1. Eastman, Peggy

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WASHINGTON-As the population ages and health care delivery becomes ever more complex, the need for excellence in graduate nursing education will become more and more important. That was the conclusion of speakers at a Congressional briefing here on Capitol Hill. The briefing, called "Preparing the Nursing Workforce for a Changing Health System," was sponsored by the Alliance for Health Reform with support from AARP and the Robert Wood Johnson Foundation.

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An issue brief prepared by the Alliance revealed that the demand for registered nurses is projected to grow 19 percent from 2012 to 2022. But in 2013 (the most recent year for which full data are available) nursing programs turned away 78,089 qualified applicants due to faculty shortages, lack of clinical training sites, and budget constraints.


Concern about an adequate number of well-trained oncology nurses is high on the agenda of the Oncology Nursing Society, ONS Director of Health Policy Alec Stone, MA, MPA: "We're concerned about making sure there's a viable workforce for the future," he told OT. "Given the complexity of cancer care, the most important issue to us is access for the patient to highly trained oncology nurses."


ONS has a certification program, which offers three advanced nursing credentials-"we are constantly reviewing the process and making sure it is the best it can be," he said.

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Speakers at the congressional briefing noted that while the education of nurses, especially advanced practice nurses, has received much less attention than the education of physicians, that is changing as society's needs change. The Alliance pointed out that:


* The nursing profession, with about three million licensed and practicing U.S. nurses, is the largest segment of the nation's health workforce;


* There is consensus among experts that nursing education should be modernized to train a greater percen-tage of nurses at the graduate level and provide the skills nurses need to evolve toward more team-based, data-driven, coordinated care; and


* Since nursing supply and demand vary by state and community, there may be shortages based on geography, and disparities may exist at the state level.



In October 2010, the Institute of Medicine issued a major report on the future of nursing (OT 10/25/2010 issue) recommending that:


1. Nurses should practice to the full extent of their education and training;


2. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression;


3. Nurses should be full partners with physicians and other health care professionals, in redesigning U.S. health care; and


4. Effective workforce planning and policy making require better data collection and an improved information infrastructure.



The IOM report, "The Future of Nursing: Leading Change, Advancing Health," stated: "In order to ensure that nurses are ready to assume leadership roles, nursing education programs need to embed leadership-related competencies throughout."


Speaking at the briefing, Edward Salsberg, MPA, Director of Health Workforce Studies at George Washington University School of Nursing and Founding Director of the National Center for Health Workforce Analysis at the federal Health Resources and Services Administration, said: "We're very concerned with the growing demand for health care services." This increasing demand for services, he added, stems from a growing population, an aging population, and the success of medical advances that keep people alive longer.


"Given increasing roles and responsibilities, graduate nursing educating plays a critical role in preparing advanced practice RNs for the future health care system-are we educating them in the right way?"

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Salsberg noted that the Affordable Care Act will bring major changes to health service delivery, and that advanced practice nurses are well suited for this change: The ACA will focus on care coordination and prevention, and encourage efficiency and value. Health care needs are concentrated especially among the elderly and chronically ill, with about 15 percent of the U.S. population using 75 percent of health services.


"I think advanced practice nurses can contribute a lot to this population... It's so clear to me that if we use other health practitioners besides physicians as part of a team, we can do a better job of meeting the needs of the population," he emphasized.


Deborah Trautman, PhD, RN, Chief Executive Officer of the American Association of Colleges of Nursing (AACN), noted that for 50 years programs under Title VIII of the U.S. Public Health Service Act have supported the supply and distribution of nurses at all levels, and that these programs serve as the largest dedicated source of federal funding for nursing education, including advanced education, and workforce development. "That support needs to continue, and we can't afford a step back," she said. "Our vision for the future is a highly educated nursing workforce."


Citing the factors mentioned by Salsberg-an aging population, an increasing number of patients with chronic disease, and the increasing complexity of the U.S. health delivery system-Trautman said, "Our work is not done. It's imperative that we have the number of advanced practice nurses that we need." According to AACN data, 11.8 percent of registered nurses in the U.S. are licensed advanced practice RNs.

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Medicare Graduate Nurse Education Demonstration Project

Recognizing the need for highly trained graduate nurses, the ACA authorized a four-year, $200 million Medicare Graduate Nurse Education Demonstration Project under the Centers for Medicare & Medicaid Services, said Linda H. Aiken, PhD, RN, FAAN, FRCN, Director of the Center for Health Outcomes and Policy Research and the Claire M. Fagin Leadership Professor of Nursing and Professor of Sociology at the University of Pennsylvania.


Now in its third year, the demonstration project is testing the feasibility, effectiveness, and cost of increasing the production of advanced practice nurses through Medicare payments to hospitals for reasonable costs of clinical training of advanced practice nurses in a range of settings. Under CMS terms, 50 percent of the demonstration project advanced training must be in primary care.

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Eligible advanced practice nurses must be RNs, and training is at the graduate degree level. The project, running in five competitively selected hospitals, has assumed two models, Aiken explained: a single hospital and its primary affiliated nursing school plus community partners; and regional consortia with multiple nursing schools and hospitals, and many community partners covering a geographic area.


"Both of these models have been very successful," she said. "It is feasible for hospitals to distribute advanced practice nursing clinical training funds to multiple schools of nursing and clinical settings, including community-based settings. Advanced practice nursing enrollments and graduations have more than doubled during the first two years... clinical training costs for advanced practice nurses have been established and suggest good value for investments."


But there have been challenges, Aiken noted, including:


* Increased but insufficient participation by community-based clinical sites to fully exploit the advanced practice training capacity of nursing schools;


* An incremental funding requirement that is difficult to implement and discourages clinical site participation;


* Exclusion of hospital-sponsored primary care settings in meeting primary care training needs, which is counterproductive in markets dominated by hospital-sponsored primary care; and


* Initial implementation delays, which have resulted in a truncated demonstration period and substantial unspent appropriated demonstration funds.



Return on Investment

Despite these challenges, Aiken said that interim conclusions are that interest is high among clinical settings caring for Medicare beneficiaries in employing advanced practice RN nurse graduates of the demonstration project, and that the project appears to show a favorable return on investment, although specific dollar figures are not yet available.


"There is absolutely no substitute for hands-on clinical training," said Brittnee MacIntyre, MSN, RN, NP-C, a participant in the Medicare Graduate Nurse Demonstration Project, who is a clinical charge nurse at MD Anderson Cancer Center. MacIntyre participated in the demonstration project at a family practice clinic serving primarily Medicare patients. "Patients appreciated the extra time I was able to spend with them, and the ability to communicate complicated health information in layman's terms," she said. On the downside, though, "there was stress to efficiently see as many patients as possible."


MacIntyre said she now plans to continue her career as an advanced practice RN at a primary care clinic. Asked by OT if she had considered pursuing her career as an oncology nurse, she said: "I did consider it; oncology is my first love. I might eventually go back to it."

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She noted that she has a personal interest in oncology, as her cousin died of acute myelogenous leukemia at age 33. But with two small children, she noted, the long commute to MD Anderson and 50-to-60-hour work weeks are difficult for her right now. So for now she has chosen to work in the clinic, which is conveniently located near where she lives.