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Nursing and Nursing Education Public Policies and Private Actions Division of Health Care Services Institute of Medicine NATIONAL ACADEMY PRESS Washington, D.C. 1983

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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the ~nmmitt-" -~^no;hl" F^_ The __ I._ ~A~ a__ ~ ~ a: ~_ ~ _ _~ _~ At_ V~ DING ~CiJV-1_ tVGL C ill 1 AL sneer special competences and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved bv a Renort Review Cnmmi tt-- consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. ~r ~ The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of Policy matters Dertainin~ t~ the health of the public. A ~ _ I __ I ~ ~ ~ ~. In this, the Institute acts under both the ^~au=.~ ~ boar congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. This study was supported by U.S. Department of Health and Human Services Contract No. 282-80-0043, T.O. 7. Library of Congress Catalog Card Number 83-60053 International Standard Book Number 0-309-03346-2 Available from NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, D.C. 20418 Printed in the United States of America First Printing, January 1983 Second Printing, October 1983 Third Printing, August 1985 Fourth Printing, May 1988

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COMMITTEE ON NURSING AND NURSING EDUCATION Arthur E. Hess, Chairman Scholar-in-Residence, Institute of Medicine Washington, D.C. Ira Trail Adams, Dean and Professor, University of Tulsa, College of Nursing, Tulsa, Oklahoma Linda H. Aiken, Vice President for Research, The Robert Wood Johnson Foundation, Princeton, New Jersey Stuart H. Altman, Dean, The Florence Heller Graduate School for Advanced Studies in Social Welfare, Brandeis University, Waltham, Massachusetts Karen W. Beaver, Director-Professor, Practical Nursing Program, Weber State College, Ogden, Utah Harry J. Bolwell, Chairman and Chief Executive Officer, Midland-Ross Corporation, Cleveland, Ohio Otis R. Bowen. Professor and Director, Undergraduate Family Practice Education, Indiana University School of Medicine, Indianapolis, Indiana Roger J. Bulger, President, University of Texas Health Science Center at Houston, Houston, Texas Saul J. Farber, Professor and Chairman, Department of Medicine, New York University, New York, New York William C. Fetch, Practicing Internist, Rye, New York Charles D. Flagle, Professor and Head, Division of Operations Research, Department of Health Services Administration, Johns Hopkins University School of Hygiene and Public Health, Baltimore, Maryland . .

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David H. Jeppson, Executive Vice President, Intenmountain Health Care, Inc., Salt Lake City, Utah Carol Lockhart, Director, Division of Health Resources, Arizona State . Department of Health Services, Phoenix, Arizona Gabrielle D. Martel, Vice President of Nursing, Northwestern Memorial Hospital, Chicago, Illinois Dorothy J. Novella, Vice President for Academic Affairs and Dean, Erie Institute for Nursing, Villa Maria College, Erie, Pennsylvania Virginia L. Olesen, Professor of Sociology, Department of Social and Behavioral Sciences, University of California, San Francisco, California Edward B. Perrin, Director, Health and Population Study Center, Battelle Human Affairs Research Centers, Seattle, Washington Elliott C. Roberts, Sr., Director, Cook County Hospital, Chicago, Illinois Isabel V. Sawhill, Senior Fellow, Employment and Labor Policy, The Urban Institute, Washington, D.C. Edyth H. Schoenrich, Associate Dean, Johns Hopkins University School of Hygiene and Public Health, Baltimore, Maryland Stechen M. Shortell. A.C. Buehler Distinguished Professor of Hospital and Health Services Management, J.L. Kellogg Graduate School of Management, Northwestern University, Evanston, Illinois Judy Solkovits, President, United Teachers--Los Angeles, Los Angeles, California John D. Thompson, Professor of Public Health and Chief, Division of Health Services Administration, Yale University School of Medicine, New Haven, Connecticut Frances D. Tomokins. Director of Nursing, Union Memorial Hospital Baltimore, Maryland Robert A. Wallhaus,* Deputy Director for Academic and Health Affairs, Illinois Board of Higher Education, Springfield, Illinois * From April 1981 to January 1982. iv

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Ruby L. Wilson, Dean and Professor, School of Nursing, Duke Durham, North Carolina University, Robert C. Wood,* Director of Urban Studies, Professor of Political Science, University of Massachusetts, Boston, Massachusetts From January 1982. v

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INSTITUTE OF MEDICINE Frederick C. Robbins President Study Staff Katharine G. Bauer Study Director and Senior Professional Associate Michael Millman, Senior Staff Officer Barbara Smith, Senior Research Associate Julia Bander, Staff Officer Sunny Yoder, Staff Officer Ilissa Light, Research Associate Deborah Parham, Research Associate Jessica Townsend, Professional Associate Sandra H. Matthews Administrative Assistant Virginia Ingram, Administrative Secretary Patricia King, Administrative Secretary Talitha Shipp, Word Processing Specialist Principal Consultants Eugene Levine Judith Ottoson Margaret D. West Daniel I. Zwick Hi

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Contents PREFACE ACKNOWLEDGMENTS SUMMARY AND RECOMMENDATIONS xv XXI 1 CHAPTER I NURSING SERVICES AND NURSING EVOCATION: AN OVERVIEW 24 The Diversity of Registered Nurses' Responsibilities, 24 Variety of Nursing Service Personnel, 26 Variations in Nursing Service Staff Mix, 29 Education for Registered and Practical Nurses, 35 Relation of Type of Generalist Nurse Education to Licensure and Practice, 37 Debate Over Appropriate Generalist Nurse Education, 41 Responsibilities of Advanced Level Nurses, 43 Education for Advanced Level Positions, 44 Federal, State, and Private Financing of Nurse Education, 46 CHAPTER II MEETING CURRENT AND FUTURE NEEDS FOR NURSES Current Supply and Demand, 52 Future Supply and Demand, 63 Supply of Registered Nurses Educated in the Three Types of Generalist Programs, 7 7 State and Local Planning for Generalist Nurse Education, 80 CHAPTER III THE EFFECTS OF EDUCATION FINANCING ON GENERALIST NURSE SUPPLY Student Decision Making, 90 State and Institutional Decision Making, 104 51 89 CHAPTER IV EDUCATION FOR GENERALIST POSITIONS IN NURSING 116 Attracting New Kinds of Students, 116 Opportunities for Educational Advancement, 119 Collaboration Between Education and Service, 126 ~ VII

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CHAPTER V EDUCATION FOR ADVANCED POSITIONS IN NURSING Advanced Education for Nursing Administration, 133 Advanced Education for Teaching and Research, 135 Advanced Education for Nurse Specialists, 138 Interrelationships Among Types of Advanced Education, 140 The Need for More Nurses With Graduate Education, 141 The Effect of Financing on Future Supply, 146 Statement of Exception to Recommendation, 151 CHAPTER VI ALLEVIATING NURS ING SHORTAGES IN MEDICALLY UNDERSERVED AREAS AND AMONG UNDERSERVED POPULATIONS Some Reasons for Areas of Underservice, 158 The Nature and Consequences of Underservice, 158 Educational Outreach, 160 Education Opportunities for Minority Students, 164 Adequate Revenues for Inner-City Hospitals, 168 Nursing Education for Care of the Elderly, 171 Upgrading Existing Staff in Nursing Homes, 173 Adequate Payment for Long-Term Care, 175 Lowering Barriers to Expanded Nurse Practice, 178 Financing Recommended Actions, 182 CHAPTER VII IMPROVING THE USE OF NURSING RESOURCES The Effects of Management Decisions on Supply and Demand, 190 Job Turnover and Attrition in Nursing, 191 Improving Career Opportunities and Working Conditions, 195 Inactive and Part-Time Nurses, 202 Accounting for Nursing Services, 209 CHAPTER VIII ADVANCING RESEARCH IN NURSING AND GETTING FACTS FOR MANPOWER PLANNING Improving the Nation's Nursing Research Capacity, 215 Comparative Competencies of Registered Nurses WitI, Different Educational Preparation, 217 Evaluation of Promising Management Approaches, 221 Information to Monitor Supply and Demand, 223 viii 133 157 190 215

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APPEND IXE: S 1 CONGRESSIONAL C~GE--E~RPTS FROM PUBLIC LAW 96-76 2 APPROPRIATIONS UNDER THE NURSE TWINING ACT 3 SUMMARY OF INFORMATION ON STATE REPORTS OF NURSING ISSUES 4 CERTIFICATES FOR SPECIALIST REGISTERED NURSES 5 PROJECTIONS OF REGISTERED NURSE SUPPLY REQU IREMENTS 6 DOCTORAL PROGRAMS IN NURS ING: ILLUSTRATIVE STATEMENTS OF PURPOSE FROM SCHOOL CATALOGS 7 MULTIV=IATE ANALYSIS OF DETERMINATION OF WOW STATUS AND WAGE RATES 8 NURSING RESEARCH: DEFINITIONS AND DIRECTIONS 9 PARTICIPANTS IN THE STUDY' S WORKSHOPS AND ADVISORY PANELS LISTING OF BACKGROUND PAPERS TABLE S 1 Examples of the Responsibilities of Hospital Nursing Service Personnel 2 Percent Distribution of Registered Nurses Aged 35-39 Years in Selected Types of Employment According to Their Highest Levels of Educational Preparation, November 1980 ix 228 230 237 253 261 283 288 297 301 311 30 38 .,

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TABLES (continued) Percent of Experienced Staff Nurses in Hospitals Reporting Performing Activities That Indicate Independent Judgment, by Highest Educational Preparation, November 1980 4 Distribution of Registered Nurses Among Positions in Nursing Service Management, Nurse Education, and Clinical Specialties by Highest Educational Preparation, November 1980 5 Median Annual Salaries for Full-Time Registered Nurses, by Years of Experience and Highest Educational Preparation, November 1980 6 Graduations From Basic Registered Nurse Programs, 1970, 1980, and 1981 7 Proportions of Graduations From Basic Registered Nurse Programs at Age 25 or Older, by Program Type, Selected Years 8 Beds, Inpatient Utilization, and Outpatient Visits in Nonfederal Short-Term General and Allied Special Hospitals, 1970 and 1980 9 Employed Registered Nurses, by Work Setting, 1977 and 1980 10 Registered Nurses and Licensed Practical Nurses (FTE) in Hospitals, 1972 and 1980 11 Supply of Active Registered Nurses, Total and FTE, 1980, and Study Projections for 1982 and 1990 12 Department of Health and Human Services Projections of Requirements for Registered Nurses (FTE), Two Models, January 1990 x 40 44 45 55 56 57 58 59 65 69

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13 Study's Illustrations of Projected Demand for Registered Nurses, Total and FTE, 1990, Under Three Sets of Assumptions 72 14 Study's Illustrations of Projected Demand for Registered Nurses (FTE) in Selected Practice Settings, December 1990, Under Three Sets of Assumptions 73 15 Summary of the Study's Alternative Projections of the Supply of and Demand for Registered Nurses (FTE), December 1990 16 The Supply of Employed Registered Nurses, 1980 and Projected to 1990, by Highest Educational Preparation (Study's Intermediate Projection) 17 Percent Distribution of Active Registered Nurses in 1990, by Highest Educational Preparation, Study's Intermediate Projection, Compared With DHHS WICHE Lower Bound Projection of Need 18 Expert Panels' Judgment of Required Nursing Staff for Hospital Inpatient Services, U.S. and Eight States, Using WICHE Methodology (Lower Bound) 19 Median Annual Tuition and Fees for Basic Nursing Education Programs, by Type of Program and Public- Private Control, 1981-1982 (dollars) 20 Average Annual Student Expenses for Books and Education Supplies by Type of Institution and Public- Private Control, Academic Year 1981-1982 (dollars) 21 Estimated Total Out-of-Pocket Education Expenses for Full-Time Students in Basic Nurse Education Programs, Academic Year 1981-1982, and Estimated Total Expenses to Complete Each Type of Program for a Student Entering in 1981-1982 (dollars) xi 74 77 79 82 91 93 93

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TABLES (continued) 22 Estimated Annual Living Expenses for Resident, Commuter, and Self-Supporting Students, by Type of Education Institution, 1981-1982 Academic Year 23 Estimated Family Income Distribution of First-Time, Full-Time Freshmen, Fall 1981 24 Sources of Financial Support for Nursing Students Who Were First-Time, Full-Time Freshmen in 1981 25 Federal Appropriations for Higher Education, Selected Programs, Fiscal Years 1981-1983 (in millions of dollars) 26 Nurse Training Act Scholarship and Loan Funds Awarded to Basic Nursing Education Programs, by Type of Program, Fiscal Years 1965-1979 27 Current-Fund Revenues of Institutions of Higher Education, by Source, Fiscal Year 1980 (in thousands of dollars) 28 Comparison of the Study's Projected Supply of Employed Registered Nurses With Graduate Degrees in 1990 With DHHS Estimates of Need Derived From Judgment-of-Need (WICHE) Model 29 Financial Support Received During Doctoral Study by Nurses With Doctorates in 1980 30 Average Hourly Salaries of Selected Hospital Workers in 21 SMSAs, 1975, 1978, 1981 31 Index of Average Hourly Salaries of Selected Hospital Workers in 21 SMSAs Relative to General Duty Registered Nurses' Salaries, 1975, 1978, 1981 ~ X11 94 97 ' 99 100 103 105 145 147 199 200

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32 Scores on the 1977 Licensure Examination of Candidates from Diploma, Associate Degree, and Baccalaureate Degree Programs FIGURES 1 Where registered nurses worked in 1980 2 Mix of full-time equivalent personnel providing nursing services in U.S. registered hospitals and in SNF nursing homes 3 Trends in number of graduates of programs preparing for registered nurse licensure, 1960-1981 4 The 1980 population of nurses graduated from basic programs preparing for registered nurse kc ensure, by age 5 Registered nurse labor force participation, by age, 1949, 1960, and 1980; all graduates of programs preparing for registered nurse licensure Employed registered nurses per 100,000 population by regions of the United States, 1962, 1972, 1977, and estimated 1980 ~ Employed registered nurses and licensed practical nurses (FTE) per 100,000 population, by state, 1977 8 Supply of active registered nurses (FTE), 1970-1980, with study projections to 1990 9 Demand for registered nurses (FTE) 1970-1980 (actual) with three illustrative study projections to 1990 10 Comparison of the projected supply of and demand for registered nurses (FTE), 1980-1990, under alternative study assumptions ~ x~, 219 27 32 36 53 54 61 62 66 72 75

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FIGURES (continued) 11 Supply of active registered nurses, 1990, by age and educational preparation (study's intermediate projection) 78 12 Contribution of educational mobility to the 1980 pool of employed RNs with baccalaureate or higher degrees Contribution of educational mobility to the 1980 pool of employed RNs with master's and doctoral degrees 14 Characteristics of registered nurses not employed in nursing, November 1980 x~v 122 123 192

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Preface This is the final report of a two-year study of nursing and nursing education undertaken early in 1981 by the Institute of Medicine of the National Academy of Sciences. The study, contracted by the Department of Health and Human Services, was mandated by Public Law 96-76, the Nurse Training Act Amendments of 1979. The study was prompted by controversy in the late 1970s as to whether further substantial federal outlays for nursing education would be needed to assure an adequate supply of nurses. The intent of the congressional mandate as expressed in the legislative history was to secure an objective assessment of the need for continued federal support of nursing education programs, to make recommendations for improving the distribution of nurses in medically underserved areas, and to suggest actions to encourage nurses to remain active in their profession. Over an 18-year period beginning in 1965, more than $1.6 billion was appropriated under the Nurse Training Act. Programs were established and periodically revised with the primary intention of expanding the supply of nurses but also to improve the quality and distribution of this supply. This was accomplished by increasing the capacity of educational institutions, providing student financial assistance, and increasing the opportunities of nurses to obtain one or another form of advanced training, such as that required to become a clinical nurse specialist or a nurse practitioner. Actions by the executive branch of four successive federal administrations suggesting decreased support for nursing education have reflected a conviction that these forms of federal support for nursing education generally have outlived their usefulness, with the possible exception of small amounts of support for selected objectives such as preparing particular kinds of nurse specialists. Throughout the period, however, Congress continued to urge more generous support of nursing education and to express concern about the effects of withdrawal of federal support. Authorizations for certain of the Nurse Training Act programs that peaked in the 1970s have been continued, albeit at decreased levels of support. xv

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The Study Charge The congressional charge embodied in Section 113 of the Nurse Training Act Amendments of 1979 spelled out the purposes of this study as follows: (a)(l)(A) to determine the need to continue a specific program of Federal financial support for nursing education, (B) to determine the reasons nurses do not practice in medically underserved areas and to develop recommendations for actions which could be taken to encourage nurses to practice in such areas, to determine the rate at which and the reasons for which nurses leave the nursing profession and to develop recommendations for actions which could be taken to encourage nurses to remain in or re-enter the nursing profession, including actions involving practice settings conducive to the retention of nurses. The part of the study described in paragraph (a)(l)(A) shall include consideration of the following: (a)~2~(A) the need for nurses under the present health care delivery system and under such system as it may be modified by increased use of ambulatory care facilities or as it may be changed by the enactment of legislation for national health insurance. Determination of such need shall include determination of the need for nurses trained in each type of school of nursing (as defined in Section 853~2] of the Public Health Service Act) [a diploma school of nursing, an associate degree school of nursing, or a collegiate school awarding baccalaureate or graduate degrees in nursing], for nurses with graduate training in the varying nurse practitioner clinical specialities, and for nurse administrators and nurse educators. (B.) The cost of nursing education and a comparison of the cost of education at each type of school of nursing (as so defined) and comparison of the costs of each of the graduate programs of nursing. (C) The availability of other sources of support for nursing education, including support under general programs of Federal financial support for postsecondary education, under State and other public programs, and from private sources. xvi

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The statute also specified that final recommendations be made after a two-year study of all the considerations described in the subparagraphs, and that, if a need for continued federal financial support for nursing is found, the study was to recommend the form it should take and the basis for such recommendations. The study also was instructed to recommend actions to encourage nurses to practice in underserved areas, to remain in or re-enter the nursing profession, and to make practice settings more conducive to the retention of nurses. The study's recommendations on federal support of nursing education are addressed principally to the Committee on Labor and Human Resources of the Senate, the Committee on Energy and Commerce (previously the Committee on Interstate and Foreign Commerce) of the House of Representatives, and the Secretary of the Department of Health and Human Services. However, the fact that Congress has directed the study to consider the nation's need for various types of nurses and to develop recommendations for actions that could be taken to encourage nurses to practice in underserved areas and to remain in or re-enter the nursing profession broadens the audience to include state governments and the private sector. Nurses and nurse educators, individually and through their organizations, are a vitally important audience, as are the state commissions on higher education, many health professional associations, and other groups with a stake in the future of nursing education. Many remedial actions can be carried out only by those who set organizational, management, and personnel policies in hospitals, nursing homes, public health departments, and other agencies that employ nurses. Conduct of the Study Under a preliminary contract awarded in 1980, the Institute of Medicine established a broadly based planning committee to outline the scope and identify the major issues for study. Upon receipt of the final contract, a full study committee was constituted in 1981 to establish specific policies and procedures for the study staff, to carry on continuing deliberations, and to be responsible for the study's recommendations. In line with established practice, the committee was composed of Institute members and other nationally recognized experts with experience in analysis and the formulation of public policy as well as in other disciplines related to nursing issues. Over the period of the projects the full study committee met five times for a total of 11 days of deliberations. In addition, individual committee members have spent countless days in preparation for meetings, participation in the work of subcommittees, advisory panels, and workshops. The committee established a number of ad hoc advisory panels of additional experts to assist in specific aspects of the study. It also engaged consultants, commissioned working papers, and secured the informal participation (through its workshops and other means) of a broad selection of the nursing profession's representatives and of others with authoritative knowledge in relevant fields. Although xvii

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Institute and Academy policy precluded committee membership by official representatives or employees of national organizations with a direct interest in the outcome of the study, ample opportunity was afforded in the course of the study to obtain information and opinions from representatives of nursing and other organizations. The study began with activities required to prepare an interim report at the end of six months, as called for in the statutory mandate. An extensive literature search was conducted; subsidiary questions relating to the congressional charge were developed and explored; an open meeting was held on May 18, 1981, at which individuals and representatives of organizations concerned with nursing testified; and written statements, data, and recommendations were solicited and received from a wide range of groups and individuals. Seventy-five recent state level studies of nursing were identified, collected, and analyzed; working papers were prepared on numerous issues pertinent to understanding nurses' satisfaction and dissatisfaction with various conceptions of nursing roles; a detailed review was conducted of survey and inventory data dealing with the characteristics and requirements of education and employment settings for both registered nurses and licensed practical/vocational nurses; and an analysis was begun of the assumptions and methods employed by the Department of Health and Human Services and by states to project the future needs and the future supply of nurses. On August 5, 1981, the study's interim report was transmitted to the Congress and to the Secretary and was made available for public consideration. Comments were received from numerous individuals and organizations. These were reviewed by the committee and staff and were taken into account during the conduct of subsequent study activities. Many activities begun earlier continued throughout the balance of the study. In addition, major workshops were conducted on the economics of nursing and graduate nursing education; ad hoc advisory panels were appointed, and members participated in group meetings and in individual consultations during the course of the study. The study staff also kept in touch with new developments in the nursing field by means of site visits in ten states and attendance at selected conferences and meetings. In particular, close liaison was maintained with the National Commission on Nursing, a study group of officials and members of national health associations and organizations, which concurrently was addressing crucial professional issues in nursing. A Note About Data The following advice from the former Committee for Interstate and Foreign Commerce of the House of Representatives is included in its report on the legislation in which the study was mandated: It is the committee's intent that the required study concentrate on review and analysis of ongoing studies and available information respecting nursing education xviii

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and the existing and potential supply and demand for nurses, rather than a wholesale duplication of present undertakings. . . . unavailable in the detail Thus, major new data collection efforts were explicitly discouraged. Instead the study based its findings primarily on its syntheses and interpretation of data secured from many existing sources. We found certain important information to be outdated or desired. Generally, there is a lag of several years between the conduct of national nursing surveys and the availability of their results. For example, both the study's interim report of July 1981 and the Secretary's Third Report to Congress in February 1982 had to rely on survey data collected in 1977. Fortunately, for this final report we have been able to draw on the results of a parallel survey of registered nurses, conducted in November 1980, made available to us during the summer of 1982. Other sources of data providing new information also became available during the latter part of the study period. In addition to the 1977 and 1980 sample surveys, the study's analyses draw on data from a great variety of other sources, referenced throughout the text. A few major ones deserve special mention: American Hospital Association, Annual Survey of Hospitals; American Nurses' Association, 1977 Inventory of Registered Nurses; National Center for Health Statistics, National Nursing Home Survey 1977; and National League for Nursing Annual Survey of Schools of Nursing, and Annual Survey of Newly Licensed Nurses. Organization of the Report After an introductory chapter that provides the reader with background on the diversity both of nurses' roles and of nurse education programs, the report focuses on the particular components of the study charge. Chapters II through V deal with various aspects of the first study question: Is there a need for continued federal support for nurse education? Chapter II reports the committee's findings on whether the aggregate supply of generalist nurses will be sufficient to meet future demand, and how changes that could occur in the health care system might affect demand. Chapter III discusses how the current and future supply of nurses may be influenced by the costs of nursing education and the sources of education financing. Chapter IV discusses education for generalist positions in nursing, and particularly the policies and practices in nursing education that affect the future supply of new nurses and the opportunities for educational and career advancement for those already in the work force. Chapter V examines the supply and demand situation for nurses educationally prepared for advanced professional positions in nursing. The second major study question--how to alleviate shortages of nurses in underserved areas and for underserved populations--is dealt with in Chapter VI. The third study question--how to improve retention of nurses in their profession--is addressed In Chapter VII in Ax

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conjunction with an analysis of how employer policies and management practices in the utilization of nursing resources influence demand and supply. The report concludes with an examination in Chapter VIII of the nation's nursing research resources and needs. This chapter identifies areas in which further data and studies are required to improve capabilities for monitoring the nation's supply of and demand for nurses, and to guide national and state planning for nursing education. The committee recognized a number of problems that, although important, after further consideration seemed not to require elucidation to answer the congressional questions and were not otherwise within the scope of the report's intent. Also, in some instances, where evidence was equivocal, we have presented data without conclusions. Moreover, we were sensitive to the fact that we should not address at a level of national policy those matters that need to be resolved through the interplay of professional and market forces. Examples include equal pay for comparable work; collective bargaining for nursing; relationships between nurses and physicians; jurisdictional and professional issues of credentialing, including specialty certification; and questions of staffing substitution and production function analysis. On the issue of what education pathways provide appropriate preparation for entry into professional nursing practice, we found ambiguity in the evidence about how well graduates of the various nurse education programs that prepare students for registered nurse licensure subsequently meet various employment needs, and disagreement among those who are professionally and managerially involved in the delivery of health care. We could reach no conclusions on this issue. We do, however, present information bearing on the question and present recommendations for research needed to enlighten policymakers. It is our conviction that this issue essentially involves matters for the profession, employers, and others to work out through collaboration of national organizations as well as in the marketplace and in the states--the arenas in which most resource allocation decisions for health education programs take place. The study has not considered the needs of the Veterans Administration or the Department of Defense for nursing personnel. To the extent that their present requirements are reflected in current supply-demand data, their normal peacetime needs may be assumed in our projections for the future. Additional requirements they may have, however, for augmented numbers or special education of RNs are properly within the purview of their manpower planning and appropriations. A study of such scope and detail as this depends for its successful conclusion on the good-spirited labors of many people. I hope that all of them are named somewhere in these pages--the members of a superbly dedicated study committee and study staff, the consultants, the work- shop panels, and those in the agencies and professional organizations who are listed on a separate page of acknowledgments. The strength of this report borrows something from the devotion of each person who worked on it. Arthur E. Hess Chairman . . xx

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Acknowled~nents - The committee and its staff are indebted to many individuals and organizations for thoughtful contributions made to various aspects of the study. The members of the committee's five advisory panels and the participants in its two workshops (Appendix 9) gave generously of their time to share their wisdom and experience. Special thanks are due to Myrtle Aydelotte, who contributed an important background paper to the project. She, Robert Derzon, Vernice Ferguson, Wayne Kirschling and Donald Yett took part in two or more panels and workshops, bringing insights that were particularly valued. We also want to extend our appreciation to Walter Johnson, John Vaughn, and Lucille Knopf at the National League for Nursing; to Judith Yates and Pauline grimmer at the American Nurses' Association; to Marian Murphy at the American Association of Colleges of Nursing; to Eileen McQuaid Dvorak at the National Council of State Boards of Nursing; to Gail Crossley at the National Association of Nurse Recruiters; and to Lucille Etheridge, formerly at the National Association for Practical Nurse Education and Service. At the American Hospital Association, Ross Mullner and Jane Gibson were most helpful. We have also enjoyed and profited from a continuing close contact with the staff and members of the National Commission on Nursing during the course of the study, for which we owe special thanks to Robert Cathcart and to Marjorie Beyers. Manv people in the Department of Health and Human Services Rave us - --~ L - - ~ - ~ _ valuable assistance. We are particularly grateful to Jo Eleanor Elliott and her associates in the Division of Nursing for providing background on the Nurse Training Act programs. We also want to thank a number of people from the Division of Health Professions Analysis. The director, Howard Stambler, was most helpful in ensuring our access to many sources of information important to the study; Evelyn Moses and William Spencer gave valuable technical advice on the use of the 1980 national sample survey data; John Drabek and William Losaw were a great help in adapting the department's mathematical manpower model to the committee's specifications. At the Department of Education, Salvatore Corrallo guided us to useful sources of information on the costs and sources of financing of education. Finally, we would like to express special appreciation to Robert Walkington, our project officer at the Department of Health and Human Services, and to Karl Yordy, director of the Division of Health Care Services at the Institute of Medicine, for their helpful suggestions at every stage of the study. Katharine G. Bauer Study Director XXI

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