Reflect on your reading of the IOM Report on The Future of Nursing (pages 136-148 only) and describe in your own words the ways in which nursing practice can be transformed through innovation and technology.
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The Future of Nursing: Leading Change, Advancing Health
“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
—Goethe
Advising the Nation. Improving Health.
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The Future of Nursing: Leading Change, Advancing Health
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responsibility given to the National Academy of Sciences by its congressional charter to
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Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
COMMITTEE ON THE ROBERT WOOD JOHNSON
FOUNDATION INITIATIVE ON THE FUTURE OF
NURSING, AT THE INSTITUTE OF MEDICINE
DONNA E. SHALALA (Chair), President, University of Miami, Coral
Gables, FL
LINDA BURNES BOLTON (Vice Chair), Vice President and Chief
Nursing Officer, Cedars-Sinai Health System and Research Institute,
Los Angeles, CA
MICHAEL R. BLEICH, Dean and Dr. Carol A. Lindeman Distinguished
Professor, Vice Provost for Inter-professional Education and Development
Oregon Health & Science University School of Nursing, Portland
TROYEN A. BRENNAN, Executive Vice President, Chief Medical Officer,
CVS Caremark, Woonsocket, RI
ROBERT E. CAMPBELL, Vice Chairman (retired), Johnson & Johnson,
New Brunswick, NJ
LEAH DEVLIN, Professor of the Practice, University of North Carolina at
Chapel Hill School of Public Health, Raleigh
CATHERINE DOWER, Associate Director of Research, Center for the
Health Professions, University of California, San Francisco
ROSA GONZALEZ-GUARDA, Assistant Professor, School of Nursing and
Health Studies, University of Miami, Coral Gables, FL
DAVID C. GOODMAN, Professor of Pediatrics and of Health Policy, and
Director, Center for Health Policy Research, The Dartmouth Institute for
Health Policy and Clinical Practice, Hanover, NH
JENNIE CHIN HANSEN, Chief Executive Officer, American Geriatrics
Society, New York
C. MARTIN HARRIS, Chief Information Officer, Cleveland Clinic, OH
ANJLI AURORA HINMAN, Certified Nurse-Midwife, Intown Midwifery,
Atlanta, GA
WILLIAM D. NOVELLI, Distinguished Professor, McDonough School of
Business, Georgetown University, Washington, DC
LIANA ORSOLINI-HAIN, Nursing Instructor, City College of
San Francisco, CA
YOLANDA PARTIDA, Director, National Center, Hablamos Juntos, and
Assistant Adjunct Professor, Center for Medical Education and Research,
University of California, San Francisco, Fresno
ROBERT D. REISCHAUER, President, The Urban Institute, Washington, DC
JOHN W. ROWE, Professor, Mailman School of Public Health, Department
of Health Policy and Management, Columbia University, New York
BRUCE C. VLADECK, Senior Advisor, Nexera Consulting, New York
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
Project Staff
SUSAN HASSMILLER, Study Director
ADRIENNE STITH BUTLER, Senior Program Officer
ANDREA M. SCHULTZ, Associate Program Officer
KATHARINE BOTHNER, Research Associate
THELMA L. COX, Administrative Assistant
TONIA E. DICKERSON, Senior Program Assistant
GINA IVEY, Communications Director
LORI MELICHAR, Research Director
JULIE FAIRMAN, Distinguished Nurse Scholar-in-Residence
JUDITH A. SALERNO, Executive Officer, IOM
Consultants
CHRISTINE GORMAN, Technical Writer
RONA BRIERE, Consultant Editor
vi
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
Reviewers
This report has been reviewed in draft form by individuals chosen for their
diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that
will assist the institution in making its published report as sound as possible and
to ensure that the report meets institutional standards for objectivity, evidence,
and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We
wish to thank the following individuals for their review of this report:
John Benson, Jr., University of Nebraska Medical Center
Bobbie Berkowitz, University of Washington
George Boggs, American Association of Community Colleges
Marilyn P. Chow, Kaiser Permanente
Jordan J. Cohen, The George Washington University
Nancy W. Dickey, Texas A&M Health Science Center
Tine Hansen-Turton, National Nursing Centers Consortium and Public
Health Management Corporation
Ann Hendrich, Ascension Health
Beverly Malone, National League for Nursing
Edward O’Neil, Center for the Health Professions, University of California,
San Francisco
Robert L. Phillips, Jr., Robert Graham Center
Joy Reed, North Carolina Department of Health and Human Services
Thomas Ricketts, University of North Carolina School of Public Health
vii
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
viii
REVIEWERS
Vinod Sahney, Institute for Healthcare Improvement
Charlotte Yeh, AARP Services Incorporated
Heather Young, Betty Irene Moore School of Nursing, University of
California, Davis
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release.
The review of this report was overseen by Kristine Gebbie, School of Nursing,
Hunter College City University of New York and Mark R. Cullen, Stanford University. Appointed by the National Research Council and Institute of Medicine,
they were responsible for making certain that an independent examination of this
report was carried out in accordance with institutional procedures and that all
review comments were carefully considered. Responsibility for the final content
of this report rests entirely with the authoring committee and the institution.
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
Foreword
The founding documents of the Institute of Medicine (IOM) call for experts
to discuss, debate, and examine possible solutions for the multitude of complex
health concerns that face the United States and the world. Equally important is
the timely implementation of those solutions in a way that improves health. The
United States is at an important crossroads as health care reforms are being carried out and the system begins to change. The possibility of strengthening the
largest component of the health care workforce—nurses—to become partners and
leaders in improving the delivery of care and the health care system as a whole
inspired the IOM to partner with the Robert Wood Johnson Foundation (RWJF)
in creating the RWJF Initiative on the Future of Nursing, at the IOM. In this partnership, the IOM and RWJF were in agreement that accessible, high-quality care
cannot be achieved without exceptional nursing care and leadership. By working
together, the two organizations sought to bring more credibility and visibility to
the topic than either could by working alone. The organizations merged staff and
resources in an unprecedented partnership to explore challenges central to the
future of the nursing profession.
To support this collaborative effort, the IOM welcomed staff from RWJF,
as loaned employees, to provide specific content expertise in nursing, research,
and communications. Combining staff from two different organizations was an
experiment that integrated best practices from both organizations and inspired us
to think in fresh ways about how we conduct our work. We are indebted to RWJF
for the leadership, support, and partnership that made this endeavor possible.
I am deeply grateful to the committee—led by Donna Shalala, committee
chair and former Secretary of the Department of Health and Human Services, and
Linda Burnes Bolton, committee vice chair—and to the staff, especially Susan
ix
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
FOREWORD
Hassmiller, Adrienne Stith Butler, Andrea Schultz, and Katharine Bothner, who
produced this report. Their work will serve as a blueprint for how the nursing
profession can transform itself into an ever more potent and relevant force for
lasting solutions to enhance the quality and value of U.S. health care in ways
that will meet the future health needs of diverse populations. The report calls on
nurses, individually and as a profession, to embrace changes needed to promote
health, prevent illness, and care for people in all settings across the lifespan. The
nursing profession cannot make these changes on its own, however. The report
calls for multisector support and interprofessional collaboration. In this sense, it
calls on all health professionals and health care decision makers to work with
nurses to make the changes needed for a more accessible, cost-effective, and
high-quality health care system.
Since its foundation 40 years ago, the IOM has produced many reports
echoing the theme of high-quality, safe, effective, evidence-based, and patientcentered care. The present report expands on this theme by addressing the critical
role of nursing. It demonstrates that achieving a successful health care system in
the future rests on the future of nursing.
Harvey V. Fineberg, M.D., Ph.D.
President, Institute of Medicine
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
Preface
This report is being published at a time of great opportunity in health care.
Legislation passed in March 2010 will provide insurance coverage for 32 million
more Americans. The implications of this new demand on the nation’s health care
system are significant. How can the system accommodate the increased demand
while improving the quality of health care services provided to the American
public?
Nursing represents the largest sector of the health professions, with more
than 3 million registered nurses in the United States. The question presented to
the committee that produced this report was: What roles can nursing assume to
address the increasing demand for safe, high-quality, and effective health care services? In the near term, the new health care laws identify great challenges in the
management of chronic conditions, primary care (including care coordination and
transitional care), prevention and wellness, and the prevention of adverse events
(such as hospital-acquired infections). The demand for better provision of mental
health services, school health services, long-term care, and palliative care (including end-of-life care) is increasing as well. Whether improvements in all these
areas of care will slow the rate of growth in health care expenditures remains to
be seen; however, experts believe they will result in better health outcomes.
What nursing brings to the future is a steadfast commitment to patient care,
improved safety and quality, and better outcomes. Most of the near-term challenges identified in the health care reform legislation speak to traditional and
current strengths of the nursing profession in such areas as care coordination,
health promotion, and quality improvement. How well nurses are trained and do
their jobs is inextricably tied to most health care quality measures that have been
xi
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
xii
PREFACE
targeted for improvement over the past few years. Thus for nursing, health care
reform provides an opportunity for the profession to meet the demand for safe,
high-quality, patient-centered, and equitable health care services. We believe
nurses have key roles to play as team members and leaders for a reformed and
better-integrated, patient-centered health care system.
This report begins with the assumption that nursing can fill such new and
expanded roles in a redesigned health care system. To take advantage of these opportunities, however, nurses must be allowed to practice in accordance with their
professional training, and the education they receive must better prepare them to
deliver patient-centered, equitable, safe, high-quality health care services. Additionally, they must engage with physicians and other health care professionals to
deliver efficient and effective care and assume leadership roles in the redesign of
the health care system. In particular, we believe that preparation of an expanded
workforce, necessary to serve the millions who will now have access to health
insurance for the first time, will require changes in nursing scopes of practice,
advances in the education of nurses across all levels, improvements in the practice of nursing across the continuum of care, transformation in the utilization
of nurses across settings, and leadership at all levels so nurses can be deployed
effectively and appropriately as partners in the health care team.
In 2008, the Robert Wood Johnson Foundation (RWJF) approached the
Institute of Medicine (IOM) to propose a partnership between the two organizations to assess and respond to the need to transform the nursing profession to
meet these challenges. The resulting collaborative partnership created a unique
blend of organizational expertise and content expertise, drawing on the IOM’s
mission to serve as adviser to the nation to improve health and RWJF’s longstanding commitment to ensuring that the nursing workforce has the necessary
capacity, in terms of numbers, skills, and competence, to meet the present and
future health care needs of the public. Recognizing that the nursing profession
faces the challenges outlined above, RWJF and the IOM established a 2‑year
Initiative on the Future of Nursing. The cornerstone of the initiative is the work
of this IOM committee. The Committee on the Robert Wood Johnson Foundation
Initiative on the Future of Nursing, at the Institute of Medicine was tasked with
producing a report containing recommendations for an action-oriented blueprint
for the future of nursing, including changes in public and institutional policies
at the national, state, and local levels. The specific charge to the committee is
presented in Box P‑1.
The committee held five meetings that included three technical workshops,
which were designed to gather information on topics related to the study charge.
In addition to these meetings, the committee hosted three public forums on the fu-
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
xiii
PREFACE
BOX P-1
Committee Charge
An ad hoc committee will examine the capacity of the nursing workforce to
meet the demands of a reformed health care and public health system. It will
develop a set of bold national recommendations, including ones that address the
delivery of nursing services in a shortage environment and the capacity of the
nursing education system. In its report, the committee will define a clear agenda
and blueprint for action including changes in public and institutional policies at the
national, state, and local levels. Its recommendations would address a range of
system changes, including innovative ways to solve the nursing shortage in the
United States.
The committee may examine and produce recommendations related to the
following issues, with the goal of identifying vital roles for nurses in designing and
implementing a more effective and efficient health care system:
•
•
•
•
Reconceptualizing the role of nurses within the context of the entire workforce, the shortage, societal issues, and current and future technology;
Expanding nursing faculty, increasing the capacity of nursing schools, and
redesigning nursing education to assure that it can produce an adequate
number of well-prepared nurses able to meet current and future health care
demands;
Examining innovative solutions related to care delivery and health professional education by focusing on nursing and the delivery of nursing services; and
Attracting and retaining well-prepared nurses in multiple care settings,
including acute, ambulatory, primary care, long-term care, community, and
public health.
ture of nursing that focused on acute care; care in the community, with emphasis
on community health, public health, primary care, and long-term care; and nursing education. Summaries of these forums have been published separately, are
available at www.iom.edu/nursing, and are included on the CD-ROM in the back
of this report. The committee also conducted a series of site visits in conjunction
with each public forum to learn how nurses function in various health care and
educational settings. In addition to the workshops, forums, and site visits, the
committee collected testimony and welcomed public input throughout the study
process, conducted a literature review, and commissioned a series of papers from
a research network of esteemed colleagues.
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
xiv
THE FUTURE OF NURSING
For this committee, the IOM assembled an extraordinary group of professionals, including experts from areas such as business, academia, health care
delivery, and health policy. The team brought diverse perspectives to the table
that went well outside the nursing profession. Most of the members did not
have a degree in nursing and were not involved in nursing education, practice,
research, or governance. We are grateful to these committee members and to the
exceptionally talented staff of the IOM and RWJF, all of whom worked hard with
enthusiasm, great skill, flexibility, clarity, and drive.
Donna E. Shalala, Ph.D., FAAN
Chair
Linda Burnes Bolton, Dr.P.H., R.N., FAAN
Vice Chair
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
Acknowledgments
To begin, the committee would like to thank the sponsor of this study. Funds
for the committee’s work were provided by the Robert Wood Johnson Foundation (RWJF).
Numerous individuals and organizations made important contributions to
the study process and this report. The committee wishes to express its gratitude
for each of these contributions, although space does not permit identifying all of
them here. Appendix A lists the individuals who provided valuable information
at the committee’s open workshops and its three forums on the future of nursing. In conjunction with each of the forums, the committee also visited several
clinical sites to gather information on the role of nurses in various settings; these
visits helped the committee understand the experiences of nurses and other health
professionals and administrators. The committee greatly appreciates the time and
information provided by all of these individuals.
The committee also gratefully acknowledges the contributions of the many
individuals who provided data and research support. The RWJF Nursing Research
Network, led by Lori Melichar and coordinated by Patricia (Polly) Pittman with
the assistance of Emily Bass of AcademyHealth, created a series of research
products that synthesized, translated, and disseminated information to inform the
committee’s deliberations. Research products from this network were managed
by Linda Aiken, University of Pennsylvania; Peter Buerhaus, Vanderbilt University; Christine Kovner, New York University; and Joanne Spetz, University of
California, San Francisco.
The committee would like to thank as well the authors whose commissioned
papers added to the evidence base for the study: Barbara L. Nichols, Catherine
R. Davis, and Donna R. Richardson of the Commission on Graduates of Foreign
xv
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
xvi
ACKNOWLEDGMENTS
Nursing Schools International; Barbara J. Safriet, Lewis and Clark Law School;
Julie Sochalski, University of Pennsylvania School of Nursing, and Jonathan
Weiner, Johns Hopkins University Bloomberg School of Public Health; Linda
Cronenwett of the University of North Carolina at Chapel Hill School of Nursing,
Christine A. Tanner of Oregon Health & Science University School of Nursing,
Catherine L. Gilliss of Duke University School of Nursing, Kathleen Dracup
of the University of California, San Francisco School of Nursing, Donald M.
Berwick, Institute for Healthcare Improvement, Virginia Tilden, University of
Nebraska Medical Center College of Nursing, and Linda H. Aiken of the University of Pennsylvania School of Nursing; and Linda Norlander, Group Health
Home Care and Hospice. The committee also thanks the following fellows of
the RWJF Executive Nurse Leadership Program: Susan Birch, Jody Chrastek,
Erin Denholm, Karen Drenkard, Lynne M. Dunphy, Christina Esperat, Kathryn
Fiandt, Jill Fuller, Catherine Garner, Mary Ellen Glasgow, Tine Hansen-Turton,
Loretta Heuer, Cynda Hylton Rushton, Jane Kirschling, Richard C. MacIntyre,
Rosalie O. Mainous, Gloria McNeal, Wanda Montalvo, Teri A. Murray, Mary E.
Newell, Victoria Niederhauser, Suzanne Prevost, Maxine Proskurowski, Cynthia
Teel, Donna Torrisi, and Marykay Vandriel.
Finally, the committee acknowledges the following individuals who provided
additional data, reports, and support to the committee: Kathy Apple, National
Council of State Boards of Nursing; William Baer and Lauren Peay, Arnold &
Porter, LLP; Geraldine “Polly” Bednash and the staff of the American Association of Colleges of Nursing; Richard Blizzard, the Gallup Organization; Julie
Dashiell, RWJF; Tine Hansen-Turton, National Nursing Center Consortium;
Charlene Hanson, Georgia Southern University; Paul C. Light, New York University; Beverly Malone and the staff of the National League for Nursing; Diana
Mason and Joy Jacobson, Hunter College, City University of New York; Mark
B. McClellan, The Brookings Institution; Mary D. Naylor, University of Pennsylvania; Julienne M. Palbusa, The National Academies; Ciaran S. Phibbs, Veterans
Affairs Medical Center; Deborah Sampson, Boston College School of Nursing;
Shoshanna Sofaer, City University of New York; Kevin M. Stange, University of
Michigan; and Ellen-Marie Whelan, Center for American Progress.
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
Contents
ACRONYMS AND ABBREVIATIONS
xxv
SUMMARY
1
OVERVIEW OF THE REPORT
17
PART I: KEY MESSAGES AND STUDY CONTEXT
1 Key Messages of the Report
2 Study Context
21
47
PART II: A FUNDAMENTAL TRANSFORMATION
OF THE NURSING PROFESSION
3 Transforming Practice
4 Transforming Education
5 Transforming Leadership
6 Meeting the Need for Better Data on the Health Care Workforce
85
163
221
255
PART III: A BLUEPRINT FOR ACTION
7 Recommendations and Research Priorities
269
xvii
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
xviii
CONTENTS
APPENDIXES*
A Methods and Information Sources
B Committee Biographical Sketches
C Highlights from the Forums on the Future of Nursing
D APRN Consensus Model
E Undergraduate Nursing Education
F Health Care System Reform and the Nursing Workforce: Matching
Nursing Practice and Skills to Future Needs, Not Past Demands
G Transformational Models of Nursing Across Different Care Settings
H Federal Options for Maximizing the Value of Advanced Practice
Nurses in Providing Quality, Cost-Effective Health Care
I The Future of Nursing Education
J International Models of Nursing
INDEX
285
307
315
323
369
375
401
443
477
565
643
*Appendixes F–J are not printed in this report but can be found on the CD-ROM in the back of
this book.
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
Tables, Figures, and Boxes
TABLES
1-1
Types of Advanced Practice Registered Nurses (APRNs), 26
1-A1 Providers of Nursing Care: Numbers, Preparation/Training, and
Roles, 43
1-A2 Pathways in Nursing Education, 44
3-1
Complexity of Evaluation and Management Services Provided Under
Medicare Claims Data for 2000, by Practitioner Type, 90
3-2
Medicare Claims Payment Structure by Provider Type, 104
3-3
Plans Regarding Nursing Employment, by Graduation Cohort,
2008, 119
3-4
Changes in Position Setting, by 2007 Setting, for Registered Nurses
Who Graduated in 2001−2008, 119
3-A1 State-by-State Regulatory Requirements for Physician Involvement in
Care Provided by Nurse Practitioners, 157
4-1
4-2
4-3
4-4
Average Earnings of Full-Time RNs, by Highest Nursing or NursingRelated Education and Job Title, 172
Years Between Completion of Initial and Highest RN Degrees, 187
Average Annual Earnings of Nurses Who Work Full Time as Faculty in
Their Principal Nursing Position, 2008, 187
Average Earnings by Job Title of Principal Position for Nurses Working
Full Time, 188
xix
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
xx
TABLES, FIGURES, AND BOXES
4-5
Estimated Distribution of Master’s and Doctoral Degrees as Highest
Nursing or Nursing-Related Educational Preparation, 2000−2008, 195
E-1
Demographic and Educational Characteristics of Registered Nurses,
by Age, 370
J-1
J-2
J-3
J-4
NCLEX Examination Statistics, 2007, 575
Titles of Nursing Personnel from Select Countries, 577
Historic Suppliers of Registered Nurses to the U.S. Workforce, 608
Emerging Suppliers of Registered Nurses to the U.S. Workforce, 621
FIGURES
1-1
1-2
Employment settings of registered nurses, 24
Employment settings of RNs, by highest nursing or nursing-related
education, 25
3-1
3-2
Map of the number of NPs per primary care MD by county, 2009, 89
Map of the number of physician assistants per primary care MD by
county, 2009, 89
Requirements for physician−nurse collaboration, by state, as a barrier to
access to primary care, 99
Physician opinions about the impact of allowing nurse practitioners to
practice independently, 113
Patient satisfaction with retail-based health clinics, 113
Reasons cited for not working in nursing, by age group, 118
Age distribution of registered nurses, 1980−2008, 126
Average age of nurses at various levels of education and of MDs, 127
Distribution of registered nurses and the U.S. population by racial/
ethnic background, 129
3-3
3-4
3-5
3-6
3-7
3-8
3-9
4-1
4-2
4-3
4-4
4-5
Trends in graduations from basic RN programs, by type,
2002−2008, 167
Highest nursing or nursing-related education by urban/rural
residence, 178
Distance between nursing education program and workplace for earlycareer nurses (graduated 2007−2008), 178
Numbers of qualified applicants not accepted in ADN and BSN
programs, 182
Age distribution of nurses who work as faculty, 183
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The Future of Nursing: Leading Change, Advancing Health
xxi
TABLES, FIGURES, AND BOXES
4-6
4-7
4-8
5-1
5-2
6-1
6-2
6-3
6-4
Distribution of the registered nurse population by highest nursing or
nursing-related educational preparation, 1980−2008, 186
Growth trends in different nursing programs, 196
Percentage of minority students enrolled in nursing programs by race/
ethnicity and program type, 2008−2009, 208
Opinion leaders’ predictions of the amount of influence nurses will have
on health care reform, 240
Opinion leaders’ views on the amount of influence nurses should have
on various areas of health care, 241
Forecast supply of and demand for full-time equivalent (FTE) RNs,
2009−2030, 258
Trends in new licenses, U.S.- and foreign-educated RNs,
2002−2008, 260
Factors to consider when assessing the health care workforce
supply, 263
Factors to consider when assessing health care workforce demand, 263
D-1
D-2
APRN Regulatory Model, 333
Relationship Among Educational Competencies, Licensure, &
Certification in the Role/Population Foci and Education and
Credentialing in a Specialty, 339
F-1
F-2
RN-to-population ratio, 1980−2008, 387
Geographic variation in rates of hospital-based RNs per 1,000
population (2006), 388
BOXES
P-1
Committee Charge, xiii
S-1
Committee Charge, 3
2-1
2-2
2-3
2-4
2-5
2-6
2-7
Case Study: When Patients and Families Call a Code, 52
Case Study: Nurse Midwives and Birth Centers, 56
Nurse Profile: Carolina Sandoval, 60
Nurse Profile: Lisa Ayers, 62
Case Study: Living Independently for Elders (LIFE), 68
Case Study: The Transitional Care Model, 70
Case Study: The Nurse–Family Partnership, 73
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The Future of Nursing: Leading Change, Advancing Health
xxii
3-1
3-2
3-3
3-4
3-5
4-1
4-2
4-3
4-4
4-5
4-6
5-1
TABLES, FIGURES, AND BOXES
Variation in State Licensure Regulations, 100
Case Study: Advanced Practice Registered Nurses, 108
Case Study: The Patient-Centered Medical Home, 134
Case Study: 11th Street Family Health Services of Drexel
University, 138
Case Study: Technology at Cedars-Sinai Medical Center, 146
Costs of Health Professional Education, 169
Case Study: The Oregon Consortium for Nursing Education
(OCNE), 174
Case Study: Community Colleges Offering the BSN, 180
Nurse Profile: Jennifer Wenzel*, 184
Case Study: The Dedicated Education Unit, 192
Case Study: Nursing for Life—The RN Career Transition Program, 204
5-2
5-3
5-4
5-5
5-6
Results of Gallup Poll “Nursing Leadership from Bedside to
Boardroom: Opinion Leaders’ Perceptions,” 224
Case Study: Arkansas Aging Initiative, 226
Nurse Profile: Connie Hill, 230
Nurse Profile: Kenya D. Haney and Billy A. Caceres, 232
Nurse Profile: Mary Ann Christopher, 236
Case Study: Prescription for Pennsylvania, 248
7-1
7-2
7-3
Research Priorities for Transforming Nursing Practice, 274
Research Priorities for Transforming Nursing Education, 276
Research Priorities for Transforming Nursing Leadership, 277
A-1
A-2
A-3
A-4
A-5
A-6
A-7
Technical Workshop #1, 292
Technical Workshop #2, 293
Technical Workshop #3, 294
Forum on the Future of Nursing: Acute Care, 295
Forum on the Future of Nursing: Care in the Community, 296
Forum on the Future of Nursing: Education, 298
Testimony Questions for the Forum on the Future of Nursing: Acute
Care, 300
Testimony Questions for the Forum on the Future of Nursing: Care in
the Community, 302
Testimony Questions for the Forum on the Future of Nursing:
Education, 304
A-8
A-9
*This nurse profile was inadvertently omitted from the prepublication version of this report.
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The Future of Nursing: Leading Change, Advancing Health
TABLES, FIGURES, AND BOXES
F-1
F-2
xxiii
RN Ambulatory Care Workforce, 383
Processes and Policy Initiatives Producing Health Care Workforce Skill
Mix Changes, 393
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The Future of Nursing: Leading Change, Advancing Health
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
Acronyms and Abbreviations*
AACN
AAI
AAMC
AARP
ACA
ACO
ADN
AIDS
AMA
ANA
ANCC
AONE
APRN
ARRA
American Association of Colleges of Nursing
Arkansas Aging Initiative
Association of American Medical Colleges
American Association of Retired Persons
Affordable Care Act
accountable care organization
associate’s degree in nursing
acquired immune deficiency syndrome
American Medical Association
American Nurses Association
American Nurses Credentialing Center
American Organization of Nurse Executives
advanced practice registered nurse
American Recovery and Reinvestment Act
BSN
bachelor’s of science in nursing
CBO
CCNE
CHC
CMA
CMS
Congressional Budget Office
Commission on Collegiate Nursing Education
community health center
California Medical Association
Centers for Medicare and Medicaid Services
*The acronyms and abbreviations used in the Summary and Chapters 1–7 appear in this list.
xxv
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The Future of Nursing: Leading Change, Advancing Health
xxvi
ACRONYMS AND ABBREVIATIONS
CNA
CNL
CNM
CNO
CNS
CRNA
CSA
certified nursing assistant
clinical nurse leader
certified nurse midwife
chief nursing officer
clinical nurse specialist
certified registered nurse anesthetist
California Society of Anesthesiologists
DEU
DNP
DRG
dedicated education unit
doctor of nursing practice
diagnosis-related group
EHR
electronic health record
FHBC
FQHC
FTC
FTE
Family Health and Birth Center
federally qualified health center
Federal Trade Commission
full-time equivalent
GAO
GCHSSC
Government Accountability Office
Gulf Coast Health Services Steering Committee
HealthSTAT
HEET
HHS
HIT
HIV
HNC
HRSA
Health Students Taking Action Together
Hospital Employee Education and Training
Health and Human Services
health information technology
human immunodeficiency virus
Harambee Nursing Center
Health Resources and Services Administration
ICU
IHI
INLP
INQRI
IOM
Intensive Care Unit
Institute for Healthcare Improvement
Integrated Nurse Leadership Program
Interdisciplinary Nursing Quality Research Initiative
Institute of Medicine
LIFE
LPN/LVN
Living Independently for Elders
licensed practical nurse/licensed vocational nurse
MD
MedPAC
MSN
medical doctor
Medicare Payment Advisory Commission
master’s of science in nursing
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The Future of Nursing: Leading Change, Advancing Health
ACRONYMS AND ABBREVIATIONS
xxvii
NA
NAQC
NASN
NCEMNA
NCLEX-RN
NCQA
NCSBN
NFP
NHIT
NHWC
NLN
NMHC
NNCC
NP
NQF
NRN
NSNA
NSSRN
nursing assistant
Nursing Alliance for Quality Care
National Association of School Nurses
National Coalition of Ethnic Minority Nurse Associations
National Council Licensure Examination for Registered Nurses
National Committee for Quality Assurance
National Council of State Boards of Nursing
Nurse–Family Partnership
national health care information technology
National Health Workforce Commission
National League for Nursing
nurse-managed health clinic
National Nursing Centers Consortium
nurse practitioner
National Quality Forum
Nursing Research Network
National Student Nurses Association
National Sample Survey of Registered Nurses
OCNE
OHSU
OPM
Oregon Consortium for Nursing Education
Oregon Health and Science University
Office of Personnel Management
PACE
PCMH
PhD
Program of All-Inclusive Care for the Elderly
Patient-Centered Medical Home™
doctor of philosophy
RN
RWJF
registered nurse
Robert Wood Johnson Foundation
SAMHSA
SEIU
SOPP
Substance Abuse and Mental Health Services Administration
Service Employees International Union
Scope of Practice Partnership
TCAB
TCM
TIGER
TWU
Transforming Care at the Bedside
Transitional Care Model
Technology Informatics Guiding Education Reform
Texas Woman’s University
UAMS
UHC
UP
UPMC
University of Arkansas for Medical Sciences
University HealthSystem Consortium
University of Portland
University of Pittsburgh Medical Center
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The Future of Nursing: Leading Change, Advancing Health
xxviii
ACRONYMS AND ABBREVIATIONS
USF
UTH
University of South Florida
University of Texas Health Science Center at Houston School of
Nursing
VA
VANA
VNACJ
VNSNY
Department of Veterans Affairs
Veterans Affairs Nursing Academy
Visiting Nurse Association of Central Jersey
Visiting Nurse Service of New York
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
Summary
The United States has the opportunity to transform its health care system to provide seamless, affordable, quality care that is accessible to
all, patient centered, and evidence based and leads to improved health
outcomes. Achieving this transformation will require remodeling many
aspects of the health care system. This is especially true for the nursing profession, the largest segment of the health care workforce. This
report offers recommendations that collectively serve as a blueprint to
(1) ensure that nurses can practice to the full extent of their education
and training, (2) improve nursing education, (3) provide opportunities
for nurses to assume leadership positions and to serve as full partners
in health care redesign and improvement efforts, and (4) improve data
collection for workforce planning and policy making.
A VISION FOR HEALTH CARE
In 2010, Congress passed and the President signed into law comprehensive
health care legislation. With the enactment of these laws, collectively referred
to in this report as the Affordable Care Act (ACA), the United States has an
opportunity to transform its health care system to provide higher-quality, safer,
This summary does not include references. Citations for the discussion presented in the summary
appear in the subsequent report chapters.
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
THE FUTURE OF NURSING
more affordable, and more accessible care. During the course of its work, the
Committee on the Robert Wood Johnson Foundation Initiative on the Future of
Nursing, at the Institute of Medicine developed a vision for a transformed health
care system. The committee envisions a future system that makes quality care
accessible to the diverse populations of the United States, intentionally promotes
wellness and disease prevention, reliably improves health outcomes, and provides
compassionate care across the lifespan. In this envisioned future, primary care
and prevention are central drivers of the health care system. Interprofessional
collaboration and coordination are the norm. Payment for health care services
rewards value, not volume of services, and quality care is provided at a price
that is affordable for both individuals and society. The rate of growth of health
care expenditures slows. In all these areas, the health care system consistently
demonstrates that it is responsive to individuals’ needs and desires through the
delivery of truly patient-centered care.
The ACA represents the broadest changes to the health care system since the
1965 creation of the Medicare and Medicaid programs and is expected to provide
insurance coverage for an additional 32 million previously uninsured Americans.
Although passage of the ACA is historic, realizing the vision outlined above will
require a transformation of many aspects of the health care system. This is especially true for the nursing profession, which, with more than 3 million members,
represents the largest segment of the health care workforce.
STUDY CHARGE
In 2008, the Robert Wood Johnson Foundation (RWJF) approached the Institute of Medicine (IOM) to propose a partnership to assess and respond to the
need to transform the nursing profession. Recognizing that the nursing profession
faces several challenges in fulfilling the promise of a reformed health care system
and meeting the nation’s health needs, RWJF and the IOM established a 2‑year
Initiative on the Future of Nursing. The cornerstone of the initiative is this committee, which was tasked with producing a report containing recommendations
for an action-oriented blueprint for the future of nursing, including changes in
public and institutional policies at the national, state, and local levels (Box S-1).
Following the report’s release, the IOM and RWJF will host a national conference
on November 30 and December 1, 2010, to begin a dialogue on how the report’s
recommendations can be translated into action. The report will also serve as the
basis for an extensive implementation phase to be facilitated by RWJF.
THE ROLE OF NURSES IN REALIZING A
TRANSFORMED HEALTH CARE SYSTEM
By virtue of its numbers and adaptive capacity, the nursing profession has
the potential to effect wide-reaching changes in the health care system. Nurses’
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The Future of Nursing: Leading Change, Advancing Health
SUMMARY
BOX S-1
Committee Charge
An ad hoc committee will examine the capacity of the nursing workforce to
meet the demands of a reformed health care and public health system. It will
develop a set of bold national recommendations, including ones that address the
delivery of nursing services in a shortage environment and the capacity of the
nursing education system. In its report, the committee will define a clear agenda
and blueprint for action including changes in public and institutional policies at the
national, state, and local levels. Its recommendations would address a range of
system changes, including innovative ways to solve the nursing shortage in the
United States.
The committee may examine and produce recommendations related to the
following issues, with the goal of identifying vital roles for nurses in designing and
implementing a more effective and efficient health care system:
•
•
•
•
Reconceptualizing the role of nurses within the context of the entire workforce, the shortage, societal issues, and current and future technology;
Expanding nursing faculty, increasing the capacity of nursing schools, and
redesigning nursing education to assure that it can produce an adequate
number of well-prepared nurses able to meet current and future health care
demands;
Examining innovative solutions related to care delivery and health professional education by focusing on nursing and the delivery of nursing services; and
Attracting and retaining well-prepared nurses in multiple care settings,
including acute, ambulatory, primary care, long-term care, community, and
public health.
regular, close proximity to patients and scientific understanding of care processes
across the continuum of care give them a unique ability to act as partners with
other health professionals and to lead in the improvement and redesign of the
health care system and its many practice environments, including hospitals,
schools, homes, retail health clinics, long-term care facilities, battlefields, and
community and public health centers. Nurses thus are poised to help bridge the
gap between coverage and access, to coordinate increasingly complex care for
a wide range of patients, to fulfill their potential as primary care providers to
the full extent of their education and training, and to enable the full economic
value of their contributions across practice settings to be realized. In addition, a
promising field of evidence links nursing care to high quality of care for patients,
including protecting their safety. Nurses are crucial in preventing medication
errors, reducing rates of infection, and even facilitating patients’ transition from
hospital to home.
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
THE FUTURE OF NURSING
Nursing practice covers a broad continuum from health promotion, to disease prevention, to coordination of care, to cure—when possible—and to palliative care when cure is not possible. While this continuum of practice is well
matched to the needs of the American population, the nursing profession has its
challenges. It is not as diverse as it needs to be—with respect to race, ethnicity,
gender, and age—to provide culturally relevant care to all populations. Many
members of the profession require more education and preparation to adopt new
roles quickly in response to rapidly changing health care settings and an evolving health care system. Restrictions on scope of practice, policy- and reimbursement-related limitations, and professional tensions have undermined the nursing
profession’s ability to provide and improve both general and advanced care.
Producing a health care system that delivers the right care—quality care that is
patient centered, accessible, evidence based, and sustainable—at the right time
will require transforming the work environment, scope of practice, education, and
numbers of America’s nurses.
KEY MESSAGES
As a result of its deliberations, the committee formulated four key messages
that structure the discussion and recommendations presented in this report:
1.
2.
3.
4.
Nurses should practice to the full extent of their education and
training.
Nurses should achieve higher levels of education and training through
an improved education system that promotes seamless academic
progression.
Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States.
Effective workforce planning and policy making require better data collection and an improved information infrastructure.
The recommendations offered in this report focus on the critical intersection
between the health needs of diverse populations across the lifespan and the actions of the nursing workforce. They are intended to support efforts to improve
the health of the U.S. population through the contributions nurses can make to
the delivery of care. But they are not necessarily about achieving what is most
comfortable, convenient, or easy for the nursing profession.
Key Message #1: Nurses Should Practice to the Full Extent
of Their Education and Training (Chapter 3)
Nurses have great potential to lead innovative strategies to improve the
health care system. However, a variety of historical, regulatory, and policy bar-
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The Future of Nursing: Leading Change, Advancing Health
SUMMARY
riers have limited nurses’ ability to generate widespread transformation. Other
barriers include fragmentation of the health care system, high rates of turnover
among nurses, difficulties for nurses transitioning from school to practice, and
an aging workforce and other demographic challenges. Many of these barriers
have developed as a result of structural flaws in the U.S. health care system;
others reflect limitations in the present work environment or the capacity and
demographic makeup of the nursing workforce itself. Regulatory barriers are
particularly problematic.
Regulations defining scope-of-practice limitations vary widely by state.
Some are highly detailed, while others contain vague provisions that are open to
interpretation. Some states have kept pace with the evolution of the health care
system by changing their scope-of-practice regulations to allow nurse practitioners to see patients and prescribe medications without a physician’s supervision
or collaboration. However, the majority of state laws lag behind in this regard. As
a result, what nurse practitioners are able to do once they graduate varies widely
for reasons that are related not to their ability, education or training, or safety concerns, but to the political decisions of the state in which they work. Depending on
the state, restrictions on the scope of practice of an advanced practice registered
nurse may limit or deny altogether the authority to prescribe medications, admit
patients to the hospital, assess patient conditions, and order and evaluate tests.
Because many of the problems related to varied scopes of practice are
the result of a patchwork of state regulatory regimes, the federal government
is especially well situated to promote effective reforms by collecting and disseminating best practices from across the country and incentivizing their adoption. Specifically, the Federal Trade Commission has a long history of targeting
anticompetitive conduct in the health care market, including restrictions on the
business practices of health care providers, as well as policies that could act as
a barrier to the entry of new competitors in the market. As a payer and administrator of health insurance coverage for federal employees, the Office of Personnel Management and the Federal Employees Health Benefits Program have a
responsibility to promote and ensure the access of employees/subscribers to the
widest choice of competent, cost-effective health care providers. Principles of
equity would suggest that this subscriber choice should be promoted by policies
ensuring that full, evidence-based practice is permitted to all providers regardless
of geographic location. Finally, the Centers for Medicare and Medicaid Services
has the responsibility to promulgate rules and policies that promote Medicare and
Medicaid beneficiaries’ access to appropriate care, and therefore can ensure that
its rules and polices reflect the evolving practice abilities of licensed providers.
In addition to barriers related to scope of practice, high turnover rates among
newly graduated nurses highlight the need for a greater focus on managing the
transition from school to practice. In 2002, the Joint Commission recommended
the development of nurse residency programs—planned, comprehensive periods
of time during which nursing graduates can acquire the knowledge and skills to
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The Future of Nursing: Leading Change, Advancing Health
THE FUTURE OF NURSING
deliver safe, quality care that meets defined (organization or professional society) standards of practice. Residency programs are supported predominantly in
hospitals and larger health systems, with a focus on acute care. This has been
the area of greatest need since most new graduates gain employment in acute
care settings, and the proportion of new hires (and nursing staff) that are new
graduates is rapidly increasing. It is essential, however, that residency programs
outside of acute care settings be developed and evaluated. Much of the evidence
supporting the success of residencies has been produced through self-evaluations
by the residency programs themselves. For example, one organization, Versant,
has demonstrated a profound reduction in turnover rates for new graduate registered nurses—from 35 to 6 percent at 12 months and from 55 to 11 percent at 24
months—compared with new graduate registered nurse control groups hired at a
facility prior to implementation of the residency program.
Key Message #2: Nurses Should Achieve Higher Levels of
Education and Training Through an Improved Education System
That Promotes Seamless Academic Progression (Chapter 4)
Major changes in the U.S. health care system and practice environment will
require equally profound changes in the education of nurses both before and
after they receive their license. An improved education system is necessary to
ensure that the current and future generations of nurses can deliver safe, quality,
patient-centered care across all settings, especially in such areas as primary care
and community and public health.
Nursing is unique among the health professions in the United States in
that it has multiple educational pathways leading to an entry-level license to
practice. The qualifications and level of education required for entry into the
nursing profession have been widely debated by nurses, nursing organizations,
academics, and a host of other stakeholders for more than 40 years. During that
time, competencies needed to practice have expanded, especially in the domains
of community and public health, geriatrics, leadership, health policy, system
improvement and change, research and evidence-based practice, and teamwork
and collaboration. These new competencies have placed increased pressures on
the education system and its curricula.
Care within hospital and community settings also has become more complex.
In hospitals, nurses must make critical decisions associated with care for sicker,
frailer patients and work with sophisticated, life-saving technology. Nurses are
being called upon to fill primary care roles and to help patients manage chronic
illnesses, thereby preventing acute care episodes and disease progression. They
Versant is a nonprofit organization that provides, supervises, and evaluates nurse transition-topractice residency programs for children’s and general acute care hospitals. See http://www.versant.
org/item.asp?id=35.
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
SUMMARY
are expected to use a variety of technological tools and complex information
management systems that require skills in analysis and synthesis to improve the
quality and effectiveness of care. Across settings, nurses are being called upon to
coordinate care and collaborate with a variety of health professionals, including
physicians, social workers, physical and occupational therapists, and pharmacists,
most of whom hold master’s or doctoral degrees. Shortages of nurses in the positions of primary care providers, faculty, and researchers continue to be a barrier
to advancing the profession and improving the delivery of care to patients.
To respond to these demands of an evolving health care system and meet the
changing needs of patients, nurses must achieve higher levels of education and
training. One step in realizing this goal is for a greater number of nurses to enter
the workforce with a baccalaureate degree or progress to this degree early in their
career. Moreover, to alleviate shortages of nurse faculty, primary care providers,
and researchers, a cadre of qualified nurses needs to be ready to advance to the
master’s and doctoral levels. Nursing education should therefore include opportunities for seamless transition to higher degree programs—from licensed practical
nurse (LPN)/licensed vocational nurse (LVN) degrees, to the associate’s degree in
nursing (ADN) and bachelor’s of science in nursing (BSN), to master’s of science
in nursing (MSN), and to the PhD and doctor of nursing practice (DNP). Further,
nursing education should serve as a platform for continued lifelong learning.
Nurses also should be educated with physicians and other health professionals
as students and throughout their careers. Finally, as efforts are made to improve
the education system, greater emphasis must be placed on increasing the diversity
of the workforce, including in the areas of gender and race/ethnicity, as well as
ensuring that nurses are able to provide culturally relevant care.
While the capacity of the education system will need to expand, and the focus of curricula will need to be updated to ensure that nurses have the right competencies, a variety of traditional and innovative strategies already are being used
across the country to achieve these aims. Examples include the use of technologies such as online education and simulation, consortium programs that create a
seamless pathway from the ADN to the BSN, and ADN-to-MSN programs that
provide a direct link to graduate education. Collectively, these strategies can be
scaled up and refined to effect the needed transformation of nursing education.
Key Message #3: Nurses Should Be Full Partners, with
Physicians and Other Health Professionals, in Redesigning
Health Care in the United States (Chapter 5)
Strong leadership is critical if the vision of a transformed health care system is to be realized. To play an active role in achieving this vision, the nursing
profession must produce leaders throughout the system, from the bedside to the
boardroom. These leaders must act as full partners with physicians and other
health professionals, and must be accountable for their own contributions to de-
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The Future of Nursing: Leading Change, Advancing Health
THE FUTURE OF NURSING
livering high-quality care while working collaboratively with leaders from other
health professions.
Being a full partner transcends all levels of the nursing profession and requires leadership skills and competencies that must be applied within the profession and in collaboration with other health professionals. In care environments,
being a full partner involves taking responsibility for identifying problems and
areas of waste, devising and implementing a plan for improvement, tracking
improvement over time, and making necessary adjustments to realize established
goals. Moreover, being a full partner translates more broadly to the health policy
arena. To be effective in reconceptualized roles, nurses must see policy as something they can shape rather than something that happens to them. Nurses should
have a voice in health policy decision making and be engaged in implementation
efforts related to health care reform. Nurses also should serve actively on advisory committees, commissions, and boards where policy decisions are made to
advance health systems to improve patient care.
Strong leadership on the part of nurses, physicians, and others will be required to devise and implement the changes necessary to increase quality, access,
and value and deliver patient-centered care. While not all nurses begin their career with thoughts of becoming a leader, leadership is fundamental to advancing
the profession. To ensure that nurses are ready to assume leadership roles, leadership-related competencies need to be embedded throughout nursing education,
leadership development and mentoring programs need to be made available for
nurses at all levels, and a culture that promotes and values leadership needs to
be fostered. Equally important, all nurses—from students, to bedside and community nurses, to chief nursing officers and members of nursing organizations, to
researchers—must take responsibility for their personal and professional growth
by developing leadership competencies. They must exercise these competencies
in a collaborative environment in all settings, including hospitals, communities,
schools, boards, and political and business arenas, both within nursing and across
the health professions. And in doing so, they must not only mentor others along
the way, but develop partnerships and gain allies both within and beyond the
health care environment.
Key Message #4: Effective Workforce Planning and
Policy Making Require Better Data Collection and an
Improved Information Infrastructure (Chapter 6)
Achieving a transformation of the health care system and the practice environment will require a balance of skills and perspectives among physicians,
nurses, and other health professionals. However, strategic health care workforce
planning to achieve this balance is hampered by the lack of sufficiently reliable
and granular data on, for example, the numbers and types of health professionals
currently employed, where they are employed and in what roles, and what types
of activities they perform. These data are required to determine regional health
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
SUMMARY
care workforce needs and to establish regional targets and plans for appropriately
increasing the supply of health professionals. Additionally, understanding of the
impact of innovations such as bundled payments, medical homes, accountable
care organizations, health information technology, and comparative effectiveness will be incomplete without information on and analysis of the necessary
contributions of the various types of health professionals. Data collection and
analysis across the health professions will also be essential because of the overlap
in scopes of practice for primary care providers such as physicians, physician
assistants, and nurse practitioners and the increasing shift toward team-based
care. In the specific context of this study, planning for fundamental, wide-ranging
changes in the education and deployment of the nursing workforce will require
comprehensive data on the numbers and types of nurses currently available and
required to meet future needs. Once an infrastructure for collecting and analyzing
workforce data is in place, systematic assessment and projection of nursing workforce requirements by role, skill mix, region, and demographics will be needed
to inform necessary changes in nursing practice and education.
The ACA mandates the creation of a National Health Care Workforce Commission whose mission is, among other things, to “[develop] and [commission]
evaluations of education and training activities to determine whether the demand
for health care workers is being met,” and to “[identify] barriers to improved
coordination at the Federal, State, and local levels and recommend ways to address such barriers.” The ACA also authorizes a National Center for Workforce
Analysis, as well as state and regional workforce centers, and provides funding
for workforce data collection and studies. A priority for these new structures and
resources should be systematic monitoring of the supply of health care workers
across professions, review of the data and methods needed to develop accurate
predictions of future workforce needs, and coordination of the collection of data
on the health care workforce at the state and regional levels. To be most useful,
the data and information gathered must be timely and publicly accessible.
RECOMMENDATIONS
Recommendation 1: Remove scope-of-practice barriers. Advanced practice
registered nurses should be able to practice to the full extent of their education
and training. To achieve this goal, the committee recommends the following
actions.
For the Congress:
•
Expand the Medicare program to include coverage of advanced practice
registered nurse services that are within the scope of practice under applicable state law, just as physician services are now covered.
Patient Protection and Affordable Care Act, H.R. 3590 § 5101, 111th Congress.
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The Future of Nursing: Leading Change, Advancing Health
10
THE FUTURE OF NURSING
•
•
•
Amend the Medicare program to authorize advanced practice registered
nurses to perform admission assessments, as well as certification of
patients for home health care services and for admission to hospice and
skilled nursing facilities.
Extend the increase in Medicaid reimbursement rates for primary care
physicians included in the ACA to advanced practice registered nurses
providing similar primary care services.
Limit federal funding for nursing education programs to only those programs in states that have adopted the National Council of State Boards
of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules (Article XVIII, Chapter 18).
For state legislatures:
•
•
Reform scope-of-practice regulations to conform to the National Council of State Boards of Nursing Model Nursing Practice Act and Model
Nursing Administrative Rules (Article XVIII, Chapter 18).
Require third-party payers that participate in fee-for-service payment
arrangements to provide direct reimbursement to advanced practice
registered nurses who are practicing within their scope of practice under
state law.
For the Centers for Medicare and Medicaid Services:
•
Amend or clarify the requirements for hospital participation in the Medicare program to ensure that advanced practice registered nurses are
eligible for clinical privileges, admitting privileges, and membership on
medical staff.
For the Office of Personnel Management:
•
Require insurers participating in the Federal Employees Health Benefits
Program to include coverage of those services of advanced practice
registered nurses that are within their scope of practice under applicable
state law.
For the Federal Trade Commission and the Antitrust Division of the Department
of Justice:
•
Review existing and proposed state regulations concerning advanced
practice registered nurses to identify those that have anticompetitive effects without contributing to the health and safety of the public. States
with unduly restrictive regulations should be urged to amend them to
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
SUMMARY
11
allow advanced practice registered nurses to provide care to patients in
all circumstances in which they are qualified to do so.
Recommendation 2: Expand opportunities for nurses to lead and diffuse collaborative improvement efforts. Private and public funders, health care organizations, nursing education programs, and nursing associations should expand
opportunities for nurses to lead and manage collaborative efforts with physicians
and other members of the health care team to conduct research and to redesign
and improve practice environments and health systems. These entities should also
provide opportunities for nurses to diffuse successful practices.
To this end:
•
•
•
•
•
The Center for Medicare and Medicaid Innovation should support the
development and evaluation of models of payment and care delivery that
use nurses in an expanded and leadership capacity to improve health outcomes and reduce costs. Performance measures should be developed and
implemented expeditiously where best practices are evident to reflect the
contributions of nurses and ensure better-quality care.
Private and public funders should collaborate, and when possible pool
funds, to advance research on models of care and innovative solutions,
including technology, that will enable nurses to contribute to improved
health and health care.
Health care organizations should support and help nurses in taking
the lead in developing and adopting innovative, patient-centered care
models.
Health care organizations should engage nurses and other front-line staff
to work with developers and manufacturers in the design, development,
purchase, implementation, and evaluation of medical and health devices
and health information technology products.
Nursing education programs and nursing associations should provide
entrepreneurial professional development that will enable nurses to initiate programs and businesses that will contribute to improved health and
health care.
Recommendation 3: Implement nurse residency programs. State boards of
nursing, accrediting bodies, the federal government, and health care organizations should take actions to support nurses’ completion of a transition-to-practice
program (nurse residency) after they have completed a prelicensure or advanced
practice degree program or when they are transitioning into new clinical practice
areas.
The following actions should be taken to implement and support nurse residency
programs:
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
12
THE FUTURE OF NURSING
•
•
•
•
State boards of nursing, in collaboration with accrediting bodies such
as the Joint Commission and the Community Health Accreditation Program, should support nurses’ completion of a residency program after
they have completed a prelicensure or advanced practice degree program
or when they are transitioning into new clinical practice areas.
The Secretary of Health and Human Services should redirect all graduate medical education funding from diploma nursing programs to support the implementation of nurse residency programs in rural and critical
access areas.
Health care organizations, the Health Resources and Services Administration and Centers for Medicare and Medicaid Services, and philanthropic organizations should fund the development and implementation
of nurse residency programs across all practice settings.
Health care organizations that offer nurse residency programs and foundations should evaluate the effectiveness of the residency programs in
improving the retention of nurses, expanding competencies, and improving patient outcomes.
Recommendation 4: Increase the proportion of nurses with a baccalaureate
degree to 80 percent by 2020. Academic nurse leaders across all schools of
nursing should work together to increase the proportion of nurses with a baccalaureate degree from 50 to 80 percent by 2020. These leaders should partner
with education accrediting bodies, private and public funders, and employers to
ensure funding, monitor progress, and increase the diversity of students to create a workforce prepared to meet the demands of diverse populations across the
lifespan.
•
•
•
The Commission on Collegiate Nursing Education, working in collaboration with the National League for Nursing Accrediting Commission,
should require all nursing schools to offer defined academic pathways,
beyond articulation agreements, that promote seamless access for nurses
to higher levels of education.
Health care organizations should encourage nurses with associate’s and
diploma degrees to enter baccalaureate nursing programs within 5 years
of graduation by offering tuition reimbursement, creating a culture that
fosters continuing education, and providing a salary differential and
promotion.
Private and public funders should collaborate, and when possible pool
funds, to expand baccalaureate programs to enroll more students by offering scholarships and loan forgiveness, hiring more faculty, expanding
clinical instruction through new clinical partnerships, and using technology to augment instruction. These efforts should take into consideration
strategies to increase the diversity of the nursing workforce in terms of
race/ethnicity, gender, and geographic distribution.
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
SUMMARY
•
•
•
13
The U.S. Secretary of Education, other federal agencies including the
Health Resources and Services Administration, and state and private
funders should expand loans and grants for second-degree nursing
students.
Schools of nursing, in collaboration with other health professional
schools, should design and implement early and continuous interprofessional collaboration through joint classroom and clinical training
opportunities.
Academic nurse leaders should partner with health care organizations,
leaders from primary and secondary school systems, and other community organizations to recruit and advance diverse nursing students.
Recommendation 5: Double the number of nurses with a doctorate by 2020.
Schools of nursing, with support from private and public funders, academic administrators and university trustees, and accrediting bodies, should double the
number of nurses with a doctorate by 2020 to add to the cadre of nurse faculty
and researchers, with attention to increasing diversity.
•
•
•
The Commission on Collegiate Nursing Education and the National
League for Nursing Accrediting Commission should monitor the progress of each accredited nursing school to ensure that at least 10 percent
of all baccalaureate graduates matriculate into a master’s or doctoral
program within 5 years of graduation.
Private and public funders, including the Health Resources and Services
Administration and the Department of Labor, should expand funding for
programs offering accelerated graduate degrees for nurses to increase
the production of master’s and doctoral nurse graduates and to increase
the diversity of nurse faculty, scientists, and researchers.
Academic administrators and university trustees should create salary and
benefit packages that are market competitive to recruit and retain highly
qualified academic and clinical nurse faculty.
Recommendation 6: Ensure that nurses engage in lifelong learning. Accrediting bodies, schools of nursing, health care organizations, and continuing competency educators from multiple health professions should collaborate to ensure
that nurses and nursing students and faculty continue their education and engage
in lifelong learning to gain the competencies needed to provide care for diverse
populations across the lifespan.
•
•
Faculty should partner with health care organizations to develop and
prioritize competencies so curricula can be updated regularly to ensure
that graduates at all levels are prepared to meet the current and future
health needs of the population.
The Commission on Collegiate Nursing Education and the National
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
14
THE FUTURE OF NURSING
•
•
•
League for Nursing Accrediting Commission should require that all
nursing students demonstrate a comprehensive set of clinical performance competencies that encompass the knowledge and skills needed
to provide care across settings and the lifespan.
Academic administrators should require all faculty to participate in
continuing professional development and to perform with cutting-edge
competence in practice, teaching, and research.
All health care organizations and schools of nursing should foster a
culture of lifelong learning and provide resources for interprofessional
continuing competency programs.
Health care organizations and other organizations that offer continuing competency programs should regularly evaluate their programs for
adaptability, flexibility, accessibility, and impact on clinical outcomes
and update the programs accordingly.
Recommendation 7: Prepare and enable nurses to lead change to advance
health. Nurses, nursing education programs, and nursing associations should
prepare the nursing workforce to assume leadership positions across all levels,
while public, private, and governmental health care decision makers should ensure that leadership positions are available to and filled by nurses.
•
•
•
•
Nurses should take responsibility for their personal and professional
growth by continuing their education and seeking opportunities to develop and exercise their leadership skills.
Nursing associations should provide leadership development, mentoring
programs, and opportunities to lead for all their members.
Nursing education programs should integrate leadership theory and business practices across the curriculum, including clinical practice.
Public, private, and governmental health care decision makers at every
level should include representation from nursing on boards, on executive
management teams, and in other key leadership positions.
Recommendation 8: Build an infrastructure for the collection and analysis of
interprofessional health care workforce data. The National Health Care Workforce Commission, with oversight from the Government Accountability Office and
the Health Resources and Services Administration, should lead a collaborative
effort to improve research and the collection and analysis of data on health care
workforce requirements. The Workforce Commission and the Health Resources
and Services Administration should collaborate with state licensing boards, state
nursing workforce centers, and the Department of Labor in this effort to ensure
that the data are timely and publicly accessible.
•
The Workforce Commission and the Health Resources and Services
Administration should coordinate with state licensing boards, including
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
15
SUMMARY
•
•
•
•
•
those for nursing, medicine, dentistry, and pharmacy, to develop and
promulgate a standardized minimum data set across states and professions that can be used to assess health care workforce needs by demographics, numbers, skill mix, and geographic distribution.
The Workforce Commission and the Health Resources and Services
Administration should set standards for the collection of the minimum
data set by state licensing boards; oversee, coordinate, and house the
data; and make the data publicly accessible.
The Workforce Commission and the Health Resources and Services
Administration should retain, but bolster, the Health Resources and
Services Administration’s registered nurse sample survey by increasing
the sample size, fielding the survey every other year, expanding the data
collected on advanced practice registered nurses, and releasing survey
results more quickly.
The Workforce Commission and the Health Resources and Services
Administration should establish a monitoring system that uses the most
current analytic approaches and data from the minimum data set to
systematically measure and project nursing workforce requirements by
role, skill mix, region, and demographics.
The Workforce Commission and the Health Resources and Services
Administration should coordinate workforce research efforts with the
Department of Labor, state and regional educators, employers, and state
nursing workforce centers to identify regional health care workforce
needs, and establish regional targets and plans for appropriately increasing the supply of health professionals.
The Government Accountability Office should ensure that the Workforce
Commission membership includes adequate nursing expertise.
CONCLUSION
Nurses are already committed to delivering high-quality care under current
regulatory, business, and organizational conditions. But the power to change
those conditions to deliver better care does not rest primarily with nurses, regardless of how ably led or educated they are; it also lies with governments,
businesses, health care institutions, professional organizations and other health
professionals, and the insurance industry. The recommendations presented in
this report are directed to individual policy makers; national, state, and local
government leaders; payers; health care researchers; executives; and professionals—including nurses and others—as well as to larger groups such as licensing
bodies, educational institutions, and philanthropic and advocacy organizations,
especially those advocating for consumers. Together, these groups have the power
to transform the health care system to provide seamless, affordable, quality care
that is accessible to all, patient centered, and evidence based and leads to improved health outcomes.
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
Overview of the Report
This report is organized into three parts. Part I presents the report’s key messages and important contextual information for the study. Chapter 1 offers the
committee’s vision for health care in the United States, explains why nurses have
an essential role in realizing this vision and why a fundamental transformation
of the nursing profession is needed if they are to fulfill this role, and details four
key messages that structure the discussion and recommendations in Parts II and
III. As context for the remainder of the report, Chapter 2 describes how the U.S.
health care system is evolving and sets forth principles the committee believes
should guide that evolution.
Part II details the fundamental transformation of the nursing profession that
is needed to achieve the improved health care system described in Chapter 1.
This transformation needs to occur in three broad areas: practice (Chapter 3),
education (Chapter 4), and leadership (Chapter 5). This part of the report also
addresses the crucial need for better data on the health care workforce to inform
this transformation and that of the overall health care system (Chapter 6).
Chapters 2 through 6 include a series of case studies and profiles illustrating
the work of nurses and innovative models that either were developed by nurses
or feature nurses in a leadership role. These case studies and profiles not only
provide texture to the report but also offer real-life examples of nurses working in
reconceptualized roles and directly affecting the quality, accessibility, and value
of health care. Cumulatively, these case studies and profiles offer a glimpse into
what the future of nursing could be.
Finally, Part III offers the committee’s blueprint for action in the form of
recommendations and related research priorities (Chapter 7).
In addition, the report includes 10 appendixes. Appendix A describes the study
17
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
18
THE FUTURE OF NURSING
methods and information sources used to inform the committee’s deliberations;
Appendix B contains biographical sketches of the committee members; Appendix C offers highlights from the three public forums held by the committee on the
future of nursing in the areas of acute care, care in the community, and education;
Appendix D contains the consensus model for advanced practice registered nurse
(APRN) regulation that is referenced in Chapter 3 and in recommendation 1 in
Chapter 7; and Appendix E provides a brief description of undergraduate nursing
education in the United States. Appendixes F−J are not printed in this report but
can be found on the CD-ROM in the back of this book and contain papers commissioned by the committee on the following topics: matching nursing practice
and skills to future needs; transformational models of nursing across different care
settings; federal options for maximizing the value of APRNs in providing quality, cost-effective health care; the future of nursing education; and international
models of nursing.
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
Part I
Key Messages and Study Context
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
1
Key Messages of the Report
The U.S. health care system is characterized by a high degree of fragmentation across many sectors, which raises substantial barriers to providing accessible,
quality care at an affordable price. In part, the fragmentation in the system comes
from disconnects between public and private services, between providers and
patients, between what patients need and how providers are trained, between the
health needs of the nation and the services that are offered, and between those
with insurance and those without (Stevens, 1999). Communication between
providers is difficult, and much care is redundant because there is no way of
sharing results.
This report is being published at an opportune time. In 2010, Congress
passed and the President signed into law comprehensive health care legislation.
These laws, the Patient Protection and Affordable Care Act (Public Law 111-148)
and the Health Care and Education Affordability Reconciliation Act (Public Law
111-152), are collectively referred to throughout this report as the Affordable Care
Act (ACA). The ACA represents the broadest changes to the health care system
since the 1965 creation of the Medicare and Medicaid programs and is expected
to provide insurance coverage for an additional 32 million previously uninsured
Americans. The need to improve the health care system is becoming increasingly
evident as challenges related to both the quality and costs of care persist.
As discussed in the preface, this study was undertaken to explore how the
nursing profession can be transformed to help exploit these opportunities and
contribute to building a health care system that will meet the demand for safe,
quality, patient-centered, accessible, and affordable care. This chapter presents
the key messages that emerged from the study committee’s deliberations. It
begins by describing a vision for a transformed system that can meet the health
21
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
22
THE FUTURE OF NURSING
needs of the U.S. population in the 21st century. The chapter then delineates the
roles of nurses in realizing this vision. The third section explains why a fundamental transformation of the nursing profession will be required if nurses are to
assume these roles. The final section presents conclusions.
A VISION FOR HEALTH CARE
During the course of its work, the Committee on the Robert Wood Johnson
Foundation Initiative on the Future of Nursing, at the Institute of Medicine
developed a vision for a transformed health care system, while recognizing the
demands and limitations of the current health care system outlined above. The
committee envisions a future system that makes quality care accessible to the
diverse populations of the United States, intentionally promotes wellness and
disease prevention, reliably improves health outcomes, and provides compassionate care across the lifespan. In this envisioned future, primary care and prevention are central drivers of the health care system. Interprofessional collaboration
and coordination are the norm. Payment for health care services rewards value,
not volume of services, and quality care is provided at a price that is affordable
for both individuals and society. The rate of growth of health care expenditures
slows. In all these areas, the health care system consistently demonstrates that it is
responsive to individuals’ needs and desires through the delivery of truly patientcentered care. Annex 1-1 lists the committee’s definitions for three core terms
related to its vision: health, health care, and the health care system.
THE ROLE OF NURSES IN REALIZING THIS VISION
The ACA provides a call to action for nurses, and several sections of the legislation are directly relevant to their work. For example, sections 5501 through
5509 are aimed at substantially strengthening the provision of primary care—a
need generally recognized by health professionals and policy experts; section
2717 calls for “ensuring the quality of care”; and section 2718 emphasizes
“bringing down the cost of health care coverage.” Enactment of the ACA offers
a myriad of opportunities for the nursing profession to facilitate improvements
to the health care system and the mechanisms by which care is delivered across
various settings. Systemwide changes are needed that capture the full economic
value of nurses and take into account the growing body of evidence that links
nursing practice to improvements in the safety and quality of care. Advanced
practice registered nurses (APRNs) should be called upon to fulfill and expand
their potential as primary care providers across practice settings based on their
For a list of nursing-related provisions included in the ACA, see http://championnursing.org/sites/
default/files/nursingandhealthreformlawable.pdf.
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
KEY MESSAGES OF THE REPORT
23
education and competency. Nursing initiatives and programs should be scaled up
to help bridge the gap between insurance coverage and access to care.
The nursing profession has the potential capacity to implement wide-reaching
changes in the health care system. With more than 3 million members, the profession has nearly doubled since 1980 and represents the largest segment of the U.S.
health care workforce (HRSA, 2010; U.S. Census Bureau, 2009). By virtue of
their regular, close proximity to patients and their scientific understanding of care
processes across the continuum of care, nurses have a considerable opportunity to
act as full partners with other health professionals and to lead in the improvement
and redesign of the health care system and its practice environment.
Nurses practice in many settings, including hospitals, schools, homes, retail
health clinics, long-term care facilities, battlefields, and community and public
health centers. They have varying levels of education and competencies—from
licensed practical nurses, who greatly contribute to direct patient care in nursing
homes, to nurse scientists, who research and evaluate more effective ways of
caring for patients and promoting health. As described in Annex 1-1 at the end
of this chapter, most nurses are registered nurses (RNs), who “complete a program of study at a community college, diploma school of nursing, or a four-year
college or university and are required to pass a nationally standardized licensing
exam in the state in which they begin practice” (AARP, 2010). Figure 1-1 shows
that of the many settings where RNs practice, the majority practice in hospitals;
Figure 1-2 shows the employment settings of nurses by highest nursing or nursing-related education. More than a quarter of a million nurses are APRNs (HRSA,
2010), who hold master’s or doctoral degrees and pass national certification exams. APRNs deliver primary and other types of health care services. For example,
they teach and counsel patients to understand their health problems and what they
can do to get better, they coordinate care and advocate for patients in the complex
health care system, and they refer patients to physicians and other health care
providers. APRNs include nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives (see Table 1-1).
Annex 1‑1 provides more detailed descriptions of the preparation and roles of
nurses, pathways in nursing education, and numbers of nurses.
Nursing practice covers a broad continuum from health promotion, to disease
prevention, to coordination of care, to cure—when possible—and to palliative
care when cure is not possible. This continuum of practice is well matched to the
current and future needs of the American population (see Chapter 2). Nurses have
a direct effect on patient care. They provide the majority of patient assessments,
evaluations, and care in hospitals, nursing homes, clinics, schools, workplaces,
and ambulatory settings. They are at the front lines in ensuring that care is delivered safely, effectively, and compassionately. Additionally, nurses attend to
patients and their families in a holistic way that often goes beyond physical health
needs to recognize and respond to social, mental, and spiritual needs. Given their
education, experience, and unique perspectives and the centrality of their role in
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
24
THE FUTURE OF NURSING
Ambulatory care
10.5%
Other
3.9%
Public/community
health
7.8%
Home health
6.4%
Academic education
3.8%
Hospital
62.2%
Nursing
home/extended care
5.3%
FIGURE 1-1 Employment settings of registered nurses.
NOTES: The totals may not add to 100 percent because of the effect of rounding. Only
Figure
1-1.epsare included in the calculations used
RNs for whom information on setting
was available
for this chart. Public/community health includes school and occupational health. Ambulatory care includes medical/physician practices, health centers and clinics, and other
types of nonhospital clinical settings. Other includes insurance, benefits, and utilization
review.
SOURCE: HRSA, 2010.
providing care, nurses will play a significant role in the transformation of the
health care system. Likewise, while changes in the health care system will have
profound effects on all providers, this will be undoubtedly true for nurses.
Traditional nursing competencies such as care management and coordination, patient education, public health intervention, and transitional care are likely
to dominate in a reformed health care system as it inevitably moves toward an
emphasis on prevention and management rather than acute care (O’Neil, 2009).
Nurses have also begun developing new competencies for the future to help bridge
the gap between coverage and access, to coordinate increasingly complex care
for a wide range of patients, to fulfill their potential as primary care providers to
the full extent of their education and training, to implement systemwide changes
that take into account the growing body of evidence linking nursing practice to
Copyright National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
25
KEY MESSAGES OF THE REPORT
100
90
80
70
Percentage
60
4.9
14.0
9.0
7.7
3.1
4.2
9.1
8.0
5.9
8.3
7.3
2.4
7.4
6.0
2.5
3.5
4.8
18.6
10.7
3.5
3.8
7.2
11.9
50
2.4
40
30
64.8
67.4
53.7
47.8
20
10
0
Diploma
Hospital
Home health setting
Other
Associate degree
Bachelor’s degree
Nursing home/extended care facility
Public or community health setting
Master’s or doctorate
Academic education program
Ambulatory care setting
(not hospital)
FIGURE 1-2 Employment settings of RNs, by highest nursing or nursing-related
education.
Figure 1-2.eps
NOTES: The total percent by setting may not equal the estimated total of all registered nurses due to incomplete information provided by respondents and the effect of
rounding.
SOURCE: HRSA, 2010.
fundamental improvements in the safety and quality of care, and to capture the
full economic value of their contributions across practice settings.
At the same time, the nursing profession has its challenges. While there
are concerns regarding the number of nurses available to…
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