1. Wallis, Laura


Nursing highlights from the past year.


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Progress and stasis in nursing roles. The Campaign for Action (CFA), organized to pursue the goals of the Institute of Medicine 2010 report The Future of Nursing: Leading Change, Advancing Health, celebrated three years of progress last year. CFA "action coalitions" became a reality in all 50 states and the District of Columbia; enrollment in advanced degree programs for nurses increased, including a jump of more than 50% in enrollment in doctor of nursing practice programs between 2010 and 2012; and 16 state-level bills were introduced in 2013 to remove barriers to advanced practice RN practice.


Attendees at a national CFA summit in February 2013 left with a list of coalition imperatives for the coming year, including a call for action coalitions to "deliver short-term results in the next 18 months, even as you develop long-term plans." Given the changing health care landscape, nurses at every level will be called upon to act as leaders.


Despite the progress in primary care, experts estimate that only 2% of hospital board members are nurses, which led the CFA to call for leadership development programs and strategies to increase the number of nurses on hospital, state, and federal boards. For more on this effort, see


One avenue for greater opportunities and leadership may be in telehealth, a growing field of care. Some questions have arisen about the cost-effectiveness of telemedicine, most notably a study in the March 20, 2013, BMJ, but several studies have found the practice to be both cost-effective and clinically successful. Regardless, telehealth is expected to reach 1.8 million Americans annually by 2017, according to the market research firm InMedica, and the Centers for Medicare and Medicaid Services will expand provider payments for telehealth services in 2014.


Staffing ratios. In the context of health care reform, the debate regarding nurse-patient ratios continued on this past year. Two federal bills on nurse staffing (S 739 and HR 1821) were proposed this spring but have languished in committee. Although state legislation may have a greater chance of success, the battle is still uphill.

Figure. RNs stage an... - Click to enlarge in new windowFigure. RNs stage an informational picket line outside Tufts Medical Center in Boston. Photo by Wendy Maeda /

* California. Still the only state with mandated nurse-patient ratios, California's example has led to more hiring, greater job satisfaction and retention, and less burnout for nurses. But the evidence surrounding patient outcomes has been less definitive. Most recently, a review of eight studies published in the November 2013 Journal of Nursing Administration showed mixed outcomes and calls for further research.


* Other state activity. Seven states plus the District of Columbia introduced bills modeled after California's in 2013, but none has yet succeeded. Minnesota passed a compromise law in May in which hospitals must file staffing plans to be submitted to the legislature in January 2015. And this fall, the Massachusetts Nurses Association petitioned to bring the matter directly to the voters through a 2014 ballot initiative.


* Staffing and health care reform. Cost savings might ultimately prompt better staffing levels. Beginning with fiscal year 2014 (October 1, 2013), the Patient Protection and Affordable Care Act's Hospital Readmissions Reduction Program imposes larger penalties on hospitals with too many readmissions of heart attack, heart failure, and pneumonia patients within 30 days of discharge (and will expand to include other conditions and higher penalties in 2015). A recent study in Health Affairs showed that hospitals with higher nurse-staffing levels may be 25% less likely to incur those penalties.



Budget shortfalls-thanks in part to sequester-driven reimbursement cuts-may lead to further cuts of support staff and other spending. Whether nurses can work more efficiently to adjust to these cuts and whether nonnursing duties will be added to bedside nurses' job descriptions remain to be seen.-Laura Wallis