Back to the Future of Nursing: What Progress Have We Made?

Laura A. Stokowski, RN, MS


March 11, 2016

Have You Seen Changes in Nursing Practice?

Editor's Note:
It's been 5 years since the "Future of Nursing" (FON) report was published.[1] What progress has been made toward meeting the goals outlined in that report? We offer our analysis in this article, but we would like to hear from you, our readers, as well.

What changes have you seen in some of the key FON areas of focus, including practicing to the full extent of education and licensure, higher levels of education for nurses, more nurse residency programs, a more diverse nursing workforce, or changes in the opportunities for nurses to take on leadership roles or participate more collaboratively in education or practice? We see some changes, but also note areas where much more progress needs to be made.

Please use the comments section to tell us about changes in nursing you have seen (or not seen) in your practice setting in the past 5 years.

The State of the Nursing Profession

Five years ago, the nursing profession was galvanized by a comprehensive, yet frank, report on the nursing profession and where it was headed. The Institute of Medicine (IOM) put the profession of nursing under the microscope in The Future of Nursing: Leading Change, Advancing Health,[1] capturing the attention of the healthcare community, government, consumers, and many other stakeholders. The FON report was, in many ways, a wake-up call that exposed the many barriers that prevented the nursing profession from contributing fully to the healthcare system: an aging workforce, regulatory restrictions on nursing practice, fragmentation of healthcare, limited capacity of the nursing education system, and lack of workforce data.[2] It was also a catalyst for finding solutions to these problems.

Coincidentally, the report was released in the same year that the Affordable Care Act made sweeping changes to healthcare, which had enormous implications for nursing practice, education, and research. In 2010, change was in the air—plans were formulated, money was allocated, and new laws entered the books. It was anticipated that new programs and an emphasis on health and prevention would open up new opportunities for nurses. A vast collection of experts collaborated on creating a vision for the future of the profession in this new healthcare landscape.

Many changes followed the original FON report, and progress was watched with great interest on many fronts. By 2015, we wanted to know whether we had made any headway on the future that had been envisioned 5 years earlier. Or were we still sitting in the starting gate?

This question was answered in a second report, released in December 2015: Assessing Progress on the Institute of Medicine Report The Future of Nursing.[2] A committee of experts led by Stuart Altman, PhD, Sol C. Chaiken Professor of National Health Policy and Heller Graduate School of Social Policy at Brandeis University, examined progress on the implementation of the original IOM recommendations—how far they had advanced, and how they might continue to be advanced, focusing on how the field of nursing has changed in the past 5 years.

"Much progress has been made in terms of furthering the recommendations of the original FON report," said Dr Altman. "Although it wasn't always clear what forces were in place already, and whether progress was a result of those forces or of new initiatives—in general, the FON report and activities that followed had a substantial impact on furthering the original report's recommendations."

The committee assessed progress on key FON recommendations, addressing the following:

  • Have scope-of-practice barricades been pushed aside? Are nurses being permitted to practice to the full extent of their education and licensure?

  • Are more nurses earning baccalaureate, master's, and doctoral degrees?

  • Are new graduate nurses being transitioned to the profession more safely and effectively through nurse residency programs?

  • Does the ethnic composition of the nursing workforce more closely match the level of diversity in the general population?

  • Have opportunities expanded for leadership and interprofessional collaboration in healthcare?

Scope of Practice

Achieving full practice authority for nurse practitioners (NPs) throughout the United States has been an uphill climb. From 2010 to 2015, the number of states granting full practice and prescriptive authority to NPs increased only from 13 to 21. State laws continue to represent a patchwork of different requirements and regulations related to NP practice. Opposition from physician groups continues to pose significant barriers to advanced practice nursing, despite growing evidence that collaboration and models that allow all healthcare professionals to practice to the full extent of their education and training improve healthcare quality and efficiency. On balance, however, incremental progress is being made.

Higher Levels of Nursing Education

Entry-level education. An ambitious goal was set to increase the proportion of baccalaureate-educated nurses to 80% by 2020. Progress has been marginal so far. According to a graphic on the website of the FON Campaign for Action, the proportion of baccalaureate-educated nurses, which was 49% in 2010, had increased only to 51% by 2014. In absolute numbers, however, baccalaureate program enrollment has increased substantially, from 147,935 in 2010 to 172,794 in 2014, and enrollment in RN-to-BSN completion programs almost doubled during that time.

Higher enrollments in baccalaureate programs are the first step in increasing the proportion of more highly educated nurses at the bedside. Employers are also showing a preference for hiring baccalaureate-prepared nurses, a trend that is supported by the evidence showing correlations between education and practice safety and quality.

Nurse residency programs. Residency programs for new graduate nurses are not a totally new concept, but their role in nurse retention received prominence from the FON report. An emphasis on transition to practice support for new graduate nurses is expected to have many benefits, from reducing turnover and associated costs, to increasing job satisfaction and improving safety and quality of care. Residency programs are increasing in number; surveys have shown that the proportion of hospitals with residency programs increased from 37% in 2011 to 45% in 2013.[3] However, the word "residency" is often used inconsistently; many questions remain about the ideal curriculum, content, or duration of residency programs; and cost remains a major barrier to residency program implementation. Furthermore, to date, few programs have been implemented outside of acute care hospital settings.

Doctoral education in nursing. Nurses with doctoral degrees are needed to lead the profession, conduct research, and educate the next generations of nurses. Since 2010, enrollment in DNP programs has increased by 161%, and in PhD programs by 15%. Despite this progress, a major barrier has been a lack of nursing faculty prepared to teach at the doctoral level.

Lifelong learning. An important goal of the original report was for nurses to engage in lifelong learning. Progress has been difficult to gauge, owing to a lack of centralized data on continuing education in nursing, or whether certification and credentialing actually improve patient outcomes. Lifelong learning should increasingly target opportunities for interprofessional education.

Diversity of the Nursing Workforce

The original FON report emphasized that efforts should be made to increase the diversity of the nursing workforce to enable nurses to provide more culturally relevant care and meet the healthcare needs of the entire, increasingly diverse population. This goal did not include specific targets for numbers or proportions of nurses from underrepresented minority groups.

In 2012, minority groups accounted for 37% of the US population, and the US Census Bureau predicts that this percentage will increase, so that by 2043, "minority populations" will become the majority in the United States. For comparison, in 2013, nurses from minority backgrounds represented only about 19% of the registered nurse workforce, which was 83% white/Caucasian, 6% black, 6% Asian, 3% Hispanic, 1% American Indian/Alaskan Native, 1% Native Hawaiian/Pacific Islander, and 1% other nurses.[4] Another underrepresented group is men, who comprise less than 10% of the nursing workforce.

Five years is probably too short a time to see significant changes in diversity of the nursing profession, but one positive signal of change is the increasing diversity of student nurse enrollments. In 2013, nursing students from minority backgrounds represented 28.3% of students in entry-level baccalaureate programs.[3] To achieve diversity in the workforce, however, efforts must extend along the entire nursing professional pathway from education and job placement to career advancement and retention of minority nurses.

Leadership and Interprofessional Collaboration

A core FON recommendation was for nurses to assume more leadership roles and to collaborate increasingly with other professionals to advance health in all settings. These objectives are closely intertwined—nurses should not merely be participants in collaborative healthcare improvement endeavors, but they should increasingly be leaders in the design and implementation of these interprofessional programs.

Leadership. Nurses can be leaders at every level of practice, from the bedside to the boardroom. Increasing the number of nurses leading at the executive level has been the most challenging, however—for example, only about 5% of hospital boards even have nurse representation. Nurses need more support to become leaders. Although they exist, more education programs must offer leadership and entrepreneurship courses to nurses. Nurses need to be more proactive in developing opportunities and taking up the reins of leadership.

Interprofessional collaboration. Interprofessional education has expanded rapidly at top-10 schools of nursing throughout the United States. With healthcare in general moving toward a more team-based, interdisciplinary approach, interprofessional collaborative practice models have also been implemented, with evidence of improved patient outcomes. A healthcare landscape dotted with silos labeled "nursing," "medicine," "pharmacists," and all of the other traditional healthcare disciplines is a relic of the past. Many of the goals of the FON will require the engagement of a broader, more diverse audience of stakeholders—including consumers. "Interprofessional collaboration will go a long way toward improving the practice and profession of nursing," said Dr Altman.

What is next for the FON? The progress report made many recommendations for efforts to continue working on the original FON goals, but acknowledged a significant limitation: a lack of data. "We need better information," said Dr Altman. "We need data at the national level, but information-gathering has been cut back in recent years. These data are needed to assess further progress for the FON recommendations."


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