Migrant farmworker children: health status, barriers to care, and nursing innovations in health care delivery.

Migrant farmworkers are one of the most health care-impoverished populations in the United States. Mobility, hazardous occupations, cultural diversity, and low socioeconomic status place migrants, and particularly migrant children, at high risk for inadequate health care and preventable health problems. This article presents a synthesis of the existing research on migrant demographics, major health risks, and geographic, financial, and cultural barriers to health care access. Innovative nursing strategies to enhance access and improve the health of migrant children are explored. These include the use of lay community outreach workers, the creation of alternative health care delivery models, and the development of information tracking systems.

Medicare funding of nurse education. The case for policy change.

OBJECTIVES: To determine the magnitude and distribution of US Medicare funding for nursing education and to assess the extent to which Medicare funding contributes to meeting national health care workforce priorities. DATA SOURCES: Medicare Hospital Cost Report Information System, American Hospital Association Annual Survey of Hospitals, and National League for Nursing national surveys of schools of nursing. DATA ANALYSIS: Using hospital identifiers, data from three data sets were merged and analyzed to estimate percentage distributions of Medicare funding according to types of educational programs, hospital characteristics, and student enrollment. RESULTS: Fifteen percent of direct Medicare graduate medical education funding goes to hospitals for the training of nurses and paramedical personnel. Totaling approximately $174 million in 1991, 71% of these funds went to hospitals for nursing education costs. Most of the nation's teaching hospitals (289 of 381 Council of Teaching Hospitals member hospitals) and nurse education programs (1112 of 1484) do not qualify under existing policies for Medicare nursing education reimbursement. Sixty-six percent of Medicare nurse training funds, totaling $114 million in 1991, went to 145 hospitals operating diploma nursing programs; these programs produce less than 10% of nurse graduates. Three states (Pennsylvania, New Jersey, and Ohio) received nearly one half (48%) of the $114 million for diploma nursing education. CONCLUSIONS: Medicare is the largest single source of federal support for nursing education. Yet, the majority of Medicare nursing education funding goes to hospitals affiliated with an increasingly smaller, idiosyncratic subset of nurse training programs. Unlike graduate medical education, Medicare supports primarily preprofessional education in nursing. Graduate education, including the preparation of nurse practitioners, does not generally qualify for reimbursement. Medicare reimbursement for nursing education must be retargeted.

The registered nurse workforce: infrastructure for health care reform.

As of March 1992, 83 percent of America's more than 2.2 million licensed registered nurses (RNs) were actively employed in nursing. RNs are the largest group of U.S. health care professionals and constitute a major part of the infrastructure necessary to any health care reform agenda. Therefore, it is critical to assess the extent to which the current nurse workforce is adequately prepared for its future role in a reformed health care system. Two central trends in the composition of the nurse workforce are noteworthy. First, while the number of RNs is large and continues to grow, cyclical, demand-driven shortages have occurred nationally since World War II. Further, hospital cost containment strategies periodically depress nurses' relative wages, contributing to the substitution of RNs for other workers. Second, there is concern in nursing, as in medicine, that the RN workforce is not optimally trained to meet future needs. While two-year associate degree programs now produce a majority of nursing graduates, the greatest need is for advanced practice nurses. Demand for such nurses is high and is expected to increase as more of the population gains access to health care services. The incentives put forth in the health care reform debate--expanded health insurance coverage, integrated health care delivery systems, and cost-effective practice--create the potential for expanded roles and increased job opportunities for nurses. Realizing this potential will depend largely on the profession's responsiveness to the changes confronting it under health care reform.