National Academies Press.ISBN: 0-309-15824-9, 620 pages, 6 x 9, (2010)This free PDF was downloaded from:http://www.nap.edu...
across the lifespan. In this envisioned future, primary care and prevention are central drivers ofthe health care system. ...
http://championnursing.org/sites/default/files/nursingandhealthreformlawable.pdf.PREPUBLICATION COPY: UNCORRECTED PROOFSCo...
153,348 Take health histories and provide complete physical exams;diagnose and treat acute and chronic illnesses; providei...
complex care for a wide range of patients, to fulfill their potential as primary care providers tothe full extent of their...
PREPUBLICATION COPY: UNCORRECTED PROOFSCopyright © National Academy of Sciences. All rights reserved.The Future of Nursing...
Copyright © National Academy of Sciences. All rights reserved.The Future of Nursing: Leading Change, Advancing Healthhttp:...
choice and patient-centered care should be foundational in the building of a reformedhealth care system.Additionally, to t...
years—from 122,000 applications in 2004 to 208,000 applications in 2009 (AACN, 2010). Whilenursing schools across the coun...
Copyright © National Academy of Sciences. All rights reserved.The Future of Nursing: Leading Change, Advancing Healthhttp:...
Copyright © National Academy of Sciences. All rights reserved.The Future of Nursing: Leading Change, Advancing Healthhttp:...
KEY MESSAGES OF THE REPORT 1-13others—as well as larger groups such as licensing bodies, educational institutions, andphil...
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National academies press futute of nursing

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  • 1. National Academies Press.ISBN: 0-309-15824-9, 620 pages, 6 x 9, (2010)This free PDF was downloaded from:http://www.nap.edu/catalog/12956.htmlThe Future of Nursing: Leading Change, AdvancingHealthCommittee on the Robert Wood Johnson FoundationInitiative on the Future of Nursing,at the Institute ofMedicine; Institute of MedicineCopyright © National Academy of Sciences. All rights reserved.The Future of Nursing: Leading Change, Advancing Healthhttp://www.nap.edu/catalog/12956.html1Key Messages of the ReportThe U.S. health care system is characterized by a high degree of fragmentation across manysectors, which raises substantial barriers to providing accessible, quality care at an affordableprice. In part, the fragmentation in the system comes from disconnects between public andprivate services, between providers and patients, between what patients need and how providersare trained, between the health needs of the nation and the services that are offered, and betweenthose with insurance and those without (Stevens, 1999). Communication between providers isdifficult, and much care is redundant because there is no way of sharing results.This report is being published at an opportune time. In 2010, Congress passed and thePresident signed into law comprehensive health care legislation. These laws, the PatientProtection and Affordable Care Act (Public Law 111-148) and the Health Care and EducationAffordability Reconciliation Act (Public Law 111-152), are collectively referred to throughoutthis report as the Affordable Care Act (ACA). The ACA represents the broadest changes to thehealth care system since the 1965 creation of the Medicare and Medicaid programs and isexpected to provide insurance coverage for an additional 32 million previously uninsuredAmericans. The need to improve the health care system is becoming increasingly evident aschallenges related to both the quality and costs of care persist.As discussed in the preface, this study was undertaken to explore how the nursing professioncan be transformed to help exploit these opportunities and contribute to building a health caresystem that will meet the demand for safe, quality, patient-centered, accessible, and affordablecare. This chapter presents the key messages that emerged from the study committee’sdeliberations. It begins by describing a vision for a transformed system that can meet the healthneeds of the U.S. population in the 21st century. The chapter then delineates the roles of nursesin realizing this vision. The third section explains why a fundamental transformation of thenursing profession will be required if nurses are to assume these roles. The final section presentsconclusions.A VISION FOR HEALTH CAREDuring the course of its work, the Committee on The Robert Wood Johnson FoundationInitiative on the Future of Nursing, at the Institute of Medicine developed a vision for atransformed health care system, while recognizing the demands and limitations of the currenthealth care system outlined above. The committee envisions a future system that makes qualitycare accessible to the diverse populations of the United States, intentionally promotes wellnessand disease prevention, reliably improves health outcomes, and provides compassionate care
  • 2. across the lifespan. In this envisioned future, primary care and prevention are central drivers ofthe health care system. Interprofessional collaboration and coordination are the norm. Paymentfor health care services rewards value, not volume of services, and quality care is provided at aprice that is affordable for both individuals and society. The rate of growth of health careexpenditures slows. In all these areas, the health care system consistently demonstrates that it isresponsive to individuals’ needs and desires through the delivery of truly patient-centered care.Annex 1-1 lists the committee’s definitions for three core terms related to its vision: health,health care, and the health care system.THE ROLE OF NURSES IN REALIZING THIS VISIONThe ACA provides a call to action for nurses, and several sections of the legislation aredirectly relevant to their work.1 For example, sections 5501 through 5509 are aimed atsubstantially strengthening the provision of primary care—a need generally recognized by healthprofessionals and policy experts; section 2717 calls for “ensuring the quality of care”; andsection 2718 emphasizes “bringing down the cost of health care coverage.” Enactment of theACA offers a myriad of opportunities for the nursing profession to facilitate improvements to thehealth care system and the mechanisms by which care is delivered across various settings.Systemwide changes are needed that capture the full economic value of nurses and take intoaccount the growing body of evidence that links nursing practice to improvements in the safetyand quality of care. Advanced practice registered nurses (APRNs) should be called upon to fulfilland expand their potential as primary care providers across practice settings based on theireducation and competency. Nursing initiatives and programs should be scaled up to help bridgethe gap between insurance coverage and access to care.The nursing profession has the potential capacity to implement wide-reaching changes in thehealth care system. With more than 3 million members, the profession has nearly doubled since1980 and represents the largest segment of the U.S. health care workforce (HRSA, 2010; U.S.Census Bureau, 2009). By virtue of their regular, close proximity to patients and their scientificunderstanding of care processes across the continuum of care, nurses have a considerableopportunity to act as full partners with other health professionals and to lead in the improvementand redesign of the health care system and its practice environment.Nurses practice in many settings, including hospitals, schools, homes, retail health clinics,long-term care facilities, battlefields, and community and public health centers. They havevarying levels of education and competencies—from licensed practical nurses, who now providethe majority of direct patient care in nursing homes, to nurse scientists, who research andevaluate more effective ways of caring for patients and promoting health. As described inAnnex 1-1 at the end of this chapter, most nurses are registered nurses (RNs), who “complete aprogram of study at a community college, diploma school of nursing, or a four-year college oruniversity and are required to pass a nationally standardized licensing exam in the state in whichthey begin practice” (AARP, 2010). Figure 1-1 shows that of the many settings where RNspractice, the majority practice in hospitals; Figure 1-2 shows the employment settings of nursesby highest nursing or nursing-related education. More than a quarter of a million nurses areAPRNs (HRSA, 2010), who hold master’s or doctoral degrees and pass national certificationexams. APRNs deliver primary and other types of health care services. For example, they teachand counsel patients to understand their health problems and what they can do to get better, theycoordinate care and advocate for patients in the complex health care system, and they referpatients to physicians and other health care providers. APRNs include nurse practitioners,clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives (see1 For a list of nursing-related provisions included in the ACA, see
  • 3. http://championnursing.org/sites/default/files/nursingandhealthreformlawable.pdf.PREPUBLICATION COPY: UNCORRECTED PROOFSCopyright © National Academy of Sciences. All rights reserved.The Future of Nursing: Leading Change, Advancing Healthhttp://www.nap.edu/catalog/12956.htmlKEY MESSAGES OF THE REPORT 1-3Table 1-1). Annex 1-1 provides more detailed descriptions of the preparation and roles of nurses,pathways in nursing education, and numbers of nurses.OtherAmbulatory care 3.9%10.5%Public/communityhealth7.8%Home health6.4%Academic education3.8%Hospital62.2%Nursin home/extendedcare5 .3%gFIGURE 1-1 Employment settings of registered nurses.NOTES: The totals may not add to 100 percent because of the effect of rounding. Only RNs for whominformation on setting was available are included in the calculations used for this chart.Public/community health includes school and occupational health. Ambulatory care includesmedical/physician practices, health centers and clinics, and other types of nonhospital clinical settings.Other includes insurance, benefits, and utilization review.SOURCE: HRSA, 2010.Copyright © National Academy of Sciences. All rights reserved.The Future of Nursing: Leading Change, Advancing Healthhttp://www.nap.edu/catalog/12956.html1-4 THE FUTURE OF NURSING: LEADING CHANGE, ADVANCING HEALTHFIGURE 1-2 Employment settings of RNs, by highest nursing or nursing-related educationNOTES: The total percent by setting may not equal the estimated total of all registered nurses due toincomplete information provided by respondents and the effect of rounding. Public/community healthincludes school health, occupational health, and home health. Other includes insurance, benefits, andutilization review.SOURCE: HRSA, 2010.PREPUBLICATION COPY: UNCORRECTED PROOFSCopyright © National Academy of Sciences. All rights reserved.The Future of Nursing: Leading Change, Advancing Healthhttp://www.nap.edu/catalog/12956.htmlKEY MESSAGES OF THE REPORT 1-5TABLE 1-1 Types of Advanced Practice Registered Nurses (APRNs)Who Are They?How Manyin UnitedStates? What Do They Do?NursePractitioners(NPs)
  • 4. 153,348 Take health histories and provide complete physical exams;diagnose and treat acute and chronic illnesses; provideimmunizations; prescribe and manage medications and othertherapies; order and interpret lab tests and x-rays; providehealth teaching and supportive counseling.ClinicalNurse Specialists(CNSs)59,242* Provide advanced nursing care in hospitals and other clinicalsites; provide acute and chronic care management; developquality improvement programs; serve as mentors, educators,researchers, and consultants.Certified RegisteredNurse Anesthetists(CRNAs)34,821 Administer anesthesia and provide related care before andafter surgical, therapeutic, diagnostic, and obstetricalprocedures, as well as pain management. Settings includeoperating rooms, outpatient surgical centers, and dentaloffices. CRNAs deliver more than 65% of all anesthetics topatients in the United States.CertifiedNurse Midwives(CNMs)18,492 Provide primary care to women, including gynecologicalexams, family planning advice, prenatal care, management oflow-risk labor and delivery, and neonatal care. Practicesettings include hospitals, birthing centers, community clinics,and patient homes.*APRNs are identified by their responses to the National Sample Survey of Registered Nurses, and thisnumber may not reflect the true population of CNSs.SOURCE: AARP, 2010. Courtesy of AARP. All Rights Reserved.Nursing practice covers a broad continuum from health promotion, to disease prevention, tocoordination of care, to cure—when possible—and to palliative care when cure is not possible.This continuum of practice is well matched to the current and future needs of the Americanpopulation (see Chapter 2). Nurses have a direct effect on patient care. They provide the majorityof patient assessments, evaluations, and care in hospitals, nursing homes, clinics, schools,workplaces, and ambulatory settings. They are at the front lines in ensuring that care is deliveredsafely, effectively, and compassionately. Additionally, nurses attend to patients and their familiesin a holistic way that often goes beyond physical health needs to recognize and respond to social,mental, and spiritual needs. Given their education, experience, and unique perspectives and thecentrality of their role in providing care, nurses will play a significant role in the transformationof the health care system. Likewise, while changes in the health care system will have profoundeffects on all providers, this will be undoubtedly true for nurses.Traditional nursing competencies such as care management and coordination, patienteducation, public health intervention, and transitional care are likely to dominate in a reformedhealth care system as it inevitably moves toward an emphasis on prevention and managementrather than acute care (O’Neil, 2009). Nurses have also begun developing new competencies forthe future to help bridge the gap between coverage and access, to coordinate increasingly
  • 5. complex care for a wide range of patients, to fulfill their potential as primary care providers tothe full extent of their education and training, to implement systemwide changes that take intoCopyright © National Academy of Sciences. All rights reserved.The Future of Nursing: Leading Change, Advancing Healthhttp://www.nap.edu/catalog/12956.html1-6 THE FUTURE OF NURSING: LEADING CHANGE, ADVANCING HEALTHaccount the growing body of evidence linking nursing practice to fundamental improvements inthe safety and quality of care, and to capture the full economic value of their contributions acrosspractice settings.At the same time, the nursing profession has its challenges. While there are concernsregarding the number of nurses available to meet the demands of the health care system and theneeds of patients, and there is reason to view as a priority replacing at least 900,000 nurses overthe age of 50 (BLS, 2009), the composition of the workforce is turning out to be an even greaterchallenge for the future of the profession. The workforce is generally not as diverse as it needs tobe—with respect to race and ethnicity (just 16.8 percent of the workforce is non-white), gender(approximately 7 percent of employed nurses are male), or age (the median age of nurses is 46,compared to 38 in 1988)—to provide culturally relevant care to all populations (HRSA, 2010).Many members of the profession lack the education and preparation necessary to adapt to newroles quickly in response to rapidly changing health care settings and an evolving health caresystem. Restrictions on scope of practice and professional tensions have undermined the nursingprofession’s ability to provide and improve both general and advanced care. Producing a healthcare 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 workenvironment, scope of practice, education, and numbers and composition of America’s nurses.The remainder of this section examines the role of the nursing profession in health care reformaccording to the same three parameters by which all other health care reform initiatives areevaluated—quality, access, and value.Nurses and QualityAlthough it is difficult to prove causation, an emerging body of literature suggests thatquality of care depends to a large degree on nurses (Kane et al., 2007; Lacey and Cox, 2009;Landon et al., 2006; Sales et al., 2008). The Joint Commission, the leading independentaccrediting body for health care organizations, believes that “the future state of nursing isinextricably linked to the strides in patient care quality and safety that are critical to the successof America’s health care system, today and tomorrow” (Joint Commission, 2010). While qualitymeasures have historically focused on conditions or diseases, many of the quality measures usedover the past few years address how well nurses are able to do their jobs (Kurtzman andBuerhaus, 2008).In 2004, the National Quality Forum (NQF) endorsed the first set of nationally standardizedperformance measures, the National Voluntary Consensus Standards for Nursing-Sensitive Care,initially designed to assess the quality of care provided by nurses who work in hospitals(National Quality Forum, 2004). The NQF measures include prevalence of pressure ulcers andfalls; nursing-centered interventions, such as smoking cessation counseling; and system-centeredmeasures, such as voluntary turnover and nursing care hours per patient day. These measureshave helped nurses and the organizations where they work identify targets for improvements incare delivery.Another important vehicle for tracking and improving quality is the National Database ofNursing Quality Indicators, the nation’s largest nursing registry. This database, which meets thenew reporting requirement by the Centers for Medicare and Medicaid Services (CMS) for
  • 6. PREPUBLICATION COPY: UNCORRECTED PROOFSCopyright © National Academy of Sciences. All rights reserved.The Future of Nursing: Leading Change, Advancing Healthhttp://www.nap.edu/catalog/12956.htmlKEY MESSAGES OF THE REPORT 1-7nursing-sensitive care, is supported by the American Nurses Association.2 More than 25 percentof hospitals participate in the database, which documents more than 21 measures of hospitalperformance linked to the availability and quality of nursing services in acute care settings.Participating facilities are able to obtain unit-level comparative data, including patient andstaffing outcomes, to use for quality improvement purposes. Comparison data are publiclyreported, which provides an incentive to improve the quality of care on a continuous basis. Thisdatabase is now maintained at the University of Kansas School of Nursing and is available toresearchers interested in improving health care quality.Nurses and AccessEvidence suggests that access to quality care can be greatly expanded by increasing the useof RNs and APRNs in primary, chronic, and transitional care (Bodenheimer et al., 2005; Cravenand Ober, 2009; Naylor et al., 2004; Rendell, 2007). For example, nurses serving in special rolescreated to increase access to care, such as care coordinators and primary care clinicians, have ledto significant reductions in hospitalization and rehospitalization rates for elderly patients (Kaneet al., 2003; Naylor et al., 2004). It stands to reason that one way to improve access topatientcenteredcare would be to allow nurses to make more care decisions at the point of care. Yet inmany cases, outdated regulations, biases, and policies prevent nurses, particularly APRNs, frompracticing to the full extent of their education, skills, and competencies (Hansen-Turton et al.,2008; Ritter and Hansen-Turton, 2008; Safriet, 2010). Chapter 3 examines these barriers ingreater depth.Nurses also make significant contributions to access by delivering care where people live,work, and play. Examples include school nurses, occupational health nurses, public healthnurses, and those working at so-called retail clinics in busy shopping centers. Nurses also workin migrant health clinics and nurse-managed health centers, organizations known for serving themost underserved populations. Additionally, nurses are often at the front lines serving as primaryproviders for individuals and families affected by natural or man-made disasters, delivering carein homes and designated community shelters.Nurses and Value“Value in health care is expressed as the physical health and sense of well-being achievedrelative to the cost” (IOM Roundtable on Evidence-Based Medicine, 2008). Compared withsupport for the role of nurses in improving quality and access, there is somewhat less evidencethat expanding the care provided by nurses will result in cost savings to society at large whilealso improving outcomes and ensuring quality. However, the evidence base in favor of such aconclusion is growing. Compared with other models of prenatal care, for example, pregnantwomen who receive care led by certified nurse midwives are less likely to experience antenatalhospitalization, and their babies are more likely to have a shorter hospital stay (Hatem et al.,2008) (see Chapter 2 for a case study of care provided by certified nurse midwives at the FamilyHealth and Birth Center in Washington, DC). Another study examining the impact of nursestaffing on value suggests that increasing the proportion of nursing hours provided by RNswithout increasing total nursing hours was associated with 1.5 million fewer hospital days,2 Formore information, see http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/PatientSafetyQuality/ Research-Measurement/The-National-Database.aspx.
  • 7. Copyright © National Academy of Sciences. All rights reserved.The Future of Nursing: Leading Change, Advancing Healthhttp://www.nap.edu/catalog/12956.html1-8 THE FUTURE OF NURSING: LEADING CHANGE, ADVANCING HEALTHnearly 60,000 fewer inpatient complications, and a 0.5 percent net reduction in costs (Needlemanet al., 2006). Chapter 2 includes a case study of the Nurse Family Partnership Program, in whichfront-line RNs make home visits to high-risk young mothers over a 2.5-year period. Thisprogram has demonstrated significant value, resulting in a net savings of $34,148 per familyserved. The program has also reduced pregnancy-induced hypertension by 32 percent, childabuse and neglect by 50 percent, emergency room visits by 35 percent, and language-relateddelays by 50 percent (AAN, 2010).THE NEED FOR A FUNDAMENTAL TRANSFORMATION OF THE NURSINGPROFESSIONGiven the crucial role of nurses with respect to the quality, accessibility, and value of care,the nursing profession itself must undergo a fundamental transformation if the committee’svision for health care is to be realized. As this report argues, the ways in which nurses wereeducated and practiced during the 20th century are no longer adequate for dealing with therealities of health care in the 21st century. Outdated regulations, attitudes, policies, and habitscontinue to restrict the innovations the nursing profession can bring to health care at a time oftremendous complexity and change.In the course of its deliberations, the committee formulated four key messages that informthe discussion in Chapters 3 and structure its recommendations for transforming the nursing 6profession:1. Nurses should practice to the full extent of their education and training.2. Nurses should achieve higher levels of education and training through an improvededucation system that promotes seamless academic progression.3. Nurses should be full partners, with physicians and other health professionals, inredesigning health care in the United States.4. Effective workforce planning and policy making require better data collection and animproved information infrastructure.These key messages speak to the need to transform the nursing profession in three crucialareas—practice, education, and leadership—as well as to collect better data on the health careworkforce to inform planning for the necessary changes to the nursing profession and the overallhealth care system.The Need to Transform PracticeKey Message #1: Nurses should practice to the full extent of their educationand training.To ensure that all Americans have access to needed health care services and thatnurses’ unique contributions to the health care team are maximized, federal and stateactions are required to update and standardize scope-of-practice regulations to takeadvantage of the full capacity and education of APRNs. States and insurance companiesmust follow through with specific regulatory, policy, and financial changes that givepatients the freedom to choose from a range of providers, including APRNs, to best meetPREPUBLICATION COPY: UNCORRECTED PROOFSCopyright © National Academy of Sciences. All rights reserved.The Future of Nursing: Leading Change, Advancing Healthhttp://www.nap.edu/catalog/12956.htmlKEY MESSAGES OF THE REPORT 1-9their health needs. Removing regulatory, policy, and financial barriers to promote patient
  • 8. choice and patient-centered care should be foundational in the building of a reformedhealth care system.Additionally, to the extent that the nursing profession envisions its future as confined to acutecare settings, such as inpatient hospitals, its ability to help shape the future U.S. health caresystem will be greatly limited. As noted earlier, care in the future is likely to shift from thehospital to the community setting (O’Neil, 2009). Yet the majority of nurses still work in acutecare settings; according to recent findings from the 2008 National Sample Survey of RegisteredNurses, just over 62 percent of working RNs were employed in hospitals in 2008—up fromapproximately 57 percent in 2004 (HRSA, 2010). Nurses must create, serve in, and disseminatereconceptualized roles to bridge whatever gaps remain between coverage and access to care.More must become health coaches, care coordinators, informaticians, primary care providers,and health team leaders in a greater variety of settings, including primary care medical homesand accountable care organizations. In some respects, such a transformation would return thenursing profession to its roots in the public health movement of the early 20th century.At the same time, new systems and technologies appear to be pushing nurses ever fartheraway from patients. This appears to be especially true in the acute care setting. Studies show thatnurses on medical surgical units spend only 31 to 44 percent of their time in direct patientactivities (Tucker and Spear, 2006). A separate study of medical surgical nurses found theywalked nearly a mile longer while on than off duty in obtaining the supplies and equipmentneeded to perform their tasks. In general, less than 20 percent of nursing practice time wasdevoted specifically to patient care activities, the majority being consumed by documentation,medication administration, and communication regarding the patient (Hendrich et al., 2008).Several health care organizations, professional organizations, and consumer groups haveendorsed a Proclamation for Change aimed at redressing inefficiencies in hospital design,organization, and technology infrastructure through a focus on patient-centered design; theimplementation of systemwide, integrated technology; the creation of seamless workplaceenvironments; and the promotion of vendor partnerships (Hendrich et al., 2009). Realizing thevision presented earlier in this chapter will require a practice environment that is fundamentallytransformed so that nurses are efficiently employed—whether in the hospital or in thecommunity—to the full extent of their education, skills, and competencies.Chapter 3 examines these issues in greater depth.The Need to Transform EducationKey Message #2: Nurses should achieve higher levels of education andtraining through an improved education system that promotes seamlessacademic progression.Major changes in the U.S. health care system and practice environment will require equallyprofound changes in the education of nurses both before and after they receive their licenses. Animproved education system is necessary to ensure that the current and future generations ofnurses can deliver safe, quality, patient-centered care across all settings, especially in such areasas primary care and community and public health.Interest in the nursing profession has grown rapidly in recent years, in part as a result of theeconomic downturn and the relative stability the health care sector offers. The number ofapplications to entry-level baccalaureate programs increased by more than 70 percent in just 5Copyright © National Academy of Sciences. All rights reserved.The Future of Nursing: Leading Change, Advancing Healthhttp://www.nap.edu/catalog/12956.html1-10 THE FUTURE OF NURSING: LEADING CHANGE, ADVANCING HEALTH
  • 9. years—from 122,000 applications in 2004 to 208,000 applications in 2009 (AACN, 2010). Whilenursing schools across the country have responded to this influx of interest, there are constraints,such as insufficient numbers of nurse faculty and clinical placements, that limit the capacity ofnursing schools to accommodate all the qualified applicants. Thus, thousands of qualifiedstudents are turned away each year (Kovner and Djukic, 2009)A variety of challenges limit the ability to ensure a well-educated nurse workforce. As noted,there is a shortage of faculty to teach nurses at all levels (Allan and Aldebron, 2008). Also, theways in which nurses during the 20th century taught each other to care for people and learned topractice and make clinical decisions are no longer adequate for delivering care in the 21stcentury. Many nursing schools have dealt with the explosion of research and knowledge neededto provide health care in an increasingly complex system by adding layers of content thatrequires more instruction (Ironside, 2004). A fundamental rethinking of this approach is needed(Benner et al., 2009; Erickson, 2002; IOM, 2003, 2009; Lasater and Nielsen, 2009; Mitchell etal., 2006; Orsolini-Hain and Waters, 2009; Tanner et al., 2008). Additionally, nurses at all levelshave few incentives to pursue further education, and face active disincentives to advancededucation. Nurses and physicians—not to mention pharmacists and social workers—typically arenot educated together, yet they are increasingly required to cooperate and collaborate moreclosely in the delivery of care.The education system should provide nurses with the tools needed to evaluate and improvestandards of patient care and the quality and safety of care while preserving fundamentalelements of nursing education, such as ethics and integrity and holistic, compassionateapproaches to care. The system should ensure nurses’ ability to adapt and be flexible in responseto changes in science, technology, and population demographics that shape the delivery of care.Nursing education at all levels needs to impart a better understanding of ways to work in thecontext of and lead change within health care delivery systems, methods for quality improvementand system redesign, methods for designing effective care delivery models and reducing patientrisk, and care management and other roles involving expanded authority and responsibility. Thenursing profession must adopt a framework of continuous, lifelong learning that includes basiceducation, residency programs, and continuing competence. More nurses must receive a solideducation in how to manage complex conditions and coordinate care with multiple healthprofessionals. They must demonstrate new competencies in systems thinking, qualityimprovement, and care management and a basic understanding of health policy and research.Graduate-level nurses must develop even greater competencies and deeper understanding in allof these areas. Innovative new programs to attract nurse faculty and provide a wider range ofclinical education placements must clear long-standing bottlenecks in nursing education.Accrediting and certifying organizations must mandate demonstrated mastery of clinical skills,managerial competencies, and professional development at all levels to complement thecompletion of degree programs and written board examinations. Milestones for mandated skills,competencies, and professional development must be updated more frequently to keep pace withthe rapidly changing demands of health care. And all health professionals should receive more oftheir education in concert with students from other disciplines. Interprofessional team training ofnurses, physicians, and other health care providers should begin when they are students andproceed throughout their careers. Successful interprofessional education can be achieved onlythrough committed partnerships across professions.Nurses should move seamlessly through the education system to higher levels of education,including graduate degrees. Nurses with graduate degrees will be able to replenish the nursePREPUBLICATION COPY: UNCORRECTED PROOFS
  • 10. Copyright © National Academy of Sciences. All rights reserved.The Future of Nursing: Leading Change, Advancing Healthhttp://www.nap.edu/catalog/12956.htmlKEY MESSAGES OF THE REPORT 1-11faculty pool; advance nursing science and contribute to the knowledge base on how nurses canprovide up-to-date, safe patient care; participate in health care decisions; and provide theleadership needed to establish nurses as full partners in health care redesign efforts (see thesection on leadership below).The Need to Transform LeadershipKey Message #3: Nurses should be full partners, with physicians and otherhealth professionals, in redesigning health care in the United States.Not all nurses begin their career with thoughts of becoming a leader. Yet strong leadershipwill be required to transform the U.S. health care system. A transformed system will need nurseswith the adaptive capacity to take on reconceptualized roles in new settings, educating andreeducating themselves along the way—indispensible characteristics of effective leadership.Whether on the front lines, in education, or in administrative positions and health policyroles, nurses have the well-grounded knowledge base, experience, and perspective needed toserve as full partners in health care redesign. Nurses’ unique perspectives are derived from theirexperiences in providing direct, hands-on patient care; communicating with patients and theirfamilies about health status, medications, and care plans; and ensuring the linkage between aprescribed course of treatment and the desired outcome. In care environments, being a fullpartner involves taking responsibility for identifying problems and areas of waste, devising andimplementing a plan for improvement, tracking improvement over time, and making necessaryadjustments to realize established goals.Being a full partner translates more broadly to the health policy arena. To be effective inreconceptualized roles, nurses must see policy as something they can shape rather thansomething that happens to them. Nurses should have a voice in health policy decision making, aswell as being engaged in implementation efforts related to health care reform. Nurses also shouldserve actively on advisory committees, commissions, and boards where policy decisions aremade to advance health systems to improve patient care. Yet a number of barriers prevent nursesfrom serving as full partners. Examples that are discussed later in the report include laws andregulations (Chapter 3), professional resistance and bias (Chapter 3), a lack of foundationalcompetence (Chapter 5), and exclusion from decision-making bodies and boards (Chapter 5). Ifnurses are to serve as full partners, a culture change will be needed whereby health professionalshold each other accountable for improving care and setting health policy in a context of mutualrespect and collaboration.Finally, the health care system is widely understood to be a complex system, one in whichresponses to internal and external actions are sometimes predictable and sometimes not. Healthcare experts repeatedly encourage health professionals to understand the system’s dynamics sothey can be more effective in their individual jobs and help shape the larger system’s ability toadapt successfully to changes and improve outcomes. In a field as intensively knowledge drivenas health care, however, no one individual, group, or discipline can have all the answers. Agrowing body of research has begun to highlight the potential for collaboration among teams ofdiverse individuals to generate successful solutions in complex, knowledge-driven systems(Paulus and Nijstad, 2003; Pisano and Verganti, 2008; Singh and Fleming, 2010; Wuchty et al.,2007). Nurses must cultivate new allies in health care, government, and business and developnew partnerships with other clinicians, business owners, and philanthropists to help realize thevision of a transformed health care system. Many nurses have heard this call to develop new
  • 11. Copyright © National Academy of Sciences. All rights reserved.The Future of Nursing: Leading Change, Advancing Healthhttp://www.nap.edu/catalog/12956.html1-12 THE FUTURE OF NURSING: LEADING CHANGE, ADVANCING HEALTHpartnerships in a culture of collaboration and cooperation. However, the committee found noevidence that these initiatives have achieved the scale necessary to have an impact throughoutthe health care system. More intentional, large-scale initiatives of this sort are needed. Theseefforts must be supported by research that addresses such questions as what new models ofleadership are needed for the increasingly knowledge-intensive health care environment andwhen collaboration is most appropriate (Singh and Fleming, 2010).Chapter 5 further examines the need for expanded leadership opportunities in the nursingworkforce.The Need for Better Data on the Health Care WorkforceKey Message #4: Effective workforce planning and policy making requirebetter data collection and an improved information infrastructure.Key messages 1, 2, and 3 speak to the need to transform the nursing profession to achieve thevision of health care set forth at the beginning of this chapter. At the same time, nurses do notfunction in a vacuum, but in the context of the skills and perspectives of physicians and otherhealth professionals. Planning for the fundamental changes required to achieve a reformed healthcare system cannot be accomplished without a clear understanding of the necessary contributionsof these various professionals and the numbers and composition of the health care workforce.That understanding in turn cannot be obtained without reliable, sufficiently granular data on thecurrent workforce and projections of future workforce needs. Yet major gaps exist in thecurrently available workforce data. These gaps hamper the ability to identify and implement thenecessary changes to the preparation and practice of nurses and to the overall health care system.Chapter 6 explores these issues in greater detail.CONCLUSIONSMost of the near-term challenges identified in the ACA speak to traditional and currentstrengths of the nursing profession in care coordination, health promotion, and qualityimprovement, among other things. Nurses are committed to improving the care they deliver byresponding to health care challenges. If their full potential is to be realized, however, the nursingprofession itself will have to undergo a fundamental transformation in the areas of practice,education, and leadership. During the course of this study, the committee formulated four keymessages it believes must guide that transformation: (1) nurses should practice to the full extentof their education and training; (2) nurses should achieve higher levels of education and trainingthrough an improved education system that promotes seamless academic progression; (3) nursesshould be full partners, with physicians and other health professionals, in redesigning health carein the United States; and (4) effective workforce planning and policy making require better datacollection and an improved information infrastructure.At the same time, the power to deliver better care—quality care that is accessible andsustainable—does not rest solely with nurses, regardless of how ably led or educated they are; italso lies with other health professionals, consumers, governments, businesses, health careinstitutions, professional organizations, and the insurance industry. The recommendationspresented in Chapter 7 target individual policy makers; national, state, and local governmentleaders; payers; and health care researchers, executives, and professionals—including nurses andPREPUBLICATION COPY: UNCORRECTED PROOFSCopyright © National Academy of Sciences. All rights reserved.The Future of Nursing: Leading Change, Advancing Healthhttp://www.nap.edu/catalog/12956.html
  • 12. KEY MESSAGES OF THE REPORT 1-13others—as well as larger groups such as licensing bodies, educational institutions, andphilanthropic and advocacy and consumer organizations. Together, these groups have the powerto transform the health care system to achieve the vision set forth at the beginning of this chapter.Copyright © National Academy of Sciences. Permission is granted for this materialto be shared for noncommercial, educational purposes, provided that this noticeappears on the reproduced materials, the Web address of the online, fullauthoritative version is retained, and copies are not altered. To disseminateotherwise or to republish requires written permission from the National AcademiesPress. REGARDING GLOBAL NURSINGInternational Models of Nursing1Barbara L. Nichols, D.H.L., M.S., R.N., FAANCatherine R. Davis, Ph.D., R.N.Donna R. Richardson, J.D., R.N. CGFNS InternationalPromote targeted educational investment in foreign-educated nurses in the U.S. nursingworkforce.2. Promote baccalaureate education for entry into nursing practice in the United States.3. Harmonize nursing curricula.4. Add global health as subject matter to undergraduate and graduate nursing curricula.5. Establish a national system that monitors and tracks the inflow of foreign-educatednurses, their countries of origin, the settings in which they work, and their education andlicensure to ensure a proper skill mix for the U.S. nursing workforce.6. Create an international body to coordinate and recommend national and internationalworkforce policies. Recommendation 1:

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