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The Future of Nursing in an Evolving Health Care SystemBy Stacey Whitney

Essential Questions

· What is the purpose of the Institute of Medicine’s 2010 report The Future of Nursing: Leading Change Advancing Health?

· How do the four key messages from The Future of Nursing propose change in the nursing profession?

· What recommendations were proposed as a result of The Future of Nursing?

· What has contributed to the nursing shortage?

Introduction

Health care in America is undoubtedly complex and challenging to navigate. It is an ever-changing system that connects many health care professionals and related service providers toward the common goal of providing quality patient care. The future of the nursing profession hinges on making positive changes related to the health care needs of patients of all ages and the preparedness of the nursing work force. The Robert Wood Johnson Foundation (RWJF) and the Institute of Medicine (IOM) identified the need to assess and respond to the necessary transformation of the nursing profession and, in 2008, assigned a committee to produce a report of recommendations. This chapter will review the future of nursing in an evolving health care system based on the IOM report in context, the initiatives related to the IOM report, and the current and future nursing shortage.

The Institute of Medicine Report

The IOM, a division of the National Academies of Sciences, Engineering, and Medicine, consists of medical professionals who work to provide evidence-based research and recommendations related to public health and science. The IOM recognized that the nursing workforce of approximately 3 million nurses has the largest potential impact of implementing change in the current health care system. The IOM also recognized that nurses are the largest component of the health care workforce in the United States. Nurses offer invaluable insight and have the ability to join forces with other health care professionals to provide safe and effective care for all patients, as encouraged by the Affordable Care Act (ACA) . The ACA has directly linked health care provider and organizational pay and reimbursement to value and performance. The IOM appointed a committee in conjunction with the RWJF in 2008 to implement a 2-year formal assessment related to the future of nursing. The committee published a report in 2010 entitled The Future of Nursing: Leading Change, Advancing Health that identified how the nursing profession should implement change for the betterment of the future of nursing (Institute of Medicine [IOM] 2011).

The IOM’s seminal report indicates that the United States has the ability to transform the health care system and that nurses should play a primary role in the transformation, thereby legitimizing nursing as a profession (Mensik, 2017). Harvey Fineberg, president of the IOM stated, “The report aims at empowering nurses to be even more effective and making long-lasting improvements to quality, access, and the value of healthcare for all Americans” (Hendren, 2010, para. 21). The report provides key messages and suggestions that offer guidance to:

1. Ensure that nurses 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 (Hendren, 2010).

Recommendations Related to the IOM Report

The responsibility to improve health care for the future does not depend on the nursing profession alone. Other entities, such as government, businesses, professional associations, health care organizations, and insurance companies, all need to be involved in the process (Mensik, 2017); however, recognizing that the nursing profession should provide a primary role in changing and improving health care, the IOM report states that nurses should respond as leaders in health care. Table 1.1 shows the recommendations for change in the nursing discipline identified in the IOM report (2011).

Table 1.1

IOM Key Message Recommendations for Improvement of Nursing as a Discipline

Recommendations	Rationale
1. Eliminate scope-of-practice barriers	Advanced practice nurses are independent practitioners who should be able to practice to the full extent of their education and training.
2. Expand opportunities for nurses to lead	Nurses should be full partners with physicians and other health professionals in redesigning health care in the United States.
3. Implement nurse residency programs	State boards of nursing, accrediting bodies, the federal government, and health care organizations should take action to support nurses’ completion of nurse residency programs when transitioning into new clinical practice areas.
4. Increase the number of nurses with bachelor’s degrees to 80% by 2020	Nurses should earn higher nursing degrees, and the educational system should flow easily from one degree to the next. There should be an increase in the diversity of students to create a workforce prepared to meet the demands of diverse populations.
5. Double the number of nurses with doctorate degrees by 2020	Increasing the number of nurses with doctoral degrees will provide much needed nursing educators and researchers.
6. Ensure nurses engage in lifelong learning	Lifelong learning allows nurses to gain competencies needed to provide care for diverse populations.
7. Prepare and enable nurses to lead change to advance health	Preparation for leadership positions should be encouraged by nurses, nursing education, and nursing associations. Health care leaders should seek to identify academically and experientially qualified nurses to fill leadership positions.
8. Build an infrastructure for the collection and analysis of interprofessional health care workforce data	An infrastructure would encourage collaborative effort to improve research, the collection and analysis of data, and ensure that data is timely and publicly accessible.

Transforming Nursing Education

Fundamental changes in nurse education are needed to reach the goals of the IOM report. Nursing education needs to be transformed to prepare graduates to work collaboratively and effectively in a variety of settings. Nursing education goals remain unchanged:

1. Nurses must be prepared to meet the patients’ diverse needs.

2. Nurses must function as leaders.

3. Nurses must advance science to benefit patients.

4. Nurses, as health professionals, must deliver safe, quality patient care (IOM, 2011).

The expected outcomes of these fundamental changes have a direct relationship to improved patient outcomes. For instance, a correlation has been established between increased levels of nursing education and mortality rates in acute care settings (IOM, 2011). Simply put, a more educated nursing workforce leads to improved patient care; therefore, emphasis should be placed on the adequate preparation of new graduates for entry into practice, increased levels of education for those already in practice, and new opportunities for ongoing professional development that prepares nurses to meet the needs of patients across a variety of roles in primary, acute, long-term and community settings (IOM, 2011).

Nursing is unique in that there are multiple ways to enter the field. Although necessary to meet complex demands and periods of nursing shortage, multiple pathways have also created confusion regarding educational expectations across groups (IOM, 2011). The IOM recommendation for nursing education states that change in prelicensure and postlicensure nursing programs is needed along with greater emphasis on achieving higher levels of education. The report suggests that graduates of nursing programs need competency in the following areas:

· continuous improvement of the quality and safety of health care systems

· informatics,

· evidence-based practice,

· knowledge of complex systems,

· ongoing leadership and management capabilities,

· population health and population-based care management, and

· health policy knowledge, skills, and attitudes (Marquis & Huston, 2017).

Despite recommendations indicating baccalaureate completion for entry into practice, numerous barriers related to nursing education exist (see Table 1.2).

Table 1.2

IOM Identified Barriers to Meeting Educational Needs of Nursing Undergraduates

Barrier	Supportive Data
1. Aging and shortage of nursing faculty	· The number of academically qualified faculty is insufficient to meet the demand for the preparation of new nursing graduates. · The nursing and nurse faculty populations are aging. · Opportunities for nurses in clinical areas are increasing. · There is a lack of competitive salaries in education.
2. Insufficient clinical placement opportunities for students	· Nurse staffing challenges and nurse faculty shortages have limited the number of opportunities available for clinical learning. · Development of new nursing programs further limit the number of clinical locations and experiences available to students.
3. Nursing curriculum needs to be updated to meet current patient needs	· The nursing educational model has been largely based on acute care competencies; additional competencies must include public, community, and geriatric health. · Health care technology and systems are changing rapidly, making it difficult to align nursing curriculum to current practice.
4. Inadequate workforce planning	· Lack of communication, insufficient data sources, and lack of continuity between systems create poor alignment between education and practice.

Several approaches have been taken to encourage educational advancement among nurses toward attainment of baccalaureate preparation of 80% of RNs by 2020. Many hospitals and health care agencies have developed incentives for nurses to continue their education. Still others have changed their hiring practices to align with the American Nurses Credentialing Center (ANCC) Magnet Recognition Program—a standard that emphasizes nursing excellence and promotes advanced degrees and continuing education for all staff (American Nurses Credentialing Center, n.d.). Employee educational assistance programs to aid in tuition costs and salary incentives are common. The IOM encourages innovative programs to attract nursing faculty, obtain clinical placements for students, and adopt a framework for continuous lifelong learning (IOM, 2011).

Check for Understanding

1. The IOM sees nursing play what role in the transformation of health care?

2. How do the IOM recommendations apply to the future of nursing?

3. Why is transforming education important to nursing?

Transforming Nursing Practice

Nurses have the opportunity to be involved in the transformation of the health care system. Empowering nursing professionals to practice to the full extent of their education and training will play a major role in successfully meeting the goals established by the IOM as well as improving the system of delivery for patient-centered primary and community care.

As the health care system changes, interprofessional collaboration will allow providers to apply innovative and cost-effective approaches to care delivery that eliminate redundancy, reduce errors, and increase safety (IOM, 2011). Addressing ineffective care and fragmentation of service delivery is key to positive health outcomes. Health care delivery models must be reevaluated to ensure a collaborative infrastructure that best utilizes the skills of all health care providers, including nurses in all care settings. One example provided in the IOM report includes advanced practice registered nurses (APRNs) practicing in schools and workplaces, performing public health community assessment, screenings, and disease surveillance as a means of ensuring health promotion and disease prevention (Finkelman, 2016).

The IOM examined existing regulatory barriers that are hindering the practice of health professionals and identified many variations in licensing and nurse practice acts across states. Despite changes in the health care system that warrant revision to the APRN scope-of-practice, many states have not updated their laws to address inconsistencies in scope of practice for APRNs. This has resulted in the inability of APRNs to practice to the extent of their training, leading to confusion and inefficiencies at point-of-care. The autonomy to see primary care patients, prescription writing authority, hospital admission privileges, and the ability to order and diagnose are just a few examples of varied scope of practice resulting in the misuse of APRNs. Combined with Medicaid and Medicare payment policies often linked to out-of-state nurse practice laws, APRNs are also often reimbursed at a lower rate, effectively devaluing the education and training APRNs have received (IOM, 2011). A shift in focus to independent practice is needed to address the varied interpretations of scope of practice from state to state.

Nursing Shortage

Meeting the goals of the IOM report is a significant challenge for the nursing profession, as there are insufficient numbers of qualified nurses to fill roles at all levels of care. Nursing is comprised of a multigenerational workforce, with a large population of nurses who are nearing retirement. In 2013, 55% of RNs were 50 years of age or older (Finkelman, 2016). The American Association for Colleges of Nursing (AACN) projects that the demand for nursing professionals will increase by 16% between the years 2014–2024. More than one million job openings will be available for nurses. The AACN has identified several factors influencing the nursing shortage:

· Many in the current nursing workforce are nearing retirement age.

· Nursing school enrollment is not increasing fast enough to meet the projected demand for RN and APRN services.

· A shortage of nursing school faculty is restricting nursing program enrollments. Nursing schools do not have enough faculty to allow all interested students to enroll in nursing programs.

· Changing demographics indicate a need for more nurses to care for the aging population.

· Nurses’ stress levels are increasing because of insufficient staffing, which, in turn, is reducing job satisfaction, causing more nurses to leave the profession.

· Access to health care is affected by high nurse retirement and turnover rates (American Association of Colleges of Nursing, 2017).

Check for Understanding

1. How are nurses driving the health care system to produce better quality patient care?

2. In what ways do nurses have the opportunity to think more globally on behalf of patients and managing care?

3. What opportunities for improvement exist to improve the nursing shortage?

Reflective Summary

Health care is an ever-changing system that connects many health care professionals and related service providers toward the common goal of delivering quality patient care that is safe and effective. The future of nursing in an evolving health care system is based on the collective response to the recommendations provided by the IOM report, which encourages improved continuity between education and practice, autonomy of APRNs to practice to the full extent of their education and training, and educational advancement for health care staff.

Key Terms

Affordable Care Act (ACA): Health care reform legislation with multiple provisions signed into law by U.S. President Barack Obama and became known as Obamacare; among the provisions include health insurance coverage to uninsured, measures to lower costs and improve health care system efficiency, preventative care, extension of care to dependents under the age of 26, and prohibited insurance claim denial or higher premiums for preexisting conditions.

References

American Association of Colleges of Nursing. (2017). Nursing shortage fact sheet. Retrieved from http://www.aacnnursing.org/News-Information/Fact-Sheets/Nursing-Shortage

American Nurses Credentialing Center. (n.d.). ANCC magnet recognition program. Retrieved from https://www.nursingworld.org/organizational-programs/magnet/

Finkelman, A. (2016). Leadership and management for nurses: Core competencies for quality care (3rd ed.). Boston, MA: Pearson.

Hendren, R. (2010). IOM report offers glimpse of nursing’s future. Retrieved from http://www.strategiesfornursemanagers.com/ce_detail/257764.cfm

Institute of Medicine. (2011). The future of nursing: Leading change, advancing health. (2011). Retrieved from https://www.nap.edu/read/12956/chapter/1

Marquis, B. L., & Huston, C. J. (2017). Leadership roles and management functions in nursing (9th ed.). Philadelphia, PA: Wolters Kluwer.

Mensik, J. (2017). Lead, drive & thrive in the system. Silver Spring, MD: American Nurses Association.

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