1. Pittman, Patricia PhD
  2. Bass, Emily BA
  3. Hargraves, John MPP
  4. Herrera, Carolina MA
  5. Thompson, Pamela MSN, RN


OBJECTIVE: The objective of this study was to assess the implementation of recommendations of the Institute of Medicine (IOM) report, The Future of Nursing: Leading Change, Advancing Health.


BACKGROUND: In 2010, the IOM made a series of recommendations aimed at transforming the role of nurses in healthcare delivery.


METHODS: We conducted a multiyear survey, in 2011 and 2013, with nurse leaders who were members of the American Organization of Nurse Executives, the National Nursing Centers Consortium, or the Visiting Nurses Association of America.


RESULTS: When comparing 2013 to 2011, we find progress in instituting the IOM's recommendations in 3 areas: (1) raising the proportion of employed RNs with at least a bachelor's degree; (2) expanding the proportion of healthcare institutions with nurse residency programs; and (3) offering opportunities for continuing nurse education


CONCLUSIONS: Our findings suggest that healthcare organizations are transforming to support the recommendations of the IOM.


Article Content

Following the release of the 2010 Institute of Medicine (IOM) report The Future of Nursing: Leading Change, Advancing Health,1 the Robert Wood Johnson Foundation (RWJF) and AARP joined to launch the Future of Nursing: Campaign for Action.2 The goal of the Campaign for Action is to encourage and track the implementation of the recommendations set forth in the IOM report.3 The IOM had 8 major recommendations, with 5 focusing specifically on the hiring and retention practices of healthcare institutions. The Campaign for Action leadership believes that these recommendations require changes in culture and the support of nursing leadership in RN-centric settings, that is, hospitals, health centers, and home health and hospice facilities.


As part of an effort to monitor these initiatives, RWJF supported a multiyear survey of nurse leaders designed and administered by our team at the George Washington University.4 We conducted a baseline survey in 2011 to assess the readiness of healthcare institutions to implement changes in nursing recommended by the IOM report.5,6 This article reports on results from the 2nd survey, administered 2 years later in the summer of 2013. The surveys focus on 5 of the recommendations that pertain to healthcare employers' hiring, retention, education and training, and nurse leadership practices.1(p9-15) Specifically, we examine the prevalence and uptake of the following:


* increasing the nurse residency programs,


* increasing the proportion of nurses with a baccalaureate degree to 80% by 2020,


* providing opportunities for nurses to engage in lifelong learning,


* doubling the number of nurses with a doctorate by 2020, and


* preparing and enabling nurses to lead change to advance health.



The challenge of attribution notwithstanding, any analysis of the degree of uptake of the IOM recommendations requires contextualization. At least 2 major events affected the nursing labor market between 2010 and 2014. First, there has been a continued financial strain on healthcare providers. We know that the recent recession in the United States led to a national slowdown in healthcare expenditure growth,7-9 and there is growing evidence that hospitals, in particular, have seen admissions decline since 2009.9 In addition, faced with the financial uncertainties inherent in the Affordable Care Act's payment reform and Medicaid expansion (or lack thereof), healthcare leaders have been keen to identify cost-cutting measures and have been understandably cautious about investing in new programs before fully understanding the implications of the reforms.10,11 While the precise effects of the economic stress on healthcare employers' likelihood of adopting the IOM recommendations are impossible to know, one could argue that, at least with regard to new educational investments such as new residencies programs, the adoption might be reduced.


The 2nd contextual factor that may have affected the implementation of the IOM recommendations is the increase in nurse supply during this period. We know that there has been a doubling in the rate of entry for new nurse graduates between 2001 and 2011.12 By some accounts, this has resulted in new nurse graduates facing delays in finding jobs, particularly in urban areas.13 The impact of this dramatic increase in new nurses was further deepened by the delayed retirement and the return to full-time work on the part of many incumbent nurses concerned about the recession. As Staiger and colleagues14 suggest, during recessions nursing becomes a safe profession, temporarily inflating the nursing supply. Again, the exact effects of this on the implementation of the IOM recommendations are hard to know, but one possibility is that it has made it easier for employers to favor baccalaureate nurses over associate degree nurses in their hiring practices. Conversely, it is possible that other policies relating to the IOM recommendations, such as tuition reimbursement for continuing education, might be less likely during a recession because retention is less of a challenge than during periods of nurse shortages and economic expansion.


In short, the evolving context of economic recession and unemployment, as well as sector-specific phenomenon such as payment reforms, Medicaid expansion, and the nursing supply, provides an important backdrop against which our findings must be examined. It is in this context that we explore 2 years of changes related to the IOM recommendations in 3 types of healthcare settings.



In order to track changes in employer practices related to the IOM's recommendations, we administered our 2nd Web-based survey in July 2013. Results from our 2011 survey were reported in 2 articles.5,6 This study was approved by the George Washington University's institutional review board. Our convenience sample in both 2013 and 2011 consisted of chief nursing officers (CNOs) and chief nursing executives who were members of the American Organization of Nurse Executives (AONE), the National Nursing Centers Consortium (NNCC), or the Visiting Nurse Associations of America (VNAA). Of the 1,700 nurse leaders invited to participate in the 2013 survey, 336 responded, representing a 19.8% response rate across all 3 settings.


The AONE is a professional organization for hospital nursing leaders. About 17.9% (n = 267) of eligible AONE nurse leaders responded to the survey, representing hospitals or hospital systems. AONE respondents represented rural hospitals (17.6%, n = 47), urban hospitals (55.4%, n = 148), healthcare systems (21.0%, n = 56), and institutions whose region could not be determined (6.0%, n = 16). The hospital subset was identified as being urban if the nurse leader provided a hospital location whose zip code was within a core-based statistical area (CBSA); if the zip code was not in a CBSA, the hospital was considered rural. About 6.0% of hospital nurse leaders did not provide a zip code, and so their location remains unidentified.


Member clinics of the NNCC are run by nurse practitioners and are focused on wellness and primary care. The NNCC response rate was 24.5% (n = 24).


The VNAA is the national association that represents nonprofit home healthcare and hospice agencies and promotes quality care within communities. The response rate among VNAA members was the highest at 40.4% (n = 44).


Our analysis was primarily descriptive, but in order to explore possible interactions between an increase in the number of employers requiring a BSN for new nurse hires, on the 1 hand, and vacancy rates on the other, we conducted regression analysis. For this analysis, we controlled for setting, months of experience required for new hires, and percentage of RNs with a BSN.


A major limitation to this study is that it is based on the convenience sample. Its importance, however, lies in the ability to suggest longitudinal signals that can be further explored at a national level. Other limitations include the response rates, in both 2011 and 2013, particularly among hospitals. This could be attributed to a number of factors, including the following:


* Never responders-If the same survey goes out to the same people 2 years later, some of those who did not answer in 2011 are unlikely to answer the 2013 survey.


* Some nurse leaders who answered the survey in 2011 may think they already answered these questions and do not want to waste time being redundant.


* Nurse leaders in settings that exhibit little change may be less likely to respond because they are reluctant to report there is nothing new.




The Increasing Proportion of Nurses With a Bachelor's Degree

Nurse leaders were asked to categorize their RN staff by educational attainment, including those with a diploma, associate's degree, bachelor's degree (BA), master's degree, or doctorate as a their highest education in any field (nursing and nonnursing). We find that the proportion of RNs with a BA (which includes but is not limited to a BSN) or higher has increased among respondent organizations from 48.2% in 2011 to 53% in 2013 (Table 1). In both years, a plurality of nurses at urban hospitals was RNs with a bachelor's degree (38.3% in 2011 and 43.1% in 2013), while nurse-led clinics employed a majority of master's and doctoral degree nurses (85.4% in 2011 and 71.1% in 2013).

Table 1 - Click to enlarge in new windowTable 1. Highest Educational Attainment (Nursing and Nonnursing) of RNs Employed in 2011 and 2013, by Setting

When asked if they preferred or required (mutually exclusive) a BA or higher when hiring new RNs, our findings suggest an even more dramatic change. The share of institutions that required an RN to have a BA was higher in 2013 than in 2011. As seen in Table 2, about 19.5% of institutions responding to the survey indicated they required new RN hires to have a BA-a 10.5% increase since 2011 (9.0%).

Table 2 - Click to enlarge in new windowTable 2. Hiring of BA-Trained RNs, 2011 Versus 2013

We also asked hospitals whether they had Magnet(R) status, a recognition program that in January 1, 2013, began requiring that all nurse managers hold a nursing degree (BSN or higher). In 2011, Magnet hospitals represented 10.5% (n = 47) of our sample and 12.8% (n = 43) in 2013. Among Magnet hospitals in our survey, there was an even sharper increase in the requirement that nurses hold a BA when hiring from 11.4% in 2011 to 38.7% in 2013. If we remove Magnet institutions from the sample, 15.6% of the remaining institutions report requiring new RN hires to have a bachelor's degree, a 6% increase since 2011. Thus, while the presence of Magnet institutions in our sample is partially driving the observed increase, it accounts for only about 3%.


Consistent with this trend, a slightly greater share of institutions required additional education and/or certification as a condition for continued employment in 2013. About 29.9% of institutions in the study reported education or certification conditional RN employment in 2013 as compared with 22.9% in 2011(Table 3). On the other hand, survey responses showed a drop in incentives offered for continued education, suggesting that the hard policies requiring further education may be replacing softer policies.5

Table 3 - Click to enlarge in new windowTable 3. Additional Education or Certification as a Condition for Employment, 2011 Versus 2013

Doubling the Number of Nurses With a Doctorate by 2020

Overall, there was little change in the number of nurses employed with a doctorate degree (Table 1). On average, about 3.1% of nurses in all institutions had doctorates in 2011; this rose slightly to 3.6% of employed nurses in 2013. However, if we look at each setting, we find that there was a noticeable increase in the share of employed nurses with doctorates for urban hospitals (0.7%-2.5%) and a notable decline of doctorate nurses employed by nurse-led clinics (down 7.3 percentage points to 18.7% of employed nurses). It is important to note that data do not distinguish between doctors of nursing practice (DNP) and other doctoral degrees and that the American Association of Colleges of Nursing has called for a change in the current level of preparation necessary for advanced practice RNs from the master's degree to the DNP by the year 2015.15


Vacancies and Willingness to Hire Less Experienced Nurses

In order to contextualize employer policies toward nurses, we asked about vacancy rates. In 2011, the average vacancy rate was 7.3%, and this rate climbed slightly to 7.5% in 2013 (a statistically insignificant change), with the highest rates in urban hospitals and clinics. In 2013, the highest vacancy rates were in clinics (15.6% in 2013), followed by home health and hospice agencies (9.4%).


During the same period, institutions requiring new hires to have a bachelor's degree increased by over 10 percentage points. We ran multiple tests, including an OLS regression framework, to see if there was an association between the bachelor's degree education requirement and vacancy rates. Using vacancy rates between 2011 and 2013 as the dependent variable, we looked at baccalaureate requirements, after controlling for setting, months of experience required for new hires, and percentage of RNs with a bachelor's degree. Our model did little to explain the variation in vacancy rates (data not shown). During this period, we find no indication of a relationship between requiring a bachelor's degree for new RN hires and vacancy rates.


While vacancy rates appear relatively stable, we found a major reduction in the average number of years of experience required for entry-level nursing jobs from 3.4 years in 2011 to 7 months in 2012 (Figure 1). The reduction in experience was particularly striking in hospitals. These data suggest that CNOs may be accepting less experienced nurses as a way to avert a rise in vacancies, signaling what may be an early indication of a decrease in the supply of nurses. It could also suggest that as CNOs have begun to prioritize the hiring of nurses with BAs over associate degree nurses, and therefore they may be willing to take new graduate bachelors prepared nurses with less experience.

Figure 1 - Click to enlarge in new windowFigure 1. Average minimum required years of nurse experience for employment, 2011 vs 2013.

Growth in New Nurse Residency Programs

We asked nurse leaders if their institution offered RN residencies, with a residency defined as "a program entered into only after graduation from a nursing program that is more formal or structured than basic new nurse orientation." Results showed that more institutions offered a residency program in 2013 (41.6%, n = 104) than they did in 2011 (31.7%, n = 84) (Figure 2). As in 2011, we find that residency programs continue to be predominately in not-for-profit, urban hospitals that are located in the South (data not shown). There was, however, also an important increase among home health and hospice agencies, where previously only 2.2% (n = 1) had nurse residencies, and by 2013, 14.2% (n = 5) offered such a program.

Figure 2 - Click to enlarge in new windowFigure 2. Institutions offering nurse residencies in 2011 and 2013.

Survey respondents were also asked if their residency programs were required or optional. Of institutions reporting they offer residencies for new RN hires, 67% (n = 73) reported that these residencies were required. This was a substantial upsurge from 7.7% (n = 6) in 2011 (Table 4).

Table 4 - Click to enlarge in new windowTable 4. Required Residencies for New RNs, 2011 Versus 2013

In 2013, a new question was added to the survey to determine when an institution's residency program was created. We find that of institutions with residency programs, 50.5% report they were created between 2010 and 2013 (data not shown). These findings, in combination with the observed increase between 2011 and 2013, provide a strong signal that the 2010 IOM recommendations may have played a role in stimulating this development.


Advances in Opportunities for Lifelong Learning

In addition to residencies, nurse leaders were asked about a variety of other programs offered by their institutions to advance opportunities for nurses to continue to learn (Table 5). The percentage of employers that offered internships or fellowships increased from 6.8% (n = 18) to 21% (n = 18) between 2011 and 2013, while "other" training opportunities also drastically increased from 1.4% (n = 4) to 38.6% (n = 34). In addition, institutions that required basic orientation grew from 39.1% (n = 116) in 2011 to 98.8% (n = 87) in 2013.

Table 5 - Click to enlarge in new windowTable 5. Required Training Programs by Setting, 2011 Versus 2013

Preparing and Enabling Nurses to Lead Change to Advance Health

Leadership advancement appears to be lagging in relation to other IOM recommendations. In all settings, the percentage of providers with leadership training declined (overall, 2011 = 86.7%, n = 219; 2013 = 76.8%, n = 174) (data not shown). We note that it is possible that leadership training has been absorbed into residency programs and is therefore less likely to be offered as standalone course. Alternatively, or concurrently, incumbents may also be receiving leadership training outside their institutions, such as that offered by AONE.16


As in 2011, approximately 64% (n = 145) of organizations overall had nurses serving on the governing board of their institution (Table 6). However, trends varied by setting. About 47.8% (n = 22) of rural hospitals in 2011 reported nurses on the board of trustees, and this rose to 64.9% (n = 24) by the time of the second survey. During the 2-year period, the percentage reporting nurses on their board declined for urban hospitals (from 66.4% [n = 71] to 62.1% [n = 64]), nurse-led clinics (from 60.0% [n = 18] to 56.3% [n = 9]), and home health and hospice providers (from 79.1% [n = 34] to 72.4% [n = 21]). Overall, the percentage of institutions reporting that nurses served in some other leadership positions (ie, vice president of patient services, board subcommittees, etc) increased slightly from 85.8% (n = 194) in 2011 to 91.0% (n = 164) in 2013.

Table 6 - Click to enlarge in new windowTable 6. Nurses in Leadership Roles


Our survey results suggest that progress by healthcare organizations toward implementing the IOM recommendations occurred in 3 areas: (1) raising the proportion of employed RNs with at least a bachelor's degree, (2) implementing nurse residency programs, and (3) offering opportunities for continuing nurse education. Our findings also provide some evidence that at least 2 of these areas of change may be directly linked to new policies that came about since the 2010 IOM report: increasing the proportion of baccalaureate-prepared nurses and increasing residency programs.


The increased proportion of organizations requiring a bachelor's degree at the point of hiring in 2013, as compared with 2011, suggests that there is a shift in policy that occurred after the release of the IOM recommendations. This is presumably at least part of the reason why our data show a higher percentage of nurse staff in 2013 have achieved a bachelor's degree or higher.


As well, a large proportion of organizations (>50%) implemented a residency after the IOM report was published. This is particularly notable, given that it occurred during a time of economic recession and during a period of high nurse supply. We know that residencies are both costly and were originally designed to increase retention.17


Although our analysis is limited, we also find no evidence that policies to require a bachelor's degree are associated with increased vacancy rates. Indeed, with the emergence of pockets of nurse shortages, the continued growth in the proportion of nurses with a bachelor's degree or higher suggests a solid cultural shift among nurses and employers alike with regard to educational expectations.


In addition, our data suggest that the drop in required years of experience may interact with both educational policies and vacancy rate in complex ways. One interpretation is that the drop in required experience reflects an emerging willingness on the part of CNOs to choose degrees over experience. Another possibility is that this shift is unrelated to the preference for BSNs and simply reflects management's response to a tightening nursing market and the need to avoid vacancies.


Progress in the area of expanding nurses' leadership on boards, on the other hand, appears to be mixed. While overall there were more leadership opportunities in terms of nurses' participation on boards, the average across sectors remained stagnant. Indeed, other research shows that in hospitals nurses account for only 6% of board members, and nurses are perceived as having the least amount of influence in healthcare reform over the next 5 to 10 years.18 A possible explanation for this is that expansion of nurse leadership bumps up against entrenched interests of other groups, while the areas in which we find greater progress tend to fall under the purview of CNOs



Despite the lack of progress on the leadership front, trends with regard to educational attainment and residency programs are particularly striking when considering the context of these last 2 years. The shift toward requiring a BSN degree, and the tremendous growth in residencies during a period of economic contraction and high nursing supply, suggests that the country was ready for the IOM recommendations and that the recommendations made business sense to healthcare leaders. These results may also be a reflection of the wisdom of the IOM/RWJF task force to invest financial resources into a grassroots implementation campaigns (Campaign for Action) in each state.


Regardless of reasons for the changes, it is clear that transformations are underway and that, consequently, the research agenda continues to evolve. Three future areas of study will be important. First, as nurse residency programs become more prevalent, more data on the variability of their curricula and their outcomes are needed.


Second, as the economy continues to recover, unemployment rates drop, and more nurses retire, it will be critical to continue to monitor employers' education policies. Our data suggest that there is currently no association between requiring a bachelor's degree and increased vacancies, but elevating education requirements may exclude older nurses from the positions faster than the recovery would suggest.


Lastly, we do not know why some healthcare employers engage nurses in leadership roles including board appointments and others do not. Answering this question will be especially important as the Campaign for Action considers its strategy for advancing implementation of this remaining IOM recommendation.




1. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2010. [Context Link]


2. The Robert Wood Johnson Foundation. Future of Nursing: Campaign for Action. 2013. Accessed March 12, 2014. [Context Link]


3. The Robert Wood Johnson Foundation. Leading Change, Advancing Health: 3 years of progress through Nursing. 2013. Accessed March 12, 2014. [Context Link]


4. Spetz J, et al. Creating a dashboard to track progress toward IOM recommendations for the Future of Nursing. Policy Polit Nurs Pract. 2014; 0( 0): 1-8.m. [Context Link]


5. Pittman P, Herrera CN, Horton K, Thompson PA, Ware JM, Terry M. Healthcare employers' policies on nurse education. J Healthc Manag. 2013; 58( 6): 399-4110. [Context Link]


6. Pittman P, Herrera C, Bass E, Thompson P. Residency programs for new nurse graduates: how widespread are they and what are the primary obstacles to further adoption? J Nurse Adm. 2013; 43( 11): 597-602. [Context Link]


7. Centers for Medicare & Medicaid Services. Table 1. National health expenditures; aggregate and per capita amounts, annual percent change and percent distribution: selected calendar years 1960-2012. Accessed April 4, 2014. [Context Link]


8. Martin A, Hartman M, Whittle L, Catlin A. National health spending in 2012: rate of health spending growth remained low for the fourth consecutive year. Health Aff. 2014; 33( 1): 67-77. [Context Link]


9. Health Care Cost Institute. 2012 Health Care Cost and Utilization Report. Washington, DC: Health Care Cost Institute; 2013. Accessed April 24, 2014. [Context Link]


10. Association for Healthcare, Resources & Materials Management. The Impact of Reform and the Recession on Supply Chain Management. Chicago, IL-Association for Healthcare, Resources & Materials Management. 2012. Accessed on April 24, 2014. [Context Link]


11. Brimmer K. Many hospitals anticipate dropped revenue due to ACA. 2012. Accessed April 24, 2014. [Context Link]


12. National Center for Health Workforce Analysis. The U.S. Nursing Workforce: Trends in Supply and Education. Washington, DC: Health Resources and Services Administration; 2013. Accessed April 28, 2014. [Context Link]


13. Mancino D. Inaction is not an option. Dean's Notes. 2011; 33( 2). Accessed April 24, 2004. [Context Link]


14. Staiger D, Auerbach D, Buerhaus P. Registered nurse labor supply and the recession-are we in a bubble? N Engl J Med. 2012; 366: 1463-1465. [Context Link]


15. American Association of Colleges of Nursing. DNP fact sheet. 2014. Accessed April 25, 2014. [Context Link]


16. AONE. Educational opportunities with AONE. Accessed April 25, 2014. [Context Link]


17. Goode CJ, Lynn MR, McElroy D, et al. Lessons learned from 10 years of research on a post-baccalaureate nurse residency program. J Nurs Adm. 2013; 43( 2): 73-79. [Context Link]


18. Hassmiller S. Taking the first steps to serving on a board. Am Nurse Today. 2012; 7( 11): 18-20. [Context Link]