WASHINGTON - Since the 2010 Institute of Medicine report The Future of Nursing: Leading Change, Advancing Health was issued, significant progress has been made related to many of the report's recommendations, which were geared toward helping nurses meet the heightened demand for health care and improving the nation's increasingly complex health system, says a new report from the National Academies of Sciences, Engineering, and Medicine. However, continued progress will require greater focus and effort in certain areas, including removing scope-of-practice barriers, strengthening pathways to higher education, increasing diversity in the workforce, building a broader coalition to expand nurses' roles in health professions and leadership, and improving the collection of workforce-related data.
Nurses make up the largest segment of the health care profession, with approximately 3 million registered nurses in the U.S. The 2010 IOM report was timely, coinciding with the Affordable Care Act's creation of new models of care to accommodate the large numbers of people previously without access to health insurance, and added momentum to a movement that was underway to help achieve an effective and affordable health care system. It provided specific recommendations and called for the transformation of nursing profession. After the report released, the Future of Nursing: Campaign for Action was launched by AARP and the Robert Wood Johnson Foundation to shepherd the report's recommendations into reality. In 2014, the Robert Wood Johnson Foundation asked the Academies to assess progress made in the nursing profession since the 2010 report and identify areas that should be emphasized over the next five years. While the committee that carried out the study and wrote the report assessed progress in implementing the recommendations of The Future of Nursing report, it was not able to attribute progress, or lack thereof, directly to the report or the Campaign for Action, given efforts by other organizations and trends in the field.
The committee found that since the 2010 report, the nursing community has been galvanized at the national and state levels. In particular, the original report proposed that states, federal agencies, and health care organizations remove scope-of-practice barriers that hinder nurses from practicing to the full extent of their education and training. Since 2010, eight more states (Connecticut, Maryland, Minnesota, Nebraska, Nevada, North Dakota, Rhode Island, and Vermont) have changed their laws to give nurse practitioners full practice and prescriptive authority, joining the 13 states that were classified in 2010 as meeting criteria for full practice authority. Additional states have made incremental progress toward removing scope-of-practice barriers, but nurse practitioners in many states are still restricted in their practice. At the federal level, the Centers for Medicare & Medicaid Services in 2012 issued a final rule broadening the concept of medical staff, permitting hospitals to allow other practitioners -- such as advanced practice registered nurses (APRNs), physician assistants, and pharmacists -- to perform all functions within their scope of practice. Despite this rule, medical staff membership and hospital privileges remain subject to existing state laws and business preferences. To foster common ground around removing scope-of-practice restrictions and other issues in policy and practice, the committee recommended that the campaign should build on its successes and broaden its coalition to include more diverse stakeholders. A broader coalition would also help carry out other key recommendations of the 2010 report, including expanding efforts and opportunities for interprofessional collaboration and leadership development for nurses and promoting the involvement of nurses in the redesign of care delivery and payment systems. The committee also recommended that the campaign expand its communication strategies to mobilize a wider and more diverse audience.
In 2010, approximately half the nation's nurses held a baccalaureate or higher degree and fewer than 1 percent of nurses held a doctoral degree. The 2010 report suggested a goal by 2020 that 80 percent of nurses attain a bachelor's degree and the number of nurses who pursue doctorates double. Baccalaureate program enrollment has increased substantially in the last five years, with entry-level enrollment increasing from 147,935 in 2010 to 172,794 in 2014 and accelerated enrollment increasing from 13,605 to 16,935 in the same time. Registered nurses who enrolled in bachelor of science in nursing completion programs increased from 77,259 in 2010 to 130,345 in 2014. Since 2010, enrollment in doctor of nursing practice (D.N.P.) programs has more than doubled, from 7,034 to 18,352 students, a 161 percent increase, and enrollment in Ph.D. in nursing programs has increased by 15 percent to 5,290 students. Many schools need more faculty to further increase enrollment at all education levels, especially for doctoral programs, the committee said. It called for continued efforts aimed at strengthening academic pathways for nurses toward the baccalaureate degree and promoting nurses' pursuit of doctoral degrees, with emphasis on the Ph.D.
The 2010 report acknowledged a high turnover rate among newly graduated nurses and recommended instituting residency training for nurses to help reduce attrition. The committee for the recent report found it was difficult to gauge growth in nurse residency programs overall, within particular settings, and for nurses of different educational levels. Cost and lack of data on the value of these programs remain barriers to broader implementation. Residencies for both RNs and APRNs are beneficial and need to be encouraged, but attention to residency programs for outpatient care is insufficient, the committee determined. It recommended exploring ways to create and fund transition-to-practice residency programs at both the RN and APRN levels.
One topic noted in the 2010 IOM report was the lack of diversity in the nursing profession, emphasizing that a more diverse workforce would better meet health care needs and provide more culturally relevant care. Today, African Americans make up 13.6 percent of the general population ages 20 to 40 years old but only 10.7 percent of the RN workforce, 10.3 percent of associate degree in nursing graduates, and 9.3 percent of baccalaureate nursing graduates. The disparity is even greater for Hispanics/Latinos who make up 20.3 percent of the general population ages 20 to 40 years old but only 5.6 percent of the RN workforce, 8.8 percent of associate degree graduates, and 7 percent of baccalaureate graduates. Men make up 9.2 percent of the RN workforce, 11.7 percent of baccalaureate nursing students, and 11.6 percent of graduates. It is too soon to see significant changes in the diversity of the national nursing workforce, the committee said. Changing the overall nurse workforce is a slow process, because only a small percentage leaves and enters each year. Any efforts to improve diversity must focus on each step along the professional pathway from recruitment to educational programs, retention and success within those programs, graduation and placement in a job, and retention and advancement within a nursing degree. The committee recommended that the campaign work with others to assess progress and exchange information about strategies that are effective in increasing the diversity if the health care workforce.
The original report recommended improving the collection and analysis of data on the health care workforce through an infrastructure built and led by a National Health Care Workforce Commission. However, the commission has not been funded by Congress, therefore, this recommendation could not be implemented as it was written. The committee for the recent report said that major gaps still exist in understanding the numbers and types of health professionals, where they are employed, and what roles they fill. It called for the campaign to play a role in convening, supporting, and promoting collaboration among organizations and associations to consider how they might create more robust datasets and organize them.
The study by the Institute of Medicine of the National Academies of Sciences, Engineering, and Medicine was sponsored by the Robert Wood Johnson Foundation. The Academies are private, nonprofit institutions that provide independent, objective analysis and advice to the nation to solve complex problems and inform public policy decisions related to science, technology, and medicine. They operate under an 1863 congressional charter to the National Academy of Sciences, signed by President Lincoln. For more information, visit http://national-academies.org. A roster follows.
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Pre-publication copies of Assessing Progress on the Institute of Medicine Report The Future of Nursing are available from the National Academies Press on the Internet at http://www.nap.edu or by calling 202-334-3313 or 1-800-624-6242. Reporters may obtain a copy from the Office of News and Public Information (contacts listed above).
THE NATIONAL ACADEMIES OF SCIENCES, ENGINEERING, AND MEDICINE
Institute of Medicine Board on Health Care Services
Committee on Assessing Progress on Implementing the Recommendations of the Institute of Medicine Report The Future of Nursing: Leading Change, Advancing Health
Stuart H. Altman, Ph.D.* (chair)
Sol C. Chaikin Professor of National Health Policy
Heller Graduate School of Social Policy
Carmen Alvarez, Ph.D., R.N., CRNP, CNM
Department of Community-Public Health
Johns Hopkins University School of Nursing
Cynthia C. Barginere, D.N.P., R.N., FACHE
Vice President and Chief Nursing Officer
Rush University Medical Center
Richard A. Berman, M.H.A., M.B.A.*
Institute for Advanced Discovery and Innovation
University of South Florida
Palm beach Gardens, FL
Karen Donelan, Sc.D., Ed.M.
Senior Scientist in Health Policy
Mongan Institute for Health Policy
MGH Institute for Technology Assessment
Massachusetts General Hospital
Suzanne Ffolkes, M.A.
Vice President of Communications
Paula M. Gubrud, Ed.D., R.N., FAAN
Oregon Health & Science University
School of Nursing
Jack Needleman, Ph.D., FAAN*
Professor of Health Policy and Management
Fielding School of Public Health
University of California, Los Angeles
Los Angeles, CA
Michele J. Orza, Sc.D.
Senior Adviser to the Executive Director
Patient-Centered Outcomes Research Institute
Robert L. Phillips Jr., M.D., M.S.P.H.*
Vice President for Research and Policy
American Board of Family Medicine
Edward Salsberg, M.P.A.
Director, Health Workforce Studies
George Washington University
Health Workforce Institute and School of Nursing
George E. Thibault, M.D.*
Josiah Macy Jr. Foundation; and
Daniel D. Federman Professor of Medicine and Medical Education Emeritus
Harvard Medical School
New York, NY
Adrienne Stith Butler
* Member, National Academy of Medicine