L. Op. cit., p. 152. 61. Brady, S., Health Care Financing Administration. Personal communication, December 15, 1982. 62. White House Conference on Aging. Final report (Vol. 3: Recommendations, post-conference survey of delegates). Washington, D.C.: White House Conference on Aging, 1981. 63. Freeman, R.B., and Henrik, J. Community health nursing practice. Philadelphia: W.B. Saunders Company, 1981, p. 178. 64. Department of Health and Human Services, Health Resources Administration. Health personnel issues in the context of long-teLlll care in nursing homes. Hyattsville, Md.: Health Resources Administration, 1980. 65. Sultz, H. A., Zielezny, M., Gentry, J. M., and Kinyon, L. Longitudinal study of nurse practitioners, Phase III (DREW Publication No. HRA-80-2~. Washington, D.C.: U.S. Government Printing Office, 1980. 66. General Accounting Office. Progress and problems in training and use of the assistants to primary care physicians. Washington, D.C.: General Accounting Office, 1975. 67. Graduate Medical Education National Advisory Committee. Report of the Graduate Medical Education National Advisory Committee to the Secretary, Department of Health and Human Services: Vol. 6. Nonphysician health care provider technical panel (DHHS Publication No. HRA-81-656~. Washington, D.C.: U.S. Government Printing Office, 1981. 68. Holmes, G. C., Livingston, G., and Mills, E. Contribution of a nurse clinician to office practice productivity: Comparison of two solo primary care practices. Health Services Research, 1976, ll(Spring), 21-33. 69. Institute of Medicine. A manpower policy for primary health care. Washington, D.C.: National Academy Press, 1978, p. 44. 70. Schultz, P. R. Primary care to the elderly: An evaluation of two health manpower patterns. Denver, Colo.: Medical Care and Research Foundation, 1977. 71. Kane, R. L., Solomon, D. H., Beck, J. C., Keeler, E. B., and Kane, R. A. Geriatrics in the United States: Mano owe r projections and training considerations. Lexington, Mass.: Lexington Books, 1981. 72. Martinson, I. University of Minnesota School of Nursing. Personal communication, October 20, 1982. 73. Graduate Medical Education National Advisory Committee. Report of the Graduate Medical Education National Advisor Committee to S_ ~ Nonphysician health care provider technical panel. Op; cit., pp.

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189 74. LeRoy, L., and Solkowitz, S . The implications of cost- effectiveness analysis of medical technology. Background paper #2: Case studies of medical technologies. Case study #16: The costs and effectiveness of nurse practitioners (OTA Publication No. OTA-BP-H-9-16) . Washingtorl, D. C.: U. S . Government Printing Office, 1981. 75. Ibid. 76. Graduate Medical Education National Advisory Committee. Report of the Graduate Medical Education National Advisory Committee to the Secretary, Department of Health and Human Services: Vol. 6. Nonphysician health care provider technical panel . Op. c it., p. 21. 7 7. Department of Health and Human Services, Of f ice of Inspec tar General . Review of nurse s de linquent in repayment of nursing student loans, Public Health Service (Audit Control No . 12-33144) . Washington, D. C.: Off ice of Inspector General , 1982.