IV. The Effect of Title VIII Activities

The NACNEP is in a unique, national position to monitor and assess the outcomes associated with Title VIII programming. This section includes the implications for policy based on outcomes of Title VIII funded projects over the past three years. Available funding. The legislation enacted in November 1998 was first implemented in 1999 for the Fiscal Year 2000 grant cycle. The 1998 legislation provides for three programmatic clusters: Part B, Section 811, Advanced Education Nursing; Part C, Section 821, Increasing Nursing Workforce Diversity; and Part D, Section 831, Basic Nursing Education and Practice. At this time, funds under this legislation are distributed according to specific appropriations for each of these parts. In these first two years of implementation, institutions in every State in the United States have received grant funds from Title VIII programs to enhance nursing education and practice. Between Fiscal Year 2000 and Fiscal Year 2001 the total appropriations increased 16.7 percent as shown in the following table.

Appropriations for the Title VIII Programs: Fiscal Years 2000 and 2001

Nursing Education Programs	(Dollars in thousands)
	FY 2000	FY 2001	Total
Advanced education nursing	$50,587	$59,048	$109,635
Nursing workforce diversity	$4,009	$4,673	$8,682
Basic nurse education and practice	$10,966	$12,791	$23,757
Total	$65,562	$76,512	$142,074

For Fiscal Year 2000 and Fiscal Year 2001, between 50 and 60 percent of over 500 applications submitted and reviewed for all purposes except the traineeship grants were approved. Experience shows that, while the majority of the applications received are meritorious and approved, less than half of those get funded in any one fiscal year because of the limited funds available. Given the time and effort that goes into developing an application for submission, increased funding could also serve to attract additional worthwhile projects.

Applications for traineeship grants from appropriate institutions are funded through a formula based on the number of institutions applying, the number of students and graduates in the institutions and the funds available. Traineeship grants are for graduate nursing students in advanced educational programs and for nurse anesthetist students. The institutions receiving funding are responsible for awarding the grants to eligible students. In the legislation, the provision for advanced educational program graduate student traineeship grants is separate from the provision for nurse anesthetist student traineeship grants.

In Fiscal Year 2000, $15.8 million was distributed to 301 graduate nursing education programs that awarded the funds to a total of 6,231 students. In Fiscal Year 2001, $18.6 million was distributed to 316 programs that provided support to 6,265 students. Although about a quarter of the enrollees in the applying institutions in each of these years received some support, because of limited total funds available, each supported student received only about $2,500-$3,000/year, on average.

In each year, the traineeship funding for nurse anesthetist students totaled $1 million. In Fiscal Year 2000, 68 educational programs received grants and 1,038 students were supported. In Fiscal Year 2001, 66 programs were awarded funding and 1,107 students were supported.

Overview of Title VIII accomplishments. Federal support for nursing education and practice under Title VIII spans almost forty years. Funding through this mechanism has resulted in major contributions to the health care available to the country’s population through the development of new and innovative approaches in the use of nursing resources, new models of education and practice that maximize the effectiveness of nursing resources, timely responses to emerging health care needs that provide nursing with the knowledge necessary to effectively provide care, and limited but important improvement in the recruitment and retention of a diverse nursing student body.

Involvement in the development of the role of the nurse practitioner in the 1960’s and its continued support through Title VIII for nurse practitioner and nurse-midwifery programs, has helped to meet the demand for primary health care services in the United States, particularly among underserved and vulnerable populations. As the health care delivery system moved from traditional hospital–based care to community and home settings, the demand for multi- skilled advanced practice nurses with expertise in primary and specialty care emerged. Preparation of the combined nurse practitioner/clinical nurse specialist role from the mid 1990’s to the present time, provides care of citizens needing both primary and specialty care for their complex illnesses, regardless of setting.

Support of innovative nursing demonstrations in the 1980’s led to the current grant program support for creating nurse-managed centers across the United States where underserved children, families and the elderly may receive primary health care. The positive effects of these programs have been documented over time. To maximize the limited funds provided for their creation through Title VIII, the availability of reliable, sustainable funds is critical to each program’s continuance.

The HIV/AIDS epidemic in the early 1980’s and the current health care system needs for nurses prepared in genetics, informatics and bio-terrorism serve as examples of issues needing immediate attention to ensure that nursing can respond. Often, without support, academic systems are unable to re-direct scarce resources within the same academic year that the resources are needed to develop and implement new programs with potentially limited numbers of students. Emerging health care needs are met by the annual grant cycle which permits distribution of funds to programs to prepare a cadre of advanced practice nurses to respond to evolving diseases/health care needs quickly.

The development of a nurse workforce that reflects the racial/ethnic diversity of the nation’s population is a long-standing issue that Title VIII has addressed by providing funding for programs to alleviate the financial and other barriers that impede the access of racial and ethnic minorities to nursing careers. Funds have been used to develop innovative approaches to recruitment of minority and other individuals from disadvantaged backgrounds into nursing educational programs and for retention of these students through graduation. Although these approaches have been implemented on a small scale because of limited funding, they have contributed to the modest increase in the minority nurse workforce that has been observed in recent years. Dramatic increases in funding would assist in accomplishing the goals of a nurse population that mirrors the diversity of the nation’s population.

Requirements across all the programs administered under Title VIII include adherence to national guidelines and competencies extant in the field. This standard ensures quality programming in primary and specialty care nursing programs and in health care delivery. Funded programs to prepare registered nurses must be nationally accredited in the field and graduates must be eligible to take State licensing examinations following preparation. At the advanced practice level, graduates must be eligible to take State and national certifying examinations following graduation. These strong eligibility requirements assure that the funding is used for support that prepares a cadre of nurses who are capable of providing quality health care.

Furthermore, the goal to improve the diversity of the RN workforce is addressed to some extent in the administration of all the programs under Title VIII. The advanced education and traineeship programs have all contributed to the goal by giving funding priorities to educational programs that demonstrate either substantial short term progress or a longstanding track record of enrolling and graduating trainees from those minority or low income populations identified as at risk of poor health outcomes.

Recent Title VIII accomplishments. The following brief review of some recent outcomes of each of the programs serves to illustrate the resulting benefits to the provision of health care to the population.

Advanced Education Nursing (Section 811)

Federal funding for graduate nursing education has been significant in the development and expansion of advanced practice nursing roles in primary and specialty care to individual patients, families and communities. This section of the legislation supports graduate nursing student traineeships and projects in advanced nursing education programming (primary and specialty care). It is this program that provides for the preparation of nurse practitioners (NPs), nurse midwives (NMWs), clinical nurse specialists, and nurse anesthetists as well as those providing leadership in nursing management and teaching positions. Some recent accomplishments are:

• 54 percent of the nearly 900 nurse practitioner and nurse- midwife graduates a year in supported programs work in Health Professions Shortage Areas. These areas are mostly rural and have 29 million underserved residents.
• In Fiscal Year 2000, in the 121 projects supported, over 3,000 students were enrolled and 1,280 graduated with advanced degrees in nurse anesthesia, psychiatric- mental health nursing, community/public health nursing, geriatric and other clinical nursing specialties, nursing education and administration. Of these, 53 percent were enrolled in NP/NMW programs; 42 percent in other advanced practice clinical, education or administration programs, and 5 percent in nurse anesthetist programs.

Innovative approaches to educate graduate nurses to current issues are illustrated by these recent grants:

• One school of nursing responded to the public health issue of an escalation in the HIV/AIDS patient population in Chicago with an expansion of its existing master of science in nursing program by adding a new specialty in HIV nursing. A primary emphasis of this program is the development of courses that facilitate the student’s knowledge acquisition and clinical experience that addresses the ambulatory and home health care needs of patients with cancer and HIV/AIDS. In addition, students have the opportunity to acquire the skills for the case management of these patient populations to foster cost-effective quality care in a managed environment.
• Support from a grant to a California entity was used to prepare nurse practitioner students to address the special risk factors and co- morbidities associated with psychiatric illness and to provide training at specialized sites where the severely mentally ill receive services. As part of the grant, students were taught the symptom management, psychoeducational and interpersonal skill necessary to work with persons experiencing a range of psychiatric symptoms and to engage those individuals in their own care. Of the 19 students currently enrolled in this program, 26 percent are from minority or disadvantaged backgrounds.

Workforce Diversity (Section 821)

This program is the principal mechanism in the legislation for improving the racial and ethnic diversity of the basic nurse workforce. Grants and contracts are awarded to increase nursing education opportunities for individuals who are from disadvantaged backgrounds (including racial and ethnic minorities underrepresented among RNs). Some recent accomplishments are:

• Supported schools with programs for students from disadvantaged backgrounds have enrollments in which 38 percent of the students are from minority groups, compared to a national average of 19 percent. Out of 1,620 disadvantaged participants in the 18 current projects, 1,203 are from racial/ethnic minority backgrounds.
• The student/participant breakout for the supported projects show that 65 percent (1,050) were nursing students, 27 percent (439) were college pre-nursing students, and 8 percent (131) were high school participants involved in recruitment and pre-entry activities.

Innovative use of these funds is illustrated by these selected examples from recent projects:

• Funding support was provided to a university in southern California to identify, recruit and select persons from disadvantaged backgrounds; facilitate their entry into clinical courses; and provide services to help them successfully complete the baccalaureate nursing program. Approximately 100 disadvantaged individuals (including underrepresented minorities) will be identified, recruited, and selected from colleges, high schools, ethnic minority churches and health care facilities. Accepted students will be assured acceptance into the university baccalaureate nursing program after completing and passing the required prerequisites.
• In North Carolina, funding support was provided to increase enrollment and enhance program success for Associate Degree nurses from disadvantaged backgrounds seeking the baccalaureate degree in nursing. Project activities include: (1) a career awareness recruitment program; (2) partnering with area community college leaders to implement an articulation program for associate degree nursing graduates; (3) peer mentoring; (4) a stipend program, and (5) a visiting nurse lecture series featuring nurses from disadvantaged backgrounds who are well known for their contributions in research, clinical nursing, and/or nursing education. It is anticipated that this project will impact the shortage of baccalaureate prepared nurses from disadvantaged backgrounds in southeastern North Carolina and will result in improved nursing care services to underserved and high risk populations of the area.

Basic Nurse Education and Practice (Section 831)

This section was established to provide grants and contracts to enhance the educational mix and utilization of the basic nursing workforce by strengthening programs that provide basic nurse education through eight targeted purposes. Some selected examples of projects undertaken under various targeted purposes serve to illustrate accomplishments under this section:

• Six projects designed to facilitate and expedite baccalaureate education for RNs in rural areas using distance learning methodologies were supported to demonstrate that quality curricula developed for delivery by distance learning methodologies (primarily computer-based) will facilitate RN to BSN education for nurses living in rural areas and working with underserved populations.
• In Fiscal Year 2001, funds were targeted for ten small seed grants ($25,000 each) to support partnerships between schools of nursing and geriatric long-term care facilities designed to strengthen the geriatric nursing didactic content and clinical components of the baccalaureate nursing program.
• Support to the Minnesota State Department of Health provides continuing education for public health nurses on population-based care in rural, often remote, medically underserved areas in five States. The project also supports an option for academic credit leading to a baccalaureate or master’s degree.
• Establishing or expanding nursing practice arrangements in noninstitutional settings to demonstrate methods to improve access to primary health care in medically underserved areas targeted for this purpose provides the following recent examples of accomplishments:
• In Fiscal Year 2000, nurse managed centers/clinics provided primary care encounters to 100,000 underserved persons representing high risk populations.
• Primary care services were expanded to an underserved, low-income culturally diverse urban population in a designated Philadelphia Public Housing Authority complex.
• Expansion of nurse managed centers under a networked service concept was accomplished in the Miami- Dade metropolitan area. Eight nurse-managed centers were linked together throughout the area by using an elementary school health center as a “hub.”
• Nurse managed primary care services for older adults were provided in Delaware.
• Primary health care access was provided to a multi-cultural, medically underserved population of adolescents in an urban high school in Massachusetts.
• A nurse-managed Children’s Wellness Center for school-age elementary children, their younger siblings, and the children of adolescent families was expanded in Texas.

Primary care services were provided to the homeless and near homeless through a downtown nursing clinic in Tennessee. It is evident that the funding for nursing education and practice made a difference in both the access to and the quality of care delivered to vulnerable populations, in rural and urban settings. Current levels of funding are woefully inadequate to accomplish all the clearly indicated objectives of the Title VIII legislation. It is important that assessments be made of all funding levels necessary to support the development of an appropriate nurse workforce that assures a nursing care presence at the bedside and in the community and that the funds be available for use for those purposes for which there is a critical need at the time. A prime and continuing critical need is that for frequent and ongoing data to monitor, assess, and correct emerging difficulties in the preparation of nurses and the delivery of nursing care.