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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.
Representative terms from entire chapter:
nurse education
