experiences in the School of Nursing changed how I thought and
how I practiced. Although I was a skilled coronary care nurse
when I started, I learned to think differently and I learned how
to integrate knowledge from the sciences, the arts, and history
into my thinking about the world and my profession. I remember
family living on one of the farms in the county and I visited
the house and it was in deplorable condition. Everything was broken.
And the family had complained to the landlord, but nothing was
ever fixed. I learned that the house was provided to the family
because the husband worked on the farm. I contacted the Health
Department to get advice and found myself in a catch-22 system.
If the Public Health Department condemned the house, the husband
would lose his job and the family would not have a house to live
in. If I did nothing, the family would at least have a roof over
their head. Experiences like these broaden our views, challenge
our values and beliefs, temper our actions, stimulate our creativity,
and illustrate the law of unintended consequences. These types
of experiences are an integral part of an University education,
no matter what one majors in. In the book titled Mr. Jefferson’s
Nurses, Barbara Brodie chronicles the history of the School of
Nursing and its many contributions over the past hundred years.
Many of these contributions are the result of the faculty leaders.
In my view, one of the school’s most significant contributions
was its role in the development in the Nurse Practitioner Movement
in this country. Faculty such as Dr. Barbara Brodie, Dr. Richard
Elick, Dr. Bob Reed, Mrs. Susan Lynch, and Dean Rose Marie Shody
were visionary in being able to see the potential in the nurse
practitioner role in providing greater access to health care in
this country. These faculty reaffirmed the fact that a University
provides fertile grounds for the exploration of new knowledge
and ideas and provides fertile grounds for the education of future
health care professionals.
In the late 60s, a concern about the lack of access to primary
health care stimulated Congress to pass legislation to educate
a new workforce. This legislation was based on the belief that
the country was experiencing a serious physician shortage. In
many areas of the country, there were too few physicians and in
other areas, there were none. Scientific advances and developments
in medical technology had encouraged physicians to specialize.
Specialization attracted physicians to urban middle class communities
and hospitals that could support the specialties and allow them
to expand their clinical skills. As a result, areas of the country
and segments of the population had no access to physicians who
could provide primary healthcare services.
Other societal changes at that time were also influencing the
need for health care. The Civil Rights Movement contributed to
the belief that healthcare was a right and the public demanded
accessible, affordable care. The baby boom from 1946 to ‘64
increased the country’s need for maternal and child healthcare
services. Pediatricians’ offices were filled with children
needing routine preventive healthcare as well as treatment for
their illnesses. And underlying the importance of good primary
care were the reports that many young men were being rejected
from military service for medical problems that could have been
avoided with early intervention. In addition, chronic diseases
often associated with unhealthy lifestyles were increasing and
these diseases were not responsive to traditional medical treatment.
So it is the confluence of these factors that underscored the
nation’s need for accessible primary healthcare.
Now at the same time that all of this was going on, the role of
the nurses was changing and expanding and clinical nurse specialists
were working side by side with physicians and developing coronary
care units and ICUs. The fact that the nurses were capable of
assuming more medical responsibility for patients was viewed by
health leaders as both a potential solution to alleviating the
physician shortage and as a way to expand the delivery of health
services in this country. In 1971, the Department of Health, Education
and Welfare established a committee on extending the roles of
nurses. And the committee recommended, “Healthcare providers
should place more emphasis on preventing diseases in addition
to curing diseases. They should also seek ways to expand and extend
the nurse’s participation in the delivery of health services.”
The committee recognized that this goal would not be easy to attain,
remember this was the late ‘60s, early ‘70s, because
few nurses were prepared for expanded roles in patient care and
because physicians had little experience working with nurses who
were educated to function in these roles. It was in this environment
that I became involved in the nurse practitioner education. In
1974, Dr. Richard Elick received a Federal Emergency Services
Grant to improve emergency care in this region. The grant was
a part of a national effort to improve emergency services throughout
the country because we realized that early intervention, those
first few minutes in an emergency, are absolutely essential.
Things that we take for granted today did not exist in the early
seventies. For example, we did not have signs on the highways
directing us to the hospitals. We did not have just one phone
number. Each rescue squad had its own number so getting everybody
to agree to 911 was a significant effort. And one of the things
that we needed to do because we tend to contract numbers and say
“nine-eleven”, we had to teach people to say “nine-one-one”
because eleven is not on the phone dial. And we were hoping that
everybody would know the number, including children. We did not
have ambulances equipped with the latest technology to provide
basic and advanced life support. Instead, we sometimes had the
ambulances provided by the funeral homes. There was no standardization
in the ambulances. We did not have mobile ICUs at football games.
Instead what we did was we packed a suitcase of drugs and took
them to the games. And we did not have trained EMTs and paramedics.
first met Dr. Elick when we were both taking a cardio pulmonary
resuscitation class and this procedure was also new at the time.
Dr. Elick asked me if I was interested in getting involved in
a very exciting opportunity - the development of a new, expanded
role for nurses, which had incredible potential for improving
emergency services. I appreciated his enthusiasm, but told him
I was very happy doing what I was doing, which was teaching on
the faculty at the School of Nursing, and that I was not interested.
But everyone needs a Dick Elick in their life at some time. He
was a visionary with dreams and drive. He envisioned a better
world and believed he could help make it happen. He would not
take no for an answer. He enlisted the support of Dean Shody and
Barbara Brodie and they kept after me until I finally said yes.
And they were right. It was a wonderful, exciting opportunity.
My involvement with this new program changed the direction of
my career and led to my involvement in the Nurse Practitioner
Movement in this country. In the early and late 70s, UVa was in
the forefront of the Nurse Practitioner Movement. We developed
a new curriculum that served as a model for other programs. Although
nurse practitioners are still only a small fraction of the total
registered nurse workforce, in my view, they expanded the intellectual
talents and skills of nurses. And in doing so, they dramatically
changed the society’s image of nursing. Nurse practitioners
changed undergraduate and Master’s Education. They changed
physicians’ views about who could carry out orders. They
expanded the scope of nursing practice. They removed legal restrictions
that nurses could not diagnose or treat patients. They rewrote
state nurse practice acts and changed federal and state regulations
regarding who could be reimbursed for patient services. But more
importantly, they provided high quality and cost effective healthcare
for many people, particularly the underserved. My work at the
University and the Nurse Practitioner Education and Practice provided
me with a new and challenging opportunity to become a part of
the federal government’s plan to develop nurse practitioner
education throughout the country.
So what does the Division of Nursing do? The Division of Nursing
is located in the Health Resources and Services Administration,
called HERSA. And HERSA is known as the access agency because
it administers many of the safety net programs such as the Ryan
White program for HIV/AIDs. You will remember that Ryan White
was the young hemophiliac who contracted AIDs through tainted
blood. We administer a network of community health centers throughout
the country who provide primary healthcare services to the underserved.
And we administer many of the maternal and child health programs.
Healthcare in the United States is among the finest in the world,
but it is not available to everyone. Nearly forty three million
Americans, including ten million children, lack health insurance.
Nearly three thousand rural and urban communities do not have
enough health care providers to meet the basic needs of their
communities. At a time when the nation enjoys unprecedented prosperity,
millions of families daily face barriers finding quality healthcare
because of their income, lack of insurance, isolation, or language
and cultural differences. HERSA programs fill in the gaps for
individuals and families who live outside the economic and medical
mainstream. Now the resources part of the agency focus on assuring
the availability and diversity of a well-trained health professionals
workforce that looks like America. This is done because we know
a diversified workforce increases access to healthcare for everyone.
One of our major goals is to ensure that there are enough health
professionals with the right skills, providing the right service,
at the right time, and in the right place. As most of you know,
we are currently facing a national and global nursing shortage.
This shortage affects people in all healthcare settings. Hospitals
are forced to close patients’ beds. Emergency departments
are diverting patients. Elective surgery schedules are delayed.
And there are mounting concerns about errors and patient safety
associated with inadequate staffing. Our projections for the year
2000 showed a shortage of 110,000 registered nurses or six percent
of the total needed in 2000. And this shortage is expected to
grow to a hundred thousand by 2020 unless we intervene now. While
we have had nursing shortages in the past, this one is different.
The shortage is not the same everywhere, resulting in wide variations
in the number of available nurses in different regions of the
country. This shortage is increasingly related to aging of the
R.N. population. The average age of a nurse today is forty-five
and less than ten percent of all nurses are under the age of thirty.
In addition to a shortage in the numbers of nurses, there is also
a shortage in the qualifications of nurses. There are shortages
of experienced nurses for ICUs, ERs, and operating rooms. As healthcare
continues to grow more complex, there is a need for more registered
nurses prepared at the bachelorate and higher level. The National
Advisory Council on Nursing Education and Practice, which is both
an Advisory Body to both the Secretary and Congress, recommended
in 1996 that by 2010, two thirds of the nursing workforce should
be prepared at the bachelorate and higher level. Today, forty-three
percent of such nurses are so prepared.
Several research studies have shown the relationship between nurse
staffing, quality of care, patient safety, and patient mortality.
These findings underscore the importance of having enough nurses.
In addition, Dr. Linda Akin, a researcher at the University of
Pennsylvania, recently completed a study that revealed an important
relationship between the education of a hospital’s nursing
staff and the quality of their patient care. Her study shows that
hospitals with higher proportions of nurses educated at the bachelorate
level or higher, had lower patient mortality rates. The lack of
bachelorate prepared nurses means fewer potential faculty - a
condition that is already causing schools of nursing to turn away
significant numbers of applicants who wish to become nurses or
wish to increase their clinical expertise. Another significant
issue with regard to the nursing workforce is the lack of cultural
diversity. Racial and ethnic minorities are underrepresented in
nursing and make up only twelve percent of the R.N. population
in comparison to thirty percent in the national population. Hispanics
are the most underrepresented in nursing, followed by African-Americans
With the changing demographics in our society, it is essential
that we address the diversity and health disparity issues. The
federal workforce policies attempt to address the need for an
adequately prepared and diverse nursing workforce.
Our policies and programs focus on expanding the pipeline of available
nurses, increasing diversity, ensuring the quality of a basic
nurse workforce, expanding the numbers of registered nurses prepared
for advanced practice, preparing graduates to work with underserved
populations and in underserved areas, and supporting efforts to
change the practice environment to retain nurses in the workforce.
Five examples of the types of programs we support are: First,
to expand the pipeline, career ladder programs that enable individuals
to move along the education continuum to become a nurse. From
being a certified nursing assistant all the way up to doctoral
programs. Second, to increase access to primary healthcare for
underserved populations, we support nursing clinics that also
serve as community-based practice sites for undergraduate and
graduate students. Third, to prepare nurses to respond to the
complex healthcare needs of individuals, we support graduate level
programs that prepare nurse practitioners, clinical nurse specialists,
faculty, and nurse administrators. Fourth, to reduce the financial
costs of nursing education, we provide loans, scholarships, and
training ships, and some of these can be paid through service
commitments in facilities with a critical shortage of nurses or
as faculty. And fifth, to reduce the attrition rate and to ease
the transition of the new graduate into the reality of nursing
practice, we support internship and residency programs. And we
also support refresher programs to attract nurses back into nursing.
federal programs provide a comprehensive approach to workforce
development and attribute to alleviating the nursing shortage.
But this is not just federal responsibility, this is a national
problem that requires interventions from many entities including
foundations, nursing organizations, and employers of nursing.
And some very effective examples are the Johnson & Johnson
media campaign to increase awareness about the opportunities in
a career in nursing. And these were showcased at the Super Bowl,
one of the largest TV. Audiences during the year and also one
with some of the highest advertising costs. But their “Be
a Nurse” campaign has been phenomenally successful. Robert
Wood Johnson is transforming Care at the Bedside and they have
several initiatives underway. And an initiative to improve the
work environment is a win – win for both the nurses and
the patients. And at Seton Northwest Hospital, they have this
strategy, now you are going to think this is very unusual, but
this is a strategy that entrusts and empowers the nurses, not
the admitting office, to manage their own capacity to care for
new admissions. Four times the shift, nurses show whether than
can accept additional patience using a traffic light system. Green
means they are able to take on new patients. Yellow means they
are nearing capacity. And red means they cannot safely accept
another patient. In other words, admission to the unit is based
on the capacity to provide care rather than the availability of
a bed. Now Johns Hopkins Hospital needed experienced nurses so
they developed an initiative to recruit and retain experienced
nurses. And they implemented a program that pay fifty percent
of the tuition for children of the experienced nurses in any undergraduate
degree program at any accredited university. Given the cost of
tuition, that is a substantial incentive. So there are many hospitals
and health systems that are now involved in trying to address
this shortage by providing scholarships and loans, by partnering
with schools to provide clinical faculty so schools can expand
their enrollment, and these all have been successful. Enrollments
are up both in undergraduate and graduate programs and there are
many efforts underway to improve the work environment, which will
world has changed a great deal since the days of Mr. Jefferson
and the rate of change occurs at a much faster pace. Jefferson
however did understand the importance of health to a human being.
In one of his letters to a friend, he stressed the importance
of walking and staying fit. Obesity would not be the health problem
it is today if more people appreciated his wisdom and advice.
I wonder what Jefferson would say to us today knowing some of
the opportunities and challenges facing the healthcare professionals
in the future. Such things such as genomics, technology, the changing
demographics, costs and global factors.
Let’s look at genomics. Dr. Francis Collins, an UVa graduate,
has led the effort in this country to unravel the mystery of the
human geno. Understanding the DNA sequencing, the genes that make
up the human body has tremendous implications. It will lead to
more effective prevention strategies and earlier diagnosis and
treatment of diseases. It will also lead to the development of
personalized drugs for your particular health problem. It also
raises ethical and legal questions regarding the appropriate use
of such genetic info and access to care. Technology is having
a tremendous impact on healthcare in this country. Technology,
which is growing exponentially both improves care and potentially
adds barriers to care. It offers new ways to diagnosis and treat
patient, for example, through microsurgery. It offers ways to
manage patient information. And it also offers the potential of
developing an integrated electronic network that will link entire
communities of healthcare providers together, putting the patient’s
record at everyone’s fingertips. But providing confidentiality
and securing the integrity of these networks will require increased
vigilance. Technology also increases access to education and has
created the virtual classroom. It has also changed how we obtain
information, even for older Americans. Sixty six percent of seniors
who have Internet access surf the net for health information.
As a result of technology, patients are more informed about their
health problems and many believe it is changing the dynamic between
the physician, the patient, or the healthcare provider. But technology
also adds to the cost of medical care, which may make it less
affordable for some. A change in demographics in our country is
impacting healthcare and will be a challenge for the future. The
aging of the population is increasing the demand for services
for the elderly. And health professionals are struggling to grow
more capable of handling the special problems of older patients.
America’s also experiencing a significant change in its
ethnic and racial composition. Understanding our diversity is
essential to providing culturally appropriate care at addressing
our health disparities. The size and the power of the baby boomers
will also be a major force for change. Informed, more demanding,
and with disposable income to pay for what they want. And workforce
shortages as well as a more diverse workforce requiring greater
understanding of cultural differences, norms, and interpersonal
skills will impact healthcare. Concerns over costs will continue.
Everyday we hear about potential shortfalls in Medicare, Medicaid,
and employee benefit plans. Without a major change in health policies,
the underserved, uninsured, and underinsured will continue to
grow. Safety net programs will continue to be needed and the tension
between resource needs and resources constraints will increase.
Global factors will also impact healthcare. Global factors such
as diseases that do not recognize geographic boarders - SARS,
Avian flu, HIV/AIDS. A resurgence of diseases – smallpox,
TB – increased resistance to antibiotics. And epidemics,
pandemics, and the threat of bioterrorism. These are just a few
examples of issues and trends facing us now and in the future
So to conclude, each generation faces a world and challenges that
are different from the previous generation. However there is one
thing in common that links generations. And that is the desire
to make the world we live in a better place for all. Thank you