Arguments Agains Title Viii Nursing Workforce

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A Comparing of Nursing Education and Workforce Planning Initiatives in the United States and England

Elizabeth White

¹Center for Health Outcomes and Policy Research, University of Pennsylvania Schoolhouse of Nursing, Philadelphia, PA, USA

Abstract

Health care systems in England and the United States are under similar pressures to provide higher quality, more efficient care in the face of aging populations, increasing care complexity, and ascent costs. In 2010 and 2011, major strategic reports were published in the two countries with recommendations for how to strengthen their respective nursing workforces to address these challenges. In England, it was the 2010 report of the Prime Minister's Commission on the Futurity of Nursing and Midwifery, Front Line Care: The Future of Nursing and Midwifery in England. In the United States, it was the Institute of Medicine's report The Future of Nursing: Leading Change, Advancing Health. The authors of both reports recommended shifting entry level nursing education to the baccalaureate degree and building chapters within their educational systems to prepare nurses every bit leaders, educators, and researchers. This article will explore how, with contrasting degrees of success, the nursing pedagogy systems in the Us and England have responded to these recommendations and examine how different regulatory and funding structures take hindered or enabled these efforts.

Keywords: nursing staff, capacity building, teaching, nursing

In 2010 and 2011, major reports were published in England and the United states of america calling for robust investment in nursing educational activity as a key strategy to strengthen nurse workforces and ameliorate health care systems. In England, information technology was the Prime number Minister'southward Commission on the Time to come of Nursing and Midwifery in England's (2010) study Front Line Care: The Future of Nursing and Midwifery in England, and in the Us, information technology was the Institute of Medicine'south (IOM, 2011) report The Future of Nursing: Leading Change, Advancing Wellness. The authors of both reports, recognizing the need to set up their workforces to address the growing complexities of health intendance, advocated shifting entry level nursing education to the baccalaureate degree, and building capacity within their educational systems to prepare nurses as leaders, educators, and researchers. Despite the similar recommendations, national responses to these two reports have been quite unlike. England has now transitioned to the baccalaureate degree requirement for entry to exercise, but its government-controlled didactics system continues to struggle with monetary constraints and actually cut nurse training places in the years following the Forepart Line Care study, contributing to a severe ongoing nurse shortage (Migration Informational Committee, 2016). The U.s., by contrast, has not fully transitioned to the baccalaureate degree. However, the Future of Nursing study added momentum to an already meaning growth trend in baccalaureate graduates that started in the early on to mid-2000s and was driven largely by individual market forces (Buerhaus, Auerbach, & Staiger, 2014, 2016). The dissimilarity in national responses to these ii reports provides an informative lesson for how the construction of a country's nursing educational activity organization affects capacity to build and strengthen nurse workforces. This article reviews background and context for the Front Line Care and Time to come of Nursing reports, examines major actions that have taken identify in the two countries following the reports, and considers time to come implications for nursing policy and practice.

Methods

The commodity is based on a review of reports, policy papers, and other materials from government sources, informational groups, and professional associations in England and the United States. Documents were constitute through online searches and citation mining of other reports, policy papers, and news articles. In add-on, websites of key stakeholders such as the National Wellness Service (NHS) in England, the Royal College of Nursing (RCN), and the American Association of Colleges of Nursing (AACN) were searched. To supplement these primary sources, a literature search of PubMed was washed using the following terms: nurse, staffing, education, bachelor of science, baccalaureate, workforce, shortage, Brexit, Affordable Care Act (ACA), and health reform. Lay press articles were besides reviewed to empathize gimmicky public responses to some of the problems discussed. The catamenia of assay for this article is primarily from 2010 to 2017; however, historical events are referenced as necessary to provide background and context.

Background and Context

Overview of Nursing Pedagogy in England and the Usa

England

To appreciate the recommendations of the Future of Nursing and Front end Line Care reports, ane must commencement understand some basic differences in nursing teaching between the two countries (see Table 1). In England, the Nursing and Midwifery Council, an independent regulatory trunk, sets education and training standards, as well as oversees licensure for the unabridged country. When Forepart Line Care was published in March 2010, two educational tracks were approved for entry to practice: the baccalaureate degree and diploma. In September 2010, the Nursing and Midwifery Council updated its education standards to require the baccalaureate caste for new nurses as of 2013.

Table ane

Differences in Entry-Level Nursing Pedagogy Between England and the U.s..

	England	United States
Educational pathways available (equally of 2017)	Baccalaureate caste (iii-yr full-fourth dimension programme)a	Baccalaureate degree (4-year full-time program)a Associate degree Diploma
Regulatory oversight of nursing didactics programs	Nursing and Midwifery Council	State Boards of Nursing Accreditation through a U.S. Department of Education-approved accrediting agency required to be eligible for federal student financial aid funding.
Key governmental funding streams for entry-level nursing teaching	Prior to August 2017: NHS bursary system pays tuition and fees for all students. Administered by Wellness Education England. Afterwards August 2017: Student loan system. Administered by Health Education England.	Title Eight, Public Health Service Human action: Nursing Workforce Development Programs. Administered by the Health Resources and Services Administration. Championship IV, College Teaching Act: Includes a number of federal grants, loans, and work-report programs. Non specific to nursing. Administered past the U.Southward. Department of Education. Carl D. Perkins Vocational and Technical Education Deed: Funding for acquaintance degree nursing programs. Administered past the U.S. Department of Pedagogy. Medicare: Graduate Medical Instruction funding for hospital diploma programs. Administered past the Centers for Medicare and Medicaid Services.
Individual funding for nursing education	Limited private scholarships and loan forgiveness programs are available.	Many private scholarships and loan forgiveness programs are bachelor. Many employers offer tuition back up

Nursing education is publicly controlled and funded past Health Educational activity England, a division of the state's Department of Health that is closely aligned with the NHS. This centrally controlled nursing educational activity system supports the NHS where 81% of all English nurses work (RCN, 2016a). As of September 2017, NHS England employed approximately 318,000 nurses (NHS Digital, 2017). Nurses outside the NHS work in private, charity, or other public sectors (RCN, 2016a).

Until August 2017, all English nursing students received non means tested NHS bursary funding to pay for tuition and fees at educational institutions approved past the Nursing and Midwifery Council. Wellness Education England determines capacity for this publicly funded system by setting the number of training places commissioned each year. This annual cap on preparation places has been a major limiting factor to increasing nursing graduates to boost supply (Migration Informational Commission, 2016; RCN, 2016a). Every bit of Baronial 2017, in an effort to eliminate the cap and increase enrollment capacity for schools, Health Teaching England and the NHS replaced the bursaries (subsidies) with a student loan plan (Department of Health, 2016). Implications of this decision are discussed afterward.

United States

In the United States, nursing didactics and licensure are regulated at the state level by state boards of nursing. Equally of 2016, approximately 2.9 million registered nurses worked in the state across an array of private and public hospitals and other clinical settings (Bureau of Labor Statistics, 2016). Three major education pathways are canonical for entry to practice: baccalaureate degree, associate degree, and diploma. Students must graduate from a Board of Nursing-approved education programme in order to qualify to take the NCLEX-RN, the national licensure exam for registered nurses. Most schools likewise voluntarily apply for accreditation from one of the U.Southward. Department of Education's approved accrediting agencies in order to demonstrate commitment to high-quality standards and be eligible for federal pupil fiscal aid programs (U.S. Department of Pedagogy, 2017).

Federal funding for undergraduate nursing education is bachelor through 2 main funding streams: Title IV of the College Education Act of 1965 (2008) and Nursing Workforce Development Programs under Title Viii of the Public Health Service Deed of 1944 (2010). These funding sources offer a variety of loans, grants, scholarships, and loan forgiveness programs. Boosted federal funding is available to associate caste programs under the Carl D. Perkins Act of 1984 (2006) and to hospital diploma programs with Medicare Graduate Medical Education dollars (AACN, 2015b). Co-ordinate to a 2012–2013 survey done by the AACN, 75.viii% of undergraduate nursing students relied on federal funding to cover at least part of their education costs, while the residue of costs were covered through private loans, personal or family income, private scholarships, employer tuition support, or other sources (AACN, 2013).

This decentralized system of funding and regulation of nursing education is substantially unlike from the English system. It is also cogitating of the decentralized, mixed private–public structures of the U.S. health care system overall. At that place is no national torso that sets enrollment capacity for nursing schools based on central monetary constraints, as there is in England. The primary obstacles limiting capacity for increasing enrollment in nursing schools are faculty shortages and lack of clinical placements (National League for Nursing, 2016). While the U.Southward. nursing educational system has more flexibility to expand to meet need than its English counterpart, its complicated fiscal and regulatory structures have historically served equally barriers to unified national workforce planning (Ricketts & Fraher, 2013).

Evidence and Changing Need for Nurses

The Futurity of Nursing and Forepart Line Intendance recommendations were based on a big body of evidence which has shown that patients fare ameliorate when nurses are educated at the baccalaureate level (Aiken, Clarke, Cheung, Sloane, & Silber, 2003; Aiken et al., 2014, Kutney, Sloane, & Aiken, 2013; Yakusheva, Lindrooth, & Weiss, 2014) and present in clinical settings in sufficient numbers (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002; Aiken et al., 2014; Kane, Shamliyan, Mueller, Duval, & Wilt, 2007; Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002; Needleman et al., 2011; Rafferty et al., 2007). The reports came at a time of major debates in both England and the Us over how all-time to reform wellness intendance systems to accost growing costs, crumbling populations, and increasing patient complexity. These health care reform efforts have significantly changed demand for nurses, who now must accept on greater roles in population wellness, intendance coordination, disease prevention, health promotion, and interprofessional collaboration (Fraher, Spetz, & Naylor, 2015; RCN, 2015a).

In the United States, the ACA was passed in 2010. The law expanded Medicaid and created federal and state-subsidized individual insurance marketplaces to reduce the number of uninsured. It also created new payment and care commitment models, such as answerable care organizations, and contained many measures to reward health care organizations for quality (Kocher, Emanuel, & DeParle, 2010). These initiatives increased the population of Americans seeking intendance and stimulated changes in health care systems to emphasize quality and value.

Around the aforementioned fourth dimension the ACA was beingness debated in the Us, policymakers, NHS leaders, and advocacy groups in England were discussing how to better integrate health care and social services to accommodate the increasingly complex needs of patients (Department of Wellness, 2013). This led to the NHS creating the National Collaboration for Integrated Care and Back up in 2013 and designating several pioneer sites to test new integrated intendance delivery models (NHS England, 2015a). As in the U.s.a., these reform efforts have increased the need for nurses to assume enhanced roles and strengthen their abilities to collaborate within team-based care models (Section of Health, 2013; Ricketts & Fraher, 2013).

England: Front Line Care Report

Written report and Response

The 2010 Front Line Care study was the concluding product of the Prime number Minister'south Committee on the Time to come of Nursing and Midwifery in England. In it, the Committee supported the movement from the diploma to baccalaureate caste equally the new standard for entry to practice past 2013. It emphasized the need to support graduate nursing education and increase the number of nursing and midwifery kinesthesia to encounter capacity. The study too dealt with strengthening nurse leadership, regulatory issues, nurses' responsibilities to the public, civilisation change, and addressed the issue of nursing's poor societal epitome, suggesting a need to counter myths and "market nursing and midwifery as careers" (p. 92).

In 2010, the Nursing and Midwifery Council updated its education standards to require all nursing educational activity programs to exist at the baccalaureate level as of 2013 (Nursing and Midwifery Council, 2010). The Department of Health's (2011) response to the Front end Line Intendance report supported the motility to the baccalaureate degree just provided no concrete commitment for building capacity within the nursing didactics system. Anne Milton, Parliamentary Under Secretary of Land for Public Health, wrote:

The state is facing very challenging fiscal times and Front Line Intendance now has to be read in this new context where funding increases are limited merely where expectations of nurses and midwives delivering the very best intendance remain every bit loftier as ever. Much of what we at present have to do heralds a modify of culture rather than a need for new funding. (Department of Health, 2011, p. v)

Here is where the government's central control over nurse education and thus, supply of nurses, becomes axiomatic. The NHS was hit hard past the 2008–2009 global recession and postrecession period (Appleby, Crawford, & Emmerson, 2009). In an effort to constrain spending, the NHS decreased nurse staffing and reduced skill mix in several trusts, or health care organizations within the NHS (Inspect Commission, 2010). And Wellness Education England cutting nurse training places starting in the 2009/2010 fiscal year, reaching a 10-yr low in 2012/2013, despite a recession-driven surge in applicants to university nursing programs (RCN, 2015a; Effigy i). Although the number of training places have started to increase over again, there were still 2,812 fewer preparation places in 2015/2016 than in that location were in 2005/2006 (RCN, 2015a).

Annual number of commissioned nurse preparation places in England in the years prior to and after the 2010 Forepart Line Care Report.

Data source: Health Instruction England (2016b).

Nursing Shortage and Concerns Over Poor Staffing in the NHS

The nurse vacancy charge per unit in NHS England was 9.4% in 2016, virtually twice that of the maximum 5% vacancy recommended by the National Institute for Health and Care Excellence (Squeamish), an contained body in charge of providing guidance for care quality to the NHS (Migration Advisory Committee, 2016). The government's Migration Advisory Committee has identified the cuts in grooming places between 2009 and 2013 as a major contributing gene to the current shortage (Migration Advisory Committee, 2016). This commission is responsible for determining which occupations authorize for shortages to be given priority for piece of work visas. The U.k.'s planned withdrawal from the European Union (EU), familiarly known every bit Brexit, has further threatened nurse supply considering of its predictable bear upon on EU immigration restrictions. Even before separation occurs, the number of Eu nurses newly admitted to the Nursing and Midwifery Council register in the U.k. dropped from 9,389 in 2015/2016 to 6,382 in 2016/2017. Moreover, 32% of EU nurses leaving the annals reported doing then because of Brexit (Nursing and Midwifery Quango, 2017). In England, EU nurses make up 4.5% of the total nursing workforce, but several NHS trusts use 10% or more than of their nurses from the EU, meaning that those trusts could be especially vulnerable to staffing shortages (Marangozov, Williams, & Bevan, 2016).

In 2013, nurse shortages in the NHS gained considerable public attention after the Secretarial assistant of Land for Wellness commissioned four independent inquiries to investigate reports of inadequate staffing and poor care across several NHS trusts. The precipitating outcome was a scandal in which the Mid-Staffordshire Trust was plant to take had loftier mortality rates and many reports of poor care from the late 2000s to early 2010s. The Francis Enquiry (2013) ended that the causes of these deficiencies included the following: understaffing of nurses, poor work environments, bullying, mistake hiding, and a culture of price-cut and target chasing. It likewise found that nursing skill mixes were being diluted with nonregistered auxiliary staff due to the shortage of registered nurses. Other inquiries followed and institute similar findings beyond multiple hospital trusts in the NHS (Berwick, 2013; Cavendish, 2013; Keogh, 2013).

Rubber Staffing Debates

Following the earlier inquiries, Squeamish was deputed with the task of reviewing the evidence around nurse staffing and providing recommendations for dissimilar patient areas in the NHS. It published staffing guidelines for adult acute wards in July 2014 and maternity settings in February 2015. With both sets of guidelines, NICE stopped short of recommending minimum nurse-to-patient ratios across the board but instead provided formulae and guidance for private hospitals and units to determine their own staffing needs (NICE, 2014, 2015). Dainty was working on guidelines for emergency, mental wellness, and community settings, when in June 2015, the Department of Health asked it to suspend its work so that information technology could be taken over past NHS Improvement, a quality comeback agency within the NHS (NICE, 2016). This motion was criticized past nurse leaders and patient safety groups who feared that, rather than accepting Overnice's independent, evidenced-based recommendations, the NHS would dilute the guidelines to avert having to respond to minimum staffing recommendations that would testify unaffordable (Campbell, 2015; Oliver, 2016).

NHS Improvement (2016, 2017a, 2017b) subsequently released staffing comeback tools for mental health, learning disabilities, and community wellness settings in 2016 and 2017. While the RCN praised these resources every bit being practical and pragmatic, it as well expressed business organisation that the tools were besides generic and lacked the teeth to accept significant impact (RCN, 2017a, 2017b, 2017c). Although nurse staffing in acute wards has improved in response to the Francis study and staffing guidelines, information technology has been at the expense of cuts in mental health, learning disabilities, community nursing, and senior nurse positions (RCN, 2014, 2016a). This suggests that unless the overall capacity for nurses within the NHS is strengthened, at that place will always exist compromises on condom staffing. While staffing needs are ultimately determined by NHS commissioners and managers at the local level, safe staffing is still contingent on having a secure and stable national supply of nurses. Equally the RCN argued in its 2013 labor market review, "local application of staffing tools is irrelevant if there are bereft nurses, with the right skills, available to be deployed locally" (p. 5).

Culture Modify

Under Secretarial assistant Milton's phone call for "a modify of culture rather than a need for new funding" (Department of Health, 2011, p. v) illustrates that the Section of Health prioritized NHS culture change over fiscal investment in nursing education in response to Front end Line Care. This was too evident in Health Pedagogy England'due south cuts in grooming places for 3 years after the study (RCN, 2015a). Since 2011, much attention has been focused on building a more caring and compassionate culture in the NHS, but it is unclear how effective these efforts accept been. The 2013 Francis Inquiry report suggested that nurses should take an bent examination prior to licensure "to explore the candidate's attitude towards caring, compassion, and other necessary professional values" (p. 77). It also recommended that nurses on an annual ground "exist required to demonstrate their ongoing commitment, compassion, and caring shown towards patients" (p. 78). The NHS has adult this into a strategic vision chosen the "6 Cs"care, compassion, competence, communication, courage, and commitment (NHS England, 2015b).

The problem with this strategy is that information technology places blame on nurses for non being empathetic plenty and diverts resource to a questionably effective culture change try, without addressing the underlying problems of inadequate supply and understaffing. In a study of 12 European countries, English nurses had the highest rates of job-related burnout 2d just to Hellenic republic, which has a health care organization in crisis (Aiken, Rafferty, & Sermeus, 2014). Exhaustion is a measure of emotional exhaustion and is linked to patient safety outcomes (Laschinger & Leiter, 2006). Seventy-three percent of nurses surveyed in Aiken, Rafferty, et al.'southward (2014) study said that they did not take enough registered nurses on staff to provide quality patient intendance, and 64% said that they lacked adequate back up services to spend time with patients. These findings suggest that a perceived lack of pity in the NHS is more probable a symptom of an underresourced, overstretched nursing workforce, rather than a deficit in organizational culture.

The The states: The Future of Nursing Report

Report and Response

The IOM, in conjunction with the Robert Woods Johnson Foundation (RWJF), released its Future of Nursing written report in 2010 and published it in 2011. Its authors called for nurses to play a fundamental office in the transformation of the U.Southward. health care system. The study independent eight recommendations that included measures to strengthen nursing teaching and training, remove scope of practise barriers for advanced exercise nurses, prepare nurses with the skills needed to take on leadership roles, and improve the quality of wellness intendance workforce information. Two of the key recommendations were to increase the proportion of nurses with baccalaureate degrees in the United States from l% to 80%, and double the number of nurses with doctorates past 2020. For these final ii recommendations, the IOM outlined specific steps for accrediting bodies, academic nurse leaders, public and private funders, and employers to take in lodge to ensure funding, increase enrollment, monitor progress, and increase diversity in the workforce (IOM, 2011).

Post-obit the release of the IOM report, RWJF and AARP (formerly the American Association of Retired Persons) launched The Future of Nursing: Campaign for Action to oversee implementation of the report's recommendations and monitor progress. The campaign is housed within AARP'southward Public Policy Institute in the Center to Champion Nursing in America, which was created in 2007 with a $10 million grant from RWJF (Campaign for Action, 2017). It has helped establish action coalitions in every state and the District of Columbia to coordinate piece of work with policymakers, health intendance professionals, educators, and business organization leaders (Campaign for Action, 2017). In dissimilarity to Forepart Line Intendance, which was government commissioned, the IOM (now called the National Academy of Medicine), AARP, and RWJF are all nongovernmental organizations. Whereas Front end Line Care has not received much attention since the initial responses post-obit its publication (Department of Health, 2011; Nursing and Midwifery Council, 2010), AARP and RWJF'southward private investments have helped the Future of Nursing campaign to endure as an ongoing active strategic framework for workforce planning (IOM, 2015).

Growth in Baccalaureate Nursing Graduates and Overall Nurse Supply

After a significant nursing shortage in the early 2000s, the number of baccalaureate and associate degree graduates surged from 77,000 in 2002 to but over 200,000 in 2014 (Buerhaus et al., 2016). This remarkable turnaround was stimulated past several national recruitment initiatives to promote nursing every bit a career, wearisome job recovery in nonhealth care sectors afterward the 2001 and 2008–2009 recessions, and a growing health care economy (Auerbach, Staiger, Muench, & Buerhaus, 2013). Still, future projections for nurse supply over the next decade remain mixed due to uncertainty in how emerging models of care will impact demand moving forward, and whether growth in school enrollments will continue at the current step (Auerbach, Buerhaus, & Staiger, 2015a; Health Resources and Services Administration, 2014).

Although enrollment has increased in both associate and baccalaureate degree programs, the virtually dramatic growth has been in the latter. This tendency began in the early 2000s and was driven past individual market demand from employers preferentially hiring baccalaureate nurses, wellness care reform efforts (Buerhaus et al., 2016), and increasing innovation in accelerated and degree-completion programs to attract a wider puddle of students (Auerbach et al., 2013). The Future of Nursing report fueled this growth (Buerhaus et al., 2016). Baccalaureate programs have steadily increased the number of students accepted, more than doubling from approximately 55,000 in 2005 to 119,000 in 2015 (AACN, 2006, 2015a; Figure two). In 2011, for the first time, the annual number of baccalaureate graduates exceeded the number of associate degree graduates (Buerhaus et al., 2016).

Almanac gross number of acceptances to baccalaureate nursing programs in the The states in the years prior to and afterward the Future of Nursing study was released in 2010 (published in 2011).

Data source: American Association of Colleges of Nursing annual reports. Retrieved from http://www.aacn.nche.edu/publications/annualreports

Despite the growth in baccalaureate nursing graduates, the proportion of nurses with a baccalaureate degree or higher in the workforce overall is still far short of the Future of Nursing goal of 80%. According to Spetz (2017), 53.2% of nurses in the United States held at least a baccalaureate caste in 2015. However, in that location is significant variation across the l states, ranging from 38.3% in Wyoming to 69.8% in Nebraska. Hence, while there have been substantial improvements in the educational pipeline to prepare nurses with baccalaureate degrees, there is notwithstanding a considerable fashion to go to transform the overall U.S. nursing workforce.

The ACA and the 2016 Presidential Election

The ACA heightened demand for jobs in the health intendance sector (Frogner, Spetz, Parente, & Oberline, 2015) and contained several provisions to support nursing education. Well-nigh notable was the reauthorization of the Title VIII Nursing Workforce Evolution Programs under the Public Health Service Act (ACA, 2010). Title 8 programs are the largest source of federal funding of nursing education and are prioritized for baccalaureate and graduate nursing education (AACN, 2010). The ACA expanded and modernized all major Title VIII programs including Advanced Educational activity Nursing grants, Workforce Diversity grants, Nurse Education, Practice and Retention grants, the Nurse Faculty Loan Plan, Comprehensive Geriatric Education grants, and the National Nurse Service Corps. It likewise created a new Graduate Nurse Education Demonstration to use Medicare dollars to back up clinical instruction of avant-garde do nurses at five hospitals over 4 years (ACA, 2010).

The momentum behind the ACA changed significantly after the 2016 presidential and congressional elections when Republicans won control of both the White House and Congress after a long campaign to "repeal and replace" the ACA. Republican efforts to overturn the law have, as of January 20, 2018, been unsuccessful. Withal, in December 2017, Congress did repeal the ACA's individual mandate requiring all U.S. taxpayers to accept health insurance as part of its revenue enhancement reform pecker (Tax Cuts and Jobs Deed, 2017). The nonpartisan Congressional Upkeep Function has estimated that this repeal will increase the number of uninsured people past 13 1000000 by 2027 (Congressional Budget Office, 2017). It is uncertain how the elimination of the individual mandate will affect demand for nurses moving forrad.

President Donald J. Trump'southward 2018 budget proposed eliminating $403 meg in health professions and nursing training programs (Part of Management & Budget, 2017). This included a $146 1000000 cut to Title Eight funding that would eliminate all Nursing Workforce Development programs with the exception of the National Nurse Service Corps (AACN, 2017). The budget also proposed cutting the Bureau of Health Professions—the agency responsible for overseeing workforce inquiry, planning, and funding—by $455 million, or 85% from fiscal year 2017 to 2018 (AACN, 2017). The American Nurses Association (ANA, 2017) strongly opposed the budget, arguing that the proposed cuts would "drastically [hamper] efforts to address critical kinesthesia shortages and recruit new nurses into the profession."

As of Jan 20, 2018, Congress has withal to pass a budget for federal financial year 2018, so it is unclear to what degree these programs will exist ultimately funded. Legislation with bipartisan support has been introduced in both the Senate and Firm of Representatives to update and continue funding for Title VIII Nursing Workforce Evolution programs through fiscal year 2022 (H.R. 959, 2017; S.1109, 2017). Although the future of Title Viii funding remains unclear, there is no doubt that national political shifts have pregnant influence over efforts to fund nursing education and workforce development programs.

Implications for Policy and Practice

It is across the scope of this article to examine the straight effects of the Front Line Care and Futurity of Nursing reports on subsequent policies and actions affecting nursing instruction and workforce planning in England and the United States. Many factors influence policy decisions, and no unmarried report tin serve as an ultimate framework. Rather, the goal of this commodity is to sympathise factors that accept helped or hindered leaders' abilities in the two countries to respond to the similar strategic recommendations in those reports. The comparisons and analyses presented here show that national efforts to transform and strengthen nursing didactics must be paired with policies to build and maintain a stable domestic supply of nurses. A few key lessons tin exist learned.

School Enrollment Capacity Is a Key Determinant of Nurse Supply

Nursing schoolhouse enrollment chapters in both the United States and England is limited by shortages of faculty and clinical placement sites (National League for Nursing, 2016; RCN, 2015b). In 2013, baccalaureate nursing programs in the United States received 259,150 applications and accepted 104,864, for an credence rate of forty.five% (AACN, 2014). In the United kingdom of great britain and northern ireland that same year, baccalaureate programs received 226,400 applications but accepted 24,700, an acceptance rate of 10.nine% (RCN, 2014). ⁱ Although these figures are for the United Kingdom overall, England accounted for approximately fourscore% of the training places in the United Kingdom in 2013 (RCN, 2014) and thus is largely driving this number. While the credence charge per unit in the United States is considerably college, schools in the United States still turned away almost 58,000 qualified applicants in 2013 (AACN, 2015a).

To build capacity within schools, efforts must keep to support nurses' pursuit of graduate pedagogy to go faculty. In the United States, this means that nurses need to push Congress to reauthorize Title Viii Nursing Workforce Evolution programs, including the Nurse Faculty Loan Plan and Avant-garde Education Nursing grants. The Trump administration has proposed eliminating both of these programs out of "lack of evidence that they significantly improve the Nation's health workforce" (Role of Management & Budget, 2017, p. 22). The National League for Nursing, AACN, land action coalitions, and other professional associations should continue to educate legislators and communicate updates on progress, to prevent such cuts from occurring. Nurses and their professional associations should likewise advocate for renewal and expansion of the Graduate Nurse Didactics Sit-in and continued back up of the National Institutes of Health, which support PhD didactics for nurses.

In England, the biggest constraint on enrollment capacity has been Health Education England's centrally imposed annual cap on grooming places. Despite a surge in the number of applicants to nursing schools during and later the 2008–2009 recession, its publicly funded bursary system could not expand to take advantage of this–—instead, Health Education England actually cut grooming places between 2009 and 2013 (RCN, 2014). Past dissimilarity, the mixed private–public funding mechanisms that finance nursing education in the United States provided flexibility for schools to aggrandize to accept more students, making the recession and postrecession years a time of meaning growth in enrollments (Buerhuas et al., 2014). To eliminate the annual cap on training places, Health Education England in Baronial 2017 switched from the public bursaries to a student loan system (Department of Wellness, 2016). Since the modify was first appear in 2015, the Nursing and Midwifery Council has seen an increase in applications from schools applying to get approved education institutions, as well as from schools offering nontraditional programs including office-time pathways, work-based models, and nurse apprenticeships (Nursing and Midwifery Council, 2017). Notwithstanding, many nurse leaders, educators, and legislators have expressed concern that, rather than boosting enrollments as intended, the move to student loans will deter potential students from entering the nursing profession (Firm of Commons, 2016).

Shifting Cost of Education to Students Carries Consequences

Nearly English nursing graduates work in the NHS, where salaries are already capped. Moreover, there has been no discussion of increasing salaries to offset loan repayment costs (House of Commons, 2016). Thus, loan repayments could substantially become pay cuts for all new nurses entering the profession. Subsequently fairly stable awarding rates to English university nursing programs in 2015 and 2016, the number of applicants in 2017—the yr the educatee loan system took issue—decreased 23% from 43,800 to 33,810 (Universities and Colleges Admissions Service, 2017; Figure 3). This i yr of application data provides limited evidence, still, information technology suggests that the shift to student loans may already be deterring potential applicants.

Nurses in the The states accept long relied on educatee loans to pay for their education, but they are also paid college salaries than nurses in England, thus offsetting loan repayment costs. As of 2015, nurses in the United States earned on average thirty% more than than the national wage, whereas nurses in the United Kingdom earned just ten% more than the national boilerplate wage (Organisation for Economic Cooperation and Evolution, 2015). The United States has also seen more than market-based adjustments of nursing salaries in areas of the country with college costs of living, such as the East and West Coasts (Bureau of Labor Statistics, 2016). In England, by dissimilarity, plush urban locations like London accept faced severe nursing shortages due to nurses being unable to beget the toll of living (RCN London, 2015). As Health Education England transitions to the student loan system, the NHS Pay Review Body needs to decide how the NHS might respond with regard to nursing wages. The Migration Informational Committee (2016) identified pay as a "lever at the disposal of public sector employers to moderate shortages" (p. 3) and noted that substantial pay increases were used to abate shortages in the late 1990s and early 2000s. Only thus far there has been no sign that wage increases are existence considered (Migration Advisory Committee, 2016).

Strategic Workforce Planning Must Be Aligned With Funding and Regulatory Mechanisms

The Nursing and Midwifery Quango and Wellness Education England's key regulatory and financial control over England'due south nursing education system has enabled a smoother transition to the baccalaureate degree than has occurred in the United States. The Nursing and Midwifery Quango is the sole trunk to gear up educational activity standards in the country, and Health Education England only pays for grooming at institutions approved past the Nursing and Midwifery Council. However, this achievement has been overshadowed somewhat past Health Education England'southward introduction of a new support worker in 2015 called the "nursing associate" (Health Education England, 2016a), which is comparable to a licensed applied nurse in the United states. England previously had a part similar to this called the enrolled nurse, but that position was phased out in the 1990s over quality concerns (Francis & Humphreys, 1999). This policy seems inconsistent with efforts to strengthen the workforce through pedagogy and appears to be an endeavour to stretch the workforce with less qualified staff. The RCN has expressed concern that this new role is beingness "driven by efficiency savings and will result in cheaper, but non necessarily safer or more effective care" (RCN, 2016b. 6).

The The states still lags backside England in requiring the baccalaureate degree for entry to practice. In 2017, New York became the kickoff and only land to pass legislation that would require all new registered nurses to obtain a baccalaureate caste within x years of initial licensure (S6768, 2017). This volition accept result after a state committee has had fourth dimension to review and address barriers for entry into baccalaureate nursing programs. In contrast to England, the U.S. nursing educational organisation functions within a complex regulatory and financial network of state boards of nursing, unlike accrediting bodies, and many public and private funding sources, making compatible policy implementation difficult. Much of the push button toward baccalaureate nursing pedagogy in the United States has been driven from the individual sector by employers, professional associations, universities, and initiatives from RWJF, AARP, and others. While this has allowed for vital investment in nursing pedagogy from outside the global budget constraints of the federal government, it has also contributed to the decentralization of coordinated workforce planning (Ricketts & Fraher, 2013).

Federal funding mechanisms for nursing pedagogy in the United States should support the Time to come of Nursing strategic recommendations. Medicare nonetheless has mandatory funding streams to pay for hospital diploma nursing programs, even though only 2.3% of nursing programs remain at the diploma level (AACN, 2015b). And, the Department of Education even so spends billions of dollars annually supporting associate degree programs with Title 4 and Carl D. Perkins funding (Aiken, 2011). In a labor market where employers preferentially hire baccalaureate nurses, acquaintance degree graduates are at a disadvantage (Auerbach, Buerhaus, & Staiger, 2015b). Many will render to school for additional education, a brunt of both time and money to the private nurse. Accrediting bodies, schools, professional associations, and legislators need to continue work in modernizing these funding sources to support associate degree and diploma schools in academic progression models to transition to the baccalaureate degree.

Conclusions

Comparisons betwixt England and the United States are useful because they help to illustrate strengths and weaknesses in workforce planning in the two countries. The Future of Nursing and Forepart Line Intendance reports were written in response to similar challenges. Health intendance systems in both England and the Us were and go on to be under growing pressure to improve the quality and efficiency of care in the face of aging populations and increasing care complication. To run into these challenges, political and nursing leaders in both countries recognized the need to strengthen their nursing workforces by investing in nursing education.

England's centrally controlled, publicly financed nursing education organization has transitioned more easily to the baccalaureate degree for entry to practise than the state regulated, public and privately financed instruction system in the U.s.. However, the English system has likewise been more constrained in its chapters to expand to come across rising demand. Mixed private and public funding mechanisms have afforded the U.S. educational system with greater flexibility to grow in size. But this fragmented financing in addition to complex regulatory structures take made uniform transformation to the baccalaureate degree much harder in the United States. In both countries, complex regulatory, economic, and political forces take challenged the abilities of policymakers, educators, wellness system administrators, and nurse leaders to influence change. A comparative analysis of how these challenges take been faced in the 2 countries makes one thing articulate: that efforts to strengthen the nursing workforce through improvements in pedagogy must be aligned with policies to produce and maintain an adequate domestic supply of nurses.

Acknowledgments

The author acknowledges Dr. Linda Aiken and Dr. Matthew McHugh for their assistance in review of early on manuscript drafts.

Funding

The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The work is supported past an NINR training grant awarded to the Center for Health Outcomes and Policy Enquiry at the University of Pennsylvania Schoolhouse of Nursing (T32-NR-007104).

Biography

•

Elizabeth White is a predoctoral fellow in the Center for Health Outcomes and Policy Research at the University of Pennsylvania Schoolhouse of Nursing.

Footnotes

¹2013 data are used hither because it is the last year in which both AACN and the Britain's Universities and Colleges Admissions Service (UCAS) reported applications, allowing for comparison. In 2014, UCAS switched to reporting applicants. The UCAS 2013 data are no longer available on its website, so I am referencing those data as published in the RCN 2014 labor market review, which only reports figures for the United Kingdom overall, not England specifically.

Announcement of Alien Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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