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1. The Future of Nursing Leading Change, Advancing Health Through its deliberations, the committee developed four key messages that structure the recommendations presented in the report. What are the four key messages, and give a brief description of each one.

2. The Future of Nursing Leading Change, Advancing Health, Report Recommendations There are eight recommendations, list them and briefly describe them.

3. The Future of Nursing Focus on Scope of Practice While challenges face nurses at all levels, the committee took particular note of the legal barriers in many states that prohibit advance practice registered nurses (APRNs) from practicing to their full education and training. The com¬mittee determined that such constraints will have to be lifted in order for nurses to assume the responsibilities they can and should be taking during this time of great need. Discuss how the inconsistent state regulations prevent advance practice nurses from practicing to the full extent of their education and training; how the health care system is changing, and the role of the federal government to promote change.

4. The Future of Nursing Focus on Education 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.

A. Discuss the advantages of a BSN nursing education.

B. Discuss lifelong learning.

C. Discuss the idea of “enough nurses with the right skills.”  Nurses should practice to the full extent of their education and training.  Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.  Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States.  Effective workforce planning and policy making require better data collection and information infrastructure.

Answer 1

1. Key 1

Nurses Should Practice to the Full Extent of Their Education and Training:

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 deliver safe, quality care that meets defined (organization or professional society) 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.

Key 2

Nurses Should Achieve Higher Levels of Education and Training Through an Improved Education System That Promotes Seamless Academic Progression :

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. Care within the 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.

Key 3

Nurses Should Be Full Partners, with Physicians and Other Health Professionals, in Redesigning Health Care in the United States

Being a full partner transcends all levels of the nursing profession and requires leadership skills and competencies that must be applied within the profession 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 the policy as something 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 advisory committees, commissions, and boards where policy decisions are made to advance health systems to improve patient care.

Key 4

Effective Workforce Planning and Policy Making Require Better Data Collection and an Improved Information Infrastructure

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 workforce requirements by role, skill mix, region, and demographics will be needed to inform necessary changes in nursing practice and education.

2. 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.

Recommendation 2: Expand opportunities for nurses to lead and diffuse collaborative improvement efforts. Private and public funders, health care organizations, 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.

Recommendation 3: Implement nurse residency programs. State boards of nursing, accrediting bodies, the federal government, and health care organizations 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.

Recommendation 4: Increase the proportion of nurses with a baccalaureate degree to 80 per cent by 2020. Academic nurse leaders across all schools of nursing should work together to increase the proportion of nurses with a baccalaureate degree from 50 to 80 per cent 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 create a workforce prepared to meet the demands of diverse populations across the lifespan.

Recommendation 5: Double the number of nurses with a doctorate by 2020. Schools of nursing, with support from private and public funders, academic administrators 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.

Recommendation 6: Ensure that nurses engage in lifelong learning. Accrediting bodies, schools of nursing, health care organizations, and continuing competency 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.

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 ensure that leadership positions are available to and filled by nurses.

Recommendation 8: Build an infrastructure for the collection and analysis of interprofessional health care workforce data. The National Health Care Workforce 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.

3. State regulations often restrict the ability of nurses to provide care legally. State legislation regarding the legal scopes of practice for nurses—which defines the activities that a qualified nurse may perform—vary widely. Some state legislation is very detailed, while in other states, there are 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 practitioners (NP) and certified nurse midwives, for example, to see patients and prescribe medications without a physician’s supervision or collaboration. Most states, however, have not made these changes. As a result, what NPs and, more broadly, APRNs are able to do after graduation varies widely across the country for reasons that are not related to their ability, education, or training, but rather to the political decisions of the state in which they work.

The federal government has a compelling interest in the regulatory environment for health care professions because of its responsibility to patients covered by federal programs including Medicare, Medicaid, the Veterans Administration, and the Bureau of Indian Affairs. Equally important is the responsibility to all American taxpayers who fund the care provided under these programs to ensure that their tax dollars are spent efficiently.

Congress, the Federal Trade Commission, the Office of Personnel Management, and the Centers for Medicare and Medicaid Services each have specific authority over or responsibility for decisions that either could or must be made at the federal level to be consistent with state efforts to remove scope-of-practice barriers. While no single actor or agency can independently make a sweeping change to eliminate current barriers, the various state and federal entities can each make relevant decisions that together can lead to needed improvements.

Because one of the greatest barriers to nurses’ capacity to transform the health care system is the patchwork of state regulations, the committee finds that the federal government is particularly well situated to enact effective reform of the practice of APRNs by disseminating best practices from across the country and creating incentives for their adoption.

4. A)  basis for graduate education
- required for certification in different fields
- better patients outcomes

B) Life long learning refers to all purposeful learning activities, both formal and informal, that take place throughout our lives. Lifelong learners are motivated to learn and develop because they want to: it is a deliberate and voluntary act. Lifelong learning can enhance our understanding of the world around us, provide us with more and better opportunities and improve our quality of life. Profound changes in the education of nurses, both before and after they receive their licenses, are required to develop a more highly-educated workforce. Nursing education should serve as a platform for continued lifelong learning and should include opportunities for a seamless transition to higher degree programs. The committee recommends that nurses and nursing students and faculty continue their education and engage in lifelong learning.

C)

Significant barriers must be overcome if the shortage of nurses is going to be offset and more advanced and expanded nursing roles are going to be filled. Having enough nurses with the right kinds of skills will contribute to the overall safety and quality of a transformed health care system. One such barrier is high turnover rates, which continue to destabilize the nurse workforce in the United States. The costs associated with these turnover rates are significant, particularly in hospitals and nursing homes. The high rates among newly graduated nurses, in particular, highlight the need for a greater focus on managing the transition from school to practice.

Nurse residency programs, recommended by the Joint Commission in 2002, can provide important hands-on experience for newly graduated nurses or those transitioning into a new area of practice. These planned, comprehensive periods of time during which nursing graduates can acquire the knowledge and skills to deliver safe, quality care that meets defined standards of practice, can help new nurses develop skills in such important areas as organizing work; establishing priorities; and communicating with physicians and other professionals, patients, and families. In addition, transition-to-practice residency programs can help develop leadership and technical skills in order to provide quality care. Residency programs are supported predominantly in hospitals and larger health systems, with a focus on acute care; they also need to be developed and evaluated outside of acute care settings to accommodate the coming shift of care from hospital to community-based settings and the need for nursing expertise in chronic illness management, care of older adults in home settings, and transitional services.

While the evidence is limited because residency programs are not widespread, they have been shown to help reduce turnover rates for new graduate RNs, reduce costs, increase stability in staffing levels, and help first-year nurses develop critical competencies in clinical decision making and autonomy in providing patient care. The committee recommends that actions be taken to support nurses’ completion of transition-to-practice nurse residency programs after they have completed a prelicensure or advanced degree program or when they are transitioning into new clinical practice areas.