Some Reasons for Areas of Underservice

Lack of access to preventive, primary, and acute care services by people living in inner cities and in rural communities remains one of the nation's most pressing health problems. It ranks with the lack of access to effective preventive and maintenance care of the nation's elderly, large numbers of whom may as a result become untimely afflicted with worsening chronic conditions that lead to long-term institutionalization. Among all underserved populations, barriers to care are created by lack of adequate financing, transportation problems, lack of health care facilities, and lack of health manpower to staff facilities or provide services outside health care institutions.

The obvious explanation of nursing and other health manpower shortages lies in the nature of the nation's health care financing arrangements. Inadequate public or private coverage to pay for services to very large numbers of low-income people results in lack of programs or lack of access to programs and facilities that can meet their medical and other health care needs. Inadequate financing and the resulting inappropriate services make it unlikely that nurses will seek or be able to find employment, even though they may wish to work in an underserved area or with underserved people.

We believe that solutions to the problems of medical underservice eventually will require a long-range restructuring not only of the nation's health care financing, but also of health services delivery arrangements. Other public commissions and studies have come to similar conclusions. While it was not within our purview to address these fundamental problems, the study necessarily became concerned with their implications as principal factors in the maldistribution of nursing personnel. In this context, the committee has responded to the request for suggestions likely to help alleviate existing nurse shortages in medically underserved areas.

The Nature and Consequences of Underservice

Many rural and semi-rural areas, where 30 percent of the nation's population lives, are characterized by low population density, disproportionate numbers of poor and elderly, vast distances, and small hospitals.³ Providing health care in these circumstances presents multiple problems.

Most nurses are employed by hospitals, nursing homes, physicians, and health departments. Therefore, most nursing care depends on the presence of such employers, but they are not found in many remote communities. Approximately 500 of the nation's more than 3,000 counties currently have no hospital.⁴ The economics of supplying adequate levels of health services to poor and remote populations and the heavy workload associated with being a solo practitioner make remote and poor rural areas unattractive to physician practice. In 1979, 143 counties had no active physician, federal or non-federal, engaged in patient care.⁵

These and other factors result in employed nurse-to-population ratios that are usually much lower for rural than for urban areas. The 1977-1978 Inventory of Registered Nurses showed that the ratio of employed registered nurses (RNs) per 100,000 population ranged from a low of 268 in Arkansas, a largely rural state, to 885 in urban District of Columbia. Moreover, such comparisons fail to reveal the often substantial pockets of underservice that frequently exist in a state. Among the areas alone that were not standard metropolitan statistical areas (SMSAs), this ratio ranged from a low of 162 in Louisiana to a high of 892 in New Hampshire.

Vacancy rates for nurses in hospitals are not markedly different in small and large institutions, but hospitals in non-SMSAs have more recruitment problems than do their urban counterparts.⁶ State studies and testimony from hospital representatives have noted the special difficulties associated with nurse shortages in rural areas. In testimony before the Senate Finance Committee, one witness commented that there was an immediate need for at least 300 RNs in 61 Montana hospitals, most of which are in rural areas. He also noted that while a nurse vacancy in a large hospital may not be really crucial, "when a small facility loses one nurse, that's a crisis situation."⁷ Further, he observed that Montana's small rural hospitals consistently upgrade their salary and fringe benefits to meet and, in some cases, exceed those of the larger facility in order to attract nurses to their hospitals.

Other testimony suggests some factors that detract nurses from rural service. "Rural nurses are asked to assume greater responsibility, are often on call 24 hours a day. … Rural public health nurses find their salaries and working conditions determined by county commissioners who are often more concerned with building and maintaining roads and bridges than quality health care. Feeling frustrated … they leave their chosen profession."⁸ Additionally, fluctuations in patient census tend to make some rural hospitals unreliable employers. And where the absence of other providers puts major responsibility for health care on public health nurses, the level of funding may support only a minimal number.⁹

These problems and others lie behind the fact that in rural areas 21 percent of black children and 14 percent of white children had no physician visits in 1981 compared with 10 percent and 9 percent, respectively, of children in SMSAs.¹⁰ Residents of non-metropolitan areas are also less likely to have preventive care and more likely to spend more than 30 minutes traveling to a physician visit and to experience longer waits once there. Seventeen percent of physician visits by residents of non-SMSAs occurred in metropolitan areas.¹¹

Nursing shortages in rural areas are only one aspect of the problem of underservice. Minority, immigrant, and other low-income populations in many urban areas of the nation also can lack access to health care. Large concentrations of these people are found in inner city areas, where nursing and other health care services present particular problems.¹ Although the gap in utilization of health care between the poor and nonpoor in both urban and rural areas that existed quite generally prior to the 1960s almost closed between the mid-1960s and 1980, serious problems of access nevertheless remain, particularly in the settings where poor and minority people--notably blacks and Hispanics--receive care.¹² For example, a study in Boston found a 4 percent decline in the number of inner-city residents who had a personal physician between 1975 and 1981, despite a 7 percent increase in the nationwide physician-to-population ratio during this period.¹³

Differences between the health status of underserved populations (whether rural, urban, poor, or minority) and better served groups also indicate unmet needs for health care. Household interview surveys conducted by the National Center for Health Statistics in 1979 found that consistently greater proportions of residents outside of the standard metropolitan statistical areas than SMSA residents reported health conditions that made them unable to carry on major activities of daily living. More than 14 percent of the non-SMSA residents rated their health as only fair or poor, compared with 11.4 of the SMSA residents.¹⁴

People in federally designated medically underserved rural areas have 24 percent higher hospital utilization, 33 percent more disability days, and 22 percent more chronic limitations than do those in rural areas not so designated.² Mexican-American migrant agricultural workers are said to have a much lower life expectancy and higher rates of illness than does the population as a whole, but scant data are yet available to describe their health status.

Educational Outreach

Since the mid-1960s the federal government, the states, and higher education systems have adopted various strategies designed to alleviate identified nurse shortages in medically underserved areas.

One such strategy has been to offer financial incentives through educational loan repayment arrangements designed to attract nurses to serve in such areas. The strategy implies a hope that an appreciable proportion of such nurses will remain in the shortage area after their service obligation has been met, but there is no evidence either way. At the federal level, examples include programs under the Nurse Training Act (NTA) of 1964 and subsequent amendments, and National Health Service Corps authorizations.

The NTA Nursing Loan Repayment Program offers repayment of a portion of an RN's educational loan in return for 2 or 3 years of service in a designated nurse shortage area (Appendix 2). Between 1974 and 1981 approximately 219,000 nurses received educational loans but only 128 accepted the option of service in return for loan repayment. The failure of the program has been commonly attributed to the more favorable terms offered by the Federal Nursing Loan Cancellation Program, which allowed cancellation of up to 85 percent of an education loan for practicing nurses working in a public or nonprofit hospital, health center, or other health care agency for more than 1 year, regardless of location or population served.¹⁶

The National Health Service Corps Scholarship Program also used the incentive of repayment of educational loan in return for a service obligation. Of the 564 nurses awarded scholarships, almost all met the service obligations, but data were not collected to indicate whether any were staying in the shortage area after their obligated service. The Nurse Practitioner Traineeship Program under NTA described in Chapter V also offered payback incentives for service in shortage areas. Again, because the current status of 50 percent of the traineeship recipients is unknown, the program cannot be evaluated. Nurse education programs are not required to keep records or report on where their graduates practice.

A second strategy--facilitating nurse education for those most likely to work in underserved areas--is built on the assumption that people who already live in such areas are more likely to remain than are those attracted for a limited tour of service. Evidence supports this hypothesis. Feldbaum's 1977-1978 survey found that nurses who grew up in rural areas were the most likely to return to work in such areas, and that a large proportion of nurses who work in inner cities had grown up in large cities.¹⁷ Another recently completed nursing study, in North Carolina, found that nurses cited living in the areas as a prime reason for remaining employed in rural areas and in long-term care institutions. The very high response rate--95 percent for hospitals, 75 percent for long-term care facilities, and 93 percent for health departments--makes these findings credible.¹⁸

Local access to education appears to be important in determining where newly licensed nurses will work. For example, the National League for Nursing's (NLN) 1980 survey of newly licensed nurses from associate degree (AD), diploma, and baccalaureate programs found that more than 61 percent of AD graduates reported their residence at licensure as being in the same county as the location of their schools, and that 75 percent of these graduates had the same residence at licensure as the location of their employer 6 to 8 months after licensure. Corresponding rates in a similar period for diploma graduates were 53 percent and 69 percent. Baccalaureate graduates were more mobile, presumably because programs were not so widely dispersed geographically. Their county residence at licensure was the same as the location of their schools for only 41 percent of the graduates. However, about 65 percent of these baccalaureate graduates reported that the location of their employer 6 to 8 months after licensure was in the county in which they had lived at the time of licensure.

No county residence data are available to show geographic mobility of nurses over the longer run of their practice. However, 10 years after licensure, 63 percent of AD and 41 percent of baccalaureate graduate nurses reported having practiced in only one state.¹⁹ Thus, there is some evidence to indicate that the location of the nursing education program is a determinant of where a licensed nurse chooses to work.

Practical nurses also tend to live and work in the areas where they receive their nurse education. The NLN 1980 survey of newly licensed practical nurses reported that at the time of licensure, over 60 percent of new LPNs were living in the same county where their nurse education program was located. Less than 5 percent had obtained their education in a different state.²⁰

Improvements in the accessibility of nursing programs are needed to encourage residents of underserved areas to enter nursing. Many potential students from such areas--especially those in rural communities--are unable to avail themselves of nursing education. Programs are not likely to be locally available and family responsibilities, costs, and travel distances often combine to prevent potential students from moving to communities where such programs are located. These factors, together with past experience, suggest that locating nursing education programs directly in or near medical underservice areas is a useful strategy in addressing nursing supply problems.

At the federal level, the Area Health Education Center program (AHEC) has in several states mounted more narrowly focused attempts to bring nurse education to residents of underserved areas. AHEC programs encourage training for a wide range of health occupations, and also provide continuing education. The programs are offered through arrangements with existing educational and health care institutions to increase courses and to offer training experiences at hospitals and other sites in and near rural and urban underserved areas. Nursing education has received special attention in the AHEC programs in California, North Carolina, Massachusetts, and Colorado.²¹

In most states, community college systems have made considerable progress in developing locally accessible programs to prepare RNs and LPNs. However, where populations are not sufficiently dense to yield sufficient numbers of students, and where local educational resources are inadequate to provide an institutional base and faculty for the types of nurse education programs that prospective students may require, it is not economically or educationally feasible to provide local nurse education programs. Outreach nursing education programs from state universities or from large schools of nursing offering generalist nursing education, continuing education, and even graduate education can provide an alternative to the proliferation of autonomous, inadequately staffed new schools. Outreach programs also can upgrade the education of nurses already practicing in these areas.

Several programs funded under the NTA are demonstrating that nursing education programs can be offered at off-campus locations to students unable to travel or to relocate. In some instances, such as at Weber State College in Ogden, Utah, nursing faculty pay regular visits to rural communities to teach basic nursing education courses. Their students come to Ogden for short, intensive clinical experience at an affiliated community hospital. There are several variants of this type of outreach. Examples include California State University at Fresno, Montana State University, the University of Maryland (offering baccalaureate degree training to RNs with ADs or diplomas), and Wayne State University (offering master's degree preparation to RNs in remote areas of Michigan).

Television, videotapes, and other technical advances are expanding the possibilities for reaching students in remote areas or areas that lack access to schools of nursing. Today, thousands of non-nursing students are enrolled in televised courses. Several hundred colleges are members of a network working in collaboration with local television stations to offer courses.²² All these various types of programs, on and off the main campus, that offer flexibility and career mobility at various levels of nurse education appear to be sufficiently promising to merit continued support for their further development, evaluation, and dissemination of results.

Education Opportunities for Minority Students

In the same way that minority racial and ethnic groups frequently lack access to health care and have more illness than many others, members of these groups also have inadequate access to opportunities for nursing education.^23,24

Although there are no easy solutions to the access problems of minority groups, studies by Sloan and Feldbaum suggest some strategies for improvements. Recruiting black and other minority people to join the nursing profession may help to increase the number of practical and registered nurses willing to practice in inner-city areas serving minority and underserved populations. This is consistent with the evidence that nurses tend to practice where they grew up. According to Feldbaum's studies of work location, black nurses are more inclined to work in the inner city (41.1 percent) than are their white colleagues (18.4 percent). Further, 30.8 percent of black nurses spend more than one-half of their RN working years in these locations, compared with only 8.1 percent of whites.²⁵

Most nurses do not want to work in the inner-city environment, which is widely perceived to be not only stressful but also unsafe. Sloan reported that 72 percent of RN respondents to a survey were not willing to work in poor sections of cities, even for higher earnings--compared with 42 percent who were unwilling to work in rural areas.²⁶ However, the obverse of Sloan's findings about unwillingness to work in inner cities is that for 28 percent of nurses that was not the case. Sloan also found that black nurses are more willing to work in inner city areas than white nurses--and that baccalaureate trained nurses are less adverse to working in central cities than AD nurses.^{3 27}

The National Sample Survey of Registered Nurses, November 1980, found that minorities have high labor force participation rates, so that increasing their access to nurse education appears to be a good investment.²⁸ The rate for whites was 76 percent, for blacks 90 percent, for Hispanics 86 percent, and for Asian and Pacific Islanders 91 percent.²⁹ Minority nurses, both RNs and LPNs, constitute a large percentage of the nursing staffs in public general hospitals in the inner city, which serve large numbers of minority patients.

Another major advantage of increasing minority representation in the nursing labor force would be that minority patients could be served by those best able to understand minority cultures and languages. The language problem is particularly acute in states with large Hispanic populations, many of whom do not speak English. Hispanic RNs are scarce. In 1974 a California study found that although Hispanics constituted over 15 percent of the population of the state they were only 1.1 percent of California RNs.³⁰ In Arizona in 1981, Hispanics were 16.2 percent of the state's population, but only 2.5 percent of the state's RNs and 6.6 percent of its LPNs.³¹

The relative poverty of minority groups, closely associated with their poor health status and lack of access to care, also creates barriers to their attaining nurse education. A number of federal programs have tried to help disadvantaged individuals gain access to nursing education by offering scholarships and loans.

Federal programs to facilitate nurse education for those with disadvantaged backgrounds and to help alleviate shortages in underserved areas include the Special Project Grants and Contracts Program to improve nurse training, authorized by NTA and its various amendments. Currently, two of the five stated purposes of these special grants are to (1) increase nursing education opportunities for individuals from disadvantaged backgrounds and (2) help to increase the supply or improve distribution by geographic area or by specialty group of adequately trained nursing personnel (including nursing personnel who are bilingual) needed to meet the health needs of the nation. The DHHS Division of Nursing awards grants to public and non-profit private schools of nursing and other education organizations. How the educators are to achieve the goals of the program is not specified.

Since 1965, almost 1,000 projects have been funded under the special grants program. (Further detail is provided in Appendix 2.) The current authorization stipulates that (1) not less than 20 percent be obligated for assistance to the disadvantaged and (2) not less than 20 percent go to projects to increase the supply or improve the distribution of adequately trained nursing personnel by geographic area or by speciality group. Again, however, data are not available to show how many students have been assisted by this program.⁴

The Nursing Student Scholarship Program, although not designed as an effort to improve access to education for those likely to serve in shortage areas, may have assisted that effort more than the programs specifically designed for that purpose. The program was first authorized in the Allied Health Professions Personnel Training Act of 1966 and continued in the Health Manpower Act of 1968, the Nurse Training Acts of 1971 and 1975, and the Nurse Training Act Amendments of 1979. As noted in Chapter III, this program is currently authorized but not funded. Nursing schools administered the program, and could award up to $2,000 per academic year to needy students. Since FY 1970, the program has awarded a total of $139.1 million to nursing schools to provide an estimated 180,502 scholarships.³³ During fiscal year 1974, 79 percent of the 23,700 scholarships awarded went to students from families with incomes of less than $10,000. Of these students, 21 percent were black and 5 percent were other minorities.³⁴

The NTA may have had a significant impact on increasing the supply of black RNs. Smith notes that ''the number of blacks enrolled in RN programs began to increase dramatically after the enactment of the Nurse Training Act of 1964. … From 1965 to 1971, black enrollment increased by about 2,000 students each year compared to an annual increase of about 400 from 1962 to 1965."³⁵ Nonetheless, by 1980 only 8 percent of the employed nurse population was black and other minority.³⁶

The committee believes that low income minority students continue to need both general and specific financial assistance to enable them to enter basic, advanced, and continuing nurse education programs, and that the net effect would be to alleviate the maldistribution of nurses. Because hospitals and other nursing employers control many of the factors that can attract or discourage nurses seeking employment, and because they suffer when they are unable to fill staff vacancies, it is important that they participate in future targeted programs to increase the supply of new nurses in underserved areas. When such nurse employers work closely with nurse education programs in providing clinical experiences for students, they stand to gain a cadre of graduates familiar with the operations of their institution. To the extent that they can offer some assurance that they will hire a number of these graduates, they help create an attractive situation for potential students.

Adequate Revenues for Inner-City Hospitals

As a result of severe resource constraints, some very large inner-city hospitals, particularly tax-supported institutions, have difficulty recruiting and retaining nurses. Constricted revenues limit the abilities of these public hospitals to offer competitive salary structures and to improve general patient services and working conditions. Some factors, such as the location of many public hospitals in deteriorating and unsafe areas, cannot be changed by recommendations within the purview of this study. However, because these institutions serve as the cornerstone of care for the urban underserved, the committee devoted special attention to their problems.

While some of the burden of caring for uninsured inner-city populations clearly falls upon the private sector voluntary hospitals, the major part falls on public facilities. For example, in 1980, the Greater Cleveland Hospital Association reported that in its area, 5 out of 51 hospitals provided 90 percent of the unreimbursed care. Further, the association noted that 80 percent of all unreimbursed in care in Cleveland was for outpatient, clinic, and emergency services.³⁷

In a 1977 report on public general hospitals it was found that they offered important services frequently not provided by other hospitals. On the basis of 1976 data, it showed that in the nation's 100 largest cities, public hospitals represented slightly less than 10 percent of community hospital facilities but provided 45 percent of all ambulatory care visits (i.e., hospital clinic visits for primary care and special diagnostic or therapeutic services). In these cities, the public hospitals also provided more than one out of every four hospital emergency room visits in the community. One-half of all public hospitals in these 100 cities provided neonatal intensive care, one-quarter provided alchohol detoxification services, and one-fifth provided emergency psychiatric care.³⁸ These hospitals are also often regional referral centers and teaching hospitals. Such factors, combined with the severity of the conditions of the patients they serve, result in high costs--often higher than other hospitals of comparable size in their regions.

Federal and state governments have a substantial responsibility for the quality of care in inner-city public and voluntary hospitals, most of which serve not only the unsponsored poor, but also large numbers of Medicare and Medicaid patients for whom payment of necessary expenditures often cannot be fully recovered because of prescribed limitations. Many of the problems that threaten the financial viability of these institutions are created by decisions made by governments about reimbursement levels and scope of services covered by public programs, as well as by other types of federal decisions or nondecisions, such as those related to illegal immigration.³⁹ Faced by a worsening economy, upward pressures on public sector spending, and a powerful public mandate to decrease taxes and government expenditures, spending restrictions are imposed on programs that serve the nation's poor citizens--particularly Medicaid, the second largest public sector program.⁴⁰

Hospitals serving minority and Medicaid patients in inner cities are more financially threatened than are other acute care hospitals. The closing of many state mental hospitals and the impending closure of neighborhood health centers in various cities compound the problem. When such closings occur, displaced patients rely ever more heavily on the larger public and voluntary hospitals. Also, as voluntary hospitals fight to retain a mix of patients by payer status, and usually by race as well, they become less able or willing to provide care to increasing numbers of nonpaying patients. So-called "dumping" or transfer of nonpaying patients from private to public hospitals is not a new phenomenon, but it appears to be increasing. Although no national data are available, accounts of individual hospital's experiences have been reported by the media. Cook County Hospital in Chicago, for example, recently experienced an increase of transfers out of private hospitals, from about 125 to almost 400 per month.⁴¹

Nursing is a particularly serious problem for inner-city hospitals. A 1980 survey of mayors, city council presidents, and city managers of cities with public hospitals reported that next to the high costs of such hospitals the shortage of nurses was the most important health problem they faced.⁴² The 12 hospitals and 4 long-term care facilities composing the New York City Health and Hospitals Corporation (HHC) offer a useful illustration. One-third of New York City municipal hospitals have less than 70 percent of the required number of registered and practical nurses. Almost none of the HHC hospitals have sufficient RNs to meet the corporation's own standard for RNs, three-quarters do not have the required number of practical nurses, and over one-half are deficient in nurses' aides.⁴³

Nursing Education for Care of the Elderly

After examining general problems of underservice and special problems of the inner cities, we turn to the largest single population group that suffers from a lack of adequate nursing services--the elderly.

Currently, there are 23 million people aged 65 and over; 18 years from now, in the year 2000, there will be nearly 32 million. The most vulnerable part of this population is growing at a particularly rapid rate. Since 1950 the number of people aged 75 years and over has doubled. This group uses hospital, nursing home and home care services at rates double or triple those of the population as a whole.⁴⁴

Only about 5 percent of the elderly are in nursing homes at any one time, although one in five will be there at some time in their lives.⁴⁵ Thus the vast majority of the elderly live at home--alone or with their families--or in residential housing for the elderly. When these people receive nursing care it is in ambulatory clinics, physician's offices, hospitals, and sometimes at home. Many experts on the needs of the elderly believe that their health care is not properly adapted to their special needs. There is a tendency for nurses and physicians alike to inappropriately dismiss treatable symptoms, too often automatically regarding them as part of an inevitable, irreversible process of aging. The result of such attitudes is unnecessary disability and institutionalization. Many elderly could remain at home, or in a less restrictive environment, if a greater emphasis were placed on their special needs, which include attention to preventive care and the active management of both acute and chronic conditions.

The committees' attempts to understand and some of the reasons for less than optimal care for the elderly and unnecessary institutionalization revealed that preparation to serve the elderly is rarely emphasized in the education of the health service professions. Most basic nurse education programs fail to provide either theoretical or clinical preparation in geriatrics or long-term care.⁴⁶ Even at advanced educational levels such preparation is scarce. In 1977 only eight schools of nursing had graduate programs in gerontology.⁴⁷ By 1980 only 20 or so schools offered such education.⁴⁸ Reif and Estes suggest that the slow growth of gerontology education may be the result of the limited availability of funds to maintain and develop such programs.⁴⁹

This lack of focus on the elderly during the years of educational preparation may be one reason licensed nurses are not attracted to geriatric care. For example, as noted in Chapter I, only about 8 percent of all employed RNs worked in nursing homes in 1980. The committee believes that if nursing education were to provide special preparation in all of the many aspects of geriatric care, licensed nurses would gain an understanding of the special needs, challenges and rewards of caring for the elderly, and thus become more attracted to employment in all the settings where those people receive care--at home, in clinics, in hospitals, and in long-term care facilities.

In recognition of these problems the Robert Wood Johnson Foundation joined with the American Academy of Nursing in sponsoring the Teaching Nursing Home Program. In 1982, 11 academic schools of nursing received 2-year grants to develop affiliations with nursing homes. The nursing schools are to assume overall responsibility for clinical care of the residents. Faculty will teach students and staff, conduct research, and develop outreach services; nursing students will have clinical experiences in the nursing homes.

Upgrading Existing Staff in Nursing Homes

Although geriatric care in all settings requires special skills and knowledge, it is particularly important in nursing homes and other institutions caring for the elderly. The multiple health problems of the institutionalized elderly present extraordinary challenges for those entrusted with their nursing care. The average nursing home patient is 78 years of age, has multiple chronic conditions, and is confined to chair or bed. About one-third are severely disoriented and 25 percent have chronic brain syndrome.⁵⁰ In 1977, skilled nursing facilities reported that they provided intensive care to almost one-half their patients in the week prior to the National Nursing Home Survey. Yet, the vast majority of nursing care in nursing homes is given by personnel prepared at less than the RN level. In 1977, the last date for which comprehensive information is available, only 22 percent of nursing homes had an RN on duty around the clock, 71 percent of nursing personnel in skilled nursing facilities were aides, 14 percent were licensed practical nurses, and 15 percent were RNs.⁵¹ Aides, generally minimally prepared for their responsibilities, provide six times as much care in nursing homes as do registered nurses, and five times as much care as do licensed practical nurses. They may often perform complex nursing tasks.

No national study has explored the actual tasks RNs, LPNs, and aides carry out in nursing homes. However, a study in Utah elicited the opinions of a panel of nurse educators to determine which of 78 nursing tasks could be safely performed by RNs, by LPNs, and by aides. The panel judged that RNs could perform all 78 tasks, LPNs 72, and aides 51. Survey questionnaires were administered to an RN, an LPN, and an aide in each of 79 nursing homes with reputations for good nursing care to learn which of these specified nursing tasks each category of personnel reported that they in fact actually carried out. The RNs reported that they performed all 78 tasks. So did the LPNs, including six tasks the panel had judged them unqualified to perform. For example, 33 percent of the LPNs reported that they regulated intravenous flow, 29 percent regulated blood transfusion flow, 26 percent inserted nasogastric tubes, 21 percent prepared and gave intravenous medications; 5 percent started intravenous fluids, and 3 percent started blood transfusions.

In this same study, nurses' aides reported that they performed a far greater number of tasks than those for which the panel had deemed them qualified--74, instead of the 51 specified. For example, 33 percent of the aides reported that they removed fecal impactions, 30 percent counted apical pulses; 25 percent suctioned patients' noses; 11 percent suctioned patients' throats, and 4 percent prepared and gave oral medications.⁵² There is no reason to believe that the nursing services provided in Utah's nursing homes differ from those in other states.

For the nation as a whole, various estimates have been made on the basis of professional judgments that indicate serious deficiencies of nurses in long-term care. As described in Chapter II, judgment-of-need model estimates indicate that nursing homes are grossly understaffed. An estimate published by the Administration on Aging indicates that, by 1985, 101,000 FTE RNs would be needed in nursing homes, a substantial increase over the 77,000 FTE RNs employed in nursing homes in 1980.^53,54

The previous recommendation, which suggested a way of dealing with this problem for future generations of nurses, can ameliorate the problem only in the long run. For the short run, upgrading the skills of current nursing home personnel appears to be urgently needed. One example of a promising program to reach RNs in nursing homes is a project funded by the W.K. Kellogg Foundation in 1981. It provides an interesting example of collaboration between educational institutions and nursing homes. The universities of Arizona, California at San Francisco, Washington, and Colorado have received grants to recruit registered nurses already working in nursing homes. These nurses will become qualified as geriatric nurse practitioners after spending 3 months on campus, followed by 8 months of clinical experience on the job under a physician or geriatric nurse practitioner preceptor.

In-service training or continuing education in geriatric nursing for LPNs, aides, and orderlies has been encouraged to some degree under the NTA Special Grants program. Not less than 10 percent of the $6.2 million FY 1982 funds for special grants was to be spent for projects to upgrade the skills of vocational or practical nurses, nursing assistants, or other paraprofessional nursing personnel.

Adequate Payment for Long-Term Care

Registered nurses are not attracted to work in nursing homes. Working conditions are poor, salaries are low, and fringe benefits rarely are offered. Root causes generally are agreed to be current lack of insurance coverage for long-term care, and policies governing Medicaid payment. Somers notes that Medicare coverage specifically excludes both preventive services and all but a modicum of long-term care. "The Medicare message to the average patient is clear. 'Get well fast or get lost.'"⁵⁵ Private insurance also generally fails to cover long-term care. Even major medical insurance usually excludes care in nursing homes and often limits home care to full-time private duty nursing.⁵⁶ Medicaid covers long-term care, but only for the elderly who have completely exhausted their financial resources.

Together, the state medicaid programs provide more than 50 percent of nursing home revenues. Current federal Medicaid standards, embodied in DHHS conditions of participation, require the presence of an RN only for the day shift in skilled nursing facilities (SNFs). (Intermediate care facilities (ICFs) can use an RN or LPN to supervise the day shift.)

The problems resulting from inadequate Medicaid payment for nursing home care are generally recognized. Testimony presented to the Select Committee on Aging of the House of Representatives avers that federal nurse staffing standards in nursing homes, while they are intended to establish only a minimum requirement, have been interpreted by Medicaid programs in some states to represent a maximum limit on licensed nurse hours. Mandatory strengthening of the staffing standards therefore appears to be required to correct this situation, and to avoid penalizing through the payment system those homes that choose to provide more generous services to their patients. More than two-thirds of the nonprofit nursing homes represented by the American Association of Homes for the Aging recommended strengthening the standard to 24-hour coverage by licensed nurses.⁵⁷ However, under the current Medicaid reimbursement system, facilities appear to be faced with a choice of paying high salaries to a few nurses or paying low wages to a greater number of unskilled aides.⁵⁸

Full-time RNs per 100 nursing home beds range from 1.2 in Texas to 9.6 in Alaska.⁵⁹ As noted in Chapter I, RNs have very little time to spend with nursing home patients--12.5 minutes of RN patient care per day in SNFs, were one to assume that RN time was entirely devoted to bedside care. In fact, most of the RN's time in nursing homes is said to be devoted to administrative and supervisory functions.

Institutional care is, of course, only one component of the elderly's need for nursing services. At any one time, 95 percent of the population 65 years of age or over maintain their own households or live with their families. Many of these people, especially at the higher end of age spectrum, have disabling conditions requiring a certain amount of nursing care. Many elderly patients are in nursing homes because they lack access to home nursing and other services that would enable them to remain at home.

Medicare does not reimburse for nursing services to the homebound unless they are in need of defined ''skilled nursing services." Medicaid pays for home health services to the destitute elderly, depending on the scope of each state program's benefit policies. However, the amount of spending for these purposes has been very limited. Up to now, less than 1 percent of Medicaid expenditures have been used to fund long-term care outside of institutions.⁶⁰ Recent changes in the law permit state Medicaid programs to obtain waivers enabling them to offer a much wider array of home and community-based services to certain categories of people living at home. These changes, made in the Omnibus Reconciliation Act of 1981 (Public Law 97-35), have stimulated 34 states to apply for waivers as of December 1982. The Health Care Financing Administration had approved waivers in 24 states as of that date.⁶¹

The movement to strengthen home care services for the elderly received a special impetus from the 1981 White House Conference on Aging. Among some 660 recommendations, those for expanding home health care and other home services received the second highest net score of favorable votes.⁶²

In 1979 there were 3,000 Medicare-approved home health agencies employing community health nurses.⁶³ The number of nurses working in home care agencies increased from 6,600 in 1972 to about 20,000 in 1979. Such agencies primarily, but by no means exclusively, have older people as clients. The new Medicaid waivers are likely to stimulate this sector of demand, provided that sufficient funds are made available for the agencies to offer competitive salaries for RN and LPN home care nurses. One result has already been to strengthen nurse practitioner programs. (Nurse practitioners will be discussed in the section to follow.)

It is evident that changes in the payment levels of federal programs could cause a major increase in demand for both home care and long-term care nurses. It is also evident that an increase in both the amount of licensed nursing care in SNFs and ICFs, and an increase in home nursing services, would immeasurably benefit the elderly population.

Lowering Barriers to Expanded Nurse Practice

The term nurse practitioner (NP) refers to nurses whose education extends beyond the basic requirements for licensure as a registered nurse and prepares them for expanded functions in relation to diagnostic and treatment needs of patients, as well as in primary prevention measures. Most are prepared in certificate programs, but an increasing number are prepared in master's degree programs (Appendix 4). This section of the report highlights the potential of NPs to provide services to underserved populations and especially to care for elderly people.

The National Sample Survey of Registered Nurses, November 1980, reported that there were more than 16,700 nurse practitioners and nurse midwives. As is noted in other chapters, NPs were employed in numerous health care settings. In that year, 5,600 worked in hospitals, 4,000 in physicians' offices (including HMOs), and approximately the same number worked in public health or community health. Together, NPs constituted about 1.3 percent of the RNs employed in nursing. Preliminary data from the Division of Nursing and American College of Nurse Midwives show that as of 1982 the overall number had grown to more than 20,000 nurse practitioners, of whom 2,598 were nurse midwives.

Nurse practitioner programs currently supported under NTA place emphasis on training to meet the particular problems of geriatric and nursing home patients, as well as to provide primary care in homes, ambulatory clinics, long-term care institutions, and other health care institutions. NP traineeship recipients must agree to practice in a health manpower shortage area for a period equal to 1 month for each month of assistance, or to repay the amount of their assistance. In fiscal year 1980 the federal government spent over $2 million on geriatric nurse practitioner training programs.⁶⁴

Nurse practitioners have demonstrated willingness to provide needed services in inner cities and rural communities. In 1977, 23 percent of NPs were employed in inner city settings and another 22 percent in rural areas.⁶⁵ Thus, 45 percent of practicing NPs were located in the geographic areas of greatest need. (Some nurse practitioner programs specifically prepare NPs for practice in rural or other underserved areas, notably those at the universities of California, Minnesota, and North Carolina.)⁶⁶ The Graduate Medical Education National Advisory Committee (GMENAC) cites data from a 1976-1977 survey indicating that 10 percent of nurse midwives work in communities with populations under 10,000.⁶⁷

Nurse practitioners and nurse midwives, working under established protocols, have proved effective in the delivery of primary care in some settings. Some studies have found that the use of NPs in organized health care settings resulted in productivity gains and cost reductions. For example, Holmes observed that a physician/nurse practitioner team was more productive than a physician working alone.⁶⁸ Such augmentation of productivity could help make physician practices in some underserved areas financially viable.

The 1978 Institute of Medicine study on manpower policy for primary care endorsed the use of NPs. That report stated:

… even with the projected increase in the supply of physicians, physician assistants and nurse practitioners have an important role to play in the delivery of primary care. Their role in those rural communities unable to support a physician is of particular importance. In the opinion of the committee, rural communities with populations of 4,000 or less may be adequately and economically served by a physician assistant or nurse practitioner with physician backup. Even in more populated rural communities, they can augment the care provided by the physician so that the patient can obtain needed primary care on a 24-hour basis. In addition, new health practitioners can improve access to primary care in urban settings, especially in hospitals, nursing homes, and as part of a team in a group practice.

Moreover, the committee views these providers as enhancing the delivery of primary care by educating patients to lead more healthful lives … By concentrating on communication with patients, (they) might help patients to adhere more closely to prescribed regimens and to assure increased responsibility for their own health …⁶⁹

The use of NPs in the care of the elderly has potential for improving the health status of this group. A study reports that an adult health nurse practitioner/physician team delivering primary health care to the elderly reduced hospital days and the use of diagnostic and therapeutic procedures.⁷⁰ A Rand study predicts a need for 12,000 to 20,000 geriatric nurse practitioners by the year 2010, depending on the amount of responsibility delegated by physicians.⁷¹ The study indicates that geriatric nurse practitioners could play a significant role in caring for elderly people. Much larger numbers of geriatric NPs have been predicted to be needed by that date in estimates being submitted to the National Institute on Aging.⁷²

Two major factors control the extent to which NPs can furnish primary care to underserved populations: (1) NP practice is regulated by state practice acts that define the scope of nursing practice, (2) payment for NP services by federal programs determines the economic feasibility of using NPs. In recent years, many states have amended physician and nurse practice acts to allow new health practitioners to perform some medical procedures under various conditions.⁶ Most nurse practice acts require physician supervision of NP activities; therefore the presence of NPs in underserved areas depends not only on their own interest, but on their ability to make arrangements with hospitals or physicians. Nurse midwives, many of whom practice in rural and urban underserved areas, also must make such arrangements. In recent years, state laws have become increasingly supportive of midwifery practice. The number of states with statutes or regulations allowing nurse midwives to practice is reported to have increased from 16 in 1977 to 32 in 1980.⁷³

The level at which nurse practitioners can be used is directly related to the licensing provisions in any given state. State legislators, in considering changes in nurse practice acts and related legislation, usually confer with representatives of the medical profession as well as with nursing groups. There are differences of viewpoint as to practice proposals. For example, physician supervision of NPs may be defined as requiring the presence of the physician at the site of practice. Some critics of organized medicine have observed that economic concerns may influence the attitudes and actions of some medical practitioners, especially in the face of the increasing supply of physicians. However, there also are genuine concerns about the quality of care that might be given by NPs in the absence of a physician. The committee did not attempt to resolve these questions because its recommendation deals only with nurse practitioners functioning in organized settings and in joint physician-nurse practices.

Medicaid and Medicare payment policies affect the ability of ambulatory clinics, physicians, and health care institutions to employ NPs. The Medicaid programs in approximately one-half the states specifically provide some type of reimbursement for physician extender services such as those by nurse practitioners or physician assistants.⁷⁴ Federal reimbursement policies in the Medicare and Medicaid programs allow institutions to include physician extender compensation in their calculation of reasonable costs. But federal payments for primary care services, provided by physician extenders outside of institutions, have been restricted. In most cases, services traditionally performed by physicians are not reimbursable under federal programs when provided by physician extenders.⁷⁵

The Rural Health Clinic Services Act of 1977 (Public Law 95-210) eliminated such restrictions in the Medicare and Medicaid programs for physician extenders practicing in certified rural health clinics in designated underserved areas. The Act provides payment for physician extender services even if not directly supervised by a physician. However, where state practice laws require on-site physician supervision, their provisions often appear to govern.

Studies confirm that NPs are willing to provide primary care in parts of rural and inner-city underserved areas where physicians at present do not practice. There is, however, considerable debate on the long-term prospects for using substantial numbers of such practitioners in ambulatory care in view of the increasing supply of primary care physicians. Physicians are increasingly moving into small communities. It is not possible now to project how many nurse practitioners will be needed in the future and where they will practice. GMENAC estimated that the supply of NPs will rise to 39,000 by 1990.⁷⁶

Financing Recommended Actions

The committee has presented recommendations in this chapter that would involve redirection and reauthorization of a number of NTA programs designed to alleviate chronic nursing shortages for various geographic areas, population groups, and institutions. These approaches can be grouped as (1) manpower distribution policies to facilitate the education and employment of individuals most likely to work in rural and inner-city areas, including nurse practitioners; (2) payment changes to enable skilled nursing facilities and inner city hospitals to support acceptable levels of service, including more adequate nursing care in such institutions, and to facilitate the employment of nurse practitioners to care for rural and elderly patients; and (3) policies to improve nursing care for the elderly through incentives to educational institutions and health care providers, first by enhancing the geriatric component of educational programs so that new graduates will be more likely to want to work with the elderly and be more skilled in doing so, and second by improving the skills and knowledge of all levels of nursing personnel who already care for elderly people in long-term care institutions.

Footnotes

1

Currently, blacks constitute 28 percent of the population of large central cities compared with 12 percent of the total United States population, and Hispanics constitute 11 percent as opposed to 5 percent. A disproportionate number of inner-city residents have incomes below the poverty level, 17 percent versus 12 percent of the total United States population.¹⁵

2

Over the years the federal government has defined geographic areas of underservice using a variety of criteria. The areas have been variously delineated as Medically Underserved Areas, Health Manpower Shortage Areas and Nurse Shortage Areas. Many technical problems have been encountered in attempting to define these areas of underservice so as to accomplish program objectives. This report does not address these technical issues but notes that discussions concerning definitions of underservice are continuing.

3

Despite the tendency for minority nurses to work in these areas, a sizable proportion do not. The Feldbaum survey, which oversampled for black nurses, showed that 76 percent of respondents had never worked in inner-city areas.³²

4

Another program, now discontinued, was the Full Utilization of Educational Talent for the Nursing Profession. It provided incentives for special recruitment of minorities and for remedial education. Operational from 1968 to 1974, it was intended to attract students from disadvantaged backgrounds to the nursing profession, and to help alleviate shortages of RNs in underserved areas. Grants were awarded to many types of organizations. The diversity of the approaches used by participating organizations made it difficult to evaluate the program. A substantial number of the targeted individuals now work in underserved areas. Most of the problems addressed by the Full Utilization Program, however, remain unsolved.

5

Some committee members question the effectiveness of service commitment obligations and their equity.

6

See Habibi, M. Legal issues influencing nursing practice. Background paper of the Study of Nursing and Nursing Education. Available from Publication-on-Demand Program, National Academy Press, Washington, D.C., 1983.