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TheEvolvingPracticeofNursing.pdf
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The Evolving Practice of Nursing
Pamela S. Dickerson, PhD, RN-BC
January, 2012
Purpose: The purpose of this session is to enable the nurse to be proactive in advocating
for the future of nursing.
Objective:
Describe changes impacting the current and future practice of nursing.
Introduction
A number of factors have converged in the first decade of the 21 st century to radically
alter the environment in which health care is provided and change the nature of the role
and responsibilities of the nurse. This study will explore these changes, with a focus on
the current and potential impacts on the profession of nursing.
Setting the Stage
Changes in the environment in which health care is practiced have occurred more rapidly
in the first decade of the 21 st century than in the past. Hospital care, which used to be the
“normal” and most common venue for the practice of nursing, is now only one of a
myriad of opportunities for the nurse. Patients are in the hospital for shorter periods of
time, and only the sickest patients are hospitalized. Consequently, hospitals are
employing nurses who are experts in the type of care needed by hospital patients. Units
which typically provided care for “medical-surgical” patients are often incorporating
telemetry and other services that used to be reserved for critical care units. Many of the
patients who used to be cared for on traditional medical-surgical units are now cared for
either in rehabilitation centers or in their homes. Long-term acute care hospitals and/or
units have been developed for those patients who need care for longer periods of time
than the typical acute care facility can now handle. Reimbursement issues have driven
many of these changes.
The health care reform provisions based on federal law passed in 2010 have yet to be
fully determined. Some elements of the anticipated changes include more focus on
preventive care, more persons having insurance to pay for primary care, and more focus
on community-based care. The nurse is well positioned to be a provider for preventive
care and services in the community. It is anticipated that resources for care in clinics,
offices, and other community-based settings will need to increase to meet demand in the
coming years.
Technological advances are impacting the types of services patients receive, where those
services are provided, and the competencies of the personnel required to manage the
technology. New equipment, telemedicine, use of electronic health records, and the
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impact of emerging fields such as genetics and genomics are altering the landscape of
health care. Nurses must be competent in use of the technological “tools” without losing
focus on the patient as the primary point of care.
Changes in funding from both private and government-related sources are dramatically
impacting the practice of nursing and the services provided to patients. As an example,
the Centers for Medicare and Medicaid Services (CMS) is no longer providing
reimbursement for certain types of situations that occur in the acute care setting. For
example, a patient who suffers a catheter-associated urinary tract infection, an injury
related to a fall, or pressure ulcers during his/her hospital stay has been the recipient of
something that CMS says should “never” happen (Modern Healthcare, 2009). "Never
events" are described in an AHRQ (2010) patient safety document as "shocking medical
errors that should never occur". Consequently, the hospital now is required to cover the
cost of any additional care, medications, or other treatment the patient may require as a
result of this complication.
The National Quality Forum (NQF), describes serious reportable events as “serious,
largely preventable, and harmful clinical events” (NQF, 2011). A fact sheet published on
the organization's web site
(http://www.qualityforum.org/Topics/SREs/Serious_Reportable_Events.aspx) provides a
detailed listing of these events. Efforts of NQF have included identification, reporting,
and sharing of information about occurrences of these events for the purpose of
education, leading to change in practice and safer patient care. Diverse examples include
infant discharge to the wrong person, patient suicide during hospitalization, patient death
or serious illness resulting from a medication error, and patient death or serious injury
related to administration of incompatible blood or blood products (AHRQ, 2010). Many
states now require hospitals to report these events, and increasingly, facilities are required
to make this information available to the public on web sites such as
http://www.hospitalcompare.hhs.gov/hospital-
search.aspx?AspxAutoDetectCookieSupport=1.
Health Care Reform
Legislation passed by the US Congress in 2010 has the potential to significantly alter the
landscape of healthcare in the United States. Some of the changes, such as parents’
insurance covering college students through age 26, are already in place. Other changes
are anticipated to be implemented within the next five years. Many of the
recommendations do not currently have funding, so their implementation is in question.
Selected provisions of the legislation, named the 2010 Affordable Care Act, that affect
nursing are summarized here. More detailed information about these provisions can be
obtained from http://www.nursing.ohio.gov/PDFS/nursingandhealthreformlawtable.pdf.
1. Funding is to be provided for community-based education for advanced practice nurses, in partnership between accredited graduate nursing education programs
and community-based healthcare centers.
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2. Several programs offering loans, scholarships, or grants are to be established or maintained to promote education at all levels of nursing education.
3. A number of initiatives are aimed at increasing diversity in the healthcare workforce and deploying healthcare providers to work in underserved areas.
4. Several programs are targeted to provide education of healthcare providers and care for patients in high-need areas, particularly pediatrics, geriatrics, and
community/public health.
5. A Patient-Centered Outcomes Institute would be established to focus on development, deployment, and implementation of evidence-based practice
standards to enhance quality of patient care.
6. Accountable care organizations (ACOs) would be developed and implemented to focus on comprehensive care throughout an entire episode of illness. These
organizations would potentially include physicians’ offices, clinics, acute care
hospitals, rehabilitation centers, and home health agencies. Services would be
“bundled” and paid in relation to the entire episode of care, not individual services
that are provided. Nurses would be key players in care coordination.
7. A National Health Care Workforce Commission / National Center for Workforce Analysis is to be created to lead the process of analyzing the existing workforce.
This will enable policy makers and educators to determine areas of need and
determine ways to most effectively deploy resources to meet those needs. There is
currently no centralized data base that provides information about numbers of
healthcare workers employed, their areas of employment, or the areas which are
underserved.
The Current Landscape of Nursing Education
There are currently multiple routes for a person to take in order to become licensed as a
registered nurse in the United States, ranging from associate degree preparation to
graduate-entry programs. This diversity in the educational process has resulted in great
confusion, both within the profession and in the eyes of the public. One of the key
characteristics of a profession is that is has a clear educational path to prepare its
practitioners. From time to time, there have been discussions within the nursing
community about a core standard for “entry into practice” at the baccalaureate level, but
this is not yet a reality.
Nursing education must be considered in two perspectives: preparation for licensure as a
registered nurse, and advanced education in nursing. First, educational programs that
prepare a person to sit for the National Council Licensure Examination (NCLEX-RN)
will be discussed, followed by information regarding advanced academic education.
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The associate degree in nursing is typically a two year program (ranging from 18-24
months reflecting either a two-academic year or two-calendar year program). Roots of the
associate degree program are based in research conducted in the early 1950’s at the time
of emergence of the community college system in the United States. Dr. Mildred Montag,
often known as the pioneer who began the ADN educational programs, was the project
director for development of the model for this type of education. Results of the studies
conducted at this time revealed that associate degree nurses were able to successfully
pass licensure examinations and provide safe patient care (Mahaffey, 2002).
Initially, the associate degree was anticipated to be a “technical” degree while the
baccalaureate degree was intended to be the “professional” degree. However, this
differentiation never occurred in either licensure examination or practice.
From the early 1960s, the American Nurses Association (ANA) has advocated for a
minimum of a baccalaureate degree as preparation for the professional practice of
nursing. Approximately 20 years after ANA began its advocacy for BSN preparation, the
National League for Nursing (NLN) also issued a position paper supporting the BSN as
essential for professional nursing practice (Mahaffey, 2002). Both of these organizations’
position statement initially met with great consternation within both the practice and
academic communities. Those issues have not been resolved.
Increasingly, however, research data has supported the premise that nurses prepared at a
minimum of a baccalaureate level are able to provide safer patient care (Aiken et al.,
2003; Friese, et al., 2008; Van den Heede et al., 2009). With this evidence in hand, and
with recommendations from several national organizations, there is now a movement
toward requiring all nurses to have a baccalaureate degree within a certain number of
years after licensure. To facilitate this process, recommendations call for better
articulation between programs so that a nurse can begin his/her career as an LPN or
Associate Degree nurse and more easily move through advanced academic programs to
attain a BSN or higher degree.
Other options for entry into nursing currently exist. One, commonly referred to as an
“accelerated” program, admits people into an undergraduate nursing major when they
have already attained a minimum of a baccalaureate degree in another field of study. The
student is then able to progress more quickly through the nursing courses and be prepared
to sit for the National Council Licensure Examination (NCLEX).
Graduate entry programs are offered by some colleges of nursing. In these programs, the
student with a minimum of a baccalaureate degree in another field of study is admitted
directly to a master’s degree program. This student takes a combination of basic nursing
and master’s level courses and sits for the NCLEX examination approximately one-half
of the way through the curriculum. Once licensure has been attained, the nurse then
continues to complete the master’s degree program.
More traditional graduate programs exist to prepare the already-licensed registered nurse
with educational and clinical preparation to practice at an advanced level. Some of the
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programs are designed to prepare nurse educators, clinical nurse leaders, administrators,
or researchers; others focus on clinical practice to prepare the graduate to become
certified as an advanced practice registered nurse (nurse practitioner, clinical nurse
specialist, nurse midwife, or registered nurse anesthetist).
At the doctoral level, there are a number of programs that offer a Doctor of Philosophy
(PhD) in nursing, typically focusing on nursing scholarship and research. More recently,
there has been an initiative to move advanced practice nursing education to the doctoral
level, creating the DNP (Doctor of Nursing Practice) as a clinician. (American
Association of Colleges of Nursing, 2010)
Changes Needed in Nursing Education
A report was issued early in 2010 from the Carnegie Foundation (Benner, 2010). This
report was the culmination of several years’ worth of work by a group of stakeholders in
the nursing education and practice environments. After thorough analysis of the current
landscape of nursing education, the report concluded that education in the traditional
formats is not working to prepare nurses to practice in today’s complex healthcare
environment. A number of recommendations were made, including better articulation
between programs. This would allow students to begin their healthcare careers as LPNs
or associate degree graduates, then advance to baccalaureate or higher education with
minimal “roadblocks”.
Another recommendation from this report is that the curricula currently used by schools
of nursing, focusing on performance of nursing tasks or skills, must be significantly
changed. Rather, the focus of undergraduate education should be on development of
knowledge, skills, and abilities to function in a complex healthcare system. Students
entering nursing today need to be knowledgeable about topics such as leadership, cultural
diversity, advocacy, and evidence-based practice.
Subsequent to academic preparation, a nurse residency program is recommended.
Residency for nurses, similar to that for new physicians, would enable the nurse to
gradually increase knowledge and skills specific to the desired area of practice. Clinical
practice would be combined with a continuation of formal learning opportunities to
facilitate development of critical thinking and clinical judgment. A residency program is
not the same as orientation or preceptor-based learning. The residency program is a
formal blend of academic and clinical experiences that focus on application of knowledge
and skills in the clinical setting, while continuing to learn and developing skills in
interprofessional collaboration. Some residency programs are currently in use, and
reports of their value have been positive.
Institute of Medicine: Mandates for Change
A series of reports from the Institute of Medicine (IOM) over the past decade have
addressed a number of needed improvements in the healthcare system. These reports
have ranged from a focus on the healthcare workforce to initiatives to improve quality of
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patient care. The underlying message in all of these reports has been that patient safety is
jeopardized when quality care is not provided. Numerous factors have impacted the
ability of nurses and other healthcare workers to provide that quality of care. Changes in
the education of healthcare providers, the infrastructure in which healthcare is provided,
and the expectations of patients, providers, and employers must all be aligned to create a
safer environment and culture for the delivery of care. Most recently, the Institute of
Medicine has collaborated with the Robert Wood Johnson Foundation in a two-year
initiative to develop a blueprint for the future of nursing.
The Future of Nursing: An Institute of Medicine/Robert Wood Johnson Foundation
Report
Over the past two years, the Institute of Medicine and the Robert Wood Johnson
Foundation have worked together to develop recommendations for the future of nursing,
taking into consideration the above factors and awareness of the need for nursing to have
a pivotal role in an evolving health care system. The final report was issued in October of
2010 and contains eight recommendations. These recommendations are summarized
below. Detailed information about the report is available at
http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-
Health.aspx.
Key Messages
Four key messages have emerged from this report. They include:
1. Nurses should practice to the full extent of their education and training. Part of this focus relates to advanced practice nurses, while part relates to
appropriate preparation and use of the registered nurse in all areas of practice.
Barriers, such as state regulatory scope of practice limitations and funding issues,
need to be addressed in order to maximize contributions that nurses can make.
2. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
As noted earlier in this study, there are currently a number of entry points into
nursing, each of which prepares the nurse to sit for the same licensure
examination. Historically, there have been challenges in nurses’ abilities to
advance their formal education. This report indicates that a better method of
articulation will enable the nurse to attain increasingly higher levels of academic
education with minimal roadblocks.
3. Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.
Nurses must learn leadership skills and develop critical thinking abilities as they
participate in analysis and evaluation of existing health care systems and
processes. The nurse at all levels of practice, ranging from front-line caregivers to
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nurse executives, must be empowered to advocate for better, safer patient care and
better functioning of healthcare systems to provide that care.
4. Effective workforce planning and policy making require better data collection and an improved information infrastructure.
There is not currently a clear picture of how many licensed nurses are currently
actively employed in health care in the United States and where they are working.
This data is essential to get a clear picture of areas of need. From this data,
educational programs can be developed to best meet the needs of a particular area
and processes can be put in place to most effectively use existing resources. For
example, data may show a need for an increase in the number of nurses working
in community-based care settings. Educational programs, which have traditionally
focused primarily on educating nurses to work in acute care settings, can add
community health information to curricula. Federal or state grants might be made
available to encourage nurses to obtain education and/or employment in these
areas of need.
Specific Recommendations
1. Remove scope of practice barriers. Currently, states have different practice legislation, and there is no consistency regarding what nurses are permitted to do.
This is particularly problematic for advanced practice nurses, and has an impact
on funding, reimbursement, and utilization. The National Council of State Boards
of Nursing (NCSBN) has developed a model nursing practice act and nursing
administrative rules, though these are not yet widely adopted. The report
recommends that all states use these standardized resources, which would allow
full and consistent practice of nursing in all states.
2. Expand opportunities for nurses to lead and diffuse collaborative improvement efforts. Nurses at all levels of the healthcare system should be
actively engaged in advocating for safe patient care. Nurses should be active
participants, and sometimes leaders, of process improvement initiatives and
should collaborate with other healthcare providers in modifying existing
methodologies as new best practice standards become available.
3. Implement nurse residency programs. Most typically, nurses graduate from their basic educational programs, have a period of “orientation” or preceptorship
with an employer, then within a number of days or weeks are expected to be fully
functional members of the healthcare team. Realizing that it takes time and
experience for nurses to be fully prepared for practice, the report recommends a
transition-to-practice interval similar to the residency programs in which
physicians participate at the conclusion of their medical education.
4. Increase the proportion of nurses with a baccalaureate degree to 80% by 2020. Recognizing that a minimum of a baccalaureate degree best prepares the
nurse for practice in today’s complex healthcare environment, the report
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recommends that educational programs offer “seamless” pathways to enable the
nurse to increase his/her academic education. Funding in the form of scholarships
and loans for nursing education is recommended, with special emphasis on
increasing the diversity of those entering the profession. Another important aspect
of this recommendation is encouraging interprofessional education, so those who
aspire to be nurses, physicians, pharmacists, and other types of healthcare
providers can learn from early in their educational experiences how to collaborate
as members of a team to promote quality patient care.
5. Double the number of nurse with a doctorate by 2020. Recognizing the need for nurses to be educators and researchers, this recommendation suggests that
programs should be expanded and opportunities created for nurses to move into
these higher level educational programs. Salary and benefit packages for
educators must be reflective of the knowledge and skill of doctorally prepared
individuals.
6. Ensure that nurses engage in lifelong learning. The rapid pace of new knowledge acquisition in healthcare requires that nurses continue to learn.
Continuing education opportunities should be relevant to the nurse’s practice,
promote interprofessional collaboration, and focus on attaining competency
relative to the knowledge, experience, and practice of the nurse.
7. Prepare and enable nurses to lead change to advance health. Nurses should be educated and have support to develop leadership skills. These activities should
take place in academic and continuing education venues as well as in the practice
environment. Recognizing that nurses have front-line knowledge that can directly
benefit safe, high-quality patient care, nurses should be actively involved in all
levels of decision-making.
8. Build an infrastructure for the collection and analysis of interprofessional healthcare workforce data. There is currently no clear data base to identify areas
of need, in terms of clinical areas of practice, roles, or geographic areas where
service is lacking. Additionally, data is needed to support planning and provision
of services for populations that would benefit from greater diversity in terms of
race, gender, or ethnicity.
Implications for Nursing Education and Practice
Opportunities for nursing in this new healthcare environment are numerous. As clearly
indicated in the Carnegie report, the health care reform legislation, and the IOM/RWJ
Foundation reports, reform of nursing education to better prepare nurses for practice is
critical.
Steps are currently underway in many nursing organizations throughout the country to
initiate some of the proposals that have been mentioned in this study. The National
Council of State Boards of Nursing (2010) has developed a model nurse practice act,
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which helps to standardize scope of practice definitions in states which have adopted the
model. This organization has also developed a consensus model addressing licensure,
accreditation, certification, and education for advanced practice nurses. These initiatives
address recommendations in all three of the above reports.
Many hospitals already have developed leadership programs to enhance leadership and
advocacy capabilities for nurses at all levels of an organization. Some have begun to
establish nurse residency programs in collaboration with academic institutions.
Numerous other initiatives are being planned for the next few years as nurse leaders
throughout the country mobilize to begin formulating the future of the nursing profession.
As an example, Action Coalitions are now in place in over half of the states in the U.S.,
working to implement sustainable changes supported by studies noted above at local,
state, and regional levels. The focus of these Action Coalitions is to "capture best
practices, determine research needs, track lessons learned, and identify replicable
models" (Center to Champion Nursing in America, 2011). Nurses interested in
participating in this initiative can learn more about ongoing national, state, and local
events and can sign up to be involved by visiting the web site,
http://www.thefutureofnursing.org/.
References
Agency for Healthcare Research and Quality. (2010) Patient Safety Primer. Retrieved
9/19/10 from http://www.psnet.ahrq.gov/primer.aspx?primerID=3
Aiken, L., Clarke, S., Cheung, R., Sloane, D. and Silber, J. (2003). Educational levels of
hospital nurses and surgical patient mortality. JAMA 290(12), 1617-1623.
American Association of Colleges of Nursing. Doctor of Nursing Practice. Retrieved
12/4/10 from http://www.aacn.nche.edu/dnp/
Benner, P., Sutphen, M., Leonard, V., Day, L. (2010). Educating Nurses: A Call for
Radical Transformation. San Francisco, Jossey-Bass.
Center to Champion Nursing in America (2011). Future of Nursing Campaign for Action.
Retrieved 1/12/12 from: http://championnursing.org/action-coalitions
Friese, C., Lake, ., Aiken, L., Silber, J., and Sochalski, J. (2008). Hospital nurse practice
environments and outcomes for surgical oncology patients. Health Services Research
43(4), 1145-1163.
Hassmiller, S. (2010). Nursing’s role in healthcare reform. American Nurse Today 5(9),
pgs. 68-69.
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Institute of Medicine (2010).The Future of Nursing: Leading Change, Advancing Health.
Washington DC. National Academies Press.
http://books.nap.edu/openbook.php?record_id=12956
Mahaffey, E. (2002). The relevance of associate degree nursing education: past, present,
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Nursing Quality Forum (2012). Serious Reportable Events. Retrieved 1/12/12 from
http://www.qualityforum.org/Topics/SREs/Serious_Reportable_Events.aspx
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from http://www.qualityforum.org/Topics/SREs/Serious_Reportable_Events.aspx;
SRE%20fact%20sheet20121411[1].pdf
Nursing Provisions PL 111-148, the Patient Protection and Affordability Care Act.
(2010). AARP. Retrieved 12/10/10 from
http://www.nursing.ohio.gov/PDFS/nursingandhealthreformlawtable.pdf
Robert Wood Johnson Foundation (2010). Initiative on the Future of Nursing. Retrieved
12/10/10 from http://www.thefutureofnursing.org/.
Van den Heede, K., Lesaffre, E., Diya, L., Vleugels, A., Clarke, S., Aiken, L., and
Sermeus, W. (2009). The relationship between inpatient cardiac surgery mortality and
nurse numbesr and educational level: analysis of administrative data. International
Journal of Nursing Studies 46(6), 796-803.
Author Information:
President, PRN Continuing Education
Westerville OH
614-208-6285
