recent findings from the 2008 National Sample Survey of Registered Nurses, just over 62 percent of working RNs were employed in hospitals in 2008—up from approximately 57 percent in 2004 (HRSA, 2010). Nurses must create, serve in, and disseminate reconceptualized roles to bridge whatever gaps remain between coverage and access to care. More must become health coaches, care coordinators, informaticians, primary care providers, and health team leaders in a greater variety of settings, including primary care medical homes and accountable care organizations. In some respects, such a transformation would return the nursing profession to its roots in the public health movement of the early 20th century.

At the same time, new systems and technologies appear to be pushing nurses ever farther away from patients. This appears to be especially true in the acute care setting. Studies show that nurses on medical–surgical units spend only 31 to 44 percent of their time in direct patient activities (Tucker and Spear, 2006). A separate study of medical–surgical nurses found they walked nearly a mile longer while on than off duty in obtaining the supplies and equipment needed to perform their tasks. In general, less than 20 percent of nursing practice time was devoted specifically to patient care activities, the majority being consumed by documentation, medication administration, and communication regarding the patient (Hendrich et al., 2008). Several health care organizations, professional organizations, and consumer groups have endorsed a Proclamation for Change aimed at redressing inefficiencies in hospital design, organization, and technology infrastructure through a focus on patient-centered design; the implementation of systemwide, integrated technology; the creation of seamless workplace environments; and the promotion of vendor partnerships (Hendrich et al., 2009). Realizing the vision presented earlier in this chapter will require a practice environment that is fundamentally transformed so that nurses are efficiently employed—whether in the hospital or in the community—to the full extent of their education, skills, and competencies.

Chapter 3 examines these issues in greater depth.

The Need to Transform Education

Key Message #2: Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression.

Major changes in the U.S. health care system and practice environment will require equally profound changes in the education of nurses both before and after they receive their licenses. An improved education system is necessary to ensure that the current and future generations of nurses can deliver safe, quality, patient-centered care across all settings, especially in such areas as primary care and community and public health.

Interest in the nursing profession has grown rapidly in recent years, in part as



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