The Future of Nursing Report: Policy Implications for Nursing

Introduction

Many Americans describe the healthcare in the United States as “the best in the world”; yet, research does not support this statement. In the United States, healthcare access is neither accessible nor affordable for many citizens. In fact, more than 46 million non-elderly Americans lack health insurance, access, or availability to healthcare. ¹ This grim statistic is coupled with a healthcare system that has inordinately high costs and low healthcare outcomes. For example, an increasingly obesogenic American population has led to premature morbidity, mortality, and an unsustainable burden on healthcare expenditures. Obesity-related comorbidites accounted for 9.1% of the total U.S. medical expenditures, reaching as high as $92.6 billion dollars in 2002. ² These dire statistics have propelled U.S. policy actors to evaluate evidence-based research to transform our current healthcare system.

The purpose of this article is to review The Future of Nursing: Leading Change, Advancing Health, a seminal 2-year study by the Institute of Medicine (IOM) calling for a transformation of the U.S. healthcare delivery system in which nursing is posited as an equal and vital actor at every step of the policy and point-of-care process.^3–5 The recommendations of this landmark report have implications for all stakeholders in healthcare, including nurses caring for patients with obesity.

The Future of Nursing: Leading Change, Advancing Health

The National Academies and the IOM have an established history of evaluating evidence in an objective, interdisciplinary process. This rich history is evident through the interagency and interdisciplinary collaborations supporting the Robert Wood Johnson Foundation (RWJF) and the IOM 2-year evaluation of evidence regarding the utilization of nurses to meet the objectives of the 2010 Affordable Care Act. ⁴ Diverse stakeholder representation ensured strong interagency backing, with support and participation from government, academia, business, healthcare, and non-profit sectors.

Representing 80% of the healthcare delivery system, more than three million registered nurses serve as a vastly underutilized healthcare resource in meeting the needs of consumers in every setting. ⁴ Based on the evidence, a number of artificial barriers prevent the full deployment to nurses to their full scope of education and credentialing in meeting consumer needs in a rapidly evolving and increasingly complex healthcare system. ⁴ This report offers four key recommendations for an action-oriented transformation of the nursing profession to meet the current and future healthcare needs of the American public, including nursing scope of practice, nursing education levels, nurses as full partners in healthcare redesign, and workforce planning and policy.

Recommendation 1: Nurses Should Practice to the Full Extent of their Education and Training

Nurses bring a rich diversity in education, training, and experience to the healthcare arena. A variable entry level into the nursing profession has created confusion and inconsistencies in how nurses are utilized, however. While the majority of nurses are educated at the baccalaureate level (36.8%), a significant portion is educated at the associate degree (36.1%) and diploma (13.9%) level. It is estimated that more than 250,000 (13.2%) advanced practice nurses (APRNs), which include advanced nursing roles such as nurse anesthetists, clinical nurse specialists, nurse midwives, and nurse practitioners, are educated at the masters or doctoral level.^4,6

Variation in state regulation of nursing practice creates inconsistencies in scopes of practice based on licensure laws rather than education or certification.^4,6–8 Wide variations in nursing regulation are based on traditional, sociopolitical processes and economic defensiveness rather than evidence for consumer safety.^8,9 These inconsistencies create scenarios where a nurse may be able to practice to the full scope based on education and certification in one state while being significantly restricted in another state. For example, a nurse practitioner may be able to lead a healthcare home, manage the healthcare needs for a panel of clients, prescribe medications, and admit clients for hospital care without physician supervision in one state, while this same NP might be limited in this scope of care in another state or institution.

The Federal Trade Commission, targeting antitrust or unfair competition conduct among businesses, could serve as a strong stakeholder in evaluating some of the restrictive state regulatory laws. In an increasingly global healthcare market, regulations limiting nurses from serving to their full scope of education and certification limits consumer access to safe, effective, accountable healthcare.

Recommendation 2: Nurses Should Achieve Higher Levels of Education and Training

There is value and a market need for nurses educated at all established entry levels. However, the current nursing educational system is highly fragmented, creating barriers for nurses to build upon and extend their educational trajectory. Nursing education should provide opportunities for a seamless transition for progressively higher levels of education. An increasingly complex healthcare delivery system requires competencies in nursing leadership, health policy, system improvement, research, and evidence-based practice. ⁴ The nursing workforce must achieve higher levels of education with a commitment to lifelong learning to meet these demands. According to the report, future access to primary healthcare will depend on increasing the number of BSN-prepared nurses from 50% to 80% by 2020. Furthermore, in order to meet the faculty needs required to educate the recommended higher numbers of baccalaureate and graduate-prepared nurses, the report recommends that the number of nurses educated at the doctoral level be doubled by 2020.

As nurses are educated in a seamless fashion, their education should take place with interdisciplinary teams to enhance shared learning regarding respective roles, scopes of practice, and collaborative care models. Furthermore, gender and ethnic diversity goals should mirror that of the U.S. demographic. ⁴

Recommendation 3: Nurses Should Be Full Partners in Healthcare

Nurses have been consistently ranked among the most trusted, ethical, and honest of professionals. Among 1,504 opinion leaders, including insurance, corporate, health services, government, industry, and university faculty, significant barriers were identified that prevent nurses from fully participating as leaders in health and healthcare. ¹⁰ Results of this report stated that nurses were not perceived as important decision makers or revenue generators compared with doctors, and that they did not present with a single voice on national issues. Despite these barriers, nurses were viewed as important stakeholders and decisionmakers in health policy. However, it was also noted that nurses are largely absent in the policy arena.

As healthcare delivery systems become increasingly complex and global, it is imperative to have highly educated and savvy nurse leaders as accountable, full partners in the redesign and application of a transformed, consumer-centric healthcare delivery system. This accountability involves systems evaluation and management, identifying areas for improvement based on evidence. Nurse leaders should lead, participate, and actively serve on policy and advisory boards that impact healthcare across all settings.^4,10 As nurses become full partners in healthcare redesign, effective workforce planning and policy making must be a priority.

Recommendation 4: Effective Workforce Planning and Policy Making

As nurses assert leadership in a transformed healthcare delivery system, the need for effective workforce planning and policy development requires better data collection and an improved information infrastructure. Simply stated, there is a need to know the numbers and types of nursing professionals needed to meet current and future needs. ⁴

Current regulatory and reimbursement inconsistencies lead to uncertainty in accounting for nursing care. For example, nursing services are often bundled with other services such as the cost of the hospital room or of the office visit. Nursing-sensitive indicators are one example where nursing leadership is essential in determining workforce needs to meet nursing sensitive outcomes. ¹¹ Advanced practice nursing workforce and outcome issues are often confounded by inconsistent regulatory and reimbursement statutes and rules requiring work completed by an APRN to be billed under the name of a supervising physician in many states, confounding accountability and productivity issues.^7–9 The National Health Care Workforce Commission and the National Center for Workforce Analysis have been tasked by the 2010 Affordable Care Act mandates to support an improved infrastructure for collecting and analyzing workforce needs in a timely and transparent manner. ⁴

Conclusion

The IOM has issued clear and convincing evidence supporting the need for a transformation of the nursing profession and healthcare delivery as we know it. Policy implications cross specialty areas, including bariatric nursing care. In some sense, it may be considered the perfect storm in the alignment of strong interagency collaboration and support calling for a shift from the traditional U.S. healthcare delivery system to a more inclusive, client-centered approach to healthcare. Nurses can and should assert their expertise as valuable clinicians and policy leaders and participants in a transformed healthcare delivery system.^4,12

The recommendations in this landmark report call for nurses to take their place as visionary leaders and participants in broad clinical and policy arenas along with executives, researchers, regulators, academia, and philanthropic and governmental organizations. Nurses should practice to their full scope based on education and certification. Nurses need a seamless pathway for higher education levels in order to advocate for clients in a complex healthcare delivery system. Nurses should be full partners in the delivery of interdisciplinary healthcare. And lastly, more consistent and reliable workforce data are needed to predict the mix and educational levels of nurses and other healthcare providers required for workforce demands. It is through the collective resources of every qualified clinician that the U.S. healthcare delivery system will be transformed into a high quality, accessible, affordable, accountable, transparent system that yields the best health outcomes in the world.