1. Holmes, Aline M. MSN, RN


This five-part editorial series examines the Institute of Medicine's (IOM) most recent report, "The Future of Nursing: Leading Change, Advancing Health." Each issue through July targets one of the four IOM global recommendations for expanding nursing practice and positively impacting healthcare systems of the future.


Article Content

One of the four key messages from the IOM focuses on the need to transform nursing education. Specifically, the Future of Nursing report states that "nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression." With the passage of the Affordable Care Act of 2010, the U. S. healthcare system will significantly change over the next decade, moving away from a hospital- or healthcare provider-centric model to much more of a patient- and family-centered model. Treatment will focus more on preventive and chronic care management, rather than on episodic hospitalizations and fragmented responses. Fewer acute care hospital nurses will be needed, as care moves into communities and public health settings, requiring clinicians to have very different skill sets and knowledge. Transforming how nurses are educated and trained, not only at the entry level but throughout their careers, will be critically important to ensuring the highest quality patient care.

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The first recommendation under this key message is that the profession needs to increase the proportion of nurses with a bachelor's of science in nursing (BSN) to 80% by 2020.1 The need to increase the number of BSN-prepared nurses is hardly a new item for discussion. Nursing is unique among healthcare professions with its multiple pathways to become a nurse; the majority of nurses don't have a baccalaureate degree, unlike other healthcare professionals such as physicians, pharmacists, rehabilitation therapists, and social workers. The most common way to become an RN is through an associate degree program, which historically has provided a cost-effective and more easily accessible avenue than a 4-year college program. The next most common way is the BSN, followed by diploma programs (3-year curriculums in hospital-based schools). Most associate degree and diploma graduates don't go on to obtain their BSN once they've entered the workforce.


Having three different pathways to obtaining an RN license has been difficult to explain to the public and other healthcare professionals, and it's further complicated by the fact that all RN graduates have to take the same exam (NCLEX-RN) for licensure, leading some to ask "why bother with a four-year degree if everyone takes the same exam?" Currently, the NCLEX content is skewed toward acute care in hospitals because that has been where the majority of care has been delivered over the past decades. But with care moving out of hospitals and into community, home health, and long-term-care settings, the exam will change, and this will impact how nurses are prepared at the entry level.


Although there's no definitive research that categorically demonstrates that care provided by BSN nurses results in better patient outcomes, it's obvious that students with experience in a wide variety of care settings and who have training in leadership, policy development, and patient safety will result in nurses able to more effectively work in a changing healthcare environment. These nurses will be ready to manage patients in a variety of settings and manage the transitions in their care. These nurses will also have an understanding of the financing of healthcare and will be able to work collaboratively with other healthcare providers in a team-based environment. They'll be knowledgeable in research strategies and will be able to implement evidence-based best practices in their work. They'll also have the basic framework upon which to build leadership skills, another key message of the IOM report.2 Nurses should be, and will be, managing the care of patients and their families to avoid repeat hospitalizations and enable patients to remain engaged and empowered to manage their own chronic conditions.


To achieve this recommendation, the areas of academia and practice will need ongoing communication, innovation, and collaboration. First and foremost, the nursing profession must reach the consensus that a BSN is the entry-level requirement for professional nursing practice. We've spent far too many years discussing the pros and cons of this issue, and it has hampered our ability to forge meaningful partnerships with other healthcare disciplines and to assume leadership roles in healthcare policy and reform.


If our profession is going to take a leadership role in the redesign and management of innovative patient care delivery models, we need to have nurses who are well educated and understand concepts of collaboration, leadership, and patient safety. Most of us have heard about the nursing faculty shortage, but there are creative strategies being piloted in sites all around the country to expand capacity-we just need to be open to newer and different ways of preparing entry-level nurses. One of these strategies involves streamlining automatic transitions from an associate degree program to a baccalaureate one, providing those nurses with a smooth approach to obtaining their BSN. Most states require continuing-education credits for relicensure; taking academic courses to attain a BSN should fulfill those requirements, so as not to be an added burden. There are also programs that provide for an associate degree nurse to move into a master's program, getting a BSN along the way.


The report also addresses the need for competency-based education and the need for interprofessional education as a way to develop the teamwork and communication skills necessary to effectively work as collaborative partners and team members.3,4 Recommendation 6 of the report addresses the need to ensure that nurses engage in life-long learning.5 Because of the complexity of healthcare, nurses, like other healthcare professionals, must commit to continuing their education and earning advanced degrees to maintain and develop new competencies. No one degree will provide nurses with everything they need to know over the course of their professional career. Healthcare organizations should explore opportunities to partner with academia to develop and prioritize new competencies and to offer innovative continuing education and competency programs.


Recommendation 5 in this report is that the number of nurses with doctorates should double by 2020.6 The IOM recommends that particular attention be focused on increasing the diversity of faculty prepared at the master's and doctoral level, in order to improve the diversity of the nursing workforce in general and to more appropriately reflect the diversity of the U. S. population at large. Less than 1% of nurses have a doctoral degree in nursing or a nursing-related field, and only approximately 550 doctorally prepared nurses graduate in this country annually, a number that won't provide the researchers and faculty necessary to grow our profession. The committee noted that there are three main reasons for this: (1) an inadequate pool of advanced degree nurses to draw upon; (2) faculty salaries and benefits that aren't comparable to those of nurses with the same degrees working in most clinical settings; and (3) a culture that promotes getting clinical experience before going on for graduate degrees.7


Generally, doctorally prepared nurses work in university settings, in tenure track teaching and research positions. With the changes coming in the healthcare delivery system and in sites of care, there's an increasing need for research into how best to provide quality, safe patient/family care. Developing new models of healthcare delivery, and focusing care more on ambulatory care sites and community-based settings, will require exploration and testing of new techniques and applications of knowledge, best conducted by nurse scientists. There are large gaps in how care is provided to an increasingly diverse ethnic and racial population, with different languages, cultures, and values, and much research is required in this area.


In the last several years, many new doctoral programs granting the doctorate of nursing practice (DNP) have been launched, focusing on expanding clinical knowledge, improving patient care, and developing skills necessary for leadership positions in healthcare institutions. DNPs hold a practice doctorate, similar to other healthcare professions, such as medicine, pharmacy, and rehabilitation, and learn the skills necessary to translate research findings into improved patient care and enhanced healthcare systems. The Future of Nursing report does acknowledge that research still needs to be done on how these new programs will impact patient outcomes of care, cost, and access to care.8 Whether DNPs will alleviate some of the nursing faculty shortages also remains to be seen.


Having more doctorally prepared nurses, especially with PhDs, will be critical to meeting the need for research in two key areas: nursing education and nursing science.9 There's actually very little evidence to support the approaches to preparing entry-level nurses that are currently used. At a time when healthcare delivery systems and models of care are changing radically, we need much more research into the best ways to prepare nurses for new roles, competencies, and responsibilities. The report calls for increased funding from governmental and private agencies to support research in nursing education and to develop researchers who can identify and develop the science of nursing education.


We also need nurse researchers who can identify and test ways to deliver care that's effective, efficient, and population- or community-based. Dr. D. Berwick, the administrator of the Centers for Medicare and Medicaid Services has called for improving the U. S. healthcare system by requiring simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing per capita costs of healthcare. He also calls for a reduction in harm that arises from poorly coordinated, fragmented, and ineffective systems of healthcare delivery. Dr. Berwick recognizes that there are many barriers to achieving the Triple Aim, including our system of supply-driven care, new technologies with limited impact on patient outcomes, provider-centric care instead of patient-centric care, and too little appreciation of system knowledge among clinicians and organizations.10


We need a larger cadre of nurse researchers to identify and develop systems and mechanisms to achieve these aims, and also to identify methodologies to assist frontline staff nurses to implement evidence-based practices into their daily care routines. The work of nurse researchers has led to improvements, especially regarding reducing pressure ulcers and various healthcare-acquired infections. How to get these best practices into how nurses deliver care on a highly reliable basis is another huge area of research that still needs to be addressed.


Finally, the report addresses the need to increase the diversity of the nursing workforce, not just with regards to race and ethnicity, but also gender. In many parts of the country, the nursing profession doesn't reflect the diversity of the communities it serves. We must explore ways to encourage minorities and men to become nurses. In 2003, the Sullivan Commission on Diversity in the Healthcare Workforce was established to develop recommendations that would "bring about systemic change . . . (to) address the scarcity of minorities in our health professions."11 There were 37 recommendations, addressing the educational pipeline for health professionals, financing education for minority students, and establishing leadership and accountability for accomplishing this, and Chapter 4 of the report includes some examples of successful initiatives in this area.


A professional blueprint

In summary, the Future of Nursing report provides the blueprint for our profession, what we need to do now, and how we need to prepare for the future. Nursing should be taking a leadership role in defining the future healthcare system, one that ensures quality, safe care to diverse populations; promotes wellness and disease prevention; improves health outcomes; and puts the patients and their family in the center of all that we do. As nurses work together toward these goals, the legacy of our professional careers will be that our communities and families flourish and we'll have made a difference in the lives of our neighbors. What are the next steps you'll take?




1. IOM: The Future of Nursing: Leading Change, Advancing Health; S-10. [Context Link]


2. IOM: The Future of Nursing: Leading Change, Advancing Health; S-6. [Context Link]


3. IOM: The Future of Nursing: Leading Change, Advancing Health; 4-30. [Context Link]


4. IOM: The Future of Nursing: Leading Change, Advancing Health; 4-34. [Context Link]


5. IOM: The Future of Nursing: Leading Change, Advancing Health; 6-11. [Context Link]


6. IOM: The Future of Nursing: Leading Change, Advancing Health; S-11. [Context Link]


7. IOM: The Future of Nursing: Leading Change, Advancing Health; 4-27. [Context Link]


8. IOM: The Future of Nursing: Leading Change, Advancing Health; 4-26. [Context Link]


9. IOM: The Future of Nursing: Leading Change, Advancing Health; 4-29. [Context Link]


10. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health and cost. Health Aff (Millwood). 2008;27(3):759-769. [Context Link]


11. IOM: The Future of Nursing: Leading Change, Advancing Health; 11-37. [Context Link]