The nursing world was rightly excited when the Institute of Medicine (IOM) published its report, The Future of Nursing: Leading Change, Advancing Health, in October. It calls for a substantial increase in the educational preparation of nurses; the inclusion of nurses in health policy decisions; and better use of nurses' skills and expertise, which are often underutilized due to institutional or state laws.
Public commentary has focused primarily on the expected increase in demand for primary care providers as the Patient Protection and Affordable Care Act goes into effect this year, and the role that fully empowered NPs could play in meeting this demand. Far less has been said about the changes that could happen if other health care workers were similarly empowered to practice to the full extent of their training and potential.
The IOM calls for 80% of practicing nurses to have at least a baccalaureate by 2020, a target that's given rise to concerns about a lack of educators and facilities. Yet an even larger issue—and one that's received far too little attention—is the need for new curricula in community and four-year schools that better prepare today's nurses to care for an increasingly diverse and aging population. The changes should also ensure a seamless transition for students seeking to move from an associate's to a bachelor's degree program. Changes in curricula should extend to other health care professionals, ensuring that all are taught to practice well together, using their collective knowledge and potential, rather than engaging in turf wars. Creative partnerships with the schools of other health professionals would help to bring together faculty and students from a variety of fields at the beginning of clinical training.
The IOM report's recommendations have been made before: in the 1923 Goldmark Report from the Committee for the Study of Nursing Education and, later, in the work of Esther Lucille Brown, Jerome Lysaught, and Gooloo Wunderlich. When I began my nursing career in 1965, the American Nurses Association published a position paper stating that the baccalaureate should become the minimum degree for entry into professional nursing practice. Only North Dakota's board of nursing established such a requirement, in 1987, but this was ultimately rescinded, in 2003.
Saying that other health professionals are "against us" or "fighting change" doesn't entirely account for the failure of nurses to heed past recommendations. It's the divisions within our profession that, time after time, have worked against us, as illustrated by the legislative fight in New York about NPs' right to practice. Warring factions of nurses—not opposition from physicians—propelled this fight (the statutes were eventually changed, allowing NPs to practice).
Might this time be different? It's encouraging that Donna Shalala, former secretary of Health and Human Services, chaired the IOM committee and has put her considerable political skill behind making the changes come to pass. Moreover, the Robert Wood Johnson Foundation has committed substantial funds to support these recommendations.
Yet nurses will have to join together to make these changes reality. Staff and management in all care settings will have to develop information systems and decision-making structures that make maximum use of all caregivers' knowledge. Financers of care (starting with federal and state governments) will have to revise and create funding streams that stimulate rather than stifle improvement. And we'll have to stop confusing psychomotor proficiency and a passion to care for others with the capacity to plan and improve care through collaboration and judicious weighing of evidence.
Now in retirement, I've moved from the United States to Australia, where I'll observe firsthand the effect on schools, hospitals, and communities of requiring baccalaureates for nurses. I'm eager to see what happens in the United States, hopeful that our profession will make the changes we've long known were needed.