1. Stubenrauch, James M.


Recommendations aim to transform nursing education and practice.


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Go to and click on "Podcasts" to hear American Nurses Association chief executive officer Marla J. Weston, PhD, RN, speak with AJN about the Institute of Medicine report.


Two years ago, the Institute of Medicine (IOM) and the Robert Wood Johnson Foundation (RWJF) joined forces to envision a transformed health care system with nursing at its center. Given that the rollout of the Patient Protection and Affordable Care Act will swell the ranks of the medically insured by an estimated 32 million, the IOM report, The Future of Nursing: Leading Change, Advancing Health, released on October 5 at the National Press Club in Washington, DC, may have arrived at just the right moment. (Read the report and watch a Webcast of its release at

Figure. RWJF preside... - Click to enlarge in new windowFigure. RWJF president and chief executive officer Risa Lavizzo-Mourey at the October 5 press conference announcing the release of the

The report is the result of intensive investigation and research by a committee chaired by former Department of Health and Human Services secretary Donna E. Shalala, now president of the University of Miami. Linda Burnes Bolton, vice president and chief nursing officer of Cedars-Sinai Health System and Research Institute in Los Angeles (and an AJN editorial board member) served as vice chair. Committee members included health care experts in business, academia, the nonprofit sector, and health care organizations. Most weren't nurses, and an independent panel whose members had equally broad expertise conducted a review of the early drafts and provided advice and guidance.


At the October 5 press conference, RWJF president and chief executive officer Risa Lavizzo-Mourey hailed the report as a huge milestone in America's efforts to improve health care. "We asked the IOM to map out exactly what it would take to reimagine and reengineer the nursing profession so that it could radically change and address the big issues confronting our health care system: cost and improved care," she said.


To do that, the experts tried to answer the question, "What roles can nursing assume to address the increasing demand for safe, high-quality, and effective health care?"



The answers to this question that emerged from the committee's two-year preparatory work are summarized in four "key messages" (in italics, below) on the need to transform the practice, education, and leadership of the nursing profession, as well as to collect better data on the health care workforce to inform planning.


Nurses should practice to the full extent of their education and training. Widely varying scope-of-practice regulations from state to state have long been a sore spot for nurses, and the proper scope-of-practice limits for NPs and other advanced practice RNs (APRNs) has long been a point of contention between nursing and the medical profession. The report says that federal and state governments should update and standardize scope-of-practice regulations across the country and remove "regulatory, policy, and financial barriers to promote patient choice and patient-centered care." Those barriers, defended by insurers, physicians' associations, and other interest groups may not be easily overcome.


As soon as the report was released, the American Medical Association issued a statement reiterating its opposition to giving NPs expanded scope of practice. "Increasing the responsibility of nurses is not the answer to the physician shortage," it said.


American Nurses Association (ANA) president Karen Daley told AJN, "We're not looking to expand NPs' scope of practice. What we want is full utilization of their skill, knowledge, and experience. That means when NPs and other APRNs are qualified to function in an advanced role such as primary care provider, they're allowed to do so. We don't want to be doctors. We want to remove the barriers that currently exist in the regulatory arena and in the private payer system." Daley noted that the ANA has been working to enact the Home Health Care Planning Improvement Act, which would allow NPs, clinical nurse specialists, certified nurse midwives, and physician assistants to order home health services under Medicare.


As an example of the inequalities in current regulations, Daley cited an anecdote told at the press conference by committee member Michael R. Bleich, professor and dean of the Oregon Health and Science University School of Nursing: in Kansas City, which straddles the Kansas-Missouri border, NPs on one side of town practice independently, without physician supervision, while NPs who work across town, though they have the same education and experience, must be supervised by physicians and are restricted in their practice.



The second message concerns nurses' educational preparation for practice, and has implications for the long-standing tussle over which kind of program-diploma, associate's degree, or baccalaureate-provides the proper foundation for RN certification: Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.


AJN asked Nancy DiMauro, dean of Long Island College Hospital School of Nursing, an associate's degree program in Brooklyn, New York, how the report's recommendations on nursing education might affect her school and its students. "Associate's degree programs are not going away," she said. "Students understand that this is the first step in their nursing education. And every dean of an associate's degree program would agree with me that further education is something we support and encourage. I hope the report will help us recruit qualified faculty. We get over 500 student applications a year for 90 seats, and I have only seven faculty members." She said the shortage of well-prepared faculty candidates wasn't the only problem. "Our graduates often take entry-level nursing jobs that pay better than faculty positions. We hope the report will help bring to the table additional funding for faculty salaries."


The other key messages of the report focus on nursing leadership and the need for more reliable data on nursing practice and outcomes and the technology required to obtain it:


* Nurses should be full partners with physicians and other health professionals in redesigning health care in the United States.


* Effective workforce planning and policymaking require better data collection and an improved information infrastructure.



To nurses who might greet such a report with a touch of skepticism about its efficacy, ANA president Daley said, "The first thing I'd say is: 'Take a look at your practice and your career and see where you want your practice to be in a few years. Set those goals and identify what you need to get there, because there are opportunities now. There are two choices: to allow whatever comes from this report and from health care reform to happen to you, or to be engaged in the process.'"-James M. Stubenrauch


Eight Recommendations

The Future of Nursing: Leading Change, Advancing Health contains a "blueprint for action" in the form of eight recommendations, along with specific actions that would be required of Congress, state legislatures, government agencies such as the Centers for Medicare and Medicaid Services and the Federal Trade Commission, insurance payers, academic institutions, health care organizations, professional associations, licensing bodies, philanthropic and advocacy organizations, and others in order to achieve the desired transformation of the nursing profession and the health care system. The recommendations are:


* Remove scope-of-practice barriers.


* Expand opportunities for nurses to lead and diffuse collaborative improvement efforts.


* Implement nurse residency programs.


* Increase the proportion of nurses with baccalaureates to 80% by 2020.


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


* Ensure that nurses engage in lifelong learning.


* Prepare and enable nurses to lead change to advance health.


* Build an infrastructure for the collection and analysis of interprofessional health care workforce data.