United States Department of Health and Human Services Health Resources and Services Administration Bureau of Health Professions NATIONAL COUNCIL OF STATE.

United States Department of Health and Human ServicesHealth Resources and Services Administration

Bureau of Health Professions

NATIONAL COUNCIL OF STATE BOARDS OF NURSING (NCSBN)

Faculty Shortage: Implications for RegulationFederal Funding Solutions

Joan Weiss, PhD, RN, CRNP

Acting Director

Division of Nursing

March 26, 2008

ANALYZING THE SUPPLY OF THE FUTURE NURSE EDUCATOR WORKFORCE FROM THE

NATIONAL SAMPLE SURVEY OF REGISTERED NURSES

DEFINITION OF NURSE FACULTY

Nurse Faculty:

Nurse Faculty are nurses who hold a primary position as a Dean, professor, or instructor who educationally prepares registered nursing students at the associates, baccalaureate, master’s and doctoral degree levels.

-NSSRN, 2004

NSSRN 2004 FINDING:NURSING FACULTY EMPLOYMENT

Program Employment Distribution of Nursing Faculty

42.1%

35.3%

9.5%

3.5%9.8%

Bachelor's or Higher Degree

Associate Degree

Diploma and Other Programs

CNS or Nurse Assistant

Other

Over 56,500 RNS are employed as faculty in nursing programs

NSSRN 2004: FACULTY IN BS OR HIGHER PROGRAMS

10.1%

28.8%

5.4%

19.3%

7.9% 0.9%

Dean, Director or Assist./Assoc.Dir.ofNursing

Prof./Assist./Assoc. Prof. full-time

Prof./Assist./Assoc. Prof. part-time

Instructors full-time

Instructors part-time

Consultants

NSSRN 2004: FACULTY RNS IN BS OR HIGHER PROGRAMS BY RACE/ETHNIC BACKGROUND

81.5%

6.2%4.6%1.3% 4.7%

White/non- Hispanic

Asian/Pacific Islander, non-Hispanic

Black, non- Hispanic

Two or more races

Not specified

NSSRN 2004: FACULTY RNs IN BS OR HIGHER PROGRAMS BY HIGHEST EDUCATIONAL

PREPARATION

22.8%

39.7%

36.6%

0.4%0.6%

Diploma in Nursing

AD in Nursing

Baccalaureate in Nursing

Masters Degree

Doctorate Degree

NSSRN 2004: PERCENTAGE OF FULL-TIME AND PART-TIME FACULTY

* N= 11,888 for Full-time Instructors

*21%

8.9%

16.5%

6.9%2.6%

Full-time Instructors

Part-time Instructors

Full-time Associate,Assistant, or FullProfessorsDean orAssistant/AssociateDirectors of NursingProfessor orAssistant/AssociateProfessor

*

NSSRN 2004: FACULTY RNs IN BS OR HIGHER PROGRAMS BY AGE OF NURSES

Average Age of RNs is 50.4 years

10.1%

15.5%

36.3%

38%

Under 35 years

35 to 45 years

45 to 55 years

55 years or older

NSSRN 2004: FACULTY RNs IN BS OR HIGHER PROGRAMS BY TIME IN ACTIVITIES

13.8%

45%7.4%

6.1%

2.7%

24.7%

Direct Patient Care

Teaching

Adminstration

Research or Consulting

Other

No Dominant Function

NSSRN 2004: FACULTY RNs IN BS OR HIGHER PROGRAMS BY UNIT WITH MOST PATIENT CARE

25.9%

22.1%7.6%

7.2%

5.8%

5.4%

4.1%6.8% 2.4%

General/ specialty inpatientcare

Critical Care (ICU/CCU)

Step Down/Transitional

Labor/Delivery Room

Outpatient Department

Emergency Department

Operating Room.Perioperative, Sub-Acute

No Specific Area/MultipleUnits

Other Specific Area

NSSRN 2004: FACULTY RNs IN BS OR HIGHER PROGRAMS BY PERCENT OF TIME IN TEACHING

19.1%

19.1%

16.6%16.1%

28.9%

None

Less than 26 percent

26-50 percent

51-75 percent

Over 75 percent

NSSRN 2004: FACULTY RNs IN BS OR HIGHER PROGRAMS BY PERCENT OF TIME IN RESEARCH

54.2%36.1%

5.8% 2.7% 2.8%

None

Less than 26 percent

26-50 percent

51-75 percent

Over 75 percent

NSSRN 2004: FACULTY RNs IN BS OR HIGHER PROGRAMS BY SATISFACTION WITH PRINCIPAL

NURSING POSITION

37.9%

47.3%

4.0%5.7% 4.0%

Extremely Satisfied

Moderately Satisfied

Neither Satisfied/Dissatisfied

Moderately Dissatisfied

Extremely Dissatisfied

NSSRN 2004: FACULTY RNs IN BS OR HIGHER PROGRAMS BY PORTION OF YEAR IN PRINCIPAL

POSITION

82.8%

17.2%

Entire calendar or academic year

Only part of year

NSSRN 2004: THE AVERAGE EARNINGS OF NURSING FACULTY BY PROGRAM

$58,880

$51,512

$45,261

$0

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

BS or Higher Programs AD Programs Diploma and Other Programs

HRSA PREPARES QUALIFIED NURSING FACULTY

IN THREE AREAS:

1. Advanced Education Nursing Program (AEN) (Supports for Masters and Doctoral education)

– Advanced Education Nursing Program (AEN)– Advanced Education Nurse Traineeship Program (AENT)– Nurse Anesthetist Traineeship Program (NAT)

2. Nurse Education Practice and Retention Program (NEPR)

– Faculty Development Initiative– Integrated Technology into Nursing Education and Practice

(ITNEP)

3. Nurse Faculty Loan Program (NFLP)

ADVANCED EDUCATION NURSING PROGRAM (AEN)

LEGLISATION: TITLE VIII- SECTION 811

Sec. 811– A major component of Title VIII legislation is to provide:

• program grants for the enhancement of advanced education and practice, and

• traineeship grants to institutions for student support in advanced education

Section 811: Levels of Programs• Master’s and Doctoral programs• Combined RN/Master’s programs• Post-nursing Master’s certificate programs• Certificate nurse-midwifery programs in existence on November 12, 1998

DIVISION OF NURSING (DN) BUDGET FY 2006- 2008

* in millions

$0.00

$20.00

$40.00

$60.00

$80.00

$100.00

$120.00

$140.00

$160.00

FY 06 FY 07 FY 08

Advanced Education Nursing

Nursing Workforce Diversity

Nurse Education, Practice andRetention

Loans and Scholarships

Nurse Faculty Loan

Comprehensive GeriatricEducation

TOTAL

ELIGIBLE APPLICANTS FOR AEN & NFLP PROGRAMS

Eligible Applicants must be accredited:• Collegiate schools of nursing; • Academic health centers; and• Other public or private entities accredited by a national

nurse education accrediting agency or State approval agency recognized by the Secretary of the U.S. Department of Education.

Length of Support:• Competing Applications

• Three (3) years

• No planning year allowed: Projects should be ready to enroll students in the first semester/quarter after funding.

GUIDELINES FOR AEN PROGRAMS

• Projects that have a nursing educator component must: – lead to a master’s degree, post-master’s certificate or doctoral degree – provide evidence of adherence to national nursing organizational guidelines and competencies

• Programs must prepare nurse educators to:– function in a complex educational environment – to teach traditional as well as non-traditional learners using a variety of emerging technologies and interdisciplinary skills.

• Graduates must be eligible for national nursing organization certification in advanced practice or advanced level specialty.

AEN GRANTS WITH A NURSE EDUCATOR FOCUS 2006-2007

Educator Programs by Degree Level

•Doctoral: A program of instruction beyond the baccalaureate and master’s degrees in nursing (e.g. PhD, DNS, DSN, DNSc, DNP). Doctoral programs in nursing fall into two principal types:  research focus and practice focus.

•MSN: An advanced program of instruction beyond the associate and baccalaureate degrees in nursing (e.g. MSN, MS). Master-level programs have a range of nursing specialties (nurse educator, nurse-midwifery, forensic, nurse practitioner, anesthesia, etc.)

•Post-MSN Certificate: A formal, post-graduate program for registered nurses with master's degrees that awards a certificate and academic credit that is documented on a graduate transcript from the school for completion of the program of study as a Nurse Practitioner, Nurse-Midwife, Clinical Nurse Specialist, or other advanced level nursing program of study.

AEN GRANTS WITH A NURSE EDUCATOR FOCUS BY DEGREE LEVEL 2006-2007

* 2007 includes 2-MSN and 2-Doctoral no-cost extension grants. In the PhD only category, one program offers the BSN/ PhD Option.

*

57

12 13

5

18

5

2

7

3 3

6

2 3

5

28

20

48

0

5

10

15

20

25

30

35

40

45

50

Doctoral only MSN only MSN and Post-MSN Certificate

MSN andDoctoral

Post-MSNCertificate and

Doctoral

Total AllProgram Levels

per year

2006

2007

Cum. Total All Program Levels 2006- 2007

*

*

AEN: GRANTS WITH NURSE EDUCATORFUNDING SUPPORT 2006-2007

$0

$2,000,000

$4,000,000

$6,000,000

$8,000,000

$10,000,000

$12,000,000

Educator-Focused Funding By Program Levels

2006

2007

Cum. Totals Award Amt. 2006- 2007

2006 $1,397,127 $2,920,594 $746,634 $839,275 $524,421 $6,428,051

2007 $1,511,830 $1,513,837 $489,747 $848,702 $849,357 $5,213,473

Cum. Totals Award Amt. 2006- 2007

2,908,957 4,434,431 $1,236,381 $1,687,977 1,373,778 $11,641,524

Doctoral only

MSN onlyMSN and

Post- MSN Certificate

MSN and Doctoral

Post-MSN Certificate

and

Total All Program Levels/yr

DOCTORAL PROGRAMS THAT PREPARE QUALIFIED NURSE FACULTY

• Arizona State University, College of Nursing (# 05320)

– DNS for roles as faculty, clinical nurse leaders, and evidence-based clinical researchers

• University of South Alabama (# 07984)– DNP for roles as a nurse educator

• University of Nevada, Las Vegas Board of Regents, NSHE (# 07966)

- PhD for roles as a nurse educator

• Marquette University (# 00571)– PhD for roles as teacher-scholars

DOCTORAL PROGRAMS THAT PREPAREQUALIFIED NURSE FACULTY (CONT.)

• University of Colorado, CO Springs (# 07976)– DNP roles in faculty development

• University of Washington (# 07344)– DNP for roles as an educator with a focus on health care

• University of Cincinnati (# 05327)– BSN-PhD for roles as faculty and clinical nurse leaders

addressing rural health, health disparities, and health promotion

• University of Texas, Arlington (# 07342)– BSN-PhD for roles as faculty and clinical nurse leaders

addressing rural health, health disparities, and health promotion

DOCTORAL PROGRAMS THAT PREPAREQUALIFIED NURSE FACULTY (CONT.)

No- Cost Extension Grants:

• Hampton University (# 00247)

- PhD roles as a nurse educator

• University of Arizona (# 03116)

- DNSc program in faculty development as a nurse leader

ADVANCED EDUCATION NURSE TRAINEESHIP PROGRAM (AENT)

PURPOSE

Authorizes grants to meet the costs of traineeships that will pay all or part of the costs of the tuition, books, reasonable living expenses and fees of graduate students enrolled in advanced education nursing programs.

USE OF GRANT FUNDS

• Stipends (maximum of $8,800 per student)

• Full tuition and fees

• Trainee travel is not allowable

• Required textbooks up to $500 per trainee.

• Books for library or personal/professional use may not be charged to the grant.

• Only full-time, first-year nurse anesthesia students may be supported under the AENT program.

• Institutions should submit a separate Nurse Anesthetist Traineeship Program grant application to support nurse anesthesia students enrolled beyond the first 12 months of study.

ELIGIBLE STUDENTS

Eligible Student must be:

• Enrolled full-time or part-time (within the last 12 months of study prior to graduation)

• In an advanced education nursing program for preparation as a:

• nurse practitioner, • nurse-midwife,• nurse anesthetist,• clinical nurse specialist, • public health nurse,• nurse administrator,• nurse educator, *• or “other” nurse specialty determined by the Secretary to require advanced education

Students must also be:

• Pursuing a Master’s or doctoral degree, a combined RN to Master’s degree, a nurse-midwifery certificate, or a post-nursing Master’s certificate

• Citizen of the United States, a non-citizen national, or foreign national who possesses a visa permitting permanent residence in the United States

• Eligible for national nursing certification in the nursing specialty or field of study (as applicable) following graduation

ELIGIBLE STUDENTS

NURSE ANESTHESIA TRAINEESHIP PROGRAM (NAT)

PURPOSE

• Authorizes grants to meet the costs of traineeships for licensed registered nurses enrolled as full-time students beyond the twelfth month of study in a master’s or doctoral nurse anesthesia program.

• Traineeships will pay all or part of the costs of the tuition, books, fees and reasonable living expenses of the individual during the period for which traineeship is provided.

ELIGIBLE STUDENTS

Eligible Students must be:

• A registered nurse enrolled at the institution in a qualified advanced education nursing program

• Citizen of the United States, a non-citizen national, or foreign national who possesses a visa permitting permanent residence in the United States

• Enrolled full-time beyond the 12 months of study

• Eligible to sit for the certification examination from the American Association of Nurse Anesthetists Council on Certification of Nurse Anesthetists to become a Certified Registered Nurse Anesthetist (CRNA)

STATUTORY FUNDING PREFERENCE (AENT & NAT)

Preference will be given to qualified applicants that demonstrate a:

• High rate of graduates accepting positions in medically underserved areas; and a

• Minimum of 40% of graduates who spend at least 50% of work time in these areas.

Special consideration will be given to eligible applicants who:

• will use the award to train advanced education nurses who will practice in Health Profession Shortage Areas (HPSAs)

• provide applicant assurance

• meet a minimum 10% of students who sign commitments to practice in HPSAs after graduation

NURSE FACULTY LOAN PROGRAM (NFLP)

NURSE FACULTY LOAN PROGRAM PURPOSE

The Nurse Faculty Loan Program (NFLP) is

authorized under-

Title VIII, Section 846A of the Public Health Service Act, as amended by the Nurse Reinvestment Act of 2002 to increase the number of qualified nursing faculty.

NURSE FACULTY LOAN PROGRAM STRATEGIC GOALS

Promote recruitment of nursing students to become nurse faculty,

Provide financial support for students enrolled in an advanced education nursing program to prepare qualified nurse faculty, and

Retain loan recipients as nurse faculty by providing loan cancellation over a consecutive four-year period.

Collegiate schools of nursing or another entity within the college/university that offers advanced degree nursing program can apply for NFLP funds.

Schools must offer an advanced education nursing degree program(s) that is fully accredited and prepares qualified nurse faculty.

Schools must be located in the U.S., District of Columbia, or U.S. territories.

NURSE FACULTY LOAN PROGRAM ELIGIBILITY

HHS enters into an agreement with a school of nursing and makes an award, the Federal Capital Contribution (FCC), to establish and operate a distinct account for the NFLP fund.

The school must contribute an Institutional Capital Contribution (ICC) amount equal to at least 1/9 of the FCC award. The ICC must be deposited and used as part of the NFLP fund.

NURSE FACULTY LOAN PROGRAM ESTABLISHMENT

The NFLP fund may only be used for the depositof the FCC and ICC; –

to make loans to students enrolled full-time in a master’s or doctoral nursing degree program with an education component that will prepare them to teach;

for the deposit of collections of principal & interest on loans made from the NFLP fund; and

for the cost of collection of NFLP loans.

NURSE FACULTY LOAN PROGRAM ESTABLISHMENT (CONT.)

Student Eligibility

U.S. Citizenship or Permanent Resident

Full-time Enrollment in the eligible nursing program (Adding part-time enrollment in FY 2008)

Good Academic Standing

Not in Default on Other Federal Loans

NURSE FACULTY LOAN PROGRAM BENEFICIARY ELIGIBILITY

NURSE FACULTY LOAN PROGRAM BENEFICIARY ELIGIBILITY

Other Requirements

NFLP loan recipients must enroll for a minimum of two consecutive terms/semesters during the academic year.

NFLP loan recipients must complete the specified education component to prepare qualified nurse faculty prior to graduating from the nursing program.

NURSE FACULTY LOAN PROGRAM PROVISIONS

Students may borrow a maximum of $30,000/ year for no more than 5 years of support.

NFLP loans may be used to cover full/ partial tuition, the costs of fees, books and other reasonable education expenses. Personal living expenses or stipends are not supported.

NOTE: NFLP is not a need-based program.

NURSE FACULTY LOAN PROGRAM PROVISIONS

Following completion of the program, NFLP loan recipients may cancel up to 85% of the NFLP loan over a consecutive four-year period when they serve as full-time faculty at a school of nursing.

NFLP loan recipients receive cancellation of the loan principal and interest –

20% cancellation upon completion of each 1st , 2nd and 3rd year of employment as full-time faculty; and

25% cancellation upon completion of the 4th year of employment as full-time faculty.

NFLP loans bear interest on the unpaid balance at

a rate of 3% per year – beginning three months after completion of the program

NFLP loans bear interest on the unpaid balance at

the prevailing market rate over the period of the

loan – beginning three months after the borrower drops from the

program

NURSE FACULTY LOAN PROGRAM INTEREST RATE

NURSE FACULTY LOAN PROGRAM INTEREST RATE

NFLP loans bear interest on the unpaid balance atthe prevailing market rate over the period of theloan –

if, following graduation from the program, the borrower does not establish employment following the 9 month grace period;

or when the borrower ceases to be employed as full-time faculty at a school of nursing within the 4-year NFLP loan cancellation period allowed.

NURSE FACULTY LOAN PROGRAM ADMINISTRATION

The School of Nursing is the eligible applicant; therefore the school of nursing must submit the NFLP application.

The Financial Aid Office generally administers the NFLP fund and conducts activities, i.e. –

Issuing the Promissory Note Loan Disbursement Employment Verification Loan Cancellation Establishing Repayment Schedules

NURSE FACULTY LOAN PROGRAM ADMINISTRATION

The NFLP Annual Operating Report (AOR) is used to monitor and evaluate institutional performance.

Schools must complete and submit the AOR annually. The AOR is used to report expenditures for the NFLP fund annually and covers the period from July 1 through June 30 the following year.

NURSE FACULTY LOAN PROGRAM AWARD APPROPRIATIONS 2003-2007

$2,819,607.00

$4,686,317.00$4,621,922.00 $4,579,710.00$4,595,484.00

$7,860,000

$29,163,040.00

$0.00

$5,000,000.00

$10,000,000.00

$15,000,000.00

$20,000,000.00

$25,000,000.00

$30,000,000.00

FY 2003 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 FY 2003-2008

Total NFLP Funds Awarded 2003- 2008

FY 2003

FY 2004

FY 2005

FY 2006

FY 2007

FY 2008

FY 2003-2008

NURSE FACULTY LOAN PROGRAM PARTICIPANTS 2003-2007

55 69

92115 119

450

0

50

100

150

200

250

300

350

400

450

2003 2004 2005 2006 2007 Cum.Total2003-2007

Total # of Participating Schools

2003

2004

2005

2006

2007

Cum.Total 2003-2007

NURSE FACULTY LOAN PROGRAM ENROLLEES 2003-2007

* The number of enrollees for years 2003 and 2004 are not available (n/a).

* *

n/a n/a

376

457

729

0

100

200

300

400

500

600

700

800

2003 2004 2005 2006 2007

# of NFLP Enrollees FY 2003-2007

Enrollees

NURSE FACULTY LOAN PROGRAM ENROLLEES FY 2007

35 24

4569

9

259

7

38

486

0

50

100

150

200

250

300

350

400

450

500

Enrollees

Enrollees : Race/Ethnicity

American Indian/ Alaskan Native

Asian

Black/African American

Hispanic/Latino

Native Hawaiian/ Pacific Islander

White

More than one race

Unavailable/ Unreported

Total # out of 119 active schools

NURSE FACULTY LOAN PROGRAM GRADUATES FY-2007

6 8

24 17

1

207

114

278

0 3 1 1 0

62

0 2

69

0 2 2 2 0

66

0 1

73

0

50

100

150

200

250

300

MSN Graduates Doctoral Graduates Graduates Employed

MSN, Doctoral, and Employed Graduates

American Indian/ Alaskan Native

Asian

Black/African American

Hispanic/Latino

Native Hawaiian/ Pacific Islander

White

More than one race

Unavailable/ Unreported

Total # out of 119 active schools

FACULTY DEVELOPMENT: INTEGRATED TECHNOLOGY INTO NURSING EDUCATION AND

PRACTICE INITIATIVE (ITNEP)

TITLE VIII: SECTION 831 LEGISLATION

Three Priority Areas:

1. Education Purposes 1: To expand enrollment in baccalaureate nursing programs 2: To develop and implement internships and residency programs 3: To provide education in new technologies including distance learning

2. Practice Purposes1: Establish or expand nursing practice arrangements in non-institutional

settings2: Provide care for underserved populations and other high risk groups3: Provide managed care, quality improvement, and other skills needed to practice in existing and emerging organized health care systems4: Develop cultural competencies among registered nurses

3. Retention Purposes1: Career ladder bridge programs which promote career advancement for registered nurses and nursing personnel 2: Enhancing patient care delivery systems

PURPOSE

Support nursing collaboratives for faculty development in the use of information and other technologies

Nursing collaboratives will use healthcare information systems to:

– Establish linkages with community colleges, Historically Black Colleges and Universities (HBCUs), Tribal Colleges and Universities (TCUs), Hispanic Serving Institutions (HSIs);

– Enhance nursing education and practice;

– Optimize patient safety; and

– Drive improvements in health care quality.

PURPOSE (CONT.)

Nursing collaboratives –

– Train nurse faculty to effectively teach students to utilize integrated technologies.

– Offer state-of-the-art training sites.

– Promote the awareness of the latest simulated learning, informatics, and telehealth trends, advances, and issues.

– Develop an innovative faculty development plan in the use of simulated learning, informatics, and telehealth.

ELIGIBILITY

Collegiate schools of nursing capable of carrying out program goals and objectives

Eligible applicants must have a formal partnership with one or more: Academic health centers Schools of nursing Accredited public or private institutions Public or private entity

TYPE OF AWARD

Cooperative Agreement –

is a form of a Federal grant;

has substantial involvement from the Federal government; and

dominant role and prime responsibilities are with grantee.

Five-year grants

PARTICIPATING ITNEP SCHOOLS FY 2007

• Duke University ( # 37263)– Collaborated with other universities to provide new information and skills to

nursing faculty seeking to include advanced educational and clinical technologies into their curricula. Topical focus on distant learning, faculty development, informatics, interdisciplinary training, medical economics, patient safety/ medical errors, and telemedicine/ telehealth.

• University of Wisconsin- Madison ( # 37272)– Has a collaborative RN-BSN curriculum, created a faculty development model,

provides faculty mentorship in new educational technologies, teaches faculty to use virtual reality, e-learning resources, mannequin-based and problem-based simulations. Topical focus on distant learning, faculty development, informatics, and telemedicine/telehealth.

• University of Wisconsin- Madison ( # 39897)– Created a collaborative faculty development model which includes simulated

learning, informatics, and telehealth.

• University of Pittsburgh ( #39961)– Faculty development program focuses on teaching faculty skills in

implementation, evaluation and dissemination of such learning technologies as telehealth, distance learning, informatics, and human simulation at the undergraduate and graduate levels.

ITNEP: ESTIMATED NUMBER OF FACULTY TRAINED FOR FY 2007

Participating Schools Proj. Est. # of Faculty to be Trained

Duke University 75

University of Wisconsin-Madison 30

University of Kansas Medical Center 30-50

University of Pittsburgh 30-50

PRESENTATION SUMMARY

HRSA addresses the nursing faculty shortage through: AEN Nurse Educator Program grants AENT/NAT NFLP FDIT for Faculty Development

In the NFLP program HRSA had 119 participating schools in 2007.

Out of those 119 participating schools; the NFLP program had: 729 enrollees, 347 graduates, and 73 graduates employed in faculty positions.

PRESENTATION SUMMARY CONT.

Summary of Outputs: Number of Participating Schools

134

347

79

119

0

50

100

150

200

250

300

350

AEN Programs AENT Programs NAT Programs NFLP Programs

AEN Programs

AENT Programs

NAT Programs

NFLP Programs

United States Department of Health and Human ServicesHealth Resources and Services Administration

Bureau of Health ProfessionsDivision of Nursing

National Council of State Boards of

Nursing Faculty Shortage: Implications for Regulation Federal Funding Solutions

Joan Weiss, PhD, RN, CRNPActing Director

Division of [email protected]

http://bhpr.hrsa.gov/nursing