The healthcare environment is one that is increasing in complexity. The expansion of the role of nurses has been commanded by the enactment of the Patient Protection and Affordable Care Act of 2010 (“Affordable Care Act”). The Affordable Care Act has given birth to medical care access for an additional 32 million Americans than had a path to healthcare before (“The Future of Nursing”). The clarion call for high quality, reliable, patient-centric healthcare accessible by all Americans, requires extraordinary nursing care and the expansion and augmentation of exceptional nursing leadership. In fact, the Institute of Medicine (IOM), in its groundbreaking report on The Future of Nursing: Leading Change, Advancing Health, developed in collaboration with the Robert Wood Johnson Foundation (RWJF), makes this call one of cacophonic proportions. The report crystallizes the heightened and unparalleled role nursing will play in the evolution of healthcare (“The Future of Nursing”). For those interested in the nursing profession, there has never been a better time to carpe diem.
Nurses represent the largest segment of healthcare professionals (“The Future of Nursing”). There are over three million registered nurses nationally. According to the Henry J. Kaiser Family Foundation, as of April 2016, there were 908,508 active doctors in the United States, including primary care physicians and specialists ("Total Professionally Active Physicians”). The challenges facing the healthcare system today include preventing harm to patients through error reduction and infection containment (Binder), chronic care management (Bendix), caregivers for an ever-growing aged population (Gupta), primary care (“The Future of Nursing”) and preventive services such as colonoscopies (Breshears Wheeler, Foreman and Rueschhoff). Almost all of the medical care challenges are endemic to the nursing profession. Research indicates that positive patient outcomes, decreases in mortality rates, and a reduction in the number of errors related to medication provision are directly associated with an increase in the education of nurses at the “baccalaureate and graduate degree levels” ("Creating a More Highly Qualified”). Raising the bar for the nursing profession in all areas will have a significant impact on American health and well-being ("Creating a More Highly Qualified”).
The IOM and the RWJF envisioned the future of healthcare in its pioneering report, in which primary care, where the patient first meets with a medical professional who, thereafter, may send the patient to a specialist; and prevention, where a patient’s needs are anticipated through disease screenings and risk factor identification; are the keys to an effective healthcare system (“The Future of Nursing”). The future would also be reflected in a more coordinated, collaborative and interprofessional environment. Further, the future would reflect a world where the value of healthcare services would be rewarded rather than the volume of services provided, while quality care would be given at a price people could actually afford. This future would ensure that the rate at which expenditures for healthcare grow would decrease dramatically. Also, patients’ necessities and wants would be addressed through a patient-centric model (“The Future of Nursing”). The vision of the IOM and the RWJF sees nurses at the helm of healthcare innovation and reform.
The IOM and the RWJF made eight key recommendations:
1. Remove scope-of-practice barriers.
2. Expand opportunities for nurses to lead and diffuse collaborative improvement efforts.
3. Implement nurse residency programs
4. Increase the proportion of nurses with a baccalaureate degree to 80 percent by 2020.
5. Double the number of nurses with a doctorate by 2020.
6. Ensure that nurses engage in lifelong learning.
7. Prepare and enable nurses to lead change to advance health.
8. Build an infrastructure for the collection and analysis of interprofessional health care workforce data (“The Future of Nursing”).
The eight recommendations form the foundation of the committees’ vision for brining the future of nursing to life, while providing guidance to the many component healthcare organizations, regulatory agencies, affiliations and associations that contribute to ensuring the objective will be fully accomplished.
Recommendation 1 – removing the scope of practice barriers that now limit advanced practice registered nurses from fulfilling their capabilities to the fullest extent of their educational backgrounds and their training (“The Future of Nursing”). In order for the vision of the IOM and the RWJF to become a reality, many entities would have to make extensive changes, including Congress, state legislatures, Medicare and Medicaid agencies, and the Office of Personnel Management, and the Federal Trade Commission and the Antitrust Division of the Department of Justice (“The Future of Nursing”). For example, expanding Medicare and Medicaid program regulations, to include advanced practice registered nurses coverage when their provision of services is in keeping with their state approved education and skills. Also, another example is the expansion of the role of advanced practice registered nurses to allow admission assessments, home healthcare certifications and patient admissions to hospice and nursing facilities. By expanding the scope of practice barriers, through regulatory and legislative adjustments, the number of people able to implement important health actions increases exponentially. Doctors are helped, nurses functions are expanded, and patients needs can be implemented more expeditiously.
Recommendation 2 – increasing the possibilities for nurses to lead, and through leadership, to create programs and opportunities that add to healthcare improvement and patient health. In order for this vision to take effect, healthcare entities would need to create a path and opportunity for nurses to lead, to effect change, and to establish opportunities for nurses to participate in collaborative circumstances that result in patient healthcare improvement and cost reduction (“The Future of Nursing”). For example, establishing positions such as the Chief Nurse Officer whose job it is to oversee healthcare improvement and to monitor cost reductions in the healthcare entity. The overall responsibility of many Chief Nurse Officers include making plans, directing, and organizing nursing and patient care operations, creating collaborative work environments, mentoring and coaching nurse and staff, and recruiting, hiring, supervising, managing and retaining nurses and nursing staff (University Alliance).
Recommendation 3 – creating residency programs, similar to those established for doctors, so that nurses who have completed prelicensing, advanced degree, or clinical transition programs are provided an opportunity to get needed experience in a real life setting, so that they can properly transition from a recent graduate to a competent provider (“The Future of Nursing”). For example, The University HealthSystem Consortium (UHC)/American Association of Colleges of Nursing (AACN) Residency Program developed to create a “better educated workforce” (“Nurse Residency Program”).
Recommendation 4 – encouraging nursing students to get their baccalaureate degree, so that by 2020 eighty percent of the nurse population have the degree (“The Future of Nursing”). Research has determined the direct link between positive healthcare outcomes and nurse education levels, so the higher the level of education achieved the higher-quality of patient health. If healthcare entities encourage nurses to achieve more, through creating an environment of expectation, nurses will join the cause.
Recommendation 5 – encouraging nursing students to achieve their doctorate will help to foster the goal of developing nursing leaders for the future (“The Future of Nursing”). Nurses who enter a doctoral program will increase the number of faculty, researchers and nursing officers. Meanwhile, diversity should be encouraged and appreciated.
Recommendation 6 – conveying the importance of lifelong learning and creation of an environment where learning can be continued, as function of nursing growth and development (“The Future of Nursing”).
Recommendation 7 – developing and empowering nurses to lead change to improve health (“The Future of Nursing”). Nurses should take responsibility for their advancement through taking ongoing courses and seeking out opportunities to utilize their leadership skills.
Recommendation 8 – creating an infrastructure that captures data on healthcare workforce demographics and other statistical information (“The Future of Nursing”).
So What Has Transpired in Nursing Since the Initial Vision? In 2015, the Institute of Medicine and the Robert Wood Johnson Foundation assessed the progress of the initiatives created as a result of its 2010 vision report ("Assessing Progress”). The advancements to date were viewed as revolutionary and lent encouragement towards the future.
Shortly after The Future of Nursing was published, the Campaign for Action (Campaign) was instituted ("Our Story"). The Campaign is a joint cooperative between RWJF, AARP Foundation and AARP and is coordinated through the Center to Champion Nursing in America, part of the Foundation, RWJF and AARP.
Significant progress is being made in the direction of expanding roles and removing barriers to practice for nurses ("Assessing Progress”). Oddly enough, doctors and doctor organizations represent a substantial obstacle to progress. Efforts toward collaboration are improving and collaboration has a positive effect on the team and on positive patient outcomes. Provider burnout is reduced.
Since the release of the initial report, enrollment in DNP programs (Doctor of Nursing Practice) has almost doubled ("Assessing Progress”). Research related PHDs have increased by 15%. Since 2006, programs that offer DNP degrees have increased over ten fold, from 20 to 262 in 2014. Graduations from DNP programs have increased exponentially.
The outcome of diversity progress in relation to the report is too soon to tell ("Assessing Progress”).
Numerous initiatives have been started by several associations and entities with the goal of increasing interprofessional collaboration and an award initiative has been established for organizations involved in innovations designed to lower costs and improve healthcare ("Assessing Progress”).
The nursing community is making advancements in the area of gathering important statistical data on the nursing workforce, though no interprofessional infrastructure has been developed yet ("Assessing Progress”).
Overall, substantial progress has been made in many areas recommended by the Institute of Medicine and the Robert Wood Johnson Foundation, but more progress is needed in the areas of removing obstacles created by doctor resistance, diversity and data infrastructure.
"Assessing Progress on the Institute of Medicine Report The Future of Nursing." Institute of Medicine. Robert Wood Johnson Foundation - National Academy of Sciences. 2015. Web. 2 July 2016. <http://www.nationalacademies.org/hmd/reports/2015/assessing-progress-on-the-iom-report-the-future-of-nursing>.
Bendix, Jeffrey. "Chronic care management facing uphill battle." Medical Economics. UBM Medical, LLC. 3 June 2015. Web. 2 July 2016. <http://medicaleconomics.modernmedicine.com/medical-economics/news/chronic-care-management-facing-uphill-battle?page=full>.
Binder, Leah. "The Five Biggest Problems In Health Care Today." Forbes. Forbes, Inc. 21 February 2013. <http://www.forbes.com/sites/leahbinder/2013/02/21/the-five-biggest-problems-in-health-care-today/#c8883a416e20>.
Breshears Wheeler, Jennifer, Foreman, Megan and Rueschhoff, Austin . "Improving Women's Health Challenges, Access and Prevention." National Conference of State Legislatures. n. d. Web. 2 July 2016. <http://www.ncsl.org/research/health/improving-womens-health-2013.aspx>.
"Creating a More Highly Qualified Nursing Workforce." American Association of Colleges of Nursing. n. d. Web. 2 July 2016. <http://www.aacn.nche.edu/media-relations/fact-sheets/nursing-workforce>.
"Nurse Residency Program." American Association of Colleges of Nursing. n. d. Web. 2 July 2016. <http://www.aacn.nche.edu/education-resources/nurse-residency-program>.
"Our Story." The Campaign for Action. Cener to Champion Nursing in America, AARP, Robert Wood Johnson Foundation. n. d. Web. 2 July 2016. <http://campaignforaction.org/about/our-story/>.
" The Future of Nursing: Leading Change, Advancing Health." Institute of Medicine. Robert Wood Johnson Foundation - National Academy of Sciences. 2011. Web. 2 July 2016. <http://www.nap.edu/catalog/12956/the-future-of-nursing-leading-change-advancing-health>.
"Total Professionally Active Physicians - April 2016." Henry J. Kaiser Family Foundation. Kaiser Family Foundation. April 2016. Web. 2 July 2016. <http://kff.org/other/state-indicator/total-active-physicians/>.
University Alliance. "Nursing Careers: Chief Nursing Officer." Villanova University. University Alliance Bisk Education. n. d. Web. 2 July 2016. <http://www.villanovau.com/resources/nursing/chief-nursing-officer-job-description/#.V3hCETU1YZE>.