Discussion URGENT

As health care delivery in the United States continues to evolve, either through mandates, improved technologies and training, or other drivers, nurses remain at the forefront in facilitating the success of new initiatives. In 2010, the Institute of Medicine formed a committee of experts to address the following question:

“What roles can nursing assume to address the increasing demand for safe, high-quality, and effective health care services?”

In the final report of the committee, The Future of Nursing: Leading Change, Advancing Health, the authors stated:

This report offers recommendations that collectively serve as a blueprint to

(1) ensure that nurses can practice to the full extent of their education and training,

(2) improve nursing education,

(3) provide opportunities for nurses to assume leadership positions and to serve as full partners in health care redesign and improvement efforts, and

(4) improve data collection for workforce planning and policy making. (p. 10)

For this Discussion, you will focus on the research recommendations presented by the committee concerning the role of nurses as leaders. The committee members believe that answers to these research questions are needed to advance the profession of nursing and to further expand their role in health care reform and improvement.

To prepare:

•Review Chapter 7 in The Future of Nursing: Leading Change, Advancing Health report provided in the Learning Resources. Focus on the information in Box 7.3, “Research Priorities for Transforming Nursing Leadership.”

(I am leaning toward one of these 2 – • Identification of the characteristics of mentors that have been (or could be) most successful in recruiting and training diverse nurses and nurse faculty. • Identification of the influence of nursing on important health care decisions at all levels.)

•Select one of the research priorities listed in Box 7.3 that is of particular interest to you and applicable to your career interests. Consider the benefits and challenges of researching and addressing this priority in nursing.

•Using the Walden library, identify two to three current articles that address your selected research priority. Consider the current state of research efforts on this priority.

•Reflect on how the research findings for your area of priority impact nurses as leaders in organizations and health care reform. Why is research on this priority important?

Post a description of the priority you selected and the benefits and challenges of further researching this area. Provide an overview of the articles you found (using appropriate APA citations) relating to this priority, and highlight any key findings. Explain how continued research in this area could strengthen the ability of nurses to lead in both individual organizations and as advocates of health care reform.
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NATIONAL ACADEMY OF SCIENCES

NATIONAL ACADEMY OF ENGINEERING

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The Future of Nursing: Leading Change, Advancing Health

Transforming Education

Key Message #2: Nurses should achieve higher lev- els of education and training through an improved education system that promotes seamless academic progression.

Major changes in the U.S. health care system and practice environ- ments will require equally profound changes in the education of nurses both before and after they receive their licenses. Nursing education at all levels needs to provide a better understanding of and experience in care management, quality improvement methods, systems-level change management, and the reconceptualized roles of nurses in a reformed health care system. Nursing education should serve as a platform for continued lifelong learning and include opportunities for seamless tran- sition to higher degree programs. Accrediting, licensing, and certifying organizations need to mandate demonstrated mastery of core skills and competencies to complement the completion of degree programs and written board examinations. To respond to the underrepresentation of racial and ethnic minority groups and men in the nursing workforce, the nursing student body must become more diverse. Finally, nurses should be educated with physicians and other health professionals as students and throughout their careers.

1�3

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1�4 THE FUTURE OF NURSING

Major changes in the U.S. health care system and practice environments will require equally profound changes in the education of nurses both before and after they receive their licenses. In Chapter 1, the committee set forth a vision of health care that depends on a transformation of the roles and responsibilities of nurses. This chapter outlines the fundamental transformation of nurse education that must occur if this vision is to be realized.

The primary goals of nursing education remain the same: nurses must be prepared to meet diverse patients’ needs; function as leaders; and advance sci- ence that benefits patients and the capacity of health professionals to deliver safe, quality patient care. At the same time, nursing education needs to be transformed in a number of ways to prepare nursing graduates to work collaboratively and effectively with other health professionals in a complex and evolving health care system in a variety of settings (see Chapter 3). Entry-level nurses, for example, need to be able to transition smoothly from their academic preparation to a range of practice environments, with an increased emphasis on community and public health settings. And advanced practice registered nurses (APRNs) need graduate programs that can prepare them to assume their roles in primary care, acute care, long-term care, and other settings, as well as specialty practices.

This chapter addresses key message #2 set forth in Chapter 1: Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. The chapter begins by focusing on nurses’ undergraduate education, emphasizing the need for a greater number of nurses to enter the workforce with a baccalaureate degree or to prog- ress to this degree early in their career. This section also outlines some of the challenges to meeting undergraduate educational needs. The chapter then turns to graduate nursing education, stressing the need to increase significantly the numbers and preparation of nurse faculty and researchers at the doctoral level. The third section explores the need to establish, maintain, and expand new com- petencies throughout a nurse’s education and career. The chapter next addresses the challenge of underrepresentation of racial and ethnic minority groups and men in the nursing profession and argues that meeting this challenge will require increasing the diversity of the nursing student body. The fifth section describes some creative solutions that have been devised for addressing concerns about educational capacity and the need to transform nursing curricula. The final sec- tion presents the committee’s conclusions regarding the improvements needed to transform nursing education.

The committee could have devoted this entire report to the topic of nursing education—the subject is rich and widely debated. However, the committee’s statement of task required that it examine a range of issues in the field, rather than delving deeply into the many challenges involved in and solutions required to advance the nursing education system. Several comprehensive reports and analy- ses addressing nursing education have recently been published. They include a 2009 report from the Carnegie Foundation that calls for a “radical transforma-

The Future of Nursing: Leading Change, Advancing Health

TRANSFORMING EDUCATION 1��

tion” of nursing education (Benner et al., 2009); a 2010 report from a conference sponsored by the Macy Foundation that charts a course for “life-long learning” that is assessed by the “demonstration of competency [as opposed to written as- sessment] in both academic programs and in continuing education” (AACN and AAMC, 2010); two consensus reports from the Institute of Medicine (IOM) that call for greater interprofessional education of physicians, nurses, and other health professionals, as well as new methods of improving and demonstrating compe- tency throughout one’s career (IOM, 2003b, 2009); and other articles and reports on necessary curriculum changes, faculty development, and new partnerships in education (Erickson, 2002; Lasater and Nielsen, 2009; Mitchell et al., 2006; Orsolini-Hain and Waters, 2009; Tanner et al., 2008). Additionally, in February 2009, the committee hosted a forum on the future of nursing in Houston, Texas, that focused on nursing education. Discussion during that forum informed the committee’s deliberations and this chapter; a summary of that forum is included on the CD-ROM in the back of this report.1 Finally, Appendix A highlights other recent reports relevant to the nursing profession. The committee refers readers wishing to explore the subject of nursing education in greater depth to these publications.

UNDERGRADUATE EDUCATION

This section begins with an overview of current undergraduate nursing edu- cation, including educational pathways, the distribution of undergraduate degrees, the licensing exam, and costs (see Appendix E for additional background infor- mation on undergraduate education). The discussion then focuses on the need for more nurses prepared at the baccalaureate level. Finally, barriers to meeting undergraduate educational needs are reviewed.

Overview of Current Undergraduate Education

Educational Pathways

Nursing is unique among the health care professions in the United States in that it has multiple educational pathways leading to an entry-level license to prac- tice (see the annexes to Chapter 1 and Appendix E). For the past four decades, nursing students have been able to pursue three different educational pathways to become registered nurses (RNs): the bachelor’s of science in nursing (BSN), the associate’s degree in nursing (ADN), and the diploma in nursing. More re- cently, an accelerated, second-degree bachelor’s program for students who pos- sess a baccalaureate degree in another field has become a popular option. This multiplicity of options has fragmented the nursing community and has created

1 The summary also can be downloaded at http://www.iom.edu.

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1�� THE FUTURE OF NURSING

confusion among the public and other health professionals about the expectations for these educational options. However, these pathways also provide numerous opportunities for women and men of modest means and diverse backgrounds to access careers in an economically stable field.

In addition to the BSN, ADN, or diploma received by RNs, another under- graduate-level program available is the licensed practical/vocational diploma in nursing. Licensed practical/vocational nurses (LPNs/LVNs) are especially impor- tant because of their contributions to care in long-term care facilities and nursing homes.2 LPNs/LVNs receive a diploma after completion of a 12-month program. They are not educated or licensed for independent decision making for complex care, but obtain basic training in anatomy and physiology, nutrition, and nursing techniques. Some LPNs/LVNs continue their education to become RNs; in fact, approximately 17.9 percent of RNs were once licensed as LPNs/LVNs (HRSA, 2010b). While most LPNs/LVNs have an interest in advancing their education, a number of barriers to their doing so have been cited, including financial con- cerns, lack of capacity and difficulty getting into ADN and BSN programs, and family commitments (HRSA, 2004). Although this chapter focuses primarily on the education of RNs and APRNs, the committee recognizes the contributions of LPNs/LVNs in improving the quality of health care. The committee also recog- nizes the opportunity the LPN/LVN diploma creates as a possible pathway toward further education along the RN and APRN tracks for the diverse individuals who hold that diploma.

Distribution of Undergraduate Degrees

At present, the most common way to become an RN is to pursue an ADN at a community college. Associate’s degree programs in nursing were launched in the mid-20th century in response to the nursing shortage that followed World War II (Lynaugh, 2008; Lynaugh and Brush, 1996). The next most common undergradu- ate nursing degree is the BSN, a 4-year degree typically offered at a university. Baccalaureate nursing programs emphasize liberal arts, advanced sciences, and nursing coursework across a wider range of settings than are addressed by ADN programs, along with formal coursework that emphasizes both the acquisition of leadership development and the exposure to community and public health com- petencies. The least common route to becoming an RN currently is the diploma program, which is offered at a hospital-based school and generally lasts 3 years. During the 20th century, as nursing gained a stronger theoretical foundation and other types of nursing programs increased in number, the number of diploma programs declined remarkably except in a few states, such as New Jersey, Ohio,

2 While titles for LPNs and LVNs vary from state to state, their responsibilities and education are relatively consistent. LPNs/LVNs are required to pass the National Council Licensure Examination for Practical Nurses (NCLEX-PN) to secure a license to practice.

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TRANSFORMING EDUCATION 1��

and Pennsylvania. Figure 4-1 gives an overview of trends in the distribution of nursing graduates by initial nursing degree.

Entry into Practice: The Licensing Exam3

Regardless of which educational pathway nursing students pursue, those working toward an RN must ultimately pass the National Council Licensure Examination for Registered Nurses (NCLEX-RN), which is administered by the National Council of State Boards of Nursing (NCSBN), before they are granted a license to practice. Rates of success on the NCLEX-RN are often used for rating schools or for marketing to potential students. As with many entry-level licensing exams, however, the NCLEX-RN uses multiple-choice, computer-based methods to test the minimum competency required to practice nursing safely. The exam is administered on a pass/fail basis and, although rigorous, is not meant to be a test of optimal performance. Following passage of the exam, individual state boards of nursing grant nurses their license to practice.

The content of the NCLEX-RN is based on surveys of what new nurses need to know to begin their practice. As with most entry-level licensing exams, the

3 See https://www.ncsbn.org/nclex.htm.

Fig 4-1.eps

100

2003 2004 2005 2006 2007 2008 Year

P er

ce n

ta g

BSN Diploma ADN

Total: 76,659

Total: 78,476

Total: 84,878

Total: 92,122

Total: 94,949

Total: 106,095

62 63 60 60 60

4 4 4 3 3

34 33 36 37 36

FIGURE 4-1 Trends in graduation from basic RN programs, by type, 2002−2008. SOURCE: NLN, 2010b.

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1�� THE FUTURE OF NURSING

content of the NCLEX-RN directly influences the curricula used to educate nurs- ing students. Currently, the exam is skewed toward acute care settings because this is where the majority of nurses are first employed and where most work throughout their careers. To keep pace with the changing demands of the health care system and patient populations, including the shift toward increasing care in community settings (see Chapter 2), the focus of the exam will need to shift as well. Greater emphasis must be placed on competencies related to community health, public health, primary care, geriatrics, disease prevention, health promo- tion, and other topics beyond the provision of nursing care in acute care settings to ensure that nurses are ready to practice in an evolving health care system.

Costs of Nursing Education

Although a limited number of educational grants and scholarships are avail- able, most of individuals seeking nursing education must finance their own education at any level of preparation. Costs vary based on the pathway selected for basic preparation and through to doctoral preparation. The LPN degree is the least expensive to attain, followed by the ADN, BSN (accelerated program), BSN, master’s of science in nursing (MSN), and PhD/doctor of nursing practice (DNP) degrees. It is no surprise that educational costs and living expenses play a major role in determining which degree is pursued and the numbers of nurses who seek advanced degrees.

To better understand the costs of nursing education, the committee asked the Robert Wood Johnson Foundation (RWJF) Nursing Research Network to estimate the various costs associated with pursuing nursing education, specifically at the advanced practice level, in comparison with those for a medical doctor (MD) or doctor of osteopathy (DO). The RWJF Nursing Research Network produced sev- eral comparison charts in an attempt to convey accurately the differences in costs between alternative nursing degrees and the MD or DO degree. This task required making assumptions about public versus private and proprietary/for-profit educa- tion options, prerequisites for entry, and years required to complete each degree. An area of particular difficulty arose in assessing costs associated with obtain- ing an ADN degree. In most non−health care disciplines, the associate’s degree takes 2 years to complete. In nursing, however, surveys have found that it takes students 3 to 4 years to complete an ADN program because of the need to fulfill prerequisites necessary to prepare students for entry into degree programs and the lack of adequate faculty, which lead to long waiting lists for many programs and classes (Orsolini-Hain, 2008). Box 4-1 illustrates the challenges of this task by outlining the difficulty of comparing the cost of becoming a physician with the cost of becoming an APRN. The task of comparing the increasing “sticker costs” of nursing and medical education was complicated further because much of the data needed to compute those costs is either missing or drawn from incomparable years. In the end, the committee decided not to include detailed discussion of the costs of nursing education in this report.

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TRANSFORMING EDUCATION 1��

BOX 4-1 Costs of Health Professional Education

Depending on the method used, the number of advanced practice registered nurses (APRNs) that can be trained for the cost of training 1 physician is between 3 and 14. Assessing the costs of education is a multidimensional problem. Manno (1998) has suggested that costs for higher education can be measured in at least four ways:

• “the production cost of delivering education to students; • the ‘sticker price’ that students/families are asked to pay; • the cost to students to attend college, including room and board, books and

supplies, transportation, tuition, and fees; and • the net price paid by students after financial aid awards” (Starck, 2005).

While the first of these measures, the production cost to the institution, is the most complete, it is the most complex to derive. One study attempted to compare the educational cost for various health professions. This study, sponsored by the Association of Academic Health Centers (Gonyea, 1998), used the 1994 method- ology of Valberg and colleagues, which included 80 percent essential education and 20 percent complementary research and service (Valberg et al., 1994). The conclusion reached was that for every 1 physician (4 years), 14 advanced nurse practitioners or 12 physician assistants could be produced (Starck, 2005). If one examines simply the cost to students of postsecondary training (the “sticker price”), the differences among professions are slightly less dramatic. The cost to students is defined as the tuition and fees students/families pay. This measure does not include costs associated with room and board, books, trans- portation, and other living expenses. Nor does it include those costs incurred by the educational programs that may be beyond what is covered by tuition revenues. Residency programs for physicians are not included in this estimate because students do not pay them. Medical residencies are funded largely by Medicare, and in 2008, totaled ap- proximately $9 billion per year ($100,000 on average for each of about 90,000 residents) for graduate medical education (MedPAC, 2009). Some of the Medicare expenditures are for indirect costs, such as the greater costs associated with oper- ating a teaching hospital. Estimates of the average cost per resident for the federal government are difficult to establish because of the wide variation in payments by specialty and type of hospital. In addition, residency costs vary significantly by year, with the early years requiring more supervision than the later years.

Why More BSN-Prepared Nurses Are Needed

The qualifications and level of education required for entry into the nursing profession have been widely debated by nurses, nursing organizations, academ- ics, and a host of other stakeholders for more than 40 years (NLN, 2007). The causal relationship between the academic degree obtained by RNs and patient outcomes is not conclusive in the research literature. However, several studies

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1�0 THE FUTURE OF NURSING

support a significant association between the educational level of RNs and out- comes for patients in the acute care setting, including mortality rates (Aiken et al., 2003; Estabrooks et al., 2005; Friese et al., 2008; Tourangeau et al., 2007; Van den Heede et al., 2009). Other studies argue that clinical experience, quali- fications before entering a nursing program (e.g., SAT scores), and the number of BSN-prepared RNs that received an earlier degree confound the value added through the 4-year educational program. One study found that the level of experi- ence of nurses was more important than their education level in mitigating medi- cation errors in hospitals (Blegen et al., 2001). Another study performed within the Department of Veterans Affairs (VA) system found no significant association between the proportion of RNs with a baccalaureate degree and patient outcomes at the hospital level (Sales et al., 2008).

This debate aside, an all-BSN workforce at the entry level would provide a more uniform foundation for the reconceptualized roles for nurses and new models of care that are envisioned in Chapters 1 and 2. Although a BSN education is not a panacea for all that is expected of nurses in the future, it does, relative to other educational pathways, introduce students to a wider range of competencies in such arenas as health policy and health care financing, leadership, quality improvement, and systems thinking. One study found that new BSN graduates reported signifi- cantly higher levels of preparation in evidence-based practice, research skills, and assessment of gaps in areas such as teamwork, collaboration, and practice (Kovner et al., 2010)—other important competencies for a future nursing workforce. More- over, as more nurses are being called on to lead care coordination efforts, they should have the competencies requisite for this task, many of which are included in the American Association of Colleges of Nursing’s (AACN’s) Essentials of Baccalaureate Education for Professional Nursing Practice.4

Care within the hospital setting continues to grow more complex, and nurses must make critical decisions associated with care for sicker, frailer patients. Care in this setting depends on sophisticated, life-saving technology coupled with complex information management systems that require skills in analysis and synthesis. Care outside the hospital is becoming more complex as well. Nurses are being called upon to coordinate care among a variety of clinicians and com- munity agencies; to help patients manage chronic illnesses, thereby preventing acute care episodes and disease progression; and to use a variety of technological tools to improve the quality and effectiveness of care. A more educated nursing workforce would be better equipped to meet these demands.

An all-BSN workforce would also be poised to achieve higher levels of edu- cation at the master’s and doctoral levels, required for nurses to serve as primary care providers, nurse researchers, and nurse faculty—positions currently in great demand as discussed later in this chapter. Shortages of nurses in these positions continue to be a barrier to advancing the profession and improving the delivery of care to patients.

4 See http://www.aacn.nche.edu/education/pdf/BaccEssentials08.pdf.

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TRANSFORMING EDUCATION 1�1

Some health care organizations in the United States are already leading the way by requiring more BSN-prepared nurses for entry-level positions. A growing number of hospitals, particularly teaching and children’s hospitals and those that have been recognized by the American Nurses Credentialing Center Magnet Recognition Program (see Chapter 5), favor the BSN for employment (Aiken, 2010). Depending on the type of hospital, the goal for the proportion of BSN-prepared nurses varies; for example, teaching hospitals aim for 90 percent, whereas community hospitals seek at least 50 percent (Goode et al., 2001). Ab- sent a nursing shortage, then, nurses holding a baccalaureate degree are usually the preferred new-graduate hires in acute care settings (Cronenwett, 2010). Like- wise, in a recent survey of 100 physician members of Sermo.com (see Chapter 3 for more information on this online community), conducted by the RWJF Nursing Research Network, 76 percent of physicians strongly or somewhat agreed that nurses with a BSN are more competent than those with an ADN. Seventy percent of the physicians surveyed also either strongly or somewhat agreed that all nurses who provide care in a hospital should hold a BSN, although when asked about the characteristics they most value in nurses they work with, the physicians placed a significantly higher value on compassion, efficiency, and experience than on years of nursing education and caliber of nursing school (RWJF, 2010c).

In community and public health settings, the BSN has long been the preferred minimum requirement for nurses, given the competencies, knowledge of com- munity-based interventions, and skills that are needed in these settings (ACHNE, 2009; ASTDN, 2003). The U.S. military and the VA also are taking steps to ensure that the nurses making up their respective workforces are more highly educated. The U.S. Army, Navy, and Air Force require all active duty RNs to have a bac- calaureate degree to practice, and the U.S. Public Health Service has the same requirement for its Commissioned Officers. Additionally, as the largest employer of RNs in the country, the VA has established a requirement that nurses must have a BSN to be considered for promotion beyond entry level (AACN, 2010c). As Table 4-1 shows, however, the average earnings of BSN-prepared nurses are not substantially higher than those of ADN- or diploma-prepared nurses.

Decades of “blue ribbon panels” and reports to Congress on the health care workforce have found that there is a significant shortage of nurses with bac- calaureate and higher degrees to respond to the nation’s health needs (Aiken, 2010). Almost 15 years ago, the National Advisory Council on Nurse Education and Practice, which advises Congress and the secretary of Health and Human Services on areas relevant to nursing, called for the development of policy ac- tions that would ensure a minimum of 66 percent of RNs who work as nurses would have a BSN or higher degree by 2010 (Aiken et al., 2009). The result of policy efforts of the past decade has been a workforce in which approximately 50 percent of RNs hold a BSN degree or higher, a figure that includes ADN- and diploma-educated RNs who have gone on to obtain a BSN (HRSA, 2010b). Of significant note, the Tri-Council for Nursing, which consists of the Ameri- can Nurses Association, American Organization of Nurse Executives, National

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1�2 THE FUTURE OF NURSING

TABLE 4-1 Average Earnings of Full-Time RNs, by Highest Nursing or Nursing-Related Education and Job Title

Position

Earnings

Diploma ($)

Associate’s Degree ($)

Bachelor’s Degree ($)

Master’s/ Doctoral Degree ($)

Overall Average ($)

All nurses 65,349 60,890 66,316 87,363 66,973 Staff nurse 63,027 59,310 63,382 69,616 61,706 First-line management 68,089 66,138 75,144 85,473 72,006 Senior/middle management 74,090 69,871 79,878 101,730 81,391 Patient coordinator 62,693 60,240 64,068 71,516 62,978

NOTE: Only those who provided earnings information to surveyors are included in the calculations used for this table. SOURCE: HRSA, 2010b.

League for Nursing (NLN), and AACN, recently released a consensus policy statement calling for a more highly educated nursing workforce, citing the need to increase the number of BSN-prepared nurses to deliver safer and more effec- tive care (AACN, 2010a).

In sum, an increase in the percentage of nurses with a BSN is imperative as the scope of what the public needs from nurses grows, expectations surround- ing quality heighten, and the settings where nurses are needed proliferate and become more complex. The formal education associated with obtaining the BSN is desirable for a variety of reasons, including ensuring that the next generation of nurses will master more than basic knowledge of patient care, providing a stronger foundation for the expansion of nursing science, and imparting the tools nurses need to be effective change agents and to adapt to evolving models of care. As discussed later in this chapter, the committee’s recommendation for a more highly educated nursing workforce must be paired with overall improvements to the education system and must include competencies in such areas as leader- ship, basic health policy, evidence-based care, quality improvement, and systems thinking. Moreover, even as the breadth and depth of content increase within prelicensure curricula, the caring essence and human connectedness nurses bring to patient care must be preserved. Nurses need to continue to provide holistic, patient-centered care that goes beyond physical health needs to recognize and respond to the social, mental, and spiritual needs of patients and their families. Other fundamental elements of nursing education, such as ethics and integrity, need to remain intact as well.

The Goal and a Plan for Achieving It

In the committee’s view, increasing the percentage of the current nursing work- force holding a BSN from 50 to 100 percent in the near term is neither practical

The Future of Nursing: Leading Change, Advancing Health

TRANSFORMING EDUCATION 1�3

nor achievable. Setting a goal of increasing the percentage to 80 percent by 2020 is, however, bold, achievable, and necessary to move the nursing workforce to an expanded set of competencies, especially in the domains of community and public health, leadership, systems improvement and change, research, and health policy.

The committee believes achieving the goal of 80 percent of the nursing work- force having a BSN is possible in part because much of the educational capacity needed to meet this goal exists. RNs with an ADN or diploma degree have a number of options for completing the BSN, as presented below. The combination of these options and others yet to be developed will be needed to meet the 80 per- cent goal—no one strategy will provide a universal solution. Technologies, such as the use of simulation and distance learning through online courses, will have to play a key role as well. Above all, what is needed to achieve this goal is the will of nurses to return to higher education, support from nursing employers and others to help fund nursing education, the elevation of educational standards, an education system that recognizes the experience and previous learning of return- ing students, and regional collaboratives of schools of nursing and employers to share financial and human resources.

While there are challenges associated with shortages of nurse faculty and clinical education sites (discussed below), these challenges are less problematic for licensed RNs pursuing a BSN than for prelicensure students, who require more intense oversight and monitoring by faculty. Additionally, most of what ADN-prepared nurses need to move on to a baccalaureate degree can be taught in a classroom or online, with additional tailored clinical experience. Online educa- tion creates flexibility and provides an additional skill set to students who will use technology into the future to retrieve and manage information.

Over the course of its deliberations and during the forum on education held in Houston, the committee learned about several pathways that are available to achieve the goal of 80 percent of the nursing workforce having a BSN (additional innovations discussed at the forum on education can be found in the forum sum- mary on the CD-ROM in the back of this report). For RNs returning to obtain their BSN, a number of options are possible, including traditional RN-to-BSN programs. Many hospitals also have joint arrangements with local universities and colleges to offer onsite classes. Hospitals generally provide stipends to employ- ees as an incentive to continue their education. Online education programs make courses available to all students regardless of where they live. For prospective nursing students, there are traditional 4-year BSN programs at a university, but there are also community colleges now offering 4-year baccalaureate degrees in some states (see the next section). Educational collaboratives between universities and community colleges, such as the Oregon Consortium for Nursing Education (described in Box 4-2), allow for automatic and seamless transition from an ADN to a BSN program, with all schools sharing curriculum, simulation facilities, and faculty. As described below, this type of model is goes beyond the conventional articulation agreement between community colleges and universities. Beyond traditional nursing schools, new providers of nursing education are entering the

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1�4 THE FUTURE OF NURSING

BOX 4-2 Case Study: The Oregon Consortium

for Nursing Education (OCNE)

Sharing Resources to Prepare the Next Generation of Nurses

In 2006, when Basilia Basin, BSN, RN, entered nursing school at Mount Hood Community Col-lege in Gresham, Oregon, near Portland, she was not sure whether she would pursue a bachelor’s de- gree. A paycheck was important, she thought, and if she could obtain an associate’s degree and a license after 3 years of schooling, why stay on for a fourth year to get her bachelor’s? She took her time answering the question, but in the end she went for “the opportunity for professional development,” she said.

Ms. Basin was in the first class of nursing students affiliated with the Oregon Consortium for Nurs- ing Education (OCNE; www.ocne. org), a partnership, formed in 2003, between the five geographically dis- persed campuses of Oregon Health & Science University (OHSU) and eight community colleges across Oregon. The 13 campuses share a standard, competency-based curriculum that was developed by faculty at full- partner community colleges and the university. The model makes the best

OCNE is an outgrowth of a great need in Oregon for a new kind of nurse. That new nurse is capable of independent decision making while practicing in acute care settings and able to marshal the best available evidence while providing leadership within changing systems.

—Christine A. Tanner, PhD, RN, A. B. Youmans-Spaulding distinguished professor, School of Nursing, Oregon Health & Science University, Portland, Oregon

use of scarce resources by pool- ing faculty, classrooms, and clinical education resources in a state with urban, rural, and frontier settings (Gubrud-Howe et al., 2003; Tanner et al., 2008). Community college nursing students can obtain their associate’s degree in 3 years and continue for another year at OHSU to receive their baccalaureate without leaving their rural communities. This is facilitated through a seamless co-enrollment process across types of schools and financial aid transfers from the community college to the

market, such as proprietary/for-profit schools. These programs are offering new models and alternatives for delivering curriculum and reaching RNs and prospec- tive students, although each of these schools should be evaluated for its ability to meet nursing accreditation standards, including the provision of clinical experi- ences required to advance the profession.

Two other important programs designed to facilitate academic progression to higher levels of education are the LPN-to-BSN and ADN-to-MSN programs.

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university. The overarching goal is twofold: to broaden and strengthen the professional competency of new nurses like Ms. Basin and to use scarce resources wisely to address the nursing shortage.

Ms. Basin took her nursing licen- sure examination after she attained her associate’s degree, remaining dually enrolled at Mount Hood and OHSU. “It was quite a unique experi- ence,” she said, “working as a nurse and being in school to become a nurse.”

That experience is one that Christine A. Tanner, PhD, RN, FAAN, would like to make less unique for nursing students in her state. “We created a system that makes the best use of faculty resources, clinical training sites, and the strengths of the community college systems and the university,” said Dr. Tanner, A. B. Youmans-Spaulding distinguished professor at OHSU’s nursing school. Using resources more efficiently was not her sole aim, however. The nation needs “a new kind of nurse,” she said, one competent in the skills needed for care in the 21st century. But only 21 percent of nurses receiv- ing an associate’s degree nation- wide go on to obtain a bachelor’s degree (HRSA, 2006), leaving the nation with an insufficient supply of nurses who can become faculty, advanced practice registered nurses, or clinicians prepared for a future

health care system that emphasizes community-based care.

Dr. Tanner knew that nursing schools needed a new kind of cur- riculum. She and her OHSU col- leagues met with representatives of the community colleges and agreed to craft a single nursing curriculum that would span all 13 campuses. The first course in the program, after prerequisites, is health promotion. It introduces students to clinical deci- sion making and nursing leadership— “learning to think like a nurse,” as Dr. Tanner put it—as they relate to prevention and wellness. Students then move on to courses in chronic illness management and acute care. Those who remain enrolled for the bachelor’s take courses in population- based care, epidemiology, leadership, and outcome management.

Although the number of nurs- ing students per faculty member in Oregon nearly doubled between 2001 and 2008 (Oregon Center for Nursing, 2009), 95 to 100 percent of graduates of OCNE schools pass the nursing licensure exam (the national average is 88 percent [NCSBN, 2009]). Of students in the OCNE system who attain an associate’s de- gree, 45 percent receive a bachelor’s degree. One important result is that nurses with a baccalaureate are becoming more widely distributed in rural areas.

Dr. Tanner is working on edu- continued

The ADN-to-MSN program, in particular, is establishing a significant pathway to advanced practice and faculty positions, especially at the community college level. Financial support to help build capacity for these programs will be impor- tant, including funding for grants and scholarships for nurses wishing to pursue these pathways. By the same token, the committee believes that diploma pro- grams should be phased out over the next 10 years and should consolidate their resources with those of community college or preferably university programs

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cational redesign with the Center to Champion Nursing in America, funded by the Robert Wood Johnson Foundation, and its state partner- ships of nursing and other stakehold- ers concerned about the nursing shortage. Ten state partnerships have committed to adopting the model; five states—Hawaii, New York, North Carolina, California, and New Mex- ico—have already begun. Dr. Tanner is consulting with faculty members in at least ten other states, and the nation’s largest urban public university system,

the City University of New York, is adopting the model as well.

Robyn Alper, MA, BSN, RN, an OCNE graduate now working as a nurse for a county in northern Or- egon, may personify the OCNE ideal. “The students coming out of OCNE have the skill to practice anywhere, but with an eye toward being a leader in the profession,” Ms. Alper said. “I feel I can go out into the community—not with every skill per- fectly honed, but I know how to find what I need to get my job done.”

BOX 4-2 continued

Bruce Beaton Nursing students study together. OCNE provides a supportive environment and opportu- nities for students to progress seamlessly to a BSN degree.

offering the baccalaureate degree. Additionally, there are federal resources cur- rently being used to support diploma schools that could better be used to expand baccalaureate and higher education programs.

The committee anticipates that it will take a few years to build the educa- tional capacity needed to achieve the goal of 80 percent of the nursing workforce being BSN-prepared by 2020, but also emphasizes that existing BSN completion programs have capacity that is far from exhausted. Regional networks of schools

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working together, along with health care organizations, may best facilitate reach- ing this goal. Moreover, the committee believes this clearly defined goal will stimulate stakeholders to take action. Examples of such action include academic and health care organizations/employers partnering to achieve strategic alignment around workforce development; government and foundations introducing fund- ing opportunities for scholarships to build faculty and provide tuition relief; state boards of nursing increasing the use of earmarks on licensure fees to offset the cost of education; and states developing statewide policy agendas and political action plans with identified leaders in nursing, government, and business to adopt measures to meet the goal.

The Role of Community Colleges

Community colleges play a key role in attracting students to the nursing education pipeline. Specifically, they provide an opportunity for students who may not have access to traditional university baccalaureate programs because of those programs’ lack of enrollment capacity, distance, or cost.

Community colleges have an important role to play in ensuring that more BSN-prepared nurses are available in all regions of the United States and that nursing education at the associate level is high quality and affordable and pre- pares ADN nurses to move on to higher levels of education. Currently, ADN- and BSN-prepared nurses are not evenly distributed nationwide. BSN-prepared RNs are found more commonly in urban areas, while many rural and other medically underserved communities depend heavily on nurses with associate’s degrees to staff their hospitals, clinics, and long-term care facilities (Cronenwett, 2010). Figure 4-2 shows the highest nursing or nursing-related education by urban/rural residence. According to a study by the Urban Institute, “medical personnel, in- cluding nurses, tend to work near where they were trained” (Bovjberg, 2009; see Figure 4-3). This suggests that state and community investments in nursing edu- cation (e.g., building nursing school capacity, building infrastructure to support that capacity, funding the purchase of technology, and offering scholarships) may be an effective way to reduce local and regional shortages. Community colleges are the predominant educational institutions in rural and medically underserved areas. Therefore, they must either join educational collaboratives or develop innovative and easily accessible programs that seamlessly connect students to schools offering the BSN and higher degrees, or they must develop their own BSN programs (if feasible within state laws and regulations). Community col- leges must foster a culture that promotes and values academic progression and should encourage their students to continue their education through strategies that include making them aware of the full range of educational pathways and oppor- tunities available to them (e.g., ADN-to-MSN and online RN-to-BSN programs). Box 4-3 describes a community college in Florida where nursing students can take advantage of lower costs and online classes to receive a BSN degree.

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Fig 4-2.eps

100

Urban Rural Residence

P er

ce n

ta g

Diploma Associate’s Baccalaureate Master Doctorate

Fig 4-3.eps

30.0

48.1

17.017.9 17.0 22.4

10.9

21.2

45.5

14.715.4

39.9

0.0

10.0

20.0

30.0

40.0

50.0

60.0

= 15/ = 40/ = 100

Diploma Associate’s Baccalaureate

P er

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ta g

Distance (miles)

FIGURE 4-2 Highest nursing or nursing-related education by urban/rural residence. SOURCE: Calculations performed using the data and documentation for the 2004 Na- tional Sample of Registered Nurses, available from the Health Resources and Services Administration’s Geospatial Data Warehouse (HRSA, 2010a).

FIGURE 4-3 Distance between nursing education program and workplace for early- career nurses (graduated 2007−2008). SOURCE: RWJF, 2010a. Reprinted with permission from Lori Melichar, RWJF.

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Barriers to Meeting Undergraduate Educational Needs

Although the committee believes the capacity needed to ensure a nursing workforce that is 80 percent BSN-prepared by 2020 can be attained using the approaches outlined above, getting there will not be easy. Nursing schools across the United States collectively turn away tens of thousands of qualified applicants each year because of a lack of capacity (Kovner and Djukic, 2009)—a situation that makes filling projected needs for more and different types of nurses difficult. Figure 4-4 shows the breakdown of numbers of qualified applicants who are turned away from ADN and BSN programs.

An examination of the root causes of the education system’s insufficient capacity to meet undergraduate educational needs reveals four major barriers: (1) the aging and shortage of nursing faculty; (2) insufficient clinical placement op- portunities of the right kind or duration for prelicensure nurses to learn their pro- fession; (3) nursing education curricula that fail to impart relevant competencies needed to meet the future needs of patients and to prepare nurses adequately for academic progression to higher degrees; and (4) inadequate workforce planning, which stems from a lack of the communications, data sources, and information systems needed to align educational capacity with market demands. This final root cause—inadequate workforce planning—affects all levels of nursing educa- tion and is the subject of Chapter 6.

Aging and Shortage of Nursing Faculty

There are not enough nursing faculty to teach the current number of nursing students, let alone the number of qualified applicants who wish to pursue nursing. The same forces that are leading to deficits in the numbers and competencies of bedside nurses affect the capacity of nursing faculty as well (Allan and Aldebron, 2008). According to a survey by the NLN, 84 percent of U.S. nursing schools tried to hire new faculty in the 2007−2008 academic year; of those, four out of five found it “difficult”5 to recruit faculty, and one out of three found it “very difficult.” The principal difficulties included “not enough qualified candidates” (cited by 46 percent) and the inability to offer competitive salaries (cited by 38 percent). The survey concluded that “post-licensure programs were much more likely to cite a shortage of faculty, whereas pre-licensure programs reported that lack of clinical placement settings were [sic] the biggest impediment to admitting more students. Specifically, almost two thirds (64 percent) of doctoral programs and one half of RN-BSN and master’s programs identified an insufficient faculty pool to draw from as the major constraint to expansion, in contrast to one third of prelicensure programs” (NLN, 2010a).

5 “Difficult” is the sum of schools responding either “somewhat difficult” or “very difficult.” Per- sonal communication, Kathy A. Kaufman, Senior Research Scientist, Public Policy, National League for Nursing, September 8, 2010.

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BOX 4-3 Case Study: Community Colleges Offering the BSN

The College of Nursing at St. Petersburg College and Others Open the Door to the Bachelor’s Degree in Nursing

Tamela Monroe was 33 and working in sales in 1997 when she decided to pursue a career in nursing. She looked into the associate’s degree program at a campus of St. Petersburg Junior College about a mile from her home in Palm Harbor, Florida. She did not consider the bachelor’s of science in nursing (BSN) program at the Univer- sity of South Florida (USF) in Tampa; she had started working as a nurse’s aide and felt she could not give up her job to go to school full time. “I was just starting out in nursing,” she said. “And to lose any more money would not have been a good thing.” She earned her associate’s degree in 2001.

When St. Petersburg Junior College changed its name to St. Petersburg College in 2002 and be- came the first baccalaureate-granting community college in Florida, Ms. Monroe pursued the BSN there. She was a licensed registered nurse (RN) working in a cardiac progressive care unit; classes were held in the com- munity hospital where she worked. She received her bachelor’s degree in 2004, and went on to USF to obtain her master’s degree in 2006. Now 46, she is a clinical nurse leader in an orthopedic and neuroscience unit in a Tampa-area facility, as well as an

adjunct instructor in nursing at Saint Petersburg College.

The more education a nurse has, the better the patient outcomes you’re go- ing to see.

—Jean Wortock, PhD, MSN, ARNP, dean and professor, College of Nursing at St. Petersburg College, St. Peters- burg, Florida

The first community college in Florida to grant baccalaureate degrees, St. Petersburg College enrolled the first students in its BSN program in 2002. Now, its 613 BSN students and 687 associate’s degree in nursing students can take classes on campus or online. Nine commu- nity colleges in Florida offer the BSN, and at least three other states are working on allowing their commu- nity colleges to offer baccalaureates, including BSNs.

Ms. Monroe is grateful to have earned a BSN at a cost 20 percent lower than the university’s tuition, and she sees this as an important development in nursing education. “It presents an opportunity for nurses in this area who might not have the finances or the time to travel all the way to a larger campus,” she said.

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Some critics argue that in granting baccalaureates, community colleges are reaching beyond the bounds of their original mission of granting 2-year degrees as a stepping stone to a university education. Other op- ponents say that community college enrollments—and funds—are already stretched to the limit. In Michigan, for instance, critics say that com- munity college tuition for the BSN will have to rise to avoid the need for more state funding (Lane, 2009).

Still, many nurses are praising the quality, convenience, flexibility, and affordability of the BSN programs available at community colleges. Jean Wortock, PhD, MSN, ARNP, dean and professor of nursing at Saint Peters- burg College, said her school’s BSN program is opening up an important channel for Florida nurses to advance their education in a state where 46 percent of qualified applicants to BSN programs were turned away in 2009 because of faculty shortages and other factors (Florida Center for Nurs- ing, 2010). “We strongly encourage all of our baccalaureate graduates to go on for master’s degrees,” she said. “And a number of ours have.”

Dr. Wortock said that St. Peters- burg College and USF have worked closely in the past 9 years to deter- mine the degrees each institution would offer: “We’re offering some that they prefer not to offer so that they can focus more on master’s programs in a particular field.” St. Petersburg College now offers 22 bachelor’s degrees, and even though both institutions have RN-to-BSN programs, the St. Petersburg nursing

school has had high enough enroll- ments to allow the hiring of eight full-time faculty members with doc- torates to teach in its BSN program.

Dr. Wortock has talked to nurses at community colleges in California, Washington, and Michigan about how her school took the lead in offer- ing the BSN in Florida. And while she acknowledged that the movement is controversial, it is a movement none- theless. “It will give us a cadre of graduates and nurses that are much more prepared for research and evidence-based practice,” she said.

Casey Feldkamp, Institutional Advancement, St. Petersburg College

Nursing instructor Tamela Monroe, herself a former BSN student at St. Petersburg college, teaches nursing students in a virtual classroom.

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Age is also a contributing factor to faculty shortages. Nursing faculty tend to be older than clinical nurses because they must meet requirements for an ad- vanced degree in order to teach. Figure 4-5 shows that the average age of nurses who work as faculty as their principal nursing position—the position in which a nurse spends the majority of his or her working hours�—is 50 to 54. By contrast, the median age of the total RN workforce is 4�. More than 19 percent of RNs whose principal position is faculty are aged �0 or older, while only 8.7 percent

� Personal communication, Joanne Spetz, Professor, Community Health Systems, University of California, San Francisco, September 2, 2010.

Fig 4-4.eps redrew bitmap

2005

120,000

100,000

80,000

60,000

40,000

20,000

0 2006

Year

N u

m b

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f q

u al

if ie

d a

p p

li ca

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2007 2008

BSN (AACN)1

BSN (NLN)2

ADN (NLN)3

Missing NLN data for 2007

2009

FIGURE 4-4 Numbers of qualified applicants not accepted in ADN and BSN programs. NOTES: 1 Number of qualified applicants not accepted in baccalaureate generic RN programs, based on AACN data in Enrollment and Graduations in Baccalaureate and Graduate Pro- grams in Nursing (200�-07, Table 37; 2007-08, Table 39; 2008-09, Table 38; 2009-2010, Table 39). 2 Number of qualified applicants not accepted in baccalaureate generic RN and RN- to-BSN programs, based on National League for Nursing data in Nursing Data Review (2004-05, Tables 3 & �; 2005-0�, Tables 2 & 5; 2007-08; Tables 2 & 5). 3 Number of qualified applicants not accepted in associate’s degree RN programs, based on National League for Nursing data in Nursing Data Review (2004-05, Tables 3 & �; 2005-0�, Tables 2 & 5; 2007-08; Tables 2 & 5). The definition of “qualified” varies from nursing program to nursing program and is based on each program’s admission requirements and completion standards at the schools that were surveyed. SOURCE: RWJF, 2010b. Reprinted with permission from Lori Melichar, RWJF.

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of nurses who have a secondary position as faculty—those who hold a nonfaculty (e.g., clinical) principal position—are aged 60 or older. Nurses who work as fac- ulty as their secondary position tend to be younger; among nurses under age 50, more work as faculty as their secondary than as their principal position (HRSA, 2010b). Moreover, the average retirement age for nursing faculty is 62.5 (Berlin and Sechrist, 2002); as a result, many full-time faculty will be ready to retire soon. Given the landscape of the health care system and the fragmented nursing education system, the current pipeline cannot easily replenish this loss, let alone meet the potential demand for more educators. In addition to the innovative strate- gies of the Veterans Affairs Nursing Academy (VANA) and Gulf Coast Health Services Steering Committee for responding to faculty shortages (discussed later in this chapter), a potential opportunity to relieve faculty shortages could involve the creation of programs that would allow MSN, DNP, and PhD students to teach as nursing faculty interns, with mentoring by full-time faculty. Box 4-4 presents a nurse profile of one assistant professor and her experience moving into an academic career.

Effects of the first degree at entry into the profession Nurses who enter the profession with an associate’s degree are less likely than those who enter with a

Figure 4-5.eps

5.7

10.0

15.3

21.0 19.9

10.9 8.8

13.6 12.1

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15.2

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8.3

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Under 35 35 to 39 40 to 44 45 to 49 50 to 54 55 to 59 60 to 64 65 & over

Age groups

P er

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Principal position Secondary position

FIGURE 4-5 Age distribution of nurses who work as faculty. SOURCE: HRSA, 2010b.

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BOX 4-4 Nurse Profile: Jennifer Wenzel*

Pursuing an Academic Career

Although she believes that “all nurses make a difference, wherever we practice, what-ever we do,” Jennifer Wenzel, PhD, RN, CCM, said that her primary motivation in choosing an academic career, one that combined research with teaching, was that it gave her a way “to have a wider, broader impact.”

She’s an assistant professor of nursing at Johns Hopkins University in Baltimore, the manager of the Center for Collaborative Intervention Research, and the principal investiga- tor or co-investigator on 17 research projects in the past decade. In her research Dr. Wenzel has explored, among other topics, rural African Americans with cancer and self-care in patients with diabetes. She has also studied “professional bereave- ment” and resilience in oncology nurses—how nurses cope with the recurring loss of patients—with lead researcher Sharon Krumm, PhD, RN. Dr. Wenzel said that one not-so-surprising finding has been a discussion of “some of the pressures and demands that nurses place on themselves and on each other.”

What she finds exciting about her work, whether with students or with

research subjects, she said, is “the opportunity for sustainability. I’m trying to build something that has a lasting effect. That’s always been my dream—what can we give people that will help them, not just in the situation that they’re in, but in future situations, as well?”

*This nurse profile was inadvertently omitted from the prepublication version of this report.

bachelor’s degree to advance to the graduate level over the course of their career (Cleary et al., 2009). Figure 4-6 gives an overview of the highest educational de- gree obtained by women and men who hold the RN license. It includes RNs who are working as nurses and those who have retired, have changed professions, or are no longer working. According to an analysis by Aiken and colleagues (2009),

Keith Weller

Jennifer Wenzel, PhD, RN, CCM

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The “broader impact,” the “last- ing effect”: these are the goals of a woman reared in a tradition of ser- vice. An adopted child, she grew up in San Diego in a military family that valued hard work, education, and helping others. And even though nei- ther of her parents finished college, they supported her decision to enter a “two-plus-two” nursing program at Southern Adventist University in Col- legedale, Tennessee, in the 1980s.

She went through a bit of culture shock there. As an Asian American, she didn’t look like most of her patients; as a Californian, she didn’t sound like them, either. There were times it became clear that her pa- tients had no idea what she was say- ing: “I would overhear somebody say to another, ‘Is she speaking English? Can you tell?’” Dr. Wenzel said that it taught a lesson that has served her well as a teacher and a researcher: in order to be understood, you have to listen.

She earned an associate’s degree after two years and went on to complete the bachelor’s in two more years while working as a staff nurse in endocrinology at a Chattanooga hospital, supporting not only her own education but also her sister’s. “There had always been this idea that it’s important to give back, that society doesn’t necessarily owe you anything,” Dr. Wenzel said of her family’s values.

After completing her bachelor’s, she taught a clinical course at a Chattanooga community college. She enjoyed it but felt more drawn

to clinical practice and worked as a case manager at a Georgia facility. Her first real immersion in education came at the University of Virginia, where as a doctoral student she was asked to teach a clinical group on inpatient oncology. Other offers soon followed, and she discovered that nurses with advanced degrees always have options.

I challenged a tradition by starting my PhD at a fairly young age. With the critical shortage of faculty, we cannot afford to lose candidates for faculty po- sitions. We probably need them sooner than we can get them.

—Jennifer Wenzel, PhD, RN, CCM, assistant professor of nursing, Johns Hopkins University, Baltimore

That’s the message she’s getting as a Robert Wood Johnson Founda- tion Nurse Faculty Scholar, as well. The national program aids junior nursing faculty in becoming aca- demic leaders, skilled teachers, and productive scholars. And it’s what she tries to impart to her students, too. She tells them: “‘I know that many of you have the ability to [get a doctor- ate] if you want to do it. And don’t let anyone tell you that you can’t.’” That sort of determination continues to fuel her career. “It’s a real pleasure to see people who are starting out doing something that you love,” said Dr. Wenzel. “Seeing their excitement about it reenergizes you and helps to remind you what drew you to the profession.”

nurses whose initial degree is the ADN are just as likely as BSN-prepared nurses to seek another degree. Approximately 80 percent of the time, however, ADN graduates fail to move beyond a BSN. Therefore, the greatest number of nurses with a master’s or doctorate, a prerequisite for serving as faculty, received a BSN as their initial degree. Since two-thirds of current RNs received the ADN as their

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initial degree, Aiken’s analysis suggests that currently “having enough faculty (and other master’s prepared nurses) to enable nursing schools to expand enroll- ment is a mathematical improbability” (Aiken et al., 2009). A separate analysis of North Carolina nurses led to a similar conclusion (Bevill et al., 2007). Table 4-2 shows the length of time it takes those nurses who do move on to higher levels of education to progress from completing initial nursing education to completing the highest nursing degree achieved.

Salary disparities Another factor that contributes to the current nursing faculty shortage is salary disparities between nurses working in education and those working in clinical service (Gilliss, 2010). As shown in Table 4-3, the average an- nual earnings of nurses who work full time as faculty (most with either a master’s or doctoral degree) total $63,949. By contrast, nurse practitioners (NPs) (with

Figure 4-6.eps

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1,500

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2,500

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1980 1984 1988 1992 1996 2000 2004 2008 Degree program

N u

m b

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o u

sa n

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Master’s/doctorate Bachelor’s Associate Diploma

54.7 45.6 40.6 33.7 27.2 22.4 17.8 13.9

17.9 22.9 25.3 28.3 31.8 34.5 34.3 36.1

22.3 25.6

27.6 30.0

31.3 32.8 34.7

36.8

13.2 13.2

10.3 9.7

8.0

5.2

5.9 6.5

FIGURE 4-6 Distribution of the registered nurse population by highest nursing or nursing-related educational preparation, 1980−2008. NOTES: The totals in each bar may not equal the estimated numbers for RNs in each survey year because of incomplete information provided by respondents and the effect of rounding. Only those who provided information on initial RN educational preparation to surveyors were included in the calculations used for this figure. SOURCE: HRSA, 2010b.

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TABLE 4-3 Average Annual Earnings of Nurses Who Work Full Time as Faculty in Their Principal Nursing Position, 2008

Annual Earnings ($)

All Faculty 63,985

Earnings by type of program Faculty in diploma/ADN programs 62,689 Faculty in BSN programs 64,789

Earnings by faculty job title Instructor/lecturer 54,944 Professor 69,691

SOURCE: HRSA, 2010b. NOTE: Only registered nurses who provided earnings information were included in the calculations used for this table.

TABLE 4-2 Years Between Completion of Initial and Highest RN Degrees

Initial RN Education

Highest Nursing or Nursing-Related Degree

Bachelor’s Master’s Doctorate

Diploma 10.5 13.9 15.6 Associate’s 7.5 11.5 12.5 Bachelor’s — 8.2 12.4

NOTE: Average years between diploma and ADN not calculated due to larger than average rates of missing data. Too few cases to report estimated percent (fewer than 30 respondents). SOURCE: HRSA, 2010b.

either a master’s or doctoral degree) average just over $85,000 (see Table 4-4). Section 5311 of the Affordable Care Act (ACA) offers an incentive designed to offset lower faculty salaries by providing up to $35,000 in loan repayments and scholarships for eligible nurses who complete an advanced nursing degree and serve “as a full-time member of the faculty of an accredited school of nursing, for a total period, in the aggregate, of at least 4 years.”7 However, the ACA does not provide incentives for nurses to develop the specific educational and clinical competencies required to teach.

Projections of future faculty demand To establish a better understanding of future needs, the committee asked the RWJF Nursing Research Network to proj-

7 Patient Protection and Affordable Care Act, HR 3590 § 5311, 111th Congress.

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ect faculty demand for the next 15 years. After reviewing data from the AACN8 and the NLN (Kovner et al., 2006), the network estimated that between 5,000 and 5,500 faculty positions will remain unfilled in associate’s, baccalaureate, and higher degree programs. This projection is based on historical nurse faculty retirement rates and on graduation trends in research-focused nursing PhD pro- grams. Although a doctoral degree is often required or preferred for all current faculty vacancies, some of these positions can be filled with faculty holding DNP or master’s degrees.

If faculty retirement rates decrease and/or new faculty positions are created to meet future demands (resulting, for example, from provisions for loan repay- ment in the ACA), these factors will affect the shortage estimates. Additionally, the faculty supply may be affected positively by growing numbers of graduates with a DNP degree (discussed later in this chapter) who, as noted above, may be eligible for faculty positions in some academic institutions.

8 Personal communication, Di Fang, Director of Research and Data Services, AACN, March 3, 2010.

TABLE 4-4 Average Earnings by Job Title of Principal Position for Nurses Working Full Time

Position Title Average Annual Earnings ($)

Staff nurse 61,706 Management/administration 78,356 First-line management 72,006 Middle management 74,799 Senior management 96,735 Nurse anesthetist 154,221 Clinical nurse specialist 72,856 Nurse midwife 82,111 Nurse practitioner 85,025 Patient educator 59,421 Instructor 65,844 Patient coordinator 62,978 Informatics nurse 75,242 Consultant 76,473 Researcher 67,491 Surveyor/auditor/regulator 65,009 Other* 64,003 Total 66,973

NOTE: *Other position title includes nurses for whom position title is unknown. Only registered nurses who provided earnings and job title information are included in the calculations used for this table. SOURCE: HRSA, 2010b.

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Insufficient Clinical Placement Opportunities

As nursing education has moved out of hospital-based programs and into mainstream colleges and universities, integrating opportunities for clinical expe- rience into coursework has become more difficult (Cronenwett, 2010). Nursing leaders continue to confront challenges associated with the separation of the academic and practice worlds in ensuring that nursing students develop the com- petencies required to enter the workforce and function effectively in health care settings (Cronenwett and Redman, 2003; Fagin, 1986). While efforts are being made to expand placements in the community and more care is being delivered in community settings, the bulk of clinical education for students still occurs in acute care settings.

The required number of clinical hours varies widely from one program to another, and most state boards of nursing do not specify a minimum number of clinical hours in prelicensure programs (NCSBN, 2008). It is likely, moreover, that many of the clinical hours fail to result in productive learning. Students spend much of their clinical time performing routine care tasks repeatedly, which may not contribute significantly to increased learning. Faculty report spending most of their time supervising students in hands-on procedures, leaving little time focused on fostering the development of clinical reasoning skills (McNelis and Ironside, 2009).9

Some advances in clinical education have been made through strong academic−service partnerships. An example of such partnerships in community settings is nurse-managed health centers (discussed in Chapter 3), which serve a dual role as safety net practices and clinical education sites. Another, commonly used model is having skilled and experienced practitioners in the field oversee student clinical experiences. According to a recent integrative review, using these skilled practitioners, called preceptors, in a clinical setting is at least as effective as traditional approaches while conserving scarce faculty resources (Udlis, 2006). A variety of other clinical partnerships have been designed to increase capacity in the face of nursing faculty shortages (Baxter, 2007; DeLunas and Rooda, 2009; Kowalski et al., 2007; Kreulen et al., 2008; Kruger et al., 2010).

In addition to academic−service partnerships and preceptor models, the use of high-fidelity simulation offers a potential solution to the problem of limited op- portunities for clinical experience, with early studies suggesting the effectiveness of this approach (Harder, 2010). The NLN, for example, has established an online community called the Simulation Innovation Resource Center, where nurse fac- ulty can learn how to “design, implement, and evaluate the use of simulation” in

9 This paragraph, and the three that follow, were adapted from a paper commissioned by the committee on “Transforming Pre-Licensure Nursing Education: Preparing the New Nurse to Meet Emerging Health Care Needs,” prepared by Christine A. Tanner, Oregon Health & Science University School of Nursing (see Appendix I on CD-ROM).

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their curriculum.10 However, there is little evidence that simulation expands fac- ulty capacity, and no data exist to define what portion of clinical experience it can replace. To establish uniform guidelines for educators, accreditation requirements should be evaluated and revised to allow simulation to fulfill the requirement for a standard number of clinical hours. The use of simulation in relationship to the promotion of interprofessional education is discussed below.

Increased attention is being focused on the dedicated education unit (DEU) as a viable alternative for expanding clinical education capacity (Moscato et al., 2007). In this model, health care units are dedicated to the instruction of students from one program. Staff nurses who want to serve as clinical instructors are prepared to do so, and faculty expertise is used to support their development and comfort in this role. DEUs were developed in Australia and launched in the United States at the University of Portland in Oregon in 2003. Since then, the University of Portland has helped at least a dozen other U.S. nursing schools establish DEUs. In programs that offer DEUs, students perform two 6-week rota- tions per semester, each instructor/staff nurse teaches no more than two students at a time, and a university faculty member oversees the instruction. Early results suggest the DEU can dramatically increase capacity and have a positive effect on satisfaction among students and nursing staff. A multisite study funded by RWJF is currently under way to evaluate outcomes of the DEU model.

DEUs offer benefits for the nursing schools, the hospitals, the faculty, and the students. Because the hospital employs the clinical instructors, the nursing school can increase its enrollment without increasing costs. The hospital benefits by training students it can hire after their graduation and licensure. Students ben- efit by having consistent clinical instructors each day, something not guaranteed under the traditional preceptorship model. As the case study in Box 4-5 shows, the benefits of DEUs extend beyond the academic environment to the practice setting as well.

Need for Updated and Adaptive Curricula

A look at the way nursing students are educated at the prelicensure level11 shows that most schools are not providing enough nurses with the required competencies in such areas as geriatrics and culturally relevant care to meet the changing health needs of the U.S. population (as outlined in Chapter 2) (AACN and Hartford, 2000). The majority of nursing schools still educate students pri- marily for acute care rather than community settings, including public health and long-term care. Most curricula are organized around traditional medical special- ties (e.g., maternal−child, pediatrics, medical−surgical, or adult health) (McNelis

10 See http://sirc.nln.org/. 11 Available evidence is based on evaluation of BSN programs and curricula. Evidence was not

available for ADN or diploma programs.

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and Ironside, 2009). The intricacies of care coordination are not adequately ad- dressed in most prelicensure programs. Nursing students may gain exposure to leading health care disciplines and know something about basic health policy and available health and social service programs, such as Medicaid. However, their education often does not promote the skills needed to negotiate with the health care team, navigate the regulatory and access stipulations that determine patients’ eligibility for enrollment in health and social service programs, or understand how these programs and health policies impact health outcomes. Nursing cur- ricula need to be reexamined and updated. They need to be adaptive enough to undergo continuous evaluation and improvement based on new evidence and a changing science base, changes and advances in technology, and changes in the needs of patients and the health care system.

Many nursing schools have dealt with the rapid growth of health research and knowledge by adding layers of content that require more instruction (Iron- side, 2004). A wide range of new competencies also are being incorporated into requirements for accreditation (CCNE, 2009; NLNAC, 2008). For example, new competencies have been promulgated to address quality and patient safety goals (Cronenwett et al., 2007; IOM, 2003a). Greater emphasis on prevention, wellness, and improved health outcomes has led to new competency requirements as well (Allan et al., 2005). New models of care being promulgated as a result of health care reform will need to be introduced into students’ experiences and will require competencies in such areas as care coordination. These models, many of which could be focused in alternative settings such as schools and workplaces, will create new student placement options that will need to be tested for scalability and compared for effectiveness with more traditional care settings. (See also the discussion of competencies later in the chapter.)

The explosion of knowledge and decision-science technology also is chang- ing the way health professionals access, process, and use information. No longer is rote memorization an option. There simply are not enough hours in the day or years in an undergraduate program to continue compressing all available informa- tion into the curriculum. New approaches must be developed for evaluating cur- ricula and presenting fundamental concepts that can be applied in many different situations rather than requiring students to memorize different lists of facts and information for each situation.

Just as curricula must be assessed and rethought, so, too, must teaching– learning strategies. Most nurse faculty initially learned to be nurses through highly structured curricula that were laden with content (NLN Board of Governors, 2003), and too few have received advanced formal preparation in cur- riculum development, instructional design, or performance assessment. Faculty, tending to teach as they were taught, focus on covering content (Benner et al., 2009; Duchscher, 2003). They also see curriculum-related requirements as a bar- rier to the creation of learning environments that are both engaging and student- centered (Schaefer and Zygmont, 2003; Tanner, 2007).

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BOX 4-5 Case Study: The Dedicated Education Unit

A New Model of Education to Increase Enrollment Without Raising Costs

Jamie Sharp, a 21-year-old Univer-sity of Portland (UP) nursing stu-dent who has performed clinical rotations in a variety of units, remembers a particularly unpleas- ant experience in a psychiatric unit where she felt she was “in the way” of her nurse preceptors. This was in stark contrast to her experience on a neurovascular unit at Providence St. Vincent Medical Center, where she had just one clinical instructor, a nurse who was eager to teach her.

That neurovascular unit was a dedicated education unit (DEU). Created in Australia in the late 1990s and launched in the United States at UP in 2003, the DEU model joins a school of nursing with units at local hospitals, where experienced staff nurses become clinical instructors of juniors and seniors in the bachelor’s degree program. Each instructor teaches no more than two students at a time, but the DEU can be used around the clock.

With a DEU, a nursing school can “cultivate a unit” as an excellent learning environment, said UP’s dean of nursing, Joanne Warner, PhD, RN, FAAN. Most important, she added, is “the expertise of the nurses there— they know the clinical procedures, the current medications, the policies of the hospital.” The DEU differs from a usual clinical rotation in the rela- tionship that develops between in- structor and student, something that cannot take place when a preceptor has eight students that change from week to week. The instructor gets to know the strengths and weaknesses

of the student and supports the student in building confidence and relevant knowledge and skills.

Our clinical instructors want the patients to go home with the best out- comes and the students to leave here with the best learning experiences. These students will be the ones taking care of us in the future, and we want them to be very well prepared.

—Cindy Lorion, MSN, RN, nurse manager, neurovascular and orthopedic units, Providence St. Vincent Medical Center, Portland, Oregon

Ms. Sharp was paired with Cathy Mead, ADN, RN, a nurse with 25 years of experience in the unit who received clinical instructor training from the nursing school. Her instruc- tion is overseen by both a university faculty member and the unit’s nurse manager.

Dr. Warner said that the benefits to her school and to students are quite tangible: “We have tripled our enrollment. If we had a traditional model I would not have the budget to hire the clinical faculty needed.” The number of students on clinical rotations increased from 227 in 14 units in 2002, before the DEUs were implemented, to 333 in 6 units in 2006, after the DEUs were instituted (Moscato et al., 2007). Now, up to 60 percent of a UP nursing student’s clinical rotations take place in DEUs. But equally important, the students

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report learning more in DEUs and are seeking clinical placements on them.

It might appear that the university profits far more than the hospital— especially since nearly 40,000 quali- fied applicants were turned away from baccalaureate nursing programs in 2009 because of shortages of faculty and clinical teaching sites (AACN, 2009c)—but that is not the case, said Cindy Lorion, MSN, RN, nurse manager of the neurovascular and orthopedic units at Providence St. Vincent Medical Center. The clini- cal instructors are enthusiastic about their new role. They receive adjunct faculty appointments at UP, gaining such benefits as library access but no additional pay from the university (some but not all facilities increase a clinical instructor’s salary).

Ms. Lorion has seen an increase in evidence-based practice and in the retention of nurses, as well as better- prepared graduates, many of whom seek jobs at the hospital. She also said that “a village” grows around

the students, with everyone from physicians to nurses’ aides taking part in “raising” them.

The partnership has led to changes in teaching and in clinical care. After a student made an error by injecting a medication into the wrong tube, the hospital changed its policy on syringe placement, and the school added a “tubes lab” to its courses.

A limited number of available clini- cal training sites in some areas may hamper widespread use of the model, and some units may take students on reluctantly, requiring a change in organizational culture. Nonetheless, more than 100 schools of nursing par- ticipated in an international sympo- sium on DEUs in 2007, and more than 20 are developing their own DEUs.

After 25 years as a nurse, Ms. Mead is pursuing her bachelor’s degree. “I definitely have to keep it fresh,” she said of the challenge of working with students like Ms. Sharp. “And not everyone can say that after being on the same unit for years.”

Jerry Hart

Seasoned nurse and clinical instructor Cathy Meade provides guidance as student Jamie Sharp examines a patient.

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GRADUATE NURSING EDUCATION

Even absent passage of the ACA, the need for APRNs, nurse faculty, and nurse researchers would have increased dramatically under any scenario (Cronen- wett, 2010). Not only must schools of nursing build their capacity to prepare more students at the graduate level, but they must do so in a way that fosters a uni- fied, competency-based approach with the highest possible standards. Therefore, building the science of nursing education research, or how best to teach students, is an important emphasis for the field of nursing education. For APRNs, gradu- ate education should ensure that they can contribute to primary care and help respond to shortages, especially for those populations who are most underserved. For nurse researchers, a focus on fundamental improvements in the delivery of nursing care to improve patient safety and quality is key.

Numbers and Distribution of Graduate-Level Nurses

As of 2008, more than 375,000 women and men in the workforce had received a master’s degree in nursing or a nursing-related field, and more than 28,000 had gone on to receive either a doctorate in nursing or a nursing-related doctoral degree in a field such as public health, public administration, sociology, or education12 (see Table 4-5) (HRSA, 2010b). Master’s degrees prepare RNs for roles in nursing administration and clinical leadership or for work in advanced practice roles (dis- cussed below) (AARP, 2010 [see Annex 1-1]). Many nursing faculty, particularly clinical instructors, are prepared at the master’s level. Doctoral degrees include the DNP and PhD. A PhD in nursing is a research-oriented degree designed to educate nurses in a wide range of scientific areas that may include clinical science, social science, policy, and education. Traditionally, PhD-educated nurses teach in university settings and conduct research to expand knowledge and improve care, although they can also work in clinical settings and assume leadership and admin- istrative roles in health care systems and academic settings.

The DNP is the complement to other practice doctorates, such as the MD, PharmD, doctorate of physical therapy, and others that require highly rigorous clinical training. Nurses with DNPs are clinical scholars who have the capacity to translate research, shape systems of care, potentiate individual care into care needed to serve populations, and ask the clinical questions that influence orga- nizational-level research to improve performance using informatics and quality improvement models. The DNP is a relatively new degree that offers nurses an opportunity to become practice scholars in such areas as clinical practice, leader- ship, quality improvement, and health policy. The core curriculum for DNPs is

12 Nursing-related doctoral degrees are defined by the National Sample Survey of Registered Nurses as non-nursing degrees that are directly related to a nurse’s career in the nursing profession. “Nursing-related degrees include public health, health administration, social work, education, and other fields” (HRSA, 2010b).

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TABLE 4-5 Estimated Distribution of Master’s and Doctoral Degrees as Highest Nursing or Nursing-Related Educational Preparation, 2000−2008

Degree

Estimated Distribution

2000 2004 2008

Master’s 257,812 350,801 375,794 Master’s of science in nursing (MSN) 202,639 256,415 290,084 Nursing-related master’s degree 55,173 94,386 85,709 Percent of master’s degrees that are nursing (MSN) 78.6 73.1 77.2

Doctoral 17,256 26,100 28,369 Doctorate in nursing 8,435 11,548 13,140 Nursing-related doctoral degree 8,821 14,552 15,229 Percent of doctorates that are nursing 48.9 44.2 46.3

SOURCE: HRSA, 2010b.

guided by the AACN’s Essentials of Doctoral Education for Advanced Nursing Practice.13

Schools of nursing have been developing DNP programs since 2002, but only in the last 5 years have the numbers of graduates approached a substantial level (Raines, 2010). Between 2004 and 2008 the number of programs offering the degree increased by nearly 40 percent, as is shown in Figure 4-7. At this point, more evidence is needed to examine the impact DNP nurses will have on patient outcomes, costs, quality of care, and access in clinical settings. It is also difficult to discern how DNP nurses could affect the provision of nursing education and whether they will play a significant role in easing faculty shortages. While the DNP provides a promising opportunity to advance the nursing profession, and some nursing organizations are promoting this degree as the next step for APRNs, the committee cannot comment directly on the potential role of DNP nurses be- cause of the current lack of evidence on outcomes.

Although 13 percent of nurses hold a graduate degree, fewer than 1 percent (28,369 nurses) have a doctoral degree in nursing or a nursing-related field, the qualification needed to conduct independent research (HRSA, 2010b). In fact, only 555 students graduated with a PhD in nursing in 2009, a number that has remained constant for the past decade (AACN, 2009a). As noted, key roles for PhD nurses include teaching future generations of nurses and conducting research that becomes the basis for improvements in nursing practice. As the need for nursing education and research and for nurses to engage with interprofessional research teams has grown, the numbers of nurses with a PhD in nursing or a related field have not kept pace (see Figure 4-7 for trends in the various nursing programs). The main reasons for this lag are (1) an inadequate pool of nurses

13 See http://www.aacn.nche.edu/dnp/pdf/essentials.pdf.

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with advanced nursing degrees to draw upon, (2) faculty salaries and benefits that are not comparable to those of nurses with advanced nursing degrees working in clinical settings, and (3) a culture that promotes obtaining clinical experience prior to continuing graduate education.

Preparation of Advanced Practice Registered Nurses

Nurses prepared at the graduate level to provide advanced practice services include those with master’s and doctoral degrees. APRNs serve as NPs, certified nurse midwives (CNMs), clinical nurse specialists (CNSs), and certified regis- tered nurse anesthetists (CRNAs). To gain certification in one of these advanced practice areas, nurses must take specialized courses in addition to a basic core curriculum. Credit requirements vary from program to program and from spe- cialty to specialty, but typically range from a minimum of 40 credits for a master’s to more than 80 credits for a DNP. Upon completion of required coursework and clinical hours, students must take a certification exam that is administered by a credentialing organization relevant to the specific specialization, such as the American Nursing Credentialing Center (for NPs and CNSs), the American Midwifery Certification Board (for CNMs), or the National Board on Certifica- tion and Recertification of Nurse Anesthetists (for CRNAs).

Figure 4-7.eps

2004 2005 2006 2007 2008

Year

C h

an g

e in

n u

m b

er o

f p

ro g

ra m

Entry-level BSN Master’s PhD DNP

FIGURE 4-7 Growth trends in different nursing programs. NOTE: BSN = bachelor’s of science in nursing; DNP = doctor of nursing practice. SOURCES: AACN, 2005, 2006, 2007, 2008a, 2009b.

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Nurses who receive certification, including those serving in all advanced practice roles, provide added assurance to the public that they have acquired the specialized professional development, training, and competencies required to provide safe, quality care for specific patient populations. For example, NPs and CNSs may qualify for certification after completing a master’s degree, post- master’s coursework, or doctoral degree through an accredited nursing program, with specific advanced coursework in areas such as health assessment, pharma- cology, and pathophysiology; additional content in health promotion, disease prevention, differential diagnosis, and disease management; and at least 500 hours of faculty-supervised clinical training within a program of study (ANCC, 2010a, 2010c).

Certification is time-limited, and maintenance of certification requires ongo- ing acquisition of both knowledge and experience in practice. For example, most advanced practice certification must be renewed every 5 years (NPs, CNSs); re- quirements include a minimum of 1,000 practice hours in the specific certification role and population/specialty. These requirements must be fulfilled within the 5 years preceding submission of the renewal application (ANCC, 2010b). CRNAs are recertified every 2 years and must be substantially engaged in the practice of nurse anesthesia during those years, in addition to completing continuing educa- tion credits (NBCRNA, 2009). Recertification for CNMs is shifting from 8 to 5 years and also involves a continuing education requirement (AMCB, 2009).

As the health care system grows in complexity, expectations are that APRNs will have competence in expanding areas such as technology, genetics, quality improvement, and geriatrics. Coursework and clinical experience requirements are increasing to keep pace with these changes. Jean Johnson, Dean of the School of Nursing at The George Washington University, notes that in terms of educa- tion, this is a time of major transition for APRNs.14 With the DNP, some nursing education institutions are now able to offer professional parity with other health disciplines that are shifting, or have already shifted, to require doctorates in their areas of practice, such as pharmacy, occupational and physical therapy, and speech pathology. As discussed above, DNP programs allow nurses to hone their expertise in roles related to nurse executive practice, health policy, informatics, and other practice specialties. (It should be noted, however, that throughout this report, the discussion of APRNs does not distinguish between those with master’s and DNP degrees who have graduated from an accredited program.)

Research Roles

Graduate-level education produces nurses who can assume roles in advanced practice, leadership, teaching, and research. For the latter role, a doctoral degree is required, yet as noted above, fewer than 1 percent of nurses have achieved

14 Personal communication, Jean Johnson, Dean, School of Nursing, George Washington Univer- sity, September 3, 2010.

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this level of education. This number is insufficient to meet the crucial need for research in two key areas: nursing education and nursing science.

Research on Nursing Education

At no time in recent history has there been a greater need for research on nursing education. As health care reform progresses, basic and advanced nursing practices are being defined by the new competencies alluded to above and dis- cussed in the next section, yet virtually no evidence exists to support the teaching approaches used in nursing education.15

Additionally, little research has focused on clinical education models or clini- cal experiences that can help students achieve these competencies, even though clinical education constitutes the largest portion of nurses’ educational costs. Like- wise, little evidence supports appropriate student/faculty ratios. Yet current clinical education models and student/faculty ratios are limiting capacity at a time when the need for new nurses is projected to increase. The paucity of evidence in nurs- ing education and pedagogy calls for additional research and funding to ascertain the efficiency and effectiveness of approaches to nursing education, advancing evidence-based teaching and interprofessional knowledge. Chapter 7 outlines specific research priorities that could shape improvements to nursing education.

In a recent editorial, Broome (2009) highlighted the need for three critical changes required to “systematically build a . . . science that could guide nurse educators to develop high quality, relevant, and cost-effective models of education that produce graduates who can make a difference in the health system”:

• funding to support nursing education research, potentially via mecha- nisms through the Health Resources and Services Administration;

• multidisciplinary research training programs, including postdoctoral training to prepare a cadre of nurses dedicated to developing the science of nursing education; and

• efforts to foster the development of PhD programs that have faculty expertise to mentor a new generation of nursing education researchers.

Research on Nursing Science

The expansion of knowledge about the science of nursing is key to providing better patient care, improving health, and evaluating outcomes. Along with an ad- equate supply of qualified nurses, meeting the nation’s growing health care needs

15 Some faculty development programs and training opportunities are offered through universities and professional organizations, such as the AACN and the NLN. Additionally, the NLN offers a certi- fication program for nurse educators, who can publically confirm knowledge in the areas of pedagogy, learning, and the complex encounter between educator and student. This certification program can provide a basis for innovation and the continuous quality improvement of nursing education.

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requires continued growth in the science of delivering effective care for people and populations and designing health systems. Nurse scientists are a critical link in the discovery and translation of knowledge that can be generated by nurses and other health scientists. To carry out this crucial work, a sustainable supply of and support for nurse scientists will be necessary (IOM, 2010).

The research conducted by nurse scientists has led to many fundamental im- provements in the provision of care. Advances have been realized, for example, in the prevention of pressure ulcers; the reduction of high blood pressure among African American males; and the models described elsewhere in this report for providing transitional care after hospital discharge and for promoting health and well-being among young, disadvantaged mothers and their newborns. Yet nursing’s research capacity has been largely overlooked in the development of strategies for responding to the shortage of nurses or effecting the necessary transformation of the nursing profession. The result has been a serious mismatch between the urgent need for knowledge and innovation to improve care and the nursing profession’s ability to respond to that need, as well as a limitation on what nursing schools can include in their curricula and what is disseminated in the clinical settings where nurses engage.

A chapter of the National Research Council’s 2005 report, Advancing the Nation’s Health Needs: NIH’s Research Training Program, focuses on nursing research; it identified factors that would likely influence its future, for example: an aging cadre of nursing science researchers, longer times required to complete doctoral degrees, increasing demands on nursing faculty to also meet workforce demands, and the emergence of clinical doctoral programs (NRC, 2005). Evalu- ating these and other factors will be essential to achieving the transformation of the nursing profession that this report argues is essential to a transformed health care system.

COMPETENCY-BASED EDUCATION

Competencies that are well known to the nursing profession, such as care management and coordination, patient education, public health intervention, and transitional care, are likely to dominate in a reformed health care system. As Edward O’Neil, Director, Center for the Health Professions at the University of California, San Francisco, pointed out however, “these traditional competencies must be reinterpreted for students into the settings of the emergent care system, not the one that is being left behind. This will require faculty to not only teach to these competencies but also creatively apply them to health environments that are only now emerging” (O’Neil, 2009). Emerging new competencies in decision making, quality improvement, systems thinking, and team leadership must be- come part of every nurse’s professional formation from the prelicensure through the doctoral level.

A review of medical school education found that evidence in favor of com- petency-based education is limited but growing (Carraccio et al., 2002). Nursing

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schools also have embraced the notion of competency-based education, as noted earlier in the chapter in the case study on the Oregon Consortium for Nursing Education (Box 4-2). In addition, Western Governors University uses compe- tency-based education exclusively, allowing nursing students to move through their program of study at their own pace. Mastery of the competency is achieved to the satisfaction of the faculty without the normal time-bound semester structure (IOM, 2010).

Defining Core Competencies

The value of competency-based education in nursing is that it can be strongly linked to clinically based performance expectations. It should be noted that “competencies” here denotes not task-based proficiencies but higher-level com- petencies that represent the ability to demonstrate mastery over care management knowledge domains and that provide a foundation for decision-making skills under variety of clinical situations across all care settings.

Numerous sets of core competencies for nursing education are available from a variety of sources. It has proven difficult to establish a single set of competen- cies that cover all clinical situations, across all settings, for all levels of students. However, there is significant overlap among the core competencies that exist because many of them are derived from such landmark reports as Recreating Health Professional Practice for a New Century (O’Neil and Pew Health Profes- sions Commission, 1998) and Health Professions Education: A Bridge to Quality (IOM, 2003b). The competencies in these reports focus on aspects of professional behavior (e.g., ethical standards, cultural competency) and emphasize areas of care (e.g., prevention, primary care), with overarching goals of (1) providing pa- tient-centered care, (2) applying quality improvement principles, (3) working in interprofessional teams, (4) using evidence-based practices, and (5) using health information technologies.

Two examples of sets of core competencies come from the Oregon Consor- tium for Nursing Education16 and the AACN. The former set features competen- cies that promote nurses’ abilities in such areas as clinical judgment and critical thinking; evidence-based practice; relationship-centered care; interprofessional collaboration; leadership; assistance to individuals and families in self-care prac- tices for promotion of health and management of chronic illness; and teaching, delegation, and supervision of caregivers. The AACN’s set of competencies is outlined in Essentials for Baccalaureate Education and highlights such areas as “patient-centered care, interprofessional teams, evidence-based practice, qual- ity improvement, patient safety, informatics, clinical reasoning/critical thinking, genetics and genomics, cultural sensitivity, professionalism, practice across the lifespan, and end-of-life care” (AACN, 2008b). While students appear to gradu-

16 See http://www.ocne.org/.

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ate with ample factual knowledge of these types of core competencies, however, they often appear to have little sense of how the competencies can be applied or integrated into real-world practice situations (Benner et al., 2009).

Imparting emerging competencies, such as quality improvement and systems thinking, is also key to developing a more highly educated workforce. Doing so will require performing a thorough evaluation and redesign of educational con- tent, not just adding content to existing curricula. An exploration of the educa- tional changes required to teach all the emerging competencies required to meet the needs of diverse patient populations is beyond the scope of this report.

Defining an agreed-upon set of core competencies across health professions could lead to better communication and coordination among disciplines (see the discussion of the Interprofessional Education Collaborative below for an example of one such effort). Additionally, the committee supports the development of a unified set of core competencies across the nursing profession and believes it would help provide direction for standards across nursing education. Defining these core competencies must be a collaborative effort among nurse educators, professional organizations, and health care organizations and providers. This ef- fort should be ongoing and should inform regular updates of nursing curricula to ensure that graduates at all levels are prepared to meet the current and future health needs of the population.

Assessing Competencies

Changes in the way competencies are assessed are also needed. In 2003, the IOM’s Health Professions Education: A Bridge to Quality called for systemwide changes in the education of health professionals, including a move on the part of accrediting and certifying organizations for all health professionals toward mandating a competency-based approach to education (IOM, 2003a). Steps are already being taken to establish competency-based assessments in medical edu- cation. In its 2009 report to Congress on Improving Incentives in the Medicare Program, the Medicare Payment Advisory Commission highlighted an initiative of the Accreditation Council for Graduate Medical Education to require greater competency-based assessment of all residency programs that train physicians in the United States (MedPAC, 2009). The NCSBN has considered various chal- lenges related to competency assessment and is considering approaches to ensure that RNs can demonstrate competence in the full range of areas that are required for the practice of nursing.17

A competency-based approach to education strives to make the competencies for a particular course explicit to students and requires them to demonstrate mas- tery of those competencies (Harden, 2002). Performance-based assessment then shows whether students have both a theoretical grasp of what they have learned

17 Personal communication, Kathy Apple, CEO, NCSBN, May 30, 2010.

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and the ability to apply that knowledge in a real-world or realistically simulated situation. The transition-to-practice or nurse residency programs discussed in Chapter 3 could offer an extended opportunity to reinforce and test core compe- tencies in real-world settings that are both safe and monitored.

Lifelong Learning and Continuing Competence

Many professions, such as nursing, that depend heavily on knowledge are becoming increasingly technical and complex (The Lewin Group, 2009). No individual can know all there is to know about providing safe and effective care, which is why nurses must be integral members of teams that include other health professionals. Nor can a single initial degree provide a nurse with all she or he will need to know over an entire career. Creating an expectation and culture of lifelong learning for nurses is therefore essential.

From Continuing Education to Continuing Competence

Nurses, physicians, and other health professionals have long depended on continuing education programs to maintain and develop new competencies over the course of their careers. Yet the 2009 IOM study Redesigning Continuing Education in the Health Professions cites “major flaws in the way [continuing education] is conducted, financed, regulated, and evaluated” and states that the evidence base underlying current continuing education programs is “fragmented and undeveloped.” These shortcomings, the report suggests, have hindered the identification of effective educational methods and their integration into coordi- nated, comprehensive programs that meet the needs of all health professionals (IOM, 2009). Likewise, the NCSBN has found that there is no clear link between continuing education requirements and continued competency.18 A new vision of professional development is needed that enables learning both individually and from a collaborative, team perspective and ensures that “all health professionals engage effectively in a process of lifelong learning aimed squarely at improving patient care and population health” (IOM, 2009).

This new comprehensive vision is often termed “continuing competence.” The practice setting, like the academic setting, is challenged by the need to integrate traditional and emerging competencies. Therefore, building the capac- ity for lifelong learning—which encompasses both continuing competence and advanced degrees—requires ingenuity on the part of employers, businesses, schools, community and government leaders, and philanthropies. The case study in Box 4-6 describes a program that extends the careers of nurses by training them to transition from the acute care to the community setting.

18 Personal communication, Kathy Apple, CEO, NCSBN, May 30, 2010.

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Interprofessional Education

The importance of interprofessional collaboration and education has been recognized since the 1970s (Alberto and Herth, 2009). What is new is the in- troduction of simulation and web-based learning—solutions that can be used to can break down traditional barriers to learning together, such as the conflicting schedules of medical and APRN students or their lack of joint clinical learning opportunities. Simulation technology offers a safe environment in which to learn (and make mistakes), while web-based learning makes schedule conflicts more manageable and content more repeatable. If all nursing and medical students are educated in aspects of interprofessional collaboration, such as knowledge of professional roles and responsibilities, effective communication, conflict resolu- tion, and shared decision making, and are exposed to working with other health professional students through simulation and web-based training, they may be more likely to engage in collaboration in future work settings. Further, national quality and safety agendas, including requirements set by the Joint Commission, the Commission on Collegiate Nursing Education, the NLN, and the Association of American Medical Colleges (AAMC), along with studies that link disrup- tive behavior between RNs and MDs to negative patient and worker outcomes (Rosenstein and O’Daniel, 2005, 2008), create a strong incentive to not just talk about but actually work on implementing interprofessional collaboration.

England, Canada, and the United States have made strides to improve in- terprofessional education by bringing students together from academic health science universities and medical centers (e.g., students of nursing, medicine, pharmacy, social work, physical therapy, and public health, among others) in shared learning environments (Tilden, 2010). Defined as “occasions when two or more professions learn with, from, and about each other to improve collabora- tion and the quality of care” (Barr et al., 2005), such education is based on the premise that students’ greater familiarity with each other’s roles, competencies, nomenclatures, and scopes of practice will result in more collaborative graduates. It is expected that graduates of programs with interprofessional education will be ready to work effectively in patient-centered teams where miscommunication and undermining behaviors are minimized or eliminated, resulting in safer, more effective care and greater clinician and patient satisfaction. Interprofessional edu- cation is thought to foster collaboration in implementing policies and improving services, prepare students to solve problems that exceed the capacity of any one profession, improve future job satisfaction, create a more flexible workforce, modify negative attitudes and perceptions, and remedy failures of trust and com- munication (Barr, 2002).19

19 This paragraph draws upon a paper commissioned by the committee on “The Future of Nursing Education,” prepared by Virginia Tilden, University of Nebraska Medical Center College of Nursing (see Appendix I on CD-ROM).

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BOX 4-6 Case Study: Nursing for Life—The RN

Career Transition Program

A New Program Extends the Working Life of Aging Nurses By Training Them to Work in Community Settings

At age 62 Jackie Tibbetts, MS, RN, CAGS, was thinking, naturally, about retirement. She was nearing the end of a 39-year teaching career when a close friend became ill, and her proxim- ity to her friend’s care and eventual death made her realize she still had a great deal to offer. She felt com- pelled to return to nursing, her first profession.

Ms. Tibbetts now provides skilled nursing care at a retirement com- munity in a suburb of Boston. She made the move to long-term care through the Nursing for Life: RN Career Transition program at Michi- gan State University (MSU) College of Nursing, an outgrowth of a 2002 online refresher course the school offered. Because she had maintained her registered nurse (RN) license, she was eligible for the course, and with a background in rehabilitation she determined that the long-term care setting would be a good fit. Ms. Tib- betts received online education and performed a clinical practicum near her Massachusetts home. Now 64, she plans to work as a nurse “as long as I’m able,” she said.

In 2006 the Blue Cross Blue Shield of Michigan Foundation, in concert with the College of Nursing at MSU, set out to broaden the opportuni- ties for Michigan’s, and the nation’s, aging nursing workforce. “We began to think about some of the needs of mid-to-late-career nurses still working

in acute care and looking to move away from that work, for the physical intensity of it,” said Terrie Wehrwein, PhD, RN, NEA-BC, associate profes- sor at the school. The Blue Cross Blue Shield of Michigan Foundation and the College of Nursing at MSU were among the first recipients of a grant from Partners Investing in Nursing’s Future, a joint venture of the Northwest Health Foundation and The Robert Wood Johnson Founda- tion. The program began in 2008 as a pilot project to train licensed RNs to work in four community settings that may be less physically demand- ing than acute care—home care, long-term care, hospice, and ambu- latory care—and that are open to any licensed nurse, not just those in Michigan. (Two new tracks, in case management and quality and safety management, are being developed.)

I still have a tremendous amount to offer here. I can see myself working well into my 60s.

—Sheri Morris, MN, RN, graduate of Nursing for Life, Lambertville, Michigan

The program has two compo- nents: an online, self-paced didactic course has seven core modules, plus seven modules specific to each specialty, and an 80-hour clinical practicum pairs the nurse, ideally, with a single preceptor in the area of

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study. Nurses have 1 year to finish the online course and are encour- aged to complete the practicum within 5 weeks.

The program has attracted not only aging nurses but also younger ones wanting to change work set- tings. And Michigan is not the only state that benefits; of the 28 nurses who have completed the program, about 10 percent live out of state. (Michigan residents who cannot afford the $1250 tuition may be eligible for aid through the state’s No Worker Left Behind program. Other states may provide similar assistance.)

After receiving a bachelor’s degree in nursing in 1974 and a master’s in 1982, Shari Morris, MN, RN, left the profession in 1990 to home-school her four sons. She took a Minnesota

refresher course in 2006, when she was 54, and got a job in a pediatri- cian’s office. She realized she would need further training to advance in ambulatory care and enrolled in Nursing for Life. For her clinical practicum she chose two pediatric clinics in a nearby hospital.

When asked what impact the program has had on her ability to remain a nurse, she said, “I think, probably, courage.” The course gave her the self-assurance to apply for a job in teaching when she could not find an opening in ambulatory care; she is now an instructor in nursing at a Michigan community college.

“I felt confident to step out of the first setting I’d been in 17 years and go into another arena, without any difficulties,” Ms. Morris said.

The online education Jackie Tibbetts received through the Nursing for Life: RN Career Transition program helped her shift back to a nursing career after almost four decades as a teacher.

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The AAMC, the American of Association of Colleges of Osteopathic Medi- cine, the American Dental Education Association, the American Association of Colleges of Pharmacy, the Association of Schools of Public Health, and the AACN recently formed a partnership called the Interprofessional Education Collaborative. This collaborative is committed to the development of models of collaboration that will provide the members’ individual communities with the standards and tools needed to achieve productive interprofessional education practices. These organizations are committed to fulfilling the social contract that every nursing, pharmacy, dental, public health, and medical graduate is proficient in the core competencies required for interprofessional, team-based care, includ- ing preventive, acute, chronic, and catastrophic care. The collaborative is also committed to facilitating the identification, development, and deployment of the resources essential to achieving this vision. As a first step, the collaborative is developing a shared and mutually endorsed set of core competencies that will frame the education of the six represented health professions.20

Efforts have been made to evaluate the effectiveness of interprofessional edu- cation in improving outcomes, including increased student satisfaction, modified negative stereotypes of other disciplines, increased collaborative behavior, and improved patient outcomes. However, the effect of interprofessional education is not easily verified since control group designs are expensive, reliable measures are few, and time lapses can be long between interprofessional education and the behavior of graduates. Barr and colleagues (2005) reviewed 107 evaluations of interprofessional education in published reports and found support for three outcomes: interprofessional education creates positive interaction among stu- dents and faculty; encourages collaboration between professions; and results in improvements in aspects of patient care, such as more targeted health promotion advice, higher immunization rates, and reduced blood pressure for patients with chronic heart disease. Reeves and colleagues (2008) reviewed six later studies of varying designs. Four of the studies found that interprofessional education improved aspects of how clinicians worked together, while the remaining two found that it had no effect (Reeves et al., 2008). Although empirical evidence is mixed, widespread theoretical agreement and anecdotal evidence suggest that students who demonstrate teamwork skills in the simulation laboratory or in a clinical education environment with patients will apply those skills beyond the confines of their academic programs.21

20 Personal communication, Geraldine Bednash, CEO, AACN, August 12, 2010. 21 This paragraph draws upon a paper commissioned by the committee on “The Future of Nursing

Education,” prepared by Virginia Tilden, University of Nebraska Medical Center College of Nursing (see Appendix I on CD-ROM).

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THE NEED TO INCREASE THE DIVERSITY OF THE NURSING WORKFORCE

Chapter 3 highlighted a variety of challenges facing the nursing profession in meeting the changing needs of patients and the health care system. A major challenge for the nursing workforce is the underrepresentation of racial and ethnic minority groups and men in the profession. To better meet the current and future health needs of the public and to provide more culturally relevant care, the nurs- ing workforce will need to grow more diverse. And to meet this need, efforts to increase nurses’ levels of educational attainment must emphasize increasing the diversity of the student body. This is a crucial concern that needs to be addressed across all levels of nursing education.

Racial and Ethnic Diversity

Although the composition of the nursing student body is more racially and ethnically diverse than that of the current workforce, diversity continues to be a challenge. Figure 4-8 shows the distribution of minority students enrolled in nurs- ing programs by race/ethnicity and by program type. Their underrepresentation is greatest for pathways associated with higher levels of education. In academic year 2008−2009, for example, ethnic minority groups made up 28.2 percent of ADN, 23.6 percent of BSN, 24.4 percent of master’s, and 20.3 percent of doctoral students (NLN, 2009). Even less evidence of diversity is present among nurses in faculty positions (AACN, 2010b).

In 2003, the Sullivan Commission on Diversity in the Healthcare Work- force was established to develop recommendations that would “bring about systemic change . . . [to] address the scarcity of minorities in our health pro- fessions.” The commission’s report, Missing Persons: Minorities in the Health Professions (Sullivan Commission on Diversity in the Healthcare Workforce, 2004), offered strategies to increase the diversity of the medical, nursing, and dentistry professions and included recommendations designed to remove bar- riers to health professions education for underrepresented minority students. The commission’s 37 recommendations called for leadership, commitment, and accountability among a wide range of stakeholders—from institutions re- sponsible for educating health professionals, to professional organizations and health systems, to state and federal agencies and Congress. The recommenda- tions focused on expediting strategies to increase the number of minorities in health professions, improving the education pipeline for health professionals, financing education for minority students, and establishing leadership and ac- countability to realize the commission’s vision of increasing the diversity of health professionals. The committee believes the implementation of these rec- ommendations holds promise for ensuring a more diverse health care workforce in the future.

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In the nursing profession, creating bridge programs and educational path- ways between undergraduate and graduate programs—specifically programs such as LPN to BSN, ADN to BSN, and ADN to MSN—appears to be one way of in- creasing the overall diversity of the student body and nurse faculty with respect to not only race/ethnicity, but also geography, background, and personal experience. Mentoring programs that support minority nursing students are another promising approach. One example of such a program is the National Coalition of Ethnic Minority Nursing Associations, a group made up of five ethnic minority nursing associations that aims to build the cadre and preparation of ethnic minority nurses and promote equity in health care across ethnic minority populations (NCEMNA, 2010). This program is described at greater length in Chapter 5. Another example of a successful program that has promoted racial and ethnic diversity is the ANA Minority Fellowship Program,22 started in 1974 under the leadership of Dr. Hattie Bessent. This program has played a crucial role in supporting minority nurses with predoctoral and postdoctoral fellowships to advance research and clinical

22 See http://www.emfp.org/.

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FIGURE 4-8 Percentage of minority students enrolled in nursing programs by race/ ethnicity and program type, 2008−2009. NOTE: ADN = associate’s degree programs; BSN = bachelor’s of science programs; BSRN = RN-to-BSN programs; DIP = diploma nursing programs; DOC = nursing school programs offering doctoral degrees; LPN = licensed practical nursing programs; LVN = licensed vocational nursing programs. SOURCE: NLN, 2010c. Reprinted with Permission from the National League for Nursing.

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practice (Minority Fellowship Program, 2010). Programs to recruit and retain more individuals from racial and ethnic minority groups in nursing education programs are needed. A necessary first step toward accomplishing this goal is to create policies that increase the overall educational attainment of ethnic minori- ties (Coffman et al., 2001).

Gender Diversity

As noted in Chapter 3, the nursing workforce historically has been composed predominantly of women. While the number of men who become nurses has grown dramatically in the last two decades, men still make up just 7 percent of all RNs (HRSA, 2010b). While most disciplines within the health professional workforce have become more gender balanced, the same has not been true for nursing. For example, in 2009 nearly half of medical school graduates were female (The Kaiser Family Foundation—statehealthfacts.org, 2010), a signifi- cant achievement of gender parity in a traditionally male-dominated profession. Stereotypes, academic acceptance, and role support are challenges for men en- tering the nursing profession. These barriers must be overcome if men are to be recruited in larger numbers to help offset the shortage of nurses and fill advanced and expanded nursing roles. Compounding the gender diversity problem of the nursing profession is the fact that fewer men in general are enrolling in higher education programs (Mather and Adams, 2007). While more men are being drawn to nursing, especially as a second career, the profession needs to continue efforts to recruit men; their unique perspectives and skills are important to the profession and will help contribute additional diversity to the workforce.

One professional organization that works to encourage men to join the nurs- ing profession and supports men who do so is the American Assembly for Men in Nursing (AAMN).23 To increase opportunities for men interested in joining the profession, the AAMN Foundation, in partnership with Johnson & Johnson, has awarded more than $50,000 in scholarships to undergraduate and graduate male nursing students since 2004 (AAMN, 2010b). Additionally, each year the AAMN recognizes the best school or college of nursing for men; in 2009, the honor was given to Monterey Peninsula College in Monterey, California, and Ex- celsior College in Albany, New York, for their “efforts in recruiting and retaining men in nursing, in providing men a supportive educational environment, and in educating faculty, students and the community about the contributions men have and do make to the nursing profession” (AAMN, 2010a).

23 See http://www.aamn.org/.

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SOLUTIONS FROM THE FIELD

This chapter has outlined a number of challenges facing nursing education. These challenges have been the subject of much documentation, analysis, and debate (Benner et al., 2009; Erickson, 2002; IOM, 2003a, 2009; Lasater and Nielsen, 2009; Mitchell et al., 2006; Orsolini-Hain and Waters, 2009; Tanner et al., 2008). Various approaches to responding to these challenges and transform- ing curricula have been proposed, and several are being tested. The committee reviewed the literature on educational capacity and redesign, heard testimony about various challenges and potential solutions at the public forum in Houston, and chose a number of exemplars for closer examination. Three of these models are described in this section. The committee found that each of these models pro- vided important insight into creative approaches to maximizing faculty resources, encouraging the establishment and funding of new faculty positions, maximizing the effectiveness of clinical education, and redesigning nursing curricula.

Veterans Affairs Nursing Academy

In 2007, the VA launched the VANA—a 5-year, $40 million pilot program— with the primary goals of developing partnerships with academic nursing insti- tutes; expanding the number of faculty for baccalaureate programs; establishing partnerships to enhance faculty development; and increasing baccalaureate enroll- ment to increase the supply of nurses, not solely for the VA, but for the country at large. VANA also was aimed at encouraging interprofessional programs and increasing the retention and recruitment of VA nurses.24

Since the program’s inception, three cycles of requests for proposals have been sent to more than 600 colleges and schools of nursing, as well as to institu- tions within the VA system. Fifteen geographically and demographically diverse pilot sites were selected to participate in VANA based on the strength of their proposals.

Each funded VANA partnership is required to have a rigorous evaluation plan to measure outcomes. Outcomes are expected to include increased staff, pa- tient, student, and faculty satisfaction; greater scholarly output; enhanced profes- sional development; better continuity and coordination of care; more reliance on evidence-based practice; and enhanced interprofessional learning. Each selected school is also expected to increase enrollment by at least 20 students a year.

The program has already resulted in 2,700 new students, with 620 receiving the majority of their clinical rotation experiences at the VA. The graduates of this program may include students who have pursued a traditional prelicensure

24 This paragraph, and the three that follow, draw upon a presentation made by Cathy Rick, chief nursing officer for the VA, at the Forum on the Future of Nursing: Education, held in Houston, TX on February 22, 2010 (see Appendix C) and published in A Summary of the February 2010 Forum on the Future of Nursing: Education (IOM, 2010).

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BSN, a BSN through a second-degree program, or a BSN through an RN-to-BSN program. The number of nursing school faculty has increased by 176 and the number of VA faculty by 264.

In addition to the new nurses and faculty, educational innovations have encompassed curriculum revision, including quality and safety standards; DEUs (described earlier in Box 4-4); and a postgraduate baccalaureate nurse residency (see Chapter 3). Other changes include interprofessional simulation training and the development of evidence-based practice committees and programs. Beyond these specific changes and accomplishments, the VANA faculty has worked to develop the program into a single community of learning and to prepare students in a genuinely collaborative practice environment with clinically proficient staff and educators.

Carondolet Health Network

The Carondolet Health Network of Tucson, Arizona, is an example of how employers can offer educational benefits that improve both patient outcomes and the bottom line. Carondelet, which includes four hospitals and other facilities and employs approximately 1,650 nurses, is featured as one of seven cases studies in the Lewin Group’s 2009 report Wisdom at Work: Retaining Experienced RNs and Their Knowledge—Case Studies of Top Performing Organizations.

After Carondelet became part of Ascension Health in 2002, the Tucson orga- nization embarked on a strategic plan to recruit and retain more nurses. Arizona faces some of the severest nursing shortages in the nation, and most nurses prefer to live and work in higher-paying markets, such as Phoenix or southern Califor- nia. When Carondelet instituted an on-site BSN program, which it subsidized in exchange for a 2-year work commitment, the response was dramatic. Instead of an anticipated class size of 20 nurses in the first semester of the program, it en- rolled 104. Of interest, it was the business case—the opportunity to decrease the amount of money the organization was spending on costly temporary nurses— that tipped the balance in favor of action (The Lewin Group, 2009).

Hospital Employee Education and Training

The Hospital Employee Education and Training (HEET) program was de- veloped through a joint effort of the 1199NW local affiliate of the Service Employees International Union and the Washington State Hospital Association Work Force Institute to help address shortages in nursing and nursing-related positions through education and upgrading of incumbent workers. The program is administered through the Washington State Board for Community and Technical Colleges. Across the state, HEET-funded programs support industry-based reform of the education system and include preparation and completion of nursing career ladder programs. HEET seeks to develop educational opportunities that support

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both employer needs and the career aspirations of health care workers. It features cohort-based programs, distance learning, worksite classes, use of a simulation laboratory for nursing prerequisites, case management, tutoring support for those reentering academia, and nontraditional scheduling of classes to enable working adults to attend and address employee barriers to education.

The findings for this union-inspired initiative demonstrate its potential to increase racial/ethnic diversity in the nursing population. HEET participants represent a pool of potential nurses who are more diverse than the current nurs- ing workforce. Providing on-site classes at hospitals appears to support the participation of working adults who are enrolled in nursing school while con- tinuing to work at least part time. Workers participating in the HEET program have had lower attrition rates and higher rates of course completion compared with community college students in nursing career tracks. The curriculum also blends academic preparation with health care career education, thereby opening the doors of college to workers who might not otherwise enroll or succeed (Moss and Weinstein, 2009).

CONCLUSION

The future of access to basic primary care and nursing education will de- pend on increasing the number of BSN-prepared nurses. Unless this goal is met, the committee’s recommendations for greater access to primary care; enhanced, expanded, and reconceptualized roles for nurses; and updated nursing scopes of practice (see Chapter 7) cannot be achieved. The committee believes that increasing the proportion of the nursing workforce with a BSN from the current 50 percent to 80 percent by 2020 is bold but achievable. Achieving this target will help meet future demand for nurses qualified for advanced practice positions and possessing competencies in such areas as community care, public health, health policy, evidence-based practice, research, and leadership. The committee concludes further that the number of nurses holding a doctorate must be increased to produce a greater pool of nurses prepared to assume faculty and research posi- tions. The committee believes a target of doubling the number of nurses with a doctorate by 2020 would meet this need and is achievable.

To achieve these targets, however, will require overcoming a number of bar- riers. The numbers of educators and clinical placements are insufficient for all the qualified applicants who wish to enter nursing school. There also is a shortage of faculty to teach nurses at all levels. Incentives for nurses at any level to pursue further education are few, and there are active disincentives against advanced education. Nurses and physicians—not to mention pharmacists and social work- ers—typically are not educated together and yet are increasingly required to cooperate and collaborate more closely in the delivery of care.

To address these barriers, innovative new programs to attract nursing faculty and provide a wider range of clinical education placements must clear long-stand-

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ing bottlenecks. To this end, market-based salary adjustments must be made for faculty, and more scholarships must be provided to help nursing students advance their education. Accrediting and certifying organizations must mandate dem- onstrated mastery of clinical skills, managerial competencies, and professional development at all levels. Mandated skills, competencies, and professional devel- opment milestones must be updated on a more timely basis to keep pace with the rapidly changing demands of health care. All health professionals should receive more of their education in concert with students from other disciplines. Efforts also must be made to increase the diversity of the nursing workforce.

The nursing profession must adopt a framework of continuous lifelong learn- ing that includes basic education, academic progression, and continuing compe- tencies. More nurses must receive a solid education in how to manage complex conditions and coordinate care with multiple health professionals. They must demonstrate new competencies in systems thinking, quality improvement, and care management and a basic understanding of health care policy. Graduate-level nurses must develop an even deeper understanding of care coordination, quality improvement, systems thinking, and policy.

The committee emphasizes further that, as discussed in Chapter 2, the ACA is likely to accelerate the shift in care from the hospital to the community set- ting. This transition will have a particularly strong impact on nurses, more than 60 percent of whom are currently employed in hospitals (HRSA, 2010b). Nurses may turn to already available positions in primary or chronic care or in public or community health, or they may pursue entirely new careers in emerging fields that they help create. Continuing and graduate education programs must support the transition to a future that rewards flexibility. In addition, the curriculum at many nursing schools, which places heavy emphasis on preparing students for employment in the acute care setting, will need to be rethought (Benner et al., 2009).

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Rubric Detail for Discussion Posts

Main Posting: Response to the discussion question is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources.–

Levels of Achievement:

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Thoroughly responds to the discussion question(s) is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources. supported by at least 3 current, credible sources

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Responds to the discussion question(s) is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module. 75% of post has exceptional depth and breadth supported by at least 3 credible references

Competent Performance 35 (35%) – 39 (39%)

Responds to most of the discussion question(s) is somewhat reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module. 50% of post has exceptional depth and breadth supported by at least 3 credible references

Proficient Performance 31 (31%) – 34 (34%)

Responds to some of the discussion question(s) one to two criteria are not addressed or are superficially addressed is somewhat lacking reflection and critical analysis and synthesis somewhat represents knowledge gained from the course readings for the module. post is cited with fewer than 2 credible references

Room for Improvement 0 (0%) – 30 (30%)

Does not respond to the discussion question(s) lacks depth or superficially addresses criteria lacks reflection and critical analysis and synthesis does not represent knowledge gained from the course readings for the module. contains only 1 or no credible references

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Written clearly and concisely Contains no grammatical or spelling errors Fully adheres to current APA manual writing rules and style

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Written clearly and concisely May contain one or no grammatical or spelling error Adheres to current APA manual writing rules and style

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Written concisely May contain one to two grammatical or spelling error Adheres to current APA manual writing rules and style

Proficient Performance 4.5 (4.5%) – 4.5 (4.5%)

Written somewhat concisely May contain more than two spelling or grammatical errors Contains some APA formatting errors

Room for Improvement 0 (0%) – 4 (4%)

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The Future of Nursing: Leading Change, Advancing Health

Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine; Institute of Medicine

The Future of Nursing: Leading Change, Advancing Health

Recommendations and Research Priorities

Reflecting the charge to the committee, the purpose of this report is to con- sider reconceptualized roles for nurses, ways in which nursing education system can be designed to educate nurses who can meet evolving health care demands, the role of nurses in creating innovative solutions for health care delivery, and ways to attract and retain well-prepared nurses in a variety of settings. The report comes at a time of opportunity in health care resulting from the passage of the Affordable Care Act (ACA), which will provide access to care for an additional 32 million Americans. In the preceding chapters, the committee has described both barriers and opportunities in nursing practice, education, and leadership. It has also discussed the workforce data needed to guide policy and workforce planning with respect to the numbers, types, and mix of professionals that will be required in an evolving health care environment.

The primary objective of the committee in fulfilling its charge was to de- fine a blueprint for action that includes recommendations for changes in public and institutional policies at the national, state, and local levels. This concluding chapter presents the results of that effort. The committee’s recommendations are focused on maximizing the full potential and vital role of nurses in designing and implementing a more effective and efficient health care system, as envisioned by the committee in Chapter 1. The changes recommended by the committee are intended to advance the nursing profession in ways that will ensure that nurses are educated and prepared to meet the current and future demands of the health care system and those it serves.

This chapter first provides some context for the development of the com- mittee’s recommendations. It details what the committee considered to be its scope and focus, the nature of the evidence that supports its recommendations,

2��

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cost considerations associated with the recommendations, and how the recom- mendations might be implemented. The chapter then presents recommendations for nursing practice, education, and leadership, as well as improved collection and analysis of interprofessional health care workforce data, that resulted from the committee’s review of the evidence.

CONSIDERATIONS THAT INFORMED THE COMMITTEE’S RECOMMENDATIONS

As discussed throughout this report, the challenges facing the health care system and the nursing profession are complex and numerous. Challenges to nursing practice include regulatory barriers, professional resistance to expanded scopes of practice, health system fragmentation, insurance company policies, high turnover among nurses, and a lack of diversity in the nursing workforce. With regard to nursing education, there is a need for greater numbers, better preparation, and more diversity in the student body and faculty, the workforce, and the cadre of researchers. Also needed are new and relevant competencies, lifelong learning, and interprofessional education. Challenges with regard to nursing leadership include the need for leadership competencies among nurses, collaborative environments in which nurses can learn and practice, and engage- ment of nurses at all levels—from students to front-line nurses to nursing execu- tives and researchers—in leadership roles. Finally, comprehensive, sufficiently granular workforce data are needed to ascertain the necessary balance of skills among nurses, physicians, and other health professionals for a transformed health care system and practice environment.

Solutions to some of these challenges are well within the purview of the nursing profession, while solutions to others are not. A number of constraints affect the profession and the health care system more broadly. While legal and regulatory constraints affect scopes of practice for advanced practice registered nurses, the major cross-cutting constraints originate in limitations of available resources—both financial and human. These constraints are not new, nor are they unique to the nursing profession. The current economic landscape has magnified some of the challenges associated with these constraints while also reinforcing the need for change. To overcome these challenges, the nursing workforce needs to be well educated, team oriented, adaptable, and able to apply competencies such as those highlighted throughout this report, especially those relevant to leadership.

The nursing workforce may never have the optimum numbers to meet the needs of patients, nursing students, and the health care system. To maximize the available resources in care environments, providers need to work effectively and efficiently with a team approach. Teams need to include patients and their families, as well as a variety of health professionals, including nurses, physicians, pharmacists, physical and occupational therapists, medical assistants, and social

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RECOMMENDATIONS AND RESEARCH PRIORITIES 2�1

workers, among others. Care teams need to make the best use of each member’s education, skill, and expertise, and health professionals need to practice to the full extent of their license and education. Just as physicians delegate to registered nurses, then, registered nurses should delegate to front-line caregivers such as nursing assistants and community health workers. Moreover, technology needs to facilitate seamless care that is centered on the patient, rather than taking time away from patient care. In terms of education, efforts must be made to expand the number of nurses who are qualified to serve as faculty. Meanwhile, curricula need to be evaluated, and streamlined and technologies such as high-fidelity simulation and online education need to be utilized to maximize available fac- ulty. Academic−practice partnerships should also be used to make efficient use of resources and expand clinical education sites.

In conducting its work and evaluating the challenges that face the nursing profession, the committee took into account a number of considerations that informed its recommendations and the content of this report. The committee care- fully considered the scope and focus of the report in light of its charge (see Box P-1 in the preface to the report), the evidence that was available, costs associated with its recommendations, and implementation issues. Overall, the committee’s recommendations are geared toward advancing the nursing profession as a whole, and are focused on actions required to best meet long-term future needs rather than needs in the short term.

Scope and Focus of the Report

Many of the topics covered in this report could have been the focus of the entire report. As indicated in Chapter 4, for example, the report could have fo- cused entirely on nursing education. Given the nature of the committee’s charge and the time allotted for the study, however, the committee had to cover each topic at a high level and formulate relatively broad recommendations. This report could not be an exhaustive compendium of the challenges faced by the nursing workforce, nor was it meant to serve as a step-by-step guide detailing solutions to all of those challenges.

Accordingly, the committee limited its recommendations to those it believed had the potential for greatest impact and could be accomplished within the next decade. Taken together, the recommendations are meant to provide a strong foundation for the development of a nursing workforce whose members are well educated and well prepared to practice to the full extent of their education, to meet the current and future health needs of patients, and to act as full partners in leading change and advancing health. Implementation of these recommendations will take time, resources, and a significant commitment from nurses and other health professionals; nurse educators; researchers; policy makers and govern- ment leaders at the federal, state, and local levels; foundations; and other key stakeholders.

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An emphasis of the committee’s deliberations and this report is nurses’ role in advancing care in the community, with a particular focus on primary care. While the majority of nurses currently practice in acute care settings, and much of nursing education is directed toward those settings, the committee sees primary care and prevention as central drivers in a transformed health care system, and therefore chose to focus on opportunities for nurses across community settings. The committee believes nurses have the potential to play a vital role in improv- ing the quality, accessibility, and value of health care, and ultimately health in the community, beyond their critical contributions to acute care. The current landscape also directed the committee’s focus on primary care; concern over an adequate supply of primary care providers has been expressed and demand for primary care is expected to grow as millions more Americans gain insurance coverage through implementation of the ACA (see Chapters 1 and 2). Addition- ally, many provisions of the ACA focus on improving access to primary care, offering further opportunities for nurses to play a role in transforming the health care system and improving patient care.

The committee recognizes that improved primary care is not a panacea and that acute care services will always be needed. However, the committee sees primary care in community settings as an opportunity to improve health by reaching people where they live, work, and play. Nurses serving in primary care roles could expand access to care, educate people about health risks, promote healthy lifestyles and behaviors to prevent disease, manage chronic diseases, and coordinate care.

The committee also focused on advanced practice registered nurses in its discussion of some topics, most notably scope of practice. Recognizing the im- portance of primary care as discussed above, the committee viewed the potential contributions of these nurses to meeting the great need for primary care services if they could practice uniformly to the full extent of their education and training.

Available Evidence

The charge to the committee called for the formulation of a set of bold national-level recommendations—a considerable task. To develop its recom- mendations, the committee examined the available published evidence, drew on committee members’ expert judgment and experience, consulted experts engaged in the Robert Wood Johnson Foundation Nursing Research Network, and com- missioned the papers that appear in Appendixes F through J on the CD-ROM in the back of this report. The committee also called on foremost experts in nursing, nursing research, and health policy to provide input, perspective, and expertise during its public workshops and forums (described in Appendix C).

In addition to the peer-reviewed literature and newly commissioned research, the committee considered anecdotal evidence and self-evaluations for emerging models of care being implemented across the country. Evidence to support the

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RECOMMENDATIONS AND RESEARCH PRIORITIES 2�3

diffusion of a variety of promising innovative models informed the committee’s deliberations and recommendations. Many of these innovations are highlighted as case studies throughout the report, and others are discussed in the appendixes. These case studies offer real-life examples of successful innovations that were developed by nurses or feature nurses in a leadership role, and are meant to complement the peer-reviewed evidence presented in the text. The committee be- lieves these case studies contribute to the evidence base on how nurses can serve in reconceptualized roles to directly affect the quality, accessibility, and value of care. Cumulatively, the case studies and nurse profiles demonstrate what is pos- sible and what the future of nursing could look like under ideal circumstances in which nurses would be highly educated and well prepared by an education system that would promote seamless academic progression, in which nurses would be practicing to the full extent of their education and training, and in which they would be acting as full partners in efforts to redesign the health care system.

The committee drew on a wealth of sources of evidence to support its rec- ommendations. The recommendations presented are based on the best evidence available. There is a need, however, to continue building the evidence base in a variety of areas. The committee identified several research priorities to build upon its recommendations. For example, data are lacking on the work of nurses and the nursing workforce in general, primarily because of a dearth of large and well-designed studies explicitly exploring these issues. Accordingly, the commit- tee calls for research in a number of areas that would yield evidence related to the future of nursing to address some of the shortcomings in the data it encountered. Boxes 7-1 through 7-3 list research questions that are directly connected to the recommendations and the discussion in Chapters 3 through 5. The committee believes that answers to these research questions are needed to help advance the profession.

Costs Associated with the Recommendations

The current state of the U.S. economy and its effects on federal, state, and local budgets pose significant challenges to transforming the health care system. These fiscal challenges also will heavily influence the implementation of the committee’s recommendations. While providing cost estimates for each recom- mendation was beyond the scope of this study, the committee does not deny that there will be costs—in some cases sizable—associated with implementing its recommendations. These costs must be carefully weighed against the potential for long-term benefit. Expanding the roles and capacity of the nursing profession will require significant up-front financial resources, but this investment, in the committee’s view, will help secure a strong foundation for a future health care system that can provide high-quality, accessible, patient-centered care. Based on its expert opinion and the available evidence, the committee believes that, de- spite the fiscal challenges, implementation of its recommendations is necessary

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BOX 7-1 Research Priorities for Transforming Nursing Practice

Scope of Practice

• Comparison of costs, quality outcomes, and access associated with a range of primary care delivery models.

• Examination of the impact of expanding the range of providers allowed to certify patients for home health services and for admission to hospice or a skilled nurs- ing facility.

• Examination of the impact of expanding the range of providers allowed to per- form initial hospital admitting assessments.

• Capture of intended and unintended consequences of alternative reimbursement mechanisms for advanced practice registered nurses (APRNs), physicians, and other providers of primary care.

• Exploration of the impact of alternative payment reform policies on the organiza- tion and effectiveness of care teams and on the role played by registered nurses (RNs), physician assistants, and APRNs on care teams.

• Capture of the impact of health insurance exchanges on the role of APRNs in the provision of primary care in the United States.

Residencies

• Identification of the key features of residencies that result in nurses acquiring confidence and competency at a reasonable cost.

• Analysis of the possible unintended consequences of reallocating federal, state, and/or facility budgets to support residencies and other nurse training opportunities.

Teamwork

• Identification of the main barriers to collaboration between nurses and other health care staff in a range of settings.

• Identification and testing of new or existing models of care teams that have the potential to add value to the health care system if widely implemented.

• Identification and testing of educational innovations that have the potential to increase health care professionals’ ability to serve as productive, collaborative care team members.

Technology

• Identification and testing of new and existing technologies intended to support nurses’ decision making and care delivery.

• Capture of the costs and benefits of a range of care technologies intended to support nurses’ decision making and care delivery.

• Identification of the contributions of various health professionals to the design and development, purchase, implementation, and evaluation of devices and information technology products.

• Development of a measure of “meaningful use” of information technology by nurses.

Value

• Capture of the impact of changes made to the system of care delivery on costs and quality over the next 5−10 years.

• Capture of the costs of implementing the recommendations in this report. • Capture of the impact of implementing the recommendations in this report on

the cost and quality of health care provided in the United States. • Analysis of the intended and unintended effects of increasing payment for pri-

mary care provided by physicians and other providers.

to increase the quality, accessibility, and value of care through the contributions of nurses.

Implementation of the Recommendations

Each of the recommendations presented in this report is supported by a level of evidence necessary to warrant its implementation. This does not mean, however, that the evidence currently available to support the committee’s recom- mendations is sufficient to guide or motivate their implementation. The research priorities presented in Boxes 7-1 through 7-3 constitute key evidence gaps that need to be filled to convince key stakeholders that each recommendation is fun- damental to the transformation of care delivered by nurses. For example, to be convinced to purchase equipment necessary to expand the number of nurses that can be educated using expensive new teaching technologies, such as high-fidelity

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BOX 7-1 Research Priorities for Transforming Nursing Practice

Scope of Practice

• Comparison of costs, quality outcomes, and access associated with a range of primary care delivery models.

• Examination of the impact of expanding the range of providers allowed to certify patients for home health services and for admission to hospice or a skilled nurs- ing facility.

• Examination of the impact of expanding the range of providers allowed to per- form initial hospital admitting assessments.

• Capture of intended and unintended consequences of alternative reimbursement mechanisms for advanced practice registered nurses (APRNs), physicians, and other providers of primary care.

• Capture of the impact of health insurance exchanges on the role of APRNs in the provision of primary care in the United States.

Residencies

• Identification of the key features of residencies that result in nurses acquiring confidence and competency at a reasonable cost.

• Analysis of the possible unintended consequences of reallocating federal, state, and/or facility budgets to support residencies and other nurse training opportunities.

Teamwork

• Identification of the main barriers to collaboration between nurses and other health care staff in a range of settings.

• Identification and testing of new or existing models of care teams that have the potential to add value to the health care system if widely implemented.

• Identification and testing of educational innovations that have the potential to increase health care professionals’ ability to serve as productive, collaborative care team members.

Technology

• Identification and testing of new and existing technologies intended to support nurses’ decision making and care delivery.

• Capture of the costs and benefits of a range of care technologies intended to support nurses’ decision making and care delivery.

• Identification of the contributions of various health professionals to the design and development, purchase, implementation, and evaluation of devices and information technology products.

• Development of a measure of “meaningful use” of information technology by nurses.

Value

• Capture of the impact of changes made to the system of care delivery on costs and quality over the next 5−10 years.

• Capture of the costs of implementing the recommendations in this report. • Capture of the impact of implementing the recommendations in this report on

the cost and quality of health care provided in the United States. • Analysis of the intended and unintended effects of increasing payment for pri-

mary care provided by physicians and other providers.

simulation, distance learning, and online education modalities, decision makers in nursing schools will likely need evidence for the impact of these technologies on increasing the capacity of the nursing education system, as well as assurance that these technologies are an effective way to educate students. Likewise, before agreeing to reorganize care and training in a way that supports nursing residen- cies, hospitals will likely want to understand the true costs of such programs, as well as the key ingredients for their success. And before state political leaders can be persuaded to enact legislation to expand and standardize the scope of practice for advanced practice registered nurses, they will need messages to convey to their constituents about what these changes will mean for acquiring timely access to high-quality primary care services.

The committee urges the health services research community to embark on research agendas that can produce the evidence needed to guide the implementa- tion of its recommendations. At the same time, the committee recognizes, from

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BOX 7-2 Research Priorities for Transforming Nursing Education

• Identification of the combination of salary, benefits, and job attributes that re- sults in the most highly qualified nurses being recruited and retained in faculty positions.

• Analysis of how alternative nurse faculty/student ratios affect instruction and the acquisition of knowledge.

• Capture of how optimal nurse faculty/student ratios vary with the implementa- tion of new or existing teaching technologies, including distance learning.

• Identification of the features of online, simulation, and telehealth nursing edu- cation that most cost-effectively expand nursing education capacity.

• Capture of the experience in nursing schools that include new curriculum related to expanded clinical settings, evidence-based practice, and interprofes- sional and patient-centered care.

• Identification and evaluation of new and existing models of nursing education implemented to ensure that nurses acquire fundamental competencies needed to lead and engage in continuous quality improvement initiatives.

• Identification or development of an assessment tool to ensure that nurses have acquired the full range of competence required to practice nursing in undergraduate, postgraduate, and continuing education.

• Analysis of the impact of a range of strategies for increasing the number of nurses with a doctorate on the supply of nurse faculty, scientists, and researchers.

• Identification of the staff and environmental characteristics that best support the success of diverse nurses working to acquire doctoral degrees.

• Identification and testing of new and existing models of education to support nurses’ engagement in team-based, patient-centered care to diverse popula- tions, across the lifespan, in a range of settings.

• Development of workforce demand models that can predict regional faculty shortages.

the work of Mary Naylor and colleagues (2009), that a strong evidence base, even if supported by the results of multiple randomized clinical trials funded by the National Institutes of Health, will not be sufficient to propel a new model, policy, or practice to a position of widespread acceptance and implementation. “Health care is rich in evidence-based innovations, yet even when such innovations are implemented successfully in one location, they often disseminate slowly—if at all. Diffusion of innovations is a major challenge in all industries including health care” (Berwick, 2003).

Experience with the Transitional Care Model (TCM), described in Chapter 2, illustrates this point. In this case, barriers intrinsic to the way care is currently organized, regulated, reimbursed, and delivered have delayed the ability of a cost-effective, quality-enhancing model to improve the lives of the chronically

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BOX 7-3 Research Priorities for Transforming Nursing Leadership

• Identification of the personal and professional characteristics most critical to leadership of health care organizations, such as accountable care organiza- tions, health care homes, medical homes, and clinics.

• Identification of the skills and knowledge most critical to leaders of health care organizations, such as accountable care organizations, health care homes, medical homes, and clinics.

• Identification of the personal and professional characteristics most important to leaders of quality improvement initiatives in hospitals and other settings.

• Identification of the characteristics of mentors that have been (or could be) most successful in recruiting and training diverse nurses and nurse faculty.

• Identification of the influence of nursing on important health care decisions at all levels.

• Identification of the unique contributions of nurses to health care committees or boards.

ill. Learning from barriers to diffuse evidence-based health care interventions within health systems, Naylor and colleagues identified several ingredients cru- cial to successful diffusion. First, the model or innovation should be a good fit in response to a critical need, either within an organization or nationwide. Second, without strong champions, especially those with decision-making power, there is very little chance of widespread adoption. The researchers learned the hard way the cost of failure to engage all stakeholders in a project—early, continually, and throughout. Engagement with the media is especially important. An understand- ing of the landscape is necessary as well and should guide efforts to market the innovation to others. Milestones and measures of success are important to all team members and throughout the entire diffusion process. Finally, flexibility, or the willingness to adapt the model or innovation to meet environmental or orga- nizational demands, increases the probability of success (Naylor et al., 2009).

Planning for the implementation of the committee’s recommendations is beyond the scope of this report. However, the committee urges health care pro- viders, organizations, and policy makers to carry out the eight recommendations presented below to enable nurses to lead in the transformation of the health care system and advance the health of patients and communities throughout the nation.

CONCLUSION

The committee believes the implementation of its recommendations will help establish the needed groundwork in the nursing profession to further the

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work of nurses in innovating and improving patient care. The committee sees its recommendations as the building blocks required to expand innovative models of care, as well as to improve the quality, accessibility, and value of care, through nursing. The committee emphasizes that the synergistic implementation of all of its recommendations as a whole will be necessary to truly transform the nurs- ing profession into one that is capable of leading change to advance the nation’s health.

RECOMMENDATIONS

Recommendation 1: Remove scope-of-practice barriers. Advanced practice registered nurses should be able to practice to the full extent of their education and training. To achieve this goal, the committee recommends the following actions.

For the Congress:

• Expand the Medicare program to include coverage of advanced practice registered nurse services that are within the scope of practice under ap- plicable state law, just as physician services are now covered.

• Amend the Medicare program to authorize advanced practice registered nurses to perform admission assessments, as well as certification of patients for home health care services and for admission to hospice and skilled nursing facilities.

• Extend the increase in Medicaid reimbursement rates for primary care physicians included in the ACA to advanced practice registered nurses providing similar primary care services.

• Limit federal funding for nursing education programs to only those pro- grams in states that have adopted the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administra- tive Rules (Article XVIII, Chapter 18).

For state legislatures:

• Reform scope-of-practice regulations to conform to the National Coun- cil of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules (Article XVIII, Chapter 18).

• Require third-party payers that participate in fee-for-service payment arrangements to provide direct reimbursement to advanced practice registered nurses who are practicing within their scope of practice under state law.

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For the Centers for Medicare and Medicaid Services:

• Amend or clarify the requirements for hospital participation in the Medi- care program to ensure that advanced practice registered nurses are eligible for clinical privileges, admitting privileges, and membership on medical staff.

For the Office of Personnel Management:

• Require insurers participating in the Federal Employees Health Benefits Program to include coverage of those services of advanced practice registered nurses that are within their scope of practice under applicable state law.

For the Federal Trade Commission and the Antitrust Division of the Department of Justice:

• Review existing and proposed state regulations concerning advanced practice registered nurses to identify those that have anticompetitive ef- fects without contributing to the health and safety of the public. States with unduly restrictive regulations should be urged to amend them to allow advanced practice registered nurses to provide care to patients in all circumstances in which they are qualified to do so.

Recommendation 2: Expand opportunities for nurses to lead and diffuse col- laborative improvement efforts. Private and public funders, health care orga- nizations, nursing education programs, and nursing associations should expand opportunities for nurses to lead and manage collaborative efforts with physicians and other members of the health care team to conduct research and to redesign and improve practice environments and health systems. These entities should also provide opportunities for nurses to diffuse successful practices.

To this end:

• The Center for Medicare and Medicaid Innovation should support the development and evaluation of models of payment and care delivery that use nurses in an expanded and leadership capacity to improve health out- comes and reduce costs. Performance measures should be developed and implemented expeditiously where best practices are evident to reflect the contributions of nurses and ensure better-quality care.

• Private and public funders should collaborate, and when possible pool funds, to advance research on models of care and innovative solutions,

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including technology, that will enable nurses to contribute to improved health and health care.

• Health care organizations should support and help nurses in taking the lead in developing and adopting innovative, patient-centered care models.

• Health care organizations should engage nurses and other front-line staff to work with developers and manufacturers in the design, development, purchase, implementation, and evaluation of medical and health devices and health information technology products.

• Nursing education programs and nursing associations should provide entrepreneurial professional development that will enable nurses to initi- ate programs and businesses that will contribute to improved health and health care.

Recommendation 3: Implement nurse residency programs. State boards of nursing, accrediting bodies, the federal government, and health care organiza- tions should take actions to support nurses’ completion of a transition-to-practice program (nurse residency) after they have completed a prelicensure or advanced practice degree program or when they are transitioning into new clinical practice areas.

The following actions should be taken to implement and support nurse residency programs:

• State boards of nursing, in collaboration with accrediting bodies such as the Joint Commission and the Community Health Accreditation Pro- gram, should support nurses’ completion of a residency program after they have completed a prelicensure or advanced practice degree program or when they are transitioning into new clinical practice areas.

• The Secretary of Health and Human Services should redirect all gradu- ate medical education funding from diploma nursing programs to sup- port the implementation of nurse residency programs in rural and critical access areas.

• Health care organizations, the Health Resources and Services Admin- istration and Centers for Medicare and Medicaid Services, and philan- thropic organizations should fund the development and implementation of nurse residency programs across all practice settings.

• Health care organizations that offer nurse residency programs and foun- dations should evaluate the effectiveness of the residency programs in improving the retention of nurses, expanding competencies, and improv- ing patient outcomes.

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Recommendation 4: Increase the proportion of nurses with a baccalaureate degree to 80 percent by 2020. Academic nurse leaders across all schools of nursing should work together to increase the proportion of nurses with a bac- calaureate degree from �0 to �0 percent by 2020. These leaders should partner with education accrediting bodies, private and public funders, and employers to ensure funding, monitor progress, and increase the diversity of students to cre- ate a workforce prepared to meet the demands of diverse populations across the lifespan.

• The Commission on Collegiate Nursing Education, working in collabo- ration with the National League for Nursing Accrediting Commission, should require all nursing schools to offer defined academic pathways, beyond articulation agreements, that promote seamless access for nurses to higher levels of education.

• Health care organizations should encourage nurses with associate’s and diploma degrees to enter baccalaureate nursing programs within 5 years of graduation by offering tuition reimbursement, creating a culture that fosters continuing education, and providing a salary differential and promotion.

• Private and public funders should collaborate, and when possible pool funds, to expand baccalaureate programs to enroll more students by of- fering scholarships and loan forgiveness, hiring more faculty, expanding clinical instruction through new clinical partnerships, and using technol- ogy to augment instruction. These efforts should take into consideration strategies to increase the diversity of the nursing workforce in terms of race/ethnicity, gender, and geographic distribution.

• The U.S. Secretary of Education, other federal agencies including the Health Resources and Services Administration, and state and private funders should expand loans and grants for second-degree nursing students.

• Schools of nursing, in collaboration with other health professional schools, should design and implement early and continuous interpro- fessional collaboration through joint classroom and clinical training opportunities.

• Academic nurse leaders should partner with health care organizations, leaders from primary and secondary school systems, and other commu- nity organizations to recruit and advance diverse nursing students.

Recommendation 5: Double the number of nurses with a doctorate by 2020. Schools of nursing, with support from private and public funders, academic ad- ministrators and university trustees, and accrediting bodies, should double the number of nurses with a doctorate by 2020 to add to the cadre of nurse faculty and researchers, with attention to increasing diversity.

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• The Commission on Collegiate Nursing Education and the National League for Nursing Accrediting Commission should monitor the prog- ress of each accredited nursing school to ensure that at least 10 percent of all baccalaureate graduates matriculate into a master’s or doctoral program within 5 years of graduation.

• Private and public funders, including the Health Resources and Services Administration and the Department of Labor, should expand funding for programs offering accelerated graduate degrees for nurses to increase the production of master’s and doctoral nurse graduates and to increase the diversity of nurse faculty and researchers.

• Academic administrators and university trustees should create salary and benefit packages that are market competitive to recruit and retain highly qualified academic and clinical nurse faculty.

Recommendation 6: Ensure that nurses engage in lifelong learning. Accredit- ing bodies, schools of nursing, health care organizations, and continuing com- petency educators from multiple health professions should collaborate to ensure that nurses and nursing students and faculty continue their education and engage in lifelong learning to gain the competencies needed to provide care for diverse populations across the lifespan.

• Faculty should partner with health care organizations to develop and prioritize competencies so curricula can be updated regularly to ensure that graduates at all levels are prepared to meet the current and future health needs of the population.

• The Commission on Collegiate Nursing Education and the National League for Nursing Accrediting Commission should require that all nursing students demonstrate a comprehensive set of clinical perfor- mance competencies that encompass the knowledge and skills needed to provide care across settings and the lifespan.

• Academic administrators should require all faculty to participate in continuing professional development and to perform with cutting-edge competence in practice, teaching, and research.

• All health care organizations and schools of nursing should foster a culture of lifelong learning and provide resources for interprofessional continuing competency programs.

• Health care organizations and other organizations that offer continu- ing competency programs should regularly evaluate their programs for adaptability, flexibility, accessibility, and impact on clinical outcomes and update the programs accordingly.

Recommendation 7: Prepare and enable nurses to lead change to advance health. Nurses, nursing education programs, and nursing associations should

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prepare the nursing workforce to assume leadership positions across all levels, while public, private, and governmental health care decision makers should en- sure that leadership positions are available to and filled by nurses.

• Nurses should take responsibility for their personal and professional growth by continuing their education and seeking opportunities to de- velop and exercise their leadership skills.

• Nursing associations should provide leadership development, mentoring programs, and opportunities to lead for all their members.

• Nursing education programs should integrate leadership theory and busi- ness practices across the curriculum, including clinical practice.

• Public, private, and governmental health care decision makers at every level should include representation from nursing on boards, on executive management teams, and in other key leadership positions.

Recommendation 8: Build an infrastructure for the collection and analysis of interprofessional health care workforce data. The National Health Care Work- force Commission, with oversight from the Government Accountability Office and the Health Resources and Services Administration, should lead a collaborative effort to improve research and the collection and analysis of data on health care workforce requirements. The Workforce Commission and the Health Resources and Services Administration should collaborate with state licensing boards, state nursing workforce centers, and the Department of Labor in this effort to ensure that the data are timely and publicly accessible.

• The Workforce Commission and the Health Resources and Services Administration should coordinate with state licensing boards, including those for nursing, medicine, dentistry, and pharmacy, to develop and promulgate a standardized minimum data set across states and profes- sions that can be used to assess health care workforce needs by demo- graphics, numbers, skill mix, and geographic distribution.

• The Workforce Commission and the Health Resources and Services Administration should set standards for the collection of the minimum data set by state licensing boards; oversee, coordinate, and house the data; and make the data publicly accessible.

• The Workforce Commission and the Health Resources and Services Administration should retain, but bolster, the Health Resources and Services Administration’s registered nurse sample survey by increasing the sample size, fielding the survey every other year, expanding the data collected on advanced practice registered nurses, and releasing survey results more quickly.

• The Workforce Commission and the Health Resources and Services Administration should establish a monitoring system that uses the most

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current analytic approaches and data from the minimum data set to systematically measure and project nursing workforce requirements by role, skill mix, region, and demographics.

• The Workforce Commission and the Health Resources and Services Administration should coordinate workforce research efforts with the Department of Labor, state and regional educators, employers, and state nursing workforce centers to identify regional health care workforce needs, and establish regional targets and plans for appropriately increas- ing the supply of health professionals.

• The Government Accountability Office should ensure that the Workforce Commission membership includes adequate nursing expertise.

REFERENCES

Berwick, D. M. 2003. Disseminating innovations in health care. JAMA 289(15):1969-1975. Naylor, M. D., P. H. Feldman, S. Keating, M. J. Koren, E. T. Kurtzman, M. C. Maccoy, and R.

Krakauer. 2009. Translating research into practice: Transitional care for older adults. Journal of Evaluation in Clinical Practice 15(6):1164-1170.
The Patient Protection and Affordable Care Act

Detailed Summary

The Patient Protection and Affordable Care Act will ensure that all Americans have access to quality,

affordable health care and will create the transformation within the health care system necessary to

contain costs. The Congressional Budget Office (CBO) has determined that the Patient Protection and

Affordable Care Act is fully paid for, will provide coverage to more than 94% of Americans while

staying under the $900 billion limit that President Obama established, bending the health care cost

curve, and reducing the deficit over the next ten years and beyond.

The Patient Protection and Affordable Care Act contains nine titles, each addressing an essential

component of reform:

 Quality, affordable health care for all Americans

 The role of public programs

 Improving the quality and efficiency of health care

 Prevention of chronic disease and improving public health

 Health care workforce

 Transparency and program integrity

 Improving access to innovative medical therapies

 Community living assistance services and supports

 Revenue provisions

Title I. Quality, Affordable Health Care for All Americans The Patient Protection and Affordable Care Act will accomplish a fundamental transformation of

health insurance in the United States through shared responsibility. Systemic insurance market reform

will eliminate discriminatory practices such as pre-existing condition exclusions. Achieving these

reforms without increasing health insurance premiums will mean that all Americans must be part of the

system and must have coverage. Tax credits for individuals and families will ensure that insurance is

affordable for everyone. These three elements are the essential links to achieve reform.

Immediate Improvements: Achieving health insurance reform will take some time to implement. In

the immediate reforms will be implemented in 2010. The Patient Protection and Affordable Care Act

will:

 Eliminate lifetime and unreasonable annual limits on benefits

 Prohibit rescissions of health insurance policies

 Provide assistance for those who are uninsured because of a pre-existing condition

 Require coverage of preventive services and immunizations

 Extend dependant coverage up to age 26

 Develop uniform coverage documents so consumers can make apples-to-apples comparisons when shopping for health insurance

 Cap insurance company non-medical, administrative expenditures

 Ensure consumers have access to an effective appeals process and provide consumer a place to turn for assistance navigating the appeals process and accessing their coverage

 Create a temporary re-insurance program to support coverage for early retirees

 Establish an internet portal to assist Americans in identifying coverage options

 Facilitate administrative simplification to lower health system costs

Health Insurance Market Reform: Beginning in 2014, more significant insurance reforms will be

implemented. Across individual and small group health insurance markets in all states, new rules will

end medical underwriting and pre-existing condition exclusions. Insurers will be prohibited from

denying coverage or setting rates based on health status, medical condition, claims experience, genetic

information, evidence of domestic violence, or other health-related factors. Premiums will vary only

by family structure, geography, actuarial value, tobacco use, participation in a health promotion

program, and age (by not more than three to one).

Available Coverage: A qualified health plan, to be offered through the new American Health Benefit

Exchange, must provide essential health benefits which include cost sharing limits. No out-of-pocket

requirements can exceed those in Health Savings Accounts, and deductibles in the small group market

cannot exceed $2,000 for an individual and $4,000 for a family. Coverage will be offered at four

levels with actuarial values defining how much the insurer pays: Platinum – 90 percent; Gold – 80

percent; Silver – 70 percent; and Bronze – 60 percent. A lower-benefit catastrophic plan will be

offered to individuals under age 30 and to others who are exempt from the individual responsibility

requirement.

American Health Benefit Exchanges: By 2014, each state will establish an Exchange to help

individuals and small employers obtain coverage. Plans participating in the Exchanges will be

accredited for quality, will present their benefit options in a standardized manner for easy comparison,

and will use one, simple enrollment form. Individuals qualified to receive tax credits for Exchange

coverage must be ineligible for affordable, employer-sponsored insurance any form of public insurance

coverage. Undocumented immigrants are ineligible for premium tax credits. The Secretary of Health

and Human Services (HHS) will establish a national public option – the Community Health Insurance

Option – and permit states to opt-out. Federal support will also be available for new non-profit,

member run insurance cooperatives. States will have flexibility to establish basic health plans for non-

Medicaid, lower-income individuals; states may also seek waivers to explore other reform options; and

states may form compacts with other states to permit cross-state sale of health insurance. No federal

dollars may be used to pay for abortion services.

Making Coverage Affordable: New, refundable tax credits will be available for Americans with

incomes between 100 and 400 percent of the federal poverty line (FPL) (about $88,000 for a family of

four). The credit is calculated on a sliding scale beginning at two percent of income for those at 100

percent FPL and phasing out at 9.8 percent of income at 300-400 percent FPL. If an employer offer of

coverage exceeds 9.8 percent of a worker‟s family income, or the employer pays less than 60 percent

of the premium, the worker may enroll in the Exchange and receive credits. Out of pocket maximums

($5,950 for individuals and $11,900 for families) are reduced to one third for those with income

between 100-200 percent FPL, one half for those with incomes between 200-300 percent FPL, and two

thirds for those with income between 300-400 percent FPL. Credits are available for eligible citizens

and legally-residing aliens. A new credit will assist small businesses with fewer than 25 workers for

up to 50 percent of the total premium cost.

Shared Responsibility: Beginning in 2014, most individuals will be required to maintain minimum

essential coverage or pay a penalty of $95 in 2014, $350 in 2015, $750 in 2016 and indexed thereafter;

for those under 18, the penalty will be one-half the amount for adults. Exceptions to this requirement

are made for religious objectors, those who cannot afford coverage, taxpayers with incomes less than

100 percent FPL, Indian tribe members, those who receive a hardship waiver, individuals not lawfully

present, incarcerated individuals, and those not covered for less than three months.

Any individual or family who currently has coverage and would like to retain that coverage can do so

under a „grandfather‟ provision. This coverage is deemed to meet the requirement to have health

coverage. Similarly, employers that currently offer coverage are permitted to continue offering such

coverage under the „grandfather‟ policy.

Employers with more than 200 employees must automatically enroll new full-time employees in

coverage. Any employer with more than 50 full-time employees that does not offer coverage and has

at least one full-time employee receiving the premium assistance tax credit will make a payment of

$750 per full-time employee. An employer with more than 50 employees that offers coverage that is

deemed unaffordable or does not meet the standard for minimum essential coverage and but has at

least one full-time employee receiving the premium assistance tax credit because the coverage is either

unaffordable or does not cover 60 percent of total costs, will pay the lesser of $3,000 for each of those

employees receiving a credit or $750 for each of their full-time employees total.

Title II. The Role of Public Programs The Patient Protection and Affordable Care Act expands eligibility for Medicaid to lower income

persons and assumes federal responsibility for much of the cost of this expansion. It provides

enhanced federal support for the Children‟s Health Insurance Program, simplifies Medicaid and CHIP

enrollment, improves Medicaid services, provides new options for long-term services and supports,

improves coordination for dual-eligibles, and improves Medicaid quality for patients and providers.

Medicaid Expansion: States may expand Medicaid eligibility as early as January 1, 2011. Beginning

on January 1, 2014, all children, parents and childless adults who are not entitled to Medicare and who

have family incomes up to 133 percent FPL will become eligible for Medicaid. Between 2014 and

2016, the federal government will pay 100 percent of the cost of covering newly-eligible individuals.

In 2017 and 2018, states that initially covered less of the newly-eligible population (“Other States”)

will receive more assistance than states that covered at least some non-elderly, non-pregnant adults

(“Expansion States”). States will be required to maintain the same income eligibility levels through

December 31, 2013 for all adults, and this requirement would be extended through September 30, 2019

for children currently in Medicaid.

Children’s Health Insurance Program: States will be required to maintain income eligibility levels

for CHIP through September 30, 2019. Between fiscal years 2014 and 2019, states would receive a 23

percentage point increase in the CHIP federal match rate, subject to a 100 percent cap.

Simplifying Enrollment: Individuals will be able to apply for and enroll in Medicaid, CHIP and the

Exchange through state-run websites. Medicaid and CHIP programs and the Exchange will coordinate

enrollment procedures to provide seamless enrollment for all programs. Hospitals will be permitted to

provide Medicaid services during a period of presumptive eligibility to members of all Medicaid

eligibility categories.

Community First Choice Option: A new optional Medicaid benefit is created through which states

may offer community-based attendant services and supports to Medicaid beneficiaries with disabilities

who would otherwise require care in a hospital, nursing facility, or intermediate care facility for the

mentally retarded.

Disproportionate Share Hospital Allotments: States‟ disproportionate share hospital (DSH)

allotments are reduced by 50 percent once a state‟s uninsurance rate decreases by 45 percent (low DSH

states would receive a 25 percent reduction). As the rate continues to decline, states‟ DSH allotments

would be reduced by a corresponding amount. At no time could a state‟s allotment be reduced by

more than 65 percent compared to its FY2012 allotment.

Dual Eligible Coverage and Payment Coordination: The Secretary of Health and Human Services

(HHS) will establish a Federal Coordinated Health Care Office by March 1, 2010 to integrate care

under Medicare and Medicaid, and improve coordination among the federal and state governments for

individuals enrolled in both programs (dual eligibles).

Title III. Improving the Quality and Efficiency of Health Care The Patient Protection and Affordable Care Act will improve the quality and efficiency of U.S.

medical care services for everyone, and especially for those enrolled in Medicare and Medicaid.

Payment for services will be linked to better quality outcomes. The Patient Protection and Affordable

Care Act will make substantial investments to improve the quality and delivery of care and support

research to inform consumers about patient outcomes resulting from different approaches to treatment

and care delivery. New patient care models will be created and disseminated. Rural patients and

providers will see meaningful improvements. Payment accuracy will improve. The Medicare Part D

prescription drug benefit will be enhanced and the coverage gap, or donut hole, will be reduced. An

Independent Medicare Advisory Board will develop recommendations to ensure long-term fiscal

stability.

Linking Payment to Quality Outcomes in Medicare: A value-based purchasing program for

hospitals will launch in FY2013 will link Medicare payments to quality performance on common,

high-cost conditions such as cardiac, surgical and pneumonia care. The Physician Quality Reporting

Initiative (PQRI) is extended through 2014, with incentives for physicians to report Medicare quality

data – physicians will receive feedback reports beginning in 2012. Long-term care hospitals, inpatient

rehabilitation facilities and hospice providers will participate in value-based purchasing with quality

measure reporting starting in FY2014, with penalties for non-participating providers.

Strengthening the Quality Infrastructure: The HHS Secretary will establish a national strategy to

improve health care service delivery, patient outcomes, and population health. The President will

convene an Interagency Working Group on Health Care Quality to collaborate on the development and

dissemination of quality initiatives consistent with the national strategy.

Encouraging Development of New Patient Care Models: A new Center for Medicare & Medicaid

Innovation will be established within the Centers for Medicare and Medicaid Services to research,

develop, test, and expand innovative payment and delivery arrangements. Accountable Care

Organizations (ACOs) that take responsibility for cost and quality received by patients will receive a

share of savings they achieve for Medicare. The HHS Secretary will develop a national, voluntary

pilot program encouraging hospitals, doctors, and post-acute providers to improve patient care and

achieve savings through bundled payments. A new demonstration program for chronically ill

Medicare beneficiaries will test payment incentives and service delivery using physician and nurse

practitioner-directed home-based primary care teams. Beginning in 2012, hospital payments will be

adjusted based on the dollar value of each hospital‟s percentage of potentially preventable Medicare

readmissions.

Ensuring Beneficiary Access to Physician Care and Other Services: The Act extends a floor on

geographic adjustments to the Medicare fee schedule to increase provider fees in rural areas and gives

immediate relief to areas harmed by geographic adjustment for practice expenses. The Act extends

bonus payments by Medicare for ground and air ambulance services in rural and other areas. The Act

creates a 12 month enrollment period for military retirees, spouses (and widows/widowers) and

dependent children, who are eligible for TRICARE and entitled to Medicare Part A based on disability

or ESRD, who have declined Part B.

Rural Protections: The Act extends the outpatient hold harmless provision, allowing small rural

hospitals and Sole Community Hospitals to receive this adjustment through FY2010 and reinstates cost

reimbursement for lab services provided by small rural hospitals from July 1, 2010 to July 1, 2011.

The Patient Protection and Affordable Care Act extends the Rural Community Hospital Demonstration

Program for two years and expands eligible sites to additional states and hospitals.

Improving Payment Accuracy: The HHS Secretary will rebase home health payments starting in

2013 based on the current mix of services and intensity of care provided to patients. The Secretary will

update Medicare hospice claims forms and cost reports to improve payment accuracy. The Secretary

will update Disproportionate Share (DSH) payments to better account for hospital uncompensated care

costs; Medicare DSH payments will reflect lower uncompensated care costs tied to decreases in the

number of uninsured. The bill also makes changes to improve payment accuracy for imaging services

and power-driven wheelchairs. The Secretary will study and report to Congress on reforming the

Medicare hospital wage index system and will establish a demonstration program to allow hospice

eligible patients to receive all other Medicare covered services during the same period.

Medicare Advantage (Part C): Medicare Advantage payments will be based on the average of the

bids submitted by insurance plans in each market. Bonus payments will be available to improve the

quality of care and will be based on an insurer‟s level of care coordination and care management, as

well as achievement on quality rankings. New payments will be implemented over a four-year

transition period. MA plans will be prohibited from charging beneficiaries cost sharing for covered

services greater than what is charged under fee-for-service. Plans providing extra benefits must give

priority to cost sharing reductions, wellness and preventive care prior to covering benefits not currently

covered by Medicare.

Medicare Prescription Drug Plan Improvements (Part D): In order to have their drugs covered

under the Medicare Part D program, drug manufacturers will provide a 50 percent discount to Part D

beneficiaries for brand-name drugs and biologics purchased during the coverage gap beginning July 1,

2010. The initial coverage limit in the standard Part D benefit will be expanded by $500 for 2010.

Ensuring Medicare Sustainability: A productivity adjustment will be added to the market basket

update for inpatient hospitals, home health providers, nursing homes, hospice providers, inpatient

psychiatric facilities, long-term care hospitals and inpatient rehabilitation facilities. The Act creates an

independent, 15-member Medicare Advisory Board to present Congress with proposals to reduce costs

and improve quality for beneficiaries. When Medicare costs are projected to exceed certain targets, the

Board‟s proposals will take effect unless Congress passes an alternative measure to achieve the same

level of savings. The Board will not make proposals that ration care, raise taxes or beneficiary

premiums, or change Medicare benefit, eligibility, or cost-sharing standards.

Health Care Quality Improvements: The Patient Protection and Affordable Care Act will create a

new program to develop community health teams supporting medical homes to increase access to

community-based, coordinated care. It supports a health delivery system research center to conduct

research on health delivery system improvement and best practices that improve the quality, safety,

and efficiency of health care delivery. And, it support medication management services by local health

providers to help patients better manage chronic disease.

Title IV: Prevention of Chronic Disease and Improving Public Health To better orient the nation‟s health care system toward health promotion and disease prevention, a set

of initiatives will provide the impetus and the infrastructure. A new interagency prevention council

will be supported by a new Prevention and Public Health Investment Fund. Barriers to accessing

clinical preventive services will be removed. Developing healthy communities will be a priority, and a

21 st century public health infrastructure will support this goal.

Modernizing Disease Prevention and Public Health Systems: A new interagency council is created

to promote healthy policies and to establish a national prevention and health promotion strategy. A

Prevention and Public Health Investment Fund is established to provide an expanded and sustained

national investment in prevention and public health. The HHS Secretary will convene a national

public/private partnership to conduct a national prevention and health promotion outreach and

education campaign to raise awareness of activities to promote health and prevent disease across the

lifespan.

Increasing Access to Clinical Preventive Services: The Act authorizes important new programs and

benefits related to preventive care and services:

 For the operation and development of School-Based Health Clinics.

 For an oral healthcare prevention education campaign.

 To provide Medicare coverage – with no co-payments or deductibles – for an annual wellness visit and development of a personalized prevention plan.

 To waive coinsurance requirements and deductibles for most preventive services, so that Medicare will cover 100 percent of the costs.

 To authorize the HHS Secretary to modify coverage of any Medicare-covered preventive service to be consistent with U.S. Preventive Services Task Force recommendations.

 To provide States with an enhanced match if the State Medicaid program covers: (1) any clinical preventive service recommended with a grade of A or B by the U.S. Preventive

Services Task Force and (2) adult immunizations recommended by the Advisory Committee on

Immunization Practices without cost sharing.

 To require Medicaid coverage for counseling and pharmacotherapy to pregnant women for cessation of tobacco use.

 To award grants to states to provide incentives for Medicaid beneficiaries to participate in programs providing incentives for healthy lifestyles.

Creating Healthier Communities: The Secretary will award grants to eligible entities to promote

individual and community health and to prevent chronic disease. The CDC will provide grants to

states and large local health departments to conduct pilot programs in the 55-to-64 year old population

to evaluate chronic disease risk factors, conduct evidence-based public health interventions, and ensure

that individuals identified with chronic disease or at-risk for chronic disease receive clinical treatment

to reduce risk. The Act authorizes all states to purchase adult vaccines under CDC contracts.

Restaurants which are part of a chain with 20 or more locations doing business under the same name

must disclose calories on the menu board and in written form.

Support for Prevention and Public Health Innovation: The HHS Secretary will provide funding for

research in public health services and systems to examine best prevention practices. Federal health

programs will collect and report data by race, ethnicity, primary language and any other indicator of

disparity. The CDC will evaluate best employer wellness practices and provide an educational

campaign and technical assistance to promote the benefits of worksite health promotion. A new CDC

program will help state, local, and tribal public health agencies to improve surveillance for and

responses to infectious diseases and other important conditions. An Institute of Medicine Conference

on Pain Care will evaluate the adequacy of pain assessment, treatment, and management; identify and

address barriers to appropriate pain care; increase awareness; and report to Congress on findings and

recommendations.

Title V — Health Care Workforce To ensure a vibrant, diverse and competent workforce, the Patient Protection and Affordable Care Act

will encourage innovations in health workforce training, recruitment, and retention, and will establish a

new workforce commission. Provisions will help to increase the supply of health care workers. These

workers will be supported by a new workforce training and education infrastructure.

Innovations in the Health Care Workforce: The Patient Protection and Affordable Care Act

establishes a national commission to review health care workforce and projected workforce needs and

to provide comprehensive information to Congress and the Administration to align workforce

resources with national needs. It will also establish competitive grants to enable state partnerships to

complete comprehensive workforce planning and to create health care workforce development

strategies.

Increasing the Supply of the Health Care Workers: The federal student loan program will be

modified to ease criteria for schools and students, shorten payback periods, and to make the primary

care student loan program more attractive. The Nursing Student Loan Program will be increased and

the years for nursing schools to establish and maintain student loan funds are updated. A loan

repayment program is established for pediatric subspecialists and providers of mental and behavioral

health services to children and adolescents who work in a Health Professional Shortage Area, a

Medically Underserved Area, or with a Medically Underserved Population. Loan repayment will be

offered to public health students and workers in exchange for working at least three years at a federal,

state, local, or tribal public health agency. Loan repayment will be offered to allied health professionals

employed at public health agencies or in settings providing health care to patients, including acute care

facilities, ambulatory care facilities, residences, and other settings located in Health Professional

Shortage Areas, Medically Underserved Areas, or with Medically Underserved Populations.

Authorization of appropriations for the National Health Service Corps scholarship and loan repayment

program will be extended 2010-2015. A $50 million grant program will support nurse-managed health

clinics. A Ready Reserve Corps within the Commissioned Corps is established for service in times of

national emergency. Ready Reserve Corps members may be called to active duty to respond to national

emergencies and public health crises and to fill critical public health positions left vacant by members

of the Regular Corps who have been called to duty elsewhere.

Enhancing Health Care Workforce Education and Training: New support for workforce training

programs is established in these areas:

 Family medicine, general internal medicine, general pediatrics, and physician assistantship.

 Direct care workers providing long-term care services and supports.

 General, pediatric, and public health dentistry.

 Alternative dental health care provider.

 Geriatric education and training for faculty in health professions schools and family caregivers.

 Mental and behavioral health education and training grants to schools for the development, expansion, or enhancement of training programs in social work, graduate psychology,

professional training in child and adolescent mental health, and pre-service or in-service

training to paraprofessionals in child and adolescent mental health.

 Cultural competency, prevention and public health and individuals with disabilities training.

 Advanced nursing education grants for accredited Nurse Midwifery programs.

 Nurse education, practice, and retention grants to nursing schools to strengthen nurse education and training programs and to improve nurse retention.

 Nurse faculty loan program for nurses who pursue careers in nurse education.

 Grants to promote the community health workforce to promote positive health behaviors and outcomes in medically underserved areas through use of community health workers.

 Fellowship training in public health to address workforce shortages in state and local health departments in applied public health epidemiology and public health laboratory science and

informatics.

 A U.S. Public Health Sciences Track to train physicians, dentists, nurses, physician assistants, mental and behavior health specialists, and public health professionals emphasizing team-based

service, public health, epidemiology, and emergency preparedness and response in affiliated

institutions.

Supporting the Existing Health Care Workforce: The Patient Protection and Affordable Care Act

reauthorizes the Centers of Excellence program for minority applicants for health professions, expands

scholarships for disadvantaged students who commit to work in medically underserved areas, and

authorizes funding for Area Health Education Centers (AHECs) and Programs. A Primary Care

Extension Program is established to educate and provide technical assistance to primary care providers

about evidence-based therapies, preventive medicine, health promotion, chronic disease management,

and mental health.

Strengthening Primary Care and Other Workforce Improvements: Beginning in 2011, the HHS

Secretary may redistribute unfilled residency positions, redirecting those slots for training of primary

care physicians. A demonstration grant program is established to serve low-income persons including

recipients of assistance under Temporary Assistance for Needy Families (TANF) programs to develop

core training competencies and certification programs for personal and home care aides.

Improving Access to Health Care Services: The Patient Protection and Affordable Care Act

authorizes new and expanded funding for federally qualified health centers and reauthorizes a program

to award grants to states and medical schools to support the improvement and expansion of emergency

medical services for children needing trauma or critical care treatment. Also supported are grants for

coordinated and integrated services through the co-location of primary and specialty care in

community-based mental and behavioral health settings. A Commission on Key National Indicators is

established.

Title VI—Transparency and Program Integrity To ensure the integrity of federally financed and sponsored health programs, this Title creates new

requirements to provide information to the public on the health system and promotes a newly

invigorated set of requirements to combat fraud and abuse in public and private programs.

Physician Ownership and Other Transparency: Physician-owned hospitals that do not have a

provider agreement prior to February 2010 will not be able to participate in Medicare. Drug, device,

biological and medical supply manufacturers must report gifts and other transfers of value made to a

physician, physician medical practice, a physician group practice, and/or a teaching hospital. Referring

physicians for imaging services must inform patients in writing that the individual may obtain such

service from a person other than the referring physician, a physician who is a member of the same

group practice, or an individual who is supervised by the physician or by another physician in the

group. Prescription drug makers and distributors must report to the HHS Secretary information

pertaining to drug samples currently being collected internally. Pharmacy benefit managers (PBM) or

health benefits plans that provide pharmacy benefit management services that contract with health

plans under Medicare or the Exchange must report information regarding the generic dispensing rate;

rebates, discounts, or price concessions negotiated by the PBM.

Nursing Home Transparency and Improvement: The Act requires that skilled nursing facilities

(SNFs) under Medicare and nursing facilities (NFs) under Medicaid make available information on

ownership. SNFs and NFs will be required to implement a compliance and ethics program. The

Secretary of Health and Human Services will publish new information on the Nursing Home Compare

Medicare website: standardized staffing data, links to state internet websites regarding state survey and

certification programs, a model standardized complaint form, a summary of complaints, and the

number of instances of criminal violations by a facility or its employee. The Secretary also will

develop a standardized complaint form for use by residents in filing complaints with a state survey and

certification agency or a state long-term care ombudsman.

Targeting Enforcement: The Secretary may reduce civil monetary penalties for facilities that self-

report and correct deficiencies. The Secretary will establish a demonstration project to test and

implement a national independent monitoring program to oversee interstate and large intrastate chains.

The administrator of a facility preparing to close must provide written notice to residents, legal

representatives of residents, the state, the Secretary and the long-term care ombudsman program in

advance of the closure.

Improving Staff Training: Facilities must include dementia management and abuse prevention

training as part of pre-employment training for staff.

Nationwide Program for Background Checks on Direct Patient Access Employees of Long Term

Care Facilities and Providers: The Secretary will establish a nationwide program for national and

state background checks of direct patient access employees of certain long-term supports and services

facilities or providers.

Patient-Centered Outcomes Research: The Patient Protection and Affordable Care Act establishes a

private, nonprofit entity (the Patient-Centered Outcomes Research Institute) governed by a public-

private board appointed by the Comptroller General to provide for the conduct of comparative clinical

outcomes research. No findings may be construed as mandates on practice guidelines or coverage

decisions and important patient safeguards will protect against discriminatory coverage decisions by

HHS based on age, disability, terminal illness, or an individual‟s quality of life preference.

Medicare, Medicaid, and CHIP Program Integrity Provisions: The Secretary will establish

procedures to screen providers and suppliers participating in Medicare, Medicaid, and CHIP.

Providers and suppliers enrolling or re-enrolling will be subject to new requirements including a fee,

disclosure of current or previous affiliations with any provider or supplier that has uncollected debt,

has had their payments suspended, has been excluded from participating in a Federal health care

program, or has had their billing privileges revoked. The Secretary is authorized to deny enrollment in

these programs if these affiliations pose an undue risk.

Enhanced Medicare and Medicaid Program Integrity Provisions: CMS will include in the

integrated data repository (IDR) claims and payment data from Medicare (Parts A, B, C, and D),

Medicaid, CHIP, health-related programs administered by the Departments of Veterans Affairs (VA)

and Defense (DOD), the Social Security Administration, and the Indian Health Service (IHS). New

penalties will exclude individuals who order or prescribe an item or service, make false statements on

applications or contracts to participate in a Federal health care program, or who know of an

overpayment and do not return the overpayment. Each violation would be subject to a fine of up to

$50,000. The Secretary will take into account the volume of billing for a DME supplier or home

health agency when determining the size of a surety bond. The Secretary may suspend payments to a

provider or supplier pending a fraud investigation. Health Care Fraud and Abuse Control (HCFAC)

funding will be increased by $10 million each year for fiscal years 2011 through 2020. The Secretary

will establish a national health care fraud and abuse data collection program for reporting adverse

actions taken against health care providers, suppliers, and practitioners, and submit information on the

actions to the National Practitioner Data Bank (NPDB). The Secretary will have the authority to

disenroll a Medicare enrolled physician or supplier who fails to maintain and provide access to written

orders or requests for payment for durable medical equipment (DME), certification for home health

services, or referrals for other items and services. The HHS Secretary will expand the number of areas

to be included in round two of the DME competitive bidding program from 79 of the largest

metropolitan statistical areas (MSAs) to 100 of the largest MSAs, and to use competitively bid prices

in all areas by 2016.

Additional Medicaid Program Integrity Provisions: States must terminate individuals or entities

from their Medicaid programs if the individuals or entities were terminated from Medicare or another

state‟s Medicaid program. Medicaid agencies must exclude individuals or entities from participating in

Medicaid for a specified period of time if the entity or individual owns, controls, or manages an entity

that: (1) has failed to repay overpayments; (2) is suspended, excluded, or terminated from participation

in any Medicaid program; or (3) is affiliated with an individual or entity that has been suspended,

excluded, or terminated from Medicaid participation. Agents, clearinghouses, or other payees that

submit claims on behalf of health care providers must register with the state and the Secretary. States

and Medicaid managed care entities must submit data elements for program integrity, oversight, and

administration. States must not make any payments for items or services to any financial institution or

entity located outside of the United States.

Additional Program Integrity Provisions: Employees and agents of multiple employer welfare

arrangements (MEWAs) will be subject to criminal penalties if they provide false statements in

marketing materials regarding a plan‟s financial solvency, benefits, or regulatory status. A model

uniform reporting form will be developed by the National Association of Insurance Commissioners,

under the direction of the HHS Secretary. The Department of Labor will adopt regulatory standards

and/or issue orders to prevent fraudulent MEWAs from escaping liability for their actions under state

law by claiming that state law enforcement is preempted by federal law. The Department of Labor is

authorized to issue “cease and desist” orders to temporarily shut down operations of plans conducting

fraudulent activities or posing a serious threat to the public, until hearings can be completed. MEWAs

will be required to file their federal registration forms, and thereby be subject to government

verification of their legitimacy, before enrolling anyone.

Elder Justice Act: The Elder Justice Act will help prevent and eliminate elder abuse, neglect, and

exploitation. The HHS Secretary will award grants and carry out activities to protect individuals

seeking care in facilities that provide long-term services and supports and provide greater incentives

for individuals to train and seek employment at such facilities. Owners, operators, and employees

would be required to report suspected crimes committed at a facility. Owners or operators of such

facilities would be required to submit to the Secretary and to the state written notification of an

impending closure of a facility within 60 days prior to the closure.

Sense of the Senate Regarding Medical Malpractice: The Act expresses the sense of the Senate that

health reform presents an opportunity to address issues related to medical malpractice and medical

liability insurance, states should be encouraged to develop and test alternative models to the existing

civil litigation system, and Congress should consider state demonstration projects to evaluate such

alternatives.

Title VII – Improving Access to Innovative Medical Therapies

Biologics Price Competition and Innovation: The Patient Protection and Affordable Care Act

establishes a process under which FDA will license a biological product that is shown to be biosimilar

or interchangeable with a licensed biological product, commonly referred to as a reference product. No

approval of an application as either biosimilar or interchangeable is allowed until 12 years from the

date on which the reference product is first approved. If FDA approves a biological product on the

grounds that it is interchangeable to a reference product, HHS cannot make a determination that a

second or subsequent biological product is interchangeable to that same reference product until one

year after the first commercial marketing of the first interchangeable product.

More Affordable Medicines for Children and Underserved Communities: Drug discounts through

the 340B program are extended to inpatient drugs and also to certain children‟s hospitals, cancer

hospitals, critical access and sole community hospitals, and rural referral centers.

Title VIII – Community Living Assistance Services and Supports

Establishment of national voluntary insurance program for purchasing community living

assistance services and support (CLASS program). The Patient Protection and Affordable Care Act

establishes a new, voluntary, self-funded long-term care insurance program, the CLASS Independence Benefit Plan, for the purchase of community living assistance services and supports by individuals

with functional limitations. The HHS Secretary will develop an actuarially sound benefit plan that

ensures solvency for 75 years; allows for a five-year vesting period for eligibility of benefits; creates benefit triggers that allow for the determination of functional limitation; and provides a cash benefit

that is not less than an average of $50 per day. No taxpayer funds will be used to pay benefits under

this provision.

TITLE IX – REVENUE PROVISIONS

Excise Tax on High Cost Employer-Sponsored Health Coverage: The Patient Protection and

Affordable Care Act levies a new excise tax of 40 percent on insurance companies and plan

administrators for any health coverage plan with an annual premium that is above the threshold of

$8,500 for single coverage and $23,000 for family coverage. The tax applies to self-insured plans and

plans sold in the group market, and not to plans sold in the individual market (except for coverage

eligible for the deduction for self-employed individuals). The tax applies to the amount of the

premium in excess of the threshold. A transition rule increases the threshold for the 17 highest cost

states for the first three years. An additional threshold amount of $1,350 for singles and $3,000 for

families is available for retired individuals age 55 and older and for plans that cover employees

engaged in high risk professions.

Increasing Transparency in Employer W-2 Reporting of Value of Health Benefits: This provision

requires employers to disclose the value of the benefit provided by the employer for each employee‟s

health insurance coverage on the employee‟s annual Form W-2.

Distributions for Medicine Qualified Only if for Prescribed Drug or Insulin: Conforms the

definition of qualified medical expenses for HSAs, FSAs, and HRAs to the definition used for the

medical expense itemized deduction. Over-the-counter medicine obtained with a prescription

continues to qualify as qualified medical expenses.

Increase in Additional Tax on Distributions from HSAs and Archer MSAs Not Used for

Qualified Medical Expenses: Increases the additional tax for HSA withdrawals prior to age 65 that

are used for purposes other than qualified medical expenses from 10 percent to 20 percent and

increases the additional tax for Archer MSA withdrawals from 15 percent to 20 percent.

Limiting Health FSA Contributions: This provision limits the amount of contributions to health

FSAs to $2,500 per year.

Corporate Information Reporting: This provision requires businesses that pay any amount greater

than $600 during the year to corporate providers of property and services to file an information report

with each provider and with the IRS.

Pharmaceutical Manufacturers Fee: This provision imposes an annual flat fee of $2.3 billion on the

pharmaceutical manufacturing sector beginning in 2010 allocated across the industry according to

market share. The fee does not apply to companies with sales of branded pharmaceuticals of $5

million or less.

Medical Device Manufacturers Fee: This provision imposes an annual flat fee of $2 billion on the

medical device manufacturing sector beginning in 2010 allocated across the industry according to

market share. The fee does not apply to companies with sales of medical devices in the U.S. of $5

million or less. The fee also does not apply to any sale of a Class I product or any sale of a Class II

product that is primarily sold to consumers at retail for not more than $100 per unit (under the FDA

product classification system).

Health Insurance Provider Fee: This provision imposes an annual flat fee of $6.7 billion on the

health insurance sector beginning in 2010 allocated across the industry according to market share. The

fee does not apply to companies whose net premiums written are $25 million or less and whose fees

from administration of employer self-insured plans are $5 million or less.

Eliminating the Deduction for Employer Part D Subsidy: This provision eliminates the deduction

for the subsidy for employers who maintain prescription drug plans for their Medicare Part D eligible

retirees.

Modification of the Threshold for Claiming the Itemized Deduction for Medical Expenses: This

provision increases the adjusted gross income threshold for claiming the itemized deduction for

medical expenses from 7.5 percent to 10 percent. Individuals age 65 and older would be able to claim

the itemized deduction for medical expenses at 7.5 percent of adjusted gross income through 2016.

Tax on Elective Cosmetic Surgery. This provision imposes a five percent excise tax on voluntary

cosmetic surgical and medical procedures performed by a licensed medical professional. The tax

would be collected by the medical professional at the point of service. The definition of voluntary

cosmetic procedures generally would be the same as the definition of cosmetic surgery or similar

procedures that are not treated as included in medical care under the current Section 213(d)(9)

definition. The excise tax would be effective for procedures performed on or after January 1, 2010.

Executive Compensation Limitations. This provision limits the deductibility of executive

compensation for insurance providers if at least 25 percent of the insurance provider‟s gross premium

income is derived from health insurance plans that meet the minimum essential coverage requirements

in the bill (“covered health insurance provider”). The deduction is limited to $500,000 per taxable year

and applies to all officers, employees, directors, and other workers or service providers performing

services for or on behalf of a covered health insurance provider.

Additional Hospital Insurance Tax for High Wage Workers. The provision increases the hospital

insurance tax rate by 0.5 percentage points on an individual taxpayer earning over $200,000 ($250,000

for married couples filing jointly).

Special Deduction for Blue Cross Blue Shield (BCBS): Requires that non-profit BCBS

organizations have a medical loss ratio of 85 percent or higher in order to take advantage of the special

tax benefits provided to them, including the deduction for 25 percent of claims and expenses and the

100 percent deduction for unearned premium reserves.

Simple Cafeteria Plans for Small Businesses. This provision would establish a new employee benefit

cafeteria plan to be known as a Simple Cafeteria Plan. This eases the participation restrictions so that

small businesses can provide tax-free benefits to their employees and it includes self-employed

individuals as qualified employees.

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