State Support for Nursing Education: Challenges & Opportunities

1. State Support for Nursing Education:Challenges & Opportunities Tim M. Henderson, MSPH National Conference of State Legislatures Washington, DC

2. RN Distribution Across the States RN National Sample Survey 2000

3. 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

4. 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 $

5. STATE ISSUES AFFECTING NURSING PRACTICE & EDUCATION • Changing composition of legislatures and governorships • State budgets • 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

6. 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

7. The Challenge of Making the Educational ProcessMore Effective and Efficient • Some Nurse Employers Say of Nursing Education: • 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’

8. Someone is Listening Strategic Partnerships Between Educators and Employers - Large and Small - Are Booming • Promoting Health Careers • Subsidizing Student Educational Costs • Supporting/Augmenting Faculty • Expanding Didactic and Clinical Training Capacity • Addressing Workplace Needs • New Graduate Recruitment/Placement

9. 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

10. Nurse Shortage Legislation in the States • 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. • 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 • EDUCATIONAL ‘PIPELINE’ INCENTIVES • Nursing education supplemental appropriations: WA, GA, TX, CA • New/expanded student loan repayment programs: Multiple States • DATA COLLECTION / WORKFORCE PLANNING • Statewide nursing workforce commissions, data centers: Over 20 States • OTHER • Career ladder training/articulation: Multiple States

11. 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

12. Support for Nursing Education:Examples of Financing Opportunities / MechanismsBetween 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)

13. State/LocalHealth 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

14. State/Local Health Workforce Board Investment:Expanding Baccalaureate Nurse Training Capacity • Arizona: Statewide WIA Goal: Expand RN graduations by nearly 200 over 2-years Approach: Implement accelerated BSN degree programs at 3 state universities Funding: WIA state discretionary funds, tuition, state resources, private sector contributions • Georgia: Statewide WIA Goal: Provide graduate training for nurses intending to become nurse educators Approach: 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). Funding: WIA state discretionary funds, Woodruff (state) Foundation funds • Washington: Local WIAs Goal: Expand education and training for high-demand health care occupations Approach: 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. Funding: WIA adult funds

15. Medicaid Payments for Nurse Training • 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 • STRATEGIES • State Medicaid agency to use IGT (Intergovernmental Transfer) mechanism to draw down additional federal matching funds to support hospital-based clinical nursing education. • 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