WASHINGTON—Five years have passed since the Institute of Medicine (IOM) released a landmark report, “The Future of Nursing: Leading Change, Advancing Health” (OT 10/25/00 issue.) Now the IOM has issued a new report that assesses how well its recommendations in that 2010 report have been implemented.
That report, “Assessing Progress on the Institute of Medicine Report The Future of Nursing,” finds that while progress has been made in helping the nation's three million registered nurses meet the increased demand for health care and improve the complex U.S. health system, continued efforts are needed in certain areas.
- Removing scope-of-practice barriers;
- Strengthening pathways to higher education;
- Increasing diversity in the workforce;
- Building a broader coalition to expand nurses' roles in the health professions and leadership; and
- Improving the collection of workforce-related data.
Like the initial report, the new one, which was sponsored by the Robert Wood Johnson Foundation, makes several specific recommendations (see box on page 4).
Much More Important Now
Stuart H. Altman, PhD, Chair of the multi-disciplinary committee that wrote the new report, said in the preface: “It is clear to me that the nursing profession is a far more important component of the U.S. health care system than it was 45 years ago.”
Altman, the Sol C. Chaikin Professor of National Health Policy at Brandeis University's Heller Graduate School of Social Policy, notes that the 2010 report was a catalyst for a number of new activities and served as a boost to several trends that had begun before the report was released.
After the first report, the Robert Wood Johnson Foundation supported the creation of the Future of Nursing: Campaign for Action, and its 51 state action coalitions. “Clearly much has been accomplished by the Campaign and other stakeholders,” Altman said, pointing to the following:
- Since 2010, eight more states (Connecticut, Maryland, Minnesota, Nebraska, Nevada, North Dakota, Rhode Island, and Vermont) have changed their laws to give nurse practitioners full practice and prescriptive authority; they join the 13 states that were classified in 2010 as meeting criteria for full practice authority;
- At the federal level, in 2012 the Centers for Medicare & Medicaid Services (CMS) issued a final rule broadening the concept of medical staff, permitting hospitals to allow health practitioners other than physicians—such as advanced practice registered nurses (APRNs), physician assistants, and pharmacists—to perform all functions within their scope of practice; and
- In 2010 about half the nation's nurses held a baccalaureate degree or higher, and fewer than one percent of nurses held a doctoral degree. In keeping with recommendations on higher education in the 2010 IOM report, baccalaureate program enrollment has increased markedly in the last five years, with entry-level enrollment increasing from 147,935 in 2010 to 172,794 in 2014, and accelerated enrollment increasing from 13,605 to 16,935 in the same time period.
Registered nurses who enrolled in bachelor of science nursing completion programs increased from 77,259 in 2010 to 130,345 in 2014. In addition, since 2010 enrollment in doctor of nursing practice (DNP) programs has more than doubled, from 7,034 to 18,352 students—an increase of 161 percent—while enrollment in PhD nursing programs has increased by 15 percent to 5,290 students.
But these upward trends may not be able to keep up with demand. At a Capitol Hill briefing in January 2015, the Alliance for Health Reform—with support from the Robert Wood Johnson Foundation and AARP—released a white paper that stated that the demand for registered nurses is projected to grow 19 percent from 2012 to 2022. Unfortunately, however, the white paper found that in 2013 nursing programs turned away 78,089 qualified applicants due to faculty shortages, lack of clinical training sites, and budget constraints.
Alec Stone, MA, MPA, Director of Health Policy for the Oncology Nursing Society—who attended that briefing—told OT he was concerned about making sure there's a viable workforce for the future. “The most important issue to us is access for the patient to highly trained oncology nurses,” he said.
ONS has a certification program, which offers three advanced oncology nursing credentials. In its policy priorities, ONS states that it closely supports the recommendations of the IOM, as do the American Nurses Association (ANA) and the American Association of Colleges of Nursing (AACN).
The ONS Board of Directors has adopted three core strategic objectives: innovation in knowledge and learning; excellence in oncology nursing and quality patient care; and advocacy for patients and the profession.
Attention Must Be Paid
The new IOM nursing report found that there are certain areas that need more attention, including a continuing focus on removing scope-of-practice barriers. As of this writing, 17 states have reduced practice authority and 12 have restricted practice authority. Some states have made incremental improvements in their laws but still have reduced or restricted practice authority for APRNs.
The new report states: “There is growing evidence that new models of practice in which all health professionals practice to the full extent of their education and training offer greater efficiency and quality of services.”
Also needing more attention, the committee concluded, are residencies for both RNs and APRNs, which are beneficial and need to be encouraged. The committee determined that attention to these nursing residency programs for outpatient care is insufficient, and recommended exploring ways to create and fund transition-to-practice residency programs at both the RN and APRN levels.
In 2011 the National Council of State Boards of Nursing began to study transition-to-practice models for new nursing graduates in hospitals, long-term care, home health, and other settings.
The 2010 report cited the need for more diversity in the nursing profession, stating that a more diverse workforce would better meet the health care needs of an increasingly diverse population. Today, African Americans make up 13.6 percent of the general U.S. population aged 20 to 40, but only 10.7 percent of the RN workforce, 10.3 percent of associate degree in nursing graduates, and just 9.3 percent of baccalaureate nursing graduates.
The diversity gap is even more marked for Hispanics and Latinos, who make up 20.3 percent of the general U.S. population age 20 to 40 but only 5.6 percent of the RN workforce, 8.8 percent of associate degree graduates, and seven percent of baccalaureate graduates.
The nursing workforce also lacks gender diversity: men make up just 9.2 percent of the RN workforce, 11.7 percent of baccalaureate nursing students and 11.6 percent of baccalaureate graduates.
The IOM assessment committee stated that five years is too short a time to thoroughly assess changes in the diversity of the nursing workforce; change is a slow process, since only a small percentage of nurses leave and enter the workforce each year. To cause meaningful change, the committee said it is necessary to focus on enhancing diversity at each step along the career pathway of preparation, from recruitment to educational programs, retention, graduation and placement in a job, and retention and advancement within the profession of nursing.
The 10 specific recommendations of the new IOM nursing report assessment committee are as follows:
- Build common ground around scope of practice and other issues in policy and practice; the Future of Nursing: Campaign for Action should broaden its coalition to include more diverse stakeholders and continue to work to remove scope-of-practice restrictions;
- Continue pathways toward increasing the percentage of nurses with a baccalaureate degree—these include encouraging partnerships between community colleges and four-year universities, employer educational assistance, and quality monitoring of new educational programs;
- Create and fund transition-to-practice residency programs, which are needed in all practice settings including community-based practices and long-term care;
- Promote nurses' pursuit of doctoral degrees in order to have an adequate supply of nurses for clinical care, research and faculty positions and leadership positions: Nurses pursuing higher education should be prepared to teach in an evolving health care system that is less focused on acute care and more focused on the chronic care needed by an aging population;
- Promote nurses' interprofessional and lifelong learning, especially through continuing education that will allow nurses to work in a variety of practice settings;
- Make diversity in the nursing workforce a priority, especially through recruitment and retention efforts by state action coalitions, an advisory group and the collection of data on diversity in the profession of nursing;
- Expand efforts and opportunities for interprofessional collaboration and leadership development for nurses, including use of nurses in collaborative planning of health care delivery, management, and entrepreneurship;
- Promote the involvement of nurses at administrative levels in the redesign of care delivery and payment systems, including health care systems; insurance companies and for-profit health-delivery systems; not-for-profit organizations that work to improve health care, such as the National Quality Forum; and federal, state, and local government bodies related to health.This is an especially important recommendation, according to Matthew D. McHugh, RN, PhD, MPH, JD, the Rosemarie Greco Term Endowed Associate Professor in Advocacy at the University of Pennsylvania School of Nursing: “Nurses should be in the boardroom, translating what it means to provide care at the bedside,” he said in an interview:
- Communicate with a wider and more diverse audience to gain broad support for objectives of the Future of Nursing: Campaign for Action, including efforts geared toward the general public and enlistment of allies in the health care professions other than nursing and in business; and
- Improve workforce data collection: The committee concluded that major gaps still exist in understanding the number and types of health professionals, where they are employed, and what roles they fill.
The full report can be accessed at http://bit.ly/IOMNursingReport. The site also includes a link to a webinar held on December 4 that featured statements by the committee chair highlighting the report's findings, conclusions, and recommendations, as well as a discussion with committee members.