Sister Rosemary Donley, SC, PhD, RN, C-ANP, FAAN
Sister Mary Jean Flaherty, SC, PhD, RN, FAAN
Eileen Sarsfield, MSN, RN
Laura Taylor, MS, RN
Heidi Maloni, RN, MSN, CRNP, CNRN
Eileen Flanagan, BA
During 2002, the 107th Congress passed landmark legislation, the Nurse Reinvestment Act, P.L. 107-205. This article discusses the specific provisions of P.L. 107-205 within the context of the contemporary literature and the experience of the nursing shortage. The authors ask nurses to examine what the Nurse Reinvestment Act means for their career development. In laying out the anatomy of the Nurse Reinvestment Act, title by title, and section by section, the article presents the Congressional plan for addressing the two faces of the shortage: Nurse Recruitment, Title I, and Nurse Retention, Title II.
Under Title I, Nurse Retention, Section 101 presents Definitions used in the public law. Section 102, promotes the development of Public Health Service Announcements about the nursing profession. In the last section of Title I, Section 103, Congress establishes a National Nurse Service Corps. Title II, Nurse Retention, Section 201, is directed toward Building Career Ladders and Retaining Quality Nurses. In Section 202, the development of Comprehensive Geriatric Education is encouraged. Section 203 establishes a Nurse Faculty Loan program, while the last section of Title II, Section 204, mandates reports from the General Accounting Office.
The 107th Congress adjourned in November 2002 without acting on the appropriation bill that would have made the Nurse Reinvestment Act a reality. Before the new Congress meets in January 2003, nurses must join with their colleagues to assure adequate funding for P.L. 107-205. The websites of the American Nurses Association (www.nursingworld.org), the National League for Nursing (www.nln.org), The American Association of Colleges of Nursing (www.aacn.org), and the Specialty Nursing Organizations (www.aspanlorg/Spec) provide direction in approaching members of Congress. However, because of the importance of the Nurse Reinvestment Act, nurses must also align themselves with representatives from the many groups who supported the legislation. Readers of this Online Journal in Nursing article should be empowered to contact the American Hospital Association, the Catholic Hospital Association, the American Association of Retired Persons, the American Medical Association, the National Association for Home Care, and the Service Employees International Union for their assistance and the support of their membership in the passage of the FY 2002 Labor/HHS/Education Appropriations Bill.
NOTE: On the evening of February 18, 2003, both chambers of Congress passed the $397.4 billion FY 2003 Omnibus Appropriations bill and thus the Nurse Reinvestment Act (PL 107-205) was enacted and funded. NINR received an increase of 11.2% and Nursing Workforce Programs gained $20 million for Nurse Reinvestment Act programs.
Citation: Donley, R; Flaherty, M.J.; Sarsfield, E; Taylor, L; Maloni, H; Flanagan, E., (December 12, 2002; Updated 2/28/03). "What Does the Nurse Reinvestment Act Mean to You?". Online Journal of Issues in Nursing. Vol. 8, No. 1. Available: www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume82003/No1Jan2003/ArticlesPreviousTopics/NurseReinvestmentAct.aspx
Key Words: Nurse Reinvestment Act, nursing shortage, nurse recruitment, nurse retention, working conditions for nurses, faculty for schools of nursing, enrollment in nursing programs, nursing education, National Nurse Service Corps, scholarship and loan repayments, public image of nurses, schools of nursing, stereotypes of nurses, women in health professions, workplace culture, hospital staffing, healthcare legislation, Public Law 107-205
What Does the Nurse Reinvestment Act Mean to You?
The Legislative History of P.L. 107-205, The Nurse Reinvestment Act of 2002.
A brief overview of the introduction of H.R. 3487 and S. 1864 and the development of P.L. 107-205.
On August 1, 2002, President Bush signed into law the Nurse Reinvestment Act, Public Law 107-205 (2002). The Congress has been significantly engaged since the sixties in efforts to provide the nation with adequate nurse manpower, P.L.107-205 reflects contemporary dialogue and provides an interesting blend of old and new ideas about ways to address the current and future nurse work force. A brief review of THOMAS thomas.loc.gov, the Library of Congress online legislative information site, shows that members of Congress were eager to enter into the debate about the nursing shortage and show support for nurses. Fifty bills are sorted under the heading Nurse Reinvestment (Fifty Bills from the 107th Congress on Nurse Reinvest, 2002). These bills were eventually synthesized into H.R. 3487 and S. 1864. The Senate version of the bill, S. 1864, received strong bi-partisan support. Six senators spoke to the importance of nursing on December 20, 2001, when Senator Barbara Mikulski (Maryland, Democrat) introduced S. 1864 into the Senate. However H.R. 3487, the Nurse Reinvestment Act, introduced with 27 co-sponsors into the House of Representatives on December 13, 2001, became the template for P.L.107-205 (Nurse Reinvestment Act, H.R.3487.IH, 2001; Nurse Reinvestment Act, H.R.3487.ENR, 2002). There were differences in the major House and Senate bills that addressed the nursing shortage and several elements in the Senate bill are not included in P.L. 107-205. These elements included grants for outreach at primary and secondary schools, expansion of the authority of Area Health Education Centers (AHECs) to increase mentoring programs and develop models of excellence for community-based nurses, and the creation of a National Commission on the Recruitment and Retention of Nurses.
Title I - Nurse Recruitment
Title I presents definitions used in the public law and addresses the development of Public Health Service Announcements and the establishment of a National Nurse Service Corps.
Section 101, Definition of Terms
Terms used in P.L. 107-205 are defined in Section 101.
The final product, Nurse Reinvestment Act, P.L.107-205 (2002), which amended the Public Health Services Act "with respect to health professions programs regarding the field of nursing," has two titles and seven sections (¶ 1). The titles, Nurse Recruitment (Title I) and Nurse Retention (Title II), showcase two faces of the nursing shortage. In Title I, section 101, Congress defines nurses’ work sites using definitions from the Social Security Act. No explanation is given for the absence of physicians’ offices from the comprehensive list of sites which does include: ambulatory surgical centers, health care facilities, Indian and Native Hawaiian health centers, hospitals, rural health clinics, nursing homes, home health agencies, hospice programs, public health clinics, state and local public health departments, skilled nursing facilities, ambulatory surgical centers, federally qualified health centers and any other facility designated by the Secretary of Health and Human Services (Secretary). Although this section does not address the profit status of health care work sites, Section 103 instructs the Secretary that members of the National Nurse Service Corps may not be assigned to for-profit work sites after 2007.
Section 102, Public Service Announcements Regarding the Nursing Profession
Section 102 emphasizes the importance of Public Service Announcements and the use of the media in promoting the nursing profession.
In Title I, Section 102, Public Service Announcements, (PSAs), the Congress endorses the argument that under-enrollment in nursing programs can be overcome by public relations initiatives (Johnson & Johnson Health Care Systems, Inc., 2002; Nurses for a Healthier Tomorrow, n.d.).
This section urges the nursing community to move beyond criticism of negative stereotypes and provides funds to present positive models of nursing.
This section urges the nursing community to move beyond criticism of negative stereotypes and provides funds to present positive models of nursing. Although the nursing community has recognized the importance of the media in image building, most articles called attention to negative images and discussed their impact on the profession. For example, Kalisch and Kalisch (1987
), the most prolific of the image builders, provided multiple examples of how "dumming down" and sexual stereotyping of nurses by the media and film industries lessened the attractiveness of the profession and diminished nurses' ability to enhance their status and compensation. Other examples from the literature of that era described how doctor-nurse games expressed the politics of gender, power, and autonomy in the work place (Stein, 1967
). The feminist literature was more graphic in showing how traditional women's work in teaching, nursing or homemaking perpetuated negative stereotypes (Betz, 1993
). Young women were urged to travel to the moon, break through glass ceilings, enroll in programs and schools traditionally reserved for men, and engage in competitive sports. They were challenged not only "to be all you can be," but also to be all that anyone can be. This laudable campaign to change the face of educational establishments and the workforce has been successful (Staiger, Auerbach & Buerhaus, 2000
). Today, approximately sixty percent of women work outside the home (U.S. Department of Labor, 2000
). Women comprise approximately half of the enrollment of medical and pharmacy schools (National Center for Health Statistics, 2002
). Classes in business, economics, law, and engineering are peopled with women. Women are enrolled in the service academies and in military preparatory schools in the south.
During the eighties and the nineties, hospitals' response to reduced Medicare reimbursements and managed care initiatives contributed to nursing’s decline as an attractive profession. Initially, hospitals adjusted to prospective payment legislation and payment by diagnostic related groups (DRGs) with layoffs and downsizing of their nursing staffs. These workforce adjustments directly and indirectly challenged hospital-based nurses. When the dust settled and the DRG payment system was in place, nurses who remained in the hospitals had increased responsibilities and fewer supporting staff members to assist them. The clinical implications of the prospective payment system were dramatic as acuity levels in hospitals rose because of delayed admissions and early discharges. By then, there were fewer nurses to care for sicker patients whose length of stay was dramatically reduced (Institute of Medicine, 1996). The publicity that surrounded lay offs and downsizing suggested that nurses were not needed in contemporary health care. Layoffs also created uncertainty about the viability of nursing as a career.
After the Clinton health care reform failed in the nineties, managed care companies, poised to respond to an initiative that never happened, entered the market with a new insurance program. Capitalizing on the growing cost of health care and rising health insurance premiums, managed care companies convinced employers, and to a lesser degree, state and federal governments, that care management could lower health care costs without affecting quality of care. When managed care organizations achieved market share in local communities, they challenged horizontally and vertically integrated health systems in power plays around hospital rates.
After hospitals negotiated new contracts with managed care companies, they found themselves in the unhappy position of providing care to sicker people for lowered payments.
After hospitals negotiated new contracts with managed care companies, they found themselves in the unhappy position of providing care to sicker people for lowered payments. To compensate for reduced income, hospitals tightened their belts again, reorganized, and reduced the size of their nursing budgets (Norrish & Randall, 2001
). These high stakes, billion dollar national battles, did not consider nursing or its recruitment or retention issues. Ironically, both sides, institutional providers and insurers, were fighting to save their industries and their profit margins.
As nurses adjusted to heavier workloads and sicker patients, the media reported the impact of poor staffing on patient care. Aiken, Clarke, Sloane, Sochalski, and Silber (2002) found that poor staffing ratios increased surgical patients' risk of dying within 30 days of admission. Earlier articles represented investigative reporting of deaths in inpatient settings. The Chicago Tribune published a series of articles that was typical of the investigative genre (Berens, 2000). These reports blamed nurses for tragic events or portrayed nurses as beleaguered employees, unable to change their destinies or protect their patients. Neither portrait enhanced the image of professional nursing or made nursing attractive to young people.
Publicity about mandatory overtime further eroded the professional image of nursing. Work schedules frustrated and angered many nurses who turned to unions to represent them in their arguments with their employers.
Publicity about mandatory overtime further eroded the professional image of nursing.
Several states, most notably California, responded by mandating staffing ratios in hospitals (Costello, 2002
). Around the country, nurse strikes publicized that hospitals forced nurses to work more than 8 or 12 hour shifts each day (Service Employees International Union [SEIU], 1993
). Such situations as these and others have portrayed a poor nursing image. Nurses are presented as under paid, under appreciated, and overworked. Is it any wonder, that there is an enrollment crisis in nursing? Sections 851a and 851b in the Nurse Reinvestment Act provide specific information for the use of funds in promoting the nursing profession through creative public service campaigns at state and local levels.
Section 102, part H, section 851a, of the Nurse Reinvestment Act (2002) challenges the nursing community to take back its image by engaging in campaigns to "advertise and promote the nursing profession, highlight the advantage and rewards of nursing and encourage individuals to enter the nursing profession" (p. 2).
If nursing does not come forward and write grants to develop media campaigns, health insurers, managed care organizations, hospitals, and unions will shape nursing's image to suit their ends.
If nursing does not come forward and write grants to develop media campaigns, health insurers, managed care organizations, hospitals, and unions will shape nursing's image to suit their ends.
Section 103, National Nurse Service Corps
This section creates a National Nurse Service Corps to address the nation’s nursing shortage by the establishment of a scholarship and loan repayment fund.
This last section of Title I, Section 103, establishes a National Nurse Service Corps. The substantive idea in this section is that full or part-time students, enrolled in schools of nursing, are eligible for loan and scholarship programs.
The concept of a National Corps supports the belief that nurses are a national resource and acknowledges the shortage of nurses as a real, national crisis.
Eligibility is contingent on students' agreement to work full time for two years after graduation in critical nurse shortage areas at work sites identified in Section 101. An arrangement for part-time fulfillment of the contract is also described. The model for Section 103 is the existing National Health Services Corps Scholarship Program, a program that has financed physicians' and nurse practitioners’ education to encourage them to work in underserved areas after graduation (Health Resources and Services Administration [HRSA], 2002a
). Interestingly, the Congress did not choose the capitation program advocated by the nursing lobby, and popular in the Nursing Education Acts of the 1970s, to encourage schools to recruit/enroll students (Rubenfeld et al., 1981
). P.L. 107-205 makes financial arrangements with students, not schools. In creating a National Nurse Service Corps as a new authority, the Congress is doing more than setting up a new financial assistance program in nursing or adding dollars to the Nursing Education Loan Repayment Program (NELRP). Eligibility for membership in this National Service Corps enhances the status of students of nursing. The concept of a National Corps supports the belief that nurses are a national resource and acknowledges the shortage of nurses as a real, national crisis.
Section 103 then addresses technical issues around existing sections in the Public Health Service Act and clarifies that after fiscal year 2007, the Secretary many not assign a nurse to any private entity unless the entity is nonprofit. It amends Section 846 of the Public Health Service Act to include scholarships as well as loan repayments. Section 103 defines the scope of the report that the Secretary must submit to Congress eighteen months after the enactment of the Nurse Reinvestment Act. Not surprisingly, this report will include the number of enrollees, scholarships, loan repayments and grant recipients, the amount of scholarship payments and loan repayments made, as well as the educational institutions attended by recipients, and the attendance and graduation rates at these respective institutions. The report will incorporate the demographics of students who participate in either program, the number and placement location of scholarship and loan repayment recipients in health care facilities with critical shortages of nurses, a justification for the allocation of funds between scholarships and loan repayments, and the overall costs and benefits of the program. The Secretary is also required to provide information about outstanding defaults in the scholarship and loan repayment programs, giving reasons for the default if they can be determined. By creating the impetus for federal tracking of the National Nurse Corps program and its graduates, this outcome section contributes to the development of nursing's data set.
Title II. Nurse Retention
Title II addresses the nursing shortage by emphasizing the role of the work place in retaining and enhancing the education and professional development of nurses.
Title II addresses nurse retention. This component of the Nurse Reinvestment Act represents a significant departure from older versions of Nurse Training and Nursing Education laws described in Title 8 of the Public Health Service Act. Typical legislation relied on schools of nursing to address the cyclical nursing shortages, focusing on increasing the supply of nurses, preparing nurses for specified areas of practice, and encouraging work force diversity by the recruitment of minority students. The literature on the current nursing shortage identifies retention as a factor and proclaims that nurses change jobs and careers because of issues in the workplace (Aiken et al., 2001). Contemporary debate often cites the culture of the hospital workplace as a factor in the shortage. Mandatory overtime became the mantra to focus attention on poor working conditions. Newspapers reflected the charge that acute care hospitals are not good places for nurses or patients (Fackelmann, 2001). On the positive side, the reawakened interest in the work place focused new attention on the value of magnet hospitals (McClure, Poulin, Sovie, & Wandelt, 1983). These institutions attracted and retained nurses because of the governance style of the organizations and their ability to engage nurses in decision making.
Section 201, Building Career Ladders and Retaining Quality Nurses
The first section of Title II, Nurse Retention, looks to the work place for solutions to the diminished supply of nursing.
- Section 831, Nurse education, practice, and retention grants: This section, composed of parts a, b, and c, addresses funding priorities in education, practice and retention. It applies practice and educational frameworks to retention with two categories: (a) nurse education, practice, and retention, and (b)building career ladders and retaining quality nurses.
- Section 831a, Education priority areas: This section provides funds to expand enrollment in baccalaureate nursing programs, to develop internships and residency programs in nursing specialties, and to encourage new educational technologies.
Under the heading of nurse education, Section 831a targets funds to expand baccalaureate enrollment, to develop/implement internship and residency programs to encourage mentoring and specialization, and to provide education in new technologies, including distance-learning methods. While these strategies are familiar, they are endorsed by a wide constituency that includes the American Association of Colleges of Nursing (AACN) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), (JCAHO, 2002; Tri-Council for Nursing, 2001).
- Section 831b. Practice priority areas: This section describes the availability of grants to demonstrate new nursing practice arrangements that improve access to primary health care for underserved and high-risk populations and to develop skill in providing managed care and quality improvement in organized health systems.
Section 831b introduces new ideas as it gives the Secretary authority to award demonstration grants or contracts; to establish/expand practice arrangements in non-institutional settings; to improve access to primary health care in medically underserved communities; to provide care for underserved and high-risk groups, such as the elderly, persons with HIV/AIDS, substance abusers, the homeless, and victims of domestic violence; to provide managed care, quality improvement, and other skills needed to practice in existing/emerging health care systems; and to develop cultural competencies among nurses. Recent manpower policies have justified support for nurses because of the need to provide care to underserved peoples, many of whom come from cultures different from their nurses (Health Resources and Services Administration [HRSA], 2002b). The multifaceted Section 831 addresses many of these priorities. However, it introduces the idea that the health care delivery system - the work place - is in need of reform. Study after study has shown that many staff nurses feel powerless because no one listens to their ideas for improvement or gives them support to initiate pilot projects or to demonstrate creative strategies (Aiken et al., 2001). The Nurse Reinvestment Act of 2002 calls for innovation in community health care highlighting the need to deliver culturally competent care in communities. It suggests that transformation and quality enhancement of new health care systems in hospitals and communities will create work sites attractive to young men and women.
No one expects contemporary law to create a vision for the future.
Section 831b challenges the nursing community to envision and create practice environments that respond to contemporary and future demands, are more supportive of patients and their families, and create healthier places for nurses to practice their profession.
However, Section 831b challenges the nursing community to envision and create practice environments that respond to contemporary and future demands, are more supportive of patients and their families, and create healthier places for nurses to practice their profession. Along with this challenge comes grant funds to individuals or agencies that develop programs that are innovative and responsive to the categories identified in Section 831b. This Section invites cross-disciplinary co-operation between colleges of nursing and among health care settings.
- Section 831c, Retention priority areas: In this section, priority is given to the development of career ladder programs and the design of systems that enhance the delivery of patient care by improving collaboration and communication within the health care team.
Section 831c discusses retention. It stimulates partnerships that build career ladder programs to encourage persons to move from home health aids or certified nurse assistants to advanced practice nurses. It emphasizes cross training and specialty training to prepare nurses to work with diverse population groups. In the sixties, the war on poverty urged the health care industry, especially hospitals, to help people rise from low paying jobs into more satisfying careers (Riessman & Poppier, 1968). Section 831c invites faculty and health system administrators to support people, currently in health care fields, by creating real world programs of advancement that lead to personal and professional growth. This Section also addresses an underlying theme in recent health manpower legislation to increase minority representation and cultural sensitivity in the health care work force. Many individuals from minority backgrounds currently work in health care fields. The Paraprofessional Healthcare Institute (2001), in its testimony before Congress, reported that 86 percent of the 2.1 million direct health care workers are women and 30 percent of these women are women of color between the ages of twenty-five and fifty-four. P.L. 107-205 urges schools and the health agencies to focus recruitment efforts within their health care networks and build career ladders in nursing.
The second retention priority enhances patient care delivery by providing grants to projects that improve collaboration and communication among nurses and other health care professionals and promotes nurse involvement in the organizational and clinical decision-making processes of health care facilities. These ideals resonate with the literature on patient safety (Kohn, Corrigan, & Donaldson, 2000), magnet hospitals (McClure & Hinshaw, 2002), and nurse satisfaction (American Hospital Association [AHA] Commission on Workforce for Hospitals and Health Systems, 2002; Aiken et al., 2002). This component of P.L. 107-205 challenges health care managers to work with nurses to create new patient-centered paradigms and build collaboration among nurses and with the health care team. P.L. 107-205 also addresses empowerment issues and provides a new avenue for nurses to become involved in organizational and clinical decision making. A consistent finding, highlighted in the early work of McClure and others (1983) and Kramer (1990) in their descriptions of management styles in magnet hospitals, is that professional nurses want to be involved in clinical decisions and in decisions that affect their practice. Large and small systems could learn from Drucker’s (1992) classic ideas about managing knowledge workers and contemporary descriptions of teaching or working with generation X (Tulgan, 2000). Section 831(c) supports demonstration grants to improve the work place and health care delivery.
Section 202, Comprehensive Geriatric Education
This section establishes programs to educate and develop nurses and others to care for the nation's aging.
Section 202 of Title II addresses comprehensive geriatric education. This Section recognizes the demography in the United States and the aging of the baby boomers by creating new grants to train individuals who provide geriatric care; to develop and disseminate curricula about the treatment of health problems of elderly people; to train faculty in geriatrics; or to provide continuing education to those who provide geriatric care.
Section 855, Comprehensive Geriatric Education, authorizes the Secretary to award grants to develop and implement programs and initiatives to educate individuals in geriatric care. This section takes a comprehensive view of the field of gerontology. It provides funds for curriculum development, formal and continuing education, and the development of nurse faculty skilled in care of the aged. The Section recognizes the diversity of long term care providers by speaking not only to schools of nursing but also to health care facilities, certification programs for nursing assistants, and partnerships between schools/programs and geriatric care facilities.
Section 203, Nurse Faculty Loan Program
To address the shortage of faculty in schools of nursing, the federal government has created a loan forgiveness program for nurses who prepare to become faculty in the nation’s nursing schools. Section 846a describes the establishment of the nurse faculty loan program. This section encourages schools of nursing to partner with the federal government in establishing and administering a nurse faculty loan fund.
Section 203 of Title II establishes a faculty loan program. This Section responds to the March 2000 federal study of the registered nurse population regarding the mean age of nursing faculty, reported by Spratley, Johnson, Sochalski, Fritz, and Spencer (2001) to be 49.4 years of age, and the inability of schools of nursing to admit students because they lack qualified faculty (American Association of Colleges of Nursing, 2002). The National League for Nursing (NLN) (2002), noting that schools of nursing within their purview (practical, diploma, associate, baccalaureate, and higher degree) enroll approximately 300,000 students in 3,500 programs, projects a significant shortage of teachers. Using a one to ten faculty-student ratio, they estimate that fifty percent more teachers are required for the current demand and to teach 100,000 additional students that need to be recruited. The AACN (2001) reported that baccalaureate and graduate nursing programs, under their purview, turned away approximately 5,000 qualified applicants in that year because of insufficient faculty, clinical and classroom sites, and budget constraints. More than a third of the schools surveyed (38.8%) by the AACN said that faculty vacancies explained why qualified students were not admitted (AACN, 2001). Section 203, allows the Secretary, acting through the administrator of HRSA, to enter into agreements with schools of nursing to establish and operate student loan refunds designed to increase the number of qualified nurse faculty. Participating schools of nursing are required to contribute to the fund in an amount equal to and not less than one-ninth of the federal contribution. Schools assume responsibilities for the collection of principle and interest on the loans and may use funds for loan collection. Although these loan funds are targeted to full-time students, the Secretary can authorize them for part-time students in advanced degree programs.
The loan program, described in Section 846, authorizes borrowing up to $30,000 a year for tuition, books, fees, and laboratory and other reasonable educational expenses.
Graduates who teach full time in schools of nursing for four years can have eighty-five percent of their school loans canceled.
If the graduate is employed full time as a faculty member, twenty percent of the principle and interest, unpaid at the first day of employment, will be cancelled at the end of each of the first three years of employment. Twenty-five percent of the principle and interest will be forgiven at the end of the fourth year. Graduates who teach full time in schools of nursing for four years can have eighty-five percent of their school loans canceled. Interest of three percent per year will be accrued on the unpaid loan balance three months after the course of study is completed. Loans are repayable in equal or graduated periodic installments over a ten-year period beginning nine months after the person completes the program of study. P.L. 107-205 also contains provisions to address loan repayment of people who fail to complete the program or do not become nurse educators.
Section 204, Reports by the General Accounting Office
The final component of P.L. 107-205 mandates that the Comptroller General of the United States prepare a series of comprehensive reports to Congress documenting how the educational and practice communities responded to this legislative initiative and describing the effectiveness of the Nurse Reinvestment Act in addressing the nation’s nursing shortage.
Section 204 of Title II requires the Comptroller General to carry out several evaluations of P.L. 107-205. Specifically, the General Accounting Office (GAO) will survey variations in nursing shortages and efforts to remedy shortages in health care facilities around the country and describe findings by ownership status. The GAO will also determine hiring differences in private, non-profit, and for-profit settings and evaluate whether scholarship and loan repayment programs demonstrably increased the number of applications to schools of nursing.
The Comptroller General will write a report to Congress four years after the law is enacted. This report will compare hiring practices, nursing shortages, and methods to decrease shortages in the nation’s non-profit and for-profit health facilities. It will also evaluate the value of the National Nurse Service Corps in increasing applications to schools of nursing.
During 2002, the Congress of the United States drafted legislation to address the nursing shortage. P.L. 107-205, priced but still unfunded at around 250 million dollars, is a reinvestment in nursing. It offers funds to project a new image of nursing in the twenty-first century. It establishes a National Nurse Corps to provide nurses for shortage areas. It finances the education of the next generation of teachers. It encourages program development and education of persons to care for the nation's aged. It offers nursing the opportunity to solve one of its own problems – the culture of the workplace. It provides funds for demonstration projects to enhance communication, to mentor young nurses through internships and residencies, and to create new methods for staffing and work force deployment. The legislation directs attention to community-based practice and asks nursing to address the needs of vulnerable people. In summary, P.L. 107-205 calls for professional accountability and invites nurses to transform nursing in the millennium.
Although the 107th Congress passed this landmark legislation, the Nurse Reinvestment Act, P.L. 107-205, in August of 2002, it adjourned without passing an appropriations bill to fund it. The continuing resolution that was passed merely extended current funding. There is not enough money in the continuing resolution to implement P.L. 107-205. There is no certainty that the 108th will pass the FY2003 Labor/HHS/Education bill that will fund The Nurse Reinvestment Act. As the 107th Congress ended, there were political disagreements about the price tag of this appropriations bill. Although Nurse Reinvestment is not controversial, its placement in this omnibus appropriations bill jeopardizes its full funding if Congress decides to avoid conflicts about the FY2003 appropriations and simply extend the FY2002 funding into FY2003. This action, if it were taken, would add no new money to fund the Nurse Reinvestment Act and make it impossible to implement the creative and helpful programs it contains. The most desirable goal for sick people in this country and for the nursing profession would be the speedy passage of the FY2003 Labor/HHS/Education appropriations bill that contains approximately 250 million dollars for the Nurse Reinvestment act. Another option, and a fall back position if Congress refuses to pass the FY2003 appropriations bill, is to ask the members of Congress to add money to the FY2002 authorization to bring the funding for the Nurse Reinvestment Act to the 250 million funding level. The 108th Congress has some options: pass another continuing resolution, pass all, or pass part of the Labor, Education and Health Appropriations bill. The 108th Congress needs to hear from the nursing community and its friends. In the past several years, many organizations have studied the impact of the nursing shortage on their constituencies. They have also supported the legislative initiative to reinvest in nursing. Now is the time to ask members of health, nursing, and public interest groups to lobby their congressmen and congresswomen to pass an appropriation bill to adequately fund the Nurse Reinvestment Act. Figure 1 provides URLs to assist in contacting organizations for support. Figure 2 and Figure 3 provide help in making these important contacts both with professional organizations and with congressmen and congresswomen.
|Figure 2. Networking With Other Professional Organizations
Nurses in hospitals can prepare a note or an e-mail for their executives, such as the CEOs of their hospitals, requesting that they write to larger membership organizations like the American Hospital Association or/and The Catholic Healthcare Association.
Individuals working in nursing homes can request that their executives send letters to the American Health Care Association or/and the American Association of Homes and Services for the Aging.
Students and faculty can contact the Presidents of colleges to send letters to the American Higher Education Association, the Association of Catholic Colleges, or American Association of Universities.
Members of any group, like AARP, Children' Defense Fund, or the American Public Health Association, can write/email these organizations to ask them to join with nurses in seeking funding for the Nurse Reinvestment Act.
Sample letters for contacting organizations:
The nurses in my organization asked me to invite INSERT NAME OF THE RELEVANT ORGANIZATION to join with them in urging the 108th Congress to quickly pass the Labor/HHS/Education Appropriations Bill that will fund The Nurse Reinvestment Act of 2002. This law, passed in August 2002, will help recruit and retain nurses. It also provides federal funds for programs that publicize what nurses do in contemporary health care. Our organization is experiencing a nursing shortage that is costly and interferes with the good care that we want to give our patients. As you know, many national studies have supported the need to reinvest in nursing. However, the good programs to encourage young people to study nursing and improve the situation for practicing nurses need a budget. Please use your contacts on Capitol Hill to help our patients have more nurses.
I am a member of XXX. I invite our association in my own name and in the name of my nurse colleagues to join us in urging the 108th Congress to quickly pass the Labor/HHS/Education Appropriations Bill that will fund The Nurse Reinvestment Act of 2002. This law, passed in August 2002, will help recruit and retain nurses. It has a grant program to publicize what nurses do in contemporary health care. Many national studies have supported the need to reinvest in nursing. Schools of nursing need more students and programs to encourage young people to study nursing and support them while in school. Patients and health care agencies need more nurses. The Nurse Reinvestment Act needs to be funded. Please use your contacts on Capitol Hill to help our patients have more nurses.
|Figure 3. Contacting Congressmen and Congresswomen
|Points to include in a message to congressmen and congresswomen:
- The 108th Congress must not delay in passing the Labor/Health and Human Services/Education Appropriations Bill to fund the Nurse Reinvestment Act P.L.107-205 at the $250 million dollar level suggested by the Senate.
- Without new funding, The Nurse Reinvestment Act cannot be implemented.
- The growing nursing shortage is affecting patient care and patient safety in every part of the country.
- The many problems that face our country, including protection against bio-terrorism and concern for home land security, require a strong nurse force.
- The new Congress can show practical support for the President’s initiative to make America safe by funding the Nurse Reinvestment Act.
|Hints for Contacting Congressmen and Congresswomen:
- Check the ANA Government Affairs web site:
- To write your Representative, go to www.house.gov/house/MemberWWW.html, select the name of your representative, go to their website and follow the directions for E-mailing a message.
- To write to your Senators, go to www.senate.gov/senators/senator_by_state.cfm, select the Senators for your state, go to their websites and follow the directions for E-mailing a message.
- Important! Don't forget to include your mailing address in the text of the message! This indicates that you are a constituent and allows your Representative and Senators to respond to you.
- Because of the November election, you may have a new Senator or Congressman. He or she may not be listed on the website. Call the local office of your Senator or Representative and ask their advice.
- Particular attention should be given to the members of the House and Senate Appropriations Committees. Please check the following websites to see if your Congressman is a member: www.house.gov/appropriations/members.htm or www.senate.gov/~appropriations/memlist.htm
|Sample Message to Congress:
Thank you for passing the Nurse Reinvestment Act P.L. 107-205. The nurses of America are appreciative of your support and recognition of the national nursing shortage and its impact on sick people in this country. Please act NOW to pass the Labor/Health and Human Services/Education Appropriations Bill and give schools, hospitals, nursing homes, and community centers the tools they need to make the nurse force in this country stronger.
Sister Rosemary Donley, SC, PhD, RN, C-ANP, FAAN
Sister Rosemary Donley, RN, PhD, FAAN, is an Ordinary Professor of Nursing and Director of a federally funded Community/Public Health Nursing Graduate Program at The Catholic University of America, Washington, D.C. She is a General Councilor and the Vice President for Advancement of the Sisters of Charity of Seton Hill. Sr. Rosemary Donley received a diploma from the Pittsburgh Hospital School of Nursing. She holds a B.S.N. summa cum laude from St. Louis University and a M.N.Ed. and Ph.D from the University of Pittsburgh. She is a certified adult nurse practitioner. Her clinical and research interests are health policy, clinical decision making and health care literacy.
Sr. Rosemary is a Fellow in the American Academy of Nursing and a member of the Institute of Medicine. She served as Executive Vice President (1986-97) and Dean of Nursing (1979-86) at The Catholic University of America. She was a Robert Wood Johnson Health Policy Fellow. She is a past President of the National League for Nursing and Sigma Theta Tau International Honor Society of Nursing, as well as past Senior Editor of Image: The Journal of Nursing Scholarship. Sr. Rosemary serves on civic, college and health system boards and the Board of the Catholic Health Care Association. She sits on the editorial boards of five journals. She has served as a member of the Secretary of Health and Human Services’ Commission on Nursing; has been a consultant to the U.S. Army and Navy Medical Commands; and is the recipient of six honorary degrees. She received the Nell J. Watts Lifetime Achievement in Nursing Award.
Sr. Rosemary has over 95 publications and has presented papers throughout the United States, Kenya, Spain, The Peoples Republic of China, Puerto Rico, the Philippines, Guam, Okinawa, Japan, Korea, Taiwan, Hong Kong, Brazil, Argentina, Germany, Israel, Canada, Russia, Azerbaijan, Georgia and Armenia. She has also participated in numerous seminars, panel discussions, and workshops in the United States.
Sister Mary Jean Flaherty, SC, PhD, RN, FAAN
Sister Mary Jean Flaherty, R.N., PhD, FAAN is an Ordinary Professor of Nursing at The Catholic University of America, Washington, D.C. Sr. Mary Jean Flaherty received a diploma from the Pittsburgh Hospital School of Nursing. She holds a B.S.N. from Duquesne University and M.S.N. and a PhD in Curriculum and Supervision from the University of Pittsburgh. She is a maternal-child clinical nurse specialist. Her research interests are grandmothers, post-partum care, breast-feeding, and mentorship. Her work has been funded by the Department of Health and Human Services, The Catholic University of America, and Sigma Theta Tau International.
Sister Mary Jean is a Fellow in the American Academy of Nursing. She served as Dean of Nursing (1992-2000), Chair of the Graduate Program, Nursing of the Developing Family (1980-1988 and 1990-1992), and Director of the Doctoral Program (1988-1990). She also served as Associate Director of Education, National Center for Family Studies (1982-1984) at the Catholic University of America. Sister Mary Jean Flaherty was a WHO nurse consultant to Indonesia (1981, 1983, and 1985). She was an educational consultant (1985-1992) and is a program evaluator for the National League for Nursing (1982-present). She was elected as a member of the Board of Review, Baccalaureate and Higher Degree Programs, National League for Nursing (1983-1989; Chair - Fall, 1989 and Vice Chair - 1988-1989) and to its Appeal Panel (1989-1992 and 1993-1996).
Sister Mary Jean has served on college and health system boards including Seton Hill College (1978-1986, 1991-1993); Bon Secours Health System, Inc. (1987-1996); Jeannette Hospital (1976-1980); The National Commission on Nursing Implementation Project (1986-1987); and the Committee of Graduate Nursing Education, China Medical Board (1988-1992). She was appointed as an External Evaluator for State-Wide Nursing Review, Board of Regents Commonwealth of Massachusetts (1984) and as a Doctoral Site Visitor for the Texas Higher Education Coordinating Board at the University of Texas at Arlington, Houston and Galveston (1995). Sister Mary Jean has also served as Middle States and Southern Regional Evaluator of colleges and universities.
Eileen Sarsfield, MSN, APRN, BC
Eileen Sarsfield, M.S.N., APRN, BC is an Adjunct Assistant Professor and Grant Manager of Promoting Healthy Families in Vulnerable Communities advanced practice program at The Catholic University of America. Ms Sarsfield received her B.S.N. from Georgetown University and an M.S.N. from The Catholic University of America in community health nursing. She is board certified as an advanced practice nurse in community health nursing.
Eileen is responsible for the daily operations and management of the Promoting Healthy Families in Vulnerable Communities advanced practice program. She conducts admission interviews, coordinates the Kids Into Health Careers project, advises students and coordinates clinical placements.
Eileen has over twenty years experience in community-based care including home health and hospice and five years as executive director of a regional home health association. As executive director, Eileen represented the concerns of Maryland and D.C. community agencies to state and local legislators and regulators. She has consulted with community agencies on program and policy development, management services, mentoring, quality of care, compliance, reimbursement and clinical review issues. She has served on the D.C. Medical Care Advisory Board, Managed Care Committee and the D.C. Long Term Care Coalition, which was instrumental in developing the first Medicaid Home and Community-Based Waiver program in the District. She is a member of the District of Columbia Mayor’s Health Policy Council and the board of the District of Columbia Area Health Education Center.
Ms. Sarsfield belongs to the following associations: American Public Health Association, Sigma Theta Tau, American Nurses Association, Metropolitan Washington Public Health Association, Maryland-National Capital Homecare Association and the Maryland Nurses Association.
Laura Taylor, MS, RN
Laura Taylor, M.S., R.N., earned her Bachelor's and her Master's degrees in Nursing from the University of Maryland School of Nursing. She is a Certified CPR Instructor. Her myriad of nursing experience includes Medical Intensive Care, Interventional Radiology, and Acute-Care and Post-Hospital care for Abdominal Organ Transplant patients and their families. As a Baccalaureate Nursing Faculty her area of educational expertise is in the area of pathophysiology, complex medical/surgical nursing and nursing informatics. In her twelve years of teaching she has seen fewer and fewer qualified, enthusiastic nurses entering the world of academia. More nurses must be encouraged to bring their excitement and their love for nursing to the classroom. The Nurse Reinvestment Act promises to support those nurses who can guide and shape new nurses by showing a love of learning and devotion to nursing.
Heidi Maloni, RN, MSN, CRNP, CNRN
Heidi Maloni, R.N., M.S.N., CRNP, CNRN, a Teaching Assistant for the Care of Vulnerable People in Communities program of The Catholic University of America and doctoral student in the School of Nursing, is a Certified Neuroscience Registered Nurse, Multiple Sclerosis Certified Nurse, and a licensed and Certified Adult Nurse Practitioner. She has worked as a research nurse clinician and coordinator of patient care and protocols involving persons with multiple sclerosis at the National Institutes of Health.
Heidi has had experience in the community as a parish nurse, utilizing case management, case finding, advocate and liaison skills. She currently educates individuals and groups in the community on health promotion and disease management. She is a member of the Patient Advisory Board of the National Multiple Sclerosis Society, and a consultant to the National Capital Multiple Sclerosis Society. As Chair of the Certification Board of the International Organization of Multiple Sclerosis Nurses, she developed the first certification for MS nurses internationally. She has presented nationally and internationally on the care of multiple sclerosis patients and is author of several publications including a June 2000 article in Journal of Neuroscience Nursing on Pain Management in Multiple Sclerosis.
She is a member of Sigma Theta Tau, the International Organization of Multiple Sclerosis Nurses, The Consortium of Multiple Sclerosis Centers, The American Association of Neuroscience Nurses, The American College of Nurse Practitioners, The American Academy of Nurse Practitioners and the District of Columbia Nurse Practitioners. She is a graduate of Catholic University (BSN, MSN).
Eileen Flanagan, BA
Eileen Flanagan, B.A., project secretary for the federally funded graduate nursing program, Care of Vulnerable People in Communities, at The Catholic University of America, Washington, D.C., is a summa cum laude graduate of Providence College, Providence, Rhode Island. She earned a degree in humanities and minored in mathematics. She has interests in public service and education in underserved communities. Ms. Flanagan, a former fifth grade teacher in Southeast, Washington D.C., participated in the Teacher Service Program, Response-Ability.
American Hospital Association (AHA) Commission on Workforce for Hospitals and Health Systems. (2002, April). In our hands now: How hospitals leaders can build a thriving workforce. Chicago: American Hospital Association.
Aiken L.H., Clarke, S.P., Sloane, D.M., Sochalski, J.A., Busse, R., Clarke, H., Giovannetti, P., Hunt, J., Rafferty, A.M., & Shamian, J. (2001, October 30).Nurses' reports on hospital care in five countries. Health Affairs, The Policy Journal of the Health Sphere, 20(3), 43-53.
Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J., & Silber, J.H. (2002, October 23-30). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of American Medical Association, 288(16), 1987-1993. Retrieved on November 1, 2002, from http://jama.ama-assn.org/issues/v288n16/rfull/joc20547.html
American Association of Colleges of Nursing (AACN) (2001). Nursing faculty shortage fact sheet. Retrieved September 9, 2002, from www.aacn.nche.edu/media/backgrounders/facultyshortage.htm
American Association of Colleges of Nursing (AACN) (2002). Faculty shortage fact sheet. Retrieved September 9, 2002, from www.aacn.nche.edu/media/backgrounders/facultyshortage.htm
Berens, M. J. (2000, September 11). Training often takes a backseat. Chicago Tribune. p. 7.
Betz, N. (1993). Women’s career development. In F.L. Denmark & M.A. Paludi (Eds.), Psychology of Women (pp. 627-684). Westport, CT.: Greenwood Press.
Costello, M. A. (2002, January 28). California seen as nurse-patient ratio testing ground. American Hospital Association News, 38 (3), 2.
Drucker, P.F. (1992). Managing for the future: The 1990’s and beyond. New York: Tally Books/Dutton.
Fackelmann, K. (2001). Working conditions send nurses walking. USA Today. Retrieved October 22, 2002, from www.usatoday.com/news/healthscience/health/2001-06-07-nursing-shortage.htm
Fifty Bills from the 107th Congress on Nurse Reinvest. (2002). Available from THOMAS website thomas.loc.gov via search word/phrase "Nurse Reinvestment Act".
Health Resources and Services Administration (HRSA), Bureau of Health Professions. (2002a). National Health Service Corps. Retrieved October 21, 2002, from http://nhsc.bhpr.hrsa.gov/
Health Resources and Services Administration (HRSA), Bureau of Health Professions. (2002b). Nursing. Retrieved October 20, 2002, from http://bhpr.hrsa.gov/nursing.
Institute of Medicine. (1996). Nursing staff in hospitals and nursing homes: Is it adequate? Washington, D.C.: National Academy Press.
Johnson & Johnson Health Care Systems, Inc. (2002). Discover nursing. Retrieved October 19, 2002, from www.discovernursing.com
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (2002). Health care at the crossroads: Strategies for addressing the evolving nursing crisis. Chicago: Author.
Kalisch, P.A., & Kalisch, B.J. (1987). The changing image of the nurse. Menlo Park, CA: Addison-Wesley Publishing Company.
Kohn, L.T., Corrigan, J.M., & Donaldson, M.S. (Eds.) (2000). To err is human: Building a safer health system. Washington, D.C.: National Academy Press.
Kramer, M. (1990). The magnet hospitals. Excellence revisited. Journal of Nursing Administration, 20(9), 35-44.
McClure, M.L., & Hinshaw, A.S. (Eds.) (2002). Magnet hospitals revisited: Attraction and retention of professional nurses. Washington, D.C.: American Nurses Association.
McClure, M.L., Poulin, M.A., Sovie, M. D., & Wandelt, M. A. (1983). Magnet hospitals: Attraction and retention of professional nurses. Kansas City, MO: American Nurses Association.
National Center for Health Statistics (2002). Health, United States, 2002 with chartbook on trends in the health of Americans, 278. Retrieved October 1, 2002, from www.cdc.gov/nchs/data/hus/hus02.pdf
National League for Nursing. (2002, 18 May). Position statement: The preparation of nurse educators. Retrieved November 26, 2002, from www.nln.org/
Norrish, B.R., & Randall, T.G. (2001, March). Hospital restructuring and the work of registered nurses. The Milbank Quarterly, 79(1), 55-79.
Nurses for a Healthier Tomorrow (n.d.). Campaign news. Retrieved October 19, 2002, from www.nursesource.org/campaign_news.html
Nurse Reinvestment Act, H.R.3487.ENR, 107th Congress (2002). Retrieved October 31, 2002, from http://thomas.loc.gov/
Nurse Reinvestment Act, H.R.3487.IH, 107th Congress (2001). Retrieved October 31, 2002, from http://thomas.loc.gov/
Nurse Reinvestment Act, P.L. 107-205, 107th Congress (2002). Retrieved November 4, 2002, from www.access.gpo.gov/nara/publaw/107publ.html
Paraprofessional Healthcare Institute, Hearing before the Senate Committee on Health, Education, Labor and Pensions 106th Congress (2001). (testimony of Michael Elsas). Retrieved October 28, 2002, from www.kaisernetwork.org/health_cast/uploaded_files/Elsas_Testimony_May%202001.pdf
Riessman, F., & Poppier, H.I. (Eds.) (1968). Up from poverty: New career ladders for non-professionals. New York: Harper & Row.
Rubenfeld, M.G., Donley, R., Falinski, E.G., Herpin, B.R., Horn, P., & Walker, S. (1981, June). The Nurse Training Act: Yesterday, today, and… . American Journal of Nursing 81(6),1202-1204.
Service Employees International Union (SEIU) (1993). The national nurse survey:10,000 dedicated healthcare professionals report on staffing, stress and patient care in U.S. hospitals and nursing homes. Washington, D.C.: SEIU, AFL-CIO.
Spratley, E., Johnson, A., Sochalski, J., Fritz, M., & Spencer, W. (2001, September). The Registered Nurse Population, March 2000, Chart 17. Rockville, MD: Health Resources and Service Administration, Bureau of Health Professions, Division of Nursing.
Staiger, D., Auerback, D., & Buerhaus, P. (2000). Expanding career opportunities for women and the declining interest in nursing as a career. Nursing Economics,18(5), 230-236.
Stein, L.I. (1967, June). The doctor-nurse game. Archives of General Psychiatry, 16, 699-703.
Tri-Council for Nursing (2001). Strategies to reverse the new nursing shortage. American Association of Colleges of Nursing. Retrieved on September 20, 2002, from www.aacn.nche.edu/Publications/positions/tricshortage.htm
Tulgan, B. (2000). Managing generation X: How to bring out the best in young talent (2nd ed). New York: W.W. Norton.
U.S. Department of Labor, Bureau of Labor Statistics (2000). Changes in women’s labor force participation in the 20th century. Retrieved October 1, 2002, from www.bls.gov/opub/ted/2000/feb/wk3/art03.htm
© 2002 Online Journal of Issues in Nursing
Article published December 20, 2002