7
Recommendations and Research Priorities

Reflecting the charge to the committee, the purpose of this report is to consider reconceptualized roles for nurses, ways in which nursing education system can be designed to educate nurses who can meet evolving health care demands, the role of nurses in creating innovative solutions for health care delivery, and ways to attract and retain well-prepared nurses in a variety of settings. The report comes at a time of opportunity in health care resulting from the passage of the Affordable Care Act (ACA), which will provide access to care for an additional 32 million Americans. In the preceding chapters, the committee has described both barriers and opportunities in nursing practice, education, and leadership. It has also discussed the workforce data needed to guide policy and workforce planning with respect to the numbers, types, and mix of professionals that will be required in an evolving health care environment.

The primary objective of the committee in fulfilling its charge was to define a blueprint for action that includes recommendations for changes in public and institutional policies at the national, state, and local levels. This concluding chapter presents the results of that effort. The committee’s recommendations are focused on maximizing the full potential and vital role of nurses in designing and implementing a more effective and efficient health care system, as envisioned by the committee in Chapter 1. The changes recommended by the committee are intended to advance the nursing profession in ways that will ensure that nurses are educated and prepared to meet the current and future demands of the health care system and those it serves.

This chapter first provides some context for the development of the committee’s recommendations. It details what the committee considered to be its scope and focus, the nature of the evidence that supports its recommendations,



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7 Recommendations and Research Priorities Reflecting the charge to the committee, the purpose of this report is to con- sider reconceptualized roles for nurses, ways in which nursing education system can be designed to educate nurses who can meet evolving health care demands, the role of nurses in creating innovative solutions for health care delivery, and ways to attract and retain well-prepared nurses in a variety of settings. The report comes at a time of opportunity in health care resulting from the passage of the Affordable Care Act (ACA), which will provide access to care for an additional 32 million Americans. In the preceding chapters, the committee has described both barriers and opportunities in nursing practice, education, and leadership. It has also discussed the workforce data needed to guide policy and workforce planning with respect to the numbers, types, and mix of professionals that will be required in an evolving health care environment. The primary objective of the committee in fulfilling its charge was to de- fine a blueprint for action that includes recommendations for changes in public and institutional policies at the national, state, and local levels. This concluding chapter presents the results of that effort. The committee’s recommendations are focused on maximizing the full potential and vital role of nurses in designing and implementing a more effective and efficient health care system, as envisioned by the committee in Chapter 1. The changes recommended by the committee are intended to advance the nursing profession in ways that will ensure that nurses are educated and prepared to meet the current and future demands of the health care system and those it serves. This chapter first provides some context for the development of the com- mittee’s recommendations. It details what the committee considered to be its scope and focus, the nature of the evidence that supports its recommendations, 2

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20 THE FUTURE OF NURSING cost considerations associated with the recommendations, and how the recom - mendations might be implemented. The chapter then presents recommendations for nursing practice, education, and leadership, as well as improved collection and analysis of interprofessional health care workforce data, that resulted from the committee’s review of the evidence. CONSIDERATIONS THAT INFORMED THE COMMITTEE’S RECOMMENDATIONS As discussed throughout this report, the challenges facing the health care system and the nursing profession are complex and numerous. Challenges to nursing practice include regulatory barriers, professional resistance to expanded scopes of practice, health system fragmentation, insurance company policies, high turnover among nurses, and a lack of diversity in the nursing workforce. With regard to nursing education, there is a need for greater numbers, better preparation, and more diversity in the student body and faculty, the workforce, and the cadre of researchers. Also needed are new and relevant competencies, lifelong learning, and interprofessional education. Challenges with regard to nursing leadership include the need for leadership competencies among nurses, collaborative environments in which nurses can learn and practice, and engage- ment of nurses at all levels—from students to front-line nurses to nursing execu- tives and researchers—in leadership roles. Finally, comprehensive, sufficiently granular workforce data are needed to ascertain the necessary balance of skills among nurses, physicians, and other health professionals for a transformed health care system and practice environment. Solutions to some of these challenges are well within the purview of the nursing profession, while solutions to others are not. A number of constraints affect the profession and the health care system more broadly. While legal and regulatory constraints affect scopes of practice for advanced practice registered nurses, the major cross-cutting constraints originate in limitations of available resources—both financial and human. These constraints are not new, nor are they unique to the nursing profession. The current economic landscape has magnified some of the challenges associated with these constraints while also reinforcing the need for change. To overcome these challenges, the nursing workforce needs to be well educated, team oriented, adaptable, and able to apply competencies such as those highlighted throughout this report, especially those relevant to leadership. The nursing workforce may never have the optimum numbers to meet the needs of patients, nursing students, and the health care system. To maximize the available resources in care environments, providers need to work effectively and efficiently with a team approach. Teams need to include patients and their families, as well as a variety of health professionals, including nurses, physicians, pharmacists, physical and occupational therapists, medical assistants, and social

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21 RECOMMENDATIONS AND RESEARCH PRIORITIES workers, among others. Care teams need to make the best use of each member’s education, skill, and expertise, and health professionals need to practice to the full extent of their license and education. Just as physicians delegate to registered nurses, then, registered nurses should delegate to front-line caregivers such as nursing assistants and community health workers. Moreover, technology needs to facilitate seamless care that is centered on the patient, rather than taking time away from patient care. In terms of education, efforts must be made to expand the number of nurses who are qualified to serve as faculty. Meanwhile, curricula need to be evaluated, and streamlined and technologies such as high-fidelity simulation and online education need to be utilized to maximize available fac- ulty. Academic−practice partnerships should also be used to make efficient use of resources and expand clinical education sites. In conducting its work and evaluating the challenges that face the nursing profession, the committee took into account a number of considerations that informed its recommendations and the content of this report. The committee care- fully considered the scope and focus of the report in light of its charge (see Box P-1 in the preface to the report), the evidence that was available, costs associated with its recommendations, and implementation issues. Overall, the committee’s recommendations are geared toward advancing the nursing profession as a whole, and are focused on actions required to best meet long-term future needs rather than needs in the short term. Scope and Focus of the Report Many of the topics covered in this report could have been the focus of the entire report. As indicated in Chapter 4, for example, the report could have fo- cused entirely on nursing education. Given the nature of the committee’s charge and the time allotted for the study, however, the committee had to cover each topic at a high level and formulate relatively broad recommendations. This report could not be an exhaustive compendium of the challenges faced by the nursing workforce, nor was it meant to serve as a step-by-step guide detailing solutions to all of those challenges. Accordingly, the committee limited its recommendations to those it believed had the potential for greatest impact and could be accomplished within the next decade. Taken together, the recommendations are meant to provide a strong foundation for the development of a nursing workforce whose members are well educated and well prepared to practice to the full extent of their education, to meet the current and future health needs of patients, and to act as full partners in leading change and advancing health. Implementation of these recommendations will take time, resources, and a significant commitment from nurses and other health professionals; nurse educators; researchers; policy makers and govern- ment leaders at the federal, state, and local levels; foundations; and other key stakeholders.

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22 THE FUTURE OF NURSING An emphasis of the committee’s deliberations and this report is nurses’ role in advancing care in the community, with a particular focus on primary care. While the majority of nurses currently practice in acute care settings, and much of nursing education is directed toward those settings, the committee sees primary care and prevention as central drivers in a transformed health care system, and therefore chose to focus on opportunities for nurses across community settings. The committee believes nurses have the potential to play a vital role in improv- ing the quality, accessibility, and value of health care, and ultimately health in the community, beyond their critical contributions to acute care. The current landscape also directed the committee’s focus on primary care; concern over an adequate supply of primary care providers has been expressed and demand for primary care is expected to grow as millions more Americans gain insurance coverage through implementation of the ACA (see Chapters 1 and 2). Addition- ally, many provisions of the ACA focus on improving access to primary care, offering further opportunities for nurses to play a role in transforming the health care system and improving patient care. The committee recognizes that improved primary care is not a panacea and that acute care services will always be needed. However, the committee sees primary care in community settings as an opportunity to improve health by reaching people where they live, work, and play. Nurses serving in primary care roles could expand access to care, educate people about health risks, promote healthy lifestyles and behaviors to prevent disease, manage chronic diseases, and coordinate care. The committee also focused on advanced practice registered nurses in its discussion of some topics, most notably scope of practice. Recognizing the im- portance of primary care as discussed above, the committee viewed the potential contributions of these nurses to meeting the great need for primary care services if they could practice uniformly to the full extent of their education and training. Available Evidence The charge to the committee called for the formulation of a set of bold national-level recommendations—a considerable task. To develop its recom- mendations, the committee examined the available published evidence, drew on committee members’ expert judgment and experience, consulted experts engaged in the Robert Wood Johnson Foundation Nursing Research Network, and com- missioned the papers that appear in Appendixes F through J on the CD-ROM in the back of this report. The committee also called on foremost experts in nursing, nursing research, and health policy to provide input, perspective, and expertise during its public workshops and forums (described in Appendix C). In addition to the peer-reviewed literature and newly commissioned research, the committee considered anecdotal evidence and self-evaluations for emerging models of care being implemented across the country. Evidence to support the

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23 RECOMMENDATIONS AND RESEARCH PRIORITIES diffusion of a variety of promising innovative models informed the committee’s deliberations and recommendations. Many of these innovations are highlighted as case studies throughout the report, and others are discussed in the appendixes. These case studies offer real-life examples of successful innovations that were developed by nurses or feature nurses in a leadership role, and are meant to complement the peer-reviewed evidence presented in the text. The committee be- lieves these case studies contribute to the evidence base on how nurses can serve in reconceptualized roles to directly affect the quality, accessibility, and value of care. Cumulatively, the case studies and nurse profiles demonstrate what is pos- sible and what the future of nursing could look like under ideal circumstances in which nurses would be highly educated and well prepared by an education system that would promote seamless academic progression, in which nurses would be practicing to the full extent of their education and training, and in which they would be acting as full partners in efforts to redesign the health care system. The committee drew on a wealth of sources of evidence to support its rec- ommendations. The recommendations presented are based on the best evidence available. There is a need, however, to continue building the evidence base in a variety of areas. The committee identified several research priorities to build upon its recommendations. For example, data are lacking on the work of nurses and the nursing workforce in general, primarily because of a dearth of large and well-designed studies explicitly exploring these issues. Accordingly, the commit- tee calls for research in a number of areas that would yield evidence related to the future of nursing to address some of the shortcomings in the data it encountered. Boxes 7-1 through 7-3 list research questions that are directly connected to the recommendations and the discussion in Chapters 3 through 5. The committee believes that answers to these research questions are needed to help advance the profession. Costs Associated with the Recommendations The current state of the U.S. economy and its effects on federal, state, and local budgets pose significant challenges to transforming the health care system. These fiscal challenges also will heavily influence the implementation of the committee’s recommendations. While providing cost estimates for each recom- mendation was beyond the scope of this study, the committee does not deny that there will be costs—in some cases sizable—associated with implementing its recommendations. These costs must be carefully weighed against the potential for long-term benefit. Expanding the roles and capacity of the nursing profession will require significant up-front financial resources, but this investment, in the committee’s view, will help secure a strong foundation for a future health care system that can provide high-quality, accessible, patient-centered care. Based on its expert opinion and the available evidence, the committee believes that, de- spite the fiscal challenges, implementation of its recommendations is necessary

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24 THE FUTURE OF NURSING BOX 7-1 Research Priorities for Transforming Nursing Practice Scope of Practice • omparison of costs, quality outcomes, and access associated with a range of C primary care delivery models. • xamination of the impact of expanding the range of providers allowed to certify E patients for home health services and for admission to hospice or a skilled nurs- ing facility. • xamination of the impact of expanding the range of providers allowed to per- E form initial hospital admitting assessments. • apture of intended and unintended consequences of alternative reimbursement C mechanisms for advanced practice registered nurses (APRNs), physicians, and other providers of primary care. • xploration of the impact of alternative payment reform policies on the organiza- E tion and effectiveness of care teams and on the role played by registered nurses (RNs), physician assistants, and APRNs on care teams. • apture of the impact of health insurance exchanges on the role of APRNs in C the provision of primary care in the United States. Residencies • dentification of the key features of residencies that result in nurses acquiring I confidence and competency at a reasonable cost. • nalysis of the possible unintended consequences of reallocating federal, A state, and/or facility budgets to support residencies and other nurse training opportunities. to increase the quality, accessibility, and value of care through the contributions of nurses. Implementation of the Recommendations Each of the recommendations presented in this report is supported by a level of evidence necessary to warrant its implementation. This does not mean, however, that the evidence currently available to support the committee’s recom- mendations is sufficient to guide or motivate their implementation. The research priorities presented in Boxes 7-1 through 7-3 constitute key evidence gaps that need to be filled to convince key stakeholders that each recommendation is fun- damental to the transformation of care delivered by nurses. For example, to be convinced to purchase equipment necessary to expand the number of nurses that can be educated using expensive new teaching technologies, such as high-fidelity

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2 RECOMMENDATIONS AND RESEARCH PRIORITIES Teamwork • dentification of the main barriers to collaboration between nurses and other I health care staff in a range of settings. • dentification and testing of new or existing models of care teams that have the I potential to add value to the health care system if widely implemented. • dentification and testing of educational innovations that have the potential to I increase health care professionals’ ability to serve as productive, collaborative care team members. Technology • dentification and testing of new and existing technologies intended to support I nurses’ decision making and care delivery. • apture of the costs and benefits of a range of care technologies intended to C support nurses’ decision making and care delivery. • dentification of the contributions of various health professionals to the design I and development, purchase, implementation, and evaluation of devices and information technology products. • evelopment of a measure of “meaningful use” of information technology by D nurses. Value • apture of the impact of changes made to the system of care delivery on costs C and quality over the next 5−10 years. • apture of the costs of implementing the recommendations in this report. C • apture of the impact of implementing the recommendations in this report on C the cost and quality of health care provided in the United States. • nalysis of the intended and unintended effects of increasing payment for pri- A mary care provided by physicians and other providers. simulation, distance learning, and online education modalities, decision makers in nursing schools will likely need evidence for the impact of these technologies on increasing the capacity of the nursing education system, as well as assurance that these technologies are an effective way to educate students. Likewise, before agreeing to reorganize care and training in a way that supports nursing residen- cies, hospitals will likely want to understand the true costs of such programs, as well as the key ingredients for their success. And before state political leaders can be persuaded to enact legislation to expand and standardize the scope of practice for advanced practice registered nurses, they will need messages to convey to their constituents about what these changes will mean for acquiring timely access to high-quality primary care services. The committee urges the health services research community to embark on research agendas that can produce the evidence needed to guide the implementa- tion of its recommendations. At the same time, the committee recognizes, from

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2 THE FUTURE OF NURSING BOX 7-2 Research Priorities for Transforming Nursing Education • dentification of the combination of salary, benefits, and job attributes that re- I sults in the most highly qualified nurses being recruited and retained in faculty positions. • nalysis of how alternative nurse faculty/student ratios affect instruction and A the acquisition of knowledge. • apture of how optimal nurse faculty/student ratios vary with the implementa- C tion of new or existing teaching technologies, including distance learning. • dentification of the features of online, simulation, and telehealth nursing edu- I cation that most cost-effectively expand nursing education capacity. • apture of the experience in nursing schools that include new curriculum C related to expanded clinical settings, evidence-based practice, and interprofes- sional and patient-centered care. • dentification and evaluation of new and existing models of nursing education I implemented to ensure that nurses acquire fundamental competencies needed to lead and engage in continuous quality improvement initiatives. • dentification or development of an assessment tool to ensure that nurses I have acquired the full range of competence required to practice nursing in undergraduate, postgraduate, and continuing education. • nalysis of the impact of a range of strategies for increasing the number A of nurses with a doctorate on the supply of nurse faculty, scientists, and researchers. • dentification of the staff and environmental characteristics that best support I the success of diverse nurses working to acquire doctoral degrees. • dentification and testing of new and existing models of education to support I nurses’ engagement in team-based, patient-centered care to diverse popula- tions, across the lifespan, in a range of settings. • evelopment of workforce demand models that can predict regional faculty D shortages. the work of Mary Naylor and colleagues (2009), that a strong evidence base, even if supported by the results of multiple randomized clinical trials funded by the National Institutes of Health, will not be sufficient to propel a new model, policy, or practice to a position of widespread acceptance and implementation. “Health care is rich in evidence-based innovations, yet even when such innovations are implemented successfully in one location, they often disseminate slowly—if at all. Diffusion of innovations is a major challenge in all industries including health care” (Berwick, 2003). Experience with the Transitional Care Model (TCM), described in Chapter 2, illustrates this point. In this case, barriers intrinsic to the way care is currently organized, regulated, reimbursed, and delivered have delayed the ability of a cost-effective, quality-enhancing model to improve the lives of the chronically

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2 RECOMMENDATIONS AND RESEARCH PRIORITIES BOX 7-3 Research Priorities for Transforming Nursing Leadership • dentification of the personal and professional characteristics most critical to I leadership of health care organizations, such as accountable care organiza- tions, health care homes, medical homes, and clinics. • dentification of the skills and knowledge most critical to leaders of health care I organizations, such as accountable care organizations, health care homes, medical homes, and clinics. • dentification of the personal and professional characteristics most important I to leaders of quality improvement initiatives in hospitals and other settings. • dentification of the characteristics of mentors that have been (or could be) I most successful in recruiting and training diverse nurses and nurse faculty. • dentification of the influence of nursing on important health care decisions at I all levels. • dentification of the unique contributions of nurses to health care committees I or boards. ill. Learning from barriers to diffuse evidence-based health care interventions within health systems, Naylor and colleagues identified several ingredients cru- cial to successful diffusion. First, the model or innovation should be a good fit in response to a critical need, either within an organization or nationwide. Second, without strong champions, especially those with decision-making power, there is very little chance of widespread adoption. The researchers learned the hard way the cost of failure to engage all stakeholders in a project—early, continually, and throughout. Engagement with the media is especially important. An understand- ing of the landscape is necessary as well and should guide efforts to market the innovation to others. Milestones and measures of success are important to all team members and throughout the entire diffusion process. Finally, flexibility, or the willingness to adapt the model or innovation to meet environmental or orga- nizational demands, increases the probability of success (Naylor et al., 2009). Planning for the implementation of the committee’s recommendations is beyond the scope of this report. However, the committee urges health care pro- viders, organizations, and policy makers to carry out the eight recommendations presented below to enable nurses to lead in the transformation of the health care system and advance the health of patients and communities throughout the nation. CONCLUSION The committee believes the implementation of its recommendations will help establish the needed groundwork in the nursing profession to further the

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2 THE FUTURE OF NURSING work of nurses in innovating and improving patient care. The committee sees its recommendations as the building blocks required to expand innovative models of care, as well as to improve the quality, accessibility, and value of care, through nursing. The committee emphasizes that the synergistic implementation of all of its recommendations as a whole will be necessary to truly transform the nurs- ing profession into one that is capable of leading change to advance the nation’s health. RECOMMENDATIONS 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. To achieve this goal, the committee recommends the following actions. For the Congress: • Expand the Medicare program to include coverage of advanced practice registered nurse services that are within the scope of practice under ap- plicable state law, just as physician services are now covered. • Amend the Medicare program to authorize advanced practice registered nurses to perform admission assessments, as well as certification of patients for home health care services and for admission to hospice and skilled nursing facilities. • Extend the increase in Medicaid reimbursement rates for primary care physicians included in the ACA to advanced practice registered nurses providing similar primary care services. • Limit federal funding for nursing education programs to only those pro- grams in states that have adopted the National Council of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administra- tive Rules (Article XVIII, Chapter 18). For state legislatures: • Reform scope-of-practice regulations to conform to the National Coun - cil of State Boards of Nursing Model Nursing Practice Act and Model Nursing Administrative Rules (Article XVIII, Chapter 18). • Require third-party payers that participate in fee-for-service payment arrangements to provide direct reimbursement to advanced practice registered nurses who are practicing within their scope of practice under state law.

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2 RECOMMENDATIONS AND RESEARCH PRIORITIES For the Centers for Medicare and Medicaid Services: • Amend or clarify the requirements for hospital participation in the Medi- care program to ensure that advanced practice registered nurses are eligible for clinical privileges, admitting privileges, and membership on medical staff. For the Office of Personnel Management: • Require insurers participating in the Federal Employees Health Benefits Program to include coverage of those services of advanced practice registered nurses that are within their scope of practice under applicable state law. For the Federal Trade Commission and the Antitrust Division of the Department of Justice: • Review existing and proposed state regulations concerning advanced practice registered nurses to identify those that have anticompetitive ef- fects without contributing to the health and safety of the public. States with unduly restrictive regulations should be urged to amend them to allow advanced practice registered nurses to provide care to patients in all circumstances in which they are qualified to do so. Recommendation 2: Expand opportunities for nurses to lead and diffuse col- laborative improvement efforts. Private and public funders, health care orga- nizations, 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. These entities should also provide opportunities for nurses to diffuse successful practices. To this end: • The Center for Medicare and Medicaid Innovation should support the development and evaluation of models of payment and care delivery that use nurses in an expanded and leadership capacity to improve health out- comes and reduce costs. Performance measures should be developed and implemented expeditiously where best practices are evident to reflect the contributions of nurses and ensure better-quality care. • Private and public funders should collaborate, and when possible pool funds, to advance research on models of care and innovative solutions,

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20 THE FUTURE OF NURSING including technology, that will enable nurses to contribute to improved health and health care. • Health care organizations should support and help nurses in taking the lead in developing and adopting innovative, patient-centered care models. • Health care organizations should engage nurses and other front-line staff to work with developers and manufacturers in the design, development, purchase, implementation, and evaluation of medical and health devices and health information technology products. • Nursing education programs and nursing associations should provide entrepreneurial professional development that will enable nurses to initi- ate programs and businesses that will contribute to improved health and health care. Recommendation 3: Implement nurse residency programs. State boards of nursing, accrediting bodies, the federal government, and health care organiza- tions 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. The following actions should be taken to implement and support nurse residency programs: • State boards of nursing, in collaboration with accrediting bodies such as the Joint Commission and the Community Health Accreditation Pro- gram, should support nurses’ completion of a residency program after they have completed a prelicensure or advanced practice degree program or when they are transitioning into new clinical practice areas. • The Secretary of Health and Human Services should redirect all gradu- ate medical education funding from diploma nursing programs to sup- port the implementation of nurse residency programs in rural and critical access areas. • Health care organizations, the Health Resources and Services Admin- istration and Centers for Medicare and Medicaid Services, and philan- thropic organizations should fund the development and implementation of nurse residency programs across all practice settings. • Health care organizations that offer nurse residency programs and foun - dations should evaluate the effectiveness of the residency programs in improving the retention of nurses, expanding competencies, and improv- ing patient outcomes.

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21 RECOMMENDATIONS AND RESEARCH PRIORITIES Recommendation 4: Increase the proportion of nurses with a baccalaureate degree to 80 percent by 2020. Academic nurse leaders across all schools of nursing should work together to increase the proportion of nurses with a bac- calaureate degree from 0 to 0 percent 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 cre- ate a workforce prepared to meet the demands of diverse populations across the lifespan. • The Commission on Collegiate Nursing Education, working in collabo - ration with the National League for Nursing Accrediting Commission, should require all nursing schools to offer defined academic pathways, beyond articulation agreements, that promote seamless access for nurses to higher levels of education. • Health care organizations should encourage nurses with associate’s and diploma degrees to enter baccalaureate nursing programs within 5 years of graduation by offering tuition reimbursement, creating a culture that fosters continuing education, and providing a salary differential and promotion. • Private and public funders should collaborate, and when possible pool funds, to expand baccalaureate programs to enroll more students by of- fering scholarships and loan forgiveness, hiring more faculty, expanding clinical instruction through new clinical partnerships, and using technol- ogy to augment instruction. These efforts should take into consideration strategies to increase the diversity of the nursing workforce in terms of race/ethnicity, gender, and geographic distribution. • The U.S. Secretary of Education, other federal agencies including the Health Resources and Services Administration, and state and private funders should expand loans and grants for second-degree nursing students. • Schools of nursing, in collaboration with other health professional schools, should design and implement early and continuous interpro- fessional collaboration through joint classroom and clinical training opportunities. • Academic nurse leaders should partner with health care organizations, leaders from primary and secondary school systems, and other commu- nity organizations to recruit and advance diverse nursing students. Recommendation 5: Double the number of nurses with a doctorate by 2020. Schools of nursing, with support from private and public funders, academic ad- ministrators 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.

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22 THE FUTURE OF NURSING • The Commission on Collegiate Nursing Education and the National League for Nursing Accrediting Commission should monitor the prog- ress of each accredited nursing school to ensure that at least 10 percent of all baccalaureate graduates matriculate into a master’s or doctoral program within 5 years of graduation. • Private and public funders, including the Health Resources and Services Administration and the Department of Labor, should expand funding for programs offering accelerated graduate degrees for nurses to increase the production of master’s and doctoral nurse graduates and to increase the diversity of nurse faculty and researchers. • Academic administrators and university trustees should create salary and benefit packages that are market competitive to recruit and retain highly qualified academic and clinical nurse faculty. Recommendation 6: Ensure that nurses engage in lifelong learning. Accredit- ing bodies, schools of nursing, health care organizations, and continuing com- petency 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. • Faculty should partner with health care organizations to develop and prioritize competencies so curricula can be updated regularly to ensure that graduates at all levels are prepared to meet the current and future health needs of the population. • The Commission on Collegiate Nursing Education and the National League for Nursing Accrediting Commission should require that all nursing students demonstrate a comprehensive set of clinical perfor- mance competencies that encompass the knowledge and skills needed to provide care across settings and the lifespan. • Academic administrators should require all faculty to participate in continuing professional development and to perform with cutting-edge competence in practice, teaching, and research. • All health care organizations and schools of nursing should foster a culture of lifelong learning and provide resources for interprofessional continuing competency programs. • Health care organizations and other organizations that offer continu- ing competency programs should regularly evaluate their programs for adaptability, flexibility, accessibility, and impact on clinical outcomes and update the programs accordingly. Recommendation 7: Prepare and enable nurses to lead change to advance health. Nurses, nursing education programs, and nursing associations should

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23 RECOMMENDATIONS AND RESEARCH PRIORITIES prepare the nursing workforce to assume leadership positions across all levels, while public, private, and governmental health care decision makers should en- sure that leadership positions are available to and filled by nurses. • Nurses should take responsibility for their personal and professional growth by continuing their education and seeking opportunities to de- velop and exercise their leadership skills. • Nursing associations should provide leadership development, mentoring programs, and opportunities to lead for all their members. • Nursing education programs should integrate leadership theory and busi- ness 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. Recommendation 8: Build an infrastructure for the collection and analysis of interprofessional health care workforce data. The National Health Care Work- force 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. • The Workforce Commission and the Health Resources and Services Administration should coordinate with state licensing boards, including those for nursing, medicine, dentistry, and pharmacy, to develop and promulgate a standardized minimum data set across states and profes- sions that can be used to assess health care workforce needs by demo- graphics, numbers, skill mix, and geographic distribution. • The Workforce Commission and the Health Resources and Services Administration should set standards for the collection of the minimum data set by state licensing boards; oversee, coordinate, and house the data; and make the data publicly accessible. • The Workforce Commission and the Health Resources and Services Administration should retain, but bolster, the Health Resources and Services Administration’s registered nurse sample survey by increasing the sample size, fielding the survey every other year, expanding the data collected on advanced practice registered nurses, and releasing survey results more quickly. • The Workforce Commission and the Health Resources and Services Administration should establish a monitoring system that uses the most

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24 THE FUTURE OF NURSING current analytic approaches and data from the minimum data set to systematically measure and project nursing workforce requirements by role, skill mix, region, and demographics. • The Workforce Commission and the Health Resources and Services Administration should coordinate workforce research efforts with the Department of Labor, state and regional educators, employers, and state nursing workforce centers to identify regional health care workforce needs, and establish regional targets and plans for appropriately increas- ing the supply of health professionals. • The Government Accountability Office should ensure that the Workforce Commission membership includes adequate nursing expertise. REFERENCES Berwick, D. M. 2003. Disseminating innovations in health care. JAMA 289(15):1969-1975. Naylor, M. D., P. H. Feldman, S. Keating, M. J. Koren, E. T. Kurtzman, M. C. Maccoy, and R. Krakauer. 2009. Translating research into practice: Transitional care for older adults. Journal of Evaluation in Clinical Practice 15(6):1164-1170.