Nursing and Nursing Education Public Policies and Private Actions (1983) / Chapter Skim
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CHAPTER VI ALLEVIATING NURSING SHORTAGES IN MEDICALLY UNDERSERVED AREAS AND AMONG UNDESERVED POPULATIONS
CHAPTER VI ALLEVIATING NURSING SHORTAGES IN MEDICALLY UNDERSERVED AREAS AND AMONG UNDESERVED POPULATIONS
Pages 157-189
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From page 157... ...
" The committee viewed these issues as being more extensive than would be implied by statutory or regulatory definitions of the term "medically underserved areas." We believed that this question called for an exploration of the problems of maldistribution as they affect certain geographic areas, certain population groups, and certain types of facilities that experience chronic nurse shortages resulting in underservice to large numbers of patients. This chapter focuses on availability of the services of nurses to residents of inner cities and rural areas, to minority ethnic groups and elderly citizens, and to patients in public hospitals and nursing homes.
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From page 158... ...
While it was not within our purview to address these fundamental problems, the study necessarily became concerned with their implications as principal factors in the maldistribution of nursing personnel. In this context, the committee has responded to the request for suggestions likely to help alleviate existing nurse shortages in medically underserved areas.
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From page 159... ...
Minority, immigrant, and other low-income populations in many urban areas of the nation also can lack access to health care. Large concentrations of these people are found in inner city areas, where nursing and other health care services present
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From page 160... ...
A disproportionate number of inner-city residents have incomes below the poverty level, 17 percent versus 12 percent of the total United States population.15 Cover the years the federal government has defined geographic areas of underservice using a variety of criteria. The areas have been variously delineated as Medically Underserved Areas, Health Manpower Shortage Areas and Nurse Shortage Areas.
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From page 161... ...
Nurse education programs are not required to keep records or report on where their graduates practice. A second strategy -- facilitating nurse education for those most likely to work in underserved areas -- is built on the assumption that people who already live in such areas are more likely to remain than are those attracted for a limited tour of service.
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From page 162... ...
The programs are offered through arrangements with existing educational and health care institutions to increase courses and to offer training experiences at hospitals and other sites in and near rural and urban underserved areas. Nursing education has received special attention in the AHEC programs in California, North Carolina, Massachusetts, and Colorado.21 In most states, community college systems have made considerable progress in developing locally accessible programs to prepare RNs and LPNs e However, where populations are not sufficiently dense to yield sufficient numbers of students, and where local educational resources are inadequate to provide an institutional base and faculty for the types of nurse education programs that prospective students may require, it is not economically or educationally feasible to provide
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From page 163... ...
Another approach, however -- attracting residents of shortage areas into nursing -- appears to have a greater potential for success. The committee notes that: o RNs and LPNs tend to practice in or near their places of origin; for rural areas that implies attracting into practice rural residents; for inner-city urban areas it implies attracting to nursing inner-city residents who are often poor and of minority racial or ethnic groups o RNs and LPN s tend to practice in the areas in which they received their nursing education · many potential candidates for nursing education are unable to relocate to gain access to nursing education · new forms of communication technology offer opportunities to develop outreach and satellite nurse education programs.
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From page 164... ...
RECOMMENDATION 9 To alleviate nursing shortages in medically underserved areas, their residents need better access to all types of nursing education, including outreach and off-campus programs. The federal government should continue to cosponsor model demonstrations of programs with states, foundations, and educational institutions, and should support the dissemination of results.
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From page 165... ...
27 The National Sample Survey of Registered Nurses, November 1980, found that minorities have high labor force participation rates, so that increasing their access to nurse education appears to be a good investment.28 The rate for whites was 76 percent, for blacks 90 percent, for Hispanics 86 percent, and for Asian and Pacific Islanders 91 percent.29 Minority nurses, both RNs and LPNs, constitute a large percentage of the nursing staffs in public general hospitals in the inner city, which serve large numbers of minority patients. Another major advantage of increasing minority representation in the nursing labor force would be that minority patients could be served by those best able to understand minority cultures and languages.
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From page 166... ...
The Nursing Student Scholarship Program, although not designed as an effort to improve access to education for those likely to serve in shortage areas, may have assisted that effort more than the programs specifically designed for that purpose. The program was first authorized in the Allied Health Professions Personnel Training Act of 1966 and continued in the Health Manpower Act of 1968, the Nurse Training Acts of 1971 and 1975, and the Nurse Training Act Amendments of 1979.
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From page 167... ...
Special efforts must be made to reduce financial barriers to nursing education for residents of such areas, to offer reasonable opportunities for future employment in these areas, and to accustom students to the situations they are likely to encounter in providing nursing services in these areas. In addition to general educational outreach efforts, nurse educators and health care employers can improve access to nursing education in underserved areas by cooperating to develop programs to ensure that students are recruited from minority groups, that they will be given special consideration for employment, and that they gain clinical experience in shortage area facilities, e.g., rural and inner-city hospitals, nursing homes, and public health clinics.
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From page 168... ...
They can make major contributions to the screening and evaluation of proposals as well as ongoing results. RE 0 MMENDATION 10 To meet the nursing needs of specific population groups in medically underserved areas and to encourage better minority representation at all levels of nursing education, the federal government should institute a competitive program for state and private institutions that offers institutional and student support under the following principles: · Programs must be developed in close collaboration with, and include commitments from, providers of health services in shortage areas.
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From page 169... ...
On the basis of 1976 data, it showed that in the nation's 100 largest cities, public hospitals represented slightly less than 10 percent of community hospital facilities but provided 45 percent of all ambulatory care visits (i.e., hospital clinic visits for primary care and special diagnostic or therapeutic services)
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From page 170... ...
Cook County Hospital in Chicago, for example, recently experienced an increase of transfers out of private hospitals, from about 125 to almost 400 per month.41 Nursing is a particularly serious problem for inner-city hospitals. A 1980 survey of mayors, city council presidents, and city managers of cities with public hospitals reported that next to the high costs of such hospitals the shortage of nurses was the most important health problem they faced.42 The 12 hospitals and 4 long-term care facilities composing the New York City Health and Hospitals Corporation (HHC)
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From page 171... ...
This group uses hospital, nursing home and home care services at rates double or triple those of the population as a whole.44 Only about 5 percent of the elderly are in nursing homes at any one time, although one in five will be there at some time in their lives.45 Thus the vast majority of the elderly live at home -- alone or with their families -- or in residential housing for the elderly. When these people receive nursing care it is in ambulatory clinics, physician's offices, hospitals, and sometimes at home.
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From page 172... ...
For example, as noted in Chapter I, only about 8 percent of all employed RNs worked in nursing homes in 1980. The committee believes that if nursing education were to provide special preparation in all of the many aspects of geriatric care, licensed nurses would gain an understanding of the special needs, challenges and rewards of caring for the elderly, and thus become more attracted to employment in all the settings where those people receive care -- at home, in clinics, in hospitals, and in long-te`~.
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From page 173... ...
Yet, the vast majority of nursing care in nursing homes is given by personnel prepared at less than the RN level. In 1977, the last date for which comprehensive information is available, only 22 percent of nursing homes had an RN on duty around the clock, 71 percent of nursing personnel in skilled nursing fac ilities were aide s, 14 percent were licensed practical nurses, and 15 percent were RNs .51 Aides, generally minimally prepared for their responsibilities, provide six times as much care in nursing homes as do registered nurses, and f ive times as much care as do licensed practical nurses.
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From page 174... ...
These nurses will become qualified as geriatric nurse practitioners after spending 3 months on campus, followed by 8 months of clinical experience on the job under a physician or geriatric nurse practitioner preceptor. In-service training or continuing education in geriatric nursing for LPNs, aides, and orderlies has been encouraged to some degree under the NTA Special Grants program.
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From page 175... ...
RECOMMENDATION 13 Nursing service staffs in nursing homes certified as "skilled nursing facilities" and in other institutions and programs providing care to the elderly often lack necessary knowledge and skills to meet the clinical challenges presented by these patients. Such facilities, in collaboration with nursing education programs and other private and public organizations, should develop and support programs to upgrade the knowledge and skills of the aides, LPNs, and RNs who work with elderly patients.
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From page 176... ...
Many elderly patients are in nursing homes because they lack access to home nursing and other services that would enable them to remain at home. Medicare does not reimburse for nursing services to the homebound unless they are in need of defined "skilled nursing services." Medicaid pays for home health services to the destitute elderly, depending on the scope of each state program's benefit policies.
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From page 177... ...
Medicaid provides extensive benefits for the destitute elderly in nursing homes, but, in most states, restrictive payments discourage the employment of more than minimal numbers of skilled nursing personnel. Among the nursing homes certified for payment under the Medicaid and Medicare programs, almost two-thirds of the patients are in homes certified either as a skilled nursing facility (SNF)
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From page 178... ...
The National Sample Survey of Registered Nurses, November 1980, reported that there were more than 16,700 nurse practitioners and nurse midwives. As is noted in other chapters, NPs were employed in numerous health care settings.
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From page 179... ...
A study reports that an adult health nurse practitioner/physician team delivering primary health care to the elderly reduced hospital days and the use of diagnostic and therapeutic procedures.70 A Rand study predicts a need for 12,000 to 20,000 geriatric nurse practitioners by the year 2010, depending on the amount of responsibility delegated by physicians. 71 The study indicates that geriatric nurse practitioners could play a signif ic ant role in caring for elderly people.
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From page 180... ...
Medicaid and Medicare payment policies affect the ability of ambulatory clinics, physicians, and health care institutions to employ NPs. The Medicaid programs in approximately one-half the states specifically provide some type of reimbursement for physician extender services such as those by nurse practitioners or physician assistants.74 Federal reimbursement policies in the Medicare and Medicaid programs allow institutions to include physician extender compensation in their calculation of reasonable costs.
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From page 181... ...
Even with the anticipated future increases in physician supply, it is likely that NPs will be needed, especially to serve hard-to-reach populations, to facilitate new organizational arrangements for providing health care in cost effective ways, and augment the quality and amount of care provided to the elderly in their own homes and in nursing homes. RECOMMENDATION 15 to There is a need for the services of nurse practitioners, especially in medically underserved areas and in programs caring for the elderly.
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From page 182... ...
manpower distribution policies to facilitate the education and employment of individuals most likely to work in rural and inner-city areas, including nurse practitioners; (2) payment changes to enable skilled nursing facilities and inner city hospitals to support acceptable levels of service, including more adequate nursing care in such institutions, and to facilitate the employment of nurse practitioners to care for rural and elderly patients; and (3)
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From page 183... ...
The committee endorses continued funding at present levels for the education of nurse practitioners, but with stronger program incentives for them to work in underserved areas and in the care of the elderly. Payment Changes Manpower policies address only part of the underservice problem Perhaps the most important obstacle to adequate nursing care for residents of skilled nursing facilities and patients in inner-city hospitals is in the lack of financial resources in these institutions.
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From page 184... ...
In the Omnibus Reconciliation Act of 1982, Congress stipulated that not less than 10 percent of special project funds be devoted to upgrading the skills of vocational or practical nurses, nursing assistants, or other paraprofessional nursing personnel. At the same time, however, Congress eliminated from the authority support for curriculum improvements and short-tenm in-service training for aides and orderlies.
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From page 185... ...
, Nursing personnel and the changing health care system. Cambridge, Mass.: Ballinger Publishing Co., 1978.
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From page 186... ...
Nursing education and training: Alternative federal approaches. Washington, D.C.: U.S.
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From page 187... ...
The registered nurse population, an overview. From national sample survey of registered nurses, November 1980.
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From page 188... ...
Longitudinal study of nurse practitioners, Phase III (DREW Publication No.
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From page 189... ...
Case study #16: The costs and effectiveness of nurse practitioners (OTA Publication No.
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