Nurses Are Perfectly Prepared to Hold Key Government Positions

ONS recently had the opportunity to interview Mary Wakefield, HRSA Administrator and nurse, about her path to becoming the Health Resources and Services Administrator, why her nursing background is essential to the position, and what her thoughts are for the future of nursing.

1. What is the HRSA?

The Health Resources and Services Administration (HRSA) is one of the operating divisions of the U.S. Department of Health and Human Services (HHS). HRSA has a portfolio of over 80 programs, a budget of about $8.5 billion, and a staff of approximately 2,000 people located in the DC area and in 10 regional offices across the nation.

Describe your path to becoming the HRSA Administrator.

I was appointed to the position of Administrator by President Obama in February 2009. I was selected for the position, in part, because of my nursing background and rural health expertise.

As the HRSA Administrator, I'm responsible for the administrative oversight of an array of programs, most of which are designed to ensure access to healthcare services for underserved populations. The populations we serve include economically, medically and geographically vulnerable individuals and communities. For example, HRSA deploys resources to rural and frontier healthcare providers and also implements the Ryan White program that supports people living with HIV/AIDS. Although being a nurse isn't a requirement for this position, it provides a tremendous educational and experiential background on which to draw.

2. Why is it important that a nurse holds this influential HRSA position?

Nurses provide care for underserved and vulnerable populations across many settings. They also provide a patient- and family-centered orientation, and that background is especially helpful in this position. Understanding the contributions and capacity of various healthcare disciplines as well as facets of healthcare infrastructure, from home health to intensive care, is useful to recognizing how our programs can be aligned and deployed effectively. I believe that my work as HRSA administrator is most effective because of my familiarity with health and health care and the associated opportunities and challenges.

The position requires knowledge that nurses bring to their positions including the ability to use data to inform program and policy changes as well as a capacity for problem solving at micro levels, even while being able to understand and advance a comprehensive view of programs and policies, and determine how they can and should align. As in many settings where nurses practice, you need to be able to turn on a dime, prioritize and manage multiple challenges. Of course, nursing expertise isn't the only background that can be brought to this position, but I believe that it's a position ideally suited for a nurse's expertise.

There are now more nurses in management positions in the federal government than ever before, and that includes Marilyn Tavenner, the acting administrator of HRSA's sister agency: the Centers for Medicare and Medicaid Services. President Obama recognizes nursing as a source of expertise to help guide key healthcare programs and policies, and when we think about the future of nursing, these breakthroughs help set the stage for the next generation of nurses and the next set of contributions from our profession.

3. What programs are managed within HRSA, and how have some of them been modified?

Comprising six bureaus and ten offices, HRSA programs include community health centers that employ thousands of nurses at thousands of sites across the nation and the Maternal Child Health block grant program that invests in every state in the nation and touches one out of six women who give birth. HRSA also supports the network of Poison Control Centers that are often staffed by nurses and oversees the organ donation and transplant networks.

Additionally, the agency is responsible for issues ranging from vaccine injury compensation to making discounted pharmaceuticals available for safety net facilities through the 340B program. Thanks to the new healthcare law, some free-standing cancer hospitals became eligible for the program. All hospitals that currently participate are able to use 340B for their outpatient infusion centers if they meet program requirements. HRSA provides leadership and financial support to healthcare providers in every state and U.S. territory, and we provide significant support to strengthen the education and deployment of health professionals ranging from Nurse Practitioners to Dentists to physicians.

With the passage of the Affordable Care Act (ACA), many HRSA programs were modified and expanded to further improve health and healthcare services.

HRSA supports several grant programs that offer opportunities to nurses through training and education, scholarship, and loan repayment. The focus of these programs includes activities to increase the number of primary care nurses, improve nurse retention, address nurse faculty shortages, prepare nurses to care for the geriatric population, improve nursing education and practice, and increase diversity in the nursing workforce, the ACA updated and strengthened many of these programs.

For example, through the Prevention and Public Health Fund, established by the ACA, the Advanced Nursing Education Expansion provided funds to increase full-time enrollment in primary care nurse practitioner (NP) and nurse midwifery (NMW) programs. By providing a stipend of $22,000 per student per year for up to two years, this funding aims to reduce the financial burden of attending school full-time and to accelerate graduation rates to increase the number of advanced practice nurses (APNs).

Through these grants, we project that 600 NPs and NMWs in total will be fully trained by 2015. The fiscal year (FY) 2013 President's budget includes a request for funds to continue the efforts of the Advanced Practice Education Expansion contributing to the overall production of 1,400 additional primary care APRNs. Primary care is all about health promotion and illness prevention, and increasing the cadre of individuals providing these services, ranging from cancer screening to managing chronic illnesses, is a core focus of the ACA.

The ACA also created a new program for Nurse Managed Health Clinics. The Nurse Managed Health Clinics provide a full range of health services, including primary care, health promotion, and disease prevention, often to low-income, underinsured, and uninsured clients.

Additional ACA changes to existing nursing programs include establishing traineeships, re-defining and expanding eligibility, and revising priorities. Examples of these modifications include:

• Authorized traineeships under the Comprehensive Geriatric Education Program for individuals preparing for advanced education nursing degrees in geriatric nursing, long-term care, gero-psychiatric nursing, or other areas of that specialize in caring for older adults
• Recognizing the expanding need for APNs and nurse educators, the ACA incorporated an extremely important change and removed the 10% cap on doctoral student eligibility for the Advanced Education Nursing Traineeship program and the Nurse Anesthetist Traineeship program
• Expanded eligibility for the Nurse Education Loan Repayment Program to include nurse faculty in accredited schools of nursing
• Revised the Nurse Faculty Loan Repayment Program by increasing the annual loan limit and giving doctoral students a funding priority
• Revised the Nursing Workforce Diversity program to include advanced education preparation, degree completion programs, and accelerated nursing degree programs that will enable students to enter the workforce more rapidly. These changes are extremely important as research clearly shows the relationship between patient outcomes and cultural competency in the provision of care. Moreover, providers who are racial or ethnic minorities are much more likely to serve these same populations.

Given the disparities in healthcare status across race and ethnicity, it's very important to ensure that we have more healthcare providers that reflect the populations they serve.

More recently, we re-structured the Advanced Education Nursing Traineeship program in two ways.

• It was converted from a formula-based to competitive grant program
• Traineeship support was targeted to primary care APRNs. This modification was made so that the size of the awards is increased, thus incentivizing schools to increase the number of students in primary care, encourage full-time enrollment, and ultimately accelerate a greater production of new primary care APRNs.

4. Are there opportunities through HRSA for nurses to advance their education and training?

Several HRSA programs support training and education for the nursing workforce with advanced nursing education programs, programs that support nursing workforce and diversity, and community-based training. These programs are open to schools of nursing and healthcare facilities engaged in training nurses and offer a variety of opportunities including traineeships, tuition assistance, infrastructure support for schools of nursing to assist in the enhancement of nursing education programs, and specialized training for nurse anesthetists. Other nursing programs in HRSA support initiatives that expand the nursing pipeline, promote career mobility, enhance nursing practice, and grant financial support to in the form of loans and scholarships for individuals from disadvantaged backgrounds. You'll find a complete list of HRSA's nursing programs following this interview. For more information, please visit the HRSA website.

5. What is HRSA's role for nurses in addressing the primary care workforce shortage?

Both President Obama and HHS Secretary Kathleen Sebelius recognize the considerable value that a strong primary care infrastructure brings to the health of individuals and communities. As a result, HRSA's role in increasing the supply and distribution of the primary care workforce has been markedly expanded. For example, we focus our advanced education nursing traineeships and our advanced nursing education expansion programs on increasing the number of primary care APNs.

The FY 2013 President's budget requests funds to build on efforts under the Advanced Nursing Education Expansion program, authorized under the ACA, to continue to increase the primary care APRN workforce by an additional 1,400 nurse providers.

The recent re-structuring of the Advanced Education Nursing traineeship program earlier this year allows for higher award amounts, incentivizing schools to expand enrollment and accelerate the production of primary care APRNs.

6. How does HRSA affect my daily practice as an oncology nurse?

HRSA investments touch the care of patients with cancer and the individuals that provide that care in many ways. The ACA has a strong focus on encouraging interdisciplinary team approaches to care that explicitly target communication, coordination, and patient-centered care. These features are essential to delivering high-quality care to individuals with cancer diagnoses. At HRSA, we've been engaging team-based care in both educational and practice settings, and we'll be focusing even more effort in this area going forward.

These competencies are critically important to managing care for people newly diagnosed to those with cancer that is being treated as a chronic condition. A major focus of the ACA and HRSA's work is on pivoting away from fragmented care to comprehensive care that transcends settings and providers and is supported with electronic health records. Many years ago, I taught nursing students in clinical rotation in a hospital oncology unit and it's hard for me to imagine a patient population for whom a patient centered medical home is more important. We're making significant investments in that approach, as are our sister agencies like CMS. Additionally, the cancer screenings available in the healthcare settings we support, like community health centers, are clearly important as is our expectation that these clinics measure and report on their efforts in areas like teaching about the importance of smoking cessation.

An important component of the cancer care trajectory involves high-quality follow-up care after cancer treatment. NPs with oncology expertise are uniquely positioned to provide education and care while overseeing patients as they proceed through the survivorship period. In addition, oncology nurse practitioners' emphasis on health promotion and focus on cancer prevention and disease reoccurrence post cancer treatment align directly with HRSA's emphasis on health and wellness, effective mitigation of symptoms associated with chronic illnesses, and supporting nursing workforce development that yields the number, skills, and distribution of nurses that can serve the public's health needs.

7. Can you explain HRSA's role in the newly formed National Health Care Workforce Commission created by the ACA?

The National Health Care Workforce Commission, is an independent, non-governmental commission tasked with reviewing healthcare workforce issues and projecting workforce needs of the nation. The overall goal of the Commission is to provide information to Congress, the administration, States, and localities about how to align federal healthcare workforce resources with national needs. Although authorized by the ACA, no funds are appropriated by Congress for this Commission. Should Congress fund it in the future, HRSA will, via our National Center for Health Workforce Analysis, work collaboratively with the Commission.

a. What are the future workforce needs, and how should nurses respond?
With the expanding and aging U.S. population, demand for health services is increasing and will increase more once the ACA is fully implemented and more people have access to healthcare services. This includes an increase in demand for primary care services, a desirable outcome of expanded coverage. We expect increased opportunities for nurses, including APRNs as they play an important role in primary care and across all services. The number of APRNs graduating each year has been rapidly increasing, in part because of the ACA, and this will help us meet future needs.

b. As the ACA is implemented and coverage increases, are there enough providers–particularly nurses–to care for patients? When we think about workforce supply, we need to consider not only the populations needing certain services but also the design of the healthcare infrastructure in which care will be provided. As systems are redesigned (e.g., Accountable Care Organizations) we need to think about how services can and should be deployed. These considerations include how we can both effectively and efficiently deploy our most precious resource, our healthcare workforce. The healthcare system and needs of the U.S. population and how people engage in their health and health care in 2020 are not the same as they were when I was practicing in 1980. And, in many respects, that's a good thing.

So, when we think about workforce adequacy, there is a lot of complexity to consider. For example, we have categories of health care providers, technologies and other features that didn't exist even a few years ago and all of this contributes to who is trained and what they're trained to do in a reengineered health care system. That's part of the reason why the ACA created HRSA's National Center for Health Workforce Analysis–so that we can better predict trends and ensure adequate supply. In terms of nurses, we have a major new study of RN supply and demand under way.

8. How can we best serve tomorrow's nurses today?

It is clear that nurses of tomorrow must be well prepared to provide comprehensive, team-oriented, patient and population-based care and capable of harnessing technology in the process. Nurses' knowledge will include the science of patient safety, quality improvement, and systems design, including the deployment of navigational skills to support those facing the daily challenge of managing complex chronic illnesses. Historically, many people with certain disabilities wouldn't have lived into adulthood, and many with serious illnesses wouldn't have survived them. Ensuring that people and their families are able to engage successfully in their own health management will be even more essential and require new evidence and knowledge.

The bottom line is that nurses need to be able to both support and lead innovative practice models that are dynamic, are interdisciplinary, and address the needs of individuals, families, and communities. In new and evolving care models, nurses must be able to fully leverage their own knowledge and skill sets as well as effectively engage with the full range of health care workers. HRSA has committed to these goals through its support for interprofessional and healthcare technology innovations and a health workforce that meets the needs of the entire spectrum of care from the beginning to the end of life.

9. What does the future of nursing look like in America?

From a personal viewpoint, and one that may be a bit biased, I can't envision a more dynamic and important field to pursue than health care, and I can't imagine a more professionally and personally fulfilling profession than nursing. The nursing profession really knows no boundaries in terms of practice settings. The breadth of opportunities from engaging in health policy to clinical and community practice to administration, research and academe, and the opportunities within each are really limitless. I made a decision to pursue nursing in 1972, and I've never once regretted it. I think the same will be said by millions of future nurses yet to make this career choice.

HRSA Nursing Programs

Advanced Nursing Education

Advanced Education Nursing Traineeship (AENT)
Funds traineeships for enrolled registered nurses to practice as primary care providers and/or nursing faculty.

Advanced Nursing Education (ANE)
Supports advanced nursing education programs for registered nurses preparing to become nurse practitioners, nurse midwives, nurse anesthetists, nurse administrators, and other specialties requiring advanced education.

Advanced Nursing Education Expansion (ANEE)
Aims to increase the production of primary care APNs by supporting more full-time students and accelerating graduation of part-time students by encouraging full time enrollment.

Faculty Development: Integrated Technology into Nursing Education and Practice (ITNEP)
Supports nursing collaboratives for faculty development in the use of information and other technologies to educate students for 21st century healthcare practice.

Nurse Anesthetist Traineeship (NAT)
Supports increasing access to nurse anesthetist care.

Nurse Faculty Loan Program (NFLP)
Seeks to increase the number of qualified nursing faculty to facilitate education of the nurses needed to address the nursing workforce shortage.

Diversity in the Nursing Workforce:

Innovative Nurse Education Technologies (INET)
Funds nurse training programs to develop innovative regional approaches to using technology, including competency-based distance learning to enhance nursing education.

Nurse Education, Practice, Quality, and Retention (NEPQR)
Provides support for academic, service, and continuing education projects designed to enhance nursing education, improve the quality of patient care, increase nurse retention, and strengthen the nursing workforce.

Nursing Workforce Diversity (NWD)
Supports increasing nursing education opportunities for individuals who are from disadvantaged backgrounds, including racial and ethnic minorities that are underrepresented among registered nurses.

Community-Based Training and Care:

Nursing Assistant and Home Health Aide (NAHHA)
Provides training grants for nursing assistants and home health aides to meet the growing healthcare needs of the aging population.

Nurse Managed Health Clinics (NMHC)
Supports nurse managed clinics that improve access to primary care services.

Other Programs:

Comprehensive Geriatric Education Program (CGEP)
Provides support to train and educate individuals who provide geriatric care for older adults.

Nursing Education Loan Repayment Program (NELRP)
Provides loan repayment in exchange for service commitment. In exchange for a two-year service commitment, participants receive 60% of their total qualifying nursing education loan balance. For an optional third year of service, participants may receive 25% of their original total qualifying nursing education loan balance.

Nursing Student Loan Program (NSLP)
Provides long-term, low-interest rate loans to full-time and half-time financially needy students pursuing a course of study leading to a diploma, associate, baccalaureate, or graduate degree in nursing.