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doi: 10.1097/01.COT.0000390564.39748.93
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New Institute of Medicine Report Calls for Transformation of Nursing, Increased Empowerment and Responsibility

Eastman, Peggy

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WASHINGTON, DC—If implemented, sweeping changes called for in a new Institute of Medicine (IOM) report will transform the roles, responsibilities, and education of the nation's 3 million nurses into a new level of leadership.

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The report, “The Future of Nursing: Leading Change, Advancing Health,” was released at a jammed news briefing at the National Press Club here. Thousands of others who could not be at the press club participated in the report's release via a webcast.

The report is the result of a two-year collaboration between the IOM and the Robert Wood Johnson Foundation (RWJF) called the Initiative on the Future of Nursing, whose purpose is to make recommendations for the future that bring nurses into the health care system as empowered, full partners with other health professionals, including physicians.

Two specific, key recommendations are to increase the number of nurses who obtain a bachelor's degree to 80% by 2020, and to double the number of nurses who pursue doctorates.

To ensure that the report's recommendations do not simply gather dust on bookshelves, Initiative on the Future of Nursing staff plan to organize a national conference in Washington on Nov. 30 to Dec. 1 to discuss ways to implement the sweeping changes the report sets forth.

The IOM committee writing the report noted that they recognized that some of the expansion of nurses' duties called for will require changes in restrictive state practice regulations.

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Empower Nurses to Be Even More Effective

“Nurses are critical to the health and health care of America,” said IOM President Harvey V. Fineberg, MD, PhD. “The report aims to empower nurses to be even more effective.”

He pointed out that with the recent passage of the Affordable Care Act (health reform), which expands health care to more than 30 million Americans, there will now be “the most profound opportunity to change health care since the passage of Medicare and Medicaid” (in 1965). Nurses will be critical to the success of the new legislation, he said.

The report “marks a difference in what nursing used to be and what it's going to be,” said Risa Lavizzo-Mourey, MD, MBA, RWJF President and CEO. “This is serious business for us,” and RWJF has committed $10 million to the Initiative on the Future of Nursing in order to transform the nursing profession.

“This is, I believe, a landmark report,” said the chair of the committee that wrote the report, Donna E. Shalala, PhD, FAAN, President of the University of Miami and former Secretary of the US Department of Health and Human Services.

“What's important here is that we're training nurses better for wider responsibilities.” The report envisions new roles for nurses, “setting a tone of collaboration.”

Another member of the committee, Rosa Gonzalez-Guarda, PhD, MSN, MPH, RN, CPH, Assistant Professor at the University of Miami School of Nursing and Health Studies, agreed: “We really need to use nurses to the full potential—that's the bottom line.”

The report is not about nursing per se, but about an enhanced capacity of nurses to deliver high-quality, patient-centered care, explained the committee's vice-chair, Linda Burnes Bolton, DrPH, RN, FAAN, IOM Vice President and Chief Nursing Officer at Cedars-Sinai Health System and Research Institute. “Nursing has always been about the science of improvement and human caring.”

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AMA Not So Enthusiastic

Committee member John W. Rowe, MD, Professor at Columbia University Mailman School of Public Health in the Department of Health Policy and Management, said he hoped the report will be welcomed by the physician community. With the increased patient access provided by health reform, he said, physicians as a group are going to be “crushed” by the demands of trying to provide high-quality health care to millions more patients, when they are already stretched thin now.

Dr. Rowe noted that the report's recommendations are based on solid data, as are all reports released by the Institute of Medicine, which is part of the National Academy of Sciences. “The NAS is about the objective evaluation of evidence,” he said, adding that the report went through an extensive review in draft form by a number of expert reviewers.

But not all physicians will welcome the report's major thrust of giving more responsibility to nurses, according to a reaction statement from the American Medical Association. AMA board member Rebecca J. Patchin, MD, Assistant Professor of Anesthesiology at Loma Linda University School of Medicine, said, “Nurses are critical to the health care team, but there is no substitute for education and training. Physicians have seven or more years of postgraduate education and more than 10,000 hours of clinical experience.... A new study shows that 80% of patients expect to see a physician when they come to the emergency department, with more than half of those surveyed willing to wait two more hours to be cared for by a physician.

“With a shortage of both nurses and physicians, increasing the responsibility of nurses is not the answer to the physician shortage.”

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Nurse Navigators

Asked by OT if she envisions roles for nurses as nurse navigators helping patients with chronic diseases such as cancer through an increasingly complex health care system, Dr. Shalala replied that nurses can shine in chronic care management, an area which she called “absolutely critical.” She also cited palliative care as an area where nurses can play key leadership roles.

The National Coalition of Oncology Nurse Navigators (NCONN) is already providing coordinated, collaborative care through the continuum of care for cancer patients, said Sharon L. Francz, RN, NCONN President and co-founder. These services will become even more important with the aging of the population, as more cancer cases are diagnosed, she said.

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Advanced Practice RNs

The Oncology Nursing Society is on record as one of 43 nursing organizations expressing their support for expanding the ranks of Advanced Practice Registered Nurses (APRNs), who are now more than a quarter million strong. The IOM report also makes clear that APRNs are vital to the health care system.

“As the health care system grows in complexity, expectations are that APRNs will have competence in expanding areas such as technology, genetics, quality improvement, and geriatrics,” states the report.

Members of nursing organizations attending the news briefing welcomed the report's sweeping recommendations. “It's clear that there is strong support for this,” Geraldine Bednash, PhD, RN, FAAN, told OT. Ms. Bednash, CEO and Executive Director of the American Association of Colleges of Nursing, added, “We are committed to working together and finding common ground.”

Kathy Apple, MS, RN, FAAN, who is CEO of the National Council of State Boards of Nursing, said, “We're very excited about it. We think the time is absolutely right.”

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Encouraging Young Nurses

Asked how young student nurses can be encouraged during their education to enter oncology nursing, given the expected increase in the number of cancer patients, committee member Michael Bleich, PhD, MPH, RN, FAAN, the Carol A. Lindeman Distinguished Professor and Dean of the School of Nursing at Oregon Health and Science University, said, “It's what you get exposed to; it's the excitement of the faculty. That relationship of faculty and students is very important.”

Dr. Bleich noted that nursing students might come into nursing school with a preconceived idea of what aspect of patient care they are interested in, but then exposure to a field such as oncology might completely change the students' minds and excite them about helping cancer patients.

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Specific Recommendations

The IOM report makes the following specific recommendations:

1. Remove scope-of-practice barriers, including state and Medicare and Medicaid regulations—”States with unduly restrictive regulations should be urged to amend them to allow advanced practice nurses to provide care to patients in all circumstances in which they are qualified to do so.”

2. Expand opportunities for nurses to lead and diffuse collaborative improvement efforts, especially innovative, patient-centered care models. Nursing education programs should provide entrepreneurial professional development.

3. Implement nurse residency programs for nurses who have completed a prelicensure or advanced practice degree program or when they are transitioning into a new clinical practice area.

4. Increase the proportion of nurses with a baccalaureate degree from 50% to 80% by 2020. Educational loans and grants should be expanded for second-degree nursing students.

5. Double the number of nurses with a doctorate by 2020.

6. Ensure that nurses engage in lifelong learning through continual professional development programs and activities.

7. Prepare and enable nurses to lead change to advance health. Nursing associations and nursing education programs should provide leadership development, and nurse-leaders should be represented on decision-making boards and management teams.

8. Build an infrastructure for the collection and analysis of interprofessional workforce data, in order to assess health care workforce needs by demographics, numbers, skill mix, and geographic distribution.

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Online Link

The full Institute of Medicine report on the future of nursing is available at http://www.nap.edu

© 2010 Lippincott Williams & Wilkins, Inc.

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