Nursing News

The Future of Nursing in a 'Reformed' Health Care System

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By Kim McCarten, contributor

February 25, 2011 - The Robert Wood Johnson Foundation (RWJF) and the Institute of Medicine (IOM) have been leading a two-year-long effort, working with nursing leaders, public policy and technology experts, demographers, educators and others to pull together their collective experience and ideas and form a comprehensive set of recommendations that address the future of nursing.

This collaboration has involved joint RWJF/IOM meetings, research and town hall meetings to learn more about what is currently being done in communities and health care facilities across the nation.

With the passage of the Health Care and Education Reconciliation Act of 2010, one committee in particular wanted to consider the role that nurses would play in a reformed health care system. 

NurseZone recently spoke with Rosa M. Gonzalez-Guarda, Ph.D., MSN, MPH, RN, assistant professor at the School of Nursing and Health Studies at the University of Miami, about her role as a key member on the RWJF/IOM Future of Nursing Committee. 

Q. Can you tell us more about the Future of Nursing Committee and how you became involved?

A. The Institute of Medicine put together the committee, and a standing IOM member gave them a recommendation to contact me. They were looking to include younger people, because traditionally IOM work is done by senior-level professionals, and they were looking specifically for people who were more junior to add to the range of the committee's [expertise]. They pulled together members from various disciplines and varying perspectives, so that issues could be looked at in an interdisciplinary, “big picture” approach.

The committee had specific tasks, with the overarching task being to reconceptualize the role of nurses within a reformed healthcare system.

Q. Reformed by the health care bill, or reformed in a more general sense?

A. The committee worked within the time that the health care debate was [in Congress], and the bill was passed during the time that we were constructing our recommendations. So the report does tap into the legislation, but it incorporates a vision that's a lot broader, and considers a reformed health care delivery system [in general].

Q. What were some of the main concerns that the committee was looking to address?

A. One main issue had to do with scope of practice: what are nurses doing currently and what should they be doing in the future?

Nurses should be used to their full capacity, with respect to their education and training, and one of the biggest barriers that currently exists is scope of practice laws at the state level.

For example, a nurse practitioner is trained to make a diagnosis, prescribe medication, order laboratory tests, and research shows that they can do so in a very safe and effective manner. Nevertheless, when you look at the laws, nurses [often] aren't allowed to practice to that full extent; in other words, they have to work in collaboration with, or under the supervision of, a physician. So that's a resource that we're not taking full advantage of.

Q. The report summary shows that another area the committee focused on was nurse education. What do you see is a priority for transforming and improving nurse education?

A. Nursing education needs to become “seamless” from one level to another. We need to provide educational opportunities for nurses that are at the beginning of their careers, at perhaps an associate's degree level, or an LPN level, and [make sure] they have access to education that will allow them to promote themselves, going from an associate's degree to a bachelor's to a master's to a Ph.D. in a way that is seamless; that allows them to take a professional and educational [upward] trajectory.

Q. The statistics show that turnover/retention issues seem to be prevalent, especially for those new to the profession. What about nurse residencies? Do you see these as a key component to education, capturing talented people at the beginning of their careers?

A. You hit the nail on the head: one of the main things that has been shown to help nurses feel satisfied with their employment, and a key to retaining nurses, is to provide them with residency programs right when they finish their education and enter the workplace for the first time, and also when they switch their areas of practice. For example, when a nurse in an acute care setting goes to work in the community, they also need access to residency programs that will help them transition in their roles.

That's a really important point under this main heading of providing seamless educational opportunities for nurses. Because [education] is not just about the degree; there are also educational opportunities while individuals are working.

The evidence is clear that these residency programs do provide a lot of benefits to employers, too, in the sense of having a workforce that's more satisfied, and being able to retain their nurse employees.

Q. Does the committee still see a shortage of nurses for the near future?

A. We looked at a lot of numbers, and there have been recent statistics that show there isn't currently a nursing shortage. What happened is, with the recession, a lot of nurses that were not working went back into the workplace, so there is a temporary alleviation of the shortage.

But our data is clear that in the future we are going to experience a nursing shortage and that shortage is likely to get more severe.

Looking at the supply side, the nursing workforce median age is older than the general population and what we see in other professions. And on the demand side, we're seeing an increased demand for health care.

Q. If you were to highlight one of the other recommendations from the report, what would it be?

A. Nurses need to be in leadership positions: they need to make decisions, lead and collaborate with physicians and other health care providers in the design and delivery of health care.

Nurses are very well informed in terms of the needs of the population; they're the ones in closest proximity to the patients and can understand their needs. However, in most situations, [nurses] are still not “at the table” in terms of making the important decisions that have to do with the delivery of health care.

So one of our main recommendations is nurses need to assume a lot more leadership positions, in order to be in a place where they are influencing the design and the delivery of health care, from policy to management to joint principles and practice; they need to assume more responsibility.

That is two-fold in the sense that nurses need to take the initiative and assume leading positions, and these positions need to be offered to them!

Q. What do you think will be biggest impact of implementing the committee’s recommendations?

A. The biggest impact, by far, would be improving the overall health of Americans.

We already have existing evidence that good nursing care results in good health for the nation, better outcomes in the health care delivery system. We have a lot of existing nursing models, nursing interventions, that improve health and are not being used.

They're not being utilized because of barriers that are out there, whether it's legal barriers, scope of practice issues, or financial barriers with insurance companies not reimbursing nurses directly for the work that they do.

These are all barriers that we'll need to overcome and that we specifically address in our recommendations, that would allow nurses to work to their capacity and training, and would translate into better health outcomes for all.

For more information:

Robert Wood Johnson Foundation, Future of Nursing Initiative 

Institute of Medicine Future of Nursing Committee report (free PDF)