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Strengthening the Healthcare
Workforce
The workforce of healthcare professionals—the backbone of the nation’s
healthcare system—labors under many pressures. Some care providers
have difficulty coping with a rapidly evolving healthcare system. Doctors
are increasingly challenged to keep up with advances in science and medi-
cine. Global health problems create shared responsibilities for health
workers everywhere. New and emerging diseases raise safety concerns
for frontline care providers. Rising patient expectations and increasing
demand from more widespread insurance coverage will heighten the
challenges.
The Institute of Medicine (IOM) has examined many aspects of the
healthcare workforce—delineating problems, identifying solutions, and
charting paths forward. Government policy makers, healthcare and educa-
tion leaders, individual care providers, and a range of other stakeholders
can draw on this knowledge to ensure that the nation takes full advantage
of a skilled, adaptive, and well-protected healthcare workforce.
The future of nursing
With more than 3 million members, the nursing profession is the largest
segment of the nation’s healthcare workforce. But even as nurses are the
primary professional caregivers for many patients, a number of barriers
prevent nurses from being able to keep up with changes in where and how
health care is delivered and in the skills required to keep pace with today’s
evolving healthcare system.
35
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36 INFORMING THE FUTURE: Critical Issues in Health
In 2008, the Robert Wood Johnson Foundation (RWJF) and the IOM
launched a 2-year study to respond to nurses’ needs and transform the nurs-
ing profession. Called the Robert Wood Johnson Foundation Initiative on
the Future of Nursing, at the Institute of Medicine,
the project followed a methodical course to ensure
comprehensive analysis. Over 2 years, the study
committee held three national forums focused
on critical aspects of health, including acute care;
community health, primary care, and long-term
care; and nursing education. The meetings enabled
stakeholders to share their knowledge and express
their concerns about the roles of nurses in the cur-
rent healthcare system, and the IOM published
summaries of each forum. The committee also
held several technical workshops at which mem-
bers further explored challenges facing the nursing
profession.
From these efforts, the committee produced The Future of Nursing:
Leading Change, Advancing Health (2010). The report describes the com-
mittee’s vision for health care and the essential role of nurses in realizing
this vision, concluding that a fundamental transformation of the nursing
profession is needed if nurses are to fulfill this role. The report presents a
blueprint for action in the form of recommendations and related research
priorities. Transformations are needed in three broad areas—nursing prac-
tice, education, and leadership—and within this framework, the committee
developed four key messages that structure
its recommendations.
The report describes the
First, nurses should practice to the
committee’s vision for health
full extent of their education and training.
care and the essential role of
Because licensing and practice rules vary
nurses in realizing this vision.
across states, the regulations regarding
scope of practice—that is, the activities that
a qualified nurse may perform—have varying effects on different types of
nurses in different parts of the country. Consequently, the tasks that nurses
are allowed to perform are often determined not by their education and
training but by the unique state laws under which they work. The report
calls on a variety of stakeholders—from state legislators to the Centers for
Medicare and Medicaid Services to the Congress—to ensure that nurses
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37
Strengthening the Healthcare Workforce
can practice to the full extent of their education and training. The federal
government is particularly well suited to promote reform of states’ scope-
of-practice laws by sharing and providing incentives for the adoption of
best practices.
Second, nurses should achieve higher levels of education and training
through an improved education system that promotes seamless academic
progression into higher-degree programs. Patient needs have become more
complicated, and nurses need to achieve requisite competencies to deliver
high-quality care in a variety of settings and in partnership with teams of
health professionals. Needed competencies include system improvement,
research and evidence-based practice, and teamwork and collaboration,
After one-time signed articulated plan
Required consultation for Controlled Substances II-III only
NP signs one-page collaboration form; no physician signature required
Restrictive Collaboration Requirement
No requirements (independent practice)
Required to prescribe
Required to diagnose, treat and prescribe
Requirements for physician−nurse collaboration, by state, as a barrier to access to primary care.
NOTE: Collaboration refers to a mutually agreed upon relationship between nurse and physician.
SOURCE: AARP, 2010b. Courtesy of AARP. All rights reserved. This figure combines Map 1,
Overview of Diagnosing and Treating Aspects of NP Practice and Map 2, Overview of Prescribing
Aspects of NP Practice, both developed by Linda Pearson (2010).
SOURCE: The Future of Nursing: Leading Change, Advancing Health, p. 99.
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38 INFORMING THE FUTURE: Critical Issues in Health
among others, as well as competencies in specific content areas, including
community and public health and geriatrics. Nurses also should be edu-
cated with physicians and other health professionals both as students and
throughout their careers in lifelong learning opportunities. And to improve
the quality of patient care, a greater emphasis must be placed on making
the nursing workforce more diverse, particularly in the areas of gender,
race, and ethnicity.
Third, nurses should be full partners with physicians and other
healthcare professionals in redesigning health care. Being a full partner will
involve taking responsibility for identifying problems and areas of system
waste, devising and implementing improve-
ment plans, tracking improvement over
Nurses should be full partners
time, and making necessary adjustments
with physicians and other
to realize established goals. In the health
healthcare professionals in
policy arena, nurses should participate in,
redesigning health care.
and sometimes lead, decision making and
be engaged in healthcare reform-related
implementation efforts. Nurses also should serve actively on advisory
boards on which policy decisions are made to advance health systems and
improve patient care. To ensure that nurses are ready to assume leadership
roles, nursing education programs need to embed leadership-related com-
petencies throughout training.
Fourth, planning for fundamental, wide-ranging changes in the
education and deployment of the nursing workforce will require compre-
hensive data on the numbers and types of health professionals—including
nurses—currently available and required to meet future needs. Once an
improved infrastructure for collecting and analyzing workforce data is in
place, systematic assessment and projection of workforce requirements by
role, skill mix, region, and demographics will be needed to inform changes
in nursing practice and education.
Building on this report, the RWJF and the IOM convened the
National Summit on Advancing Health through Nursing. Held in late 2010,
it brought together more than 500 stakeholders from multiple sectors to
discuss implementing the report’s recommendations. Thousands more
participants joined via webcast and more than 120 satellite meetings in
45 states.
At the summit, RWJF, in collaboration with AARP, the advocacy
group for older people, announced the launch of the Initiative on the Future
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39
Strengthening the Healthcare Workforce
of Nursing Campaign for Action. Using the IOM report as a framework,
the campaign works in partnership with numerous healthcare groups and
professionals on a variety of activities, such as data collection and dissemi-
nation of educational tools, aimed at ensuring that nurses are prepared to
meet the demands of the 21st-century health system.
Lifelong learning
Every segment of the healthcare workforce must comprise professionals
who provide high-quality health care and assure patient safety. However,
the nation lacks a comprehensive, effective system of continuing education
in the health professions, and that this gap contributes to knowledge and
performance deficiencies at the individual and system levels. Many stake-
holders have called for a national interprofessional continuing education
institute that would advance the science of continuing education. With
support from the Josiah Macy Jr. Foundation, the IOM examined options
for bridging the education gap.
The IOM study committee’s report, Redesigning Continuing Educa
tion in the Health Professions (2009), described the merits and drawbacks
of current programs, explored development of a national continuing edu-
cation institute, and offered guidance on the establishment and operation
of such an institute. To add perspective to its deliberations, the committee
evaluated a number of possible alternatives
to an institute. They included maintaining There are major flaws in the
the status quo, developing a government way continuing education
program within an existing agency, forming is conducted, financed,
a coalition of continuing education stake- regulated, and evaluated,
holders and other organizations focused on and the science underpinning
healthcare quality and patient safety, and continuing education for health
creating a new entity drawn from profes- professionals is fragmented
sional societies. The committee judged each and underdeveloped.
alternative to be feasible, but concluded that
a public-private institute held the most promise for fostering collaboration
among all stakeholders that would improve the nation’s system of continu-
ing education for all health professionals.
The report identifies a set of key messages that should help guide
reforms. Among them, there are major flaws in the way continuing edu-
cation is conducted, financed, regulated, and evaluated, and the science
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40 INFORMING THE FUTURE: Critical Issues in Health
Overview of Current Continuing Education Financing in Medicine
Current System
Industry funding? Yes, ~58% of total
Out-of-pocket cost ~42% of total, or $1,200 per physician per year
to physicians
Mode of delivery Primarily in-person lectures and workshops,
with a small amount of simulation training and
performance improvement exercises taking hold
Educational value, Unclear
impact on patient care
SOURCE: Redesigning Continuing Education in the Health Professions, p. 67.
underpinning continuing education for health professionals is fragmented
and underdeveloped. Continuing education efforts should bring health
professionals from various disciplines together in carefully tailored learn-
ing environments. And in an overarching shift, the nation should develop a
comprehensive new vision of professional development to replace the cul-
ture that now envelops continuing education in health care.
The new vision should be based on an approach called continuing
professional development, in which learning takes place over a lifetime and
stretches beyond the classroom to the point of care. Unlike today’s more
structured approach, this holistic approach would incorporate a broad
variety of learning methods and theories, and it would be learner driven,
allowing learning to be tailored to individuals’ needs.
To help in reaching these goals, the Department of Health and
Human Services (HHS) should commission a blue-ribbon panel to oversee
the design and implementation of an inde-
The nation should develop pendent public-private Continuing Profes-
a comprehensive new vision sional Development Institute. As a neutral
of professional development body, not embedded within any agency,
to replace the culture that the institute could promote and catalyze
now envelops continuing stakeholder collaboration. The IOM report
education in health care. presents a detailed action plan for the insti-
tute. Among other actions, the institute
should develop and prioritize a national research agenda in continuing
education, work toward harmonizing the complex web of regulations cov-
ering continuing education, and explore new financing mechanisms that
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41
Strengthening the Healthcare Workforce
will support a broader-based continuing professional development system
while avoiding potential conflicts of interest.
Guarding worker safety
Given that professionals across the healthcare workforce grapple regularly
with a variety of medical threats, including new and emerging diseases,
it is important to protect them where they work. One such risk emerged
with the recent outbreak in the United States and other nations of a new
type of influenza, called H1N1 influenza A. At the request of the Centers for
Disease Control and Prevention (CDC) and the Occupational Safety and
Health Administration (OSHA), the IOM convened an expert committee
to rapidly develop recommendations on how best to provide respiratory
protection for healthcare workers who might be exposed to the virus on
their jobs.
In Respiratory Protection for Healthcare Workers in the Workplace
Against Novel H1N1 Influenza A: A Letter Report (2009), the committee
recommends that personnel in hospitals and other care settings who are
in close contact with individuals with H1N1 influenza A or influenza-like
illnesses use an N95 respirator (or one equally effective) that is adjusted for
proper fit. Employers should ensure that the use and fit testing of N95 res-
pirators be conducted in accordance with OSHA regulations, and health-
care workers should use the equipment as required by regulations and
employer policies.
The committee also calls for the CDC and other federal agencies,
as well as private health groups, to fund or conduct additional research to
resolve unanswered questions about the relative contribution of various
routes of influenza transmission; explore the effectiveness through ran-
domized clinical trials of personal respiratory protection technologies in
a variety of clinical settings; and design and develop the next generation
of personal respiratory protection technologies for healthcare workers to
enhance safety, comfort, and ability to perform work-related tasks.
While this study answered some particularly pressing health ques-
tions raised by the emergence of a new influenza virus, the healthcare
community clearly faces broader challenges in dealing with influenza
pandemics and other viral diseases. To help in efforts to better protect
the healthcare workforce, the National Personal Protective Technology
Laboratory at the National Institute for Occupational Safety and Health
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42 INFORMING THE FUTURE: Critical Issues in Health
(NIOSH) asked the IOM to assess the personal protective equipment (PPE)
on which workers rely. PPE may include respirators, face masks, gloves,
gowns, eye protection, and face shields. The IOM previously had examined
this issue and reported the findings in Pre
paring for an Influenza Pandemic: Personal
The healthcare community
Protective Equipment for Healthcare Work
clearly faces broader
ers (2008). The new IOM study focused on
challenges in dealing with
updating progress in research and identify-
influenza pandemics and
ing future directions for PPE for healthcare
other viral diseases.
personnel.
In Preventing Transmission of Pan
demic Influenza and Other Viral Respiratory Diseases: Personal Protective
Equipment for Healthcare Personnel—Update 2010, the committee proposes
an integrated approach that embraces the full spectrum of research (from
basic research to policy research) and translates research findings into
improvements in healthcare practice. Feedback loops will be critical, with
adaptations made along the way as new equipment and processes are devel-
oped and tested in real-world settings. Such an integrated approach will call
for collaboration and discourse among scientists, clinicians, policy makers,
and other stakeholders who may not have had previous interactions.
Among research needs, basic questions remain about how the vari-
ous modes of influenza transmission—droplet spray, aerosol, and direct or
indirect contact—contribute to the overall spread of illness. Improvements
PROOF OF STANDARD OF
CONCEPT PRINCIPLE PRACTICE
Policy and
Regulatory
Basic Science Research
Clinical/Applied Systems
Research (Disease Reduction
Research Research
(Safety) (Efficacy) (Effectiveness) in Populations)
T2 T3
T1 T4
An integrated system moving research into practice, depicting the translation of research from
basic science (T1) through policy and regulatory research (T4).
SOURCE: Preventing Transmission of Pandemic Influenza and Other Viral Respiratory Diseases:
Personal Protective Equipment for Healthcare Personnel—Update 2010, p. 8.
R01859 Fig 1-2.eps
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43
Strengthening the Healthcare Workforce
also are needed in equipment design. For example, safety devices known
as filtering facepiece respirators are widely used and much improved in
recent years, but new technologies are needed to improve their fit and
reduce inward leakage of potentially con-
taminated air. In addition, better under- Better understanding is needed
standing is needed of how safety equipment of how safety equipment
and processes are used in various types of and processes are used in
healthcare settings where a number of fac- various types of healthcare
tors—the user, the device, the task, and the settings where a number of
general work and organizational context— factors—the user, the device,
come into play. Paying greater attention to the task, and the general
interactions among such contextual fac- work and organizational
tors will better align research on PPE use in context—come into play.
health care with other branches of occupa-
tional safety and health research.
But the committee said that even as research continues, enough
is known to implement a number of new approaches and technologies
immediately, and it recommended a four-pronged strategy. There should
be deliberate planning and preparation at the leadership and organiza-
tional levels; comprehensive training of personnel, including supervisors
and managers; widespread and convenient availability of appropriate
PPE devices; and accountability at all levels of the organization. Policies
for PPE use by healthcare personnel need to be carefully planned at the
organizational and institutional level to ensure a culture of safety, compli-
ance, and buy-in at all levels. Managers and frontline workers alike need
to understand and accept their roles and responsibilities, and using PPE
needs to be as easy and convenient as possible for all healthcare personnel.
Occupational health nursing (OHN) is one healthcare profession
particularly focused on PPE in the workplace. Occupational health nurses
(OHNs) work in a variety of workplace environments, including agricul-
ture, construction, health care, manufacturing, and public safety. In these
environments, OHNs have a wide range of roles and responsibilities that
span management and organization, worker health assessment and direct
healthcare services, and prevention and research. In many settings where
OHNs work, employees require protective measures to safeguard them
from a range of respiratory hazards—for example, respirable dust in con-
struction and chemical sprays in agriculture. As key members of the occu-
pational health and safety workforce, OHNs need adequate education and
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44 INFORMING THE FUTURE: Critical Issues in Health
training in respiratory protection in order to ensure both their own safety
and the safety of America’s workers.
At the request of NIOSH’s National Personal Protective Technol-
ogy Laboratory, the IOM examined existing
respiratory protection curricula in occupa-
As key members of the
tional health nursing programs and made
occupational health and safety
recommendations to improve the education
workforce, occupational
and training of OHNs. The IOM identified
health nurses need adequate
essential content that should be included in
education and training in
education and training programs for OHNs
respiratory protection in
and the best approaches to teaching that
order to ensure both their
content. The report, Occupational Health
own safety and the safety
Nurses and Respiratory Protection: Improving
of America’s workers.
Education and Training—Letter Report (2011)
finds that current respiratory protection education for OHNs receives vary-
ing amounts of dedicated time and resources and is taught using a variety
of approaches. The report makes several recommendations to occupational
health nursing education and training programs and the National Personal
Protective Technology Laboratory, such as expansion of respiratory protec-
tion information provided across all levels of nursing education and train-
ing; consistent integration of essential content into graduate curricula and
continuing education programs for OHNs; continued and expanded use of
innovative teaching methods, such as online courses, use of simulation and
case studies, and field observation and practice; and exploration of the devel-
opment of core competencies in respiratory protection.
Millions of workers rely on a variety of personal protective technolo-
gies (PPT) to keep them safe. PPT encompass a range of specialized clothing
and equipment, including gloves, hearing protection, fall arrest harnesses,
respirators, and eye protection. To ensure that PPT will perform as intended,
government agencies, manufacturers, test-
ing laboratories, workers, and other stake-
Millions of workers rely on a
holders participate in an array of activities
variety of personal protective
collectively called conformity assessment.
technologies to keep them safe.
Activities include testing to ensure that
the product meets specific design or per-
formance criteria, examining the test results to declare conformity to the
specifications, inspecting manufacturing sites, and conducting postmarket
evaluations.
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Strengthening the Healthcare Workforce
The National Personal Protective Technology Laboratory asked the
IOM to appoint an expert committee to examine PPT conformity assess-
ment issues and recommend improvements. The committee’s report,
Certifying Personal Protective Technologies: Improving Worker Safety (2010)
concluded that current approaches to evaluating occupational PPT, often
by job sector, are fragmented and vary in rigor. The committee recommends
as a first step that a comprehensive framework be established for PPT con-
formity assessment. The framework would catego-
rize products into tiers, based on the degree of risk
to the safety and health of the user, while also con-
sidering various pragmatic factors, such as the cost
or feasibility of developing a new product and the
size of the intended target population.
Within the framework, risks would be rated
as high, medium, or low, with each category requir-
ing different levels of conformity assessment. When
risks are low, manufacturers would need only to
attest that their products meet certain standards
recognized by the federal government. When risks
are medium, products would need to be tested and
assessed by an independent testing laboratory and
certifying organization to ensure that they meet
federal standards. When risks are high, third-party testing and certification
would be required, coupled with intensive government involvement at all
stages, from design to manufacture and follow-up testing in the workplace.
Numerous stakeholders must participate in developing, implement-
ing, and supporting this new framework. The National Personal Protective
Technology Laboratory at NIOSH can play a lead role, and it should work
with other federal agencies, certifying and accrediting organizations, man-
ufacturers, and workers who use PPT. Other efforts also will be needed to
improve communications between government and employers and work-
ers about the availability and effectiveness of PPT, and to expand federal
surveillance programs to monitor the effectiveness of PPT products in the
workplace. With such a comprehensive system in place, the government
and others will be better able to direct conformity assessment efforts, iden-
tify remaining gaps in assessment, and prioritize resources to ensure that
workers receive the best protection possible on their jobs.
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46 INFORMING THE FUTURE: Critical Issues in Health
Fighting HIV/AIDS in Africa
In addition to working to improve the health and well-being of Americans,
the U.S. workforce of healthcare professionals, by necessity, tackles inter-
national health challenges as well. No challenge is greater than combating
HIV/AIDS in sub-Saharan Africa, which in 2009 accounted for 68 percent
of cases worldwide and 69 percent of new infections. In a major U.S. effort,
the President’s Emergency Plan for AIDS Relief has provided approxi-
mately $32 billion to HIV/AIDS-related
programs since it was established in 2003.
No challenge is greater than
But this and other assistance efforts are
combating HIV/AIDS in sub-
being overwhelmed as the epidemic contin-
Saharan Africa, which in 2009
ues to spread.
accounted for 68 percent
In this context, the IOM appointed
of cases worldwide and 69
a committee of experts to recommend
percent of new infections.
affordable, sustainable strategies that both
African nations and the United States can
implement to reduce the long-term burden of HIV/AIDS. The committee’s
report, Preparing for the Future of HIV/AIDS in Africa: A Shared Respon
sibility (2010), concludes that the burden of morbidity and mortality in
Africa cannot be alleviated through treatment alone. Treatment can reach
only a fraction of those who need it, and its costs are unsustainable. Greater
emphasis must be placed on preventing new infections. The report identi-
fies a number of specific, tailored strategies for building African capacity—
including human, scientific, technological, organizational, institutional,
and/or resource capabilities—to prevent, treat, and care for HIV/AIDS.
African countries, with the support of international donors, including
the United States, should develop and implement methods for measuring the
level of and change in new HIV infections to enable better planning and eval-
uation of prevention programs. The nations also should focus on strength-
ening their healthcare systems by making the most of existing capacities,
such as healthcare workers on the ground and local institutions. Needed
actions include making use of management and support staff from outside
the clinical health sector to free up time for healthcare providers to perform
clinical work; delegating tasks of health professionals, when appropriate, to
health workers with less-specialized training; tapping the potential of mod-
ern information and communications technology, such as smart phones and
distance learning; and forming partnerships between developing countries
and creating regional collaborations to exchange technical assistance.
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Strengthening the Healthcare Workforce
For the United States, strategies should focus on supporting
partnerships—particularly institutional partnerships—that can help Africa
move forward independently in HIV/AIDS treatment and prevention. Such
partnerships can be formed in the public and private sectors and include
collaborations among academic institutions, faith-based organizations,
and the militaries of the United States and African nations. Among other
actions, the White House and the Office of the Global AIDS Coordinator
should develop a U.S. roadmap for HIV/AIDS in 2020 that incorporates
a model of U.S.-African shared responsibility. This roadmap should give
priority to HIV/AIDS prevention and strike an optimal balance between
bilateral and multilateral funding mechanisms. Likewise, HIV/AIDS coor-
dinating groups in Africa should develop a 20-year roadmap for combating
the epidemic, including sufficient investment in prevention and the devel-
opment of more efficient models of care and treatment.
12
Health workers per 1,000 population
10.9
10.4
10
8.5
8
6
Global average 4.0
4
2.8 2.7
2.3
2
1.0
0
North Europe Western South & Middle Asia Sub-
America Pacific Central East & Saharan
America North Africa
Africa
Health worker density by region.
SOURCE: JLI, 2004, compiled from WHO, 2004.
SOURCE: Preparing for the Future of HIV/AIDS in Africa: A Shared Responsibility, p. 108.
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