As the current debate surrounding the Affordable Care Act (ACA) continues in Congress, a number of strengths and weaknesses of the legislation are being emphasized. One specific issue is how the American health care system will treat an additional 32 million Americans.
In order to make quality care accessible to the diverse populations of the United States, many stakeholders in the health care industry believe it is necessary to expand the role of health care providers including primary care physicians, pharmacists, and especially nurses. Consequently, the Committee on The Robert Wood Johnson Foundation (RWJF) Initiative on the Future of Nursing, at the Institute of Medicine (IOM), developed a vision for a transformed health care system to address these issues.
In their report entitled “The Future of Nursing: Leading Change, Advancing Health,” IOM envisions a future where “primary care and prevention are central drivers of the health care system, interprofessional collaboration and coordination are the norm, and payment for health care services rewards value, not volume of services, and quality care is provided at a price that is affordable for both individuals and society.” To achieve these goals, IOM recognized that many of the aspects of the health care system must be changed, including the nursing profession, which, with more than 3 million members, represents the largest segment of the health care workforce.
In 2008, RWJF approached the IOM to establish a 2-year Initiative on the Future of Nursing, with the primary mission of producing a report containing recommendations for an action-oriented blueprint for the future of nursing, including changes in public and institutional policies at the national, state, and local levels. To produce this report, a committee examined and produced recommendations related to the following issues, with the goal of identifying vital roles for nurses in designing and implementing a more effective and efficient health care system:
Reconceptualizing the role of nurses within the context of the entire workforce, the shortage, societal issues, and current and future technology;
Expanding nursing faculty, increasing the capacity of nursing schools, and redesigning nursing education to assure that it can produce an adequate number of well prepared nurses able to meet current and future health care demands;
Examining innovative solutions related to care delivery and health professional education by focusing on nursing and the delivery of nursing services; and
Attracting and retaining well prepared nurses in multiple care settings, including acute, ambulatory, primary care, long term care, community and public health.
Framing the Discussion
The question presented to the committee that produced this report was: What roles can nursing assume to address the increasing demand for safe, high quality, and effective health care services? IOM recognized that the new health care laws will require ways to address challenges in the management of chronic conditions, primary care (including care coordination and transitional care), prevention and wellness, and the prevention of adverse events (such as hospital-acquired infections). The report also identified the demand for better provision of mental health services, school health services, long-term care, and palliative care (including end-of-life care) is increasing as well.
Accordingly, IOM noted that “nursing brings to the future a steadfast commitment to patient care, improved safety and quality, and better outcomes. “ In fact, the report asserts that most of these challenges “speak to traditional and current strengths of the nursing profession in such areas as care coordination, health promotion, and quality improvement.” As a result, IOM emphasized that “nurses have key roles to play as team members and leaders for a reformed and better-integrated, patient-centered health care system.”
Expanding the Role of Nurses
In order to expand the role of nurses, the report first recognizes the need to allow nurses to practice in accordance with their professional training. IOM also recognized the need for nurse education to “better prepare them to deliver patient-centered, equitable, safe, high-quality health care services; engage with physicians and other health care professionals to deliver efficient and effective care; and assume leadership roles in the redesign of the health care system.” Consequently, IOM asserted that “an expanded workforce to serve the millions who will now have access to health insurance for the first time will require:
- Changes in nursing scopes of practice
- Advances in the education of nurses across all levels
- Improvements in the practice of nursing across the continuum of care
- Transformation in the utilization of nurses across settings, and
- Leadership at all levels so nurses can be deployed effectively and appropriately as partners in the health care team.
As a result of its deliberations, the committee formulated four key messages that structure the discussion and recommendations presented in this report:
- Nurses should practice to the full extent of their education and training.
- Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
- Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States.
- Effective workforce planning and policy making require better data collection and an improved information infrastructure.
IOM arrived at these recommendations by acknowledging the unique role that nurses play in the health care system. Because nurses have regular and close proximity to patients and scientific understanding of care processes across the continuum of care, they have a unique ability to act as partners with other health professionals and to lead in the improvement and redesign of the health care system and its many practice environments, including hospitals, schools, homes, etc.
In addition, the recommendations reflect the ability of nurses to help bridge the gap between coverage and access, to coordinate increasingly complex care for a wide range of patients, and to enable the full economic value of their contributions across practice settings to be realized. This includes nurse’s crucial role in preventing medication errors, reducing rates of infection, and even facilitating patients’ transition from hospital to home.
Nursing practice covers a broad continuum from health promotion, to disease prevention, to coordination of care, to cure—when possible—and to palliative care when cure is not possible. However, IOM acknowledged that “many members of the profession require more education and preparation to adopt new roles quickly in response to rapidly changing health care settings and an evolving health care system.”
The recommendations also recognize how restrictions on scope of practice, policy- and reimbursement-related limitations, and professional tensions have undermined the nursing profession’s ability to provide and improve both general and advanced care. As a result, IOM asserts the need to transform the work environment, scope of practice, education, and numbers of America’s nurses by creating a health care system that delivers the right care—quality care that is patient centered, accessible, evidence based, and sustainable—at the right time.
Ultimately, the IOM recommendations focus on the critical intersection between the health needs of diverse populations across the lifespan and the actions of the nursing workforce. Based on these recommendations, it is clear that America will need to educate and train nurses to handle many areas of medicine and to help create a patient-centered health care system if health care reform will be successful and improving care and reducing costs.
This is encouraging, but some system changes need to happen for nurses, including changes in compensation towards procedures and productivity, the shift work mentality often found with hospital nurses needs to change. Nurses taking on more responsibility will mean greater accountability.
The role of continuing education (CE) will be crucial in realizing the IOM recommendations. Not only will CE for nurses need to cover many more areas of training and education, it will also need to focus on team-based approaches for collaborating with other physicians, which also means that CE for physicians will have to focus on interacting with nurses. Accordingly, CE must play a critical role in realizing the potential benefits of health care reform by improving the role nurses play in the health care system and improving patient outcomes.