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OCR for page 157
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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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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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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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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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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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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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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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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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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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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. . . 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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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
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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
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Mullner, R. American Hospital Association. Personal
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Chicago, Ill.: American Medical Association, 1979, unpublished
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6. Roth, A., and Patchin, N. Geographic distribution of nurses in
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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
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13. Blendon, R.J. Op. cit., p. 7.
14. Secretary of Health and Human Services. Health. United States
~ 1 h
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Washington. D. C. The Brooking
1981, Op. cit. Table 27, p.
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17. Feldbaum, E.G. Registered nurses at work. A report to
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of Governmental Research, University of Maryland, 1980, p. 32.
18. North Carolina Area Health Education Centers Program. North
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19. Knopf, L., and Vaughn, J.C. Work-life behavior of registered
nurses: A report to the nurse career-pattern study (Appendix,
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Resources Administration, 1979, p. 124.
20. National League for Nursing. NLN nursing data book 1981
(Publication No. 19-1882~. New York: National League for
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21. Secretary of Health, Education, and Welfare. An assessment of
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22. Cross, K.P. Living in the learning society. Paper presented at
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Secretary of Health, Education, and Welfare. Health, United
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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
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Commission on the Accreditation of Health Services Inc.' 1980,
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44. Rice, D. Morbidity, mortality, and population trends in the
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the Council~ of Teaching Hospitals, Atlanta, Gal, May 1981.
45. Gurel, L., Linn, Lid., and Linn, B.S. Patients in nursing
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46. Kayser-Jones, J.S.A. Gerontological nursing research revisited.
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48. Kayser-Jones, J.S. Op. cit., p. 218.
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50. Department of Health, Education and Welfare, Administration on
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industry (DHEW Publication No. OHDS-80-20093~. Washington,
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51. National Center for Health Statistics. The national nursing home
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52. Beaver, Kid. Task analysis of nursing personnel: Long-term care
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Dissertation Abstracts International, 1978, 39/03-B, 1208, Table
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54. Department of Health and Human Services, Health Resources
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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
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56. Ibid., p. 222.
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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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59. American Nurses r Association. Facts about nursing 80-81. New
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63. Freeman, R.B., and Henrik, J. Community health nursing
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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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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
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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.
Representative terms from entire chapter:
nursing education
