Institute of Medicine Recommends More Training, Independence for Nurses

Laurie Barclay, MD

October 06, 2010

October 6, 2010 — Healthcare reform and greater patient needs require transformation of the nursing profession to include more training and independence, according to an Institute of Medicine (IOM) report released October 5. The Robert Wood Johnson Foundation Initiative on the Future of Nursing convened a committee to review scientific literature on the nursing profession, to hold a series of public forums to collect additional evidence and opinions from a variety of experts, and to generate this report.

"The report's recommendations provide a strong foundation for the development of a nursing work force whose members are well educated and prepared to practice to the fullest extent of their training, meet the current and future needs of patients, and act as full partners in leading advances in the nation's healthcare system," IOM Report Committee Chair Donna E. Shalala, president of the University of Miami in Florida, said in a news release.

Implementing healthcare reform and advances in care delivery within the increasingly complex US healthcare system requires that nurses collaborate with other healthcare professionals and take on leadership positions in redesigning US healthcare, according to the IOM Report Committee.

Specific recommendations in the report include residency training for nurses, increasing the percentage of nurses who have a bachelor's degree to 80% by 2020, and doubling the number of nurses who seek doctoral degrees. To help achieve this goal, public and private organizations should offer resources to help nurses who have associate degrees and diplomas to pursue a bachelor of science in nursing within 5 years of graduation. These organizations should also help nursing schools ensure that 10% of their baccalaureate graduates enter a master's or doctoral program within 5 years.

The report also suggests that for the healthcare system to achieve optimal benefit from nurses' specific training, skills, and knowledge regarding patient care, limits on nurses' scope of practice imposed by regulatory and institutional barriers should be removed. These barriers are particularly problematic for advanced practice registered nurses (APRNs), even though their skills could help meet the increased demand for primary care. Studies of outcomes from healthcare organizations that have increased the roles and responsibilities of APRNs, including the Veterans Health Administration, Geisinger Health System, and Kaiser Permanente, have shown that APRNs deliver safe, high-quality primary care.

"Transforming the nursing profession is a crucial element to achieving the nation's vision of an effective, affordable healthcare system that is accessible and responsive to all," said Committee Vice Chair Linda Burnes Bolten, who is vice president for nursing, chief nursing officer, and director of nursing research at Cedars-Sinai Medical Center in Los Angeles, California.

Key Messages and Recommendations

Specific areas addressed by the committee in their quest to develop innovative ways to solve the US nursing shortage include the following:

  • Reconceptualizing the optimal role of nurses within the setting of the entire workforce, healthcare and nursing shortages, societal issues, and current and future technology;

  • Expanding nursing faculty and nursing school capacity, and redesigning nursing education so that it can give rise to a sufficient number of well-prepared nurses who can meet current and future healthcare demands;

  • Assessing novel strategies related to care delivery and healthcare professional education by focusing on nursing and on delivery of nursing services; and

  • Attracting and retaining well-prepared nurses in a range of healthcare settings, including acute, ambulatory, primary care, long-term care, community, and public health.

"Nurses are already committed to delivering high-quality care under current regulatory, business, and organizational conditions," the report states. "But the power to change those conditions to deliver better care does not rest primarily with nurses, regardless of how ably led or educated they are; it also lies with governments, businesses, healthcare institutions, professional organizations and other health professionals, and the insurance industry."

After a review and discussion of the available evidence, the committee formulated 4 key messages underlying its more detailed recommendations:

  1. Nurses should practice to the full extent of their education and training.

  2. Through an improved education system facilitating seamless academic progression, nurses should achieve higher levels of education and training.

  3. Nurses should be full partners with physicians and other health professionals in redesigning US healthcare.

  4. Improvements in data collection and information infrastructure are needed for effective workforce planning and policymaking.

"The recommendations presented in this report are directed to individual policymakers; national, state, and local government leaders; payers; healthcare researchers; executives; and professionals — including nurses and others — as well as to larger groups, such as licensing bodies, educational institutions, and philanthropic and advocacy organizations, especially those advocating for consumers," the report concludes. "Together, these groups have the power to transform the health care system to provide seamless, affordable, quality care that is accessible to all, patient centered, and evidence based and leads to improved health outcomes."

To discuss strategies to implement the recommendations in the IOM report, the Initiative on the Future of Nursing will organize a national conference from November 30 through December 1, 2010.

AMA Response to IOM Report Calls for Physician-Led Teams

In response to the IOM report, the American Medical Association (AMA) issued a statement calling for a physician-led team approach to healthcare.

"With a shortage of both physicians and nurses and millions more insured Americans, healthcare professionals will need to continue working together to meet the surge in demand for healthcare," said AMA board member Rebecca J. Patchin, MD. "A physician-led team approach to care — with each member of the team playing the role they are educated and trained to play — helps ensure patients get high-quality care and value for their healthcare spending."

The statement compares training of physicians (at least 7 years of postgraduate education and >10,000 hours of clinical experience) with that of most nurse practitioners (2-3 years of postgraduate education and less clinical experience than a physician typically obtains in the first year of a 3-year medical residency).

"These additional years of physician education and training are vital to optimal patient care, especially in the event of a complication or medical emergency, and patients agree," Dr. Patchin said. "...The AMA is committed to expanding the healthcare workforce so patients have access to the care they need when they need it. With a shortage of both nurses and physicians, increasing the responsibility of nurses is not the answer to the physician shortage."

The statement cites a recent survey showing that 80% of patients presenting to the emergency department expect to see a physician and that more than half of respondents were willing to wait 2 more hours to receive care from a physician.

"Research shows that in states where nurses can practice independently, physicians and nurses continue to work in the same urban areas, so increasing the independent practice of nurses has not helped solve shortage issues in rural areas," Dr. Patchin concluded. "Efforts to get healthcare professionals in areas where shortages loom must continue in order to increase access to care for all patients."

The Robert Wood Johnson Foundation sponsored the IOM report and the Initiative on the Future of Nursing.

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