ANA gratefully acknowledges this Subcommittee's support for nursing education and research. We appreciate your continued recognition of the important role nurses play in the delivery of health care services and the increased need to fund nursing education programs and innovative practice models. Today, the changing demographics of American society and the health care delivery system demand a nursing workforce that has a sound foundation in a broad range of basic sciences, as well as a unique set of critical thinking and problem solving skills. Unfortunately, the nursing community at large is starting to observe a shortage of nurses with competence, skills and experience to meet the current demand for more complex patient care. New admissions into nursing schools have dropped dramatically over the past six years. This demographic shift within the nursing workforce has caused the average age of resident nurses to rise to 43.3 years. This disturbing trend will continue to increase: The average is projected to continue to increase to 45.5 years in 2010. And, as the average age of nurses increases, America's demand for nursing care is expected to balloon over the next 20 years due to the aging population. A recent study published in the Journal of the American Medical Association projects that by 2020, the demand for nurses will exceed supply by 20 percent. Therefore, we believe that our shared goal of ensuring the nation of an adequate supply of well-educated nurses, to meet the increasing demands of our rapidly changing health care system, will reaffirm the need for increased funding of these programs. Today, ANA offers our professional recommendations for federal funding of nursing education, nursing research and workforce programs.

DEPARTMENT OF HEALTH AND HUMAN SERVICES PROGRAMS NURSE EDUCATION ACT

Advanced practice nurses - registered nurses with education and clinical experience generally at a master's degree level - are providing primary care services in place of physicians or are providing an expanded type of primary care, either as nurse practitioners, certified nurse midwives or clinical nurse specialists. Due to the continued changes in our health care delivery system and the changing demographics and complexity of care, nurse practitioners will be in increasing demand and the nurse education system will be stretched to provide first-quality training for them. These changes call for the fullest utilization possible of the multi-disciplinary providers who care for patients and families in an ever-increasing array of settings: hospitals, subacute care facilities, rehabilitation facilities, long term care facilities, schools and universities, workplaces and communities.

Federal support for nursing education in Title VIII of the Public Health Service Act (PHSA) is unduplicated and essential to achieve future goals for the public's health. When Congress reauthorized these programs by enacting the Health Professions Partnership Act of 1998, P.L. 105-392, it provided the Secretary of Health and Human Services broad discretion to determine which projects to fund, with priority given to projects which would substantially benefit rural or underserved populations, including public health departments. Under the improved Nurse Education Act (NEA) included in P.L. 105-392, the Division of Nursing has the needed flexibility to focus on curriculum development and other programs to address the changing health care environment and assist in the preparation of more nurses who are able to function where there is a greater demand. NEA will better address the need for increasing the numbers of minority nurses available to provide culturally competent, linguistically appropriate health care services to underserved communities by providing funding to support projects that would increase nursing education opportunities for individuals from disadvantaged backgrounds. These nurses would then be better prepared to assist these populations in changing the way they access our health care system, and in helping these patients understand the advantages of developing relationships with primary providers. By itself, the behavior change from accessing health care services through emergency departments, to one in which the consumer routinely seeks care through a primary provider, decreases health care costs exponentially.

Since the recent reauthorization of NEA allows for a more responsive approach to addressing health care needs, it is crucial that the Division of Nursing be provided with the funding necessary to effectively implement these programs. For FY 2001, due to the work of this Subcommittee, the Nurse Education Act was funded at $78.7 million. For FY 2002, we propose to increase funding for the activities of the NEA by at least $25 million to $103.7 million.

The NEA authorities are as follows:

Advanced education nurses: Advanced education nurses are registered nurses trained in advanced degree programs, generally at a master's degree level. They provide primary care in lieu of physicians or provide an expanded type of primary care. This category includes nurse practitioners, nurse midwives, nurse anesthetists, clinical nurse specialists, nurse administrators, public health nurses and other nurses as determined by the Secretary of the Department of Health and Human Services. Traineeships for advanced nursing education is provided under this category. Title VIII funds have supported the development of virtually all initial State and regional outreach models which first demonstrated the delivery of part or all of a graduate program to students at sites using distance learning methodologies from university settings thereby providing advanced study opportunities for nurses in rural and remote areas.

Programs to increase workforce diversity: Both overutilization of costly emergency services and decreased access to primary care have been associated with a low representation of minority health care providers. This legislation provides for increased flexibility in the use of funds to enhance diversity in nursing education and practice. It supports projects to increase nursing education opportunities for individuals from disadvantaged backgrounds - - including racial and ethnic minorities. Some support will be provided through student scholarships or stipends and can be used for pre-entry preparation and retention activities. Continued funding for programs that access this type of funding is dependent on demonstrated outcomes.

Projects to strengthen the capacity of basic nursing education: Funding under this category assists toward expanding basic nurse education, thereby enhancing the basic nursing workforce. Priority areas identified include: skills development for practice in organized health care systems; nursing practice arrangements, care for underserved populations and other high risk groups; cultural competency; baccalaureate enrollment; career mobility; informatics education, including distance learning methodologies and other areas as needed. Nurse managed clinics are included under this category. During the past several years, data show that nurse-managed centers provide an average of 130,000 primary care encounters per year to individuals from vulnerable and underserved populations.

Nurse Loan Repayment (Section 836)
This program provides for up to 85 percent repayment of student loans for nurses who agree to a service payback in nursing shortage areas. We recommend funding for FY2002 at $10 million.

National Institute of Nursing Research (NINR)
The second funding priority for nursing is funding for the NINR, on the campus of the National Institutes of Health (NIH). Again we applaud this Subcommittee's commitment to advancing behavioral science research. Nursing research is an integral part of the effectiveness of nursing care. The NINR provides the knowledge base for practice of 2.7 million registered nurses. Advances in nursing care arising from nursing and other biomedical research improves the quality of patient care and has shown excellent progress in reducing health care costs and health care demands. Research programs supported by the NINR address a number of critical public health and patient care questions. The research is driven by real and immediate problems encountered by patients and families. Study results offer the clear prospect of improving health, reducing morbidity and mortality, and lowering costs and demand for health care.

Recent studies have included looking at the effects of hospital restructuring, such as changes in nurse staffing, on patient care; looking at the success of early intervention programs in helping young disadvantaged mothers care for themselves and their infants; and examining training programs that assist nurse aides in detecting agitation and aggression in patients with dementia. We recommend increasing funding by $40 million from $104 million for FY2001 to $144 million for FY2002.

Substance Abuse and Mental Health Services Administration (SAMHSA) Clinical Training Program
The SAMHSA Clinical Training Program has been a major source of the nation's mental health clinical training funds, and is a source of funding for ANA's Minority Fellowship Project (MFP). The funding is allocated through SAMHSA to the minority mental health training programs in nursing, psychology, social work and psychiatry. The MFP graduates have an outstanding record of public service to minority and indigent communities.

MFP graduates receive doctoral degrees and, as clinicians, work in high risk urban and rural areas providing care to children and families who are victims of violence, HIV/AIDS, and substance abuse as well as the mentally ill. These nurses work in community based clinics and outreach programs and often are the primary care providers for indigent clients who might otherwise go without needed mental health services. In addition, MFP graduates generate research on minority mental health services, treatments and client outcomes. Culturally appropriate research helps us to identify ways to provide services faster and to more people, ultimately improving health care outcomes and reducing health care costs. This works to change the poor health outcomes and high risk health status that continues to plague minority communities. These graduates also work as teachers in schools of nursing that serve minority students, serving as role models and providing leadership to future nurses. We believe this program is a good investment in reducing mental health care costs and recommend funding of $5.0 million for FY 2002 for the SAMHSA Clinical Training program.

The National Institutes for Occupational Safety and Health (NIOSH)
NIOSH is the only federal agency with the mission to conduct research and develop practical solutions to prevent work injury and illness. NIOSH played a key scientific role in the development of the blood borne pathogens standard which provides significant protection to front-line health care providers from possible exposure to blood borne pathogens, such as HIV, Hepatitis-B and Hepatitis-C. In addition, NIOSH funds Educational Resource Centers. These multi-disciplinary, university-based occupational health and safety training and research centers are the primary vehicle for the development and training of a corps of trained occupational health nurses and other safety professionals. We recommend an increase of $50 million in program dollars for FY 2002.

OTHER WORKFORCE FUNDING RECOMMENDATIONS:
As an advocate for the economic and general welfare of registered nurses, the American Nurses Association also recommends appropriate funding for the Department of Labor and related agencies that serve to ensure a safe and fair workplace. ANA believes the work done by the Bureau of Labor Statistics, with respect to the ongoing collection and analysis of employment and economic data, is necessary for tracking changing economic conditions and essential to making workforce projections. We urge your support of the Bureau.

National Labor Relations Board (NLRB)
ANA is concerned about the ability of the NLRB to meet its statutory responsibility of enforcing and interpreting the National Labor Relations Act (NLRA). Potential delays in the processing of complaints and holding representation elections may jeopardize the progress in employee and employer relations. ANA considers this a core independent agency function that must be preserved. We support a funding level of $238 million for the NLRB.

Occupational Safety and Health Administration (OSHA)
The rapid restructuring of the health industry has increased, and in some cases exacerbated, the risk of exposure to illness and injury for nurses and other health care workers. Hospitals and HMOs are downsizing both to cut costs and to be competitive in the health care marketplace. These economic pressures have led to a reduction in the number of registered nurses providing care at the bedside. The remaining nurses in these acute care settings have to work harder and take care of more and sicker patients than ever before. The nurses themselves are sustaining more frequent incidences of injury and illness. According to the Bureau of Labor Statistics, in 1993, back and shoulder injuries accounted for 50 percent of the 31,422 injuries and illnesses that kept registered nurses away from work. Overall, lifting was specified as the cause of 26 percent of all registered nurse injuries. ANA is concerned about the increased occupational risks in nursing and their negative effect on nurses today and the future of this profession.

ANA continues to be concerned about the strength of the Office of Occupational Health Nursing and its parity with similar offices. Occupational health nurses are the largest group of health care providers at the nation's work sites. As such, they are uniquely qualified to assess the practical realities of work sites and related regulatory activities. This office must be fully staffed in order to accomplish its critical task of linking the ongoing work of occupational safety and health nurses to OSHA. We recommend FY2002 funding of $469 million for OSHA.

Conclusion
We appreciate the opportunity to comment on funding for nursing education, research and workforce programs. We thank you for your continued support and look forward to working with you as you proceed through the appropriations process.

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