My 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.

I 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 and Asians.

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.

These 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 increase retention.

The 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 of healthcare.
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 very much.