The Future Of Nursing: Leading Change, Advancing Health
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ISBN: 0-309-15824-9, 620 pages, 6 x 9, (2010)
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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; Institute of Medici
Copyright © National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
http://www.nap.edu/catalog/12956.html
Summary1
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, 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.
1
This summary does not include references. Citations for the findings presented in the summary appear in the
subsequent report chapters.
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S-1
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S-2 THE FUTURE OF NURSING: LEADING CHANGE, ADVANCING HEALTH
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.
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.
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SUMMARY S-3
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’ 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.
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:
- 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
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S-4 THE FUTURE OF NURSING: LEADING CHANGE, ADVANCING HEALTH
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 barriers 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 (FTC) 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 deliver safe, quality care that meets defined (organization or
professional society) standards of practice. Residency programs are supported predominantly in
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SUMMARY S-5
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,2
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 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
2
Versant is a nonprofit organization that provides, supervises, and evaluates nurse transition-to-practice residency
programs for children’s and general acute care hospitals. See http://www.versant.org/item.asp?id=35.
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S-6 THE FUTURE OF NURSING: LEADING CHANGE, ADVANCING HEALTH
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 delivering 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 patientcentered
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
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SUMMARY S-7
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
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.”3
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 profession, 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.
3 Patient Protection and Affordable Care Act, H.R. 3590 § 5101, 111th Congress.
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S-8 THE FUTURE OF NURSING: LEADING CHANGE, ADVANCING HEALTH
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.
• 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 programs in states that have
adopted the National Council of State Boards of Nursing advanced practice registered
nurse model rules and regulations (Article XVIII, Chapter 18).
For state legislatures:
• Reform scope-of-practice regulations to conform to the National Council of State Boards
of Nursing advanced practice registered nurse model rules and regulations (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
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SUMMARY S-9
health and safety of the public. States with unduly restrictive regulations should be urged
to amend them to 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:
• 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.
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S-10 THE FUTURE OF NURSING: LEADING CHANGE, ADVANCING HEALTH
• 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.
• 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.
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SUMMARY S-11
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 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.
PREPUBLICATION COPY: UNCORRECTED PROOFS
Copyright © National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
http://www.nap.edu/catalog/12956.html
S-12 THE FUTURE OF NURSING: LEADING CHANGE, ADVANCING HEALTH
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 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
PREPUBLICATION COPY: UNCORRECTED PROOFS
Copyright © National Academy of Sciences. All rights reserved.
The Future of Nursing: Leading Change, Advancing Health
http://www.nap.edu/catalog/12956.html
SUMMARY S-13
PREPUBLICATION COPY: UNCORRECTED PROOFS
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.
CONCLUSIONS
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
http://www.nap.edu/catalog/12956.html
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