Interview with: Denise Geolot, PhD, RN, FAAN
Director, Health and Human Services
Health Resources and Services Administration, Division of Nursing
The following is an interview with Denise Geolot, PhD, RN, FAAN, Director, Health and Human Services, Health Resources and Services Administration, Division of Nursing. We interviewed Dr. Geolot because there is widespread confusion about the Nurse Reinvestment Act (NRA). What follows are the questions and answers presented during the interview that should help clarify the specific provisions of the NRA and its historical background as well as implications for nurses.
What is the Nurse Reinvestment Act? Please tell us a little about the history of it, and how it evolved. Who were the key stakeholders, and what were the key points of the legislation?
The Nurse Reinvestment Act, commonly referred to as the NRA, is legislation that amends the existing Title VIII of the Public Health Service Act – the nursing education legislation. This legislation was passed to address the growing nursing shortage resulting from the aging nursing workforce, retention problems due to a stressful work environment, and problems recruiting young people into nursing.
The NRA added six new provisions to the Title VIII legislation resulting in a broad, comprehensive and flexible legislative authority by which the Federal government could help address the nursing shortage. Specifically, the NRA includes a nurse scholarship program and a nurse faculty loan program – both providing support to individuals for nursing education with a payback provision following graduation. At the institution/organization level, the NRA supports grants for career ladder programs, internship and residency programs, retention programs tied to quality patient care and geriatric education programs. The NRA also addresses support for public service announcements to promote the nursing profession.
What is Title VIII?
Title VIII is the legislation that covers nursing education and practice. Originally referred to as the Nurse Training Act, Title VIII was added to the Public Health Service Act in 1964. In recent years, programs under Title VIII have focused on the preparation of the basic and advanced nursing workforce and on increasing diversity within the nursing workforce.
What is the history of the NRA?
The NRA evolved out of concerns about the shortage of nurses around the country. In the late 1990s, enrollments in nursing schools were declining and reports indicated nurses were leaving nursing because of a stressful work environment and concerns about the quality of care. By 2000, the data showed that the average age of the registered nurse was over 43 years and workforce projections indicated a worsening of the shortage because of the aging of the workforce, the increases in demand for registered nurses, decreases in the supply, and concerns about the adequacy of the pipeline.
As these concerns grew in the states and became more visible in the media, Congress began to seriously address the nursing workforce issues. Several bills were introduced in Congress, including those by Representative Lois Capps, Senator Kerry, and Senator Hutchinson. In the end, conference negotiations between the House and Senate resulted in the passage of Nurse Reinvestment Act, Public Law 107-205 signed by President Bush in August 2002. Strong bipartisan support for this legislation was demonstrated in both the House and Senate leadership. The tireless efforts of many individuals including Representatives Bilirakis and Capps, and Senators Mikulski, Collins, Gregg, Kerry, Jeffords, Frist and Hutchinson, among many others, played a key role in the passage of this legislation. In addition, nursing organizations and the health care community played a significant role in working with Congress to formulate this legislation and advocate for its passage.
How has grassroots support helped or hindered the NRA?
The different nursing organizations and alliances were very active in getting grassroots support for this legislation. The American Nurses Association, American Organization of Nurse Executives, the National League for Nursing and the American Association of Colleges of Nursing were actively involved at state and national levels. The grassroots support from nursing was good. However, one of the challenges of trying to fund legislation is that there are always competing interests, as there are now, for Federal tax dollars.
Could you talk a little bit about how the competing interests of national security and the economy all impacted the passage of the NRA, and now the amendments?
When the NRA passed in August 2002 it authorized new types of activities that could be started under the Title VIII legislation. Once legislation is passed, funds must be appropriated to carry out the specific activities. The appropriation process is handled separately by Congress on a yearly basis and then signed by the President once he agrees with the appropriation level and plan. Often, there are differences in opinion on what should be funded – competing interests, as you suggest, with national security and the economy overall. In fiscal year 2003, Senator Mikulski added an amendment to the appropriation bill to fund parts of the NRA. The appropriation level for fiscal year 2004 recommended by a joint House and Senate Conference Report recommends an additional $30 million for Title VIII and the NRA components.
Could you give our readership some strategies that they might use to become more politically active? What ways can they go about helping to obtain funding for the legislation?
What I would suggest is that nurses work through their member nursing organizations. The nursing organizations are very active in raising issues related to the nursing workforce and spend considerable time educating their local politicians and members of Congress about the needs.
It has always seemed that the way nurses get involved in the political process is when they think something directly impacts them. Could you be more specific in terms of why this is important to a staff nurse who is reading this? Why is this important to a nurse educator? And a nurse administrator?
This legislation has several provisions that I think would be of interest to the staff nurse. First, there are grants that support internships and residency programs. When new graduates begin practice in various health care settings, they find it very stressful. They could benefit from an internship period where they would have mentoring and additional education and support from others while they are transitioning from the new graduate into the more experienced graduate, so there are internships and residency programs. There are programs that help returning nurses who have been out of nursing for a while and want to renew, refresh, and expand their knowledge and skills. There are also residency programs for those who are changing from one role to another.
Another area that may be of great interest to the staff nurse focuses on grants that enhance patient care delivery systems. The purpose of these grants is to implement some of the organizational characteristics that have been so successful in the magnet hospitals: those that address greater involvement of nursing in determining patient care, having greater involvement in decision making, enhancing communication between all professionals in the setting, and innovations in terms of work hours or work environments. We expect that these grants will help retain nurses in the workplace and improve the quality of care.
For clarification for the readership, when we talk about grants, how does that differ from loans? I think many people don’t understand that difference in terms of repayment.
The distinction between individual loans and/or scholarships and the general grant programs is important. Generally speaking, loans and scholarships are awarded to individuals and most often they have some type of payback provision. For example, the Nurse Scholarship Program provides funds to cover educational expenses in nursing school; however, there is an expectation that once the individual graduates from the nursing program, she/he will work in a health care facility with a critical shortage of nurses for at least two years. In the Nurse Faculty Loan Program, graduates are expected to teach full time in a school of nursing for four years – this results in a cancellation of 85 percent of their student loan over this timeframe. On the other hand, program grants are generally awarded to academic institutions or community-based organizations to carry out a specific project related to nursing education and/or practice. Here the funds go to support the infrastructure of the organization to carry out the program
That helps because many people do ask about the grant process and it does seem very convoluted, or very hard to do. Other nurses that I talk with think the NRA is really nice, but they have loans that they are going to have to pay off.
We do have a program called the Nursing Education Loan Repayment Program (NELRP) that actually existed prior to the NRA, but the NRA expanded the types of sites that nurses could work in for their service commitment. NELRP participants must agree to work full-time for two years in a health care facility with a critical shortage of nurses. The NELRP will pay 60% of the participant’s total qualifying loan balance. After two years, if the participant agrees to work a third year at the critical shortage facility, the NELRP will pay an additional 25% of the qualifying loan balance. To be eligible, the individual must be an RN who has an associate or baccalaureate degree in nursing; diploma in nursing or graduate degree in nursing from an accredited school of nursing; have unpaid qualifying loans obtained for nursing education; be a citizen, national or permanent resident of the United States; be employed full-time at a critical shortage facility; have a permanent, current and unrestricted license as a registered nurse recognized in the state in which they intend to practice; and submit a completed application, including a signed contract, to serve full-time as a registered nurse for two years at a health care facility with a critical shortage of nurses.
This is very helpful. People look at the NRA and think it is a way to get loans to go to school, but it really is much broader based and that is what we want to get out to people and help them understand.
Yes there is also a scholarship program in the NRA which pays tuition and fees, and provides a monthly stipend. The Nurse Scholarship Program (NSP) (http://bhpr.hrsa.gov/nursing/scholarship) provides scholarships to nursing students in exchange for a service commitment at a health care facility with a critical nursing shortage. The student must be enrolled or accepted for enrollment in a professional program at an accredited school of nursing; be a U.S. citizen or national; be a full- or part-time student; and be free of any federal judgment liens, federal debt, and existing service commitments. Preferential funding is provided to full-time, undergraduate students with the greatest demonstrated financial need.
Would the program be administered through the schools?
Actually, the individual applies to the federal government for this scholarship program.
We have covered staff nurses, could we go on to the nurse educators?
In terms of the nurse educators, there is the Nurse Faculty Loan Program where an agreement is established with a school of nursing. The school receives the money and then gives the loan to the person who is interested in becoming a teacher. It has a cancellation provision whereby for every year the individual works in a school of nursing in a faculty role, a portion of the loan is cancelled. For four years of working full-time as a faculty member, 85% of the loan can be cancelled.
How would it work for a potential faculty member or someone who is planning to go on to graduate school?
This is for someone who is interested in becoming a faculty member. The program was established to address the faculty shortage and get people interested in teaching. Students interested in teaching can obtain a loan to go to school and then if they go into a faculty position when they graduate, they can have a portion of their loan cancelled.
If I think I want to be a faculty member and I am ready to go to graduate school, what would I do?
You would look to see what schools are participating in the Nurse Faculty Loan Program, enroll in the school, and then apply to get a loan through the school.
Where would such a list exist of the schools that are part of the program?
Our web site (http://bhpr.hrsa.gov/nursing/) contains the list of schools receiving the awards.
Are there programs for nurses who don’t want to become faculty members?
The Nurse Faculty Loan Program was specifically designed to address the faculty shortage and then of course under the other part of the Title VIII legislation, there is the whole advanced education nursing grant section. Those are grants to schools of nursing to provide program support for advanced education programs, which include master’s and doctoral level programs, that educate graduates for various roles and specialties. In addition to the program support for advanced education, funds are available for traineeship support. Currently we provide traineeship funds to over 400 schools of nursing for individual student support at the graduate level. These schools are also listed on our web site (http://bhpr.hrsa.gov/nursing/).
The NRA is really quite broad when you start to look at it from all these different perspectives.
Right, the addition of the NRA to the existing legislation results in a very comprehensive, flexible piece of legislation. As a result, the Title VIII legislation for nursing education and practice addresses basic and advanced nursing education through support for expanded career ladder programs and separate programs for baccalaureate, master’s and doctoral level students. It supports the practice setting through nurse managed centers which provide access to primary health care to underserved populations. It helps ease the transition from student to new nurse through the internship and residency programs, and helps retain nurses in the workplace through projects designed to improve the work environment. It fosters mentoring opportunities and programs to increase diversity and cultural competence. All of these things help in developing and keeping nurses in the workforce. This legislation helps assure that patients get the quality care they need.
I have one more thing I want to ask you about, based on the article by Linda Aiken (Aiken, Clarke, Cheung, Sloane, & Silber, 2003). It showed that the type of education is related to health care outcomes. I have heard some discussion that there are some people who believe that the funding should be directed to baccalaureate education. We are just curious about how you view that?
Under the NRA one of the purposes under the education priority areas, which we had in the past and continue to have, is expanding the enrollment in baccalaureate nursing programs. So, we continuw to have that as one of the provisions of our legislation. Another part that comes from the NRA is the expansion of the career ladder program that provides opportunities for education along the entire continuum, starting at certified nursing assistants all the way up to doctoral education.
To keep that career ladder moving along, it also shows the support that the program has for advanced practice by the grant programs that you mentioned for advanced nursing programs. What do you foresee for the future related to the funding of the NRA?
What we know so far is that the House has passed its version, the Senate has passed its version and I think both of them include about $113 million for 2003. I understand Senator Mikulski (D-MD) is proposing an amendment for additional funds. We will watch to see how much of that amendment, if any, will be included in the final appropriations for the NRA and Title VIII. The bill needs to go to conference because the House and Senate bills are different with the addition of the amendment.
Then it comes back to what you said before: Nurses need to work through their member organizations. They can go on the web sites of, for example, the American Nurses Association, Government Affairs (www.nursingworld.org/gova/) or the American Association of Colleges of Nursing (www.aacn.nche.edu/Government/index.htm). There they can find out who is on the conference committee so that they can voice their strong support for the increased funding.
I always encourage nurses to learn more about the nursing legislation and to get actively involved with the nursing organizations they are members of. Even though we are seeing an increase in the number of students enrolled in nursing schools, projections on the need for more nurses over the next 20 years are significant. Nurses need to understand what is going on at the local and national levels in nursing education and practice. They need to understand what the implications are from the aging workforce. They need to understand what the implications are for them in the workplace and for their patients. Then they can work through the nursing organizations to help educate others, including Congress, about the ongoing nursing needs.
Yes, we would really like to have the readership understand that this is for them as well – not just for somebody else, and they can take advantage of these things.
Since the interview took place, the NRA passed through the Conference Committee and was funded for $141.92 million.
Greer Glazer, PhD, RN, FAAN
Director, Parent Child Nursing
College of Nursing
Kent State University
Kent, OH 44202
Email Address: GGlazer@kent.edu
Dr. Glazer is Professor and Director of Parent Child Nursing at Kent State University College of Nursing. Besides her many research activities in the field of women's health and stress, Dr. Glazer is the chair of ANA-PAC, the political arm of the American Nurses Association. She is currently the legislative liaison to Congressman Steve LaTourette and has previously been on health care committees at the state and national level. Locally, she serves on the Board of Cuyahoga County (Ohio) Children's Trust Fund and recently completed four years on the Health Care Committee allocation panel for the United Way in Cuyahoga County. Dr. Glazer is also currently a Robert Wood Johnson Executive Nurse Fellow.
Margaret Doheny, PhD, RN, ONC
Professor, College of Nursing
Kent State University
Kent, OH 44202
Email Address: firstname.lastname@example.org
Dr. Peggy Doheny received her PhD from Kent State University. She is a Professor at Kent State University College of Nursing, where she teaches in the graduate adult CNS nursing program and the web-based post-master's certificate program in nursing education. Currently she is the College of Nursing web manager and an Associate Editor for OJIN with responsibility for development of the online CE offerings. She has numerous publications and presentations in the area of orthopaedic nursing. Her research is in the area of osteoporosis prevention and currently has NINR funding.