The 2010 Affordable Care Act represents the broadest health care overhaul since the 1965 creation of the Medicare and Medicaid programs. Transforming the health care system to provide safe, quality, patient-centered, accessible, and affordable care will require a comprehensive rethinking of the roles of many health care professionals, nurses chief among them. To realize this vision, nursing education must be fundamentally improved both before and after nurses receive their licenses.
In 2008, the Robert Wood Johnson Foundation (RWJF) and the Institute of Medicine (IOM) launched a two-year initiative to respond to the need to assess and transform the nursing profession. The IOM appointed the Committee on the RWJF Initiative on the Future of Nursing, at the IOM, with the purpose of producing a report that would make recommendations for an action-oriented blueprint for the future of nursing.
As part of its report, The Future of Nursing: Leading Change, Advancing Health, the committee considered many challenges that face the nursing education system and some of the solutions that will be required to advance the system. It determined that nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.
The Need for Highly-Educated Nurses
In the 21st century, the health challenges facing the nation have shifted dramatically. The American population is older—Americans 65 and older will be nearly 20 percent of the population by 2030—as well as more diverse with respect not only to race and ethnicity but also other cultural and socioeconomic factors. In addition to shifts in the nation’s demographics, there also have been shifts in that nation’s health care needs. Most health care today relates to chronic conditions, such as diabetes, hypertension, arthritis, cardiovascular disease, and mental health conditions, due in part to the nation’s aging population and compounded by increasing obesity levels. While chronic conditions account for most of the care needed today, the U.S. health care system was primarily built around treating acute illnesses and injuries, the predominant health challenges of the early 20th century.
The ways in which nurses were educated during the 20th century are no longer adequate for dealing with the realities of health care in the 21st century. As patient needs and care environments have become more complex, nurses need to attain requisite competencies to deliver high-quality care. These competencies include leadership, health policy, system improvement, research and evidence-based practice, and teamwork and collaboration, as well as competency in specific content areas such as community and public health and geriatrics. Nurses also are being called upon to fill expanding roles and to master technological tools and information management systems while collaborating and coordinating care across teams of health professionals. To respond to these increasing demands, the IOM committee calls for nurses to achieve higher levels of education and suggests that they be educated in new ways that better prepare them to meet the needs of the population.
An Improved Education System
Much of nursing education revolves around acute care rather than community settings that include aspects of primary care, public health, and long-term care. Nursing education frequently does not incorporate the intricacies of care coordination and transitions. Nor does it promote the skills needed to negotiate with the health care team, navigate the regulatory and access stipulations that determine patients’ eligibility for enrollment in health and social service programs, or understand how these programs and health policies affect patients and health outcomes. Nursing curricula need to be reexamined, updated, and adaptive enough to change with patients’ changing needs and improvements in science and technology, the IOM committee says.
Many nursing schools have dealt with the rapid growth of health research and knowledge by compressing available information into the curriculum and adding layers of content that require more instruction. New approaches and educational models must be developed to respond to burgeoning information in the field. For example, fundamental concepts that can be applied across all settings and in different situations need to be taught, rather than requiring rote memorization. Competencies also must move from task-based proficiencies to higher-level competencies that provide a foundation for care management knowledge and decision-making skills under a variety of clinical situations and care settings. Additionally, emerging new competencies in decision making, quality improvement, systems thinking, and team leadership must become part of every nurse’s professional formation.
Entering the Profession
Nursing is unique among the health care professions in the United States in that it has multiple educational pathways leading to an entry-level license to practice. Nursing students are able to pursue three different educational pathways to become registered nurses (RNs): the bachelor’s of science in nursing (BSN), the associate’s degree in nursing (ADN), and the diploma in nursing. More recently, an accelerated, second-degree bachelor’s program for students who possess a baccalaureate degree in another field also has become a popular option. These various pathways provide numerous opportunities for women and men of modest means and diverse backgrounds to access careers in an economically stable field.
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. Although a BSN education is not a panacea for all that is expected of nurses in the future, it does, relative to other educational pathways, introduce students to a wider range of competencies in such arenas as health policy and health care financing, community and public health, leadership, quality improvement, and systems thinking. Care within the hospital continues to grow more complex, with nurses having to make critical decisions associated with care for sicker, frailer patients and having to use more sophisticated, life-saving technology coupled with information management systems that require skills in analysis and synthesis. Care outside the hospital is becoming more complex as well. Nurses are being called on to coordinate care among a variety of clinicians and community agencies; to help patients manage chronic illnesses, thereby preventing acute care episodes and disease progression; and to use a variety of technological tools to improve the quality and effectiveness of care. A more educated nursing workforce would be better equipped to meet the demands of an evolving health care system, and this need could be met by increasing the percentage of nurses with a BSN. An increase in the proportion of nurses with a BSN also would create a workforce poised to achieve higher levels of education at the master’s and doctoral levels, required for nurses to serve as primary care providers, nurse researchers, and nurse faculty— positions currently in great demand across the profession and within the health care system. The committee recommends that the proportion of nurses with baccalaureate degrees be increased to 80 percent by 2020. While it anticipates that it will take a few years to build the educational capacity needed to achieve this goal, the committee maintains that it is bold, achievable, and necessary to move the nursing workforce to an expanded set of competencies, especially in the domains of community and public health, leadership, systems improvement and change, research, and health policy.
Improving the education system and achieving a more educated workforce—specifically increasing the number of nurses with baccalaureate degrees—can be accomplished through a number of different programs and educational models, including: traditional RN-to-BSN programs; traditional 4-year BSN programs at both universities and some community colleges; educational collaboratives that allow for automatic and seamless transitions from an ADN to a BSN; new providers of nursing education such as proprietary/for-profit schools; simulation and distance learning through online courses; and academic-service partnerships.
In addition to increased numbers of BSN-educated nurses, schools of nursing must build their capacities to prepare more students at the graduate level who can assume roles in advanced practice, leadership, teaching, and research. While 13 percent of nurses hold a graduate degree, fewer than one percent have a doctoral degree. Nurses with doctorates are needed to teach future generations of nurses and to conduct research that becomes the basis for improvements in nursing science and practice. The committee recommends doubling the number of nurses with a doctorate by 2020.