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CHAPTER I Nursing Services and Nursing Education: An Overview Nursing in the United States is characterized by great diversity. This is reflected in the scope of nursing responsibilities and activities, in levels of personnel, in organization of services, in educational preparation, and in financing of education. An apprecia- tion of this diversity is necessary to provide the context for the findings and recommendations the committee presents throughout the remainder of this report in answer to our study charge. This chapter, after outlining the broad range of responsibilities of registered nurses (RNs), first reviews their roles in relation to those of licensed practical nurses (LPNs) and other members of the typical organized nursing service staff, and how staffing mix and roles may vary among and within the different settings where patients receive direct care. Next, it describes the educational programs that prepare generalist RNs and those that prepare LPNs, as well as some of the issues currently under debate about such education. The discussion then moves to the responsibilities and educational preparation of RNs in the profession's advanced positions--the managers of nursing services, nurse educators, clinical nurse specialists, and nurse researchers. The chapter concludes with a historical review of the respective roles of federal and state governments and private sources in the financing of nursing education. The Diversity of Registered Nurses' Responsibilities Nursing education must supply the nation with RNs prepared for a wide range of roles and responsibilities: providing direct care to patients in hospitals, nursing homes, and patients' homes; helping to safeguard the health of community and school populations; assisting with ambulatory care of individuals and families; performing clinical nurse specialist services; administering nursing services at both middle and top management levels; conducting nursing research; and providing professional and educational leadership to the profession. Responsibilities of RNs vary greatly among the different settings in which they practice. The daily round of activities of the acute care hospital staff nurse bears scant resemblance to that of the psychiatric hospital nurse, the public health nurse, the nurse ~4

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25 educator, the nurse administrator, the pediatric nurse practitioner, the visiting nurse, the school nurse, or the nurse researcher. In hospitals and nursing homes, major activities focus on the care of sick patients confined to bed. But in many other settings, RNs work with ambulatory patients or, as in schools and industry, with presumably healthy people. Here, as in most other patient care settings, the RN has an important role in health promotion and disease prevention. In still other settings, in the roles of teaching, administration, consultation, and research, RNs' major activities involve nursing students, other nursing staff, and colleagues from non-nursing backgrounds. Even among institutions and agencies of the same general type that differ in geographic location and size, the functions of RNs are strikingly diverse. The activities of the public health nurse in a small town health department are quite different from those of her counterpart in the health department of a large city; the challenges to nursing school faculty in a university, where research and publication are expected, are quite different from those to faculty in a 2-year community college; the wide variety of daily activities of RNs in small rural hospital are different from the more narrowly differentiated activities of their counterparts in large urban hospitals and medical centers whose patients seek care for multiple or highly complex conditions. In such large hospitals, many RNs have highly specialized responsibilities. As in-service instructors, they manage and conduct orientation, staff development, and continuing education for RNs and all other nursing staff personnel; KNs with advanced clinical training provide consultation and patient care in clinical nursing specialities, such as coronary care or renal dialysis. At the staff nurse level, where most direct patient care is handled, a large proportion of the RN staff may be monitoring patients on complex life support systems in various types of intensive care units, while others will be at the bedside caring for patients with widely differing physical and emotional needs in medical, surgical, pediatric, obstetrical, and psychiatric units of the institution. Still others are dealing with critical trauma in the hospital emergency room. In every hospital the staff XNs monitor, record, and respond to the changing status of their patients. They are responsible for assessing patients' nursing needs and for making, implementing, and modifying nursing plans of care as conditions change. This includes instruction of patients and families in self-care. Supervisors and head nurses in middle management positions coordinate all activities that affect the care of patients on the clinical units within their jurisdictions. New roles are emerging for nurses in community nursing. Nurses are now involved in programs dealing with developmental disabilities, hypertension detection and control, midwifery, emergency treatment for rape victims, substance abuse, and counseling to the dying and their families. They are increasingly involved in home care.

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26 Variety of Nursing Service Personnel In the nation's approximately 7,000 hospitals, 19,000 nursing homes,* and large numbers of health centers, visiting nurse services, and other organized clinical settings, nursing personnel typically work in formally organized nursing services administered by RN nursing service directors. In hospitals, these directors of nursing services and their assistants typically manage nursing services with hundreds of staff personnel whose education and skills range through those of specialist and generalist RNs, and those of LPNs, to simple staff support by such ancillary personnel as aides and orderlies.+ Registered nurses are the single largest component of health care personnel in the United States. There are also very large numbers of LPNs and aides. In 1980, approximately 1.3 million KNs and more than half a million LPNs were employed and probably more than 850,000 aides, orderlies, and attendants.l,2,3~4 The nursing service staff constitutes the largest single personnel component of a hospital. In hospitals, as well as in many other institutional settings, both administrative and staff RNs work in close association with physicians; with many different allied health workers, such as physical therapists and laboratory technicians; and with housekeeping, building maintenance, and other support personnel. Effective KN relationships with physicians, with other health providers, and with support staff play a large part in determining the productivity and efficiency of services. By the terms of their legal licensure or by custom, nursing personnel are expected to perform at different levels of responsibility and functions. Brief descriptions follow. The Registered Nurse State boards of nursing license RNs as professionals, as distinct from practical nurses, who take a different licensing examination. Tithe term "nursing home" applies to facilities that provide long-term care to patients with various degrees of impaired health and/or mobility. As with hospitals, the term includes a range of institutions, licensed to provide different levels of care. In this report, "nursing home" connotes the generic long-term care facility. Where applicable, the report also refers to "skilled nursing facilities" (SNFs) and "intermediate care facilities" (ICFs). These subsets of nursing homes are certified as qualified to receive payment for care to Medicare patients (SNFs) and for Medicaid patients (SNFs and ICFs) under the provisions of the Social Security Act and state laws and regulations. As their names imply, SNFs care for patients whose conditions appear to call for more skilled and/or extensive care than patients in ICFs. +In a few states, practical nurses are licensed as "vocational nurses," (LVNs). However, for the purpose of simplicity, the report refers to both licensed practical nurses and vocational nurses as LPNs.

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27 Besides providing direct care to patients, lens manage all nursing services and educate all echelons of nursing personnel. Many KNs figure importantly in public health, and some in the formulation of national health policy. Lic ensure as a RN is the first and basic credential for all these roles; additional credentials are customary for some of them. In 1980, about 20 percent of the nation's approximately 1.3 million employed RNs were engaged in nursing service management, education, or leadership in special areas of clinical nursing practice designed to strengthen and support either directly or indirectly the delivery of basic nursing care.5 Most of the remainder-- approximately 915,000--were primarily providing general nursing care to patients. Of these, more than 735,000 were in staff or head nurse positions in hospitals and nursing homes. In these roles they were expected not only to have high level technical nursing skills and to work closely with physicians, but also, as we have seen, to assess patients' nursing needs on a 24-hour basis and to plan, coordinate, and document the nursing care given by other nursing and non-nursing personnel. In so doing, they were expected to exercise judgments and make informed decisions in all aspects of the nursing care that patients under their charge received and to instruct and provide emotional support to patients and their families. Almost 50,000 RNs were staff or head nurses in public or community health agencies. About an equal number worked in physicians' offices. As Figure 1 illustrates, by far the largest proportion of employed RNs in 1980, 66 percent, worked in hospitals. Another 8 percent worked in nursing homes, and about 7 percent in one or another public Nursing Homes 8.0% Community and Public At/ \ Health 7.0% / \ Physicians' ~\ Off ices 5.7% by \ \ Nursing ~ \ \ Education 3.7% ~ ~ ~ \\ School Health 3.5% Self Employed 2.6/ Hospitals ~ ~ ~ FIGURE 1 Where registered nurses worked in 1980.

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28 or community health setting, such as health departments, visiting nurse services, and health centers. Less than 3 percent of KNs were self-employed; most of them were private duty nurses. Physicians' and dentists' offices and health maintenance organizations (HMOs) employed slightly less than 6 percent of the RN work force; student health services employed another 3.5 percent. Nursing education accounted for another 3.7 percent. The remainder worked in such disparate fields as occupational health in industry, government agencies, and nursing organizations.6 More than three of every four RNs who held licenses in 1980 were employed in nursing, but almost a third worked only part time. The fact that almost all RNs are women obviously influences the nature of their participation in the work force. About 97 percent of the almost 1.7 million RNs who held active licenses in that year were women, with a median age of about 38. More than 70 percent were married, and most had children living at home. Their family responsibilities appeared to make part-time work attractive; almost two out of three RNs who worked full time either were not married or had no children living at home.7 All in all, however, as we will see in Chapter II, the RN labor participation rate has been increasing steadily and almost exactly parallels that of other women with post- secondary education. The Licensed Practical Nurse State boards license practical or vocational nurses to provide nursing services under the supervision of RNs and/or physicians. In 1980 approximately 300,000 LPNs were employed in hospitals, where they performed routine nursing tasks, largely under supervision.8 In 1977, the National Nursing Home Survey estimated that 97,500 LPNs were employed in nursing homes.9 In these settings they have greater responsibilities than they do in hospitals, because, as is described in Chapter VI, they often are the only licensed nurses on the premises. The survey found that only 22 percent of such institutions have RNs on duty around the clock.l No recent data are available to show the number and distribution of LPN s employed outside of hospital and nursing home settings. In 1974, private duty nursing and work in physicians' offices accounted for 14 percent of their employment.ll Nor is current detailed information available on the demographic characteristics of LPNs. However, as with RNs, the great majority of LPN s are women. In recent years, practical nurse education programs have been graduating older students; in 1980, more than one-third of newly licensed graduates were between the ages of 30 and 50, and about one-fifth between the ages of 25 and 29.12 Ancillary Nursing Personnel Aides, orderlies, and attendants are unlicensed and may not necessarily be high school graduates. Their training typically is

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29 provided by the institutions where they work, although vocational programs in some states and localities offer brief training programs. In addition to this traditional core of aides, same undetermined numbers of nursing and other health professional students help support their educational expenses by working in this capacity. Approximately 386,000 aides were employed in the nation's hospitals in 1980 and 463,000 in nursing homes in 1977.13,14 In hospitals, they carry out routine patient care tasks such as assisting in personal hygiene under the direction of either RNs or LPNs. In nursing homes, they often carry out a much wider variety of direct patient care tasks and functions. Other nursing service personnel include unit clerks and managers employed to carry out a variety of administrative functions. Hospitals employed about 230,000 such personnel in 1980.15 The Functions of Organized Nursing Services Most efforts to arrive at generally applicable, standardized categorizations of the functions of nursing service personnel are so general as to be insufficiently informative or so detailed as to be unmanageable. However, the listing in Table 1, developed for use by hospital nursing service administrators in delegating responsibilities to various levels of personnel, provides an illustration of the range and scope of nursing service responsibilities and activities in hospitals. The frequencies of task occurrence, of course, depend heavily on patient mix. The distribution of assignments among RNs, LPNs, and aides depends on provisions of state licensure acts, staffing philosophy, the availability of personnel, and their experience and demonstrated capabilities. It also depends on the extent to which physicians, social workers, health educators, physical and respiratory therapists, nutritionists, and many other kinds of health personnel are present or absent in any particular institution at any particular time. Variations in Nursing Service Staff Mix Nursing service staff account for a large share of the operating costs of hospitals and nursing homes. In hospitals, estimates of the proportion are about 30 percent. When these institutions face pressures to contain costs, ways to attain the most cost effective staffing are widely sought. In efforts to identify the most effective and efficient mixes, more than a thousand studies have examined various aspects of nursing personnel staffing.16,17 Widely differing patterns are found in hospitals, ranging from all-RN staffs who carry out the entire range of nursing activities for patients assigned to them,l8 to configurations that depend on a few highly experienced nurses supported by large numbers of unlicensed auxiliary personnel--sometimes with special training as "technical aides.''l9 Same nursing service directors in mult~hospital systems predict

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30 TABLE 1 Examples of the Responsibilities of Hospital Nursing Service Personnel I. Patient Assessment: 1. Perform admission assessment-- nursing history 2. Perform physical assessment-- skin, heart, abdomen, circulation, lungs Identify nursing needs of patients in various stages of health or illness 4. Observe apparent change in patient's condition 5. Analyze factors such as test results and came to a ~ e nursing Diagnoses II. Nursing Care Planning: 1. Develop appropriate nursing care plan 2. Evaluate changes indicated on patient care plan 3. Establish priorities as demanded by a situtation 4. Adapt nursing actions to mee needs of an individual patient Ill. Interaction with MD: 1. Interact and collaborate (discuss) with MD about patient's plan of care 2. Contact MD regarding patient problems and/or change in condition 3. Interpret MD orders 4. Receive MD telephone orders 5. Relate nursing orders to MD 6. Assist MD with special procedures IV. Supervision and Communication 1. Assume charge of a unit 2. Assume responsi bility for a group of patients 3. Supervise staff 4. Assign others to care of patients 5. Work closely with other patient care services (e.g., occupa tional therapy, physical therapy, speech therapy) 6. Give "change of shift" report 7. Participate in team conferences and t nursing team rounds V. Patient and Family Teaching: 1. Orient patient to unit 2. Teach patient and family about health problems (e.g., diabetes, colostomy care) 3. Serve as patient advocate 4. Support patient and family when in physical and emotional distress 5. Reinforce teaching, give out information, help patient and family under stand course of care (e.g., postop, preop, simple instructions)

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31 TABLE 1 (continued) VI. Documentation and Patient Care: 1. Initiate charting and review charts for completeness--sign name 2. Chart nursing care progress, if patient condition changes 3. Chart routine activities of daily living 4. Chart vital signs 5. Chart narcotics and narcotic counts VII. Nursing Procedures: 1. c Routine temperature, pulse, respirations 2. Routine blood pressure 3. Invasive procedures, i.e., nasogastric tubes, Cantor tubes, Miller-Abbot tubes, remove subclavian catheters, arterial lines, etc. 4. Maintain parenteral fluid flow, replace bottles, establish infusion rate Observe and report infusion rate Airway suctioning Assist with intermittent positive pressure breathing, incentive spirometer, O2 administration, etc. 8. Soak and sitz bath, etc. 9. Surgery preps, major lab, x-ray prep 10. Major dressing change--wound irrigation, suture removal, sterile dressing, etc. 11. Dressing changes after initial change, wound assessment, application of ACE bandages, decubitus care 12. CPR--Cardiopulmonary X. resuscitation 13. Advanced cardiac life support 14. Arrythmia detection VII. (continued) 15. Handle special equip- ment required by patients (e.g., monitor, respirator 16. Give enemas and douches 17. Coordinate care during death and dying 18. Collect specimens, perform tests: stool, emesis, occult blood, clinitest, specific gravity, etc. 19. Turn, cough, deep breath VIII. Medication: 1. Pass routine oral e medlcat Ions 2. Give IV medications 3. Give IM medications IX. Direct Patient Care: Provide direct care to patient including per- sonal hygiene needs, i.e., bedbath, backrubs, mouth care, changing bed, assis- tance with bedpan and voiding. Also includes transfer of patients from bed to chair and patient positioning 1. Class I patients 2. Class II patients 3. Class III patients 4. Class IV patients Meet Patient's Nutritional Needs: 1. Pass meal trays 2. Pass drinking water 3. Assist with feeding SOURCE: Vandan, M.T. Measurement of task delegations among nurses by nominal group process analysis. Medical Care, 1982, 20~2), 154-164.

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32 that in the medical centers of the future, in contrast to the ever growing numbers of RNs in the recent past, a few highly trained specialized clinical KNs will coordinate the care of a defined number of patients, supported by technical nurses and technicians. Today, however, hospitals for the most part employ a variety of mixes of KNs, LPNs, and auxiliary staff. Individual nursing service directors determine the proportions of the mix on the basis of their institution's mission, policies, and resources and their own perceptions of patients' needs. Variations By Setting of Care--Hospitals and Nursing Homes Some of the complexities surrounding definition of the XN's role in relation to patients and to other nursing personnel can be illuminated by comparing the mix of nursing personnel staff in different settings of care. As Figure 2 illustrates, RNs constitute 46 percent of the nursing personnel in United States hospitals registered by the American Hospital Association (AHA),* in contrast to only 15 percent in nursing homes certified as skilled nursing tithe American Hospital Association membership includes approximately 6,000 hospitals and other patient care organizations in the United States and Canada and 24 hospital schools of nursing. In addition, the AHA has individual members. RNs \/ ~RNs 46% \/ \ 15% \/ LPNs \ \/ 14% LPNs 17% / \ \/ \ - Hospitals Aides / \ 23% 1 \ / \ Aides 71% / Nursing Homes Certified as Skilled Nursing Facility FIGURE 2 Mix of full-t ime equivalent personnel providing nursing services in U.S. registered hospitals and in SNF nursing homes.

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33 facilities (SNFs).20,21 The average hospital patient receives an average of 2.5 hours of KN time in a 24-hour period, but a study of nursing homes found that their patients receive RN care for an aggregate of 12 minutes in SNFs and 7 minutes in nursing homes certified to give intermediate care.22 Aides and other unlicensed ancillary nursing personnel constitute 71 percent of the nursing service staff in SNF nursing homes, but only 23 percent in hospitals. The proportion of LPNs is more nearly the same in both types of institutions--14 percent and 17 percent, respectively. Variation by Hospital Characteristics Hospitals have widely varying characteristics. As would be expected, their mix of nursing services staff varies greatly according to the type of institution, geographic location, size, mission, and sources and amount of revenue. The annual surveys of hospitals conducted by the AHA reveal many of these differences. In 1980 for example, 49 percent of the full-time equivalent (FTE) nursing service personnel in general hospitals (acute care) were RNs and 21 percent were aides, while in chronic hospitals the proportions were almost reversed--21 percent RNs and 44 percent aides.* The proportions of LPNs were l8 and 17 percent, respectively, in the two types of institutions.23 Staffing mix differences among community hospitals in different geographic regions also are substantial. For example, in the AMA's western region, community hospitals averaged 52 percent FTE RNs and 18 percent aides, but in the southern region, FTE RNs averaged 41 percent and aides 25 percent. However, the proportion of FTE LPNs to total nursing service staff was about the same--17 percent and 19 percent, reSpectively.24 The proportion of RNs in the nursing staff services increases with increase in hospital size. In 1980, in small hospitals (50-99 beds), only 39 percent of the nursing service staff were FTE RNs compared with 53 percent in hospitals of 500 beds and more.25 Conversely, the proportion of FTE LPN s decreased with increasing hospital size, dropping from 23 percent of the nursing personnel of small hospitals to 15 percent in the largest hospitals. On the other hand, the proportion of FTE aides and other nursing personnel remained fairly constant in hospitals of different sizes. The ratios of RNs to other nursing personnel in hospitals and other settings suggest only part of the complex problem of differing roles and responsibilities. In its 1980 annual survey, the AHA for the first time delineated two categories of RNs--those who function in staff and head nurse positions in hospitals and those who function in *The number of full-time equivalent personnel (FTE) is calculated by adding half the number of persons employed part time to the actual number of those employed full time.

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34 management and clinical nurse specialist positions. In contrast to the wide variations in overall nursing service staff mix cited above, in general and chronic disease hospitals of all sizes and geographic locations, administrative and clinical specialist RNs consistently make up approximately 7-8 percent of the total nursing personnel. This means that in hospitals that have fewer total RNs to begin with, an even smaller number of KNs at the staff and head nurse level are available to deliver patient care. For example, when, for purposes of analysis, the advanced nurse positions are removed from the overall nursing personnel staff mix, RNs constitute only 15 percent of the nursing personnel in chronic hospitals compared with 42 percent in general hospitals, and RNs are only 32 percent of the nursing personnel in small hospitals compared with 44 percent in hospitals of 500 beds or more. Variation Within States and Within Institutions National averages conceal a range of staffing patterns among hospitals of the same general type in the same state. For example, among 88 community hospitals in Virginia having patient care patterns more or less conforming to the national average and responding to a 1978 staffing survey, two had all RN nursing staffs, one had only RNs and aides, seven had only RNs and LPNs, and the remaining 78 had the traditional mixes of all three types of nursing service personnel.26 The proportions of RN staff can be expected to be adjusted to the types of services provided. Thus, staffing patterns vary greatly among the different nursing units of any individual institution. In some large public hospitals, as much as three-quarters of the available total RN staff are assigned to intensive care units and emergency services, their general care patients being left with only skeleton RN coverage.27 In hospitals and nursing homes alike, the proportion of RNs to LPN s and aides is reported to be considerably higher during daytime shifts. There are frequent anecdotal reports of LPNs serving as charge nurses on night shifts. The numbers and ratio of RN staff to other nursing personnel are obviously a strong determinant of the functions that RNs have time and resources to perform. These factors in relation to patients' nursing Needs largely determine their actual day-to-day responsibilities and roles. For example, at one extreme, when a nursing home has only one RN for one 8-hour shift to serve 100 patients, about 40 percent of whom require intensive nursing care, this nurse's time will be mainly occupied by supervision and paperwork.* KNs in such settings have . . Tithe National Nursing Home Survey in 1977 reported that 43.8 percent of residents "had received intensive nursing care" within the 7 days immediately preceding the survey. (Some measures of "intensive nursing care" included oxygen therapy, intravenous injections, and catheterizations.) From DHHS, NCHR. Nursing home utilization in California, Illinois~ Massachusetts, New York, and Texas: 1977 national nursing home survey (see Reference 3 for complete citation).

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40 TABLE 3 Percent of Experienced Staff Nurses in Hospitals Reporting Performing Activities That Indicate Independent Judgment, by Highest Educational Preparation, November 1980 Associate Bacca Activity Diploma Degree laureate Activities indicating . independent judgment Obtaining health histories Performing physical examinations using instruments (e.g., stethoscope, otoscope) Performing some proportion of examinations Instructing patients in management of defined illness 67 Instructing patients in health maintenance Primary responsibility for follow through on care Assisting activities 65 71 63 17 43 Assisting during patient exams 70 Administering medications 78 Sustaining and supporting persons during diagnosis or therapy Implementing therapy 18 47 70 63 50 62 57 75 81 72 59 67 67 48 56 71 57 59 SOURCE: Study analysis of data from National Sample Survey of Registered Nurses, November 1980. nurse, those with baccalaureate and diploma preparation were more apt to be occupied in record keeping and other kinds of responsibilities that drew them away from direct patient care. A parallel analysis of the responses of RN staff nurses in hospitals with only 1-5 years of experience also showed little difference in the percentage of nurses performing the various activities according to their educational background.* *These results and other details on the differentiation of RN employment, activity, and salary according to type of educational preparation may be found in Bauer, K.G., and Levine, E. Analysis of career differences among registered nurses with different types of nurse education. Background paper by the Institute of Medicine Study of Nursing and Nursing Education. Available from Publication-on- Demand program, National Academy Press, Washington, D.C., 1983.

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41 Debate Over Appropriate Generalist Nurse Education Over the past two decades, there has been considerable controversy about the desirability of continuing three separate education pathways to prepare students for professional licensure as RNs and also about the role of education programs preparing students for practical nursing. Nursing leaders, through their professional association, the American Nurses' Association (ANA), have since 1965 been advocating a formal differentiation in the roles and titles of graduates of the AD and baccalaureate programs.* ANA takes the position that a baccalaureate degree in nursing should be the minimal educational preparation for entry into professional nursing practice. It holds that the AD graduate should be prepared for "technical" practice, should have a more limited scope of practice (as yet unspecified), and should function with direction from the baccalaureate prepared nurse. Although the ANA is silent on diploma programs currently preparing for RN kc ensure and on programs currently preparing for LPN licensure, by implication there would be no future place for either. The ANA position derives from a statement of principles developed in 1965 that "the education for all who are licensed to practice nursing should take place in institutions of higher learning," and that "minimum preparation for technical nursing practice at the present time should be an AD education in nursing."38 In 1978, the ANA House of Delegates adopted the following formal resolutions to advance its position:39 that the ANA ensure that two categories of nursing practice be clearly identified and titled by 1980; ~ that by 1985 the minimum preparation for entry into professional nursing practice be the baccalaureate in nursing; and that the ANA, through appropriate structural units, work closely with state nursing associations and other nursing organizations to identify and define the two categories of nursing practice. *The American Nurses' Association is the professional organization of RNs. In August 1982 it had 163,724 members--approximately 10 percent of RNs holding active licenses. Its stated purposes are to (1) work for improvement of health standards and the availability of health care services for all people, (2) foster high standards of nursing, and (3) stimulate and promote the professional development of nurses and advance their economic and general welfare (ANA Bylaws as revised July 1982~. The ANA also sponsors the American Academy of Nursing, the American Nurses' Foundation, and the Nurses Coalition for Action in Politics (N-CAP). In July 1982, the ANA House of Delegates adopted bylaws that change the ANA from an individual membership organization to a federation of state constituent members. The new federation structure will be fully operational in July 1984.

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4~ Most recently, in 1982 the ANA House of Delegates directed that "ANA move forward in the coming biennium to expedite implementation of the baccalaureate in nursing as the minimal educational qualification for entry into professional practice." Hospitals and nursing home organizations, organizations representing AD and diploma RNs and their education programs, and organizations of practical nurses have opposed the ANA position. They believe that the current diversity of educational pathways responds to the needs of diverse practice settings where different kinds and mixes of nursing service personnel are employed. For example, the most recent official position of the AHA House of Delegates, adopted in August 1982, is that "the American Hospital Association reiterates its support for all three types of programs of nursing education: associate, diploma and baccalaureate. All three are needed to provide an adequate supply of nurses for hospitals."40 At the same time, the AHA and other employers of nurses recognize the need for many nurses prepared for responsibilities in an ever more sophisticated health care system and support the goal of individual nurses to advance their education. Some nursing organizations take somewhat intermediate positions. In February 1982, the Board of Directors of the NAN, which accredits practical, diploma, AD, and baccalaureate nursing education programs, adopted a statement that explicitly supports the retention of all current types of nurse education programs and the current system of state licensure but nevertheless recognizes the goal of baccalaureate preparation for entry into professional practice.41 The controversy over the education to be required for entry into professional practice has divided nursing, particularly in its influence at the state level, where legislation to change current nurse practice acts would usually be required to implement a position limiting entry into professional practice. Such legislation has been introduced in some states but not enacted. Established differentiation of employment and titles among RNs prepared in the three types of programs has not yet occurred but may well evolve in the future. It is unclear at this time whether it would be more likely to occur through changes in laws, through professional certification, through the natural functioning of the marketplace, or through some combination of approaches. Public health and community health agencies have long given preference to baccalaureate nurses, as have the military and veterans hospitals. In site visits to university medical centers and teaching hospitals, the study found many instances in which nursing service directors, recognizing the potential career growth not~nti ~1 of h~rr~1 Or graduates, sought to employ levels of responsibility. ~ r ~ ~^ ~ -~ GC&~C them exclusively or for certain defined this impression was confirmed in a recent report of the Association of Academic Health Centers on the impact of changes in federal policy on academic health centers. The report noted that almost all hospital administrators interviewed in its survey voiced complaints over the amount of orientation time needed for the newly graduated nurses they employ who have come from baccalaureate and AD

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43 degree programs. But it also noted that almost all university hospital administrators expressed a preference for baccalaureate, if not master's degree, nurses for the staffing of intensive care and other specialized patients care units, and for nurse supervisory and administrative positions.42 By means of job counseling and response to promotional opportunities, nursing students and RNs who have graduated from other programs may find that future career progression in large hospitals may be conditional on earning the baccalaureate degree in nursing. Thus, to the extent that baccalaureate graduates increasingly establish their value to hospitals and to other nursing employers, position and salary differentiation can be expected to respond to market forces, as in other occupations. Responsibilities of Advanced Level Nurses A large proportion of RNs occupy important leadership positions in many aspects of nursing service and nursing education. To cite but a few examples, directors of nursing service and their assistants often manage multi-million-dollar nursing service budgets in hospitals. The nursing service staff, on the average, makes up 43 percent of total hospital personnel; it is by far the largest single personnel component. The National Sample Survey of Registered Nurses, November 1980 estimated that hospitals employed 23,100 nurses in top administrative positions and an additional 48,600 in middle management supervisory positions, while nursing homes employed more than 19,700 nursing service administrators and 14,400 nurse supervisors.43 The count of nurses who have had advanced training and who practice in one or more clinical specialties is made difficult by the variety of position titles they hold. According to the same National Sample Survey of Registered Nurses, November 1980, about 24,000 such nurses, including 5,700 nurse practitioners, provided specialized clinical support to hospital nursing services. In addition, hospitals employed 11,800 nurse anesthetists. By contrast, the nation's 19,000 nursing homes employed fewer than 1,300 clinical nurse specialists, almost all of whom were consultants.44 Of the 83,400 RNs who worked in public and/or community health in 1980, about 15,000 occupied administrative or supervisory positions and about 9,200 were some type of clinical nurse specialist, including almost 4,500 nurse practitioners or midwives.45 Another important component~of nursing is the nurse educator. Estimates from the same survey reported slightly over 37,000 nurses were instructors in nursing education programs preparing nurses for initial licensing or for graduate degrees.46 In addition, almost 16,000 nurses in hospitals and 2,000 in nursing homes reported themselves as instructors--presumably in diploma programs, conducting staff development, or continuing education programs, or with adjunct teaching appointments in academic nursing education programs.

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44 Educ at lo n f o r Advanc ed Lease 1 P o s it ion s Advanced preparation is necessary for nurses who will work in nurse education. Yet in 1980 only slightly more than 5 percent of RNs had graduate degrees in nursing. Others, in undetermined numbers, had one or another form of special non-degree training to earn either professional or institutional certif ication. Certif ication programs are offered to kNs by the ANA, by nurse specialty associations, and by some academic nursing education programs. Most certifying bodies require that applicants have substantial c linical experince in the area of their specialty within the preceding 3 years. About 10,300 RNs hold certif icates in one of the 17 nurse specialty areas for which the AM offers certif ication; about 59, 000 others hold certif icates frown one of more than 25 member bodies of the National Federation for Specialty Nursing Organizations (Appendix 4~. Many large hospitals also offer institutional certif ication to successful graduates of their various stat f development programs in some spec ial nursing f ield, such as coronary care or trauma care. Table 4 shows the highest nursing-related educational preparation TABLE 4 Di s tribut ion of Reg i st ered Nurse s Among Po s it ions in Nursing Service Management, Nurse Education, and Clinical Specialties by Highest Educational Preparation, November 1980 Associate Bacca- Doctor Title Total Degree Diploma laureate Masters ate Administrator or assistant 100.0 9.7 46.7 Consultant 100.0 8.8 39.3 Supervisor or assistant 100.0 17.4 59.8 Instructor (all nurse educators) 100.0 7.0 20.1 Nurse practitioner/ midwife 100.0 10. 5 40. 1 Clinical nurse specialist 100.0 15 . 3 36.7 Nurse clinician 100.0 14.0 43 . 9 Nurse anesthetist 100.0 19.5 55.5 TOTAL 100.0 20.2 51.1 24.0 18.2 1.4 28.2 23.2 0.5 19.4 32.2 38.2 30.1 20.2 3.4 - 2.5 19.1 0.2 27.1 0.7 26.8 13.0 2.3 23.4 23.4 1.6 5.1 0.2 SOURCE: National Sample Survey of Registered Nurses, November 1980, Table 10, p. 18 (percentages recalculated to eliminate unknowns) (see Reference 1 for complete citation).

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45 of RNs in advanced nursing positions in 1980, not including certification. To the extent that graduate education at the master's or doctoral level is considered important for the management, education, and advanced nurse specialist and consultant positions listed (which 264,258 RNs filled in 1980), there appear to be deficits in the formal educational attainments of many nurses in advanced positions. Except for those in nursing education, the great majority of such positions are filled by RNs whose highest education is a diploma or a 2=ear AD degree. Even in the field of nursing education, as will be documented in Chapter V, there is an appreciable deficit. The relatively low average level of formal educational attainment of nurses in management positions may be explained in part by larger proportions of diploma nurses being employed in small hospitals and in nursing homes. Many nurses in clinical specialist positions probably received their training in certification programs. Today, however, from testimony the cities has received, and from its analysis of the move toward post-RN programs, it is apparent that increasing numbers of diploma and AD nurses are working toward baccalaureate degrees and that increasing numbers of baccalaureate nurses are seeking graduate education. These trends and their implications for future nursing education funding policy will be discussed in Chapters IV and V. In part, they may be a response to the varied career opportunities open to nurses with Tnaster's and doctoral degrees. In part, also, they may be a response to the higher salaries earned by nurses with advanced education. The study analyzed salary data from the National Sample Survey of Registered Nurses, November 1980, according to the RN respondents' years of experience and their highest educational preparation. As can be seen in Table 5, at most levels of experience there is a small but steady increment in the median salaries from the RNs with diplomas, who rank lowest, to the KNs with graduate degrees, who rank highest. Salary differentiation among the three types of generalist nurse TABLE 5 Median Annual Salaries for Full-Time Registered Nurses, by Years of Experience and Highest Educational Preparation, November 1980 - Years of Associate Bacca Experience Diploma Degree laureate Graduate 1-2 $15,322 $15,741 $16,568 $17,367 3-5 16,440 16,714 17,178 18,653 6-10 16,955 17,475 18,210 20,773 11-15 17,179 18,528 18,898 22,117 16-20 17,490 20,870 19,569 22,997 21-25 17,915 18,086 19,965 22,352 26+ 18,040 18,393 21,100 23,851 SOURCE: Study analysis of data from National Sample Survey of Registered Nurses, November 1980.

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46 graduates is usually less than $2,000 per year. However, nurses with graduate degrees have annual salaries $2,000-$4,000 higher than nurses with lesser preparation. Federal, State, and Private Financing of Nurse Education The nation's huge annual investment in higher education has traditionally been planned and supported largely by state governments and the private sector. Collectively, state appropriations for higher education totaled approximately $23 billion in fiscal 1982.47 The federal government's support of post-secondary education has been given in two main directions. First, it has added to and disseminated fundamental knowledge by supporting research and by collecting and disseminating information. Second, since World War II, the federal government has assumed a basic responsibility to make post-secondary and vocational education available to qualified needy students for the general purpose of enriching the nation's overall resources of educated and technically skilled people. In 1982, federal appropriations for financial assistance programs to students, including Pell Grants and campus-based student aid, but not including Social Security and veterans' benefits, totaled $6.9 billion (see Chapter III). In addition to these major roles, federal support has also taken the form of technical assistance and support of innovative programs. In special circumstances and at special times when critical manpower shortages have arisen, the federal government has stepped in with specific programs to alleviate them. Such assistance has been particularly notable in health and scientific manpower legislation. It is important to view the financing of nurse education, including the Nurse Training Act and its successive amendments, in this general context. Before World War II, nurse education, with a few exceptions, was largely the responsibility of the private sector. Nurse education took place almost entirely in hospitals, often in an apprentice-type mode where formal and informal instruction of students was exchanged for the students' services in patient care. At the same time, however, schools of nursing in a few universities were establishing the models that education for RNs would follow in the postwar period, when it largely moved out of hospitals and into institutions of higher learning. Since World War II, nurse education has been increasingly supported by state and local tax dollars as the number of diploma programs (almost entirely private) dwindled and the number of AD programs in community colleges (almost entirely public) soared. Since 1970, the proportion of baccalaureate nursing programs has remained almost evenly divided between private and public colleges and universe t ies .48 , 49 Al though the federal government had been tangentially invo lved in nursing since the 1930s , the Nurse Training Act of 1964 (P.L. 88-581) was the first comprehensive federal legislation to provide funding for

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47 nurse education. In response to the 1963 report of the Surgeon General's Consultant Group on Nursing that called for more concerted federal involvement to prevent future nurse shortages, the act consolidated several existing programs and expanded the authorizattons.50 Adding Title VIII to the Public Health Service Act, it authorized (1) grants to assist in the construction of teaching facilities, (2) grants to defray the costs of special projects to strengthen nurse education programs, (3) formula payments to schools of nursing, and (4) extension of professional nurse traineeships. Subsequent enactments in 1966 (P.L. 89-751), 1968 (P.L. 90-49O), 1971 (P.L. 92-158), 1975 (P.L. 94-63), and 1981 (P.L. 97-35) reauthorized and revised provisions of the nurse training program. The current authorization expires in 1984. These successive renewals of the Nurse Training Act reflected continuing congressional efforts to ensure an adequate and properly distributed supply of nursing personnel. In recent years, they have been made in the face of moves by successive administrations of both political parties to reduce or eliminate federal funding on the grounds that the projected supply would be sufficient in its characteristics and distribtution to meet the nation's needs. Successive authorizations and shifts in appropriations have brought about changes in the kinds of programs that have been funded, in the types of students supported, and in annual budgetary allocations. These are presented in Appendix 2 and discussed in other chapters of the report. In summary, almost $1.6 trillion has been appropriated under the Nurse Training Act between 1965 and 1982. Of this sum, approximately 55 percent went for various forms of support to institutions and 43 percent for various forms of support for students. During this same period, under other authorities of the Public Health Services Act, about $72 million was appropriated for nursing research fellowships and grants. For 1982, appropriations under the Nurse Training Act and for nursing research programs were $50.7 million. The National Institutes of Health have also been a source of funds to support teaching costs and student stipends for nurses pursuing advanced degrees. From 1970 to 1981 inclusive about $105 million was awarded, largely to support master's degree programs and students through the National Institute of Mental Health. The full extent to which nursing students have been relying on general federal loans and other student aid programs is not known, because federal and institutional records are not kept in ways that permit such analysis. However, in 1981 about three out of five entering college freshmen who expected to enter nursing reported that they expected to receive some form of federal student aid. Finally, although most formal nurse education is no longer located in hospitals, according to an estimate by the Health Care Financing Administration, in 1979, hospitals were reimbursed approximately $350 million for nursing education under the Medicare program.51 Private sources, including students and their families, and local government funds are other major sources of nurse education financing.

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48 REFERENCES AND NOTES 1. Department of Health and Human Services, Health Resources Administration (DHHS, HRA). The registered nurse population, an overview. Fran 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. 2. Department of Health and Human Services, Health Resources Administration. Source book--Nursing personnel (DHHS Publication No. HRA-81-21~. Washington, D.C.: U.S. Government Printing Office, 1981, Table 144, p. 192. 3. Department of Health and Human Services, National Center for Health Statistics (NCHS). Nursing home utilization in California, Illinois, Massachusetts, New York, and Texas: 1977 national nursing home survey (DHHS Publication No. PHS-81-1799~. Washington, D.C.: U.S. Government Printing Office, 1980, Table 2, p. 7. 4. American Nurses' Association. Facts about nursing 80-81. New 5. York: American Journal ot Nursing company, 1951, Table IV-A-4, p. 251. DHHS, HRA. The registered nurse population, an overview. From national sample survey ot registered nurses, November 1980, 2 cit., Table 7, p. 15. 6. Ibid., Table 5, p. 13. 7. Ibid., Table 1, p. 9 and Table 2, p. 10. 8. Department of Health and Human Services, Health Resources Administration. Statistics on hospital personnel, from the American Hospital Association's 1980 annual survey of hospitals. Paper presented for the Interagency Conference on Nursing Statistics Exhibit at the American Nurses' Association Convention, Washington, D.C., June 1982. 9. Department of Health and Human Services National Center for Health Statistics. The national nursing home survey: 1977 summary for the United States (DHHS Publication No. - PHS-79-1974~. Washington, D.C. : U.S. Government Printing Office, 1979, Table 10, p. 17. 10. DHHS, NODS. Nursing home utilization in California, Illinois, Massachusetts, New York, and Texas: 1977 national nursing home survey. 9~. cit., Table 2, p. 7. 11. American Nurses' Association. Facts about nursing 80-81. Op. cit., Table IV-A-4, p. 251. 12. National League for Nursing. NLN nursing data book 1981 (Publication No. 19-1882~. New York: National League for Nursing, 1982, p. 187. 13. DHB , BRA. Statistics on hospital personnel, from the American Hospital Association's 1980 annual survey of hospitals, Op. cit., Table 1.

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49 14 . DHHS, NCHS . The net lone l nursing home survey: 19 7 7 summary f or the United States, En. cit., Table 10, p. 17. 15. DHHS, BRA. Statistics on hospital Personnel, from the American _ Hospital Association's 1980 annual survey of hospitals, ~ cit., Table 1. 16. Aydelotte, M.K. Nurse staffing methodology: A review and critique of selected literature (DHEW No. NIH-73-433). Washington, D.C.: U.S. Government Printing Office, 1973. 17. Department of Health and Human Services, Health Sources Administration. Factors affecting nurse staffing and acute care hasp itals: Review and critique of the literature ~ Report _ No. 81-10~. Hyattsville, ~ ~ dearth Resources Administration, 1981. 18. Christman, L. A micro-analysis of the nursing division of one medical center. In M.L. Millman (Ed.), Nursing personnel and the changing health care system. Cambr idge, Mass .: Ballirlger Publishing Co., 19780 19. Site visit to Kings County Hospital, Brooklyn, N.Y., by staff of the Study of Nursing and Nursing Education, National Academy of Sc fences, May 1981. 20. DHHS, HRA. Statistics on hospital personnel, from the American Hospital Association's 1980 annual survey of hospitals, Op. cit., Tabl e 1 . 21. DHHS, NCHS. The national nursing home survey: 1977 sublunary for the United States, Op. cit., Table 10, p. 17. 22. Flagle, C.D. Issues in staffing long-term care activities. In M.L. Millman (Ed.), Nursing personnel and the changing health care system. Cambridge, Mass.: Ballinger Publishing Co., 1978. 23. DHHS, ~A. Statistics on hospital personnel, from the American Hospital Association's 1980 annual surv~y_of hospitals, Op. cit @ Table 7. Ibid., Table 4. Ibid., Table 3. Virginia Hospital Association. Analysis of 1978 nursing survey questionnaire (Part I). Richmond, Va.: Virginia Hospital Association, 1979, Table 10, p. 24. 27. Site visit to New York Health and Hospital Corporation, New York, by staff of the Study of Nursing and Nursing Education, National Academy of Sciences, May 198' 28. Walsh, lI.E., Executive Director, National League for Nursing. Personal communication, March 9, 1982. 29. National League for Nursing. NLN nursing data book 1982. In press, 1982, Table 52. 30. National League for Nursing. Survey of diploma nurse education programs, 1982. In press, 1982. 31. National League for Nursing. NLN nursing data book 1981, Op. c it., Table 137, p . 138. 32. Ibid., Table 125, p. 130. 33. Ibid., Table 126 9 p. 130. 34. Ibid., p . 13 1 . 24. 25. 26.

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50 35. Knopt, L., and Vaughn, J.C. nurses: A report of Work-life behavior of regi 8 tered nurse career-pattern study (Appendix, Md. Health Resources Administration, 1979. 36. Kramer, M. Philosophical foundations of baccalaureate nursing education. Nursing Outlook, 1981, 29~4), 224-228. 37. Montag, M. Looking back: Associate degree education in perspective. Nursing Outlook, 1980, 28~4), 248-250. 38. American Nurses Association. A case for baccalaureate preparation in nursing (Publication No. NE-6. New YorK: American Nurses' Association, 1979, p. 4. Ibid., pp. 5-6. . ~, . ~. . ~ 39. 40. Assembly of Hospital Schools of Nursing of the American Hospital Association, Hospital Schools of Nursing (newsletter) September-October 1982, 15~5), 7. 41. National League for Nursing. Position statement on nursing roles--Scope and preparation (Publication No. 11-1893). New York: National League for Nursing, 1982. 42. Association of Academic Health Centers. Report of a study of the impact of changes in federal policy on academic health centers (final report). Washington, D.C.: Association of Academic Health Centers, 1982. 43. DHHS, HRA. The registered nurse population, an overview. From national sample s cit., Table 7, p. 15. 44. Ibid. 45. Ibid. 46. Ibid. 47. Chambers, M.M. Appropriations of state tax funds for operating expenses for higher education, 1981-1982. Washington, D.C.: National Association of State Universities and Land-Grant Colleges, 1981. 48. National League for Nursing. NLN nursing data book 1981 (Publication No. 19-1882~. New York: National League for Nursing, 1982, Table 2, p. 2. 49. NLN nursing data book 1982, Op. cit., Table 2. 50. Surgeon General's Consultant Group on Nursing. 51. _ _ ~ Toward quality in n~rsi~: Needs my goals (Public Health Service Publication No. ~ U.S. Government Printing Office, 1963. Patasnik, B., Health Care Financing Administration. Personal communication, July 27, 1982.