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A Bold New Vision for America's Health Care System

Hassmiller, Susan B. PhD, RN, FAAN; Reinhard, Susan C. PhD, RN, FAAN

AJN, American Journal of Nursing: February 2015 - Volume 115 - Issue 2 - p 49–55
doi: 10.1097/01.NAJ.0000460677.04942.7c
Advancing Health Through Nursing: Progress of the Campaign for Action
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The Future of Nursing report becomes a catalyst for change.

This article introduces a new series examining the impact of the Institute of Medicine's 2010 report, The Future of Nursing: Leading Change, Advancing Health, at five years. This first installment reviews the barriers to implementing the report's recommendations, the progress made, and the work that lies ahead.

Susan B. Hassmiller is director of the Future of Nursing: Campaign for Action and senior adviser for nursing at the Robert Wood Johnson Foundation, Princeton, NJ. Susan C. Reinhard is senior vice president of the AARP Public Policy Institute and chief strategist at the Center to Champion Nursing in America, Washington, DC. Contact author: Susan B. Hassmiller, shassmi@rwjf.org. The authors have disclosed no potential conflicts of interest, financial or otherwise.

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The 2010 Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health,1 offers a bold vision for a new kind of health care system in America. The report redefines the field of nursing and asserts that nurses should be full partners in reforming health care. It recognizes the invaluable contributions nurses make as both acute care and primary care providers and envisions pivotal roles for nurses in public health, education, research, business, governance, and public policy. The report challenges the nation's 3 million nurses, the largest segment of the professional health care workforce, to learn more and lead more—and it urges decision makers to create circumstances that will help nurses to succeed in all of these roles.

Issued at a time when the United States was reinventing its health care system through unprecedented national reform, the IOM report generated both broad and deep interest. It quickly became the primary reason people visited the IOM Web site, and it has been the IOM's most-read report since its release. It has generated conversation among a wide array of stakeholders, including policymakers, and has set in motion not just incremental changes but significant momentum toward a new U.S. health care delivery system—one that offers the promise of improving access and quality while lowering costs.

Less than two months after the report's release in early October 2010, the Robert Wood Johnson Foundation (RWJF) and AARP teamed up to launch the far-reaching, multifaceted Future of Nursing: Campaign for Action to implement the IOM's recommendations. Risa Lavizzo-Mourey, MD, the president and chief executive officer of the RWJF, noted the importance of the campaign, which was announced during the National Summit on Advancing Health Through Nursing in Washington, DC, by declaring it “the first day of a new future for nursing.”

The IOM report asserted that a transformed nursing profession would lead to an improved health care system—one that was more accessible, affordable, and patient- and family-centered, and, at the same time, safe, effective, and efficient. The joint initiative between the RWJF, the nation's largest philanthropy devoted to health, and AARP, one of the nation's largest consumer organizations, was intended to help make this vision a reality.

In the four years since, the Campaign for Action has helped to make the Future of Nursing report a genuine catalyst for change. From the start, it was envisioned that the work of the campaign would take place at the state level, carried out by action coalitions. These state coalitions quickly multiplied—from just a handful at the time of the campaign's launch to 51 today. They have had a nationwide impact.

This article, which is also reprinted in Nursing Outlook and freely available online, examines the progress, barriers, and not inconsiderable work still needed to implement the IOM's recommendations. Subsequent articles, which will be published in AJN and Nursing Outlook, examine the IOM report's recommendations and detail the progress that has been made—offering an in-depth look at the achievements of the Campaign for Action as well as a roadmap for the work that lies ahead.

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Promoting Lasting Change

The Campaign for Action was intended to transform and diversify the nursing profession. Because building awareness of this work is essential, those involved in the campaign began educating the public by speaking to groups across the country, often using one of their greatest assets: the members of the IOM committee that produced the Future of Nursing report. Former U.S. Health and Human Services secretary Donna E. Shalala, PhD, president of the University of Miami and chair of the IOM committee, and Linda Burnes Bolton, DrPH, RN, FAAN, vice president and chief nursing officer of Cedars-Sinai Medical Center and IOM committee vice chair, both devoted considerable time to ensuring that leaders in nursing, health care, education, business, and other fields recognized the importance of implementing the IOM recommendations.

Other high-profile leaders, too, have spoken out in support of the campaign's work, almost from the start. Former Pennsylvania governor Ed Rendell, a Democrat, was an early supporter and advocated to expand nurses’ scope of practice; more recently, New Mexico governor Susana Martinez, a Republican, advocated for the education and scope of practice recommendations.

The campaign has also sought to use social media to engage key communities, generated thousands of news stories, and contributed articles and commentaries to prestigious journals, including AJN, the Journal of Professional Nursing, AARP International: The Journal, BoardRoom Press, Frontiers of Health Services Management, Health Affairs, the Journal of Change, and the Journal of Healthcare Management, among others.2-9

Awareness was critical, but the campaign aimed even higher: it wanted to inspire nurses, other health care workers, and educational leaders to help implement the IOM's recommendations and bring about lasting change. Although elaborate plans were made to advance each IOM recommendation, it was clear from the start that only a sustained commitment and a shift in attitude about nurses and nursing could secure the progress the campaign envisioned.

To begin addressing this challenge, the campaign brought in powerful partners. It created a strategic advisory committee led by Sheila Burke, MPA, RN, FAAN, of the Harvard School of Public Health, and including leaders in business, health care, and education to guide the national implementation of the IOM recommendations and to serve as campaign ambassadors.10

The campaign also engaged two entities created by the Center to Champion Nursing in America (CCNA), a joint initiative of the RWJF and AARP created in 2007 to strengthen the nursing workforce, in the effort to advance the IOM report's recommendations: the Champion Nursing Council,11 which brought together 23 leading nursing associations, and the Champion Nursing Coalition,12 which engaged national business, consumer, and health professional organizations.

These efforts generated significant national momentum. For example, in 2011 the Leapfrog Group, a nonprofit organization made up of large purchasers of health care, began considering Magnet status when scoring hospital safety. Additional action, however, was needed at the state level through the passage of state laws and regulations. Therefore, the campaign began to establish action coalitions in each state that were modeled after similar entities created for the CCNA. Within two years, each state and the District of Columbia had an action coalition working to advance the goals of the Future of Nursing report.

These state coalitions were deliberately structured to ensure a variety of perspectives, and each was co-led by a nurse and nonnurse. Leaders of the Indiana Action Coalition, for example, are Kimberly J. Harper, MS, RN, chief executive officer of the Indiana Center for Nursing, and Richard Kiovsky, MD, director of the state's Area Health Education Centers network. All action coalitions include nurses, other health care providers, consumers, educators, businesses, and other stakeholders.

With grants from the RWJF totaling nearly $18 million to date—and supplemented by more than $11 million in additional funding raised within the states—these 51 action coalitions have formed a powerful community that tests strategies, shares lessons learned, and achieves goals. The RWJF has also provided substantial financial resources to the CCNA to give action coalitions technical assistance in addition to communications and research and evaluation support. Finally, generous in-kind resources have been devoted to the campaign by the states and AARP.

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Progress on IOM Recommendations

Table 1

Table 1

The Campaign for Action is making progress implementing the recommendations in the Future of Nursing report (see Table 1), particularly in regard to education, scope of practice, workforce diversity, nurse leadership, and workforce data collection.

Education. The campaign is focusing on three IOM education recommendations: to increase the number of nurses with baccalaureates, to double the number of nurses with doctoral degrees, and to encourage interprofessional education, in which students from different health specialties are educated together, at least some of the time, in classrooms or during academic activities.

Baccalaureate-prepared nurses. The IOM report noted that the United States needs many more highly educated nurses. This is because Americans are living longer and with more chronic conditions; there is a fast-growing need to provide preventive and primary care at home, in schools, and in the community; and there is a debilitating nurse faculty shortage. And although the report recognized the enormous contributions of nurses with an associate's degree in nursing (ADN), the IOM issued a call to make it easier for nurses to obtain bachelor of science in nursing (BSN) and more advanced degrees.1

When the Campaign for Action launched in 2010, 49% of employed nurses in the United States had BSNs (according to figures compiled from the U.S. Census Bureau's American Community Survey Public Use Microdata Sample). The IOM report recommends that 80% of RNs have a bachelor's or more advanced degree by 2020.1

The action coalitions set out to advance this recommendation by encouraging strong partnerships between community colleges and universities to make it easier for nurses to transition to programs that confer higher degrees. Every action coalition is working to advance the IOM's education recommendations. However, nine of these—Texas, California, Washington, Hawaii, North Carolina, New York, Montana, Massachusetts, and New Mexico—were chosen to be part of the RWJF's Academic Progression in Nursing program, which is helping to lead this work.

The campaign has established measurable goals that are tracked through the use of “dashboard indicators” to assess progress.13 These focus on nurse education, barriers to practice and care, interprofessional collaboration, RN leadership, and the collection of workforce data. The campaign collects information from various data sources and uses this to measure progress regarding these indictors.

In 2014, for instance, the campaign was able to show that the percentage of employed nurses with a baccalaureate is on the rise: in 2013, 51% of the nation's employed nurses had a BSN, and there was a 10% rise in the number of RNs with bachelor's degrees between 2010 and 2012, from 1.37 million to 1.52 million (according to figures compiled from the U.S. Census Bureau's American Community Survey Public Use Microdata Sample). More nurses are enrolling in baccalaureate programs, according to the American Association of Colleges of Nursing,14 and the number of enrollees in RN-to-BSN programs is ballooning, rising 57% from 2010 to 2014.

Doctoral degrees. A second IOM education recommendation is to double the number of nurses with doctoral degrees by 2020.1 The IOM report notes that only 1% of the nation's 3 million nurses had doctoral degrees in 2010. It recommends that this number double, because nurses with doctorates are needed to conduct scientific research, provide advanced care, assume leadership roles in health care, end the critical shortage of nursing faculty, and educate the next generation of nurses.

The dashboard indicators revealed significant progress toward this goal. From 2010 to 2013, the number of nurses enrolled in doctoral programs rose 70%, from 11,645 to 19,828. Much of this growth was in doctor of nursing practice (DNP) programs: the number of students enrolled in these practice-oriented programs jumped from 7,304 in 2010 to 14,688 in 2013. Enrollment in research-oriented PhD programs has also grown: in 2013, 5,140 students were enrolled in these programs, up from 4,611 in 2010.

To accelerate the progress, the RWJF has created the Future of Nursing Scholars program, which is supported by the Independence Blue Cross Foundation, UnitedHealth Group, the Rhode Island Foundation, North Shore-LIJ Health System, the Johnson and Johnson Campaign for Nursing's Future, Cedars-Sinai Medical Center, and Ascension Health and is providing grants to schools of nursing to support a growing number of nurse PhD candidates each school year.

Interprofessional education. The IOM also called for an end to “educational silos,” in which students of one health profession are isolated from those in other fields.1 According to the dashboard indicators, in the 2013–2014 academic school year, of the 10 nursing schools at universities with graduate health professional schools that were surveyed, nine required at least one interprofessional clinical course or activity—up from four during the 2010–2011 academic year.

Scope of practice. Advanced practice RNs (APRNs) provide highly skilled care to an increasingly complex population of patients. The IOM report said that the United States needs more APRNs, but in many states, overly restrictive laws and regulations prevent APRNs from practicing to the full extent of their education and training. This has led to what an appendix to the IOM report calls a “crazy quilt of widely varied, often inconsistent, sometimes contradictory licensure and payment laws.”1

Opponents of lifting restrictions on APRN practice sometimes claim that doing so will compromise the quality and safety of care. However, the IOM report notes that there is no evidence that care is better in states with more restrictive scope-of-practice laws or that APRNs are any less able than physicians to provide safe, effective, and efficient care. The National Conference of State Legislatures has noted that removing APRN restrictions benefits patients by improving access to care, especially in regions in which there are shortages of primary care providers.15 In many states, the local AARP offices are bringing consumers’ voices to these debates, as staff write letters and visit state legislatures to emphasize the need for access to nursing care.

Since 2010, seven states—Connecticut, Kentucky, Minnesota, Nevada, North Dakota, Rhode Island, and Vermont—have removed statutory barriers that prevented NPs from providing care to the full extent of their education and training. Other states have passed laws toward guaranteeing full practice authority for NPs. Texas, for example, has removed a restriction requiring on-site physician supervision of nurse-led retail health clinics, and Utah has allowed NPs to be reimbursed by Medicaid for services they provide to beneficiaries.

Diversify the nursing workforce. The nursing workforce has historically been, and remains, predominantly white and female. A more diverse workforce is needed to provide culturally and linguistically appropriate health care services to an increasingly diverse population. Racial and ethnic diversity among nurses can also strengthen the relationship between nurses and minority communities and is an important step toward reducing disparities in health and health care, according to the IOM, which also notes that greater gender diversity among nurses would be beneficial.1 Currently, men make up less than 10% of the nursing workforce.16

The number of minorities in the nursing workforce is gradually rising, as is the share of the nursing workforce they represent, according to the Campaign for Action. In 2010, approximately 24% of the nation's RNs identified themselves as minorities; that percentage inched up closer to 25% in 2012. Data collection is improving, too. In 2011, 34 states collected race and ethnicity data regarding their nursing workforces; in 2013, that number jumped to 45.

Nurse leadership. Nursing is consistently ranked as the nation's most trusted profession.17 Nurses represent the largest group of health care professionals, and they are the providers who spend the most time with patients. As such, they have unique and valuable insights into health and health care. Nevertheless, the IOM report pointed out that nurses are often overlooked during discussions and decisions about health care reform, even though patients, providers, and payers would benefit from their input.

One principal reason for this is that relatively few nurses occupy positions of influence in the health care system or society. The nursing profession, the IOM report argues, must do its part to correct this. It calls on the profession to “produce leaders throughout the health care system, from bedside to boardroom, who can serve as full partners with other health professionals and be accountable for their own contributions to delivering high-quality care while working collaboratively with leaders from other health professions.”1

Action coalitions around the country are working to do just that, putting in place programs that train nurses to serve on a variety of health and health care boards, and keeping track of board openings and encouraging nurses to apply. Progress toward this goal is difficult to measure because the American Hospital Association last issued survey results in 2011, when it found that 6% of the nation's hospital boards included nurse members.18 A new study has confirmed that the number is probably even lower, with about 2% of nurses included as voting members on hospital, health system, and academic medical center boards.19 The Campaign for Action, with the support of action coalitions, is working with nursing associations nationwide to meet its ambitious goal of putting 10,000 new nurses on boards by 2020.

Workforce data collection. Policymakers need comprehensive data on the health care workforce to make informed decisions about policies that can influence the supply of and demand for nurses and other health professionals. At present, such analysis is hampered by gaps in data on the numbers and types of health professionals currently employed, where they are employed, and in what role. To address this lack of consistent data, the IOM report calls for the creation of a national health care workforce commission, state and regional workforce centers, and funding for workforce data collection and studies. This was authorized under the Affordable Care Act but remains an unfunded mandate.

Action coalitions are helping to ensure that this recommendation is realized by working with state boards of nursing to increase the number of data items collected when nurses are licensed or renew their licenses. From 2010 to 2014, 24 states increased the number of data items collected about the nursing workforce, including information about race and ethnicity, entry-level education, and employment setting. This is helping to build the national infrastructure for the collection and analysis of interprofessional health care workforce data.

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More Work Ahead

Although the progress made during these first four years of the Campaign for Action has been impressive, it has been predictably uneven, and considerable work remains. To fully realize the IOM's vision for the future of nursing, the campaign must expand its leadership, strengthen its action coalitions, increase and stabilize its resources, and win the hearts and minds of many more stakeholders.

Even among nurses, campaign leaders know there is more work to do. The community of highly educated nurses has embraced the IOM vision and many nursing students are engaged, but some staff-level nurses remain unaware of the report. Further, the recommendation that 80% of nurses have BSNs by 2020 has been polarizing, alienating some nurses who have ADNs.

To more fully engage the nursing community and create a sustained force for change, campaign leaders are appealing to nurses’ social mandate to contribute to the good of society. Many nurses take the Florence Nightingale pledge in recognition of their mission to contribute to society through research and evidence-based practice and to do all they can to elevate professional nursing standards. The IOM report outlined a way to fulfill this oath. The campaign is thus asking all nurses, “How are you going to implement the IOM report in your institution and state?” The goal is to inspire each nurse to become an active participant in implementing the IOM recommendations.

Another priority is to strengthen the action coalitions across the country. Some—including those in California, New Jersey, North Carolina, and Texas—have been extremely successful, bringing in diverse and powerful stakeholders and large grants to support their work. They have set up active workgroups that are advancing a range of IOM recommendations.

Other action coalitions have started more slowly, encountered more barriers, and made more modest progress. Some are raising money through bake sales and other small events, still building their infrastructure and seeking to engage stakeholders. Most continue to rely on in-kind support.

The campaign is using a model of evidence-based indicators of success20 to identify effective coalitions. The goal is to share lessons learned about the most effective ways to strengthen the infrastructure of action coalitions across the country.

To learn how you can implement the IOM recommendations, see Ten Ways You Can Help.

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Conclusion

The IOM's groundbreaking Future of Nursing report called for a radical overhaul of the nursing profession as a way to transform U.S. health and health care. Five years after its release, it is clear that the IOM did much more than chronicle an ongoing conversation about expanding the role of nurses. It imagined a world in which all nurses could become lifelong learners, practice to the extent of their education and training, and serve as full partners in providing care and promoting health on the front lines as well as in boardrooms.

The IOM did not simply suggest that nurses contribute to changing our health care system—it warned that change would not succeed unless nurses helped shape and lead it. It said that a highly educated, skilled, diverse nursing workforce is a prerequisite for a high-quality health care system poised to meet current and emerging needs.

In doing so, one of the nation's most prestigious institutions launched a new era for health care in the United States. But the promise of that era will only be fully realized if the progress to implement the Future of Nursing recommendations continues.

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Ten Ways You Can Help

Implementing the recommendations of the IOM's Future of Nursing report.

  1. Read the Future of Nursing report and encourage colleagues to do the same.
  2. Follow the Future of Nursing: Campaign for Action on Twitter and “like” it on Facebook.
  3. Learn what your state action coalition is doing and get involved by visiting www.campaignforaction.org.
  4. Invite your state action coalition to send a speaker to an upcoming forum at your place of employment or to the local chapter of a nursing or other association to which you belong.
  5. Seek out a mentor who will help you to develop as a nurse.
  6. Dedicate yourself to mentoring and supporting a nurse in the next generation.
  7. Contact the dean at the school(s) where you studied nursing and ask if the school has integrated the IOM report into its curricula. Ask if there is an opportunity to speak to students about how the IOM report is shaping their future.
  8. Consider obtaining a more advanced degree—a BSN, MSN, PhD, or DNP—or encourage a colleague to do so.
  9. Seek an appointment to a board of directors—of a community group, nonprofit organization, health clinic, or similar entity—in your local community, or encourage another nurse to do so.
  10. Blog about Future of Nursing: Campaign for Action activities and goals. Submit a letter to the editor of your local newspaper about the IOM's Future of Nursing report.
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REFERENCES

1. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine. The future of nursing: leading change, advancing health. Washington, DC: National Academies Press; 2011. http://www.nap.edu/catalog.php?record_id=12956.
2. Hassmiller SB, Truelove J. Are you the best leader you can be? Am J Nurs. 2014;114(1):61–7
3. Reinhard SC, Hassmiller SB. Partners in solutions to the nurse faculty shortage J Prof Nurs. 2009;25(6):335–9
4. Reinhard S, Hassmiller S. The future of nursing: transforming health care AARP International Journal. 2012(Winter):54–60 http://journal.aarpinternational.org/a/b/2012/02/the-future-of-nursing-transforming-health-care.
6. Shalala D. Nursing leaders can deliver a new model of care [in press] Frontiers of Health Service Management. 2015
7. Hassmiller SB. The RWJF's investment in nursing to strengthen the health of individuals, families, and communities Health Aff (Millwood). 2013;32(11):2051–5
8. [no author]. Looking ahead: trends and challenges in the future of nursing. Journal of Change [Independence Blue Cross Foundation] 2013;2(1):8-9. http://webversion.staywellcustom.com/ibc/2013/spring.
9. Hassmiller S, Combes J. Nurse leaders in the boardroom: a fitting choice J Healthc Manag. 2012;57(1):8–11
10. Future of Nursing. Campaign for action: who's involved—strategic advisory committee. Center to Champion Nursing in America. n.d. http://campaignforaction.org/whos-involved/strategic-advisory-committee.
11. Future of Nursing. Campaign for action: who's involved—champion nursing council. Center to Champion Nursing in America. n.d. http://campaignforaction.org/whos-involved/champion-nursing-council.
12. Future of Nursing. Campaign for action: who's involved—champion nursing coalition. Center to Champion Nursing in America. n.d. http://campaignforaction.org/whos-involved/champion-nursing-coalition.
13. Future of Nursing. Campaign for action: campaign progress—dashboard indicators. Center to Champion Nursing in America. n.d. http://campaignforaction.org/dashboard.
14. American Association of Colleges of Nursing. AACN finds slow enrollment growth at schools of nursing [press release]. 2014 Jan 9. http://www.aacn.nche.edu/news/articles/2014/slow-enrollment.
15. Ewing J, Hinkley KN Meeting the primary care needs of rural America: examining the role of non-physician providers. 2013 Apr Denver National Conference of State Legislatures Rural health connection; http://www.ncsl.org/documents/health/RuralBrief313.pdf.
16. U.S. Census Bureau. Male nurses becoming more commonplace, Census Bureau reports [press release]. 2013 Feb 25. http://www.census.gov/newsroom/press-releases/2013/cb13-32.html.
17. Riffkin R Americans rate nurses highest on honesty, ethical standards. 2014 Dec 18 Washington, DC Gallup Gallup Poll social issues; http://www.gallup.com/poll/180260/americans-rate-nurses-highest-honesty-ethical-standards.aspx#.
18. Van Dyke K, et al. 2011 AHA health care governance survey report. Chicago: American Hospital Association 2011 Jan.
19. Szekendi M, et al. Governance practices and performance in US academic medical centers Am J Med Qual. 2014 Aug 19 [Epub ahead of print].
20. Raynor J What makes an effective coalition? Evidence-based indicators of success. 2011 Philadelphia TCC Group http://www.mcf.org/system/article_resources/0000/1297/What_Makes_an_Effective_Coalition.pdf.
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