CONTEXT

The Future of Nursing was produced at a propitious moment in health care in the United States, a time of growing awareness that dramatic changes in the care delivery system were needed to accomplish the “Triple Aim” of better patient experience, better health of the public, and lower costs. The increasing burden of chronic disease, changing demographics, and demands for greater access to care lent added urgency to the calls for change. The Future of Nursing in many ways anticipated these trends in its recommendations. Now, 5 years later, one can appreciate how prescient and appropriately timed these recommendations were. But many changes have occurred since that report was released, and these changes have created both new opportunities and new challenges in achieving the goals laid out in the report.

As described in The Future of Nursing, it was anticipated that with the passage of the Patient Protection and Affordable Care Act (ACA), nurses would play a larger role in delivering health care, facilitating efforts that would increasingly emphasize health promotion and disease prevention, and helping to bridge the gap between coverage and access (IOM, 2011). As the report notes, “by virtue of their regular, close proximity to patients, and their scientific understanding of care processes across the continuum of care, nurses have a considerable opportunity to act as full partners with other health professionals and to lead in the improvement and redesign of the health care system and its practice environment” (IOM, 2011, p. 23). It is precisely because nurses practice in various health care settings and across the continuum of care and enter the profession through different pathways and achieve varying levels of education that they are poised to affect health and health care delivery at every level.

As a result of the ACA, more than 16 million previously uninsured people have gained health insurance coverage (HHS, 2015). To fulfill the promise of access to care for these newly insured people, as well as more affordable, better-coordinated care for all, incentives have been created for new delivery and payment models. The new delivery models emphasize teamwork, care coordination for specialty care and chronic disease management, prevention, and a greater focus on population health and community-based care. The new payment models are moving from fee-for-service and episodic payment to more comprehensive payment based on value.

At the same time, there has been growing awareness of the need for more attention to a health professions workforce that must be appropriately prepared to work in this changing health care system. This awareness has led to greater emphasis on interprofessional education, teamwork training, and a better understanding of the roles of all health professionals in creating an optimal health care delivery system. Rapid advances in information technology, including mobile and digital health tools, also are changing the way health professionals and the public receive information and communicate with one another. Properly harnessed, these advances can enable greater engagement of patients in their own care, as well as support better teamwork and care coordination.

Thus, the context of health care in the United States in 2015 is dramatically different from what it was when The Future of Nursing was released in 2010. While the report anticipated many of these changes, it could not have foreseen exactly how they would play out. The terms of the ACA dictated many of these changes, but they also set a tone and direction for the health care system regarding how care should be delivered.

All of these changes are consistent with the key messages in The Future of Nursing, which call for enhanced education and greater roles for nurses in the health care system (IOM, 2011). While The Future of Nursing focuses on advanced practice registered nurses (APRNs) and registered nurses (RNs) with higher educational attainment, implications for nurses' roles are significant. The shift from individual providers to interprofessional teams, for example, has implications for the role of nurses in teams and the education and competencies needed to provide care and function within those teams. Similarly, the shift to delivering care in the community, including retail clinics and patient homes, has important implications for how and where nurses receive clinical training. The changing landscape may enable additional strategies for achieving these goals, including value-based care, interprofessional collaboration and education, patient engagement, and new technologies.

The Future of Nursing coincided with dramatic changes in the health care landscape, and many other organizations released reports shortly before or after that report calling for similar changes in nursing and health care. Examples include

• the World Health Organization's (2009) Global Standards for the Initial Education of Professional Nurses and Midwives, developed from 2005 to 2007 and published in 2009, which calls for raising the initial education requirements for professional nurses;
• the Carnegie Foundation report Educating Nurses: A Call for Radical Transformation, published in December 2009 (Benner et al., 2009);
• the consensus statement of the Tri-Council for Nursing (comprising the American Association of Colleges of Nursing [AACN], American Nurses Association [ANA], American Organization of Nurse Executives, and National League for Nursing) titled Educational Advancement of Registered Nurses, published in May 2010, which calls for all RNs to pursue further education in order to improve the quality and safety of care across all settings (AACN, 2010);
• Josiah Macy Jr. Foundation efforts around care delivery and interprofessional education (AACN and AAMC, 2010; Josiah Macy Jr. Foundation, 2010, 2012, 2013); and
• various position statements and issue briefs from professional and trade organizations related to advancing the educational preparation of nurses, interprofessional education, interprofessional collaboration and team-based care, and health workforce diversity (AACN, 2015; AONE, 2015b; NLN, 2015).

Building on the changing health care landscape and the release of The Future of Nursing and these other reports, many organizations have been working diligently to make changes in nursing and health care. Nursing organizations have long been active in addressing the issues identified by the report, which lent momentum to a movement that was already under way and gave stakeholders tangible and specific recommendations toward which to work. After the report was released, these organizations continued or advanced their efforts to implement the recommended changes. Their efforts ranged from simple statements of support for the IOM report's recommendations to the establishment of new and far-reaching initiatives, such as the Campaign.

For example, the ANA released a statement citing areas in which that organization and its members were actively pursuing change, such as the efforts of state nursing associations to make state-level changes to scope-of-practice laws (ANA, 2011). The AACN held a strategic planning session to identify areas in which its activities could align with the IOM report's recommendations and it developed a new tactical plan for moving forward (AACN, n.d.). The National Council of State Boards of Nursing (NCSBN) undertook several new efforts, including the Campaign for Consensus, designed to assist states in adopting the Consensus Model regulations regarding scope of practice for APRNs, and a pilot study on lifelong learning and continued competency (Alexander, 2011). And the Jonas Center for Nursing and Veterans Healthcare, which had been supporting doctoral education for nurses through its Jonas Scholars program since 2008, began requiring students to complete a leadership project that incorporates the IOM report's recommendations (Curley, 2015; see also Jonas Center for Nursing and Veterans Healthcare, 2015). In addition to such individual efforts, many organizations signed on to the Campaign's Champion Nursing Council, which gives the Campaign strategic guidance on fulfilling its goal of implementing the IOM report's recommendations to improve health care and to prepare nurses to be essential partners in addressing the nation's health care system challenges (CCNA, n.d.-c). The Future of Nursing and the Campaign helped accelerate these and other efforts to ensure that nurses are able to provide and lead efforts in health care delivery and system redesign.

STUDY SCOPE

In 2014, RWJF asked the IOM to convene a committee to assess progress made toward implementing the recommendations of The Future of Nursing, assess the progress of the Campaign toward meeting its goals, and issue a brief report including recommendations for the Campaign (see Box 1-1 for the committee's statement of task). To conduct this study the IOM assembled a committee of 12 experts from the fields of nursing, communications, public health, research and evaluation, and medicine. The committee held four meetings over the course of 5 months that included three public workshops, during which stakeholders provided testimony on the nursing field's progress in the areas of practice, education, leadership, diversity, interprofessional collaboration, and data needs. The committee also considered data collected and provided by RWJF, as well as from other sources (see Appendix A for further information about the study methods).

BOX 1-1

Statement of Task.

The committee's task was not to reexamine the merits of or amend the recommendations of The Future of Nursing. The committee did not perform a comprehensive or formal evaluation of the impact of the report's recommendations or of the Campaign's impact on health outcomes or access to care—two of the broader goals of the report's recommendations—as 5 years is an insufficient amount of time over which to evaluate these outcomes. In addition, the committee did not perform a comprehensive assessment of the state of the nursing profession. Instead, the committee focused on how the field of nursing has been impacted by the Campaign and other such efforts. The committee reviewed how the current context of health care delivery and nursing education and practice may affect how the IOM report's recommendations are being implemented, and it identified barriers to and unintended consequences of their implementation. In the present report, the committee notes when it conducted original analyses. When data were provided by the Campaign, the committee attempted to cross-reference those data with outside sources.

Further, while the committee did assess progress in implementing the recommendations of The Future of Nursing, it was not able to attribute progress or the lack thereof directly to the report or the Campaign, given efforts by other organizations and trends in the field. Progress in the areas of education, practice, collaboration, leadership, diversity, and workforce data may be attributable to those other efforts (described below) and contemporary factors. Regardless, the committee considered how the recommendations of The Future of Nursing have been advanced and how they might continue to be advanced.

The next section of this chapter provides an overview of The Future of Nursing and its findings and recommendations. This is followed by a description of the Campaign's efforts to implement the recommendations over the past 5 years, as well as salient RWJF activities outside of the Campaign. Finally, this chapter lays out the content of remaining chapters of the report.

OVERVIEW OF THE FUTURE OF NURSING: LEADING CHANGE, ADVANCING HEALTH

The Future of Nursing¹ was the product of a 2-year Initiative on the Future of Nursing, established by RWJF and the IOM (IOM, 2011). The 18-person committee convened by the Initiative was led by Donna Shalala, former U.S. Secretary of Health and Human Services, and included experts in such arenas as nursing, business, education, research, and public health. The committee was asked to “examine the capacity of the nursing workforce to meet the demands of a reformed health care and public health system” and to develop a set of recommendations for changes at the national, state, and local levels (IOM, 2011, p. xiii). Specifically, the committee was asked to identify vital roles for nurses in the design and implementation of a more effective and efficient health care system and to make recommendations on how to

• reconceptualize the role of nurses within the context of the entire health care system;
• expand the capacity of nursing education to produce an adequate number of well-prepared nurses to meet current and future demand;
• develop innovative solutions related to professional education and health care delivery by focusing on the delivery of nursing services; and
• attract and retain well-prepared nurses in multiple care settings.

The Future of Nursing identifies a variety of barriers that have limited the nursing profession's ability to contribute fully to the health care system. These barriers include an aging workforce, regulatory restrictions on nursing practice, fragmentation of health care, limited capacity of the nursing education system, and a lack of workforce data. The report is centered on four key messages.

Key Message #1: Nurses should practice to the full extent of their education and training. The study committee found that historical, regulatory, and policy barriers have prevented nurses from being able to perform the full range of activities for which their education and training have prepared them. For example, regulations on nurse practitioners (NPs) vary by state, and many states limit or deny an NP's ability to prescribe medications, assess patient conditions, order and evaluate tests, or admit a patient to the hospital. The committee formulated recommendations for Congress, state legislatures, and various federal agencies on actions that could help remove these scope-of-practice barriers. In addition, the committee found that newly graduated nurses could benefit from additional assistance in the transition to practice, and it recommended the development of residency programs to help nursing graduates further hone their skills.

Key Message #2: Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. The committee observed that major changes in the health care system will require equally major changes in the education of nurses to prepare them to work with sophisticated technology, analyze and synthesize complex information to make critical decisions, and collaborate with a variety of other health professionals. To meet these advanced needs, the committee recommended that more nurses obtain higher degrees so that by 2020, 80 percent of nurses would have a baccalaureate degree and the number of nurses with a doctorate would double. The committee also recommended that nurses engage in lifelong learning throughout their careers, and that efforts be made to increase the diversity of the nursing workforce.

Key Message #3: Nurses should be full partners, with physicians and other health professionals, in redesigning health care in the United States. The committee found that for nurses to participate fully in the transformation of the health care system, they need to act in positions of leadership and work collaboratively with leaders from other health professions. The committee noted that these nurse leaders need to be full partners at all levels of the system—from bedside to boardroom—and to contribute actively to policy making by serving on committees, commissions, and boards. To develop this leadership capacity, the committee recommended that health care organizations, funders, and education programs provide, expand, and fund opportunities for nurses to develop leadership skills and assume leadership positions, and that health care decision makers ensure that nurses are represented in key leadership positions on boards and management teams.

Key Message #4: Effective workforce planning and policy making require better data collection and an improved information infrastructure. The committee determined that to plan and prepare for fundamental changes in the health care system, it is necessary to have reliable and granular data on the health care workforce. The needed data include the numbers and types of health professionals working in the field, where and in what roles they work, and what types of activities they perform. These data are necessary to plan for workforce needs and to establish a baseline upon which to improve. The committee recommended that the National Health Care Workforce Commission (mandated by the ACA) work with the Health Resources and Services Administration to improve research and the collection and analysis of data in this area.

From the foundation of these key messages, the committee developed eight recommendations for addressing the barriers that have prevented the nursing profession from realizing its full potential in leading the transformation of the health care system (see Box 1-2). The Future of Nursing acknowledges the growing diversity of the U.S. population and the concomitant need for an increasingly diverse nursing workforce, incorporating this critical and crosscutting issue into its recommendations relating to nurses' educational attainment (recommendations 4, 5, and 6). The study committee directed its recommendations not only at the nursing profession but also at other entities that play a role in improving the system, including government, businesses, health care organizations, professional associations, and the insurance industry.

BOX 1-2

Recommendations from The Future of Nursing: Leading Change, Advancing Health.

THE FUTURE OF NURSING: CAMPAIGN FOR ACTION

Activities

The Campaign operates at both the national and state levels. The national Campaign convenes leadership and advisory groups—including a Strategic Advisory Committee, Diversity Steering Committee, Champion Nursing Coalition, and Champion Nursing Council—to advance the goals of the IOM report and the Campaign (CCNA, n.d.-e). In addition, the Campaign convenes meetings around the major topics of the IOM report (including leadership, education, and scope of practice) and provides technical assistance to the state Action Coalitions, which, as noted, work to advance the recommendations of The Future of Nursing at the state and local levels (CCNA, 2015c).

The state Action Coalitions are considered “the driving force of the Campaign” because they are able to work as a network to effect change at the local level (CCNA, n.d.-f). The first state Action Coalitions—in California, Michigan, Mississippi, New Jersey, and New York—were formed in November 2010; within 1 year after the launch of the Campaign, 36 Action Coalitions were operating around the country; and by January 2013, all 51 Action Coalitions were active (CCNA, n.d.-g). The Campaign provides funding to some state Action Coalitions, mainly through the State Implementation Program (SIP), but it also encourages (and in the case of SIP grantees, requires) that the Action Coalitions find external funding (CCNA, 2011, 2012, 2014, 2015a). As of January 2015, only 9 Action Coalitions had not received external funding. The remainder were receiving various amounts of funding (from a few thousand dollars to more than $1 million) from various sources, including foundations, government, colleges and universities, health and hospital systems, nursing organizations, and businesses (CCNA, 2015a). Figure 1-1 shows the allocation of total state Action Coalition funds to efforts relating to the recommendations of The Future of Nursing, the Campaign pillars, and Campaign imperatives.

FIGURE 1-1

State Action Coalition funds by the Campaign pillar and/or imperative. SOURCE: CCNA, 2015c.

Thirty-one state Action Coalitions currently receive funding from Campaign SIP grants (CCNA, 2015c). These Action Coalitions receive up to $150,000 from RWJF, but they also are required to secure $75,000 in matching funds from other sources (CCNA, 2011, 2012, 2014). All state Action Coalitions work to advance the recommendations of the IOM report, but SIP grantees are required to identify one or two recommendations from the report that they will work toward implementing at the state level using this funding.

A 2013 survey of all state Action Coalitions by the Campaign's external evaluator, TCC Group (see Evaluation section), asked respondents to indicate whether specific topics relating to the IOM report's recommendations were (1) a main focus for their efforts, (2) not a main focus but an issue on which they were working, or (3) not an issue on which they were working (TCC Group, 2013a). Figure 1-2 shows the attention paid to these priority areas of the IOM report and the Campaign. Figure 1-3 shows the top priority area for each state, based on aggregated scores for respondents from each state.

FIGURE 1-2

State Action Coalition members' focus on priority areas of The Future of Nursing and the Campaign. NOTES: Data are based on responses of 1,100 survey respondents from 49 state Action Coalitions, including that of the District of Columbia. Scores were (more...)

FIGURE 1-3

Priority focus area for each state Action Coalition. NOTES: Survey respondents categorized the amount of focus given to each priority area. State scores were aggregated, and the highest score was identified as the top priority. The number of responses (more...)

Measuring Progress

To track its progress toward implementation of the IOM report's recommendations, the Campaign developed dashboard indicators—specific, measurable data points that approximate success for that recommendation (CCNA, 2015d) (see Table 1-1). The Campaign also utilizes supplemental indicators for some recommendations. In addition to the indicators and supplemental indicators for six of the eight recommendations from The Future of Nursing, the Campaign identified a supplemental indicator for progress on increasing the diversity of the nursing workforce: racial/ethnic composition of the RN workforce in the United States (CCNA, 2015d).

TABLE 1-1

Recommendations from The Future of Nursing and Campaign Indicators.

The Campaign recognized data limitations that hampered measuring progress toward implementation of the IOM report's recommendations (CCNA, n.d.d; Spetz et al., 2014). For example, the IOM report calls for a doubling of the number of nurses with doctorates. Given that doctoral programs take 3 or more years to complete, however, the number of doctorally prepared nurses in the workforce would not show much progress due to efforts attributable to the report or the Campaign just 5 years after the report's release. Thus, the Campaign is looking at interim indicators to identify progress toward the report's goals, such as nurses' enrollment in doctoral programs. Further, the Campaign notes that “for national indicators, it is important to use a source of data that provides consistent information across states” (CCNA, n.d.-d, p. 3).

RWJF ACTIVITIES OUTSIDE OF THE CAMPAIGN

RWJF has a portfolio of work related to advancing the nursing profession that is separate from the work of the Campaign but still advances the messages and goals of The Future of Nursing and the Campaign. In many cases, these programs interface and collaborate with the Campaign at the national and state levels. These programs include the following:

• The APIN program was established in 2012 as an initiative of RWJF and the Tri-Council for Nursing, with program offices located in the American Organization of Nurse Executives. The program collaborates with and funds are distributed to state Action Coalitions and their stakeholders to establish models of seamless academic progression for nurses to further the IOM report's recommendation that 80 percent of nurses have a baccalaureate degree by 2020 (AONE, 2015a; RWJF, 2012) (see a more detailed description of this program in Chapter 3).
• The Future of Nursing Scholars program, established in 2013, supports nurses in obtaining their PhD and furthers the IOM report's recommendation that the number of nurses with a doctorate be doubled by 2020 (RWJF, 2015a) (see a more detailed description of this program in Chapter 3).
• Executive Nurse Fellows, established in 1997, is a 3-year program that provides leadership development and support to nurses in executive leadership positions, and includes leadership curriculum, coaching and mentoring, and team-based learning projects (RWJF, 2014b, 2015b).
• Nurse Faculty Scholars, established in 2008, provides career development awards to nurse faculty. The program requires that awardees have a doctorate in nursing or another related discipline, and that they be junior faculty in a tenure-track position. The 3-year award provides support for the scholar's research expenses and part of the scholar's salary. Scholars also receive leadership training and mentoring through the program. With the closing of the program scheduled for 2017, the 2014 call for proposals was this program's last (RWJF, 2014a, n.d.-e,g).
• The Nursing and Health Policy Collaborative at the University of New Mexico offers opportunities for PhD-prepared nurse fellows to engage in health policy through academic study in health policy; mentorship opportunities; and collaborative efforts with researchers, other health professionals, policy makers, and the community (RWJF, n.d.-f).
• The Interdisciplinary Nursing Quality Research Initiative (INQRI) was established in 2005 to fund research conducted by interdisciplinary teams that addresses gaps in knowledge relating to nursing and health care delivery and care quality, efficiency, and cost-effectiveness (RWJF, n.d.-a). Responding to the publication of the IOM report in 2010, RWJF created the Future of Nursing National Research Agenda, a research program coordinated by INQRI that supports studies specifically related to the report's recommendations (RWJF, n.d.-b,c).
• The New Careers in Nursing (NCIN) scholarship program (RWJF/ AARP) was established in 2008 to provide support for students returning to school to obtain baccalaureate and master's degrees in nursing (RWJF, 2013).
• Partners Investing in Nursing's Future (PIN) was established in 2006 as a partnership between RWJF and the Northwest Health Foundation to support local and regional foundations in advancing leadership in nursing. This program ended in June 30, 2015 (RWJF, n.d.-d).

In addition to the PIN program, four other nursing-related programs will be ending in the coming years as the result of RWJF's new focus on a “Culture of Health” and a review of its portfolio of human capital investments. These four programs are NCIN (closing in 2017), Executive Nurse Fellows (2017), Nurse Faculty Scholars (2017), and the Nursing and Health Policy Collaborative at the University of New Mexico (2018) (RWJF, 2014a, n.d.-h).

ORGANIZATION OF THE REPORT

Chapters 2 through 6 review the progress made in implementing the recommendations of The Future of Nursing in the areas of delivery of care, education, diversity, leadership and interprofessional collaboration, and data, respectively. These chapters include the committee's findings and conclusions in each of these areas, as well as its recommendations for how the Campaign and others should move forward in the next 5 years, considering the successes and challenges that have occurred over the past 5 years and the new context within which the recommendations of The Future of Nursing are being implemented.

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