Despite President Bush's signing of the popular Nurse Reinvestment Act last week, the healthcare industry is left hanging about just how much help it will get from the federal government to reverse the national nursing shortage.
Yet some say that could work in their favor. Hospitals, which have invested millions in programs to attract and retain nurses, lauded the legislation last week as welcome assistance that could come as early as this fall. Still, after passing the major hurdle of creating new incentive programs for nurses, they'll have to spend the next several months persuading Congress to appropriate funds.
"It's a hill, but it's not a vertical climb," said Dan Boston, vice president of legislation and political affairs for the Federation of American Hospitals.
Nurse associations, hospitals and other healthcare providers lobbied heavily for the legislation, which augments measures already taken to combat the nurse shortage. They overcame opposition from unions, who warned that the law will not adequately improve workforce conditions (See story, p. 7).
"It is a major step," said Dorel Harms, vice president of professional services for the California Healthcare Association. "It addresses the basic aspects of the nursing shortage-recruitment, retention and faculty."
The Sacramento-based association estimates its 460 for-profit and not-for-profit hospitals will have 31,000 nurse vacancies by 2006, Harms said. They are not alone. The nursing shortage has been characterized as a national crisis as hospital nurses retire or simply leave for other nursing jobs with no clear signs of a new supply entering the workforce.
Statistics continue to reinforce hospitals' concerns. An American Hospital Association survey last fall showed 126,000 nurses were needed in the nation's hospitals, constituting 75% of all job openings. According to the HHS' Health Resources and Services Association, the nursing shortage will grow from 30 states in 2000 to 44 states by 2020, in part because more nurses are retiring than entering the field. The U.S. Bureau of Labor Statistics projects that by 2010 the nation will have a deficit of more than 1 million nurses.
Signed Aug. 1, the Nurse Reinvestment Act authorizes a variety of grants and scholarships to attract and keep nurses in the field. Most of the funding, directed through HHS, would go to nursing schools, but hospitals would benefit directly from grants that would encourage nurses to advance in their profession through additional education and training, nurse internship and residency programs, and retention programs that enhance nurses' roles in the workplace (See chart, p. 7).
Although nurse unions say the legislation does not go far enough to address retention issues, healthcare providers say it does a good job of targeting the key drivers of the shortage: lack of autonomy and advancement opportunities, negative perception of nursing as a career, and faculty shortages. "The provisions are encouraging-the proof will be in the appropriations," said John Marzano, spokesman for MedStar Health, a seven-hospital, not-for-profit system based in Columbia, Md., which has a nurse vacancy rate of 19%.
A Senate bill passed in December earmarked $137 million for the first year, but Congress omitted the allocation when it reconciled that legislation with a House version. As a result, the new law allocates "such sums as may be necessary," thus leaving it up to Congress to set funding levels in the Labor, HHS and Education appropriations bill each year until the law expires in 2007.
An AHA lobbyist last week put a positive spin on the situation, saying it could work in favor of hospitals by leaving the door open for higher funding than was proposed by the Senate. "It allows a flexibility that really wasn't there when there was a set amount," said Carla Luggiero, senior associate director of federal relations for the American Hospital Association.
There is widespread disagreement in the healthcare community about how much federal funding is needed. Estimates have ranged from $135 million annually to $250 million. Anything would help, Luggiero said. "It's going to result in more nurses-and that's good for hospitals," she said.
Last week, providers were already wondering how they might benefit. In Grand Blanc, Mich., Norma Hagenow, chief executive officer of the 379-bed Genesys Regional Medical Center, asked her chief nursing officer to find out how the law could supplement her current nurse recruitment programs. "It would help a lot," she said. "Right now, we are just doing it out of our own operational earnings."
Over the past 12 months, Genesys, which has annual revenue of $340 million, has spent $450,000 finding incentives to attract nurses and entice the current 600 nurses to stay. It has provided scholarships and offered bonuses for nurses for everything from attendance to seniority-efforts that have paid off. Since October, Genesys has reduced its 10% vacancy rate by half. The hospital, which is part of St. Louis-based Ascension Health, plans to spend an additional $850,000 from a local foundation grant to build a career-ladder system, designed to promote nurses to higher trained positions.
Increasing enrollment in nursing schools tops many hospitals' agendas. An American Association of Colleges of Nursing study last fall showed a slight uptick of 3.7% in the number of students enrolled in entry-level nursing programs, but that only came after a steady six-year decline. Since 1995, enrollment in nursing programs was down 17%, or 21,126 students, from 1995.
Hospitals have spent millions of their own dollars to boost enrollment. Earlier this year, Nashville-based HCA, which has 186 for-profit hospitals, launched a joint $10 million partnership with the U.S. Labor Department to increase nursing school enrollment through scholarships and educational funds.
"It was initiated in response to displaced workers from the terrorist attacks, but it has expanded," said HCA spokesman Jeff Prescott. "The primary focus is to bring new people into healthcare," he added. HCA could not provide a systemwide vacancy rate.
Some facilities, such as 359-bed Georgetown University Hospital in Washington, which has a 10% nurse vacancy rate, have relied on relationships with nursing schools. Students in the 19 nursing schools with ties to MedStar-owned Georgetown are offered scholarships in exchange for a work commitment.
The Arizona Hospital and Healthcare Association recently bolstered efforts to reduce the state's 16% nurse vacancy rate. It plans to expand an annual $50,000 scholarship program to a total of $4 million over the next four years. Almost all will go to nursing students, said Fran Roberts, vice president of professional services for the association, which represents 80 hospitals. In addition, the state is a target in a nationwide nursing campaign created by healthcare product manufacturer Johnson & Johnson to bring more people into the nursing field.
Roberts welcomed the federal law. "This is a layering effect. It's going to take all of this to move this issue," she said. Still, the association has concerns about funding. It already has urged the state's hospitals to lobby their congressional representatives for money to support the programs. "It has the potential of having a large impact, but the devil is in the details," Roberts said.
One major impact could be felt through a provision that will allow nursing students to repay loans through teaching. In the 2000-2001 academic year, nursing schools turned away nearly 6,000 applicants because of a shortage of faculty and other classroom constraints, according to the AACN. That same year, 220 schools reported 379 nurse faculty vacancies. In another study, the AACN found the median age of nursing faculty to be 51 years, fueling concerns that many instructors will soon retire.
"We're in desperate need of having competent-and enough-staff to help teach our students," said Ellis Youngkin, associate director of the Florida Atlantic University's College of Nursing in Boca Raton, Fla.
The Florida Nurses Association forecasts 20% of the state's nurse faculty will retire in the next five years, said spokeswoman Willa Fuller. The state Legislature has taken measures such as expanding student ratios.
Even some hospitals are beginning to fund faculty salaries. This fall, Florida Atlantic will add 20 more students to the 60 enrolled in its baccalaureate program, thanks to two faculty positions bankrolled by hospitals. Tenet Healthcare Corp. is paying a two-year position with no strings attached; new students enrolled can work at any hospital upon graduation. It has funded a similar position for Florida International in North Miami, said Tenet spokesman Greg Harrison.
An HCA employee will fill the other Florida Atlantic position in an arrangement that allows the school to admit students who want to participate in HCA's scholarship program, which requires a two-year work commitment.
In Waco, Texas, not-for-profit Providence Hospital is paying over half the salary of a faculty position at McClennan Community College. So far it's the only Ascension-owned hospital that has made such a commitment, but Ascension's corporate headquarters may encourage more to follow that example. "It's an interesting potential solution to providing more nursing educators," said Lisa Bedian, Ascension's spokeswoman.
While healthcare providers would indirectly benefit from grants and scholarships for students, they would directly profit from retention grants that encourage career-ladder programs and elevate the role of nurses in decision-making.
Many hospitals already have career-ladder programs-and some are truly starting from the ground up. In Birmingham, Ala., Ascension's 255-bed St. Vincent's Hospital recruited local residents for its own ladder program. In the last year, it has paid for books, fees, uniforms, transportation and child care for 15 students to attend a two-week American Red Cross nurse training program. It ended up hiring every participant.