are few integrated delivery systems or ACO-type entities that are responsible for, and explicitly rewarded for, their overall performance across the settings that comprise their system of care rather than a single setting. In the main, financial performance is captured and rewarded at the level of the individual setting (e.g., hospitals) and not at the system level (e.g., ACO), so the behavior of each setting is independent and driven by its own goals. Consequently, hospitals lack the financial incentive to hire and deploy RNs to provide transitional care if the outcome is reduced income in the form of reduced admissions. ACO-type organizations lack the incentive to employ RNs to provide care coordination and team management services if these entities are not rewarded for improved financial performance and quality outcomes that these services produce.

The second challenge lies in the educational sector. As currently designed primary nursing education prepares nurses to function in discrete settings rather than across settings (Benner et al., 2009) and as individual clinical providers rather than team members. Team-based care and care coordination are not meaningfully integrated in primary nursing educational pedagogies. Reorienting nursing education to incorporate these themes will require significant redesign of both classroom and clinical education. Furthermore, primary nursing education is still largely focused on the acute care setting. Preparing RNs, in addition to advanced practice clinicians, to practice in ambulatory care settings where the demand for care is clearly growing will require a substantial shift in classroom education but even a greater shift in the clinical practica for students. Finally, the scope and breadth of nursing education needed to meet the needs of reformed health care delivery will require assessment of whether the current educational modality—where the majority of nurses complete their primary nursing education in associate degree programs—produces the right mix of RNs and skills needed to enact these reforms. Without a change in demand, however, the educational system will continue to produce the RN supply—the numbers and skill composition—that it has in the past.

Finally, workforce planning and forecasting will likewise require a comparable paradigm shift. Forecasting models based on current RN demand will not produce useful estimates to guide future policy, i.e., the capacity of the RN workforce to meet the needs of future models of health care services. The current RN workforce is deficient in a number of dimensions to support health reform. Specifically, there is a shortage of RNs deployed to ambulatory care settings and a shortage of advanced practice nurses delivering primary care services. There is a shortage of RNs trained and working as care managers directing and delivering care coordination for patients in acute and post-acute care systems. There is a shortage of RNs with sufficient training and experience in the full array of clinical practice and team management skills that reorganized care delivery models will require. Estimating these shortages, and developing the pathway to resolving them argues for a wholesale new approach to assessing future nursing requirements and preparing and allocating nursing resources to meet those requirements.

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