State Support for Nursing Education:
Challenges & Opportunities
Tim M. Henderson, MSPH
National Conference of State Legislatures
Washington, DC
RN Distribution Across the States
RN National Sample Survey 2000
Nationwide Nurse Vacancies - 2002
• Average: 13 to 15 percent
• HOSPITALS
– 125,000 in 2001; “temporary reduction” in 2002
• NURSING HOMES
– 44,000 in 2002; up sharply from 2001
FEDERAL ISSUES AFFECTING
NURSING EDUCATION AND PRACTICE
• Health Professions Education and Research of Diminishing
Importance in HHS and Congress
– Title VIII funding not in sync with publicized nurse shortage
– Title VII support waning Exception ?: proposed legislation to increase
allied and public health workforce
– Little attention given to promoting evidence-based research on the health
workforce in AHRQ and NIH
– NCHWA in HRSA: uncertain future
• Addressing the High Demand for Entry-Level Health Workers
a Priority for Dept. of Labor/State WIBs because it’s a high
priority for employers
• Medicaid:
– New attention by CMS to limit use of special Medicaid financing schemes (&
federal funds) – not likely affect ‘small fish’ opportunities to support training costs
– Pressure on Congress to extend temporary federal infusion of $
STATE ISSUES AFFECTING
NURSING PRACTICE & EDUCATION
• Changing composition of legislatures and governorships
• State budgets
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Higher education on the ‘chopping block’; ‘Privatization’ of public institutions
Cutting Medicaid costs; Pressure to leverage more federal / private dollars
Smaller or more limited government programs
Self sufficiency
Fiscal outlook improving: 32 states expect a surplus in FY 2004-05
• Growing concerns about bioterrorism and the inadequacy of the public
health workforce
– Rapidly aging, diminishing cohort of PH nurses, lab techs, epidemiologists, others
• Strengthening the link between appropriations and
mission/accountability
– Future public investment tied more to workforce needs of state and matching support from
industry partnerships
– More attention to addressing ‘industry’ demands for more focused clinical skills, etc.; ensure
‘structured accountability’ in education-service partnerships
– Building a better continuum of education to support new continuums of service
– Do we need new state ‘oversight’ models/incentives that better link education and practice?
E.g., federal matching funds that flow to state higher education boards
The Challenge of Creating
New Practice/Professional Models
• Nursing and Scope of Practice: Does Nursing
Professionalism Cover the Continuum of Service?
• Nursing and Collective Bargaining: Can Service Workers Live
in an Industrial Work Model?
• Nursing and Service: Does the Nurse as Employee Still
Work?
• Emerging and Conflicting Issues
– Aging population
– Competition for workers
– Old practice and regulatory models
The Challenge of Making the Educational Process
More Effective and Efficient
• Some Nurse Employers Say of Nursing Education:
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Inadequate to meet new challenges
Is not customer responsive
Slow time to training
Too theoretical; Inadequate integration of education and work
• Some Nurse Educators Say of Nurse Employers:
– Too much abdication of educational responsibilities
• Some Policymakers Say of Both Educators and Employers:
– Shortages are growing and public need is great
– We want to help, BUT:
• you don’t provide a clear message of needs and capabilities
• you have got to work better together
– Nursing is the only major health profession not going through a ‘sex change’
Someone is Listening
Strategic Partnerships Between Educators and
Employers - Large and Small - Are Booming
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Promoting Health Careers
Subsidizing Student Educational Costs
Supporting/Augmenting Faculty
Expanding Didactic and Clinical Training Capacity
Addressing Workplace Needs
New Graduate Recruitment/Placement
Recent State Legislation
to Address Nursing Shortages
• 2001-2002
– Most states remain fiscally strong or stable
– 2/3 of nursing workforce measures focused on putting in place
more costly educational ‘pipeline’ remedies
• Increased $ to training programs and students
– Balance of measures ‘examine’ workplace regulation
• Staffing ratios; limiting mandatory overtime
• 2002-2003
– Most states having major fiscal problems
– Workplace regulation and educational capacity concerns continue
– Attention on lower-cost approaches
• Establishing statewide nursing workforce commissions and data centers
• 2004
– Most states seeing signs of fiscal recovery, but caution remains via new
legislation
Nurse Shortage Legislation in the States
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NURSING HOME STAFFING LEVELS
– 37 states enacted staffing requirements that supplement minimum federal standard; state
standards (generally give NHs less flexibility) either require certain # of nursing care
hours/patient day or maintain a specified staff-to-patient ratio.
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OTHER WORKPLACE REGULATORY INITIATIVES
– Minimum staffing ratios/plans in acute care facilities:
• Laws mandating fixed ratios:
CA (1999) MA (2004-pilot program)
• Laws/regs requiring plan development: OR, TX, KY, VA
• Recent bills w/fixed ratios:
Multiple States (none passed)
– At least 15 states enacted or considered limiting mandatory overtime.
– 11 states have strengthened RN supervisory responsibility for CNAs
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EDUCATIONAL ‘PIPELINE’ INCENTIVES
– Nursing education supplemental appropriations:
– New/expanded student loan repayment programs:
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WA, GA, TX, CA
Multiple States
DATA COLLECTION / WORKFORCE PLANNING
– Statewide nursing workforce commissions, data centers: Over 20 States
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OTHER
– Career ladder training/articulation:
Multiple States
A Broader Approach for States
in Addressing the Nursing/Allied Health Shortage
• Enlarge data collection, analysis, dissemination
• Call attention to emerging state/local issues
• Convene stakeholders from industry, education and
policy to problem-solve at state/local level
• Support demonstrations of innovations that emerge
from such partnerships
• Invest in leadership development at all levels and
across professions and institutions
Support for Nursing Education:
Examples of Financing Opportunities / Mechanisms
Between States, Educators and Employers
FEDERAL MATCHED/SUPPORTED STATE FUNDING
• State/local workforce investment board and special DOL industry funding
• Medicaid payments
• Economic development funding
EMPLOYER MATCHED STATE FUNDING
• Supplemental appropriations / student scholarship/loan forgiveness program
funds to expand/target enrollment
• Supplemental appropriations to expand training capacity
OTHER STATE FUNDING SOURCES
• Lottery
• Tobacco settlement
• Dedicated (line-item)
State/Local
Health Workforce Investment
Over 20 states using state/local WIBs to support NURSE/ALLIED
HEALTH career ladder, skills training, education capacity
• RN TRAINING:
AZ, CA, CO, FL, GA, IL, MA, MN, OR, SC, TX, WA, WI
• LPN/LVN TRAINING:
CA, CO, FL, GA, IL, ME, MA, MN, OR, SC, TX, VA, WA, WI, WV
• VARIOUS ALLIED HEALTH WORKER TRAINING:
CA, CO, GA, FL, SC, TX, VA, WA, WI
NEW:
DOL’s Health Industry High-Growth Job Training Initiative
To date: $24 million in grants; forthcoming formal solicitation
State/Local Health Workforce Board Investment:
Expanding Baccalaureate Nurse Training Capacity
– Arizona: Statewide WIA
Goal:
Approach:
Funding:
Expand RN graduations by nearly 200 over 2-years
Implement accelerated BSN degree programs at 3 state universities
WIA state discretionary funds, tuition, state resources, private sector
contributions
– Georgia: Statewide WIA
Goal:
Approach:
Funding:
Provide graduate training for nurses intending to become nurse educators
Make available 160 service-cancelable loans (up to $10,000 each) for RNs to
pursue graduate nursing study (masters or doctoral) in any public or private
program. Recipients must agree to teach in GA (1 year for each $2,500).
WIA state discretionary funds, Woodruff (state) Foundation funds
– Washington: Local WIAs
Goal:
Approach:
Funding:
Expand education and training for high-demand health care occupations
Local educational programs surveyed to identify local nurse training capacity
and determine which programs are most in need of expansion. Funds and
information on career changes distributed to expand training capacity to enroll
nurses wanting to become BSNs.
WIA adult funds
Medicaid Payments for Nurse Training
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OPPORTUNITY
As of 2002, at least 13 states explicitly allow Medicaid funding for
nursing education:
CA, IA, IN, LA, ME, MI, MN, MS, NH, ND, OH, OR, SC
FL: does not specify which professions are eligible for GNE payments
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STRATEGIES
a) State Medicaid agency to use IGT (Intergovernmental Transfer)
mechanism to draw down additional federal matching funds to support
hospital-based clinical nursing education.
b) State Medicaid agency to use federal administrative matching funds to
support a time-limited policy demonstration by one or more nursing
schools to improve the knowledge/skills of nurses to care for vulnerable
Medicaid populations (MI)
Potential support for APNs, public health nursing, future faculty