Leading Change, Advancing Health

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The numbers are staggering, an American Association of Medical Colleges’ report in December, projected by 2015, we will be dealing with a shortage of over 65,000 physicians in this country. At the same time, the National Institutes of Health indicates that as a result of the Patient Protection and Affordable Care Act, 32-million Americans will need healthcare coverage beginning in 2014. In addition, there are over 78-million baby boomers in the United States born in the 1940s and 1950s growing older requiring more healthcare services. The current healthcare system can’t absorb the influx of patients and provide the same level of quality patient care.
Still hampered by workforce shortages and barriers that impede their ranks from delivering quality healthcare to the full extent of their education and training, nurses across the country may have finally received a much needed shot in the arm to transform their profession. In October, a committee commissioned by the Institute of Medicine (IOM) and the Robert Wood Johnson Foundation (RWJF), released the results of a 500-page report recommending sweeping changes to improve and advance the nursing profession and patient care.

The report, “The Future of Nursing: Leading Change, Advancing Health,” is the product of a committee chaired by University of Miami President Donna Shalala, recommends four key steps: Nurses should be allowed to practice to the full extent of their education and training, Nurses should achieve higher levels of education and training through advanced degrees and an improved educational system that promotes seamless academic progression to Nurse Leaders, Nurses should be full partners with physicians and other healthcare providers in redefining healthcare in the United States, and improved workforce planning and policy making tied to better data collection and an improved information infrastructure.
“This is, we believe, a landmark report,” President Shalala said at the National Press Club in Washington D.C., where she and a contingent of other committee members including Rosa Gonzalez-Guarda, PhD, an Assistant Professor at the University of Miami School of Nursing and Health Studies, detailed the major recommendations of the document. According to Shalala, “this report will usher in the golden age of nursing in which nursing takes it’s rightful place on the front lines in leadership positions with physicians to design the blueprint for a new American healthcare system.”
The School of Nursing and Health Studies since January, has held two large public forums with President Shalala, Dean and Professor Nilda (Nena) P. Peragallo Montano, DrPH, RN, FAAN, Doctor Gonzalez-Guarda, and world renowned nursing and medical experts to discuss that healthcare “blue print” along with revisions to the SONHS curriculum to implement the Committee recommendations.
The (IOM) report is really about the future of healthcare for the American public,” explained Gonzalez-Guarda. “The 18-member committee is comprised of an interdisciplinary group with expertise in nursing, public health, medicine, economics, business administration, technology, workforce planning, healthcare consumers, managed care experts and others in pertinent health related areas. The nature of the committee, coupled with the IOM process of only providing recommendations based on strong evidence help ensure that these recommendations are not self-serving and consequently respected.”

The report calls for the elimination of regulatory and institutional obstacles including limits on nurses’ scope of practice which are state rules about what care people who are not physicians can provide. According to Gonzalez-Guarda, “it is critical to allow nurses to practice to the full extent of their education and training. When nurses and nurse practitioners are used to their full capacity and allowed to make quality of care decisions for their patients, it frees up doctors to be involved in more advanced patient care and critical care resulting in better health outcomes for the American public.”
As soon as the report was issued, the American Medical Association (AMA) issued a statement reiterating its opposition to giving nurses and nurse practitioners expanded scope of practice claiming, “increasing the responsibilities of nurses is not the solution to the physician shortage.” Various, physician’s organizations argue that physician’s longer more intensive training means that nurse practitioners cannot deliver primary care services that are as high-quality or safe as those of physicians.

However, the Future of Nursing committee addressed that issue, calling for higher levels of education and training for nurses to be able to meet the new areas of responsibilities dealing with advanced patient care. In specific, the committee is recommending that the proportion of nurses in the United States who hold at least a bachelor’s degree be increased from current levels around 50% up to 80% by 2020. At the same time the committee is calling for doubling the number of advanced practice professionals with doctoral degrees.
Gonzalez-Guarda says there is no data supporting the AMA argument that NP’s can’t deliver the same level of care as physicians.”The committee looked at states that impose greater restrictions on nurse practitioners to see if there was any data indicating those states provide safer and better care than nurse practitioners in less restrictive states and the findings indicate, “there is no correlation between stricter guidelines on NPs and improved patient care.”

American Nurse Association (ANA) president Karen Daley in a published report in the American Journal of Nursing indicated, “It’s important to understand we’re not looking to expand NP’s scope of Practice. What we want is full utilization of their skill, knowledge and experience. That means when NP’s and other Advanced Practice Registered Nurses (APRN’s) are qualified to function in an advanced practice role, such as primary care provider, they are allowed to do so. We do not want to be doctors. We simply want to remove the barriers that exist in the regulatory arena and the private payer system.”
Sixteen states plus the District of Columbia have already rewritten their scope of practice regulations and today allow nurse practitioners to practice and prescribe independently. According to Shalala, “Florida remains in the restrictive category, somewhere in the middle of the pack requiring direct physician supervision. It’s time to take the handcuffs off advanced practice nurses and let these professionals practice to the full extent of their education, training and competence.”

Gonzalez-Guarda says, “in order to optimize the use of nurses in a reformed healthcare system, bedside nurses and nurses in all levels and areas of practice need to step up to the plate and assume leadership positions. They must initiate changes that will translate into better care for patients. They must be part of the decision making of health care organizations. However, in order for this to be possible, leadership positions need to be available to nurses. This is why the IOM Committee report calls for opportunities to be expanded for nurses to lead and coordinate collaborative efforts to improve patient care.”
Nilda (Nena) P. Peragallo Montano, DrPH, RN, FAAN, Dean and Professor, University of Miami School of Nursing and Health Studies says fighting the expansion of nursing leaders and scope of practice is no longer a defensible strategy. “Nurses need the ability to practice to the full extent of their education and training. Why are we prohibiting highly educated and trained professional advanced practice nurses from making independent decisions to benefit their patients? The increased need for primary care, the deficits in primary care providers and all the research supporting the safety, quality and effectiveness of primary care provided by advanced practice nurses weighed heavily in the committee’s recommendation that nurses need to play a greater role in patient care.”
Many of the committee recommendations are already part of the SONHS curriculum and the school plans to continue increasing nurse education at the baccalaureate, master’s and doctoral levels. Peragallo says “increasing the number of nurses with advanced practice and doctoral degrees will help to address nurse attrition and insure we have enough nurse (faculty) to educate the next generation of healthcare providers.
Committee members say that along with education, the next critical component is retention of new nursing graduates. The report cites a high rate of nursing turnover, as many new graduates reference a lack of preparedness for their new responsibilities. The report calls for State Boards of Nursing, accrediting bodies, the federal government, and health care organizations to take actions to support nurses’ completion of a transition-to-practice program (nurse residency) after they have completed a pre-licensure or advanced practice degree program or when they are transitioning into new clinical practice areas.
Shalala is a supporter of establishing a nurse residency program, “nurse retention, along with advanced education and training are critical. We cannot create significant improvements in the quality of healthcare or coverage unless professional highly educated nurses’ who are on the front lines of patient care, are transitioned into new system and moved front and center in leadership, education, training and design of the new healthcare system. We can’t be fighting with each other if we are sincere about building a new and improved high quality system that we can afford.”
With the IOM committee recommendations on the table, the Robert Wood Johnson Foundation (RWJF) is moving to the next phase, working with all 50-states to implement the recommendations. The RWJF has formed ten Regional Action Committees to move the key healthcare workforce-related issues forward at the local, state and national levels. California, New Jersey, New York, Michigan and Mississippi launched the initial regional action committees last year. Florida is in the second wave with Colorado, Idaho, Illinois, Indiana, Louisiana, New Mexico, Virginia and Washington.
In the United States, 2.9-million nurses represent 80% of the total number of healthcare providers. According to Shalala, “based on their sheer numbers alone, nurses have a powerful voice for change. The nurses who comprise the vast majority of employees in the healthcare system underscore their importance and impact on the delivery of patient care. Their numbers combined with their direct proximity to patients, and knowledge about what patients need, makes them particularly suited to advance strategies for improving care and saving resources.”
The Committee is not alone in calling for an increased role for nurses, the Macy Foundation is supporting broader scope of practice boundaries, increased education and leadership positions for nurses and the American Association of Retired Persons (AARP) is now also supporting a broader role for nurse practitioners in primary care. The Committee is calling for healthcare providers to provide leadership development, mentoring programs, and opportunities to lead for all members. Nursing education programs should integrate leadership theory and business practices across the curriculum, including clinical practice. Public, private, and governmental health care decision makers at every level should include representation from nursing on boards, on executive management teams, and in other key leadership positions.
Dean Peragallo says, “This report should serve as a catalyst for nurses to turn these recommendations into regulations. Nurses with the education and skills must be placed in leadership positions. The time has come to work together to implement an affordable healthcare system providing outstanding patient care that promotes patient safety and is accessible to all patients. I am hopeful that we will find common ground and take a major step forward to improve patient care in the United States.”


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