Summary1

The United States has the opportunity to transform its health care system to provide seamless, affordable, quality care that is accessible to all, patient centered, and evidence based and leads to improved health outcomes. Achieving this transformation will require remodeling many aspects of the health care system. This is especially true for the nursing profession, the largest segment of the health care workforce. 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.

A VISION FOR HEALTH CARE

In 2010, Congress passed and the President signed into law comprehensive health care legislation. With the enactment of these laws, collectively referred to in this report as the Affordable Care Act (ACA), the United States has an opportunity to transform its health care system to provide higher-quality, safer,

1

This summary does not include references. Citations for the discussion presented in the summary appear in the subsequent report chapters.



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Summary1 The United States has the opportunity to transform its health care sys- tem to provide seamless, affordable, quality care that is accessible to all, patient centered, and evidence based and leads to improved health outcomes. Achieving this transformation will require remodeling many aspects of the health care system. This is especially true for the nurs- ing profession, the largest segment of the health care workforce. 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. A VISION FOR HEALTH CARE In 2010, Congress passed and the President signed into law comprehensive health care legislation. With the enactment of these laws, collectively referred to in this report as the Affordable Care Act (ACA), the United States has an opportunity to transform its health care system to provide higher-quality, safer, 1 Thissummary does not include references. Citations for the discussion presented in the summary appear in the subsequent report chapters. 1

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2 THE FUTURE OF NURSING more affordable, and more accessible care. During the course of its work, the Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine developed a vision for a transformed health care system. The committee envisions a future system that makes quality care accessible to the diverse populations of the United States, intentionally promotes wellness and disease prevention, reliably improves health 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 society. The rate of growth of health care expenditures slows. In all these areas, the health care system consistently demonstrates that it is responsive to individuals’ needs and desires through the delivery of truly patient-centered care. 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 additional 32 million previously uninsured Americans. Although passage of the ACA is historic, realizing the vision outlined above will require a transformation of many aspects of the health care system. This is espe- cially true for the nursing profession, which, with more than 3 million members, represents the largest segment of the health care workforce. STUDY CHARGE In 2008, the Robert Wood Johnson Foundation (RWJF) approached the In- stitute of Medicine (IOM) to propose a partnership to assess and respond to the need to transform the nursing profession. Recognizing that the nursing profession faces several challenges in fulfilling the promise of a reformed health care system and meeting the nation’s health needs, RWJF and the IOM established a 2-year Initiative on the Future of Nursing. The cornerstone of the initiative is this com- mittee, which was tasked with producing a report containing recommendations for an action-oriented blueprint for the future of nursing, including changes in public and institutional policies at the national, state, and local levels (Box S-1). Following the report’s release, the IOM and RWJF will host a national conference on November 30 and December 1, 2010, to begin a dialogue on how the report’s recommendations can be translated into action. The report will also serve as the basis for an extensive implementation phase to be facilitated by RWJF. THE ROLE OF NURSES IN REALIZING A TRANSFORMED HEALTH CARE SYSTEM By virtue of its numbers and adaptive capacity, the nursing profession has the potential to effect wide-reaching changes in the health care system. Nurses’

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3 SUMMARY BOX S-1 Committee Charge An ad hoc committee will examine the capacity of the nursing workforce to meet the demands of a reformed health care and public health system. It will develop a set of bold national recommendations, including ones that address the delivery of nursing services in a shortage environment and the capacity of the nursing education system. In its report, the committee will define a clear agenda and blueprint for action including changes in public and institutional policies at the national, state, and local levels. Its recommendations would address a range of system changes, including innovative ways to solve the nursing shortage in the United States. The committee may examine and produce recommendations related to the following issues, with the goal of identifying vital roles for nurses in designing and implementing a more effective and efficient health care system: • econceptualizing the role of nurses within the context of the entire work- R force, the shortage, societal issues, and current and future technology; • xpanding nursing faculty, increasing the capacity of nursing schools, and E redesigning nursing education to assure that it can produce an adequate number of well-prepared nurses able to meet current and future health care demands; • xamining innovative solutions related to care delivery and health profes- E sional education by focusing on nursing and the delivery of nursing ser- vices; and • ttracting and retaining well-prepared nurses in multiple care settings, A including acute, ambulatory, primary care, long-term care, community, and public health. regular, close proximity to patients and scientific understanding of care processes across the continuum of care give them a unique ability to act as partners with other health professionals and to lead in the improvement and redesign of the health care system and its many practice environments, including hospitals, schools, homes, retail health clinics, long-term care facilities, battlefields, and community and public health centers. Nurses thus are poised to help bridge the gap between coverage and access, to coordinate increasingly complex care for a wide range of patients, to fulfill their potential as primary care providers to the full extent of their education and training, and to enable the full economic value of their contributions across practice settings to be realized. In addition, a promising field of evidence links nursing care to high quality of care for patients, including protecting their safety. Nurses are crucial in preventing medication errors, reducing rates of infection, and even facilitating patients’ transition from hospital to home.

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4 THE FUTURE OF NURSING Nursing practice covers a broad continuum from health promotion, to dis- ease prevention, to coordination of care, to cure—when possible—and to pal- liative care when cure is not possible. While this continuum of practice is well matched to the needs of the American population, the nursing profession has its challenges. It is not as diverse as it needs to be—with respect to race, ethnicity, gender, and age—to provide culturally relevant care to all populations. Many members of the profession require more education and preparation to adopt new roles quickly in response to rapidly changing health care settings and an evolv- ing health care system. Restrictions on scope of practice, policy- and reimburse- ment-related limitations, and professional tensions have undermined the nursing profession’s ability to provide and improve both general and advanced care. Producing a health care system that delivers the right care—quality care that is patient centered, accessible, evidence based, and sustainable—at the right time will require transforming the work environment, scope of practice, education, and numbers of America’s nurses. KEY MESSAGES As a result of its deliberations, the committee formulated four key messages that structure the discussion and recommendations presented in this report: 1. Nurses should practice to the full extent of their education and training. 2. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. 3. Nurses should be full partners, with physicians and other health profes - sionals, in redesigning health care in the United States. 4. Effective workforce planning and policy making require better data col - lection and an improved information infrastructure. The recommendations offered in this report focus on the critical intersection between the health needs of diverse populations across the lifespan and the ac- tions of the nursing workforce. They are intended to support efforts to improve the health of the U.S. population through the contributions nurses can make to the delivery of care. But they are not necessarily about achieving what is most comfortable, convenient, or easy for the nursing profession. Key Message #1: Nurses Should Practice to the Full Extent of Their Education and Training (Chapter 3) Nurses have great potential to lead innovative strategies to improve the health care system. However, a variety of historical, regulatory, and policy bar-

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 SUMMARY riers have limited nurses’ ability to generate widespread transformation. Other barriers include fragmentation of the health care system, high rates of turnover among nurses, difficulties for nurses transitioning from school to practice, and an aging workforce and other demographic challenges. Many of these barriers have developed as a result of structural flaws in the U.S. health care system; others reflect limitations in the present work environment or the capacity and demographic makeup of the nursing workforce itself. Regulatory barriers are particularly problematic. Regulations defining scope-of-practice limitations vary widely by state. Some are highly detailed, while others contain vague provisions that are open to interpretation. Some states have kept pace with the evolution of the health care system by changing their scope-of-practice regulations to allow nurse practitio- ners to see patients and prescribe medications without a physician’s supervision or collaboration. However, the majority of state laws lag behind in this regard. As a result, what nurse practitioners are able to do once they graduate varies widely for reasons that are related not to their ability, education or training, or safety con- cerns, but to the political decisions of the state in which they work. Depending on the state, restrictions on the scope of practice of an advanced practice registered nurse may limit or deny altogether the authority to prescribe medications, admit patients to the hospital, assess patient conditions, and order and evaluate tests. Because many of the problems related to varied scopes of practice are the result of a patchwork of state regulatory regimes, the federal government is especially well situated to promote effective reforms by collecting and dis- seminating best practices from across the country and incentivizing their adop- tion. Specifically, the Federal Trade Commission has a long history of targeting anticompetitive conduct in the health care market, including restrictions on the business practices of health care providers, as well as policies that could act as a barrier to the entry of new competitors in the market. As a payer and adminis- trator of health insurance coverage for federal employees, the Office of Person- nel Management and the Federal Employees Health Benefits Program have a responsibility to promote and ensure the access of employees/subscribers to the widest choice of competent, cost-effective health care providers. Principles of equity would suggest that this subscriber choice should be promoted by policies ensuring that full, evidence-based practice is permitted to all providers regardless of geographic location. Finally, the Centers for Medicare and Medicaid Services has the responsibility to promulgate rules and policies that promote Medicare and Medicaid beneficiaries’ access to appropriate care, and therefore can ensure that its rules and polices reflect the evolving practice abilities of licensed providers. In addition to barriers related to scope of practice, high turnover rates among newly graduated nurses highlight the need for a greater focus on managing the transition from school to practice. In 2002, the Joint Commission recommended the development of nurse residency programs—planned, comprehensive periods of time during which nursing graduates can acquire the knowledge and skills to

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 THE FUTURE OF NURSING deliver safe, quality care that meets defined (organization or professional soci- ety) standards of practice. Residency programs are supported predominantly in hospitals and larger health systems, with a focus on acute care. This has been the area of greatest need since most new graduates gain employment in acute care settings, and the proportion of new hires (and nursing staff) that are new graduates is rapidly increasing. It is essential, however, that residency programs outside of acute care settings be developed and evaluated. Much of the evidence supporting the success of residencies has been produced through self-evaluations by the residency programs themselves. For example, one organization, Versant,2 has demonstrated a profound reduction in turnover rates for new graduate regis- tered nurses—from 35 to 6 percent at 12 months and from 55 to 11 percent at 24 months—compared with new graduate registered nurse control groups hired at a facility prior to implementation of the residency program. Key Message #2: Nurses Should Achieve Higher Levels of Education and Training Through an Improved Education System That Promotes Seamless Academic Progression (Chapter 4) Major changes in the U.S. health care system and practice environment will require equally profound changes in the education of nurses both before and after they receive their license. An improved education system is necessary to ensure that the current and future generations of nurses can deliver safe, quality, patient-centered care across all settings, especially in such areas as primary care and community and public health. Nursing is unique among the health professions in the United States in that it has multiple educational pathways leading to an entry-level license to practice. The qualifications and level of education required for entry into the nursing profession have been widely debated by nurses, nursing organizations, academics, and a host of other stakeholders for more than 40 years. During that time, competencies needed to practice have expanded, especially in the domains of community and public health, geriatrics, leadership, health policy, system improvement and change, research and evidence-based practice, and teamwork and collaboration. These new competencies have placed increased pressures on the education system and its curricula. Care within hospital and community settings also has become more complex. In hospitals, nurses must make critical decisions associated with care for sicker, frailer patients and work with sophisticated, life-saving technology. Nurses are being called upon to fill primary care roles and to help patients manage chronic illnesses, thereby preventing acute care episodes and disease progression. They 2 Versant is a nonprofit organization that provides, supervises, and evaluates nurse transition-to- practice residency programs for children’s and general acute care hospitals. See http://www.versant. org/item.asp?id=35.

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 SUMMARY are expected to use a variety of technological tools and complex information management systems that require skills in analysis and synthesis to improve the quality and effectiveness of care. Across settings, nurses are being called upon to coordinate care and collaborate with a variety of health professionals, including physicians, social workers, physical and occupational therapists, and pharmacists, most of whom hold master’s or doctoral degrees. Shortages of nurses in the posi- tions of primary care providers, faculty, and researchers continue to be a barrier to advancing the profession and improving the delivery of care to patients. To respond to these demands of an evolving health care system and meet the changing needs of patients, nurses must achieve higher levels of education and training. One step in realizing this goal is for a greater number of nurses to enter the workforce with a baccalaureate degree or progress to this degree early in their career. Moreover, to alleviate shortages of nurse faculty, primary care providers, and researchers, a cadre of qualified nurses needs to be ready to advance to the master’s and doctoral levels. Nursing education should therefore include opportu- nities for seamless transition to higher degree programs—from licensed practical nurse (LPN)/licensed vocational nurse (LVN) degrees, to the associate’s degree in nursing (ADN) and bachelor’s of science in nursing (BSN), to master’s of science in nursing (MSN), and to the PhD and doctor of nursing practice (DNP). Further, nursing education should serve as a platform for continued lifelong learning. Nurses also should be educated with physicians and other health professionals as students and throughout their careers. Finally, as efforts are made to improve the education system, greater emphasis must be placed on increasing the diversity of the workforce, including in the areas of gender and race/ethnicity, as well as ensuring that nurses are able to provide culturally relevant care. While the capacity of the education system will need to expand, and the fo- cus of curricula will need to be updated to ensure that nurses have the right com- petencies, a variety of traditional and innovative strategies already are being used across the country to achieve these aims. Examples include the use of technolo- gies such as online education and simulation, consortium programs that create a seamless pathway from the ADN to the BSN, and ADN-to-MSN programs that provide a direct link to graduate education. Collectively, these strategies can be scaled up and refined to effect the needed transformation of nursing education. Key Message #3: Nurses Should Be Full Partners, with Physicians and Other Health Professionals, in Redesigning Health Care in the United States (Chapter 5) Strong leadership is critical if the vision of a transformed health care sys- tem is to be realized. To play an active role in achieving this vision, the nursing profession must produce leaders throughout the system, from the bedside to the boardroom. These leaders must act as full partners with physicians and other health professionals, and must be accountable for their own contributions to de-

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 THE FUTURE OF NURSING livering high-quality care while working collaboratively with leaders from other health professions. Being a full partner transcends all levels of the nursing profession and re- quires leadership skills and competencies that must be applied within the profes- sion and in collaboration with other health professionals. In care environments, being a full partner involves taking responsibility for identifying problems and areas of waste, devising and implementing a plan for improvement, tracking improvement over time, and making necessary adjustments to realize established goals. Moreover, being a full partner translates more broadly to the health policy arena. To be effective in reconceptualized roles, nurses must see policy as some- thing they can shape rather than something that happens to them. Nurses should have a voice in health policy decision making and be engaged in implementation efforts related to health care reform. Nurses also should serve actively on advi- sory committees, commissions, and boards where policy decisions are made to advance health systems to improve patient care. Strong leadership on the part of nurses, physicians, and others will be re- quired to devise and implement the changes necessary to increase quality, access, and value and deliver patient-centered care. While not all nurses begin their ca- reer with thoughts of becoming a leader, leadership is fundamental to advancing the profession. To ensure that nurses are ready to assume leadership roles, leader- ship-related competencies need to be embedded throughout nursing education, leadership development and mentoring programs need to be made available for nurses at all levels, and a culture that promotes and values leadership needs to be fostered. Equally important, all nurses—from students, to bedside and com- munity nurses, to chief nursing officers and members of nursing organizations, to researchers—must take responsibility for their personal and professional growth by developing leadership competencies. They must exercise these competencies in a collaborative environment in all settings, including hospitals, communities, schools, boards, and political and business arenas, both within nursing and across the health professions. And in doing so, they must not only mentor others along the way, but develop partnerships and gain allies both within and beyond the health care environment. Key Message #4: Effective Workforce Planning and Policy Making Require Better Data Collection and an Improved Information Infrastructure (Chapter 6) Achieving a transformation of the health care system and the practice en- vironment will require a balance of skills and perspectives among physicians, nurses, and other health professionals. However, strategic health care workforce planning to achieve this balance is hampered by the lack of sufficiently reliable and granular data on, for example, the numbers and types of health professionals currently employed, where they are employed and in what roles, and what types of activities they perform. These data are required to determine regional health

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 SUMMARY care workforce needs and to establish regional targets and plans for appropriately increasing the supply of health professionals. Additionally, understanding of the impact of innovations such as bundled payments, medical homes, accountable care organizations, health information technology, and comparative effective- ness will be incomplete without information on and analysis of the necessary contributions of the various types of health professionals. Data collection and analysis across the health professions will also be essential because of the overlap in scopes of practice for primary care providers such as physicians, physician assistants, and nurse practitioners and the increasing shift toward team-based care. In the specific context of this study, planning for fundamental, wide-ranging changes in the education and deployment of the nursing workforce will require comprehensive data on the numbers and types of nurses currently available and required to meet future needs. Once an infrastructure for collecting and analyzing workforce data is in place, systematic assessment and projection of nursing work- force requirements by role, skill mix, region, and demographics will be needed to inform necessary changes in nursing practice and education. The ACA mandates the creation of a National Health Care Workforce Com- mission whose mission is, among other things, to “[develop] and [commission] evaluations of education and training activities to determine whether the demand for health care workers is being met,” and to “[identify] barriers to improved coordination at the Federal, State, and local levels and recommend ways to ad- dress such barriers.”3 The ACA also authorizes a National Center for Workforce Analysis, as well as state and regional workforce centers, and provides funding for workforce data collection and studies. A priority for these new structures and resources should be systematic monitoring of the supply of health care workers across professions, review of the data and methods needed to develop accurate predictions of future workforce needs, and coordination of the collection of data on the health care workforce at the state and regional levels. To be most useful, the data and information gathered must be timely and publicly accessible. 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. 3 Patient Protection and Affordable Care Act, H.R. 3590 § 5101, 111th Congress.

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10 THE FUTURE OF NURSING • 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. 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

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11 SUMMARY 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, 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:

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12 THE FUTURE OF NURSING • 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. 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.

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13 SUMMARY • 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. • 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, scientists, 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

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14 THE FUTURE OF NURSING 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 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

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1 SUMMARY 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 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. CONCLUSION Nurses are already committed to delivering high-quality care under current regulatory, business, and organizational conditions. But the power to change those conditions to deliver better care does not rest primarily with nurses, re- gardless of how ably led or educated they are; it also lies with governments, businesses, health care institutions, professional organizations and other health professionals, and the insurance industry. The recommendations presented in this report are directed to individual policy makers; national, state, and local government leaders; payers; health care researchers; executives; and profession- als—including nurses and others—as well as to larger groups such as licensing bodies, educational institutions, and philanthropic and advocacy organizations, especially those advocating for consumers. Together, these groups have the power to transform the health care system to provide seamless, affordable, quality care that is accessible to all, patient centered, and evidence based and leads to im- proved health outcomes.

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