Iom Future of Nursing Report Summary Peer Reviewed Article

The U.S. wellness care organisation is characterized past a high degree of fragmentation across many sectors, which raises substantial barriers to providing accessible, quality care at an affordable price. In part, the fragmentation in the system comes from disconnects between public and individual services, between providers and patients, between what patients need and how providers are trained, between the health needs of the nation and the services that are offered, and between those with insurance and those without (Stevens, 1999). Communication between providers is difficult, and much intendance is redundant because there is no fashion of sharing results.

This report is being published at an opportune time. In 2010, Congress passed and the President signed into constabulary comprehensive health care legislation. These laws, the Patient Protection and Affordable Intendance Deed (Public Police 111-148) and the Wellness Care and Education Affordability Reconciliation Human action (Public Police 111-152), are collectively referred to throughout this report equally the Affordable Care Act (ACA). The ACA represents the broadest changes to the health care system since the 1965 creation of the Medicare and Medicaid programs and is expected to provide insurance coverage for an boosted 32 million previously uninsured Americans. The need to meliorate the health intendance system is becoming increasingly evident as challenges related to both the quality and costs of care persist.

As discussed in the preface, this study was undertaken to explore how the nursing profession can be transformed to help exploit these opportunities and contribute to building a health care system that will come across the need for safe, quality, patient-centered, attainable, and affordable care. This affiliate presents the central messages that emerged from the study committee'south deliberations. It begins by describing a vision for a transformed system that can run across the health needs of the U.S. population in the 21st century. The affiliate then delineates the roles of nurses in realizing this vision. The third section explains why a fundamental transformation of the nursing profession will be required if nurses are to presume these roles. The terminal section presents conclusions.

A VISION FOR HEALTH CARE

During the class of its work, the Commission on the Robert Wood Johnson Foundation Initiative on the Hereafter of Nursing, at the Institute of Medicine developed a vision for a transformed wellness care system, while recognizing the demands and limitations of the current health care organisation outlined higher up. The committee envisions a time to come system that makes quality intendance accessible to the diverse populations of the United States, intentionally promotes wellness and illness prevention, reliably improves wellness outcomes, and provides compassionate care across the lifespan. In this envisioned future, primary care and prevention are central drivers of the health care system. Interprofessional collaboration and coordination are the norm. Payment for health care services rewards value, not volume of services, and quality care is provided at a price that is affordable for both individuals and guild. The rate of growth of health care expenditures slows. In all these areas, the health care organisation consistently demonstrates that it is responsive to individuals' needs and desires through the delivery of truly patient-centered care. Annex one-one lists the commission'southward definitions for three core terms related to its vision: wellness, health intendance, and the health care system.

THE ROLE OF NURSES IN REALIZING THIS VISION

The ACA provides a call to activeness for nurses, and several sections of the legislation are directly relevant to their work.¹ For example, sections 5501 through 5509 are aimed at substantially strengthening the provision of primary care—a demand generally recognized by health professionals and policy experts; section 2717 calls for "ensuring the quality of care"; and department 2718 emphasizes "bringing down the cost of health care coverage." Enactment of the ACA offers a myriad of opportunities for the nursing profession to facilitate improvements to the wellness care arrangement and the mechanisms by which care is delivered beyond diverse settings. Systemwide changes are needed that capture the full economical value of nurses and accept into business relationship the growing body of prove that links nursing practice to improvements in the safety and quality of care. Avant-garde practise registered nurses (APRNs) should be called upon to fulfill and expand their potential as chief care providers across do settings based on their educational activity and competency. Nursing initiatives and programs should exist scaled upwardly to help bridge the gap betwixt insurance coverage and access to care.

The nursing profession has the potential capacity to implement wide-reaching changes in the health intendance system. With more than 3 million members, the profession has nearly doubled since 1980 and represents the largest segment of the U.S. health care workforce (HRSA, 2010; U.Southward. Census Bureau, 2009). By virtue of their regular, close proximity to patients and their scientific agreement of care processes across the continuum of care, nurses have a considerable opportunity to act as full partners with other wellness professionals and to atomic number 82 in the comeback and redesign of the health care system and its practice surroundings.

Nurses practice in many settings, including hospitals, schools, homes, retail wellness clinics, long-term care facilities, battlefields, and community and public wellness centers. They have varying levels of pedagogy and competencies—from licensed practical nurses, who profoundly contribute to direct patient care in nursing homes, to nurse scientists, who enquiry and evaluate more than constructive ways of caring for patients and promoting wellness. As described in Addendum 1-1 at the end of this chapter, most nurses are registered nurses (RNs), who "complete a program of written report at a community college, diploma schoolhouse of nursing, or a iv-year college or university and are required to pass a nationally standardized licensing test in the country in which they begin exercise" (AARP, 2010). Effigy ane-one shows that of the many settings where RNs practice, the majority practice in hospitals; Figure 1-2 shows the employment settings of nurses by highest nursing or nursing-related education. More than than a quarter of a million nurses are APRNs (HRSA, 2010), who concur main'southward or doctoral degrees and pass national certification exams. APRNs deliver primary and other types of health care services. For example, they teach and counsel patients to empathise their health bug and what they can do to get better, they coordinate intendance and advocate for patients in the complex health care organisation, and they refer patients to physicians and other health care providers. APRNs include nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives (come across Table ane-one). Addendum one-1 provides more than detailed descriptions of the training and roles of nurses, pathways in nursing educational activity, and numbers of nurses.

FIGURE 1-i

Employment settings of registered nurses. NOTES: The totals may not add to 100 per centum because of the effect of rounding. Only RNs for whom information on setting was available are included in the calculations used for this nautical chart. Public/customs health (more...)

FIGURE one-2

Employment settings of RNs, by highest nursing or nursing-related education. NOTES: The full percent by setting may non equal the estimated full of all registered nurses due to incomplete information provided past respondents and the effect of rounding. (more...)

Table i-1

Types of Advanced Practise Registered Nurses (APRNs).

Nursing practice covers a broad continuum from wellness promotion, to disease prevention, to coordination of care, to cure—when possible—and to palliative care when cure is not possible. This continuum of practice is well matched to the current and future needs of the American population (see Chapter 2). Nurses have a direct consequence on patient care. They provide the bulk of patient assessments, evaluations, and care in hospitals, nursing homes, clinics, schools, workplaces, and ambulatory settings. They are at the front lines in ensuring that care is delivered safely, effectively, and compassionately. Additionally, nurses attend to patients and their families in a holistic manner that oft goes across concrete health needs to recognize and respond to social, mental, and spiritual needs. Given their pedagogy, experience, and unique perspectives and the axis of their role in providing care, nurses volition play a significant office in the transformation of the wellness care system. Likewise, while changes in the health care system will take profound furnishings on all providers, this volition exist undoubtedly true for nurses.

Traditional nursing competencies such as care direction and coordination, patient instruction, public health intervention, and transitional care are likely to dominate in a reformed wellness care organization equally it inevitably moves toward an emphasis on prevention and management rather than acute intendance (O'Neil, 2009). Nurses have also begun developing new competencies for the future to help span the gap between coverage and access, to coordinate increasingly complex intendance for a wide range of patients, to fulfill their potential every bit master care providers to the total extent of their education and training, to implement systemwide changes that take into account the growing trunk of evidence linking nursing practice to key improvements in the safety and quality of care, and to capture the full economic value of their contributions across practice settings.

At the same fourth dimension, the nursing profession has its challenges. While there are concerns regarding the number of nurses available to encounter the demands of the health care system and the needs of patients, and in that location is reason to view as a priority replacing at least 900,000 nurses over the age of 50 (BLS, 2009), the composition of the workforce is turning out to exist an even greater challenge for the hereafter of the profession. The workforce is generally not as various as it needs to be—with respect to race and ethnicity (just 16.viii percent of the workforce is non-white), gender (approximately 7 percent of employed nurses are male person), or age (the median age of nurses is 46, compared to 38 in 1988)—to provide culturally relevant care to all populations (HRSA, 2010). Many members of the profession lack the instruction and preparation necessary to adapt to new roles apace in response to quickly changing wellness care settings and an evolving wellness care sys tem. Restrictions on scope of practice and professional tensions accept undermined the nursing profession's power to provide and ameliorate both general and advanced care. Producing a wellness care system that delivers the right care—quality care that is patient centered, accessible, evidence based, and sustainable—at the correct time will crave transforming the work environment, scope of exercise, pedagogy, and numbers and composition of America's nurses. The residue of this section examines the function of the nursing profession in health care reform co-ordinate to the aforementioned three parameters by which all other health care reform initiatives are evaluated—quality, admission, and value.

Nurses and Quality

Although it is difficult to prove causation, an emerging body of literature suggests that quality of care depends to a large degree on nurses (Kane et al., 2007; Lacey and Cox, 2009; Landon et al., 2006; Sales et al., 2008). The Joint Commission, the leading independent accrediting body for health care organizations, believes that "the future land of nursing is inextricably linked to the strides in patient care quality and condom that are critical to the success of America's health care system, today and tomorrow" (Joint Commission, 2010). While quality measures have historically focused on conditions or diseases, many of the quality measures used over the past few years address how well nurses are able to do their jobs (Kurtzman and Buerhaus, 2008).

In 2004, the National Quality Forum (NQF) endorsed the commencement set of nationally standardized performance measures, the National Voluntary Consensus Standards for Nursing-Sensitive Care, initially designed to assess the quality of care provided by nurses who work in hospitals (National Quality Forum, 2004). The NQF measures include prevalence of pressure level ulcers and falls; nursing-centered interventions, such as smoking cessation counseling; and organisation-centered measures, such every bit voluntary turnover and nursing care hours per patient twenty-four hour period. These measures have helped nurses and the organizations where they work identify targets for improvements in care delivery.

Another important vehicle for tracking and improving quality is the National Database of Nursing Quality Indicators, the nation'due south largest nursing registry. This database, which meets the new reporting requirement by the Centers for Medicare and Medicaid Services for nursing-sensitive care, is supported past the American Nurses Clan.² More than than 25 percent of hospitals participate in the database, which documents more than 21 measures of hospital performance linked to the availability and quality of nursing services in acute care settings. Participating facilities are able to obtain unit-level comparative information, including patient and staffing outcomes, to use for quality improvement purposes. Comparison data are publicly reported, which provides an incentive to improve the quality of intendance on a continuous footing. This database is now maintained at the University of Kansas School of Nursing and is available to researchers interested in improving wellness care quality.

Nurses and Access

Show suggests that access to quality care can exist profoundly expanded by increasing the use of RNs and APRNs in primary, chronic, and transitional care (Bodenheimer et al., 2005; Craven and Ober, 2009; Naylor et al., 2004; Rendell, 2007). For case, nurses serving in special roles created to increase access to intendance, such as intendance coordinators and main intendance clinicians, have led to significant reductions in hospitalization and rehospitalization rates for elderly patients (Kane et al., 2003; Naylor et al., 2004). Information technology stands to reason that one way to improve admission to patient-centered care would be to allow nurses to make more than care decisions at the point of care. Yet in many cases, outdated regulations, biases, and policies foreclose nurses, especially APRNs, from practicing to the full extent of their education, skills, and competencies (Hansen-Turton et al., 2008; Ritter and Hansen-Turton, 2008; Safriet, 2010). Chapter 3 examines these barriers in greater depth.

Nurses also brand significant contributions to admission past delivering care where people live, work, and play. Examples include schoolhouse nurses, occupational health nurses, public health nurses, and those working at so-called retail clinics in busy shopping centers. Nurses likewise work in migrant health clinics and nurse-managed health centers, organizations known for serving the most underserved populations. Additionally, nurses are often at the forepart lines serving every bit main providers for individuals and families affected by natural or man-made disasters, delivering intendance in homes and designated community shelters.

Nurses and Value

"Value in health intendance is expressed every bit the physical health and sense of well-being accomplished relative to the cost" (IOM Roundtable on Evidence-Based Medicine, 2008). Compared with support for the role of nurses in improving quality and access, there is somewhat less bear witness that expanding the care provided past nurses will result in toll savings to lodge at large while also improving outcomes and ensuring quality. However, the bear witness base in favor of such a conclusion is growing. Compared with other models of prenatal care, for case, meaning women who receive care led past certified nurse midwives are less likely to experience antenatal hospitalization, and their babies are more than likely to have a shorter hospital stay (Hatem et al., 2008) (see Chapter 2 for a case study of care provided past certified nurse midwives at the Family Health and Birth Center in Washington, DC). Another study examining the affect of nurse staffing on value suggests that increasing the proportion of nursing hours provided by RNs without increasing total nursing hours was associated with 1.5 1000000 fewer hospital days, nearly 60,000 fewer inpatient complications, and a 0.five percent net reduction in costs (Needleman et al., 2006). Chapter 2 includes a case study of the Nurse–Family Partnership Program, in which front-line RNs make dwelling visits to loftier-risk young mothers over a 2.5-year flow. This program has demonstrated pregnant value, resulting in a internet savings of $34,148 per family served. The program has also reduced pregnancy-induced hypertension past 32 percentage, child corruption and neglect by 50 per centum, emergency room visits by 35 pct, and language-related delays by 50 per centum (AAN, 2010).

THE Demand FOR A FUNDAMENTAL TRANSFORMATION OF THE NURSING PROFESSION

Given the crucial role of nurses with respect to the quality, accessibility, and value of care, the nursing profession itself must undergo a fundamental transformation if the committee'due south vision for wellness care is to be realized. As this report argues, the means in which nurses were educated and practiced during the 20th century are no longer adequate for dealing with the realities of health care in the 21st century. Outdated regulations, attitudes, policies, and habits go along to restrict the innovations the nursing profession can bring to health care at a time of tremendous complexity and modify.

In the course of its deliberations, the committee formulated four key messages that inform the word in Chapters 3–6 and structure its recommendations for transforming the nursing profession:

ane.

Nurses should practice to the full extent of their education and grooming.

2.

Nurses should achieve higher levels of instruction and training through an improved educational activity system that promotes seamless academic progression.

3.

Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the U.s..

four.

Effective workforce planning and policy making require meliorate data collection and an improved data infrastructure.

These key messages speak to the need to transform the nursing profession in three crucial areas—practice, education, and leadership—equally well every bit to collect meliorate data on the wellness care workforce to inform planning for the necessary changes to the nursing profession and the overall wellness intendance system.

The Need to Transform Practice

Key Bulletin #1 : Nurses should exercise to the full extent of their educational activity and training.

To ensure that all Americans have admission to needed health care services and that nurses' unique contributions to the health care team are maximized, federal and state deportment are required to update and standardize telescopic-of-practice regulations to take reward of the full capacity and didactics of APRNs. States and insurance companies must follow through with specific regulatory, policy, and financial changes that give patients the freedom to choose from a range of providers, including APRNs, to best meet their health needs. Removing regulatory, policy, and financial barriers to promote patient choice and patient-centered care should exist foundational in the building of a reformed health care organisation.

Additionally, to the extent that the nursing profession envisions its future as confined to acute care settings, such as inpatient hospitals, its ability to help shape the future U.S. wellness intendance organization will be greatly limited. As noted earlier, care in the future is likely to shift from the hospital to the customs setting (O'Neil, 2009). Withal the bulk of nurses still piece of work in astute care settings; according to recent findings from the 2008 National Sample Survey of Registered Nurses, just over 62 percent of working RNs were employed in hospitals in 2008—up from approximately 57 percent in 2004 (HRSA, 2010). Nurses must create, serve in, and disseminate reconceptualized roles to bridge whatever gaps remain betwixt coverage and access to care. More must go health coaches, care coordinators, informaticians, primary intendance providers, and health team leaders in a greater variety of settings, including chief care medical homes and accountable care organizations. In some respects, such a transformation would render the nursing profession to its roots in the public wellness movement of the early 20th century.

At the same fourth dimension, new systems and technologies appear to exist pushing nurses always farther away from patients. This appears to be especially true in the acute care setting. Studies show that nurses on medical–surgical units spend but 31 to 44 percent of their time in direct patient activities (Tucker and Spear, 2006). A dissever study of medical–surgical nurses found they walked nearly a mile longer while on than off duty in obtaining the supplies and equipment needed to perform their tasks. In full general, less than twenty percent of nursing practice time was devoted specifically to patient care activities, the majority being consumed by documentation, medication administration, and advice regarding the patient (Hendrich et al., 2008). Several health care organizations, professional organizations, and consumer groups have endorsed a Annunciation for Alter aimed at redressing inefficiencies in hospital design, organisation, and engineering science infrastructure through a focus on patient-centered design; the implementation of systemwide, integrated technology; the creation of seamless workplace environments; and the promotion of vendor partnerships (Hendrich et al., 2009). Realizing the vision presented earlier in this affiliate will require a exercise environment that is fundamentally transformed so that nurses are efficiently employed—whether in the hospital or in the customs—to the full extent of their didactics, skills, and competencies.

Chapter iii examines these issues in greater depth.

The Need to Transform Education

Key Message #2 : Nurses should reach higher levels of instruction and training through an improved education sys tem that promotes seamless academic progression.

Major changes in the U.S. wellness care organisation and do environment volition require every bit profound changes in the education of nurses both before and after they receive their licenses. An improved instruction system is necessary to ensure that the electric current and future generations of nurses tin evangelize rubber, quality, patient-centered intendance across all settings, especially in such areas equally main intendance and community and public wellness.

Interest in the nursing profession has grown rapidly in recent years, in office as a result of the economic downturn and the relative stability the health care sector offers. The number of applications to entry-level baccalaureate programs increased past more than 70 percentage in only 5 years—from 122,000 applications in 2004 to 208,000 applications in 2009 (AACN, 2010). While nursing schools beyond the state have responded to this influx of interest, there are constraints, such equally insufficient numbers of nurse faculty and clinical placements, that limit the capacity of nursing schools to adapt all the qualified applicants. Thus, thousands of qualified students are turned away each year (Kovner and Djukic, 2009).

A variety of challenges limit the ability to ensure a well-educated nurse workforce. As noted, there is a shortage of kinesthesia to teach nurses at all levels (Allan and Aldebron, 2008). Also, the ways in which nurses during the 20th century taught each other to care for people and learned to practice and make clinical decisions are no longer acceptable for delivering intendance in the 21st century. Many nursing schools have dealt with the explosion of enquiry and cognition needed to provide health care in an increasingly complex organization by calculation layers of content that requires more instruction (Ironside, 2004). A primal rethinking of this approach is needed (Benner et al., 2009; Erickson, 2002; IOM, 2003, 2009; Lasater and Nielsen, 2009; Mitchell et al., 2006; Orsolini-Hain and Waters, 2009; Tanner et al., 2008). Additionally, nurses at all levels accept few incentives to pursue farther teaching, and face active disincentives to advanced pedagogy. Nurses and physicians—not to mention pharmacists and social workers—typically are non educated together, yet they are increasingly required to cooperate and interact more closely in the delivery of care.

The teaching system should provide nurses with the tools needed to evaluate and better standards of patient care and the quality and safety of intendance while preserving fundamental elements of nursing education, such as ethics and integrity and holistic, empathetic approaches to intendance. The system should ensure nurses' power to adapt and be flexible in response to changes in science, technology, and population demographics that shape the delivery of care. Nursing education at all levels needs to impart a better understanding of means to work in the context of and pb change within health intendance delivery systems, methods for quality comeback and system redesign, methods for designing effective care commitment models and reducing patient adventure, and care management and other roles involving expanded authority and responsibility. The nursing profession must adopt a framework of continuous, lifelong learning that includes basic instruction, residency programs, and standing competence. More nurses must receive a solid education in how to manage complex weather and coordinate care with multiple health professionals. They must demonstrate new competencies in systems thinking, quality improvement, and care management and a bones understanding of health policy and research. Graduate-level nurses must develop fifty-fifty greater competencies and deeper agreement in all of these areas. Innovative new programs to attract nurse faculty and provide a wider range of clinical pedagogy placements must clear long-standing bottlenecks in nursing education. Accrediting and certifying organizations must mandate demonstrated mastery of clinical skills, managerial competencies, and professional development at all levels to complement the completion of degree programs and written board examinations. Milestones for mandated skills, competencies, and professional evolution must exist updated more frequently to keep stride with the apace changing demands of wellness intendance. And all health professionals should receive more of their education in concert with students from other disciplines. Interprofessional team training of nurses, physicians, and other health care providers should begin when they are students and proceed throughout their careers. Successful interprofessional education tin can exist achieved but through committed partnerships across professions.

Nurses should move seamlessly through the education arrangement to college levels of educational activity, including graduate degrees. Nurses with graduate degrees will exist able to replenish the nurse faculty puddle; advance nursing science and contribute to the cognition base on how nurses can provide upwardly-to-engagement, safe patient care; participate in health care decisions; and provide the leadership needed to institute nurses every bit full partners in health intendance redesign efforts (see the section on leadership beneath).

The Demand to Transform Leadership

Key Message #3 : Nurses should be full partners, with physi cians and other wellness professionals, in redesigning wellness care in the Usa.

Not all nurses begin their career with thoughts of becoming a leader. Withal potent leadership volition exist required to transform the U.S. health care arrangement. A transformed organisation will need nurses with the adaptive chapters to take on reconceptualized roles in new settings, educating and reeducating themselves along the fashion—indispensible characteristics of effective leadership.

Whether on the front lines, in education, or in administrative positions and health policy roles, nurses have the well-grounded knowledge base, experience, and perspective needed to serve equally full partners in health care redesign. Nurses' unique perspectives are derived from their experiences in providing direct, handson patient care; communicating with patients and their families about health status, medications, and care plans; and ensuring the linkage betwixt a prescribed course of handling and the desired outcome. In care environments, being a full partner involves taking responsibleness for identifying issues and areas of waste product, devising and implementing a plan for improvement, tracking improvement over time, and making necessary adjustments to realize established goals.

Being a full partner translates more broadly to the health policy loonshit. To be effective in reconceptualized roles, nurses must see policy equally something they can shape rather than something that happens to them. Nurses should have a voice in health policy decision making, as well as being engaged in implementation efforts related to wellness care reform. Nurses besides should serve actively on advisory committees, commissions, and boards where policy decisions are made to accelerate health systems to improve patient care. Yet a number of barriers forbid nurses from serving every bit total partners. Examples that are discussed later in the report include laws and regulations (Chapter 3), professional person resistance and bias (Chapter 3), a lack of foundational competence (Affiliate five), and exclusion from decision-making bodies and boards (Chapter five). If nurses are to serve every bit full partners, a civilisation change volition exist needed whereby health professionals concur each other accountable for improving care and setting health policy in a context of mutual respect and collaboration.

Finally, the health care system is widely understood to be a complex system, 1 in which responses to internal and external deportment are sometimes anticipated and sometimes not. Wellness care experts repeatedly encourage health professionals to understand the organisation'due south dynamics so they tin can be more than constructive in their private jobs and help shape the larger system's power to adapt successfully to changes and meliorate outcomes. In a field as intensively knowledge driven as health care, notwithstanding, no one individual, group, or discipline can have all the answers. A growing body of research has begun to highlight the potential for collaboration among teams of diverse individuals to generate successful solutions in complex, knowledge-driven systems (Paulus and Nijstad, 2003; Pisano and Verganti, 2008; Singh and Fleming, 2010; Wuchty et al., 2007). Nurses must cultivate new allies in health care, government, and business concern and develop new partnerships with other clinicians, concern owners, and philanthropists to help realize the vision of a transformed wellness care arrangement. Many nurses have heard this call to develop new partnerships in a civilisation of collaboration and cooperation. However, the committee found no evidence that these initiatives have achieved the calibration necessary to accept an touch on throughout the health care system. More intentional, large-scale initiatives of this sort are needed. These efforts must be supported by research that addresses such questions as what new models of leadership are needed for the increasingly noesis-intensive health care surroundings and when collaboration is about appropriate (Singh and Fleming, 2010).

Chapter 5 further examines the need for expanded leadership opportunities in the nursing workforce.

The Need for Better Data on the Wellness Care Workforce

Fundamental Message #4 : Effective workforce planning and policy making require better data collection and an improved in formation infrastructure.

Key letters 1, 2, and 3 speak to the need to transform the nursing profession to accomplish the vision of wellness care set forth at the beginning of this chapter. At the same time, nurses exercise not function in a vacuum, but in the context of the skills and perspectives of physicians and other health professionals. Planning for the fundamental changes required to achieve a reformed health care arrangement cannot be achieved without a clear agreement of the necessary contributions of these various professionals and the numbers and composition of the health care workforce. That understanding in turn cannot be obtained without reliable, sufficiently granular information on the current workforce and projections of futurity workforce needs. Withal major gaps exist in the currently available workforce information. These gaps hamper the ability to place and implement the necessary changes to the preparation and practice of nurses and to the overall health intendance arrangement. Chapter six explores these issues in greater item.

Determination

Well-nigh of the near-term challenges identified in the ACA speak to traditional and electric current strengths of the nursing profession in care coordination, health promotion, and quality improvement, among other things. Nurses are committed to improving the intendance they deliver by responding to health intendance challenges. If their full potential is to exist realized, even so, the nursing profession itself will take to undergo a primal transformation in the areas of practice, education, and leadership. During the grade of this study, the committee formulated four fundamental messages it believes must guide that transformation: (ane) nurses should practise to the total extent of their education and training; (2) nurses should accomplish higher levels of education and training through an improved didactics organization that promotes seamless academic progression; (three) nurses should be full partners, with physicians and other health professionals, in redesigning health care in the Us; and (4) effective workforce planning and policy making crave meliorate data collection and an improved information infrastructure.

At the same fourth dimension, the power to deliver better care—quality care that is accessible and sustainable—does not rest solely with nurses, regardless of how ably led or educated they are; information technology as well lies with other wellness professionals, consumers, governments, businesses, wellness care institutions, professional organizations, and the insurance manufacture. The recommendations presented in Chapter vii target private policy makers; national, state, and local government leaders; payers; and wellness care researchers, executives, and professionals—including nurses and others—likewise as larger groups such as licensing bodies, educational institutions, and philanthropic and advocacy and consumer organizations. Together, these groups have the power to transform the health care organization to achieve the vision ready forth at the beginning of this affiliate.

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• Naylor, 1000. D., D. A. Brooten, R. Fifty. Campbell, G. Maislin, M. Thou. McCauley, and J. Due south. Schwartz. 2004. Transitional care of older adults hospitalized with eye failure: A randomized, controlled trial. Journal of the American Geriatric Society 52(5):675-684. [PubMed: 15086645]

• Needleman, J., P. I. Buerhaus, M. Stewart, K. Zelevinsky, and Southward. Mattke. 2006. Nurse staffing in hospitals: Is there a business instance for quality? Health Affairs 25(ane):204-211. [PubMed: 16403755]

• O'Neil, E. 2009. 4 factors that guarantee health care change. Periodical of Professional Nursing 25(6):317-321. [PubMed: 19942196]

• Orsolini-Hain, Fifty., and 5. Waters. 2009. Education evolution: A historical perspective of acquaintance caste nursing. Periodical of Nursing Education 48(5):266-271. [PubMed: 19476031]

• Paulus, P. B., editor; , and B. A. Nijstad, editor. , eds. 2003. Grouping creativity: Innovation through collaboration . New York: Oxford Academy Press.

• Pisano, G. P., and R. Verganti. 2008. Which kind of collaboration is right for you? Harvard Business organization Review 86(12):78-86.

• Rendell, E. K. 2007. Prescription for Pennsylvania: Right state, right plan, right now . Harrisburg, PA: Office of the Governor. [PubMed: 17472051]

• Ritter, A., and T. Hansen-Turton. 2008. The primary intendance paradigm shift: An overview of the statelevel legal framework governing nurse practitioner practice. Health Lawyer 20(4):21-28.

• Safriet, B. J. 2010. Federal options for maximizing the value of advanced practice nurses in providing quality, cost-effective wellness care . Newspaper commissioned by the Committee on the RWJF Initiative on the Futurity of Nursing, at the IOM (see Appendix H on CD-ROM).

• Sales, A., N. Sharp, Y. F. Li, E. Lowy, G. Greiner, C. F. Liu, A. Alt-White, C. Rick, J. Sochalski, P. H. Mitchell, Chiliad. Rosenthal, C. Stetler, P. Cournoyer, and J. Needleman. 2008. The clan betwixt nursing factors and patient mortality in the Veterans Health Administration: The view from the nursing unit of measurement level. Medical Care 46(ix):938-945. [PubMed: 18725848]

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ANNEX ane-1. KEY TERMS AND FACTS Most THE NURSING WORKFORCE

DEFINITIONS FOR Core TERMS

Throughout the study, the committee uses three terms—health, health care, and health intendance organisation—that are used routinely past policy makers, legislators, health care organizations, health professionals, the media, and the public. While these terms are ordinarily used, the definitions tin can vary and are frequently nuanced. In this section, the committee offers its definitions for these 3 core terms. In addition to the terms discussed beneath, other important terms are defined throughout the report in conjunction with relevant discussion. For case, value and primary care are divers and discussed in Chapter two.

Health

In a previous Constitute of Medicine (IOM) report, "health" is divers equally "a state of well-existence and the capability to function in the face of irresolute circumstances." Information technology is "a positive concept emphasizing social and personal resources too as physical capabilities" (IOM, 1997). Improving wellness is a shared responsibility of society, communities, wellness care providers, family, and individuals. Sure social determinants of health—such as income, educational activity, family, and community—play a greater function than mere access to biomedical care in improving health outcomes for large populations (Commission on Social Determinants of Health, 2008; IOM, 1997). Yet, access to primary care, in contrast to specialty care, is associated with better population health outcomes (Starfield et al., 2005).

Health Intendance

"Health care" can be divers as the prevention, diagnosis, treatment, and management of illness and affliction through a wide range of services provided by health professionals. These services are supplemented past the efforts of private individuals (patients), their families, and communities to achieve optimal mental and physical health and health throughout life. The committee considers the full range of services to exist encompassed past the term "health intendance," including prevention and health promotion, mental and behavioral health, and principal care services; public health; acute care; chronic disease management; transitional care; long-term care; palliative care; finish-of-life care; and other specialty wellness care services.

Health Care System

The term "wellness care organisation" refers to the organization, financing, payment, and commitment of wellness intendance. Equally described in greater detail in the IOM report Crossing the Quality Chasm: A New Health Organization for the 21st Century (IOM, 2001), the U.Due south. health care arrangement is a circuitous, adaptive organisation (as opposed to a elementary mechanical system). As a result, its many parts (including homo beings and organizations) have the "liberty and ability to respond to stimuli in many different and fundamentally unpredictable ways." In addition, the system has many linkages and then that changes in i function of the system often change the context for other parts (IOM, 2001). Throughout this report, the commission highlights what information technology believes to be one of the strongest linkages that has emerged inside the U.South. health care organisation: that between health reform and the future of nursing. Equally the written report emphasizes, the future of nursing—how it is shaped and the directions it takes—will take a major impact on the future of health intendance reform in the United States.

Preparation AND ROLES OF NURSING Care PROVIDERS IN AMERICAⁱⁱⁱ

The range of nursing intendance providers described below piece of work in a variety of settings including ambulatory intendance, hospitals, community wellness centers, public wellness agencies, long-term care facilities, mental health facilities, war zones, prisons, and schools of nursing, also every bit patients' homes, schools, places of worship, and workplaces. Basically anywhere at that place are health care needs, nurses can ordinarily be found. Types of nursing care providers include

Nursing Assistants/Certified Nursing Assistants (NA/CNAs) provide basic patient care under the direction of licensed nurses: they feed, breast-stroke, dress, groom, and move patients, change linens and may assume other delegated responsibilities. The greatest prevalence of these providers is in home care and in long-term care facilities. Grooming fourth dimension varies from on-the-chore training to 75 hours of country approved training for certification (CNA).

Licensed Practical/Licensed Vocational Nurses (LPN/LVNs) provide bones nursing care including monitoring vital signs, performing dressing changes and other ordered treatments, and manipulate medications in nearly states. LPNs work under the supervision of a physician or registered nurse. While at that place is declining demand for LPNs in hospitals, demand is high in long-term care facilities and to a bottom caste in out-patient settings, such equally physicians' offices. They complete a 12–18 month education plan at a vocational/technical schoolhouse or community college and are required to pass a nationally standardized licensing examination in the state in which they brainstorm practise. LPNs may become RNs by bridging into an Associate Degree or in some cases, Baccalaureate Nursing Program.

Registered Nurses (RNs) typically consummate a program of report at a community college, diploma schoolhouse of nursing or a iv-year college or university and are required to pass a nationally standardized licensing exam in the state in which they begin practice. The essential cadre of their nursing practice is to deliver holistic, patient-centered intendance that includes assessment and monitoring, administering a variety of treatments and medications, patient and family unit education and serving equally a member of an interdisciplinary team. Nurses treat individuals and families in all phases of the health and health continuum besides as provide leadership in wellness care delivery systems and in academic settings. There are over 57 RN specialty associations in nursing and others newly emerging. Many RNs practice in medical-surgical areas; another mutual specialties among registered nurses, many of which offer specialty certification options, include:

Critical Care Nurses provide intendance to patients with serious, complex, and astute illnesses or injuries that crave very shut monitoring and extensive medication protocols and therapies. Disquisitional care nurses most often work in intensive care units of hospitals; even so, nurses also provide highly acute and circuitous care in emergency rooms.

Public Wellness Nurses work to promote and protect the health of populations based on knowledge from nursing, social, and public wellness sciences. Public Wellness Nurses about often work in municipal and State Wellness Departments.

Domicile Health/Hospice Nurses provide a variety of nursing services for both acute, but stable and chronically ill patients and their caregivers in the home, including end-of-life care.

Occupational/Employee Health Nurses provide health screening, wellness programs and other health education, minor treatments, and illness/medication management services to people in the workplace. The focus is on promotion and restoration of wellness, prevention of affliction and injury, and protection from piece of work related and environmental hazards.

Oncology Nurses care for patients with various types of cancer, administering chemotherapy, and providing follow-upwardly care, didactics and monitoring. Oncology nurses work in hospitals, out-patient clinics and patients' homes.

Perioperative/Operating Room Nurses provide preoperative and postoperative care to patients undergoing anesthesia, or assist with surgical procedures by selecting and handling instruments, controlling bleeding, and suturing incisions. These nurses work in hospitals and out-patient surgical centers.

Rehabilitation Nurses care for patients with temporary and permanent disabilities inside institutions and out-patient settings such as clinics and dwelling health intendance.

Psychiatric/Mental Wellness Nurses specialize in the prevention of mental and behavioral health problems and the nursing care of persons with psychiatric disorders. Psychiatric nurses work in hospitals, out-patient clinics, and private offices.

School Nurses provide wellness cess, intervention, and follow-up to maintain schoolhouse compliance with healthcare policies and ensure the wellness and safety of staff and students. They refer students for boosted services when hearing, vision, obesity, and other issues become inhibitors to successful learning.

Other mutual specialty areas are derived from a life span approach beyond healthcare settings and include maternal-child, neonatal, pediatric, and gerontological nursing.

There are several entry points besides as progression points for registered nurses:

Acquaintance Degree in Nursing (ADN) or Diploma in Nursing prepared RNs provide directly patient care in diverse health care settings. The two to three years of didactics required is received primarily in community colleges and hospital-based nursing schools and graduates may bridge into a baccalaureate or higher caste programme.

Baccalaureate Caste in Nursing (BSN) prepared RNs provide an additional focus on leadership, translating research for nursing practice, and population health; they practice across all healthcare settings. A BSN is often required for military nursing, example direction, public wellness nursing, and school-based nursing services. Four-year BSN programs are offered primar ily in a university setting. The BSN is the about common entry point into graduate didactics.

Master's Degrees in Nursing (MSN/Other) ready RNs primarily for roles in nursing administration and clinical leadership, faculty, and for advanced practice in a nursing specialty area. The up to 2 years of education typically occurs in a university setting. Advanced Practise Registered Nurses (APRNs) receive avant-garde clinical preparation (generally a Principal's caste and/or post Master'southward Certificate, although the Doc of Nursing Practice caste is increasingly being granted). Specific titles and credentials vary by state approval processes, formal recognition and telescopic of practice as well every bit by board certification. APRNs fall into 4 wide categories: Nurse Practitioner, Clinical Nurse Specialist, Nurse Anesthetist, and Nurse Midwife:

Nurse Practitioners (NPs) are Advanced Do RNs who provide a wide range of healthcare services across healthcare settings. NPs take health histories and provide complete physical examinations; diagnose and treat many common astute and chronic issues; translate laboratory results and Ten-rays; prescribe and manage medications and other therapies; provide wellness teaching and supportive counseling with an emphasis on prevention of illness and health maintenance; and refer patients to other health professionals as needed. Broad NP specialty areas include: Acute Intendance, Developed Health, Family Health, Geriatrics, Neonatal, Pediatric, Psychiatric/Mental Health, School Health, and Women's Wellness.

Clinical Nurse Specialists (CNS) do in a variety of health care environments and participate in mentoring other nurses, case management, research, designing and conducting quality improvement programs, and serving as educators and consultants. Specialty areas include but are not limited to: Developed Health, Customs Wellness, Geriatrics, Home Wellness, Pediatrics, Psychiatric/Mental Wellness, Schoolhouse Health and Women's Health. There are also many sub-specialties.

Certified Registered Nurse Anesthetists (CRNAs) administer anesthesia and related care before and subsequently surgical, therapeutic, diagnostic and obstetrical procedures, too every bit pain management and emergency services, such as airway management. Practice settings include operating rooms, dental offices and outpatient surgical centers. CRNAs deliver more than than 65 per centum of all anesthetics to patients in the United states.

Certified Nurse Midwives (CNMs) provide principal care to women, including gynecological exams, family unit planning advice, prenatal care, management of low risk labor and delivery, and neonatal care. Practice settings include hospitals, birthing centers, community clinics and patient homes.

Doctoral Degrees in Nursing include the Doc of Philosophy in Nursing (PhD)⁴ and the Dr. of Nursing Practice (DNP). PhD-prepared nurses typically teach in a academy setting and behave research, merely are also employed increasingly in clinical settings. DNP programs prepare graduates for advanced practice and clinical leadership roles. A number of DNPs are employed in academic settings every bit well.

TABLE one-A1 Providers of Nursing Care: Numbers, Preparation/Training, and Roles

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Blazon of Nursing Intendance Provider	Blazon of Caste	Preparation Fourth dimension	Roles and Responsibilities	Salaries
Registered Nurses	Physician of Philosophy (PhD) or Doctor of Nursing Practice (DNP) Degrees	4 to vi years across baccalaureate degree	Serve as wellness system executives, educators, deans, clinical experts/Advanced Practice Registered Nurses (APRNs), researchers, and senior policy analysts.	Mean faculty salaries range from $58,051.00 to $96,021.00 Administrators' and other non-faculty salaries not available simply are generally higher
	Main's Degree (MSN/MS)	Typically upwardly to two years beyond baccalaureate degree	Serve equally educators, clinical leaders, administrators or APRNs certified as a Nurse Practitioner (NP), Clinical Nurse Specialist (CNS), Certified Nurse Midwife (CNM), or Certified Registered Nurse Anesthetist (CRNA).	Median salaries for APRNs range from $81,708.00 to $144,174.00 Mean Master'south prepared teacher salary $54,426.00
	Baccalaureate Degree (BSN)	4 years	Provide straight patient intendance, nursing leadership, and translating research into nursing exercise across all health care settings.	Mean bacon $66,316
	Associate Degree (ADN) or a Diploma in Nursing	2 to three years	Provide direct patient care in various wellness intendance settings.	ADN mean salary $60,890 Diploma mean salary $65,349
Other Nursing Intendance Providers	Licensed Applied Nurse/Licensed Vocational Nurse (LPN/LVN)	12 to xviii months	Provide basic nursing care primarily in long-term-care or ambulatory settings under the supervision of the Registered Nurse or Physician.	Mean salary $twoscore,110.00
	Nursing Assistant (NA)	Up to 75 hours training	Provide basic care to patients virtually commonly in nursing care facilities and patient homes.	Hateful salary $26,110.00

SOURCE: Adapted from AARP, 2010c. Courtesy of AARP. All rights reserved. Original data provided past the American Association of Colleges of Nursing, the Bureau of Labor Statistics, the Health Resource and Service Assistants, and the National League for Nursing.

TABLE 1-A2 Pathways in Nursing Didactics

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Type of Degree	Clarification of Program
Doctor of Philosophy in Nursing (PhD) and Doctor of Nursing Exercise (DNP)	PhD programs are research-focused, and graduates typically teach and behave research, although roles are expanding. DNP programs are exercise-focused and graduates typically serve in Advanced Practice Registered Nurse (APRN) roles and other advanced positions, including faculty positions. Fourth dimension to completion: 3–5 years. BSN or MSN to nursing doctorate options available.
Masters Degree in Nursing (MSN/MS)	Prepares Advanced Practice Registered Nurses (APRNs), Nurse Practitioners, Clinical Nurse Specialists, Nurse-Midwives, and Nurse Anesthetists, equally well equally Clinical Nurse Leaders, nurse educators and administrators. Fourth dimension to completion: eighteen–24 months. Three years for ADN to MSN choice.
Accelerated BSN or Masters Degree in Nursing	Designed for students with baccalaureate caste in another field. Time to completion: 12–8 months for BSN and three years for MSN depending on prerequisite requirements.
Bachelor of Science in Nursing (BSN) Registered Nurse (RN)	Educates nurses to exercise the full scope of professional nursing responsibilities across all health care settings. Curriculum provides additional content in concrete and social sciences, leadership, research and public health. Time to completion: Four years or upwards to 2 years for ADN/Diploma RNs and three years for LPNs depending on prerequisite requirements.
Acquaintance Degree (ADN) in Nursing (RN) and Diploma in Nursing (RN)	Prepares nurses to provide direct patient care and practice within the legal scope of professional nursing responsibilities in a diversity of health care settings. Offered through community colleges and hospitals. Time to completion: Two to three years for ADN (less in the case of LPN-entry) and three years for diploma (all hospital-based training programs) depending on prerequisite requirements.
Licensed Practical Nurse (LPN)/Licensed Vocational Nurse (LVN)	Trains nurses to provide bones intendance, e.g. take vital signs, administer medications, monitor catheters and apply dressings. LPN/LVNs work under the supervision of physicians and registered nurses. Offered past technical/vocational schools and customs colleges. Time to completion: 12–8 months.

SOURCE: AARP, 2010a. Courtesy of AARP. All rights reserved.

REFERENCES

• Committee on Social Determinants of Health. 2008. Closing the gap in a generation: Wellness equity through activeness on the social determinants of health. Final report of the commission on social determinants of health . Geneva, Switzerland: Earth Health Organization. [PubMed: 20506619]

• IOM (Institute of Medicine). 1997. Improving health in the community: A role for operation monitoring . Washington, DC: National University Printing. [PubMed: 25121202]

• IOM. 2001. Crossing the quality chasm: A new wellness system for the 21st century . Washington, DC: National Academy Press. [PubMed: 25057539]

• Starfield, B., L. Shi, and J. Macinko. 2005. Contribution of principal intendance to health systems and wellness. The Milbank Quarterly 83(3):457-502. [PMC free commodity: PMC2690145] [PubMed: 16202000]

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This section is reprinted from AARP, 2010b. Courtesy of AARP. All rights reserved. Original data provided past the American Academy of Nurse Practitioners, the American Association of Colleges of Nursing, the American Nurses Credentialing Eye, the Bureau of Labor Statistics, the Wellness Resource and Service Administration, and the National League for Nursing.

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There are also a very small-scale number of Doctor of Nursing Science (DNS, DNSc) programs still in existence today. A significant number of doctorally-prepared RNs concord doctoral degrees in related fields.

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Source: https://www.ncbi.nlm.nih.gov/books/NBK209881/

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